Immunizations: Protecting One Another and Our Future

FP OCTOBER-DECEMBER 2018

MISSOURI FAMILY PHYSICIAN VOLUME 37, ISSUE 4

IMMUNIZATIONS PROTECTING ONE ANOTHER AND OUR FUTURE

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FP MISSOURI FAMILY PHYSICIAN

EXECUTIVE COMMISSION

BOARD CHAIR Mark Schabbing, MD (Perryville) PRESIDENT Sarah Cole, DO, FAAFP (St. Louis) PRESIDENT-ELECT Jamie Ulbrich, MD, FAAFP (Marshall) VICE PRESIDENT John Paulson, MD, PhD, FAAFP (Joplin) SECRETARY/TREASURER Lisa Mayes, DO (Macon)

CONTENTS 6 IMMUNIZATIONS: PROTECTING ONE ANOTHER AND OUR FUTURE

BOARD OF DIRECTORS DISTRICT 1 DIRECTOR John Burroughs, MD (Kansas City)

ALTERNATE Jared Dirks, MD (Kansas City) DISTRICT 2 DIRECTOR Robert Schneider, DO (Kirksville)

ALTERNATE Brooks Biele, DO (Kirksville) DISTRICT 3 DIRECTOR Emily Doucette, MD, FAAFP (St. Louis)

DIRECTOR Kara Mayes, MD (St. Louis)

ALTERNATE Dawn Davis, MD (St. Louis) DISTRICT 4 DIRECTOR Jennifer Scheer, MD, FAAFP (Gerald)

ALTERNATE Kristin Weidle, MD (Washington) DISTRICT 5 DIRECTOR Vacant

ALTERNATE Vacant DISTRICT 6 DIRECTOR David Pulliam, DO, FAAFP (Higginsville)

ALTERNATE Carrie Peecher, DO (Marshall) DISTRICT 7 DIRECTOR Wael Mourad, MD, FAAFP (Kansas City)

DIRECTOR Afsheen Patel, MD (Kansas City)

ALTERNATE Beth Rosemergey, DO, FAAFP (Kansas City) DISTRICT 8 DIRECTOR Kurt Bravata, MD (Buffalo)

ALTERNATE Charlie Rasmussen, DO, FAAFP (Branson) DISTRICT 9 DIRECTOR Patricia Benoist, MD, FAAFP (Houston)

ALTERNATE Vacant DISTRICT 10 DIRECTOR Deanne Siemer, MD (Jackson)

ALTERNATE Vicki Roberts, MD, FAAFP (Cape Girardeau) DIRECTOR AT LARGE Jacob Shepherd, MD (Grain Valley)

RESIDENT DIRECTORS Ann Lottes, MD, SLU Misty Todd, MD, UMC (Columbia) (Alternate)

STUDENT DIRECTORS Mimi Liu, SLU Morgan Dresvyannikov, UMKC (Alternate)

AAFP DELEGATES Todd Shaffer, MD, MBA, FAAFP, Delegate Keith Ratcliff, MD, FAAFP, Alternate Delegate Kate Lichtenberg, DO, MPH, FAAFP, Alternate Delegate Peter Koopman, MD, FAAFP, Alternate Delegate

MAFP STAFF EXECUTIVE DIRECTOR Kathy Pabst, MBA, CAE COMMUNICATIONS & EDUCATION MANAGER Sarah Mengwasser MEMBERSHIP & PROGRAMS COORDINATOR Becki Hughes The information contained in Missouri Family Physician is for information purposes only. The Missouri Academy of Family Physicians assumes no liability or responsibility for any inaccurate, delayed or incomplete information, nor for any actions taken in reliance thereon. The information contained has been provided by the individual/organization stated. The opinion expressed in each article(s) is the opinion of its author(s) and does not necessarily reflect the opinion of MAFP. Therefore, Missouri Family Physician carries no responsibility for the opinion expressed thereon.

Missouri Academy of Family Physicians, 722 West High Street Jefferson City, MO 65101 p. 573.635.0830 • f. 573.635.0148 mo-afp.org • office@mo-afp.org

4 A Letter from the President Opening remarks

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MO-AFP.ORG 3

A LETTER FROM THE PRESIDENT

Over the past hundred years, two simple medical interventions are likely to have saved more lives than any others --

hand hygiene and vaccines."

Sarah Cole, DO, FAAFP

O

ver the past hundred years, two simple medical interventions are likely to have saved more lives than any others -- hand hygiene and vaccines. We devote this issue of the Missouri Family Physician to the latter. As family physicians, we are responsible for childhood and adult vaccination recommendations for both general prevention and a variety of chronic conditions.

Some of the most rewarding professional conversations I’ve had centered around vaccines. Some of those conversations involved educating individual patients or their loved ones on the benefits and potential harms of vaccines for which they are eligible. Other conversations included our clinic staff as we work to reduce barriers such as access, cost, fear or pain for our clinic population. Still, other conversations were to remind medical students, residents or other health providers as to indications or contraindications for vaccines.

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MISSOURI FAMILY PHYSICIAN OCTOBER-DECEMBER 2018

Several years ago, I completed a process improvement project that incorporated all three by seeking to increase rates of pneumococcal vaccination in our clinic for adults aged 18 to 64 years with diabetes mellitus. I educated residents and faculty in our clinic about indications for pneumococcal vaccination, created patient information sheets, set patient and physician reminders in the lobby and exam rooms and added pneumococcal vaccine administration to our rooming workflow. In the end, my results echoed other studies in that the most effective strategies involved automated reminders or standing orders, which became valuable and practice-changing information for our clinic.

As you peruse this issue of MFP, I invite you to reflect upon your own practice and consider ways in which you, too, might save more lives through vaccines!

MISSOURI ACADEMY OF FAMILY PHYSICIANS'

Advocacy Day 2019

You are the Voice of Missouri Family Physicians

February18-19

Capital Plaza Hotel and Missouri State Capitol, Jefferson City, MO Monday, February 18, 2019 6:30 – 8:30 pm Legislative Briefing of Key Issues and Buffet Dinner, Capital Plaza Hotel Tuesday, February 19, 2019 8:00 am – 1:00 pm Legislative Briefing and Breakfast, Capital Plaza Hotel Visit Legislators’ Offices (appointments to be scheduled for you by MAFP staff) Lunch buffet at hotel 1:30 – 5:00 pm Board of Directors Meeting

Register online at mo-afp.org *There are a limited number of complimentary sleeping rooms available through the MAFP. Contact Kathy Pabst at kpabst@mo-afp.org or call 573.635.0830 for more information and availability.

MO-AFP.ORG 5

Expla in to my p why aren they prote should ts ct m e.

IMMUNIZATIONS PROTECTING ONE ANOTHER AND OUR FUTURE

YOU are the most trusted source of vaccine information by parents and patients. Immunization providers

should be prepared to discuss the benefits and risks of vaccines using vaccine information statements (VIS) and other reliable resources. In this issue you will find information on the importance of vaccines, how to talk to your patients about the safety of vaccines, how to deal with vaccine refusal, and more.

d n a e t Educa . e m d remin

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ious r e s o t e l usceptib s e r o ing m n e t a e r I am h t life y l b i s s o hich p w and w o n k et me L . s n o i t c r me. infe o f t s e b e r vaccines a

MO-AFP.ORG 7

INFANT & ADOLESCENT PREPARING FOR VACCINE QUESTIONS PARENTS MAY ASK

M

any parents won’t have questions about vaccines when you give your strong recommendation and use language that assumes parents will accept vaccines for their child. If a parent questions your recommendation, this does not necessarily mean they will not accept vaccines. They consider you their most trusted source of information when it comes to vaccines and sometimes parents simply want your answers to their questions.

This article outlines some of the topics parents ask about most and tips for how to answer their questions. It is intended as a companion to Talking with Parents about Vaccines for Infants. (Page 10)

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MISSOURI FAMILY PHYSICIAN OCTOBER-DECEMBER 2018

Questions about the vaccine schedule and number of vaccines Some parents may be concerned that there are too many vaccines or their child will receive too many at one time. But, they may not understand that following the recommended vaccine schedule provides the best protection at the earliest possible time against serious diseases that may affect infants early in life.

Parents may ask: Can it harm my child to get several vaccines at one time? Does my child need all of the vaccines recommended? To respond, you can: Share that no evidence suggests that receiving several vaccines at one time will damage or overwhelm a healthy child’s immune system.

Explain what antigens are (parts of germs) and emphasize the small amount of antigens in vaccines compared to the antigens babies encounter every day in their environment.

Remind parents that they must start each vaccine series on time to protect their child as soon as possible and their child must complete each multi-dose series for the best protection.

There is no data to support that spacing out vaccines offers safe or effective protection from these diseases.

“There’s no proven danger in getting all recommended vaccines today. Any time you delay a vaccine you leave your baby vulnerable to disease. It’s really best to stay on schedule.”

Questions about whether vaccines are more dangerous for infants than the diseases they prevent Because vaccines are very effective, many parents have not seen a case of a vaccinepreventable disease firsthand. Therefore, they may wonder if vaccines are necessary and if the risks of vaccinating infants outweigh the benefits of protection from vaccine preventable diseases.

Parents may ask: Are these diseases that dangerous? Is it likely that my baby will catch this disease? Will ingredients in vaccines hurt my baby more than possibly getting the disease could? To respond, you can: Share your experience of how these serious diseases still exist and explain that outbreaks still occur in the U.S. For example: From year to year, measles cases in the U.S. can range from roughly less than 100 to a couple hundred. However, in 2014, health departments reported cases in 667 people from 27 states.

Between 1970-2000, health officials reported less than 8,000 cases of whooping cough each year in the U.S. But since 2010, health officials have reported between 15,000 and 50,000 cases of whooping cough each year to the CDC. Teach parents that diseases eliminated in the U.S. can infect unvaccinated babies if travelers bring the diseases from other countries. If you need up-to-date information on specific diseases, share disease facts with parents.

Remind parents that many vaccine preventable diseases can be especially dangerous for young children and there is no way to tell in advance if their child will get a severe or mild case. Without vaccines, their child is at risk for getting seriously ill and suffering pain, disability, and even death from diseases like measles and whooping cough.

“I know you didn’t get all these vaccines when you were a baby. Neither did I. But we

were both at risk of serious diseases like Hib and pneumococcal meningitis that could lead to deafness or brain damage. Today, we’re able to protect your baby from 14 serious diseases before his second birthday with vaccines.”

Questions about known side effects It is reasonable for parents to be concerned about possible reactions or side effects listed on Vaccine Information Statements. Vaccines, like any medication, can cause some side effects. Many of these effects are minor, treatable, and last only a few days.

Parents may ask: Will my child be okay if she has a side effect? I know someone whose baby had a serious reaction – will my baby too? To respond, you can: Remind parents that most side effects are mild and go away within a few days.

Reassure parents that you and your staff are prepared to deal with serious vaccine reactions.

Encourage parents to watch for possible side effects (fussiness, low-grade fever, soreness where the shot was given) and provide information on how they should treat them and how to contact you if they observe something they are concerned about.

Share your own experience, or lack thereof, of seeing a serious side effect from a vaccine. Explain that serious side effects are very rare.

Reassure parents that the disease-prevention benefits of getting vaccines are much greater than the risks of possible side effects.

“I’ll worry if your child doesn’t get vaccines today, because the diseases can be very dangerous - most, including Hib, pertussis, and measles, are still infecting children in the U.S. We can look at the Vaccine Information Statements together and talk about how rare serious vaccine side effects are.”

Questions about unknown serious long-term side effects Parents who look for information about vaccine safety will likely encounter information that says vaccines can lead to serious long-term side effects from vaccines. It is understandable that parents may find this alarming.

Parents may ask: Do vaccines cause long-term side effects? Will getting a vaccine permanently hurt my child’s health? To respond, you can share that: Vaccines are not linked to increases in health problems such as autism, asthma, or auto-immune diseases.

There is no evidence to suggest that vaccines MO-AFP.ORG 9

INFANT & ADOLESCENT threaten a long, healthy life. Conversely, we know lack of vaccination threatens a long and healthy life.

“We have years of experience with vaccines and no reason to believe that vaccines cause long-term harm. I understand your concern, but I truly believe that the risk of diseases is greater than any risks posed by vaccines. Vaccines will get your baby off to a great start for a long, healthy life.”

Questions about whether vaccines cause autism Although many parents are aware that numerous studies show vaccines do not cause autism, some parents have lingering questions and concerns.

Many rigorous studies show that there is no link between MMR vaccine or thimerosal and autism.

If parents raise other possible hypotheses linking vaccines to autism, three items are key: Give patient and empathetic reassurance that you understand their infant’s health is their top priority, and it also is your top priority, so putting children at risk of vaccine-preventable diseases without scientific evidence of a link between vaccines and autism is a risk you are not willing to take.

Share that the onset of autism symptoms often coincides with the timing of vaccines but is not caused by vaccines.

Give your personal and professional opinion that vaccines are very safe.

“Autism is a burden for many families and people want answers—including me. But well designed and conducted studies that I can share with you show that MMR vaccine is not a cause of autism.”

Additional Questions Parents May Ask: • Isn’t natural immunity better than the kind from vaccines?

• Do I have to vaccinate my baby on schedule if I’m breastfeeding him?

• Why are so many doses needed for each vaccine?

Resources: www.cdc.gov. For information on vaccines, vaccine safety, and vaccine preventable diseases: www.cdc.gov/vaccines/ conversations

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MISSOURI FAMILY PHYSICIAN OCTOBER-DECEMBER 2018

Remind parents that many vaccine preventable diseases can be especially dangerous for young children and there is no way to tell in advance if their child will get a severe or mild case.

Without vaccines, their child is at risk for getting seriously ill and suffering pain, disability, and even death from diseases like measles and whooping cough."

"

one of the most successful medical advances in modern times, While vaccines are

most vaccine-preventable illnesses are unfamiliar to today’s parents2."

VACCINE REFUSAL Scope of the problem accine refusal is an increasingly common topic that providers are discussing with their patients. This ranges from parents who don’t want their young children vaccinated, to families who decline the adolescent HPV vaccine, to adults who refuse the annual flu vaccine. In a Blue Cross Blue Shield study of insured children, vaccine refusal increased from 2.5% in 2010 to 4% in 20161. While vaccines are one of the most successful medical advances in modern times, most vaccine-preventable illnesses are unfamiliar to today’s parents2. Because of this, some parents question the necessity of immunizing their children, especially because no vaccine is completely free of adverse effects or complications. However, with more families refusing vaccines, outbreaks have occurred. In 2014, there were 667 cases of measles in the U.S., mainly within an unvaccinated Amish community3. In 2012, there was an outbreak of pertussis in the U.S., including 48,277 cases and 20 deaths.

V

Physician approaches to families who don’t want to vaccinate The time spent by a physician counseling families is valuable and can lead to behavior change. A provider recommendation is the most important factor in patients’ decisions to vaccinate, especially for teens and the HPV vaccination4. The presumptive approach (“we’re going to do three vaccines today – Tdap, HPV, and MCV”) is more effective than the participatory approach (“we could do several vaccines if you want, what do you think about vaccines today?”). Using patientcentered communication skills are key in these encounters. Develop good rapport, establish a trusting relationship, and use motivational interviewing techniques to make sure you understand the patient’s concerns and can address those in a supportive yet directive approach. Keep trying, even if the first answer to vaccines is no, you can bring the topic up at subsequent visits.

Don’t wait for scheduled well visits to discuss vaccinations – any visit is a chance to discuss vaccine recommendations.

Sarah Swofford, MD, MSPH

MO-AFP.ORG 11

INFANT & ADOLESCENT The Autism Science Foundation recommends the CASE method for discussing vaccines with concerned parents5.

Corroborate: acknowledge the parents’ concern and find some points on which you can agree. About me: describe what you have done to build your knowledge base and expertise on this issue. Science: describe what the science says. Explain/advise: give your advice to the patient, based on the science.

Autism and vaccines For families who are concerned that there is a link between vaccines and autism, you can reassure them that myth has been debunked. It was based on a 1988 study

by Andrew Wakefield which suggested there was a link between the MMR vaccine (specifically mercury in the form of thimerosal) and autism. The article was later retracted for fraud, the author was stripped of his medical license and multiple studies have found no causal link between vaccination and autism. Thimerosal was removed as an ingredient in vaccines in 2001 just to be safe, yet the rates of autism continue to increase. It might be helpful to tell parents what we do know about autism, that there is a link to genetic predisposition and prenatal exposures5.

Vaccine ingredients aren’t safe Another common concern from parents of young children is that vaccines aren’t safe or tested enough. While there is no concrete evidence of harm from thimerosal, it was removed from all vaccines except multi-dose flu vials in 2001. Aluminum is another ingredient that

has parents worried. Aluminum is in many foods and our environment, and compared to other sources of aluminum, the exposure in vaccines is minimal. Over the course of the first six months of immunizations, infants are exposed to 4.4mg of aluminum, compared to 7mg in breastmilk and 38 mg in formula over those same six months7. You can also assure families that vaccines are the most thoroughly studied products brought to the market. There is rigorous testing and oversight for 10-15 years before they are released for distribution, and after-market surveillance for any vaccine adverse events has been in place since 1990.

Too many childhood vaccines overwhelm the immune system This is an alternative theory for the vaccine-autism link.

The concern among parents and skeptics is that multiple vaccines overwhelm the immune system, which creates an interaction with the nervous system that triggers autism in a susceptible host. There is good evidence that vaccines don’t even come close to overwhelming the immune system6.

Combination vaccines induce similar immune responses to individual vaccines, indicating that the immune system can handle multiple vaccines simultaneously. Today’s vaccines 12

MISSOURI FAMILY PHYSICIAN OCTOBER-DECEMBER 2018

also include less individual immunological components today then previous vaccines due to advances in protein chemistry and recombinant DNA technology. The 14 childhood vaccines given today contain <200 bacterial and viral proteins or polysaccharides, compared to the seven vaccines given in 1980 which had >3000 of these proteins or polysaccharides. So while the number of vaccines is more, the actual immunological load is less. Finally, vaccines represent a minute fraction of what a child’s immune system routinely handles on a daily basis– from viruses to environmental allergens to dirt on the floor.

Adolescents and HPV The presumptive approach to vaccines works best here.

“Today we are going to give the HPV vaccine”. Focusing on cancer prevention aspect rather than sexual transmission of HPV results in greater vaccine acceptance7. Provider recommendation is a strong predictor for teens receiving the HPV vaccine. Other talking points that can be helpful include the fact that HPV causes genital warts and cancer of the cervix, as well as cancer of the vagina, vulva, anus, rectum, penis, and oropharynx. It takes no high-risk sexual activity to be exposed to the HPV virus. Completing the series before sexual activity begins is the best way to protect our children.

The vaccine has been on the market since 2006, is highly effective, and considered safe. Receiving the HPV vaccine does not encourage earlier sexual activity.

I don’t need a flu shot, I never get sick The healthy adult can be a difficult person to convince they need a flu vaccine. The idea of vaccinated healthy adults and children in the community really gets at herd immunity. Depending on the illness, herd immunity is achieved when ~80% of the population is immune to the disease to prevent spread of illness. Influenza takes a greater toll on the very young, the very old, chronically ill, and immunocompromised. Those are often the groups who don’t respond as well to the flu vaccine. Immunizing healthy adults and children helps to keep the rest of our community safe. But even healthy adults can get really sick from the flu. There are 140,000 to 720,000 hospitalizations each year from the flu and 12,000 to 56,000 deaths each year. Of those who died from the flu, 80% did not receive a flu shot.

It also takes two weeks before the vaccine is effective, so encourage your patients to get the vaccine early before flu season takes hold (that way they can’t tell you the flu shot made them sick).

Resources: 1. Early Childhood Vaccine Trends in America. Blue Cross Blue Shield, the Health of America Report. Jan 2018. 2. Omer et al. Vaccine Refusal, Mandatory Immunization, and the Risks of Vaccine-Preventable Diseases. N Engl J Med 2009; 360: 1981-1988.

3. Spencer JP et al. Vaccine Adverse Events: Separating Myth from Reality. Am Fam Physician. 2017; 95:786-794 4. Ylitalo KR et al. Health Care Provider Recommendation, Human Papillomavirus Vaccination, and Race/Ethnicity in the US National Immunization Survey. Am J Public Health 2013 Jan: 103(1): 164-169. 5. Making the CASE for vaccines: a new model for talking to parents about vaccines. Autism Science Foundation http://autismsciencefoundation.org/wp-content/uploads/2015/12/ Making-the-CASE-for-Vaccines-Guide_final.pdf 6. Gerber JS and Offit PA. Vaccines and Autism: A Tale of Shifting Hypotheses. Clinical Infectious Diseases. 2009; 48: 456-61. 7.

LaSalle G. When the answer to vaccines is “no”. J Fam Pract. 2018; 67:348-351

2 0 1 8 R E C O M M E N D E D I M M U N I Z AT I O N F O R C H I L D R E N BIRTH THROUGH 6 YEARS

At 1 month of age, HepB (1-2 months), At 2 months of age, HepB (1-2 months), DTaP, PCV, Hib, Polio, and RV At 4 months of age, DTaP, PCV, Hib, Polio, and RV At 6 months of age, HepB (6-18 months), DTaP, PCV, Hib, Polio (6-18 months), RV, and Influenza (yearly, 6 months through 18 years)* At 12 months of age, MMR (12-15

2018 Recommended Immunizations for Children from Birth Through 6 Years Old

Birth

HepB

2

1

month

†

months), PCV (12-15 months) , Hib (12-15 months), Varicella (12-15 months), HepA (12-23 months)§, and Influenza (yearly, 6 months through 18 years)* At 4-6 years, DTaP, IPV, MMR, Varicella, and Influenza (yearly, 6

months

4

months

6

12

months

months

HepB

months through 18 years)*

Is your family growing? To protect your new baby and yourself against whooping cough, get a Tdap vaccine.

The recommended time is the 27th through 36th week of pregnancy. Talk to your doctor for more details.

15

18

months

19–23

months

2–3

months

4–6

years

years

HepB RV

RV

RV

DTaP

DTaP

DTaP

Hib

Hib

Hib

Hib

PCV13

PCV13

PCV13

PCV13

IPV

IPV

DTaP

DTaP

IPV

IPV Influenza (Yearly)

*

MMR

MMR Varicella

Shaded boxes indicate the vaccine can be given during shown age range.

Varicella HepA

§

See back page for more information on vaccinepreventable diseases and the vaccines that prevent them.

FOOTNOTES:

NOTE:

If your child misses a shot, you don’t need to start over, just go back to your child’s doctor for the next shot.

Talk with your child’s doctor if you have questions about vaccines.

* Two doses given at least four weeks apart are recommended for children aged 6 months through 8 years of age who are getting an influenza (flu) vaccine for the first time and for some other children in this age group. §

Two doses of HepA vaccine are needed for lasting protection. The first dose of HepA vaccine should be given between 12 months and 23 months of age. The second dose should be given 6 months after the last dose. HepA vaccination may be given to any child 12 months and older to protect against HepA. Children and adolescents who did not receive the HepA vaccine and are at high-risk, should be vaccinated against HepA. If your child has any medical conditions that put him at risk for infection or is traveling outside the United States, talk to your child’s doctor about additional vaccines that he may need.

For more information, call toll free 1-800-CDC-INFO (1-800-232-4636) or visit www.cdc.gov/vaccines/parents

2 0 1 8 R E C O M M EINFORMATION N D E D FORI M M U N I2018 Z ATRecommended I O N F OImmunizations R C H I L D RforE Children N PARENTS 7-18 Years Old 7-18 YEARS Talk to your child’s doctor or nurse about the vaccines recommended for their age.

Flu Influenza

Tdap Tetanus, diphtheria, pertussis

HPV Human papillomavirus

Meningococcal MenACWY

MenB

Pneumococcal

Hepatitis B

Hepatitis A

MMR Measles, mumps, rubella

Inactivated Polio

Chickenpox Varicella

7-8 Years

9-10 Years

11-12 Years At 1 month of age, HepB (1-2 months), At 2 months of age, HepB (1-2 months), DTaP, PCV, Hib, Polio, and RV At 4 months of age, DTaP, PCV, Hib, Polio, and RV At 6 months of age, HepB (6-18 months), DTaP, PCV, Hib, Polio (6-18 months), RV, and Influenza (yearly, 6 months through 18 years)* At 12 months of age, MMR (12-15

2018 Recommended Immunizations for Children from Birth Through 6 Years Old

13-15 Years

Birth

16-18 Years More information:

HepB

Preteens and teens should get a flu vaccine every year.

Preteens and teens should get one shot of Tdap at age 11 or 12 years.

All 11-12 year olds should get a 2-shot series of HPV vaccine at least 6 months apart.

A 3-shot series is needed for those with weakened immune systems and those age 15 or older.

All 11-12 year olds should get a single shot of a meningococcal conjugate (MenACWY) vaccine. A booster shot is recommended at age 16.

Teens, 16-18 years old, may be vaccinated with a serogroup B meningococcal (MenB) vaccine.

2

1

month

months

4

months

6

months

HepB

†

months), PCV (12-15 months) , Hib (12-15 months), Varicella (12-15 months), HepA (12-23 months)§, and Influenza (yearly, 6 months through 18 years)* At 4-6 years, DTaP, IPV, MMR, Varicella, and Influenza (yearly, 6 months through 18 years)*

Is your family growing? To protect your new baby and yourself against whooping cough, get a Tdap vaccine.

The recommended time is the 27th through 36th week of pregnancy. Talk to your doctor for more details.

These shaded boxes indicate the vaccine should be NOTE: given if a child is catching-up on missed vaccines.

If your child misses a shot,

These shaded boxes indicate the vaccine is recommended for children with certain health or lifestyle conditions that put them at an increased risk for serious diseases. See vaccine-specific recommendations at www.cdc.gov/vaccines/pubs/ACIP-list.htm.

This shaded box indicates children not at increased risk may get the vaccine if they wish after speaking to a provider.

you don’t need to start over, just go back to your child’s doctor for the next shot.

Talk with your child’s doctor if you have questions about vaccines.

For more information, call toll free 1-800-CDC-INFO (1-800-232-4636) or visit www.cdc.gov/vaccines/parents

15

months

18

months

19–23 months

2–3

years

4–6

years

HepB RV

RV

RV

DTaP

DTaP

DTaP

Hib

Hib

Hib

Hib

PCV13

PCV13

PCV13

PCV13

IPV

IPV

DTaP

DTaP

IPV

IPV Influenza (Yearly)*

Shaded boxes indicate the vaccine can be given during shown age range.

These shaded boxes indicate when the vaccine is recommended for all children unless your doctor tells you that your child cannot safely receive the vaccine.

12

months

MMR

MMR

Varicella

Varicella HepA§

FOOTNOTES:

* Two doses given at least four weeks apart are recommended for children aged 6 months through 8 years of age who are getting an influenza (flu) vaccine for the first time and for some other children in this age group. §

Two doses of HepA vaccine are needed for lasting protection. The first dose of HepA vaccine should be given between 12 months and 23 months of age. The second dose should be given 6 months after the last dose. HepA vaccination may be given to any child 12 months and older to protect against HepA. Children and adolescents who did not receive the HepA vaccine and are at high-risk, should be vaccinated against HepA. If your child has any medical conditions that put him at risk for infection or is traveling outside the United States, talk to your child’s doctor about additional vaccines that he may need.

See back page for more information on vaccinepreventable diseases and the vaccines that prevent them.

MO-AFP.ORG 13

INFANT & ADOLESCENT

Talking to Parents about HPV Vaccine Recommend HPV vaccination in the same way and on the same day as all adolescent vaccines. You can say, “Now that your son is 11, he is due for vaccinations today to help protect him from meningitis, HPV cancers, and whooping cough. Do you have any questions?” Remind parents of the follow-up shots their child will need and ask them to make appointments before they leave.

Why does my child need HPV vaccine?

HPV vaccine is important because

Some HPV infections can cause

it prevents infections that can

cancer—like cancer of the cervix

cause cancer. That’s why we need

or in the back of the throat—but

to start the shot series today.

we can protect your child from

What diseases are caused by HPV?

these cancers in the future by

How do you know the vaccine works?

getting the first HPV shot today.

Studies continue to prove HPV vaccination works extremely well, decreasing the number of infections and HPV precancers in young people since it has been available.

Why do they need HPV vaccine at such a young age?

HPV is a very common infection in women and men that can cause

Is my child really at risk for HPV?

cancer. Starting the vaccine series today will help protect your child from the cancers and diseases

Like all vaccines, we want to give

caused by HPV.

HPV vaccine earlier rather than later. Getting the vaccine now protects your child long before they are ever exposed. If you wait until your child is older, he/she may end up needing three shots instead of two.

Studies tell us that getting HPV vaccine doesn’t make kids more likely to start having sex. I made sure my child (or grandchild,

I’m worried my child will think that getting this vaccine makes it OK to have sex.

etc.) got HPV vaccine, and I recommend we give your child her first HPV shot today.

Why do boys need the HPV vaccine?

HPV vaccination can help prevent future infections that can lead to cancers of the penis, anus, and back of the throat in men.

Yes, HPV vaccination is very safe.

Like any medication, vaccines can cause side effects, including pain,

I’m worried about the safety of HPV vaccine.

Do you think it’s safe?

swelling, or redness where the

Are all of these vaccines actually required?

shot was given. That’s normal for I strongly recommend each of

HPV vaccine too and should go

these vaccines and so do experts

away in a day or two. Sometimes

at the CDC and major medical

kids faint after they get shots and

organizations. School entry

they could be injured if they fall

requirements are developed for

from fainting. We’ll have your child

public health and safety, but don’t

stay seated after the shot to help

always reflect the most current

protect him/her.

medical recommendations for your child’s health.

There is no evidence available to

Would you get HPV vaccine for your kids?

suggest that getting HPV vaccine Yes, I gave HPV vaccine to my child (or grandchild, etc.) when he was 11, because I wanted to help protect him from cancer in the future.

Can HPV vaccine cause infertility in my child?

will have an effect on future fertility.

However, women who develop an HPV precancer or cancer could require treatment that would limit their ability to have children.

CS269453B Last updated MAY 2018

HPV TESTING BETTER THAN CYTOLOGY FOR WOMEN VACCINATED AGAINST HPV POEMs Am Fam Physician. 2018 Sep 15;98(6):384-385.

POEMs (Patient-Oriented Evidence that Matters) are summaries of research that is relevant to physicians and their patients and meet three criteria: address a question that primary care physicians face in day-to-day practice; measure outcomes important to physicians and patients, including symptoms, morbidity, quality of life, and mortality; and have the potential to change the way physicians practice.

Clinical Question What is the best means of cervical cancer screening in women who have received the human papillomavirus (HPV) vaccination?

Bottom Line In women who had received the HPV vaccine, screening for HPV every five years, with cytology and colposcopy follow-up as needed, resulted in higher rates of identification of high-grade precancerous disease (cervical intraepithelial neoplasia grade 2 or higher [CIN2+]) than standard liquidbased cytology every 2.5 years with HPV follow-up cotesting as needed. (Level of Evidence = 1b) Synopsis In Australia, where this study was performed, all women included in this aspect of the study had been offered the HPV vaccination, either at age 12 or 13 years or later as a catch-up, with an estimated 50% to 77% of women receiving all three doses. In this study, 1,078 women younger than 33 years who had been offered the HPV vaccine were randomized, using concealed allocation, to cervical cancer screening using one of three strategies: (1) liquid-based cytology (ThinPrep) every 2.5 years with follow-up HPV cotesting if the results were abnormal; (2) HPV testing every five years with follow-up cytology or colposcopy if the results were abnormal; or (3) HPV testing every five years with follow-up cell staining for oncogenic markers in

women with identified oncogenic HPV (HPV 16 or 18) on initial screening (further details of followup testing and confirmation is available at https:// goo.gl/J3MX4V). Rates of identification of highgrade precancerous disease (CIN2+) were higher in women in each HPV testing arm (2.6% and 2.9%) than with cytology (0.5%; P = .05). The researchers do not know the percentage of eligible women who received the vaccine, and most of the women had been screened at some point before the study was started, biasing the sample toward lower rates of disease.

Study design: Randomized controlled trial (nonblinded) Funding source: Foundation Allocation: Concealed Setting: Outpatient (any) Reference: Canfell K, Caruana M, Gebski V, et al. Cervical screening with primary HPV testing or cytology in a population of women in which those aged 33 years or younger had previously been offered HPV vaccination: results of the Compass pilot randomised trial. PLoS Med. 2017;14(9):e1002388.

Allen Shaughnessy, PharmD, MMedEd Professor of Family Medicine Tufts University Boston, Mass.

POEMs (patient-oriented evidence that matters) are provided by Essential Evidence Plus, a point-of-care clinical decision support system published by Wiley-Blackwell. For more information, see http://www.essentialevidenceplus.com. Copyright WileyBlackwell. Used with permission.

For definitions of levels of evidence used in POEMs, see http://www.essentialevidenceplus.com/product/ebm_loe. cfm?show=oxford.

To subscribe to a free podcast of these and other POEMs that appear in AFP, search in iTunes for “POEM of the Week” or go to http://goo.gl/3niWXb. This series is coordinated by Sumi Sexton, MD, Editor-in-Chief.

A collection of POEMs published in AFP is available at https:// www.aafp.org/afp/poems.

MO-AFP.ORG 15

INFANT & ADOLESCENT

HPV VACCINATION AND THE FAMILY DOCTOR: OUR WORDS HAVE MEANING “Zach is ready in room three and his mom is with him today. She doesn’t want to do the Gardasil yet, but she said yes to the TDap and Menactra.” My clinic nurse is a

Laura Morris, MD, MSPH, FAAFP

16

great preventive care advocate and usually preps patients about their recommended vaccines as she is rooming them.

Vaccine hesitancy is on the rise. What used to be a no-brainer, taking kids to the doctor to get their shots, has suddenly become an area of uncertainty. Parents, without any memory of children hospitalized with Hib meningitis or measles encephalitis, no longer feel compelled to follow vaccine schedules and may request vaccine exemptions for non-medical reasons. Social media sites propagate misinformation or blatant falsehoods about vaccine safety, and promote a sense of community around the “right to refuse.”

Dr. Swofford’s article in this issue does an excellent job of summarizing current evidence around vaccine hesitancy and gives important guidance to busy family docs looking to improve immunization rates. My nurse and I have employed several strategies to target vaccine hesitant adolescent families.

My interest in preventive care and evidencebased medicine is moving to a new arena. Earlier this summer, I began a yearlong Vaccine Science Fellowship sponsored by the American Academy of Family Physicians. My professional educational experiences include attending national vaccine advisory meetings, such as the National Vaccine Advisory Committee (NVAC) and Advisory Council on Immunization Practices (ACIP). I will complete a scholarly project centered on HPV disease and vaccination rates, and hopefully bring back new insight and innovations to the patients I serve in my own clinic, across my larger local health system, and across our state.

“Hi, Zach. Good to see you guys again. How’s middle school going?” A continuous relationship with my patients is my first weapon of choice.

MISSOURI FAMILY PHYSICIAN OCTOBER-DECEMBER 2018

I have earned their trust through well-baby visits, sprained ankles, sinusitis (no antibiotics needed!) and many visits in between. Today we’ll work through the long questionnaire for a pre-participation sports physical, chat about his favorite subject in school (math!) and get to the root of mom’s concerns about HPV vaccination. I finish up the portion of our visit with mom in the room by leading into the vaccine talk.

“I know my nurse already mentioned that Zach is due for three shots today. At this middle-school checkup we give Tdap, Gardasil, and Menactra.

Tdap covers for tetanus and whooping cough, Gardasil prevents cancer, and Menactra prevents meningitis. What questions do you have about

"

O

n a recent afternoon in my busy rural clinic in Fulton, I encountered an opportunity.

I continually return to my family medicine roots: a strong recommendation from a trusted physician, delivered in a strategic manner, is our strongest weapon."

those shots?” I sandwich the HPV vaccine between the less controversial shots and focus on cancer prevention rather than the sexually transmitted nature of the disease.

On both the state and national level, health education and advocacy groups are focusing on HPV vaccination, for several reasons. HPV vaccine completion rates are the lowest of any routinely recommended childhood or adolescent vaccine.1 A national survey conducted by the Centers for Disease Control found that about 53% of females and 44% of males aged 13 to 17 were up to date

A continuous relationship with my patients is my first weapon of choice."

with their HPV vaccine series, compared to a Tdap coverage rate of 88% in both males and females.1 Why is that? According to a June, 2018 NVAC report, HPV vaccination coverage may be low due to four main reasons:2 1. Adolescents don’t visit the doctor regularly.

In 2014, only about one in three teens had a preventive care office visit.3 2. Parents refuse the vaccine on behalf of their child. Dr. Swofford’s article reviews several issues often cited by parents who say no to vaccines.

3. Doctors take an optional approach rather than including HPV in our usual strong recommendations to vaccinate. A 2015 study in Cancer Epidemiology, Biomarkers & Prevention reported that nearly three quarters of primary care physician respondents did not actually strongly recommend the vaccine.4 Our words have meaning. The endorsement of a

trusted family physician makes a difference.

4. HPV vaccination is not required to attend public schools in most states. Only two states (Virginia, Rhode Island) and the District of Columbia mandate adolescent students receive HPV along with the usual Tdap and meningitis vaccines.5 Completion rates of other vaccines improved after mandate implementation, but broad opt-out

language limits interpretation of current HPV data.6 Back to Zach and his mom. She expresses concern that the HPV vaccine isn’t as safe as the other childhood vaccines and also mentions her worry that getting the vaccine might make kids more likely to take risks in their sexual behaviors down the line. My patient’s mom is Caucasian and well-educated, and she hasn’t raised similar concerns about other shots he received as a younger child. The demographics of HPV vaccination are strikingly different than other vaccines, and this family fits the bill. The parents most likely to refuse the HPV vaccine are white, educated, and of mid to upper socioeconomic status.

According to the same NVAC 2018 report2, HPV vaccination rates show: • Lower coverage among non-Hispanic white adolescents (54.7%) compared with Hispanic (69.8%) and non-Hispanic black (65.9%) adolescents; • Lower coverage among adolescents living at or above the federal poverty level (57.3%) compared with those living below the federal poverty level (70.2%); and • Lower coverage among those living in rural MO-AFP.ORG 17

(50.4%) compared with urban (65.9%) settings.

At the September, 2018 NVAC meeting I heard presentations by vaccine innovators in all sectors of the field. Many resources are directed toward researching how to improve HPV vaccination rates. One of the most enlightening presentations highlighted the National Foundation for Infectious Diseases partnership with DoSomething.org, an online organization dedicated to digital information campaigns in the realm of health and safety.7 An online ad urged teens to make a personalized card they could give to their parents requesting them to have “The Talk” about HPV—a fantastic example of patient empowerment. Tens of thousands of teens participated in the campaign, posting waiting room selfies with their parents and creating an impressive network of social media impressions.

“Zach, you’ve been listening to us talk about these vaccines. What do you think about getting the HPV vaccine today?” His mom initially looks surprised at my question, but interested in what he has to say. Zach reports that several kids on his soccer team got the shot over the summer and he was expecting to get it at his checkup, too. “It prevents cancer, mom.” I chime in that studies have shown receiving the vaccine does not change risky sexual behavior in teens.8 Here in Missouri, state Department of Health and Senior Services officials have teamed up with Area Health Education Centers to offer free half day education sessions designed to provide strategies to improve immunization rates for children and adolescents, with a focus on HPV. Titled “Immunizations 411: Move the Needle on Immunization Rates” (pun intended), these meetings held in collaboration with local public health departments across Missouri are intended to reach out to providers who may not have other resources available to support innovative immunization practice changes.9 Interested providers can register for the October sessions online at www.health.mo.gov/immunizations/ rates-registration.php.

As I gain knowledge about vaccine science and exposure to state and national vaccine policy-making, I continually return to my family medicine roots: a strong recommendation from a trusted physician, delivered in a strategic manner, is our strongest weapon. Our relationships with families brings us into the exam room, where our words have meaning.

Dr. Swofford’s sage advice to use patientcentered communication strategies and persist with counseling in favor of vaccines are key 18

MISSOURI FAMILY PHYSICIAN OCTOBER-DECEMBER 2018

components in a family doctor’s toolkit.

Zach got all three recommended shots that day. His mom stopped at the door on her way out and thanked me for spending the time to address her concerns, and for bringing him into the conversation. Her final words as she left the office were “It means a lot to me that you are our doctor. I trust you have our best interests at heart.”

References: 1. National, Regional, State, and Selected Local Area Vaccination Coverage among Adolescents Aged 13–17 Years — United States, 2017. MMWR. 2018; 67(33):909-907.

2. Strengthening the Effectiveness of National, State, and Local Efforts to Improve HPV Vaccination Coverage in the United States: Recommendations From the National Vaccine Advisory Committee. Public Health Reports 2018; 133(5):543550. https://doi.org/10.1177/0033354918793629 3. Rand, CM, Goldstein, NPN. Patterns of primary care physician visits for US adolescents in 2014: implications for vaccination. Acad Pediatr. 2018;18(2S):S72–S78 4. Gilkey MB, Malo TL, Shah PD, Hall ME, Brewer NT. Quality of Physician Communication about Human Papillomavirus Vaccine: Findings from a National Survey.

Cancer Epidemiol Biomarkers Prev. 2015;24(11);1673–9.

5. http://www.immunize.org/laws/hpv.asp Immunization action coalition. State Information: HPV Mandates for Children in Secondary Schools. Accessed 9/21/18.

6. Perkins RB, Lin M, Wallington SF, Hanchate AD. Impact of school-entry and education mandates by states on HPV vaccination coverage: Analysis of the 2009–2013 National Immunization Survey-Teen. Hum Vaccin Immunother.

2016;12(6):1615–1622.

7. The Talk Community page. https://www.dosomething. org/us/campaigns/the-talk/community Accessed 9/12/18.

8. Mayhew A, Mullins TL, Ding L, et al. Risk perceptions and subsequent sexual behaviors after HPV vaccination in adolescents. Pediatrics. 2014 Mar;133(3):404-11. doi: 10.1542/peds.2013-2822.

9. You are the Key to HPV Cancer Prevention. Immunization Education and Training. https://www.cdc.gov/vaccines/ed/ hpv/you-are-key.html Accessed 9/21/18.

Disclosure: Funding from the AAFP Vaccine Science Fellowship Program is provided by an unrestricted grant from Merck & Co., Inc.

Print and cut charts of current VIS dates for posting around your clinic and work place.

Current Dates of Vaccine Information Statements (VISs) as of August 24, 2018

Current Dates of Vaccine Information Statements (VISs) as of August 24, 2018

Check your supply of VISs against this list. If you have outdated VISs, get current versions at www.immunize.org/vis.

Check your supply of VISs against this list. If you have outdated VISs, get current versions at www.immunize.org/vis.

Adenovirus ...................... 6/11/14 Anthrax ............................ 3/21/18 Cholera ............................... 7/6/17 DTaP ................................... 8/24/18 Hib ........................................ 4/2/15 Hepatitis A ..................... 7/20/16 Hepatitis B ..................... 7/20/16 HPV .................................... 12/2/16 Influenza ............................ 8/7/15 Japanese enceph .......... 1/24/14 MenACWY ....................... 8/24/18 MenB ................................... 8/9/16 MMR .................................. 2/12/18

Adenovirus ...................... 6/11/14 Anthrax ............................ 3/21/18 Cholera ............................... 7/6/17 DTaP ................................... 8/24/18 Hib ........................................ 4/2/15 Hepatitis A ..................... 7/20/16 Hepatitis B ..................... 7/20/16 HPV .................................... 12/2/16 Influenza ............................ 8/7/15 Japanese enceph .......... 1/24/14 MenACWY ....................... 8/24/18 MenB ................................... 8/9/16 MMR .................................. 2/12/18

MMRV................................. 2/12/18 Multi-vaccine ................ 11/5/15 PCV13 ................................ 11/5/15 PPSV ................................. 4/24/15 Polio .................................. 7/20/16 Rabies ............................... 10/6/09 Rotavirus .......................... 2/23/18 Td......................................... 4/11/17 Tdap .................................. 2/24/15 Typhoid ............................ 5/29/12 Varicella ............................ 2/12/18 Yellow fever.................... 3/30/11 Zoster ............................... 2/12/18

Immunization Action Coalition www.immunize.org/catg.d/p2029.pdf • Item #P2029 (8/18)

MMRV................................. 2/12/18 Multi-vaccine ................ 11/5/15 PCV13 ................................ 11/5/15 PPSV ................................. 4/24/15 Polio .................................. 7/20/16 Rabies ............................... 10/6/09 Rotavirus .......................... 2/23/18 Td......................................... 4/11/17 Tdap .................................. 2/24/15 Typhoid ............................ 5/29/12 Varicella ............................ 2/12/18 Yellow fever.................... 3/30/11 Zoster ............................... 2/12/18

Immunization Action Coalition www.immunize.org/catg.d/p2029.pdf • Item #P2029 (8/18)

 Current Dates of Vaccine Information Statements (VISs) as of August 24, 2018

Current Dates of Vaccine Information Statements (VISs) as of August 24, 2018

Check your supply of VISs against this list. If you have outdated VISs, get current versions at www.immunize.org/vis.

Check your supply of VISs against this list. If you have outdated VISs, get current versions at www.immunize.org/vis.

Adenovirus ...................... 6/11/14 Anthrax ............................ 3/21/18 Cholera ............................... 7/6/17 DTaP ................................... 8/24/18 Hib ........................................ 4/2/15 Hepatitis A ..................... 7/20/16 Hepatitis B ..................... 7/20/16 HPV .................................... 12/2/16 Influenza ............................ 8/7/15 Japanese enceph .......... 1/24/14 MenACWY ....................... 8/24/18 MenB ................................... 8/9/16 MMR .................................. 2/12/18

Adenovirus ...................... 6/11/14 Anthrax ............................ 3/21/18 Cholera ............................... 7/6/17 DTaP ................................... 8/24/18 Hib ........................................ 4/2/15 Hepatitis A ..................... 7/20/16 Hepatitis B ..................... 7/20/16 HPV .................................... 12/2/16 Influenza ............................ 8/7/15 Japanese enceph .......... 1/24/14 MenACWY ....................... 8/24/18 MenB ................................... 8/9/16 MMR .................................. 2/12/18

MMRV................................. 2/12/18 Multi-vaccine ................ 11/5/15 PCV13 ................................ 11/5/15 PPSV ................................. 4/24/15 Polio .................................. 7/20/16 Rabies ............................... 10/6/09 Rotavirus .......................... 2/23/18 Td......................................... 4/11/17 Tdap .................................. 2/24/15 Typhoid ............................ 5/29/12 Varicella ............................ 2/12/18 Yellow fever.................... 3/30/11 Zoster ............................... 2/12/18

Immunization Action Coalition www.immunize.org/catg.d/p2029.pdf • Item #P2029 (8/18)

MMRV................................. 2/12/18 Multi-vaccine ................ 11/5/15 PCV13 ................................ 11/5/15 PPSV ................................. 4/24/15 Polio .................................. 7/20/16 Rabies ............................... 10/6/09 Rotavirus .......................... 2/23/18 Td......................................... 4/11/17 Tdap .................................. 2/24/15 Typhoid ............................ 5/29/12 Varicella ............................ 2/12/18 Yellow fever.................... 3/30/11 Zoster ............................... 2/12/18

Immunization Action Coalition www.immunize.org/catg.d/p2029.pdf • Item #P2029 (8/18)

INFANT & ADOLESCENT

INFLUENZA RECOMMENDATIONS FOR 2018-19: FROM THE AMERICAN ACADEMY OF PEDIATRICS

S Pham Thuylinh, MD, FAAP

20

eptember in Missouri brings chilly weather, football, and preparation for the next influenza season. This is the time we begin discussions and reminders for patients and families to receive their annual influenza vaccinations. As we prepare, we also reflect on the prior influenza season and the important role of influenza vaccinations.

Last month, Dr. Robert Redfield, director of the Centers for Disease Control and Prevention (CDC) announced that the 2017-2018 influenza season was the deadliest year in decades. Although difficult to assess the exact total mortality rate, the CDC estimates around 80,000 deaths from influenza across the country, the highest on record since 1976-1977.i In that period, 2,081 deaths from pneumonia and influenza were reported in Missouri.ii Influenza on average, kills an estimated 12,000 to 56,000 Americans per year.i There were 180 pediatric deaths in the country, the highest outside of a pandemic year. Of those with medical records available, 42% of these children were healthy with no underlying medical conditions and 80% of children who died had not received the recommended influenza vaccination.iii The influenza vaccine is the best prevention measure against influenza and influenza complications. Last year, influenza vaccines’ overall effectiveness was 40% against the circulating strains.iv However, it has greater effectiveness in decreasing hospitalizations and deaths from influenza than it does prevention of illness. In 2017, Pediatrics published an article demonstrating that the influenza vaccine decreased influenzarelated deaths by 51% in children with underlying high-risk medical conditions and 65% in healthy children.v Unfortunately, influenza vaccination rates in Missouri continue to be low despite the Healthy People 2020 goal of 80%.

The American Academy of Pediatrics released their 2018 policy statement in Pediatrics regarding the influenza vaccination role in prevention and control of influenza for the next year.iii Here are key highlights of their full policy statement:

MISSOURI FAMILY PHYSICIAN OCTOBER-DECEMBER 2018

Indications • All children, especially those with underlying medical conditions that would put them at high risk for influenza complications, should receive the influenza vaccine as soon as it is available, preferably by the end of October. It takes two full weeks for immunity to develop following the vaccination.

• Pregnant women, women who are postpartum, and all breastfeeding women should receive the influenza vaccine.

• All healthcare personnel should receive an influenza vaccine to prevent spread of influenza.

As healthcare providers, we have a duty to patient safety by decreasing the possibility of transmitting disease to our high-risk patients and to our colleagues.

Choice of vaccines • Nasal vs injectable. FluMist is available for 2018-2019 after being removed from the market last year after poor effectiveness. However, due to unknown effectiveness this year, for the 2018– 2019 influenza season, the AAP recommends the intranasal spray influenza vaccine to be used “for children who would not otherwise receive an influenza vaccine (e.g., refusal of an IIV) and for whom it is appropriate according to age (i.e., two years of age and older) and health status (i.e., healthy and without any underlying chronic medical condition).” In contrast, the Advisory Committee on Immunization Practices (ACIP) recommends vaccination “with any licensed age-appropriate flu vaccine including inactivated influenza vaccine (IIV), recombinant influenza vaccine (RIV4) or live attenuated influenza vaccine (LAIV4) with no preference expressed for any one vaccine over another."vi (https://www. cdc.gov/flu/about/qa/nasalspray.htm) • Number of strains. The injectable influenza vaccine comes in two formulations, containing either three (trivalent) or four (quadrivalent) virus strains. This year’s vaccine contains one new strain of influenza A (H3N2) and one new

strain of influenza B (Victoria lineage). Neither formulation is preferred over the other for children.

• Number of doses. If they have not had prior influenza vaccinations, children aged six months to eight years need two doses that are given at least four weeks apart. Children nine years of age and older require only one dose regardless of vaccine history.

Contraindications and precautions •Egg allergy. Children with an egg allergy can receive the influenza vaccine with no additional precautions.

• Anaphylaxis or a serious reaction to any component of the vaccine is the only medical contraindication. Children who have had an allergic reaction to a vaccine should be evaluated formally by an allergist to determine if they can safely receive it in the future.

• History of Guillain-Barre syndrome (GBS) is considered a precaution for the vaccine. The estimated risk for GBS is low for children. Those who are not at high risk for severe influenza and developed GBS within six weeks of influenza vaccine generally should not be vaccinated.

However, risk and benefits of the vaccine must be discussed with the family fully in these cases.

• Concurrent illness. People with a minor illness, including those with and without fevers, may receive the influenza vaccine. Those with moderate to severe illness should wait for vaccination until the resolution of the illness at the discretion of their provider.

Antiviral medications Antivirals are important for treatment and control of influenza, but should not be used as a substitute for vaccination.

Vaccinations are one the greatest public health achievements in the last century. The annual influenza vaccine is no less important than other routine childhood immunizations. Although I understand a parent’s frustration when their child comes down with influenza despite vaccination, I always emphasize the child’s decreased risk of severe disease and death due to the flu. Many times, this alleviates parents’ fears, especially during an especially bad influenza season.

Resources: i Stobbe, Mike. APNewsBreak: 80,000 people died of flu last winter in US. APNews.com 09/26/18 ii Missouri Department of Health and Senior Services Weekly Influenza Surveillance Report: Week 20 iii AAP COMMITTEE ON INFECTIOUS DISEASE: Recommendations for Prevention and Control of Influenza in Children, 2018-2019.

Pediatrics. 2018; 142(4):e20182367 iv Centers for Disease Control and Prevention. Summary of 20172018 Influenza Season v Flannery B, Reynolds SB, Blanton L, et al. Influenza Vaccine Effectiveness Against Pediatric Deaths 2010-2014. Pediatrics.

2017;139(5):e20164244 vi Centers for Disease Control and Prevention. Live Attenuated Influenza Vaccine (LAIV) (The Nasal Spray Flu Vaccine.)

MO-AFP.ORG 21

INFANT & ADOLESCENT

THE TOP 10 VACCINES NECESSARY FOR YOUNG CHILDREN AND THE THREE YOUR TEEN NEEDS NOW!

A

Angela Myers, MD, MPH, FAAP, FPIDS

s we enter the holiday season, we also enter into cold and influenza season. At this time of year, it is a good idea to stop and pause to make sure your family has all received the annual influenza vaccine. Since the number one cause of death from influenza in children is secondary bacterial infection (e.g. pneumonia), this is also the ideal time to ensure that your child’s immunizations are up to date.1 Below is the list of vaccines your child should get based on age, and why they are important for all children.

Vaccines for Infants & toddlers

1. DTaP a. Tetanus is a bacteria that causes painful muscle tightening and stiffness that can make it difficult to swallow or breath. Clostridium tetani is found in the soil and enters the body through open wounds. b. Corynebaterium diphtheriae is a bacteria that causes a thick coating on the back of the throat and can lead to breathing problems, heart failure, and death. Despite widespread vaccination, cases still occur due to contact with unvaccinated people and travel to a country where disease is still endemic. c. Bordetella pertussis is a bacteria that causes pertussis (whopping cough). This disease results in fast, uncontrollable coughing that can result in difficulty breathing. Whooping cough still occurs in the U.S., and nearly 50,000 cases were reported in 2012.2 2. Haemophilus influenzae type b (Hib) is a bacteria that causes meningitis, pneumonia, and bone and joint infections. Children who are < five years and not immunized, are at risk for invasive infection. Sporadic cases still occur in the U.S. in unvaccinated populations (e.g. Amish).

3. Pneumococcus (PCV13) is the major cause of bacterial meningitis and pneumonia in children, and is also a common cause of ear infections and sinusitis. This vaccine prevents meningitis and 22

MISSOURI FAMILY PHYSICIAN OCTOBER-DECEMBER 2018

some pneumonias in both young children and adults over 60 years, who are also at high risk of infection. Pneumococcus is also a major cause of secondary pneumonia in children who present with influenza. Children < five years of age are particularly at risk for developing pneumococcal pneumonia following influenza infection.

4. Poliovirus can cause sudden onset flaccid paralysis that is irreversible. While polio is currently very rare in the U.S., there are still countries in which polio cases occur, causing paralysis and death. The World Health Organization is working very hard to eliminate this infection world-wide, but imported cases occur in the U.S. and local transmission has occurred.

5. Hepatitis B is a virus that causes liver disease that can lead to liver cancer in people who become chronically infected. This vaccine is important at birth and throughout the first year of life, because infants who become infected are at the highest risk to develop chronic disease.

6. Hepatitis A is a virus that causes liver disease and is spread person-to-person through fecal contamination. This vaccine is important for all children at one year of age (six months if traveling internationally) in order to prevent infection. When infected, young children often transmit infection to their adult caretakers. While chronic infection does not exist for hepatitis A, disease in adults may be severe with liver failure and lead to death.

7. Rotavirus causes diarrhea that can be severe enough to require intravenous fluids and hospitalization in young children and also causes more mild disease in older children and adults, as disease does not confer life-long immunity. Since this vaccine was introduced, there has been >75% decrease in hospitalizations due to this infection.

However, cases still continue to occur in the U.S.4 8. MMR a. Measles is a virus that causes high fevers, rash, cough, congestion and red eyes. Children with measles may become very sick with 1:10 having hearing loss, 1:20 developing pneumonia and 1:1000 developing encephalitis, which can lead to

permanent brain damage. Unimmunized children are at risk. There was an outbreak of measles with 35 cases in Kansas City in the spring of 2018.3 There have been several outbreaks around the globe this past year including, China, Venezuela, and several European countries. b. Mumps is a virus that causes salivary gland swelling and orchitis in teens. Mumps can also cause pneumonia, meningitis, and hearing loss.

Mumps outbreaks occur periodically in the U.S., and children and teens who have not received all the recommended vaccine doses are at highest risk. Additionally, it is known that mumps immunity wanes overtime, thus the risk of infection in older teens and young adults, especially on college campuses. In some outbreak settings a third dose of the vaccine is recommended. c. Rubella is a virus that causes fever, rash and swollen glands. About 1:3000 will develop thrombocytopenia and 1:6000 will develop encephalitis. Pregnant women who are not immune to Rubella may become infected and pass the infection to the unborn baby, which can cause miscarriage or congenital infection, leading to blindness from cataracts, congenital heart defects, and neurologic abnormalities.

9. Varicella is also known as ‘chicken pox’.

This virus has often been thought of as a normal childhood illness, but before there was vaccine ~150 children died from complications of chicken pox every year in the U.S. Infants, teens, and people with suppressed immune systems are at highest risk for complications, which include pneumonia, encephalitis and severe hemorrhagic disease.

10. Influenza is a virus that causes infections yearly in the winter months in the U.S. This virus causes fever, cough, congestion, and ill feeling.

Most people know exactly when their symptoms started because it hits hard and fast. The vaccine does not prevent all disease, but greatly reduces hospitalizations and death. Nearly 180 children died from influenza in the U.S. during the 201718 influenza season.5 While disease is not always prevented following vaccination, death is largely preventable.

Teens

1. Tdap provides the same tetanus immunity as the DTaP and is also a booster for whooping cough immunity. This is important because teens are at risk for whooping cough due to waning immunity over time from the childhood vaccine, and serve as a reservoir to infect those at both extremes of age who are more susceptible to severe disease.

2. Human papillomavirus (HPV) vaccine provides protection against several types of cancers including cervical, throat and mouth, anus, and penis. More than 100 million doses of vaccine have been given worldwide, showing that the vaccine is safe and effective and is able to prevent cancer caused by the serotypes covered in the vaccine.

Thousands of women and men die every year in the U.S. from HPV related cancers. This is preventable.

3. Meningococcal vaccine (MCV) prevents sepsis, meningitis, and death caused by the meningococcus bacteria. This bacteria is the leading cause of meningitis in teenagers and can cause infection that leads to shock and death in 12 hours. While meningococcal infection is rare, outbreaks of college campuses do occur, and have been well publicized. Vaccination is important to reduce the risk of disease in teenagers and young adults, as well as immune compromised hosts, and travelers to endemic countries (e.g. sub-Saharan Africa).

References: 1. Hill HA, Elam-Evans LD, Yankey D, Singleton JA, Dietz V. Vaccination Coverage Among Children Aged 19–35 Months — United States, 2015. MMWR Morb Mortal Wkly Rep 2016;65:1065–1071. DOI: http://dx.doi.org/10.15585/mmwr. mm6539a4.

2. CDC. 2018. Pertussis Cases by Year (1922-2015). [ONLINE] Available at: https://www.cdc.gov/pertussis/surv-reporting/ cases-by-year.html. [Accessed 28 September 2018].

3. CDC. 2018. Measles Cases and Outbreaks. [ONLINE] Available at: https://www.cdc.gov/measles/cases-outbreaks.html.

[Accessed 28 September 2018].

4. CDC. 2018. Rotavirus in the U.S.. [ONLINE] Available at: https://www.cdc.gov/rotavirus/surveillance.html. [Accessed 28 September 2018].

5. Garten R, Blanton L, Elal AI, et al. Update: Influenza Activity in the United States During the 2017–18 Season and Composition of the 2018–19 Influenza Vaccine. MMWR Morb Mortal Wkly Rep 2018;67:634–642. DOI: http://dx.doi.org/10.15585/mmwr. mm6722a4.

MO-AFP.ORG 23

ADULT & SENIOR STANDARDS FOR ADULT IMMUNIZATION PRACTICE

T

he National Vaccine Advisory Committee (NVAC) revised the Standards for Adult Immunization Practice in 2013. These updated Standards call on ALL healthcare professionals – whether they provide vaccinations or not – to take steps to help ensure that their adult patients are fully immunized.

Why were the Standards for Adult Immunization Practice updated?

• Adult vaccination rates are extremely low.

• Most adults are NOT aware that they need vaccines.

• Recommendation from their healthcare professional is the strongest predictor of

24

MISSOURI FAMILY PHYSICIAN OCTOBER-DECEMBER 2018

whether patients get vaccinated.

• There are many missed opportunities for vaccination because many healthcare professionals are not routinely assessing vaccination status.

Practice Standards for All Healthcare Professionals 1. ASSESS immunization status of all your patients at every clinical encounter.

• Stay informed. Get the latest CDC recommendations for immunization of adults.

• Implement protocols and policies. Ensure that patients’ vaccine needs are routinely reviewed and patients get reminders about vaccines they need.

2. Strongly RECOMMEND vaccines that patients need.

• Share tailored reasons why vaccination is right for the patient.

• Highlight positive experiences with vaccination.

• Address patient questions and concerns.

• Remind patients that vaccines protect them and their loved ones against a number of common and serious diseases.

• Explain the potential costs of getting sick.

3. ADMINISTER or REFER your patients to a vaccination provider.

• Offer the vaccines you stock.

• Refer patients to providers in the area that offer vaccines that you don’t stock.

4. DOCUMENT vaccines received by your patients.

• Participate in your state’s immunization registry. Help your office, your patients, and your patients’ other providers know which vaccines your patients have had.

20%

Only of adults 19 years or older have received Tdap vaccination.

28%

Only of adults 60 years or older have received zoster (shingles) vaccination.

• Follow up. Confirm that patients received recommended vaccines that you referred them to get from other immunization providers.

Learn More about the New Standards The Recommendations from the National Vaccine Advisory Committee: Standards for Adult Immunization Practice are supported by CDC as well as a number of national healthcare provider organizations. For a complete list of supporters or to sign up to support the standards, visit the National Adult and Influenza Immunization Summit site. (https://www.izsummitpartners.org/adultimmunization-standards/) You Can Make a Difference Patients trust you to give them the best advice on how to protect their health. Vaccinepreventable diseases can result in serious illness, hospitalization, and even death. Make adult vaccination a standard of care in your practice.

Sources: NHIS 2014 (MMWR 2016; 64(4)), BRFSS 2014-2015 (www.cdc.gov/flu/fluvaxview

20%

Only of adults 19 to 64 years old, at high risk, have received pneumococcal vaccination.

#FIGHTFLU www.cdc.gov/flu/nivw

NATIONAL INFLUENZA VACCINATION WEEK DECEMBER 2-8, 2018

The National Influenza Vaccination Week (NIVW) is a national awareness week focused on highlighting the importance of influenza vaccination.

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ADULT & SENIOR

ADULT IMMUNIZATION PLANS

T

he National Adult Immunization Plan (NAIP) (hhs.gov) provides an overview of actions needed to be undertaken by federal and nonfederal partners to protect public health and achieve optimal prevention of infectious diseases and their consequences through vaccination of adults. The plan establishes four key goals, each of which is supported by objectives and strategies to guide implementation through 2020.

The companion document, the National Adult Immunization Plan: A Path to Implementation (hhs.gov) facilitates action on the goals outlined in the NAIP by identifying eight implementation priorities and suggesting potential activities to support each priority.

FOUR KEY GOALS TO GUIDE IMPLEMENTATION Goal 1: Strengthen the Adult Immunization Infrastructure The adult immunization infrastructure in the United States is complex and multifaceted, 26

MISSOURI FAMILY PHYSICIAN OCTOBER-DECEMBER 2018

consisting of numerous components with unique functions. This goal of the National Adult Immunization Plan (NAIP) focuses on high-level issues with the potential to have significant impact on adult vaccination rates in the next several years, by improving and leveraging elements that already exist, rather than creating new systems, programs, and entities.

Goal 1 Objectives The following six objectives, and a number of sub-objectives detailed further in the NAIP, were developed to strengthen the adult immunization infrastructure. The fourth and fifth objectives were chosen in the National Adult Immunization Plan: A Path to Implementation as two of eight implementation priorities.

• Monitor and report trends in adult vaccinepreventable disease levels and vaccination coverage data for all recommended vaccines.

• Enhance current vaccine safety monitoring systems and develop new methods to accurately and more rapidly assess vaccine safety and effectiveness in adult subpopulations, like pregnant women.

• Continue to analyze claims filed as part of the National Vaccine Injury Compensation Program (VICP) to assess whether there was an association between vaccines that a claimant received and adverse events experienced.

• Increase the use of electronic health records (EHRs) and immunization information systems (IIS) to collect and track adult immunization data.

• Evaluate and advance targeted quality improvement initiatives.

• Generate and disseminate evidence about the health and economic impact of adult immunization, including potential diseases averted and cost-effectiveness with the use of current vaccines.

Goal 2: Improve Access to Adult Vaccines The passage of the Affordable Care Act marked an important opportunity for adult vaccination. The National Adult Immunization Plan (NAIP) aims to leverage the full potential of the Affordable Care Act to improve access to adult vaccinations and to identify solutions to ongoing challenges. However, the inability to access vaccines is a commonly cited barrier to increasing adult vaccination, so understanding and reducing these barriers is an important objective of the NAIP. Goal 2 Objectives The following four objectives, and a number of sub-objectives detailed further in the NAIP, were developed to improve access to adult vaccines. The first, second and third objectives were chosen in the National Adult Immunization Plan: A Path to Implementation as three of eight implementation priorities.

• Reduce financial barriers for individuals who receive recommended adult vaccines.

• Assess and improve understanding of providers’ financial barriers to delivering vaccinations, including stocking and administering vaccines.

• Expand the adult immunization provider network.

• Ensure a reliable supply of vaccines and the ability to track vaccine inventories, including during public health emergencies.

Goal 3: Increase Community Demand for Adult Immunizations Communication activities concerning vaccination should be strategic, evidence-based, and culturally-

appropriate and should reflect the health literacy, language proficiency, and functional and access needs of specific target populations.

Communications and outreach to the public are critical to address a lack of knowledge, as well as common misconceptions and skepticism about adult vaccinations. Likewise, health care providers are a highly influential source of information and advice about vaccinations, and a strong recommendation about the importance of immunizations can exert a strong influence over the vaccination decisions of patients, including those patients who may have reservations about some or all vaccines. A variety of other networks can also be leveraged, including faithbased and community organizations, employers, and individual trusted leaders.

Goal 3 Objectives The following three objectives, and a number of sub-objectives detailed further in the National Adult Immunization Plan (NAIP), were developed to increase community demand through communications and outreach strategies. The second and third objectives were chosen in the National Adult Immunization Plan: A Path to Implementation as two of eight implementation priorities.

• Educate and encourage individuals to be aware of and receive recommended adult immunizations.

• Educate and encourage health care providers to recommend and/or deliver adult vaccinations.

• Educate and encourage other groups (e.g., community and faith-based groups, tribal organizations) to promote the importance of adult immunization.

Goal 4: Foster Innovation in Adult Vaccine Development And Vaccine-Related Technologies This goal of the National Adult Immunization Plan (NAIP) recognizes that there are opportunities for the development of new vaccines, more effective versions of existing vaccines for adults, and technological advancements to improve vaccine delivery.

Goal 4 Objectives The following two objectives, and a number of sub-objectives detailed further in the NAIP, were developed to foster innovation and future advancements in both adult vaccine development and new technology. The first objective was chosen in the National Adult Immunization Plan: A Path to Implementation as one of eight implementation priorities.

• Develop new vaccines and improve the effectiveness of existing vaccines for adults.

• Encourage new technologies to improve the distribution, storage, and delivery of adult vaccines. (Find more information at hhs.gov) MO-AFP.ORG 27

Vaccinations for Adults

You’re never too old to get vaccinated!

Getting vaccinated is a lifelong, life-protecting job. Don’t leave your healthcare provider’s office without making sure you’ve had all the vaccinations you need.

Vaccinatio

Yo

Vaccine

Do you need it?

Hepatitis A (HepA)

Maybe. You need this vaccine if you have a specific risk factor for hepatitis A* or simply want to be protected from this disease. The vaccine is usually given in 2 doses, 6–12 months apart.

Hepatitis B (HepB)

Maybe. You need this vaccine if you have a specific risk factor for hepatitis B* or simply want to be Hepatitis A protected from this disease. The vaccine is given in 2 or 3 doses, depending on the brand.

Hib (Haemophilus influenzae type b)

Maybe. Some adults with certain high-risk conditions, for example, lack of a functioning spleen, need Hepatitis B vaccination with Hib. Talk to your healthcare provider to find out if you need this vaccine.

(HepB)

Human papillomavirus (HPV)

Yes! You need this vaccine if you are a woman age 26 or younger or a man age 21 or younger. MenHib age(Haemophilus 22 May influenzae through 26 with a risk condition* also need vaccination. All other men age 22 through 26 who want to be type b) vacc protected from HPV may receive it too. The vaccine is usually given in 3 doses over a 6-month period.

Influenza

Get offic

Vaccine

Do

(HepA)

May prot

May prot

Human papillomavirus Yes! You need a dose every fall (or winter) for your protection and for the protection of others around(HPV) you.

Influenza a Measles, mumps, Maybe. You need at least 1 dose of MMR vaccine if you were born in 1957 or later. You may also need second dose.* rubella (MMR)

Yes! thro prot Yes!

Measles, mumps, May seco rubella (MMR)

Meningococcal ACWY (MenACWY)

Maybe. You may need MenACWY vaccine if you have one of several health conditions,* for example, if you don’t have a functioning spleen. You need MenACWY if you are age 21 or younger and a first-yearMeningococcal college student living in a residence hall and you either have never been vaccinated or were vaccinated beforeACWY age 16.

Meningococcal B (MenB)

Maybe. You should consider MenB vaccine if you are age 23 or younger (even if you don’t have a high-risk Meningococcal B May medical condition). You need MenB if you have one of several health conditions,* for example, if you do med (MenB) not have a functioning spleen. not h

Pneumococcal (Pneumovax 23, PPSV23; Prevnar 13, PCV13)

Yes! If you are age 65 (or older), you need both pneumococcal vaccines, Prevnar (if you haven’t had itPneumococcal before) (Pneumovax and Pneumovax. Get Prevnar first and then get Pneumovax 1 year later. If you are younger than age 65 and 23, PPSV23; have a certain high-risk condition (for example, asthma, heart, lung, or kidney disease, immunosuppresPrevnar 13, sion, or you lack a functioning spleen or are a smoker),* you need 1 or both vaccines. Talk to yourPCV13) healthcare provider to find out when you need them.*

(MenACWY)

Tetanus, diphtheria, whooping Yes! If you have not not received a dose of Tdap during your lifetime, you need to get a Tdap shot now cough (pertussis) (the adult whooping cough vaccine). And all women need to get a dose during each pregnancy. After that, (Tdap, Td)

Tetanus, diphtheria, whooping cough (pertussis) you need a Td booster dose every 10 years. Consult your healthcare provider if you haven’t had at least 3 (Tdap, Td) tetanus and diphtheria toxoid-containing shots sometime in your life or if you have a deep or dirty Varicella wound.

(Chickenpox)

Varicella (Chickenpox)

May don’ stud

Yes! and have sion care

Yes! (the you tetan

May talk t

Maybe. If you’ve never had chickenpox, never were vaccinated, or were vaccinated but received only 1 dose, Zoster (shingles) Yes! talk to your healthcare provider to find out if you need this vaccine.* even

Zoster (shingles) Yes! If you are age 50 or older, you should get the 2-dose series of the Shingrix brand of shingles vaccine, even if you already were vaccinated with Zostavax.

YOU'RE NEVER TOO OLD! * Consult your healthcare provider to determine your level of risk for infection and your need for this vaccine.

Are you planning to travel outside the United States? Visit the Centers for Disease Control and Prevention’s (CDC) website at wwwnc.cdc.gov/travel/ destinations/list for travel information, or consult a travel clinic.

Technical content reviewed by the Centers for Disease Control and Prevention

* Cons deter and y

Saint Paul,

2018 RECOMMENDED IMMUNIZATIONS FOR ADULTS: BY AGE

2018 Recommended Immunizations for Adults: By Age

INFORMATION FOR ADULT PATIENTS

If you are this age,

talk to your health care professional about these vaccines Flu Influenza

Tdap or Td Tetanus, diphtheria, pertussis

Shingles Zoster RZV

Pneumococcal

ZVL

PCV13

PPSV23

Meningococcal

MenACWY

MenB

MMR Measles, mumps, rubella

HPV Human papillomavirus for women

Chickenpox Varicella

Hepatitis A

Hepatitis B

for men

Hib Haemophilus influenzae type b

19 - 21 years

22 - 26 years

27 - 49 years If born in 1957 or later

50 - 64 years

65+ year

More Information:

You should get flu vaccine every year.

You should get 1 dose of Tdap if you did not get it as a child or adult.

You should also get a Td booster every 10 years.

Women should get 1 dose of Tdap during every pregnancy.

There are 2 types of zoster vaccine. You should get 2 doses of RZV at age 50 years or older (preferred) or 1 dose of ZVL at age 60 years or older, even if you had shingles before.

There are 2 types of pneumococcal vaccine. You should get 1 dose of PCV13 and at least 1 dose of PPSV23 depending on your age and health condition.

There are 2 types of meningococcal vaccine. You may need one or both types depending on your health condition.

You should get this vaccine if you did not get it when you were a child.

You should get HPV vaccine if you are a woman through age 26 years or a man through age 21 years and did not already complete the series.

For more information, call 1-800-CDC-INFO (1-800-232-4636) or visit www.cdc.gov/vaccines Recommended For You: This vaccine is recommended for you unless your health care professional tells you that you do not need it or should not get it.

If you are traveling outside the United States, you may need additional vaccines.

Ask your health care professional about which vaccines you may need at least 6 weeks before you travel.

May Be Recommended For You: This vaccine is recommended for you if you have certain risk factors due to your health condition. Talk to your health care professional to see if you need this vaccine.

CS272886-G

2018 RECOMMENDED IMMUNIZATIONS FOR ADULTS: BY HEALTH CONDITION 2018 Recommended Immunizations for Adults: By Health Condition

INFORMATION FOR ADULT PATIENTS If you have this health condition,

talk to your health care professional about these vaccines Flu Influenza

Tdap or Td Tetanus, diphtheria, pertussis

Shingles Zoster RZV

Pneumococcal

ZVL

PCV13

Meningococcal

PPSV23

MenACWY

MenB

MMR Measles, mumps, rubella

HPV Human papillomavirus for women

Chickenpox Varicella

Hepatitis A

Hepatitis B

for men

Hib Haemophilus influenzae type b

Pregnancy SHOULD NOT GET VACCINE

Weakened Immune System HIV: CD4 count less than 200

If you are this age,

Flu Influenza

SHOULD

Tdap or Td Tetanus, diphtheria, pertussis

Shingles Zoster RZV

Pneumococcal

ZVL

PCV13

PPSV23

Meningococcal

MenACWY

MenB

MMR Measles, mumps, rubella

HPV Human papillomavirus for women

Chickenpox Varicella

Hepatitis A

for men

Hepatitis B

Hib Haemophilus influenzae type b

19 - 21 years

Spleen removed or does not work well

22 - 26 years

Heart disease Chronic lung disease Chronic alcoholism

27 - 49 years

Diabetes (Type 1 or Type 2)

50 - 64 years

Chronic Liver Disease

More Information:

SHOULD

NOT GET NOT GETAdults: By Age 2018 Recommended Immunizations for VACCINE VACCINE

talk to your health care professional about these vaccines

HIV: CD4 count 200 or greater Kidney disease or poor kidney function

INFORMATION FOR ADULT PATIENTS

If born in 1957 or later

65+ year

You should get flu vaccine every year.

You should get 1 dose of Tdap if you did not get it as a child or adult.

You should also get a Td booster every 10 years.

Women should get 1 dose of Tdap vaccine during every pregnancy.

Recommended For You: This vaccine is recommended for you unless your health care professional tells you that you do not need it or should not get it.

There are 2 types of zoster You should vaccine.

2 MoreYou should get getyears flu doses of RZV at age 50 Information: vaccine every or older (preferred) or 1 dose year. of ZVL at age 60 years or older, even if you had shingles before.

There are 2 types of There are 2 types of You should There are 2 types There are 2 types of vaccine.

You pneumococcal vaccine.

Youof zostermeningococcal get 1 dose of 1 dose vaccine. should get 2 may need pneumococcal vaccine.

You one or both types should get ofYou PCV13 Tdap if you doses of RZV at age 50 years should get 1 dose of PCV13 depending on your and at least 1 dose of PPSV23 did not get or older (preferred) or 1 dose and at least 1 dosehealth of PPSV23 depending and it as a child on ofyour ZVL atage age 60 years or condition. depending on your age and or adult. older, even if you had shingles health condition. health condition.

You should also get a Td booster every 10 years.

Women should get 1 dose of Tdap during every pregnancy.

before.

Recommended For You: This vaccine is recommended for you unless your health care professional tells you that you do not need it or Maynot Beget Recommended For You: This should it.

vaccine is recommended for you if you May Be Recommended For You: This vaccine have certainfor other due risk to your is recommended you ifrisk youfactors have certain health Talk to yourTalk health care factors duecondition. to your health condition. to your health care professional if you need this professional to seetoifsee you need this vaccine. vaccine.

You should get this vaccine if you did not get it when you were a child.

There are 2 types of You should get this vaccine if you did not get it when you were a child. meningococcal vaccine. You if may need one or both You typesshould get HPV vaccine You should get HPV vaccine if depending on your health you are a woman through you areage a woman through age condition.

26 years or a man through 26 years or a man through age 21 years and did not age 21 years and did not already complete thealready series.complete the series.

You should get Hib vaccine if you do not have a spleen, have sickle cell disease, or received a bone marrow transplant.

For more information, call 1-800-CDC-INFO For more information, call 1-800-CDC-INFO (1-800-232-4636) or visit www.cdc.gov/vaccines (1-800-232-4636) or visit www.cdc.gov/vaccines If you are traveling outside the United States, you may additional vaccines.

YOUneed SHOULD NOT GET THIS VACCINE Ask your health care professional about which vaccines you may need at least 6 weeks before you travel.

MO-AFP.ORG MO-AFP.ORG 29 29 MO-AFP.ORG 29 CS272886-G

❿

Reasons To Be Vaccinated

Not just for kids!

diseases haven’t gone away. ❶Vaccine-preventable

The viruses and bacteria that we vaccinate against and that cause illness and death still exist. Without the protection of vaccines, we will experience more disease outbreaks, more severe illnesses, and more deaths.

❷Vaccines will help keep you healthy.

The Centers for Disease Control and Prevention recommends vaccinations through your whole life to protect against many infections. When you skip your vaccines, you leave yourself vulnerable to illnesses such as shingles, pneumococcal disease, influenza, and HPV and hepatitis B, both leading causes of cancer.

are as important to your overall health as diet and exercise. ❸Vaccines

Like eating healthy foods, exercising, and getting regular check-ups, vaccines play a vital role in keeing you healthy. Vaccines are one of the simplest, most convenient, and safest preventive care measures available.

can mean the difference between life and death. ❹Vaccination

Vaccine-preventable infections are dangerous.

Every year, tens of thousands of US adults die from diseases they could have avoided with vaccination.

30 MISSOURI MISSOURI FAMILY FAMILY PHYSICIAN PHYSICIAN JULY-SEPTEMBER OCTOBER-DECEMBER 30 20182018

0 whatdoctorsknow.com

❺Vaccines are safe.

The US has the best post-licensure surveillance system in the world. That’s why we can say with absolute confidence that our vaccines are extremely safe. There is extraordinarily strong data from many different medical investigators all pointing to that same result. Make no mistake; vaccines are among the safest products in all of medicine.

won’t give you the disease they are designed to prevent. ❻Vaccines

You cannot “catch” the disease from the vaccine. Some vaccines contain “killed” virus, and it is impossible to get the disease from them. Others have weakened viruses designed to ensure that you cannot catch the disease.

and healthy people can get very sick, too. ❼Young

Infants and the elderly are at a greater risk for serious infections and complications in many cases, but vaccine-preventable diseases can strike anyone. If you’re young and healthy, getting vaccinated can help you stay that way.

diseases are expensive. ❽Vaccine-preventable

An average influenza illness can last up to 15 days, translating into five or six missed work days. Adults who get hepatitis A lose an average of one month of work.

you get sick, your children, grandchildren and parents are at risk, too. ❾When

A vaccine-preventable disease that might make you sick for a week or two could prove deadly for your children, grandchildren, or parents if it spreads to them. When you get vaccinated, you’re protecting yourself and your family. For example, adults are the most common source of pertussis (whooping cough) infection in infants, which is deadly in infants. In 2010 alone, 25 US infants died from whooping cough.

❿Your family and coworkers need you.

Each year, millions of Americans get sick from vaccine-preventable diseases, causing them to miss work and leaving them unable to care for those who depend on them, including their children and/or aging parents. -This information provided courtesy of the National Foundation for Infectious Diseases. www.adultvaccination.org MO-AFP.ORG 31 31 MO-AFP.ORG

whatdoctorsknow.com

ABROAD

MEETING REFUGEE IMMUNIZATION CHALLENGES AT THE DOOR

D David Campbell, MD, FAAFP Samantha Marquard, MPH, FNP Brook Raye, MSN, FNP

32

espite a recent decline in refugee resettlements nationwide (Department of the State, 2018), St. Louis remains a mainstay for families being resettled by refugee agencies, and of immigrants entering the country through other alleys. Once projected to be the fastest growing metropolitan area for foreign born residents, St. Louis City is rich in its multicultural diversity with bustling neighborhoods centered around Hispanic residents, Bosnian residents, Vietnamese residents, and now Middle Eastern and African communities as well.

Grocery stores, restaurants, and other businesses pepper the city, and create a melting pot.

While the influx of new Americans is largely positive for the city, some challenges present themselves. The resettlement process involves many complicated processes, one of which is the assurance that those being resettled have received the standard vaccination series recommended for age. As families flee previous homelands, vaccine records are often an afterthought and thus when families arrive and are being processed, they require multiple sets of vaccines to bring them into compliance (Office of Refugee Resettlement, 2017).

Along with lost records, many immigrants are susceptible to vaccine-preventable diseases upon arrival because of a lack of availability of vaccines in their home country. An example of this are the large percentages of new immigrants who are susceptible to tetanus, measles, mumps and rubella (Pottie, Greenaway, Feightner, Welch, Swinkles, et al, 2011). Especially of concern to St. Louis is the large number of new Americans from Hepatitis B endemic countries that are not immune and have not been immunized, since Saint Louis has been known to resettle a large number of patients from Southeast Asian countries such as Vietnam and Myanmar.

Reducing barriers to health care for underserved populations is a primary goal of iFM Community Medicine (formerly the Institute for Family Medicine). That is, bringing healthcare to the places and spaces where patients live their lives.

In the case of a new American patient, those places and spaces may be schools such as the Nahed Chapman New American Academy, refugee resettlement agencies such as the International

MISSOURI FAMILY PHYSICIAN OCTOBER-DECEMBER 2018

Institute, social service agencies such as Catholic Charities, Saint Francis Community Center, or Youth in Need, all locations within which iFM works. By eliminating the barriers of transportation, language services, and trust building, iFM is able to ensure patient immunization needs are met more easily.

Patients already have access to these organizations and have established a rapport that allows for continued interprofessional work. Caseworkers, interpreters, teachers, and the like that are already familiar with the patient’s history are able to assist iFM providers in treating the patient and their story, allowing compassion for previous trauma and medical needs.

As mentioned previously, since there is often no reliable documentation of previous childhood vaccines, patients of all ages have to undergo a catch-up schedule involving multiple appointments over the course of the first year. Creating clinics embedded in these agencies provides for minimal lost-time at work and school for patients needing lots of services.

Nahed Chapman New American Academy (NCNAA) is one such iFM partnership clinic. It is a unique school within the St. Louis Public School system that provides an opportunity for children new to this country to acclimate and improve their language skills before being thrust into the traditional school setting. iFM Community Medicine has worked with the St Louis Public Schools for the last decade to provide services within the school setting, offering immunizations as well as well child exams and acute care when needed. Children merely have to be excused from class for a few minutes on a day when vaccines are needed, so long as parents have signed a consent to treat, and are back in class where they need to be. It’s a win-win; kids don't have to miss school and parents don't have to miss work or find transportation to take their kid to a clinic. Kids are so eager to keep their vaccines up to date that they have been known to come knocking on the clinic door asking for “my shots!” One patient’s family even joked with Nurse Practitioner, Samantha, that their children’s first English words were “one, two, three, ouch!” because of the number of visits they were spending with her. The Nurse Practitioner, Brook Raye, now stationed at NCNAA,

can also continue to assess the child post vaccine appointment and mitigate any discomforts that may arise. Because Brook is there week after week, students and families grow comfortable with her, knowing that she knows their history. So often, immigrant patients move from clinic to clinic meeting multiple providers. This lack of continuity not only puts the patient at risk for missing services, but is simply exhausting for the patient; telling their story over and over again. iFM operates similar clinics in other areas with high refugee immigrant populations such as the Youth in Need (YIN) Headstart program serving children birth to six years of age. YIN services the youngest of new Americans and ensures that well-child exams, vaccines, and necessary health screenings occur on time despite the many challenges of resettlement. The family educators working at YIN drive families to appointments, translate in the visits, and ensure follow-up for abnormal screenings. This helps prevent families from being lost to follow-up, a common reality of resettling patients. Ensuring those frequent wellchild exams is hard enough for a family with all of

the necessary resources, so immigrant and refugee families certainly benefit from these services in their schools and agencies. Families report peace at knowing the same person has been in their school clinic for nine years now. Our provider can celebrate births, and green cards, and preschool graduations with them.

When first taking on the role of provider to new Americans, the task can feel daunting, but providing a steady, regular, culturally sensitive approach to care is a task iFM now feels confident it can continue to provide for the St. Louis Metro Area.

References: Department of the State (2018). Admissions and arrivals.

Retrieved from http://www.wrapsnet.org/admission-andarrivals/ iFM Community Medicine is a 501(c)(3) not-for-profit organization developed in 1999 by MAFP member David Campbell, MD. Office of Refugee Resettlement (2017). The refugee resettlement program. Retrieved from acf.hhs.gov Pottie, K., Greenaway, C., Feightner, J., Welch, V., Swinkles, H., & Rashid, M. (2011). Evidence-based clinical guidelines for immigrants and refugees. CMAJ 183(12), E824-E925 MO-AFP.ORG 33

ABROAD

TRAVELER'S VACCINATION UPDATE FDA TRIAL IN PROGRESS FOR ALTERNATE YELLOW FEVER VACCINE

W Emily D. Doucette, MD, MSPH, FAAFP

34

hile yellow fever is likely not top-ofmind for most family physicians in Missouri, the potential for morbidity and mortality from yellow fever infection is significant, and outbreaks in recent years in both Nigeria and Brazil make it more important than ever that international travelers are informed and protected. While yellow fever vaccination has been available at travel clinics, health departments and some doctors’ offices for years, a recent shortage of the only FDA approved yellow fever vaccine in the United States has changed access to vaccination for many people.1 Yellow fever virus is a flavivirus transmitted to humans through Aedes or Haemagogus mosquitoes through several complex transmission cycles involving primate to primate transmission. Mild cases of illness are characterized by self-limited flu-like illness after a three to six day incubation period, but in 15% of cases illness recurs 48 hours after initial viremia which can lead to end organ failure and bleeding diatheses. Mortality rate for those who develop recurrence of illness is 30-60%.

Treatment is supportive and symptom driven.2 Yellow fever is endemic to tropical South America and sub-Saharan Africa (Figures 1 and 2).3 The Centers for Disease Control and Prevention (CDC) recommends that all individuals ages nine months or older who are traveling to or living in areas deemed by CDC to be endemic be vaccinated, at least 10 days before departure for travelers.2 Additionally, yellow fever vaccination is required for entry into some countries.3 This practice is intended to prevent importation of disease into the country, and in some cases country entry requirements are different from CDC’s determination of endemic

MISSOURI FAMILY PHYSICIAN OCTOBER-DECEMBER 2018

areas. Federal approval is required for a facility to administer yellow fever vaccinations and specific documentation on an International Certificate of Vaccination or Prophylaxis (ICVP) form is required to allow entry into countries in which vaccination is mandated.2 While risks associated with yellow fever vaccination are very low in the general population, the vaccine does carry several rare but serious adverse events, namely YF vaccine-associated neurologic disease (YEL-AND) and YF vaccineassociated viserotropic disease (YEL-AVD). YEL-AND manifests as meningoencephalitis, Guillain-Barré syndrome, acute disseminated encephalomyelitis and bulbar palsy. While rates of serious adverse events are variable based on source, vaccine adverse event reporting data in the U.S. shows the rate of YEL-AND to be 0.4-0.8 cases per 100,000 doses distributed and is rarely fatal. YEL-AVD presents similarly to naturally acquired yellow fever and rates range from 0.3-0.4 cases per 100,000 doses distributed. Risk of mortality among those with YEL-AVD is as high as 65%. Serious adverse events are most common in those over the age of 60 or those with thymus disease or thymectomy.

Other immunosuppression is also a risk factor.2,4 YF-VAX is currently the only FDA approved yellow fever vaccine in the United States. Due to manufacturing shortages, YF-VAX has been unavailable in the U.S. since mid-2017. The FDA has approved a trial of an alternate yellow fever vaccine called Stamaril during the shortage. Stamaril is produced in France and uses the same strain of virus in production (17D-204 strain) as YF-VAX.1 Stamaril is approved for use in 100 countries (28 in Europe, including Great Britain); more than 400

"

AP 3314.

million doses have been given in 70 countries in the last 30 years. While there is no study comparing YF-VAX to Stamaril directly, there is no known significant difference in immunogenicity and adverse event profiles between the two vaccines.5 The FDA and Sanofi (Stamaril’s manufacturer) have limited FDA trial sites where Stamaril can be given, and currently there are only three sites in Missouri participating in the trial – two in St. Louis and one in Kansas City.6 At the St. Louis County Department of Public Health, we have given over 600 Stamaril doses to date and are finding significant demand with travelers coming from across the Midwest to get vaccinated. Sanofi estimates that YF-VAX will be available again in mid-2019.1 Yellow fever might not make it to the top of the list of vaccination guidelines you reference in your daily practice, but it is an important vaccine for selected populations in the United States. Because we are often the first point of contact for the health needs of travelers, this vaccine is important for family physicians to keep on their radar!

For more information visit CDC’s yellow fever page: https://www.cdc.gov/yellowfever/index. html. For availability of the Stamaril vaccine by

location visit: https://wwwnc.cdc.gov/travel/page/ search-for-stamaril-clinics.

References: 1. Clinical Update Announcement: Temporary Total Depletion of US Licensed Yellow Fever Vaccine Addressed by Availability of Stamaril Vaccine at Selected Clinics. Centers for Disease Control and Prevention Website. https://wwwnc.cdc.gov/travel/ news-announcements/yellow-fever-vaccine-access. Updated September 7, 2018. Accessed September 26, 2018.

2. Staples JE, Gershman M, Fischer M. Yellow Fever Vaccine: Recommendations of the Advisory Committee on Immunization Practices (ACIP). Morbidity and Mortality Weekly Report.

2010;59:1-27.

3. Travelers’ Health: Yellow Fever & Malaria Information, by County. Centers for Disease Control and Prevention Website. https://wwwnc.cdc.gov/travel/yellowbook/2018/infectiousdiseases-related-to-travel/yellow-fever-malaria-information-bycountry. Updated May 31, 2018. Accessed September 26, 2018.

4. Staples JE, Bocchini JA, Rubin L, Fischer M. Yellow Fever Vaccine Booster Doses: Recommendations of the Advisory Committee on Immunization Practices, 2015. Morbidity and Mortality Weekly Report. 2015;63(23):647-650.

5. Thomas RE. Evaluating the safety and immunogenicity of yellow fever vaccines: a systematic review. Vaccine: Development and Theory. 2015;5:1-8.

6. Travelers’ Health: Search for Stamaril yellow fever vaccination clinics. Centers for Disease Control and Prevention Website. https://wwwnc.cdc.gov/travel/page/search-forstamaril-clinics. Updated September 25, 2018. Accessed September 27, 2018.

Yellow fever might not make it to the top of the list of vaccination guidelines you reference in your daily practice, but it is an important vaccine for selected populations in the United States. Because we are often the first point of contact for the health needs of travelers, this vaccine is important for family physicians to keep on their radar"

AREAS OF RISK: SOUTH AMERICA

FIGURES 1 & 2:

AREAS OF RISK: AFRICA

Yellow fever vaccine recommendations in Africa1

MAP 3-15.

Yellow fever vaccine recommendations in the Americas¹ (Updated May 5, 2018)

MO-AFP.ORG 35

¹ This map with recommendations published by the World Health Organization (WHO). It is an updated version of the 2010 map urrent as of September 2016. This map, which aligns with recommendations also published by the World Health Organization (WHO), is an updated version ofaligns the 2010 map created created by the Informal WHO Working Group on the Geographic Risk of Yellow Fever. the Informal WHO Working Group on the Geographic Risk of Yellow Fever.

Inconsidered 2017, CDC for expanded ellow fever (YF) vaccination is generally not recommended in areas where there is low potential for YF virus exposure. However, vaccination might be a smallyellow subsetfever of vaccination recommendations for travelers to Brazil due to a large outbreak of yellow fever in 2

AFC

Schedule of Events

ANNUAL FALL CONFERENCE

All sessions will be held in Grandview Ballroom C/D

FRIDAY, NOVEMBER 9 REGISTRATION 7:00-8:00 am & BREAKFAST

WITH EXHIBITORS

SATURDAY, NOVEMBER 10 REGISTRATION 7:00-8:00 am & BREAKFAST

WITH EXHIBITORS

KSA Working Group: Preventative Care

ssion

8:00-9:45 am

Beyond Addiction: Obtaining and Sustaining Long Term Recovery

PANEL SPEAKERS: Randall Williams, MD David Stoecker, LCSW Charles Sutherland, MD Kurt Bravata, MD

15 MINUTE BREAK

10:00-11:00 am Improving the Diagnosis and Treatment of Lupus

11:00-11:45 am

SPEAKER: Michelle Petri, MD, MPH SPONSOR: PeerView Institute

Exercise for a Concussion, Really? *WORKING LUNCH

SPEAKER: Brian Mahaffey, MD

1:00-2:00 pm

SPEAKER: Michael King, MD, MPH, Examining the Role of Family FAAFP Physicians in the Early SPONSOR: Recognition and Management PeerView Institute of Chronic Heart Failure 15 MINUTE BREAK

2:15-3:15 pm

Primary Care of Refugee Populations

3:15-4:15 pm

Hippocratic Medicine in the 21st Century: Challenges for Individualizing Treatment

SPEAKER: Dawn Davis, MD

5:30-7:00 pm

MAFP

WINE + Dessert pairing Separate Registration Required $50.00

Engage in Advocacy

*CME credit not available

SPEAKER: Jennifer Powell, MD, FAAFP

HOST/SPONSOR: Missouri Wine and Grape Board Location: Worman Room

*

Proceeds benefit the Family Health Foundation of Missouri

SPEAKERS: MAFP Advocacy Commission

8:00-9:00 am

SPEAKER: Sarah Colwick, MD

9:00-10:00 am Elevate: Your GenderAffirming Healthcare Environment for Optimal HIV Care

SPEAKER: Chance Krempasky, FNP-BC, WHNP-BC, AAHIVS SPONSOR: Annenberg Center for Health Sciences at Eisenhower

10:00-10:45 am

VISIT WITH EXHIBITORS

10:45-11:45 pm

SPEAKERS: Matt Mayes Kara Mayes, MD

Imaging Guidelines for Breast Cancer Screening

In-Flight Medical Emergencies

15 MINUTE BREAK/ PREPARE FOR LUNCH

12:00-1:00 pm Ankle Sprains and Their Imitators *WORKING LUNCH

1:00-2:00 pm

Delivering Trauma-Informed Care to Patients in the Family Medicine Clinic

ents ents and Stud

Support Resid

7:30-8:00 am

VISIT WITH EXHIBITORS

15 MINUTE BREAK/ PREPARE FOR LUNCH

12:00-1:00 pm

e Special S

SUNDAY, NOVEMBER 11 SPEAKERS: 8:00 amJames Stevermer, MD, 2:30 pm FAAFP

SPEAKER: Mark Halstead, MD

his!

Don't Miss T bility!

L imited Availa

SATURDAY BREAKOUT SESSION Location: Lakeview Room A/B (Downstairs)

12:00-4:15 pm SPEAKER: Miranda Huffman, MD

ASAM Treatment of Opioid Use Disorder Course MUST HAVE PREVIOUSLY COMPLETED THE 4-HOUR ONLINE COURSE TO ATTEND

*WORKING LUNCH

15 MINUTE BREAK

2:15-3:15 pm

SPEAKER: James Stevermer, MD, FAAFP

3:15-4:15 pm

SPEAKER: Joseph Tollison, MD

4:30-5:30 pm Commission Meetings

Location: Business Lounge B (Member Services) Lakeview Room A/B (Advocacy) Lakeview Room C (Education)

5:30-7:30 pm

Location: Lakeview Room A/B

News You Can Use: An Update from Medical Literature

ABFM's Required Performance Improvement

MAFP Board Meeting

Natalie Long, MD Location: Grandview Ballroom A *BREAKFAST (7:45 am) & LUNCH (11:30 am) INCLUDED

ANNUAL FALL CONFERENCE REGISTRATION FORM

November 9-10, 2018 | Big Cedar Lodge AAFP ID: Name:

 MD

 DO

Address:

City/State/Zip:

Telephone:

Email:

 FAAFP

One Day Only

 Other:

Full

Amount

MAFP Member*

$200

 Friday

 Saturday

$375

$

New Physician, Life Member

$175

 Friday

 Saturday

$325

$

AAFP Member (Out of State)

$210

 Friday

 Saturday

$400

$

Non-Member

$225

 Friday

 Saturday

$450

$

$0

 Friday

 Saturday

$0

$

Student/Resident Treatment of Opioid Use Disorder Course (TOUD) Please visit www.mo-afp.org for details on this course format. Requires 4-hours of self-paced online learning to be completed BEFORE November 3, 2018.

 $225 TOUD only  $75 with One Day Registration  $0 with Full Conference Registration

KSA Working Group

Sunday – (8:00 a.m. – 2:30 p.m.)

Printed Syllabus (Free for Life members)

$25

*AAFP Membership includes state chapter membership.

Event Conference Attendee (Check all that apply)

Friday Breakfast

Friday Lunch



Guests

_____ x $25 Each

RSVP

$ $200

$

$50

$

Total A

$

Saturday Breakfast

Saturday Lunch







_____ x $30 Each

____ x $25 Each

_____ x $30 Each

Total B + Total A Wine & Dessert Pairing $50 (Proceeds benefit FHFM) (Optional) Family Health Foundation of Missouri 50/50 Raffle (Optional) Tax ID 43-1480324 | $10 per ticket or 6 for $50 Total Amount Due

Amount $

Included

$ $ $ $ $

Special Dietary Needs or Physical Accommodations: ____________________________________________________________________________ Registration Information: • CME sessions, meals, breaks, and electronic syllabus are included in the registration fee. All functions in the Exhibit Hall are for registrants only.

• KSA Working Group includes continental breakfast, lunch, and refreshments.

• By registering for this conference, I authorize MAFP to use photographs of me with or without my name for any lawful purpose, including print or online marketing.

• Registration cancellations must be in writing (to office@mo-afp.org) and received no later than October 8, 2018. A $50 administrative fee will be deducted from each refund processed. No refunds will be issued after this date.

Questions? Call (573) 635-0830, Fax (573) 635-0148, or email at office@mo-afp.org Payment Information:

Check (Made payable to MAFP-enclosed)

MasterCard

VISA

Discover

 AMEX

Name on Credit Card:__________________________________________ Expiration Date:___________ Security Code:___ ___ ___ Card #: ___ ___ ___ ___

___ ___ ___ ___ ___ ___ ___ ___

___ ___ ___ ___

Billing Zip Code:____ ____ ____ ____ ____

Signature:__________________________________________________________ Missouri Academy of Family Physicians 722 West High Street Jefferson City, Missouri 65101

SEP 16, 2017 8:00 am – 12:00 pm The Pyle Center UW Extension

November 10, 2018 | 12:00 pm – 4:15 pm SEP 16 2017 | 8 00 12 00 LOCATION

MAFP Annual Fall Conference Big Cedar Lodge 190 Top of the Rock Road Ridgedale, MO 65739

The ASAM Treatment of Opioid Use Disorder (TOUD) Course covers all evidence-based practices and medications for treating patients with opioid use disorder.

The ASAM Treatment of Opioid Use Disorder Course is designed for:

COST- $225 (or FREE when you sign up for a FULL registration)

• •

REGISTRATION

www.mo-afp.org/cme-events/ annual-fall-conference/

CONTACT

Email: education@ASAM.org Call: (301) 656-3920

Are you an NP or PA? ASAM also provides the additional 16 hours required for NPs and PAs to qualify for a waiver free of charge.

Physicians, nurse practitioners, physician assistants, and healthcare team members working with patients with opioid use disorder.

Physicians, nurse practitioners, and physician assistants who wish to obtain a waiver to prescribe buprenorphine in office-based treatment of opioid use disorder.

COURSE FORMAT: • Blended – four hours online, four hours live o Four hours of self-paced online learning to be completed before November 3, 2018 o Four hours of live learning on November 10, 2018 in Ridgedale, MO

Course faculty are expecting learners to complete the first portion of the course before attending the live portion. This 4 hour online/4 hour live blended training satisfies eight hours of education requirements for providers to qualify for a DEA DATA2000 waiver. NPs and PAs can qualify after completing an additional 16 hours provided by ASAM free of charge.

PRICING STRUCTURE $225: TOUD Only $75: TOUD with One Day Registration $0: TOUD with Full Conference Registration ASAM is an approved provider by CSAT/SAMHSA of DATA 2000 training.

ACCME ACCREDITATION STATEMENT: The American Society of Addiction Medicine (ASAM) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to sponsor continuing medical education for physicians.

AMA CREDIT DESIGNATION STATEMENT: The American Society of Addiction Medicine designates this enduring material for a maximum of 4 AMA PRA Category 1 Credits ™. Physicians should claim credit commensurate with the extent of their participation in the activity.

The American Society of Addiction Medicine designates this live activity for a maximum of 4 AMA PRA Category 1 Credits™.

Physicians should claim credit commensurate with the extent of their participation in the activity.

38

MISSOURI FAMILY PHYSICIAN OCTOBER-DECEMBER 2018

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nm5001

AAFP, MAFP ADDRESS CMS ON PROPOSED MEDICARE PHYSICIAN FEE SCHEDULE

T

he Missouri Academy of Family Physicians submitted comments in September on the Centers for Medicare and Medicaid proposed rule, “Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2019; Medicare Shared Savings Program Requirements; Quality Payment Program; and Medicaid Promoting Interoperability Program.” The five-page letter expressed our commitment to reduce the administrative burden of modern medical practices and preserving independent physician practices.

The four high-level items submitted for consideration addressed: Alternative Payment Models for Primary Care Most family physicians, especially those in independent practices, believe these proposed changes would have a net-negative impact on their practices. The feedback we 40

MISSOURI FAMILY PHYSICIAN OCTOBER-DECEMBER 2018

have received has been appreciative of the concepts proposed but negative on the actual policies themselves. It is our opinion that the pathway to true reform of the Medicare program, especially for primary care, lies in the broader proliferation of Alternative Payment Models (APMs) versus efforts to tweak the legacy fee-for-service system.

To achieve meaningful transformation of primary care – and the health system more broadly – the American Academy of Family Physicians (AAFP) has put forth the Advanced Primary Care Alternative Payment Model (APC-APM). The APC-APM is consistent with the proposed changes put forth in the 2019 Medicare Physician Fee Schedule proposed rule – as well as the goals outlined in the April 2018 Direct Provider Contracting Request for Information to increase access, reduce administrative burden, and provide predictable revenue streams for providers to deliver patient-centered care. The APCAPM achieves both simplification in coding

and documentation. It prioritizes comprehensive, continuous, and coordinated primary care, and it includes an evaluation of performance that is based in both quality and utilization. Additionally, while the APC-APM would require the use of an electronic health record system, the APC-APM would incentivize physicians to focus on using the EHR as a tool to assist them in care delivery, not as a tool focused solely on payment. The implementation of this primary care APM would drive Medicare toward the proven values of primary care: first contact, comprehensive, continuous, and coordinated care.

Furthermore, it would be an important step towards achieving the Administration’s goal of transforming the Medicare program into one that prioritizes the delivery of high-quality, patient-centered, and efficient care.

Priority Proposals in the 2019 Medicare Physician Fee Schedule The 2019 Medicare Physician Fee Schedule seeks to improve the Medicare program by creating a practice environment that facilitates high-quality care delivered in the most efficient manner. The rule proposed four major changes to the Medicare Part B Fee-For-Service program that would have an immediate and measurable impact on family medicine. Those items are: 1. Simplify payment by adopting a single payment rate for evaluation and management (E/M) codes for new patients (99201-99205) and existing patients (99211-99215); 2. Reduce documentation burden by allowing physicians to document only at the 99202 or 99212 level; 3. Establish a new G-code valued at approximately $5.00 per visit that could be added to the newly established value for existing patient E/M services; and 4. Reduce by 50% payment for services provided in connection with an E/M code using the modifier -25.

In addition to these four items, the proposed rule outlined several other polices that aim to enhance patient care via telemedicine, coverage of other non-face-to-face services, and extended visits for complex patients. We commended CMS’ efforts to create neutrality in payments between sites of care proposed in a separate rule.

With respect to the 50 percent reduction in value for services provided at the same visit as an E/M service, using a modifier -25, the MAFP opposed the reduction of payment for services provided to patients in connection to E/M services. We believe that the valuation of such services, as established through the RUC process, already accurately accounts

for any efficiencies that may exist, and further reductions are not justified.

The MAFP did not support the proposed changes to E/M codes as proposed by CMS because we believe the proposal would have a negative impact on Missouri family physicians, especially those in small, independent practices. We recommended the following changes that would strengthen the proposed policies included in the 2019 MPFS: 1. Proceed with the proposed changes in documentation and implement these immediately – but without the collapse to a single payment for codes 99202-99205 and 99212-99215. Furthermore, we urge CMS to use its unique position to drive changes in documentation not only in Medicare, but through all public and private health plans.

2. Delay implementation of any changes to E/M policies or codes and their descriptors until the AAFP and other medical associations can work with CMS to develop new or revised office visit codes, descriptors, and values that incentivize comprehensive, continuous, and coordinated primary care and not fragmentation and churn.

3. Eliminate the proposed primary care addon code and replace it with a 15% increase in payment for E/M services provided by physicians who list their primary practice designation as family medicine, internal medicine, pediatrics, or geriatrics.

4. Eliminate the proposed 50 percent Multiple Procedure Payment Reduction (MPPR) for physicians who list their primary practice designation as family medicine, internal medicine, pediatrics, or geriatrics.

5. Work with Congress to eliminate the applicability of deductible and coinsurance requirements for the chronic care management (CCM) codes. Eliminating CCM cost-sharing requirements would facilitate greater utilization of these codes and increase coordination of care for those beneficiaries with the greatest health care needs.

Furthermore, we urge CMS to further reduce excessive CCM documentation requirements.

Impact on Medicare Beneficiaries The MAFP expressed concern that the changes included in the proposed rule may harm the quality and cost of care for Medicare beneficiaries. The value of primary care is achieved when delivery systems are foundational in first contact, comprehensive, continuous, and coordinated primary care. To achieve these four principles, delivery and payment models must be aligned with these goals. We are concerned that the proposed changes would move us further MO-AFP.ORG 41

from these principles by incentivizing greater fragmentation in care delivery. Since the proposed rule would place an emphasis on maximizing an allotted amount of time with a patient, versus comprehensiveness, it is likely that patients would experience more frequent, shorter duration physician visits.

This incentivization of churn is inconsistent with the principles of advanced primary care and could not only be frustrating for patients but could also harm access to care in rural and other health professional shortage areas.

Additionally, since beneficiaries are required to pay 20 percent of most Part B services, it is possible that beneficiary out-of-pocket costs would increase due to more frequent physician or clinician visits. Also, visits paid at a higher rate than was the case before the proposed collapse of payment levels could multiply out-of-pocket costs. Many beneficiaries already face challenges accessing physicians due to logistical and financial challenges. We are very concerned that the proposed rule has the potential to create fragmentation and churn that could exacerbate these challenges.

Again, we believe the implementation of APMs such as the APC-APM, which focus on comprehensive, continuous, and coordinated primary care, are a better approach.

Impact on Solo and Small Physician Practices Small, independent family medicine (primary care) practices are the foundation of our health care system, yet they face unique challenges that require some accommodation if they are to be successful in the future. The narrow margins of

42

MISSOURI FAMILY PHYSICIAN OCTOBER-DECEMBER 2018

small, independent practices leave little room for variation in revenue. In addition, patient panels for these practices are more populated by Medicare and Medicaid beneficiaries and they tend to have fewer Medicare Advantage patients. These factors cause changes in Medicare fee-for-service to have a disproportionate impact on these practices. The collapsing of E/M payment, in conjunction with the 50% reduction in payment for multiple services through the modifier -25 will be an economic death knell by these practices. Most have expressed that the implementation of the proposed changes would result in significant financial strains that would require either a decrease in the number of Medicare beneficiaries they care for or the sale of their practice to a larger organization.

The further elimination of independent practices through consolidation is not positive for communities in our state, Medicare beneficiaries, or the financial sustainability of the Medicare program.

The MAFP believes the best way to sustain these independent practices and preserve the important role they play in our health care system is to transition them away from fee-for-service towards APMs such as the APC-APM. The volatility fee-for-service causes is inconsistent with the comprehensive, continuous, coordinated primary care practiced by these family physicians.

The full text of the letter is available by contacting MAFP Executive Director, Kathy Pabst, at kpabst@mo-afp.org.

"

MISSOURI RESIDENTS & STUDENTS ATTEND NATIONAL CONFERENCE

O

ver 1,200 residents and 1,800 students gathered at the Kansas City convention center in early August for the annual AAFP National Conference of Family Medicine Residents and Medical Students. Missouri’s representation at this year’s conference increased over 22% from 2017, and 37% from 2016. The MAFP is actively working to recruit and retain our residents and students to become involved in their organization. They all had opportunities to listen, learn and network during the three-day conference. Business at hand generated more than 24 resolutions aimed at making patients healthier and ensuring physicians are equipped to do their jobs. These resolutions will undergo the AAFP policymaking process, and potential be presented at the AAFP Congress of Delegates in early October.

Amisha Parikh, a second year medical student at Washington University, St. Louis, and this year’s Student Delegate from Missouri (based on a rotation cycle), had a wonderful experience at the National Conference for Family Medicine Residents and Students. “As a rising M2, I had

not had much exposure to what it meant to be a family medicine doctor, and through this conference and attending the various sessions and workshops, I learned how each physician in this field had a unique journey and was able to create their practice incorporating parts of medicine that they were passionate about.”

one on Transgender Medicine – the speaker did not just cover the basics but also the clinical aspects of serving the transgender community. It was informative and engaging and showed me how the family medicine physician is truly the physician for the community, and how incorporating social aspects of health is key in providing adequate care,” she continued.

It was informative and engaging and showed me how the family medicine physician is truly the physician for the community, and how incorporating social aspects of health is key in providing adequate care.”

- Amisha Parikh, second year medical student, Washington University, St. Louis

“The most informative session I attended was

MO-AFP.ORG 43

“Through this conference, I also had experience as the Missouri delegate to the Student Congress and had a lot of fun participating in those sessions!

Getting to vote on resolutions presented by students and contributing my own opinions in this session was a great way to experience vocalizing my thoughts to my peers and future colleagues and better understand how change can be enacted even at the student level. Overall, I learned a lot from this conference, especially coming from an orphan school that does not have a family medicine residency program, I was very grateful for this opportunity to attend and learn more!”

Kaci Larsen, MD, of the University of MissouriColumbia Family Medicine Residency, co-authored a resolution addressing the need for correctional institutions and detention facilities to recognize menstrual hygiene products as medical necessities.

"It was appalling to me when I realized that women who are incarcerated in state institutions have to pay for tampons and pads out of their commissary.

There are plenty of studies out there that show women would have to work on average of 20-27 hours -- depending on what state they are in -- to buy one box of tampons." Larsen added that the Federal Bureau of Prisons already supports the idea of free access to menstrual hygiene products.

During the Congress on Saturday, residents adopted the resolution asking the AAFP to recognize the problem and to encourage chapters to advocate for access to unlimited free menstrual hygiene products including pads, tampons and clean underwear.

Other issues addressed included pediatric mental health, EHRs, and family medicine research workforce, creating one resident and one student seat on the FamMedPAC Board of Directors, working with stakeholders to design systems that allow for medication assisted-treatment for opioid use disorder to be initiated in the hospital and continued when the patient is discharged to

44

MISSOURI FAMILY PHYSICIAN OCTOBER-DECEMBER 2018

a skilled nursing facility, advocating to overturn the Risk Evaluation Mitigation Strategy (REMS) classification on mifepristone because that classification is not based on scientific evidence and limits the best evidence-based medical management of miscarriages, including access to abortion care, lobbying against legislative efforts to criminalize self-induced abortion; and opposing use of language that refers to "fetal personhood" in government policies and legislation.

Missouri Street at this year’s exhibit hall included all Missouri residency programs and two physician recruiters. Energy and excitement filled the isle that was strategically located near one of the entrances/ exits of the exhibit hall. The Missouri Reception drew over 40 residents, students, and academic leaders to discuss MAFP targeted programs for residents and students. The election of the 201819 resident and student alternate board members were elected during this reception.

Misty Todd, MD, Resident, University of Missouri Columbia, was elected to a one-year term as Alternate Resident Board Member, and will transition to the Resident Board Director position in 2019. Morgan Dresvyannikov, a fourth year (of 6 years) medical student, at University of Missouri Kansas City, was elected to serve at the Alternate Student Director. Past alternate directors, Mimi Liu, Student, St. Louis University, and Ann Lottes, MD, Resident, Mercy Family Medicine Residency, succeeded to the director positions.

Again, thank you to the Missouri Health Professional Placement Services for sponsoring the Missouri Reception. We appreciate your continued support of family medicine residents and students!

Congratulations to all who participated in this event and made it a huge success!

Portions of the article are obtained from the AAFP Recap of the National Conference of Family Medicine Residents and Students.

NATIONAL CONFERENCE 2018

Thank You to Our Donors Residents and students attend these conferences with the financial support from the Family Health Foundation of Missouri – which is ultimately you, our members. We appreciate you giving your time and treasure to mentor and support our future family physicians. As the year draws to a close, please remember to donate to the FHFM. Your charitable contribution is tax deductible!

Donate online at https://www. mo-afp.org/foundation/

MO-AFP.ORG 45

"

FAMILY MEDICINE

TRANSITION

CONFERENCE FOR RESIDENTS AND STUDENTS

SECOND YEAR: A SUCCESS

O

ver 25 Missouri residents and students gathered in Jefferson City in August to attend this year’s Transition Conference for Family Medicine Residents and Students. The excellent line up of speakers and topics showcased the important issues that were identified in November, 2017, at the MAFP Annual Fall Conference.

With the positive feedback from the speakers, attendees, and exhibitors, this conference is sure to grow and improve each year. One participant stated that “This is the first conference I’ve attended and it has set the bar high. I’m looking forward to future MO-AFP events!” Another attendee participated because, “I wanted to be surrounded by others interested in family medicine and learn practical things that aren’t taught in medical school.”

Attendees were given the opportunity to meet with residency programs and recruiters during the Missouri Mingle that wrapped up the twoday conference. Experts in contract negotiations shared information about employment contracts and benefits specific to physician employment contracts. A panel discussed a day in the life of a family physician which provided an overview of the many subspecialties within family medicine.

Prior to the Missouri Mingle, interviewing techniques for students applying for residency, and residents applying for employment, identified important strategies for help them stand out from the rest of the applicants. And lastly, advice from two married family physicians shared how they balance work and personal life to prevent burnout.

In addition to six sessions, the attendees were provided an opportunity to participate in a “mock legislative committee hearing” at the Missouri State Capitol. Whether they played the role of a legislator on the committee, or someone testifying for or against the issue (which was whether medical marijuana should be legalized), they received hands

46

MISSOURI FAMILY PHYSICIAN OCTOBER-DECEMBER 2018

This is the first conference I’ve attended and it has set the bar high. I’m looking forward to future MO-AFP events!”

on experience in a hearing room which will help prepare them to advocate for their chosen field, family medicine. That evening, MAFP hosted a prison tour of the historic Missouri State Penitentiary and a dinner and beer tasting at a local brewery, Prison Brews.

The attendees will be encouraged to continue their participation in MAFP meetings and programs during the next 6 months, including the Annual Fall Conference and the Missouri Family Medicine Advocacy Day in February, 2019.

Your support of the Family Health Foundation of Missouri has made this program possible…so thank you for your continued support!

Thank you to the Missouri Society of the American College of Osteopathic Family Physicians for their sponsorship of this event! Family physicians working together!

Today

more than 3,500 children will try their first cigarette.

Stop kids from starting.

Volunteer to be a Tar Wars presenter.

www.tarwars.org

Supported in part by a grant from the American Academy of Family Physicians Foundation.

MO-AFP.ORG 47 TW hlf vert.10_v2.indd 1

9/3/10 11:57 AM

MEMBERS IN THE NEWS Larsen Re-appointed Delegate to AMA Resident Fellow Section Kaci Larsen, MD, has been re-appointed to represent the American Academy of Family Physicians (AAFP) as a delegate to the American Medical Association Resident Fellow Section.

Dr. Larsen's term begins in November 2018 and lasts through fall of 2019.

Drs. Allmon and Frank, Dr. McDonald, Presented with AAFP Program of Excellence Award

Morris, 2018 AAFP Vaccine Science Fellowship Program Recipient Dr. Laura Morris is the recipient of the AAFP 2018 Vaccine Science Fellowship Program.

As a recipient of this initiative, Dr. Morris will gain knowledge and practical handson experience through participation in meetings with leading experts in public health and immunizations, federal and state vaccine policy groups, and vaccine manufacturers. Dr. Morris will work with mentors to become more knowledgeable about vaccine science and policy. The AAFP Vaccine Science Fellowship Program will address the interface between public health and the family physician community to make vaccine information effective and practical to the membership of the AAFP. The proposed outcome of the program will be improved use of immunizations by the U.S. public and the highest level possible of vaccine safety and public acceptance of vaccines.

Dr. McDonald, St. Louis University, and Drs. Allmon and Frank, University of Missouri - Columbia, were recently recognized by the American Academy of Family Physicians as one of 18 medical school Family Medicine Interest Groups to win the 2018 Program of Excellence Award for their exemplary efforts to grow and support interest in family medicine.

48

MISSOURI FAMILY PHYSICIAN OCTOBER-DECEMBER 2018

PAY YOUR

DUES

https://nf.aafp.org/Shop/ Invoice/QuickPay

NEWS TO SHARE?

The Missouri Family Physician magazine welcomes your input!

Please submit newsworthy items for review to: office@mo-afp.org

2018 Externs Share Their Experiences "I can’t say enough positive things about my summer externship experience. I was fortunate

enough to be placed with the family medicine residency program at the University of Missouri in Columbia, Missouri, and it served to open my eyes to the breadth of what family medicine can offer here in my home state. I am currently in my final year of medical school at UMKC, and so much of my training has been focused on practice in a larger urban environment. However, by spending some time in Columbia to train with the residents there was eye-opening in just how many ways a family medicine physician can impact the lives of their patients. My supervising physicians were gracious enough to tailor my externship experience to coincide with my particular interests in family medicine, giving me multiple avenues to explore underserved medicine and how it was addressed within their program.

Additionally, the entire residency program went out of their way to discuss the pros and cons of training at their institution such that I was able to get a much more intimate understanding of the program than I would ever have the opportunity to do during an interview or researching where to apply for my upcoming Match. All in all, I would recommend that any medical student who wants to train and practice in Missouri to apply for this externship. It’s a truly fantastic experience."

Matthew Decker - UMKC

EXTERNSHIP OPPORTUNITIES

Co-sponsored by the American Academy of Family Physicians Foundation & the Family Health Foundation of Missouri.

The AAFP and FHFM have partnered to offer four-week summer externships to Missouri medical students interested in pursuing a career in Family Medicine.

Find out more at www.mo-afp.org

"The summer externship was a tremendous experience. I had

the opportunity to work in many different aspects of family medicine, including participating in sports physicals at Chaminade, working at Mercy’s outpatient clinic as well as the family medicine inpatient service at Mercy Hospital, and helping to care for the elderly at St. Agnes nursing home. I also was able to partake in OB boot camp and attend both clinic and lectures in sports medicine. One of the most valuable things about the externship was completing a community needs assessment of my hometown as well as going to see how a School Based Health Center operates with Dr. Cole.

As a summer extern, I not only had exceptional clinical opportunities and was able to learn from excellent residents and attendings at Mercy Hospital in St. Louis, but I also learned how to be a better advocate for my patients as a future family medicine physician."

Mitchell McCord - UMKC "During my Summer Externship, I was able to see and experience the true impact Family Medicine has on a community. I saw that family medicine meets people where they are. It is one of the only specialties I have seen that always puts the patient before the problem at hand. For some patients, this impact was seen while encouraging them during the birth of their first child. For others, the biggest impact was comforting worried parents at their child’s four month appointment. I was even able to see how by controlling a patient’s asthma, they were able to finally go on their dream vacation and hike in high altitudes without any complications. During this time I also learned how to better care for patients in their last days.

This externship really showed me what family medicine is all about and completely confirmed my interest in this specialty. My words cannot express the full extent of my gratitude for having this opportunity."

Morgan Dresvyannikov - UMKC

MO-AFP.ORG 49

Missouri Physicians Can Access HIE Data To: • Enhance Patient Encounters • Effectively Coordinate Care • Increase Workflow & Productivity • Realize Cost & Time Savings

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Join SHINE of Missouri, the physician‐led HIE of Missouri.

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www.SHINEofMissouri.com | 844.424.4370 In partnership with Missouri State Medical Association

In partnership with Missouri State Medical Association

A member of the KAMMCO Network

2018-2019

COX FAMILY MEDICINE RESIDENCY Third-Year Resident Physicians

Jennifer C. Bulcock, MD Chief Resident

Matthew D. Dalke, MD, MA

Whitney J. Davis, DO, MS

Alyssa A. Easter, MD

Jenny M. Eichhorn, MD

J. Cliff Ganus, MD, MPH Chief Resident

J. Evan Johnson, MD

John P. Long, III, MD

Lauren J. Branham, DO, MBA

Evan A. Branscum, MD

Trevor J. Conner, DO

Joshua W. Gaede, MD

Brian D. Kennedy, MD

Kelsey L. Keoppel, DO

Kayla B. Matzek, MD

Cody S. Rogers, MD

Joseph W. Barnard, DO

Gabriela P. Cox, DO, MS

Steven A. James, MD

Karissa A. Merritt, DO

Bjai A. Rice, DO

M.H. Melany Su, MD

Caleb K. Tague, MD, MPH

Theodros M. Zemanuel, DO

Second-Year Resident Physicians

Kyle A. Gillett, MD

First-Year Resident Physicians

Christopher A. Odehnal, MD

MO-AFP.ORG 51

DEPARTMENT OF FAMILY & COMMUNITY MEDICINE UNIVERSITY OF MISSOURI | SCHOOL OF MEDICINE 2018-2019 HOUSE STAFF Chief Residents

Geoffrey Dankle, MD Fulton

Brady Fleshman, MD SP-Gold

Kaci Larsen, MD Fayette

Kaitlin Saucier, MD Fayette

Third-Year Residents

Nick Bratten, MD SP-Blue

Parker Kohlfeld, MD Fulton

Ben Crary, DO Fulton

Stephanie Lersch, MD Family Health Center

Calvin Tai, MD SP- Blue

Second-Year Residents

Justin Chang, MD SP-Gold

Joshua Bacon, MD Fulton

Lisa Camilleri, MD SP-Gold

Jonathan Hoskins, MD Fayette

Eric Kadlec, MD Fulton

Laquita Brown, MD SP-Blue

Miles Crowley, MD SP-Gold

Alyssa Emery, MD Fulton

Kyle Hadden, MD Fayette

Ethan Jaeger, DO SP-Blue

Colin McDonald, MD Family Health Center

Mary Murphy, MD SP-Green

Gabriel Eljdid, DO SP-Gold

Misty Todd, MD Fulton

MISSOURI FAMILY PHYSICIAN OCTOBER-DECEMBER 2018

Kristen Killen, MD Family Health Center

Aaron Wood, MD Family Health Center

Stephanie Espinoza, MD Family Health Center

Tyler Gouge, MD Fayette

Carl Tunink, MD Fulton

Lisa Wadowski, MD SP-Blue

Savannah Ericksen, DO Family Health Center

Alexander Finck MD Fayette

Rose Glastetter, DO Fulton

Matthew Roehrs, DO SP-Green

Jessica Snyder, MD Fulton

Zachary Treat, MD Fulton

First-Year Residents

Integrated Residents

Cody Holmes Fulton

52

John Jayroe, MD SP-Green

Brea Lombardo Family Health Center

Marc Propst South Providence

Mercy Family Medicine 2018-2019 First-Year Resident Physicians

Kinsey Cornick, DO Des Moines University Osteopathic Medical Center

Chelsea Drissell, MD University of MissouriColumbia School of Medicine

Vanessa Murillo, MD University of Texas School of Medicine at San Antonio

Kris Pullam, MD Saint Louis University School of Medicine

Larry Rudolf, MD Amanda Schumacher, DO Saint Louis University AT Still University of Health School of Medicine Sciences Kirksville

Second-Year Resident Physicians

Robyn Brownell, MD Rush Medical College

Dallas Chase, MD Ross University School of Medicine

Kyle Johnson, DO AT Still University of Health Sciences Kirksville

Whitney Knapp, DO AT Still University of Health Sciences Kirksville

Kim McClure, MD Saint Louis University School of Medicine

Ryan Menchaca, MD University of Texas School of Medicine at San Antonio

Third-Year Resident Physicians

Ann Lottes, MD University of Missouri Columbia School of Medicine

Eric Martin, DO Des Moines University College of Osteopathic Medicine

Kate Rampon, MD University of Tennessee Health Science Center College of Medicine

James Starrett, DO Kansas City University of Medicine and Biosciences

Brittanie Weinhaus, DO AT Still University of Health Sciences Kirksville

Rebecca Winchester, DO Kansas City University of Medicine and Biosciences

MO-AFP.ORG 53

54

rvedi,

ferra,

MPH

Jennifer Tieman, MD, Program Director

Kavitha Arabindoo, MD, MPH

Jennifer Kelley, MD

Sandra Lepinski, MD

Shari Ommen, MD

Gazala Parvin, MD

Don Philgreen, MD

Anne Sly, MD

INMED Institute for International Medicine Founder & CEO

Warren Stark, DO

Tatum Stephanie Schauner, Mead, PharmD PharmD

Adjunct Faculty

Donna Prill, MD

RESEARCH FAMILY MEDICINE RESIDENCY PROGRAM

Faculty

Revathi Bhat, MD

Mark Suenram, MD

Daniel Haire, DO

Sourab Chopra, MD

Gewel de los Santos, MD

Julie Wood‐Warner, PhD

Emily Hansen, DO

Oscar Lu, DO

Rachel McDonald, MD

Sarah Ziva Patt‐Rappaport, Otter, DO DO

Class of 2021

Searn Sabrina Sahadevan, Rutschke, DO MD

Hazen Short, MD

Nicholas Comninellis, Logan Emily Rice, MD Stoll, DO MD, MPH

Gewel de los Santos, MD

Manveer Flora, MD

Class of 2019

Joseph Meier, MD

Class of 2020

Brittney Frisby, MD

Will Patton, DO

Maureen Weber, MD

Anne Sly, MD

Max Zollikcer, MD

Jessica Testa, MD

Hazen Short, MD

St

Varsha Pawate, MD

M We

2018‐2019 R3

Tatum Stepha Dianne Winter, DO Mead, PharmD P Anne Valburg, MD

Chelsea Willis, DO

Adjunct Faculty

Donna Prill, MD

Varsha Pawate, MD

2018‐2019 R3 CHIEF RESIDENTS

INMED Kayt Rhiannon Schlepphorst, MD Talbot, DO Institute for International Medicine Founder & CEO Ben Saylor, DO

Don Philgreen, MD

Joseph Sayegh, MD

Gazala Parvin, MD

Will Patton, DO

Nicholas Comninellis, MD, MPH

FOR MORE INFORMATION ON OUR PROGRAM, FACULTY AND RESIDENTS VISIT OUR WEBSITE AT WWW.RESEARCHRESIDENCY.COM

Addia DeAllie, MD

Christine Khong, MD

Joseph Meier, MD

Class of 2020

Brittney Frisby, MD

Shari Ommen, MD

Manveer Flora, MD

Class of 2019

Sandra Lepinski, MD

Casey Julie Tiffany Ashley Angie Bland, MD Cefalu, DO Chuda, DO Tramp, MD Wood‐Warner, PhD

Rachel Allen, MD

Faculty

Jennifer Kelley, MD

Sourab Chopra, MD

Priscilla Borden, Gaurav Chaturvedi, MD MD

Revathi Bhat, MD

Casey Tramp, MD

Terry Sam Teferra, Suppes, DO MD

6675 Holmes, Suite 450 Kansas City, Missouri 64131 Phone: 816 276‐7650 Fax: 816 276‐7090 Faculty

MISSOURI FAMILY PHYSICIAN OCTOBER-DECEMBER 2018

Saint Louis University

Family Medicine Residency 2018-2019

Brittany Goodrich-Braun, MD – PGY3 Chief Resident Saint Louis University

Ashley Meyr, MD – PGY3 Chief Resident Saint Louis University

Deanna Chavez, MD – PGY3 Creighton University

Ritesh Gandhi, MD – PGY3 Chicago Medical School

Yibing Li, MD – PGY3 Alison Matsunaga, MD – PGY3 University of NC-Chapel Hill Saint Louis University

Bob Hieger, MD – PGY2 Saint Louis University

Peter Ireland, MD – PGY2 Saint Louis University

Randy Jackson, MD – PGY2 Rutgers University

Nesa Mohebpour, MD – PGY2 University of Texas

Daniel Stevens, DO – PGY2 Des Moines University

Michael Baltes, MD – PGY1 Saint Louis University

Mindy Guo, MD – PGY1 Washington University

John Heafner, MD – PGY1 Saint Louis University

Yu Jen Lun, MD – PGY1 Saint Louis University

Rebecca Rada, DO – PGY1 Kansas City University of Medicine & Bioscience

SSM Health St. Mary’s Hospital Family Medicine Inpatient Service

Kelly Dye, MD – PGY2 Texas Tech University

Daytime (7:00am-5:30pm) First Contact PGY1 Pager Marina Tawfik, MD – PGY1 Saint Louis University

ATTENDING/SENIOR PAGER 314-360-5785

MO-AFP.ORG 55

56

MISSOURI FAMILY PHYSICIAN OCTOBER-DECEMBER 2018

Advanced OB Fellow

Fox Valley Family Medicine

Rawinder Parmar, DO

Whitnee Maycock, MD University of Texas

Chicago Medical School Rosalind Franklin University

Jordyn Ginter, MD

Brandon Abbott, DO ATSU Kirksville

Daniel Purdom, MD UMKC Family Medicine Geriatric Medicine Fellow

Andrew Patton, MD

Advanced OB Fellow

John Peter Smith Family Medicine

Bhavishya Narotam, DO Kansas City University

Sarah Michaels, DO Kansas City University

Cheyenne McKahan, DO AT Still Kirksville Hong Nguyen, MD University of Kansas

Helen Hill, DO, MPH ATSU—SOMA

Matt Hendrix, MD UMKC

Sara Howe, MD MU Columbia

Robbie Harriford, MD University of Kansas

UFR des Sciences Médicales de l’université de Bordeaux

Jessica Braure, MD, PhD

Joshua Booth, MD University of Arkansas

Karina Belino, DO ATSU

Hannah Anderson, MD University of Kansas

Maranda Nguyen, DO Kansas City University

Christopher Koehn, DO, MBA Kansas City University

Megan Buri, MD Creighton

Michael Nordquist, DO Des Moines University

Andrew Kwan, MD, MBA University of Kansas

Josh Buschling, DO Rocky Vista

Carlos Pacheco III, MD University of Kansas

Benson Lan, MD St Louis University

Chelsie Cain, DO ATSU

Holly Perkins, MD Creighton

LiYin Lan, DO, MBA Kansas City University

Ryan Carey, DO, MA, MPH Touro CA

Steven Taki, MD University of Washington SOM

Peter Lazarz, MD UMKC

Spencer Cline, DO Kansas City University

Kevin Munger, DO, MS UMKC Family Medicine Sports Medicine Fellow

Joshua Williams, MD UMKC Andrew Wherley, MD University of Illinois

Chadwick Byle, MD UMKC Family Medicine Sports Medicine Fellow

Adam Legg, DO Kansas City University

Elizabeth Dedon, DO Kansas City University

Nicole Lee, MD University of Virginia

Carolyn Coyle, MD University of Texas

7900 Lee's Summit Road Kansas City, MO 64139 Ph: 816-404-7751 Fax: 816-404-7756 Email: info@umkcfm.org

We are dedicated to rural and underserved areas of our great state! MHPPS partners with safety-net providers and health care systems throughout Missouri to help health care professionals, like yourself, find a community that best fits your personal and professional needs. Whether it’s a scenic rural se�ng, dynamic urban loca�on, or somewhere in between, we are commi�ed to focusing on your interests and careers that count!

Find Out More: Contact Us Today!

Joni Adamson Manager of Recruitment 573.636.4222 jadamson@mo-pca.org www.3rnet.org/missouri

Opportuni�es t�roug�out our Rura� � Ur�an Areas:  �oan Repayment Op�ons  Compe���e �a�ary � Compre�ensi�e �ene�ts  Team �ased Mode�s of Care / Care Coordina�on  �i��e or no Ca�� / Mo�ing A��owance / �igning �onus

Ask us about complimentary career planning luncheon presenta�ons for FMIG and Residency Programs on topics such as: CV Wri�ng; Compensa�on Packages; �ob Search Strategies; Interviewing; �ob Selec�on; �oan Repayment Incen�ve Programs; Finance Basics; Contract �ego�a�on, and�or �ob �ransi�on.

Pride, Passion, Purpose: Careers That Count!

Proud Partners Of:

MHPPS is non-profit and located within the MO Primary Care Associa�on

! s t n e d u t S & s t n e d i s e

AFC

Support R

ANNUAL FALL CONFERENCE

FRIDAY, NOVEMBER 8 5:30-7:00

MAFP

WINE + Dessert pairing

Sponsored By: Missouri Wine & Grape Board

$50/person All Proceeds Benefit the Family Health Foundation of Missouri

The Core Content Review of Family Medicine Why Choose Core Content Review?

• Online and Flash Drive Versions available • Cost Effective CME • For Family Physicians by Family Physicians • Print Subscription also available • Discount for M AAFP members • Money back guarantee if you don’t pass the Board exam • Provides non-dues revenue for your State Chapter

North America’s most widely-recognized program for: • Family Medicine CME • ABFM Board Preparation • Self-Evaluation • Visit www.CoreContent.com • Call 888-343-CORE (2673) • Email mail@CoreContent.com