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CPD

Overcoming Vaccination Barriers: Communicating With Caregivers/Patients

  • Authors: George Kassianos, MD
  • CPD Released: 6/4/2018
  • THIS ACTIVITY HAS EXPIRED
  • Valid for credit through: 6/4/2019
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Target Audience and Goal Statement

This educational activity is intended for an international audience of non-US healthcare professionals, specifically primary care physicians, pediatricians, and infectious disease/HIV specialists.

The goal of this activity is to improve clinicians' competence in discussing vaccines to prevent serogroup B meningococcal (MenB) disease in adolescents and young adults.

Upon completion of this activity, participants will have greater competence related to:

  • Communicating with patients/caregivers regarding vaccination


Disclosures

WebMD Global requires each individual who is in a position to control the content of one of its educational activities to disclose any relevant financial relationships occurring within the past 12 months that could create a conflict of interest.


Faculty

  • George Kassianos, MD

    General Practitioner, National Health Service UK, Bracknell, Berkshire, United Kingdom

    Disclosures

    Disclosure: George Kassianos, MD, has disclosed the following relevant financial relationships: 
    Served as an advisor or consultant for: Merck; Sanofi Pasteur; Seqirus; Valneva
    Served as a speaker or a member of a speakers bureau for: AstraZeneca; Pfizer; Sanofi Pasteur; Seqirus

Editor

  • Maria B. Uravich, BSc

    Scientific Director, WebMD Global, LLC

    Disclosures

    Disclosure: Maria B. Uravich, BSc, has disclosed no relevant financial relationships.

Medical Writer

  • Kevan Chambers

    Medical Writer, WebMD Global, LLC

    Disclosures

    Disclosure: Kevan Chambers has disclosed no relevant financial relationships.

Content Reviewer

  • Nafeez Zawahir, MD

    CME Clinical Director , Medscape, LLC

    Disclosures

    Disclosure: Nafeez Zawahir, MD, has disclosed no relevant financial relationships.


Accreditation Statements

    For Physicians

  • The Faculty of Pharmaceutical Medicine of the Royal Colleges of Physicians of the United Kingdom (FPM) has reviewed and approved the content of this educational activity and allocated it 0.25 continuing professional development credits (CPD).

    Contact WebMD Global

For questions regarding the content of this activity, contact the accredited provider for this CME/CE activity noted above. For technical assistance, contact [email protected]


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Follow these steps to claim a credit certificate for completing this activity:

  1. Read the information provided on the title page regarding the target audience, learning objectives, and author disclosures, read and study the activity content and then complete the post-test questions. If you earn a passing score on the post-test and we have determined based on your registration profile that you may be eligible to claim CPD credit for completing this activity, we will issue you a CPD credit certificate.
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CPD

Overcoming Vaccination Barriers: Communicating With Caregivers/Patients

Authors: George Kassianos, MDFaculty and Disclosures
THIS ACTIVITY HAS EXPIRED

CPD Released: 6/4/2018

Valid for credit through: 6/4/2019

processing....

Introduction

Host: Hello, I'm Kevan Chambers, the host for Meningitis B Television on Medscape. Welcome to the third episode in our series on "Adolescents and Young Adults: A Critical At-Risk Population." In the previous program, we looked at the benefits of immunizing adolescents and young adults against serogroup B meningococcal disease (MenB). Two vaccines are now available for use in this population, and there are good data showing that both of these vaccines can help protect individuals from developing invasive meningococcal disease, a serious and potentially fatal infection.

But, how can we make sure that patients in our own clinical practice who most need immunization do actually receive the vaccine? And what impact will vaccination have on the overall risk of developing invasive meningococcal disease due to MenB? I'm joined today by Dr George Kassianos, who is going to discuss how the benefits of immunization against MenB can be achieved in real-world, everyday clinical practice.

Status of MenB Vaccination

Host: Hello Dr Kassianos, thank you for joining me for the final episode in this 3-part series. What I would like to do today is look at real-world aspects of MenB immunization: what doctors can tell their patients, and how they can overcome barriers to vaccination.

Dr Kassianos: Alright.

Host: Where are we today, in terms of immunizing individuals who should be immunized against MenB?

Dr Kassianos: Well, let's start with young infants, where the situation is most straightforward. In Europe, as you know, serogroup B causes the majority of cases of invasive meningococcal disease,[1] and immunization is the most effective strategy for prevention of meningococcal disease.[2]

  • So, in September 2015, the UK became the first country to introduce the multicomponent meningococcal serogroup B (4CMenB) vaccine into its national infant immunization schedule.[3]

    Host: Because it's a part of the publicly funded national immunization program, I would assume there is pretty good coverage among the population?

    Dr Kassianos: Yes, Public Health England estimates that more than 95% of infants under the age of 2 years now receive at least 2 doses of vaccine.[4]

    Host: What about older children and adolescents? I believe there has been a large public petition asking for the vaccine to be extended beyond infants.

    Dr Kassianos: That's true. The situation for older children, adolescents, and young adults is a bit more complex. Teenagers in the UK, as well as young adults who are starting university, are now offered a combined vaccine that protects against the A, C, W, and Y strains of meningococcal disease.[3] Immunization against MenB, on the other hand, is not yet included in the national vaccination program for children older than 2 years, adolescents, and adults unless they fall into a high-risk group.

    Host: Why is that? Why has it not also been recommended for those age groups?

    Dr Kassianos: That's a question that has led to considerable debate during the last couple of years, and I have I raised it myself with Public Health England. I asked, "Why are we not vaccinating school leavers and early entrants to universities against MenB?"

    Host: And what was the rationale?

    Dr Kassianos: Well, they want to give it a bit longer to assess the impact of vaccinating infants, particularly on carriage of the meningococcus. In the meantime, it is up to practicing physicians to discuss the risks of meningococcal disease with their patients, and to initiate a conversation about the importance of immunizing adolescents and young adults against MenB.

  • Slide 1.

    Slide 1.

    (Enlarge Slide)

Recommending MenB Vaccination to Patients

Host: Immunization policies involve weighing the epidemiologic and clinical benefits of vaccination against economic projections. At the moment, there do not appear to be sufficient data for any countries to recommend routinely immunizing all adolescents and adults against MenB.[5,6] So I wondered whether doctors can confidently recommend vaccination for their own patients.

We know from work with other vaccines that when a physician or healthcare professional clearly and confidently communicates the importance of immunizing against a disease, patients very often follow that professional's recommendation,[7,8] even if they have to pay for the vaccine.

Dr Kassianos: Yes, I agree. The family doctor (or pediatrician, because in many countries 16- and 18-year-olds are still being seen by a pediatrician) should consider recommending the vaccine. If the physician strongly recommends a vaccine, any recommended vaccine, it is more or less guaranteed that vaccination will take place -- that it will be accepted. If the family doctor is not sure, however, and is not confidently giving advice, the patient will be unsure about the benefit of immunization. Therefore, family doctors and other healthcare professionals who are recommending vaccination must do so confidently and with enthusiasm.

Host: In the absence of policy recommendations regarding MenB immunization in adolescents and young adults, can physicians still recommend the vaccine in these age groups with enthusiasm?

Dr Kassianos: I think so. It's important to separate the economic issues, which are a major driver of government policy,[9] from the clinical issues that we must prioritize when advising our own individual patients.

Host: When should a family doctor give such advice?

Dr Kassianos: There are a few clinical factors that support confident recommendation of MenB vaccination for our patients. First and foremost, if our patients fall into certain high-risk categories, there is a clear-cut recommendation for them to be immunized against MenB.

Host: So those would be the groups that Professor Martinón-Torres described in the previous episode:

  • Anybody who is at increased risk because of a MenB outbreak or, for example, because they have persistent deficiencies in the complement pathway; patients who are receiving certain medications that suppress the immune system; and people with functional or anatomic asplenia, including those with sickle cell disease.[10,11]

    Dr Kassianos: That's correct, but I would add patients with celiac disease, too, as these patients are at risk of developing hyposplenism. From both a public policy perspective and a clinical perspective, there is no debate: Individuals who are at high risk for the development of meningococcal disease should be immunized against MenB.[10,11]

  • Slide 2.

    Slide 2.

    (Enlarge Slide)

Recommending Vaccination for Non-High-Risk Patients

Host: The majority of adolescents and adults do not fall into those high-risk groups. Yet behavioral changes and, in some cases, group living arrangements increase the opportunity for MenB infection in these age groups.[12] Physicians have no clear guidance on how to protect these individuals.

What about patients who do not fall into that high-risk category? What do you tell those individuals about MenB?

Dr Kassianos: For all patients, regardless of whether they are at increased risk for meningococcal disease, I think that it's important to explain the serious risks associated with meningococcal disease, including MenB.

  • We need to give them clear information about the risk of contracting this infection -- make sure they know that although meningococcal disease is not very common, it can occur without warning. And when it does occur, it often has devastating consequences.[13,14]

    Host: Of course, people may think that they, or their children, are protected if they have received the vaccine against serogroups A, C, W, and Y.

    Dr Kassianos: That's true. Therefore, physicians practicing in the majority of high-income countries need to emphasize that more cases today of meningococcal disease are caused by serogroup B than by any other serogroup,[1] and let patients know that they are not cross-protected by vaccination against A, C, W, and Y.

    Host: Yes, I think that's an important point.

    Dr Kassianos: In addition to explaining the serious risks associated with meningococcal infection, we can be confident in recommending the MenB immunization to our patients because it has been shown in clinical studies to generate a robust immune response.[10,15-19]

  • Slide 3.

    Slide 3.

    (Enlarge Slide)
  • And, in addition, data presented by Public Health England have shown the vaccine effectiveness to be 82.9%.[20] If they assumed that 88% of MenB strains were covered by the vaccine, the vaccine effectiveness against vaccine preventable strains was actually even higher: 94.2%.[21] In addition, data also show a significant decrease in the number of cases of MenB among vaccine-eligible infants as a result of immunization.[20] Patients may ask about the effectiveness of the vaccine, or we may volunteer these data. Either way, it's a good idea to have information about the effectiveness of the MenB vaccines available to give patients, particularly if they ask about it.

  • Slide 4.

    Slide 4.

    (Enlarge Slide)

Vaccine Side Effects and Needle Phobia

Host: Although available data indicate that MenB vaccines are safe, it is important for doctors to let patients know that they may experience some side effects. In adolescents and young adults, the most common side effects include soreness, redness, and swelling where the shot was given.[21] Fatigue, headache, muscle or joint pain, and nausea or diarrhea can occur in these age groups, but they are not very common[21] and they usually get better on their own within 3 to 7 days.[22]

Across most infectious diseases, not just meningococcal disease, there often seems to be concern about side effects and risks due to the use of vaccines. How do you handle that?

Dr Kassianos: Of course, we do need to give patients -- and, when appropriate, their parents -- information about the possible side effects of the vaccine so they are fully informed.

  • At the same time, I will contrast those risks against the symptoms and risk of complications that can occur as a result of contracting the infection. In addition, we need to remember that when we inject any vaccine, the body must react to that vaccine in order to trigger an immune response. Usually we experience no symptoms but sometimes we may experience some mild symptoms such a tiredness, aching, or something similar. Some patients may develop some local reactions such as redness or an aching arm. During that time, our immune system is producing lasting antibodies against that infection.

    Host: When you're dealing with adolescents and adults, do you find that so-called needle-phobia can be an issue?

    Dr Kassianos: Yes, this is something that we do sometimes encounter. So we need to be prepared for it. There are actually 2 aspects to the problem. Firstly, there is fear of injections: Looking at the needle itself freezes some people. And then there is fear of pain. So we ask patients if there is any possibility that they have fear of either needles or pain.

    Host: What do you tell them if they are afraid?

    Dr Kassianos: If they are worried about the needle, what I say is, "Look, I promise you, you are not going to see the needle, provided you look away and don't try to see my hand." If they are worried about pain, I say to them, "I will actually give you the vaccine in a way that will minimize the pain, if you get any at all."

    Host: I see. And what do you then do to minimize their pain?

    Dr Kassianos: If there are concerns about pain, then there are ways of helping the patient. One way to do it is by pressing with your thumb on the site where you are going to give the injection. When you do that, the brain is picking up the message of the discomfort created by the pressure. Then you remove your thumb, insert the needle, and pull the needle out. The brain has been confused, and patients hardly ever feel any pain. If a patient is afraid of the needle or report they feel faint with injections, I ask them to lie down on the couch. I then ask them to "look at the wall away from me, and I will tell you what I am doing; but do not look at me, just look at the wall."

  • Slide 5.

    Slide 5.

    (Enlarge Slide)

Scheduling Immunization

Host: In many high-income countries, the coverage rates for recommended vaccines remain below the target levels established by national and international advisory committees.[23] So I wanted to explore how physicians can increase the chances of adolescents and young adults in their practice being protected against meningococcal disease.

Of course, you cannot vaccinate patients unless they show up at your office. How do you try to make sure that adolescents come in for immunization.

Dr Kassianos: It's a challenge. Many adolescent patients are not seeing their family doctor for immunizations. If there is an outbreak of meningitis, they will all be at our doorstep; otherwise, it is not a priority for them. So, it's important for us to remember, opportunistically in the clinic, when we see a patient who is in the group at risk (ie, in the target group for meningitis vaccination) we must bring up the subject. If we see them for something else and we fail to actually recognize that they are due to be immunized against meningitis -- whether it is the MenB vaccine, the ACWY vaccine, or both -- then we have failed them.

Host: How do you make sure that you don't overlook the need to vaccinate the patients?

Dr Kassianos: In the UK, it's relatively straightforward for me to identify them. I have a contract with the government regarding who I should immunize against MenB, and we have a national information technology (IT) system, so these patients are flagged in the notes on my computer. In other countries that don't have such a system, I would advise physicians to find another way to be informed when they open their notes; some way of flagging that the patient is in the target group for immunization against MenB and has not yet been given the vaccine. When we were using paper notes in the previous century, I used to put a colored card in the patient's file to remind me. The card would say which vaccines were due and had not been given. No matter where you live, how you practice, there are ways to remind yourself, opportunistically, to promote vaccination.

Host: What about patients who you may not have a chance to immunize opportunistically?

Dr Kassianos: We need to write to these patients and tell them they are due for this vaccination, let them know why they are in a group that is at increased risk for meningococcal disease, give them information, and invite them to come and see us for vaccination. In our clinic, we take our patients' mobile numbers -- hardly anybody does not have a mobile nowadays -- and we make phone calls and more often send out text messages as a reminder. For patients who are at school or university, it's sometimes possible to target them through their educational organization.

Host: It's quite typical; however, for adolescents to have multiple activities competing for their time and attention.

Dr Kassianos: That's true. But a recent study conducted in London found that text message reminders can be particularly effective with this age group.[24] And another thing that I think is important for me to do, as a family doctor, is ensure that I am providing a convenient time for teenagers to come in for their vaccinations. If I say that vaccination can take place between 8 and 10 in the morning, and they are at school or university, how are they going to come in? We need to think about times that are convenient for our patients so that it does not become a problem. We will hear adolescents say, "I did not have the time." If we enable them to come in when it is more convenient for them, they are more likely to make the time.

Host: I think that's a good suggestion. This has been an interesting conversation with some valuable insight that can be used in clinical practice. Thank you, Dr Kassianos.

Closing Comments

Host: As we have heard throughout this series, adolescents and young adults have an increased risk of developing invasive meningococcal disease. And in Europe, serotype B is responsible for around two thirds of all cases of this disease. So, there is good reason to vaccinate patients in this age group against MenB. Some patients have underlying medical conditions that increase their risk of complications from infectious diseases, so it is especially important that we make sure those individuals are immunized.

Of course, there are barriers that sometimes make it difficult to administer vaccines to all patients who should be immunized. But as Dr Kassianos explained, a proactive, organized, and confident approach by pediatricians and general practitioners can overcome those barriers and help ensure that patients in their practice receive the appropriate vaccines. And, although it is too soon to be able to measure the benefits of immunizing adolescents and young adults at the population level, surveillance data demonstrate a substantial reduction in the incidence of meningococcal disease due to MenB in infants through routine immunization.

Thank you for joining us for Meningitis B TV on Medscape. We hope that you have found this series both interesting and informative. You may now take the posttest by clicking on the "Earn CME Credit" link. Please also take a moment to complete the program evaluation that follows. Goodbye, and thank you again for watching.

This transcript has been edited for style and clarity.