How to increase vaccination rates in adolescents

Case scenario

Kushal is a 16-year-old male who missed his dTpa vaccination in 2021 due to school closures during the COVID-19 pandemic. Neither Kushal nor his mother fully understand the importance of vaccination or the diseases that this vaccine protects against.

Learning objectives After reading this article, pharmacists should be able to: Identify diseases targeted by adolescent vaccines Describe reasons for lagging adolescent vaccination rates in Australia Discuss how pharmacists can increase adolescent vaccination uptake Identify the primary goal when talking to patients who are ready to vaccinate Outline when adolescent immunisations are recommended to be given according to the National Immunisation Program (NIP) schedule. Competency standards (2016) addressed: 1.1, 1.4, 1.5, 3.1, 3.5 Accreditation number: CAP2503SYPNB Accreditation expiry: 29/02/2028

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Introduction

Immunisation has reduced disease, disability and death from 26 infectious diseases. While Australia has a relatively high immunisation coverage by global standards, there are opportunities for improvement, particularly in the adolescent cohort. Reduced vaccination uptake in young people has consequences for their future health status as well as the health of the Australian population.

Immunisation in Australia

The World Health Organization considers immunisation to be the most effective medical intervention available to prevent death and reduce disease in our communities. Since routine immunisations of infants were introduced in Australia in the 1950s, death or disability from many once-common infectious diseases is now rare.

All vaccines currently used in Australia offer enough protection to prevent disease in most vaccinated individuals. However, high rates of immunisation are essential to protect the population from preventable diseases.

The National Immunisation Program (NIP)

The NIP aims to increase national immunisation coverage to reduce vaccination-preventable diseases by administering immunisations at specific times throughout a person’s life. Free vaccines on the NIP are available to people who hold or are eligible to hold a Medicare card, including adolescents. Free catch-up vaccinations are also provided to people if they are missed for any reason. The National Immunisation Program Vaccinations in Pharmacy (NIPVIP) Program was introduced on 1 January 2024 and allows eligible patients to receive free NIP vaccines in a community pharmacy, which makes vaccination accessible and affordable. On 29 April 2024, the program expanded to include off-site vaccinations in residential aged care and disability homes, enabling pharmacies to claim payments for administering NIP vaccines in these settings.

The NIP Schedule outlines recommended vaccines and schedule points.

Diseases targeted by adolescent vaccines

Adolescent vaccines protect against five key diseases.

Diphtheria

Diphtheria is a serious bacterial disease that primarily affects the nose and throat and can cause skin infections. It is spread through coughing and sneezing or direct contact with infected wounds or contaminated objects. Toxins released by the bacterium may cause a membrane to grow across the throat or windpipe, potentially leading to airway obstruction, making breathing difficult. If the membrane completely blocks the airways, the patient can suffocate and die. The disease can also cause systemic complications, including myocarditis and neuropathy. Due to high rates of vaccination, diphtheria is rare in Australia.

Tetanus

Tetanus is caused by Clostridium tetani bacteria found in soil and animal faeces, which can affect the nerves in the brain and spinal cord. Bacteria can enter the body through a wound (particularly dirty or deep wounds) or a bite. The infection can lead to severe muscle spasms, particularly in the neck and jaw (lockjaw). Around 10% of people who get tetanus will die, with babies and older people having the highest risk of death.

Tetanus is now rare in Australia due to vaccination rates, although it mostly occurs in older adults who are not adequately vaccinated.

Pertussis

Pertussis (whooping cough) is a highly contagious bacterial respiratory infection caused by Bordetella pertussis, spread through coughing or sneezing. It can lead to severe coughing fits, difficulty breathing, pneumonia, brain damage and sometimes death. Despite the availability of vaccines for more than 50 years, pertussis remains a challenging disease to control as immunity wanes over time. Pertussis is especially serious for babies, but it can affect people of any age. It is always circulating in the community and epidemics occur in Australia every 3–4 years. There is currently a pertussis epidemic in Australia.

Human papillomavirus (HPV)

HPV is a group of viruses spread through sexual contact. HPV is responsible for almost all cases of genital warts and cervical cancer. It can also lead to cancer of the anus, vagina, vulva and penis. Since the introduction of HPV vaccination in 2007, there has been a steady decline in high-grade cervical abnormalities in younger women. Research shows that widespread use of the HPV vaccine dramatically reduces the number of women who will develop cervical cancer. The Australian target of vaccinating 90% of all eligible people against HPV is one of three pillars in the Cervical Cancer Elimination Initiative to achieve cervical cancer elimination by 2030.

Men who have sex with men (MSM) may be disproportionally at risk of HPV infection and associated diseases. This cohort may be up to 20 times more likely to develop anal cancer and 2–3 times more likely to develop genital warts compared with heterosexual males.

Males born before 1999 may not previously have been offered the HPV vaccine and may derive little herd benefit from the vaccination of females.

Prevention of HPV infection is important as there is currently no routine screening program for early detection of anal cancer.

Meningococcal ACWY

Meningococcal disease is a serious infection caused by Neisseria meningitidis, commonly referred to as meningococcus. Serogroups A, B, C, W and Y most commonly cause the disease and are transmitted in secretions from the back of the nose and throat, generally through close and prolonged contact. Meningococcal disease can develop quickly and is a medical emergency as it can be fatal within hours without treatment. Since the introduction of the meningococcal ACWY vaccination, the incidence of meningococcal disease has reduced, and the overall rate of invasive meningococcal disease fell to 0.3 per 100,000 in 2021.

Immunisations for adolescents

The NIP provides a series of immunisations for adolescents, which are primarily delivered through school-based vaccination programs and other health services, including pharmacies.⁸

Diphtheria-tetanus-pertussis (dTpa)

Adolescents aged 11–13 years (Year 7) should receive a booster dose of combined diphtheria-tetanus-pertussis (dTpa) reduced-antigen vaccine. A booster dose is required as pertussis immunity wanes after the childhood primary series, the last vaccine being administered at 4 years.^, Fully vaccinated adolescents will be protected from these diseases for many years, although they may need a tetanus or pertussis booster in the future. Adolescents should receive one dose of pertussis-containing vaccine, regardless of the number of previous doses they received before 10 years of age.²⁶

Two dTpa vaccines are available: Boostrix and Adacel. Both are in 0.5 mL pre-filled syringes and are administered as an intramuscular injection (IMI) into the deltoid muscle of the upper arm.

Human papillomavirus (HPV)

Adolescents are recommended to receive the 9vHPV (9-valent HPV) vaccine starting from age 9. However, the optimal age is 12–13 years (Year 7).³⁰

Gardasil 9 is the adolescent HPV vaccine available on the NIP from age 12–13 years with a recommended single-dose schedule for those who are not immunocompromised. Free catch-up vaccinations are offered up to and including 25 years of age.³⁰

Meningococcal ACWY (MenACWY)

It is recommended adolescents aged 14–16 years (Year 10) receive one dose of meningococcal ACWY vaccine. MenQuadfi is the vaccine available on the NIP for adolescents aged 14–16 years.³¹ Meningococcal ACWY vaccine comes in a pre-measured 0.5 mL dose and is given as an IMI, usually in the deltoid muscle.³² Catch-up immunisations for meningococcal ACWY are free for eligible people under 20 years old under the NIP.

Patients who are not eligible under the NIP can access them privately, by paying a fee. If they have private health insurance, they may be able to claim a rebate, depending on their policy and coverage.

Adolescent immunisation rates in Australia

Immunisation uptake in adolescents declined in 2023 when compared with 2022.²

In 2023, 85.5% of adolescents turning 15 years received the dTpa adolescent booster dose compared to 86.9% in 2022.

In 2023, 84.2% of Australian girls had received at least one dose of HPV vaccine by 15 years of age, down from 85.3% in 2021; 81.8% of boys had received at least one dose, down from 83.1%.

Coverage of an adolescent dose of meningococcal ACWY vaccine in adolescents turning 17 years in 2023 was 72.8%, compared with 75.9% in 2022.

Coverage rates for all types of vaccines in First Nations adolescents were lower than rates for non-First Nations adolescents, while adolescents in lower socioeconomic areas had lower immunisation rates than those from higher socioeconomic areas. These differences may be a result of a lack of accessibility due to location, fewer financial resources, or lower rates of education and health literacy.

Why are adolescent vaccinations lagging?

The decrease in immunisation uptake in Australian adolescents is due to several factors, one of which is the impact of the COVID-19 pandemic. Lengthy school closures in some jurisdictions during 2020 and 2021 that disrupted school-based immunisation programs during that time have been well documented.²

In addition, COVID-19 has led to a change in attitude towards immunisation. People, particularly parents, are asking more questions, and increasing levels of concern about vaccinations are evident.³³ Furthermore, lack of parental support and consent for vaccination means that vaccine uptake in young people (aged 12–17 years) continues to be a challenge.³

Lagging vaccination rates are also attributable to accessibility factors, including distance to a vaccination provider, available appointments, and costs involved in vaccination, such as doctor visits, and the need to take time off work or put other children into care to attend doctor appointments.²

The importance of catch-up vaccines

Catch-up vaccinations aim to provide the best protection against vaccine-preventable diseases as quickly as possible by completing a person’s recommended vaccination schedule. Catch-up vaccinations should be offered to all adolescents who have not received the vaccines scheduled in the NIP and should be administered according to age-appropriate guidelines in the Australian Immunisation Handbook. Free catch-up vaccines are available for missed vaccines under the NIP until the age of 20, except for the HPV vaccine which is available up to and including age 25.⁸ Pharmacists can administer these vaccines.

Knowledge to practice

Research shows pharmacists are uniquely positioned to increase vaccination coverage rates among adolescents and other eligible populations.³⁴ Pharmacists can identify individuals who have missed vaccinations by checking the Australian Immunisation Register (AIR) and ensuring they are offered catch-up immunisation. They can advocate for and encourage vaccination in adolescents, and appropriately trained pharmacists can administer immunisations.³⁵

Increasing adolescent immunisation rates

Community pharmacists are among the most trusted and respected health professionals across Australia.³⁶ Pharmacists have been administering vaccinations since 2014, and it is widely accepted across all states and territories that vaccination is within the scope of practice for appropriately trained pharmacists. Through proactive discussions within the pharmacy environment, pharmacists are in a prime position to boost adolescent immunisation rates.

Pharmacists should ascertain vaccination status in adolescents to facilitate conversations around immunisation.

Ascertaining vaccination status

Check the Australian Immunisation Register (AIR)

Pharmacists should routinely check prior immunisation history on the AIR when dispensing prescriptions. If the adolescent is overdue for their vaccination, this can be mentioned when giving them their medication and a discussion initiated. Running AIR reports in advance (e.g. AIR10A Due/Overdue Report) for regular patients or certain cohorts may provide greater efficiencies. This could be particularly helpful if pharmacists wish to run vaccination clinics to coincide with various health awareness campaigns, (e.g. World Immunisation Week or National Meningococcal Week).

Vaccination status on the AIR must be checked before administering any vaccine, and any vaccines administered must be recorded on the AIR.³⁵

Ask about immunisation history

During general conversations, pharmacists can ask about immunisation history and explain that the pharmacy offers catch-up vaccinations for those who need them. Pharmacists should also offer to check the AIR if the patient is unsure about their immunisation status.

Initiate conversation

Pharmacists who have identified adolescents behind in their scheduled immunisations should initiate a conversation about a catch-up immunisation. The goals of these discussions will depend upon the patient’s attitude towards vaccination.³⁷

Talking to patients who are ready to vaccinate

The goal of the consultation is to prevent hesitancy and support timely vaccination. People who are ready to vaccinate tend to trust medical advice. However, as many as half will have questions about vaccination.³⁸ Ensure patients feel confident to ask questions without judgement. Some in this cohort say they are concerned providers will think they are ‘antivaxxers’ if they ask questions about vaccination.³⁹ The following actions are recommended⁴⁰:

• Ask if the adolescent or parent has any questions, as this supports their sense of agency and facilitates valid consent.
• Provide resources on vaccination to help answer questions, if appropriate.
• Talk about what to expect after vaccination, including what the patient can do to alleviate any adverse effects.
• Vaccinate the patient and book any follow-up appointments if required.

Talking to patients who have questions

The goal of the consultation is to vaccinate and increase vaccine confidence. Some people report feeling they are not sufficiently informed to agree to vaccination confidently, while some need permission to express and explore their concerns.³⁸ It is recommended you:

• Ask the patient or parent if they have any questions or concerns about vaccination to saturation. After answering the first question, ask “Is there something else you’re concerned about?” followed by “Are these all of your questions, or do you have some more?” Eliciting questions and concerns to saturation reduces the chance of ‘late breaker’ questions, reduces consultation time and makes consultations more satisfying.⁴¹
• Where relevant, ask about the views of the parent’s partner, and if the presenting parent is not the primary decision-maker, invite them to schedule another consultation where the partner attends.
• Avoid the temptation to correct misinformation before the patient or parent has had a chance to express all their concerns, as this tends to close down the conversation. Instead, ask for a complete list of questions that you can work through one at a time.
• Acknowledge that the person has considered the issue of vaccination carefully and summarise their concerns.
• Establish a preferred agenda by asking whether the patient or parent is happy to provide medical history first, and then go on to talk about concerns they may have.
• Maintain control of the consultation’s timeframe by temporal signposting. For example, say “We have about 10 minutes left. Let’s spend a few minutes talking about your most serious concerns, and then I’d like to tell you why I think vaccination is important.”
• Share any resources that may be appropriate.
• Recommend vaccination confidently and explain why. Evidence suggests that when consultations include a clear, confident recommendation to vaccinate, vaccination is more likely to be accepted.⁴¹
• Recheck patient or parent intentions about vaccination by asking them how they feel about vaccination.
• Book an appointment for follow-up vaccinations, if appropriate.
• Offer a referral to a Specialist Immunisation Service if relevant.

Tips for talking to parents or adolescents declining vaccination

The goal of the consultation is to maintain trust and engagement and keep the conversation brief. It’s recommended you:

• Seek permission to discuss their decision. Most adolescents and parents of under-vaccinated adolescents have not made an active decision to decline, so it’s important to confirm whether this was an active choice or unintended choice.
• Avoid getting into debates about the validity of their beliefs or to correct misconceptions. Doing so can reinforce or strengthen these beliefs,⁴² establish an adversarial environment,⁴³ and increase their risk of disengaging from the healthcare system altogether.
• Acknowledge their choice as this signals your respect for them and builds trust in you.⁴³
• Ask if they are concerned about their child or themselves getting any diseases, or if their decision would be different if the risk was high.
• Share information about the seriousness of the disease they’re hesitant to get a vaccine
  for, if appropriate.
• Share your recommendation about vaccination, if appropriate, including answering any questions the patient may have about vaccination.
• Offer patient resources and details on where they can find more information.
• Ask for permission to revisit the discussion at a later date.
• Offer a referral to a Specialist Immunisation Service if relevant.

Opportunities for vaccination

The NIPVIP Program has been developed to increase patient access and affordability of vaccinations. From 1 January 2024, there are no out-of-pocket expenses for patients receiving NIP vaccines at participating pharmacies.⁴⁴

Pharmacies that are registered for the NIPVIP will also receive payment of $19.32 per vaccination (current as at November 2024) for administering NIP vaccines to individuals aged 5 years and over in a pharmacy setting.⁴⁵

Conclusion

Adolescent vaccination rates remain below optimal levels, often due to the COVID-related interruption to the school vaccination programs, increased vaccine hesitancy, and accessibility challenges. Pharmacists are uniquely positioned to educate and advocate for immunisation in adolescents who have missed their scheduled vaccinations and increase overall immunisation rates in this cohort by providing catch-up immunisations.

Case scenario continued When filling a script for Kushal, you check the AIR and notice that he has missed his scheduled dose of dTpa vaccine. When he and his mother return to the pharmacy to collect his script, you ask if they’re aware of the missed dose. Both were vaguely aware of cancelled school vaccinations but didn’t think it was that important. You explain why vaccination is important and advise that Kushal could have a catch-up immunisation in the pharmacy if they choose. They both have some questions about the vaccine and potential adverse effects, which you answer. Kushal agrees to be vaccinated immediately, with his mother’s support. Both are grateful that you discussed the missed immunisation with them.

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Key points

• Immunisation significantly reduces disease, disability and death from various infectious diseases in Australia.
• The National Immunisation Program (NIP) Schedule outlines recommended vaccines and schedule points to reduce vaccine-preventable diseases through the provision of free vaccines to eligible people.
• Under the NIP Schedule, adolescents are immunised against diphtheria-tetanus-pertussis (dTpa vaccine), HPV and meningococcal ACWY disease.
• Due to COVID-related interruptions to school vaccination programs, increased vaccine hesitancy, and accessibility issues, adolescent immunisation rates are not as high as they should be.
• Catch-up immunisations are important to complete vaccination schedules and provide optimal protection against vaccine-preventable diseases.
• Pharmacists play a key role in educating, advocating and providing in-clinic catch-up vaccinations to adolescents who have missed their scheduled vaccinations.
• Pharmacists should routinely check the AIR to identify patients who may have missed vaccinations, and then initiate conversations about the importance of immunisation.
• While the ultimate goal is to provide vaccination, pharmacists must avoid getting into debates about the validity of patient beliefs or to correct misconceptions.
• Maintaining trust and building vaccine confidence is important in groups that are vaccine-hesitant or decline immunisation.

References

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Our author

Nerissa Bentley (she/her) is The Melbourne Health Writer – an award-winning professional health and medical writer who creates credible, evidence-based, AHPRA-compliant health copy for national organisations, global companies and Australian health practitioners.

Our reviewer

Associate Professor Mary Bushell (she/her) is a pharmacist and academic at the University of Canberra.

DISCLAIMER

Vaccine administration should be in accordance with relevant legislation, the Australian Immunisation Handbook, and state-based conditions specific to the vaccine.