1. 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.

2. Outline
Why schools?
Polio
Rubella
Hepatitis B

3. 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 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

4. 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 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

5. 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

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

7. Outline
Why schools?
Polio
Rubella
Hepatitis B

8. “Schools were the major source of inoculations
1955
                                             
File photo
The first shipments of polio vaccine arrived in San Diego in 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 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

9. Outline
Why schools?
Polio
Rubella
Hepatitis B

10. 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)

11. 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
Tremendous difficulty in proving safety in adolescents

12. Why Schools?
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

13. Outline
Why schools?
Polio
Rubella
Hepatitis B

14. 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

15. 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

16. Why Schools? (Hepatitis B)
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

17. Why Schools? (Hepatitis B)
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

18. 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

19. 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.

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

21. 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
Network HMO $ $118
Adapted from Deuson, AJPM, 1999

22. 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.

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

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