Teenhood vaccines: Seizing the opportunity

Certain circumstances lead teenagers to their doctors. Maybe their acne is out of control. Their parents might be concerned about their moodiness or depression. Sometimes there's a broken bone or a bad cold. And, of course, the preparticipation sports physical also is a draw.

In general, though, teens represent a healthy patient population. That's why some health systems, such as Kaiser Permanente of Georgia, have set up mechanisms to ensure that, when these youngsters do cross the doctor's office threshold, the opportunity to provide preventive care does not slip away.

For example, every time a teen sees a physician at one of these Kaiser clinics, his or her immunization record is automatically checked. If it's not up to date, the teen is asked to stop by the pediatrics department on the way out to get whatever vaccinations are missing. There's no charge for any routine shots, and appointments for the sometimes-necessary second or third doses are booked on the spot.

"We really have to immunize them whenever we see them, or it's probably not going to happen," said Catherine Dragstedt, MD, chief of pediatrics at Kaiser Permanente of Georgia.

Such is an example of the herculean efforts experts say are integral to connecting adolescents with these important shots, especially as more for this age group are developed.

"With a wave of new adolescent vaccines coming in the near future, physicians as well as parents must be prepared to maximize their benefits to this vulnerable population," said AMA President J. Edward Hill, MD.

Up until a couple of years ago, the teen years were a time of catch-up regarding any immunizations missed in childhood and to administer the tetanus-diphtheria booster. But this situation is changing rapidly, and adolescence is becoming an age of vaccines -- much like early childhood. Last year, the Td shot was replaced with one that provides additional immunity against pertussis. A vaccine that protects against meningococcal disease was approved and recommended for children ages 11 and 12, those entering high school and college freshmen living in dormitories.

Several other new shots are also imminent. Approval for one that provides protection against the human papillomavirus is expected before the end of year. Others for herpes simplex and Chlamydia are on the horizon.

To be fair, adolescent vaccination efforts so far have been satisfactory. According to data from the Centers for Disease Control and Prevention, 91% of those 13 to 15 years old received the tetanus-diphtheria booster as of 2003.

Experts warn, though, that such coverage rates will become far more challenging with an increased number of immunizations targeted to teens. Some of these new vaccines, such as the one for HPV, also will require more than one jab -- further complicating the situation, because such attempts have sputtered when preparations require multiple doses.

"It behooves us to make it very clear that some of these vaccines need boosters," said Anne Eliades, MD, a pediatrician from Muncie, Ind. "But we're going to lose some people who don't come back for the follow-up shots."

For instance, rates for the hepatitis B vaccine, which requires three doses, are only around 81%, which is why emphasis for administering it has shifted to infancy as part of the childhood series.

Finding paths to success

Most advocates feel that moving all shots to the already crowded infant and toddler period will not be the answer. There are existing strategies, such as school requirements -- a proven approach to increase vaccination rates in younger children and early adolescence -- that could play a significant role.

"[It is] one of the most effective public policy levers that we have," said Peter Szilagyi, MD, MPH, professor of pediatrics at the University of Rochester in New York. "It's very powerful."

Additionally, many have been calling for the establishment of a well-child visit at 11 or 12 years old, when a range of preventive services, including vaccines, could be provided.

"Eleven is not magic medically, but it is an age at which we have a chance to capture them," said Charles Shubin, MD, director of pediatrics for Mercy FamilyCare in Baltimore. "It's an age when parents are still in charge. The older the kid gets, the harder it is."

Such visits were first officially recommended by CDC's Advisory Committee on Immunization Practices, the American Academy of Pediatrics, the American Academy of Family Physicians and the American Medical Association nearly a decade ago.

But while the early adolescent visit is considered the ideal, it nonetheless has gained only limited utilization.

Thus, the message is clear: Any chance to vaccinate an older adolescent should be taken. "Catch them if you can," said William Schaffner, MD, a spokesman for the National Foundation for Infectious Diseases and professor of preventive medicine at Vanderbilt University School of Medicine in Nashville, Tenn.

But don't expect it to be easy. As kids get older, they often lose contact with their childhood medical home. Teens may not want to visit their pediatricians because they may view them as a "little-kid doctor." Some pediatricians also have an age cutoff of 13 years old for patients.

"You have to face the facts that kids are not going to keep going to the pediatrician. The teenager basically drops out of the system," said Stanley A. Gall, MD, professor of obstetrics and gynecology at the University of Louisville School of Medicine in Kentucky. "Pediatricians really don't see them. Family physicians really don't see them. Ob-gyns don't see them.Internists, for sure, don't see them."

While the link to a medical home may be tenuous, teens may continue to receive care. The interaction, though, tends to be fragmented into acute-care visits that may take place in a variety of settings ranging from a school-based clinic to the emergency department. Athletes may show up for a required check-up, and young women may come in for contraception.

"They just aren't typically in the office on a routine basis," said Clif Knight, MD, program director for the family medicine residency at Community Health Network in Indianapolis.

Therefore, taking advantage of these occasions can be tricky. Depending on the nature of the visit, the patient may prefer to stay focused on the matter at hand. The vaccination record also may not be accessible.

"If the things are not so acute that ... other discussion [is possible], then certainly we do mention these vaccines," said Dr. Eliades. "Many people will say, 'not now -- we'll do it some other time.' But whether they actually make the appointment or come back, that's up in the air."

Physicians say sports physicals are also not an easy platform from which vaccines can be offered. The physical may occur at the school, which may be a less-than-conducive setting because of a lack of appropriate storage facilities for vaccines. And challenges still exist even when the physical occurs in the doctor's office.

"Some of them are children who haven't been seen here before," said Carson Rounds, MD, a family physician from Wake Forest, N.C. "They don't bring an immunization record with them. They think they may have had a shot. They don't know for sure. Their parents don't know for sure. Despite asking them to come back, they often don't."

Meanwhile, teen medical contact may begin to involve specialties less accustomed to dealing with vaccines. Pediatricians and family physicians are old hands, but girls, in particular, may go to a ob-gyn for birth control or even prenatal care. In order to raise the awareness of vaccines among these physicians, the American College of Obstetricians and Gynecologists recently formed a task force to address the barriers to delivering shots to both adults and adolescents in this setting.

"Historically, obstetricians-gynecologists have not been good vaccinators," said Dr. Gall, who is chair of the task force and the organization's ACIP liaison.

Additional concern exists because, despite how well-intentioned efforts are, they may still miss plenty of kids. Not every teen has a preparticipation physical because not every teen is involved in sports. Not every teen will have a need to approach the health system for birth control. And school requirements only apply as long as the adolescent is a student. How to reach those who drop out or never attend college remains an open question.

"There are profound disparities out there," said Jonathan Temte, MD, PhD, the AAFP's liaison to the ACIP and an associate professor of family medicine at the University of Wisconsin in Madison. "We really run a huge risk of a very patchwork distribution of vaccines."

But parents may be central to overcoming these hurdles. In a survey of 150 adolescents ages 11 to 19 by the nonprofit organization Parents of Kids with Infectious Diseases, the young respondents ranked parents as the most trusted source for health information, with health professionals coming in a close second.

"Parents may not like their adolescents and vice-versa, but I know they love them and want to protect them against bad diseases," said Carol J. Baker, MD, professor in the Dept. of Pediatrics and head of infectious disease at Baylor College of Medicine in Houston. "If you've got the parents educated, I think it's pretty easy to educate the adolescent."

Many experts also theorize that the ultimate payoff will be more than just getting adolescents their shots. Many speculate that the increasingly robust vaccination schedule will fill in some of the long-standing holes in adolescent health care. It may draw them into a medical home, much as vaccinations targeting infants and toddlers already do.

"We're hoping that the benefits of all these vaccines are going to help attract the teenagers into medical care and into the medical home for primary care," said Lance Rodewald, MD, director of the CDC's immunization services division. "Certainly, that works for young infants."