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On-Site Review and Administration of

Immunizations Improves Vaccination

Compliance in Children with Cochlear Implants

Prashant S. Malhotra, MD, FAAP Director, Hearing Program Nationwide Children’s Hospital Columbus, OH

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Disclosures

None

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Meningitis In Cochlear Implants •  Spike in post-implantation bacterial meningitis noted in

2002 by FDA •  16-30x greater than healthy children •  Primarily Streptococcal pneumoniae and Haemophilus

influenzae •  Inner ear malformations, immunodeficiency, hx of VP

shunt, AOM increase risk

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Immunizations and Cochlear Implants 2000 PCV 7 licensed by FDA 2002 CDC recommends all CI recipients have PCV7 & PPSV23 2010 PCV-13 licensed, succeeds PCV-7 2010 AAP Policy Statement (focused on children <6) 2012 PCV-13 recommended for adults 2013 PCV-13 recommended for kids 6-18 yrs old regardless of

PCV-7 or PPSV 23 status

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AAP Policy Statement (2010) “Before implant surgery, PCPs and CI teams should ensure that

immunizations are up to date, preferably with completion of indicated vaccines at least 2 weeks before implant surgery.”

PCPs… •  Another visit •  Familiarity with CI-related recommendations? •  Most pediatric providers do not routinely carry Pneumovax 23 as it is

a special population/adult vaccination •  Meningococcal vs. pneumococcal confusion…

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AAP Policy Statement (2010) All CI patients need to have age appropriate doses of: •  Pneumococcal conjugate (PCV 13 or 7) •  Haemophilus influenza type b conjugate vaccines In addition, age 24 months and older, a single dose of

PPSV 23 should be administered.

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AAP Policy Statement (2010)… •  Kids 14-71 months that had all PCV 7 shots should get one dose of PCV 13 •  Everyone 6-18 y/o should have had at least 1 dose of PCV 13 •  If not previously received, all children should receive one done of PCV 13 prior

to PPSV 23 •  If they are 24-71 months, they should receive 2 doses of PCV 13 if 2 doses or

less were given prior to 24 months •  If they had 3 doses PCV 7/13 under age 24 months, need one more dose if

under 6 •  Annual influenza vaccine recommended

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So how were we doing? •  56% rate (Ou 2010, US - Washington state) •  46% (Moore 2012, UK)

•  Suggestions for assessing documentation better

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Methods •  Retrospective •  Inclusion:

• Pediatric cochlear implants 8/1/2010-11/2014 • Bilateral simultaneous counted as 1 event, sequentials counted as separate documentation events

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On-site, Clinic Based Intervention Nurse Practitioner and Nurse in Hearing Program take on

role of: •  Obtaining documentation of vaccinations •  Assessing vaccinations for compliance with guidelines •  Administering CI-related vaccinations in clinic

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Methods Implementation of new protocol

•  Evaluate documentation of vaccination •  Evaluate compliance with AAP policy statement

8/1/2010 8/1/2012

Start

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Results - Overview •  Total N=87

Pre-Intervention: N=21 (24.14%) • 21 vaccines administered at any time

Post-Intervention: N=66 (75.86%) • 64 vaccines administered at any time

•  Total 85 vaccines were provided in our Hearing Clinic

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Results – Descriptive Stats

Period   Variable   Median   Mean   Min   Max  Pre                                  

(N=21)  Age  at  CI  (yrs)   4.73   6.94   1.03   24.25  

Follow  up  (months)   32.97   33.74   0.00   49.57  Post  (N=66)  

Age  at  CI  (yrs)   3.80   5.16   0.75   17.58  Follow  up  (months)   8.00   10.05   0.80   28.10  

Overall  (N=87)  

Age  at  CI  (yrs)   3.95   5.59   0.75   24.25  Follow  up  (months)   10.47   15.77   0.00   49.57  

No statistically significant difference (at an α=0.05 level) in age at CI between the two groups (Wilcoxon rank sum p-value=  0.3237)

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Results - Meningitis •  No post-CI meningitis in any group •  No difference in cochleovestibular anomalies on imaging

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Results – HIb Documentation

Fisher’s exact test p-values= 0.0019

•  Documentation at time of surgery

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Results – PCV-7 Documentation

Fisher’s exact test p-values= 0.0019 and 0.0046

•  Documentation at time of surgery

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Results – PCV-13 Compliance •  Compliance at time of surgery

p-value <.0001

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Results – PPV23 Compliance •  Compliance at time of surgery

p-value <.0001 p-value <.0001

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Results – Learning curve (PPV23 6 mos)

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Results – Current Compliance All CI kids are now evaluated at each visit, we have

updated unvaccinated children: •  95% of patients currently compliant with PPV-13 •  92% of patients currently compliant with PPV23

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Future Prospectively, study outcomes: •  Rates of AOM in our population •  Rates of post-implant meningitis •  Rates of post-implant related infections to see how

compares with reported literature

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NCH Hearing and Implant Program Medical Director: Prashant Malhotra, MD Audiology Manager: Gina Hounam, Ph.D.-CCC-A Otolaryngology Oliver Adunka, MD (Director, OSU) Ed Dodson, MD Kris Jatana, MD Prashant Malhotra, MD Audiology: Rebecca Belt, Au.D., CCC-A, FAAA Nikia L. Bridges, Au.D., CCC-A Jamie Hadley Godsey, AuD-CCC-A Kimberly Harhager, Au.D., CCC-A Gina Hounam, Ph.D.-CCC-A Alecia Jayne, Au.D., CCC-A Melissa Skarl Kappes, M.A., CCC-A Shana Moore, M.A., CCC-A Jennifer Phelan, AuD, CCC-A Brittney Sprouse, Au.D., ABA Lindsey Turover, Au.D., CCC-A Jori Weingarten, AuD., CCC-A Cindi Warner, Au.D., CCC-A

Program/Clinical Coordinator: Kimberly Davis, APN Speech and Language: Jennifer Davitz, CCC-SLP Jean Hruschak, MA, CCC-SLP Shana Lucius, MA, CCC-SLP, LSLS Cert. AVT Andrea Purvis, CCC-SLP Neuropsychology: Jennifer Cass, PhD Vestibular Therapy/OT: Marianne Mayhan Nursing: Kimberly Davis, APN Lura Keating, RN Social Work: Charae Williams, MSW

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Nationwide Children’s Hospital

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Nationwide Children’s Hospital

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Hiring Pediatric CI Audiology positions!! Gina Hounam Gina.Hounam@nationwidechildrens.org Prashant Malhotra Prashant.Malhotra@nationwidechildrens.org