Shannon Stokley

National, Regional, State, and Selected Local Area Vaccination Coverage Among Adolescents Aged 13-17 Years — United States, 2014

The Advisory Committee on Immunization Practices (ACIP) recommends that adolescents aged 11-12 years routinely receive vaccines to prevent diseases, including human papillomavirus (HPV)-associated cancers, pertussis, and meningococcal disease (1). To assess vaccination coverage among adolescents in the United States, CDC analyzed data collected regarding 21,875 adolescents through the 2015 National Immunization Survey-Teen (NIS-Teen).* During 2014-2015, coverage among adolescents aged 13-17 years increased for each HPV vaccine dose among males, including ≥1 HPV vaccine dose (from 41.7% to 49.8%), and increased modestly for ≥1 HPV vaccine dose among females (from 60.0% to 62.8%) and ≥1 quadrivalent meningococcal conjugate vaccine (MenACWY) dose (from 79.3% to 81.3%). Coverage with ≥1 HPV vaccine dose was higher among adolescents living in households below the poverty level, compared with adolescents in households at or above the poverty level.(†) HPV vaccination coverage (≥1, ≥2, or ≥3 doses) increased in 28 states/local areas among males and in seven states among females. Despite limited progress, HPV vaccination coverage remained lower than MenACWY and tetanus, diphtheria, and acellular pertussis vaccine (Tdap) coverage, indicating continued missed opportunities for HPV-associated cancer prevention.

Barriers to human papillomavirus vaccination among US adolescents: a systematic review of the literature.

IMPORTANCE Since licensure of the human papillomavirus (HPV) vaccine in 2006, HPV vaccine coverage among US adolescents has increased but remains low compared with other recommended vaccines. OBJECTIVE To systematically review the literature on barriers to HPV vaccination among US adolescents to inform future efforts to increase HPV vaccine coverage. EVIDENCE REVIEW We searched PubMed and previous review articles to identify original research articles describing barriers to HPV vaccine initiation and completion among US adolescents. Only articles reporting data collected in 2009 or later were included. Findings from 55 relevant articles were summarized by target populations: health care professionals, parents, underserved and disadvantaged populations, and males. FINDINGS Health care professionals cited financial concerns and parental attitudes and concerns as barriers to providing the HPV vaccine to patients. Parents often reported needing more information before vaccinating their children. Concerns about the vaccines effect on sexual behavior, low perceived risk of HPV infection, social influences, irregular preventive care, and vaccine cost were also identified as potential barriers among parents. Some parents of sons reported not vaccinating their sons because of the perceived lack of direct benefit. Parents consistently cited health care professional recommendations as one of the most important factors in their decision to vaccinate their children. CONCLUSIONS AND RELEVANCE Continued efforts are needed to ensure that health care professionals and parents understand the importance of vaccinating adolescents before they become sexually active. Health care professionals may benefit from guidance on communicating HPV recommendations to patients and parents. Further efforts are also needed to reduce missed opportunities for HPV vaccination when adolescents interface with the health care system. Efforts to increase uptake should take into account the specific needs of subgroups within the population. Efforts that address system-level barriers to vaccination may help to increase overall HPV vaccine uptake.

Recent Resurgence of Mumps in the United States

BACKGROUND The widespread use of a second dose of mumps vaccine among U.S. schoolchildren beginning in 1990 was followed by historically low reports of mumps cases. A 2010 elimination goal was established, but in 2006 the largest mumps outbreak in two decades occurred in the United States. METHODS We examined national data on mumps cases reported during 2006, detailed case data from the most highly affected states, and vaccination-coverage data from three nationwide surveys. RESULTS A total of 6584 cases of mumps were reported in 2006, with 76% occurring between March and May. There were 85 hospitalizations, but no deaths were reported; 85% of patients lived in eight contiguous midwestern states. The national incidence of mumps was 2.2 per 100,000, with the highest incidence among persons 18 to 24 years of age (an incidence 3.7 times that of all other age groups combined). In a subgroup analysis, 83% of these patients reported current college attendance. Among patients in eight highly affected states with known vaccination status, 63% overall and 84% between the ages of 18 and 24 years had received two doses of mumps vaccine. For the 12 years preceding the outbreak, national coverage of one-dose mumps vaccination among preschoolers was 89% or more nationwide and 86% or more in highly affected states. In 2006, the national two-dose coverage among adolescents was 87%, the highest in U.S. history. CONCLUSIONS Despite a high coverage rate with two doses of mumps-containing vaccine, a large mumps outbreak occurred, characterized by two-dose vaccine failure, particularly among midwestern college-age adults who probably received the second dose as schoolchildren. A more effective mumps vaccine or changes in vaccine policy may be needed to avert future outbreaks and achieve the elimination of mumps.

Geographic Clustering of Nonmedical Exemptions to School Immunization Requirements and Associations With Geographic Clustering of Pertussis

School immunization requirements are important in controlling vaccine-preventable diseases in the United States. Forty-eight states offer nonmedical exemptions to school immunization requirements. Children with exemptions are at increased risk of contracting and transmitting vaccine-preventable diseases. The clustering of nonmedical exemptions can affect community risk of vaccine-preventable diseases. The authors evaluated spatial clustering of nonmedical exemptions in Michigan and geographic overlap between exemptions clusters and clusters of reported pertussis cases. Kulldorfs scan statistic identified 23 statistically significant census tract clusters for exemption rates and 6 significant census tract clusters for reported pertussis cases between 1993 and 2004. The time frames for significant space-time pertussis clusters were August 1993-September 1993, August 1994-February 1995, May 1998-June 1998, April 2002, May 2003-July 2003, and June 2004-November 2004. Census tracts in exemptions clusters were more likely to be in pertussis clusters (odds ratio = 3.0, 95% confidence interval: 2.5, 3.6). The overlap of exemptions clusters and pertussis clusters remained significant after adjustment for population density, proportion of racial/ethnic minorities, proportion of children aged 5 years or younger, percentage of persons below the poverty level, and average family size (odds ratio = 2.7, 95% confidence interval: 2.2, 3.3). Geographic pockets of vaccine exemptors pose a risk to the whole community. In addition to monitoring state-level exemption rates, health authorities should be mindful of within-state heterogeneity.

Human papillomavirus vaccination practices: a survey of US physicians 18 months after licensure.

OBJECTIVES: The objectives of this study were to assess, in a nationally representative network of pediatricians and family physicians, (1) human papillomavirus (HPV) vaccination practices, (2) perceived barriers to vaccination, and (3) factors associated with whether physicians strongly recommended HPV vaccine to 11- to 12-year-old female patients. METHODS: In January through March 2008, a survey was administered to 429 pediatricians and 419 family physicians. RESULTS: Response rates were 81% for pediatricians and 79% for family physicians. Ninety-eight percent of pediatricians and 88% of family physicians were administering HPV vaccine in their offices (P < .001). Among those physicians, fewer strongly recommended HPV vaccination for 11- to 12-year-old female patients than for older female patients (pediatricians: 57% for 11- to 12-year-old patients and 90% for 13- to 15-year-old patients; P < .001; family physicians: 50% and 86%, respectively; P < .001). The most-frequently reported barriers to HPV vaccination were financial, including vaccine costs and insurance coverage. Factors associated with not strongly recommending HPV vaccine to 11- to 12-year-old female patients included considering it necessary to discuss sexuality before recommending HPV vaccine (risk ratio: 1.27 [95% confidence interval: 1.07–1.51]) and reporting more vaccine refusals among parents of younger versus older adolescents (risk ratio: 2.09 [95% confidence interval: 1.66–2.81]). CONCLUSIONS: Eighteen months after licensure, the vast majority of pediatricians and family physicians reported offering HPV vaccine. Fewer physicians strongly recommended the vaccine for younger adolescents than for older adolescents, and physicians reported financial obstacles to vaccination.

A National Survey of Pediatrician Knowledge and Attitudes Regarding Human Papillomavirus Vaccination

OBJECTIVE. A human papillomavirus vaccine was licensed in June 2006. The vaccine is quadrivalent, protecting against 2 human papillomavirus strains that cause cervical cancer and 2 that cause genital warts. The objective of this study was to determine physician characteristics, knowledge, and attitudes associated with an intention to recommend human papillomavirus vaccination. METHODS. Between August and October 2005, a cross-sectional survey was administered to a national network of 431 pediatricians. The network was developed from a random sample of American Academy of Pediatrics members and was designed to be representative of the organization’s membership with respect to urban/rural location, practice type, and region. The survey was conducted before human papillomavirus vaccine licensure and therefore focused on a candidate quadrivalent human papillomavirus vaccine and a range of potential vaccination recommendations. The main outcome measure was intention to recommend a quadrivalent human papillomavirus vaccine to young adolescent (10- to 12-year-old) females. RESULTS. Survey response rate was 68%. If endorsed by national health organizations, 46% of respondents would recommend vaccination for 10- to 12-year-old females, 77% for 13- to 15-year-old females, and 89% for 16- to 18-year-old females. Corresponding rates for males were 37%, 67%, and 82%, respectively. Whereas 60% of respondents thought that parents would be concerned that human papillomavirus vaccination may encourage risky sexual behaviors, 11% reported that they themselves had this concern. Respondents who believed that other new adolescent immunization recommendations (eg, meningococcal, pertussis) would facilitate human papillomavirus vaccine implementation were more likely to intend to recommend vaccination. CONCLUSIONS. Although a national sample of pediatricians expressed a high level of acceptance of human papillomavirus vaccination in older adolescent females, fewer than one half anticipated giving human papillomavirus vaccine to younger female patients. Provider concerns about parental vaccine acceptance will need to be addressed to optimize human papillomavirus vaccination implementation.

Barriers to the Use of Herpes Zoster Vaccine

BACKGROUND The herpes zoster vaccine is the most expensive vaccine recommended for older adults and the first vaccine to be reimbursed through Medicare Part D. Early uptake has been 2% to 7% nationally. OBJECTIVE To assess current vaccination practices, knowledge and practice regarding reimbursement, and barriers to vaccination among general internists and family medicine physicians. DESIGN Mail and Internet-based survey, designed through an iterative process and conceptually based on the Health Belief Model. SETTING National survey conducted from July to September 2008. PARTICIPANTS General internists and family medicine physicians. MEASUREMENTS Survey responses on current vaccination practices, knowledge and practice regarding reimbursement, and barriers to vaccination. RESULTS Response rates were 72% in both specialties (301 general internists and 297 family medicine physicians). Physicians in both specialties reported similar methods for delivering vaccine, which included stocking and administering the vaccine in their offices (49%), referring patients to a pharmacy to purchase the vaccine and bring it back to the office for administration (36%), and referring patients to a pharmacy for vaccine administration (33%). Eighty-eight percent of providers recommend herpes zoster vaccine and 41% strongly recommend it, compared with more than 90% who strongly recommend influenza and pneumococcal vaccines. For physicians in both specialties, the most frequently reported barriers to vaccination were financial. Only 45% of respondents knew that herpes zoster vaccine is reimbursed through Medicare Part D. Of respondents who began administering herpes zoster vaccine in their office, 12% stopped because of cost and reimbursement issues. LIMITATIONS Survey results represent reported but not observed practice. Surveyed providers may not be representative of all providers. CONCLUSION Physicians are making efforts to provide herpes zoster vaccine but are hampered by barriers, particularly financial ones. Efforts to facilitate the financing of herpes zoster vaccine could help increase its use. PRIMARY FUNDING SOURCE Centers for Disease Control and Prevention.

Factors That Influence Parental Vaccination Decisions for Adolescents, 13 to 17 Years Old National Immunization Survey–Teen, 2010

Objectives. We aim to describe factors that influence parental decisions to vaccinate their adolescents. Methods. Data from the July to December 2010 National Immunization Survey–Teen Parental Concerns Module were analyzed to determine factors that influence parental decisions to vaccinate their adolescents. Results. Parents reported that their adolescent’s health care provider recommended tetanus toxoid/tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Td/Tdap; 74.4%), meningococcal conjugate (MenACWY; 60.3%), and human papillomavirus (HPV; 71.3%). Vaccination coverage estimates were significantly higher among parents who reported receiving a provider recommendation: 85.2% versus 76.7% (Td/Tdap), 77.3% versus 49.7% (MenACWY), and 62.2% versus 21.5% (HPV). Compared with Td/Tdap and MenACWY, fewer HPV vaccination conversations included recommendations for vaccination. Other than health care providers, school requirements (46.1%), news coverage (31.2%), and family (31.0%) were most frequently reported influences on parental vaccination decisions. Conclusions. Many factors influence parental decisions to vaccinate their adolescents; one of the most important factors is the provider recommendation. Missed opportunities for vaccination persist when strong vaccination recommendations are not given or are delayed.

Effectiveness and Net Cost of Reminder/Recall for Adolescent Immunizations

OBJECTIVE: To assess the effectiveness of reminder/recall (R/R) for immunizing adolescents in private pediatric practices and to describe the associated costs and revenues. METHODS: We conducted a randomized controlled trial in 4 private pediatric practices in metropolitan Denver. In each practice, 400 adolescents aged 11 to 18 years who had not received 1 or more targeted vaccinations (tetanus-diphtheria-acellular pertussis, meningococcal conjugate, or first dose of human papillomavirus vaccine for female patients) were randomly selected and randomized to intervention (2 letters and 2 telephone calls) or control (usual care) groups. Primary outcomes were receipt of >1 targeted vaccines and receipt of all targeted vaccines 6 months postintervention. We calculated net additional revenue for each additional adolescent who received at least 1 targeted vaccine and for those who received all targeted vaccines. RESULTS: Eight hundred adolescents were randomized to the intervention and 800 to the control group. Baseline rates of having already received tetanus-diphtheria-acellular pertussis, meningococcal conjugate, and first dose of human papillomavirus vaccine before R/R ranged from 33% to 54%. Postintervention, the intervention group had significantly higher proportions of receipt of at least 1 targeted vaccine (47.1% vs 34.6%, P < .0001) and receipt of all targeted vaccines (36.2% vs 25.2%, P < .0001) compared with the control group. Three practices had positive net revenues from R/R; 1 showed net losses. CONCLUSIONS: R/R was successful at increasing immunization rates in adolescents and effect sizes were comparable to those in younger children. Practices conducting R/R may benefit financially if they can generate additional well-child care visits and keep supply costs low.

U.S. Physicians’ Perspective of Adult Vaccine Delivery

Context Vaccination rates in adults are low, even though more than 95% of Americans who die of vaccine-preventable disease each year are adults. General internists and family medicine physicians were surveyed about vaccine perceptions and practices. Contribution Barriers related to vaccine delivery included lack of regular assessment of vaccine status, insufficient stocking of some vaccines, and financial disincentives for vaccination in the primary care setting. Use of electronic tools to record and prompt vaccination was low. Most physicians surveyed accepted vaccination outside of the medical home but believed communication between themselves and alternate vaccinators was suboptimal. Implication System changes are necessary to improve adult vaccination in the United States. The Editors Vaccination remains underutilized in adults. An annual average of more than 30 000 Americans die of vaccine-preventable diseases, mostly influenza, and more than 95% of these persons are adults (1). The Advisory Committee on Immunization Practices recommends 12 vaccines for adults, including vaccines recommended universally, vaccines for persons who did not receive them in childhood (catch up), and vaccines for those in high-risk groups (2). According to recent estimates (3, 4), only 62% and 65% of adults aged 65 years or older received a pneumococcal or influenza vaccine, respectively; only 20% of high-risk adults aged 19 to 64 years received a pneumococcal vaccine; and only 16% of adults aged 60 years or older received a herpes zoster vaccine. All of these percentages are well short of Healthy People 2020 goals (5). None of the studies that examined reasons for low rates of adult vaccination (612) comprehensively examined adult vaccination. Furthermore, the context of adult vaccination has changed in recent years: There are newly recommended adult vaccines, some vaccines are now covered by Medicare Part D (a pharmaceutical benefit), and the site of vaccine delivery has shifted away from primary care settings. Almost half of adult seasonal influenza vaccinations in the 20102011 season occurred in health departments, pharmacies, work places, or other nonmedical locations (13), but physician perceptions regarding collaboration with alternate vaccinators have only been documented limitedly (14). Given the increase in the number of vaccines recommended for adults and the increasing importance of alternative sites for vaccine delivery, we sought to describe the following among U.S. primary care physicians: practices regarding assessing vaccination status and stocking of recommended adult vaccines; barriers to stocking and administering vaccines; characteristics of physicians who report greater financial barriers to delivering vaccines; and practices, experiences, and attitudes regarding vaccination outside of the medical home. Methods Study Setting From March to June 2012, we administered a survey to a network of primary care physicians (Supplement). The Human Subjects Review Board at the University of Colorado Denver approved this study as exempt research that did not require written informed consent. Supplement. Survey on Adult Immunization and Preventive Care Study Sample The Vaccine Policy Collaborative Initiative conducted this study (15). The Initiative was designed collaboratively with the Centers for Disease Control and Prevention (CDC) to perform rapid-turnaround surveys to assess physician attitudes about vaccine issues. We developed a network of primary care physicians for this program by recruiting general internists (GIMs) and family medicine physicians (FMs) from the memberships of the American College of Physicians (ACP) and the American Academy of Family Physicians (AAFP). We conducted quota sampling (16) to ensure that network physicians were similar to the ACP and AAFP memberships with respect to region, urban versus rural location, and practice setting (GIMs only). We previously demonstrated that survey responses from network physicians compared with those of physicians randomly sampled from American Medical Association physician databases (which reflect all practicing physicians and not just members of the American Medical Association) had similar demographic characteristics, practice attributes, and attitudes about a range of vaccination issues (16). Survey Design We developed a survey appraising physician practices regarding assessment of vaccination status for and stocking of the 11 adult vaccines routinely recommended in 2012 (17), as well as referral practices to alternate vaccinators when vaccines were not stocked. We used 4-point Likert scales for questions assessing attitudes about the role of different adult vaccine providers (strongly agree to strongly disagree) and barriers to stocking and administering vaccines in the practice (major barrier to not a barrier) (18). For brevity, certain questions were asked in a generic manner and were not related to specific vaccines. After an advisory panel of GIMs (n= 6) and FMs (n= 7) pretested the survey, we modified it on the basis of their feedback. The survey was then piloted by 86 primary care physicians (63 GIMs and 23 FMs) and further modified according to this feedback. Survey Administration According to physician preference, we sent the survey either over the Internet (Verint; Melville, New York) or through the U.S. Postal Service. We sent the Internet group an initial e-mail with up to 8 e-mail reminders, and we sent the mail group an initial mailing and up to 2 additional reminders. Nonrespondents in the Internet group were also sent a mail survey in case of problems with e-mail correspondence. We patterned the mail protocol on Dillmans tailored design method (19). Statistical Analysis We pooled Internet and mail surveys together for analyses because other studies have found that physician attitudes are similar when obtained by either method (2022). We compared respondents with nonrespondents on all available characteristics using Wilcoxon and chi-square analyses. Characteristics of nonrespondents were obtained from the recruitment survey for the sentinel networks. We found financial barriers to be commonly reported and therefore assessed whether certain characteristics of primary care physicians were associated with perceiving more financial barriers because this information could lead to actionable policymaking. To assess associations with perception of financial barriers and to avoid issues associated with multiple comparisons, we created a financial barriers scale composed of 8 financial barrier survey questions (Table 1). We combined the scores of these 8 variables (not a barrier= 0; minor barrier= 1; moderate barrier= 2; major barrier= 3) and divided that sum by the number of questions answered. We excluded respondents who had answered fewer than 5 of the 8 questions on financial barriers. A Cronbach was calculated to determine the internal consistency of the financial barriers scale. We used this scale as the outcome measure to evaluate associations between financial barriers and demographic and practice characteristics (sex, age, region, practice location, practice setting, number of providers in the practice, and proportion of patients with Medicare Part D and Medicaid) in a multivariable linear regression model for each specialty. Analyses were done by using SAS, version 9.2 (SAS Institute, Cary, North Carolina). Table 1. Perceived Barriers to Stocking and Administering Vaccines for Adult Patients in Respondents Practice Role of the Funding Source Investigators at the CDC were involved with the survey design, analysis, and the decision to submit the manuscript for publication. Results Survey Response Rates and Respondent Characteristics Response rates were 79% for GIMs (352 of 443) and 62% for FMs (255 of 409). All questions had fewer than 8% missing items, with most having fewer than 5% missing. The number of missing items did not differ between GIMs and FMs or between physicians who responded by Internet and those who responded by mail. No GIMs and only 2 FMs were from the same practice site. Respondents and nonrespondents did not differ significantly by sex, age, region, practice location, practice setting, or number of providers in the practice. Table 2 displays characteristics of respondents and their practices and patient populations. Table 2. Comparison of Respondents and Nonrespondents and Additional Characteristics of Respondents Practices Current Practices Regarding Assessing Need for and Stocking of Routinely Recommended Adult Vaccines Almost all physicians reported assessing patients vaccination status at annual visits (GIMs and FMs, 97%) or initial visits (GIMs, 94%; FMs, 89%), whereas fewer physicians (GIMs, 29%; FMs, 32%) reported doing so at every visit. The most commonly reported method for assessing immunization status was to check the medical record (GIMs, 95%; FMs, 96%). Although most physicians reported asking patients about vaccination status verbally (GIMs, 89%; FMs, 90%), by questionnaire (GIMs, 57%; FMs, 52%), or by having a staff member ask (GIMs, 57%; FMs, 66%), very few (GIMs, 1%; FMs, 2%) relied exclusively on patient-supplied information. A minority used immunization information systems (IISs) (GIMs, 8%; FMs, 36%). Forty-six percent of GIMs and 48% of FMs reported that it was moderately/very difficult to determine an adult patients vaccination status for vaccines other than seasonal influenza. Almost all physicians reported assessing the vaccination status for seasonal influenza; pneumococcal; tetanus and diphtheria (Td); tetanus, diphtheria, and acellular pertussis (Tdap); and zoster vaccines. Fewer reported assessing the status for the remainder of the recommended vaccines (Figure 1). Family physicians were more likely than GIMs to assess the need for hepatitis A; hepatitis B; measles, mumps, and rubella (MMR); human papillomavirus; meningococcal; and varicella vaccines. Figure 1. Percentage of physicians w