1. Immunization of Adolescents: An Update Daniel B. Fishbein, MD Health Services Research and Evaluation Branch Immunization Services Division National Immunization Program Centers for Disease Control and Prevention

2. Outline Vaccine preventable diseases in adolescents –Incidence –Deaths Vaccination of adolescents Interventions to increase vaccination coverage in adolescents Priorities for the future

3. Vaccine-Preventable Disease Deaths in Adolescents 11-21 Years of Age, United States, 1991-2000 Source: NCHS, National Multiple Cause Mortality File (underlying deaths)

4. Vaccine-Preventable Disease Deaths in Adolescents 11-21 Years of Age, United States, 1991-2000 Source: NCHS, National Multiple Cause Mortality File (underlying deaths)

5. Vaccine-Preventable Disease Deaths in Adolescents 11-21 Years of Age, United States, 1991-2000 Source: NCHS, National Multiple Cause Mortality File (underlying deaths)

6. Varicella* Cases/100,000, 1995-2001 * Antelope Valley, California, ESD, NIP, CDC 95 96 97 98 99 00 01 ACIP statement

7. Varicella* & Hepatitis A † Cases/100,000, 1995-2001 * Antelope Valley, California, ESD, NIP, CDC † States w/ consistently elevated rates, National Notifiable Dis. Surv. System, CDC 95 96 97 98 99 00 01 ACIP statement

8. Varicella*, Hepatitis A †, & Hepatitis B Cases/100,000, 1995-2001 Varicella*, Hepatitis A †, & Hepatitis B ‡ Cases/100,000, 1995-2001 * Antelope Valley, California, ESD, NIP, CDC † States w/ consistently elevated rates, National Notifiable Dis. Surv. System, CDC ‡ National Notifiable Dis. Surv. System, CDC 95 96 97 98 99 00 01 ACIP statement

9. Estimated Hepatitis B Incidence by Race, Ages 19-24 Years, 1997-2002 Source: National Notifiable Diseases Surveillance System (NNDSS)

10. Outline Vaccine preventable diseases in adolescents Vaccination of adolescents –Recommendations –Immunization requirements –Coverage Interventions to increase vaccination coverage in adolescents Priorities for the future?

11. Hepatitis B Tetanus-diphtheria Measles, Mumps, Rubella Varicella Pneumococcal Hepatitis A Influenza 11-12 13-18 for selected populations. Age. for all adolescents not already up-to-date Vaccines Recommended for Adolescents 2-10 Recommended ages Catch-up Birth-1 (…..DTaP #1-4……) 1-2 #1#2

12. Vaccines and the Target Populations All adolescents –Tetanus Diphtheria: Five years after 5 th dose of DTaP Adolescents not fully vaccinated as children –Hepatitis B –Measles, mumps, rubella –Varicella, if not naturally immune

13. Vaccines and the Target Populations Selected populations at increase risk of infection –Influenza –Pneumococcal –Hepatitis A

14. DC Number of Different Vaccines Required for Middle School Entry, 2003* CA OR WA NV ID AK MT HI AZ UT NM WY CO OK KS NB SD ND LA AK MO IA MN WI IL IN OH MI MS AL GA FL TN SC NC KY VA WV PA NY ME NJ MD DE VT NH MA RI CT None One Two Three Four or Five * Includes progressive school entrance laws that apply to middle schools as of 2003 TX

15. Number Of States With Immunization Requirements* For Middle School, By Vaccine, 1989-2003 7 Varicella 34 Hepatitis B 17 Tetanus ACIP statement 39 Measles *Excludes laws for new entrants only. For states with progressive laws, year effective is year 11 year olds were affected

16. Immunization Coverage Among Adolescents National Health Interview Survey –Household face-to-face survey of non-institutionalized population of the United States –Expanded to include children less than 18 years of age (1997) –Data available from 1997 (year after harmonized adolescent vaccination recommendations released) through 2001. Number of doses of four vaccines obtained for children aged 13-15 years of age and source of information –Immunization record –Parental recall First nationally representative data on adolescent immunization coverage

17. Immunization Record Availability Adolescents 13-15 Years of Age, National Health Interview Survey

18. MMR (2 or more doses) Estimated Vaccination Coverage Adolescents, 13-15 Years Of Age

19. Hepatitis B (3 or more doses) Estimated Vaccination Coverage Adolescents, 13-15 Years Of Age

21. Estimated Vaccination Coverage, 1+ Td, Adolescents 13-15 Years Of Age

22. Varicella Immunity, Adolescents 13-15 years of age

23. Outline Vaccine preventable diseases in adolescents Vaccination of adolescents Interventions to increase vaccination coverage among adolescents –Health care settings Primary care Non-traditional –School focused Voluntary school based programs Entry laws and requirement Vision for the future

24. Changes in 3-dose Hepatitis B Coverage, San Diego* *Using parent-held vaccination record Grade Law passed Law effective

25. Voluntary School-based Vaccination (Upper income countries) Study Lancman, 2000 Middleman, 2000 Cassidy, 1997 Dobson, 1995 Unti, 1998 Wilson, 2000 Peavy, 1999 control

26. Next Steps Data –Projections through 2010? Number of laws Population coverage Disease incidence –Understanding racial and ethnic disparities in coverage Interventions? –Age group specific: Should there be priorities? –Race and ethnicity specific: Should we focus on disparities? –VPD specific: Varicella? –Geographic areas –Infrastructure to facilitate vaccination of adolescents to address all currently recommended vaccines and new vaccines that may become priorities in the future.

27. Are the immunizations…. Recommended?Required? Is there are a program? Who drives it? Where are the shots given? Health settings GAPs STD clinics Adolescent health clinics Evaluations of require- ments Education settings School-based clinics School-based special programs Interventions to Increase Vaccination Coverage Among Adolescents

28. Hepatitis B Adolescent Incidence Rates 1995-2001

29. Varicella Reported Cases/1000 by Age Antelope Valley CA, 1995-2001 1995 1996 1998 1999 2000 2001 1997

30. Varicella Reported Cases/1000 by Age Antelope Valley CA, 1995-2001 1995 1996 1998 1999 2000 2001 1997

31. Varicella and Hepatitis B: Reported Cases/1000 1995 1996 1998 1999 2000 2001 1997

32. Hepatitis B Coverage, 13-15 Year Olds, By Income Level Shot Card Data, National Health Interview Survey Poor Near Poor Middle-High

33. Urban Rural Hepatitis B Coverage, 13-15 Year Olds, By Urbanicity Shot Card Data, National Health Interview Survey

34. Hepatitis A Adolescent Incidence Rates 1995-2001