Elyse Olshen Kharbanda, MD, MPH, is Clinician Research Investigator at Health Partners Research Foundation, Minneapolis, MN. Jessica A. Kahn, MD, MPH, is Assistant Chair, Academic Affairs and Faculty Development, and Associate Professor, Pediatrics, Division of Adolescent Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH.
Dr. Kharbanda and Dr. Khan have disclosed no relevant financial relationships.
Address correspondence to: Jessica A. Kahn, MD, MPH, Division of Adolescent Medicine, MLC 4000, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH 45229; fax: 513-636-1129; e-mail firstname.lastname@example.org.
The widespread use of vaccines and consequent reductions in vaccine-preventable illnesses has been heralded as one of the greatest public health achievements of the 20th century. Some of the most notable accomplishments include the eradication of smallpox, the elimination of polio from the Western Hemisphere, and the near elimination of measles in the United States. In general, vaccines are recommended for the youngest age group in which they are likely to be safe and effective. Therefore, most vaccines are recommended for young children, and vaccine schedules have been harmonized with recommended early childhood preventive health visits.
In the past several years, new vaccines have been introduced and recommended specifically for adolescents. In many countries, new vaccines to prevent meningitis, pertussis, and cervical cancer have been recommended. In the United States, these three vaccines are recommended for 11- to 12-year-olds, with catch-up vaccinations for older teens. The influenza vaccine is now indicated annually for all U.S. adolescents and young adults.1
These vaccines have been recommended for adolescents for several reasons. The human papillomavirus and meningococcal vaccines target infections more likely to be acquired during adolescence, while the pertussis booster is needed because of waning immunity in early adolescence.
In addition, recommendations that adolescents receive a pertussis booster and an annual influenza vaccine were based in part on the demonstrated secondary benefits of these vaccines. That is, by vaccinating teens, we protect infants and elderly people who are most at risk for morbidity and mortality caused by pertussis or influenza. An additional benefit of new adolescent immunization recommendations is that they are likely to lead to more frequent office visits by adolescents and provide an opportunity to provide teens with other recommended preventive health services.2 Therefore, adolescent vaccines have the potential to improve greatly the health of our youth and prevent the spread of diseases within communities.
Despite the known benefits of adolescent vaccines, immunizing teens in the office setting can be difficult. Because of multiple factors, including failure to present for preventive care, scattered medical records, and competing priorities, 3 adolescent vaccine coverage remains far lower than that for younger children.4 In this article, we review current vaccine guidelines for adolescents and recent data on vaccine coverage for U.S. teens. We will then examine practical challenges to vaccinating adolescents and provide strategies for pediatricians to overcome these difficulties.
Current Vaccine Guidelines
Pediatric and adolescent vaccine recommendations in the U.S. are determined by the Advisory Committee on Immunization Practices (ACIP). This 15-member panel, appointed by the U.S. Secretary of the Department of Health and Human Services, comprises experts from a variety of fields, including immunology, infectious diseases, vaccine delivery, and vaccine safety. ACIP provides specific guidelines regarding age for routine vaccination, recommended dosing schedules, and catch-up schedules.
All ACIP-recommended vaccines are provided at no cost to children and adolescents who are eligible to participate in the Vaccines for Children Program (VFC). In addition, most private insurers include all ACIP-recommended vaccines as covered benefits. Professional societies, such as the American Academy of Pediatrics (AAP), the American Academy of Family Physicians (AAFP), and the Society for Adolescent Health and Medicine (SAHM) generally endorse ACIP recommendations.
In the past several years, ACIP has made several changes to the routine adolescent immunization schedule. The tetravalent meningococcal polysaccharideprotein conjugate vaccine (MCV4) and the tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap), are now recommended for children 11 to 12 years, with catch-up vaccination for older teens. The influenza vaccine is indicated annually for everyone 6 months and older, including adolescents and young adults. It is also recommended that adolescents receive any vaccines they may have missed when younger, such as the varicella, hepatitis A, hepatitis B, measles-mumps-rubella, and/or polio vaccines. The 2010 adolescent vaccine schedule is shown in the Figure (see page 485).1
Figure 1. 2010 Immunization Schedule. From: Centers for Disease Control and Prevention (CDC). Recommended Immunization Schedules for Persons Aged 0 Through 18 Years — United States, 2010. MMWR. 2010;58(51&52):1–4. Available at: www.cdc.gov/mmwr/preview/mmwrhtml/mm5851a6.htm.
Recommendations regarding the human papillomavirus vaccine differ somewhat from other adolescent vaccine recommendations. In June 2006, the three-dose quadrivalent human papillomavirus vaccine (HPV4) was recommended for routine administration in girls 11 to 12 years, with catch-up vaccination in adolescents up to age 26.5 Providers were advised they could also immunize younger girls 9 to 10 years at their discretion. The quadrivalent HPV vaccine induces immunity to four HPV types: 6, 11, 16, and 18. Approximately 70% of cervical cancers are caused by types 16 and 18, and approximately 90% of genital warts are caused by types 6 and 11.
At the October ACIP meeting, a bivalent HPV vaccine (HPV2) was also approved for girls, with the same age indications and dosing schedule. The bivalent vaccine induces immunity to HPV 16 and 18.6 This vaccine will prevent cervical dysplasia and has the potential to prevent cervical cancer but does not provide significant protection against genital warts.
ACIP did not state a preference for either the bivalent or the quadrivalent vaccine. Although these vaccines have comparable efficacy to prevent cervical cancer and precancers, and similar safety profiles, their overall benefits are different. This leaves providers in the difficult position of deciding which vaccine(s) to stock and which to recommend.
In some countries outside the United States, the bivalent HPV vaccine has been offered at prices below those for the quadrivalent vaccine. At this writing, the Centers for Disease Control and Prevention (CDC) contract price for the bivalent vaccine has not been published.7 Private sector prices for both vaccines vary based on negotiations with distributors, discounts for ordering multiple vaccines from the same manufacturer, and participation in vaccine purchasing groups.8 Therefore, although some providers may prefer one of the HPV vaccines for economic reasons, others may not appreciate significant price differentials. It is too early to determine whether parents or third-party payers will have a preference between the bivalent and the quadrivalent HPV vaccine.
In October, ACIP gave a permissive recommendation that boys could receive the quadrivalent HPV vaccine: “The three-dose series of quadrivalent HPV vaccine may be given to boys 9 through 26 years to reduce their likelihood of acquiring genital warts. Ideally, vaccine should be administered before potential exposure to HPV through sexual contact.” 6 This recommendation is unusual, because providers are allowed to vaccinate boys but are not advised to do so routinely. Furthermore, no specific guidance is provided regarding subgroups of boys who may be at increased risk for HPV infections and should be encouraged to be vaccinated. Although HPV types 16 and 18 are known to be associated with penile, anorectal, and oropharyngeal cancers,9 because of limitations in the clinical trials data submitted for review, the only indication for the quadrivalent HPV vaccine in boys is to prevent genital warts. The VFC program will be providing HPV4 for eligible boys at no cost. It is not yet clear whether thirdparty payers will routinely cover the cost of this vaccine for boys.
Current Adolescent Immunization Coverage
Until recently, relatively little was known about immunization coverage in adolescents. Most immunization data for this age group came from regional or nonrepresentative samples, but the importance of measuring vaccine coverage cannot be overstated. These measurements allow public health officials to determine which populations need increased efforts to promote vaccination, to monitor the effect of immunization programs and policies, and to identify communities at risk for outbreaks caused by low immunization coverage. Given the many additions to the routine adolescent immunization schedule, there was a need for reliable data on vaccine coverage for this age group.
Starting in 2006, the CDC instituted the National Immunization Survey — Teen (NIS-Teen), a survey of immunization coverage among 13- to 17-yearolds across the United States. Similar to the National Immunization Survey for children 19 to 35 months, the NIS-Teen uses random digit dialing to identify a nationally representative sample of adolescents. Immunization coverage is verified by review of medical records. The NIS-Teen Survey provides estimates of vaccine coverage in national, state, and even some urban areas. The survey also allows comparisons of vaccine coverage by race/ethnicity and poverty status.
Data from the most recent NIS-Teen (2008) are generally encouraging, but areas of concern remain. On a positive note, national coverage for new and older adolescent immunizations continues to increase. In addition, for the first time, the Healthy People 2010 target of 90% coverage among 13- to 15-year-olds was achieved for several vaccines/vaccine series (three doses of hepatitis B vaccine, two doses of measles-mumps-rubella vaccine, one dose of tetanus containing vaccine, and one dose of varicella vaccine.)4 Of course, these vaccines are routinely administered to younger children, so high coverage may simply represent improved childhood immunization rates for these antigens.
The 2008 NIS-Teen data highlight that, despite some gains, there is a need for further efforts to promote immunization uptake among adolescents. Although increasing, coverage for newly introduced adolescent vaccines is far from optimal. National coverage for MCV4 and Tdap was 42% and 41%, respectively. Among girls aged 13 to 17, only 37% had received their first HPV4 dose and only 18% had completed the three-dose series.
Furthermore, substantial differences in immunization coverage were noted across states. For example, state-level MCV4 coverage ranged from a low of 14% to a high of 61%. Similarly, the percentage of girls 13 to 17 years who had received at least one HPV4 dose ranged across states from a low of 15% to a high of 55%. Variation in immunization coverage by race/ethnicity was also noted, although disparities were at times different than those traditionally observed. For instance, Hispanic girls had higher coverage rates than white girls for one or more HPV4 vaccine doses (44% versus 35%). On the other hand, poverty was associated with lower protection against varicella.4
Adolescent Challenges, Practical Strategies
In this section, we highlight some of the many issues inherent in immunizing teens and provide practical strategies that may be useful for overcoming these challenges.
Challenge #1: Parents Are Unfamiliar with Vaccine Recommendations
Given the frequent changes to the routine adolescent immunization schedule, it is not surprising that many parents report being unaware that their teen is due or overdue for a vaccine.10,11 At nearly every ACIP meeting, adjustments are made to the recommended vaccine schedule, and keeping up to date with all these changes can be difficult for parents.
Strategy: Start Conversations Early, and Be Familiar with Available Resources
Providers can play an important role in educating parents regarding immunization schedules and changes to these schedules. These discussions can start early. When a 9- or 10-year-old presents for a physical exam, anticipatory guidance should include information on vaccines that are recommended for those 11 to 12 years. The CDC recently introduced an educational campaign to assist providers in these efforts. English, Spanish, Vietnamese, and Korean language fliers and posters are also available for downloading and office-based printing. These materials can also be ordered directly from the CDC at no cost. Banners to add to websites are also available. For further information about the Pre-Teen Vaccine Campaign, and for all related materials, visit: www.cdc.gov/vaccines/spec-grps/preteensadol/07gallery/default.htm.
Vaccine information statements (VIS) are also available in many languages and can be downloaded directly from the CDC: www.cdc.gov/vaccines/pubs/vis/default.htm.
It is required that VIS statements be distributed at the time vaccines are administered. However, these statements can also be useful for educating parents about vaccines their child will soon need. The Maternal and Child Health Library at Georgetown University has recently compiled an excellent webbased guide with many useful links to organizations providing reliable and accessible vaccine information. Other excellent resources for parents are the Children’s Hospital of Philadelphia Vaccine Education Center and the National Network for Immunization Information. Websites for these organizations are listed in the Sidebar.
Recommended Immunization Resources (CDC)
Challenge #2: Providers Are Unfamiliar with Adolescent Vaccine Guidelines
Parents are not the only ones with busy schedules and competing priorities. Many providers also report that frequent changes to the adolescent immunization schedule can be confusing.3 Along with adding several new vaccines to the immunization schedule, ACIP has also changed age indications, dosing intervals, and contraindications for several other vaccines. The 2010 recommended adolescent immunization schedule is included in the Figure (see page 485).
Strategy: Stay up to Date and Know Your Resources
Parents report that provider recommendation is one of the most important factors they consider when deciding whether or not to immunize their child.12 This can be especially important when new vaccines are introduced, and parents may have more uncertainty or hesitation. Therefore, it is very important that clinicians providing care for adolescents stay up to date with current vaccine recommendations. One of the best resources for finding the most current recommendations is the CDC website: www.cdc.gov/vaccines. This site also maintains information regarding vaccine recalls and how providers should handle these recalls. Recently, the CDC has begun posting ACIP provisional recommendations on its website as they are passed. However, vaccine guidelines are not final until published in the Morbidity and Mortality Weekly Report (MMWR). Some insurers and VFC may wait for vaccine guidelines to be published before reimbursing for or distributing vaccine. Nevertheless, if financially feasible, clinicians are encouraged to adopt ACIP provisional guidelines as soon as they are released.
Challenge #3: Concerns Regarding Vaccine Safety
Parental concerns regarding vaccine safety are at an all-time high, despite the fact that serious vaccine-related adverse events are quite rare. In the past several years, to further reduce real or perceived risks, vaccine manufacturers and/or the CDC have recalled existing vaccines (Hib, Rotashield) and recommended the use of thimerosol-free vaccines. These actions, meant to further reduce potential or perceived risks of vaccine-related adverse events, may have inadvertently increased public fears regarding vaccine safety. With the rise in the use of social media, those opposed to immunization can now more easily advertise their views to a wide audience. Across multiple studies, conducted in diverse populations, concerns regarding vaccine safety remain the primary reason for low vaccine acceptance or vaccine refusal.13,14
Safety concerns have been particularly high for two of the new adolescent vaccines — MCV4 and HPV4 — but safety data for both vaccines are reassuring. When first introduced, there was a concern that MCV4 was associated with increased risk of Guillain-Barré syndrome. With further study, it was determined that MCV4 is safe and that the rate of Guillain-Barré reported after MCV4 was no more than that expected to occur by chance.
Numerous concerns about HPV4 vaccine safety have been raised by the media, including alleged associations with autoimmune and neurologic complications. These issues have been examined extensively; reports of illness after HPV vaccination have not exceeded the rates to be expected by chance alone.15,16 To date, the only precaution related to the HPV vaccine relates to the immediate risk of syncope, which may be a concern with any vaccination.17 To avoid this risk, teens are advised to remain seated in the office for 15 minutes after vaccination.
Strategy: Be Knowledgeable, and Take the Time to Listen to Parents
Vaccines undergo rigorous testing pre- and postlicensure. Despite this, concerns regarding vaccine safety persist. The U.S. Food and Drug Administration (FDA) requires that phase 1, 2, and 3 vaccine clinical trials be conducted in healthy adults and children before licensure. In these studies, researchers actively monitor for any events after immunization, and these events are compared with a similar population who receive a placebo injection. Vaccines are tested in approximately 10,000 children before licensure. This allows researchers to monitor for common side effects but, admittedly, does not allow for the detection of rare side effects.
After licensure, any event occurring after vaccination can be reported to the Vaccine Adverse Event Reporting System (VAERS). VAERS reports can be made by providers, parents, or even the teens themselves. Instructions on how to report are included in every VIS statement. The goal of VAERS is not to establish causality or to determine rates of side effects. Rather, the goal is to identify events that may be occurring following immunization and warrant further study.
The Vaccine Safety Datalink (VSD) project uses administrative data from eight large health maintenance organizations to capture possible adverse events after immunization. This system allows possibly-vaccine-associated risks to be identified soon after a vaccine is introduced. In addition, the Clinical Immunization Safety Assessment (CISA) Network evaluates complex vaccine safety issues, including the role of genetics and individual variation in how people respond to vaccines.
The best strategy for addressing parental concerns is to be an empathic listener and to be knowledgeable, prepared, and able to answer questions. Providers should elicit and address specific parental concerns. They should be able to explain known risks of vaccines and also be able to acknowledge situations when risks are not known (such as whether there may a rare adverse event caused by a newly released vaccine or whether there are unique vaccine risks for patients with other underlying medical conditions).
These conversations take time. If they work in a population with high rates of vaccine refusal, providers should be prepared with information and resources. The CDC, AAP, and National Network for Immunization Information websites all contain information that can assist with these conversations.
Challenge #4: Teens Do not Present for Routine Care as Often as Younger Children
Despite recommendations that teens have at least three preventive health visits during adolescence, relatively few teens present specifically for well-child care.18 On the other hand, many do come for acute visits or sports physicals. These other visits provide important opportunities to vaccinate.
Strategy: Reduce Missed Opportunities, and Facilitate Vaccination Services
The best strategy for immunizing adolescents is to reduce missed opportunities by reviewing vaccine records and offering vaccines at every medical encounter. As part of this strategy, providers should be familiar with relative and absolute contraindications to vaccinate. For example, a teen with an upper respiratory tract infection or other mild illness can still receive vaccines. Furthermore, to be able to immunize at every visit, providers must ensure that patient immunization records are up-to-date. When available, providers should be strongly encouraged to report immunizations to an immunization registry. This can be especially important for adolescents, as they may receive vaccines at school or other venues outside of their medical home. Use of an immunization registry can prevent uncertainty regarding which vaccines have been administered and can also prevent overimmunization.
There are numerous additional office-based practices that providers can adopt to facilitate adolescent vaccination. Standing orders are preapproved vaccination orders that allow vaccines to be administered without direct physician input. These can be especially useful for repeat vaccines, such as the annual influenza vaccine or the second or third HPV vaccine doses.
Reminder-recall systems are also widely recommended for increasing pediatric and adolescent immunization coverage. Reminders notify patients (or their families) when a vaccine is due, while recalls notify them that the vaccine is overdue. These traditionally have been conducted via mail or phone and are associated with modest increases in vaccine coverage and timeliness.19 Text message immunization reminder-recalls may also be an additional effective office-based strategy to improve adolescent immunization coverage.10 Many electronic health records and immunization registries have the capacity to deliver reminder-recalls. In addition, to facilitate the delivery of adolescent vaccines, providers should be familiar with their population and their preferences. In some areas, providing evening or weekend office hours may greatly improve access and the ability to immunize.
Challenge #5: Teens Come to the Office Without Their Parents
Teens often present for medical care without an accompanying adult. This can be either because parents are busy (working, home with other children) or because the teen is seeking confidential medical services. Given that adolescents are infrequent users of preventive health services, to improve immunization coverage among adolescents, it is important to vaccinate at every visit. Providers are required to provide a VIS statement, reviewing the risks of benefits of immunization, to a responsible adult. There is no federal provision explicitly requiring parents to consent for vaccines. Some states are currently considering legislation to allow minors to consent for vaccines, but at this time, no legislation has been passed.
Strategy: Develop Immunization Protocols for Unaccompanied Minors
Ideally, states would adopt statutes allowing teens to consent for vaccines, similar to those allowing teens to consent for reproductive health services.20 Until that time, providers can develop alternate strategies for allowing unaccompanied minors to be immunized. If feasible, providers can contact parents via phone and obtain oral consent for the child to be immunized. Alternatively, providers can develop systems to allow advanced consent for vaccines, giving parents VIS forms in advance and allowing parents to provide advanced written consent for future recommended vaccines.
Challenge #6: Costs of Newer Vaccines
Most adolescents younger than 19 years can receive vaccines through private insurance or the federal VFC Program. However, for uninsured young adults 19 and older and those who are underinsured (where insurance does not fully cover the cost of vaccines), cost can be a significant barrier. Private sector costs of the newly approved adolescent vaccines range from $37.55 for the pertussis booster, $98.52 for the meningococcal vaccine, to $390.81 for the three-dose HPV vaccine. Some states provide additional support to reduce out-ofpocket vaccine costs. However, states are under increased financial pressures and many are not able to cover the costs of newer vaccines.
Strategy: Participate in VFC, and Be Familiar with Other Funding Mechanisms
To reduce financial barriers to immunization, providers are encouraged to participate in the VFC program. This program allows providers to stock and administer ACIP-recommended vaccines to eligible youth. Adolescents younger than 19 who are Medicaid eligible, uninsured, American Indian, or Alaskan Native can all receive free vaccines through this program. Underinsured youth (those whose insurance does not fully cover the cost of vaccines) can also receive free vaccines through the VFC program at federally qualified health centers or rural health clinics. Providers should be familiar with where to refer teens who may benefit from these services.
In addition, providers should be familiar with other local-, state- and/or industry-sponsored programs that can reduce financial barriers to immunization. The AAP recently published a comprehensive list of resources that may assist providers with financial and practical issues regarding the ordering, stocking and administering of vaccines.21
Vaccines are one of the most effective available preventive health strategies.22 Although childhood immunization coverage is at an all-time high, coverage for the newer adolescent vaccines lags far behind. Providers can play a key role in improving adolescent vaccine coverage by adopting vaccine-friendly practices as reviewed in this article. Although obtaining high vaccine coverage for teens will be a challenge, its importance cannot be overstated. Delivering recommended vaccines to teens will afford them direct protection against communicable diseases and will prevent the spread of these diseases in communities. Furthermore, providers can use vaccine visits as opportunities to provide teens with other needed general preventive and medical services.
- Centers for Disease Control and Prevention (CDC). Recommended Immunization Schedules for Persons Aged 0 Through 18 Years — United States, 2010. MMWR. 2010;58(51&52):1–4. Available at: www.cdc.gov/mmwr/preview/mmwrhtml/mm5851a6.htm. Accessed July 15, 2010.
- Broder KR, Cohn AC, Schwartz B, et al. Working Group on Adolescent Prevention Priorities. Adolescent immunizations and other clinical preventive services: A needle and a hook?Pediatrics. 2008;121(Suppl 1):S25–S34. doi:10.1542/peds.2007-1115D [CrossRef]
- Humiston SG, Rosenthal SL. Challenges to vaccinating adolescents: vaccine implementation issues. Pediatr Infect Dis J. 2005;24(6 Suppl): S134–S140. doi:10.1097/01.inf.0000166161.12087.94 [CrossRef]
- CDC. National, state, and local area vaccination coverage among adolescents aged 13–17 years — United States, 2008. MMWR Morb Mortal Wkly Rep. 2009;58(36):997–1001.
- Markowitz LE, Dunne EF, Saraiya M, Lawson HW, Chesson H, Unger ERCDCAdvisory Committee on Immunization Practices (ACIP). Quadrivalent Human Papillomavirus Vaccine: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2007;56(RR-2):1–24.
- CDC. ACIP Provisional Recommendations for HPV Vaccine. Available at 22.214.171.124/vaccines/recs/provisional/default.htm. Accessed July 26, 2010.
- Fairchild A, Bayer R, Colgrove J, Wolfe D. Searching Eyes: Privacy, the State, and Disease Surveillance in America. Berkeley: University of California Press; 2007.
- Freed GL, Cowan AE, Gregory S, Clark SJ. Variation in provider vaccine purchase prices and payer reimbursement. Pediatrics. 2009;124Suppl 5:S459–S465. doi:10.1542/peds.2009-1542E [CrossRef]
- Palefsky JM. HPV infection in men. Dis Markers. 2007;23(4):261–272.
- Kharbanda EO, Stockwell MS, Fox HW, Rickert VI. Text4Health: A qualitative evaluation of parental readiness for text message immunization reminders. Am J Public Health. 2009;99(12):2176–2178. doi:10.2105/AJPH.2009.161364 [CrossRef]
- Ford CA, English A, Davenport AF, Stinnett AJ. Increasing adolescent vaccination: barriers and strategies in the context of policy, legal, and financial issues. J Adolesc Health. 2009;44(6):568–574. doi:10.1016/j.jadohealth.2008.11.015 [CrossRef]
- Taylor JA, Newman RD. Parental attitudes toward varicella vaccination. The Puget Sound Pediatric Research Network. Arch Pediatr Adolesc Med. 2000;154(3):302–306.
- Freed GL, Clark SJ, Butchart AT, Singer DC, Davis MM. Parental vaccine safety concerns in 2009. Pediatrics. 2010;125(4):654–659. doi:10.1542/peds.2009-1962 [CrossRef]
- Gellin BG, Maibach EW, Marcuse EK. Do parents understand immunizations? A national telephone survey. Pediatrics. 2000;106(5):1097–1102. doi:10.1542/peds.106.5.1097 [CrossRef]
- Block SL, Brown DR, Chatterjee A, et al. Clinical trial and post-licensure safety profile of a prophylactic human papillomavirus (types 6, 11, 16, and 18) l1 virus-like particle vaccine. Pediatr Infect Dis J. 2010;29(2):95–101. doi:10.1097/INF.0b013e3181b77906 [CrossRef]
- Slade BA, Leidel L, Vellozzi C, Woo EJ, et al. Post-licensure safety surveillance for quadrivalent human papillomavirus recombinant vaccine. JAMA. 2009;302(7):750–757. doi:10.1001/jama.2009.1201 [CrossRef]
- CDC. Syncope after vaccination--United States, January 2005–July 2007. MMWR Morb Mortal Wkly Rep. 2008;57(17):457–460.
- Rand CM, Shone LP, Albertin C, Auinger P, Klein JD, Szilagyi PG. National health care visit patterns of adolescents: Implications for delivery of new adolescent vaccines. Arch Pediatr Adolesc Med. 2007;161(3):252–259. doi:10.1001/archpedi.161.3.252 [CrossRef]
- Briss PA, Brownson RC, Fielding JE, Zaza S. Developing and using the Guide to Community Preventive Services: Lessons learned about evidence-based public health. Annu Rev Public Health. 2004;25:281–302. doi:10.1146/annurev.publhealth.25.050503.153933 [CrossRef]
- English A, Shaw FE, McCauley MM, Fishbein DBWorking Group on Legislation, Vaccination, and Adolescent Health. Legal basis of consent for health care and vaccination for adolescents. Pediatrics. 2008;121(Suppl 1):S85–S87. doi:10.1542/peds.2007-1115J [CrossRef]
- Sobczyk E. Vaccine finance resources for physicians. Pediatrics. 2009;124(Suppl 5): S573–S576. doi:10.1542/peds.2009-1542V [CrossRef]
- Maciosek MV, Edwards NM, Coffield AB, et al. Priorities among effective clinical preventive services: methods. Am J Prev Med. 2006;31(1):90–96. doi:10.1016/j.amepre.2006.03.011 [CrossRef]