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Latest Developments in Adolescent Health Care. Mark G. Martens, M.D. Vice-President and Chief Medical Officer Planned Parenthood of Arkansas and Eastern Oklahoma Research Center Professor Department of Obstetrics & Gynecology The University of Oklahoma-Tulsa

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latest developments in adolescent health care

Latest Developments in Adolescent Health Care

Mark G. Martens, M.D.

Vice-President and Chief Medical Officer

Planned Parenthood of Arkansas and Eastern Oklahoma Research Center

Professor

Department of Obstetrics & Gynecology

The University of Oklahoma-Tulsa

President- International Infectious Disease Society for Obstetricians and Gynecologists

slide2
BACKGROUND
  • Majority of adolescent morbidity/ mortality is preventable
morbidity mortality
MORBIDITY/MORTALITY
  • Accidents and injuries leading cause of death for both males and females
  • Many of these accidents involve alcohol and other substances
morbidity mortality5
MORBIDITY/MORTALITY
  • Sexually transmitted diseases are common infectious diseases among adolescents
  • Among adolescents ages 15-19, pregnancy and childbirth are the leading causes of hospitalization
slide6
BACKGROUND
  • Risky behaviors co-occur
  • Behaviors responsible for leading causes of morbidity/mortality during adulthood are initiated during second decade of life (e.g., smoking, substance use, physical inactivity, risky sexual behavior)
slide7
PROMOTE ADOLESCENT HEALTH
  • Requires participation of
    • Adolescents
    • Families
    • Schools
    • Communities
    • Federal, state & community policies
slide8
PROMOTE ADOLESCENT HEALTH
  • Health care system
    • Most adolescents see a primary care provider at least once a year
adolescent clinical guidelines
ADOLESCENT CLINICAL GUIDELINES

Recommend that primary care providers screen & counsel adolescent patients for risky health behaviors

adolescent clinical guidelines10
ADOLESCENT CLINICAL GUIDELINES
  • National Committee for Quality Assurance (NCQA) Guidelines (HEDIS) have Adolescent-Specific Measures:
    • Screening for alcohol use
    • Annual visit to provider
    • Immunization status
    • Screening sexually active females for Chlamydia trachomatis (Over 15 years old)
adolescent clinical guidelines11
ADOLESCENT CLINICAL GUIDELINES
  • Despite guidelines, current delivery of preventive services below recommended levels
  • Limited research on how to implement adolescent preventive services
risk areas
RISK AREAS
  • Risky behaviors associated with major morbidity and mortality in adolescence:
          • Tobacco
          • Alcohol
          • Drugs
          • Sexual Behavior
          • Seatbelt
          • Helmet
slide13
SEXUAL BEHAVIOR
  • Increase condom use
  • Delay onset
  • SUBSTANCE USE
  • Decrease initiation
  • Decrease use
  • TOBACCO
  • Decrease initiation
  • Decrease smoking
  • SEATBELTS
  • Increase seatbelt use
  • HELMETS
  • Increase helmet use
  • SYSTEM IMPLEMENTATION OF PREVENTIVE SERVICES
  • Increased Screening
  • Increased Counseling

INCREASE PREVENTIVE SERVICES TO ADOLESCENTS

slide14
GOAL
  • Develop and evaluate a system intervention to increase the delivery of adolescent clinical preventive services
system intervention to increase delivery of clinical preventive services
SYSTEM INTERVENTION TO INCREASE DELIVERY OF CLINICAL PREVENTIVE SERVICES

CURRENT DELIVERY OF PREVENTIVE SERVICES

IMPROVED DELIVERY OF PREVENTIVE SERVICES

Provider Training

Tools

Health Educator

slide16
TRAINING
  • 8-Hour Training for Pediatric Primary Care Providers
  • Adolescent Health and Development
  • Effective Communication with Adolescents
  • Give Clinicians Targeted Specific Messages about Risk Behaviors
tools
TOOLS
  • Adolescent Health Screening Questionnaire
  • Provider Charting Form
    • Provides information from the Adolescent Health Screening Questionnaire to indicate health behavior of the patients
    • Provides prompts and cues for provider intervention
guidelines for provider intervention
GUIDELINES FOR PROVIDER INTERVENTION
  • Not Engaging in Risky Behavior
    • Reinforce positive behaviors
guidelines for provider intervention19
GUIDELINES FOR PROVIDER INTERVENTION
  • Engaging in Risky Behavior
    • Confirm response
    • Express concern about risky behavior
    • Provide key messages
key messages key messages for sexual behavior
KEY MESSAGESKey Messages for Sexual Behavior

Message 1

Avoiding sex is the safest way to prevent pregnancy and sexually transmitted diseases or AIDS.

slide22
KEY MESSAGESKey Messages for Sexual Behavior

Message 2

If you choose to have sex, be responsible. Use a condom every time you have sex. If you don’t have a condom, don’t have sex.

To ensure you don’t get pregnant or get your partner pregnant, and as a backup to a condom, use another form of birth control

intervention procedure
INTERVENTION PROCEDURE
  • Adolescent Health Screening Questionnaire prior to well-visit
  • Provider well-visit
      • 20 to 30 minutes
  • Health Educator visit
      • 15 to 30 minutes
four in ten girls get pregnant at least once before age 20
Four in ten girls get pregnant at least once before age 20.

Source: National Campaign to Prevent Teen Pregnancy analysis of Henshaw, S.K., U.S.. Teenage Pregnancy Statistics, New York: Alan Guttmacher Institute, May, 1996; and Forrest, J.D., Proportion of U.S. Women Ever Pregnant Before Age 20, New York: Alan Guttmacher Institute, 1986, unpublished.

international pregnancy and birth rates teens 15 19
International Pregnancy and Birth Rates, Teens 15-19

The United States has much higher teen pregnancy and birth rates than other fully industrialized countries. U.S. teen pregnancy rates are twice as high as rates in Canada and eight times as high as rates in Japan.

UNICEF. (2001). A league table of teenage births in rich nations. Innocenti Report Card, 3. Pregnancy rates were calculated by the National Campaign using birth and abortion data from this report and miscarriage data which were estimated using the formula the Alan Guttmacher Institute uses in generating U.S. teen pregnancy data, with miscarriages=20% of births + 10% of abortions.

Just the Facts (September 2004) – Page PB-3

the consequences of teen motherhood are many
The consequences of teen motherhood are many:
  • Less likely to complete high school
  • Dependence on welfare
  • Single parenthood
  • More likely to have more children sooner on a limited income
  • More likely to abuse or neglect the child

National Campaign to Prevent Teen Pregnancy. (1997). Whatever Happened to Childhood? The Problem of Teen Pregnancy in the United States. Washington, DC: Author.

risks to children of teen mothers
Risks to children of teen mothers
  • growing up without a father
  • low birthweight and prematurity
  • school failure
  • mental retardation
  • insufficient health care
  • abuse and neglect
  • poverty and welfare dependence

Source: Maynard, R.A., (ed.), Kids Having Kids: A Robin Hood Foundation Special Report on the Costs of Adolescent Childbearing, New York: Robin Hood Foundation, 1996.

only 32 percent of teen mothers get their high school diploma
Only 32 percent of teen mothers get their high school diploma
  • Teen mothers: Educational attainment by age 30

68%

32%

National Campaign to Prevent Teen Pregnancy. (1997). Whatever Happened to Childhood? The Problem of Teen Pregnancy in the United States. Washington, DC: Author.

the children of teen mothers are at greater risk of abuse and neglect
The children of teen mothers are at greater risk of abuse and neglect

110

51

29

18

National Campaign to Prevent Teen Pregnancy. (1997). Whatever Happened to Childhood? The Problem of Teen Pregnancy in the United States. Washington, DC: Author.

taxpayers spend about 6 9 billion 2 831 per teen parent on teen childbearing
Taxpayers spend about $6.9 billion ($2,831 per teen parent) on teen childbearing

Estimated annual costs to taxpayers of teen childbearing in billions

$1.0

$1.4

$2.7

$1.7

$0.1

National Campaign to Prevent Teen Pregnancy. (1997). Whatever Happened to Childhood? The Problem of Teen Pregnancy in the United States. Washington, DC: Author.

teen birth rates girls aged 15 19 number of births per 1 000 girls
Teen birth rates, girls aged 15-19(number of births per 1,000 girls)

The teen birth rate declined steadily from 1960 through the mid-1970s, stayed fairly constant for the next decade, then increased 24 percent between 1986 and 1991. Between 1991 and 1999, the teen birth rate decreased 20 percent to a record low.

Note: data for 1999 are preliminary. Curtin, S.C., & Martin, J.A. (2000). Births: Preliminary data for 1999. National Vital Statistics Reports 48(14). Ventura, S.J., Mathews, T.J., & Curtin, S.C. (1998). Declines in teenage birth rates, 1991-97: National and state patterns. National Vital Statistics Reports 47(12).

slide33
Nearly 1 million teen pregnancies. To put it another way, more than 100 U.S. teens become pregnant each hour. Forty percent of these pregnancies were to girls under age 18, and 60 percent were to girls aged 18-19.

100 teen girls get pregnant each hour

Total: 905,000

542,640

337,530

24,830

The Alan Guttmacher Institute. (1999). Special report: U.S. teenage pregnancy statistics with comparative statistics for women aged 20-24. New York: Author.

each year half a million teens give birth
Each year, half a million teens give birth

Just over one-half of teen pregnancies to girls aged 15-19 ended in birth, about one-third ended in abortion, and 14 percent ended in miscarriage.

124,700

491,577

263,890

The Alan Guttmacher Institute. (1999). Special report: U.S. teenage pregnancy statistics with comparative statistics for women aged 20-24. New York: Author.

55 teen girls give birth each hour
55 teen girls give birth each hour

Nearly one-half million teen births occurred. To put it another way, more than 55 U.S. teens give birth each hour. Thirty-six percent of these births were to girls under age 18, and 64 percent were to girls aged 18-19.

Total: 484,794

312,186

9,049

163,559

* Data for 1999 are preliminary. Curtin, S.C., & Martin, J.A. (2000). Births: Preliminary data for 1999. National Vital Statistics Reports 48(14).

state teen pregnancy rates pregnancies per 1 000 girls aged 15 19
State teen pregnancy rates(pregnancies per 1,000 girls aged 15-19)

50-62 per 1,000

65-85 per 1,000

86-90 per 1,000

95-106 per 1,000

108-140 per 1,000

Teen pregnancy rates vary widely by state, ranging from 50 per 1,000 in North Dakota to 140 per 1,000 in Nevada.

The Alan Guttmacher Institute. (1999). Teenage pregnancy: Overall trends and state-by-state information. New York: Author.

changes in teen pregnancy rates pregnancies per 1 000 girls aged 15 19
Changes in teen pregnancy rates(pregnancies per 1,000 girls aged 15-19)

16.4-31.2% decline

12.2-15.5% decline

9.4-11.5% decline

3.4-9.2% decline

No change

Teen pregnancy rates declined in every state but New Jersey; declines ranged from 3.4 percent in Nevada to 31.2 percent in Alaska.

The Alan Guttmacher Institute. (1999). Teenage pregnancy: Overall trends and state-by-state information. New York: Author.

teen pregnancy rates racial ethnic subgroups number of pregnancies per 1 000 girls aged 15 19
Teen pregnancy rates, racial/ethnic subgroups(number of pregnancies per 1,000 girls aged 15-19)

Teen pregnancy rates vary substantially among the three largest racial/ethnic subgroups. The rate for African-American teens declined 20 percent and the rate for non-Hispanic White teens declined 24 percent. The teen pregnancy rate for Hispanics increased between 1990 and 1994, but then declined 6 percent.

Non-Hispanic Black

Hispanic

(any race)

Non-Hispanic White

Darroch, J.E., & Singh, S. (1999). Why is teenage pregnancy declining? The roles of abstinence, sexual activity and contraceptive use. Occasional Report 1. New York: The Alan Guttmacher Institute.

teen birth rates by race ethnicity girls aged 15 19 number of births per 1 000 girls
Teen birth rates by race/ethnicity, girls aged 15-19(number of births per 1,000 girls)

Teen birth rates vary substantially among the largest racial/ethnic subgroups. Between 1991 and 1999, the rate for African-American teens declined 30 percent, the rate for all White teens declined 16 percent and the rate for non-Hispanic White teens declined 21 percent, the rate for Hispanics decreased 13 percent, the rate for Native Americans declined 20 percent, and the rate for Asian/Pacific Islanders declined 17 percent.

Hispanic (any race)

African American

Native American

TOTAL

White (total)

Non-Hispanic White

Asian/Pacific Islander

Note: data for 1999 are preliminary. Curtin, S.C., & Martin, J.A. (2000). Births: Preliminary data for 1999. National Vital Statistics Reports 48(14). Ventura, S.J., Martin, J.A., Curtin, S.C., Mathews, T.J., & Park, M.M. (2000). Birth: Final data for 1998. National Vital Statistics Reports 48(3).

pregnancy outcomes teens aged 15 19 number of pregnancies per 1 000 girls aged 15 19
Pregnancy Outcomes, Teens Aged 15-19(number of pregnancies per 1,000 girls aged 15-19)

Hispanic teens are most likely, and non-Hispanic Black teens least likely, to have a pregnancy that ends in a birth.

The Alan Guttmacher Institute. (2004). U.S. teenage pregnancy statistics: Overall trends, trends by race and ethnicity and state-by-state information. New York: Author

Just the Facts (April 2004) – Page P-25

number of teen births
Number of teen births

Among teens aged 15-19, more births occur to non-Hispanic White teens than to any other racial/ethnic group.

* Data for 1999 are preliminary. Curtin, S.C., & Martin, J.A. (2000). Births: Preliminary data for 1999. National Vital Statistics Reports 48(14).

number of teen births by birth order births to girls aged 15 19
Number of teen births by birth order(births to girls aged 15-19)

Nearly four-fifths of all teen births are first births. Of the other 22 percent, 18 percent are births to teens who already have one child, 3 percent are births to teens who already have two children, less than one percent are fourth or higher-order births, and the final 1 percent of births do not have a birth order stated on the birth certificate.

Total: 475,745

(85,455)

(14,643)

(370,749)

(2,148)

(2,750)

* Data for 1999 are preliminary. Curtin, S.C., & Martin, J.A. (2000). Births: Preliminary data for 1999. National Vital Statistics Reports 48(14).

pregnancy outcomes
Pregnancy Outcomes

Pregnancies to girls aged 15 or younger are less likely to end in birth than pregnancies to other age groups.

Henshaw, S.K. (2004). U.S. teenage pregnancy statistics with comparative statistics for women aged 20-24. New York: The Alan Guttmacher Institute.

Just the Facts (April 2004) – Page P-20

slide45
Association of HPV with Cervical Cancer

HPV is present in virtually all cervical cancers, estimated at 99.7%

J MM Walboomers et al., Journal of Pathology 189:12-19,1999

1980s

1990s

2000s

1999

hpv prevalence and cervical cancer incidence by age 1 2
30

30

25

25

20

20

15

15

10

10

5

5

0

0

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

HPV Prevalence and Cervical Cancer - Incidence by Age 1,2

Cancer incidence per 100,000

HPV Prevalence (%)

Age (Years)

1. Sellors et al. CMAJ. 2000;163:503.

2. Ries et al. Surveillance, Epidemiology and End Results (SEER) Cancer Stats NCI, 1973-1997. 2000.

hpv types differ in disease associations
HPV Types Differ in Disease Associations

Cutaneous

Mucosal/Genital

~40 Types

~ 60 Types

“High” Risk : HPV 16, 18, 31, 33, 34, 35, 39, 45, 51, 52, 56, 58, 59, 66, 68, 70, etc

“Low” Risk: HPV 6, 11, 42, 43, 44, etc

Low grade cervical disease

Cervical cancer precursors

Cervical cancer

“Common” hand

and foot warts

Genital warts

Low grade cervical disease

Laryngeal papillomas

HPV = Human papillomavirus

Adapted from Unger ER. CDC. June 2005 ACIP meeting

Burd EM. Clin Microbiol Rev 2003;16:1-17.

hpv vaccine
HPV Vaccine
  • News of Phase II HPV Vaccine Results released April, 2005 in Lancet
  • HPV 6,11,16,18 Vaccine
  • 552 Women ages 16-23
  • After 2 ½ years, 100% prevention of HPV (36 patients vs 4 in HPV negative women)
  • 100% effective at preventing any cervical abnormalities /cancer*
  • 25,000 more women vaccinated now
impact of gardasil in the general population
Impact of GARDASIL®in the General Population
  • GARDASIL is a prophylactic vaccine.
  • There was no clear evidence of protection from disease caused by HPV types for which subjects were PCR positive and/or seropositive at baseline.
  • Individuals who were already infected with 1 or more vaccine-related HPV types prior to vaccination were protected from clinical disease caused by the remaining vaccine HPV types.
general population impact reduced hpv 6 11 16 and 18 related genital warts
General Population Impact: Reduced HPV 6-, 11-, 16- and 18-related Genital Warts

*Includes all subjects who received at least 1 vaccination and who were naïve (PCR (-) and sero (-)) to HPV 6, 11, 16, and/or 18 at Day 1. Case counting started at 1 month Postdose 1.

†Includes 1 subject with missing serology/PCR data at Day 1.

‡Includes all subjects who received at least 1 vaccination (regardless of baseline HPV status at Day 1). Case counting started at 1 month Postdose 1.Table does not include disease due to nonvaccine HPV types.

bridging the efficacy of gardasil from young adult women to adolescent girls
Bridging the Efficacy of GARDASIL® From Young Adult Women to Adolescent Girls

9 to 15 years of age

N = 1,121

16 to 26 years of age

N = 4,229

GMTs*

*GMT = Geometric mean titer in mMU/mL (mMU = milli-Merck units).

indications and usage
Indications and Usage
  • GARDASIL is a vaccine indicated in girls and women 9 to 26 years of age for the prevention of the following diseases caused by HPV types 6, 11, 16, and 18:
    • Cervical cancer
    • Genital warts (condyloma acuminata)

and the following precancerous or dysplastic lesions:

    • Cervical AIS
    • CIN grades 2 and 3
    • VIN grades 2 and 3
    • VaIN grades 2 and 3
    • CIN grade 1
herpes is the most prevalent std 1 million new genital herpes infections per year in the us
Although Genital Herpes is one of the most common STDs, many primary care physicians believe it is virtually nonexistent in their patient populationHerpes is the Most Prevalent STD1 Million New Genital Herpes Infections per Year in the US

HPV (warts)

20 million

Chlamydia

2 million

Hepatitis B

417,000

HIV

560,000

Herpes

45 million

Henry J. Kaiser Family Foundation.

CDC Web site. Tracking the hidden epidemics: trends in STDs in the United States 2000:1-31.

Armstrong G et al. Am J Epidemiol. 2001;153:912-920.

9 7 of partners with hsv 2 transmitted genital herpes to their susceptible partners
9.7% of Partners with HSV-2 Transmitted Genital Herpes to Their Susceptible Partners

Study of 144 healthy couples discordant for genital herpes. Couples were followed for a median of 334 days:

14of 144 acquired genital herpes: 3 of 79 susceptible males11 of 65 susceptible females

Adapted from Mertz GJ et al. Ann Intern Med. 1992;116:197-202.

up to 70 of transmission may occur during asymptomatic viral shedding
Up to 70% of Transmission May Occur During Asymptomatic Viral Shedding

Transmission during asymptomatic

viral shedding

Up to

70%

~30%

Transmission during symptomatic

outbreaks

Adapted from Mertz GJ et al. Ann Intern Med. 1992;116:197-202.

hsv vaccine results
HSV Vaccine Results
  • 847 Men and Women negative for HSV I and II
  • 1867 Men and Women negative either HSV I or HSV II
  • Overall 38% effective
  • HSV II negative women- 42% effective
  • HSV I and II neg women- 73% effective
herpes is the most prevalent std 1 million new genital herpes infections per year in the us65
Although Genital Herpes is one of the most common STDs, many primary care physicians believe it is virtually nonexistent in their patient populationHerpes is the Most Prevalent STD1 Million New Genital Herpes Infections per Year in the US

HPV (warts)

20 million

Chlamydia

2 million

Hepatitis B

417,000

HIV

560,000

Herpes

45 million

Henry J. Kaiser Family Foundation.

CDC Web site. Tracking the hidden epidemics: trends in STDs in the United States 2000:1-31.

Armstrong G et al. Am J Epidemiol. 2001;153:912-920.

2006 std treatment guidelines
2006 STD Treatment Guidelines
  • MMWR August 4, 2006
  • Vol. 55
  • www.cdc.gov
ob gyn routine tests
OB-GYN Routine Tests
  • Suggested:
    • GYN
      • N. gonorrhoeae < 25 y.o.
      • C. trachomatis < 25 y.o.
      • Pap test
      • HIV, if seeking evaluation for STD’s or with risk factors
pelvic inflammatory disease
Pelvic Inflammatory Disease

Minimum Diagnostic Criteria

Uterine/adnexal tenderness or cervical motion tenderness

Additional Diagnostic Criteria

Oral temperature >38.3 C Elevated ESR

Cervical CT or GC Elevated CRP

WBCs/saline microscopy Cervical discharge

pelvic inflammatory disease definitive diagnostic criteria
Pelvic Inflammatory DiseaseDefinitive Diagnostic Criteria
  • Endometrial biopsy with histopathologic evidence of endometritis
  • Transvaginal sonography or MRI showing thick fluid-filled tubes
  • Laparoscopic abnormalities consistent with PID
pelvic inflammatory disease hospitalization
Pelvic Inflammatory DiseaseHospitalization
  • Surgical emergencies not excluded
  • Pregnancy
  • Clinical failure of oral antimicrobials
  • Inability to follow or tolerate oral regimen
  • Severe illness, nausea/vomiting, high fever
  • Tubo-ovarian abscess
pelvic inflammatory disease parenteral regimen a
Cefotetan 2 g IV q12h

or

Cefoxitin 2 g IV q6h

PLUS

Doxycycline 100 mg orally/IV q12h

Pelvic Inflammatory DiseaseParenteral Regimen A
pelvic inflammatory disease parenteral regimen b
Clindamycin 900 mg IV q8h

PLUS

Gentamicin loading dose IV/IM (2 mg/kg) followed by maintenance dose (1.5 mg/kg) q8h. Single daily dosing may be substituted

Pelvic Inflammatory DiseaseParenteral Regimen B
pelvic inflammatory disease alternative parenteral regimens
Ofloxacin 400 mg IV q12h

or

Levofloxacin 500 mg IV qd

WITH OR WITHOUT

Metronidazole 500 mg IV q8h

or

Ampicillin/Sulbactam 3 g IV q6h

PLUS

Doxycycline 100 mg orally/IV q12h

Pelvic Inflammatory DiseaseAlternative Parenteral Regimens
pelvic inflammatory disease oral regimen a
Ofloxacin 400 mg bid for 14 days

or

Levofloxacin 500 mg qd for 14 days

WITH or WITHOUT

Metronidazole 500 mg bid for 14 days

Pelvic Inflammatory DiseaseOral Regimen A
pelvic inflammatory disease oral regimen b
Ceftriaxone 250 mg IM in a single dose

or

Cefoxitin 2 g IM in a single dose and Probenecid 1 g administered concurrently

PLUS

Doxycycline 100 mg bid for 14 days

WITH or WITHOUT

Metronidazole 500 mg bid for 14 days

Pelvic Inflammatory DiseaseOral Regimen B
pelvic inflammatory disease management of sex partners
Pelvic Inflammatory DiseaseManagement of Sex Partners
  • Male sex partners of women with PID should be examined and treated for sexual contact 60 days preceding patient’s onset of symptoms
  • Sex partners should be treated empirically with regimens effective against CT and GC
osteoporosis
Osteoporosis
  • Depo- Provera
  • Vitamin D
  • Calcium
  • Smoking
  • Alcohol
slide79
PROMOTE ADOLESCENT HEALTH
  • Requires participation of
    • Adolescents
    • Families
    • Schools
    • Communities
    • Federal, state & community policies
adolescent clinical guidelines80
ADOLESCENT CLINICAL GUIDELINES

Recommend that primary care providers screen & counsel adolescent patients for risky health behaviors

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