The American Nurses Association (ANA) recognizes continuing advancement in widespread public immunization against vaccine preventable diseases (VPDs) as among of the greatest public health achievements in the 20^th century. Further, ANA acknowledges the essential role of nurses in progress toward control of VPDs and in maintaining and improving vaccine coverage levels in all age groups. But while vaccination rates for infants and children are now reaching record levels, achieving optimal coverage levels for protection against VPDs during adolescence presents unique challenges requiring specific strategies to reduce risks and meet the special needs of this population. To meet immunization goals for adolescents, nurses must participate fully in developing and implementing strategies to reach this sometimes hard-to-reach and often neglected population. The American Nurses Association, the National Center for School Health Nursing, and the National Nursing Coalition for School Health have joined together to promote the incorporation of adolescent immunization recommendations into nursing practice so that adolescents, and in turn, the general public, are optimally protected against VPDs.

Background:

Given the expected presence of an intact and healthy immune system and the long term active immunity and protection bestowed by having received childhood vaccines, both the public and health care providers often view adolescents (persons between the ages of 11 and 19) as health individuals with limited risk and minimal vulnerability to attack by infectious diseases. Health care providers therefore often overlook assessment of immunization status among adolescents. As a consequence, many in this age group lack optimal protection against VPDs. Barriers to adolescent immunization may therefore include lack of awareness that immunizations are needed, misconceptions about specific vaccines, and failure of health care providers to deliver recommended vaccines linked to specific provider practice patterns.

The federal Centers for Disease Control and Prevention (CDC) reports that "While infant and child vaccination levels are reaching historic levels in the United States, and morbidity and mortality from vaccine-preventable diseases are reaching all-time lows for these age groups, unnecessary morbidity due to hepatitis B, measles, varicella and other vaccine-preventable diseases continues for adolescents."¹ To address this challenge, several national health and medical organizations agreed in 1996 to develop a new strategy to improve the delivery of vaccination services to adolescents and to integrate recommendations for vaccination with other preventive services for adolescents. The Advisory Committee on Immunization Practices (ACIP) consists of 15 experts in fields associated with immunization who have been selected by the Secretary of the U.S. Department of Health and Human Services to provide advice and guidance to the Secretary, the Assistant Secretary for Health, and the Centers for Disease Control and Prevention (CDC) on the most effective means to prevent vaccine-preventable diseases. The ACIP recommendations are published in Immunization of Adolescents: Recommendations of the Advisory Committee on Immunization Practices, the⁽¹⁾ American Academy of Pediatrics, the American Academy of Family Physicians, and the American Medical Association.²

¹ Centers for Disease Control and Prevention (CDC), Proceedings from meeting March 11-12, 1996; Adolescent Immunization: Focus on Implementation, Averhoff, FM, Brink, E, Pollard, B. Bryan, G and Vaillancourt, MV.

² Centers for Disease Control and Prevention (CDC). (1996). Immunization of Adolescents: Recommendations of the Advisory Committee on Immunization Practices, the AAP, the AAFP, and AMA. MMWR, 45 (RR-13), 1-16

Recommendations

1. All adolescents should be protected by receiving one or more doses of tetanus and diptheria (Td) booster vaccine between the ages of 11 and 12 provided it has been at least five years since receiving the last tetanus and diphtheria toxoid-containing vaccine.
2. Subsequent Td boosters are recommended every 10 years.
3. Adolescents not fully vaccinated as children should receive a total of three or more doses of hepatitis B vaccine, two or more doses of measles, mumps, and rubella (MMR) vaccine, and one or more doses of varicella vaccine (if not naturally immune through acquired and documented varicella disease).
4. Susceptible teens 13 years of age and older should receive two doses of varicella vaccine, given at least four weeks apart.³

³Centers for Disease Control and Prevention (2002). Recommended Childhood Immunization Schedule - United States, 2002. Atlanta, GA: Author.

These recommendations have been widely disseminated to health care providers and are now subsequently reinforced through specific objectives (objectives 14-27a through 14-27d) for adolescent immunization appearing in the Healthy People 2010 health objectives for the nation.⁴ Newer recommendations also call for selective immunization of adolescents against influenza, hepatitis A, pneumococcal, and meningococcal diseases. Despite the confusion generated when new vaccines are added to the vaccine schedule and advances in vaccine development require frequent changes in the recommended vaccine schedule, increased emphasis on administration of vaccines to more and more adolescent and adult subgroups is expected in the future to reduce disease rates and attain better protection of the general population against VPDs.

⁴U.S. Department of Health and Human Services. (2001) Healthy People 2010. Washington, DC: Author. (online) Available: www.health.gov/healthypeople.

While the ACIP recommendations provide an essential blueprint for the nation to protect adolescents against VPDs, it is recognized that implementation requires ongoing political, organizational, and financial commitment of multiple stakeholders. This position statement outlines recommendations of the ANA and key challenges the nursing profession faces in facilitating implementation of standards to optimize health benefits of the ACIP recommendations for adolescent immunizations.

Nurses Role in Adolescent Immunization (AI)

The American Nurses Association supports the crucial role of nurses in adolescent immunization (AI) by supporting the following:

Leadership: ANA supports the adoption of the ACIP-AI recommendations and their incorporation into standard practice for nurses in all settings. ANA supports targeted and coordinated efforts at the national, state, and local levels promoting adolescent immunization to achieve at least 90% immunization coverage levels against selected VPDs for adolescents aged 13 to 15 years as outlined in the Healthy People 2010 objectives. ANA supports activities to reduce disparities in VPD immunization coverage levels based on race, ethnicity, gender, family income, geographical location, and disability status. ANA supports the promotion of partnerships among public and private organizations and linkages between organizations that facilitate vaccination of seniors, adults, children and infants with those that focus on adolescents.

Specific suggestions for strategies include marketing adolescent immunization with businesses and corporations, developing culturally sensitive and user-friendly educational materials for use by schools, encouraging managed care organizations to prioritize the importance of immunizing adolescents, and promoting school-based immunizations, especially in communities with a significant proportion of children who are eligible for vaccinations through the Vaccines for Children (VCF) program.

Education: ANA supports efforts to educate health-care providers, middle and secondary school teachers and administrative officials, parents, adolescents, the general public, community leaders, elected officials, and others involved in AI service delivery and in shaping AI vaccine policy about the importance of immunizations for adolescents. ANA therefore supports the work of the National Network for Immunization Information (NNII) of which ANA is an organizational partner as a reliable source of scientific information about immunizations (see www.immunizationinfo.org).

Nurses practicing in school, public health, and pediatric settings should participate in development and evaluation of multi-disciplinary educational AI materials. Nurses should support education and dissemination of information about AI through publications, media events, public service announcements, organized health activities targeting adolescents, education of nursing students and practicing nurses, development of web-based AI information resources, and other communication vehicles. Educational resources should be developed with respect to cultural and language differences recognized as increasingly prevalent in communities across the United States.

Policy and Regulation: ANA supports the implementation of policies, regulations, and other legal devices to support adolescent health, including immunizations recommended by the ACIP focus on:

• assuring consistency between state and local health authority school immunization policies and ACIP recommendations;
• assuring public funding to support vaccine purchase and distribution in jurisdictions where immunization mandates have been enacted;
• assuring availability of comprehensive middle and secondary school nursing services which include routine immunization screening and vaccine administration services;
• support for school-based AI initiatives including voluntary school-based ⁽²⁾ immunization programs coupled with middle school immunization requirements;
• expanded VCF program coverage for young people otherwise lacking access to health care inclusive of immunization services;
• waivers to allow sharing of confidential vaccine history and registry information on a "need to know" basis;
• expanding insurance coverage to include administration of all ACIP-recommended vaccines for children and adolescents; and
• simplification of consent procedures to allow easier access for adolescents to receive vaccines according to the recommended schedule, including routine vaccination immunization during emergency and reproductive health visits.

Research: ANA supports research on all aspects of AI in which nurses are involved including but not limited to:

• basic research for vaccine development and clinical testing;
• approaches to assuring vaccine availability and safety;
• vaccine program service delivery and evaluation;
• cost-effectiveness studies;
• better understanding of underimmunized and at-risk populations;
• disease epidemiology
• assessment of vaccine coverage levels;
• demonstration projects and planned interventions;
• vaccine policy issues; and
• analysis of barriers to immunization.

ANA believes research funding related to improving immunizations for adolescents (as well as other age groups) must remain a public health priority. Further, ANA believes funding allocations for research should reflect the importance of immunizations against VPDs as a cornerstone among all disease prevention efforts.

Social Justice, Service Access, and Program Development: ANA supports assessment of vaccine status and administration of recommended vaccines to adolescents during routine as well as emergency care visits. ANA also supports egalitarian approaches to health care in which all individuals including children and adolescents have access to basic preventive health care services including immunization against VPDs.

ANA supports development of innovative AI programs to reach at-risk youth and those in special circumstances, including: (a) refugees, immigrants, and undocumented immigrants; (b) the uninsured and underinsured; (c) those placed in foster care, homeless shelters, the juvenile justice system, and drug treatment centers; (d) youth accessing services for occupational, mental or reproductive health services or through STD clinics; (e) marginalized youth including gang members, sex workers, and those subjected to discrimination by virtue of race, ethnicity, language, religion, disability, or sexual orientation; and (f) youth participating in club, faith-based, school-based athletic, or similar extra-curricular activities. Efforts to reach these groups should be collaborative, building on existing resources including public-private cooperative agreements involving health departments, primary care providers, hospitals, schools, managed-care organizations, service organizations, churches, juvenile justice programs, and other voluntary community-based organizations and agencies.

Conclusion:

As an association for registered nurses committed to advancing principles of health promotion and disease prevention for all individuals and throughout the health care system, the American Nurses Association promotes the goal of reducing VPDs among adolescents and other populations by increasing access to vaccine delivery services. Thus, ANA encourages and endorses incorporation of appropriate immunization standards into nursing practice in all settings. The positions and strategies outlined in this document support the important role of nurses as health care providers whose responsibilities include advocacy for adolescents while assuring services for this group are integrated throughout the health care system and that adolescents have access to basic preventive services including vaccination for the prevention of VPDs.

References

1. American Academy of Pediatrics (2000) Immunization in special clinical circumstances: adolescents and college populations. In G. Peter (Ed.) Red Bood 2000: Report of the Committee on Infectious Diseases (25^th ed.) Elk Grove Village, IL: Author
2. American Academy of Pediatrics: Committee on Infectious Diseases. (1997). 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. Pediatrics, 99, 479-488.
3. American Medical Association (1994). Rationale and recommendations: Infectious diseases. In A.B. Elster, & N.J. Kuznets (Eds.) AMA Guidelines for Adolescent Preventive Services (GAPS): Recommendations and Rationale (pp. 165-171). Chicago, IL: Williams & Wilkins.
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19. Molliconi, S.A., & Zing, T. (1997) Managed care organizations and public health: Exploring collaboration on adolescent immunization. Journal of School Health 67, 286-289.
20. National Coalition for Adult Immunization (1998). Bethesda, MD: Author
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23. Sworts, V.D. & Riccitelli, C.N. (1997) Health education lessons learned: The H.A.P.I. kids program. Journal of School Health 67, 283-285
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26. U.S. Bureau of the Census (1998) Washington, DC: Author. (on-line). Available: www.census.gov/statab/freq/
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