Fear and dosing schedules are barriers
The track record of childhood immunizations to prevent illness is impressive. More than 100 million cases of seven once-common diseases have been prevented in the last 12 decades through immunization, according to the Centers for Disease Control and Prevention (CDC).
The preventive care provision of the Affordable Care Act (ACA) that eliminated copays for many vaccinations is lowering the barriers for more Americans, but it is not the sole solution.
“We have very high levels of immunization and have maintained those levels for years,” says Shannon Stokley, associate director of science in the immunization services division of the CDC.
“Immunizations are certainly a high priority for health plans” -Carol Wilhoit, MD
One of the biggest barriers to higher vaccination rates are the misconceptions that persist among some parents about the need for vaccinations or perceived negative effects. Despite overwhelming evidence that immunizations are not linked to an increase in autism rates, many parents still fear a connection.
Scott Krugman, MD, chairman of pediatrics at MedStar Franklin Square Medical Center, agrees that immunization rates are routinely high, but worries that spots of low immunization like those seen in parts of California and Vermont are causing unnecessary outbreaks. Despite being thoroughly discredited, a 1998 study by Andrew Wakefield that supposedly showed a link between the measles, mumps and rubella (MMR) vaccine and autism rates has affected a generation of parents, including some high-profile celebrities who have used their prominence to argue against routine vaccinations.
“Parents have never seen the effects of these diseases,” Dr. Krugman says.
The risk of the diseases should, in theory, be motivation enough to have parents rethink their denial of the preventive care for their children. He credits Paul Offit, MD, with helping turn back the tide in favor of childhood vaccinations, particularly as they relate to the autism scare. Dr. Offit is the director of the Vaccine Education Center at Children’s Hospital of Philadelphia and a Founding Board Member of the Autism Science Foundation.
“The medical profession is doing a better job of [public relations] these days, but there is still a lot of misinformation out there,” Dr. Krugman says.
One trouble spot Stokley sees is the vaccination rates for human papillomavirus (HPV), which the Advisory Committee on Immunization Practices recommends for teen boys as well as girls.
According to CDC figures, 54% of adolescent girls have received one or more doses of the vaccine, while just one-third have received all three recommended doses. The standards are newer for adolescent boys, which may explain the lower rates of immunization. Only one in five boys have received one or more doses of the HPV vaccine, with just 7% receiving all three doses.
HPV vaccines should be given as a three-dose schedule, with the second dose given one to two months after the first dose, and the third dose six months after the first dose. The timing of the doses and the multiple office visits could present an adherence issue for many parents.
Because HPV is a sexually transmitted disease, another barrier to higher immunization rates may be parental fears that immunized teens may become promiscuous, despite studies showing no link.
Misconceptions about vaccinations can cause pockets of preventable diseases. The incidence of measles in the United States has nearly tripled in the past 11 months to 175 cases, with 20 of those requiring hospitalization. Most of those cases have been linked to overseas travel.
This year, Colorado health officials have seen more than 1,100 diagnosed cases of pertussis, or whooping cough. For each reported case, there are likely 10 more cases that go unreported.
The whooping cough outbreak is especially troublesome because infants don’t receive their first dose until two months. However, Dr. Krugman notes that physicians are doing a good job of vaccinating pregnant women.
Some insurance plans have recognized provider procedure codes that identify physician-patient discussion of such topics as immunizations, which Dr. Krugman says have been sorely needed.
“It can sometimes take 15 minutes to talk to parents about immunizations when the whole wellness visit is supposed to be 15 minutes,” Dr. Krugman says. In general, though, he says plans have been slow to recognize non-procedure based primary care.
As children become teen-agers, the issue of privacy can stymie parental discussion of immunizations, says David Moromisato, MD, a pediatrician and chief medical officer at Cardon Children’s Medical Center.
“Some health plans use patient portals to reach out to adults to increase their access and education,” Dr. Moromisato says. “But children at some point become a gray area because of teen privacy issues.”
Banner Health and Cardon Children’s Medical Center have taken several steps to increase awareness of immunization, according to Dr. Moromisato. For example, Banner provided a web seminar for pregnant mothers on the importance of the whooping cough vaccine.
Yearly influenza vaccinations for staff are mandatory, and the system uses the HEDIS immunization recommendations as part of individual physician scorecards, which Dr. Moromisato calls “a big part of how we rate pediatricians in our network.”
“Immunizations are certainly a high priority for health plans,” says Carol Wilhoit, MD, senior medical director for quality and outcomes at Health Care Service Corp. (HCSC).
The plan’s approach varies by product line but includes mailers to parents; measurement of immunization rates at the physician group level; feedback to individual physicians; and twice-yearly physician get-togethers.
Coverage changes mandated by the ACA have not impacted HMO products for HCSC since immunizations were routinely covered without a co-pay, however many of its PPO plans were changed after the immunization mandate became effective.
Dr. Wilhoit explains that physicians in HMOs and accountable-care organizations must take greater responsibility to perform the necessary outreach and education to increase immunization rates since they are paid on a population basis.
“There is a little more structure and motivation to physicians to reach out to parents,” she says.
A new study shows the importance of such outreach. Citing an article published online November 4 on the Pediatrics website, Dr. Wilhoit says that physicians who tell parents their child needs a vaccination are met with less resistance than if the physician asks. The study showed that one in four parents were reluctant when the physician used the presumptive approach, versus an 83% resistance rate when the physician used a more participatory approach (asking) that invites parental involvement. When meeting with resistance, physicians persisted in half of those instances, receiving parental approval 47% of the time.
“It’s a wonderful thing-vaccinations covered under the Affordable Care Act-but it’s too early to tell what the impact of ACA will be on immunization rates,” Stokley says.