Category Archives: Research

Pharmacists Impact on Immunization

Quynh Tran, Pharm.D Candidate 2016

Pacific University School of Pharmacy

The role of pharmacists has come a long way from the classical “lick, stick, and pour” dispensary role (that is, “lick and stick the label, count and pour the pills”) and is experiencing significant growth and development. With the expansion in the scope of practice, community pharmacists are able to take on a stronger role in support of public health to improve vaccination rates and reduce the burden of vaccine preventable diseases. According to the American Pharmacist Association, three proposed roles that pharmacists can play in improving immunization rates include acting as immunization advocates, acting as facilitators and hosting other health care professionals to provide immunizations to the public, and lastly, taking on active roles as immunizers.

Pharmacists in all states are permitted to administer vaccinations, and the role of pharmacists in adult immunizations has increased significantly over the past few years. In 2011, Oregon pharmacy law allowed pharmacists to immunize adolescents down to age 11, and then in January of 2015, the law further lowered the age to 7. With less than half of adolescents receiving their yearly influenza vaccination, this change in pharmacy law can help more children get vaccinated and provide better access to immunizations.

The Oregon Immunization Program evaluated the impact of this change in the Oregon pharmacy law by using data from the Oregon ALERT Immunization Information System (IIS) limited to Clackamas, Marion, Multnomah, Polk, Washington and Yamhill Counties. The program compared influenza immunization rates before 2011 (2001 – 2010) and after the law was passed in 2011 (2011 -2014), between adolescents aged 11 -17 and those aged 7 – 10. Results revealed that between 2007 and 2014, adolescent influenza immunizations at community pharmacies increased from 36 to 6,372, with the largest increase happening after the law change, from 262 in 2010 to 2,083 in 2011. This evaluation demonstrated that expanding the scope of the pharmacist in immunizing adolescents can provide better accessibility to an adolescent population who may otherwise be unlikely to receive immunizations at clinics. This in turn can substantially help increase adolescent influenza immunization rates.


  1. Robison, Steve G. (2016). Impact of Immunizing Pharmacists on Adolescent Influenza Immunizations. Manuscript submitted for publication.
  2. Rothholz, Mitchel C. (2013). Role of community pharmacies/pharmacists in vaccine delivery in the United States [PowerPoint slides]. Retrieved from


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Filed under ALERT IIS, DataPokes, Education, Flu, Oregon Immunization, Research, School Law, VFC

Why We Care About HPV

By Isabel Stock, Colorado State University

Oregon Immunization Program Intern

The idea immunizing your child to prevent a sexually transmitted infection may seem foreign to many parents. People across the world have different views regarding vaccination, but all can agree on cancer prevention. It is our duty as public health advocators, medical professionals and community stakeholders to promote the importance of the HPV vaccination. Here are some astounding numbers to show the impact Human Papilloma Virus has compared to other diseases that we commonly vaccinate children for:

  • 1,904 polio deaths in the U.S. in 1950 (near the height of the epidemic)
  • 450 measles deaths every year in the U.S. before the vaccine
  • 500 tetanus deaths every year before widespread use of the vaccine in the U.S.
  • 100 chickenpox deaths every year in the U.S. before introduction of the vaccine
  • 4,000 HPV-related cervical cancer deaths in the U.S. every year

With 12,000 women being diagnosed every year with cervical cancer, it’s noteworthy that 1 in 3 of them do not survive for five years, especially when the HPV vaccination and screening can prevent up to 93% of these cancers. Other than the cervix, HPV is associated with cancer of the anus, vulva, vagina, oropharynx and cervix in women and HPV related cancers in men are found in the anus, oropharynx and penis.

With 79 million people in the U.S. currently infected with HPV, 14 million new infections every year, the National Cancer Institute has released a Call to Action. In the U.S. 40% of females and 21% of males are receiving all three doses of the HPV vaccine. In Oregon, 36.4% of females and 20.6% of males are receiving all three doses of the HPV vaccine. It is clear that the U.S. will fail to meet the Healthy People 2020 goal of 80% HPV vaccination rate for all three doses. We are faced with a significant public health threat if we don’t take immediate action to improving our vaccination rates.

Here are the best ways to begin improving HPV rates in your clinic today:

  • Know how to frame your conversation regarding HPV with parents and provide them with educational resources
  • Start the vaccine on time; schedule wellness visits at age 11 and 12
  • Schedule follow-up visits before they leave the office
  • Practice reminder/recall for 2nd and 3rd doses
  • Provide walk-in or immunization only visits
  • Immunize at sports physicals

For more information on how to implement these actions, go to:
HPV kids


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Filed under Education, Nurses Notes, Oregon Immunization, Private Clinics, Public Clinics, Research, School Law, Social Media, VFC

Framing the HPV Conversation

By Isabel Stock, Colorado State University

Oregon Immunization Program Intern

Many parents who choose to vaccinate their children are faced with the worry, “Do I vaccinate my child for Human papillomavirus?” According to the 2012 National Teen Immunization Survey, one of the main reason parents that didn’t intend to vaccinate their children against HPV was a lack of healthcare provider recommendation. It’s time to frame the conversation between parents and providers on the importance of the HPV vaccination.

As a provider, it is important to recommend HPV vaccine as you would any other, especially on the same visit as other vaccinations. Here is a list of other important factors to highlight when discussing the HPV vaccine with parents:

  • It is one of the only vaccines available to prevent cancer.
  • HPV infection can be passed through any type of sexual activity, not just intercourse. Some types of HPV are spread by skin-to-skin contact.
  • Multiple research studies have shown that HPV vaccine does not make kids more likely to be sexually active.
  • HPV vaccine has a strong safety record. More than 62 million doses have been given in the United States, and there are no serious safety concerns.
  • Put HPV first when listing the vaccines that the child needs during the visit. For example, “Your child needs three shots today: HPV vaccine, meningococcal vaccine and Tdap vaccine.”
  • Vaccinate for HPV well before children might be exposed to it, just as you would for other diseases such as measles.
  • Emphasize your personal belief in the HPV vaccine, and let them know that you have given it to your son/daughter/family member/friend. This is a powerful tool to help parents feel more secure about their decision

All of these tips will help educate the parent to make a decision and avoid missed opportunities to increase HPV vaccination rates. There are many more resources available to frame the conversation between providers and parents on the CDC website. Below is a great resource for providers to start.

         HPV Tips FINAL

When talking with vaccine hesitant parents, it is helpful to use a communication approach that guides rather than directs and encourages the parent to ask questions. Engaging with good communication strategies allows parents to come to a decision on their own, using evidence based facts delivered by the provider. This technique has been shown to help families and providers address concerns in a way that allows the provider to convey respect and empathy while sharing medical information. For more information on effective communication strategies see,

To help parents understand just how safe, effective, and necessary this vaccine is for their children check out the National Cancer Institute’s recent Call to Action at, Now, more than ever, it is important we give parents all the necessary facts about HPV vaccination to give their child the best possible chance to live a cancer free life.



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DATA POKES: June 2013

Staff Update- Adam Boyette

The Oregon Immunization Program (OIP) is pleased to announce the hiring of Adam Boyette as a research analyst. Adam recently finished a PhD in anthropology from Washington State University. His dissertation work focused on children’s social learning among hunting and gathering societies in Africa. Despite his Indiana Jones-like appearance, Adam professes little experience with dangerous relics and obscure temples. Instead his main area of academic focus was on how ideas and culture are transmitted between individuals. Adam believes in an ‘epidemiology of ideas’ to explain how ideas, like diseases, can spread.

Adam is replacing Scott Jeffries, whose new role in OIP is working on an adolescent immunization grant. Adam will be in charge of the Population-Based Rates program and other special projects. Adam is looking forward to applying his research experience to public health and immunizations in Oregon. He is also extremely excited to talk about the birth of his now month-old daughter, Delphine. (Baby pictures on request).

Staff Publications
Steve Robison. Sick visit immunizations and delayed well-baby visits. Pediatrics, June 3rd, 2013.

Sick visits is one of the hardest barriers to address when trying to keep kids on an immunization schedule. Many kids are likely to be sick during one or more of the periods when shots are due in early childhood, and having a sick visit when immunizations are due is a common reason for infants falling behind.

AAP/ACIP policy calls for giving immunizations on sick visits for mild or moderate illnesses such as otitis media (earaches), regardless of whether there is a fever or not. However some providers worry that giving due immunizations on sick visits may discourage further shot seeking, or discourage returning to make-up missed well-baby checks.

A new study by Steve Robison in Pediatrics looked at whether giving sick visit shots discouraged returning for make-up well baby visits or further immunization seeking. Using ALERT and DMAP data, this study found that giving sick visit shots was not a risk for lower immunization or well baby visit rates. In contrast over a third of those who did not get a sick visit immunization failed to return for a make-up visit, and had significantly lower immunization rates and lower numbers of well-baby visits by age two. So avoiding sick visit shots has little benefit and carries a risk of children falling behind and not catching up on immunizations.

As a take-away message, if a child presents sick when shots are due consider giving them their immunizations. If you can’t, make sure that the parent has a make-up appointment scheduled before they leave the clinic.

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DataPokes: May 2013


An Introductory Note

DataPokes is an ongoing monthly forum for the Oregon Immunization Program’s Evaluation & Surveillance team. We will use this as a place to talk about our work and highlight some local, national and international research about immunizations. Even though we can’t promise baskets of kittens or vaccine refrigerators transforming into giant robots, we’ll find some interesting things for you here.

-Steve Robison, Oregon Immunization Program Epidemiologist

Staff Publication: Priming with Whole Cell Pertussis Vaccine

Our own Juventila Liko (et al.) examined whether children who started their early pertussis immunizations with a whole-cell vaccine (DTwP) had less pertussis than those who only had an acellular DTaP vaccine. Using ALERT data for kids born between 1998 and 2000, Liko et al. found that those primed with DTwP had substantially lower pertussis rates, including into their teen years. This benefit to DTwP priming was observed regardless of how many DTaPs a child got or whether they had a tdap booster. Despite these advantages, the whole-cell pertussis vaccine was replaced by acellular DTaP in the United States because of concerns about higher rates of side effects with the whole-cell vaccine. Because of these side effects, returning to the whole-cell vaccine is not a likely option.

(Source: Liko, J., Robison, S., & Cieslak, P. (2013). Priming with whole-cell versus acellular pertussis vaccine, New England Journal of Medicine. 386, 581-582

Why We Immunize Teens for HPV

A recent study from Australia has found that the prevalence of genital warts among teens and young adults has drastically been reduced since the introduction of the human papillomavirus (HPV) vaccine in 2007. The reduction was stronger for girls than boys, but both were substantial. In 2007 before the introduction of the HPV vaccine, 11 percent of Australian women under age 21 who visited a sexual health service were diagnosed with genital warts. After the introduction of the HPV vaccine, this prevalence fell to under 1 percent, followed by no reported diagnoses of genital warts in 2011. During the same period, rates for genital warts among adults age 30 and up who did not participate in the Australian HPV program did not change. This study provides good evidence that the HPV vaccine is working.

So what did it take to achieve this result in Australia? In 2010 the Australian HPV vaccine coverage rates for their school-based programs was 83 percent HPV vaccine initiation among 12–13-year-old girls, with a 73 percent series completion rate. In contrast, here in Oregon 45 percent of 12–13-year-old girls have started on HPV vaccine, and only 16 percent have had all three shots, according to ALERT data. We have made progress, but we have a long way to go.

(Source: Ali, H., Donovan, B., Wand, H., et al. (2013). Genital warts in young Australians five years into national human papillomavirus vaccination programme: national surveillance data. British Medical Journal, 346:f2032.)

A Vaccine for Staph? Try and Try Again

One long-running failure in immunology is the inability to develop an effective vaccine against staph bacteria. The evolution of Methicillin-resistant Staphylococcus aureus (MRSA) has led to near panic among some medical authorities, who worry that soon we won’t have any antibiotic options left. In 2012 one more potential staph vaccine failed in human trial. The vaccine was intended for surgery patients two weeks prior to being admitted.

While no adverse effects were seen initially and recipients built resistance to a staph surface protein, the trial was halted early due to adverse surgical outcomes among those who received the vaccine.

This is not the first vaccine failure for staph; historically many have been developed with failure as a uniform result. The ability of staph to acquire and express factors to specifically thwart the human immune system has meant that lab and animal testing cannot reliably guide vaccine development. As staph is a common and harmless colonizer of over a third of the world’s population, disease eradication is not likely anytime soon even if a vaccine for hospital use is found.

(Source: Keller, D. (2012, Oct 22). Staph vaccine linked to multi-organ failure and death. Medscape Medical News. Available at

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How does your county measure up? 2010 Population-Based Immunization Rates for Oregon communities available online


What are PBRs?: Oregon has developed Population-Based Rates (PBRs) that provide detailed state, county and potentially census tract immunization coverage information.

 Why are they important?: Measles are making a comeback. In 2011, there were tens of thousands of measles cases in Europe, some of which spread to the United States by travelers. There were 17 measles outbreaks in the United States last year, and more than 220 cases. Oregon had four cases, which all failed to start an outbreak because the immunization rates were over the 92-94 percent required to keep measles at bay. It’s easy to look at statistical reports and know where in the state those single measles cases occurred. But now the Oregon Immunization Program (OIP), or anyone for that matter, can simply look online to find out where a community might need to beef up their measles vaccinations to stay outbreak-free.

 PBRs provide detail: Most states use the annual National Immunization Survey (NIS) to gauge vaccination coverage. The Centers for Disease Control and Prevention conducts this phone survey of randomly selected residents, with follow up calls to the participants’ health care providers. The NIS provides a snapshot of what’s going on in each state—and some cities and counties—but doesn’t include more area-specific information. What if you need to know how well children are protected in specific communities? Oregon has developed Population-Based Rates (PBRs) that provide detailed state and county, and potentially census tract immunization coverage information.

 Find the information YOU need: For example, someone may wonder if Oregon children who participate in the federally funded Vaccines for Children (VFC) program are more likely than the rest of the population to be fully protected from vaccine-preventable diseases. PBRs can be used to tell us that yes, in 2010 children receiving at least one VFC are at least as well vaccinated than those who do not receive any VFC vaccine. This helps to support the important role VFC plays in providing needed access to vaccines among Oregon’s children who may otherwise have challenges in receiving healthcare due to lack of insurance or under-insurance issues.

 Track health equity: PBRs also helps OIP to track health equity, making sure that a child’s race or ethnicity does not predict how well protected they are from vaccine-preventable diseases. If a problem is identified, the public health system can act swiftly to address the inequity.

 Who need this?: Anyone, such as local health departments or organizations like United Way, can access this data to use in a number of ways, from grant writing to evaluations to legislative issues. The public can check to see how one county stacks up against the rest of the state. And when it comes to a serious health concern, such as measles, OIP can use PBRs to gauge community protection levels. Health officials can look at measles vaccination rates and determine where to do interventions and outreach to keep Oregonians healthy.

 Need even more detail?: If you would like to get a detailed summary of vaccination rates by census tract, or if you have any other questions, please contact Scott Jeffries at

 PBRs can be accessed by visiting the Oregonian Immunization Program web site:

  Follow OIP on Facebook and Twitter.


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