Journal of Adolescent Health
Volume 46, Issue 2, Supplement 2 , Pages S1-S3, February 2010

The Importance of Overcoming Barriers to Adolescent Vaccination

Associate Professor, Department of Family Medicine, School of Medicine & Biomedical Sciences, SUNY at Buffalo, Buffalo, NY

Article Outline

 

Over the past few years, we have experienced an unprecedented expansion of vaccines recommended for adolescents, including quadrivalent meningococcal conjugate vaccine (MCV4) and tetanus toxoid, diphtheria, and acellular pertussis (Tdap) vaccine in 2005 and the quadrivalent human papillomavirus vaccine (HPV4) in 2006. A bivalent HPV vaccine (HPV2) was FDA approved in late 2009. Also, catch-up vaccination against hepatitis A is recommended for children and adolescents in states/communities with existing hepatitis control programs in place, for those at increased risk, and for anyone desiring to be protected [1], and a second dose of varicella vaccine is recommended for all children and adolescents who have received only a single dose [2]. In addition, the 2009–2010 season marked the beginning of universal recommendations for influenza vaccine for all children aged between 6 months and 18 years [3]. Together, these changes resulted in the development of separate vaccine schedules beginning in 2007 for children aged 0–6 years and 7–18 years; the 2009 vaccination schedule for children and adolescents appears in Table 1 [4]. The 2010 schedule was in preparation as this manuscript went to press. It will be available online at http://cdc.gov/vaccines/recs/schedules/default.htm.

Table 1. Recommended immunization schedule for persons aged 7–18 years, United States, 2009 [4]

Tdap → Minimum age: 10 years for BOOSTRIX® and 11 years for ADACEL®.

HPV → Minimum age: 9 years.

This schedule indicates the recommended ages for routine administration of currently licensed vaccines, as of December 1, 2008, for children aged 7 through 18 years. Any dose not administered at the recommended age should be administered at a subsequent visit, when indicated and feasible. Licensed combination vaccines may be used whenever any component of the combination is indicated and other components are not contraindicated and if approved by the US Food Drugs Administration for that dose of the series. Providers should consult the relevant Advisory Committee on Immunization Practices statement for detailed recommendations, including high-risk conditions: http://www.cdc.gov/vaccines/pubs/acip-list.htm. Clinically significant adverse events that follow immunization should be reported to the Vaccine Adverse Event Reporting System (VERS). Guidance about how to obtain and complete a VAERS form is available at http://www.vaers.hhs.gov or by telephone at 800-822-7967.

Although vaccination rates among younger children aged 19–35 months have met the Healthy People 2010 objective of 90% coverage [5] for 3+ doses of inactivated polio vaccine (IPV), 3+ doses of Haemophilus influenzae type b (Hib), 3+ doses of hepatitis B (HepB), and 1+ dose of measles, mumps, and rubella (MMR), or are approaching the objective of 3+ doses of diphtheria, tetanus toxoid, and acellular pertussis (DTaP) and 1+ dose of varicella [6], the experience among adolescents is altogether different. Data from recent National Immunization Surveys focused on adolescents aged 13–17 years show vaccination rates of 32.4% for one or more doses of MCV4, 30.4% for one or more doses of Tdap, and 25.1% for one or more doses of HPV4 in 2007 [7]. During 2008, there were incremental increases in coverage rates, with 41.8% for one or more doses of MCV4, 40.8% for one or more doses of Tdap, and 37.2% for one or more doses of HPV4 [8]. In contrast, coverage rates for MMR, HepB, and varicella (vaccine and/or disease history) remained at >87%. It is interesting to note that vaccine coverage for Tdap (10.8% in 2006) and MCV4 (11.7% in 2006) showed marked increases in just 2 years [7], [8] (Figure 1). However, the suboptimal coverage rates for these newer adolescent vaccines place substantial numbers of adolescent patients at risk of developing vaccine-preventable diseases.

  • View full-size image.
  • Figure 1 

    U.S. National Immunization Survey: Vaccination Coverage Among Adolescents 13–17 years, United States, 2006–2008 [7], [8]. ∗The Healthy People 2010 objective is 90% vaccination coverage among adolescents aged 13-15 years. †Any new universally recommended vaccine for adolescents should be at a 90% coverage level within 5 years of the recommendation. Recommendations were published for MCV4 in 2005, for Tdap in 2006, and for HPV in 2007. HepB = hepatitis B; MMR = measles, mumps, rubella; Tdap = tetanus, diphtheria, pertussis; MCV4 = meningococcal quadrivalent vaccine; HPV4 = quadrivalent human papillomavirus vaccine.

This journal supplement focuses on the importance of and current opportunities for the prevention of meningococcal disease. Although the classic signs and symptoms of meningococcal meningitis and meningococcemia are recognizable, the case vignette [9] serves to remind clinicians of the challenges with recognition of early meningococcal disease, given both the overlap in early symptoms with more commonly encountered viral respiratory infections and the seasonal and symptom overlap with influenza. The advantages afforded by conjugate vaccines, namely longer-lasting immunity, induction of an anamnestic immune response, and reduction of nasopharyngeal carriage, make quadrivalent meningococcal conjugate vaccines well suited for prevention. In addition, the need for chemoprophylaxis and options for therapy are also highlighted in that article.

Pelton provides a comprehensive review of Neisseria meningitidis disease epidemiology and factors associated with disease transmission [10]. Although N. meningitidis carriage is relatively common, only a small proportion of colonized individuals develop invasive disease. Mixing of populations from different regions seems to facilitate the transfer of N. meningitidis strains to susceptible individuals [11]. A concurrent upper respiratory infection, active smoking, and/or exposure to secondhand smoke appear to compromise the protective integrity of the pharyngeal mucosa, resulting in meningococcal disease. Also, the case-fatality rate among adolescent patients with meningococcal disease is increased by twofold to fourfold relative to younger children [12], [13]. Although the serogroup distribution varies by age group, region, and temporally (e.g., dramatic increase in serogroup Y between 1989 and 2007 in the United States), the quadrivalent meningococcal vaccine, which protects against serogroups A, C, Y, and W-135, provides an opportunity to prevent a substantial proportion of disease in the United States.

Next, the article by Kaplan discusses a number of unique challenges related to vaccine delivery among adolescent populations, including less frequent use of medical care; a greater focus on acute care, rather than preventive services; developmental/behavioral issues during adolescence; and fiscal challenges [14]. As an example of the financial issues, the federal contract price of all recommended childhood vaccines through age 18 totaled $155 in 1995 compared to $1,105 for males and $1,407 for females in 2008 [15]. This situation creates microconcerns regarding management of office stocks and cash flows, and macroconcerns about adequate financing through both private and public sources.

Kimmel [16] considers the perspective of clinicians in addressing vaccination gaps among adolescents and notes that, although the majority of medical care provided to adolescents in ambulatory settings is delivered by pediatricians and family physicians, about one-third of medical visits among females aged 18–21 years are to obstetrician-gynecologists (OB/GYNs) [17]. This has preventive care implications because OB/GYNs are generally less active in vaccine delivery and less frequently stock vaccines. In addition, a substantial proportion of pediatric and family medicine offices report having delayed the purchase of new vaccines, and approximately one-third of the senior leadership in family medicine offices and 7% in pediatric offices have contemplated withdrawing from offering vaccines to privately insured patients [18]. Clinician knowledge gaps also remain as a barrier to greater rates of vaccination [19]. Although knowledge assessments have generally focused on childhood vaccines, the situation for adolescent vaccination is equally poor given that these vaccines are relatively new. In addition, Kimmel provides some recommendations for credible sources of vaccine information to counter misperceptions regarding vaccine safety.

In addition to the information mentioned earlier, system factors also have the potential to influence rates of vaccination among adolescents. It is critical that an adequate and uninterrupted vaccine supply be available. For example, interruptions in the supply of MCV4 shortly after the issuance of universal recommendations for use among children and adolescents in 2005 likely contributed to delays and/or missed opportunities to vaccinate and confusion among clinicians. Moreover, resolution of financing issues is critical to ensuring access to recommended vaccines so as to minimize the racial/ethnic disparities in coverage rates that continue among adolescents [7], [8].

Clinicians are encouraged to enhance their delivery of vaccines to adolescent patients by following the harmonized vaccine schedules and empowering office staff to assess the need for vaccines at each office visit and to provide a clear recommendation for patients to complete vaccination at that visit.

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References 

  1. Fiore AE, Wasley A, Bell BP. Prevention of hepatitis A through active or passive immunization: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2006;55:1–23
  2. Marin M, Guris D, Chaves SS, et al. Prevention of varicella: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2007;56:1–40
  3. Fiore AE, Shay DK, Broder K, et al. Prevention and control of influenza: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2008;2008(57):1–60
  4. Centers for Disease Control and Prevention. Recommended immunization schedule for persons aged 7 through 18 years–United States, 2009. Available at: http://www.cdc.gov/vaccines/recs/schedules/downloads/child/2009/09_7-18yrs_schedule_pr.pdf. Accessed June 10, 2009.
  5. US Department of Health and Human Services. Objective 14–27: Increase routine vaccination coverage levels for adolescents. Available at: www.healthypeople.gov/document/html/objectives/14-27.htm. Accessed June 10, 2009.
  6. Centers for Disease Control and Prevention. Statistics and surveillance: July 2007 to June 2008 table data. Available at: http://www.cdc.gov/vaccines/stats-surv/nis/data/tables_0708.htm#overall. Accessed June 10, 2009.
  7. Vaccination coverage among adolescents aged 13-17years - United States, 2007. MMWR Morb Mortal Wkly Rep. 2008;57:1100–1103
  8. National, state, and local area vaccination coverage among adolescents aged 13-17 years–United States, 2008. MMWR Morb Mortal Wkly Rep. 2009;58:997–1001
  9. Mahoney MC, Pelton SI. Adolescents at risk: The case for meningococcal vaccine. J Adolesc Health. 2010;46:S4–S8
  10. Pelton SI. Meningococcal disease awareness: Clinical and epidemiological factors affecting management and prevention in adolescents. J Adolesc Health. 2010;46:S9–S15
  11. Harrison LH, Kreiner CJ, Shutt KA, et al. Risk factors for meningococcal disease in students in grades 9–12. Pediatr Infect Dis J. 2008;27:193–199
  12. Harrison LH, Pass MA, Mendelsohn AB, et al. Invasive meningococcal disease in adolescents and young adults. JAMA. 2001;286:694–699
  13. Kaplan SL, Schutze GE, Leake JA, et al. Multicenter surveillance of invasive meningococcal infections in children. Pediatrics. 2006;118:e979–e984
  14. Kaplan DW. Barriers and potential solutions to increasing immunization rates in adolescents. J Adolesc Health. 2010;46:S24–S33
  15. Lindley M, Orenstein W, Shen A, et al. National Vaccine Advisory Committee Vaccine Financing Working Group. Assuring Vaccination of Children and Adolescents without Financial Barriers: Recommendations from the National Vaccine Advisory Committee (NVAC). Washington, DC: U.S: Department of Health and Human Services; 2009;
  16. Kimmel SR. Adolescent vaccination: Physician challenges and solutions. J Adolesc Health. 2010;46:S16–S23
  17. Rand CM, Shone LP, Albertin C, et al. National health care visit patterns of adolescents: Implications for delivery of new adolescent vaccines. Arch Pediatr Adolesc Med. 2007;161:252–259
  18. Freed GL, Cowan AE, Clark SJ. Primary care physician perspectives on reimbursement for childhood immunizations. Pediatrics. 2008;122:1319–1324
  19. Cohen NJ, Lauderdale DS, Shete PB, et al. Physician knowledge of catch-up regimens and contraindications for childhood immunizations. Pediatrics. 2003;111:925–932

PII: S1054-139X(09)00680-6

doi:10.1016/j.jadohealth.2009.12.012

Journal of Adolescent Health
Volume 46, Issue 2, Supplement 2 , Pages S1-S3, February 2010

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