Understanding and improving adolescent immunization rates

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1 Understanding and improving adolescent immunization rates Lee Ann E. Conard, RPh, DO, MPH Shutterstock.com ealthy People 2020 has set goals to improve adolescent immunization rates. As seen in 2011 data shown in Table 1, (p. 16) some of the better accepted (and often required for school entry) vaccines, such as tetanusdiptheria-acellular pertussis (Tdap) and meningococcal (meningococcal conjugate vaccine 4; MCV4), are approaching the goal. Others, that often are not required, such as human papillomavirus (HPV) and influenza, are well behind. 1 October 2013 New emphasis on pediatric and adolescent vaccinations AOA Health Watch 15

2 Adolescents have low immunization rates for a few reasons. First, vaccines were not a major component of the adolescent well visit until recently, when several new vaccines routinely were recommended for this age group. Second, unlike younger children, adolescents tend not to make regular visits to their primary care provider, and third, when they do, it usually is for an acute or ill visit, rather than for preventive care. 2 One study of the nationally representative Medical Expenditure Panel Survey using data from 2001 to 2004 found that of adolescents aged 10-17, only 37.9% had attended a preventive care visit in the past year. 3 Additional barriers may exist, including lack of insurance, vaccine cost, and concerns about vaccine safety. Adolescents may come to the clinic by themselves, making it difficult to get parental consent for vaccines. Health care professionals (HCPs) also may not have access to the teen s vaccination records. 4 Health care professionals who care for adolescents need to be knowledgeable about the latest immunization recommendations for this age group in order to decrease disease burden, morbidity, and mortality as well as promote optimal health. Tetanus-diptheria-acellular pertussis vaccine Tetanus and diptheria are diseases that occur rarely in adolescents. However, the incidence of pertussis has been increasing and adolescents are susceptible to this infection due to waning immunity. This occurs 5-7 years after childhood immunizations are completed. Adolescents can pass the infection on to infants and young children, for whom the disease causes increased morbidity and mortalilty. The Tdap vaccine should lower incidence of the disease in the adolescent age group and decrease the amount of pertussis in the community. This, in turn, will decrease infection risk for younger children and infants. Provisional data from the Centers for Disease Control and Prevention (CDC) show 41,551 cases of pertussis in 2012, which is the highest number since Adolescents aged years accounted for 29.8% of the cases, the highest of any age group. The data also show that rates are increasing among adolescents, especially those aged 13 and 14 years. 5 Transmission occurs by close contact with aerosolized droplets. Cases occur year round, with a late summer to early autumn peak. Neither infection nor immunization provides lifelong immunity. The incubation period is 7-10 days, with a range of 5-21 days. 6 Pertussis (whooping cough) is a respiratory infection caused by Bordetella pertussis. The illness has 3 stages. The first is the catarrhal stage, which begins with mild upper respiratory symptoms similar to those of the common cold. This stage may last 1-14 days. The second is the paroxysmal stage, which is characterized by a spasmodic cough, post-tussive emesis, and, possibly, the inspiratory whoop, which may last 1-6 weeks. The cough can be heard on the CDC website ( -video.html#pertussis-sounds). The third is the convalescent stage, in which symptoms wax and wane over weeks to months. Average duration of the illness is 6-10 weeks. Pertussis is most contagious in the late catarrhal and early paroxysmal stages, often before the disease is diagnosed and before patients realize that they are contagious. 6 Complications in adolescents include syncope, sleep disturbance, incontinence, rib fractures, and pneumonia. Coughing may cause problems as well, including facial bruising and conjuctival hemorrhaging (Figure 1). Complications increase with age. Infants younger than 6 months are at risk for more severe complications and are at highest risk for morbidity and mortality. Adolescents and adults with mild or undiagnosed pertussis are the main source of pertussis infection for infants and children. 6 Currently, 2 forms of Tdap are available in the United States. Boostrix (GlaxoSmithKline; GSK) is recommended as an intramuscular (IM) injection for persons aged years. Adacel (Sanofi Pasteur) is another IM injection for persons aged years. 7 Table 1. Healthy People 2020 goals for selected adolescent immunization rates VACCINE Tetanus-diptheriaacellular pertussis (Tdap) Meningitis (meningococcal conjugate vaccine) Human papilloma virus Influenza GOAL FOR 13- TO 15-YEAR-OLDS Increase coverage with 1 booster Increase coverage with one dose Increase coverage with 3 doses for females No goal for males Increase the percentage who are vaccinated annually Figure 1. Photograph of a child with facial bruising and conjunctival hemorrhage from coughing due to pertussis. Source: Immunization Action Coalition, courtesy of Thomas Schlenker, MD, MPH, Chief Medical Officer, Children s Hospital of Wisconsin. GOAL LEVEL 2011 LEVEL FOR 13- TO 17-YEAR-OLDS 78.2% had at least 1 dose Tdap 70.5% had at least 1 dose 34.8% of females had received all 3 doses 1.3% of males had received all 3 doses 9.8% in the season 16 AOA Health Watch New emphasis on pediatric and adolescent vaccinations October 2013

3 Schedule Adolescents should get a single dose of Tdap between age 11 and 12 years. Only 1 lifetime dose of Tdap should be administered after the primary childhood series (all others should be tetanus and diphtheria [Td]). It may be given with other vaccines. 6 If an adolescent aged 11 years or older received Td instead of Tdap, the adolescent should be revaccinated with Tdap to protect against pertussis. It may be administered without regard to the timing of the Td vaccine. 6 Pregnant adolescents may receive Tdap, preferably during the late second or third trimester (after 20 weeks gestation). It may be administered immediately postpartum. It is critical to screen and immunize adolescent females who are considering pregnancy. 6 The most common vaccine side effect in adolescents is syncope, which can result in serious injury. It is recommended that 15 minutes after vaccines have been given before leaving the office. Common mild side effects of the vaccine include localized pain, redness and swelling, mild fever, headache, fatigue, nausea, vomiting, and diarrhea. Uncommon mild side effects include chills, body aches, sore joints, rash, and swollen glands. Severe allergic reactions (anaphylaxis) are uncommon. 6 Absolute contraindications for Tdap vaccine include a history of an anaphylactic reaction to diptheria, tetanus and/or pertussis, or to vaccine components. If the patient has a history of encephalopathy within 7 days of receiving the vaccine that was not attributable to another cause, the patient should not receive the Tdap vaccine. 6 Precautions for the Tdap vaccine include a history of Guillain-Barré syndrome occurring within 6 weeks of the vaccine or an unstable neurologic condition. Those patients who developed an Arthus reaction after a tetanus vaccine should defer the Tdap vaccine for 10 years. 6 Conditions that are not contraindications to the Tdap vaccine include history Figure 2. Young child with gangrene of the hands due to meningococcemia. Source: CDC Public Health Image Library, courtesy of Mr. Gust. of extensive limb-swelling reaction after pediatric Diphtheria and tetanus toxoids and pertussis vaccine adsorbed USP/DTaP or Td immunization that was not an Arthus hypersensitivity reaction, a stable neurological disorder (eq, seizures or cerebral palsy), breastfeeding, and immunosuppression, including human immunodeficiency virus (HIV). For patients with a latex allergy, the Boostrix single-dose vial and the Adacel products do not contain latex. 6 Meningitis vaccine Neisseria meningitidis causes meningitis, bacteremia, or pneumonia and is a leading cause of meningitis in those aged 2-18 years. Although rates are highest during infancy, there is a second peak during adolescence (ages years). The CDC reports that in the United States, since 2005, there have been about 1000 cases of bacterial meningitis. Outbreaks account for less than 5% of reported cases, with most of the cases being sporadic. Figure 3. Patient positive for human immunodeficiency virus with oral human papillomavirus. Source: CDC Public Health Image Library, courtesy of Sol Silverman, Jr., DDS. However, the frequency of outbreaks is increasing. The disease is serious, because 10%-15% of the patients die and 11%-19% of survivors have serious sequelae, such as hearing loss, neurologic disability, amputations, and scarring. 8 The most common serotypes in the United States are B, C, and Y. In adolescents (those older than 11 years), 75% of cases are caused by C, Y, or W-135. Most of the outbreaks have been caused by serotype C. 8 Meningitis is transmitted by close contact with aerosolized droplets or secretions from the nasopharynx of colonized persons. The bacteria attach to mucosal cells and may enter the bloodstream and cross the blood brain barrier into the cerebrospinal fluid. Those in crowded living situations (eg, college freshmen in dormitories and military recruits in boot camp) have higher rates of disease. Patients with complement deficiencies or functional asplenia are also at greater risk. 8 The incubation period is 3-4 days, with a range of 2-10 days. Patients are able to transmit the bacteria for up to 24 hours after receiving effective antibiotics. 8 Symptoms may be nonspecific; the patient may have fever, chills, malaise, myalgias, and a rash. The rash may be petechial or appear as purpura. In cases of sepsis, the patient may have raised intracranial pressure, limb ischemia (which may lead to gangrene and amputation; see (Figure 3), coagulopathies, pulmonary edema, and shock. The patient may go from being slightly ill to coma and death within hours, even with appropriate treatment. The case fatality rate for adolescents is greater than 10%. 8 Currently, 2 MCV4s are available in the United States. Menactra (Sanofi Pasteur) and Menveo (Novartis). Both are quadrivalent vaccines that protect against serotypes A, C, Y, and W-135. Neither prevents infection by serotype B. Both are approved for adolescents and young adults. Clinical trials have shown that MCV4 has better immunogenicity than Menomune, which is an older meningitis vaccine. All adolescents should receive October 2013 New emphasis on pediatric and adolescent vaccinations AOA Health Watch 17

4 the newer MCV4 vaccine. Those who remain in high-risk groups (functional or anatomical asplenia, complement deficiencies, or travelers to areas with high rates of meningococcal disease) should be revaccinated every 5 years. 8 Schedule For routine vaccination, the first dose is given at age years, with a booster dose at age 16 years. For catch-up vaccination, the first dose is given at age years. If the first dose is given between ages 13 and 15 years, a booster should be given between ages 16 and 18. If the first dose is given at age 16 or older, a booster is not needed. The minimum interval between the 2 doses is 8 weeks. If a patient was given Menomune, the patient should be revaccinated with 1 of the MCV4 vaccines at least 3 years after the Menomune was given. 8 The most common vaccine side effect in adolescents is syncope, which can result in serious injury. It is recommended that 15 minutes after vaccination before leaving the office. Common adverse reactions include localized pain, irritability, headache, and fatigue. Fever is reported in 2%-5% of adolescents. 8 Severe allergic (anaphylactic) reaction to a vaccine component or following a previous dose of the vaccine is a contraindication to further doses. 8 Pregnancy, breastfeeding, and immunosuppression are not contraindications. 8 Moderate or severe illness is a reason to defer the vaccine until later; mild illness is not. 8 Isolated cases of Guillian Barré Syndrome (GBS) following vaccination with MCV4 have been reported, but the data are sparse. The current recommendation is that patients with a history of GBS not receive MCV4. 8 Human papillomavirus vaccine Human papillomavirus (HPV) infection is the most common sexually transmitted infection in the United States. Approximately 20 million people are infected in the United States; half are adolescents between the ages of 15 and 24 years. Data from 2003 to 2005 showed that the prevalence of high-risk HPV was 35% in females aged years. 9 The virus may cause anogenital warts and intraepithelial lesions, which may clear on their own or progress to malignancy. Persistent HPV infection can lead to cervical, vulvovaginal, and anal cancer in women and penile and anal cancers Human papillomavirus (HPV) is transmitted from person to person by close contact. The incubation period is thought to be anywhere from 3 months to several years. Most infections clear spontaneously within 2 years. 10 in men 5-30 years after initial infection. The CDC states that, each year, there are approximately 19,000 cancers caused by HPV in women and about 8000 in men. The most common female cancer is cervical, and the most common male cancer is oropharyngeal (throat). 10 Human papillomavirus (HPV) vaccines can prevent infection and clinical sequelae and therefore are an excellent strategy to prevent these cancers. A recent study reviewed National Health and Nutrition Examination Survey data from 2007 to 2010 and compared it to data from 2003 to 2006, before the HPV vaccine was in use. Human papillomavirus (HPV) prevalence decreased 56% during that 4-year period, even with low vaccine uptake. 11 Human papillomaviruses (HPVs) are DNA viruses, and there are more than 100 types. The mucosal types that infect the genital tract and oral mucosa are divided into low- and high-risk types. Types 16 and 18 are high risk and are associated with cervical cancer (more than 70% of cases); type 16 is associated with other anogenital and oropharyngeal cancers. Types 6 and 11 are also high risk and are associated with anogenital warts (more than 90% of cases). 10 Most HPV infections are asymptomatic and transient. The virus can cause warts of the skin and mucous membranes and are associated with cervical, anogenital, and oropharyngeal (back of the throat or base of tongue and tonsils) (Figure 3) dysplasias and cancers. 10 Anogenital warts are skin colored, with a cauliflower-like surface that range in size from a few millimeters to several centimeters. In females, these lesions may occur on the vulva or perianal areas and, less commonly, in the vagina or on the cervix. In males, these warts may be found on the penis, scrotum, anal, and perianal areas. Warts usually are painless, although they may cause itching, burning, local pain, or bleeding. 10 Human papillomavirus (HPV) is transmitted from person to person by close contact. The incubation period is thought to be anywhere from 3 months to several years. Most infections clear spontaneously within 2 years. 10 Currently, 2 vaccines are available in the United States. Gardasil (Merck & Co.) is the quadrivalent vaccine for females and males that protects against HPV types 6, 11, 16, and 18. In females, it protects against cervical cancer, genital warts, and anal, vaginal, and vulvar cancers. In males, it protects against genital warts and anal cancers. 10 Cervarix (GSK) is the bivalent vaccine for females that protects against HPV types 16 and Both vaccines are given as a 3-dose series. In order to prevent HPV infection and subsequent malignancy, the vaccine should be given before the initiation of sexual activity. The vaccines do not treat current HPV disease. Patients who have aquired HPV before vaccination will get 18 AOA Health Watch New emphasis on pediatric and adolescent vaccinations October 2013

5 protection from the types they do not already have. 12 For females, Gardasil or Cervarix is recommended. Vaccination may begin at age 9 years, but is recommended for girls ages 11 and 12 years. Girls ages 13 through 26 years may also get the vaccine series if they did not receive it when they were younger. 12 For males, Gardasil is recommended for 11- and 12-year-old boys and for those ages 13 through 21 years who did not receive it when they were younger. Men who have sex with men and men who are immunosuppressed (HIV disease) should receive the vaccine through age 26 years, because they are at high risk for anal cancers. Men ages 22 through 26 years also may receive the vaccine. 12 Schedule The vaccine should be given IM, preferably in the deltoid. The second dose should be administered 1-2 months after the first. The third dose should be administered 6 months after the first. The minimum interval between dose 1 and 2 is 4 weeks and between dose 2 and 3 is 12 weeks (and at least 24 weeks after dose 1). 10 If the dosing interval is too short, the vaccine should be repeated. If the dosing interval is too long, the series does not need to be restarted. 10 If possible, the same vaccine (Gardasil or Cervarix) should be used for the entire series. The HPV vaccine can be administered with other vaccines at the same visit. 10 The most common side effect in adolescents is syncope, which can result in serious injury. It is recommended that 15 minutes after vaccination before leaving the office. 10 Human papillomavirus (HPV) vaccine should not be given to patients with a past history of a hypersensitivity reaction to the vaccine or its components, including yeast, and in patients with moderate or severe acute illness. Patients with latex allergy should not be given HPV vaccine from a prefilled syringe. 10 The vaccine may be given to patients who are breastfeeding (quadrivalent form Figure 4. Plume of droplets from an uncovered sneeze. Source: CDC Public Health Image Library, courtesy of Brian Judd. only), those with minor acute illness, and those who have had HPV disease. Patients who are immunosuppressed may get the vaccine, but efficacy may be decreased. 10 Adolescents who are pregnant should not receive the HPV vaccine. The provider should ask about pregnancy, but a pregnancy test is not required. If the patient becomes pregnant during the series, the rest of the doses should be held until the postpartum period. If the vaccine is given inadvertently during pregnancy, the provider should report the case to the pregnancy registry of the vaccine that was given. 10 Seasonal influenza vaccine Incidence of influenza in healthy children ranges from 10% to 40% each year. In the flu season, the cumulative hospitalization rate (per 100,000) for 5- to 17-year-olds was 14.5, and there were 46 deaths in the 12- to 17-year-old age group. The highest risk is in adolescents with chronic health conditions, such as asthma, cystic fibrosis, sickle cell disease, cancer, diabetes, chronic renal disease, and HIV. However, 50% of deaths occur in previously healthy children. 13 A recent CDC study showed the benefits of the flu vaccine during the season. 14 The vaccine averted more than 18.5% of potential flu cases across all age groups in the United States. This means that approximately 5 million flu cases, 2.1 million flu-related medical visits, and 40,400 flu-related hospitalizations were averted. The influenza viruses are orthomyxoviruses (types A, B, and C). Epidemics are caused by types A and B, and both are included in the vaccine. Since the virus changes yearly, there is a new vaccine formulation each year and therefore a need for vaccination each year. 13 Influenza is spread by respiratory tract droplets with coughing or sneezing (Figure 4). Contact with surfaces contaminated with droplets is also possible. Peak influenza season in the United States is between November and May, but is most common in January and February. Patients are infectious 24 hours before the onset of symptoms. Viral shedding occurs between the first 3 and 7 days of the illness and is directly correlated with degree of fever. The incubation period is 1-4 days, with a mean of 2 days. 13 The disease causes a sudden onset of fever, often accompanied by chills or rigors, myalgias, headache, malaise, nonproductive cough, sore throat, nasal congestion, and rhinitis. Abdominal pain, nausea, vomiting, and diarrhea are less common. Influenza may cause a viral October 2013 New emphasis on pediatric and adolescent vaccinations AOA Health Watch 19

6 pneumonia and exacerbate underlying medical conditions. 13 Currently, 3 vaccine types are available for the flu season for adolescents. The inactivated influenza vaccine (IIV) will be available as a trivalent (3 virus strains) or quadrivalent (4 virus strains) form for IM use. The live, attenuated influenza vaccine (LAIV) will be available as a quadrivalent form this year and is administered intranasally (IN). For many vaccine recipients, more than one type or brand of vaccine may be appropriate within indications and ACIP recommendations. Where more than one type of vaccine is appropriate and available, no preferential recommendation is made for use of any influenza vaccine product over another. (see Table 1). 15 Protection from influenza with IIV for children over the age of 2 years is approximately 70%, with a range of 50%-95%, depending on the match of the vaccine strain to the strain circulating in the community. Efficacy of LAIV was 86%- 96% in a pediatric clinical trial. Antibodies to influenza develop within 2 weeks of receiving the vaccine. 13 Schedule Children aged 9 years or older require 1 dose of influenza vaccine per year. 13 The influenza vaccine can be administered with other vaccines. Live virus vaccines may be given at the same time, but if the LAIV form is given, patients should wait 1 month before receiving other vaccines. Vaccination should begin as soon as the vaccine is available (August or September) and continue through April. Adolescents who will be pregnant during flu season should receive the inactivated vaccine in the fall (August, September, or October). The most common side effect in adolescents is syncope, which can result in serious injury. It is recommended that 15 minutes after vaccination before leaving the office. Minor side effects from the IM vaccine include soreness, redness, Currently, all influenza vaccines for adolescents younger than 18 years are derived from embryonic chicken eggs, so the vaccine is contraindicated for those with severe egg allergy. or swelling at the injection site, low-grade fever, and body aches. If they occur, these effects last 1-2 days. Ten percent of adolescents will have a local reaction. A major side effect is a severe allergic reaction. 15 Mild side effects from the nasal spray vaccine (FluMist from MedImmune) include rhinorrhea, headache, vomiting, muscle aches, sore throat, cough, and fever. LAIV is approved for healthy, nonpregnant individuals with no chronic conditions. A patient with severe nasal congestion may be a better candidate for an IM injection. The IN form should not be given if the patient has received another live vaccine within the past 4 weeks. 13 Breastfeeding adolescents may receive either vaccine, as long as they have no other risk factors. 15 The inactivated vaccine (IIV3 or IIV4) is preferred in those patients with underlying medical conditions, such as asthma, known or suspected immunodeficiency, or a history of GBS. Close contacts of severely immunosuppressed people and pregnant women should receive the inactivated vaccine. Patients with moderate to severe febrile illness may receive the inactivated vaccine, but they may want to defer until they are no longer febrile. 13 Currently, all influenza vaccines for adolescents younger than 18 years are derived from embryonic chicken eggs, so the vaccine is contraindicated for those with severe egg allergy. Data show that most children with egg allergy are able to tolerate the inactivated vaccine. Table 2 shows a decision tree for deciding whether or not to give an influenza vaccine to a patient with an egg allergy. 13,16 For young adults (ages 18 and over), there is a new product available this year called FluBlok, which is manufactured by Protein Sciences. It is a trivalent recombinant hemagglutinin vaccine, which does not use the influenza virus or chicken eggs in the manufacturing process. It has a short shelf life of 16 weeks and has the same side effects as the other influenza vaccines. 16 There may be adolescents who have no known history of exposure to egg, but who are suspected of being egg allergic on the basis of previously performed allergy testing. For these patients, consultation with a physician with expertise in the Table 2. Approach for administration of influenza vaccine for those <18 years of age with known or suspected egg allergy Can the person eat lightly cooked egg (eg, scrambled egg) without reaction?* NO After eating eggs or egg-containing foods, does the person experience ONLY hives? NO Does the person experience other symptons such as: Cardiovascular changes (eg, hypotension)? Respiratory distress (eg, wheezing)? Gastrointesinal (eg, nausea/vomitting)? Reaction requiring epinephrine? Reaction requiring emergency medical attention? Administer vaccine per usual protocol. Administer IIV. Observe for reaction for at least 30 minutes after vaccination. Refer to a physician with expertise in management of allergic conditions for further evaluation. Source: Lisa Grohskopf, MD, MPH, Influenza Division, NCIRD, CDC, ACIP Influenza Vaccine Recommendations Season, National Center for Immunization & Respiratory Diseases, Influenza Division, July 25, YES YES YES 20 AOA Health Watch New emphasis on pediatric and adolescent vaccinations October 2013

7 Figure 5. Young woman receiving a vaccine with family support. Source: CDC Public Health Image Library, courtesy of Judy Schmidt. management of allergic conditions should be obtained before to vaccination. Recommendations for increasing vaccination rate in adolescents As a primary prevention strategy, vaccination is highly effective. To increase vaccination rates among adolescents, providers can increase opportunities to vaccinate. Adolescents should have a routine health care visit (well check) between the ages of 11 and 12 years to update immunizations. The Society for Adolescent Health and Medicine also recommends routine care visits between ages 14 and 15 years and between 17 and 18. These extra visits ensure that the vaccines are received before age 19, while the patient may still qualify for the for Children Program (for un- or underinsured patients). Because adolescents tend to be seen more frequently for acute issues, providers can increase immunization rates by attempting to update vaccines at all visits. 4 A second way to increase immunization rates is for providers to have access to vaccine records. Many states now have electronic immunization information systems, which are helping increase vaccine rates among younger children. As these children become adolescents, providers should have more complete, accurate records. In the meantime, providers can create alliances with local schools to share vaccine records, when parents are unable to find their copies. 4 Provider and family education are important to increasing vaccine uptake. Providers should continue to be updated on current vaccine guidelines, and they should use this information to assist patients and their families in making informed decisions about vaccines. References 1. Healthy People Immunizations and infectious diseases. topicsobjectives2020/objectiveslist.aspx?topicid=23. Accessed July 10, Wong CA, Taylor JA, Wright JA, Opel DJ, Katzenellenbogen RA. Missed opportunities for adolescent vaccination, J Adolesc Health June 25. doi: /j.jadohealth [Epub ahead of print] 3. Irwin CE, Jr., Adams SH, Park MJ, Newacheck PW. Preventive care for adolescents: few get visits and fewer get services. Pediatrics. 2009;123(4):e565-e Middleman AB. Adolescent immunizations: policies to provide a shot in the arm for adolescents. J Adolesc Health. 2007;41(2): Centers for Disease Control and Prevention. Pertussis surveillance and reporting. Accessed July 10, American Academy of Pediatrics. Summaries of infectious diseases: pertussis (whooping cough). In: Pickering LK, editor. Red Book: 2012 Report of the Committee on Infectious Diseases. 29th ed. Elk Grove Village, IL: American Academy of Pediatrics; Centers for Disease Control and Prevention. Preteen and teen vaccines. who/teens/vaccines/tdap.html. Accessed July 10, Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine-Preventable Diseases. 12th ed., second printing. Atkinson W, Wolfe S, Hamborsky J, editors. Washington, DC: Public Health Foundation; vaccines/pubs/pinkbook/mening.html. Accessed July 10, Datta SD, Koutsky L, Ratelle S, et al. Human papillomavirus infection and cervical cytology in women screened for cervical cancer in the United States, Ann Intern Med. 2008;148(7): American Academy of Pediatrics. Summaries of infectious diseases: human papillomaviruses. In: Pickering LK, editor. Red Book: 2012 Report of the Committee on Infectious Diseases. 29th ed. Elk Grove Village, IL: American Academy of Pediatrics; Markowitz LE, Hariri S, Lin C. Reduction in human papillomavirus (HPV) prevalence among young women following HPV vaccine introduction in the United States, National Health and Nutrition Examination Surveys, J Infect Dis. 2013;208(3): Centers for Disease Control and Prevention. Sexually transmitted diseases. HPV vaccine information for clinicians fact sheet. STDFact-HPVvaccine-hcp.htm. Accessed July 10, American Academy of Pediatrics. Summaries of infectious diseases: influenza. In: Pickering LK, editor. Red Book: 2012 Report of the Committee on Infectious Diseases. 29th ed. Elk Grove Village, IL: American Academy of Pediatrics; Kostovea D, Reed C, Finelli L. Influenza illness and hospitalizations averted by influenza vaccination in the United States, PloS One. 2013;8(6):e CDC Influenza reference for seasons: summary-recommendations.htm#table1. Accessed 9/7/2013. HW About the Author Lee Ann E. Conard, RPh, DO, MPH, is assistant professor of pediatrics in the Division of Adolescent Medicine at Cincinnati Children s Hospital Medical Center in Cincinnati, Ohio. She is board certified in pediatrics and adolescent medicine and is a member of the executive committee of the Section on Osteopathic Pediatricians for the American Academy of Pediatricians. She can be reached at October 2013 New emphasis on pediatric and adolescent vaccinations AOA Health Watch 21

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