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Adolescent vaccination – the important role of GPs

Cristyn Davies, S. Rachel Skinner
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Ms Davies is a Research Fellow and PhD candidate in Child and Adolescent Health at the Faculty of Medicine and Health, The University of Sydney.

 

Dr Skinner is a Paediatrician and Adolescent Physician at the Sydney Children’s Hospitals Network; and Professor of Child and Adolescent Health at the Faculty of Medicine and Health, The University of Sydney, Sydney, NSW.

Abstract

GPs have an important role in supporting adolescent vaccination, including ensuring vaccinations are up to date and in promoting health literacy among parents and adolescents. With the recently approved COVID-19 vaccines and boosters for adolescents, it is timely for GPs to consider missed doses and catch-up vaccination as part of standard preventive health activity for the adolescent patient in general practice.

This article was first published in 2021 (Med Today 2021; 22(1-2): 57-61). It has been updated to include important advice on recently approved COVID-19 vaccinations for adolescents aged 12 years and above.

Key Points
    • Australia has high rates of vaccination in children, which also need to be achieved in adolescents.
    • School-based vaccination programs include human papillomavirus (9vHPV), diphtheria–tetanus–acellular pertussis (dTpa) and meningococcal vaccines, and are an effective and cost-efficient means to promote relatively high vaccination coverage for adolescents.
    • Providing catch-up vaccinations to low-coverage groups, such as Aboriginal and Torres Strait Islander adolescents, is important.
    • GPs should actively assess the immunisation status of adolescents attending their practice for other reasons and opportunistically vaccinate them if needed.
    • Recommendation from a health-care provider is the most important driver to increase vaccination uptake; therefore, GPs are in a unique position to help promote health and vaccine literacy among adolescents and parents.
    • COVID-19 vaccination is now recommended for adolescents aged 12 years and above in a two-dose schedule, with two mRNA vaccines available; a booster is also approved for those aged 16 years and above.
    • COVID-19 vaccines, including the booster, are not part of the school-based vaccination program.

Australia has achieved high rates of childhood vaccination, with substantial increases over the past 20 years.1,2 Much of this success can be attributed to the commitment of GPs and the effective strategies they have implemented. Vaccination of adolescents has become increasingly important, especially since the introduction of the national human papillomavirus (HPV) vaccination program, which has had a substantial impact on HPV-related disease, and other vaccines relevant to this age group. These have included the pertussis booster (diphtheria-tetanus-acellular pertussis [dTpa] vaccine), meningococcal ACWY and B vaccines, the influenza vaccine for  vulnerable groups, and now coronavirus disease 2019 (COVID-19) vaccines (Table 1).3 Equally high rates of vaccination need to be achieved in adolescents as in young children. 

As vaccination of adolescents primarily occurs through the school-based vaccination program, GPs may not see themselves as playing an important role. However, working alongside the school program, GPs are crucial, not only in achieving the same high coverage that is seen in early childhood vaccination programs for routine vaccines, but also for improving COVID-19 vaccine coverage. Disruption to student attendance at school from closures or restrictions during the COVID-19 pandemic may have interrupted vaccination initiation or completion, especially when more than one vaccine dose is required.4 Although GPs have always had a crucial role in providing vaccinations to adolescents with anxiety or special needs, as well as those who are Aboriginal or Torres Strait Islander, culturally and linguistically diverse, homeless or do not regularly attend school, reviewing all adolescents’ vaccination status in general practice has never been more timely.

School-based vaccination and vaccination coverage 

The Australian National Immunisation Program (NIP) funds vaccination across the lifespan, with vaccines listed in the schedule provided free for target groups. Unlike other populations, adolescents are primarily vaccinated en masse at school after parental consent is obtained.5 School-based vaccination has proven to be an effective and cost-efficient means to promote relatively high vaccination coverage for adolescents.6-9 In 2017, when the Australian quadrivalent HPV vaccine schedule required three doses, 80.2% of girls aged 15 years and 75.9% of boys aged 15 years received a full course of the vaccine.2 Of Aboriginal and Torres Strait Islander girls and boys aged 15 years who received the first dose, 79% and 77%, respectively, completed the three doses, compared with 91% and 90% of non-Indigenous girls and boys, respectively.2 Data are not yet available on coverage of the two-dose nonavalent HPV vaccine (implemented from 2018 for adolescents aged 14 years or younger at the first dose) or dTpa and meningococcal ACWY vaccines.

It is important to provide catch-up vaccinations to low-coverage groups, particularly Aboriginal and Torres Strait Islander adolescents, given their lower vaccination completion rates and longer time to completion.2,10 As Aboriginal and Torres Strait Islander women have twice the incidence and four times the mortality rate of cervical cancer as other Australian women, recommending HPV vaccination to Aboriginal and Torres Strait Islander adolescents represents an opportunity to reduce this health disparity.2,11,12 

Although school programs aimed at adolescents generally result in relatively high vaccination uptake, coverage for adolescent vaccinations remains more than 10 percentage points lower than that achieved for childhood vaccinations.1 Ideally, vaccination coverage rates in adolescence should be higher; for example, the WHO has called for coverage of 90% to achieve elimination of cervical cancer.13 GPs are an important part of the solution for achieving this goal (Box). 

Role of GPs in adolescent vaccination

Addressing missed opportunities for vaccination in general practice 

Missed vaccination opportunities during consultations in healthcare settings are a major concern during both childhood and adolescence. Adolescents who have missed vaccinations offered in the school program because of school absence or other reasons are usually provided with a letter and recommendation to visit a GP or council clinic to catch up on the vaccine doses missed. Given the decline in frequency of visits to GPs in adolescence compared with childhood, this often does not eventuate.14 Young people aged 15 to 25 years have the lowest proportion of face-to-face time spent with GPs in Australia.15 

Unlike in some countries, such as the United States, where reimbursements are provided for preventive primary care visits in adolescence, during which HEEADSSS (home environment, education/employment, eating habits, activities, drugs, sex/sexuality, suicide/depression and safety) screening and vaccinations routinely take place, there is no Medicare rebate for GP preventive health care visits for adolescents and young adults in Australia.16,17 This means that GPs need to actively consider assessing immunisation status of adolescents attending their practice for other reasons and opportunistically vaccinate them when it is clear they have missed a vaccine dose in the school program or have not completed their recommended COVID-19 vaccine course (Table 2). Adolescence is also an opportune time to ensure catch-up of missed doses of childhood vaccines.3,18 

Providing a strong recommendation 

GPs also play a key role in facilitating adolescent vaccination through the school program, with multiple studies showing that a recommendation from a healthcare provider is the most important driver to increase vaccination uptake.19,20 Parental vaccination decision-making on behalf of adolescents is influenced by physician recommendation, government recommendation, perceived benefits of the vaccine and concerns about side effects and vaccine safety.19,21-23 Social determinants of health, including socioeconomic status and ethnicity, and factors relating to patient engagement have also been found to influence vaccination uptake, although to a lesser extent in school-based programs.24,25 Parental barriers to adolescent vaccination include not receiving a provider’s recommendation, lack of information about vaccination, concerns about timing of vaccination (e.g. adolescent’s age for HPV vaccination) and misconceptions about efficacy and safety. 

Offering vaccines as a package

It is important to present adolescent vaccinations that may have been missed as a ‘package’.26 If more than one vaccination has been missed, more than one should be offered at the same time. If an appointment is made to complete the course on another day, there is increased risk of noncompletion. For example, emphasising cancer prevention benefits and discussing HPV vaccination at the same time as recommending dTpa vaccination is more likely to result in higher uptake of both vaccinations. This may not apply to pandemic vaccines (such as COVID-19 vaccines) as they may need to be administered outside of routine vaccine schedules and may not yet be approved for coadministration.

Promoting vaccine health literacy among adolescents and their parents 

GPs have a unique opportunity to overcome health and vaccine literacy deficits among adolescents and parents. Parents’ health literacy is positively correlated with adolescent health literacy and health.27 Providing recommendations and education to parents and adolescents about vaccination as a prevention strategy to reduce disease burden and promote health and wellbeing is crucial. Challenges may include specific cultural and religious beliefs, low literacy generally, misinformation and inequities, such as reduced access to health services and diminished ability to seek help with the vaccine decision-making process.24 These factors should be considered when dealing with parent and adolescent queries and concerns about vaccines; well-designed resources, such as the Sharing Knowledge About Immunisation ‘Is the HPV vaccine really safe?’ factsheet, can be used to support conversations.28 

Challenges that providers face in discussing vaccination with adolescents and their parents include discomfort with talking about sexual behaviour (e.g. with HPV vaccination), lack of time or incentive for patient education, and lack of a system that issues reminders about vaccine status and whether multiple doses are needed.29,30 Overcoming these barriers, such as by using automated systems for reminders, can directly affect adolescent vaccination uptake. 

Overcoming incomplete vaccination of adolescents

Assessing vaccination history of all adolescents in the practice

Young people aged 10 to 19 years require an assessment of their immunisation history to ascertain any missing childhood or adolescent vaccinations and to develop a catch-up schedule. The vaccination records of all adolescent patients in the practice can be reviewed by checking their records in the Australian Immunisation Register (AIR), including checking that any previous vaccines were administered in the recommended dosing intervals and at the correct age.18 Appointments should be scheduled to complete vaccinations for patients who are clearly behind on the schedule.

Assessing vaccination history of adolescents presenting as new patients

An adolescent presenting to the practice as a new patient for any reason should be asked about vaccination, ideally when undertaking a HEEADSSS assessment, but any time is appropriate. As parents and adolescents may not have accurate records or knowledge of vaccination status, GPs can identify whether vaccinations are up to date using Health Professional Online Services (www.servicesaustralia.gov.au/organisations/health-professionals/services/medicare/hpos) or by calling the AIR enquiries line (1800 653 809).3

If a vaccination may have been administered but is not recorded on the AIR, the relevant immunisation provider for that vaccine should be contacted.3 If doses cannot be confirmed because of incomplete documentation, it should be assumed that those doses have not been administered. Serological testing is not routinely recommended.18 There are no risks associated with additional doses of vaccines when they have already been received, apart from a possible increase in local adverse events with frequent doses of dTpa-containing vaccines.18 All vaccine doses administered should be reported to the AIR, and data will need to be entered directly if the general practice software does not automatically report vaccinations. 

Missing out or being late for vaccinations listed in the NIP may have financial ramifications for families who will be unable to receive their appropriate childcare and Family Tax Benefit payments on time.

SARS-CoV-2 and COVID-19 vaccination for adolescents

Most adolescents with COVID-19 have mild symptoms, including fever, cough, sore throat, blocked or runny nose, sneezing, muscle aches and fatigue, or no symptoms at all.31 Less common symptoms include changes in smell or taste and diarrhoea or vomiting.31 Severe COVID-19 symptoms such as pneumonia with respiratory distress may require admission to hospital or intensive care, although these are uncommon in children and adolescents and very rarely cause death.31-33 

Vaccination against COVID-19 is recommended for adolescents aged 12 years and above in a two-dose schedule, with two mRNA vaccines available; Comirnaty (tozinameran; Pfizer) and Spikevax (elasomeran; Moderna) (Table 3).34 Adolescents  who are severely immunocompromised are recommended to receive a third primary dose four weeks to two months after administration of the second primary dose. A booster  vaccine is now also recommended for adolescents aged 16 years and above, to be administered three months after the primary course.35,36 The booster is still recommended for adolescents who have recently had severe acute respiratory syndrome coronavirus 2 (SARS CoV-2) infection and can be administered (if eligible) from the time of recovery from acute illness and within four months.35 Currently, only one vaccine is registered for use as a booster for this age group.35

Direct benefits of vaccinating adolescents against COVID-19 include:31,34

  • strong immunogenicity and efficacy against symptomatic COVID-19 infection
  • prevention of SARS-CoV-2 infection 
  • effectiveness against hospitalisations and deaths due to COVID-19 
  • prevention of other complications associated with SARS-CoV-2 infection, such as paediatric multisystem inflammatory syndrome and ‘long COVID’. 

Adolescents appear to have similar COVID-19 infection rates to adults, but lower severity of disease, with around 4 to 7% experiencing severe outcomes.34,37,38 Vaccinating adolescents will help reduce SARS-CoV-2 transmission in the broader population, and support their mental health by reducing disruption to education through preventing disease and reducing potential transmission and outbreaks in schools.34 

Supporting COVID-19 vaccination 

The attitudes of parents and guardians strongly influence the likelihood of young people under the age of 18 years receiving COVID-19 vaccination.39 Healthcare providers, including GPs, remain the most relied on source for COVID-19 vaccine information and are well placed to promote vaccine acceptance by addressing parental and adolescent concerns about safety and effectiveness. GPs should keep up to date with emerging evidence on COVID-19 vaccines, as adverse events surveillance monitoring systems are frequently updated, and support confidence in the safety of COVID-19 vaccines for this age group.40,41 GPs are also encouraged to keep abreast of updates and approvals on boosters, as they may be approved for younger age groups in the future. 

Providing clear, concise communication to address any misinformation about vaccine safety and efficacy, as well as being aware of demographic characteristics associated with low health literacy and inequities in access to evidence-based information are crucial.39 Disadvantaged young people (e.g. low socioeconomic or minority ethnic status) and those with pre-existing health conditions (e.g. cancer, obesity, chronic respiratory disease, chronic kidney disease, cardiovascular disease, neurological disorders, immune disorders, metabolic disease and haematologic disorders) are at greater risk from COVID-19 disease. The National Centre for Immunisation Research and Surveillance has developed decision aids to help people decide if COVID-19 vaccination is right for them and their children. Decision aids are available for children aged 5 to 15 years (https://www.ncirs.org.au/covid-19-decision-aid-for-children) and those aged 16 years and above (https://www.ncirs.org.au/covid-19-decision-aid-for-adults).

Vaccine side effects 

SARS-CoV-2 infection is associated with an increased risk of myocarditis, pericarditis and cardiac arrhythmia.42 Messenger RNA vaccines have also been associated with a small increased risk of pericarditis and myocarditis, mostly in young men.43,44 Myocarditis and pericarditis are rare conditions that occur more often in young men, and most commonly after the second vaccine dose.43,44 The cause of myocarditis in the absence of a vaccine is often unknown, but can be an immune response to an infectious agent, toxin or autoimmune disorder. 

Myocarditis and pericarditis are seen much less often after vaccination than as a result of SARS-CoV-2 infection.45 Most people who have developed myocarditis or pericarditis after vaccination have made a complete recovery within a short time, although no data exists as yet on long-term follow up.43,44 The Australian Technical Advisory Group on Immunisation (ATAGI) advises that pre-existing cardiac conditions are not a contraindication to mRNA COVID-19 vaccination.43 The Guidance on Myocarditis and Pericarditis after mRNA COVID-19 Vaccines provides advice on how to manage patients who develop pericarditis or myocarditis after vaccination and is available online (www.health.gov.au/sites/default/files/documents/2021/11/covid-19-vaccination-guidance-on-myocarditis-and-pericarditis-after-mrna-covid-19-vaccines_1.pdf).43 

Communicating with adolescents and parents about vaccination 

Trust can be built with adolescents  and parents through open and respectful communication, underpinned by evidence-based information on vaccination risks and benefits. At the same time, it is important that clear recommendations to vaccinate are provided and that opportunities to vaccinate are not missed. Regardless of the reason for a consultation, when vaccinations are outstanding, using language such as ‘I recommend you receive these vaccinations today’, rather than ‘What would you like to do about these vaccinations?’, can influence parent and adolescent decision-making.26 

Given that policies in the education environment mean that parents usually provide consent for vaccination of adolescents under 18 years of age in the school vaccination program, there are ethical considerations in balancing emerging adolescent autonomy and their desire to also be involved in vaccine decision-making.46 All states and territories have medical consent policies that recognise the competency of mature minors. This means that adolescents under the age of 18 years are able to provide their own consent to vaccination if they are assessed as Gillick competent by the practitioner. Generally, healthy adolescents aged at least 14 years have capacity to consent to a low-risk intervention, such as vaccination.47 

Adolescents do not always make connections between their behaviour (e.g. sexual activity or smoking) and their current or future health outcomes, and they can experience difficulty assessing the quality of health information, which they most frequently access online. Nuanced messaging targeted at specific age groups may be needed, recognising that different barriers may exist to receiving HPV vaccination for a younger adolescent compared with barriers to receiving meningococcal ACWY vaccination for an older adolescent. 

Younger adolescents are less able to moderate their needle-related fear and anxiety because of incomplete cognitive maturation. Vasovagal syncope is the most common severe adverse event experienced with vaccination in adolescence.48 Needle-related anxiety can affect an adolescent’s choice of whether to have a vaccine, despite parental consent. Using youth-friendly language and resources to explain vaccination benefits and side effects can promote adolescent vaccination literacy and facilitate discussion with parents and involvement in vaccination decision-making, as well as helping to mitigate needle-related anxiety. The WHO has produced an excellent resource to assist vaccination providers in managing this anxiety.49 Explanations of exactly what will happen and what the needle will feel like, along with appropriate distraction methods, can also assist younger adolescents to cope with needle-related anxiety.50 Communicating successes achieved through vaccination programs can assist in counteracting concerns about vaccine efficacy and safety and mitigate vaccine hesitancy.

Conclusion

GPs are key players in parents’ and adolescents’ decisions to have vaccinations. They can opportunistically prioritise vaccination during routine consultations and ensure the adolescent is up to date with the vaccination schedule recommended in the NIP. The partnership between GPs and the school-based vaccination program is important for achieving high vaccination uptake in adolescence. We need to eliminate the long-standing health inequity experienced by adolescents due to lower vaccination coverage compared with that in early childhood. GPs are also key to improving uptake in marginalised adolescent populations with persisting low vaccination coverage. MT

COMPETING INTERESTS: Ms Davies: None.  Dr Skinner reports her institution has received honoraria for educational presentations from Merck and Seqirus, outside the submitted work.

 

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