Immunization of Immunization of Adolescents: An UpdateAdolescents: An Update

Daniel B. Fishbein, MDDaniel B. Fishbein, MDHealth Services Research and Evaluation BranchHealth Services Research and Evaluation Branch

Immunization Services DivisionImmunization Services DivisionNational Immunization ProgramNational Immunization Program

Centers for Disease Control and PreventionCenters for Disease Control and Prevention

OutlineOutline

Vaccine preventable diseases in Vaccine preventable diseases in adolescentsadolescents– IncidenceIncidence– DeathsDeaths

Vaccination of adolescentsVaccination of adolescents

Interventions to increase vaccination Interventions to increase vaccination coverage in adolescentscoverage in adolescents

Priorities for the futurePriorities for the future

Varicella* Varicella* Cases/100,000, 1995-2001Cases/100,000, 1995-2001

0.1

1

10

100

1000

10000

Re

po

rte

d c

as

es

pe

r 1

00

,00

0

Varicella, 10-14 y/o

Varicella, 15-19 y/o

* Antelope Valley, California, ESD, NIP, CDC

95 96 97 98 99 00 01

ACIPstatement

Varicella* & Hepatitis AVaricella* & Hepatitis A†† Cases/100,000, 1995-2001Cases/100,000, 1995-2001

0.1

1

10

100

1000

10000

Re

po

rte

d c

as

es

pe

r 1

00

,00

0

Varicella, 10-14 y/o

Varicella, 15-19 y/o

Hep A, 2-18 y/o

* Antelope Valley, California, ESD, NIP, CDC† States w/ consistently elevated rates, National Notifiable Dis. Surv. System, CDC

95 96 97 98 99 00 01

ACIPstatement

Varicella*, Hepatitis AVaricella*, Hepatitis A†,†, & Hepatitis B & Hepatitis B‡

Cases/100,000, 1995-2001Cases/100,000, 1995-2001

0.1

1

10

100

1000

10000

Re

po

rte

d c

as

es

pe

r 1

00

,00

0

Varicella, 10-14 y/o

Varicella, 15-19 y/o

Hep A, 2-18 y/o

Hep B, 12-19 y/o

* Antelope Valley, California, ESD, NIP, CDC† States w/ consistently elevated rates, National Notifiable Dis. Surv. System, CDC‡ National Notifiable Dis. Surv. System, CDC

95 96 97 98 99 00 01

ACIPstatement

Estimated Hepatitis B Incidence by Race, Estimated Hepatitis B Incidence by Race, Ages 19-24 Years, 1997-2002Ages 19-24 Years, 1997-2002

0

10

20

30

40

1997 1998 1999 2000 2001 2002

Year

Cas

es p

er 1

00,0

00

Black AI/AN A/PI White HispanicSource: National Notifiable Diseases Surveillance System (NNDSS)

OutlineOutline

Vaccine preventable diseases in Vaccine preventable diseases in adolescentsadolescentsVaccination of adolescentsVaccination of adolescents– RecommendationsRecommendations– Immunization requirements Immunization requirements – CoverageCoverage

Interventions to increase vaccination Interventions to increase vaccination coverage in adolescentscoverage in adolescentsPriorities for the future?Priorities for the future?

Hepatitis B

Tetanus-diphtheria

Measles, Mumps, Rubella

Varicella

Pneumococcal

Hepatitis A

Influenza

11-12 13-18

for selected populations

. Age .

for all adolescents not already up-to-date

Vaccines Recommended for Adolescents

2-10

Recommended agesCatch-up

Birth-1

(…..DTaP #1-4……)

1-2

#1 #2

DC

Number of Different Vaccines Required for Middle School Entry, 2003*

CA

OR

WA

NV

ID

AK

MT

HI

AZ

UT

NM

WY

CO

OK

KS

NB

SD

ND

LA

AK

MO

IA

MNWI

IL INOH

MI

MS AL GA

FL

TNSC

NCKY

VAWV

PA

NY

ME

NJ

MD

DE

VT

NH

MA

RI

CT

None One Two Three Four or Five

* Includes progressive school entrance laws that apply to middle schools as of 2003

TX

Number Of States With Immunization Number Of States With Immunization Requirements* For Middle School, By Requirements* For Middle School, By

Vaccine, 1989-2003Vaccine, 1989-2003

0

10

20

30

40

7 Varicella

34 Hepatitis B

17 Tetanus

ACIPstatement

39 Measles

*Excludes laws for new entrants only. For states with progressive laws, year effective is year 11 year olds were affected

Immunization Coverage Among Immunization Coverage Among AdolescentsAdolescents

National Health Interview SurveyNational Health Interview Survey– Household face-to-face survey of non-institutionalized population Household face-to-face survey of non-institutionalized population

of the United Statesof the United States– Expanded to include children less than 18 years of age (1997)Expanded to include children less than 18 years of age (1997)– Data available from 1997 (year after harmonized adolescent Data available from 1997 (year after harmonized adolescent

vaccination recommendations released) through 2001.vaccination recommendations released) through 2001.

Number of doses of four vaccines obtained for children Number of doses of four vaccines obtained for children aged 13-15 years of age and source of information aged 13-15 years of age and source of information – Immunization recordImmunization record– Parental recallParental recall

First nationally representative data on adolescent First nationally representative data on adolescent immunization coverageimmunization coverage

Immunization Record AvailabilityImmunization Record Availability Adolescents 13-15 Years of Age,Adolescents 13-15 Years of Age,National Health Interview SurveyNational Health Interview Survey

19.7 19.818.5

20.418.3

0

5

10

15

20

25

1997 1998 1999 2000 2001

Year

% U

se S

hot

Car

d

MMR (2 or more doses)MMR (2 or more doses) Estimated Vaccination Coverage Estimated Vaccination Coverage Adolescents, 13-15 Years Of AgeAdolescents, 13-15 Years Of Age

95

73

96 97 96

68 7276

97

76

0

20

40

60

80

100

Shot Card Recall

Per

cent

Vac

cinat

ed

19971998199920002001

2010 Target

Hepatitis B (3 or more doses)Hepatitis B (3 or more doses) Estimated Vaccination Coverage Estimated Vaccination Coverage Adolescents, 13-15 Years Of AgeAdolescents, 13-15 Years Of Age

57

27

6974 74

55

79

15

3444

0

20

40

60

80

100

Shot Card Recall

Perc

ent

Vacc

inate

d

19971998199920002001

2010 Target

Hepatitis B (3 or more doses)Hepatitis B (3 or more doses) Estimated Vaccination Coverage Estimated Vaccination Coverage Adolescents, 13-15 Years Of AgeAdolescents, 13-15 Years Of Age

5

16 171723

28

1826

3530

5243

31

5761

0

20

40

60

80

100

Afr Amer Hispanic White

Per

cent

Vac

cinat

ed

19971998199920002001

2010 Target

Estimated Vaccination Coverage, 1+ Estimated Vaccination Coverage, 1+ Td, Adolescents 13-15 Years Of AgeTd, Adolescents 13-15 Years Of Age

29

95

32

95

33

96

33

94

34

96

0

20

40

60

80

100

Shot Card Recall

% V

acci

nat

ed

19971998199920002001

OutlineOutline

Vaccine preventable diseases in adolescentsVaccine preventable diseases in adolescentsVaccination of adolescentsVaccination of adolescentsInterventions to increase vaccination coverage Interventions to increase vaccination coverage among adolescentsamong adolescents– Health care settingsHealth care settings

Primary carePrimary careNon-traditionalNon-traditional

– School focusedSchool focusedVoluntary school based programsVoluntary school based programsEntry laws and requirementEntry laws and requirement

Vision for the futureVision for the future

Changes in 3-dose Hepatitis B Changes in 3-dose Hepatitis B Coverage, San Diego*Coverage, San Diego*

*Using parent-held vaccination record

Grade

0

20

40

60

80

1995 1996 1997 1998 1999

7th Grade8-12th Grade

Law passed

Law effective

0 20 40 60 80 100Percentage point change in coverage

Median = +63 pct points (range: +33 to +91)Size of population: meidan 4558 (range 227-24000)

Voluntary School-based VaccinationVoluntary School-based Vaccination(Upper income countries)(Upper income countries)

Study

Lancman, 2000

Middleman, 2000

Cassidy, 1997

Dobson, 1995

Unti, 1998

Wilson, 2000

Peavy, 1999

control

Next StepsNext Steps

DataData– Projections through 2010?Projections through 2010?

Number of laws Number of laws Population coveragePopulation coverageDisease incidenceDisease incidence

– Understanding racial and ethnic disparities in coverageUnderstanding racial and ethnic disparities in coverage

Interventions?Interventions?– Age group specific: Should there be priorities?Age group specific: Should there be priorities?– Race and ethnicity specific: Should we focus on disparities?Race and ethnicity specific: Should we focus on disparities?– VPD specific: Varicella?VPD specific: Varicella?– Geographic areasGeographic areas– Infrastructure to facilitate vaccination of adolescents to address Infrastructure to facilitate vaccination of adolescents to address

all currently recommended vaccines and new vaccines that may all currently recommended vaccines and new vaccines that may become priorities in the future.become priorities in the future.

Are the immunizations….Are the immunizations….Recommended?Recommended? Required?Required?

Is there are Is there are a program?a program?

Who drives Who drives it?it?

Where are Where are the shots the shots given?given?

Health Health settingssettings

GAPsGAPs

STD clinicsSTD clinics

Adolescent Adolescent health clinicshealth clinics Evaluations Evaluations

of require-of require-mentsments

Education Education settingssettings

School-based School-based clinicsclinics

School-based School-based special programsspecial programs

Interventions to Increase Vaccination Interventions to Increase Vaccination Coverage Among AdolescentsCoverage Among Adolescents