by Henry H. Bernstein, D.O., M.H.C.M., FAAP,
and Joseph A. Bocchini Jr., M.D., FAAP
Over the past decade, the AAP-rec-ommended immunization schedule
for 11- through 18-year-olds has become more complex due to the introduction of vaccines that protect
against serious pathogens such as meningococcus,
pertussis and human papillomavirus (HPV) and the
recommendation for annual vaccination against influenza.
The Academy has released two clinical reports
to consolidate information on these vaccine-preventable diseases and their consequences, and to
support pediatricians in achieving high vaccination
rates in their adolescent population. The Need to Optimize Adolescent Immunization, available at http://
dx.doi.org/10.1542/peds.2016-4186, explores the
epidemiology of meningococcus, pertussis, HPV
and influenza in adolescents. Practical Approaches
to Optimize Adolescent Immunization, available at
strategies clinicians can use to improve immunization rates and address adolescent vaccine hesitancy
or refusal. Both clinical reports are published in the
March issue of Pediatrics.
Following are key points highlighted in the reports.
Adolescent immunization rates are lower than
those for younger children.
Vaccination rates vary greatly depending on the
vaccine and state.
In 2015, the national vaccination rate for tetanus, diphtheria, acellular pertussis (Tdap) vaccine
was 86% (range 70%-97%) and 81% (range 55%-
98%) for quadrivalent meningococcal conjugate
(MenACWY) vaccine. However, completion of the
three-dose HPV series was only 42% (range 24%-
68%) for females and 28% (range 16%-58%) for
males. Similarly, only 46.8% of adolescents ages 13
through 17 received an influenza vaccine in 2015.
Understanding the epidemiology, opportunities
and barriers to vaccination can help health care
providers create better implementation strategies to
Every health care visit is an opportunity to
review and update immunization status.
A complete vaccine history should be reviewed
at every health visit. The recommended adolescent
immunization schedule includes MenACWY, Tdap,
HPV and influenza vaccines.
Meningococcal B vaccine is recommended rou-
A strong recommendation from the health care
tinely for those at increased risk; it also is available
for healthy adolescents based on individual coun-
seling and provider evaluation (Category B rec-
ommendation). Adolescents may require catch-up
of recommended immunizations not received at a
younger age, such as hepatitis B, hepatitis A, mea-
sles-mumps-rubella or varicella.
provider is the most important reason why
parents choose to vaccinate their children.
Providers are parents’ most trusted sources of in-
formation and offer some of the most important
• A lack of recommendation is a major reason
for non-receipt of vaccines. In a 2009 survey,
88% and 91% of parents whose children did not
receive the Tdap and meningococcal vaccines,
respectively, reported not receiving a recommendation. For those who might be vaccine hesitant
initially, approximately 40% stated that health
care provider information and reassurance were
major reasons why they changed their minds.
• Other reasons why parents decline a vaccine for
Vaccine hesitancy and refusal in adolescent
their child include the belief that: a) their child was
at low risk for acquiring the disease; b) the risks for
adverse effects were “too great”; c) there was not
enough research on the vaccine; and d) the vaccine
had not been on the market “long enough.”
• Additional barriers to adolescent immunization
include misinformation about vaccines, especial-
ly safety, from internet and media sources; racial
and ethnic disparities in health care, including
immunization coverage; financial difficulties;
and inadequate supply of vaccines in offices.
health care can be challenging.
It is necessary to understand the range of parental
attitudes toward vaccines to address potential concerns appropriately. Health care providers should assess for vaccine readiness, ascertain parents’ positions
and feelings on vaccines, emphasize the benefits of
vaccines, clarify any misconceptions, and determine
whether there is a lack of understanding or education
about a specific vaccine. Ethnic or cultural-specific
factors should be considered.
Motivational interviewing is a valuable skill to
build rapport with parents and adolescent patients,
as well as improve vaccine acceptance and
overcome hesitancy. Different strategies
may be more effective with different types
of vaccine-hesitant parents.
HPV vaccination presents a
distinctive set of challenges.
Studies indicate that HPV immunization rates are improved with a strong
provider recommendation and when HPV
is co-administered with other needed
vaccines. Providers should presumptively
state that the vaccine is a routine part of
the immunization schedule, emphasize its
impact on cancer prevention, clarify any
misconceptions and underscore the vaccine’s safety record.
A 2009 study found that some parents
had concerns and misperceptions about
increased sexual activity, discomfort toward a new
vaccine and vaccine requirements for school. Providers should be prepared to identify and answer these
and other parental misconceptions or concerns.
Health care technology can be useful and
effective in decreasing missed opportunities
Review of immunization information system records and health care provider prompts are useful
and effective ways to reduce missed opportunities
in vaccine delivery. The health care provider sees
the prompt and identifies whether the adolescent
is a candidate for immunization. If the patient is a
candidate, the health care provider then should offer
the indicated vaccine(s). Prompts for parents also
may be useful in ensuring follow-up visits.
Electronic health records and immunization information systems also can run reports listing patients who are due or overdue for immunizations.
Delivering reminders or recalls via phone call, text
or mail can be a useful way of targeting patients.
Setting up exclusive immunization days or hours
is another strategy that can be considered.
Extending care into school-based settings is
an alternative strategy that may help improve
adolescent immunization rates.
The use of schools as a pathway to educate and
vaccinate adolescents could help increase immunization rates. Other vaccination sites that can facilitate
immunizing adolescents include pharmacies, mobile
vans, clinics for substance abuse or obstetrics/gyne-cology care, and shelters. All vaccinations administered in alternate settings should be shared with the
adolescent’s medical home and documented in the
state’s electronic immunization information system.
Dr. Bernstein, associate editor of Red Book
Online and an ex-officio member of the AAP
Committee on Infectious
Diseases (COID), and
Dr. Bocchini, former
chair of COID, are co-authors of the clinical reports.
AAP reports highlight how to optimize adolescent immunization
The recommended adolescent immunization schedule includes
the quadrivalent meningococcal conjugate, Tdap, HPV and
A panel of experts will discuss a variety of topics pertaining to HPV during a webinar at 1 p.m. ET March 6.
For more information, go to https://cc.readytalk.com/r/
n3hwwnach7ns&eom. Dr. Bernstein Dr. Bocchini