How Effectively Can Health Care Settings Beyond the Traditional Medical Home Provide Vaccines to Adolescents?
OBJECTIVES. Our goal was to evaluate the capacity of various health care settings to supplement the activities of the traditional medical home by delivering vaccines to adolescents.
METHODS. A group of experts in the fields of adolescent-immunization delivery and the provision of preventive care in various health care settings summarized the available literature, considered setting-specific factors, and assessed the ability of various health care settings beyond the traditional medical home to conform to the immunization quality standards set by the National Vaccine Advisory Committee, report vaccination information for the quantitative assessment of vaccine-coverage rates, be likely to offer vaccines to adolescents, and be viewed by adolescents as acceptable sites for receiving vaccinations.
RESULTS. Seven candidate settings were evaluated: pharmacies, obstetrics-gynecology practices, sexually transmitted disease clinics, hospital emergency departments, family planning clinics, teen clinics, and local public health department immunization clinics. The panel concluded that all could safely provide vaccinations to adolescents but that vaccination efforts at some of the settings could potentially have a markedly greater impact on overall adolescent-immunization rates than could those at other settings. In addition, for adolescent-vaccination services to be practical, candidate settings need to have a clear interest in providing them. Conditional on that, several issues need to be addressed: (1) funding; (2) orienting facilities to provide preventive care services; (3) enhancing access to immunization registries; and (4) clarifying issues related to immunization consent.
CONCLUSIONS. With supporting health policy, health education, and communication, health care settings beyond the traditional medical home have the potential to effectively augment the vaccination efforts of more traditional settings to deliver vaccines to adolescents. These health care settings may be particularly well suited to reach adolescents who lack access to traditional sources of preventive medical care or receive fragmented medical care.
The successful introduction of a new adolescent vaccine (such as the recently recommended meningococcal conjugate, pertussis, and human papillomavirus vaccines1–3), requires careful consideration of a range of issues including, but not limited to, the capacity of health care systems to achieve high coverage levels and adolescent health care utilization patterns. Although many adolescents obtain some medical care from a primary care physician, significant proportions of them, especially in mid- or late adolescence, infrequently (or never) seek preventive care services from traditional sources.4–6 Hence, high overall immunization coverage rates can potentially be achieved by complementing the efforts of primary care physicians with efforts to deliver vaccines in other health care settings that adolescents tend to frequent. Efforts to vaccinate adolescents in those settings may be of particular benefit for subpopulations who lack access to a medical home or segment their medical care. However, the ability to implement adolescent-immunization services in these settings has not been studied adequately.
One key to success will be the ability of the medical home and other health care settings to successfully coordinate their efforts. A vaccine such as the human papillomavirus vaccine that prevents sexually transmitted diseases (STDs) is best administered in early to midadolescence, before the initiation of sexual activity; hence, that is when administration of this vaccine is recommended. Other vaccines are recommended for early adolescence, in part to promote the use of routine preventive care services.7 Although young adolescents may be more likely to strengthen their relationship with a pediatric or family practice medical home, in part as a result of the new vaccine recommendations, the need to administer several vaccines to adolescents nevertheless represents a major challenge for providers, particularly for multidose vaccines. In addition, older adolescents will need catch-up vaccination, which increases the number of adolescents who must be served in the near term. Thus, to achieve uniformly high adolescent-immunization rates, the combined efforts of the medical home and other health care settings and providers are likely to be necessary.
The Institute of Medicine recognizes that current systems of medical care are not meeting the complex needs of the US adolescent population and has called for the development of innovative programs for the achievement of better health outcomes.8 Can other health care settings plausibly supplement the adolescent-vaccination efforts of the traditional medical home? The National Immunization Program (now a part of the National Center for Immunization and Respiratory Diseases) of the Centers for Disease Control and Prevention (CDC) convened a working group of individuals with expertise in immunization research and adolescent health care to address this question. This report summarizes the group's findings about what is presently known and what has yet to be determined about the ability of such settings to function as effective providers of vaccines to adolescents.
The working group established successive agendas, identified the candidate health care settings to be considered, defined terms, assigned individual scientific review and evaluation tasks, and assessed the results of the reviews over a 4-month period from February through May of 2005. The candidate health care settings were defined as sites that tend to offer services in nontraditional settings or offer limited or episodic health care services, in contrast to the coordinated, comprehensive services offered in the traditional medical home. The settings selected for evaluation were (1) pharmacies, (2) obstetrics-gynecology (Ob-Gyn) practices, (3) STD clinics, (4) hospital emergency departments, (5) family planning clinics, (6) teen clinics, and (7) public health department immunization clinics. School-based and school-linked clinics were not included, because they represented the exclusive focus of a separate working group. In addition, walk-in clinics located inside retail businesses were not addressed, because they are a new phenomenon for which there is insufficient information with which to permit an evaluation of their potential effect on adolescent-immunization efforts.
Key components of this evaluation included comparative assessments of the candidate settings in terms of their:
previous experience with providing adolescent vaccines, alignment of adolescent-vaccination efforts with the primary mission of each setting, resource issues, and likelihood that decision-makers in each setting would elect to have the facility provide some or all of the vaccines to adolescents;
overall client mix and the characteristics of adolescents receiving services in each setting, including sociodemographic features, frequency and continuity of contact in these settings, and acceptability and attractiveness of these settings as resources for the receipt of preventive health services;
capacity to report or refer clients to a primary care physician, to provide educational materials about the importance of other preventive health care measures, and to recover or sustain the additional costs of adolescent-immunization services; and
capacity to report vaccine-related adverse events and contribute data to assist in community assessments of adolescent vaccine-coverage rates.
A subjective matrix that summarizes these key components and provides a structure for comparing the candidate sites was developed and is shown in Table 2.
In many cases, the working group found a dearth of published data concerning the experience of the candidate settings in providing vaccines to adolescents. In those instances, the working group had to depend on as-yet-unpublished data or base its conclusions on information related to the settings' experiences in providing vaccinations to adult populations. It should be noted that these settings' experiences with vaccinating adult populations are not always applicable to the adolescent population, particularly with respect to adolescent-specific issues (eg, securing parental consent for vaccination) that are not faced by facilities when providing vaccinations to adult populations.
A draft of the initial findings was presented in June 2005 at the National Stakeholders' Meeting: Strengthening the Delivery of New Vaccines for Adolescents, a national conference in Washington, DC, cosponsored by the National Vaccine Program Office and the CDC, during which participants were invited to submit comments. Those comments were evaluated and incorporated as appropriate. The findings presented here summarize what is presently known and not known about the ability and capacity of health care settings beyond the medical home to provide immunizations to adolescents; barriers that might impede efforts to provide immunizations in these settings are also identified.
Increased recognition of the role of pharmacies in population-based vaccination services is reflected in the Department of Health and Human Services' 1994 recommendation, made in a meeting with Secretary Shalala, that pharmacists' competencies include vaccine education and mobilization, vaccine distribution, vaccine access and administration, and participation in vaccine registries and tracking systems. In 1996, the American Pharmacists Association published Pharmacy-Based Immunization Delivery: A National Certificate Program for Pharmacists, which was based on CDC, Advisory Committee on Immunization Practices, and NVAC standards.10,11 The program includes practice-management skills and vaccine-administration techniques and teaches pharmacists the functions and responsibilities associated with providing vaccination services.12 According to the American Pharmacists Association, the program has been used to train ∼25000 student pharmacists and professionals as of 2006. A study published in 2004 indicated that 77% of pharmacists who completed the certification program directly administered vaccines, of whom 96% administered influenza vaccine, 77% administered pneumococcal vaccine, 55% administered hepatitis vaccines, and 19% administered the combined childhood diphtheria and tetanus toxoids and acellular pertussis vaccine.13
Pharmacists' commitment to providing vaccine services was demonstrated in recent surveys of pharmacists who had completed vaccination training. Respondents reported that they had done so because of their commitment to improving the health of the public rather than for business or financial reasons or for continuing education credit.13–15 Various published studies have also shown that most consumers trust pharmacy vaccination services and are attracted to this type of setting because of the convenience that pharmacies offer their customers.16,17 These findings are consistent with a recent review that concluded that pharmacist-administered vaccination, particularly for adult patients, has become routinely accepted as an important role of the pharmacist.15 Nevertheless, to date, there is little experience with administration of vaccines to adolescents in the pharmacy setting.
The number and distribution of pharmacies throughout the nation make them a unique resource. Pharmacies are readily accessible to and frequently visited by adolescents. Many of them have extended hours on evenings and weekends, and they are a particularly important source of health care in rural communities.18
At present, 46 states grant pharmacists statutory permission to administer vaccinations19; most such efforts in the past have centered on the provision of influenza vaccine. Although a few states have not yet authorized pharmacists to administer vaccines, explicit statements from public health authorities that encourage immunization-trained pharmacists to take proactive roles in immunization delivery would likely prompt these states to support increased pharmacist involvement in this aspect of public health.
Obstetrician-gynecologists have unique opportunities to deliver vaccines to women of all ages. They serve as the first and most frequent point of contact for young women who seek medical consultation for reproductive health and as primary caregivers for many nonpregnant women who have little or no other contact with the health care system.20 The vast majority of obstetrician-gynecologists serve both adolescents and adults.20 Although few adolescents under 15 years of age see obstetrician-gynecologists,5 one third of all medical visits for women aged 17 to 21 years are to obstetrician-gynecologists.21 Indeed, obstetrician-gynecologists provide more office-based, general medical examinations to women aged ≥15 years than either family practice or internal medicine specialists.22 Most young women who see obstetrician-gynecologists are or have been sexually active.
Nationwide, 64% of obstetrician-gynecologists have reported that they work in practices that offer at least 1 vaccine, with rubella (52%) and influenza (50%) vaccines being the most commonly offered, followed by hepatitis B vaccine (35%) and tetanus toxoid-diphtheria vaccine (32%).20 Yet, fewer than 60% of obstetrician-gynecologists report that they routinely obtain patient vaccination or infection histories. Barriers that have been commonly noted by obstetrician-gynecologists who do not vaccinate their patients include the costs associated with vaccination (44%), the belief that vaccinations should be provided by other primary care providers (41%), and lack of adequate vaccine-storage and -handling facilities (32%).20 Nevertheless, studies have shown that most obstetrician-gynecologists feel that the provision of vaccines should be within the scope of their responsibilities.21 As noted previously, human papillomavirus vaccine and vaccines that are currently being developed to prevent other sexually transmitted infections primarily target early and middle adolescents before sexual debut. In contrast, obstetrician-gynecologists see relatively few women before mid- to late adolescence5 and, thus, have relatively few opportunities to vaccinate women before the initiation of sexual activity.
Studies have demonstrated interesting patterns associated with the administration of vaccine in Ob-Gyn practices. One survey noted a wide range in knowledge level among obstetrician-gynecologists regarding vaccine-preventable diseases, immunization recommendations, and vaccine safety.21 In another recent survey of obstetrician-gynecologists, provision of vaccines was associated with working in a multispecialty practice and identifying oneself as a primary care provider.20 Almost all of the respondents indicated a willingness to administer vaccines to adult women to prevent human papillomavirus–associated cervical cancer and infections caused by genital herpes simplex virus (92% and 91%, respectively). Recommendations from the American College of Obstetricians and Gynecologists (ACOG) were viewed as the strongest determinant of practice-specific decisions on the use of newly licensed vaccines. Although vaccination has not traditionally been stressed by obstetrician-gynecologists,20 >90% of respondents felt that the ACOG should make the development of educational tools related to vaccination of obstetrician-gynecologists' patients a priority, which suggests a willingness among obstetrician-gynecologists to integrate immunization more formally into their routine practice guidelines.20 Hence, support from the ACOG will be key in determining whether more obstetrician-gynecologists adopt immunization services as part of their routine scope of care and offer vaccinations to adolescents.
STD clinics serve a high-risk population that tends to be poor, relatively young, male, and uninsured. Although most have access to primary care, their clients commonly seek STD-clinic services because of the availability of walk-in services, low cost of care, privacy or confidentiality concerns, convenience, or the expertise of STD-clinic providers in treating sexually transmitted infections.23 In response to recommendations from the Advisory Committee on Immunization Practices, the Institute of Medicine, and the CDC, many STD clinics have successfully implemented hepatitis B immunization programs,24–29 which suggests that such clinics may represent an effective capture point at which some adolescents at high risk might also be able to receive vaccinations to prevent other sexually transmitted infections such as human papillomavirus.24,30,31 However, some of the difficulties encountered in efforts to institute hepatitis B vaccination in STD clinics may also apply to other vaccination initiatives that may be proposed for these settings. Studies have found that approximately half of STD program managers nationally do not view hepatitis B vaccination as a project responsibility.24,29 Major barriers that have prevented some STD clinics from instituting hepatitis B vaccination programs include lack of adequate funding for procurement of vaccines and inadequate resources to implement effective vaccination efforts.24 In addition, in typical underfunded and understaffed STD clinics, prevention strategies that require personal counseling or injections may be relegated to secondary status.32 Other specific issues encountered with hepatitis B vaccination efforts in STD clinics include difficulty tracking clients who are highly mobile and who value anonymity,24,32 variable rates of completion of the immunization series,24,32 and relatively low vaccine acceptance rates.32,33
There are several challenges related to the potential provision of new vaccines to adolescents through STD clinics. As the range of vaccines recommended for adolescents increases, it is hard to know whether many STD clinics will consider providing vaccines to prevent conditions other than sexually transmitted infections or whether they will limit their efforts to vaccines such as hepatitis B and human papillomavirus vaccines that prevent diseases commonly acquired by sexual contact. The ∼2-to-1 male/female ratio among STD-clinic clients23 limits the number of individuals receiving services at STD clinics who could directly benefit from the human papillomavirus vaccine. In addition, although STD clinics see young adults and some older adolescents,23 they are unlikely to have much contact with the young adolescents who are the primary target group for most adolescent-immunization efforts. Funding sources and vaccine-procurement efforts also must be ensured for vaccination efforts to be successful in STD clinics. Finally, STD clinics serve a small, defined population,23 which limits the potential impact of vaccination efforts in this setting on overall adolescent-immunization rates. Nevertheless, despite these considerations, STD clinics can play an important role in efforts to vaccinate the particularly high-risk group of adolescents that they serve.34 As such, they should not be overlooked as comprehensive strategies are developed to vaccinate as many adolescents as possible.
Hospital Emergency Departments
In 1995, the American College of Emergency Physicians (ACEP) published a policy statement recognizing that underimmunization of children is a serious problem in the United States and that populations at greatest risk, including the urban poor and racial and ethnic minorities, often use emergency departments as their principal source of primary care.35 A subsequent study has noted that 5% of all adolescents nationally and 7% of nonwhite adolescents report that emergency departments are their only source of medical care.36 Adolescents are particularly likely to use emergency departments for episodic medical care,37–39 and the vaccine they currently are most likely to receive there is the tetanus-diphtheria toxoid booster.40 For other vaccines, emergency departments usually refer adolescents to primary care providers.
Although the 1995 ACEP policy statement and its 2000 revision encouraged an active role by emergency department personnel in childhood vaccination efforts (including awareness of currently recommended immunization recommendations, screening of immunization status, education of parents, referral of patients with deficient immunizations, and administration of vaccinations in certain circumstances),35,41,42 the ACEP has not published specific policy recommendations concerning the vaccination of adolescents in emergency departments. Furthermore, the potential for large-scale routine provision of adolescent vaccinations in emergency departments has not been systematically evaluated but would most likely not be cost-effective from an institutional perspective. Because emergency departments are generally not reimbursed for the provision of preventive care services, vaccine-purchase costs incurred by emergency departments and administration fees associated with vaccination would not necessarily be reimbursed by all insurers. As a result, emergency departments would have to absorb or shift vaccine costs for some patients. Furthermore, although emergency departments may enroll in the federal Vaccines for Children (VFC) program, administration costs related to providing vaccines in emergency departments are believed to significantly exceed VFC reimbursement levels for vaccine administration.42 In addition, unreimbursed personnel time and decreased operating efficiencies that result from provision of vaccinations would constitute opportunity costs for emergency departments that consider broad vaccination initiatives.
Although emergency departments are able to participate in adolescent-vaccination programs, their core mission of providing acute care is inconsistent with the routine provision of preventive health services. Although some pilot studies have demonstrated the efficacy of vaccinating hard-to-reach populations in emergency departments,43–45 the impact of those efforts has been questioned because of a lack of sustained programmatic success. In addition, a limited ability to ascertain adolescents' immunization status in the emergency department and a general reluctance of parents to allow their children to be vaccinated during emergency department visits, especially if immunization records are not readily available, continue to be barriers that hinder efforts to provide vaccinations there.46,47 Hence, it is unlikely that the routine administration of vaccines to adolescents in emergency departments will soon become a widespread practice or will have a substantial impact on adolescent-immunization rates. Nevertheless, because emergency departments provide services to large numbers of adolescents who do not routinely receive preventive care elsewhere,36 their potential to contribute to adolescent-vaccination efforts should be explored further. With more widespread access to immunization-information systems, adequate reimbursement, and potential support from the ACEP, efforts to provide routine vaccinations to some adolescents during emergency department visits may eventually become more feasible.
Family Planning Clinics
Approximately 3100 Title X and other family planning clinics provide gynecologic care and contraceptive management to US adolescents and adults, often focusing on economically disadvantaged and high-risk populations. They primarily serve young women who seek confidential family planning services.48 Nationally, the population of clients of family planning clinics is 61% non-Hispanic white, 19% black, 14% Hispanic, and 7% Asian or of another race.49 Overall, 30% of all women served at family planning clinics are younger than 20 years. Minority and economically disadvantaged patients are more likely to receive services at family planning clinics that are run by hospitals, public health departments, and community or migrant health centers than at independent or Planned Parenthood facilities.48–50 Many family planning clinics are located in rural communities and serve otherwise hard-to-reach patient populations.
Family planning clinics' orientation toward serving young, economically disadvantaged women and those who do not have easy access to other sources of care could potentially contribute significantly to vaccination efforts among these populations of adolescents. Moreover, many family planning clinics have successfully implemented previous recommendations to provide hepatitis B vaccinations to their adolescent and high-risk adult clients.51–53 Such efforts are likely to serve as a model for them if they expand their efforts to immunize adolescents and young women by providing other vaccines as well. Furthermore, the human papillomavirus vaccine may be particularly well suited to be provided to women who obtain care in this setting, because it is licensed for administration to women up to age 26 and the timing of vaccination can be coordinated with their regular return visits for Depo-Provera injections or oral contraceptive refills. However, there are some potential challenges associated with efforts to immunize adolescents in family planning clinics. As is also the case with Ob-Gyn practices, almost all women who receive services at family planning clinics are sexually active, which makes it unlikely that family planning clinics would be able to vaccinate many adolescents before their sexual debut. Patients' confidentiality concerns may dissuade family planning clinics from notifying their clients' primary care physicians that they have provided vaccinations.48,50 Requirements for parental consent or notification before vaccination may also be a barrier. In addition, family planning clinics may not be inclined to be a setting for the provision of vaccines to prevent conditions other than those that are specifically associated with sexually-transmitted infections. Nevertheless, family planning clinics can certainly contribute to adolescent-immunization efforts, particularly in rural areas and for adolescents who are unlikely to receive preventive health care services elsewhere.
Teen clinics are facilities that provide services exclusively to adolescents. They are usually staffed by community health centers, local health departments, hospitals, managed care organizations, or nonprofit agencies. Most teen clinics receive some federal funding. The majority of their vaccine supplies come from the VFC program. Many operate as drop-in clinics that neither require clients to make appointments nor require that they have an established relationship with the facility. A survey in 1 community found that 15% of urban youth received services at a teen clinic, with higher percentages found among older adolescents than younger adolescents.54 Nationally, the proportion of adolescents who use teen clinics is unknown. However, 24% of US adolescents usually obtain primary care services from some sort of health center or clinic36; of these, presumably many are seen in teen clinics.
Teen clinics predominantly serve economically disadvantaged and uninsured teens who choose to receive medical services there because of convenience of scheduling and location, ease of access, low cost, the desirability of receiving services at a facility that is exclusively oriented to teens, or the perceived expertise of clinic staff or who seek assurance of confidentiality (particularly around the onset of sexual activity).55–59 Although some adolescents consider a teen clinic to be their medical home, others maintain a medical home elsewhere and only use the teen clinic on an episodic basis.54,59
Almost all teen clinics offer adolescents the hepatitis B vaccine.52,53 They are likely to also offer most of the other vaccines that have recently been recommended for adolescents. Although teen clinics have been very successful in their vaccination efforts, they have reported that their most significant difficulties are in (1) getting their patients to complete vaccination series that require multiple injections and (2) frequent unavailability of up-to-date immunization records.52,53 These hurdles are not specific to teen clinics and have not prevented many of them from successfully offering vaccinations. Thus, teen clinics are likely to remain important venues for adolescent vaccination as the number of vaccines recommended for adolescents increases.
Public Health Department Immunization Clinics
Vaccination is a shared responsibility between private providers, publicly funded clinics, and public health departments.60 Currently, health departments continue to play an important role in vaccine-related efforts, particularly as a safety-net provider of immunizations for those who cannot afford the cost of vaccinations or do not have an established medical home.61–63 Ninety-eight percent of health departments continue to provide adolescent-vaccination services.64 In addition, health departments help coordinate efforts to immunize hard-to-reach populations and improve community-wide immunization rates.
Fifty-six percent of public health department immunization clinics use tracking and recall systems, and 38% use vaccination reminder systems.65 Fifty-five percent have reported using medical charts to store vaccination histories, and 83% store vaccination information in an electronic database.65 However, only 5% of clinics routinely communicate vaccination activities to primary care providers.65
As a result of shifting responsibilities and funding sources, the role of community health department immunization programs has changed from one of the traditional “vaccinator of choice” to that of “safety-net provider.” This role is likely to continue with the advent of new adolescent vaccines.
COMPLIANCE WITH THE NVAC QUALITY STANDARDS
Table 2 describes the ability of candidate health care settings outside the traditional medical home to comply with the 7 NVAC quality standards (which are described in detail in Table 1). Each of the candidate settings evaluated has a basic capacity to meet these standards, although the extent to which they do so varies.
CHALLENGES AND BARRIERS TO PROVIDING VACCINATIONS TO ADOLESCENTS
Table 2 also summarizes how site capacity and other constraints may affect the ability of the various settings to provide vaccinations to adolescents. Of particular importance is that sites have an orientation toward the provision of preventive care services to adolescents and demonstrate a willingness to assume responsibility for providing routine immunizations to adolescents. These 2 crucial attributes will affect the contribution that health care settings outside the traditional medical home can make to adolescent-immunization efforts.
EXPECTED HEALTH OUTCOMES
Additional study will be required to determine how consistently each site is able to meet the 7 NVAC quality standards. It should be noted that sites' organizational imperatives may not be consistent with, or may even conflict with, core competencies (eg, confidentiality constraints may conflict with data-sharing needs, and an emphasis on treating acute conditions may conflict with an emphasis on providing preventive care).
Implicit in efforts to offer adolescents a host of new vaccines in a variety of settings is the requirement for information sharing among health care professionals. Electronic immunization-information systems (registries) that are widely accessible are crucial if these efforts are to be successful. At present, ∼85% of CDC-funded immunization-information systems include adolescents (D. Bartlett, MPH, personal communication, CDC, April 13, 2006). However, relatively few health care facilities outside the traditional medical home report that they have access to immunization-information systems.52,53 This is especially likely to be the case for those health facilities (eg, Ob-Gyn offices, STD clinics, and family planning clinics) that primarily serve an adult population. Now that data specifications for immunization-information systems have been defined,66 future efforts should focus on enrollment and participation of providers working in health care settings beyond the traditional medical home.
In addition to the provision of vaccine, the capability of health care settings beyond the traditional medical home to collect and report data regarding vaccine-coverage rates and vaccine-related adverse events must be examined. Successful data-collection efforts depend not only on a site's capability and willingness to collect and report data but also on the ability of the local public health department to collect and analyze them. As has occurred with community-based immunization-information systems, collaboration is facilitated by clearly defined business rules that define what type of data are to be shared, who shares the data and with whom, and the preferred data-exchange format. Each of the candidate sites examined has the capacity to provide data, but not all of them are equally capable of providing the many types of information of interest.
Another variable that must be considered when determining the potential to deliver vaccines at each site is cost. The average unit cost for delivering adolescent vaccinations can be calculated for each specific delivery setting by analyzing standard workflow and using econometric methods. Pharmacies and public health clinics are already engaging in this process. Costs for patients will affect vaccination uptake. Although some sites participate in the VFC program, expanding VFC participation to additional facilities is a crucial component if efforts to vaccinate adolescents are to be successful.
Some have expressed concern that the provision of vaccinations outside the traditional medical home may interfere with the receipt of other preventive health care services that are typically received in traditional primary care settings.67 However, there is limited evidence that adolescents forego preventive health care services provided in primary care settings if they receive vaccinations elsewhere.68 The risks and benefits must be weighed. Data from the 2003 National Survey of Children's Health indicate that ∼60% of adolescents do not receive care from a medical home.69 Thus, it is likely that many of the adolescents who seek services in the settings described in this article cannot identify a primary care provider36 and, thus, would be unlikely to receive vaccinations elsewhere, whereas others who have primary care physicians seek care outside the traditional medical home out of convenience or because they want the assurance of confidentiality.57–59 Minorities, immigrants, and persons who engage in high-risk behaviors are particularly likely to use health care settings outside the traditional medical home58,59,69; these groups would benefit from having vaccination services available in such settings. In addition, many adolescents use more than 1 site of care59; making vaccinations available to these patients at various sites could significantly increase the likelihood that they will be vaccinated. The key to such an approach is ready access to vaccination records through the expansion of immunization-information systems to include all adolescents by increasing the participation of providers outside of the traditional medical home.
Statutory requirements that necessitate parental consent for adolescents' receipt of preventive care services and immunizations diminish the ability of adolescents to receive vaccines outside of the traditional medical home.70 Adolescents who seek medical care in such settings often are unaccompanied by a parent or guardian. Although states generally allow adolescents to consent to receive confidential reproductive care, few states have statutes that specifically allow adolescents to provide their own consent for routine preventive medical care services or vaccinations.71 Most states' laws do not explicitly determine if vaccines to prevent sexually transmitted infections fall under parental consent rules or would be exempt from those rules; hence, this remains a gray area. In addition, federal law requires that a parent or legal guardian be provided with an approved vaccine-information statement before vaccines can be given to unemancipated minors. These factors limit the extent to which vaccines can be provided to adolescents who seek confidential medical care and should be addressed if widespread adolescent-vaccination efforts are to succeed.
Each type of setting evaluated in this article has strengths and weaknesses with regard to its ability to deliver vaccines to adolescents. Some serve hard-to-reach groups of individuals at high risk, whereas others serve those who seek specialized or confidential services. In addition, many adolescents obtain medical care in more than 1 type of setting.58,59 Hence, an approach that provides easy access to immunization records and allows adolescents to be vaccinated in multiple settings would be beneficial if high immunization rates are to be achieved in this population. Because conditions and patterns of health care utilization vary geographically and according to community characteristics, local health authorities should consider the following factors when evaluating how best to provide vaccines to adolescents in their communities:
demographic characteristics of the community and local patterns of health care utilization;
availability and utilization of health care settings outside of the traditional medical home;
ability of vaccination sites to meet NVAC practice standards;
volume capacity of each site;
extent of participation in immunization-information systems; and
whether the provision of immunizations corresponds with the core mission of potential sites.
In most communities, immunization-delivery systems that combine the resources of the traditional medical home and other health care settings are necessary to achieve optimal adolescent-immunization rates. A collaborative approach that enlists public health departments and community providers representing all of these settings would benefit local adolescent-immunization efforts by identifying approaches that would most readily be applicable to specific communities.
Health care settings beyond the traditional medical home have an important role to play in the provision of vaccines to adolescents, especially for those who are unlikely to receive primary care medical services through conventional venues. Although several challenges exist, these health care settings can serve a pivotal and complementary role in ensuring that all adolescents receive recommended vaccinations.
We acknowledge the contributions of Duane Kilgus, Nicole Liddon, and Mark Sawyer to the work of the Complementary Settings Working Group. This article is dedicated to the memory of our colleague and friend, Donna Rickert, MA, PhD.
- Accepted August 22, 2007.
- Address correspondence to Stanley J. Schaffer, MD, MS, Division of General Pediatrics, University of Rochester Medical Center, 601 Elmwood Ave, Box 777, Rochester, NY 14642. E-mail:
Financial Disclosure: Dr Grabenstein is now employed by Merck. The other authors have indicated they have no financial relationships relevant to this article to disclose.
The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the funding agency.
Dr Fishbein's current affiliation is National Center for Preparedness, Detection, and Control of Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA.
Dr Grabenstein's current affiliation is Merck Vaccine Division, West Point, PA.
- ↵Bilukha OO, Rosenstein N; National Center for Infectious Diseases, Centers for Disease Control and Prevention. Prevention and control of meningococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep.2005;54(RR-7) :1– 21
- Broder KR, Cortese MM, Iskander JK, et al. Preventing tetanus, diphtheria, and pertussis among adolescents: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccines—recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep.2006;55(RR-3) :1– 34
- ↵Markowitz LE, Dunne EF, Saraiya M, Lawson HW, Chesson H, Unger ER. Quadrivalent human papillomavirus vaccine: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep.2007;56(RR-2) :1– 24
- ↵Albertin CS, Rand CM, Fryer GE, Shone LP, Schaffer SJ, Szilagyi PG. Adolescent healthcare utilization across the U.S.: who may be reached for immunization [abstract]. E-PAS2006:59:2747.4. Presented at 2006 Annual Meeting of the Pediatric Academic Societies, San Francisco, CA, April 29–May 2, 2006
- ↵Centers for Disease Control and Prevention. Immunization of adolescents: recommendations of the Advisory Committee on Immunization Practices, the American Academy of Pediatrics, the American Academy of Family Physicians, and the American Medical Association. MMWR Recomm Rep.1996;45(RR-13) :1– 16
- ↵Institute of Medicine. Vaccines for the 21st Century: A Tool for Decisionmaking. Washington, DC: National Academy Press; 2000
- ↵Postema AS, Breiman RF; National Vaccine Advisory Committee. Adult immunization programs in nontraditional settings: quality standards and guidance for program evaluation. MMWR Recomm Rep.2000;49(RR-1) :1– 29
- ↵Hogue MD, Foster SL, eds. Pharmacy-Based Immunization Delivery: A National Certificate Program for Pharmacists. 9th ed. Washington, DC: American Pharmacists Association; 2004
- ↵APhA promotes pharmacists' role. Am Pharm. 1994;NS34 :71– 72
- ↵Hogue MD, Grabenstein JD, Foster SL, Rothholz MC. Pharmacist involvement with immunizations: a decade of professional advancement [published correction appears in J Am Pharm Assoc (Wash DC). 2006;46 :308] . J Am Pharm Assoc (Wash DC).2002;46:168–179; quiz 179–182
- ↵Ndiaye SM, Madhavan S, Washington ML, et al. The use of pharmacy immunization services in rural communities. Public Health.2003;117(2) :88– 97
- ↵Ernst ME, Chalstrom CV, Currie JD, Sorofman B. Implementation of a community pharmacy-based influenza vaccination program. J Am Pharm Assoc (Wash DC).1997;37 :570– 580
- ↵Immunization Action Coalition. States authorizing pharmacists to vaccinate. Available at: www.immunize.org/laws/pharm.htm. Accessed August 9, 2007
- Centers for Disease Control and Prevention. Hepatitis B virus: a comprehensive strategy for eliminating transmission in the United States through childhood vaccination—recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR Recomm Rep.1991;40(RR-13) :1– 25
- Institute of Medicine. The Hidden Epidemic: Confronting Sexually Transmitted Diseases. Washington, DC: National Academy Press; 1997
- Centers for Disease Control and Prevention. 1998 guidelines for treatment of sexually transmitted diseases. MMWR Recomm Rep.1998;47(RR-1) :1– 118
- ↵Klausner JD, Shaw H, Williams-Taki D, Taylor F, Bolan G. The changing epidemiology of hepatitis B vaccination follow-up compliance in patients at San Francisco City STD clinic, 1995–1996 [abstract]. Presented at: the 31st National Immunization Conference; May 19–May 22, 1997; Detroit, MI. Abstract 62
- ↵Weinstock HS, Bolan G, Moran JS, Peterman TA, Polish L, Reingold AL. Hepatitis B vaccination trials in sexually transmitted disease clinics: implications for program development [abstract]. Program and Abstracts of the 26th National Immunization Conference Proceedings. June 1–5, 1992; St. Louis, MO; 1992:107– 109
- Ziv A, Boulet JR, Slap GB. Emergency department utilization by adolescents in the United States. Pediatrics.1998;101 :987– 994
- ↵Wood DL, Hayward RA, Corey CR, Freeman HE, Shapiro MF. Access to medical care for children and adolescents in the United States. Pediatrics.1990;86 :666– 673
- ↵American College of Emergency Physicians. Policy statement: immunization of pediatric patients. Available at: www3.acep.org/practres.aspx?id=29520. Accessed July 30, 2007
- ↵Schaffer SJ, Szilagyi PG, Ambrose S, et al. Hepatitis B vaccine availability in complementary health-care settings [abstract]. Pediatr Res.2004;55 :317A . Abstract 1798
- ↵Schaffer SJ, Szilagyi PG, Ambrose S, et al. Availability of hepatitis B vaccine for high-risk teens [abstract]. Presented at: the 38th National Immunization Conference; May 12, 2004; Nashville, TN. Available at http://cdc.confex.com/cdc/nic2004/techprogram/paper_4938.htm. Accessed December 11, 2006
- ↵McKee MD, Karasz A, Weber CM. Health care seeking among urban minority adolescent girls: the crisis at sexual debut. Ann Fam Med.2004;2 :549– 554
- ↵Santoli JM, Rodewald LE, Maes EF, Battaglia MP, Coronado VG. Vaccines for Children program, United States, 1997. Pediatrics.1999;104 (2). Available at: www.pediatrics.org/cgi/content/full/104/2/e15
- ↵Lieu TA, Smith MD, Newacheck PW, Langthorn D, Venkatesh P, Herradora R. Health insurance and preventive care sources of children at public immunization clinics. Pediatrics.1994;93 :373– 378
- ↵National Association of County and City Health Officials. Research Brief: Preliminary Result From the 1997 Profile of U.S. Local Health Departments. Washington, DC: National Association of County and City Health Officials; 1998
- ↵Centers for Disease Control and Prevention. IIS: 2001 minimum function standards for immunization registries. Available at: www.cdc.gov/nip/registry/st_terr/tech/stds/min-funct-stds2001.htm. Accessed June 27, 2006
- ↵US Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. The National Survey of Children's Health 2003. Rockville, Maryland: US Department of Health and Human Services; 2005
- ↵Farrell RM, Rome ES. Adolescents' access and consent to the human papillomavirus vaccine: a critical aspect for immunization success. Pediatrics.2007;120 :434– 437
- ↵Center for Adolescent Health and the Law. State Minor Consent Laws: A Summary. 2nd ed. Chapel Hill, NC: Center for Adolescent Health and the Law; 2003
- Copyright © 2008 by the American Academy of Pediatrics