Immunize Georgia, Vol. 2 (Aug. 2007)

What's Inside

3

Spot Light Take Action This Fall

4

Vaccines for Teens Protect Their Future

5

GRITS Champion

Insert Parent Pages

Immunize 2007vol.2
Georgia
A PUBLICATION OF CHILDREN'S HEALTHCARE OF ATLANTA AND DHR'S GEORGIA IMMUNIZATION PROGRAM

Vaccine Preventable Diseases Do Happen in Georgia
Why do we give vaccines? Do vaccine preventable diseases (VPDs) occur in Georgia? Every year outbreaks of vaccine preventable disease happen in our community, exemplifying the need to be comprehensive with immunization practices and vigilant in identifying and following up on vaccine preventable diseases among Georgia's residents.
Pertussis (whooping cough) outbreak in a church community In north Georgia in the fall of 2006, a single laboratory-confirmed case of pertussis was reported in a 10-month-old infant. The public health investigation uncovered household members with recent cough illness and several members of the family's church community who also reported cough illness in the previous one to two months. Out of 150 church members, 31 suspect cases were identified. Partially or under-immunized children in the church community potentially facilitated the spread.
Pertussis cases are difficult to identify for several reasons. Infections, particularly in adolescents and adults, may resemble the common cold. Adolescents and adults may not seek medical care for an upper respiratory illness, and suspect cases may not be diagnosed. These persons often serve as the source of infection for young infants who are at high risk for serious complications.
Even when ill patients see their doctors, less than optimal laboratory tests for pertussis hinder case confirmation. Currently the culture is the gold standard and only laboratory test for confirmation of pertussis. Other diagnostic tests, such as polymerase chain reaction (PCR) and serology, are available but have not been validated and should not be used alone.
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Vaccine Preventable Diseases Do Happen in Georgia continued from page 1

Take action against pertussis E nsure that patients and healthcare workers are current on receipt
of immunizations. Adolescents and adults between the ages of 10 and 64 years of age should receive a one-time dose of tetanus, diphtheria and pertussis (Tdap), and children under the age of seven years need to receive diphtheria, tetanus and pertussis (DTaP) as routinely recommended, starting at 6 to 8 weeks of age. P romptly obtain a culture on all suspect pertussis cases. R eport pertussis or any cluster of illness to public health immediately. W hen a case is identified, all household and close contacts should be given chemoprophylaxis, regardless of age and vaccination status. C urrent ACIP recommendations for pertussis vaccination can be reviewed at: Adolescent http://www.cdc.gov/mmwr/preview/ mmwrhtml/rr5503a1.htm?s_cid=rr5503a1_e Adult http://www.cdc.gov/mmwr/preview/mmwrhtml/ rr5517a1.htm
Measles at an International Science Fair This May, a high school student with measles traveled from India to Albuquerque, New Mexico for an annual international science fair attended by 1,500 students grades K-12 from the U. S. (including Georgia) and 51 other countries. In route, multiple flight connections were made including one at Hartsfield-Jackson Atlanta International Airport, but the student was not diagnosed with measles until after arriving in New Mexico and attending the fair.
One case of measles is considered an outbreak and consequently a public health emergency. Therefore it is critical to quickly identify exposed persons in order to immunize those who are susceptible and have no vaccine contraindications within 72 hours of exposure. Immune globulin can be given within six days of exposure to susceptible persons with vaccine contraindications to prevent or ameliorate disease. Officials at the New Mexico State Department of Health (NM DOH) rapidly determined that persons may have been exposed on the flights, at the science fair and various hotels, and at a large retail store in Albuquerque.
Imported measles cases almost always involve exposures in multiple states and result in large-scale investigations led by the Centers for Disease Control and Prevention (CDC). In addition to conducting a local investigation, the NM DOH immediately alerted CDC who subsequently notified appropriate state officials across the country and outside the U.S. NM DOH provided measles vaccine for fair attendees and the general public. State and local public health officials continued follow-up with fair attendees after they arrived home. No secondary cases were attributed to this outbreak.

Take action against measles E nsure patients and healthcare workers are current on receipt of
immunizations. E ducate staff and patients about measles and other VPDs
emphasize that persons infected with VPDs can easily cross borders. If you suspect measles in a patient, notify public health immediately.
Acute hepatitis B infections in teenagers A series of three hepatitis B vaccinations or a positive hepatitis B serology is required for all students entering schools or child care facilities in Georgia. This requirement was implemented in 1997, and therefore some adolescents who entered school prior to this year may not have been vaccinated and remain susceptible to hepatitis B infection. The following acute hepatitis B cases reported in 2006 are examples of infections in adolescents that could have been prevented. All four adolescents were born in the U.S.
Cases 1 and 2: A 15-year-old male and female were seen by their respective physicians with gastrointestinal symptoms and elevated liver function tests (LFTs). The female was jaundiced and hospitalized. Both were diagnosed with acute hepatitis B. Both teenagers had always attended Georgia schools. Although their schools may have checked their immunization records, due to their age, hepatitis B vaccine was not required for school entry.
Case 3: A 16-year-old female was seen with jaundice and elevated LFTs. She was diagnosed with acute hepatitis B infection. Previously her physician had not seen her for a while and had overlooked the patient's need for hepatitis B vaccine.
Case 4: During an STD evaluation, a 17-year-old female was found to have elevated LFTs, acute hepatitis B and another STD. Similar testing months earlier showed no STD or history of hepatitis B infection. Despite risk factors, no vaccination was begun at that time.
Take action against hepatitis B CDC's Healthy People 2010 goals include the elimination of hepatitis B transmission in the U.S. Current national guidelines recommend hepatitis B immunization for all susceptible adolescents and adults at high risk of infection. Remember that older adolescents may not be immunized for hepatitis B, so if they present in your office for a sports injury or physical, don't miss the opportunity to vaccinate them for hepatitis B.
When you identify or suspect a notifiable disease, contact public health at 1-866-782-4584. To access the "Notifiable Disease/ Condition Reporting Form," which includes a complete list of the notifiable diseases, please visit http://health.state.ga.us/pdfs/epi/notifiable/reporting form.05.pdf. n

Immunize Georgia / 2007 / VOL. 2 2

Spot Light

Take Action this Fall to Protect Our Communities

The back-to-school rush at the end of each summer typically means a rush to the doctor for annual physicals and getting children caught up with their immunizations. The fall is also a time for checking the immunization status of all family members, especially with flu season approaching. A key to increasing awareness and ultimately the immunization rates of our communities is to utilize every available healthcare visit as an opportunity to educate families. This does not just apply to your patients, but to your staff as well.
In June 2007, the Infectious Diseases Society of America (IDSA) released the "Actions to Strengthen Adult and Adolescent Immunization Coverage in the United States" (published in Clinical Infectious Diseases). IDSA developed a set of policy principles and recommendations as a call to action for all healthcare providers (HCPs), health officials and policymakers. Recommendations include increasing the demand for adult and adolescent immunization by raising public and provider awareness.
For HCPs, influenza outbreaks can involve staffing shortages and increased staffing costs. HCPs can transmit influenza to their patients. While influenza can be less severe for healthy HCPs, it can be deadly if transmitted to patients who are very young or have underlying medical conditions. The IDSA report calls for all HCPs to be immunized according to the Advisory Committee on Immunization Practices (ACIP) recommendations as a means not only of protecting themselves and their patients but also of setting a positive example.* HCPs can and should be role models by being up-to-date on recommended vaccinations. However, influenza immunization rates for HCPs were under 40 percent as of June 20061.
The IDSA principles also advise hospitals to institute policies to vaccinate eligible inpatients and outpatients, and support that the Joint Commission should establish criteria for assessing influenza, pertussis and hepatitis B immunization rates in HCPs as a measure of institutional compliance and performance. All parts of the blueprint and additional information on adult and adolescent immunization can be accessed from http://www.idsociety.org/adultimmunization.htm.

specified awareness week, throughout this fall, utilize the suggested promotion activities, which can be found at http://www.immunizecaadults.org/naiaw/naiaw4.asp to promote immunizations in your practice.
Make a commitment now to ensure your staff are up to date on HCP vaccinations such as Tdap and influenza. Take the time also to partner with your local hospitals, Rotary and Kiwanis Clubs, grocery stores, libraries, movie theaters or even churches to disseminate immunization materials.
For information on National Immunization Awareness Month, which is held every August, please visit http://www.cdc.gov/vaccines/events/niam/default.htm. Many of these materials or messages can also be used year round.
* For a complete review of ACIP recommendations for healthcare workers, visit the following links: http://www.cdc.gov/mmwr/preview/mmwrhtml/ rr5502a1.htm?s_cid=rr5502a1_e
http://www.cdc.gov/mmwr/preview/mmwrhtml/ rr5517a1.htm
http://www.cdc.gov/mmwr/preview/mmwrhtml/ 00050577.htm
1 "National Foundation for Infectious Diseases Applauds New Standard by the Joint Commission on Accreditation of Healthcare Organizations as an Important Step to Improve Influenza Vaccination of the Nation's Health Care Workers." National Foundation for Infectious Diseases. June 16, 2006. n

Key messages for families and HCPs can emphasize that

immunizations help reduce absences at work, school and social

events by decreasing the spread of illness in the home, workplace

and community. This year, the National Adult Immunization Awareness Week is September 23-29. Awareness activities can increase understanding of the need for immunizations across the lifespan. Rather than just promoting immunizations during the

Take

Action!

Immunize Georgia / 2007 / VOL. 2 3

Vaccines for Teens Protect their Future

Two years ago, a brochure promoting adolescent vaccines, called Take 5 for Teens was produced by Children's Healthcare of Atlanta and the Georgia Department of Human Resources, in partnership with the Georgia Chapter of the American Academy of Pediatrics, the Georgia Chapter of the American Academy of Family Physicians, the Society for Adolescent Medicine and the Georgia Department of Education. Since that time, approximately 225,000 of the brochures have been distributed throughout Georgia.

A recent survey of the Take 5 for Teens brochure involved sending the brochures home with 1,656 5th grade students in Fayette County schools. Of the 147 surveys returned, 66 percent of respondents reported making an appointment with their child's doctor after reading the brochure. One parent stated "great explanation on why your student must be vaccinated." Another expressed, "I was concerned about immunizations and what they were when my children were infants," indicating some parents still have the perception that immunizations do not apply to their adolescent. Also, several parents asked for information on the human papillomavirus (HPV) vaccine.
The Take 5 for Teens brochure has been updated to include the HPV vaccine and the new Georgia school requirements for sixth grade entry. Since more than five vaccines are now recommended for teens, the title has changed to Vaccines for Teens - Protect their Future. In addition, for the first time, this brochure is now available in both English and Spanish.
The Centers for Disease Control and Prevention (CDC) launched a new media campaign August 1 promoting "preteen" adolescent vaccination. Focus groups and in-depth interviews across the country were completed earlier this year by the CDC to identify what campaign materials should include. Information from the focus groups was utilized in updating the Vaccines for Teens brochure.
Insights received from CDC focus groups: Caregivers of 11 and 12 year olds Preteen vaccination is not on the radar for caregivers. Few caregivers knew about HPV's relationship to cervical cancer. Very few caregivers knew any details about HPV vaccine. Motivators to vaccinate daughters with HPV vaccine include:
o Information on safety, efficacy, what HPV is and how it is related to cancer.
o Provider's recommendation - "I recommend" or "Your daughter needs."
o Cancer prevention promote HPV vaccine as anti-cancer vaccine.
o "Your daughter has an 80 percent chance of getting HPV by the time she is 50."
o " Giving your daughter the HPV vaccine is something you can do to protect her future for many years to come."

Avoid talking about too many strains of HPV. No knowledge of tetanus, diphtheria and pertussis (Tdap) vaccine. U naware that immunity from childhood vaccines wanes over time. Some knew that young children get boosters against tetanus. Some recognized "whooping cough" but did not know what
pertussis was. No recognition of MCV4, meningococcal vaccine or
meningococcal disease. Some but not many recognized the word meningitis, which was
most associated with college. Since some are skeptical of new vaccines, do not promote
vaccines as "new." Information about Vaccines for Children (VFC) is very important,
as parents otherwise may not take their preteen with no insurance to get vaccinated.
Physician In-Depth Interviews Tdap was often cited as the most important preteen vaccine. MCV4 was associated with college years, not early adolescence. Immunizing adolescents was perceived to be less important than
immunizing infants. Lack of or partial insurance coverage seen as a major barrier. Some smaller practices were less likely to stock vaccines for
adolescents.
The CDC's new campaign targets mothers of 11 and 12 year olds and healthcare providers, emphasizing the importance of the preteen check-up as an opportunity to discuss "growing up" with their healthcare providers.
For a complimentary supply of the Vaccines for Teens brochures in both English and Spanish, please go to www.choa.org/immunization to download an order form.
For more information about the new CDC campaign for teen vaccines and to download materials to be used with your patients, please go to www.cdc.gov/vaccines/preteen/. n

Immunize Georgia / 2007 / VOL. 2 4

GRITS Champion

Harry R. Foster, Jr., M.D., P.A Benefits from GRITS

In practice for 38 years, Dr. Harry R. Foster, Jr., and his staff focus on providing quality pediatric care, including making a special effort to ensure that immunization procedures are timely and complete.
Four years ago, Dr. Foster began utilizing the Georgia Registry of Immunization Transactions and Services (GRITS) as a tool for offering even better care to his pediatric clients. Initially, the practice purchased a new computer and set up an office just to enter GRITS. They also successfully completed GRITS training. Currently, his staff have entered 41,457 immunizations for approximately 5,000 clients.
"Our office has done its best to make GRITS work for us, and indeed, it has," said Emily Foster, Office Manager for 36 years. "We use GRITS to keep accurate records of immunizations given in our office and to keep track of immunizations given elsewhere. It is wonderful to locate records on patients who have received immunizations elsewhere without going through the hassle of attempting to locate them in personal family records, other physicians' offices and public health centers."
Some of the benefits Dr. Foster's office has reaped from using GRITS include access to inventory management, client management, immunization management and reports. GRITS also makes it easy for staff to identify children who need specific shots to meet the new immunization requirements for child care and school.

According to the American Academy of Pediatrics, approximately 85 percent of American children are vaccinated at pediatricians' offices. Consequently, there is a great need and demand for doctors to have accurate immunization records. "If all providers used GRITS, it would make universal access to immunizations a reality," Emily Foster said, adding that duplication of immunizations and missed opportunities have been major concerns for the practice.
"With the majority of children in Georgia receiving immunizations in private offices, we see the need to build private partnerships to make immunization records accessible and accurate," said Michelle Conner, Director of the Georgia Immunization Program. "We are committed to train public and private staff to use GRITS as a valuable resource and daily tool to provide immunizations."
The Georgia Immunization Program salutes Dr. Harry R. Foster, P.A. and his staff as GRITS Champions for going the extra mile to care for Georgia's children!
"Dr. Foster and his staff have consistently used GRITS since being trained in 2003 and submitted thousands of shots right after being trained," said Jotonna Horton, Immunization Program Consultant. "I have never once had to call them and encourage them to start submitting shot data. They are one of my best and biggest users of GRITS."
Since its inception over five years ago, GRITS maintains a statewide database of 62,981,003 immunizations, 6.2 million clients and over 3,000 partners.

For questions on how to request GRITS training for your staff, call the Georgia Immunization Program/GRITS at (404) 463-0810 or visit http://health.state.ga.us/programs/immunization/grits/.

Dr. Harry Foster, Jr., MD is located in Lithonia, Georgia, in DeKalb County.

Front Row: Serena, Medical Assistant; Lisa, R.N; Debra, R.N; and Beverly, Medical Secretary. Second Row: Nichole, R.N.; Joy, Medical Secretary; and Mary, Medical Assistant. Third Row: Linda, Medical Assistant; Emily, Office Manager; Dr. Foster, Brooke, Medical Secretary; and Nona (not pictured), Medical Secretary.

This article was contributed by Connie F. Smith, Program Information/Marketing Coordinator with the Georgia Immunization Program, Division of Public Health. n
Immunize Georgia / 2007 / VOL. 2 5

Your Monthly News and Resource Update

More than a decade ago, two sets of standards were introduced to guide the delivery of immunizations for children and adults Revised Standards for Child & Adolescent and Adult Immunization Practices.* The standards focus on: making vaccines easily accessible effectively communicating vaccination information implementing strategies to improve vaccination rates developing community partnerships to reach target patient populations
Using the standards as a guide, Immunize Georgia now provides a monthly email update which includes timely immunization information and resources. The resources are categorized by the standards and include Web links and tips on how best to implement the standards in your practice.
If you would like to receive these monthly email updates, please go to www.choa.org/immunization or email Angie Matthiessen at angie.matthiessen@choa.org.
* S tandards for Child and Adolescent Immunization Practices. PEDIATRICS Vol. 112 No. 4 October 2003, pp. 958-963. http://www.cdc.gov/nip/recs/rev-immz-stds.htm

ImmunGizeeorgia
Published by Children's Healthcare of Atlanta 1655 Tullie Circle NE, Atlanta, Georgia 30329-2321
Children's Healthcare of Atlanta 404-250-kids, www.choa.org
Immunize Georgia Angie Matthiessen, M.S.W. 404-785-7225, fax 404-785-7258 angie.matthiessen@choa.org
Georgia Immunization Program Ruth Gilmore, B.S.N. 404-657-3158, fax 404-657-1463 http://health.state.ga.us/programs/immunization/
Vaccines For Children Program 404-657-5013, fax 404-657-5736 800-848-3868, fax 800-372-3627
American Academy of Family Physicians Georgia Chapter 404-321-7445, www.gafp.org

American Academy of Pediatrics Georgia Chapter 404-876-7535, www.gaaap.org

Visit www.choa.org/immunization to access previous volumes of the Immunize Georgia newsletter and the Vaccines for Teens brochure.
2007 Children's Healthcare of Atlanta/CHDA924635 jt08.07 DPH07/107HW

CDC-INFO Contact Center 800-232-4636, www.cdc.gov/nip
CDC Spanish-Language Hotline 800-232-4636, www.cdc.gov/spanish/

Children's Healthcare of Atlanta Child Health Promotion 1655 Tullie Circle Atlanta, Georgia 30329-2321

Please route to:
o Physician(s) o Nurse Practitioner(s) o Registered Nurse(s) o Nurse Tech(s) o Office Manager

Parent Pages / Immunize Georgia / 2007 / VOL. 2
ParentPages ShotSmarts From Immunize Georgia

Vaccine Preventable Diseases do Happen in Georgia
Why do we give vaccines (shots)? Your young children should be up-to-date on shots, but you and your teenager also need to be up-to-date in order to protect the whole family. Despite efforts to fight vaccine preventable diseases, they can occur in Georgia. Here are a few examples of recent vaccine preventable disease outbreaks in Georgia that highlight the fact that we all need to be prepared.

Pertussis (whooping cough) outbreak in a church community Pertussis is on the rise and can be hard to recognize because adolescent and adult symptoms may look like the common cold.
Pertussis spreads through coughing and sneezing. While most children receive pertussis shots during early childhood, the protection from these shots does not last a lifetime, and a booster dose (Tdap) is needed. Adults and adolescents who do not receive a booster dose can spread pertussis to infants who have not had their shots, or have only received a few shots and may not be fully protected. Infants can and do die from pertussis.
In the fall of 2006, a 10-monthold Georgia baby tested positive for pertussis. The baby's grandfather, grandmother and mother had a cough illness several days before the baby got sick. The family was active in their church and several church members reported a cough illness in the previous weeks, too. Out of 200 church members, 31 persons ranging from 2 months to 55 years of age were found to

possibly have pertussis. In this case, the infant was not up-to-date on his shots and got pertussis from the sick family members. In fact, a number of children at the church were not up-to-date with their shots or had never received any shots, which may have led to the spread of pertussis in the church community.
Take action against pertussis Talk with your doctor about getting the pertussis shot (Tdap) to protect you and your family. If you have a cough that lasts more than a week, talk to your doctor about pertussis and avoid contact with infants and pregnant women. If your doctor suspects pertussis, he/she will prescribe antibiotics to treat the ill person and everyone else in your family should take antibiotics to prevent spread of the disease.
Measles at an International Science Fair Measles is a very contagious disease that causes a high fever and rash. In some cases, measles can also cause swelling of the brain and pneumonia. Measles is spread by direct contact with infected people or saliva (through coughing, sneezing, talking, sharing utensils or drinking cups, etc.). Once someone has been exposed to measles, however, it can take from one-and-a-half weeks up to three weeks for symptoms to appear.
Last May, a high school student with measles traveled from India to Albuquerque, New Mexico for an annual international science fair attended by 1,500 students grades K-12 from the U.S. (including Georgia) and 51 other countries. In route, the child made multiple flight connections including one at Hartsfield-Jackson Atlanta International Airport. The student was diagnosed with measles after arriving in New Mexico and attending the fair, but she was infectious for several days during her travel from India.

2007 Children's Healthcare of Atlanta/CHDA924635 jt08.07 DPH07/107HW Parent Pages are intended to be copied and distributed to parents.

continued on back page

www.choa.org 404-250-kids www.health.state.ga.us/programs/immunization/

Parent Pages / Immunize Georgia / 2007 / Vol. 2

Vaccine Preventable Diseases do Happen in Georgia
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Officials at the health department in New Mexico quickly determined that other people may have been exposed to measles on the flights, at the science fair and various hotels, and at a large retail store in Albuquerque. To try to reduce any possibility of spread, the New Mexico Health Department provided measles vaccine for certain fair attendees and the general public. Public Health officials in other states continued follow-up with fair attendees when they arrived in their home states. No other measles cases were linked to this outbreak.
Take action against Measles The best way to protect yourself and your family against measles is to get vaccinated. If you will be traveling outside of the country, it is also very important to make sure you and your family are up-to-date on all required shots.
Hepatitis B in teenagers Hepatitis B is a viral infection that can cause liver damage, cancer or death. It spreads from person to person through infected blood or sexual contact. Each year, many cases of hepatitis B in Georgia could be prevented by receiving the series of three shots to protect against this serious disease.

A 15-year-old male was born in Georgia and had been attending school in one county, but when the family moved to a county nearby, he changed schools. While both school systems may have checked his shot record, due to his age, hepatitis B vaccine was not required for school entry. In 2006, he went to see his doctor with symptoms of nausea, vomiting and loss of appetite. Blood tests showed acute (new) hepatitis B infection. Three other teenagers in Georgia, ages 15, 16 and 17, were diagnosed with acute hepatitis B infections in 2006. None had been vaccinated against this disease.
Take action against hepatitis B A series of three shots of hepatitis B vaccine is required for all students entering schools or childcare facilities in Georgia. Because this requirement only applied to newly enrolled students when it was implemented in 1997, there are many older adolescents and young adults in Georgia who never received their shots for hepatitis B and are not protected. Check with your child's doctor to see if he/she needs to receive the series of three hepatitis B shots. In addition, if someone in your household has hepatitis B, it is recommended that others in the home receive the series of three shots. n

2007 Children's Healthcare of Atlanta/CHDA924635 jt08.07 DPH07/107HW Parent Pages are intended to be copied and distributed to parents. www.choa.org 404-250-kids www.health.state.ga.us/programs/immunization/