Practices of French family physicians concerning varicella
Transcription
Practices of French family physicians concerning varicella
+Model ARTICLE IN PRESS MEDMAL-3320; No. of Pages 6 Disponible en ligne sur www.sciencedirect.com Médecine et maladies infectieuses xxx (2012) xxx–xxx Original article Practices of French family physicians concerning varicella vaccination for teenagers Évaluation des pratiques des médecins généralistes concernant la vaccination contre la varicelle chez les adolescents F. Blaizeau a,∗,b , A. Lasserre a,b , L. Rossignol a,c,∗ , T. Blanchon a,b , S. Kernéis a,b , T. Hanslik a,d , D. Levy-Bruhl e a Inserm U707, 27, rue de Chaligny, 75571 Paris cedex 12, France UPMC université Paris 06, UMR S707, 27, rue de Chaligny, 75571 Paris cedex 12, France c UPMC université Paris 06, département de médecine générale, 27, rue de Chaligny, 75571 Paris cedex 12, France d UFR de médecine Paris-île-de-France-Ouest, université Versailles Saint-Quentin-en-Yvelines, 9, boulevard d’Alembert, 78280 Guyancourt, France e Unité des maladies à prévention vaccinales, département des maladies infectieuses, institut de veille sanitaire (InVS), 12, rue du Val-d’Osne, 94415 Saint-Maurice, France b Received 29 March 2012; received in revised form 18 June 2012; accepted 24 July 2012 Abstract Objectives. – The authors assessed the knowledge and practices of French family physicians concerning the application of the new 2007 varicella vaccination guidelines for non-immune teenagers, 12 to 18 years of age. They also estimated the vaccination coverage in this population. Method. – A questionnaire link was sent by to 1008 family physicians of the French Inserm Sentinel network. Each family physician had to include the last teenager aged 12 to 18 years seen in consultation, with no or uncertain history of clinical varicella. Results. – One hundred and forty-one family physicians agreed to participate and included one patient (participation rate = 14%) between 4th November 2010 and 4th January 2011. One hundred and thirty-three questionnaires out of 141 (94%) were analyzed. Three patients were vaccinated and 127 were not, giving a weak vaccination coverage in the investigated population at 2%. Eighty-nine family physicians (70%) did not know about the recommendation, and 90 (71%) declared that they had no intention to vaccinate their patient against varicella. Conclusion. – Guidelines on varicella vaccination of non-immune teenagers are poorly followed and accepted by family physicians. Vaccination coverage is very low, and efforts should be made to improve application of recommendations. © 2012 Elsevier Masson SAS. All rights reserved. Keywords: Varicella; Vaccination; Family physicians; Vaccination coverage Résumé Objectifs. – Évaluer les attitudes, les connaissances et les pratiques des médecins généralistes concernant l’application de la recommandation de 2007 de vaccination contre la varicelle des adolescents de 12 à 18 ans non immuns. Évaluer la couverture vaccinale pour la population étudiée. Méthode. – Un questionnaire électronique a été proposé aux 1008 médecins généralistes (MG) du réseau Sentinelles de l’Inserm, acceptant de participer aux études épidémiologiques qui leur sont proposées en plus de leur activité de surveillance continue de huit indicateurs de santé. Chacun devait inclure le dernier adolescent de 12 à 18 ans vu en consultation, sans antécédent connu de varicelle ou dont le statut était douteux. Résultats. – Entre le 4 novembre 2010 et le 4 janvier 2011, 141 MG ont inclus un patient, soit un taux de participation de 14 %. Cent trentetrois questionnaires sur 141 (94 %) ont pu être analysés. Trois patients étaient vaccinés et 127 n’étaient pas vaccinés ; la couverture vaccinale dans la population enquêtée est donc de 2 %. Parmi les 127 MG ayant inclus des patients non vaccinés, 89 (70 %) n’étaient pas informés de la recommandation vaccinale de 2007 et 90 (71 %) n’ont pas l’intention de vacciner leur patient. ∗ Corresponding authors. E-mail addresses: [email protected] (F. Blaizeau), [email protected] (L. Rossignol). 0399-077X/$ – see front matter © 2012 Elsevier Masson SAS. All rights reserved. http://dx.doi.org/10.1016/j.medmal.2012.07.013 Please cite this article in press as: Blaizeau F, et al. Practices of French family physicians concerning varicella vaccination for teenagers. Med Mal Infect (2012), http://dx.doi.org/10.1016/j.medmal.2012.07.013 +Model MEDMAL-3320; No. of Pages 6 2 ARTICLE IN PRESS F. Blaizeau et al. / Médecine et maladies infectieuses xxx (2012) xxx–xxx Conclusion. – Cette recommandation vaccinale semble encore mal connue et mal acceptée par les MG. La couverture vaccinale dans la population enquêtée reste très faible. Un effort de diffusion et de justification de la recommandation semble devoir être réalisé. © 2012 Elsevier Masson SAS. Tous droits réservés. Mots clés : Varicelle ; Vaccination ; Médecins généralistes ; Couverture vaccinale 1. Introduction Varicella is a very contagious disease related to a first infection by the Varicella-Zoster virus (VZV). Around 700,000 cases of varicella occur every year in France, 90% of which before 10 years of age [1]. Most of the time it is benign, but there are severe presentations the frequency of which increases with age (20 deaths per year, 70% of which in patients over 10 years of age) [2]. Severe presentations can also be observed in neonates (neonatal varicella), as well as in immuno-depressed patients, and pregnant women (risk for fetopathy). The first varicella vaccine using the OKA strain was developed by Takahashi in 1974 in Japan, where it has been used since. The United States launched a universal vaccination campaign for children in 1995, targeting the VZV using a live attenuated vaccine derived from the OKA strain, effective and safe [3]. Two types of varicella vaccine were given government approval in France in 2004. The High Council for Public Health (French acronym = HCSP) guidelines in 2004 [4] identified as target population, for this vaccination, some people without any history of varicella (or with uncertain history) and with negative serology: healthcare professionals, people working with small children, immuno-depressed patient’s close relatives, and children candidates for solid organ graft. A recommendation for vaccination in the immuno-competent adult without any history of varicella in the 3 days following exposure was also issued [4,5]. The vaccination indication was extended, in 2007, to: all teenagers from 12 to 18 years of age without any history of clinical varicella; and to women in age for child-bearing or following the first pregnancy, without any history of clinical varicella or with uncertain history, possibly after serology [5,6]. This new recommendation was justified by will to prevent future severe cases of varicella in adults not immunized by the disease during their childhood. Furthermore, the availability of varicella vaccines on the market could induce a decrease of viral circulation if an important rate of children was vaccinated, despite the July 2007 HCSP recommendation, not to vaccinate infants. The currently recommended vaccination scheme includes two injections, 1 month apart. The Inserm Sentinel Network (www.sentiweb.fr), including 1318 family physicians (FP) in metropolitan France, has monitored, among other issues, the incidence of varicella cases since 1990. Two thousands one hundred and thirty-three cases of varicella were notified and described in 2010 [7] by network physicians, 37 cases concerned teenagers from 12 to 18 years of age, or 1.7% of notified cases. Only one had been vaccinated. Thus, between 2007, date of recommendation extension, and 2010, the vaccination recommendations for teenagers from 12 to 18 years of age without any history of clinical varicella, do not seem to have been optimally implemented. Today, no study assessing vaccination practice in family medicine has ever been made in France. The vaccination coverage has not been documented either. The main objective of our study was to assess the attitudes, knowledge, and practices of FP concerning the new 2007 recommendation for the varicella vaccine in teenagers from 12 to 18 years of age, not immune, and to estimate the vaccination coverage of this population. 2. Patients and method We made an observational, national, cross-sectional, and retrospective study in metropolitan France. The study was proposed to all FP having given their and accepting to participate in studies of the Inserm Sentinel network (n = 1008). These FP were distributed all over metropolitan France. This study complies with the surveys made by the Inserm Sentinel network which were authorized by the French Data Protection Authority (notification no. 471,393, September 1996). The 9-week study began on 4th November 2010 and finished on 4th January 2011. The mail calling for participation was sent to the FP in October 2010. FP could indicate, via a link in the mail, the reasons why they did not want to participate in the study: they could specify if they refused because they were opposed to this vaccination, because they lacked time, or because they did not have any patient to include. They could indicate any other reason by writing it out in a textbox. Every physician had to include, retrospectively, the last patient (male or female) aged between 12 and 18 years of age without any documented history of varicella. The first part of the questionnaire included four questions and was common to all participants. It allowed knowing whether the participating FP was the usual physician of the included patient and to document characteristics of the included patient: age, sex, and varicella vaccination status. If the patient had been vaccinated, the FP answered questions describing how the vaccination had been initiated. If not, the FP had to give the reasons for non-vaccination and to mention his intentions to vaccinate the teenager or not. The FP was also asked to give details on serology. The statistical analysis was made with the STATA IC-11.0 software. A descriptive analysis was made on all studied variable. Any abnormal value was checked. The qualitative variables were the number of every class and its frequency. The quantitative were the average, the median, and standard deviation. Please cite this article in press as: Blaizeau F, et al. Practices of French family physicians concerning varicella vaccination for teenagers. Med Mal Infect (2012), http://dx.doi.org/10.1016/j.medmal.2012.07.013 +Model MEDMAL-3320; No. of Pages 6 ARTICLE IN PRESS F. Blaizeau et al. / Médecine et maladies infectieuses xxx (2012) xxx–xxx 3 one of the three patients had been given the two recommended doses of vaccine. 3. Results One hundred and forty-one FP filled out the online questionnaire (participation rate of 14% 141/1008) between 4th November 2010 and 4th January 2011. Five reminders were sent every 15 days for physicians who had not answered. One hundred and thirty-three out of 141 completed questionnaires were analyzed (94%). Eight others were excluded because the included patients did not meet inclusion criteria. 3.1. Characteristics of participating physicians The participating FP were distributed over 21 French regions (Metropolitan France), region of Limousin was the only region not represented. Most FP were men (n = 108, 81%). The FP average age was 52 years (±8 years) and the median 54 years [min. 31–max. 68]. 3.2. Cause of non-participation One hundred and twenty-two FP did not want to participate in the study: 54 did not give any reason (44%) and 68 explained why they did not want to participate (8% of non-answering FP 68/867). The main reasons for non-participation of these 68 FP were: absence of patients meeting inclusion criteria (n = 42, 62%), and lack of time (n = 12, 18%) (Table 1). 3.3. Patient data One hundred and thirty-three patients were included in the study, 98 (74%) had never presented with varicella according to the FP and for 35 (26%) history of varicella was uncertain. The average age of included patients was 15 years (±1.74), with a minimum of 12 years and a maximum of 18 years. More than half of included patients were between 14 and 16 years of age (56%). Three patients out of the 133 included had been vaccinated against varicella, all by the answering FP. The vaccination status was unknown for three others. The 127 patients left had never been vaccinated; 73% (93/127) did not have any known history of varicella and for 27% (34/127) the history of de varicella was uncertain (Fig. 1). The vaccination had been performed because of recommendation for this population, without any previous serology. Only Table 1 Documented reasons for non-participation in the study. Motifs renseignés de non-participation à l’étude. Reasons for non-participation n = 68 No patient meeting inclusion criteria Lack of time Changing activity Dose not wish to vaccinate against varicella Technical problems (no ADSL, etc.) Expensive vaccination for patients 42 12 6 5 2 1 3.3.1. Family physician (FP) management of non-vaccinated patients or patients with an unknown vaccination status (n = 130) 3.3.1.1. Varicella-Zoster virus (VZV) serology. Serology was performed for two out of 130 non-vaccinated patients or patients with an unknown vaccination status. The results were negative for one and the FP stated he would vaccinate this patient. The results were not available yet for the second patient when the questionnaire was filled out. The data for serology was not documented by the FP in one case. Most participating FP mentioned they would not propose any serology to the patient (n = 98, 77%) for the 127 patients without any serology, 20 FP said they would propose a serology to the patient (16%), and nine FP did not know yet when they filled out the questionnaire (7%). 3.3.1.2. Vaccination intention (for the 127 patients without any serology). Ninety FP who had not proposed VZV serology claimed they would not vaccinate their patient (90/127 = 71%), eight FP mentioned they would propose vaccination without any previous serology (6%). Twenty FP (16%) mentioned they would require serology before vaccination, 17 FP said they would vaccinate according to serology results, and three FP said they would vaccinate without waiting for serology results. Finally, nine FP were not sure they would require serology, and eight of these FP would probably vaccinate their patient. Fig. 1 illustrates the various intentions for vaccination according to the FP position for VZV serology. A maximum of 36 vaccinations could be performed for patients without any serology on the survey day, accounting for 28% of non-vaccinated patients (36/127). 3.4. Consequences in terms of vaccination coverage We considered two extreme scenarii with the collected results on participating FP’s vaccination intentions in Fig. 1: a pessimistic one and an optimistic one allowing the assessment of vaccination coverage for the patients included in the study. In the pessimistic scenario, the intentions of physicians to vaccinate, but who had not taken any steps for varicella vaccination or for serology, will not be implemented. Only five of the 133 included patients were or will very likely be vaccinated (3.8%). These five patients correspond to the three vaccinated ones and to the two for whom serology was performed. For the one with a negative serology, vaccination was considered, and for the one expecting results, we may suppose he will be vaccinated if the result is negative, even though the physician did not state his intention for vaccination. In the optimistic scenario, the intentions of physicians for vaccination or serology will be implemented. The final vaccination coverage will depend on serological results. A maximum of 41 teenagers could be vaccinated (31%), if all serologies were negatives. These 41 patients (out of 133) include the five patients mentioned in the first scenario plus 36 in Fig. 1 corresponding to FP considering vaccination without serology (n = 8), or after Please cite this article in press as: Blaizeau F, et al. Practices of French family physicians concerning varicella vaccination for teenagers. Med Mal Infect (2012), http://dx.doi.org/10.1016/j.medmal.2012.07.013 +Model MEDMAL-3320; No. of Pages 6 4 ARTICLE IN PRESS F. Blaizeau et al. / Médecine et maladies infectieuses xxx (2012) xxx–xxx Fig. 1. Vaccination intentions for 130 non-vaccinated patients or patients with unknown vaccination status. Intentions de vaccinations parmi les 130 sujets non vaccinés ou de statut vaccinal inconnu. serology, if they decide to prescribe it (n = 8), or after serology which they mentioned they would prescribe later (n = 20). If all the serologies were positive, the 28 patients who would maybe or probably be prescribed serological tests and who the FP will decide to vaccinate according to results should be removed from denominator as well as for numerator. The final vaccination coverage would then be (41–28)/(133–28) that is 13/105 or 12.4%. 3.5. Causes of non-vaccination (n = 127 non-vaccines) The main reason for non-vaccination, as reported by FP, was the ignorance of varicella vaccination recommendation for potentially non-immune teenagers (70%), followed by the physician’s opposition to varicella vaccination (22%). Six physicians (5%) reported refusal by parents as a cause for non-vaccination. The four left gave other reasons (3%). 4. Discussion The main conclusion of this study is that the 2007 varicella vaccination recommendations for non-immune teenagers between 12 and 18 years of age are neither well-applied nor well-known by FP. This study allowed determining the position of FP on varicella vaccination recommendations for non-immune teenagers between 12 and 18 years of age. One hundred and thirty-three patients were included, only 2% of these were vaccinated and 69% of physicians having included non-vaccinated teenagers had no intention of vaccinating their patient (a priori eligible for vaccination since without any known history of clinical varicella). The vaccination coverage of these teenagers should, after implementing all clinical measures (prescription of vaccination with or without prior serology) range between 4% and 31%, according to the degree of true implementation and proportion of negative serologies. Two elements support a final coverage closer to the lower range. First, the rate of non-varicella immune teenagers is expected to be low, even without prior history of varicella known by the physician. But the vaccination coverage increases with the proportion of seronegative cases, with the reasonable hypotheses that seronegative teenagers are vaccinated. Second, only two of the 130 FP having examined teenagers in consultation without proof of varicella vaccination prescribed a serology; this may lead to doubt their true motivation for varicella serology and the vaccination. Furthermore, some of these teenagers will probably not consult again in, the months or years to come. More globally, the low rate of Sentinel FP participation may be interpreted as a lack of interest for these new vaccination Please cite this article in press as: Blaizeau F, et al. Practices of French family physicians concerning varicella vaccination for teenagers. Med Mal Infect (2012), http://dx.doi.org/10.1016/j.medmal.2012.07.013 +Model MEDMAL-3320; No. of Pages 6 ARTICLE IN PRESS F. Blaizeau et al. / Médecine et maladies infectieuses xxx (2012) xxx–xxx recommendations. Usually, this type of study made with the Inserm Sentinel network has an FP participation rate of around 30% [8,9]. Indeed, some FP mentioned during telephone or mail conversations upstream of the study, that they did not wish to participate simply because they did not consider vaccinating teenagers against varicella. The reasons for non-vaccination mentioned by FP allow stating that a lot of participating FP did not know about these recommendations (70%) and/or were opposed to this vaccination (22%). Only 5% of physicians mentioned parental refusal. This lack of participants is also related to the lack of teenagers not having presented with varicella before 12 years of age. Indeed, at this age, close to 90% of the population is immune [6]. A lot of physicians did not have any patients to include in the study (42/68 = 62% of the FP having declared a reason for non-participation). This data shows that 70% of participating FP did not know about varicella vaccination recommendations and that only 3.8% of FP vaccinated or required serology for teenagers eligible for vaccination (Table 1). It raises questions on the distribution of new recommendations and on available tools for physicians to be informed. The opposition to varicella vaccination for teenagers is probably related to the fear of physicians — or of the family — to vaccinate against a disease considered as benign, even for a teenager. There seems to be a misunderstanding, on the part of FP, on the objectives of vaccination for non-immune teenagers: indeed, vaccination has for essential aim to prevent varicella in adults and thus to decrease the incidence of severe presentations and of deaths due to the disease (around 20 deaths per year currently, two thirds of which occur in patients more than 10 years of age) [1]. In France, the seroprevalence data according to age allow estimating that around 300,000 individuals between 15 and 19 years of age, in the 2009–2010 period, were not vaccinated against varicella [10]. The reimbursement data for the social security system shows that only 2750 doses of varicella vaccine were reimbursed for this age range in 2009 or 2010 (data not available for 2008); this correlates to our study results. The USA have been vaccinating against varicella since 1995; the good vaccination coverage in this country has lead to an important decrease of the disease incidence between 76 and 86% and up to 91% in some areas. The varicella death rate has also decreased from 105 deaths per year before vaccination to six deaths in 2002 [11]. In Europe, only Germany, Austria, Poland, Luxemburg, Italy, and Cyprus have added varicella vaccination to the routine vaccination schedule for children. Several epidemiological studies and clinical trials have proved the great effectiveness and good safety of varicella vaccines; Varilix® (100% of seroconversion after two vaccine doses) and Varivax® (99% of seroconversion after two vaccine doses) [6]. The effectiveness is the greatest when the vaccination scheme is respected; that is after administration of two vaccine doses [6,11]. Accepting serological tests and knowing about the patient’s immune status was also questioned. Indeed, 127 patients, out of the 130 non-vaccinated whose immune status was doubtful, did not undergo any serological tests (not documented for two) and for 90 (72%) the FP stated he would not vaccinate his patient. 5 A contrario, three of the 20 FP having the intention to propose serological tests, indicated they would vaccinate without waiting fore results (15%), a rather incoherent position leading to doubt the reliability of these answers. Our study, even if somewhat limited for sample size and representativeness of participating physicians, allowed documenting the application of varicella vaccination recommendations for teenagers. It raises the question of the gap between vaccination recommendations and their implementation. In 1996, Pathman et al. [12] developed a concept of four steps required for the application of new recommendations, especially concerning vaccination of children. These four steps include information, acceptation, adoption, and adhesion. The last step is defined by application of recommendations to more than 90% of patients. Mickan et al. made a meta-analysis, based on this model, on the follow-up of recommendations in the USA in 2011, for various medical domains, and concluded on the loss of physician adhesion (15%) when going from one step to the other [13]. Furthermore, in 2005, Oster et al. [14] made a study with the objective to assess attitudes and practice of FP and pediatricians for vaccination of teenagers, and to assess obstacles contributing to a low rate of vaccination. The results were that most physicians having answered declared recommending appropriate vaccinations during preventive checkups for children, whereas older teenagers were less susceptible to be targeted by administration for all recommended vaccinations. These results prove that the perception of disease risk is still insufficient for physicians. Our study confirms that, concerning varicella vaccination for nonimmune teenagers by FP, there is a deficit at each step: lack of information, of understanding epidemiological implications, of acceptation, and of implementation. Some tools facilitating the implementation and updating of the patient’s vaccination status in family medicine appear to be necessary. The authors of a study in the USA reported that using a computerized medical file (French acronym = DMI) would increase the opportunity to update pediatric vaccinations with vaccinations performed earlier [15]. Likewise, a tool was set up in a rheumatology unit, reminding physicians when immuno-depressed patients needed to be vaccinated against the pneumococcus and influenza (electronic clinical reminder) [16]. The physicians had to either prescribe the vaccine or mention reasons for non-vaccination in the computerized alert system. These two studies revealed a significant increase of vaccination coverage rate due to using these computerized alert system. Other solutions have been proposed to improve the update of vaccination status, such as taking advantage of all contacts with healthcare units, including for an acute disease, to vaccinate, implement yearly audits assessing vaccination practices, or meeting among peers to discuss vaccination recommendations, using the telephone, e-mails, or instant messages to set up consultation appointments for vaccination. The impact of using such tools in France needs to be assessed. Our study stresses the need to perform studies with vaccinating physicians before modifying the vaccination schedule so as to identify possible obstacles for the implementation of new vaccination strategies and to better take into account constraints for Please cite this article in press as: Blaizeau F, et al. Practices of French family physicians concerning varicella vaccination for teenagers. Med Mal Infect (2012), http://dx.doi.org/10.1016/j.medmal.2012.07.013 +Model MEDMAL-3320; No. of Pages 6 6 ARTICLE IN PRESS F. Blaizeau et al. / Médecine et maladies infectieuses xxx (2012) xxx–xxx vaccinating physicians. The HCSP’s decision to perform a survey in 2011 on a sample of FP and pediatricians, before strongly modifying the vaccination schedule, is a very encouraging element. Disclosure of interest The authors have not supplied their declaration of conflict of interest. Acknowledgements We thank all participating general practitioners of the Sentinelles network. 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Med Mal Infect (2012), http://dx.doi.org/10.1016/j.medmal.2012.07.013