Teen vaccines: Where we are now, and how can we go further?

Adolescents remain undervaccinated for several diseases, and clinicians need to lead the charge to change this reality, according to new clinical reports issued by the American Academy of Pediatrics Committee on Infectious Diseases.

Teens are lagging behind the Healthy People 2020 vaccination goals for the Tdap, quadrivalent meningococcal conjugate (menACWY), and human papillomavirus (HPV) vaccines, lead authors Henry H. Bernstein, DO, and Joseph A. Bocchini Jr., MD, wrote in the Feb. 6 issue of Pediatrics.

Much of the problem can be attributed to the notorious difficulty of regularly getting teens to visit their medical home. But parental fears about safety of vaccines and cultural, social, and religious philosophies also interfere with vaccine compliance – especially when it comes to the HPV shots, they said (Pediatrics. 2017 Feb 6. doi: 10.1542/peds.2016-4168).

“Although HPV vaccination rates are slowly improving, they continue to lag far behind Tdap and menACWY rates for both boys and girls,” the authors wrote. Only 63% of girls and 50% of boys have gotten at least one HPV vaccine dose; just 42% of girls and 28% of boys finished the entire three-dose series in 2015.

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A recent study found that parents declined the HPV vaccine 56% of the time. The three most common reasons were the belief that their child had a low risk of acquiring HPV; fear that the risk of adverse events was too great and belief that the vaccine wasn’t well researched and hasn’t been on the market long enough.

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Last fall, in an effort to increase compliance with the series, the CDC’s Advisory Committee on Immunization Practices established a two-vaccine protocol using a 9-valent HPV vaccine for patients aged 9-14 years. “A two-dose HPV vaccine schedule has the potential to improve completion rates and reduces costs,” the authors wrote. The schedule also has been studied in Canada and found to be as effective as the three-dose schedule.

But teens also are falling behind with less controversial vaccines, the report noted. Fewer than half of teens got a flu shot in the 2015-2016 season. Rates for the MenACWY and Tdap are better, but not optimal (81% and 86%, respectively).

Barriers to optimal immunization

The clinical report puts clinicians on the first line of responsibility and makes no apologies for that.

“One of the greatest challenges is health care provider recommendation, which often lacks consistency and urgency,” the authors said. “Many health care providers do not universally recommend vaccines to eligible populations and do not offer concomitant vaccination with indicated vaccines during a single patient encounter.”

In fact, they noted, a recent physician survey found that only about 60% of pediatricians and family doctors strongly recommend the HPV vaccine for 11- and 12-year-old girls. Several parent surveys have determined that lack of provider recommendation is a leading reason for undervaccination among adolescents.

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Mass-targeted misinformation about vaccines continues to exert a negative effect. Providers can, and do, make a difference here by listening, asking open-ended questions about parental concerns, and providing factual information about vaccines’ safety and efficacy.

A companion clinical report, also authored by Dr. Bernstein and Dr. Bocchini, discusses practical ways to confront these barriers (Pediatrics. 2017 Feb 6. doi: 10.1542/peds.2016-4187). It opens with a strong call to physicians to lead the charge in increasing immunization rates.

“Up to 65% of parents have reported not receiving a recommendation … for immunizations. The major reason for nonreceipt [of Tdap and menACWY] was lack of a health care provider recommendation,” they said.

Overcoming parental vaccine hesitancy is a thorny struggle, the authors acknowledge. But they offer some helpful suggestions, including:

• Don’t offer immunizations as “optional.” This opens the door to vaccine dismissal. Instead, “strongly endorse all universally recommended vaccines as important for adolescents’ health.”

• Ask open-ended questions to get at the root of parental hesitancy. Give fact-based, medically sound information. Stress that doctors are parent partners in raising healthy children and protecting them from disease.

• Stress the big-picture benefits of vaccines. Telling parents that the HPV vaccine prevents cancer lifelong is a powerful message. “Up-to-date information on current events and disease outbreaks is a tool to bring into the conversation about vaccines as well.”

• Review the vaccine timeline. Do everything possible to ensure parents follow up and complete each series. “Follow-up immunization visits should be scheduled before the family leaves the care setting.”

• Don’t give up when a parent refuses a vaccine. “Although it may be challenging, it’s important that health care providers offer the vaccine at the next most appropriate time. Perseverance is critical for vaccine uptake and immunization rates.”