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Adolescence – A Challenging Time to Promote Prevention and Immunization . Juan Carlos Batlle, MD ‘04 University of Pennsylvania School of Medicine Thomas K. Zink, MD GlaxoSmithKline, Immunization Policy and Scientific Affairs. Adolescence: A Hidden Opportunity.

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Adolescence – A Challenging Time to Promote Prevention and Immunization

Juan Carlos Batlle, MD ‘04

University of Pennsylvania School of Medicine

Thomas K. Zink, MD

GlaxoSmithKline, Immunization Policy and Scientific Affairs

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Adolescence: Immunization A Hidden Opportunity

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Adolescence: A Hidden Opportunity Immunization

  • 41 million youths aged 10-19

  • Age group a crucible for high-risk behavior

    • 45% of high school students have had sex

    • 10% have tried cocaine

  • Older adolescents not accessing health care

    • ~20% have foregone needed care in the past year

    • ~20% have no insurance or medical home

  • One study puts cost of preventable adolescent morbidities at $700 billion / year (Adolescent Medicine: StARs. 1999;10(1):131-151.)

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Adolescent Immunity (Or Lack Thereof) Immunization

  • Vaccination rates range from 20-90%

  • 35 mm youths 11-21 missing at least one vaccine

  • Late 80s/Early 90s: 47% of measles cases were among adolescents/young adults

  • Adolescents represent 70% of the 100-140K cases/year of hepatitis B and 29% of all pertussis cases

Handal G. Adolescent immunization. Adolescent Medicine: State of the Art Reviews. 2000;11(2):439-452.; MMWR 2002; 51: 73-76.

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Challenges to an Adolescent Approach Immunization

  • Age group changeability - Adolescents are a moving target, aged somewhere between 6 and 21

  • Physicians tough to target - Adolescents are not the exclusive province of any MD

  • Deficient data - Most health and immunization data focuses on children 0-3

  • Lack of a medical targeting model - Few products prescribed primarily to teens

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Teens Engage In Risky Behaviors Immunization

YRBS: CDC-conducted national school-based survey of 13,601 students in grades 9-12 during Feb-Dec 2001.

  • 46% had ever had sex (61% of blacks). 7% had sex before age 13 (16% of blacks).

  • 33% of students had sex within 3 mos. of survey.

  • 42% had not used a condom at last intercourse.

  • 870,000 pregnancies/year among 15-19 year olds.

  • 3mm STDs among 10-19 year olds.

    Youth risk behavior surveillance--United States, 2001. Morbidity & Mortality Weekly Report. Surveillance Summaries. 51(4):1-62, 2002 Jun 28.

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Health Care “Risk” Also Increases Immunization

1999 Add Health Study: 12,105 adolescents (grades 7-12), 1994-95 school year.

  • 18.7% had foregone care in the past year.

  • 13.0% of teens had no insurance and another 6.5% had interrupted insurance.

  • Uninsured teens were most likely to forego care (23.9%).

  • 33.0% of all teens had no physical exam in the past year.

    Ford CA. Bearman PS. Moody J. Foregone health care among adolescents. JAMA. 282(23):2227-2234, 1999 Dec 15.

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No insurance Immunization


Alternative Site 10%*

25% Don’t

Public insurance


15% Don’t

Private insurance


17% Don’t

Other 1° 20-25%**

FP 20-25%

Peds 20-25%

E.R. 20-25%

80% Access Care

20% Don’t

The Teen Health Care Universe

65-70 million visits / yr

*Includes School Health Centers, Family Planning Clinics

**Includes OB/GYN, Internal Medicine, Hospital Outpatient

Source: JAMA 1999;282(23): 2227-34.; NAMCS

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Physician Change Fragments Care Immunization

NAMCS Office Visit Data

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Health Care Guidance Slowly Rising Immunization

  • In 1995, ACIP recommended catch-up Hep B of all children 10-12 at “early adolescent visit”

  • In 1996, professional societies join (AMA, AAFP, AAP) with ACIP to promote prevention-oriented early adolescent visit

  • Guidelines appear (Bright Futures, GAPS)

  • 2004 Childhood Immunization Schedule includes a preadolescent visit

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Adolescent Vaccines On The Way Immunization

NIAID: The Jordan Report 2002.

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Messaging Is Missing Immunization

  • For kids <15, 50% of visits for an acute issue; only 27% for non-illness care.

  • In 63% of visits, no therapeutic or preventive services were ordered or provided.

  • HIV/STD transmission discussed in 0.6% of visits. (Counseling most often on diet, 15.0% of visits).

  • Yet 86% of teens 15-17 rated sexual health a “big personal concern” and the highest rated concern overall.

Source: NAMCS 2000 data. Advance No. 328.; Kaiser Family Foundation National Survey of Adolescents and Young Adults 2003.

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Immunization registries Immunization

Physician education

Improved insurance

Improved access to care

Middle school mandates

Patient education


Incentive programs

Passive: Attempt to “catch” patients.

Active: Influence patients to ask for immunization.

“Passive-Teen” vs. “Active-Teen” Strategies

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Passive Strategy: Catch the Teens Immunization

  • School based health clinics - Proven entities with broad support; high enrollment of teens.

  • Job-related efforts - Employer incentives to build in paid time for minimum wage employees to seek health care.

  • Mobile clinic - Access under-served or fragmented areas. Concerts, malls, etc.

  • Mall kiosks - Low cost, confidential clinics to administer reproductive health services, immunizations, minor acute care.

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Active Strategy: Immunization Quid Pro Quo

  • School entry requirements - Proof of immunization at a certain grade level.

  • Sports participation / Camp participation requirements

  • Motor voter type effort - Require immunization for driver’s license or SAT exam.

  • Tattoo/body piercing - Policy requirement of proof of immunization.

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Thought Experiment: Churn Rate Immunization

  • 4 mm new 10 year olds each year – how do we catch them before they are 14?

  • Assume 30% are immunized annually

  • 1.2 mm immunized each year, then? No problem immunizing all 4mm by 14.

  • But, some kids never present to the system

  • Churn rate becomes important

  • Need to improve % of kids newly presenting to system, “churning” in the unimmunized

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Takeaways Immunization

At 30% annual rate, entire cohort is easily caught if all teens presented to system.

# of years of catch-up is fixed.

Churn rate is crucial: Increasing teens new to system to 58.3% yields 0.7mm incremental catchup each year and no lost teens

The Churn Factor

New 10 yr olds 4mm

Imm. rate (4mmx30%) -1.2mm

Churn Rate 58.3%

Incremental gain/yr -0.7mm


Years of catch-up 4yrs

Incremental Catchup (-0.7mmx4yrs) -2.8mm

Lost 10 year olds 0

Getting Teens Into System Is Key

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Alternative Care Sites Simulate Churn Immunization

  • Clinics catch teens outside the traditional patient-doctor relationship

    • School-based health centers

    • Planned Parenthood / Teen clinics

    • HMO-based clinics

  • Immunization programs similarly catch teens

    • Motor/voter type drives

    • Canvassing campaigns

    • “Vaccinate Before You Graduate”

  • 70%+ of physicians agree that alternative care sites are acceptable for immunization.

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Other Tools Effective At Churn Immunization

  • CHIP Enrollment: CHIP children were 85.6% UTD on at 24 months compared to 54% of non-CHIP

  • Tracking/Outreach: Increased mean health visits by 0.44/child/yr; raised immunization rate 20 % points.

  • Information systems: AFIX, using CASA system, increased immunization rate by 10 % points in 1 year in Maine.

  • Immunization drives: Baton Rouge drive immunized 5000 teens in 5 years with little financial support; GET HEP B in Missouri.

Pediatrics 2002;110: 940-945.,Pediatrics 1999;103:31-38., Pediatrics. 1999; 103:1218-1223., Ped Inf Disease Journal. 1998;17(7 Suppl):S43-6.

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F I N I SH Immunization


Crowded schedule … until 24 months

  • 0-24 months = “shots”

    • 4-6 years = “boosters”

      • 10-12 years = “not my kid”

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Hep B virus isolated Immunization


Hep B vax available


ACIP reco



Kid coverage hits 90%


Hep B Vaccine As A Model

  • “High-risk”-oriented STD, not always reimbursed

  • ACIP recommendation initiates growth, but growth not uniform over time.

  • Boosting growth: reimbursement, mandates, public health initiatives, additional recos.

  • Lesson: progress has been slow...

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STOP Immunization



Hep B Immunization, Kids 19-35mos.

ACIP Birth dose reco Oct 01

ACIP Reco Nov 91

CDC/NHIS Healthy People 2000 & 2010 Database;

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Expanding Physician Involvement Immunization

Family Physicians

  • 33% to 50% of adolescent visits made to FP

Emergency Physicians

  • 25% of adolescent visits to ER (13mm visits)


  • Reach almost all women

  • Represent 40%-50% of all female teen visits


  • Insurance coverage; new CPT codes

  • Patient / parent / provider attitudes

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Milestone Prevention Visits As A Tool Immunization

  • Pre-adolescent visit at age 10-12

  • Recommended visits at age 5, 10, 15, 20?

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Questions? Immunization

… Thank you!