# Presentation: 463040

## Immunization:What Happens at Ages 11 – 12?National Health Interview Survey, 1997 – 2003

**Mary McCauley**
**John Stevenson**
**Shannon Stokley**
**Dan Fishbein**
**National Immunization Program**

*The findings and conclusions in this presentation have not been formally disseminated by CDC*
*and should not be construed to represent any agency determination or policy.*

**Notes:**
Good morning.  I’ll quickly review what the National Health Interview Survey tells us about the recent history of success in vaccinating 11- and 12-year-olds following recommendations that they receive vaccine.  I’m happy to say that Shannon and Dan are here to help with questions and discussion, and many thanks to John Stevenson on our team for the statistical analyses.

## History vs the Future

- Until 2005, Td was the only vaccine universally recommended for 11- and 12-year-olds
- Today, an 11- or 12-year-old who has not received all doses of Hep B, MMR, or varicella needs “catch-up”
- Because of high childhood coverage, the impact of adolescent catch-up recommendations is coming to an end—as children born later receive the vaccines as infants and young children
- New adolescent vaccines are permanent additions to a growing adolescent schedule

**Notes:**
This slide summarizes one key difference between the recent history of adolescent vaccination and the future, which is upon us...

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## Therefore...

- Adolescent providers will be on the front lines to assure high coverage with new vaccines, such as MCV4, Tdap, HPV, and others

**Notes:**
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## Study Question

- How many children in the NHIS were brought up to date with Hep B, MMR, and Td when they were 11 or 12?
- Differs from the traditional measure of “vaccination coverage,” which counts all vaccines accumulated during the child’s entire life, from birth to the interview date

**Notes:**
We looked at the available National Health Interview Survey data and asked how many children were...

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## National Health Interview Survey

- Face-to-face household survey of non-institutionalized U.S. residents
- Covers various health topics
- In 1991, an immunization supplement was added for children 0-6 years old
- In 1997, the immunization section was expanded to include all children < 18 years old
- Parents can report from vaccination record, memory, or both
- In 2003, data collection for adolescent vaccination ended

**Notes:**
Briefly, the National Health Interview Survey is a...

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## Methods

- We included all those who were at least age 13 at the time of the interview
- We limited this analysis to respondents who reported information from a vaccination record

**Notes:**
For this study of vaccination of 11- and 12-year-olds, we...

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## Who are these adolescents?

- Born in 1979 – 1990
- Ages 11 or 12 in 1990 - 2002

**Notes:**
The adolescents in the study were...

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## What recommendations applied?

- For 11- and 12-year-olds
- 1989 AAP recommended 2nd dose MMR
- 1995 ACIP recommended the Hep B series, 2nd dose MMR, and Td
- 1996: ACIP and other major professional organizations recommended a health visit to assess for and deliver vaccines and other preventive services

**Notes:**
The recommendations that applied to these cohorts included the 1989 AAP recommendation for the 2nd dose of MMR and the 1995 ACIP recommendations for...

In 1996...

## We Examined

- Coverage attained by age 10 and during ages 11 and 12 for 3 Hep B,
- 	2 MMR, and Td
- Yearly trends in vaccine administration to assess impacts of recommendations
- Percent of each birth cohort who were eligible for vaccine and who received it while age 11 or 12

**Notes:**
We looked at three things:

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## Results

- Sample size
- Hep B
- MMR
- Td

**Notes:**
I’ll present the results in the order you see here.

## Vaccination record in the home by year of birth for all adolescents surveyed

**Notes:**
As you can see, about 20% of the respondents reported vaccination history from a record.  The range by birth cohort was 36 – 581...more in the middle cohorts...

## Vaccination coverage, 3+ Hep B by age 10 years*

- *     Among those age ≥ 13 years with vaccination record in the home

**Notes:**
First, we’ll go through the results for Hep B step by step, and then with MMR, we’ll go MUCH faster on a single slide...

Vaccination with three doses of Hep B during the first ten years of life for these cohorts ranged from 0 to about 30%....

## Vaccination coverage, 3+ Hep B by age 10 years and during age 11 years* ‡

- *     Among those age ≥ 13 years with vaccination record in the home
- ‡     For vaccine receipt at 11 and 12 years, includes receipt of Hep B 3 only

**Notes:**
The incremental increase in coverage during age 11 ranged from 0 to about 10%.

## Vaccination coverage, 3+ Hep B by age 10 years and during age 11 years* ‡

- *     Among those age ≥ 13 years with vaccination record in the home
- ‡     For vaccine receipt at 11 and 12 years, includes receipt of Hep B 3 only

- 11 yrs old in 1995

**Notes:**
For 11-year-olds, you can begin to look for a trend in vaccine receipt attributable to the 1995 recommendation in the 1984 cohort.

## Vaccination coverage, 3+ Hep B by age 10 years and during ages 11 and 12* ‡

- *     Among those age ≥ 13 years with vaccination record in the home
- ‡     For vaccine receipt at 11 and 12 years, includes receipt of Hep B 3 only

**Notes:**
The incremental increase in coverage during age 12 ranged from 0 to about 12%.

## Vaccination coverage, 3+ Hep B by age 10 years and during ages 11 and 12* ‡

- *     Among those age ≥ 13 years with vaccination record in the home
- ‡     For vaccine receipt at 11 and 12 years, includes receipt of Hep B 3 only

- 12 yrs old in 1995

**Notes:**
And for 12-year-olds, you can begin to look for a trend attributable to the 1995 recommendation in the 1983 cohort.

Note that the highest coverage attained by age 13 was only 49% in these cohorts.

## Percent eligible who received Hep B 3 at ages 11 and 12*‡

*** Among those age ≥ 13 years with vaccination record in the home**
**‡ ****For vaccine receipt at 11 and 12 years, includes receipt of Hep B 3 only**

**Notes:**
This slide presents the data differently.  It’s still by birth cohort on the X axis, but it shows the percent of 11- and 12-year-olds who were ELIGIBLE to be brought up to date who WERE brought up to date when they were 11 or 12.  The range is 0 to 28%

## Vaccination coverage, 2+ MMR by age10 years and during ages 11 and 12*

*** Among those age ****≥ 13 years ****with vaccination record in the home**

- 11 yrs old in 1990:
- 12 yrs old in 1991

- 11 yrs old in 1995

- 12 yrs old in 1995

**Notes:**
Here’s the story for MMR all on two slides:
In the first 10 years of life, coverage in these cohorts ranged from about 8% to about 64%.

The incremental increase from vaccine administered to 11-year-olds ranged from 3% to about 13%...

To look for a trend for MMR uptake following recommendations, you’d need earlier data than we have to see the impact of the 1989 recommendation, and for 11-year-olds you could also look in the 1984 cohort to see if you see a bump or a renewed rise due to the 1995 recommendation.  That’s really not apparent.

The incremental increase from vaccination received among 12-year-olds ranged from about 3% to about 19%...

That 19% was among the first cohort for which we have data, and I think it’s safe to attribute that uptake to a combination of the 1989 recommendation and the measles outbreak...

One last note while we’re here:  It’s true that fewer members of later cohorts needed vaccine, but it’s also true that highest coverage attained by age 13—the end of year 12—was only 75%.  Some work remained.

## Percent eligible who received MMR at ages 11 and 12*

*** Among those age ≥ 13 years with vaccination record in the home**

**Notes:**
Among those who needed to be brought up to date with MMR at 11 and 12, from 15% to 33% were.  Again, the highest percent was in the earliest cohort.

## Vaccination coverage, 1+ Td by age13 years*

*** Among those age ≥ 13 years with vaccination record in the home**

**Notes:**
Note that for Td, the only routine vaccine on the adolescent schedule until 2005, we had to change the Y axis so you could see the results:  The highest coverage for Td was only about 9%.  One caveat:  in many states, providers likely continued to administer the first Td at ages 14 – 16.

## Limitations

- Vaccination history not provider validated
- We can only evaluate visits at which a vaccine was administered; children may have seen a provider at age 11 or 12 and had a missed opportunity
- Data are not weighted to represent the entire adolescent population
- The sampling strategy was not devised with this type of analysis in mind

**Notes:**
The limitations of this analysis include...

## Conclusions from Data

- The number of adolescents who received Hep B and MMR during birth through 10 years increased steadily
- Overall, few adolescents who needed vaccine received it while ages 11 – 12 during 1990 - 2002
- Nevertheless, we can observe some effect of recommendations in the timing of vaccine administration

**Notes:**
We can safely conclude from these data that...

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## Discussion

- The capacity to deliver multiple doses of multiple vaccines to adolescents should be considered
- Where feasible based on epidemiology and logistics, including vaccine supply, consideration should be given to recommending new vaccines for all adolescent age groups to reach as many as possible, especially given data that suggest that adolescents make few visits, especially for preventive care

**Notes:**
And this group is no doubt well versed in the issues that require discussion and action...

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Menactra supply aside...

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## Challenges

- Reaching adolescents with the recommended visit at ages 11 and 12
- Assuring vaccine financing and equity
- Assuring the system’s capacity to deliver an ever-increasing number of vaccines, some multi-dose
- Educating providers, parents and adolescents about risks of the VPDs, the efficacy of the vaccines, and the safety of interventions for sexually transmitted infectious in general for NOT increasing risk-taking behavior

**Notes:**
In summary, as YOU no doubt know, challenges include...

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## Thank you.

**Mary McCauley, CDC**
**MMcCauley@cdc.gov**