# Presentation: 086533

## Immunization of Adolescents: An Update

- Daniel B. Fishbein, MD
- Health Services Research and Evaluation Branch
- Immunization Services Division
- National Immunization Program
- Centers for Disease Control and Prevention

## Outline

- Vaccine preventable diseases in adolescents
- Incidence
- Deaths
- Vaccination of adolescents
- Interventions to increase vaccination coverage in adolescents
- Priorities for the future

## Vaccine-Preventable Disease Deaths in Adolescents 11-21 Years of Age, United States, 1991-2000

**Source:  NCHS, National Multiple Cause Mortality File (underlying deaths)**

**Notes:**
With respect to the distribution of vaccine preventable deaths among adolescents, varicella accounts for the majority in this age group. One effect of varicella vaccination of infants may be a greater degree of herd immunity which may result in a shift in occurrence from children to adolescents and young adults.  This changing epidemiology is of concern given that the morbidity, including death, is greater for persons who contract varicella as adolescents or adults.

It is important to note that this chart only depicts those deaths occurring among adolescents that could have been prevented by vaccination during adolescence.  However, it does NOT reflect the additional thousands of future adult vaccine preventable deaths that can be averted by vaccination of adolescents.  

## Vaccine-Preventable Disease Deaths in Adolescents 11-21 Years of Age, United States, 1991-2000

**Source:  NCHS, National Multiple Cause Mortality File (underlying deaths)**

**Notes:**
With respect to the distribution of vaccine preventable deaths among adolescents, varicella accounts for the majority in this age group. One effect of varicella vaccination of infants may be a greater degree of herd immunity which may result in a shift in occurrence from children to adolescents and young adults.  This changing epidemiology is of concern given that the morbidity, including death, is greater for persons who contract varicella as adolescents or adults.

It is important to note that this chart only depicts those deaths occurring among adolescents that could have been prevented by vaccination during adolescence.  However, it does NOT reflect the additional thousands of future adult vaccine preventable deaths that can be averted by vaccination of adolescents.  

## Vaccine-Preventable Disease Deaths in Adolescents 11-21 Years of Age, United States, 1991-2000

**Source:  NCHS, National Multiple Cause Mortality File (underlying deaths)**

**Notes:**
With respect to the distribution of vaccine preventable deaths among adolescents, varicella accounts for the majority in this age group. One effect of varicella vaccination of infants may be a greater degree of herd immunity which may result in a shift in occurrence from children to adolescents and young adults.  This changing epidemiology is of concern given that the morbidity, including death, is greater for persons who contract varicella as adolescents or adults.

It is important to note that this chart only depicts those deaths occurring among adolescents that could have been prevented by vaccination during adolescence.  However, it does NOT reflect the additional thousands of future adult vaccine preventable deaths that can be averted by vaccination of adolescents.  

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

*** Antelope Valley, California, ESD, NIP, CDC**

**  ****95  96  97  98  99  00  01**

**ACIP**
**statement**

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

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

**  ****95  96  97  98  99  00  01**

**ACIP**
**statement**

## Varicella*, Hepatitis A†, & Hepatitis B‡ Cases/100,000, 1995-2001

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

**  ****95  96  97  98  99  00  01**

**ACIP**
**statement**

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

**Source: National Notifiable Diseases Surveillance System (NNDSS)**

## Outline	

- Vaccine preventable diseases in adolescents
- Vaccination of adolescents
- Recommendations
- Immunization requirements
- Coverage
- Interventions to increase vaccination coverage in adolescents
- Priorities for the future?

## Vaccines Recommended for Adolescents

**Hepatitis B**

**Tetanus-diphtheria**

**Measles, Mumps, Rubella**

**Varicella**

**Pneumococcal**

**Hepatitis A**

**Influenza**

**11-12 **

**  ****13-18 **

**for selected populations **

_**.                 Age                     .     **_

**for all adolescents not already up-to-date**

**Vaccines Recommended for Adolescents**

**2-10**

**Recommended ages**
**Catch-up**

**Birth-1  **

**                 ****(.....DTaP #1-4......) **

**1-2**

**#1**

**#2**

**Notes:**
Adolescent health visit
NHIS age 13-15

## Vaccines and the Target Populations

- All adolescents
- Tetanus Diphtheria: Five years after 5th dose of DTaP
- Adolescents not fully vaccinated as children
- Hepatitis B
- Measles, mumps, rubella
- Varicella, if not naturally immune

## Vaccines and the Target Populations

- Selected populations at increase risk of infection
- Influenza
- Pneumococcal
- Hepatitis A

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

**DC**

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

**CA**

**OR**

**WA**

**NV**

**ID**

**AK**

**MT**

**HI**

**AZ**

**UT**

**NM**

**WY**

**CO**

**OK**

**KS**

**NB**

**SD**

**ND**

**LA**

**AK**

**MO**

**IA**

**MN**

**WI**

**IL**

**IN**

**OH**

**MI**

**MS**

**AL**

**GA**

**FL**

**TN**

**SC**

**NC**

**KY**

**VA**

**WV**

**PA**

**NY**

**ME**

**NJ**

**MD**

**DE**

**VT**

**NH**

**MA**

**RI**

**CT**

**     ****None          One           Two         Three       Four or Five       **

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

**TX**

## Number Of States With Immunization Requirements* For Middle School, By Vaccine, 1989-2003

**  ****7 Varicella**

**34 Hepatitis B**

**17 Tetanus**

**ACIP**
**statement**

**39 Measles**

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

**Notes:**
I would like you to remember the order of the four vaccines as I move to the next part of this presentations

## Immunization Coverage Among Adolescents

- National Health Interview Survey
- Household face-to-face survey of non-institutionalized population of the United States
- Expanded to include children less than 18 years of age (1997)
- Data available from 1997 (year after harmonized adolescent vaccination recommendations released) through 2001.
- Number of doses of four vaccines obtained for children aged 13-15 years of age and source of information
- Immunization record
- Parental recall
- First nationally representative data on adolescent immunization coverage

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

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

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

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

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

## Varicella Immunity, Adolescents 13-15 years of age

## Outline	

- Vaccine preventable diseases in adolescents
- Vaccination of adolescents
- Interventions to increase vaccination coverage among adolescents
- Health care settings
- Primary care
- Non-traditional
- School focused
- Voluntary school based programs
- Entry laws and requirement
- Vision for the future

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

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

- *Using parent-held vaccination record

- Grade

**Law passed**

**Law effective**

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

- Voluntary School-based Vaccination(Upper income countries)

**   **_**Study**_
**Lancman, 2000**
**Middleman, 2000**
**Cassidy, 1997**
**Dobson, 1995**
**Unti, 1998**
**Wilson, 2000**
**Peavy, 1999**

**control**

**Notes:**
Pe avy: High risk communities according to behavioral and socioeconomic criteria” 
Cassidy > 50% blackUnti: 
Wilson 70% cauicasian 
Lancman: most hispanic (60) and black (35)
Middleman: 19% white
Dobson:  no data

## Next Steps	

- Data
- Projections through 2010?
- Number of laws
- Population coverage
- Disease incidence
- Understanding racial and ethnic disparities in coverage
- Interventions?
- Age group specific: Should there be priorities?
- Race and ethnicity specific: Should we focus on disparities?
- VPD specific: Varicella?
- Geographic areas
- Infrastructure to facilitate vaccination of adolescents to address all currently recommended vaccines and new vaccines that may become priorities in the future.

## Interventions to Increase Vaccination Coverage Among Adolescents

|  |  |  | Are the immunizations.... |  |
| --- | --- | --- | --- | --- |
|  |  |  | Recommended? | Required? |
| Is there are a program?
Who drives it?
Where are the shots given? | Health settings |  | GAPs
STD clinics
Adolescent health clinics | Evaluations of require-ments |
|  | Education settings |  | School-based clinics
School-based special programs |  |

## Hepatitis B Adolescent Incidence Rates 1995-2001

## Varicella Reported Cases/1000 by Age Antelope Valley CA, 1995-2001

- 1995

- 1996

- 1998

- 1999

- 2000

- 2001

- 1997

## Varicella Reported Cases/1000 by AgeAntelope Valley CA, 1995-2001

- 1995

- 1996

- 1998

- 1999

- 2000

- 2001

- 1997

## Varicella and Hepatitis B:Reported Cases/1000

- 1995

- 1996

- 1998

- 1999

- 2000

- 2001

- 1997

## Hepatitis B Coverage, 13-15 Year Olds,By Income Level Shot Card Data, National Health Interview Survey

**  ****Poor                  Near Poor             Middle-High **

## Hepatitis B Coverage, 13-15 Year Olds,By UrbanicityShot Card Data, National Health Interview Survey

**Urban                                    Rural**

**Hepatitis B Coverage, 13-15 Year Olds,****By Urbanicity****Shot Card Data, National Health Interview Survey**

## Hepatitis A Adolescent Incidence Rates 1995-2001