1. Carol Mansfield, M.D., M.P.H. Winthrop Pediatrics and Adolescent Medicine

2. The Advisory Committee on Immunization Practices recommended that these vaccines be administered at ages 11-12 years of age, thereby strengthening the “adolescent platform.” For HPV, vaccination prior to onset sexual activity improves the efficacy of the vaccine. Pediatrics, December 2011, volume 128, number 6 Adolescent Vaccination Coverage Level in the United States: 2006-2009 From 2005-2007, three vaccines were added to the adolescent shedule, Tdap, Menactra, and for girls, Gardasil.

3.  HPV vaccination prior to onset sexual activity maximizes its efficacy  CDC Youth Risk Behavior Surveillance- United States, 2009. Grades 9-12  First Sexual Intercourse before age 13 yrs: Nationwide, 5.9%, white female 2.2%  Ever had sexual intercourse: Nationwide 46% (range from 39% to 61% across state surveys)

4.  Winthrop Pediatrics and Adolescent Medicine embraced the Gardasil vaccination recommendation due to too many ASCUS and LGSIL reports and referrals!  However, providers harbored concerns about duration of immunity, age appropriateness of timing of vaccine administration, parental readiness, and aggressiveness of advertising by the vaccine maker. Provider Reactions

5. Parental Reactions

7. 1. Safety concerns 2. Lack of knowledge 3. New vaccine 4. Not sexually active 5. Child does not like shots 6. Not needed/necessary 7. Too many vaccines at once 8. Need to consult with her father/mother, delay tactics 9. Expense Parental Reasons for Not Vaccinating

8. In the annual National Immunization Survey-Teen (NIS-Teen), among parents of teenagers who had not initiated the HPV series, report of a provider recommendation was significantly associated with vaccination and an intent to vaccinate in the future. Pediatrics, December 2011, Adolescent Vaccination-Coverage Levels in the US: 2006-2009

9.  Quality improvement efforts at Winthrop Pediatrics and Adolescent Medicine for Gardasil 1. Providers and staff to recommend Gardasil vaccination starting at age 11 years “to strengthen the adolescent platform,” and annually thereafter, with a very strong push upon entry to high school if not done already. We are patient and sensitive to religious and cultural considerations when parents are not yet ready to embark with the series.

10. 2. Due to 50% no show for subsequent nurse vaccination appointments, we are starting follow-up phone calls to all no-shows for subsequent Gardasil vaccinations (our present PDSA cycle). Quality improvement efforts at Winthrop Pediatrics and Adolescent Medicine for Gardasil (continued)

11. 3. Due to problems with scheduling follow-up vaccinations too soon, we are educating all of our staff about the vaccination schedule

12. 4. At every visit, physicals, acute and follow-up, we are printing the patient’s ImmPact vaccination record for the medical assistant and provider to review to reduce any missed vaccine opportunities (previous PDSA cycle.)