- Email: [email protected]
Vaccination: An Opportunity to Enhance Early Adolescent Preventative Services
Journal of Adolescent Health 39 (2006) 461– 464
Review article
Vaccination: An Opportunity to Enhance Early Adolescent Preventative Services Richard Rupp, M.D.,a,* Susan L. Rosenthal, Ph.D.,a and Amy B. Middleman, M.D., M.P.H., M.S.Ed.b a
Department of Pediatrics and Sealy Center for Vaccine Development, University of Texas Medical Branch, Galveston, Texas b Department of Pediatrics, Adolescent Medicine and Sports Medicine Section, Baylor College of Medicine, Houston, Texas Manuscript received February 10, 2006; manuscript accepted April 7, 2006.
Abstract:
New vaccines are being developed that will be recommended for adolescents Adolescence is a time period when adolescent-parent dynamics change and when adolescents may be confronted with increasing opportunities to engage in risk-taking behaviors such as sexual behavior and substance use. Despite clear recommendations regarding preventative counseling, many adolescents do not receive adequate preventive care. In this manuscript, we provide suggestions as to how a new vaccination schedule can be used to enhance preventative services to both adolescents and their parents. © 2006 Society for Adolescent Medicine. All rights reserved.
Keywords:
Vaccination; Prevention; HPV, Pertussis; Meningococcal disease
New and Future Adolescent Vaccines In all likelihood there will be a succession of new adolescent vaccines introduced over the next decade. Already we are witnessing the replacement of the tetanus and diphtheria toxoids (Td) vaccine with the tetanus, diphtheria, acellular pertussis (Tdap) vaccine [1] and the addition of the meningococcal conjugate vaccine (MCV4) to the recommendations for adolescents [2]. More changes are afoot as a vaccine targeting human papillomavirus (HPV) is before the Food and Drug Administration for licensure [3,4]. Other vaccines for herpes simplex virus (HSV) and cytomegalovirus (CMV) are in clinical trials and are expected to target teens as well [5,6]. These new vaccines have the potential not only to prevent infectious diseases, but to provide repeated contact with a population that historically has received little preventive care. Just as we have organized the medical care visit structure of infants around the vaccine schedule, this same degree of preventive care structure could be accomplished with the adolescent population. *Address correspondence to: Dr. Richard Rupp, Division of Adolescent & Behavioral Health, UTMB Primary Care Pavilion , 301 University Blvd., Galveston, TX 77555-1119. E-mail address: [email protected]
Those infant visits provide opportunity for anticipatory guidance to families, and similarly, an early adolescent vaccine schedule could provide opportunities for health care screening and anticipatory guidance to both parents and adolescents. Catch-up vaccination will provide similar opportunities for the middle and late adolescent.
Need for Greater Preventive Services for Adolescents The justification for more effective preventative services for the adolescent population is clear. The major morbidities/mortalities of adolescence are psychosocial in nature, and thus, likely to be preventable. By far, unintentional injuries, violence and suicide are the major causes of death among this age group [7]. Substance use, sexual behaviors, and dieting are behaviors with which adolescents begin to experiment and can be associated with significant morbidity and mortality. The 2003 Youth Risk Behavior Surveillance Survey revealed that, when surveyed, over a quarter of high school students across the four years reported heavy episodic drinking during the month before being surveyed, whereas 22% report using marijuana in the same period. Nearly half of high school students report having had sexual intercourse, with 4.9% of the girls reported having been
1054-139X/06/$ – see front matter © 2006 Society for Adolescent Medicine. All rights reserved. doi:10.1016/j.jadohealth.2006.04.007
462
R. Rupp et al. / Journal of Adolescent Health 39 (2006) 461– 464
pregnant. In the month before being surveyed, almost 10% of students had taken some sort of diet pill, powder or liquid, and 6% had used vomiting or laxatives to control their weight [8]. To decrease the likelihood that adolescents will engage in health-compromising behaviors, several organizations have developed comprehensive guidelines for health care providers to use to promote health-enhancing behaviors among their adolescent patients. Among the best known is the American Medical Association Guidelines for Adolescent Preventative Services (GAPS) published in 1992 [9]. Another well-known program, Bright Futures, was developed under the direction of the Maternal and Child Health Bureau and funded by the U.S. Department of Health and Human Services [10]. Published in 1994, the program includes guidelines for the health supervision of children including adolescents. Both programs subscribe to an evidence-based system of annual visits focusing on screenings and health guidance for both youth and their parents, and routine health screening and guidance for adolescents is endorsed by the American Academy of Pediatrics. Despite the existence of these excellent guidelines, the reality is that few preventative services are actually delivered [11–13]. For some adolescents, this is due to a lack of access to care because of such difficulties such as inadequate or no insurance, or limited transportation to get to a clinic [14]. However, the majority of adolescents do access health care during a 12-month period of time [15]. Unfortunately, even adolescents with access to medical care receive very little guidance and counseling during routine health care visits, as demonstrated by a recent article in this journal [16]. The reasons are manifold, including providers’ doubts of self-efficacy (i.e., the provider lacks confidence in his counseling skills), beliefs that such services would be unwelcome by families, beliefs that the teen is not at risk, and/or skepticism of the effectiveness of counseling. Other factors include constraints on provider time and inadequate reimbursement [17–19]. In addition to enhancing the preventive care counseling during routine visits, it is important that care providers take advantage of acute care and other visits (e.g., sports physicals) to provide general health maintenance and vaccination. Another possibility may lay in the enormity of the task. We should ask ourselves if it is possible for providers to effectively counsel parents and adolescents on so many topics with the present time constraints and given the limitation in adolescent and parent attention spans. GAPS recommendations include 14 health topics and Bright Futures is just as extensive in its scope. [9,10] Anyone experienced with teenagers is familiar with their frequent laundry list of concerns, which may not be on the list of recommended topics. Addressing their priorities in addition to the 14 health topics in a limited amount of time could indeed require Herculean effort. Unfortunately, important subjects involving parenting may be missed at the early adolescent
visits when the parents need to expand their knowledge and skills to best raise their developing adolescent. Some providers may fear that screening may open the proverbial “can of worms”; psychosocial problems that can take an immense amount of time and effort to resolve. Both GAPS and Bright Futures attempt to address these constraints by utilizing questionnaires and handouts while encouraging providers to prioritize the problem list and maintain a ready list of resources for adolescents requiring referral. It is wishful thinking that a single annual visit will suffice. Additional visits could invigorate the early adolescent well visits by providing the time and reimbursement required to cover the health topics so clearly elucidated in the aforementioned guidelines. Vaccination as an Opportunity for Preventive Care Recent modifications to the adolescent immunization recommendations have not necessitated added health care visits, although it may be that they will be a motivator for parents to ensure that adolescents come in for the routine visits already recommended. However, if the vaccines currently in the pipeline are recommended, there will be additional adolescent visits required. Presently, Merck has its HPV vaccine (Gardasil™) before the Food and Drug Administration for licensure, and GlaxoSmithKline is expected to seek licensure of its HPV vaccine (Cervarix) in the near future [3,4]. HSV and CMV vaccines are currently in clinical trials and may be licensed in the foreseeable future [5,6]. All of these immunizations require repeat injections. These vaccines will likely place additional demands on provider time as parents may desire discussion of transmission and prevalence of the diseases targeted as well as vaccine safety. This will require that providers feel qualified and competent enough to discuss sexuality and to be familiar with the data addressing the likely impact of both possible disease and vaccination on sexual behavior and future fertility [20 –23]. On the other hand, if reimbursement is structured appropriately, the topic of vaccination against sexually transmitted infections provides a segue into many of the adolescent health risks discussed above and may increase current levels of screening and anticipatory guidance pertinent to these issues. There were many lessons learned from the introduction of the hepatitis B vaccine into the adolescent population in the 1990s. Reaching and immunizing adolescents can be challenging. For Hepatitis B, school mandates and schoolbased delivery programs significantly improved uptake [24,25], although some clinics were able to demonstrate success in immunizing high-risk adolescents [26]. Because of the more widely known connection of HPV and HSV to sexual activity, it may be less likely that there will be requirements for school entry or delivery in a school setting. These vaccines may best be delivered in an office or clinic with guidance and counseling by a health care provider.
R. Rupp et al. / Journal of Adolescent Health 39 (2006) 461– 464
Modeling the early adolescent visits after the infant well checks requires a change in mindset for parents and providers. Most parents recognize the value in infant well checks and have come to expect the education and anticipatory guidance provided. Even parents who bring their infant for “shots only” are exposed to anticipatory guidance. The same opportunity could be had through repeated visits during early adolescence. The family and child would be fully apprised of the physical, emotional and cognitive changes occurring during adolescence. This might have two outcomes: increasing the likelihood of compliance with full immunization because the parents and adolescents would receive much needed information and support, and providing a method for providing (and billing) for additional risk reduction communication to both parents and adolescents. Who among us currently finds enough time to adequately address all of these issues under the current system of annual visits? Potential Schedule for Integrating Vaccination and Health Promotion Counseling The Advisory Committee on Immunization Practices (ACIP) and the Centers for Disease Control (CDC) currently recommend that the adolescent vaccines (Tdap and MCV-4) should be administered simultaneously whenever possible due to the possibility of local reactions from the diphtheria component, and because there has been concern about the ability to have 11–12-year-olds attend two visits within a 12-month time period. However, with the addition of an HPV vaccine, this will require that either the adolescent have three shots in one visit or four visits. To be consistent with ACIP and CDC recommendations, we have described a series with three shots in one visit. However, we recommend that patient preferences regarding multiple shots or multiple visits should be researched because families may prefer splitting Tdap and MCV-4 across Visit 1 and Visit 2. In addition, research that establishes the flexibility of the schedules for the multi-dose vaccines will improve our ability to meet the needs of families and successfully immunize the maximal number of adolescents. Once the new vaccines are available on the market, we propose the following change in preventive health care to adolescents. Parents and their adolescents could be informed during the early adolescent time period (9 to 11 years of age) that there will be a series of visits designed to ensure that the adolescents remain up-to-date on immunizations as well as address the rapidly changing needs of a physically and cognitively maturing young person. The expanded visits will afford the opportunity to meet with the parent alone, the adolescent alone, and both together while covering the topics included in GAPS or Bright Futures. The implementation of this schedule would require changes in the reimbursement structure of many plans, which limit the adolescent to one preventive visit a year. One option is
463
to cover three to four visits for preventive services during the 11–12-year period—similar to the reimbursement schedule determined for the year of infancy. Another option is to reimburse immunization visits at a greater rate for adolescents than is typically reimbursed because they will not, in fact, be “shots only” visits. The schedule would be as follows: Visit 1: (age 11 or 12). This visit will set the stage for the future visits and is critical for investing the adolescent and parents in the process. The provider broadly covers the construct of the visits for the adolescent years and screens for risk behaviors and immediate concerns. The discussion should include the provider’s role and issues pertaining to confidentiality. Potential issues that are not of immediate concern can be noted in the chart for detailed discussion at later visits. The chart should be reviewed for the need for catch-up vaccination and counseling should be provided on all of the issues surrounding vaccination. The adolescent should be examined and growth chart plotted. The Tdap, meningococcal conjugate vaccine, and the first shot of the HPV vaccine series should be administered. At this point, it is not known whether the HPV vaccine will be indicated for only girls or for girls and boys. In addition, the chart should be reviewed so that any other indicated primary or catch-up vaccinations can be given. Visit 2: (1–2 months later). In-depth parental counseling is the hallmark of this visit. This would include a discussion of the difference between normal risk-taking during adolescence and problematic behavior. The warning signs of early experimentation should be discussed. Parents also should be encouraged to review their own behavior with regard to substances, sexuality, and driving with regard to how those might be viewed from the eyes of an adolescent. The importance of supervision and communication, and how to facilitate both of these should be emphasized. Meningococcal vaccine, if it has not been given, and the second HPV vaccine should be administered to those who have started the series. Visit 3: (5– 6 months later). The provider meets separately with the early adolescent and addresses issues concerning physical and mental development along with increasing opportunities and interest in substance use and sexual behaviors. The care provider should review how the adolescent plans to manage those opportunities, how the adolescent can access help from parents or other adults if needed, and reinforce the adolescent and family values regarding appropriate behavior. The provider then would meet briefly with the parent and patient to see if there are any questions and to wrap things up. The third shot in the HPV vaccine series should be administered at this appointment. Future visits. Ideally, at this point, the adolescent should be scheduled for annual visits to cover routine health care
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R. Rupp et al. / Journal of Adolescent Health 39 (2006) 461– 464
needs [9,10]. As noted above, most adolescents do access health care annually [15], but it is important that these services include preventive care and a review of immunization status. The Society of Adolescent Medicine also has recommended specific vaccination platforms at ages 14 –15 and 17–18 years to assure vaccination compliance with both catch-up and new vaccine recommendations [27]. Conclusions The value of using the additional visits for “shots” as an opportunity to provide preventive health care counseling will need to be assessed. Historically, most counseling has been focused on the adolescent and not the parents. Counseling from many providers tends to be reactive and not preventive; starting only after a health compromising behavior has begun. It may be that the greatest dividends will be derived from the extra time spent with parents discussing issues such as supervision and communication. Parents faced with the challenges of having adolescents may find this extra attention and guidance a reason to have these additional visits. This also may help identify those parents in need of additional professional support regarding parenting. We will never find out unless afforded the opportunity. The advent of these new vaccines provides the opportunity for provider organizations and patient advocacy groups to campaign for an expansion of the early adolescent health care visits and to ensure adequate reimbursement. References [1] Broder KR, Cortese MM, Iskander JK, et al. Preventing tetanus, diphtheria, and pertussis among adolescents: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccines recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2006;55(RR-3):1–34. [2] Bilukha OO, Rosenstein N, Centers for Disease Control and Prevention (CDC). Prevention and control of meningococcal disease. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2005;54(RR-7):1–21. [3] Merck Submits Biologics License Application to FDA for GARDASIL®, the Company’s Investigational Vaccine for Cervical Cancer [cited 2005 Dec 30]. Available from: http://www.merck.com/ newsroom/press_releases/research_and_development/2005_1205.html. [4] GlaxoSmithKline reviews pipeline of novel vaccines with the potential to dramatically improve global health [cited 2005 Dec 30]. Available from: http://www.gsk.com/ControllerServlet?appId⫽4 &pageId⫽402&newsid⫽601. [5] U.S. National Institutes of Health. Safety Study of Herpes Simplex Vaccine in HSV Seronegative and Seropositive Females Between 10 and 17 Years Old [cited 2005 Dec 30]. Available from: http://www. clinicaltrials.gov/ct/gui/show/NCT00224484?order⫽1. [6] U.S. National Institutes of Health. GB/MF59 Vaccine in Preventing CMV Infection in Healthy Adolescent Females [cited 2005 Dec 30]. Available from: http://www.clinicaltrials.gov/ct/gui/show/ NCT00133497?order⫽1.
[7] Centers for Disease Control. Unintentional Injuries, Violence, and the Health of Young People [cited 2005 Dec 30]. Available from: http:// www.cdc.gov/HealthyYouth/injury/facts.htm. [8] Grunbaum JA, Kann L, Kinchen S, et al. Youth risk behavior surveillance—United States, 2003. MMWR Surveill Summ 2004;53(2): 1–96. [9] Elster AB, Kuznets N. Guidelines for Adolescent Preventive Services (GAPS): Recommendations and Rationale. Chicago, IL: American Medical Association, 1994. [10] Green M, Palfrey JS, eds. Bright Futures: Guidelines for Health Supervisions for Infants, Children and Adolescents, 2nd edition. Arlington, VA: National Center for Education in Maternal and Child Health, 2000. [11] Irwin CE. Clinical preventive services for adolescents: still a long way to go. J Adolesc Health 2005;37:85– 6. [12] Merenstein D, Green L, Fryer GE, Dovey S. Shortchanging adolescents: room for improvement in preventive care by physicians. Fam Med 2001;33:120 –3. [13] Klein JD, Wilson KM. Delivering quality care: adolescents’ discussion of health risks with their providers. J Adolesc Health 2002;30: 190 –5. [14] Newacheck PW, Hung YY, Park MJ, et al. Disparities in adolescent health and health care: does socioeconomic status matter? Health Serv Res 2003;38:1235–52. [15] Klein J, Wilson K, McNulty M, Kapphahn C, et al. Access to medical care for adolescents: results from the 1997 Commonwealth Fund Survey of the Health of Adolescent Girls. J Adolesc Health 1999;25: 120 –30. [16] Rand CM, Auinger P, Klein JD, Weitzman M. Preventive counseling at adolescent ambulatory visits. J Adolesc Health 2005;37:87–93. [17] Cabana MD, Rand CS, Powe NR, et al. Why don’t physicians follow clinical practice guidlelines? A framework for improvement. JAMA 1999;282:1458 – 65. [18] Yarnall KS, Pollak KI, Ostbye T, et al. Primary care: is there enough time for prevention? Am J Public Health 2003;93:635– 41. [19] Cheng TL, DeWitt TG, Savageau JA, et al. Determinants of counseling in primary care pediatric practice: physician attitudes about time, money, and health issues. Arch Pediatr Adolesc Med 1999;153: 629 –35. [20] Zimet GD, Perkins SM, Sturm LA, et al. Predictors of STI vaccine acceptablility among parents and their adolescent children. J Adolesc Health 2005;37:179 – 86. [21] Davis K, Dickman ED, Ferris D, et al. Human papillomavirus vaccine acceptability among parents of 10- to 15-year-old adolescents. J Low Genit Tract Dis 2004;8:188 –94. [22] Rosenthal SL. Protecting their adolescents from harm: parental views on STI vaccination. J Adolesc Health 2005;37:177– 8. [23] Sturm LA, Mays RM, Zimet GD. Parental beliefs and decision making about child and adolescent immunization: from polio to sexually transmitted infections. J Dev Behav Pediatr 2005;26:441–52. [24] Tung CS, Middleman AB. An evaluation of school-level factors used in a successful school-based hepatitis B immunization initiative. J Adolesc Health 2005;37:61– 8. [25] Wilson TR, Fishbein DB, Ellis PA, et al. The impact of a school entry law on adolescent immunization rates. J Adolesc Health 2005;37: 511– 6. [26] Kollar LM, Rosenthal SL, Biro FM. Hepatitis B vaccine series compliance in adolescents. Pediatr Infect Dis J 1994;13:1006 – 8. [27] Middleman AB, Rosenthal SL, Rickert VI, et al. Adolescent immunization: a position paper of the Society For Adolescent Medicine. J Adolesc Health 2006;38:321–7.
Review article
Vaccination: An Opportunity to Enhance Early Adolescent Preventative Services Richard Rupp, M.D.,a,* Susan L. Rosenthal, Ph.D.,a and Amy B. Middleman, M.D., M.P.H., M.S.Ed.b a
Department of Pediatrics and Sealy Center for Vaccine Development, University of Texas Medical Branch, Galveston, Texas b Department of Pediatrics, Adolescent Medicine and Sports Medicine Section, Baylor College of Medicine, Houston, Texas Manuscript received February 10, 2006; manuscript accepted April 7, 2006.
Abstract:
New vaccines are being developed that will be recommended for adolescents Adolescence is a time period when adolescent-parent dynamics change and when adolescents may be confronted with increasing opportunities to engage in risk-taking behaviors such as sexual behavior and substance use. Despite clear recommendations regarding preventative counseling, many adolescents do not receive adequate preventive care. In this manuscript, we provide suggestions as to how a new vaccination schedule can be used to enhance preventative services to both adolescents and their parents. © 2006 Society for Adolescent Medicine. All rights reserved.
Keywords:
Vaccination; Prevention; HPV, Pertussis; Meningococcal disease
New and Future Adolescent Vaccines In all likelihood there will be a succession of new adolescent vaccines introduced over the next decade. Already we are witnessing the replacement of the tetanus and diphtheria toxoids (Td) vaccine with the tetanus, diphtheria, acellular pertussis (Tdap) vaccine [1] and the addition of the meningococcal conjugate vaccine (MCV4) to the recommendations for adolescents [2]. More changes are afoot as a vaccine targeting human papillomavirus (HPV) is before the Food and Drug Administration for licensure [3,4]. Other vaccines for herpes simplex virus (HSV) and cytomegalovirus (CMV) are in clinical trials and are expected to target teens as well [5,6]. These new vaccines have the potential not only to prevent infectious diseases, but to provide repeated contact with a population that historically has received little preventive care. Just as we have organized the medical care visit structure of infants around the vaccine schedule, this same degree of preventive care structure could be accomplished with the adolescent population. *Address correspondence to: Dr. Richard Rupp, Division of Adolescent & Behavioral Health, UTMB Primary Care Pavilion , 301 University Blvd., Galveston, TX 77555-1119. E-mail address: [email protected]
Those infant visits provide opportunity for anticipatory guidance to families, and similarly, an early adolescent vaccine schedule could provide opportunities for health care screening and anticipatory guidance to both parents and adolescents. Catch-up vaccination will provide similar opportunities for the middle and late adolescent.
Need for Greater Preventive Services for Adolescents The justification for more effective preventative services for the adolescent population is clear. The major morbidities/mortalities of adolescence are psychosocial in nature, and thus, likely to be preventable. By far, unintentional injuries, violence and suicide are the major causes of death among this age group [7]. Substance use, sexual behaviors, and dieting are behaviors with which adolescents begin to experiment and can be associated with significant morbidity and mortality. The 2003 Youth Risk Behavior Surveillance Survey revealed that, when surveyed, over a quarter of high school students across the four years reported heavy episodic drinking during the month before being surveyed, whereas 22% report using marijuana in the same period. Nearly half of high school students report having had sexual intercourse, with 4.9% of the girls reported having been
1054-139X/06/$ – see front matter © 2006 Society for Adolescent Medicine. All rights reserved. doi:10.1016/j.jadohealth.2006.04.007
462
R. Rupp et al. / Journal of Adolescent Health 39 (2006) 461– 464
pregnant. In the month before being surveyed, almost 10% of students had taken some sort of diet pill, powder or liquid, and 6% had used vomiting or laxatives to control their weight [8]. To decrease the likelihood that adolescents will engage in health-compromising behaviors, several organizations have developed comprehensive guidelines for health care providers to use to promote health-enhancing behaviors among their adolescent patients. Among the best known is the American Medical Association Guidelines for Adolescent Preventative Services (GAPS) published in 1992 [9]. Another well-known program, Bright Futures, was developed under the direction of the Maternal and Child Health Bureau and funded by the U.S. Department of Health and Human Services [10]. Published in 1994, the program includes guidelines for the health supervision of children including adolescents. Both programs subscribe to an evidence-based system of annual visits focusing on screenings and health guidance for both youth and their parents, and routine health screening and guidance for adolescents is endorsed by the American Academy of Pediatrics. Despite the existence of these excellent guidelines, the reality is that few preventative services are actually delivered [11–13]. For some adolescents, this is due to a lack of access to care because of such difficulties such as inadequate or no insurance, or limited transportation to get to a clinic [14]. However, the majority of adolescents do access health care during a 12-month period of time [15]. Unfortunately, even adolescents with access to medical care receive very little guidance and counseling during routine health care visits, as demonstrated by a recent article in this journal [16]. The reasons are manifold, including providers’ doubts of self-efficacy (i.e., the provider lacks confidence in his counseling skills), beliefs that such services would be unwelcome by families, beliefs that the teen is not at risk, and/or skepticism of the effectiveness of counseling. Other factors include constraints on provider time and inadequate reimbursement [17–19]. In addition to enhancing the preventive care counseling during routine visits, it is important that care providers take advantage of acute care and other visits (e.g., sports physicals) to provide general health maintenance and vaccination. Another possibility may lay in the enormity of the task. We should ask ourselves if it is possible for providers to effectively counsel parents and adolescents on so many topics with the present time constraints and given the limitation in adolescent and parent attention spans. GAPS recommendations include 14 health topics and Bright Futures is just as extensive in its scope. [9,10] Anyone experienced with teenagers is familiar with their frequent laundry list of concerns, which may not be on the list of recommended topics. Addressing their priorities in addition to the 14 health topics in a limited amount of time could indeed require Herculean effort. Unfortunately, important subjects involving parenting may be missed at the early adolescent
visits when the parents need to expand their knowledge and skills to best raise their developing adolescent. Some providers may fear that screening may open the proverbial “can of worms”; psychosocial problems that can take an immense amount of time and effort to resolve. Both GAPS and Bright Futures attempt to address these constraints by utilizing questionnaires and handouts while encouraging providers to prioritize the problem list and maintain a ready list of resources for adolescents requiring referral. It is wishful thinking that a single annual visit will suffice. Additional visits could invigorate the early adolescent well visits by providing the time and reimbursement required to cover the health topics so clearly elucidated in the aforementioned guidelines. Vaccination as an Opportunity for Preventive Care Recent modifications to the adolescent immunization recommendations have not necessitated added health care visits, although it may be that they will be a motivator for parents to ensure that adolescents come in for the routine visits already recommended. However, if the vaccines currently in the pipeline are recommended, there will be additional adolescent visits required. Presently, Merck has its HPV vaccine (Gardasil™) before the Food and Drug Administration for licensure, and GlaxoSmithKline is expected to seek licensure of its HPV vaccine (Cervarix) in the near future [3,4]. HSV and CMV vaccines are currently in clinical trials and may be licensed in the foreseeable future [5,6]. All of these immunizations require repeat injections. These vaccines will likely place additional demands on provider time as parents may desire discussion of transmission and prevalence of the diseases targeted as well as vaccine safety. This will require that providers feel qualified and competent enough to discuss sexuality and to be familiar with the data addressing the likely impact of both possible disease and vaccination on sexual behavior and future fertility [20 –23]. On the other hand, if reimbursement is structured appropriately, the topic of vaccination against sexually transmitted infections provides a segue into many of the adolescent health risks discussed above and may increase current levels of screening and anticipatory guidance pertinent to these issues. There were many lessons learned from the introduction of the hepatitis B vaccine into the adolescent population in the 1990s. Reaching and immunizing adolescents can be challenging. For Hepatitis B, school mandates and schoolbased delivery programs significantly improved uptake [24,25], although some clinics were able to demonstrate success in immunizing high-risk adolescents [26]. Because of the more widely known connection of HPV and HSV to sexual activity, it may be less likely that there will be requirements for school entry or delivery in a school setting. These vaccines may best be delivered in an office or clinic with guidance and counseling by a health care provider.
R. Rupp et al. / Journal of Adolescent Health 39 (2006) 461– 464
Modeling the early adolescent visits after the infant well checks requires a change in mindset for parents and providers. Most parents recognize the value in infant well checks and have come to expect the education and anticipatory guidance provided. Even parents who bring their infant for “shots only” are exposed to anticipatory guidance. The same opportunity could be had through repeated visits during early adolescence. The family and child would be fully apprised of the physical, emotional and cognitive changes occurring during adolescence. This might have two outcomes: increasing the likelihood of compliance with full immunization because the parents and adolescents would receive much needed information and support, and providing a method for providing (and billing) for additional risk reduction communication to both parents and adolescents. Who among us currently finds enough time to adequately address all of these issues under the current system of annual visits? Potential Schedule for Integrating Vaccination and Health Promotion Counseling The Advisory Committee on Immunization Practices (ACIP) and the Centers for Disease Control (CDC) currently recommend that the adolescent vaccines (Tdap and MCV-4) should be administered simultaneously whenever possible due to the possibility of local reactions from the diphtheria component, and because there has been concern about the ability to have 11–12-year-olds attend two visits within a 12-month time period. However, with the addition of an HPV vaccine, this will require that either the adolescent have three shots in one visit or four visits. To be consistent with ACIP and CDC recommendations, we have described a series with three shots in one visit. However, we recommend that patient preferences regarding multiple shots or multiple visits should be researched because families may prefer splitting Tdap and MCV-4 across Visit 1 and Visit 2. In addition, research that establishes the flexibility of the schedules for the multi-dose vaccines will improve our ability to meet the needs of families and successfully immunize the maximal number of adolescents. Once the new vaccines are available on the market, we propose the following change in preventive health care to adolescents. Parents and their adolescents could be informed during the early adolescent time period (9 to 11 years of age) that there will be a series of visits designed to ensure that the adolescents remain up-to-date on immunizations as well as address the rapidly changing needs of a physically and cognitively maturing young person. The expanded visits will afford the opportunity to meet with the parent alone, the adolescent alone, and both together while covering the topics included in GAPS or Bright Futures. The implementation of this schedule would require changes in the reimbursement structure of many plans, which limit the adolescent to one preventive visit a year. One option is
463
to cover three to four visits for preventive services during the 11–12-year period—similar to the reimbursement schedule determined for the year of infancy. Another option is to reimburse immunization visits at a greater rate for adolescents than is typically reimbursed because they will not, in fact, be “shots only” visits. The schedule would be as follows: Visit 1: (age 11 or 12). This visit will set the stage for the future visits and is critical for investing the adolescent and parents in the process. The provider broadly covers the construct of the visits for the adolescent years and screens for risk behaviors and immediate concerns. The discussion should include the provider’s role and issues pertaining to confidentiality. Potential issues that are not of immediate concern can be noted in the chart for detailed discussion at later visits. The chart should be reviewed for the need for catch-up vaccination and counseling should be provided on all of the issues surrounding vaccination. The adolescent should be examined and growth chart plotted. The Tdap, meningococcal conjugate vaccine, and the first shot of the HPV vaccine series should be administered. At this point, it is not known whether the HPV vaccine will be indicated for only girls or for girls and boys. In addition, the chart should be reviewed so that any other indicated primary or catch-up vaccinations can be given. Visit 2: (1–2 months later). In-depth parental counseling is the hallmark of this visit. This would include a discussion of the difference between normal risk-taking during adolescence and problematic behavior. The warning signs of early experimentation should be discussed. Parents also should be encouraged to review their own behavior with regard to substances, sexuality, and driving with regard to how those might be viewed from the eyes of an adolescent. The importance of supervision and communication, and how to facilitate both of these should be emphasized. Meningococcal vaccine, if it has not been given, and the second HPV vaccine should be administered to those who have started the series. Visit 3: (5– 6 months later). The provider meets separately with the early adolescent and addresses issues concerning physical and mental development along with increasing opportunities and interest in substance use and sexual behaviors. The care provider should review how the adolescent plans to manage those opportunities, how the adolescent can access help from parents or other adults if needed, and reinforce the adolescent and family values regarding appropriate behavior. The provider then would meet briefly with the parent and patient to see if there are any questions and to wrap things up. The third shot in the HPV vaccine series should be administered at this appointment. Future visits. Ideally, at this point, the adolescent should be scheduled for annual visits to cover routine health care
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needs [9,10]. As noted above, most adolescents do access health care annually [15], but it is important that these services include preventive care and a review of immunization status. The Society of Adolescent Medicine also has recommended specific vaccination platforms at ages 14 –15 and 17–18 years to assure vaccination compliance with both catch-up and new vaccine recommendations [27]. Conclusions The value of using the additional visits for “shots” as an opportunity to provide preventive health care counseling will need to be assessed. Historically, most counseling has been focused on the adolescent and not the parents. Counseling from many providers tends to be reactive and not preventive; starting only after a health compromising behavior has begun. It may be that the greatest dividends will be derived from the extra time spent with parents discussing issues such as supervision and communication. Parents faced with the challenges of having adolescents may find this extra attention and guidance a reason to have these additional visits. This also may help identify those parents in need of additional professional support regarding parenting. We will never find out unless afforded the opportunity. The advent of these new vaccines provides the opportunity for provider organizations and patient advocacy groups to campaign for an expansion of the early adolescent health care visits and to ensure adequate reimbursement. References [1] Broder KR, Cortese MM, Iskander JK, et al. Preventing tetanus, diphtheria, and pertussis among adolescents: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccines recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2006;55(RR-3):1–34. [2] Bilukha OO, Rosenstein N, Centers for Disease Control and Prevention (CDC). Prevention and control of meningococcal disease. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2005;54(RR-7):1–21. [3] Merck Submits Biologics License Application to FDA for GARDASIL®, the Company’s Investigational Vaccine for Cervical Cancer [cited 2005 Dec 30]. Available from: http://www.merck.com/ newsroom/press_releases/research_and_development/2005_1205.html. [4] GlaxoSmithKline reviews pipeline of novel vaccines with the potential to dramatically improve global health [cited 2005 Dec 30]. Available from: http://www.gsk.com/ControllerServlet?appId⫽4 &pageId⫽402&newsid⫽601. [5] U.S. National Institutes of Health. Safety Study of Herpes Simplex Vaccine in HSV Seronegative and Seropositive Females Between 10 and 17 Years Old [cited 2005 Dec 30]. Available from: http://www. clinicaltrials.gov/ct/gui/show/NCT00224484?order⫽1. [6] U.S. National Institutes of Health. GB/MF59 Vaccine in Preventing CMV Infection in Healthy Adolescent Females [cited 2005 Dec 30]. Available from: http://www.clinicaltrials.gov/ct/gui/show/ NCT00133497?order⫽1.
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