Minor Consent and Delivery of Adolescent Vaccines

PurposeTo explore whether, and to what extent, minor consent influences adolescent vaccine delivery in the United States.MethodsA telephone survey was completed by 263 professionals with responsibilities for adolescent health care and/or vaccination in 43 states. Measures included perceived frequency of unaccompanied minor visits and perceived likelihood of vaccine delivery to unaccompanied minors in hypothetical scenarios that varied by adolescent age, vaccine type, visit type, and clinical setting.ResultsAmong the 76 respondents most familiar with private primary care clinics, 47.1% reported perceptions that 17-year-old patients often present without a parent/legal guardian. Among the 104 respondents most familiar with public primary care clinics, 56.7% reported that 17-year-old patients often present alone. In response to hypothetical scenarios, approximately 30% of respondents familiar with private clinics and 50% of respondents familiar with public clinics reported perceptions that unaccompanied 17-year-old adolescents would not receive influenza, Tdap, or human papillomavirus vaccines during routine check-ups because they could not provide consent. Perceived likelihood of unaccompanied minors receiving vaccines when seen for confidential services in primary care, sexually transmitted disease, and Title X/family planning clinics varied significantly by vaccine type and clinical setting. On average, respondents reported that they would support minors having the ability to self-consent for vaccines at age 14.ConclusionsThe inability of minors to consent for vaccines is likely one barrier to vaccination. Interventions to increase adolescent vaccination should consider strategies that increase the ability of unaccompanied minors, particularly older minors, to receive vaccines within the context of legal, ethical, and professional guidelines.     

Immunization update: pertussis, meningoccocus, and human papillomavirus

New vaccines are being recommended for adolescents at a brisk pace. Immunization is an effective preventive measure, and by bringing adolescents in for a medical intervention, the new vaccines promise not only to protect adolescents from the specific diseases they address, but also to enhance other health care services, including screening for other health risk behaviors. This article discusses the newest vaccination recommendations for adolescents pertaining to the meningococcal and tetanus, diphtheria, and acellular pertussis vaccines and reviews the human papillomavirus vaccines developed for use in the United States. With the advent of these new vaccines, the potential exists to improve adolescent health significantly through prevention, adding new incentive to increase adolescent immunization rates for all indicated vaccines.     

Adolescent vaccination in the developing world: time for serious consideration?

The number of vaccinations and vaccine boosters that are becoming relevant to delivery among adolescents is growing. For sexually transmitted infections (STIs) in particular, such as HIV, vaccine delivery in this (pre-sexually active) age group is going to be an integral component of the strategy to control these diseases in the future. Currently, however, adolescent vaccination does not routinely occur because the traditional method of delivery is through secondary schools, and in developing countries school attendance has historically been low. But with school attendance growing rapidly throughout the developing world, the cost of vaccines falling over time, and an increasing number of current and future vaccines targeted at adolescents, it is an ideal opportunity to place this route of delivery on the national and international health agenda. Therefore, this paper examines the rationale for adolescent vaccination, looks at the success of other adolescent-targeted health care interventions, and finally, considers the challenges associated with future adolescent vaccination programmes in developing countries.     

What Parents and Adolescent Boys Want in School Vaccination Programs in the United States

PurposeSchools are increasingly a part of vaccine provision, because of laws mandating provision of information by schools about vaccination, school entry requirements, and mass vaccination campaigns. We examined preferences for programmatic aspects of voluntary school mass vaccination programs (i.e., “vaccination days”).MethodsWe analyzed data from a national sample of United States parents of adolescent males ages 11–19 years (n = 308) and their sons (n = 216), who completed an online survey in November 2011.ResultsSons believed that adolescents should be able to get vaccinated without parental consent at a younger age than parents did (p < .001) and were more willing to participate in vaccination days without a parent present (p = .04). Parents perceived school vaccination days to be a more convenient way to get their sons recommended vaccines if they were younger parents, had older adolescent sons, supported laws letting schools share vaccination records with health care providers, or had sons who were previously immunized at school (all p < .05). Parents of older sons were less likely to want their sons' vaccination records sent home (odds ratio [OR] = .47; 95% confidence interval [CI], .29–.77) or to their sons' physicians (OR = .61; 95% CI, .37–.98) compared with parents of younger sons, but more likely to prefer their sons' records be entered in an immunization registry (OR = 1.66; 95% CI, 1.05–2.63).ConclusionsSons' age had an important role in support for vaccination days and preferences for sharing vaccination information with health care professionals. Parents and sons had similar beliefs about vaccination in schools, but the sons' responses suggested an interest in greater autonomy.     

Health care professional communication about STI vaccines with adolescents and parents

Vaccination of adolescents against sexually transmitted infections (STIs) is an important prevention strategy that may reduce the global burden of disease. The World Health Organization, Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices, and other national health agencies recommend the use of existing STI vaccines, and many countries have incorporated them into their routine vaccination schedule. Despite this, however, data indicate that STI vaccine uptake is suboptimal for a variety of reasons. Health care professionals (HCP) have been shown to have a strong beneficial effect on STI vaccine uptake, yet studies demonstrate that many HCPs fail to discuss or recommend them to adolescent patients. This review article focuses on HCP communication about STI vaccines with adolescents and their parents. It describes STI vaccine message content and delivery as well as the context in which HCPs formulate their messaging approach. It also examines other contextual factors that may shape communication about STI vaccines. Studies from many countries indicate that HCPs often possess misinformation about adolescents, including their sexual risk behaviors, as well as STIs, vaccine safety and efficacy, and STI vaccination recommendations. They also have misconceptions of parental barriers to STI vaccination. These may impact STI vaccine communication and have a negative influence on STI vaccine uptake. These findings highlight the critical need for improved HCP education related to adolescent health, sexuality, and STI vaccination. This may be particularly important in settings without an existing infrastructure or expertise in caring for this unique patient population.     

Financing Vaccines for Adolescents: A Position Paper of the Society for Adolescent Health and Medicine

An increasing number of vaccines are now recommended for adolescents. These vaccines may greatly improve the health of adolescents and their communities. However, adolescent vaccine coverage rates lag behind those for infants and behind goals set by Healthy People 2010 [1]. Financial constraints have been reported to be a significant obstacle to immunizing adolescents and young adults [2]. At the Society for Adolescent Health and Medicine, we believe that to achieve increased vaccine coverage in this age group, financial barriers to immunization must be removed.     

Multilevel correlates for human papillomavirus vaccination of adolescent girls attending safety net clinics

Background

Adolescent HPV vaccination in minority and low income populations with high cervical cancer incidence and mortality could reduce disparities. Safety-net primary care clinics are a key delivery site for improving vaccination rates in these populations.

Purpose

To examine prevalence of HPV initiation (≥1 dose), completion (receipt of dose 3 within 12 months of initiation), and receipt of 3 doses in four safety-net clinics as well as individual-, household-, and clinic-level correlates of initiation.

Methods

We used multilevel modeling to investigate HPV initiation among 700 adolescent females who sought primary care in four safety-net clinics in Dallas, Texas from March 2007 to December 2009. Data were abstracted from patients’ paper and electronic medical records.

Results

HPV vaccine uptake varied significantly by clinic. Across clinics, initiation was 36.6% and completion was 39.7% among those who initiated. In the total study population, only 15.7% received all three doses. In multivariate, two-level logistic regression analyses, initiation was associated with receipt of other adolescent vaccines, influenza vaccination in the year prior to data abstraction, being sexually active, and having more chart documentation (presence of health maintenance questionnaire and/or immunization record). There was no association between initiation and age, race/ethnicity, or insurance status.

Conclusions

In four urban safety-net clinics, HPV initiation rates paralleled 2008 national rates. The correlation of HPV initiation with other adolescent vaccines underscores the importance of reviewing vaccination status at every health care visit. HPV vaccine uptake in safety-net clinics should continue to be monitored to understand impact on cervical cancer disparities.     

Adolescent pregnancy in Israel

Teenage or adolescent pregnancy requires the extensive involvement of health care workers in respect to the medical and social aspects of pregnancy, delivery, and later care of both mother and child. Trends in adolescent pregnancy over the last few years from the United States, Canada, and the United Kingdom are presented and related to data from Israel. Adolescent pregnancy in Israel has been on the decline, but in 1999 it was still 3.4% of all live births (131,936 children) with more pregnancies in this group among the non-Jewish population (7.2%) than in the Jewish population (1.7%).     

Vaccination coverage among children enrolled in Head Start programs and licensed child care centers and entering school--United States and selected reporting areas, 1999-2000 school year

Undervaccinated children enrolled in child care centers and schools are vulnerable to outbreaks of vaccine-preventable disease. One of the national health objectives for 2010 is to maintain > or = 95% vaccination coverage among children attending licensed child care centers and kindergarten through postsecondary school (objective 14-23). To identify children who have not been vaccinated in compliance with state law, all states, five large cities (Chicago, Houston, New York, Philadelphia, and San Antonio), and eight territories conduct annual vaccination assessment surveys of coverage with basic vaccines among children enrolled in the Head Start program, enrolled in licensed child care centers, and entering kindergarten or first grade. These survey results are aggregated and analyzed by CDC to estimate national vaccination coverage. This report summarizes estimated coverage with the basic vaccines: > or = 3 doses of poliovirus vaccine, > or = 3 tetanus containing doses (diphtheria and tetanus toxoids and acellular pertussis vaccine [DTaP]), diphtheria and tetanus toxoids (DT), or tetanus toxoids (Td), and 1 dose each of measles, mumps, and rubella vaccines forthe September 1999-June 2000 school year. Results indicate that among reporting programs, the mean coverage for all vaccines was >95% for the surveyed population. However, coverage varied from state to state, and approximately 30% of states did not submit reports. High rates of vaccination coverage must be maintained to prevent transmission of vaccine-preventable disease. States should conduct yearly assessments to maintain these rates among preschool- and school-aged children.     

Adolescent and adult pertussis vaccination: computer simulations of five new strategies

Approximately one million adult pertussis cases occur annually in the US, and infants still die from pertussis. Computer simulations were used to predict the impact of vaccination of children, adults and/or adolescents, and household members of newborns (cocoon strategy). Childhood vaccination greatly reduced cases in children, but increased the incidence in adolescents and adults. Routine adolescent and adult vaccination had a large direct effect, whereas the cocoon strategy had a predominantly indirect effect on young infants. The number needed to vaccinate (NNV) to prevent a case of typical pertussis in the entire population was lowest for the adolescent strategy. The cocoon strategy had the lowest NNV to prevent a case of typical pertussis in young infants. The current vaccination schedule, local epidemiological data, age-specific cost of pertussis cases, and accessibility of the target population will determine which strategy has the highest likelihood of success in achieving the public health goal.     

Coordinating the delivery of vaccinations and other preventive health care recommendations for adolescents

Although recommendations for annual preventive care for adolescents have been in place for decades, the need to bring adolescents to the medical setting for newly recommended vaccines has placed this issue in the public health spotlight. Aggressive efforts have been ongoing to increase adolescent adherence to new vaccine recommendations--a measured outcome variable, and the hope has been that enhanced adherence to comprehensive health care visits will follow. Evidence indicates that the implementation of more comprehensive preventive health care elements among adolescents may be improving; however, a passive approach to bringing more adolescents to preventive health visits using vaccine as an incentive may not be effective for all youth. This paper reviews the history of recommendations for new vaccines as well as comprehensive health care visit recommendations for adolescents, how these recommendations may synergistically improve preventive care for adolescents, and how we may need to continue to think creatively to further access all youth for preventive health care using vaccination implementation as a model for reaching out beyond the providers' office walls.     

Knowledge,attitudes and practices on adolescent vaccination among adolescents,parents and teachers in Africa: A systematic review

IntroductionVaccines are the most successful and cost-effective public health interventions available to avert vaccine-preventable diseases and deaths. Despite global progress in adolescent health, many adolescents in Africa still get sick and die from vaccine-preventable diseases due to lack of vaccination. Adolescents, parents and teachers are key players in the development and implementation of adolescent vaccination policies. Optimal knowledge, attitudes and practices towards adolescent vaccination among these key players may improve vaccine uptake among adolescents. We conducted a qualitative and quantitative systematic review on knowledge, attitudes and practices of adolescent vaccination among adolescents, parents and teachers in Africa.MethodsWe searched PubMed, Cochrane Central Register of Controlled Trials, Scopus, Web of Science, WHOLIS, Africa Wide and CINAHL for eligible quantitative and qualitative primary studies with no time limits. We also checked reference lists of included studies for eligible studies and searched grey literature. Two authors independently screened the search outputs, selected studies and extracted data; resolving discrepancies by consensus and discussion. Qualitative data were analysed using thematic analyses where applicable, while analyses from quantitative studies used different methods based on the type of outcomes.ResultsWe included 18 cross-sectional studies in this review. The included studies were conducted in 10 out of the 54 countries in Africa. The 18 studies focused on a wide range of adolescent vaccines. Thirteen studies evaluated vaccines against Human Papilloma Virus, while each of the remaining 5 studies, evaluated vaccines against rabies, HIV, tetanus toxoid, tuberculosis and adolescent vaccines in general. Among the key players, we found low to moderate levels of knowledge about adolescent vaccination. Positive attitudes and practices towards adolescent vaccination, especially against Human Papilloma Virus were reported. Despite the low knowledge, our results showed high levels of acceptability to adolescent vaccination among adolescents, parents and teachers.ConclusionsIt was evident in our review that all key demographics (parents, adolescents and teachers) were receptive towards adolescent vaccines. We propose relevant policy makers in Africa to consider continuous education programs such as those aimed to inform the parents, adolescents and teachers on adolescent vaccination.     

Promoting Health Through A Developmental Analysis of Adolescent Risk Behavior

Adolescents are the only U.S. population group not to improve morbidity and mortality since 1960. Social and behavioral etiologies of adolescent morbidity and mortality are best addressed in schools, since health care providers rarely are seen by teen-agers for other than organic health complaints. The relevance of physical, cognitive, and psychosocial development for adolescent risk-taking and their attendant health problems are discussed. Recognizing adolescent risk-taking as a means of achieving autonomy and identity, nurses and health educators can intervene to promote health-enhancing alternatives to achieve those ends. Social learning theory provides a basis for interventions to personalize the curricula, change behaviors, and shape the environment.     

Vaccine hesitancy among parents of adolescents and its association with vaccine uptake

BackgroundAddressing parental vaccine hesitancy may increase adolescent vaccination acceptance. However, no validated measure exists to identify parents hesitant toward adolescent vaccines.ObjectiveTo determine if a modified version of the Parent Attitudes about Childhood Vaccines (PACV) survey, a previously validated tool to identify parental hesitancy toward vaccines in infants, predicts adolescent vaccine uptake at office visits.MethodsWe modified the PACV for use in the adolescent setting and distributed it to a convenience sample of parents of adolescents aged 11 to 17 presenting for care at a diverse group of six pediatric practices in Oklahoma and South Carolina. We determined the vaccination status of the parents’ adolescents for 3 vaccines (Tetanus–diphtheria–acellular pertussis [Tdap], meningococcal conjugate [MCV4], and human papillomavirus [HPV] vaccines). We used Fisher's exact tests to compare vaccination status with each survey item and with an overall general hesitancy scale that we constructed.ResultsWe analyzed 363 surveys. At the time of the visit, vaccination coverage was 84% for Tdap, 73% for MCV, and 45% for any dose of HPV. Thirty-nine percent of parents expressed concern about vaccine efficacy and 41% expressed concern about side effects. Forty-five percent of parents disagreed with the statement that “teens can get all of the vaccines that are due at a single visit.” Two individual items were associated with not receiving a dose of HPV vaccine that was due. The overall modified PACV score failed to predict adolescent vaccine uptake at an office visit.ConclusionSeveral individual items were associated with vaccine uptake. The cumulative modified PACV, a general measure of vaccine hesitancy, was not associated with vaccination status despite illuminating parental hesitancy. We need to better understand vaccine-specific concerns for the adolescent population.     

Attitudes towards mandatory vaccination and sanctions for vaccination refusal

AimsInvestigating attitudes towards mandatory vaccination and sanctions for vaccination refusal in an area with insufficient vaccination coverage may help health authorities to assess which strategies for increasing vaccination coverage are appropriate. This study examines attitudes to vaccine mandates and asks questions regarding what kinds of sanctions could legitimately result from vaccination refusal. It seeks to find out if people’s attitudes towards mandates and towards sanctions for vaccination refusal are related to their attitudes to vaccines and the degree of trust they feel towards health care professionals and health care authorities. The study also discusses how the observed attitudes towards mandates may be related to perceptions of autonomy, responsibility, and equitability.MethodsData collection was carried out in Finland through an online survey in a region with suboptimal vaccine uptake. Statistical analysis was conducted on a sample of 1101 respondents, using confirmatory factor analysis and structural regression analysis.ResultsPersons hold different views on mandates and sanctions. Importantly, the persons who support vaccination mandates and sanctions for vaccination refusal are to a great degree the same people who have positive attitudes to vaccines and high trust in health care professionals and health authorities.ConclusionTrust is a key factor which has a bearing on people’s attitudes towards mandates and sanctions for noncompliance. A focus on the reasons for lack of trust, and on how to enhance trust, is a more feasible long-term way (than mandates) to promote large- scale compliance with childhood vaccine programmes in the studied country context.     

Correlates of receiving recommended adolescent vaccines among youth with special health care needs: Findings from a statewide survey

BackgroundMany youth with special health care needs (YSHCN) have not received recommended adolescent vaccines, yet data are lacking on correlates of vaccination among this population. Such information can identify subgroups of YSHCN that may be at risk for under-immunization and strategies for increasing vaccination.MethodsWe analyzed weighted data from a population-based sample of parents with an 11- to 17-year-old child with a special health care need from the 2010–2012 North Carolina Child Health Assessment and Monitoring Program (n = 604). We used ordinal logistic regression to identify correlates of how many recommended vaccines (tetanus booster, meningococcal, and HPV [at least one dose] vaccines) adolescents had received.ResultsOnly 12% of YSHCN (18% of females and 7% of males) had received all three vaccines. More YSHCN had received tetanus booster vaccine (91%) than meningococcal (28%) or HPV vaccines (32%). In multivariable analyses, YSHCN who were female (OR = 2.59, 95% CI: 1.57–4.24), ages 16–17 (OR = 2.06, 95% CI: 1.10–3.87), or who had a preventive check-up in the past year (OR = 2.98, 95% CI: 1.24–7.21) had received a greater number of the vaccines. YSHCN from households that contained a person with at least some college education had received fewer of the vaccines (OR = 0.57, 95% CI: 0.33–0.96). Vaccine coverage did not differ by type of special health care need.ConclusionsVaccine coverage among YSHCN is lacking and particularly low among those who are younger or male. Reducing missed opportunities for vaccination at medical visits and concomitant administration of adolescent vaccines may help increase vaccine coverage among YSHCN.     

Risk factors of underutilization of childhood immunizations in ultraorthodox Jewish communities in Israel despite high access to health care services

Background

The risk factors of underutilization of childhood vaccines in populations with high access to health services are not fully understood.

Objectives

To determine vaccination coverage and factors associated with underutilization of childhood vaccines in a population with sub-optimal vaccination compliance, despite a high health care access.

Methods

The study was conducted among 430 children from ultraorthodox Jewish communities in the Bnei Brak city and Jerusalem district. Data on immunization status, socio-demographic factors and on parents’ attitudes regarding vaccines were obtained from medical records and through parents’ interviews.

Results

The proportion of fully vaccinated children was 65% in 2- to 5-year-old ultraorthodox children from Jerusalem district, and 86% in 2.5-year-old children from Bnei Brak city. The factors that were significantly associated with vaccines underutilization in Bnei Brak were having >6 siblings, maternal academic education, parental religious beliefs against vaccination, perceived risk of vaccine preventable diseases as low, and mistrust in the Ministry of Health (MOH). Similarly, in Jerusalem, religious beliefs against vaccination, and the perceived low risk of vaccine preventable diseases significantly increased the likelihood of under-immunization, while having a complementary health insurance was inversely related with vaccines underutilization.

Conclusions

The risk factors of under-immunization are in part modifiable, by means of health education on the risks of vaccine preventable diseases and by improving the trust in the MOH. The leaders of the ultraorthodox communities could play an important role in such interventions.     

Factors Associated With Medicaid Providers' Recommendation of the HPV Vaccine to Low-Income Adolescent Girls

PurposeHuman papillomavirus (HPV) vaccination in the United States remains a public health challenge with vaccine rates of 50%. Although health care providers can facilitate HPV vaccination, several factors may impede their ability to universally recommend the vaccine. To maximize the potential of HPV vaccines, it is important to understand challenges providers face in the clinical environment. The study sought to identify factors associated with recommendation of the HPV vaccine for low-income adolescents in the early (9–10), target (11–12), early adolescent catch-up (13–14), and late adolescent catch-up (15–17) vaccination groups.MethodsSurveys were mailed between October 2009 and April 2010 to a random sample of Florida-based physicians serving Medicaid-enrolled adolescents. Data were analyzed in 2013.ResultsAmong early adolescents, discomfort discussing sexually transmitted infections (STIs) with teens (odds ratio [OR] = 1.75), difficulty ensuring vaccine completion (OR = .73), and discomfort discussing STIs with parents (OR = .44) were associated with recommendation. For target adolescents, discomfort discussing STIs with teens (OR = 2.45), time constraints (OR = .70), vaccine efficacy concerns (OR = .65), discomfort discussing STIs with parents (OR = .33), obstetrics/gynecology (OR = .25) and family medicine (OR = .24) specialty, and non-Hispanic black patient (OR = .15) were associated with recommendation. In early catch-up adolescents, concerns that teens will practice riskier behaviors (OR = .57), discomfort discussing STIs with parents (OR = .47), and family medicine specialty (OR = .20) were associated with recommendation. For late catch-up adolescents, family medicine specialty (OR = .13) was associated with recommendation.ConclusionsModifiable factors that impede or influence provider recommendations of HPV vaccines can be addressed through intervention. Overall, findings suggest that efforts should focus on sexuality communication and family medicine specialty.