Adolescent catch-up vaccination through school based programs: What happened in the last 50 years and could we do it again? Daniel B. Fishbein, MD National Immunization Program Centers for Disease Control and Prevention Disclaimer: The findings and conclusions in this presentation have not been formally disseminated by the CDC and should not be construed to represent any agency policy or determination.

Outline Why schools? Polio Rubella Hepatitis B

Why Schools Vaccination coverage, 3+ Heb B at ages 11 and 12 years, 1997-2003 NHIS*‡ Adolescents born in 1984 were 11 in 1995. ...and a child born in 1983 was 12 in 1995. Put another way, vaccination of 12-year-olds born in 1983 took place in 1995, for those born in 1984, vaccination at 12-years-old took place in 1996, and so on. So, we can see that vaccine use increased in response to the 1995 recommendation to vaccinate this age group against hepatitis B, and might have been bolstered by the 1996 recommendation for a health care visit for 11- and 12-year olds. * Among those age ≥ 13 years with vaccination record in the home ‡ For vaccine receipt at 11 and 12 years, includes receipt of Heb B 3 only

Why Schools Vaccination coverage, 3+ Heb B at ages 11 and 12 years, 1997-2003 NHIS*‡ Adolescents born in 1983 were 12 in 1995. ...and a child born in 1983 was 12 in 1995. Put another way, vaccination of 12-year-olds born in 1983 took place in 1995, for those born in 1984, vaccination at 12-years-old took place in 1996, and so on. So, we can see that vaccine use increased in response to the 1995 recommendation to vaccinate this age group against hepatitis B, and might have been bolstered by the 1996 recommendation for a health care visit for 11- and 12-year olds. * Among those age ≥ 13 years with vaccination record in the home ‡ For vaccine receipt at 11 and 12 years, includes receipt of Heb B 3 only

Why Schools? Uptake of new vaccines in adolescents will be slow A number of settings might supplement the primary care setting Schools are without doubt the only one where a majority of adolescents can effectively be reached, especially those with limited or no access to preventive services

What has been will be again, there is nothing new under the sun. Ecclesiastes 1:9-10

Outline Why schools? Polio Rubella Hepatitis B

“Schools were the major source of inoculations 1955                                               File photo The first shipments of polio vaccine arrived in San Diego in 1955. Throughout the county, some 30,000 children lined up at schools to receive inoculations against the childhood crippler and killer. The first shipments of polio vaccine arrived in San Diego in 1955. Throughout the county, some 30,000 children lined up at schools to receive inoculations against the childhood crippler and killer. “Schools were the major source of inoculations for children 10 – 19” Sirken MG and Brenner B. Poliomyelitis Vaccination Participation Differentials. National Office of Vital Statistics, PHS, US Dept of Health, Education and Welfare, August 1957

Outline Why schools? Polio Rubella Hepatitis B

Rubella – 1960s and 1970 1964 and 1965: rubella epidemic in the United States caused ~12.5 million cases of rubella, ~20,000 cases of congenital rubella syndrome (CRS)

Rubella – 1960s and 1970 1969 Following vaccine licensure, a national rubella vaccination program targeted children aged 1 year to puberty To increase coverage among school-aged children rapidly, mass campaigns were conducted, particularly in schools 1969-1978 Tremendous difficulty in proving safety in adolescents

Why Schools? 1978-1979 Resurgence of rubella and outbreaks among older adolescents and young adults Vaccination recommended for post-pubertal females and other adolescents School records reviewed and unvaccinated adolescents offered vaccination in schools

Outline Why schools? Polio Rubella Hepatitis B

Hepatitis B Vaccine 1985 Hepatitis B vaccine recommended only for members of risk groups 1991 Universal vaccination of infants recommended Universal vaccination of adolescents not recommended despite Strong epidemiological rationale Extremely cost-effective

Hepatitis B Vaccine Difficulties in delivering new vaccines in the medical home Lack of or under-insurance Lack of time or compelling reason to receive preventive care on the part of adolescents, their parents, or both

Why Schools? (Hepatitis B) 1992-1995 Consensus that only a minority of adolescents would receive hepatitis B “No way we are going to get this done without schools” “Core group” at all levels who believed in school-based immunization

Why Schools? (Hepatitis B) 1992-1995 Vaccination of adolescents had to be part of comprehensive strategy for disease reduction and cessation of transmission CDC began funding school-based hepatitis B programs to determine feasibility of delivering hepatitis B vaccine in school-based programs

Median = +63 pct points (range: +33 to +91) Evidence-based Analysis School-base hepatitis B vaccination Change in Coverage: All Students Study Lancman, 2000 Middleman, 2000 Cassidy, 1997 Dobson, 1995* Unti, 1998 Wilson, 2000 Peavy, 1999 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 Median = +63 pct points (range: +33 to +91) * Canada

Guide to Community Preventive Services Large effect size compared with other interventions that increase vaccine coverage Recommended for the introduction of new vaccines such as hepatitis B 23: Again, the evidence summation We conclude, that there is strong evidence to support a Task Force recommendation for multi-component interventions which include provider reminders. This evidence is based on 9 studies which measured improvement in smoking cessation. The effect size of the intervention is sufficient with a median improvement of 2.6 percentage points and a range of from -1.0 to +7.2 The studies are consistent. Again, there is no information based on other benefits, or harms to warrant a modification to the Task Force recommendation.

Voluntary School-based vaccination Caveats (cont): Changes in 3-dose Hepatitis B Coverage, San Diego, 1995-99 Voluntary School-based vaccination Law passed Law effective Adapted from Averhoff, AJPM, 2004

Vaccination in Schools Saves Society Money Denver school-based adolescent hepatitis B vaccination program Per dose cost-effectiveness compared with a network health maintenance organization Direct Societal School-based delivery: $31 $ 31 Network HMO $68 $118 Adapted from Deuson, AJPM, 1999

Caveats Widely varying resources and competing priorities must be taken into account The priorities of schools are education (test scores) money (to educate) Issues such as pregnancy, sexually transmitted diseases, drug and alcohol abuse, and violence will often take precedence.

Conclusion To significantly hasten the introduction of new vaccines for adolescents, we cannot ignore the importance of School based vaccination School entry laws

Thanks to Megan Lindley, MPH Mary Huynh, MPH, MPP