Adolescent immunisation: the next big thing?

Finn A, Clarke E, Mytton J. Arch Dis Child (2010). doi:10.1136/adc.2010.192070 1 of 3 Adolescent immunisation: the next big thing? Adam Finn,1 Ed Clarke,1 Julie Mytton2 has already been instituted in a number of countries including France, Germany and the USA following its recommendation by the Global Pertussis Initiative.9 10 Currently, severe and fatal cases of pertussis continue to occur in infants too young to have been fully immunised. Epidemiological studies suggest that this is because Bordetella pertussis continues to circulate, particularly in young adults whose vaccine-induced immunity has worn off, causing persistent coughs and, on rare but devastating occasions, transmission to their recently born offspring or other infant contacts.11 Notwithstanding the eventual triumph, in the UK in 1988, of universal rubella immunisation over selective immunisation of young adolescent girls, cost-benefi t calculations have effectively ruled out offering HPV vaccine to adolescent boys, at least for the present12 and have also resulted in UK use of bivalent rather than quadrivalent HPV vaccine. However, such considerations might not apply to immunisation against the other vaccine-preventable, sexually transmitted, cancer-causing virus—hepatitis B, as the vaccine is much cheaper. In 1992, the WHO recommended universal hepatitis B immunisation in all countries, giving the option of adolescent, rather than infant immunisation in low prevalence countries, such as the UK.13 Discussions about the implementation of universal hepatitis B immunisation in the UK are on-going and could eventually culminate in inclusion of the vaccine into the infant schedule if the logistics and cost can be got right. An alternative for the UK could be the immunisation of young teenagers, close to the age of onset of sexual activity. The communication issues are similar to those relating to HPV—in the end the only major difference from the recipient’s perspective is that the cancer to be prevented is in a different organ. Furthermore, the three dose schedules match and it is already known that the vaccines can be given concomitantly without loss of the protective effi cacy of either.14 Meningococcal disease in the UK primarily affects infants and young children, with a second smaller peak occurring in adolescents.15 The overall incidence rates and relative predominance of different meningococcal serogroups varies widely between continents and regions and this has infl uenced how vaccines have been developed and used. Effective conjugated capsular polysaccharide vaccines are now licensed and available in Europe against of between 80% and 90%.2 Furthermore, despite concerns to the contrary, a workable and effective means of involving both parents and children in the consent process has been implemented.3–5 Inevitably, disorders developing during the days, weeks and months after immunisation will continue to be attributed to the vaccine by some, despite the availability of valuable baseline epidemiology against which incidence rates can be benchmarked.6 7 But, with luck, both the public and the media will have learnt enough following the false alarmism surrounding measles mumps rubella (MMR) and autism, to know that chronology does not always denote causality. On the back of this success, is there scope to widen this approach to include other vaccines for which a case can be made for universal administration, to young teenagers and, in association with this, is there a case for offering HPV immunisation to boys as well as girls? It is not hard to fi nd additional candidates. A booster vaccine combining tetanus, low dose diphtheria and trivalent inactivated polio (Td/IPV) is already recommended for teenagers aged between 13 and 18 years of age within the standard schedule. However, reported uptake rates of Td/IPV are highly variable between primary care trusts (PCTs) due to differences in the Child Health reporting systems. Some areas are unable to report any data, while others underreport due to incomplete age groups or incomplete identifi cation of children eligible to receive the booster.8 Transferring this programme to run alongside HPV for girls, and as a platform upon which to build a secondary school-based programme for boys would require standardisation of collection systems for the Td/IPV booster and should lead to complete and accurate recording of uptake rates. Ensuring that more individuals receive a fi fth dose of these antigens is important as they are thought to be required to ensure reliable individual protection into adult life. A small further step would see the addition of acellular pertussis to the Td/IPV adolescent vaccine. Indeed, adolescent pertussis vaccination ABSTRACT The recent introduction of the human papillomavirus (HPV) vaccine into the routine immunisation schedule for girls in the UK has reaffi rmed the possibility of widespread adolescent immunisation, assuming appropriate prior consultation and resource allocation. On the back of this success, it is timely to consider the case for extending the programme of school-based adolescent immunisations to include the provision of both additional primary immunisations as well as important booster doses of vaccines given earlier in childhood. Such a programme, if well designed, would ensure that individual protection from vaccine preventable disease was maximised prior to school leaving and, of equal importance in some cases, that herd immunity was sustained more effectively in the population as a whole. The possible contents of a re-invigorated adolescent immunisation programme are discussed considering those vaccines which are already available and for which costbenefi t calculation may therefore be of prime importance, as well as vaccines which may become available in the future and for which the issues may be more complicated. The importance of providing balanced, accurate, appropriate and accessible information regarding adolescent immunisation is also highlighted.