BETHESDA, MD. — Physicians face several barriers when it comes to immunizing adolescents, including infrequent access to the age group, low reimbursements, difficulty tracking immunization history, and lack of education about vaccine safety, Dr. Amy B. Middleman said.
The 2009 National Immunization Survey shows that the vaccination rates “remain unacceptably low for those vaccines that are targeted specifically to prevent disease in adolescents,” according to a Society for Adolescent Health and Medicine (SAHM) statement. The survey shows that among 13- to 17-year-old teens, roughly 54% received meningococcal meningitis vaccines; 44% got human papillomavirus (HPV) vaccine (with only 27% receiving all three recommended doses), and nearly 56% got tetanus-diphtheria-pertussis (Tdap) vaccines.
“Low rates among adolescents may be responsible for the epidemic of pertussis that is presently occurring in California,” according to the SAHM statement.
But there are opportunities to improve adolescent immunization rates, Dr. Middleman said at the meeting, which was sponsored by the National Foundation for Infectious Diseases.
Some polls show that 80% or more of adolescents have visited a health care provider within the last 12 months, but those visits may not necessarily be preventive in nature, and physicians can turn them into comprehensive visits and update the patients' vaccinations, said Dr. Middleman, who is an SAHM liaison to the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices.
Reimbursement rates are another barrier, Dr. Middleman pointed out, saying that there is a “significant correlation between reimbursement rates and childhood immunizations,” with a correlation of 0.42 (Pediatrics 2006;115:833). A 2009 Pediatrics article (124:S466-71) shows that 49% of primary care physicians delayed vaccine purchase because of finances, and 53% had decreased profit margins due to immunizations.
There is a need for a standardized vaccination visit during adolescence, said Dr. Middleman, and so far state policies and school mandates have shown a great impact on increasing the rates.
For instance, a 2004 study showed that adolescents were significantly more likely to have completed their hepatitis B series in states with school mandates (75%) versus those without a mandate (39%), she said (J. Adolesc. Health 2004;34:420-23). Such mandates also help eliminate preventive care disparities, given available funding, she added.
Dr. Middleman said that in one of her recent surveys in Houston, 41% of the parents indicated they would be willing to immunize their children in schools (Vaccine 2010;28:2674-6).
The rate, however, varies depending on the type of vaccines, with the influenza vaccine getting the highest support (57% of parents) and human papillomavirus the least (27%), according to one study (J. Adolesc. Health 2010;47:249-53). She added that other studies have shown that as many as 88% of practicing pediatricians are receptive to programs such as school vaccinations, and 61% said they would participate in such programs (BMC Pediatrics 2009;9:8).
In addition, alternative immunization sites, such as pharmacies, city and county clinics, emergency departments, and even ob.gyn. offices and clinics, provide additional opportunities to immunize the adolescent age group. Dr. Middleman said there are drawbacks for alternative sites, including poor follow-up and lack of access to immunization information systems. But there are potential benefits for adolescents who lack a medical home or need to complete multiple-dose regimens.
Immunization Information Systems are another tool recommended by the National Vaccine Advisory Committee and the National Immunization Program as a way to consolidate fragmented records and automate reminders and recalls. Such programs have been very successful, even in extreme situations such as Hurricane Katrina, she said.
Dr. Middleman stressed the importance of education about vaccine recommendations and safety for physicians, their staff, and parents. She recommended physicians “capitalize on noncomprehensive visits” such as camp or sports physicals or precollege visits to immunize the otherwise-hard-to-reach adolescents.
Dr. Middleman said that she receives research funding from Sanofi Pasteur and MedImmune.
Resources for Immunization Info.
▸ Centers for Disease Control and Prevention:
▸ Immunization Action Coalition:
▸ National Foundation for Infectious Diseases:
▸ National Network for Immunization Information:
▸ Texas Children's Hospital Center for Vaccine Awareness and Research: