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Immunization Rates in a Canadian Juvenile Corrections Facility
Journal of Adolescent Health 43 (2008) 609 – 611
Adolescent health brief
Immunization Rates in a Canadian Juvenile Corrections Facility Leah Bartlett, M.D.*, Marina Kanellos-Sutton, B.Sc.N., and Richard van Wylick, M.D., F.R.C.P.C. Department of Pediatrics, Queen’s University, Kingston, Ontario, Canada Manuscript received January 14, 2008; accepted April 22, 2008
Abstract
In Canada’s judicial system there are more than 31,700 youths admitted to correctional services each year. Given the prevalence of documented medical problems and high-risk behavior in this population, it is important to assess the immunization status of adolescents admitted to juvenile detention facilities. We completed a chart review of all youth admitted to an adolescent custody facility in Kingston, Ontario, between January 2003 and October 2005. There were 234 admissions, representing a total of 148 youths between the ages of 12 and 17 years. Of the youths, 73% had incomplete immunizations according to National Advisory Committee on Immunizations. In all, 49% (73 of 148) were missing tetanus, diphtheria, and acellular pertussis immunizations; 33% (49 of 148), meningococcus; 2% (four of 148), measles, mumps, and rubella; and 37% (55 of 148), hepatitis B. Successful immunization delivery within the detention facility increased complete immunization rates from 27% to 65%. This study shows the prevalence of incomplete immunizations in this population of adolescents. Given this data, there should be a greater focus on obtaining immunization records and on consistently delivering immunizations. © 2008 Society for Adolescent Medicine. All rights reserved.
Keywords:
Juvenile; Corrections; Immunization; Adolescence; Incarcerated youths
Canadian statistics reveal that approximately 15,900 youth annually are admitted to correctional services and sentenced to custody. These admissions include open and secure sentences as well as remand (pretrial detention) [1]. The St. Lawrence Youth Association admits children in remand and those sentenced to custody in the Eastern Ontario region. Position statements from both the Canadian Pediatric Society (CPS) and American Academy of Pediatrics (AAP) outline appropriate health standards of care for these incarcerated youths [2,3]. Juvenile offenders have been identified as a population at risk of comorbid health conditions. In a large study of 47,288 adolescents, 46% of detainees had documented health problems on admission [4]. The most common medical problems were drug and substance use, trauma, psychiatric disorders, dermatologic, respiratory, and sexually transmitted illnesses [4]. Given the
*Address correspondence to: Richard van Wylick, M.D., F.R.C.P.C., Hotel Dieu Hospital, 166 Brock St., Kingston, ON, K7L 3G2 Canada. E-mail address: [email protected]
high prevalence of multiple medical problems, an appropriate individual health assessment, including vaccination records, is essential upon admission to youth custodial facilities [2]. A survey of 752 detainees report only 33.6% of these individuals had a regular source of medical care before admission. More than half of detainees had not received, nor could they remember having received, any medical care within the past year. When asked where they would seek medical care, only 25% reported that they would seek care with a private physician [5]. Furthermore, on release from the detention facility, more than half of detainees did not have family support to ensure proper follow-up even if a health care provider was available [6]. Two studies have published immunization data on incarcerated adolescents. The first was a recent study from Spain, which revealed that 16.8% of adolescents between the ages of 13 and 17 years had incomplete immunizations on initial medical screening examination [7]. The second was a large study of 12 detention centers in Washington State, which
1054-139X/08/$ – see front matter © 2008 Society for Adolescent Medicine. All rights reserved. doi:10.1016/j.jadohealth.2008.04.008
610
L. Bartlett et al. / Journal of Adolescent Health 43 (2008) 609 – 611
reported on health care use in detention facilities. The mean number of total vaccinations given was 26.8 per month, with hepatitis B vaccines accounting for 25% of total vaccinations [6].
ing 35% had follow-up arranged to complete their recommended immunizations.
Discussion Methods In the current study, charts were reviewed for all adolescents admitted to the St. Lawrence Youth Association, a custody facility for youth in the Eastern Ontario region, between January 2003 and October 2005. All youths had an intake history and physical examination, and their immunization records were retrieved on admission. Records were obtained from multiple sources including family records, legal guardians, or public health departments’ computerbased registries. Eleven youths were excluded from the study because immunization records were unattainable for reasons relating to consent or refusal or for short duration of stay. Multiple admissions of the same individual were assessed upon first admission for immunization status, their immunizations were tallied and included in data as representing one individual. Results There were 234 admissions over a 34-month period. This group represented a total of 159 adolescents, 81 male and 78 female, between ages 12 and 17 years. Of the 148 youth admitted and eligible for this study, 73% were incompletely immunized according to National Advisory Committee on Immunization (NACI) guidelines [8]. Upon release from detention, incomplete immunizations decreased to 35%. Rates of specific missing individual immunizations ranged from 49% for tetanus, diphtheria, and acellular pertussis (Tdap) to 2% for measles, mumps, and rubella (MMR). The meningococcal C conjugate vaccine (MenC-C) was missing in 33% of patients, and 37% were lacking at least one of the hepatitis B series (Table 1). Of note, only two patients had not received DTaP-IPV series in infancy and required the “catch-up” Tdap series. Successful immunization intervention during detention stay increased the rate of complete immunization from 27% to 65%. Upon release, the remain-
Population demographics of detainees revealed youth of primarily Caucasian descent from low to middle socioeconomic groups. It is the current standard of practice at the detention center to provide immunizations to detainees [2]. Youth who did not complete immunizations are accounted for by minimum interval considerations between vaccine series, refusal of immunizations, short detention stay, or lack of repeat admissions. One of the barriers to immunization is timely retrieval of accurate immunization records. Family members and legal guardians often had no up-to-date immunization records, and detainees inaccurately self-reported complete immunization status. Regional public health data were found to be the most accessible immunization record for most detainees. Regional public health immunization comparisons were attempted. However, because of the lack of monitoring and surveillance, immunization data for the general adolescent population provided an inaccurate basis for comparison. The public health department requires immunization records for MMR and Tdap upon entering the education system (4 –5 years), at age 7 years, and at age 17 years. Undeniably this system will potentially miss youth who move between regions, drop out of school, or receive vaccines from different health care providers. Study data found the most common missing immunizations to be Tdap, Hep B, and MenC-C vaccines. Currently these are the vaccines required for the youth between 12 and 16 years of age [8]. Given the age of the study population, we may be capturing youth who are of an age to receive the Tdap booster. However poor hepatitis B immunization rates is a strong indicator of poor overall immunization rates, given that the Hep B series should be given before the age at which these youth encounter the youth detention system. The difference between 98% completed MMR vaccine vs. only 49% of Tdap may result from early public health initiatives that emphasize infant immunization schedules. In
Table 1 Rates of initial incomplete immunization and final complete immunizations Vaccine type
No. of immunizations administered
No. of youth with incomplete immunizations
No. of youth with incomplete series receiving required immunization
Final no. of youth with complete immunizations
Tdap MenC-C MMR Hep B (two-dose series) All vaccine series
42% (65/156) 28% (43/156) 1% (1/156) 30% (47/156)
49% (73/148) 33% (49/148) 2% (4/148) 37% (55/148) 73% (108/148)
89% (65/73) 88% (43/49) 25% (1/4) 78% (43/55) 51% (56/108)
70% (103/148) 96% (142/148) 98% (145/148) 92% (136/148) 65% (96/148)
Tdap ⫽ tetanus, diphtheria, acelluar pertussis; MenC-C ⫽ meningococcal C conjugate; MMR ⫽ measles, mumps, rubella; Hep B ⫽ hepatitis B.
L. Bartlett et al. / Journal of Adolescent Health 43 (2008) 609 – 611
1996 a second dose of measles vaccine was delivered to all school-aged children. Presumably many of the youth in our study received their MMR vaccine from this successful campaign. However a Tdap booster is required at age 14 –16 years, during the time when many of our youth encounter the detention system and may not be connected with family or public education to update their immunizations. Although our study did not determine the reasons for poor immunization rates, experience with this population has revealed factors such as problems with access to health care that limit contact with the public health system. Incarcerated youth may be disconnected from their schools or homes or may have changed abodes multiple times, thus losing continuity of health care and making regular updates of public health records difficult. Therefore admission to a custodial facility is an important point of contact to receive immunizations, health education, and routine medical care, as well as to update public health records. In conclusion, there is a high prevalence of incomplete vaccinations in this group of high-risk adolescents. Given this documented finding, there should be a greater emphasis
611
on providing consistent immunization delivery to this population of adolescents. References [1] Calverley D. Youth custody and community services in Canada 2004/ 2005. Statistics Canada 85-002 XIE [Online]. Available at: http:// www.statcan.ca/english/freepub/85-002-XIE/85-002-XIE2007002.pdf. Accessed January 9, 2008. [2] Canadian Pediatric Society. CPS position statement (AH 2005-01): Health care standards for youth in custodial facilities. Paediatr Child Health 2005;10:287–9. [3] Kaplan DW, Feinstein RA, Fisher MM, et al. Health care for children and adolescents in the juvenile correctional care system. Pediatrics 2001;107:799 – 803. [4] Hein K, Cohen MI, Litt IF, et al. Juvenile detention: Another boundary issue for physicians. Pediatrics 1980;66:239 – 45. [5] Feinstein RA, Lampkin A, Lorish CD, et al. Medical status of adolescents at time of admission to a juvenile detention center. J Adolesc Health 1998;22:190 – 6. [6] Anderson B, Farrow JA. Incarcerated adolescents in Washington State. J Adolesc Health 1998;22:363–7. [7] Olivan G. The health profile of Spanish incarcerated delinquent youths. J Adolesc Health 2001;29:384. [8] Canadian Immunization Guide, Seventh Edition. Public Health Agency of Canada. Ottawa, ON: Public Works and Government Services Canada, 2006.
Adolescent health brief
Immunization Rates in a Canadian Juvenile Corrections Facility Leah Bartlett, M.D.*, Marina Kanellos-Sutton, B.Sc.N., and Richard van Wylick, M.D., F.R.C.P.C. Department of Pediatrics, Queen’s University, Kingston, Ontario, Canada Manuscript received January 14, 2008; accepted April 22, 2008
Abstract
In Canada’s judicial system there are more than 31,700 youths admitted to correctional services each year. Given the prevalence of documented medical problems and high-risk behavior in this population, it is important to assess the immunization status of adolescents admitted to juvenile detention facilities. We completed a chart review of all youth admitted to an adolescent custody facility in Kingston, Ontario, between January 2003 and October 2005. There were 234 admissions, representing a total of 148 youths between the ages of 12 and 17 years. Of the youths, 73% had incomplete immunizations according to National Advisory Committee on Immunizations. In all, 49% (73 of 148) were missing tetanus, diphtheria, and acellular pertussis immunizations; 33% (49 of 148), meningococcus; 2% (four of 148), measles, mumps, and rubella; and 37% (55 of 148), hepatitis B. Successful immunization delivery within the detention facility increased complete immunization rates from 27% to 65%. This study shows the prevalence of incomplete immunizations in this population of adolescents. Given this data, there should be a greater focus on obtaining immunization records and on consistently delivering immunizations. © 2008 Society for Adolescent Medicine. All rights reserved.
Keywords:
Juvenile; Corrections; Immunization; Adolescence; Incarcerated youths
Canadian statistics reveal that approximately 15,900 youth annually are admitted to correctional services and sentenced to custody. These admissions include open and secure sentences as well as remand (pretrial detention) [1]. The St. Lawrence Youth Association admits children in remand and those sentenced to custody in the Eastern Ontario region. Position statements from both the Canadian Pediatric Society (CPS) and American Academy of Pediatrics (AAP) outline appropriate health standards of care for these incarcerated youths [2,3]. Juvenile offenders have been identified as a population at risk of comorbid health conditions. In a large study of 47,288 adolescents, 46% of detainees had documented health problems on admission [4]. The most common medical problems were drug and substance use, trauma, psychiatric disorders, dermatologic, respiratory, and sexually transmitted illnesses [4]. Given the
*Address correspondence to: Richard van Wylick, M.D., F.R.C.P.C., Hotel Dieu Hospital, 166 Brock St., Kingston, ON, K7L 3G2 Canada. E-mail address: [email protected]
high prevalence of multiple medical problems, an appropriate individual health assessment, including vaccination records, is essential upon admission to youth custodial facilities [2]. A survey of 752 detainees report only 33.6% of these individuals had a regular source of medical care before admission. More than half of detainees had not received, nor could they remember having received, any medical care within the past year. When asked where they would seek medical care, only 25% reported that they would seek care with a private physician [5]. Furthermore, on release from the detention facility, more than half of detainees did not have family support to ensure proper follow-up even if a health care provider was available [6]. Two studies have published immunization data on incarcerated adolescents. The first was a recent study from Spain, which revealed that 16.8% of adolescents between the ages of 13 and 17 years had incomplete immunizations on initial medical screening examination [7]. The second was a large study of 12 detention centers in Washington State, which
1054-139X/08/$ – see front matter © 2008 Society for Adolescent Medicine. All rights reserved. doi:10.1016/j.jadohealth.2008.04.008
610
L. Bartlett et al. / Journal of Adolescent Health 43 (2008) 609 – 611
reported on health care use in detention facilities. The mean number of total vaccinations given was 26.8 per month, with hepatitis B vaccines accounting for 25% of total vaccinations [6].
ing 35% had follow-up arranged to complete their recommended immunizations.
Discussion Methods In the current study, charts were reviewed for all adolescents admitted to the St. Lawrence Youth Association, a custody facility for youth in the Eastern Ontario region, between January 2003 and October 2005. All youths had an intake history and physical examination, and their immunization records were retrieved on admission. Records were obtained from multiple sources including family records, legal guardians, or public health departments’ computerbased registries. Eleven youths were excluded from the study because immunization records were unattainable for reasons relating to consent or refusal or for short duration of stay. Multiple admissions of the same individual were assessed upon first admission for immunization status, their immunizations were tallied and included in data as representing one individual. Results There were 234 admissions over a 34-month period. This group represented a total of 159 adolescents, 81 male and 78 female, between ages 12 and 17 years. Of the 148 youth admitted and eligible for this study, 73% were incompletely immunized according to National Advisory Committee on Immunization (NACI) guidelines [8]. Upon release from detention, incomplete immunizations decreased to 35%. Rates of specific missing individual immunizations ranged from 49% for tetanus, diphtheria, and acellular pertussis (Tdap) to 2% for measles, mumps, and rubella (MMR). The meningococcal C conjugate vaccine (MenC-C) was missing in 33% of patients, and 37% were lacking at least one of the hepatitis B series (Table 1). Of note, only two patients had not received DTaP-IPV series in infancy and required the “catch-up” Tdap series. Successful immunization intervention during detention stay increased the rate of complete immunization from 27% to 65%. Upon release, the remain-
Population demographics of detainees revealed youth of primarily Caucasian descent from low to middle socioeconomic groups. It is the current standard of practice at the detention center to provide immunizations to detainees [2]. Youth who did not complete immunizations are accounted for by minimum interval considerations between vaccine series, refusal of immunizations, short detention stay, or lack of repeat admissions. One of the barriers to immunization is timely retrieval of accurate immunization records. Family members and legal guardians often had no up-to-date immunization records, and detainees inaccurately self-reported complete immunization status. Regional public health data were found to be the most accessible immunization record for most detainees. Regional public health immunization comparisons were attempted. However, because of the lack of monitoring and surveillance, immunization data for the general adolescent population provided an inaccurate basis for comparison. The public health department requires immunization records for MMR and Tdap upon entering the education system (4 –5 years), at age 7 years, and at age 17 years. Undeniably this system will potentially miss youth who move between regions, drop out of school, or receive vaccines from different health care providers. Study data found the most common missing immunizations to be Tdap, Hep B, and MenC-C vaccines. Currently these are the vaccines required for the youth between 12 and 16 years of age [8]. Given the age of the study population, we may be capturing youth who are of an age to receive the Tdap booster. However poor hepatitis B immunization rates is a strong indicator of poor overall immunization rates, given that the Hep B series should be given before the age at which these youth encounter the youth detention system. The difference between 98% completed MMR vaccine vs. only 49% of Tdap may result from early public health initiatives that emphasize infant immunization schedules. In
Table 1 Rates of initial incomplete immunization and final complete immunizations Vaccine type
No. of immunizations administered
No. of youth with incomplete immunizations
No. of youth with incomplete series receiving required immunization
Final no. of youth with complete immunizations
Tdap MenC-C MMR Hep B (two-dose series) All vaccine series
42% (65/156) 28% (43/156) 1% (1/156) 30% (47/156)
49% (73/148) 33% (49/148) 2% (4/148) 37% (55/148) 73% (108/148)
89% (65/73) 88% (43/49) 25% (1/4) 78% (43/55) 51% (56/108)
70% (103/148) 96% (142/148) 98% (145/148) 92% (136/148) 65% (96/148)
Tdap ⫽ tetanus, diphtheria, acelluar pertussis; MenC-C ⫽ meningococcal C conjugate; MMR ⫽ measles, mumps, rubella; Hep B ⫽ hepatitis B.
L. Bartlett et al. / Journal of Adolescent Health 43 (2008) 609 – 611
1996 a second dose of measles vaccine was delivered to all school-aged children. Presumably many of the youth in our study received their MMR vaccine from this successful campaign. However a Tdap booster is required at age 14 –16 years, during the time when many of our youth encounter the detention system and may not be connected with family or public education to update their immunizations. Although our study did not determine the reasons for poor immunization rates, experience with this population has revealed factors such as problems with access to health care that limit contact with the public health system. Incarcerated youth may be disconnected from their schools or homes or may have changed abodes multiple times, thus losing continuity of health care and making regular updates of public health records difficult. Therefore admission to a custodial facility is an important point of contact to receive immunizations, health education, and routine medical care, as well as to update public health records. In conclusion, there is a high prevalence of incomplete vaccinations in this group of high-risk adolescents. Given this documented finding, there should be a greater emphasis
611
on providing consistent immunization delivery to this population of adolescents. References [1] Calverley D. Youth custody and community services in Canada 2004/ 2005. Statistics Canada 85-002 XIE [Online]. Available at: http:// www.statcan.ca/english/freepub/85-002-XIE/85-002-XIE2007002.pdf. Accessed January 9, 2008. [2] Canadian Pediatric Society. CPS position statement (AH 2005-01): Health care standards for youth in custodial facilities. Paediatr Child Health 2005;10:287–9. [3] Kaplan DW, Feinstein RA, Fisher MM, et al. Health care for children and adolescents in the juvenile correctional care system. Pediatrics 2001;107:799 – 803. [4] Hein K, Cohen MI, Litt IF, et al. Juvenile detention: Another boundary issue for physicians. Pediatrics 1980;66:239 – 45. [5] Feinstein RA, Lampkin A, Lorish CD, et al. Medical status of adolescents at time of admission to a juvenile detention center. J Adolesc Health 1998;22:190 – 6. [6] Anderson B, Farrow JA. Incarcerated adolescents in Washington State. J Adolesc Health 1998;22:363–7. [7] Olivan G. The health profile of Spanish incarcerated delinquent youths. J Adolesc Health 2001;29:384. [8] Canadian Immunization Guide, Seventh Edition. Public Health Agency of Canada. Ottawa, ON: Public Works and Government Services Canada, 2006.