Technically Speaking: Addressing Missed Opportunities for Vaccination

This month we focus on a single study published by a team of researchers from the Children’s Hospital of Philadelphia, several other children’s hospitals, and the American Academy of Pediatrics (AAP). (By way of disclosure, I am a proud co-author.) The study, “Missed Opportunities for Adolescent Immunizations at Well-Care Visits during the COVID-19 Pandemic,” was published in the Journal of Adolescent Health. It was funded by the National Cancer Institute of the National Institutes of Health and was part of a larger study evaluating methods to increase HPV vaccination rates.

The team evaluated trends in missed opportunities (MOs) for vaccination at in-person adolescent well-care visits between January 1, 2018, and December 31, 2021, for three vaccines: human papillomavirus (HPV); quadrivalent meningococcal conjugate (MenACWY); and tetanus, diphtheria, and acellular pertussis (Tdap). A missed opportunity was defined as any office visit during which a patient was vaccine-eligible but did not receive the relevant vaccination. A MO could be due to a host of potential issues (e.g., parental refusal, provider forgot to include an order for HPV vaccination, HPV vaccine wasn’t available that day), but the reason for the MO was not evaluated as part of the study. Electronic health records from 24 pediatric primary care practices in 13 states were reviewed. The dataset represented 106,605 well-care visits. Lest you have forgotten, the COVID-19 pandemic reached the U.S. in March 2020, so visits occurring from January 2018 to February 2020 were considered “pre-pandemic” visits, and those occurring June 2020 to December 2021 were considered “pandemic” visits. Visits at the outset of the pandemic, from March through May 2020, were not evaluated.

During the pre-pandemic phase, MOs were, to my thinking, surprisingly high, but decreased for each vaccine. The MO rate for HPV vaccine dropped from 45.5% to 39.4%, MenACWY 21.4% to 16.5%, Tdap 18.0% to 14.9%. During the pandemic phase, MOs increased for each vaccine. The MO rate for HPV vaccine rose to 49.1%, MenACWY to 20.0%, and Tdap to 18.6%. The largest MO increase was for HPV vaccination — rising even higher than pre-pandemic MO rates.

The authors concluded, “Increases in vaccine MOs during the pandemic equaled or exceeded pre-pandemic decreases,” citing increased parental vaccine hesitancy that began during the pandemic as well as disruptions in staffing and workflow as possible explanations. Importantly, if not addressed, the increase in MOs could result in long-term gaps in vaccine coverage; therefore, implementation of catch-up programs has become critical. Unfortunately, because exposure to HPV is common shortly after sexual debut, some young people may be infected before their vaccination status is up to date, so a missed opportunity to vaccinate early in adolescence could lead to cancerous consequences later in life.

The authors stated, “Further exploration of methods to optimize vaccine delivery … will also be crucial...”

Evidence-based interventions

The Community Preventive Services Task Force (CPSTF) has developed a list of interventions to increase vaccination rates. The CPSTF website includes reviews of the evidence behind each. The interventions are divided into three categories:

1. Enhancing access to vaccination services — Examples of this type include holding home visits to increase vaccination rates, reducing client out-of-pocket costs, and conducting vaccination programs in schools or other locations beyond primary care practices.
2. Increasing community demand for vaccinations — Examples of this type include instituting reminder and recall systems, disseminating community-based education, offering family incentives (e.g., food vouchers, gift cards, chances to win a prize), and implementing vaccination requirements for school attendance.
3. Instituting provider- or system-based interventions — Examples include introducing provider assessment and feedback programs, disseminating provider reminders, and using standing orders (see the Immunize.org publication, “Clinical Resources: Standing Orders,” for more on this topic). Intentional, proven forms of provider communications are another example. In fact, effective provider communication about HPV vaccination was shown to increase vaccination rates in a randomized controlled trial that was a component of the efforts by the team who published the aforementioned paper.

As we move out of respiratory illness season and toward “back to school” season, it’s a great time for office leaders to make plans for catching up patients who are behind and for focusing on decreasing missed opportunities for all patients. Whether focusing on improving coverage with a particular vaccine, such as HPV, or improving coverage overall, check out the resources above and see what will work for your team and your patients. The time is right.