pediatrics
January 2008, VOLUME121 /ISSUE Supplement 1

Adolescent Immunizations and Other Clinical Preventive Services: A Needle and a Hook?

  1. Karen R. Broder, MD, FAAPa,b,
  2. Amanda C. Cohn, MDa,b,
  3. Benjamin Schwartz, MDb,c,
  4. Jonathan D. Klein, MD, MPH, FAAPd,
  5. Martin M. Fisher, MD, FAAPe,
  6. Daniel B. Fishbein, MDa,b,
  7. Christina Mijalski, MPHa,
  8. Gale R. Burstein, MD, MPH, FAAPf,
  9. Mary E. Vernon-Smiley, MD, MPHg,
  10. Mary M. McCauley, MTSCa,
  11. Charles J. Wibbelsman, MD, FAAPh,i,
  12. for the Working Group on Adolescent Prevention Priorities
  1. aNational Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia;
  2. bCommissioned Corps of the US Public Health Service, Atlanta, Georgia;
  3. cNational Vaccine Program Office, Department of Health and Human Services, Atlanta, Georgia;
  4. dDepartments of Pediatrics and Community and Preventive Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York;
  5. eDivision of Adolescent Medicine, Schneider Children's Hospital of the North Shore-Long Island Jewish Health System, New Hyde Park, New York;
  6. fErie County Department of Health, Buffalo, New York;
  7. gNational Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia;
  8. hDivision of Adolescent Medicine, Kaiser Permanente, San Francisco, California;
  9. iCommittee on Adolescence, American Academy of Pediatrics, Elk Grove Village, Illinois
  1. * The definition of “adolescent” differs across studies and organizations; in this report, an adolescent is a person aged 11 to 18 years, unless otherwise specified.

  2. Financial Disclosures: Dr Fisher is a member of the Speakers Bureau for Merck & Co. Dr Burstein is a member of the Speakers Bureaus for Merck & Co. and GlaxoSmithKline. The other authors have indicated they have no financial relationships relevant to this article to disclose.

  3. The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the funding agency. Dr Broder's current affiliation is Immunization Safety Office, Office of the Chief Science Officer, Centers for Disease Control and Prevention, Atlanta, GA. Dr Fishbein's current affiliation is National Center for Preparedness, Detection, and Control of Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA.

Abstract

Advances in technology have led to development of new vaccines for adolescents, but these vaccines will be added to a crowded schedule of recommended adolescent clinical preventive services. We reviewed adolescent clinical preventive health care guidelines and patterns of adolescent clinical preventive service delivery and assessed how new adolescent vaccines might affect health care visits and the delivery of other clinical preventive services. Our analysis suggests that new adolescent immunization recommendations are likely to improve adolescent health, both as a “needle” and a “hook.” As a needle, the immunization will enhance an adolescent's health by preventing vaccine-preventable diseases during adolescence and adulthood. It also will likely be a hook to bring adolescents (and their parents) into the clinic for adolescent health care visits, during which other clinical preventive services can be provided. We also speculate that new adolescent immunization recommendations might increase the proportion and quality of other clinical preventive services delivered during health care visits. The factor most likely to diminish the positive influence of immunizations on delivery of other clinical preventive services is the additional visit time required for vaccine counseling and administration. Immunizations may “crowd out” delivery of other clinical preventive services during visits or reduce the quality of the clinical preventive service delivery. Complementary strategies to mitigate these effects might include prioritizing clinical preventive services with a strong evidence base for effectiveness, spreading clinical preventive services out over several visits, and withholding selected clinical preventive services during a visit if the prevention activity is effectively covered at the community level. Studies are needed to evaluate the effect of new immunizations on adolescent preventive health care visits, delivery of clinical preventive services, and health outcomes.

  • adolescent
  • immunization
  • clinical preventive service
  • Abbreviations:
    AAP =
    American Academy of Pediatrics
    STI =
    sexually transmitted infection
    CPS =
    clinical preventive service
    MCV4 =
    tetravalent meningococcal conjugate vaccine
    TdaP =
    tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis
    ACIP =
    Advisory Committee on Immunization Practices
    HPV =
    quadrivalent human papillomavirus
    GAPS =
    Guidelines for Adolescent Preventive Services
    HEDIS =
    Health Plan Employer Data and Information Set
    VFC =
    Vaccines for Children
  • Pediatricians have a unique opportunity to influence adolescents and their families by helping young people build a strong foundation of good health that will continue into their adult lives.

    American Academy of Pediatrics (AAP)1

    Delivering preventive services to US adolescents* is a public health priority.2,3 Although most US adolescents are healthy, millions of adolescents initiate behaviors and lifestyles that can adversely affect their immediate and long-term health.4 Potentially modifiable adolescent behaviors include failure to use seat belts, unsafe operation of motor vehicles, carrying weapons, using alcohol and other drugs, unprotected sex, inactivity, and overeating. These behaviors are directly linked to injuries and death, as well as to sexually transmitted infections (STIs), unintended

    pregnancies, and obesity.4 They also contribute to chronic diseases in adulthood including cancer, heart disease, diabetes, and infertility. Among adolescents, injuries related to motor vehicle accidents, homicides, and suicides are the leading causes of mortality and account for three fourths of deaths among this group in the United States.4,5

    Clinical preventive services (CPSs) are delivered by a health care provider to an asymptomatic individual in a clinical setting.6 Immunizations are a highly effective CPS, and the impact of administering vaccines that are universally recommended for children is 1 of the 10 great public health achievements of the 20th century; rates of many vaccine-preventable diseases have been greatly reduced among infants and children.7-9 However, infections that are preventable by immunization continue to occur among substantial numbers of adolescents and adults, and these persons may transmit vaccine-preventable diseases to vulnerable populations.10-15

    Advances in immunology and biotechnology have led to development of new vaccines, many of which have been or will be targeted to adolescents (see the report by Fishbein et al16 in this issue). During 2005 and 2006, a new tetravalent meningococcal conjugate vaccine (MCV4) and 2 tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (TdaP) vaccines were licensed and recommended by the Centers for Disease Control and Prevention Advisory Committee on Immunization Practices (ACIP) for use in adolescents.17,18 In 2006, a quadrivalent human papillomavirus (HPV) vaccine to prevent cervical cancer and genital warts was licensed for use in female adolescents and young adults, and ACIP recommendations for it came out in 2007.19,20,21 Vaccines to prevent genital herpes and congenital cytomegalovirus infection are being studied in healthy adolescents in US clinical trials.22

    New adolescent immunizations create opportunities to enhance health but also pose challenges. In this article, we review adolescent clinical preventive health care guidelines and patterns of adolescent CPS delivery; evaluate how new adolescent immunizations might affect delivery and effectiveness of other CPSs; and provide suggested guidance for clinicians and policy makers, including potential areas for future research.

    Adolescent Preventive Health Care

    Clinical Preventive Health Care Guidelines for Adolescents

    Providing comprehensive preventive health care, including CPSs, to adolescents to prevent present and future morbidity is an important goal of adolescent provider organizations. Several federal and national medical organizations have created clinical adolescent health care guidelines (Table 1).23-27 Recommendations vary regarding the frequency of routine preventive care visits.3 Reflecting the physical and psychological changes that occur during adolescence, both the Guidelines for Adolescent Preventive Services (GAPS) and Bright Futures present guidelines for early (11-14 years), middle (15-17 years), and late (18-21 years) adolescence. These guidelines provide a framework for the clinician to deliver comprehensive preventive care to adolescents, but they do not rank the CPSs in order of importance. In addition, no 1 guideline is accepted as a best practice, and although the presence of multiple guidelines offers clinicians choice, it may also generate confusion.

    TABLE 1

    US Guidelines for Adolescent Clinical Preventive Care

    The CPSs recommended in these guidelines can be divided into 5 categories: immunizations, health guidance for adolescents, health guidance for parents, behavioral screening and risk-reduction counseling, and laboratory screening tests3,28 (Table 2). In a 1998 review of published adolescent CPS guidelines, Elster3 concluded that the recommendations were generally in agreement, although the formats varied. All guidelines recommend CPSs to prevent or screen for STIs, and all except the US Preventive Services Task Force recommend CPSs directed at the prevention of intentional and unintentional injuries and tobacco use. All organizations support the immunization schedule recommended for adolescents by the ACIP.29

    TABLE 2

    Selected CPSs Recommended for Adolescents

    Adolescent Health Care Visits and CPS Delivery

    In considering the effect of adolescent immunizations on the delivery of CPSs, it is important to understand current patterns of adolescent preventive care visits and CPS delivery. Studies have suggested that immunizations and other CPSs are more likely to be administered to adolescents and adults during preventive care visits than during visits for acute illnesses,30-33 but acute-care visits also provide an opportunity for CPS delivery.

    As reviewed in a report by Szilagyi et al34 in this issue, studies of adolescent health care utilization have shown 3 key findings: most adolescents have a usual source of health care; the type of adolescent health care provider varies according to age, with the highest proportion of pediatrician visits among younger adolescents; and older adolescent boys have lower visit rates than other adolescents.33-37

    Estimates of the proportion of adolescents who receive preventive care visits vary widely by study. In nationally representative surveys of adolescents or parents, conducted during the 1990s, most respondents reported having had a preventive health care visit within the past year; rates ranged from 57% of boys in grades 9 to 12 to 89% of girls in grades 5 to 938-41 (Table 3). The highest estimate perhaps reflects the broader definition of a preventive health care visit and inclusion of younger adolescents. Three of these surveys only included adolescents who were in school38-40; youth who were not in school because they dropped out or were absent as a result of chronic illness may be less likely to have preventive health care visits. The rate of preventive health care visits, as determined on the basis of diagnostic and procedure codes in health care databases (eg, International Classification of Diseases, Ninth Revision, codes) rather than adolescent or parent reports, was lower.42 According to 2002 Health Plan Employer Data and Information Set (HEDIS) data, 34% of US adolescents made 1 or more preventive health care visits during the study year.42 The extent to which the difference in rates of preventive health care visits between HEDIS and selfreported adolescent and parent data that reflect undercoding of preventive visits versus adolescent/parent overreporting is not clear.

    TABLE 3

    Summary of Studies Assessing the Proportion of Adolescents With at Least One Preventive Health Care Visit During Past Year

    Despite the observation that adolescents are more likely to receive CPSs during preventive care visits, rather than acute-care visits, national and state-based surveys of adolescents and providers have shown that adolescents frequently do not receive recommended CPSs during either type of visit.35,39,43,44 Of the students who reported a preventive visit within the past year in the national 1999 Youth Behavioral Risk Surveillance survey, only 43% of girls and 26% of boys reported discussing STIs, HIV, or pregnancy prevention during that visit.39 Consistent with the Youth Behavioral Risk Surveillance survey data, in a survey of adolescents enrolled in managed care in 3 states, Bethell et al43 noted that the average proportion of those who reported screening and counseling during well and acute-care visits was 50% for weight, diet, and exercise, 36% for sexual activity and STIs, and 18% for other risky behaviors (eg, smoking and alcohol use). Screening and counseling rates were higher among adolescents who reported having had private time with the physician or who were engaging in risky behaviors, compared with those who did not meet privately or engage in risky behaviors.

    Providers also report suboptimal rates of CPS delivery during adolescent visits. In 1997, Halpern-Felsher et al44 surveyed pediatricians in a California health maintenance organization. These pediatricians reported “usually” providing only 9 (38%) of the 24 recommended services during non-acute-care visits (eg, routine well checks, sports physicals). Fewer than one half of the physicians reported screening or educating all of their adolescent patients for drug and alcohol use, sexual behavior and birth control, peer and family problems, and depression or suicide. Findings from a 1997-2000 combined analysis of National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Surveys data, in which the unit of analysis was office based or hospital outpatient department visits, showed substantially lower rates of CPS delivery to adolescents than those found in the other surveys described. Physicians and health care staff only reported providing counseling/education during 39% of “general medical/physical examination” adolescent visits.45 The counseling/education rates for exercise (22%) and STI/HIV screening (5%) were ∼2 and 7 times lower, respectively, than rates reported in the Bethell et al43 survey of adolescents enrolled in managed care, which suggests that discussions perceived to be counseling/education by adolescents may not be coded as counseling/education CPSs by providers.

    Although overall rates of adolescent CPS-delivery are low, data suggest that adolescent immunization-delivery rates may be higher than those of other CPSs.30,44,46 Although a minority of pediatricians in the Halpern-Felsher et al study44 reported conducting behavior screening for all of their adolescent patients, 76% reported universally assessing their immunization status. Likewise, in another 1997 survey, nearly all pediatricians and family physicians, reported routinely checking immunization status of their adolescent patients (95%) and administering immunizations (94%) if they were eligible during preventive care visits.30 During illness related visits, rates of assessing immunization status (43%) and administering immunizations if eligible (23%) were substantially lower than well visits but were still higher than rates of providing some of the counseling CPSs during general medical visits.30,45 Another survey of pediatricians and family physicians in 1999 showed that providers were more likely to assess immunization status of their younger adolescent patients (11-to 13-year-olds), when indicated, compared with older patients (19-to 21-year-olds); providers reported administering indicated vaccines to 96% and 77% of younger and older adolescents, respectively.46

    Taken together, these studies of adolescent health care services suggest that most adolescents have annual health care visits. However, most adolescents either have no preventive visits or are seen for a preventive visit but do not receive a comprehensive package of CPSs. Although immunizations may fare better than behavioral CPSs, rates of immunization delivery during acute-care visits and for older adolescents also seem to be suboptimal.

    Barriers to Delivery of CPSs During Adolescent Health Care Visits

    Physicians and adolescents have reported a wide range of barriers to the delivery of CPSs (Tables 4; see ref 34 for a review of specific barriers for immunizations). Among physicians, lack of adolescent visits is a frequently cited barrier.46 However, even when an adolescent presents for a preventive health care visit, several factors impede delivery of CPSs. Lack of patient interest and lack of time are the 2 most frequently cited barriers (43%-57% and 41%-74%, respectively), especially regarding counseling-based interventions.30,46,47 During visits, physicians also report lack of interest by the patient/parent, lack of time, inadequate compensation, insufficient insurance coverage for the patient, absence of clear practice guidelines and lack of perceived self-efficacy as common barriers.30,46,47,48 As with physicians, adolescents have reported not accessing health care as a primary barrier to receiving CPSs. During health care visits, other barriers include adolescent anxiety and concerns about confidentiality, lack of private time with providers, and concern about reporting risky behavior to providers.43,49,50

    TABLE 4

    Barriers to CPSs

    Potential Impact of New Immunization: Recommendations on Adolescent Preventive Health Care

    What impact will the introduction of new adolescent immunizations into an already crowded schedule of recommended CPSs have on the delivery of the other adolescent CPSs? To explore this question we considered the potential positive and negative influences of immunization recommendations on adolescent, parent, and clinician behaviors by using a simplified model for delivery of CPSs to adolescents. Our conceptual model has 3 components. The first component is an adolescent preventive or acute health care visit, which provides the opportunity for immunization and other CPSs to be provided. The second component is that the clinician delivers other CPSs during the visit. The third component is that the quality of the CPS delivery is consistent with best effectiveness. Opportunities and challenges are presented separately for each component of our conceptual model.

    Adolescent Health Care Visits and Immunizations

    Opportunities

    Immunization recommendations are likely to increase adolescent health care visit rates for those who targeted for vaccination, which provides an opportunity for the delivery of not only the vaccine but also other recommended CPSs. The routine infant and childhood immunization schedule, for which high coverage has been achieved in the United States, provides an example of this opportunity. There is a strong association between a child receiving immunizations and other childhood preventive services such as lead testing and tuberculosis screening.51,52

    Immunizations for adolescents are generally perceived by clinicians and the public as an important preventive measure.53,54 Surveys of family physicians and pediatricians that were conducted before the MCV455 and TdaP56 vaccines were recommended by the ACIP suggested that physicians recognize the burden of meningococcal disease and pertussis among adolescents and support routine administration of these vaccines at the 11- to 12-year visit. In a survey of pediatricians about their attitudes toward the HPV vaccine before its licensure, >95% of respondents reported that they would likely administer HPV vaccine to their adolescent patients if it were recommended by the ACIP or AAP.57 Before 2007 national coverage data for these new adolescent vaccines were not available yet. An analysis of the Michigan Childhood Immunization Registry suggested that patterns of MCV4 use in adolescents during 2005 were consistent with ACIP recommendations; however, overall coverage was low.58 Although adolescent-vaccination coverage levels are likely to be lower than that achieved for young children, the perception of vaccination as an important preventive service and the actions that clinicians, managed care organization leaders (eg, monitoring HEDIS measures) take to implement an immunization program and achieve high coverage likely will increase health care visits at the ages recommended for adolescent vaccines. For a multidose vaccine such as hepatitis B or HPV, in-office reminders to return for a second or third dose also can increase adolescent visit rates. In a multistate survey, most physicians (≥60%) reported scheduling a follow-up vaccination visit when indicated as part of providing preventive care to adolescents.46

    Federal financing policies and local and state health department immunization programs also are likely to increase visit rates for immunizations and opportunities to deliver other CPSs, particularly among low-income populations. The Vaccines for Children (VFC) program provides recommended vaccines free of charge to participating public and private providers for administration to eligible low-income children and adolescents <19 years of age.59 In addition, many states currently have middle and high school vaccination laws for hepatitis B and tetanus and diphtheria toxoids vaccines, and studies have demonstrated that state laws increase coverage levels for mandated vaccines.60-62 One study compared rates of preventive visits among adolescents aged 11 to 15 years who were residing in states with and without middle school laws for the hepatitis B vaccine.63 In addition to increasing coverage for hepatitis B vaccine, the presence of a hepatitis B vaccination law was associated with increased likelihood of having a preventive health care visit (77% with a law versus 66% without a law).

    Challenges

    The potential for adolescent vaccination to increase health care visits and the opportunity to provide other CPSs may not be realized if adolescent vaccines are provided outside the medical home (see ref 34 for discussion of the medical home). In fact, it is possible that vaccination outside the medical home could decrease preventive visits to a provider's office or clinic. School based vaccination has been proposed as 1 strategy to achieve high coverage levels, particularly for influenza vaccine (for which delivery is seasonal).64 Vaccination-only office visits also have been proposed,65 but they might limit opportunities to deliver other CPSs; however, vaccination only visits might be necessary if reimbursements do not cover follow-up clinical practitioner visits for vaccines that require multiple doses (eg, HPV vaccine).

    Clinician Delivery of Other CPSs

    Opportunities

    In addition to the likely effect of immunizations on increasing delivery of CPSs as a result of an increase in adolescent health care visit rates, the number of other CPSs that are delivered during each of these visits might increase, although fewer data are available to support this hypothesis. Incorporating new adolescent immunizations into practice might increase health care providers' general awareness of CPS guidelines and may lead to implementation of practice systems to monitor vaccination as well as delivery of other services. Studies have suggested that training clinicians about CPSs and providing screening and charting tools increase the delivery of CPSs to adolescents.66,67 It is also possible that immunization recommendations may indirectly improve the doctor-patient relationship by increasing the number of encounters between the doctor and the adolescent, facilitating CPS delivery. Better communication between the doctor and adolescent may promote counseling and trust.43

    Administering the HPV vaccine may also provide an opportunity to discuss other CPSs related to sexual health. Of pediatricians surveyed, 63% perceived as important the opportunity to discuss sexual health issues as part of HPV vaccination.57 In addition, HPV and future STI vaccines may lead providers to learn more about sexual health topics and improve their confidence in delivery of related CPSs. A provider's perceived selfefficacy to deliver CPSs has been associated with adolescent and physician reports of screening for high-risk behaviors.48,68

    Challenges

    The amount of time it takes to provide new vaccinations during preventive or acute-care visits may “crowd out” delivery of other CPSs. A time-motion study of well-child visits for children aged <2 years showed that 1.9 minutes of a median 21.4-minute visit (9%) was spent by the physician explaining vaccinations, and 1.6 minutes (7%) was spent by nursing staff administering the vaccines. In comparison, of the total of 16.3 minutes physicians spent with the patient, the median time spent discussing all other health-related issues was 9.5 minutes (58%).69 Vaccinations will likely take a similar amount of time from the adolescent preventive visit and may affect the time allowed for other important components of the visit.

    Quality of CPS Delivery

    Opportunities

    In the same way that immunization recommendations might lead to adoption of new CPSs into practice, they have potential to improve the quality and overall effectiveness of CPSs. In particular, the HPV vaccine may influence quality CPSs related to sexual health. For example, as part of learning about the HPV vaccine, clinicians may become aware of new technologies for STI and Papanicolaou testing.70,71 Education about CPSs improves adherence to recommendations.72 If these immunizations lead to better communication between the adolescent and clinician, the effectiveness of delivery of other CPSs might also improve. Studies among adults have suggested that a patient's trust in his or her physician improves adherence to treatment regimens and recommended health behaviors (eg, smoking cessation).73

    Challenges

    Although time constraints may reduce delivery of CPSs, having less time available for CPS delivery during the clinical visit also might diminish the quality and effectiveness of these CPSs. For screening/counseling, time consuming intensive interventions may be more effective than brief interventions.68 In addition, lack of time might limit the effectiveness of counseling. Among adolescents surveyed, only 40% indicated that the providers always spent enough time with them.43 Brief screening discussions of sensitive issues can negatively affect the doctor-patient relationship.74

    Discussion

    Adolescent immunization recommendations hold great promise for improving adolescent health, both as a “needle” and a “hook.” As a needle, immunizations will enhance an adolescent's health by preventing vaccine-preventable diseases during adolescence and adulthood. Among the adolescent CPSs, immunizations are unique: they are the only CPS that has both a strong evidence base for efficacy and safety and robust funding and in frastructure at federal, state, and local levels to promote delivery, particularly to the most vulnerable adolescents eligible for the VFC program. Funding may not be adequate to permit immunization of adolescents who do not qualify for the VFC program but rely on vaccines financed through federal and state discretionary funding mechanisms, including the Section 317 grant program.75 In addition, strong partnerships between clinicians and community public health organizations have been established to promote awareness and education about vaccines.

    In addition to preventing vaccine-preventable diseases, adolescent immunizations will likely be a hook to bring adolescents and their parents into the clinic for immunization visits, during which other CPSs can be provided. New immunization recommendations may also increase the number of CPSs provided to adolescents and the quality of CPS delivery. To best take advantage of this opportunity, funding and infrastructure to support systematic improvements in CPS-delivery systems at the practice level are needed. Systematic improvements might include providing education and resource materials (eg, screening tools, trigger questions) for clinicians and patients, implementing recall-reminder systems, and ensuring confidential visits (ie, time alone with the provider).

    Immunizations are most likely to increase visits and delivery of other CPSs among adolescents in age groups that are recommended for vaccination by ACIP29 and partner organizations. Since 1996, the 11- to 12-year early-adolescent visit has been promoted as the adolescent-vaccination platform and an opportunity to provide other CPSs; later visits are used to verify coverage and provide catch-up vaccination if needed.76 In response to new adolescent immunization recommendations, the Society for Adolescent Medicine endorsed expansion of the adolescent-vaccination platform to include 3 vaccination visits at ages 11 to 12, 14 to 15, and 17 to 18 years.77 Additional new adolescent vaccines are in the pipeline and have the potential to create a “culture” for adolescent immunization that is similar to that for infants and toddlers.78

    Although increases in adolescent health care visits would provide the opportunity to deliver other CPSs, the time required for immunization counseling and administration might decrease the per-visit time available for their delivery. This effect could lead to the other CPSs not being delivered at all or being delivered suboptimally. Prioritizing and triaging CPSs has been proposed to mitigate this risk. Interest in prioritizing and triaging CPSs is not new, and although none of the clinical preventive health care guidelines for adolescents prioritize CPSs, it is widely acknowledged that not all of these services can be delivered in 1 visit.79

    Increasing the amount of time allotted for an adolescent visit is 1 strategy that could reduce crowding from adolescent immunizations, but it is unlikely to occur without changes in reimbursement policies. In the absence of these changes, 3 complementary strategies could be considered to help triage and prioritize which CPSs to provide during an adolescent health care visit: prioritizing CPSs with a strong evidence base for effectiveness; spreading the CPSs out over several visits; and not providing selected CPSs during a visit if the prevention activity is effectively provided at the community level.

    All organizations consider the strength of evidence to develop guidelines for CPSs, but use of expert opinion varies. Moyer and Butler80 reviewed the evidence for effectiveness for behavioral counseling, screening, and prophylaxis CPSs for children and adolescents; immunizations were not assessed. Few CPSs were shown to be effective among adolescents; however, insufficient evidence was available to evaluate many of the CPSs. Effective CPSs included counseling (especially if it was time intensive) to prevent injuries and screening for STIs for sexually active adolescents. A few widely used interventions, such as brief counseling to prevent alcohol abuse, were demonstrated to be ineffective.80,81

    Relying on evidence for effectiveness to prioritize interventions has limitations. First, lack of evidence does not mean lack of effectiveness. For many CPSs, it is not practical to conduct rigorous clinical trials to test an intervention, especially in smaller high-risk groups, but the intervention may be effective. Second, the effectiveness of an intervention needs to be considered together with the prevalence of disease or behavior. For example, if counseling delivered by a primary care provider against smoking resulted in a behavior change for only a small proportion of persons targeted (eg 5%), when delivered broadly to an adolescent population with a 22% prevalence of smoking,82 this small change could result in a significant health benefit.

    A second triage strategy is to space out the CPSs over several annual visits rather than administer them annually. Many CPSs are currently recommended annually for adolescents without an evidence base for this frequency (by the AAP and GAPS). By contrast, among adults, the frequency of several recommended cancer prevention services is supported by evidence.83-85 In October 2007, a revised set of Bright Futures Guidelines replaced earlier Bright Futures, AAP, and GAPS guidelines for health supervision of adolescents. The harmonized guidelines emphasized CPS prioritization during visits. These guidelines might also enhance adherence to recommendations for CPS delivery.86

    A third potential triage strategy is not to provide some CPSs during visits if the prevention activity is provided effectively at the community level, particularly if the strength of evidence for effectiveness is high. A variety of preventive services delivered at the community level have been shown to be effective against many of the leading causes of morbidity and mortality in adolescents. These services include interventions that prevent motor vehicle injuries, violence, tobacco use, and STIs and have been recommended by the Community Preventive Services Task Force.87-92 Applying this strategy could mean, for example, that if a community or school had a good injury-prevention program, a clinician might omit or limit discussions about injury during office visits to make more room for other CPSs that can only be provided in the clinical setting (eg, immunizations or STI laboratory screening). For this strategy to work, clinicians would need a high level of awareness of local community health activities.

    As the new era of adolescent vaccination begins, addressing research gaps in adolescent health services will help policy makers and clinicians develop, revise, and implement recommendations for adolescent immunizations and other CPSs to improve the health of adolescents. Studies are needed to evaluate whether new immunization recommendations for adolescents are associated with increases in the proportion of adolescents who have preventive health care visits, including differences for VFC and non-VFC-eligible adolescents; increases or decreases in the delivery and effectiveness of adolescent CPSs during visits; changes in the delivery and effectiveness of sexual health CPSs (eg, increased counseling, decreased STI testing); improved or diminished quality of CPS delivery; and improved office-based systems for CPS delivery. Research is also need to determine if changes in the time allotted to adolescent healthcare visits or CPS delivery occurs. Health outcomes among adolescents who receive immunizations and other CPSs during visits should be defined and assessed, and the effects of triaging CPSs on these outcomes should be evaluated. We are potentially at the beginning of a new era, not only of adolescent vaccination but also of improved total health care for adolescents.

    ACKNOWLEDGMENTS

    We gratefully acknowledge the contributions of the other members of the Working Group on Adolescent Prevention Priorities: Carolyn Deal, PhD, David Delozier, MPH, Edith Gary, MPH, Claire Hannan, MPH, Alison Mawle, PhD, Mary Jean Schumann, Laura Shone, DrPH, Susan Shepardson, and Shannon Stokley, MPH. We also thank Amy B. Middleman, MD, Larry K. Pickering, MD, Peter Szilagyi, MD, MPH, and Nancy Messonnier, MD.

    Footnotes

      • Accepted August 22, 2007.
    • Address correspondence to Karen R. Broder, MD, FAAP, Office of the Chief Science Officer, Centers for Disease Control and Prevention, 1600 Clifton Rd NE, Mail Stop D-26, Atlanta, GA 30333. E-mail: kbroder{at}cdc.gov

    References

    1. 1.
    2. 2.
    3. 3.
    4. 4.
    5. 5.
    6. 6.
    7. 7.
    8. 8.
    9. 9.
    10. 10.
    11. 11.
    12. 12.
    13. 13.
    14. 14.
    15. 15.
    16. 16.
    17. 17.
    18. 18.
    19. 19.
    20. 20.
    21. 21.
    22. 22.
    23. 23.
    24. 24.
    25. 25.
    26. 26.
    27. 27.
    28. 28.
    29. 29.
    30. 30.
    31. 31.
    32. 32.
    33. 33.
    34. 34.
    35. 35.
    36. 36.
    37. 37.
    38. 38.
    39. 39.
    40. 40.
    41. 41.
    42. 42.
    43. 43.
    44. 44.
    45. 45.
    46. 46.
    47. 47.
    48. 48.
    49. 49.
    50. 50.
    51. 51.
    52. 52.
    53. 53.
    54. 54.
    55. 55.
    56. 56.
    57. 57.
    58. 58.
    59. 59.
    60. 60.
    61. 61.
    62. 62.
    63. 63.
    64. 64.
    65. 65.
    66. 66.
    67. 67.
    68. 68.
    69. 69.
    70. 70.
    71. 71.
    72. 72.
    73. 73.
    74. 74.
    75. 75.
    76. 76.
    77. 77.
    78. 78.
    79. 79.
    80. 80.
    81. 81.
    82. 82.
    83. 83.
    84. 84.
    85. 85.
    86. 86.
    87. 87.
    88. 88.
    89. 89.
    90. 90.
    91. 91.
    92. 92.
    93. 93.
    94. 94.
    95. 95.