1. The effect of patient education on tetanus, diphtheria, and pertussis (Tdap) immunization rates in post-partum women

2. Can pediatricians improve adult Tdap immunization rates ?
Janet Sullivan MD1, Benjamin Kinnear BS2, Kristin Koehn MD3
Department of Child Health1,3
Division of Pediatric Hospital Medicine3
University of Missouri – Columbia1,2,3
Columbia, Missouri
42nd National Immunization Conference
March 17th, 2008

3. Objectives
By the end of this presentation, participants will be able to describe
the effect of education on Tdap immunization rates
barriers to immunization
potential solutions to improve rates

4. Background1
Pertussis
Major cause of infant and childhood mortality until development of vaccine in 1940s
Vaccine resulted in dramatic fall in reported US cases from 1940s s (3).
Recent increase in cases from the mid-1990s to present (3,4).
Thought to be secondary to waning immunity in the adolescent and adult populations (10)

5. Background2 - Summary of Notifiable Diseases CDC
25,616 reported US cases in 2005

6. Background3 Pertussis in Infants
Clinical manifestations can be atypical
Serious complications including pneumonia, respiratory failure, seizures, encephalopathy, and death are more common, especially in young infants (3,4)
The incidence of pertussis in infants less than 12 months of age may actually be more than originally thought (6)

7. Background4 Transmission
Adult and adolescent caregivers are thought to be primary source of transmission to infants. (2)

8. Background5 2006 ACIP Recommendations (1)
Recommended Tdap booster in the immediate post-partum period for eligible women
Supported by AAP and ACOG

9. Background6 Tdap vaccine coverage
Largely unknown in adolescent and adult populations
Comparable studies with influenza vaccination in pregnant women demonstrate poor coverage rates (7)

10. Background7 Role of pediatrician Integral role in early infant care
Often are well-versed in immunization recommendations including Tdap
May have some influence on parental behaviors via education and anticipatory guidance measures (8,9)

11. Study Aims

12. Methods1
A selected patient sample of all post-partum women on the OB-GYN service who delivered healthy infants between the dates of 7/13/07 to 9/13/07 inclusive at our primary maternal – neonatal facility, Columbia Regional Hospital
Columbia Regional Hospital (CRH) admits approximately 2,000 infants per year

13. Methods2
Both verbal and written Tdap vaccine information (Vaccine Information Statements from the CDC website) were given to all post-partum patients by the nursery medical team for a 4 week period beginning 8/13/07.
No additional education was provided in the preceding 4 week period (7/13-8/12/07).

14. Methods3
An electronic medical record was used to gather basic demographic data
Age
Contact information (including phone #)
Primary care obstetrician (if known) and date of follow-up visit
Primary care physician
Electronic record of immunization

15. Methods4
A voluntary telephone survey was then completed using an IRB-approved format at least 6 weeks after delivery (following routine post-partum visit) where the following information was obtained.

16. Methods5 Tdap eligibility? (defined as last Td booster ≥ 2 years ago)
Tdap education? (as inpatient or outpatient)
Tdap administration? (as inpatient or pre or post-partum as outpatient)
Agreeable to receive vaccine?
Potential barriers (insurance coverage, identifiable PCP, etc.)

17. Methods6
Approval for this project was obtained from the Health Sciences Institutional Review Board at the University of Missouri-Columbia

18. Results1 Demographics No Tdap Education Tdap Education
Total number of patients 93
120
Number of patients completing survey
64 (69%)
88 (73%)
Age range (in years)
13-42
16-48
Columbia, Missouri residents
41 (44%)
55 (46%)

19. Results2 Immunization Rates No Tdap Education Tdap Education
Tdap eligible
55/64 (86%)
80/88 (91%)
Would have received if offered
54/64 (84%)
83/88 (94%)
Tdap given (post-partum)
7/64(11%) (1 as inpt)
19/88 (22%) (all as inpt)
Tdap given (pre-partum)
2/64 (3%) both by FP
4/88 (4%) all by PCP (FP/IM)
Overall Tdap immunization rate
9/64 (14%)
23/88 (26%)

20. Results3

21. Results4 Potential Barriers No Tdap Education Tdap Education
Patients without PCP
26 (41%)
42 (48%)
Patients without post-partum visit
13 (20%)
12 (14%)
Education by OB at post-partum visit
0 (0%)
2 (2%)

22. Limitations
Design of study relies on patient recollection of education
A combined survey and electronic medical record search may not completely catch all vaccinated individuals
Small sample sizes in some groups

23. Conclusions
Vaccine education alone did not improve post-partum immunization rates as outpatients.
A combination of inpatient education and vaccination as a collaborative effort between pediatricians and OB-GYNs was most successful.
There were a significant number of barriers preventing outpatient immunization.

24. Future Directions
Development of standardized immunization form to facilitate capture of this population

25. Future Directions IMMUNIZATIONS
CRH Post-Partum Immunization Orders - version January 1, 2008
IMMUNIZATIONS
[ ] Measles / Mumps / Rubella Virus Vaccine (M-M-R II) 0.5 mL SubQ
if mother is rubella non-immune
[ ] Tetanus / Diphtheria / Acellular Pertussis (Tdap, ADACEL) 0.5 mL IM
if mother has received Td > 2 years ago and if no prior doses of Tdap given
SEASONAL IMMUNIZATIONS
[ ] Influenza Virus Vaccine 0.5 mL IM.
[ ] Influenza Virus Vaccine 0.5 mL IM, for ____ adult caregiver(s).
Nurse: Please document Immunizations in patient’s PowerChart Immunization Tab.

26. Acknowledgements
Well-Baby Nursery medical staff at Columbia Regional Hospital
Department of Obstetrics and Gynecology at Columbia Regional Hospital
Child Health Residents from University of Missouri-Columbia

27. References1
1. ACIP. Preventing tetanus, diphtheria, and pertussis among adults: use of Tdap vaccine. MMWR. 2006;55: 1-33.
2. Bisgard KM. et al. Infant pertussis: who was the source? PIDJ. 2004;23:985-9.
3. CDC. Final 2005 reports of notifiable diseases. MMWR. 2006;55:880-1.
4. CDC. National Notifiable Disease Surveillance System and Supplemental Pertussis Surveillance System, 2005.
5. Clark SJ. et al. Attitudes of US obstetricians toward a combined Tdap vaccine for adults. Infect Dis Obstet ;87:1-5.

28. References2
6. Cortese MM. et al. Pertussis hospitalizations among infants in the United States, 1993 to Pediatrics. 2008;121;
7. Naleway AL. et al. Delivering influenza vaccine to pregnant women. Epidemiologic Reviews. 2006;28:47-53.
8. Pappano D. et al. Efficacy of a pediatric emergency department-based influenza vaccination program. Arch Pediatr Adolesc Med ;158:
9. Severson HH. et al. Reducing maternal smoking and relapse: long-term evaluation of a pediatric intervention. Preventative Medicine. 1997;26:
10. Wendelboe AM. et al. Duration of immunity against pertussis after natural infection or vaccination. PIDJ. 2005;24:S58-S61.

29. Thank You