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Low Proportion of High School Senior Athletes Receiving Recommended Immunizations Ashley Rowatt Karpinos MD, MPH, Katherine H. Rizzone MD, Sarah P. Cribbs MD & Christianne L. Roumie MD, MPH To cite this article: Ashley Rowatt Karpinos MD, MPH, Katherine H. Rizzone MD, Sarah P. Cribbs MD & Christianne L. Roumie MD, MPH (2014) Low Proportion of High School Senior Athletes Receiving Recommended Immunizations, The Physician and Sportsmedicine, 42:2, 71-78 To link to this article: http://dx.doi.org/10.3810/psm.2014.05.2059
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C L I N I C A L F E AT U R E S
Low Proportion of High School Senior Athletes Receiving Recommended Immunizations
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DOI: 10.3810/psm.2014.05.2059
Ashley Rowatt Karpinos, MD, MPH 1,2 Katherine H. Rizzone, MD 1–3 Sarah P. Cribbs, MD 1,2 Christianne L. Roumie, MD, MPH 1,3 Section of Internal Medicine and Pediatrics, Department of General Internal Medicine and Public Health; 2 Division of Sports Medicine, Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN; 3 Geriatric Research Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, TN 1
Abstract
Background: The preparticipation physical evaluation (PPE) often serves as the only preventive health care visit for athletes, but immunization status is not uniformly addressed in such visits. Thus, athletes may not be receiving recommended immunizations. Our aim was to determine the proportion of high school senior athletes who received all recommended immunizations. Hypothesis: Our hypothesis was that females would be less likely than males to receive all recommended immunizations given suboptimal human papillomavirus (HPV) vaccine uptake. Methods: We conducted a cross-sectional survey evaluation of the immunization status of high school senior athletes in Davidson County, TN. The primary composite outcome was receipt of recommended immunizations for tetanus, meningococcal, and seasonal influenza. For females, the primary outcome also included completion of the HPV series. Results: A total of 162 participants, 104 males and 58 females, were included. More males than females received all recommended immunizations (15.4% vs 3.5%; P = 0.02). When HPV immunization was excluded from the composite outcome, there was no difference in the proportion of males and females who received all recommended immunizations (15.4% vs 15.5%; P = 0.98). The odds of receiving all recommended immunizations was 0.14 (95% CI, 0.03–0.72) for females compared with males when adjusted for covariates. Athletes seen at retail-based clinics for their PPE were less likely to receive all recommended immunizations compared with athletes seen in primary care (OR, 0.13; 95% CI, 0.02–0.69). Conclusions: Only 1 in 6 high school senior athletes received the recommended tetanus, meningococcal, and influenza immunizations. A lower proportion of females, only 1 in 28, received all recommended immunizations due to the HPV series. Policy changes requiring a review of immunizations at the PPE would benefit many high school athletes. Keywords: adolescents; athletes; illness prevention; immunizations; vaccines
Introduction
Correspondence: Ashley Rowatt Karpinos, MD, MPH, Primary Care Sports Medicine Fellow, Vanderbilt University Medical Center, 7th Floor, Medical Center East, North Tower, Suite II, Nashville, TN 37232-8550. Tel: 615-936-1969 Fax: 615-936-3224 E-mail: [email protected]
Athletes are usually required to have a preparticipation physical evaluation (PPE) prior to participation in high school athletics. The American Academy of Pediatrics (AAP) recommends addressing immunization status at the PPE,1 but athletes may use a retail-based clinic, sports medicine clinic, health department, or a primary care provider for this service. Several of the immunizations recommended during adolescence by the AAP and the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention,2 such as tetanus, meningococcal, seasonal influenza, and human papillomavirus (HPV) vaccines, are not uniformly required for school enrollment.3 Although the PPE is not intended to replace the annual routine health screening examination recommended for adolescents,4 it may be the only
© The Physician and Sportsmedicine, Volume 42, Issue 2, May 2014, ISSN – 0091-3847 71 ResearchSHARE®: www.research-share.com • Permissions: [email protected] • Reprints: [email protected] Warning: No duplication rights exist for this journal. Only JTE Multimedia, LLC holds rights to this publication. Please contact the publisher directly with any queries.
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Karpinos et al
preventive health care visit for adolescent athletes5,6; thus, the PPE offers a unique opportunity to review immunization status for adolescents. Collegiate athletes and college-bound high school athletes have more and riskier alcohol use,7–9 more smokeless tobacco use,7 less seatbelt use,7 less helmet use,7 and a lower perceived risk than non-athletes.8 Additionally, among older adolescents, participation in athletics is associated with an increase in high-risk sexual behaviors, such as increased number of partners,7,8,10 which raises the risk of acquiring sexually transmitted infections. The most commonly transmitted sexual infection in the United States is HPV and the HPV vaccine is efficacious for prevention of HPV-related infection and disease.11 In 2007, the AAP12 and the ACIP11 began recommending routine immunization with a HPV vaccine for females; however, vaccine uptake has generally been suboptimal.13 Our objective was to determine the proportion of high school senior athletes who received all recommended immunizations. Our hypothesis was that the proportion of females who received all recommended immunizations would be lower than males, and that the proportion of female senior athletes who received HPV immunization would be less than that of the general population of adolescents in Tennessee.
Materials and Methods Study Design and School Participation
We conducted a cross-sectional evaluation of immunization status among high school senior athletes. Eligible students were attendees at a convenience sample of high schools who participated in the Vanderbilt Sports Medicine Outreach Program during the 2010–2011 academic year. The Vanderbilt Sports Medicine Outreach Program is an established community connection through which certified athletic trainers provide daily medical coverage of athletic events at public and private high schools in the Nashville metropolitan area. During the 2010–2011 academic year, there were 15 public schools and 3 private coeducational schools in Davidson County, Tennessee that participated in the outreach program. All 15 public schools and 2 of the private schools participated in our study. All participating schools provided written approval of the project. All parents were given an informed consent document. The Institutional Review Board at Vanderbilt University approved the study.
Population and Data Collection
Surveys were distributed in October and November of 2010 to parents of high school senior athletes who were participating 72
in any sport during the 2010–2011 academic year. Surveys were distributed and collected at team meetings, practices, and competitions by certified athletic trainers. The survey included a cover letter stating parental participation was voluntary. Athletes whose parents completed the survey were compensated with a PowerBar. Surveys were excluded if the age of the athlete was not reflective of a typical high school senior student (aged , 16 or . 20 years), or if , 75% of the survey items were completed.
Survey Development
We developed a single-page survey to assess immunization status and health care utilization (Appendix). The survey assessed for immunizations recommended for adolescents by the AAP and the ACIP as of Fall 2010,14 including tetanus (Td or TdaP), quadrivalent meningococcal conjugate vaccine (MCV4), seasonal influenza vaccine, and the quadrivalent or bivalent, HPV4 or HPV2 vaccine. In 2010, recommendations included HPV immunization routinely for females only and a single dose of MCV4.14 The survey also garnered demographic characteristics, timing of most recent PPE, type of health care provider seen at most recent PPE (primary care physician, sports medicine physician, health department, retail-based clinic, other, unsure), type of health care provider seen most often, and zip code of residence. The survey asked which sport(s) the athlete played. All sports were subsequently categorized by season. Fall sports were: cheerleading, cross country, football, golf, girls’ soccer, and volleyball. Winter sports were: basketball, bowling, swimming, and wrestling. Spring sports were: baseball, lacrosse, softball, boys’ soccer, and track and field. Principal factor analysis of the survey returned 1 factor, which explained 74% of the variance. The Crohnbach α of the 8 survey items was 0.52.
Outcome Measures
The primary study outcome was a gender-specific composite of receipt of all recommended immunizations. For males, this included a dose of any tetanus vaccine within the last 10 years, a single dose of meningococcal conjugate vaccine ever, and a dose of seasonal influenza vaccine within the past 12 months. For females, the primary outcome also included completing a 3-dose series of the HPV vaccine. The secondary study outcome was to determine if the proportion of female athletes receiving HPV immunization in our sample was similar to that of female adolescents in the general population in Tennessee. Thus we compared the proportion of adolescents in our study sample who received
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Immunizations in High School Athletes
each immunization to the proportion of adolescents in Tennessee and the United States in 2010 who received each immunization as reported by the National Immunization Survey-Teen.15
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Covariates
Important covariates were selected a priori for inclusion in our model, including age, self-reported race (combined into the following categories for analyses: white, black, and other), type of health care provider seen at most recent PPE (primary care physician, sports medicine physician, retail-based clinic, and health department/other/unknown), and parental income divided into tertiles (# $34 000, $34 001–$44 999, and $ $45 000). Estimated parental income was derived based on respondents’ zip code using 2000 US Census Bureau data for median household income in 1999 USD.16 For 6 respondents, estimated parental income was unavailable, and the median household income for Davidson County in 2000 was used in these cases.
Statistical Analysis
Baseline characteristics were compared with a t test assuming equal variances, Pearson’s Χ 2, and Fisher exact test, as appropriate. The composite outcome of receiving all recommended immunizations and the proportion receiving each recommended immunization were compared with Pearson’s Χ2 and Fisher exact test. We conducted a multivariable logistic regression model comparing receipt of all recommended immunizations among both males and females adjusting for the covariates mentioned. Odds ratios (OR) and 95% confidence intervals (95% CI) for the odds of receiving all recommended immunizations are reported. We also repeated our multivariable logistic regression model with robust standard errors clustering at the level of the school because patients who attend a particular school may be more similar to each other with respect to immunization patterns. We estimated that the proportion of males who received all recommended immunizations would be 50%. If the proportion of females who received all recommended immunizations was 18%, we estimated a sample size of 40 males and 40 females would be needed to be able to reject the null hypothesis with a power of 80% and type I error of α = 0.05.
seventy (37%) were returned, and 95% of the surveys were complete for analysis. Eight surveys were excluded from the analysis (2 surveys were , 75% complete; 6 females were aged , 16 years). One school did not return any surveys (Figure 1).
Study Sample Characteristics
The study sample included 104 males and 58 females; by gender, mean ages were 17.3 ± 0.5 and 17.1 ± 0.5 years, respectively (P = 0.01; Table 1). Of the sample population, 77% of males and 59% of females were black (P = 0.01). Sixty-four percent of males and 55% of females played a single sport (P = 0.37). Sixty-five percent of males and 64% of females played a fall sport (P = 0.64). Of the male respondents, the most common primary sports were football (64%), basketball (18%), and wrestling (8%). Of the female respondents, the most common primary sports were basketball (31%), soccer (28%), volleyball (22%), and cheerleading (10%). The majority of both male (56%) and female (76%) respondents identified a primary care provider as the health care provider seen most often for routine medical care (P = 0.12). Twenty percent of males and 17% of females used a retail-based clinic, whereas 7% of males and 2% of females used a sports medicine physician most often for routine health care. However, males and females differed with regard to the type of health care provider seen for their most recent PPE. Females used primary care (50%) and retail-based clinics Figure 1. Flow of survey distribution and return.
Results Study Flow
During the fall of 2010, 462 surveys were distributed at 17 Davidson County, Tennessee high schools. One hundred © The Physician and Sportsmedicine, Volume 42, Issue 2, May 2014, ISSN – 0091-3847 73 ResearchSHARE®: www.research-share.com • Permissions: [email protected] • Reprints: [email protected] Warning: No duplication rights exist for this journal. Only JTE Multimedia, LLC holds rights to this publication. Please contact the publisher directly with any queries.
Karpinos et al
Table 1. Survey Population Characteristics
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Characteristic Age Years (Mean ± SD) Race (%) White Black Other/Unknown Number of Sports (%) 1 2 $3 Season of Primary Sport (%) Fall Winter Spring Unknown Health Care Provider Seen Most Often (%) Primary Care Provider Sports Medicine Retail-Based Clinic Health Department/Other/ Unknown Health Care Provider Seen for Most Recent PPE (%) Primary Care Provider Sports Medicine Retail-Based Clinic Health Department/Other/ Unknown Timing of Most Recent PPE , 6 months 6–12 months . 12 months Unknown Median Annual Household Income Tertiles (%)a # $34,000 $34 001–$44 999 $ $45 000
Males
Females
P Value
n = 104
n = 58
17.3 ± 0.5
17.1 ± 0.5
0.01
11.5 77.0 11.5
31.0 58.6 10.4
0.01
64.0 32.0 4.0
55.0 38.0 7.0
0.37
65.4 26.9 5.8 1.9
63.8 32.8 1.7 1.7
55.8 6.7 20.2 17.3
75.9 1.7 17.2 5.2
28.9 23.1 33.6 14.4
50.0 39.7 8.6 1.7
73.8 18.5 4.8 2.9
77.6 22.4 0 0
35.6 34.6 29.8
32.7 27.6 39.7
0.64
0.12
0.002
0.24
Secondary Outcome: Comparison of Tennessee With General US Adolescent Population 0.42
Median household income in 2000, given in 1999 USD.16
a
(40%), whereas males used retail-based (34%), primary care (29%), and sports medicine clinics (23%) for their most recent PPE (P = 0.002). Most male (74%) and female (78%) respondents had had their most recent PPE within the last 6 months (P = 0.24). Median annual household income was similar between male and female respondents (P = 0.42).
Primary Outcome: Receipt of All Recommended Immunizations
Only 15.4% of male athletes and 3.5% of female athletes received all recommended immunizations (P = 0.02; Figure 2A). However, when receipt of the HPV vaccine series 74
was excluded, 15.5% of females received the recommended immunizations (P = 0.98). As shown in Figure 2B, similar proportion of males and females received Td or TdaP (72% and 78%, respectively; P = 0.45); MCV4 (40% and 40%, respectively; P = 0.93), and seasonal influenza (32% and 31%, respectively; P = 0.93) vaccines. Only 13% of males reported receiving $ 1 dose of HPV vaccine compared with 52% of females (P , 0.001). Two percent of males and 24% of females completed the 3-dose HPV vaccine series (P , 0.001). In a multivariable logistic regression model adjusted for age, race, type of health care provider seen at most recent PPE, and parental income, the odds of receiving all recommended immunizations was 0.14 (95% CI, 0.03–0.72) for females compared with males (Table 2). The adjusted odds of receiving all recommended immunizations was 0.13 (95% CI, 0.02–0.69) for athletes who were seen at a retail-based clinic compared with those seen by a primary care provider for their most recent preparticipation physical evaluation. The adjusted odds of receiving all recommended immunizations was similar if the athlete had had their most recent PPE completed by a primary care provider (reference), sports medicine physician (OR, 0.50; 95% CI, 0.12–2.03), or at a health department or other clinic (OR, 0.38; 95% CI, 0.07–2.16). The adjusted odds of receiving all recommended immunizations did not differ by parental income. Results were consistent in a sensitivity analysis that accounted for athlete clustering by school.
A higher proportion of our study sample received Td or TdaP immunization (74% vs 67%) compared with the general population of adolescents in Tennessee,15 but a lower proportion of our study sample received MCV4 (40% vs 51%) and seasonal influenza (31% vs 49%) immunizations (Figure 3). Fewer respondents in our sample received Td or TdaP (74% vs 81%), MCV4 (40% vs 57%), and seasonal influenza (31% vs 44%) immunizations compared with 17-year-olds in the United States.15 The proportion of females in our study sample who received $ 1 dose of a HPV vaccine was comparable to the general population of US 17-year-old females, and greater than other Tennessee adolescent females (52% vs 53% vs 33%, respectively). The proportion of females in our sample who completed the 3-dose HPV vaccine series was marginally lower than both US 17-year-old females, and adolescent females in Tennessee (24% vs 38% vs 26%, respectively).
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Immunizations in High School Athletes
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Figure 2A. Proportion of respondents receiving all recommended immunizations.
Figure 2B. Proportion of respondents receiving each recommended immunization.
*HPV vaccine among females only. Abbreviation: HPV, human papillomavirus.
Discussion
In our sample of Tennessee high school senior athletes, only 15.4% of males and 3.5% of females received all recommended immunizations. Females had lower odds of receiving all recommended immunizations compared with males when adjusted for age, race, health care provider seen at most recent PPE, and family income (OR, 0.14; 95% CI, 0.03–0.72). When we excluded HPV immunization from the composite outcome, both 15% of males and females received all recommended immunizations. Failure to complete the 3-dose HPV vaccine series is the most likely reason that fewer females than males received all recommended immunizations. The more concerning finding is that only about 1 of every 6 high school senior athletes received the recommended Td or TdaP, MCV4, and influenza immunizations. Fewer students in our sample received the MCV4 vaccine, seasonal influenza
vaccine, and the 3-dose HPV vaccine series compared with both Tennessee adolescents and US adolescents.15 Although the PPE is an important opportunity to address immunization status,1 Td or TdaP, MCV4, seasonal influenza, and HPV immunizations may be overlooked because they are not uniformly required for school entry or participation in athletics.3 The second finding of our study was that high school senior athletes who had had their most recent PPE at a retailbased clinic had lower odds of receiving all recommended immunizations compared with athletes who had had their most recent PPE with a primary care provider (OR, 0.13; 95% CI, 0.02–0.69). The availability and use of retail-based clinics is increasing17 and has grown from only 60 in 200618 to 1355 in 2012.19 Most retail-based clinics are equipped to provide immunizations,20 however, immunization status is
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Table 2. Proportion, Unadjusted, and Adjusted ORs of Respondents Receiving All Recommended Immunizations
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Characteristic N + 159
Gender Male Female Race White Black Other Health Care Provider Seen for Most Recent PPE PCP Sports Medicine Retail-Based Clinic Health Department/Other/Unknown Median Annual Household Incomes # $34 000 $34 001–$44 999 $ $45 000
Complete Immunizations,a Incomplete n (%) (n = 18) Immunizations, n (%) (n = 141)
Unadjusted OR (95% CI)b
Adjusted ORb,c (95% CI)
16 (89) 2 (11)
85 (60) 56 (40)
Reference 0.19 (0.04–0.86)
Reference 0.14 (0.03–0.72)
4 (22) 13 (72) 1 (6)
26 (18) 101 (72) 14 (10)
Reference 0.84 (0.25–2.78) 0.46 (0.05–4.56)
Reference 0.92 (0.19–4.35) 0.80 (0.06–10.9)
10 (56) 4 (22) 2 (11) 2 (11)
49 (35) 24 (17) 54 (38) 14 (10)
Reference 0.82 (0.23–2.87) 0.18 (0.04–0.87) 0.70 (0.14–3.57)
Reference 0.50 (0.12–2.03) 0.13 (0.02–0.69) 0.38 (0.07–2.16)
5 (28) 6 (33) 7 (39)
49 (35) 45 (32) 47 (33)
Reference 1.31 (0.37–4.58) 1.46 (0.43–4.92)
Reference 1.21 (0.30–4.84) 1.66 (0.39–7.03)
Tetanus immunization within 10 years, meningococcal immunization ever, influenza immunization within 12 months, and 3 doses of HPV immunization (females only). Bolded text indicates the CI does not include 1, thus stastically significant. c Logistic regression model for the odds of complete immunization status adjusted for age, race, health care provider seen for most recent preparticipation physical evaluation, and parental income. N = 159 because race was unknown for 3 respondents. d Median household income as of 2000, in 1999 USD.16 Abbreviations: CI, confidence interval; OR, odds ratio; PCP, primary care provider; PPE, preparticipation physical evaluation. a
b
not necessarily reviewed during the PPE. As the PPE may be the only preventive health care visit for some adolescents,5,6 it is an important opportunity for physicians to address the health care needs of adolescents. Policy changes requiring a review of immunizations for athletic participation could help to increase the uptake of vaccines and proportion of high school athletes who receive all recommended immunizations. A strength of our study is that we surveyed a representative sample of students living in the community. Some of the athletes did not have health insurance or receive preventive health care through mainstream primary care resources, therefore, our participants may more accurately represent the immunization status of athletes attending predominantly public high schools. We were also able to assess the type of health care provider high school athletes see for PPEs when primary care providers are not providing this service. Our study was cross-sectional in nature, and therefore has certain limitations. We cannot infer causality of athletics participation on immunization status. We relied on parents of high school senior athletes rather than medical records, to determine whether an athlete received recommended immunizations, which may have introduced information bias. Parents were used as the source of information to evaluate immunization status because our participant athlete population may not have used a consistent health care 76
provider for all medical encounters. The use of medical records to determine immunization status from local health care providers would have introduced selection bias towards adolescent athletes who were more likely to have had health insurance and received consistent health care through mainstream sources. Additionally, we only had a 37% response rate from our target population. There may have been a responder bias such that parents who completed the survey were more likely to know which immunizations their child had received and to have a child that had received recommended immunizations. If such selection bias existed, then the respondent sample may actually be an overestimate of the proportion of athletes with complete immunization status. Finally, our study sample may have had selection bias because we distributed our survey during the fall. Athletic trainers generally have the most contact with athletes who participate in fall sports, of which football typically has the largest roster; therefore our sample included a high proportion of males, blacks, and other athletes whose primary sport occurred during the fall season. Among US high school senior athletes, only 1 in 6 males and 1 in 28 females received all recommended immunizations. Fewer females than males received all recommended immunizations due to suboptimal uptake of the HPV
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Figure 3. Proportion of respondents receiving each recommended immunization compared to adolescents in Tennessee and the United States.15
*Aged 13–17 years in 2010.15 † Aged 17 years in 2010.15 ‡ Aged 6 months–7 years in 2009–2010 influenza season.21 § Among females respondents only. Abbreviation: HPV, human papillomavirus.
vaccine. As health care providers for adolescents, it is our responsibility to ensure that immunization status is addressed at all clinical encounters. Families and practitioners should be made aware that the PPE does not serve as a substitute for a routine health screening examination. However, policy changes requiring a review of immunizations at the PPE would benefit many high school students.
Acknowledgments
This work was supported by the Veterans Affairs National Quality Scholars Program with use of facilities at Veterans Health Administration Tennessee Valley Healthcare System, Nashville, Tennessee. The project described was supported by the National Center for Research Resources, Grant UL1 RR024975-01, and is now at the National Center for Advancing Translational Sciences, Grant 2 UL1 TR000445-06. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. We thank the Vanderbilt Sports Medicine Outreach Program for assisting with survey administration.
Conflict of Interest Statement
Ashley Rowatt Karpinos, MD, MPH, Katherine H. Rizzone, MD, Sarah P. Cribbs, MD, and Christianne L. Roumie, MD, MPH, disclose no conflicts of interest.
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14. Centers for Disease Control and Prevention. Recommended immunization schedules for persons aged 0 through 18 years—United States, 2010. MMWR Morb Mortal Wkly Rep. 2010;58(51–52):1–4. 15. National and state vaccination coverage among adolescents aged 13 through 17 years—United States, 2010. MMWR Morb Mortal Wkly Rep. 2011;60(33):1117–1123. 16. United States Census Bureau. http://factfinder2.census.gov/legacy/ aff_sunset. html. Accessed August 10, 2011. 17. Weinick RM, Betancourt RM. No Appointment Needed: The Resurgence of Urgent Care Centers in the United States. Oakland, CA: California Healthcare Foundation; 2007. 18. Tu HT, Cohen GR. Checking Up on Retail-Based Health Clinics: Is the Boom Ending? The Commonwealth Fund; 2008:48. 19. Medicine Medicine. http://www.merchantmedicine.com/home.cfm. Accessed June 22, 2012. 20. Rudavsky R, Pollack CE, Mehrotra A. The geographic distribution, ownership, prices, and scope of practice at retail clinics. Ann Intern Med. 2009;151(5):315–320. 21. Centers for Disease Control and Prevention. http://www.cdc.gov/flu/ fluvaxview/earlier-seasons.htm. Accessed November 29, 2011.
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Appendix. Example of Survey
School Code: ID: Child’s school___________________ Child’s home zip code: _________ Child’s age: _________ Sport(s):___________________ Child’s gender (circle one): Male Female Child’s race (circle one): White Black/African American Asian American Indian Asian Indian Other Do you consider your child to be Hispanic or Latino? No Yes 1. What type of health care provider does your child see for basic health care most often? a. Primary Care Provider (Pediatrician, Family Practice doctor, Nurse Practitioner) b. Sports Medicine doctor c. Health Department e. Don’t know d. Walk-in Clinic (ex. drug store or urgent care) f. Other _____________________________ 2. When was the last time your child had a sports physical or annual check-up? a. Within 6 months b. 6–12 months ago c. Over 1 year ago d. Don’t know 3. What type of health care provider did your child see for their last sports physical or annual check-up? a. Primary Care Provider (Pediatrician, Family Practice doctor, Nurse Practitioner) b. Sports Medicine doctor c. Health Department e. Don’t know d. Walk-in Clinic (ex. drug store or urgent care) f. Other _____________________________ 4. When was your child’s last tetanus shot? A shot to protect against tetanus is recommended at 11–12 years old and every 10 years. It is called the Tetanus, diphtheria, and acellular pertussis vaccine (Tdap) or tetanus and diphtheria toxoid (Td). a. Within the last year b. Within the last 1–5 years c. Within the last 6–10 years d. Don’t know 5. Has your child received the meningitis shot? A shot to help prevent meningitis is recommended for all teenagers over 11 years old. It is called the meningococcal conjugate vaccine, or MCV4. a. Yes b. No c. Don’t know 6. Has your child ever received a dose of the Human Papillomavirus (HPV) vaccine? The HPV vaccine is recommended for all girls 11 years and older and is optional for boys. The vaccine helps to prevent genital warts and cervical cancer in girls. It is 3 shots given over 6 months. It is also called “the cervical cancer shot,” Gardasil, or Cervarix. a. Yes b. No c. Don’t know 7. How many doses of the HPV vaccine did your child receive? a. None b. at least 1 dose c. at least 2 doses d. all 3 doses e. Don’t know 8. Did your child receive a seasonal flu shot (not H1N1 or swine flu) last year? The flu shot, or influenza vaccine, is recommended every year during flu season (November–May) for all teenagers. a. Yes b. No c. Don’t know © The Physician and Sportsmedicine, Volume 42, Issue 2, May 2014, ISSN – 0091-3847 79 ResearchSHARE®: www.research-share.com • Permissions: [email protected] • Reprints: [email protected] Warning: No duplication rights exist for this journal. Only JTE Multimedia, LLC holds rights to this publication. Please contact the publisher directly with any queries.
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Low Proportion of High School Senior Athletes Receiving Recommended Immunizations Ashley Rowatt Karpinos MD, MPH, Katherine H. Rizzone MD, Sarah P. Cribbs MD & Christianne L. Roumie MD, MPH To cite this article: Ashley Rowatt Karpinos MD, MPH, Katherine H. Rizzone MD, Sarah P. Cribbs MD & Christianne L. Roumie MD, MPH (2014) Low Proportion of High School Senior Athletes Receiving Recommended Immunizations, The Physician and Sportsmedicine, 42:2, 71-78 To link to this article: http://dx.doi.org/10.3810/psm.2014.05.2059
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C L I N I C A L F E AT U R E S
Low Proportion of High School Senior Athletes Receiving Recommended Immunizations
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DOI: 10.3810/psm.2014.05.2059
Ashley Rowatt Karpinos, MD, MPH 1,2 Katherine H. Rizzone, MD 1–3 Sarah P. Cribbs, MD 1,2 Christianne L. Roumie, MD, MPH 1,3 Section of Internal Medicine and Pediatrics, Department of General Internal Medicine and Public Health; 2 Division of Sports Medicine, Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN; 3 Geriatric Research Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, TN 1
Abstract
Background: The preparticipation physical evaluation (PPE) often serves as the only preventive health care visit for athletes, but immunization status is not uniformly addressed in such visits. Thus, athletes may not be receiving recommended immunizations. Our aim was to determine the proportion of high school senior athletes who received all recommended immunizations. Hypothesis: Our hypothesis was that females would be less likely than males to receive all recommended immunizations given suboptimal human papillomavirus (HPV) vaccine uptake. Methods: We conducted a cross-sectional survey evaluation of the immunization status of high school senior athletes in Davidson County, TN. The primary composite outcome was receipt of recommended immunizations for tetanus, meningococcal, and seasonal influenza. For females, the primary outcome also included completion of the HPV series. Results: A total of 162 participants, 104 males and 58 females, were included. More males than females received all recommended immunizations (15.4% vs 3.5%; P = 0.02). When HPV immunization was excluded from the composite outcome, there was no difference in the proportion of males and females who received all recommended immunizations (15.4% vs 15.5%; P = 0.98). The odds of receiving all recommended immunizations was 0.14 (95% CI, 0.03–0.72) for females compared with males when adjusted for covariates. Athletes seen at retail-based clinics for their PPE were less likely to receive all recommended immunizations compared with athletes seen in primary care (OR, 0.13; 95% CI, 0.02–0.69). Conclusions: Only 1 in 6 high school senior athletes received the recommended tetanus, meningococcal, and influenza immunizations. A lower proportion of females, only 1 in 28, received all recommended immunizations due to the HPV series. Policy changes requiring a review of immunizations at the PPE would benefit many high school athletes. Keywords: adolescents; athletes; illness prevention; immunizations; vaccines
Introduction
Correspondence: Ashley Rowatt Karpinos, MD, MPH, Primary Care Sports Medicine Fellow, Vanderbilt University Medical Center, 7th Floor, Medical Center East, North Tower, Suite II, Nashville, TN 37232-8550. Tel: 615-936-1969 Fax: 615-936-3224 E-mail: [email protected]
Athletes are usually required to have a preparticipation physical evaluation (PPE) prior to participation in high school athletics. The American Academy of Pediatrics (AAP) recommends addressing immunization status at the PPE,1 but athletes may use a retail-based clinic, sports medicine clinic, health department, or a primary care provider for this service. Several of the immunizations recommended during adolescence by the AAP and the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention,2 such as tetanus, meningococcal, seasonal influenza, and human papillomavirus (HPV) vaccines, are not uniformly required for school enrollment.3 Although the PPE is not intended to replace the annual routine health screening examination recommended for adolescents,4 it may be the only
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Karpinos et al
preventive health care visit for adolescent athletes5,6; thus, the PPE offers a unique opportunity to review immunization status for adolescents. Collegiate athletes and college-bound high school athletes have more and riskier alcohol use,7–9 more smokeless tobacco use,7 less seatbelt use,7 less helmet use,7 and a lower perceived risk than non-athletes.8 Additionally, among older adolescents, participation in athletics is associated with an increase in high-risk sexual behaviors, such as increased number of partners,7,8,10 which raises the risk of acquiring sexually transmitted infections. The most commonly transmitted sexual infection in the United States is HPV and the HPV vaccine is efficacious for prevention of HPV-related infection and disease.11 In 2007, the AAP12 and the ACIP11 began recommending routine immunization with a HPV vaccine for females; however, vaccine uptake has generally been suboptimal.13 Our objective was to determine the proportion of high school senior athletes who received all recommended immunizations. Our hypothesis was that the proportion of females who received all recommended immunizations would be lower than males, and that the proportion of female senior athletes who received HPV immunization would be less than that of the general population of adolescents in Tennessee.
Materials and Methods Study Design and School Participation
We conducted a cross-sectional evaluation of immunization status among high school senior athletes. Eligible students were attendees at a convenience sample of high schools who participated in the Vanderbilt Sports Medicine Outreach Program during the 2010–2011 academic year. The Vanderbilt Sports Medicine Outreach Program is an established community connection through which certified athletic trainers provide daily medical coverage of athletic events at public and private high schools in the Nashville metropolitan area. During the 2010–2011 academic year, there were 15 public schools and 3 private coeducational schools in Davidson County, Tennessee that participated in the outreach program. All 15 public schools and 2 of the private schools participated in our study. All participating schools provided written approval of the project. All parents were given an informed consent document. The Institutional Review Board at Vanderbilt University approved the study.
Population and Data Collection
Surveys were distributed in October and November of 2010 to parents of high school senior athletes who were participating 72
in any sport during the 2010–2011 academic year. Surveys were distributed and collected at team meetings, practices, and competitions by certified athletic trainers. The survey included a cover letter stating parental participation was voluntary. Athletes whose parents completed the survey were compensated with a PowerBar. Surveys were excluded if the age of the athlete was not reflective of a typical high school senior student (aged , 16 or . 20 years), or if , 75% of the survey items were completed.
Survey Development
We developed a single-page survey to assess immunization status and health care utilization (Appendix). The survey assessed for immunizations recommended for adolescents by the AAP and the ACIP as of Fall 2010,14 including tetanus (Td or TdaP), quadrivalent meningococcal conjugate vaccine (MCV4), seasonal influenza vaccine, and the quadrivalent or bivalent, HPV4 or HPV2 vaccine. In 2010, recommendations included HPV immunization routinely for females only and a single dose of MCV4.14 The survey also garnered demographic characteristics, timing of most recent PPE, type of health care provider seen at most recent PPE (primary care physician, sports medicine physician, health department, retail-based clinic, other, unsure), type of health care provider seen most often, and zip code of residence. The survey asked which sport(s) the athlete played. All sports were subsequently categorized by season. Fall sports were: cheerleading, cross country, football, golf, girls’ soccer, and volleyball. Winter sports were: basketball, bowling, swimming, and wrestling. Spring sports were: baseball, lacrosse, softball, boys’ soccer, and track and field. Principal factor analysis of the survey returned 1 factor, which explained 74% of the variance. The Crohnbach α of the 8 survey items was 0.52.
Outcome Measures
The primary study outcome was a gender-specific composite of receipt of all recommended immunizations. For males, this included a dose of any tetanus vaccine within the last 10 years, a single dose of meningococcal conjugate vaccine ever, and a dose of seasonal influenza vaccine within the past 12 months. For females, the primary outcome also included completing a 3-dose series of the HPV vaccine. The secondary study outcome was to determine if the proportion of female athletes receiving HPV immunization in our sample was similar to that of female adolescents in the general population in Tennessee. Thus we compared the proportion of adolescents in our study sample who received
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Immunizations in High School Athletes
each immunization to the proportion of adolescents in Tennessee and the United States in 2010 who received each immunization as reported by the National Immunization Survey-Teen.15
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Covariates
Important covariates were selected a priori for inclusion in our model, including age, self-reported race (combined into the following categories for analyses: white, black, and other), type of health care provider seen at most recent PPE (primary care physician, sports medicine physician, retail-based clinic, and health department/other/unknown), and parental income divided into tertiles (# $34 000, $34 001–$44 999, and $ $45 000). Estimated parental income was derived based on respondents’ zip code using 2000 US Census Bureau data for median household income in 1999 USD.16 For 6 respondents, estimated parental income was unavailable, and the median household income for Davidson County in 2000 was used in these cases.
Statistical Analysis
Baseline characteristics were compared with a t test assuming equal variances, Pearson’s Χ 2, and Fisher exact test, as appropriate. The composite outcome of receiving all recommended immunizations and the proportion receiving each recommended immunization were compared with Pearson’s Χ2 and Fisher exact test. We conducted a multivariable logistic regression model comparing receipt of all recommended immunizations among both males and females adjusting for the covariates mentioned. Odds ratios (OR) and 95% confidence intervals (95% CI) for the odds of receiving all recommended immunizations are reported. We also repeated our multivariable logistic regression model with robust standard errors clustering at the level of the school because patients who attend a particular school may be more similar to each other with respect to immunization patterns. We estimated that the proportion of males who received all recommended immunizations would be 50%. If the proportion of females who received all recommended immunizations was 18%, we estimated a sample size of 40 males and 40 females would be needed to be able to reject the null hypothesis with a power of 80% and type I error of α = 0.05.
seventy (37%) were returned, and 95% of the surveys were complete for analysis. Eight surveys were excluded from the analysis (2 surveys were , 75% complete; 6 females were aged , 16 years). One school did not return any surveys (Figure 1).
Study Sample Characteristics
The study sample included 104 males and 58 females; by gender, mean ages were 17.3 ± 0.5 and 17.1 ± 0.5 years, respectively (P = 0.01; Table 1). Of the sample population, 77% of males and 59% of females were black (P = 0.01). Sixty-four percent of males and 55% of females played a single sport (P = 0.37). Sixty-five percent of males and 64% of females played a fall sport (P = 0.64). Of the male respondents, the most common primary sports were football (64%), basketball (18%), and wrestling (8%). Of the female respondents, the most common primary sports were basketball (31%), soccer (28%), volleyball (22%), and cheerleading (10%). The majority of both male (56%) and female (76%) respondents identified a primary care provider as the health care provider seen most often for routine medical care (P = 0.12). Twenty percent of males and 17% of females used a retail-based clinic, whereas 7% of males and 2% of females used a sports medicine physician most often for routine health care. However, males and females differed with regard to the type of health care provider seen for their most recent PPE. Females used primary care (50%) and retail-based clinics Figure 1. Flow of survey distribution and return.
Results Study Flow
During the fall of 2010, 462 surveys were distributed at 17 Davidson County, Tennessee high schools. One hundred © The Physician and Sportsmedicine, Volume 42, Issue 2, May 2014, ISSN – 0091-3847 73 ResearchSHARE®: www.research-share.com • Permissions: [email protected] • Reprints: [email protected] Warning: No duplication rights exist for this journal. Only JTE Multimedia, LLC holds rights to this publication. Please contact the publisher directly with any queries.
Karpinos et al
Table 1. Survey Population Characteristics
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Characteristic Age Years (Mean ± SD) Race (%) White Black Other/Unknown Number of Sports (%) 1 2 $3 Season of Primary Sport (%) Fall Winter Spring Unknown Health Care Provider Seen Most Often (%) Primary Care Provider Sports Medicine Retail-Based Clinic Health Department/Other/ Unknown Health Care Provider Seen for Most Recent PPE (%) Primary Care Provider Sports Medicine Retail-Based Clinic Health Department/Other/ Unknown Timing of Most Recent PPE , 6 months 6–12 months . 12 months Unknown Median Annual Household Income Tertiles (%)a # $34,000 $34 001–$44 999 $ $45 000
Males
Females
P Value
n = 104
n = 58
17.3 ± 0.5
17.1 ± 0.5
0.01
11.5 77.0 11.5
31.0 58.6 10.4
0.01
64.0 32.0 4.0
55.0 38.0 7.0
0.37
65.4 26.9 5.8 1.9
63.8 32.8 1.7 1.7
55.8 6.7 20.2 17.3
75.9 1.7 17.2 5.2
28.9 23.1 33.6 14.4
50.0 39.7 8.6 1.7
73.8 18.5 4.8 2.9
77.6 22.4 0 0
35.6 34.6 29.8
32.7 27.6 39.7
0.64
0.12
0.002
0.24
Secondary Outcome: Comparison of Tennessee With General US Adolescent Population 0.42
Median household income in 2000, given in 1999 USD.16
a
(40%), whereas males used retail-based (34%), primary care (29%), and sports medicine clinics (23%) for their most recent PPE (P = 0.002). Most male (74%) and female (78%) respondents had had their most recent PPE within the last 6 months (P = 0.24). Median annual household income was similar between male and female respondents (P = 0.42).
Primary Outcome: Receipt of All Recommended Immunizations
Only 15.4% of male athletes and 3.5% of female athletes received all recommended immunizations (P = 0.02; Figure 2A). However, when receipt of the HPV vaccine series 74
was excluded, 15.5% of females received the recommended immunizations (P = 0.98). As shown in Figure 2B, similar proportion of males and females received Td or TdaP (72% and 78%, respectively; P = 0.45); MCV4 (40% and 40%, respectively; P = 0.93), and seasonal influenza (32% and 31%, respectively; P = 0.93) vaccines. Only 13% of males reported receiving $ 1 dose of HPV vaccine compared with 52% of females (P , 0.001). Two percent of males and 24% of females completed the 3-dose HPV vaccine series (P , 0.001). In a multivariable logistic regression model adjusted for age, race, type of health care provider seen at most recent PPE, and parental income, the odds of receiving all recommended immunizations was 0.14 (95% CI, 0.03–0.72) for females compared with males (Table 2). The adjusted odds of receiving all recommended immunizations was 0.13 (95% CI, 0.02–0.69) for athletes who were seen at a retail-based clinic compared with those seen by a primary care provider for their most recent preparticipation physical evaluation. The adjusted odds of receiving all recommended immunizations was similar if the athlete had had their most recent PPE completed by a primary care provider (reference), sports medicine physician (OR, 0.50; 95% CI, 0.12–2.03), or at a health department or other clinic (OR, 0.38; 95% CI, 0.07–2.16). The adjusted odds of receiving all recommended immunizations did not differ by parental income. Results were consistent in a sensitivity analysis that accounted for athlete clustering by school.
A higher proportion of our study sample received Td or TdaP immunization (74% vs 67%) compared with the general population of adolescents in Tennessee,15 but a lower proportion of our study sample received MCV4 (40% vs 51%) and seasonal influenza (31% vs 49%) immunizations (Figure 3). Fewer respondents in our sample received Td or TdaP (74% vs 81%), MCV4 (40% vs 57%), and seasonal influenza (31% vs 44%) immunizations compared with 17-year-olds in the United States.15 The proportion of females in our study sample who received $ 1 dose of a HPV vaccine was comparable to the general population of US 17-year-old females, and greater than other Tennessee adolescent females (52% vs 53% vs 33%, respectively). The proportion of females in our sample who completed the 3-dose HPV vaccine series was marginally lower than both US 17-year-old females, and adolescent females in Tennessee (24% vs 38% vs 26%, respectively).
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Immunizations in High School Athletes
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Figure 2A. Proportion of respondents receiving all recommended immunizations.
Figure 2B. Proportion of respondents receiving each recommended immunization.
*HPV vaccine among females only. Abbreviation: HPV, human papillomavirus.
Discussion
In our sample of Tennessee high school senior athletes, only 15.4% of males and 3.5% of females received all recommended immunizations. Females had lower odds of receiving all recommended immunizations compared with males when adjusted for age, race, health care provider seen at most recent PPE, and family income (OR, 0.14; 95% CI, 0.03–0.72). When we excluded HPV immunization from the composite outcome, both 15% of males and females received all recommended immunizations. Failure to complete the 3-dose HPV vaccine series is the most likely reason that fewer females than males received all recommended immunizations. The more concerning finding is that only about 1 of every 6 high school senior athletes received the recommended Td or TdaP, MCV4, and influenza immunizations. Fewer students in our sample received the MCV4 vaccine, seasonal influenza
vaccine, and the 3-dose HPV vaccine series compared with both Tennessee adolescents and US adolescents.15 Although the PPE is an important opportunity to address immunization status,1 Td or TdaP, MCV4, seasonal influenza, and HPV immunizations may be overlooked because they are not uniformly required for school entry or participation in athletics.3 The second finding of our study was that high school senior athletes who had had their most recent PPE at a retailbased clinic had lower odds of receiving all recommended immunizations compared with athletes who had had their most recent PPE with a primary care provider (OR, 0.13; 95% CI, 0.02–0.69). The availability and use of retail-based clinics is increasing17 and has grown from only 60 in 200618 to 1355 in 2012.19 Most retail-based clinics are equipped to provide immunizations,20 however, immunization status is
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Table 2. Proportion, Unadjusted, and Adjusted ORs of Respondents Receiving All Recommended Immunizations
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Characteristic N + 159
Gender Male Female Race White Black Other Health Care Provider Seen for Most Recent PPE PCP Sports Medicine Retail-Based Clinic Health Department/Other/Unknown Median Annual Household Incomes # $34 000 $34 001–$44 999 $ $45 000
Complete Immunizations,a Incomplete n (%) (n = 18) Immunizations, n (%) (n = 141)
Unadjusted OR (95% CI)b
Adjusted ORb,c (95% CI)
16 (89) 2 (11)
85 (60) 56 (40)
Reference 0.19 (0.04–0.86)
Reference 0.14 (0.03–0.72)
4 (22) 13 (72) 1 (6)
26 (18) 101 (72) 14 (10)
Reference 0.84 (0.25–2.78) 0.46 (0.05–4.56)
Reference 0.92 (0.19–4.35) 0.80 (0.06–10.9)
10 (56) 4 (22) 2 (11) 2 (11)
49 (35) 24 (17) 54 (38) 14 (10)
Reference 0.82 (0.23–2.87) 0.18 (0.04–0.87) 0.70 (0.14–3.57)
Reference 0.50 (0.12–2.03) 0.13 (0.02–0.69) 0.38 (0.07–2.16)
5 (28) 6 (33) 7 (39)
49 (35) 45 (32) 47 (33)
Reference 1.31 (0.37–4.58) 1.46 (0.43–4.92)
Reference 1.21 (0.30–4.84) 1.66 (0.39–7.03)
Tetanus immunization within 10 years, meningococcal immunization ever, influenza immunization within 12 months, and 3 doses of HPV immunization (females only). Bolded text indicates the CI does not include 1, thus stastically significant. c Logistic regression model for the odds of complete immunization status adjusted for age, race, health care provider seen for most recent preparticipation physical evaluation, and parental income. N = 159 because race was unknown for 3 respondents. d Median household income as of 2000, in 1999 USD.16 Abbreviations: CI, confidence interval; OR, odds ratio; PCP, primary care provider; PPE, preparticipation physical evaluation. a
b
not necessarily reviewed during the PPE. As the PPE may be the only preventive health care visit for some adolescents,5,6 it is an important opportunity for physicians to address the health care needs of adolescents. Policy changes requiring a review of immunizations for athletic participation could help to increase the uptake of vaccines and proportion of high school athletes who receive all recommended immunizations. A strength of our study is that we surveyed a representative sample of students living in the community. Some of the athletes did not have health insurance or receive preventive health care through mainstream primary care resources, therefore, our participants may more accurately represent the immunization status of athletes attending predominantly public high schools. We were also able to assess the type of health care provider high school athletes see for PPEs when primary care providers are not providing this service. Our study was cross-sectional in nature, and therefore has certain limitations. We cannot infer causality of athletics participation on immunization status. We relied on parents of high school senior athletes rather than medical records, to determine whether an athlete received recommended immunizations, which may have introduced information bias. Parents were used as the source of information to evaluate immunization status because our participant athlete population may not have used a consistent health care 76
provider for all medical encounters. The use of medical records to determine immunization status from local health care providers would have introduced selection bias towards adolescent athletes who were more likely to have had health insurance and received consistent health care through mainstream sources. Additionally, we only had a 37% response rate from our target population. There may have been a responder bias such that parents who completed the survey were more likely to know which immunizations their child had received and to have a child that had received recommended immunizations. If such selection bias existed, then the respondent sample may actually be an overestimate of the proportion of athletes with complete immunization status. Finally, our study sample may have had selection bias because we distributed our survey during the fall. Athletic trainers generally have the most contact with athletes who participate in fall sports, of which football typically has the largest roster; therefore our sample included a high proportion of males, blacks, and other athletes whose primary sport occurred during the fall season. Among US high school senior athletes, only 1 in 6 males and 1 in 28 females received all recommended immunizations. Fewer females than males received all recommended immunizations due to suboptimal uptake of the HPV
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Figure 3. Proportion of respondents receiving each recommended immunization compared to adolescents in Tennessee and the United States.15
*Aged 13–17 years in 2010.15 † Aged 17 years in 2010.15 ‡ Aged 6 months–7 years in 2009–2010 influenza season.21 § Among females respondents only. Abbreviation: HPV, human papillomavirus.
vaccine. As health care providers for adolescents, it is our responsibility to ensure that immunization status is addressed at all clinical encounters. Families and practitioners should be made aware that the PPE does not serve as a substitute for a routine health screening examination. However, policy changes requiring a review of immunizations at the PPE would benefit many high school students.
Acknowledgments
This work was supported by the Veterans Affairs National Quality Scholars Program with use of facilities at Veterans Health Administration Tennessee Valley Healthcare System, Nashville, Tennessee. The project described was supported by the National Center for Research Resources, Grant UL1 RR024975-01, and is now at the National Center for Advancing Translational Sciences, Grant 2 UL1 TR000445-06. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. We thank the Vanderbilt Sports Medicine Outreach Program for assisting with survey administration.
Conflict of Interest Statement
Ashley Rowatt Karpinos, MD, MPH, Katherine H. Rizzone, MD, Sarah P. Cribbs, MD, and Christianne L. Roumie, MD, MPH, disclose no conflicts of interest.
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© The Physician and Sportsmedicine, Volume 42, Issue 2, May 2014, ISSN – 0091-3847 ResearchSHARE®: www.research-share.com • Permissions: [email protected] • Reprints: [email protected] Warning: No duplication rights exist for this journal. Only JTE Multimedia, LLC holds rights to this publication. Please contact the publisher directly with any queries.
Immunizations in High School Athletes
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Appendix. Example of Survey
School Code: ID: Child’s school___________________ Child’s home zip code: _________ Child’s age: _________ Sport(s):___________________ Child’s gender (circle one): Male Female Child’s race (circle one): White Black/African American Asian American Indian Asian Indian Other Do you consider your child to be Hispanic or Latino? No Yes 1. What type of health care provider does your child see for basic health care most often? a. Primary Care Provider (Pediatrician, Family Practice doctor, Nurse Practitioner) b. Sports Medicine doctor c. Health Department e. Don’t know d. Walk-in Clinic (ex. drug store or urgent care) f. Other _____________________________ 2. When was the last time your child had a sports physical or annual check-up? a. Within 6 months b. 6–12 months ago c. Over 1 year ago d. Don’t know 3. What type of health care provider did your child see for their last sports physical or annual check-up? a. Primary Care Provider (Pediatrician, Family Practice doctor, Nurse Practitioner) b. Sports Medicine doctor c. Health Department e. Don’t know d. Walk-in Clinic (ex. drug store or urgent care) f. Other _____________________________ 4. When was your child’s last tetanus shot? A shot to protect against tetanus is recommended at 11–12 years old and every 10 years. It is called the Tetanus, diphtheria, and acellular pertussis vaccine (Tdap) or tetanus and diphtheria toxoid (Td). a. Within the last year b. Within the last 1–5 years c. Within the last 6–10 years d. Don’t know 5. Has your child received the meningitis shot? A shot to help prevent meningitis is recommended for all teenagers over 11 years old. It is called the meningococcal conjugate vaccine, or MCV4. a. Yes b. No c. Don’t know 6. Has your child ever received a dose of the Human Papillomavirus (HPV) vaccine? The HPV vaccine is recommended for all girls 11 years and older and is optional for boys. The vaccine helps to prevent genital warts and cervical cancer in girls. It is 3 shots given over 6 months. It is also called “the cervical cancer shot,” Gardasil, or Cervarix. a. Yes b. No c. Don’t know 7. How many doses of the HPV vaccine did your child receive? a. None b. at least 1 dose c. at least 2 doses d. all 3 doses e. Don’t know 8. Did your child receive a seasonal flu shot (not H1N1 or swine flu) last year? The flu shot, or influenza vaccine, is recommended every year during flu season (November–May) for all teenagers. a. Yes b. No c. Don’t know © The Physician and Sportsmedicine, Volume 42, Issue 2, May 2014, ISSN – 0091-3847 79 ResearchSHARE®: www.research-share.com • Permissions: [email protected] • Reprints: [email protected] Warning: No duplication rights exist for this journal. Only JTE Multimedia, LLC holds rights to this publication. Please contact the publisher directly with any queries.
