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How to Immunize Parents in the Pediatric Setting © Ruth Jenkinson/Dorling Kindersley/Getty Images

Dear Colleague: I sincerely hope that the first newsletter in this 2-part series piqued your interest in vaccinating adults in your practice. Pertussis prevention begins at home, literally, and we as pediatricians are the obvious ones to make it happen. By getting outside of our comfort zone and immunizing key adult contacts of our newborn patients, we can spin a cocoon of protection against pertussis. This concluding installment of the newsletter addresses implementation of a cocooning plan and offers examples so that you can find the approach that best fits your style of practice. In my office, the parents of every new infant patient are given a copy of the Vaccine Information Statement for both Tdap and influenza. We highlight in yellow the small section on adult contacts of infants. My staff asks parents to read the statements while they are waiting for me and tells them that these are vaccines I suggest they get ASAP. I have built into our electronic health record check boxes for this discussion for all of the first-year visits, including acute visits. We made posters for our offices that show a beautiful little baby and the slogan “Protect me before I Continued on page 2

Faculty Reviewer Alix Casler, MD, FAAP Partner, Physician Associates Assistant Professor University of Central Florida College of Medicine Orlando, Florida


ediatric clinicians are the acknowledged experts when it comes to immunizing patients against vaccine-preventable diseases. Some pediatric offices are putting that expertise to even greater use by offering tetanus, diphtheria, and acellular pertussis (Tdap) immunization to parents and other key adult contacts of their infant patients. In so doing, pediatricians are implementing the Advisory Committee on Immunization Practices (ACIP) recommendation that all adults—including those ≥65 years of agea— who have or anticipate having close contact with an infant <12 months of age be vaccinated with a 1-time dose of Tdap as soon as possible, regardless of when they last received a tetanus and diphtheria (Td) vaccine.1,2 The goal is to reduce the risk that an unimmunized adult will contract and transmit pertussis to a vulnerable infant (see Part 1 of this newsletter series for a review of the rationale for “cocooning”). Pediatric practitioners have been routinely immunizing adolescent patients with a dose of Tdap since 2006, in accordance with the ACIP recommended immunization schedule. The involvement of pediatricians in getting parents, grandparents, and other family members immunized ranges from assessing Tdap status vigilantly and referring unimmunized adults for vaccination elsewhere, to vaccinating all key adult contacts on the spot. (The American Academy of Pediatrics has not issued a policy statement on immunizing adults with Tdap in a pediatric setting.) While immunizing adults may seem daunting to a busy pediatrician, many pediatric practices have demonstrated that it is possible, even profitable, and need not require extensive changes a This recommendation is inconsistent with the currently

licensed indication for one of the Tdap vaccines.

or resources. “We treat patients up to the age of 21,” said pediatrician Keith Ramsey, DO, who immunizes key adult contacts at his solo practice in West Jordan, Utah.“There isn’t much difference in what we do if the person is age 21 or 25 or 35. All we are really doing is giving them the vaccine.” This newsletter answers questions you may have about incorporating cocooning into your daily practice. Drawing from real-life experience, it provides examples and suggestions from pediatric practices that have been vaccinating adults successfully. What’s the first step? Immunization of close adult contacts begins quite simply with a conscious decision to spearhead the effort and a willingness to stand behind it 100%. At Willows Pediatrics in Westport, Connecticut, the 9 providers made a joint decision in 2010 to implement the ACIP recommendations for Tdap immunization of adults, said Susan Amster, PA-C, the office’s administrator. “We wanted to try and do the best thing to protect our kids,” she said. “We have a lot of new moms and families with extended help, such as grandparents and nannies.We offer Tdap immunization to any adult who lives in the home or has direct contact with the child.” At Jordan Ridge Kids and Teens in Utah, Dr. Ramsey started immunizing adults with influenza vaccine 2 years ago during the H1N1 influenza pandemic.Working with a staff of 2 (a medical assistant and a receptionist), he began immunizing family members of his young patients with Tdap in 2010 following an outbreak of pertussis in the community. Patterson and Tedford Pediatrics, a 4provider practice in Atascadero, California, with an active patient roster of 5000, embarked on an

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can protect myself. Get vaccinated.” We designed brochures about Tdap and influenza vaccination that match the posters and sit at the check-in stations for all of the doctors company-wide in our multispecialty group. (Practices can also make use of existing, publicly available brochures and other educational materials on adult immunization.) Parents are told to get vaccinated against pertussis and influenza, no matter how, the sooner the better. Most parents of my patients ask if we will vaccinate them on the spot to save them the trouble of going elsewhere. My answer: “Of course.” We file insurance claims for parents who wish us to do so or accept cash. My nurse and the rest of my staff are totally on board for the tiny extra bit of work. Those of you who work closely with other offices can go a step further if you dare. In my group, I have spoken at the annual meeting of the obstetrics/gynecology department and developed a process for educating the Ob/Gyn staff to get them to vaccinate adult contacts preconception and, failing that, before the baby is born. With the June 2011 vote by the Advisory Committee on Immunization Practices to recommend immunization with Tdap during pregnancy, our obstetricians are likely to begin vaccinating unimmunized expectant mothers during second and third trimester visits as well. I also travel to other pediatric offices within our group, educating the staff there to start vaccinating adults company-wide. This is my passion. If you are part of a large group, find someone in your ranks who will make it theirs. Maybe that someone should be you? My challenge to you is this: Don’t just set this newsletter aside after you read it, with the promise to think about it later. Instead, take out a piece of paper now, then jot down a few notes as you read. Once you are finished, spend 5 minutes making a plan. Talk to your associates on your next workday and implement that plan. Whether you simply educate and refer adult contacts or vaccinate them against pertussis on the spot, we can make a difference in limiting the incidence of this life-threatening and preventable disease, 1 parent and 1 family at a time. Sincerely,

Alix Casler, MD, FAAP 2


ambitious cocooning program to help prevent both pertussis and influenza in 2006, following release of the ACIP guidelines on pertussis prevention and a pertussis outbreak in the county. Today, upwards of 95% of eligible new parents have been immunized with Tdap.The program involves the entire 12-member staff, from the receptionist to the billing specialist. Initially, the practice’s personnel were reluctant to embrace the idea of vaccinating adults, given the expanded duties that a full-scale program requires. “Our goal was to get the entire staff committed to the idea of cocooning, and that really involved a cultural change,” said Brian D. Patterson, MD. Showing his employees statistics about the high rate of pertussis transmission didn’t convince them of the critical importance of cocooning; sharing compelling stories of vaccine-preventable deaths in children, however, did.“Telling stories and watching videos of actual cases made emotional connections with staff,” Dr. Patterson said. Large practices may want to identify a staff member who will serve as the office vaccine champion.That individual should have strong leadership, organizational, and communication skills and be versed in (or interested in learning about) vaccines, vaccine-preventable diseases, and vaccine purchasing. At Patterson and Tedford Pediatrics, the office manager developed expertise in vaccine procurement and immunization and now coordinates their expanded immunization program. How can I minimize potential liability? Experts recommend that pediatricians first contact their malpractice carrier to see if their insurer will cover immunization of close adult contacts.3 If the answer is yes, request written verification of that coverage. Some practices obtain policy riders that specifically cover immunization of key adult contacts of patients with Tdap and influenza vaccines. As with vaccination of pediatric patients, the steps needed to ensure safe vaccine administration apply: inquire about allergies, medications, and recent or present illness; distribute and discuss the most current Vaccine Information Statement (VIS) from the Centers for Disease Control and Prevention (CDC); and document the immunization according to federal and state requirements (see the checklist on this page).4 Practice management expert and pediatrician Richard H.Tuck, MD, Medical Director of Quality Care Partners in Zanesville, Ohio, suggests that pediatricians who inquire about adult immunization with their carrier “ask

How to Immunize Parents in the Pediatric Setting

Cocooning vaccination checklist 4 ✔ Assess Tdap status ✔ Check for contraindications and precautions ✔ Discuss vaccine benefits and risks ✔ Provide the current Vaccine Information Statement (VIS) ✔ Solicit questions and discuss concerns ✔ Have the adult sign a waiver or consent form if required ✔ Document the encounter – Edition and date of VIS – Date vaccine administered – Name, title, and office address of person administering vaccine – Vaccine specifics (manufacturer, lot number, expiration date) – Site and route of vaccine administration ✔ Tell the adult whom to notify if a reaction occurs ✔ Comply with adverse event reporting requirements

‘How do I do it?’ not ‘Can I do it?’ You need to approach it very positively.” When Norman (Chip) Harbaugh, Jr., MD, of Children’s Medical Group in Atlanta initially inquired about vaccinating adults in 2007, his carrier—a leading nationwide provider of medical malpractice insurance—told him that he would be covered only for influenza immunization of parents or household contacts of the office’s patient. In 2009, the company extended coverage to Tdap immunization of parents and household members.“Their position is that the main purpose of giving flu and Tdap immunizations to these particular adults is the health of the pediatric patient,” said Dr. Harbaugh. The insurer requires the practice to keep a brief medical record that includes a standard history and consent form for each adult vaccinated. Giving influenza and Tdap vaccines to certain adults is a narrow exception to a policy that otherwise excludes treating adults, according to Dr. Harbaugh.“Our insurer advised me that while I can immunize an adult against influenza, I cannot give oseltamivir to an adult who has influenza. Doing so would be considered treating an adult and would not be covered.” At Willows Pediatrics in Connecticut, the providers made a single phone call to their malpractice carrier, who judged the risk of

Contraindications and precautions for Tdap vaccination1 Contraindications • History of serious allergic reaction after receiving any component of the vaccine • History of encephalopathy within 7 days of administration of a vaccine with pertussis components Precautions • History of Guillain-Barré syndrome within 6 weeks of a dose of a tetanus toxoid-containing vaccine Reasons to defer immunization • Existence of a progressive or unstable neurologic disorder • Moderate or severe acute illness with or without fever • Arthus-type hypersensitivity reactions following a prior dose of tetanus toxoid-containing or diphtheria toxoid-containing vaccine

liability to be minimal and gave the okay to immunize adults with Tdap, provided that the adult signs a waiver form.The waiver includes a disclaimer of any medical or legal responsibility by the practice in connection with the immunization and contains a contraindications checklist that serves as a mini-screening tool. (The box above lists contraindications and precautions for Tdap vaccination.) The form also includes a statement recommending that adults check with their physician to make sure they have no additional contraindications that would preclude them from receiving Tdap. At Patterson and Tedford Pediatrics, adults are given a 1-page Tdap screening questionnaire and consent form, modeled in part after the Immunization Action Coalition’s Screening Questionnaire for Adult Immunization (available at form includes an acknowledgement that the individual has received and understands the Tdap VIS and that any questions about the vaccine have been answered to their satisfaction. What if the adult has an adverse reaction? Pediatricians should always obtain informed consent prior to immunizing adults. Part of this process should include guidance on where to seek follow-up care should an adverse reaction occur; typically, adults are instructed to contact their primary care provider (PCP). At Patterson and Tedford Pediatrics, the policy is to treat emergent adverse reactions on the spot (only 1 such event—a laryngospasm— has occurred, after hours, and was treated successfully at the local emergency room). Nonemergent adverse events are referred to the adult’s PCP. “We have not had any significant medical issues arise in the 5 years since we started our program,” Dr. Patterson said.

Willows Pediatrics has been contacted by an adult vaccinee about an adverse reaction on only 1 occasion, according to Ms. Amster. Once the nurse who took the call determined that the reaction—a mild fever and headache, which improved quickly—was not an emergency, she instructed the woman to call her PCP, then documented the phone call and put a record of it in the chart of the pediatric patient. The rate of adverse reactions following Tdap immunization is comparable to that of Td vaccine, and no serious adverse events have been conclusively attributed to Tdap, according to the CDC.5 In the primary US study conducted for licensure of 1 of the Tdap vaccines, serious adverse events within 6 months after Tdap immunization were reported for 44 of 2936 (1.5%) vaccinated adults, of which 2 events were considered possibly vaccine related. Both events (nerve compression and severe migraine with facial paralysis) resolved within days.6 How is reimbursement handled? Most pediatric practices that vaccinate adults find it simplest to adopt a cash-only payment model, said Dr. Tuck. Practices should charge enough so that they do not lose money on the service.3 Practices that choose to submit bills to health insurers should make sure they use the proper coding. According to Dr. Tuck, offices will miss out on revenue opportunities if they bill for vaccine administration but fail to include additional codes that might apply, such as codes for extensive counseling or vaccine refusal. Some health plans may have policies that preclude reimbursing a pediatrician for immunization of an adult. Others may require a referral for adult immunization. It is important to inform adults of possible insurance company restrictions before immunizing them and to

have a billing procedure in place for any charges that are denied by the insurer. Parents may prefer to see their PCP in order to guarantee insurance coverage, though many opt for the convenience of on-the-spot vaccination and accept the fact that they may receive a bill. What’s the process for getting adults vaccinated? The logistics of immunizing adults vary depending on the resources of the practice and the extent of the cocooning program. Here’s a look at the approaches used at 3 pediatric practices, including their procedures for recordkeeping. At a baby’s 2-week visit, Dr. Ramsey of Jordan Ridge Kids and Teens gives parents a handout from the health department on last year’s local pertussis outbreak and asks if they’ve been vaccinated with Tdap or (since many don’t know) whether they’ve received a tetanus shot in recent years. If the answer is no—which is the case for most of the mothers and almost all of the fathers—Dr. Ramsey encourages the parent to see their PCP to get vaccinated with Tdap. Most unvaccinated parents say they want to check with their doctor about getting the vaccine, but many do not follow through, particularly fathers. “If an adult family member has the same insurance as the baby and wants the vaccine, we offer to give it to them on the spot,” said Dr. Ramsey, a process that doesn’t necessitate setting up a new insurance record. Adults who have no insurance are referred to a Women, Infants, and Children (WIC) location or to a health department clinic. Before being immunized, adults receive the VIS as well as a Tdap screening questionnaire and consent form that was adapted from the form the office uses for adult influenza vaccination. The signed consent sheet goes in a group file for vaccinations given to people who are not patients of the practice. The process of extending influenza and Tdap immunizations to adults was uncomplicated, said Dr. Ramsey. Cocooning requires a minimal amount of additional staff time and has not resulted in any revenue loss because the office is reimbursed for the vaccine and its administration. At Willows Pediatrics, the staff initially asks about Tdap status at the baby’s first visit, noting the answer in a check-off box on the infant’s physical examination form. Adult contacts can be vaccinated with Tdap during any of the baby’s well visits.Those who work during the day are offered an evening appointment. The office accepts cash only for the service. Adults

How to Immunize Parents in the Pediatric Setting



who prefer to have their insurance billed are referred to their PCP. Once an adult is immunized with Tdap, the nurse places the signed waiver form and the vaccine administration record in the child’s chart. Adults can request a form from the office to give to their PCP that shows they were immunized with Tdap. Families appreciate the convenience of the service, which has not placed a significant logistical or financial burden on the practice, said Ms. Amster. “We had standard policies and procedures in place that we adapted. It required an extra step or 2 at the beginning, but if we can save 1 child from getting ill and suffering the potentially devastating effects of disease, it’s worth it.” Patterson and Tedford Pediatrics administers some 900 immunizations each month to its patients and key contacts.The importance of vaccines is communicated not just by the providers but by everyone on staff. The recommended immunization schedules for children, adolescents, and adults are displayed throughout the office, emphasizing that vaccination is the expected routine. The practice offers vaccinations to adults at well visits, sick visits, regularly scheduled in-office vaccine clinics, and special events, like an annual harvest party held in the parking lot. Cash, credit card, or insurance billing is accepted. When parents arrive for an appointment with their baby, they receive the vaccine screening and consent form and the VIS from the receptionist, who asks if they would like to be vaccinated during their visit. Because the immunization status of caregivers is noted in the infant’s electronic medical record (EMR), that status can be determined on the spot by the office staff. Once a caregiver is vaccinated, a separate record is made for that adult. The practice’s switch from paper to electronic recordkeeping in 2006 was vital to implementing its cocooning program—and in eliciting the nursing staff ’s support and enthusiasm for it. Instead of documenting vaccine administration manually in multiple locations on the paper chart as had been done, the nurse need enter the information only once. From the practice’s perspective, the cocooning program has been an unqualified success.“As a rule the parents and grandparents are outspoken in their appreciation for being able to take care of this important and time-sensitive matter in our office,” Dr. Patterson said. “Over time, immunizing adults has become second nature to our staff.”

Figure 1. Buttons worn by health department clinic staff are printed in English and Spanish; several different races are represented in the photo of the baby. Source: Salt Lake Valley Health Department.

How do I make parents aware of this service? Have your staff present immunization of key adult contacts as a vital service provided by your office and a convenience to parents. Pediatricians who immunize adults get the word out through their Web site, on billing statements, in their office newsletter, through literature placed in waiting areas and exam rooms, by signs posted in the office (“We are pleased to announce that …”), and via word of mouth.To promote its cocooning program, the Salt Lake Valley Health Department in Utah has its clinic staff wear buttons that read “Ask me about Tdap” (Figure 1), a method for starting a dialogue with parents that could also be applied in office settings.

or a prescription for Tdap along with some literature on pertussis may increase the likelihood that he or she will follow through.When referring to a health department clinic, provide the clinic’s phone number, address, and hours of operation. Staff should follow up on referrals by reassessing the parent’s Tdap status at the infant’s next visit. Whether you choose to immunize adults in your practice or to facilitate their getting immunized elsewhere, the message that needs to be communicated to families is the same. Consider preparing a short talk that you and your staff can give to new parents: that pertussis, or whooping cough, is often transmitted to infants by a family or household member; that reported pertussis is on the rise and can be deadly; and that by getting a dose of Tdap vaccine themselves, they are helping to protect their baby until he is old enough to protect himself. Using real-life examples will personalize the message.As part of its cocooning initiative, the Salt Lake Valley Health Department shows educational DVDs in its clinic waiting areas that include audio of the classic pertussis cough.Videos help families see whooping cough as a real disease that affects actual people, rather than as a thing of the past. Stories of parents whose lives have been changed by pertussis or influenza can be found at such Web sites as, www.,, and Pediatricians can play a role in reducing the number of parents in the position of having their own sad stories to share. References

What can I do if I’m not ready to cocoon? Pediatricians who do not choose to immunize adults can still help increase immunization rates among key contacts by referring them to PCPs and other providers, such as obstetricians, hospitals, schools, public health departments, pharmacies, and walk-in clinics. Immunization can be encouraged at prenatal visits (for Dad too), with growing families who are contemplating having another child, and at newborn visits. Many PCPs do not stock all adult vaccines,7 so it’s helpful to know which ones in your community offer Tdap and influenza immunization. And because not all health departments offer vaccination free of charge, it is a good idea for your staff to know what the health department typically charges. Providing the adult with a referral form

1. Centers for Disease Control and Prevention (CDC). Preventing tetanus, diphtheria, and pertussis among adults: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine: recommendations of the Advisory Committee on Immunization Practices (ACIP) and recommendation of ACIP, supported by the Healthcare Infection Control Practices Advisory Committee (HICPAC), for use of Tdap among health-care personnel. MMWR. 2006;55(RR-17):1-37. 2. CDC. Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis (Tdap) vaccine from the Advisory Committee on Immunization Practices, 2010. MMWR. 2011;60(1):13-15. 3. Kennedy K. Cocooning conundrum: should pediatricians vaccinate parents for the baby’s sake? AAP News. 2010;31(12):18. 4. O’Keefe L. Experts differ on whether benefits outweigh risks of providing influenza vaccine to parents. AAP News. 2009;30(1):8. 5. CDC. Pertussis. In: Epidemiology and Prevention of VaccinePreventable Diseases. (The Pink Book). Atkinson W, Wolfe S, Hamborsky J, eds. 12th ed. Washington, DC: Public Health Foundation; 2011:215-232. 6. Pichichero ME, Rennels MB, Edwards KM, et al. Combined tetanus, diphtheria, and 5-component pertussis vaccine for use in adolescents and adults. JAMA. 2005;293(24):3003-3011. 7. Freed GL, Clark SJ, Cowan AE, Coleman MS. Primary care physician perspectives on providing adult vaccines. Vaccine. 2011;29(9):1850-1854.

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How to Immunize Parents in the Pediatric Setting  

Part 2 of a two-part Pertussis Cocooning Consult.

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