Ocular syphilis is a serious complication of Treponema pallidum infection that can occur at any stage of syphilis and affect any eye structure. It remains unknown if certain T. pallidum strains are associated with ocular infections; therefore, we performed genotyping and whole genome sequencing (WGS) to characterize strains from patients with ocular syphilis. Seventy-five ocular or non-ocular specimens from 55 ocular syphilis patients in 14 states within the United States were collected between February 2016 and November 2020. Sufficient T. pallidum DNA was available from nine patients for genotyping and three for WGS. Genotyping was done using the augmented Centers for Disease Control and Prevention typing scheme, and WGS was performed on Illumina platforms. Multilocus sequence typing allelic profiles were predicted from whole genome sequence data. T. pallidum DNA was detected in various specimens from 17 (30.9%) of the 55 patients, and typing was done on samples from 9 patients. Four complete strain types (14d10/g, 14b9/g, 14d9/g, and 14e9/f) and five partial types were identified. WGS was successful on samples from three patients and all three strains belonged to the SS14 clade of T. pallidum. Our data reveal that multiple strain types are associated with ocular manifestations of syphilis. While genotyping and WGS were challenging due to low amounts of T. pallidum DNA in specimens, we successfully performed WGS on cerebrospinal fluid, vitreous fluid, and whole blood.IMPORTANCESyphilis is caused by the spirochete Treponema pallidum. Total syphilis rates have increased significantly over the past two decades in the United States, and the disease remains a public health concern. In addition, ocular syphilis cases has also been on the rise, coinciding with the overall increase in syphilis rates. We conducted a molecular investigation utilizing traditional genotyping and whole genome sequencing over a 5-year period to ascertain if specific T. pallidum strains are associated with ocular syphilis. Genotyping and phylogenetic analysis show that multiple T. pallidum strain types are associated with ocular syphilis in the United States.

Reports of bacterial sexually transmitted infections are at the highest levels ever reported in the United States, and state and local budgetary issues are placing specialized sexually transmitted disease (STD) care at risk. This study collected information from 4138 patients seeking care at 26 STD clinics in large metropolitan areas across the United States with high levels of reported STDs to determine patient needs and clinic capabilities. Surveys were provided to patients attending these STD clinics to assess their demographic information as well as reasons for coming to the clinic and surveys were also provided to clinic administrators to determine their operational capacities and services provided by the clinic. For this initial study, we conducted univariate analyses to report all data collected from these surveys. Patients attending STD clinics across the country indicated that they do so because of the relative ease of getting an appointment; including walk-in and same-day appointments as well as the welcoming environment and expertise of the staff at the clinic. Additionally, STD clinics provide specialized care to patients; including HIV testing and counseling as well as on-site, injectable medications for the treatment of gonorrhea and syphilis in an environment that helps to reduce the role of stigma in seeking this kind of care. Sexually transmitted disease clinics continue to play an important role in helping to curb the rising epidemic of sexually transmitted diseases.

Fertility challenges are a personal and important part of a woman's reproductive health and are associated with health and lifestyle factors. Limited data exist on infertility among women in Palau. We describe the lifetime prevalence of self-reported infertility in a nationally representative sample of women in Palau and investigate the association between tobacco and/or betel nut use and infertility. During May-December 2016, a population-based survey of noncommunicable diseases was conducted in Palau using a geographically stratified random sample of households (N=2409). Men and women >/=18 years of age were chosen randomly from each selected household. The prevalence of a self-reported lifetime episode of infertility (having tried unsuccessfully to become pregnant for >/=12 months) was evaluated among 874 women aged >/=18 years by key health and lifestyle factors. Prevalence ratios (PR) and 95% confidence intervals (CI) were calculated. Of 315 women who ever tried to become pregnant, 39.7% (95% CI: 34.2%, 45.3%) reported a lifetime episode of infertility. Prevalence was higher in women of Palauan vs other ethnicity (PR=1.6, 95% CI: 1.1, 2.3), those who self-reported poor/not good vs. excellent/ very good health status (PR=2.1, 95% CI: 1.4, 3.3), and those with a body mass index (BMI) >/=30 vs <30 (PR=1.7, 95% CI: 1.3, 2.2). Adjusted models showed that tobacco and/or betel nut users were almost twice as likely to report infertility versus non-users (PR=1.8, 95% CI: 1.3, 2.5). More research is needed to understand the infertility experiences of women in Palau and to promote lifestyle factors contributing to optimal reproductive health.

This report (hereafter referred to as STD QCS) provides CDC recommendations to U.S. health care providers regarding quality clinical services for sexually transmitted diseases (STDs) for primary care and STD specialty care settings. These recommendations complement CDC's Sexually Transmitted Diseases Treatment Guidelines, 2015 (hereafter referred to as the STD Guidelines), a comprehensive, evidence-based reference for prevention, diagnosis, and treatment of STDs. STD QCS differs from the STD Guidelines by specifying operational determinants of quality services in different types of clinical settings, describing on-site treatment and partner services, and indicating when STD-related conditions should be managed through consultation with or referral to a specialist. These recommendations might also help in the development of clinic-level policies (e.g., standing orders, express visits, specimen panels, and reflex testing) that can facilitate implementation of the STD Guidelines. CDC organized the recommendations for STD QCS into eight sections: 1) sexual history and physical examination, 2) prevention, 3) screening, 4) partner services, 5) evaluation of STD-related conditions, 6) laboratory, 7) treatment, and 8) referral to a specialist for complex STD or STD-related conditions.CDC developed the recommendations by synthesizing relevant, evidence-based guidelines and recommendations issued by other experts; reviewing current practice in the United States; soliciting Delphi ratings by subject matter experts on STD care in primary care and STD specialty care settings; discussing the scientific evidence supporting the proposed recommendations at a consultation meeting of experts and institutional stakeholders held November 20, 2015, in Atlanta, Georgia; conducting peer reviews of draft recommendations and supporting evidence; and discussing draft recommendations and supporting evidence during meetings of the CDC/Health Resources and Services Administration Advisory Committee on HIV, Viral Hepatitis, and STD Prevention and Treatment STD Work Group. These recommendations are intended to help health care providers in primary care or STD specialty care settings offer STD services at their clinical settings and to help the persons seeking care live safer, healthier lives by preventing and treating STDs and related complications.

Guidelines can help healthcare practitioners manage syphilis in pregnancy and prevent perinatal death or disability. We conducted systematic reviews to locate guidance documents describing management of syphilis in pregnancy, 2003-2017. We compared country and regional guidelines with current World Health Organization (WHO) guidelines. We found 64 guidelines with recommendations on management of syphilis in pregnancy representing 128 of the 195 WHO member countries, including the two WHO guidelines published in 2016 and 2017. Of the 62 guidelines, 16 were for countries in Africa, 21 for the Americas, two for Eastern Mediterranean, six for Europe and 17 for Asia or the Pacific. Fifty-seven (92%) guidelines recommended universal syphilis screening in pregnancy, of which 46 (81%) recommended testing at the first antenatal care visit. Also, 46 (81%) recommended repeat testing including 21 guidelines recommended this during the third pregnancy trimester and/or at delivery. Fifty-nine (95%) guidelines recommended benzathine penicillin G (BPG) as the first-line therapy for syphilis in pregnancy, consistent with WHO guidelines. Alternative regimens to BPG were listed in 42 (68%) guidelines, primarily from Africa and Asia; only 20 specified that non-penicillin regimens are not proven-effective in treating the fetus. We identified guidance recommending use of injectable penicillin in exposed infants for 112 countries. Most guidelines recommended universal syphilis testing for pregnant women, repeat testing for high-risk women and treatment of infected women with BPG; but several did not. Updating guidance on syphilis testing and treatment in pregnancy to reflect global norms could prevent congenital syphilis and save newborn lives.

BACKGROUND: The recommended regimen for treating uncomplicated gonorrhea has changed over time, due to the emergence of antimicrobial resistance. We assessed physician knowledge of the recommendation for treating uncomplicated urogenital gonorrhea in adolescents and adults using ceftriaxone and azithromycin dual therapy. METHODS: We analyzed DocStyles 2015 survey data from 1357 primary care physicians practicing for at least 3 years who provided screening, diagnosis, or treatment for sexually transmitted diseases to one or more patients in an average month. Logistic regression and chi analyses were used to identify factors associated with knowledge of dual therapy. RESULTS: Among the options of treatment with ceftriaxone alone, azithromycin alone, both of these, or spectinomycin plus levofloxacin, 64% of physicians correctly preferred ceftriaxone plus azithromycin. Knowledge of the recommended dual therapy decreased with increasing years of practice, ranging from 74% among physicians with 3-9 years of practice to 57% among those practicing for ≥24 years (adjusted odds ratio, ORa, for ≥24 vs 3-9 years of practice, 0.50; 95% confidence interval [CI], 0.35-0.70). Knowledge of dual therapy decreased with higher socioeconomic status of patients (ORa for high income vs poor/lower middle income patients, 0.47; 95% CI, 0.32-0.69). Physicians who pursued continuing medical education using journals, podcasts, and government health agencies were more likely to report dual therapy than those who did not use these sources (ORa, 2.09; 95% CI, 1.31-3.33). CONCLUSIONS: Knowledge of the recommended regimen for treating gonorrhea decreased with increasing years of practice and with higher socioeconomic status of patients.

Measles is an acute, highly infectious, viral disease transmitted through respiratory droplets and aerosolized droplet nuclei.1 It is characterized by fever, cough, coryza, conjunctivitis and generalized maculopapular rash typical of the disease. | After 20 years with no reported measles cases, a widespread outbreak occurred in the Federated States of Micronesia (FSM), an Oceanic island nation just north of the Equator.2 From February to August 2014, a multi-state outbreak affected three of the four FSM states. As part of a systematic outbreak-response following the first laboratory-confirmed case of measles, an emergency mass vaccination campaign was launched successively in each FSM state, to interrupt transmission and contain the outbreak.

On May 15, 2014, CDC was notified of two laboratory-confirmed measles cases in the Federated States of Micronesia (FSM), after 20 years with no reported measles. FSM was assisted by the World Health Organization (WHO), the United Nations Children's Fund (UNICEF), and CDC in investigating suspected cases, identify contacts, conduct analyses to guide outbreak vaccination response, and review vaccine cold chain practices. During February-August, three of FSM's four states reported measles cases: Kosrae (139 cases), Pohnpei (251), and Chuuk (3). Two thirds of cases occurred among adults aged >/=20 years; of these, 49% had received >/=2 doses of measles-containing vaccine (MCV). Apart from infants aged <12 months who were too young for routine vaccination, measles incidence was lower among children than adults. A review of current cold chain practices in Kosrae revealed minor weaknesses; however, an absence of historical cold chain maintenance records precluded an evaluation of earlier problems. Each state implemented vaccination campaigns targeting children as young as age 6 months through adults up to age 57 years. The preponderance of cases in this outbreak associated with vaccine failure in adults highlights the need for both thorough case investigation and epidemiologic analysis to guide outbreak response vaccination. Routine childhood vaccination coverage achieved in recent years limited the transmission of measles among children. Even in areas where transmission has not occurred for years, maintaining high 2-dose MCV coverage through routine and supplemental immunization is needed to prevent outbreaks resulting from increased measles susceptibility in the population.

OBJECTIVE: To assess effectiveness and feasibility of public-private collaboration in delivering influenza immunization to children. METHODS: Four pediatric and four family medicine (FM) practices in Colorado with a common public health department (PHD) were randomized at the beginning of baseline year (10/2009) to Intervention (joint community clinics and PHD nurses aiding in delivery at practices); or control involving usual care without PHD. Generalized estimating equations compared changes in rates over baseline between intervention and control practices at end of 2nd intervention year (Y2=5/2011). Barriers to collaboration were examined using qualitative methods. RESULTS: Overall, rates increased from baseline to Y2 by 9.2% in intervention and 3.2% in control (p<.0001), with significant increases in both pediatric and FM practices. The largest increases were seen among school-aged and adolescent children (p<.0001 for both), with differences for 6-month-old to 5-year-old children and for children with high-risk conditions not reaching significance. Barriers to collaboration included uncertainty regarding the delivery of vaccine supplies, concerns about using up all purchased vaccine by practices, and concerns about documentation of vaccination if collaboration occurred. CONCLUSIONS: In spite of barriers, public-private collaboration resulted in significantly higher influenza immunization rates, particularly for older, healthy children who visit providers less frequently.

Clinicians who routinely take patient sexual histories have the opportunity to assess patient risk for sexually transmitted diseases (STDs), including human immunodeficiency virus (HIV), and make appropriate recommendations for routine HIV/STD screenings. However, less than 40% of providers conduct sexual histories with patients, and many do not receive formal sexual history training in school. After partnering with a national professional organization of physicians, we trained 26 (US and US territory-based) practicing physicians (58% female; median age=48 years) regarding sexual history taking using both in-person and webinar methods. Trainings occurred during either a 6-h onsite or 2-h webinar session. We evaluated their post-training experiences integrating sexual histories during routine medical visits. We assessed use of sexual histories and routine HIV/STD screenings. All participating physicians reported improved sexual history taking and increases in documented sexual histories and routine HIV/STD screenings. Four themes emerged from the qualitative evaluations: (1) the need for more sexual history training; (2) the importance of providing a gender-neutral sexual history tool; (3) the existence of barriers to routine sexual histories/testing; and (4) unintended benefits for providers who were conducting routine sexual histories. These findings were used to develop a brief, gender-neutral sexual history tool for clinical use. This pilot evaluation demonstrates that providers were willing to utilize a sexual history tool in clinical practice in support of HIV/STD prevention efforts.

Eleventh- and 6th-grade students from an urban public school district were surveyed concerning vaccination outside the traditional medical home. Survey response rates were 50% for 11th- and 73% for 6th-grade students. Seventy-two percent of 11th-grade students reported that public health clinics were definitely or probably acceptable locations for vaccination; 70% reported this for emergency departments, 65% for school-based health centers, 55% for family planning clinics, and 44% for obstetrics/gynecology clinics. Corresponding percentages for 6th-grade students were 60% for public health clinics, 49% for emergency departments, 39% for school-based health centers, and 36% for family planning clinics. Sixth-grade students were not asked about obstetrics/gynecology clinics. Forty-seven percent of respondents identified a doctor's office as the "best" setting to receive vaccines, more than identified any other setting. We concluded that vaccination in one or more settings outside the traditional medical home was acceptable to most adolescents.

BACKGROUND AND OBJECTIVE: Effectiveness of recall for immunizations has not been examined in the setting of school-based health centers (SBHCs). We assessed (1) immunization rates achieved with recall among sixth-grade girls (demonstration study); (2) effectiveness of recall among sixth-grade boys (randomized controlled trial [RCT]); and (3) cost of conducting recall in SBHCs. METHODS: During October 2008 through March 2009, in 4 Denver public SBHCs, we conducted (1) a demonstration study among 265 girls needing ≥1 recommended adolescent vaccine and (2) an RCT among 264 boys needing vaccines, with half randomized to recall and half receiving usual care. Immunization rates for recommended adolescent vaccines were assessed 6 months after recall. First dose costs were assessed by direct observation and examining invoices. RESULTS: At the end of the demonstration study, 77% of girls had received ≥1 vaccine and 45% had received all needed adolescent vaccines. Rates of receipt among those needing each of the vaccines were 68% (160/236) for tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine, 57% (142/248) for quadrivalent meningococcal conjugate vaccine, and 59% (149/253) for the first human papillomavirus vaccine. At the end of the RCT, 66% of recalled boys had received ≥1 vaccine and 59% had received all study vaccines, compared with 45% and 36%, respectively, of the control group (P < .001). Cost of conducting recall ranged from $1.12 to $6.87 per recalled child immunized. CONCLUSIONS: SBHC-based recall was effective in improving immunization rates for all adolescent vaccines, with effects sizes exceeding those achieved with younger children in practice settings.

OBJECTIVE: To assess the effectiveness of reminder/recall (R/R) for immunizing adolescents in private pediatric practices and to describe the associated costs and revenues. METHODS: We conducted a randomized controlled trial in 4 private pediatric practices in metropolitan Denver. In each practice, 400 adolescents aged 11 to 18 years who had not received 1 or more targeted vaccinations (tetanus-diphtheria-acellular pertussis, meningococcal conjugate, or first dose of human papillomavirus vaccine for female patients) were randomly selected and randomized to intervention (2 letters and 2 telephone calls) or control (usual care) groups. Primary outcomes were receipt of >1 targeted vaccines and receipt of all targeted vaccines 6 months postintervention. We calculated net additional revenue for each additional adolescent who received at least 1 targeted vaccine and for those who received all targeted vaccines. RESULTS: Eight hundred adolescents were randomized to the intervention and 800 to the control group. Baseline rates of having already received tetanus-diphtheria-acellular pertussis, meningococcal conjugate, and first dose of human papillomavirus vaccine before R/R ranged from 33% to 54%. Postintervention, the intervention group had significantly higher proportions of receipt of at least 1 targeted vaccine (47.1% vs 34.6%, P < .0001) and receipt of all targeted vaccines (36.2% vs 25.2%, P < .0001) compared with the control group. Three practices had positive net revenues from R/R; 1 showed net losses. CONCLUSIONS: R/R was successful at increasing immunization rates in adolescents and effect sizes were comparable to those in younger children. Practices conducting R/R may benefit financially if they can generate additional well-child care visits and keep supply costs low.

PURPOSE: Numerous barriers to vaccination exist for adolescents. Using the medical home as the sole source of adolescent vaccination has potential limitations. The objectives of the present study were to examine parents' acceptance of adolescent vaccination outside of the medical home and parents' preferred setting for adolescent vaccination. METHODS: A standardized, pilot-tested telephone survey was administered to a stratified random sample (n = 1,998) of Colorado households between August 2007 and February 2008. Households with English-speaking parents and adolescent(s) aged 11-17 years were eligible. RESULTS: Survey response rate was 43%; there were no significant differences between respondents and nonrespondents for three known demographic variables. Although most parents (78%) preferred a doctor's office for adolescent vaccination, a majority were also definitively or probably accepting of vaccination in public health clinics (74%), school health clinics (70%), obstetrics and gynecology clinics (69%; asked for females only), and emergency departments (67%). Parents were less accepting of vaccination in family planning clinics (41%) and retail-based clinics (36%). Perceived convenience and adolescents' comfort in the setting were positively associated with vaccination acceptance in most settings; concern with keeping track of vaccines given outside of the medical home was negatively associated with acceptance. Parents in rural areas were more likely than parents in urban areas to identify a setting outside of the medical home as the preferred "best" setting for vaccination. CONCLUSIONS: Most parents assessed a doctors' office as the best setting for adolescent vaccination. However, vaccination in certain settings outside of the medical home seems to be acceptable to many parents.

Teratology is the study of congenital anomalies and their causes, and interest in teratology has been longstanding, with Egyptian wall paintings depicting children with birth defects over 5,000 years ago [Barrow, 1971]. By definition, teratogenic factors include both non-genetic and genetic factors that increase the risk for birth defects [Fraser, 2010]; however, traditionally, the term “teratogenic” has been used to refer to non-genetic factors that cause birth defects. The study of human teratogenic exposures is a relatively new one, emerging in the past 70 years. Before maternal rubella infection during pregnancy was identified as a cause of birth defects and developmental disabilities in 1941 by an ophthalmologist, Norman Gregg, birth defects were generally believed to be inherited [Gregg, 1991; Webster, 1998]. The uterus was thought to serve as a barrier, protecting the infant from the effects of external factors [Fraser, 2010]. But recognition of maternal rubella syndrome and subsequently, of thalidomide as a cause of birth defects in 1961 by McBride and Lenz [McBride, 1961; Lenz and Knapp, 1962], increased awareness of the effects that non-genetic factors could have on the development of the embryo or fetus. | Much more is now known about teratogenic factors. Understanding these teratogenic exposures is important to geneticists and genetic counselors for several reasons. First, teratogenic conditions need to be included in the differential diagnosis for children and adults presenting to genetics clinic. Clinicians need to ask about potential exposures during pregnancy, be aware of those exposures recognized as causing adverse outcomes, and finally, think beyond what is known, to consider whether an exposure could be the cause of the abnormalities observed in a particular patient. In the past, key observations by astute clinicians have often been critical to the recognition that a particular exposure could be related to an adverse outcome [Carey et al., 2009]. Another reason that geneticists and genetic counselors need to know about teratogenic exposures is that genetic clinicians often serve as a source of information about these exposures. Clinicians who see women during pregnancy are often asked about the safety of a particular medication, and families who have had a child with a birth defect or developmental disability often also ask about whether a particular exposure during their pregnancy might have caused the defects in their child. Finally, identification of non-genetic factors that increase the risk for adverse outcomes can lead to the development of strategies for primary prevention, such as those developed for the prevention of fetal alcohol syndrome, following identification of alcohol as a teratogen [Rasmussen et al., 2009].

OBJECTIVES: The objectives of this study were to assess, in a nationally representative network of pediatricians and family physicians, (1) human papillomavirus (HPV) vaccination practices, (2) perceived barriers to vaccination, and (3) factors associated with whether physicians strongly recommended HPV vaccine to 11- to 12-year-old female patients. METHODS: In January through March 2008, a survey was administered to 429 pediatricians and 419 family physicians. RESULTS: Response rates were 81% for pediatricians and 79% for family physicians. Ninety-eight percent of pediatricians and 88% of family physicians were administering HPV vaccine in their offices (P<.001). Among those physicians, fewer strongly recommended HPV vaccination for 11- to 12-year-old female patients than for older female patients (pediatricians: 57% for 11- to 12-year-old patients and 90% for 13- to 15-year-old patients; P<.001; family physicians: 50% and 86%, respectively; P<.001). The most-frequently reported barriers to HPV vaccination were financial, including vaccine costs and insurance coverage. Factors associated with not strongly recommending HPV vaccine to 11- to 12-year-old female patients included considering it necessary to discuss sexuality before recommending HPV vaccine (risk ratio: 1.27 [95% confidence interval: 1.07-1.51]) and reporting more vaccine refusals among parents of younger versus older adolescents (risk ratio: 2.09 [95% confidence interval: 1.66-2.81]). CONCLUSIONS: Eighteen months after licensure, the vast majority of pediatricians and family physicians reported offering HPV vaccine. Fewer physicians strongly recommended the vaccine for younger adolescents than for older adolescents, and physicians reported financial obstacles to vaccination.

OBJECTIVES: The goals were to determine among pediatricians and family physicians (1) knowledge of interim recommendations regarding Haemophilus influenzae type b (Hib) vaccine administration, (2) current practices, and (3) factors associated with nonadherence. METHODS: An Internet-based survey was conducted in April 2008 among national samples. RESULTS: Response rates were 68% (220 of 325 physicians) among pediatricians and 51% (153 of 302 physicians) among family physicians. Seventy-three percent of pediatricians and 45% of family medicine physicians reported insufficient Hib vaccine supplies, and 22% to 24% reported having to defer doses for infants 2 to 6 months of age > or =10% of the time. Ninety-eight percent of pediatricians and 81% of family physicians were aware of the interim recommendations (P < or = .0001), and virtually all knew that the booster dose should be deferred; however, 22% of pediatricians and 33% of family medicine physicians reported not deferring this dose. Physicians in both specialties were less likely to adhere to recommendations to defer in this age group if they thought that their practice had sufficient vaccine supplies (pediatricians, odds ratio: 0.01 [95% confidence interval: 0.003-0.03]; family medicine physicians, odds ratio: 0.10 [95% confidence interval: 0.03-0.33]). Family medicine physicians were less likely to adhere to recommendations if they had not heard about the interim recommendations (odds ratio: 0.04 [95% confidence interval: 0.01-0.21]). CONCLUSIONS: Most primary care physicians experienced Hib vaccine shortages, and many have had to defer doses for 2- to 6-month-old children. Most are knowledgeable regarding interim recommendations, but one-fifth to one-third reported nonadherence.

OBJECTIVES: The goals were to assess, among pediatricians and family medicine physicians, (1) rates of offering the vaccine in their office; (2) knowledge of Advisory Committee on Immunization Practices recommendations; (3) barriers to use; and (4) factors associated with offering the vaccine. METHODS: Surveys of pediatricians and family medicine physicians were conducted in August to October 2007. RESULTS: Response rates were 84% for pediatricians and 79% for family medicine physicians (N = 623). Proportions routinely offering the vaccine were 85% of pediatricians and 45% of family medicine physicians (P < .0001); 70% of pediatricians and 22% of family medicine strongly recommended the vaccine (P < .0001). Sixty-two percent of pediatricians and 32% of family medicine physicians (P < .0001) knew the age by which all 3 doses should be completed. Definite barriers to vaccine use included reported lack of coverage by insurance companies (family medicine physicians: 22%; pediatricians: 19%; not significant), costs of purchasing vaccine (family medicine physicians: 22%; pediatricians: 17%; not significant), lack of adequate reimbursement (family medicine physicians: 18%; pediatricians: 15%; not significant), concerns about safety (family medicine physicians: 25%; pediatricians: 9%; P < .0001), and concerns about adding another vaccine to the schedule (family medicine physicians: 22%; pediatricians: 5%; P < .0001). CONCLUSIONS: Rates of offering the new rotavirus vaccine are high among pediatricians but <50% among family medicine physicians. Both specialties identified financial barriers to use of the vaccine, but family medicine physicians had significantly more concerns about safety and about adding another vaccine to the vaccination schedule.

PURPOSE: Vaccinating adolescents in a variety of settings may be needed to achieve high vaccination coverage. School-based health centers (SBHCs) provide a wide range of health services, but little is known about immunization delivery in SBHCs. The objective of this investigation was to assess, in a national random sample of SBHCs, adolescent immunization practices and perceived barriers to vaccination. METHODS: One thousand SBHCs were randomly selected from a national database. Surveys were conducted between November 2007 and March 2008 by Internet and standard mail. RESULTS: Of 815 survey-eligible SBHCs, 521 (64%) responded. Of the SBHCs, 84% reported vaccinating adolescents, with most offering tetanus-diphtheria-acellular pertussis, meningococcal conjugate, and human papillomavirus vaccines. Among SBHCs that vaccinated adolescents, 96% vaccinated Medicaid-insured and 98% vaccinated uninsured students. Although 93% of vaccinating SBHCs participated in the Vaccines for Children program, only 39% billed private insurance for vaccines given. A total of 69% used an electronic database or registry to track vaccines given, and 83% sent reminders to adolescents and/or their parents if immunizations were needed. For SBHCs that did not offer vaccines, difficulty billing private insurance was the most frequently cited barrier to vaccination. CONCLUSIONS: Most SBHCs appear to be fully involved in immunization delivery to adolescents, offering newly recommended vaccines and performing interventions such as reminder/recall to improve immunization rates. Although the number of SBHCs is relatively small, with roughly 2000 nationally, SBHCs appear to be an important vaccination resource, particularly for low income and uninsured adolescents who may have more limited access to vaccination elsewhere.