From the Journals

Many physicians don’t discuss MenB vaccine in teen well visits

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Strength of recommendation may influence physician enthusiasm

These survey results suggest primary care physicians’ zeal for discussing meningococcal serogroup B (MenB) vaccines during adolescent well visits is affected by the recommendation that they “may be administered” in this setting, according to Michael T. Brady, MD.

“When pediatricians are fortunate to have 16- to 18-year-old patients come to a routine visit, there are many important issues to discuss, such as sexual activity, tobacco, alcohol and illicit drug use, contraception, and mental health,” Dr. Brady wrote in an editorial discussing the survey results.

The new Category B designation, used by the Advisory Committee on Immunization Practices to recommend MenB vaccines for adolescents and young adults not at increased risk for meningococcal B disease, puts the recommendation in the realm of individual clinical decision making, Dr. Brady noted. “Without specific and clear guidance as to how to quantify benefits, risks, and costs for their individual patients, it is easy to understand why providers would have disparate responses reflecting the challenge associated with a new vaccine and a new vaccine recommendation classification.”

Pediatricians can achieve “exceptional rates of immunization” when recommendations are “evidence based, clear, and unequivocal,” but by contrast, they will remain challenged by Category B or permissive recommendations when clear guidance on how to implement the recommendation is not provided, he concluded.

Dr. Brad is a pediatric infectious diseases specialist at Nationwide Children’s Hospital and the Ohio State University, Columbus. These comments are from his editorial in Pediatrics (2018 Aug 20. doi: 10.1542/peds.2018-1633) . Dr. Brady reported receiving royalties from Up-To-Date for a chapter on human herpesvirus 6, but received no external funding for this editorial. He reported no potential conflicts of interest.


 

FROM PEDIATRICS

Only one-third to one-half of physicians treating teens are discussing serogroup B meningococcal (MenB) vaccines during routine adolescent visits, survey results showed.

Doctor talking with teen girl. Rawpixel/Thinkstock

About half of pediatricians and one-third of family physicians said they always or often initiate discussion of MenB vaccines for adolescents aged 16- 18 year, according to a report on the survey published in Pediatrics.

However, it is challenging to say whether or not that level of discussion is on track with ideal clinical practice, according to Allison Kempe, MD, MPH, of the University of Colorado at Denver and Children’s Hospital Colorado, Aurora, and her coauthors. While MenB vaccines are recommended in this setting, the new Category B designation used for the recommendation indicates that the vaccines “may be administered” in the context of individual clinical decision making.

While some interpret the new Category B recommendation to mean that a discussion should always occur, others may interpret the recommendation as applicable to their own assessment of risks and benefits, without the need to involve patients and parents.

“Providers not initiating a discussion may not think the time required to discuss the MenB vaccine is justified by the risks posed by the disease or the benefits offered by these vaccines,” wrote Dr. Kempe and her associates. “Alternatively, they may have a low level of awareness regarding the disease or the MenB vaccine and feel insufficiently knowledgeable to have an informed discussion about the pros and cons of vaccination. They also may have been entirely unaware of the ACIP [Advisory Committee on Immunization Practices] recommendation for MenB vaccination.”

Dr. Kempe and her colleagues invited a nationally representative sample of primary care physicians to complete the survey, which was administered via Internet or mail between October and December 2016. They heard back from 374 of 475 (79%) pediatricians and 286 of 441 (65%) family physicians.

A total of 50% of pediatricians and 31% of family physicians said they always or often discussed MenB vaccines during routine visits with adolescents aged 16-18 years, with slightly higher percentages saying they initiated discussions during precollege physical exams, according to the report. Of the pediatricians, 58% recommended the MenB vaccine to those in this age group, compared with 50% of family physicians. Not all physicians who recommended the vaccine reported consistently initiating a discussion about it.

Nearly three-fourths of pediatricians and 41% of family physicians reported currently administering the MenB vaccine in their practices, the authors said, adding that greater awareness of disease outbreaks was linked to higher likelihood of discussing the vaccine, while working in an HMO setting was linked to lower likelihood of initiating that discussion.

Recommending MenB vaccination was closely tied to discussing the vaccine. Physicians who said they initiated discussion almost always reported making a recommendation to vaccinate, and conversely, those who rarely initiated discussions were unlikely to recommend it, according to Dr. Kempe and her colleagues.

Factors that made physicians more likely to recommend vaccine included awareness of outbreaks, effectiveness and safety data, and duration of vaccine protection.

The Category B recommendation, on the other hand, was one of the key factors that made physicians less likely to recommend MenB vaccine, according to this survey. ACIP made the Category B recommendation in October 2015, stating that those aged 16- 23 years may be vaccinated, with a preferred age of 16-18 years for administration. The accompanying rationale for the Category B designation referenced the low disease prevalence and insufficient data on effectiveness and safety for the two vaccines, which were both licensed under an accelerated approval mechanism following the outbreaks that have occurred on college campuses.

The Centers for Disease Control and Prevention did not provide additional guidance on how that Category B recommendation should be implemented, Dr. Kempe and her coauthors noted in their report.

“With our data, we highlight the challenges providers face with implementing recommendations for vaccination based on individual clinical decision making when they have limited experience with a disease and limited knowledge of a new vaccine,” they wrote.

The research was funded by the CDC. Dr. Kempe and her coauthors reported no relevant financial relationships or potential conflicts of interest.

SOURCE: Kempe A et al. Pediatrics. 2018 Aug 20. doi: 10.1542/peds.2018-0344.

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