Teen Health Supervision


The beginning of adolescence serves as a platform for vaccination. The term "platform" is used as the intention is for health providers to discuss with adolescents and their parents growth, puberty and mental development. Discussions with the parents should include communicating with and parenting adolescents, with a segue into vaccinations that provide additional protection for their adolescent.

For adolescents who do not receive an annual influenza vaccine, this set of vaccinations is often met with a great deal of trepidation. This is because the last time they were vaccinated was at 4-6 years of age, which for them was half a lifetime ago. In the interim, vaccination may become extremely painful in their mind and it is not unusual for adolescents to fight being vaccinated or to faint following vaccination. Clinic staff and parents should be reassuring but not be apologetic or castigating.

Currently, the adolescent vaccination platform consists of the Tdap (tetanus, diphtheria, acellular pertussis) booster, HPV9 (Human papillomavirus) series and meningococcal series. 


Tdap Vaccine

Protection against tetanus, diphtheria, and pertussis with a booster vaccination (Tdap) is important in adolescents. Of the three pathogens, adolescents are most at risk from pertussis because large outbreaks occur annually. Pertussis, caused by Bordatella pertussis, is divided into three clinical stages - catarrhal, paroxysmal, and recovery. The catarrhal stage is characterized by mild upper respiratory symptoms. The paroxysmal stage follows and consists of paroxysms of cough with an inspiratory whoop (at least in younger children) which is why it is commonly known as Whooping Cough. The paroxysms of cough frequently result in posttussive emesis. Symptoms eventually wane over weeks to months in the recovery (or convalescent) stage. In approximately 50% of adolescents, the cough lasts 10 weeks or longer, and antibiotics will not shorten the clinical course. Significant complications can include weight loss, syncope, sleep disturbances, rib fractures, and pneumonia, and can lead to poor school performance and school dropout.

Diphtheria is caused by toxigenic strains of Corynebacterium diphtheria with clinical manifestations including membranous pharyngitis, bloody nasal discharge, and laryngotracheitis. Untreated, the case fatality rate is nearly fifty percent but even with treatment, the case fatality rate is 5-10%. Due to vaccination, diphtheria is an exceedingly rare disease although in the 1920s there were upwards of a quarter million cases a year in the United States.

Tetanus is caused by neurotoxins produced by Clostridium tetani which result in severe muscle spasms and autonomic dysfunction. The bacterium is introduced into wounds from objects contaminated with dirt or manure containing its spores. Tetanus has also become very rare due to vaccination with only about thirty cases each year in the United States.

Tdap should be given as a single dose at 11-12 years of age.   If Td (tetanus, diphtheria without pertussis) was previously administered, a single dose of Tdap should be given regardless of the time of receipt of the last tetanus- or diphtheria-containing vaccine. Pregnant adolescents are recommended to receive a Tdap during each pregnancy to protect the infant from Pertussis. In order to maximize placental transfer of antibodies, Tdap is best given at 27-36 weeks of gestation.


HPV Vaccine

Human papillomaviruses (HPV) infect the skin and mucous membranes. Of the more than 150 types known, about forty preferentially grow in the anogenital tract and are primarily transmitted through sexual contact. About half of anogenital HPV types are considered high risk in that they have the ability to cause cancer. Anogenital HPV account for over 17,000 cases of cancer in women and 9,000 cases in men each year in the United States. These include cervical, oropharyngeal, rectal, vulvar, vaginal, and penile cancers.

The first generation of vaccines focused on HPV types 16 and 18 as together they account for about 70% of cervical cancer. The first vaccine licensed in the U.S. was Gardasil®, which additionally protects against types 6 and 11 that together account for 90% of the cases of genital warts. Cervarix® is another vaccine licensed in the US. Although Cervarix® is extensively used in other countries; it did not command much of the market in the US. This may be due in part to Cervarix® lacking protection against genital warts.

Gardasil®9 was licensed in 2014. In addition to the original four types in the first vaccine, it protects against five more HPV types. The seven high-risk types (16, 18, 31, 33, 45, 52 and 58) bring the protection from cervical cancer up to about ninety percent.

The American Academy of Pediatrics and the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention recommend routine HPV immunization of females and males 11 or 12 years of age, although the vaccine can be started as early as 9 years.

As of October 2016, a two-dose schedule is recommended for children younger than 15 years of age who are starting HPV vaccination. The second dose is administered 6-12 months after the initial dose. The two-dose regimen is suitable because antibody responses to the vaccine are much higher in young adolescents compared to older adolescents.

Adolescents and adults 15-26 years of age should continue to receive three doses of the vaccine on a schedule of 0, 1-2, and 6 months. Adolescents younger than 15 years of age who received two doses less than 6 months apart also require a third dose.

If the vaccine schedule is interrupted, the series does not need to be restarted. Follow up studies 8 to 10 years after HPV4 vaccination have shown no waning of protection. Long term follow-up studies are being conducted to determine the duration of effectiveness for all HPV vaccines.

Despite the decades of pre-licensure research and large clinical trials demonstrating HPV vaccination safe and effective, providers still face resistance vaccinating adolescents. In fact, under the older (three-doses at every age) recommendation, only 42% of adolescent females and 28% of adolescent males completed the series.

Parental concerns include questions about safety (stirred up anti-vaccination groups) and worries that vaccinating gives teens the green light to have sex. Studies show that vaccinated adolescents are no more likely to have sex, obtain a sexually transmitted infection or become pregnant than their peers. Indeed the only things shown to prevent sexual activity in adolescents is clear communications about the subject from their parents and parental monitoring. Monitoring refers to parents knowing where their adolescents are and removing them from risky situations.


Meningococcal Vaccines

Meningococcal infections are caused by Neisseria meningitides and can result in diseases such as meningitis (50% of cases), conjunctivitis, septic arthritis, and most severely, meningococcemia. Meningococcal infections can have an insidious onset appearing like the flu with fever, headache, and body aches.   Many providers mistakenly believe meningococcal meningitis and meningococcemia are readily recognizable by their petechial, purpuric or ecchymotic skin changes but such signs exist in only about sixty percent of cases at first presentation. Meningococcal illness can rapidly progress to include symptoms such as photophobia, altered mental status, nuchal rigidity, limb ischemia, hypotension and shock. The disease can be fatal in a matter of hours. The overall mortality rate is between 10 and 15%, with the highest morbidity and mortality rates in adolescents.

Transmission of meningococcal infections requires close contact, spreading primarily through respiratory droplets. Adolescents have higher rates of disease due to activities such as kissing and smoking and living in crowded environments such as college dormitories and military barracks.

While meningococcal disease remains rare, and the overall annual incidence has decreased, routine immunization of adolescents is recommended. Meningococcal immunization against serogroups A, C, W, Y is recommended for immunocompetent children starting with 1 dose at age 11 through 12 years, with a booster dose given after their 16th birthday. If not previously immunized, the first dose can be given from ages 13-15 years. If the first dose is administered at age 16 years or older, a booster dose is not needed. Serogroups C, W, and Y account for approximately three quarters of cases among adolescents and young adults. Menactra® and Menveo® are the vaccines available to vaccinate adolescents against serotypes A, C, W, and Y.  

Serogroup B accounts for most of the rest of the cases of meningococcal disease in adolescents in the U.S. There are two licensed vaccines in the U.S., Bexsero® and Trumenba®. The two vaccines are not interchangeable and their dosing schedules differ. Bexsero® requires two doses given at least 1 month apart while Trumenba® is either given in a 2 dose series (0, 6 months) or a three dose series (0,2, 6 months). The AAP and the ACIP of the CDC recommend that people 10 years and older who are at increased risk of meningococcal disease receive this vaccine (people with persistent complement component deficiencies, anatomic or functional asplenia, and people at risk because of an outbreak).

MenB vaccination is not routinely recommended for healthy individuals. It may, however, be given to healthy adolescents who wish to obtain short-term immunity at the preferred age of 16-18 years. This is a category B recommendation and thus administration should be discussed between the family and the physician. It is an expensive vaccine and long-term efficacy is still unknown.


More Info: HPV Counseling Tips

Here are some tips to remember when counseling patients and their caregivers: 

1. The HPV vaccine should be treated like all other vaccines. Do not separate the HPV vaccine out making it seem special or different. Say something like, "Your son is going to receive three vaccines today, the Tdap, the HPV and the meningococcal.

2. If a parent hesitates, reinforce the vaccines safety and its necessity to prevent cancer. Reassure parents with a statement like, "The HPV vaccine is not new, and has been recommended for more than 10 years. Hundreds of millions of doses have been given worldwide and if there was a safety problem, we would know." Also let them know that studies indicate vaccinated adolescents are no more likely than other adolescents to be sexually active.

3. Address any specific questions or concerns the parent may have. Give the parent a handout or a trusted website on the subject.

  1. It is important to be non-judgmental about both value issues and maturity issues. We all do stupid things and we don't know it all. Teens should feel comfortable sharing their mistakes.
  2. Behaviors should be termed as "healthy" or "unhealthy" and not as "good" or "bad". Good and bad have moral implications. A highly charged example is premarital sex. It is best to discuss the associated health risks and not the religious implications. Most providers know not to "scold" teens over morality issues but fewer know not to praise them. For instance, a provider may tell a teen that she is proud of the young lady for not having sex. Of course, if the girl misled the provider and is already sexually experienced or if she does have sex in the future, she will be reluctant to share this information to avoid disappointing the provider. A better conversation would have been, "not having sex is a healthy decision, so you don't have to worry about being pregnant or having an STI."
  3. The teen should be engaged in the discussion. For example, while talking about smoking, you might ask questions such as these: "Do people you know smoke?" "What do you think about that?" "Why do they smoke?" "Do you see any problems with smoking?" "What else could cigarette money be spent on?" "What do you know about what it does to hearts or lungs?" "Why don't smokers think it will happen them?" Sure, it is much quicker to say, "don't smoke because it is bad for you," but advising without engaging is often not effective. Everyone already knows smoking is bad.

More Info: immunization schedule from Center for Disease Control