Vaccinate for the health of your patients
and your practice

By Todd Wolynn, M.D.
Medical Director, Atlantic Health Partners

The adolescent: gawky, Internet savvy, likely suffering with acne and at risk for vaccine- preventable disease. The family physician: clinically astute, EMR-wary, over-worked and adept at providing immunizations. A match made in heaven? Well, if you can improve patient care with vaccinations while also improving the financial performance of your practice, then hello pearly gates!

As you are aware, there has been a significant increase of recommended adolescent vaccines. Physicians can do the right thing for their patients’ health and for public health in a fiscally and operationally responsible manner. Adolescents represent a significant challenge—and opportunity—to us as they are less likely to comply with their regular follow-up and repeated vaccine series compared to infants (who don’t protest and evade as effectively).

Additionally, new vaccines and new schedules put a significant strain on our already overstretched office staff and resources primarily in the form of time and money. Unless we and our staff truly understand why a particular vaccine is important we are less likely to be effective in preventing the targeted disease. Let’s focus on pertussis and meningitis protection.

Why vaccinate adolescents and adults for pertussis?

For decades we purposefully immunized children from 2 months to 5 years old against pertussis and purposefully used non-pertussis containing “tetanus boosters” to immunize adolescents and adults. What has changed? Multiple studies dispelled commonly held myths.

• Pertussis is not that common.
• Adolescents and adults have life-long immunity to pertussis if they received pertussis immunizations in childhood.
• Even if an adolescent or adult gets pertussis, they only develop mild symptoms.
• It’s not worth the resources to immunize adolescents.

Over the past two decades there has been a large and rapidly increasing number of reported cased of pertussis cases, particularly in the past couple of years. An estimate from J.D. Cherry1 indicates there may be 800,000 to 3.3 million cases of adolescent and adult pertussis each year in the United States.

Adolescent and adult pertussis is not benign. A study in Quebec2 evaluated 664 adolescents and adults with confirmed pertussis and found that the cough lasted at least three weeks in nearly 100 percent of patients, and in half, the cough persisted for nine weeks or more. Paroxysmal cough occurred in three-fourths of these adolescents and adults, whoop in about two-thirds and post-tussive emesis also in about two-thirds. Teens typically missed a week of school, adults missed seven days of work and most suffered extensive disruption to their normal sleep pattern. Additionally, in the Quebec study, 16 percent of adolescents and 28 percent of adults had some type of complication. One of the more serious complications was pneumonia, particularly in older patients. For patients younger than 50 years of age, about 2 percent were hospitalized for a mean stay of three days. For those 50 years and older, about 6 percent were hospitalized with a mean stay of 17 days.

The high risk of death and morbidity for infants with pertussis is a driving factor in the push to immunize adolescents and adults. Infants who suffer through a pertussis infection face significant rates of hospitalization, pneumonia, seizures, encephalopathy and even death. The piece that ties this all together is the realization of just exactly who is giving the babies pertussis in the first place. A study titled “Infant pertussis: Who was the source?”3 showed that the clear majority of transmission is from adolescents at 20 percent and adults at 56 percent of the time. So adults are primarily the ones who give pertussis to vulnerable infants.

Interestingly, mothers are often cited as a common source of exposure to the infant. This is part of the reason why some maternity hospitals have chosen to offer and provide Adacel (Sanofi’s Tdap) prior to mom’s discharge appointment. While there are two Tdap vaccines on the market, only Adacel has the broad range of 11- to 64-year-olds making this an excellent choice for family physicians, as well as pediatricians, internists and obstetricians.

Vaccinating against meningitis

A more obvious life-threatening vaccine-preventable disease is caused by Neisseria meningitidis. As a result of the successful implementations of Hib and Pneumococcus (PCV7) vaccines, the most prevalent cause of bacterial meningitis is now Neisseria meningitidis. These bacteria cause devastating disease, which can be initially difficult to diagnose and progress so rapidly that prevention is paramount to avoiding complications. Beyond death, severe neurologic sequelae and gangrene with amputations is a very real risk. We are all aware that this is yet one more vaccine that has been crammed into the early adolescent schedule but this one is a no-brainer. Sanofi’s Menactra is effective and well tolerated in protecting children and is approved from ages 11 to 55.

The Bottom Line

Remember at the beginning of this article I mentioned to “do the right thing?” Hopefully the preceding helped address the clinical pieces but just as important to your practice is the ability to provide these vaccines and realize an appropriate margin. Adolescents are difficult to track down, but due to mandatory vaccines for these older children, you have a chance to incorporate them into a regular process.

Review charts and vaccine records for immunization compliance at all visits. Call families with adolescents behind on their immunizations. Use the opportunity to consider Hepatitis A vaccine and HPV for girls. In this fashion, you will also be able to provide recommended well visits to your adolescent patients—thereby improving patient care and your practice’s financial performance.

To achieve acceptable financial results, you must not make the mistake of ordering vaccines at inflated prices. Paying list price for these vaccines or obtaining them via a supplier or distributor is almost never a good idea. It’s great for medical supplies but typically expensive for vaccines. Furthermore the vast majority of hospital group contracts typically provide no or minimal vaccine discounts. The best prices for the Adacel and Menactra vaccines can be obtained through a physician buying group.

Whether you affiliate with Atlantic Health Partners, which has a partnership with TAFP, or another program, these contracts are seamless in that you continue to order directly from the manufacturer and have the support of your local Sanofi Pasteur representative, with respect to Adacel and Menactra.

While we are not always completely satisfied with managed care vaccine reimbursement, you can certainly improve your margins by lowering your vaccine costs. In general, practices participating in a purchasing program such as Atlantic can expect Adacel and Menactra margins of 20 to 30 percent and 10 to 20 percent respectively, along with the additional payment for administration. Needless to say, by realizing an appropriate vaccine margin you can more confidently provide these products and help stop preventable disease.

If you would like more information about Atlantic Health Partners please contact Jeff Winokur at (800) 741-2044 or jwinokur@atlantichealthpartners.com. If you would like to discuss or review clinical aspects of these vaccines please contact me at twolynn@atlantichealthpartners.com.

Resources:

1. Pediatrics, 2005;115:1422-1427.
2. De Serres G, Shadmani R, Duval B, et al., “Morbidity of pertussis in adolescents and adults,” Journal of Infectious Disease, 2000;182:174-179.
3. Bisgard KM, Pascual FB, Ehresmann KR, et al. Infant pertussis: Who was the source? Pediatr Infect Dis J. 2004;23:985-989.