Adolescent Immunization: Newest Vaccines, Updated Recommendations

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Recommendations

Program Overview

A number of guidelines from national organizations support the

provision of preventive healthcare during adolescence, a time of

increasing autonomy in making health-related and lifestyle choices.

[1,2] These guidelines are similar in approach -- recommending

regular, confidential care and emphasizing education and counseling

aimed at reducing major health risks.

A crucial component of such care is immunization against preventable

disease. Recently, several vaccines that have been developed and

targeted specifically for initial use in adolescents have been

approved by the US Food and Drug Administration (FDA). These include

meningococcal conjugate vaccine (MCV-4), tetanus toxoid-reduced

diphtheria toxoid-acellular pertussis (Tdap) vaccine, and human

papillomavirus (HPV) vaccine.

Although ensuring that infants and younger children are up-to-date

with recommended immunizations is no easy task, this may be

especially challenging with adolescent patients. Data from the

National Committee for Quality Assurance, Health Plan Employer Data

and Information Set (HEDIS) revealed an adherence rate to recommended

immunizations of 24% for adolescents, compared with 60% for children.

[3] Any healthcare encounter with an adolescent provides an important

opportunity to both administer vaccines specifically recommended for

this age group and to " catch up " on immunizations that had been

missed in earlier years.

Using the latest in interactive technology, this Medscape activity

provides 3 cases involving adolescent girls. Although two of the 3

patients are seeking healthcare for a specific physical complaint,

the important focus in all of the cases is immunization. In each

case, you will be asked to make decisions, and the system will

automatically provide you with feedback in regard to your choices,

including laboratory tests, diagnoses, and treatments. This feedback

is drawn from 3 primary sources: (1) drug prescribing information;

(2) current references, published evidence-based data, and national

guidelines; and (3) the TheraSim Clinical Advisory Panel. The

sophisticated case-based interactive tool in the activity will help

you to both test your diagnostic and management skills and hone your

knowledge about the most current immunization recommendations for

adolescents.

HPV and HPV Vaccine

Although the activity will address all of the vaccines recommended

for adolescents, there is particular emphasis on the most recently

approved vaccine. In June 2006, the FDA licensed a quadrivalent

vaccine for HPV. Later that month, the Advisory Committee on

Immunization Practices (ACIP) issued provisional guidelines for

clinical use of the new vaccine, which is targeted to preadolescent

and adolescent girls, and to women aged 26 or younger.[4]

There are over 100 strains of HPV, but only approximately 30 types

infect the genital tract of humans; both females and males are at

risk for virus-associated sequelae. The quadrivalent vaccine protects

against HPV genotypes 6, 11, 16, and 18. A large majority of genital

warts are caused by types 6 and 11, and types 16 and 18 are

responsible for approximately 70% of all cervical cancers.[5,6]

Therefore, the HPV vaccine has tremendous potential for reducing the

prevalence of both cervical disease, including cancer, and genital

warts.

Following the introduction of the cervical cancer screening programs,

rates of invasive cervical cancer fell dramatically in the United

States. On the other hand, such programs are very expensive, with

millions of women with minor Pap smear abnormalities being subjected

to cervical biopsy and colposcopic examination aimed at detecting

premalignant cervical disease.[6,7] The primary benefit of the HPV

vaccine in the United States will be the reduction of the incidence

of abnormal Pap smears and a decrease in treatment required for

cervical abnormalities. However, the situation is much different in

the developing world, where cytologic screening programs are not

available. Cervical cancer is the second leading cause of cancer

death among women worldwide -- and the vaccine can significantly

reduce HPV-related morbidity and mortality.

The provisional recommendations from the ACIP are for routine use of

HPV vaccine in females aged 9-26 years, with immunization initiated

at age 11-12 years.[4] Girls as young as age 9 may also be provided

vaccine at the discretion of the provider. The vaccine can be given

at the same time as other vaccines recommended for adolescents. Full

immunization against HPV requires 3 doses of vaccine -- administered

in the deltoid muscle at 0, 2, and 6 months.

Females aged 13-26 are considered a " catch-up " cohort. This catch-up

group will be increasingly interacting with healthcare providers as

they seek other immunizations, routine primary care that may include

contraception, and begin a screening program for cervical disease

once sexually active. Optimally, vaccination should be completed

prior to onset of sexual activity, but immunization is still

recommended for anyone in the identified age range. Pediatricians,

family physicians, and gynecologists, along with other providers of

healthcare for adolescents and young women, will need to be aware of

both the importance of preventing HPV-related diseases and the

recommendations of the ACIP and professional organizations concerning

the HPV vaccine.

Proceed to the Case Simulations

References

Pintz C. Issues in providing health maintenance to adolescents.

Medscape Nurses, Topics in Advanced Practice Nursing eJournal. 2002;2

(2). Available at: http://www.medscape.com/viewarticle/430530

Accessed September 28, 2006.

Tountas Y, Dimitrakaki C. Health education for youth. Pediatr

Endocrinol Rev. 2006;3(suppl1):222-225.

McInerny TK, Cull WL, Yudkowsky BK. Physician reimbursement levels

and adherence to American Academy of Pediatrics well-visit and

immunization recommendations. Pediatrics. 2005;115:833-838. Abstract

Centers for Disease Control and Prevention (CDC). CDC's Advisory

Committee recommends human papillomavirus vaccination [press

release]. Atlanta: CDC; June 29, 2006. Available at:

http://www.cdc.gov/od/oc/media/pressrel/r060629.htm Accessed

September 28, 2006.

Trottier H. Franco EL. The epidemiology of genital human

papillomavirus infection. Vaccine. 2006;24(suppl1):S1-15.

Scheurer ME, Tortolero-Luna G, Adler-Storthz K. Human papillomavirus

infection: biology, epidemiology, and prevention. Int J Gynecol

Cancer. 2005;15:727-746. Abstract

Ahmed AM, Madkan V, Tyring SK. Human papillomaviruses and genital

disease. Derm Clin. 2006;24:157-165.

Section 1 of 1

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Sheri Nakken, R.N., MA, Hahnemannian Homeopath

Vaccination Information & Choice Network, Nevada City CA & Wales UK

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