Adolescent Vaccine Coverage

By Ramon Brooks,2014-05-08 20:23
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Adolescent Vaccine Coverage


    The Promise and Challenge of Adolescent Immunization

    Adolescent Working Group of the

    National Vaccine Advisory Committee

Manuscript word count: 3,114

    Corresponding Author:

    Gary L. Freed, MD, MPH

    University of Michigan

    300 North Ingalls Building, 6E08

    Ann Arbor, MI 48109-0456

    Office: (734) 615-0616

    Fax: (734) 764-2599

    Version 25 1 Revised 5/8/2012


    The National Vaccine Advisory Committee (NVAC) created a working group to address issues related to adolescent immunization. In response to a request from the Assistant Secretary for Health, this Working Group conducted an assessment of the current landscape of adolescent immunization and identified issues that will require national attention in the coming months and years if current and future recommended adolescent immunizations will be used to their potential. Following identification and the achievement of a national consensus on the issues to be addressed, the NVAC, through its Adolescent Working Group, will receive input from a variety of stakeholders to develop policy recommendations to address these issues.

    There is now a unique and important opportunity through immunization to reduce morbidity and save lives of adolescents in the United States. Adolescents hold the promise of a productive and satisfying adulthood, but this promise may be threatened by a variety of preventable health conditions. Several health issues are of national concern for the adolescent population, including obesity and substance abuse. However, many of these problems are frustrating because there are no clear and effective actions which, if implemented, can impact virtually the entire age group. Conversely, vaccine preventable diseases are unique in that they are both serious and

    readily preventable.

    Our country has a long history of using immunizations to protect individuals and populations at both ends of the age spectrum, but little experience between those ranges. Now, several new vaccines have created an imperative to reach the adolescent population and to protect them against a group of significant but eminently

    preventable diseases, thereby increasing the chance of our youth to enjoy long and productive lives. However, to achieve the promise of these new preventive health interventions our nation must focus on effective vaccine delivery to this population.

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    Specifically, three new vaccines are now available and recommended for adolescents that prevent a total of 5 diseases that can have a range of devastating health

    1consequences. Individual vaccines protect against meningococcal meningitis and human papilloma virus and a combined vaccine protects against tetanus, diphtheria and pertussis. All three vaccines have been shown to be safe and effective.


    Meningococcal Vaccine

    Meningococcal disease is a bacterial infection that is a leading cause of meningitis among children 2 18 years of age in the United States and a cause of severe and

    2devastating sepsis. Of the 1,400-2,800 individuals in the U.S. who contract

    meningococcal disease each year, 10-14% will die despite aggressive treatment. Of those who survive, debilitating side effects are common, including loss of limbs, deafness, mental retardation, seizure disorders, and strokes. The meningococcal conjugate vaccine was licensed in 2005 and is recommended for all children at their routine recommended early adolescent visit (11-12 years of age) as well as those

     3,4entering high school and for college freshmen living in dormitories.

Human Papilloma Virus Vaccine

    In 2003, more than 11,000 women were diagnosed with, and almost 4,000 women died from, cervical cancer in the United States each year. The overall incidence of cervical cancer was 8.1 per 100,000 women. Almost all cervical cancers are caused by the

    5human papillomavirus. The recently licensed HPV vaccine was shown in clinical trials to provide close to 100% protection against cervical cancer precursor lesions due to the two types of human papillomavirus (types 16 and 18) that cause 70% of cervical cancer as well as genital warts due to two types (6 and 11) that cause 90% of genital warts. The vaccine is recommended to be given to 11-12 year old adolescent girls in a three-dose series over six months. Previously unvaccinated females 13-26 years of age are

    5also recommended to receive this vaccine.

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Tdap Vaccine

    6 The combined Tdap vaccine protects against tetanus, diphtheria and pertussis.

    Despite substantial success in vaccinating infants against these diseases, coverage is not complete, and protection against pertussis appears to wane after 5 10 years.

    Consequently, a large proportion of reported cases of pertussis in the United States are now found in the adolescent age group, and many outbreaks occur in school settings where adolescents congregate. Further, adolescents are now a reservoir of disease which can infect infants. A large proportion (38%) of adolescents in Massachusetts with pertussis reported prolonged coughing of at least one month at the time of diagnosis,

    6resulting in multiple health care visits as well as school absenteeism. In 2006, the

    Advisory Committee on Immunization Practices (ACIP) recommended that adolescents

    aged 11-18 years should receive a single dose of Tdap instead of tetanus and diphtheria toxoids vaccine (Td) for booster immunization against tetanus, diphtheria,

    67and pertussis. The preferred age for receiving the vaccine is 11-12 years.


    Understanding and acting upon the imperative of ensuring that these new vaccines as well as the previously recommended vaccines are administered to the adolescent population requires a paradigm shift on the part of health care providers, policy makers, and parents alike. Historically, vaccination has been framed as an intervention for young children, while behavioral health challenges like nutrition and sexual behavior are illustrative of key issues that compromise adolescent health. Indeed, vaccinations for young children are important. And the behavioral health challenges that face

    adolescents are critical. But at the same time, there are now immunizations that can prevent serious and life-threatening diseases among adolescents.

    The ability to effectively prevent significant morbidity and potential mortality, especially among a population that constitutes our Nation’s future, creates an imperative to make adolescent vaccination a national health priority.

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    Adolescent Health Care Utilization

    Ensuring that there exists an effective means of delivering these vaccines is a necessary precursor for high vaccine coverage rates. Unfortunately, unlike infants, the delivery of preventive care for adolescents is more complex. The imperative to provide and promote adolescent vaccination will require the support of an infrastructure for this to be accomplished effectively and at a reasonable cost.

    The unfortunate reality is that fewer adolescents, compared with other pediatric age groups, access the medical system for preventive care, either in public or private delivery venues. When they do access the health care system, it is most often for acute

    8 care. If the U.S. is to achieve high rates of vaccine coverage for adolescents, there will need to be a system that meets their needs and fits their patterns of behavior.

    Currently, the utilization of the existing private or public health preventive care infrastructure to achieve high vaccination coverage rates for these new vaccines among adolescents is woefully inadequate. Adolescents access a patchwork of sites and services for health information and health care; in fact, research to date is mixed on the extent to which adolescents get health care particularly preventive care - at all.

    Recent analyses of national data suggest that over 30% of adolescents receive no

    9health care in a 12 month period. Although more than 50% do have some type of visit

    to a primary care provider, the probability of having a primary care visit in a given year

    8declines substantially with increasing age. A study of medical records from Harvard

    Pilgrim Health Care, demonstrated that most visits by adolescents (73%) were for acute, not preventive care. Within this insured population, all with assigned primary care providers, 33% of 11 year olds had no preventive care visits in any given year. This number increased to 44% for those 17 years of age. Even fewer adolescents have the

    10three health visits required to complete the HPV vaccine series. Thus, even in a “best

    case” scenario of insured children in a well-organized health care delivery system, with

    assigned primary care providers, preventive care is markedly underutilized and not sufficiently organized to reach desired immunization rates.

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    Other research has shown that adolescents self-report a much higher rate of preventive

     11visits in a given year. However, this finding is not supported by billing data from the Health Plan Employer Data Information Set (HEDIS), in which a study demonstrated

    12that only 34% of adolescents had a preventive visit over a 12-month period. This

    apparent contradiction may be the result of adolescents erroneously perceiving health care visits in general to be preventive when many of them are, in fact addressing specific health concerns. Another possibility is that physicians may be providing preventive services but coding the visit for something other than well care when preventive care is not covered by insurance. Regardless, it appears likely that adolescents overestimate their own use of preventive care.

    Adolescents do, however, identify unmet needs in their own health care use; in the National Longitudinal Study of Adolescent Health, almost 20% reported that there was a

    13time in the past year when they thought they should obtain medical care, but did not.

    Bringing adolescents into the health care system by promoting vaccinations could be thought of as a an invitation that brings them into the system for other important health and health care messages and activities, including important advice and screening as they transition into adulthood.

New Ideas for Old Problems

    The issues surrounding adolescent immunization compel our nation to consider new ways of looking at old problems. Although adolescents have long not utilized preventive health care, it is now even more important they do so. This results in the need to raise new issues that warrant public debate including the identification of where fiscal and programmatic responsibility lies within the government (e.g., local, state, federal) and the private sector to achieve preventive health goals for this age group. Further, levels

    of responsibility for adolescent immunization across and among diverse entities (i.e., public health and educational systems) must be considered.

    In order to create a system for adolescent immunization, we have to assess the motivation and obstacles for participation across potential settings, identify real and Version 25 6 Revised 5/8/2012


    potential logistical issues, and assess funding constraints and solutions. It is likely that unprecedented collaborative efforts and creative approaches may be necessary to achieve recommended vaccination rates among the adolescent population.


    There are several unique issues that challenge the U.S. health care system to fully vaccinate the adolescent population. These challenges must be acknowledged, evaluated and discussed openly if our nation is to create an accessible and effective network for adolescent vaccination. Among those topics with unique applications to adolescent immunization are venues for vaccine administration, consent for immunizations, communication, financing, surveillance, and the potential for school mandates.


    There exist limited entry points used regularly by adolescents to enter the health care system. Helping adolescents move into a system of care would require both increasing utilization at the entry points that do exist and also creating new, and more easily accessible entry points some of which will necessarily fall outside of what we typically consider the traditional health care system.

    Although physician offices can provide vaccines to a significant portion of adolescents, without a significant change in health care seeking behavior patterns and greater attention being paid to missed opportunities for immunization in this age group, other venues must be considered to reach national immunization goals and assure maximum protection.

    The question therefore arises as to what aspect of the health care community best serves to identify, capture and provide service to adolescents. Certainly, vaccinations have long been the purview of the primary care physician. However, in the case of adolescents’ health care utilization patterns, this venue may actually not be the ideal Version 25 7 Revised 5/8/2012


    location for all adolescents. Additional health care settings likely to provide additional access include pharmacies, family planning and sexually transmitted infection clinics, obstetrician-gynecologist offices, emergency departments, teen clinics and health departments. Each venue must be evaluated to assess its potential in both attracting critical numbers of adolescents as well as supporting the necessary infrastructure for their immunization with all recommended vaccines for this age group. However, these sites will not replace the role of the primary care physician in the delivery of comprehensive preventive care.

    When considering locations where adolescents congregate and may be available to receive health care, schools are frequently cited as an obvious locale. Vaccinating adolescents in schools has a number of obvious challenges (e.g., organization, financing) that warrant substantial study and consideration over whether this is a potential “best” venue. Therefore, the advantages and disadvantages of school-based

    vaccinations for adolescents have to be assessed empirically and fully.

    Likely none of these potential venues, by itself, attracts a significant enough proportion of adolescents on which to base a population-wide strategy. Public discourse is also needed to consider the public and private investment required to explore approaches to improving access/availability and perhaps most importantly, to create the productive collaborations without which a move toward achieving full adolescent vaccine coverage cannot succeed.


    The ability of adolescents to consent for health care including vaccinations differs

    14substantially by state and by health condition. This variability could have a significant

    impact on our nation’s ability to achieve immunization coverage in this age group. Therefore significant and potentially controversial issues arise upon making a vaccination available to adolescents especially in nontraditional settings. For example, some states may allow adolescents to consent to receive their own vaccinations, but others may not. Although consent requirements are the purview of states, there may be Version 25 8 Revised 5/8/2012


    utility in the provision of a federal template for recommendations on the issue. It is also possible that in some states new vaccines which protect against sexually transmitted diseases may have different consent status than other vaccines, as does treatment for sexually transmitted infections. A review and examination of consent laws as they exist and pertain to adolescent vaccines in the context of creating the infrastructure necessary to achieve high levels of adolescent vaccination must be conducted.

Communication Specific to Adolescents

    A new approach to communication and new communications materials is necessary to ensure that the public, providers, parents and the adolescents themselves understand the need and the appropriate timing of these vaccinations. In the infant and childhood vaccine setting, education and information are geared toward parents. However, if adolescents are receiving care with or without parental involvement, information must be focused on the adolescents themselves in addition to parents and providers. Knowledge about reaching adolescents should be garnered from other health and health care areas and brought to bear on vaccine issues. Convincing adolescents and young adults to engage in preventive behaviors is difficult. It is unknown whether the need for an injection will be even more challenging to disseminate than other messages. Current policies and programs have not been successful in immunizing a significant portion of adolescents with the previously recommended tetanus booster. Especially in the case of those vaccines against STIs, it will be critical to ensure that adolescents understand the limitations of the vaccines and continue to protect themselves in other ways.


    Financing issues regarding adolescent immunization are unique in two specific areas, the cost of adolescent vaccines, and the rate of insurance coverage for adolescents.

    These new vaccines for adolescents are among the most expensive vaccines recommended today for any age group. Their aggregate estimated price in the private sector is approximately $500. As such, their inclusion in the recommended Version 25 9 Revised 5/8/2012


    immunization series has the potential to put a significant strain on both the public and private financing sectors. These costs, when combined with the fact that fewer adolescents have insurance coverage (public or private) for preventive services than other children must be addressed if we as a nation hope to realize the promise of these

     15,16vaccines. Otherwise, the financial barriers for adolescents themselves, as well as the providers who may also incur significant financial burden associated with these vaccines, may impede implementation of these recommendations.

    In the public sector, a smaller proportion of adolescents, compared with infants, are

     eligible for the federal Vaccines For Children program. Thus, greater strain on state

    budgets will likely result if these recommendations are to be fully implemented.


    Experts worldwide recognize surveillance as important to effective implementation and

    17-20 evaluation of public health programs.U.S. surveillance systems have constrained

    capacity to yield data related to disease burden, vaccination coverage, and vaccination impact among adolescents. For example, while data pertaining to adolescents will be

    thcollected through the National Immunization Survey for the 4 quarters of 2006 and

    2007, these data will not be state-specific. Furthermore, there is no funding source for future, more comprehensive surveillance critical to guiding program planning and


Well-defined national vaccination coverage targets are needed for adolescents. A

    limited number of goals for coverage among adolescents aged 13-15 years were

    21included in the Healthy People 2010. However, future goals should be defined clearly.

    For surveillance systems to work, many healthcare providers delivering immunizations to adolescents in communities and other settings (e.g., military, corrections facilities, colleges) will require education regarding the importance of disease reporting, adverse event reporting, and participating in immunization information systems (IIS). In turn, Version 25 10 Revised 5/8/2012

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