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Improving flu vaccination rates among adolescents remains a challenge

Issue: November 2008

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Many adolescents who routinely visit a physician still do not receive influenza vaccine — suggesting that health care providers continue to miss important opportunities to vaccinate.

“The high rate of missed opportunities for vaccination suggests that implementing provider reminder systems at the point of care could improve vaccination rates substantially,” Mari Nakamura, MD, MPH, Center for Child Health Care Studies fellow, Department of Ambulatory Care and Prevention at Harvard Medical School and Harvard Pilgrim Health Care told Infectious Diseases in Children.

Approximately 85% of 18,703 adolescents at high risk for influenza-related complications, retrospectively studied by Nakamura and colleagues, remained unvaccinated even though about half had visited a physician during the first four months of an influenza season. Patient data were obtained from a large, multisite practice and spanned influenza seasons from 1992 to 2002.

“Many of these encounters seem to have been true missed opportunities, because the most commonly associated diagnoses (preventive care, asthma, pharyngitis, cough and other vaccinations) were not major febrile illnesses for which vaccination would have been contraindicated,” the researchers wrote.

By 2001, influenza vaccine coverage had improved from 8.3% in 1992 to 15.4% among the study population. Despite these improvements, data indicated that individual vaccine continuity was poor, with 11.1% of patients receiving the vaccine in each of four consecutive influenza seasons from 1992 to 2002.

Simplifying risk-based recommendations into a single, universal, age-based recommendation may improve coverage, according to Nakamura. However, health officials must resolve the following challenges if a universal recommendation is to be effective:

• Expanding vaccination programs to additional sites, such as schools.
• Creating a more stable vaccine supply.
• Financing systems that make the vaccine more affordable.

– by Nicole Blazek

Although the study could not determine whether various sites or providers may have been “better immunizers” than others, the data emphatically validate the Advisory Committee on Immunization Practices’ important decision to recommend universal influenza vaccination for all adolescents as of the 2008 influenza season. History has shown us that strategies that attempt to select high-risk adolescents for vaccination do not work — hepatitis B immunization rates went from nearly zero in 1993 to 67% in 2000 after a universal adolescent vaccination policy supplanted a high-risk adolescent vaccination policy in 1997 (MMWR. 2002:51;549-552,563).

Universal influenza vaccination also will likely decrease the large number of missed opportunities for vaccination documented in this study. There will no longer be a need for providers to think about who needs the influenza vaccine, but rather who may not be a candidate for the influenza vaccine, thus catching many more vulnerable youth in the safety net of vaccine protection.

– Amy Middleman, MD

Infectious Diseases in Children Editorial Board member

For more information:

• Nakamura MM, Lee GM. Influenza vaccination for adolescents with high-risk conditions. Pediatrics. 2008;doi:10.1542/peds.2007-3032.