Consent for Adolescent Vaccination: Issues and Current Practices

Article excerpt

Childhood immunization programs have achieved dramatic reductions in the incidence of vaccine preventable disease.[1,2,3] However, many children still do not receive all the recommended childhood vaccinations prior to school entry, despite school-entry immunization requirements in all states and the District of Columbia.[4] Additionally, after a child enters school, few compliance mechanisms assure adequate vaccination of newly recommended vaccines.

To improve vaccination of adolescents, the Advisory Committee on Immunization Practices (ACIP), American Academy of Pediatrics (AAP), American Academy of Family Physicians (AAFP), and American Medical Association (AMA) recommended the establishment of an adolescent immunization visit.[5] This visit is recommended at 11 to 12 years of age to ensure adolescents are vaccinated with the second dose of measles, mumps, and rubella vaccine; hepatitis B vaccine; tetanus and diphtheria toxoids; varicella vaccine (if indicated); and other vaccines indicated for certain adolescents. In addition, other indicated preventive services should be administered at this visit.

Adolescents and young adults account for much of the morbidity associated with hepatitis B virus (HBV) infection.[6] High morbidity due to HBV infection makes hepatitis B vaccination of adolescents a priority for public health officials at the local, state, and federal levels. Since most cases of acute hepatitis B reported among adolescents have no identifiable risk factor, vaccination of all adolescents is the only way to ensure adequate protection of those at risk. Although hepatitis B vaccination is recommended for high-risk persons,[7] in 1995 the recommendation for vaccination of adolescents with hepatitis B vaccine was expanded to include all adolescents 11 to 12 years old.[8]

To date, much of the success in vaccinating adolescents can be attributed to school-based programs.[9,10] vaccination of adolescents in school-based programs has advantages: Because school-based programs give access to the target population, they carry potential for high vaccination coverage among this group. School-based programs can also help lower the dropout rate among those receiving multidose vaccines such as hepatitis B vaccine. However, obtaining informed consent is a potential barrier to school-based vaccination programs. As minors, adolescents typically cannot be immunized without parental consent. Though clearly derived from the legal recognition of parental authority over and responsibility for the health of their minor children, such consent requirements nonetheless create logistical challenges to achieving high immunization coverage among adolescents. Additionally, federally purchased vaccine requires that parents receive certain information (eg the vaccine information statement) prior to vaccination. Such challenges are exacerbated in school-based vaccination programs because parents or legal guardians are rarely present at the time of vaccine administration.

State laws influence immunization practices in at least three critical ways, by: 1) specifying required childhood immunizations; 2) providing exemptions to immunization requirements; and 3) establishing parameters for parental consent for minors' receipt of medical services. Previous studies showed substantial variations in state regulations and practices, but did not specifically examine how issues of consent apply to minors' receipt of medical services.[7,8]

With particular attention to implications for improving immunization services for adolescents, this article examines state immunization requirements and the regulatory context in which immunization programs operate.

METHODS

The study was conducted December 1995 to January 1996. Data collection involved: 1) identification of state legislation relating to consent and immunizations through LEXIS-NEXIS,[R] a legal research database containing complete legal codes of every state and the District of Columbia; and 2) a telephone survey of state immunization program managers, project directors, and hepatitis coordinators. …