• Q&A With John Merrill-Steskal, M.D.

    Expert Lists Ways to Boost Adolescent Immunization Rates

    April 24, 2019 10:33 am Chris Crawford – AAFP Vaccine Science Fellowship alumnus John Merrill-Steskal, M.D., of Ellensburg, Wash., recently took time to speak with AAFP News about strategies he uses to keep adolescent immunization rates high in his practice. What follows are highlights from that conversation.

    merrill steskal headshot

    Q: What are the biggest challenges you face trying to keep adolescents current on their vaccinations?

    A: One of the biggest obstacles to vaccinating adolescents is that they typically do not come into the clinic as often as adults or infants.

    If they're involved in sports, the sports physical is a great opportunity to give recommended vaccines, but not all adolescents are involved in sports. Consequently, it's important that physicians use every possible clinical encounter to offer vaccines.

    In addition, when adolescents come in for sports physicals or acute care concerns, the visit is sometimes without a parent; if the parent is not readily available by phone, obtaining consent for the vaccine can be a barrier.

    Q: What are some best practices you have used to increase adolescent vaccination rates?

    A: At my clinic, we approach a patient's vaccine status as a vital sign; in other words, our medical assistants and physicians assess whether vaccines are needed at every visit, be it for a sore throat, acne or a sprained ankle.

    This process allows us to vaccinate our adolescents at every possible clinical encounter, decreasing missed opportunities.

    In addition, the HPV vaccine can be given as early as age 9, and I encourage parents to vaccinate at this age. HPV vaccine efficacy is improved at younger ages, and when the vaccine is discussed with parents before the onset of sexual maturation, parents seem to be more comfortable discussing the vaccine.

    Q: When is the best time during a visit to discuss vaccines with teens?

    A: While any time during the visit is a good time to discuss vaccines, I prefer to recommend needed vaccines early in the visit, which allows adequate time to discuss potential parental concerns.

    It's important to avoid missed opportunities, and it's important to allow adequate time to answer questions.

    Q: How can family physicians use electronic health records (EHRs) to their advantage when it comes to vaccinating teens?

    A: Many EHRs generate reminders for vaccines, and some state immunization systems do, as well.

    When adolescents receive their first HPV dose, it's very helpful to schedule a follow-up nurse visit, as well as enter a reminder into the EHR, for the second HPV dose before the adolescent leaves the clinic.

    Q: How have immunization champions in your practice helped promote adolescent vaccination?

    A: Having champions who are medical assistants (MAs) or nurses is extremely important. Physicians are often busy, with many topics competing for their attention. Nurturing a passion for vaccination in MAs and nurses can help decrease the load for physicians.

    Standing orders also empower MAs and nurses to play an active role in vaccinating patients and remove the possibility that physicians will forget to discuss needed vaccines by allowing MAs to vaccinate. With the use of standing orders for vaccines, it's often the MA who recommends the vaccine to adolescents and parents before the physician even enters the room.

    I believe this added autonomy in their work enhances their sense of purpose and improves job satisfaction, while reinforcing the notion that vaccination is truly a team effort.

    Taking the time to educate these champions about effective communication strategies such as "the presumptive approach" and giving a "strong recommendation" is also highly effective in vaccinating adolescents.

    The presumptive approach is a way of recommending vaccines such that getting a vaccine is the default, or norm. An example of the presumptive approach is saying, "You are due for the HPV vaccine; I will get that for you and get you up to date."

    The presumptive approach is much more effective than what is called the "participatory approach," where one might say, "You are due for the HPV vaccine; we can do that today if you want. What would you like to do today?"

    A strong recommendation is just as it sounds -- clear, confident and direct: "I strongly recommend the HPV vaccine for you. It's important for your health."

    Q: What can family physicians take away from the study published online April 3 in The BMJ that found routine administration of bivalent HPV vaccine in girls ages 12-13 in Scotland led to a dramatic reduction in preinvasive cervical disease later in their lives?

    A: The study supports what the body of research has been telling us all along about this vaccine: that the HPV vaccine provides excellent protection from the high-risk HPV types and that by providing protective immunity, cervical dysplasia and cancer are prevented.

    Q: Is there other research on adolescent vaccines you think is important?

    A: There is evidence that HPV vaccine acceptance is improved when the recommendation for it is sandwiched between those for the tetanus, diphtheria and acellular pertussis (Tdap), and meningococcal conjugate vaccines (MCV4). Health care professionals can say, "You are due for the Tdap, HPV and MCV vaccines today. Let's get you updated!"

    Also, the value of a clear, confident and strong recommendation cannot be overstated. It has been shown that physicians are most likely to give weak -- or lukewarm -- recommendations for the HPV and influenza vaccines. Not surprisingly, vaccination rates are lowest for these two vaccines. A strong recommendation is very important for vaccine acceptance.

    Q: What are the public health ramifications of vaccinating adolescents?

    A: There are tremendous benefits. The HPV vaccine prevents cancer for both women and men. These are cancers of the cervix for women, penis for men, as well as anus, mouth and throat for both genders that are prevented with this vaccine.

    Furthermore, there is significant morbidity associated with cancer treatment, in addition to expense. The vaccine is inexpensive in comparison.

    Because HPV vaccination rates lag behind those of other adolescent vaccines, there is a great deal of effort to increase HPV vaccination rates. However, clinicians should not lose sight of the importance of the Tdap and meningococcal vaccines.

    Clostridium tetani spores are present in 30% of U.S. soil samples. Tdap immunizes against the toxin, but that doesn't change the fact that the bacteria are present in our soils as much today as they were in the 1930s, when the vaccine first became available. Tetanus immunization protects against a potentially fatal infection.

    Similarly, meningitis can be devastating for youth and is a preventable infection with vaccination.

    Q: Is there anything else you want to add on this topic?

    A: I would like to remind family physicians that when discussing the HPV vaccine with parents, the adolescent is present and listening, as well.

    In other words, the physician is speaking to both the parent, as well as the adolescent, and if the parent declines the vaccine, the young adult can elect to receive the vaccine at age 18, when they can consent on their own to vaccination.

    Lastly, being mindful of vocabulary is important when discussing the HPV vaccine. Parents are more likely to express reluctance when physicians use terms such as "sexual activity" and "sexually transmitted infection."

    Most experts recommend framing HPV vaccine discussions around the notion that it is a vaccine that prevents cancer. Also, avoiding the word "sex" seems to increase parents' receptiveness to HPV vaccination.