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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

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 opportunity1
Adolescence: A Hidden Opportunity
  • 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.)
adolescent immunity or lack thereof
Adolescent Immunity (Or Lack Thereof)
  • 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.

challenges to an adolescent approach
Challenges to an Adolescent Approach
  • 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
teens engage in risky behaviors
Teens Engage In Risky Behaviors

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.

health care risk also increases
Health Care “Risk” Also Increases

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.

the teen health care universe

No insurance


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

physician change fragments care
Physician Change Fragments Care

NAMCS Office Visit Data

health care guidance slowly rising
Health Care Guidance Slowly Rising
  • 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
adolescent vaccines on the way1
Adolescent Vaccines On The Way

NIAID: The Jordan Report 2002.

messaging is missing
Messaging Is Missing
  • 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.

passive teen vs active teen strategies
Immunization registries

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
passive strategy catch the teens
Passive Strategy: Catch the Teens
  • 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.
active strategy quid pro quo
Active Strategy: 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.
thought experiment churn rate
Thought Experiment: Churn Rate
  • 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
getting teens into system is key

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
alternative care sites simulate churn
Alternative Care Sites Simulate Churn
  • 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.
other tools effective at churn
Other Tools Effective At Churn
  • 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.

crowded schedule until 24 months



Crowded schedule … until 24 months
  • 0-24 months = “shots”
      • 4-6 years = “boosters”
          • 10-12 years = “not my kid”
hep b vaccine as a model

Hep B virus isolated


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...
hep b immunization kids 19 35mos




Hep B Immunization, Kids 19-35mos.

ACIP Birth dose reco Oct 01

ACIP Reco Nov 91

CDC/NHIS Healthy People 2000 & 2010 Database;

expanding physician involvement
Expanding Physician Involvement

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
milestone prevention visits as a tool
Milestone Prevention Visits As A Tool
  • Pre-adolescent visit at age 10-12
  • Recommended visits at age 5, 10, 15, 20?

… Thank you!