Practices of French family physicians concerning varicella

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MEDMAL-3320; No. of Pages 6
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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
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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.
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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
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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
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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
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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.
References
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Practices of French family physicians concerning varicella

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