2019-20 TOW #7: Immunizations

A huge thanks to our amazing immunization experts Drs. Doug Opel and Annika Hofstetter for developing materials for next weeks’ TOW on immunizations. This is a timely topic given the measles outbreaks and back-to-school visits, and the relatively lower immunization rates for WA state compared to national rates. Hopefully, thanks to our colleagues here, we will continue to make inroads to protect our children.

Teaching materials for immunizations:

Take-home points:

  1. Why are issues around immunizations so important to know well as pediatricians? Immunizations are arguably the biggest success story of public health in the 20th century and the most important component of the recommended well child visit schedule. While vaccine safety has been extensively studied, no vaccine is 100% safe or 100% effective. This has contributed to the controversies around vaccines. Yet, we know vaccines are overwhelmingly effective to decrease morbidity and mortality from vaccine-preventable diseases.
  2. How many parents are vaccine hesitant? While only about 1% of parents are anti-vaccine (choosing no vaccines), about 1/3 are considered vaccine hesitant, and the vast majority (about 2/3) are vaccine accepters. Vaccine-hesitant parents are the ones where we may have the most influence to change their approach/decision.
  3. How is it best to bring up the topic of vaccines in clinic? As Doug Opel and team identified in a study in Pediatrics (see above), choosing a “presumptive stance” (i.e., “today your child is due for these vaccines”) rather than a more collaborative approach (e.g. “what vaccines did you want to give today?”) was associated with more likelihood of vaccines being accepted by parents. It’s always important to use good general communication skills including being open to questions, honest, respectful of parents, and not coming across as offended or defensive. The CHOP vaccine app has helpful info for parents as well.
  4. Why have vaccines developed such a negative reputation? Partly it’s because there are many more of them and that’s been worrisome to some parents. But mostly it’s been related to vaccines, especially MMR, being wrongly associated with causing autism. The study that first suggested this association was published in the Lancet and was eventually retracted as people recognized the poor study design and even falsified data. The lead author had his medical license revoked. Unfortunately, the repercussions of this unethical study were incredibly detrimental, and we are still dealing with them.
  5. What are the most controversial ingredients in vaccines? Those that have specifically raised concerns are thimerosol (a preservative that was taken out of most vaccines despite lack of evidence that it could cause neurological problems), aluminum (an adjuvant that helps vaccines work better – concentrations are less than what a baby ingests in breastmilk by age 6 months), animal-derived gelatin (used as a stabilizer in some vaccines – objectionable to some people in Muslim faith though there have been statements from imams that they can be given) and aborted fetal material (used as cell strains to grow MMR, varicella – of special concern to devout Christians or Catholics – the Vatican has said parents could accept these vaccines).

2018-19 TOW #47: Tuberculosis screening

We are fortunate to live in an increasingly diverse city with immigrants from around the world. At this time of year families are often planning summer travel to visit family members abroad, so this is a good time to think about how to screen for TB after travel. Materials for this week:

Key take-home points:

  1. What are the rates of TB in the US, and what are the risk factors among children? TB has been declining in the US and reached an historic low of 3.2 cases per 100,000 in 2012. The biggest risks are being born outside the US, or traveling to another country, especially for >1 week and staying with family. For children, additional risks include living among family members or visitors born in endemic countries, or living with high risk adults (including those affected by homelessness, incarceration, drug use or HIV). Those with chronic diseases, immunodeficiency, and/or those using high-dose steroids are also at higher risk of developing TB.
  2. Who do we need to screen for TB in clinic? It’s recommended to start screening for latent TB infection (LTBI) from the first time we meet patients and annually at well visits, or 10 weeks after return from travel (although considered acceptable to wait for annual check-ups). To assess LTBI risk factors, there are 4 validated questions: 1) Has a family member or contact had TB? 2) Has a family member had a positive TB test? 3) Was the child born in a high-risk country (i.e., outside US, Canada, Australia, New Zealand or Western Europe)? 4) Has the child traveled to a high-risk country for more than 1 week? (and SCH ID team adds: or has child had household visitors from a high-risk country?)
  3. Which screening tests do we use? Screening tests vary by age group: per the CDC, tuberculin skin test (TST or PPD) is still preferred for children less than 5. The preferred test for ages 5 and older is a blood test, the interferon gamma release assay (IGRA, e.g., QuantiFERON -TB Gold). IGRA tests measures interferon gamma response to mycobacterial antigens so are relatively specific to M. tuberculosis. They do not require a return visit, and are not cross-reactive with BCG vaccine. We can use a combination of tests to help establish diagnosis when there are indeterminate results, or concern for false positives or negatives.
  4. What happens if there is a positive TB screen? To establish a diagnosis of latent TB, rule out active disease through a chest x-ray, history and exam. The initial preferred treatment for positive latent TB is with isoniazid (INH) for 9 months (there are alternative schedules to this based on special patient needs).
  5. How common is BCG vaccine? How does BCG vaccine affect interpretation? Bacille Calmette-Guerin (BCG) immunization is widely used in TB endemic countries; the WHO estimates that 83% of the world’s population has received this vaccine. Most countries recommend giving the vaccine at birth, and the majority of children receive it before age 5. Because of the varying effects of BCG on interpreting TB tests, we use a conservative approach, and BCG status is not used in interpreting PPD reactions, and is not a contraindication for receiving PPD. Quantiferon gold testing is not affected by cross-reactivity with BCG, however the test has been less accurate for younger children, and may be more difficult to administer due to phlebotomy requirement.

2018-19 TOW #46: Adolescent immuniztions

There’s a lot going on in adolescence, including trying to complete additional recommended vaccines, the most challenging being HPV and flu. We will review some of the barriers and recommendations to address this.

Materials for this week:

Key take-home points:

  1. What types of clinical settings do adolescents use? Most teenagers have a medical home in the US, and >90% of adolescent vaccinations are received in a pediatric, family medicine or community health clinic. A few receive vaccines in school clinics, internal medicine and OB-GYN settings.
  2. What are the recommended vaccines for pre-teens and adolescents? Starting at age 11, we recommend a 2-dose meningococcal series (1 dose at 11-12, 2nd at age 16), single dose of Tdap, 2-dose HPV vaccine series (separated by minimum of 5 months; it’s 3 doses if started at age 15 or older), and an annual influenza vaccine.
  3. What are adolescent immunization rates in the US? The 2016 National Immunization Survey showed that adolescents aged 13-15 years met the Healthy People 2020 goal of 80% coverage for Tdap (88% coverage) and first dose of meningococcal vaccine (82% coverage), but did not meet the HPV vaccine benchmark (50% of females, 38% of males). Flu vaccine rates are especially low for teens (49% of 13- to 17-year-olds).
  4. What are common barriers to adolescent immunizations? Provider/clinic factors include not offering vaccines at acute visits, and not having follow-up visits; family factors include not coming for annual wellness visits. There has been particular parental concern about the HPV vaccine safety and need for it at a younger age. The HPV vaccine is only effective against HPV strains before exposure to the strains. Even before teens start having sex, they may be at risk for HPV related disease. HPV DNA has been detected in cervicovaginal swabs from girls who report never having had vaginal intercourse, so the virus is also transmitted through other forms of sexual contact. Data suggest better immunogenicity to the vaccine when given at a younger age, and teens are motivated that it is only 2 doses if done before age 15.
  5. What are ways we can help increase vaccination rates? A strong provider recommendation is one of the most important factors that positively affects vaccination, as has been shown in several studies for the HPV vaccine. Other strategies are to review immunization records at visit, offer immunizations at each visit, and schedule follow-up visits for the next vaccines due. System-level approaches include family-oriented ones like text reminders to families, web-based education and social marketing, as well as clinician-focused ones like automatic EMR reminders and incentives.

2018-19 TOW #14: Antibiotics in primary care

School is in full swing, and we have already had the first cold of the season at our house. As we gear up for flu vaccines in preparation for viral season, it’s time to think about antibiotic use and stewardship in primary care setting. Our amazing general pediatrics and hospital medicine chair, Dr. Rita Mangione-Smith MD MPH, has been a lead researcher in informing this topic.

Materials for this week:

Take-home points:

  1. How often are antibiotics prescribed in outpt settings? More than 1 in 5 ambulatory visits for children results in antibiotic prescription. Studies have shown up to 1/3 of patients diagnosed with a common cold receive an antibiotic prescription. This increases up to 60% among patients presenting with bronchitis and other viral illnesses.
  2. What are some harms of antibiotic use from both an individual and a community-based standpoint? Individual harm includes diarrhea, upset stomach, adverse drug reactions, higher rates of resistant bacteria, and disruption of the gut microbiome. From a society standpoint, unnecessary antibiotic use contributes to excess health care costs and promotes antibiotic resistance.
  3. What situations trigger physicians to prescribe antibiotics for respiratory infections? Dr. Mangione-Smith and team found physicians were more likely to prescribe antibiotics for children with a cold if 1) they perceived the parent or patient expects it, 2) there is parental anxiety about the child’s illness before the visit, 3) they reported wheezing or rhonchi on exam, and 4) parents had very low SES (perhaps MDs may mistakenly believe it is faster to give ABX than explain what to do instead). Other studies have also found we prescribe more in visits that occur later in the day (consistent with decision fatigue).
  4. What are the principles of responsible antibiotic prescribing? 1) Determine the likelihood of a bacterial infection-use diagnostic criteria and guidelines, as well as tests to determine pre-test probability when possible, such as Centor criteria for sore throat and strep infection, and clear clinical findings for acute otitis media; 2) Weigh benefits and risks of ABX treatment to determine whether they should be given, and 3) Use judicious prescribing strategies (i.e., the most narrow-spectrum and effective antibiotic for the appropriate duration – this might include a watch and wait approach, if appropriate).
  5. What methods can we use to counsel family members about antibiotics? As per Dr. Mangione-Smith’s research, we are likely to get more questioning of the treatment if we specifically say “antibiotics are not needed” when we summarize the treatment plan, rather than focusing on positive, supportive treatment that parents can implement. When parents suggest a “candidate diagnosis” that might require antibiotics, like ear infection, sinusitis, or pneumonia, we should explain how we will determine the diagnosis based on the exam. Other strategies we can use: align with parents on goals of helping the child get well as quickly and safely as possible, legitimize symptoms and concerns for bringing the child in, and address parent anxiety and effort. Addressing specific ways to manage symptoms (analgesics, elevated head of bed, steam/ warm baths, honey for cough, etc.) is helpful. I’ve also taken to highlighting the benefit of building the immune system in young ages, as this potentially helps lower risk of autoimmune diseases later.

TOW #45: Lymphadenopathy

This week’s topic is a review of lymphadenopathy and how to characterize those lumps and bumps that parents worry about (and us too!). Interesting fact of the day: there are about 600 lymph nodes in the body! One of the fascinating zebras on the differential for lymphadenopathy is Kikuchi disease, a necrotizing lymphadenitis, recently reviewed in an excellent morning report by R3 Josiah Peterson MD PhD.

The teaching materials for the week:

Take-home points on lymphadenopathy:

  1. What’s the definition of lymphadenopathy? Abnormality in size, number, or consistency of lymph nodes (whereas lymphadenitis is an inflammatory or infectious enlargement of lymph nodes). Lymph nodes are normally up to 1cm in the axillary and cervical regions and up to 1.5cm in the inguinal region. “Shotty lymphadenopathy” refers to multiple small, mobile lymph nodes resembling birdshot (~2mm) or buckshot (~8mm) under the skin. This is a common, self-limited finding in children under five typically during viral illnesses. Any node >2cm should be considered abnormal. Generalized lymphadenopathy refers to two or more noncontiguous sites of lymph node enlargement.
  2. Why lymph?: An “ultrafiltrate” of blood, lymph carries immune cells in lymph capillaries through the entire body except the brain and heart. The bone marrow and thymus are the primary lymphoid organs because they generate B and T lymphocytes. Secondary lymphoid organs are lymph nodes, spleen, and mucosa-associated lymphoid tissue (MALT), including the tonsils, appendix, and Peyer patches of the ileum. Because young children’s immune systems are actively developing, we commonly feel enlarged lymph nodes.
  3. What’s on the differential diagnosis? The broad categories are infectious, immune disorders, and malignancy. Under age 5, we know cervical lymph nodes are almost always infectious-don’t forget scalp and dental sources. Supraclavicular nodes are always abnormal, most commonly caused by lymphoma, mycobacterial infection, or sarcoidosis. Generalized lymph node swelling is more likely to be systemic infection (viruses, including EBV, CMV, HIV, syphilis or toxoplasmosis), but also may be a sign of malignancy or autoimmune disorders.
  4. What are key parts of history and physical exam? Ask about systemic symptoms, including fever, weight loss, night sweats, poor appetite, and fatigue. Ask about the time course, and change in the size or number of lymph nodes. Review exposure to insects, animal contacts, travel, and immunizations. Determine locations of lymph nodes, whether unilateral versus bilateral, soft versus hard, mobile versus fixed, and tender versus non-tender. Focus the rest of the exam on chief complaint/symptoms. More worrisome signs for malignancy include hard/ rubbery, immobile, persistent and non-tender lymph nodes (though malignant ones can also be tender).
  5. When should we do a work-up and what should it include? If nothing suggests malignancy, observe for 2-4 weeks, then follow-up. If not resolved, work-up would include viral serologies and CBC, ESR and CRP. Additional testing is done based on history (e.g., Bartonella henselae PCR when concerns for cat scratch, or TB testing for patients at risk). When there is concern for malignancy, including prolonged duration, location, large or increasing size, abnormal texture, and/or the presence of constitutional symptoms, we should refer for biopsy and obtain CXR to look for mediastinal lymphadenopathy.

TOW #26: Otitis media

Next week’s topic is otitis media, a quintessential topic year-round in pediatrics, but particularly during viral season. Indeed, we currently have an 8 yr old at home with recent URI and 24 hours of otalgia… at her request, pediatrician mom pulled out the trusty portable otoscope from med school last night (it’s gotten good use through the years!). Sure enough, a bulging, purulent TM with severe erythema… so how do we treat, and how does that vary by age group? Let’s review!

Materials for next week:

A few take-home points:

  1. How common is acute otitis media (AOM) and what are the pathogens? AOM is the most common condition for which medications are prescribed in children. Antibiotic stewardship has become an important goal in appropriately diagnosing and treating AOM. In the current vaccine era, S. pneumonia and non-typeable Haemophilus influenzae (H. flu) are now equally prevalent (~40-45%), followed by Moraxella catarrhalis (10-15%). Much less common are staph and group A strep. Viruses are also common and usually concurrent with the bacteria; in one study, 92% of AOM fluid had a bacteria, 70% had a virus, and 66% had both a virus and bacteria.
  2. What are the criteria to diagnose AOM? This has evolved somewhat through the years. The most recent guidelines have 3 main diagnostic components: 1) AOM is diagnosed in children who present with moderate to severe bulging of the tympanic membrane (TM) or new onset of otorrhea not due to acute otitis externa; 2) AOM may be diagnosed in children with “mild bulging of the TM” AND either “recent (less than 48 hours) onset of ear pain” (including rubbing, tugging, or holding in a nonverbal child) or “intense erythema of the TM;” 3) Diagnosis should NOT be made in children without middle ear effusion based on pneumatic otoscopy or tympanometry (we enhance the accuracy of diagnosis with pneumatic techniques especially for inconclusive visual findings). Studies have found a bulging TM has the highest predictive value for AOM, followed by a cloudy TM and impaired TM mobility. Note, slight redness of the TM does not indicate AOM, though moderate to severe erythema (including hemorrhagic) does correlate with AOM.
  3. How should we treat otalgia of AOM? Pain should be assessed with AOM, and we should provide clear guidance on how to manage it with oral analgesics. My daughter got a dose of ibuprofen last night (preferred at our house given the longer half life and dosing every 6 hours, and better taste of the generic brand compared to acetaminophen, per my kids’ taste buds!). It’s important to counsel that the ear pain may require scheduled pain medication for a day or two. We no longer have prescription topical otic analgesics on the market, as the prior medications were pulled by the FDA due to concerns about lack of safety and efficacy. To my knowledge, OTC otic analgesics (such as homeopathic or herbal remedies) have not been adequately studied to recommend them.
  4. When should we use antibiotics to treat? Antibiotics should be provided for children under 2 when AOM is diagnosed, unless it’s unilateral AOM and non-severe presentation (afebrile, mild otalgia), then we can use observation when jointly decided with parents. For children over 2 yo we can treat, or observe if they are non-severe, based on joint decision making. One recent RCT showed that middle ear effusion did indeed persist longer for children not treated (as above). For my daughter, given her age group and unilaterality, we are currently trying the watchful waiting approach and hoping for resolution (promising sign she slept well and had no complaints of pain this morning!). In her last bout a couple of years ago, after days of otalgia (pediatrician mom was stubbornly holding out), she had great improvement within 24 hours of starting antibiotics; it was a good reminder they really are warranted in some cases.
  5. What antibiotic treatment should we use? As pediatricians, we should probably be able to answer this in our sleep! High-dose amoxicillin (80-90mg/kg divided BID, up to 3g daily) remains the initial antibiotic of choice. Although beta-lactamase production is common among certain AOM pathogens (e.g., H. flu, M. catarrhalis), severe, invasive disease is often associated with Group A strep (susceptible to amox), or S. pneumoniae, whose resistance from penicillin-binding-proteins can be overcome by using high-dose regimens. Treatment duration is 10 days for children with severe disease or under 2 years of age. Shorter duration is appropriate for children >2yo with mild disease: 7 days in 2 to 5 years old, and 5-7 days in children over 5. We use amoxicillin-clavulanate (Augmentin, 90mg/kg/day divided BID) for children who either received amox in the past 30 days, have had recurrent infection unresponsive to amox, or have concurrent purulent conjunctivitis concerning for otitis-conjunctivitis syndrome (more likely non-typeable H. flu). If patients are allergic to penicillin, then we should choose a 2nd or 3rd generation cephalosporin (macrolides are not recommended), orally, or we can do 1-3 days of ceftriaxone IM (most respond to 1 dose, but there’s less treatment failure with 3).

 

TOW #22: Community Acquired Pneumonia

Next week’s topic is community acquired pneumonia (CAP), a relevant topic as we enter the winter months.

Materials for this week

A few take home points to review:

  1. What is the global burden of pneumonia? The WHO reports pneumonia is the single highest cause of death in children worldwide under 5, accounting for 18% of deaths. Fortunately it has become much less of a problem for us in an era of widespread access to vaccines against pneumococcal and HIB. In the US, pneumonia occurs in an estimated ~2.6% of children under age 17.
  2. How do we diagnose pneumonia? Pneumonia is a clinical diagnosis that can be challenging to confirm, and no single definition is used in pediatrics. In diagnosing it, we look for the most common symptoms of cough, fever, and/or tachypnea in the setting of findings of parenchymal disease by either physical exam or chest x-ray. Crackles (rales) are the most common exam finding, but we should also look for decreased breath sounds, egophany, tactile fremitus, and/or dullness to percussion. X-rays are not needed to confirm diagnosis or resolution of pneumonia, but should be obtained when diagnosis is less certain and/or patient symptoms are more severe. Labs such as blood cultures are not routinely indicated for children treated as outpatients.
  3. What is the recommended treatment? Treatment is based on age and severity. Viral pneumonia is much more common in preschool age children, so observation and supportive care is often appropriate. Older children are more likely to have bacterial pneumonia and are treated as appropriate with high-dose amoxicillin as first line therapy for lobar disease. Use azithromycin for suspected atypical pneumonia, or both amox and a macrolide, especially if they are sicker.
  4. Who can be managed as an outpatient? Outpatient management of pneumonia is appropriate for mild-to-moderate disease for children who are not hypoxic or in distress who can tolerate oral antibiotics. The Pediatric Infectious Diseases Society guidelines  recommend hospitalization for children with moderate to severe CAP including respiratory distress and/or hypoxemia (pulse ox <= 90%).

TOW #21: Sore throat

As we prepare for the holidays, ’tis the season to be preparing for viral respiratory season as well! One of our big roles as pediatricians when we see children with a sore throat is helping distinguish between viral infections and strep throat (Group A Strep Pharyngitis or GASP). Thanks to our incredibly knowledgeable emeritus general pediatrics guru Dr. Jeff Wright, we have a brief algorithm to help guide our decisions. *Reminder – you can review our other general pediatrics outpatient guidelines posted here.

This week’s materials:

Take-home points for evaluating a possible diagnosis of strep throat:

  1. Which children with sore throat should we test for strep infection? We can use the Centor criteria to help. Positive criteria include age 3-14, exudate or swelling on tonsils, tender/swollen anterior lymph nodes, temp >38.0, and absence of cough. We should not test children who have symptoms strongly suggesting a viral infection such as cough, rhinorrhea, hoarseness, or oral ulcers. Presence of either a scarlitiniform rash or palatal petechiae are also predictors of GASP, but not foolproof, so testing is recommended for these symptoms as well. Only test children under 3 who have a known contact or highly concerning exam.
  2. When should we initiate antibiotics for strep pharyngitis? Contrary to prior practices, we now recommend that all children have a confirmed positive rapid strep or strep culture before being treated with antibiotics. This is due mostly to a larger concern about overuse of antibiotics and a prolonged and persistent decline in rate of rheumatic fever.
  3. What should we use to treat GASP? Treat confirmed strep throat with oral penicillin, amoxicillin, or cephalexin given for 10 days, a single injection of Benzathine G penicillin, or 5 days of oral azithromycin (reserved for penicillin allergic patients).
  4. Should we treat sick contacts without testing? It is no longer recommended to presumptively treat sick contacts – clinical guidelines now recommend that all people who are treated have testing that confirms the presence of GAS. (We just had an example of this in clinic for a sibling sick contact who had some concerning symptoms, but did not test positive, even on culture. That sibling then infected the first one with the virus!)
  5. How many kids are GAS carriers? There is a fairly high normal carriage rate for Group A streptococcus in children – as high as 15%. This really reinforces we do not test unless we have a higher concern for strep throat.

TOW #49: Tuberculosis screening

We are fortunate to live in an increasingly diverse city with many immigrants from around the world. At this time of year we see more families planning their summer travel to visit family members abroad, so this is a good time to think about how to screen them for TB after traveling. Materials for this week:

Key take-home points:

  1. What are the rates of TB in the US and what are the risk factors among children? TB has been declining in the US and reached an historic low of 3.2 cases per 100,000 in 2012. The biggest risk is being born outside the US or traveling to another country, especially for >1 week, and staying with family. For children, additional risks include living among family members or visitors born in endemic countries, or living with high risk adults, including those affected by homelessness, incarceration, drug use or HIV. Those with chronic diseases, immunodeficiency, and/or using high-dose steroids are also at higher risk of developing TB.
  2. Who do we need to screen in clinic? It’s recommended to start screening for latent TB infection (LTBI) from the first time we meet patients and annually at well visits, or 10 weeks after return from travel (although considered acceptable to wait for annual check-up). To assess LTBI risk factors, there are 4 validated questions: 1) Has a family member or contact had TB? 2) Has a family member had a positive TB test? 3) Was the child born in a high-risk country (i.e., outside US, Canada, Australia, New Zealand or Western Europe)? 4) Has child traveled to a high-risk country for more than 1 week? (and SCH ID team add: or has child had household visitors from a high-risk country?)
  3. Which screening tests do we use? Screening tests vary by age group: tuberculin skin test (TST or PPD) is still preferred for children less than 5. Interferon gamma release assays (IGRAs, including QuantiFERON -TB Gold) measure interferon-gamma response to mycobacterial antigens. IGRAs are now the preferred test for ages 5 and older as they are relatively specific to M. tuberculosis, do not require return visit, and are not cross-reactive with BCG vaccine. We can use both tests to help establish diagnosis when there are indeterminate results, or concern for false positives or negatives.
  4. What happens if there is a positive TB screen? To establish a diagnosis of latent TB, rule out active disease through a chest x-ray, history and exam. The initial preferred treatment for positive latent TB is with isoniazid (INH) for 9 months (there are alternative schedules to this based on special patient needs).
  5. How common is BCG vaccine? How does BCG vaccine affect interpretation? Bacille Calmette -Guerin (BCG) immunization is widely used in TB endemic countries; the WHO estimates that 83% of the world’s population has received this vaccine. Most countries recommend giving the vaccine at birth, and the majority of children receive it before age 5. Because of the varying effects of BCG on interpreting TB tests, we use a conservative approach and BCG status is not used in interpreting PPD reactions. Quantiferon gold testing is not affected by cross-reactivity with BCG.

TOW #46: Adolescent immunizations

There's a lot going on in adolescence, including trying to complete additional recommended vaccines. There's been a bigger emphasis on completing newer immunization series recommended for adolescents, the most controversial being HPV. We will review some of the barriers and recommendations to address this.

Materials for this week:

Key take-home points:

  1. What types of practice settings do adolescents use? Most teenagers do have a medical home in the US and >90% of adolescent vaccinations are received in a pediatric, family medicine or community health clinic. A few receive vaccines in school clinics, internal medicine and OB-GYN settings.
  2. What are adolescent immunization rates in the US? The 2014 National Immunization Survey results showed that vaccination rates among adolescents ages 13-17 are improving, but are still consistently lower than among young children. Coverage rates in 2014 were: Tdap -88% coverage, quadrivalent meningococcal conjugate vaccine or MCV4-79%, and HPV vaccine Girls:>1 dose [60%], 3 doses [40%]; Boys: >1 dose [42%], 3 doses [22%].
  3. What are the recommended vaccines for pre-teens and adolescents? Starting at age 11, we recommend a 2-dose meningococcal series, single dose of Tdap, 2-dose HPV vaccine series (2 doses if started before age 15; 3 doses if started at 15+ yo), and an annual influenza vaccine.
  4. What are common barriers to adolescent immunizations? Provider/clinic factors include not offering vaccines at acute visits, and not having follow-up visits; and family factors include not coming for annual wellness visits. There has been particular parental concern about the HPV vaccine safety and need for it at a younger age. The HPV vaccine is only effective against HPV strains before exposure to the strains. Even before teens start intercourse, they may be at risk for HPV related disease. In fact, HPV DNA has been detected in cervicovaginal swabs from girls who report never having had sexual intercourse, so the virus is also transmitted through other forms of sexual contact. Some data suggest better immunogenicity to the vaccine when given at a younger age.
  5. What are ways we can help increase vaccination rates? A strong provider recommendation is one of the most important factors that positively affects vaccination, as has been shown in several studies for the HPV vaccine. Other strategies are to review immunization records at every visit, offer immunizations at each visit, and schedule follow-up visits for the next vaccine due.