Child, Adolescent, and Adult Immunization Schedules

Course #91742 - $20 • 5 Hours/Credits


Self-Assessment Questions

    1 . In the United States, what group is responsible for regulating vaccines?
    A) Centers for Disease Control and Prevention
    B) Advisory Committee on Immunization Practices
    C) FDA Center for Biologics Evaluation and Research
    D) FDA Vaccines and Related Biological Products Advisory Committee

    AN OVERVIEW OF IMMUNIZATION SCHEDULES

    It is helpful to understand how vaccines are approved and then recommended as part of a schedule. The U.S. Food and Drug Administration's (FDA) Center for Biologics Evaluation and Research (CBER) is responsible for regulating vaccines in the United States. Vaccine clinical development follows the same general pathway as drugs and other biologics. A sponsor who wishes to begin clinical trials with a vaccine must submit an investigational new drug application (IND) to the FDA. The IND describes the vaccine, its method of manufacture, and the types of quality control testing done prior to administering the vaccine to humans. Also included is information about the vaccine's safety and ability to elicit an immune response in animal testing. In addition, the IND contains the proposed clinical protocol.

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    2 . According to the 2019 immunization schedule, what are the recommended vaccine doses for a healthy, 2-month-old infant with no special risks or contraindications who is up-to-date on vaccinations so far?
    A) DTaP, Hib, IPV, and HepB if needed
    B) DTaP, Hib, PCV, IPV, and HepB if needed
    C) Rotavirus, DTaP, Hib, IPV, and HepB if needed
    D) Rotavirus, DTaP, Hib, PCV13, IPV, and HepB if needed

    AN OVERVIEW OF IMMUNIZATION SCHEDULES

    RECOMMENDED IMMUNIZATION SCHEDULE FOR PERSONS 0 THROUGH 18 YEARS OF AGE, 2019

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    3 . Assuming no special risk groups or contraindi­cations and assuming that the ACIP recommendations are followed, what vaccines would a male patient, 50 years of age, be likely to receive?
    A) Tdap or Td only
    B) Tdap or Td, IIV, and zoster
    C) Tdap or Td, IIV, and PPSV23
    D) Tdap or Td, IIV, zoster, and PPSV23

    AN OVERVIEW OF IMMUNIZATION SCHEDULES

    RECOMMENDED ADULT IMMUNIZATION SCHEDULE BY VACCINE AND AGE GROUP, 2019

    Vaccine19–21 years22–26 years27–49 years50–64 years65 years and older
    Influenza (IIV, RIV, or LAIV)1 dose (IIV, RIV, or LAIV) annuallya1 dose (IIV or RIV) annuallya
    Tetanus, diphtheria, pertussis (Td or Tdap)One dose of Tdap, then boost with Td every 10 years
    Varicella2 doses (if born in 1980 or later)a
    Human papillomavirus (female)2 or 3 dosesa
    Human papillomavirus (male)2 or 3 dosesa2 or 3 dosesb
    Zoster2 doses RZV (preferred) or 1 dose ZVLa
    Measles, mumps, rubella1 or 2 doses (if born 1957 or later)a
    Pneumococcal 13-valent conjugate (PCV13)1 doseb1 dosea
    Pneumococcal polysaccharide (PPSV23)1 or 2 dosesb1 dosea
    Hepatitis A2 or 3 dosesb
    Hepatitis B2 or 3 dosesb
    Meningococcal ACWY1 or 2 doses, then booster every 5 yearsb
    Meningococcal B (MenB)2 or 3 dosesb
    Haemophilus influenzae type b (Hib)1 or 3 dosesb
    aFor all patients in this category who lack evidence of immunity.
    bRecommended if other risk factor is present.
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    4 . The ACIP rationale for expanding the recommendation for influenza vaccination to include all children from 6 months to 18 years of age includes
    A) adolescents typically have high rates of physician visits.
    B) universal childhood vaccination is expected to help increase coverage for at-risk groups.
    C) missed school days due to influenza have been low but proven to adversely affect children's grades.
    D) a large new clinical trial reinforced confidence in the safety and efficacy of influenza vaccination in school-age children.

    VACCINES AND RECOMMENDATIONS

    The expansion of the recommended ages for the vaccination of children and adults against influenza is one of the most significant changes to the schedule in recent years. It requires an annual visit to a healthcare provider, including among older children and young adults who typically have low rates of physician visits.

    The ACIP considered multiple factors in making this recommendation. First, according to accumulated evidence, the influenza vaccine appears to be both safe and effective, with the benefits of vaccination outweighing the small risk of adverse effects [21]. Widespread vaccination is also intended to lower the social and economic impact of influenza. The number of missed days of school for children and missed days of work for parents is substantial. Physician visits for the flu may lead to a prescription for antibiotics—treatment that is unnecessary and potentially dangerous.

    The recommendation is also intended to simplify the decision to advise vaccination for children [21]. In previous years, vaccination was recommended for a number of groups with specific risk factors. These included older children with certain medical conditions and children who were close contacts of people who should be immunized. Making vaccination routine for all children is expected to lead to a 50% increase in coverage for those children who have a specific risk-based or contact-based indication.

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    5 . According to the ACIP recommendations, and considering healthy patients without special risk factors or contraindications, who should receive the HPV vaccine?
    A) Girls 11 to 12 years of age, plus adult women at high risk of contracting HPV
    B) Girls 15 years of age or older, plus adult women at high risk of contracting HPV
    C) Girls younger than 18 years of age who are sexually active, plus adult women through age 26 who have not been vaccinated
    D) Girls and boys 11 to 12 years of age, older girls and boys who have not yet been vaccinated, adult women (through age 26) who have not been vaccinated, and men up to 21 years of age (or up to age 26 if desired or a risk factor is present)

    VACCINES AND RECOMMENDATIONS

    Recommendation for Adolescents: HPV vaccine is recommended for girls and boys 11 to 12 years of age and for older adolescents who have not yet been vaccinated. Children 9 to 10 years of age may also be vaccinated.

    Recommendation for Adults: HPV vaccine is recommended for adult women up to 26 years of age who have not completed the vaccine series. HPV vaccine is also recommended for men up to 21 years of age and older men (up to 26 years of age) if desired or if a risk factor is present.

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    6 . The ACIP rationale for recommending HPV vaccination to preteen girls includes all of the following, EXCEPT:
    A) HPV infection is particularly common in teenagers and young women.
    B) Vaccination before the age of sexual debut is likely to offer the most benefit.
    C) Infection with HPV often occurs within the first few years after sexual debut.
    D) After a woman has been infected with any type of HPV, the vaccine is no longer of benefit.

    VACCINES AND RECOMMENDATIONS

    Epidemiologic data on HPV incidence and age of sexual debut suggest that the pre-teen years are an appropriate time to begin HPV protection [32]. Genital HPV is the most common sexually transmitted infection in the United States, with 14 million new infections among people 15 to 59 years of age each year. Teens and young adults are particularly at risk; 49% percent of those infections occur in individuals 15 to 24 years of age. One multisite, clinic-based study of sexually active females found the highest prevalence of HPV in girls 14 to 19 years of age. In another study, using a representative, population-based sample, HPV prevalence was 26.9% among sexually active women 18 to 25 years of age [33]. The prevalence of types 16 or 18 was 7.8%. Another study, also intended to be representative of the general population, found that the prevalence of HPV was 26.8% for women 14 to 59 years of age and nearly 45% among women 20 to 24 years of age [34]. In the overall study population, the prevalence of type 16 was 1.5%, and type 18 was 0.8%.

    An important consideration in protecting girls who are not yet sexually active is that HPV infection is common within the first few years after sexual debut [32]. In addition, studies have shown high antibody titers with vaccination at age 11 to 12 years. The projected impact of vaccinating girls at 12 years of age is a 20% to 66% reduction in lifetime cervical cancer risk, depending on the effectiveness of the vaccine and the duration of protection. Vaccination could also lead to a 21% reduction in low-grade abnormalities on Pap tests over the life of a cohort of vaccinated females. A comparison of HPV prevalence data from the vaccine era (2009–2012) and the prevaccine era (2003–2006) found that the prevalence of the HPV types included in the quadrivalent vaccine decreased by 64% (from 11.5% to 4.3%) among girls 14 to 19 years of age [17]. Considering the modest uptake of this vaccine, the potential impact is significant.

    The recommendation to vaccinate young adult women takes into account the fact that many will already be sexually active and may have been exposed to one or more types of HPV. Young women who are not yet sexually active can receive the full benefit of vaccination. In addition, it is likely that many women who are infected have not yet encountered each of the vaccine-covered types, so they can receive at least partial benefit [35,36]. The recommendation to vaccinate adults to the age of 26 years, but not after, reflects the safety and efficacy testing on which the vaccines' approvals were based [30,31,37]. Use in older women is being studied, and as noted, the FDA has approved use up to 45 years of age.

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    7 . What change was made to the recommendations regarding vaccination against rotavirus in 2009?
    A) Three rotavirus vaccines are now available.
    B) Ages for dosing were harmonized for the two available vaccines.
    C) The number of doses was standardized, with both vaccines now requiring 2 doses.
    D) The age to initiate rotavirus vaccination was expanded to include infants up to 1 year of age.

    VACCINES AND RECOMMENDATIONS

    In 2009, the age parameters for vaccine administration were adjusted to harmonize the schedules of the two approved rotavirus vaccines [40]. One is a pentavalent reassortant vaccine based on a bovine rotavirus, often abbreviated as RV5. The other is a live, attenuated human rotavirus vaccine, often abbreviated as RV1. RV5 has a three-dose schedule, while RV1 requires two doses [41]. The maximum ages for these vaccines are somewhat different, according to their prescribing information, but an ACIP workgroup has concluded that safety and efficacy are unlikely to be affected if the same age limits are used for both [40].

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    8 . Why is MCV included as a routine vaccination for healthy children?
    A) Unlike MPSV, MCV covers all of the most common meningococcal serotypes.
    B) The high number of cases, about 45,000 in the United States each year, makes vaccination essential.
    C) Vaccinating children protects them against meningococcal disease in middle age, when incidence becomes highest.
    D) In addition to the high case-fatality rate, each case of meningococcal disease requires substantial resources to identify additional cases and prevent disease spread.

    VACCINES AND RECOMMENDATIONS

    Historically, before widespread vaccination, there were about 1,400 to 2,800 cases of meningococcal disease in the United States each year [42]. Although not a common illness, meningococcal disease has a rapid course and a high degree of mortality, with a case-fatality ratio of about 10% to 14%. Among survivors, 11% to 19% will experience serious sequelae, such as neurologic deficit, deafness, or loss of a limb [43]. The degree of severity means that, in addition to putting the patient's life at risk, each case requires a substantial public health effort to identify additional cases quickly and prevent the disease from spreading [44].

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    9 . The zoster vaccine is included on the adult immunization schedule. The recommendation for this vaccine includes
    A) adults 50 years of age and older.
    B) adults 65 years of age and older.
    C) only adults with certain medical risk factors.
    D) only adults who have never had chickenpox.

    VACCINES AND RECOMMENDATIONS

    Recommendation for Adults: Zoster vaccine is recommended for individuals 50 years of age and older.

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    10 . Before vaccination was available, what proportion of the population experienced herpes zoster at some point in their lives?
    A) About one-tenth
    B) About one-third
    C) About one-half
    D) About two-thirds

    VACCINES AND RECOMMENDATIONS

    There are an estimated 1 million cases of herpes zoster each year, and incidence increases with age [49]. Without vaccination, about one-third of Americans will experience shingles at some point in their lives [49]. In addition to discomfort and inconvenience for the patient, there is also a risk of viral transmission leading to primary varicella in at-risk contacts. Postherpetic neuralgia (PHN) is an unfortunate but fairly common complication. A community-based study in Minnesota looked at the incidence of PHN as defined by various durations of pain [50]. Eighteen percent of patients experienced PHN-type pain for at least 30 days, 13% for at least 60 days, and 10% for at least 90 days [50]. The ACIP added the zoster vaccine to the adult immunization schedule to take advantage of the opportunity to decrease both the burden of disease and the risk of complications. In 2018, the recombinant zoster vaccine (RZV) was added as the preferred vaccine for adults 50 years of age and older [19]. This newer vaccine has better proven efficacy in preventing herpes zoster, and breakthrough cases are associated with less severe herpes zoster-related pain and less interference on activities of daily living [56].

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    11 . If a patient has a severe (anaphylactic) latex allergy, how would this affect the vaccinations he or she could receive?
    A) No vaccinations should be given.
    B) Some vaccines would be contraindicated.
    C) All vaccines can be used, but 15 minutes of observation is recommended.
    D) There would be no change, because latex is not used in manufacturing vaccines.

    VACCINE CONTRAINDICATIONS

    HYPERSENSITIVIES AND VACCINE RECOMMENDATIONS

    HypersensitivityVaccineCDC Recommendation
    YeastHPVDo not use
    EggsInfluenza (LAIV)Do not usea
    LatexRotavirus (RV1), MenBCheck packaging to see if latex is used and for guidance
    Gelatin
    MMR
    Varicella
    Use extreme caution if administering
    ZosterDo not use
    Neomycin
    IPV
    MMR
    Varicella
    Zoster
    HepA
    Some influenza vaccines
    Do not use
    StreptomycinIPVDo not use
    Polymyxin B
    IPV
    Some influenza vaccines
    Do not use
    ThimerosalSome brands/formulations, including certain DTaP, influenza (IIV), Td, DTCheck package insert
    aProtocols have been devised for administering IIV to patients with egg allergies.
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    12 . A father brings his 5-year-old son, Patient S, in for a checkup one morning in November. He states that Patient S has had "the sniffles" for the past two days and that he has been "running a bit of a fever." On exam, Patient S appears well except for nasal congestion. His temperature is 99.0°F. Patient S's medical history is unremarkable, he has no known allergies, and he tolerated his previous vaccinations well. He was up-to-date on all recommended vaccinations through 2 years of age, but has not received any vaccinations since then. At today's visit, which of the following vaccines should probably be deferred?
    A) IPV
    B) DTaP
    C) MMR
    D) LAIV

    VACCINE CONTRAINDICATIONS

    The ACIP recommends that LAIV not be used in patients with asthma or other conditions predisposing to flu complications [12,21]. In most cases, IIV can be used instead. LAIV should also be avoided in children and adolescents who are receiving aspirin or salicylate therapy. Acute respiratory illness with nasal congestion, which could interfere with delivery of the vaccine, is a reason to consider delaying the use of this vaccine until the congestion has decreased. Children younger than 5 years of age who have recent or recurrent wheezing should not receive LAIV [12,21].

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    13 . A mother brings her young daughter to a new pediatrician for the first time. She is changing doctors because her previous pediatrician refuses to see patients whose parents decline to have them vaccinated. She explains, "I know that MMR vaccine can cause autism, and I don't want that to happen to my child." What can you tell her?
    A) Large observational studies have failed to find a link between MMR and autism.
    B) Experts do not believe that MMR causes autism, but this issue has not been studied.
    C) An older type of MMR was a cause of autism, but this specific vaccine is no longer used.
    D) Good evidence links MMR and autism, but the benefits of vaccination are considered to outweigh the risks.

    VACCINE SAFETY

    Although measles was considered effectively eliminated in the United States in 2000, resurgence in the disease and regional outbreaks have resulted from suboptimal vaccination rates. In 2014, there were 667 cases of measles in the United States, more than 10 times the number of cases in 2000; another spike (372 cases) occurred in 2018 [95]. A large outbreak in 2014–2015 was linked to unvaccinated children visiting Disneyland, the source patient probably being infected overseas (likely the Philippines) [6,95]. The decrease in vaccine coverage is in part attributed to the false belief that the MMR vaccine may cause autism. Based on multiple studies, experts generally agree that there is no evidence for a link between the MMR vaccine and autism, and it is important that clinicians address these misconceptions with patients. In 2004, the Institute of Medicine (IOM) reported that "the body of epidemiological evidence favors rejection of a causal relationship between the MMR vaccine and autism" [83]. The American Academy of Pediatrics has also concluded that the evidence does not support such a connection. In addition, autism is not thought to be immune-mediated, and there is no clear mechanism by which MMR would cause this disorder [84].

    Research on the topic includes a Canadian study involving 27,749 children born between 1987 and 1998 [85]. This study found no association between rates of pervasive developmental disorder and either one or two doses of the MMR vaccine. In a 2015 retrospective cohort study of 95,727 children, MMR vaccine receipt was not found to predict autism diagnosis, even among children with older siblings with an autism spectrum disorder [78]. A study of 657,461 children born in Denmark between 1999 and 2010 found no increased risk of autism in those who received the MMR vaccine, including in special subgroups (e.g., autism risk factors, other childhood vaccinations) [115].

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    14 . Some parents have concerns about the presence of thimerosal in childhood vaccines. Which of the following is correct?
    A) Experts believe that thimerosal does not cause autism, but this has not been studied.
    B) Thimerosal remains a component of most childhood vaccines, but observational studies have not found a connection with autism.
    C) Vaccines recommended for children 6 years of age and younger now either contain no thimerosal or contain only trace amounts, because thimerosal was shown to cause autism.
    D) Vaccines recommended for children 6 years of age and younger now either contain no thimerosal or contain only trace amounts, although observational studies have not found a connection between thimerosal and autism.

    VACCINE SAFETY

    Some of the concerns about autism involve the use of thimerosal, a mercury-containing preservative. The IOM has concluded that, as with concerns about MMR, the evidence favors rejecting the idea of a causal relationship between thimerosal-containing vaccines and autism [83]. In addition, the same study that looked at MMR and autism in a large cohort of Canadian children also looked for any relationship between ethylmercury exposure and autism and failed to find a connection [85]. Exposure levels were comparable to levels in the United States during the 1990s. Another study, which examined the incidence of autism in California children before and after thimerosal was removed from childhood vaccines, found no decrease in autism following the change [88].

    Most vaccines for children 6 years of age or younger that had contained thimerosal either no longer contain this preservative or contain only trace amounts—small enough that the FDA considers them "preservative free" [89]. IIV is an exception. Thimerosal-free preparations of IIV are available, however, in limited quantities.

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    15 . A woman, 70 years of age, who is in generally good health, comes in to discuss some knee pain she has been having. While she is in your office, you take advantage of the opportunity to offer vaccination against seasonal influenza. She tells you that one of her friends is recovering from Guillain-Barré syndrome (GBS), and she recalls hearing something about the flu shot and GBS. What can you tell her?
    A) There is a proven risk with some of the current influenza vaccines, but not all.
    B) The rumor that incidence of GBS increased with the 1976 swine flu vaccine is untrue.
    C) There is a proven risk with the current influenza vaccines, but it is small, about 1 case per 1 million people.
    D) There is a theoretical risk with the current influenza vaccines, but even if there is a risk it would probably be small, about 1 case per 1 million people.

    VACCINE SAFETY

    GBS was associated with a swine flu vaccine in 1976, with an estimated 1 case per 100,000 people vaccinated [21]. Some observational studies since then have found a small increase in GBS cases associated with influenza vaccination, while others have found no link. Whether there is an association between current influenza vaccines and GBS is not known. According to the CDC, based on studies in prior seasons, if an association does exist the risk would likely be low (i.e., one case per 1 million people vaccinated). The IOM conducted a thorough scientific review of this issue in 2003 and concluded that people who received the 1976 swine influenza vaccine had an increased risk for developing GBS. Scientists have multiple theories regarding why this increased risk may have occurred, but the exact reason for this association remains unknown [93].

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    16 . As of 2019, what is known about HPV and problems following vaccination?
    A) The majority of events reported to VAERS have been considered non-serious.
    B) Postmarketing reports rule out any connection between vaccination and syncope.
    C) The only events reported to VAERS have been non-serious, such as fainting, swelling at the injection site, headache, nausea, or fever.
    D) All of the above

    VACCINE SAFETY

    Clinical trials and the post-licensure monitoring data of both Cervarix and Gardasil show that both vaccines are safe [29]. Since the licensure of the HPV vaccines, both the CDC and the FDA have monitored HPV vaccine safety through VAERS, VSD, and CISA systems. A 2009 CDC/FDA report found that the most common adverse events reported to VAERS following vaccination with Gardasil were fainting, swelling at the injection site, headache, and nausea. Seven percent were considered serious. However, no common pattern for serious events has emerged, making it difficult to form theories about causality. GBS was reported but did not appear to occur at a rate above background levels. Blood clots were reported in a small number of patients, most of whom had pre-existing risk factors (e.g., smoking, obesity, use of oral contraceptives). VSD surveillance examined adverse events associated with administration of Gardasil (e.g., GBS, stroke, venous thromboembolism) and found no statistically significant increased risk for any of these adverse events [79]. Ongoing safety studies for HPV include review of serious individual reports to VAERS; VAERS data reviews by the FDA; review of two years of safety data on Gardasil used in boys and men; research on venous thromboembolism following HPV vaccination; and continued consultation with CISA [29].

    Because of postmarketing reports, the prescribing information for the HPV vaccines includes a warning that syncope, sometimes associated with seizure-like activity, has been reported following vaccination [29]. Patients should be observed for 15 minutes following injection.

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    17 . Research regarding parents' concerns about vaccination suggests that
    A) it is unusual for parents to have questions or concerns about vaccines.
    B) the majority of parents have some level of uncertainty about vaccinating their children.
    C) information from healthcare providers is unlikely to influence decisions about vaccination.
    D) information from healthcare providers can have an important impact on parents' decisions to vaccinate.

    OVERCOMING BARRIERS FOR CHILDREN AND ADOLESCENTS

    Healthcare providers can have an influence when parents are concerned or confused about vaccines. For example, in one survey, 28% of parents had some level of uncertainly about vaccines [97]. For those who ultimately decided to allow timely vaccination, assurances or information provided by a healthcare provider were important reasons for the decision.

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    18 . In addition to children who are enrolled in Medicaid, children who are eligible for free vaccines under the Vaccines for Children program include children who
    A) are underinsured.
    B) have no health insurance coverage.
    C) are American Indian or Alaska Native.
    D) All of the above

    OVERCOMING BARRIERS FOR CHILDREN AND ADOLESCENTS

    The Vaccines for Children (VFC) program is designed to help overcome cost as a barrier to childhood vaccination. All of the ACIP-recommended vaccines are available for children enrolled in Medicaid, with VFC covering children through 18 years of age, and Medicaid funding covering young adults 19 and 20 years of age [101]. Children who have no health insurance coverage, children who are underinsured, and children who are American Indian or Alaska Native are also eligible for vaccines through VFC.

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    19 . You have found that there is room for improvement in pediatric vaccination rates. One of the nurses suggests sending letters to remind both adult patients and the parents of pediatric patients when vaccinations are needed. However, your office manager reminds you that the budget is tight this year. Sending letters would be an extra expense. Based on evidence and current recommendations, what should you do?
    A) Either send the letters or institute a system of reminder phone calls.
    B) Send letters only for pediatric patients, because reminders work for children but not adults.
    C) Do not use letters or phone calls, because reminder systems for patients do not work.
    D) Institute a system of reminder phone calls instead of letters, because calls have been proven to have greater effect.

    OVERCOMING BARRIERS FOR CHILDREN AND ADOLESCENTS

    Reminding parents to bring their children in for vaccinations is a proven way to increase coverage and is recommended in standards developed by the National Vaccine Advisory Committee and supported by other organizations [102,103]. Reminders need not take up extensive staff time. Mailed reminders have been shown to increase child vaccination rates and so have telephone calls, which may be computer-generated to save work by the office staff [104,105,106]. Outreach should be more intensive for families at high risk of missing appointments [102].

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    20 . Your group practice recently conducted a chart audit and discovered many "missed opportunities" for adult vaccination. You would like to institute a reminder system for yourself and your colleagues, but the others ask if there is any evidence it will work. Based on the evidence, what can you tell them?
    A) A review of studies was inconclusive, but a reminder system will do no harm and might help.
    B) The office should only use an electronic medical records system, because placing reminders in paper charts has been proven not to work.
    C) A review of studies found that physician reminder systems, such as chart notations, stickers, and patient lists, can improve vaccination coverage.
    D) Reminder systems for patients work, so even though reminder systems for physicians have not been studied, they can also be expected to increase vaccination rates.

    OVERCOMING BARRIERS FOR ADULTS

    There is evidence that when physicians recommend preventive services, patients are interested in receiving them. For example, 95.1% of patients in a national survey stated that they would accept the herpes zoster vaccination if their doctor recommended it [111]. Standards provided by the National Vaccine Advisory Committee, in cooperation with more than 60 organizations, offer evidence-based methods to help reduce missed opportunities for adults [110]. Providers should assess the vaccination status of all new patients and review vaccination status annually. Pneumococcal vaccination status should be reviewed when patients present for influenza vaccination.

    Standing orders for vaccination should be used, based on evidence that they improve adult vaccination coverage in many different settings [110]. Reminder systems for staff can also improve vaccination rates. In one review of studies, use of physician reminder systems, such as chart notations, stickers, and patient lists, improved coverage by a median of 22% [112]. Assessing a practice's success at vaccinating patients who are eligible and reporting the results to staff can also help to improve coverage [110].

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