The effect of patient education on tetanus diphtheria

The effect of patient education on tetanus, diphtheria, and pertussis (Tdap) immunization rates in postpartum women

Can pediatricians improve adult Tdap immunization rates ? Janet Sullivan MD 1, Benjamin Kinnear BS 2, Kristin Koehn MD 3 Department of Child Health 1, 3 Division of Pediatric Hospital Medicine 3 University of Missouri – Columbia 1, 2, 3 Columbia, Missouri 42 nd National Immunization Conference March 17 th, 2008

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

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

Background 2 - Summary of Notifiable Diseases CDC o 25, 616 reported US cases in 2005

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

Background 4 o Transmission o Adult and adolescent caregivers are thought to be primary source of transmission to infants. (2)

Background 5 o 2006 ACIP Recommendations (1) o Recommended Tdap booster in the immediate post-partum period for eligible women o Supported by AAP and ACOG

Background 6 o Tdap vaccine coverage o Largely unknown in adolescent and adult populations o Comparable studies with influenza vaccination in pregnant women demonstrate poor coverage rates (7)

Background 7 o Role of pediatrician o Integral role in early infant care o Often are well-versed in immunization recommendations including Tdap o May have some influence on parental behaviors via education and anticipatory guidance measures (8, 9)

Study Aims

Methods 1 o 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 o Columbia Regional Hospital (CRH) admits approximately 2, 000 infants per year

Methods 2 o Both verbal and written Tdap vaccine information (Vaccine Information Statements from the CDC website) were given to all postpartum patients by the nursery medical team for a 4 week period beginning 8/13/07. o No additional education was provided in the preceding 4 week period (7/13 -8/12/07).

Methods 3 o An electronic medical record was used to gather basic demographic data o Age o Contact information (including phone #) o Primary care obstetrician (if known) and date of follow-up visit o Primary care physician o Electronic record of immunization

Methods 4 o 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.

Methods 5 o Tdap eligibility? (defined as last Td booster ≥ 2 years ago) o Tdap education? (as inpatient or outpatient) o Tdap administration? (as inpatient or pre or post-partum as outpatient) o Agreeable to receive vaccine? o Potential barriers (insurance coverage, identifiable PCP, etc. )

Methods 6 o Approval for this project was obtained from the Health Sciences Institutional Review Board at the University of Missouri-Columbia

Results 1 Demographics Total number of patients Number of patients completing survey Age range (in years) Columbia, Missouri residents No Tdap Education 93 120 64 (69%) 88 (73%) 13 -42 16 -48 41 (44%) 55 (46%)

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

Results 3

Results 4 Potential Barriers Patients without PCP Patients without postpartum visit Education by OB at post -partum visit No Tdap Education 26 (41%) 42 (48%) 13 (20%) 12 (14%) 0 (0%) 2 (2%)

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

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

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

Future Directions CRH Post-Partum Immunization Orders - version January 1, 2008 IMMUNIZATIONS [ ] Measles / Mumps / Rubella Virus Vaccine (M-M-R II) 0. 5 m. L Sub. Q if mother is rubella non-immune [ ] Tetanus / Diphtheria / Acellular Pertussis (Tdap, ADACEL) 0. 5 m. L IM if mother has received Td > 2 years ago and if no prior doses of Tdap given SEASONAL IMMUNIZATIONS [ ] Influenza Virus Vaccine 0. 5 m. L IM, for ____ adult caregiver(s). urse: Please document Immunizations in patient’s Power. Chart Immunization Tab.

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

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

References 2 o 6. Cortese MM. et al. Pertussis hospitalizations among infants in the United States, 1993 to 2004. Pediatrics. 2008; 121; 484 -492. o 7. Naleway AL. et al. Delivering influenza vaccine to pregnant women. Epidemiologic Reviews. 2006; 28: 47 -53. o 8. Pappano D. et al. Efficacy of a pediatric emergency department-based influenza vaccination program. Arch Pediatr Adolesc Med. 2004; 158: 1077 -1083. o 9. Severson HH. et al. Reducing maternal smoking and relapse: long-term evaluation of a pediatric intervention. Preventative Medicine. 1997; 26: 120 -130. o 10. Wendelboe AM. et al. Duration of immunity against pertussis after natural infection or vaccination. PIDJ. 2005; 24: S 58 -S 61.

Thank You