Adolescent immunization
Note: This report represents information on this subject as of December 1995.
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The American Medical Association (AMA) has long supported improvement of the health of children through age-appropriate immunizations. This includes promoting efforts to develop a national immunization program (AMA Policy Compendium, Policies 440.920, 440.991, 440.992); identify and reduce the barriers to increased utilization of immunizations (60.967, 440.928); increase resources for immunizations (60.969, 440.968); reduce liability from adverse reactions (440.963, 440.978); include vaccination in proposed standard benefit packages (165.925, 165.975); and support the use of specific new vaccines (e.g., hepatitis B vaccine) and vaccination schedules (440.952, 440.958).
Immunization programs have dramatically decreased the occurrence of many childhood infections.1 However, diseases such as hepatitis B, rubella, and measles remain problematic within the adolescent population. The development of new vaccines, especially against hepatitis B virus, and the rising national concern for adolescent health risk behaviors prompted the Advisory Committee for Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) to revise its recommendations for adolescent immunizations.2
The purposes of this report are to review the changes recommended for adolescent immunization by the ACIP, consolidate and update AMA policy related to adolescent immunizations, and recommend AMA action for promoting adolescent immunization at the state level.
Adolescent immunization recommendations of the ACIP
According to the CDC, the revised schedule of adolescent immunizations will be released in late 1995 or early 1996. These recommendations have been endorsed by the member groups of the ACIP, including the American Academy of Pediatrics and the American Academy of Family Physicians. The ACIP recommendations, with supplemental CSA commentary are:
1. The establishment of an immunization visit to screen for and administer indicated vaccines that have not been received is recommended for all adolescents between the ages of 11-12 years. Indicated vaccines not administered or requiring multiple doses should be scheduled at this visit. The ACIP also recommends that other indicated preventive services should be provided during this visit.
The health status of adolescents has changed substantially over the past several decades. Most adolescent mortality and morbidity is now the result of personal behaviors rather than natural causes; more adolescents engage in health-risk behaviors and they do so at earlier ages than previously; a sizable number of adolescents, perhaps as much as 25 percent, engage in multiple health risk behaviors; and all adolescents, regardless of demographic and family characteristics, are at risk for engaging in some type of behavior that might adversely affect their health.3 Thus, adolescents from financially poor families are more at risk for homocide and unintended pregnancy, while those from more affluent backgrounds are at risk for suicide, eating disorders, smoking, drug use, and deaths from motor vehicle accidents.
Concern among health professionals and others about the health and well-being of adolescents has provided impetus for the development of new clinical preventive services initiatives. Thus, the AMA through its Guidelines for Adolescent Preventive Services (GAPS) initiative, the American Academy of Pediatrics through its revised schedule of periodic health care visits, the Health Resources and Services Administration through its Bright Futures initiative, the United States Preventive Services Task Force through its Guide to Clinical Preventive Services and the Put Prevention Into Practice Initiative, and now the ACIP through its revised schedule for adolescnet immunizations have all provided recommendations for organizing the delivery of clinical preventive services to adolescents.2,4-7
Central to each of these efforts is the belief that primary care physicians should assume a greater role in providing health guidance for adolescents and their families; screening for physical, emotional, and behavioral conditions; and ensuring that immunizations are updated. Data from several studies support the conclusion that while most physicians provide some preventive services to adolescents, few provide comprehensive services.8-9
The ACIP was cognizant of the fact that immunization services are a core component of routine health examinations. A routine health visit during early adolescence to begin the hepatitis B vaccine series (if not administered previously), to administer a booster dose of tetanus and diptheria toxoids (Td), and to ensure that children receive a second measles, mumps, rubella vaccine (MMR) and other necessary vaccines would, therefore, provide physicians with the opportunity to offer other preventive services, such as health guidance and screening. Following discussions with various national groups and experts, the ACIP chose to focus on promoting preventive services at age 11-12 years. This recommendation was based on the assumption that entry into adolescence provides physicians with access both to young people before they leave home or engage in health risk behaviors and to parents who could benefit from anticipatory guidance.
2.All adolescents 11-12 years of age who were not previously vaccinated with hepatitis B vaccine should be vaccinated with a 3-dose series.
In the United States, infection with hepatitis B virus (HBV) is a disease predominantly of adolescents and young adults. Since 1991, the ACIP and other national organizations, including the AMA, have advocated universal immunization of children and adults at risk against HBV.10 Because of logistical considerations associated with vaccinating an entire population, however, implementation was limited to all infants and to adolescents and adults who engage in behaviors that place them at high risk for the disease (i.e., intravenous drug use, male homosexual relationships, working in health care settings, and having intercourse with multiple sexual partners or having multiple sexually transmitted diseases). Unfortunately, this strategy has not been as effective as expected for two reasons: First, 25 percent-33 percent of people with hepatitis B infection have no identifiable risk factors11 and, second, most adolescents are not routinely screened by their physicians for factors that place them at risk for infection.8-9
In order to expand protection against hepatitis B infection, the ACIP decided to focus on ensuring that all adolescents not immunized during infancy are vaccinated at 11-12 years of age and, thus, are immunized before they enter the risk-taking age of middle to late adolescence. Three doses of HBV vaccine are needed to ensure immunity. Data from pilot projects done through school health programs indicate the feasibility of delivering hepatitis B vaccine to young adolescents.12 Since the recommendation for immunizing all infants was implemented during the early 1990s, it can be expected that as this cohort goes into adolescence within the next 5 to 7 years, the number of teenagers needing HBV vaccine will decrease.
3. The second dose of MMR should be given at 4-6 or 11-12 years of age. The adolescent health care visit should be used to assure that the second dose of MMR vaccine has been administered.
The recommendation for two doses of MMR was developed in 1989 in response to sporadic outbreaks of measles among school-age children and college students as a result of vaccine failure. State policies for mandating the second dose of MMR vary, with some states requiring it prior to entering elementary school and some requiring it for entry into middle or junior high school.
4. Immunization with varicella vaccine is recommended for adolescents age 11-12 years who do not have a reliable history of chicken pox and have not received this vaccine.
According to unpublished CDC data, over 20 percent of adolescents are susceptible to varicella infection.2 This estimate is corroborated by data from the 1980-1990 National Health Interview Survey (NHIS) indicating that 20 percent of cases of chicken pox occurred among people 10 years of age and older. Varicella infection among older children and adults is associated with a higher rate of medical complications than is infection that occurs in pre-school children. Two doses of the varicella vaccine are recommended for youth age 13 and older, while only one dose is needed for youth under age 13.
5. For adolescents who have had their primary series, a booster dose of Td vaccine can be given at age 11-12 years instead of 14-16 years, if no dose has been received during the previous 5 years.
Although booster doses of Td are recommended at 10-year intervals, there has not been a specific strategy to ensure adolescents and young adults receive coverage. Immunity status varies according to age. Thus, according to unpublished CDC data, the prevalence of immunity to tetanus decreases during early adolescence, leaving 15 percent-36 percent of youth 9-13 years of age unprotected.2 Recent data from a population-based survey suggest that approximately 10 percent of children 6-11 years of age and 20 percent of children aged 12-19 lack immunity to tetanus.13 In addition, immune status also relates to length of time since last vaccination. Thus, 28 percent of children who were immunized 6 to 10 years previously lack immunity to tetanus, compared with 14 percent and 5 percent who received tetanus vaccination 1 to 5 years previously and within 1 year respectively.13 The ACIP thought that lowering the age for administering the first Td booster from 14-16 years and providing this booster during a "catch-up" preventive health care visit at age 11-12 would increase compliance and reduce susceptibility of older adolescents and young adults.2 However, if a Td booster was administered after age 4-6, then the next dose should be provided 10 years later and not at age 11-12.
In addition to routine, universal immunization recommendations just described, the ACIP also recommended the following immunizations for special groups of adolescents.
6. Influenza vaccine is recommended for adolescents who, because of an underlying medical condition, are at increased risk for complications of influenza. Others, including adolescent household members in close contact with persons in high-risk groups also should be vaccinated. Any adolescent may receive the vaccine to reduce their likelihood of acquiring influenza infection.
7. Pneumococcal vaccine should be given to all adolescents with chronic illnesses associated with increased risk of pneumococcal disease or its complications. The adolescent health care visit should be used to assure that the vaccine has been administered to persons for whom it is indicated.
8.Hepatitis A vaccine (HAV) should be given to adolescents who travel or live in countries with high or intermediate endemicity of hepatitis A virus, live in communities with high endemic rates of hepatitis A, have chronic liver disease, are injecting drug users, or are males who have sex with males.
Promoting adolescent immunizations through state education requirements
The recommendations for adolescent immunizations provided by the ACIP represent an advancement in efforts to improve the health of this population. Implementation, however, presents a different set of challenges. As stated by Caroline B. Hall, MD, a member of the ACIP, "Only if the recommendation is universal and required by school laws are the necessary funds and insurance coverage for the vaccines and visit likely to be forthcoming".14 All states require that students receive certain immunizations in order to attend school. Although the requirements are fairly uniform in regard to immunizations for younger children, they are inconsistent in regard to adolescent vaccinations. For example, as of 1993-1994 only 9 of 52 states, including the District of Columbia and Puerto Rico, specifically require a Td booster after age 10 in order to attend secondary school and only 37 states require a second measles vacination.15 Of these, 10 states require the second MMR for entry into elementary school, 10 require it for entry into secondary school, and 17 have mixed requirements. According to CDC (personal communication, F. Averhoff, August, 1995) 13 states have passed or are considering legislation requiring hepatitis B vaccine for children in day care, foster care, and/or as a requirement for school admission. As yet, no states require varicella vaccine (for susceptible youth) for school entrance.
Recommendations
The following statements, recommended by the Council on Scientific Affairs, were adopted by the AMA House of Delegates as AMA policy at the 1995 AMA Interim Meeting.
- The AMA will lobby Congress to provide both the resources and the programs necessary, using the recommendations of the National Vaccine Advisory Committee and in accordance with the provision set forth in the National Vaccine Injury Compensation Act, to ensure that children nationwide are immunized on schedule, thus representing progress in preventive medicine.
- The AMA endorses the recommendations on adolescent immunization developed by the Advisory Committee for Immunization Practices and approved by both the American Academy of Family Physicians and the American Academy of Pediatrics.
- The AMA will develop model state legislation to require that students entering middle or junior high schools be adequately immunized according to current national standards.
- The AMA encourages state medical societies to advocate legislation or regulations in their state that are consistent with the AMA model state legislation.
- The AMA will continue to work with managed care groups and state and specialty medical societies to support a dedicated preventive health care visit at 11-12 years of age.
References
1. Centers for Disease Control and Prevention. Update: Childhood vaccine preventable diseases-United States, 1994. MMWR. 1994;43:718-720.
2. Center of Disease Control and Prevention. Adolescent immunization: Recommendations of the Advisory Committee on Immunization Practices (ACIP), draft, June 1995.
3. Gans JE, Blyth DA, Elster AB, Gavaras LL. America's Adolescents: How Healthy Are They? AMA Profiles of Adolescent Health. Chicago, IL: American Medical Association, 1990. 4. Elster AB, Kuznets NJ, eds. AMA Guidelines for Adolescent Preventive Services: Recommendations and Rationale. Baltimore, MD: Williams and Wilkins, 1993.
5. Recommendations for Preventive Health Care. Committee on Practice and Ambulatory Medicine, American Academy of Pediatrics, 1995.
6. Green M, ed. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. Arlington, VA: National Center for Education in Maternal and Child Health, 1995.
7. Guide to Clinical Preventive Services: A Report of the US Preventive Services Task Force. Baltimore, MD: Williams and Wilkins, 1989.
8. Millstein SG, Igra V, Gans J. Delivery of STD/HIV preventive services to adolescents by primary care physicians. (submitted for publication)
9. Centers for Disease Control and Prevention. HIV prevention practices of primary care physicians - United States, 1992. MMWR. 1994;42:988-992.
10. Centers for Disease Control and Prevention. Hepatitis B virus: a comprehensive strategy for eliminating transmission in the United States through childhood vaccination. MMWR. 1991;40:No.RR-13.
11. Alter MJ, Hadler SC, Margolis HS, Alexander J, Hu Py, Judson FN, et al. The changing epidemiology of hepatitis B in the United States: Need for alternative vaccination strategies. JAMA 1990;263:1218-1222.
12. Centers for Disease Control and Prevention. Hepatitis B Vaccination of adolescents: California, Louisiana, and Oregon 1992-1994. MMWR. 1994;43:605-608.
13. Gergen PJ, McQuillan GM, Kiely M, et al. A population-based serologic survey of immunity to tetanus in the United States. N Engl J Med. 1995;332:761-766.
14. Hall CB. Adolescent immunization: The access and anchor for health services? Pediatrics. 1995;85:936-937.
15. State Immunization Requirements 1993-1994. National Immunization Program, Centers for Disease Control and Prevention, Atlanta, GA.
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