What's Inside 2 Spot Light - Talking With Parents 3 GRITS Champion 5 Vaccines for Teens Immunize 2008vol.2 Georgia A PUBLICATION OF CHILDREN'S HEALTHCARE OF ATLANTA AND DHR'S GEORGIA IMMUNIZATION Section Measles Is On the Rise Take Action Now Measles is one of the most infectious of the vaccine preventable diseases. However, since the implementation of the two-dose MMR (measles, mumps and rubella) vaccine series, measles is no longer endemic in the United States (U.S.). Prior to the introduction of the vaccine in 1963, 3 to 4 million children in the U.S. would become infected with measles every year resulting in approximately 500 deaths and an additional 1,000 children with chronic long-term disabilities.1 In 2008, though, the U.S. has experienced a resurgence of measles cases. Sixty-four cases of measles were reported between January 1 and April 25, 2008, the highest number reported for this time period since 2001. Among these 64 confirmed measles cases, 10 were travelers, either Americans or visitors from abroad, and 54 of the 64 were associated with a case that was imported.1, 2 Cases were reported from nine states - Arizona, California, Hawaii, Illinois, Michigan, Pennsylvania, New York, Virginia and Wisconsin. Outbreaks in the U.S. have resulted from unvaccinated travelers to countries currently experiencing large outbreaks or ongoing cases of measles, such as Switzerland, Israel, India or Japan; from exposure to infected visitors from abroad; or persons linked to the former. Additional details are outlined below: T hese measles cases have been transmitted in multiple settings including childcare centers, schools, healthcare facilities and doctors' offices. S ixty-three of the 64 cases were unvaccinated or had unknown or undocumented vaccination history. Two-thirds of the cases have been in children old enough to be immunized who were not due to personal or religious exemptions. continued on page 4 Spot Light Talking With Parents about Vaccines and Vaccine Safety Studies show that the uptake of vaccines in individual practices is related to a physician's enthusiasm about vaccines and how the physician conveys this message to the individual families.1 With the constraints of scheduling and reimbursement, it may not be feasible for a physician to spend unlimited amounts of time with parents on the immunization question. What is the best way to balance a parent's needs with the provider's schedule? In a presentation entitled "Effectively Addressing Parents Concerns about Immunizations," Patricia Stinchfield, RN, MS, CPNP emphasized that parents want more information from their providers.2 Stinchfield makes great suggestions, such as taking a little time at the first visit (new to the practice or new baby) to educate parents on the power of the human immune system. According to Stinchfield, Paul Offit, MD at the Vaccine Education Center uses the analogy of an ocean to effectively describe the immune system's ability to handle the antigens in vaccines (i.e. the antigens in the first round of newborn vaccines can be likened to cups of water poured into the ocean of antigens which the human immune system takes on in any given day). This discussion alone can address some of the issues up front and prevent future longer conversations. Stinchfield recommends several options for maximizing time with parents by educating them from a proactive preventive stance. Share real experiences with vaccine preventable diseases (VPDs) through visuals and storytelling, including anonymous stories about actual patients you have known over the years who have contracted a VPD. The Immunization Action Coalition offers "Unprotected People Reports" at www.immunize.org/reports, which includes personal stories on most of the VPDs.* Current issues with VPDs, such as the ongoing measles outbreaks in the U.S., can be powerful examples of the risk that parents are taking by choosing not to vaccinate. Other prevention activities include holding a vaccine education class for parents in the community or in the physicians' practice. Rather than addressing questions throughout the day, invitations can be sent to families and a set amount of time can be used to provide education on VPDs, vaccines and the immunization schedule. Videos, visual aids and analogies all serve to personalize the message for families. A phone message can be taped and played for parents on hold. In addition, parent-to-parent links can be provided for new or concerned parents with parents who are vaccine advocates. According to Stinchfield, some CPT codes offer additional reimbursement for counseling parents about vaccines. The American Academy of Pediatrics provides a "Comprehensive Overview: Immunization Administration" which details the immunization administration codes, frequently asked questions and vignettes for examples.3 Vaccine Safety - Web Resources for Physicians The Immunize Georgia program at Children's Healthcare of Atlanta would like to be an immunization resource for you - the busy healthcare provider. Please visit www.choa.org/immunizegeorgia for easy access to resources when talking with parents about vaccine safety. Be sure to sign up for the Immunize Georgia monthly resource email which is designed to offer you quick access to immunization specific resources. * For easy access to listed Web sites, please visit www.choa.org/immunizegeorgia and open the pdf to this newsletter. 1."Association Between Health Care Providers' Influence on Parents Who Have Concerns About Vaccine Safety and Vaccination Coverage." Pediatrics 118, no. 5 (Nov. 2006): e1287-1292 (doi:10.1542/peds.2006-0923). 2. Stinchfield, Patricia, RN, MS, CPNP. "Effectively Addressing Parents Concerns about Immunizations." http://www.cdc.gov/vaccines/ed/ciinc/2008June.htm 3. "Comprehensive Overview: Immunization Administration," www.aap.org/visit/OverviewImmunization Administration2008.pdf. n Immunize Georgia / 2008 / VOL. 2 2 GRITS Champion Dr. Mohammad O. Tometh Mohammad O. Tometh, MD has served the Fulton County pediatric community since 1974. During the past 34 years, Dr. Tometh has had the opportunity to experience firsthand the many barriers physicians face to ensure their patients are adequately immunized. With a total of eight full-time staff members, Dr. Tometh makes sure every patient in his practice has been entered into GRITS. Since 2006, Dr. Tometh and staff have entered over 4,100 patients and over 44,000 immunizations into GRITS. With the practice seeing over 100 patients a day, this is a tremendous undertaking for him and his staff. "We made it a point to verify each and every patient's historical immunization history was entered into GRITS," said Andrea Garwood, MA "We spent countless hours working weekends, overtime and through lunch breaks to enter every patient in our practice. We started at A and ended at Z." Dr. Tometh stated he has seen an incredible increase in vaccine rates since being a part of GRITS. With having access to GRITS, he is assured his patients are not only being immunized but correctly immunized. "The biggest obstacle in our practice is language barriers," said Dr. Tometh. "With more than half of my clients speaking foreign languages, we were having issues of patients receiving duplicate vaccinations. This is no longer an issue with the implementation of GRITS. I just wish there were a way to have access to the patient's complete medical record structured like GRITS." Left to right: Row 1: Donna Heil, Marisol Velaquez, MA, Dr. Prasad. Left to right: Row 2: Sammy Anderson, Sylvia Figureoa, Dr. Tometh, Dr. McKinde, Andrea Garwood, MA, Sharon Kelsey. Not Pictured: Celeste Daniel and Selena Kelsey stock he needs to order and keep on hand. "With being a private entity, overhead is heavy; this reduces my wastage and overall expenses," said Dr. Tometh. Since its inception over five years ago, GRITS maintains a statewide database of 7.3 million clients, and over 73 million immunizations. With GRITS being a birth to death registry, data is collected and reported by many sources. For more information on GRITS, call 1-888-223-8644. n Dr. Tometh added that since maintaining his inventory in GRITS, he has been able to accurately forecast how much private vaccine Immunize Georgia / 2008 / VOL. 2 3 Measles Is On the Rise Take Action Now continued from page 1 F ifty-nine were U.S. residents - 13 were less than 12 months of If a known "suspect" case is coming in for an office visit, schedule age and too young to be vaccinated. Seven were between 12 it for the end of the day and ask the family to avoid contact with and 15 months old, but had not yet received a MMR vaccine. others in the community. T he five visitors to the U.S. had not been vaccinated. Isolate suspect measles cases promptly; do NOT refer or send suspect patients to other areas of the healthcare facility. Have the Between April 25 and May 31, 2008, an additional 51 patient wear a mask. measles cases have been reported to the Centers for Disease Control and Prevention (CDC), for a total number of 115 cases in 16 states.3 One confirmed measles case was recently identified in Georgia in a resident who traveled to the Middle East. Immediately report a suspect measles case to 1-866-PUB-HLTH (866-782-4584) or call your local Immediately report a suspect measles case to 1-866-PUB-HLTH (866-782-4584) or call your local health department. In collaboration with Public Health, obtain specimens for laboratory confirmation and viral genotyping. Refer to the "Measles: Specimen In the context of the ongoing measles outbreak, health department. providers should consider several key points: Submission for Laboratory Diagnosis" at http://health.state.ga.us/pdfs/epi/GPHL_Measles_ R emain vigilant for measles. Increase/refresh Template.pdf for details. your measles expertise. The below resources are available*: While Public Health (PH) has the primary responsibility of G CDC measles information: prevention and control measures in potential measles cases, PH http://www.cdc.gov/ncidod/dvrd/revb/measles/measles_gen- may ask for assistance with the implementation of the following eral_info.htm#sec_1 measures, such as: G Measles photos: G advising the patient to remain on a voluntary home quarantine http://www.vaccineinformation.org/measles/photos.asp during his or her infectious period (four days before to four Implement recommended infection control guidelines and routinely days after rash onset). monitor for compliance. G developing a list of persons exposed to the patient during the G Infection Control Guidelines can be found at: infectious period. http://www.cdc.gov/ncidod/dhqp/gl_isolation.html Make sure staff have documented evidence of measles immunity on file. Recent exposures in three states required verification of hundreds to thousands of healthcare worker records, which G administering MMR vaccine to susceptible patient contacts or immune globulin to susceptible contacts for whom vaccine is contraindicated as recommended by Public Health. included serologic testing for those with no documentation. Use this as an opportunity to enter all staff into the GRITS Immunization Registry - this will facilitate easy assessment of immunization status in these situations. Educate parents about measles when appropriate, especially those who plan to travel abroad, those who refuse vaccination, With recent and ongoing parental concern about the safety of vaccines, particularly the MMR vaccine, it is important that parents be educated so that they can make appropriate decisions regarding the risks and benefits of vaccines for their children (see enclosed article on talking with parents). and those with infants less than 12 months of age. *For easy access to listed Web sites, please visit Increase surveillance for unimmunized or under-immunized www.choa.org/immunizegeorgia and open the pdf for this newsletter. patients and ensure patients are immunized as recommended by the Advisory Committee for Immunization Practices. G MMR vaccine information statement: http://www.immunize.org/vis/vis_mmr.asp 1. "MeaslesUnited States, January 1-April 25, 2008." Morbidity and Mortality Weekly Report 57, no. 18 (May 9, 2008): 494-498. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5718a5.htm If measles is suspected in a patient, take action with the following steps: Early identification of measles is critical to prevent transmission. Measles should be considered in persons who have clinically compatible illness, a history of recent international travel, exposure to international travelers or exposure to a confirmed measles case. Remember that persons infected with measles are infectious up to four days before rash onset. 2. "CDC Update on Measles Outbreaks in United States." CDC Media Relations Transcript, May 1, 2008. http://www.cdc.gov/media/transcripts/2008/t080501.htm 3. Provisional unpublished data from the CDC. Curtis Allen, spokesperson. June 9, 2008. n Immunize Georgia / 2008 / VOL. 2 4 Vaccines for Teens Protect Their Future Brochure Makes an Impact in Georgia Vaccine preventable diseases can have devastating effects on adolescents and their ability to function at their highest level. Some of these diseases are life-threatening, and some have chronic long-term effects. In addition, adolescents are thought to be a strong factor in spreading some of these diseases to either young children, too young to get vaccinated, or to anyone who is not able to be vaccinated due to their compromised health status. Vaccinating our adolescents is smart and will continue to be an issue. As a result, spreading the word about these vaccines has been an important initiative in Georgia. taking such action averaged 62 percent for the three years the survey was completed. Over the course of the three years, an average of 81 percent of parents agreed the "brochure made it easier to understand the vaccines their adolescent needs." A few parent comments are noted below: "Thank you for this information. I hope that you will continue to provide this service to parents of students in Troup County and to add other information as needed or as it becomes available." With this in mind, the Immunize Georgia program at Children's Healthcare of Atlanta created a brochure in 2005 to address the growing number of vaccines that adolescents are recommended to have in order to keep them healthy from vaccine preventable diseases, such as meningitis, hepatitis B, chickenpox and pertussis. A major goal is to help parents better understand the vaccines their adolescent needs and the seriousness of these diseases. Developed in partnership with the Georgia Department of Human Resources, the Georgia Chapter American Academy of Pediatrics, the Georgia Chapter American Academy of Family Physicians and the Society for Adolescent Medicine, the brochure was originally titled "Take 5 for Teens," but as the number of recommended vaccines for teens increased, the brochure was renamed in 2007 to "Vaccines for Teens Protect their Future." Since 2005, Immunize Georgia has distributed 323,000 English and 26,300 Spanish brochures. Many of the brochures have been circulated through the efforts of school nurses who are giving them out with report cards or other mailings home to parents. School nurses have been using them to educate parents about the Georgia requirements for school entry, particularly for those students entering middle and high school for the first time. Surveys have been distributed for this brochure through a unique process over the past three years. The surveys have been provided for parents either as a perforated postcard attached to the brochure or as a one-page survey sent home from school. The postcards were mailed back to Children's, and the one-page surveys were collected by staff at the schools. Over the course of the three years, the surveys have shown that parents do take action after reading the vaccine brochure. For example, many parents reported "making an appointment with their child's doctor after reading the brochure" (78, 66 and 43 percent respectively from 2006-2008). The number of parents "I am glad you sent me this information. I have three children in high school. I like having a head start on their needs." "Great explanation on why your student must be vaccinated." "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. "I am saving the brochure for her annual well child appointment around her summer birthday. I found this brochure to be most informative and helpful." "After reading this brochure, I will make sure my child receives her vaccines needed at next physical." "Thank you for sending the information; it really explains what we need to know, and how important the vaccines are for our children." Immunize Georgia is in the process of completing a brochure revision to add the recommendation for all children between 6 months and 18 years of age to receive the influenza vaccine. The updated brochure will be available for distribution in late summer or early fall. If you would like to receive a complimentary supply of these brochures to use in your work with adolescents, please visit www.choa.org/immunizegeorgia to download an order form. Go ahead and send in the order form, and when brochures are available, they will be mailed to you. The current version of the brochure is also available for download on this page. For questions or comments about the Vaccines for Teens brochure, please contact Angie Matthiessen at angie.matthiessen@choa.org or 404-785-7225. n Immunize Georgia / 2008 / VOL. 2 5 Welcome Laura Moore Laura M. Moore, Ed.D., R.N. came to the Immunization Section of the Georgia Division of Public Health in February after working at the Georgia Department of Human Resources as the Children's Medical Services program manager for seven years. Moore's undergraduate educational background includes an associate of science degree in nursing (ASN) and a bachelor of science degree in nursing (BSN). Her graduate degrees include a master of science degree in nursing (MSN) in family and community nursing with an academician role and a doctorate in education (EdD) in curriculum and instruction. Moore has worked primarily in public health settings and taught nursing in colleges and universities in both Florida and Georgia. Her teaching assignments were often public health courses. Moore's new role as immunization nurse consultant is one she has sought for many years. Moore reports always having an interest in and a passion for immunizations that dates back to her days as a public health nurse in Florida. She reports the most exciting aspect of her job is the availability of so many disease-preventing immunizations to protect all of us. The most challenging aspect is the ongoing battle of families making immunization decisions based upon misinformation. Moore is ready for the task of providing resources and education to the providers in Georgia her passion will serve her well. Welcome! Visit www.choa.org/immunizegeorgia to access previous volumes of the Immunize Georgia newsletter and the Vaccines for Teens brochure. Please also visit this site to sign up for the Immunize Georgia News and Resource Update, which is sent monthly to your email. 2008 Children's Healthcare of Atlanta/CHDA928872 jt06.08 DPH 08.196 H ImmunGizeeorgia Published by Children's Healthcare of Atlanta 1655 Tullie Circle NE, Atlanta, Georgia 30329-2321 Children's Healthcare of Atlanta www.choa.org/immunizegeorgia Immunize Georgia Angie Matthiessen, MSW 404-785-7225, fax 404-785-7258 angie.matthiessen@choa.org Georgia Immunization Section Laura Moore, EdD, RN 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 404-881-5020, www.gaaap.org 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 Need to update or delete contact information? Go to choa.org/ immunizegeorgia Parent Pages / Immunize Georgia / 2008 / VOL. 2 ParentPages ShotSmarts From Immunize Georgia Measles Close to Home Before the measles vaccine started being used in 1963, 3 to 4 million children in the U.S. would get measles every year. Five hundred children would die and 1,000 children would have life-long health problems.1 Two doses of the measles vaccine were recommended for children starting in the mid-1990s. Since then, there have been few measles cases in the U.S. Some measles cases have been seen though where groups of people choose to not get the measles vaccine for religious or personal beliefs.1 In 30 percent of people with measles (3 out of 10 people), serious problems can happen such as pneumonia and/or encephalitis (swelling of the brain).4 Several of the people with measles have been admitted to the hospital, but as of May 31, 2008, there had been no deaths. In 2008, the U.S. has seen more people with measles, the most since 2001.1 By April 25, 2008, 64 people came down with the measles in nine states. In just over a month, from April 25 to May 31, 2008, this number almost doubled to 115 people with measles in 16 states.2 As of May 31, 2008, one person from Georgia got the measles after a visit to the Middle East. Some of the U.S. measles cases or outbreaks started after people who had not received the measles vaccine traveled to countries with current large outbreaks or cases of measles. These countries include Switzerland, Israel, India and Japan. Because these people had not received a measles vaccine, they caught measles and brought it home. In other cases, measles was passed to U.S. residents from ill visitors from other countries.1 As a parent, what can you do? If you have questions about measles or the vaccine, talk with your doctor. Check your immunization (shot) records. If you or your child has not received two measles vaccines, be sure to see your doctor to get this vaccine. R emember that infants (babies) less than 12 months of age are too young to be vaccinated against measles and can catch measles easily. Be sure other people in the household, including older siblings and family members, get their measles vaccine to help protect infants. If you or anyone in your family is planning a trip to a foreign country, including European countries, make sure everyone is up to date on all their vaccines. Of the people with measles between January 1 and April 25, 2008, 99 percent had not received their measles vaccine or it was not * For easy access to listed Web sites, please visit www.choa.org/vaccines and open the pdf to this parent page. known if they had received their measles vaccine. Two-thirds of the measles cases were in children who were old enough to have the measles vaccine but had not received it due to personal or religious exemptions. Thirteen of the 59 U.S. residents were less than 12 1. " Measles--United States, January 1-April 25, 2008." Morbidity and Mortality Weekly Report 57, no. 18 (May 9, 2008): 494-498. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5718a5.htm months of age and too young to get the measles vaccine.1 2. Provisional unpublished data from the CDC. Curtis Allen, Measles has been passed on to others in busy settings such as spokesperson. June 9, 2008. childcare centers, schools, healthcare facilities and doctors' offices. Measles is very easy to catch as it can stay active for a couple of hours. If active measles virus was put in a room with people who 3. " CDC Update on Measles Outbreaks in United States." CDC Media Relations Transcript, May 1, 2008. http://www.cdc.gov/media/transcripts/2008/t080501.htm have not received their measles vaccine, most everyone in that room would get measles.3 4. C enters for Disease Control and Prevention. Epidemiology and Prevention of Vaccine-Preventable Diseases. Atkinson W, Hamborsky J, McIntyre L, Wolfe S, eds. 9th ed. Washington, DC: Public Health Foundation, 2006. n 2008 Children's Healthcare of Atlanta/CHDA928872 jt06.08 DPH 08.196H Parent Pages are intended to be copied and distributed to parents. www.choa.org/vaccines www.health.state.ga.us/programs/immunization/ Parent Pages / Immunize Georgia / 2008 / Vol. 2 Meningococcal Disease Close to Home Picture your healthy teen getting sick with a headache, stiff neck and high fever. In a few hours, he starts having nausea and vomiting. He is confused and sensitive to bright light. Your teen now has a red splotchy rash. This can be very scary for you and your child. Two teens in Georgia died this way during the 2007-2008 school year. Within 24 hours of these symptoms starting, they both died from a disease that can be prevented with a vaccine. This disease is called meningococcal meningitis (meningitis). Meningococcal meningitis is a bacterial infection of the fluid surrounding the brain and spinal cord. These bacteria can also infect the bloodstream and spread through the body. There is a vaccine that protects against four types of the bacteria that cause meningococcal disease. Two of these types are the most common in the U.S. and are responsible for most of the meningitis cases in the country. The two Georgia teens that died had one of the types that could have been prevented with the vaccine. The risk for meningitis is higher for those between 15 to 24 years of age and college students living in dorms than for other age groups. Meningitis is spread through close personal contact, such as coughing, sneezing, kissing or sharing items that touch a person's mouth (utensils, drinks, cigarettes or lip balm). Those who get meningitis may lose an arm or leg--while others may die. This disease can quickly take over the body with little warning. There is nothing to stop the disease once it takes over the body. The meningitis vaccine (shot) is one shot that is recommended for teens starting at age 11. Don't let this happen to your teen make sure he or she gets the meningitis vaccine. For more details, visit the below Web sites: Centers for Disease Control and Prevention Meningitis Information http://www.cdc.gov/meningitis/ National Meningitis Association http://www.nmaus.org/ n "I received my meningitis vaccination and I am ready for college." 2008 Children's Healthcare of Atlanta/CHDA928872 jt06.08 DPH 08.196H Parent Pages are intended to be copied and distributed to parents. www.choa.org/vaccines www.health.state.ga.us/programs/immunization/