VANCOUVER, B.C. — The inability of older adolescents to provide consent for vaccinations creates a barrier to vaccine delivery, research has shown.
In a survey of 280 medical providers from 43 states, 95% said that 17-year-olds “sometimes” or “often” present without a parent. Ten percent reported that this is true for 12-year-olds.
The providers were then asked how likely it was that an unaccompanied minor adolescent in their state would be vaccinated for influenza; combined tetanus, diphtheria, and pertussis (Tdap); and human papillomavirus (HPV) if the vaccines were available for free, the patient was medically eligible, and the parent was not available to consent.
Responses varied by vaccine type, patient age, and clinical setting, said Dr. Carol Ford of the University of North Carolina at Chapel Hill.
If a 17-year-old presented alone for routine care in a private primary care clinic and were due for all three vaccines and “all the stars were lined up for them to get the vaccines,” except that a parent could not be reached, 30% would not get any of the vaccines.
If the same patient presented alone to a private clinic for confidential services, 40% would not get vaccinated. If the unaccompanied minor were 12 years old, 50% would not get influenza or Tdap, and 70% would not get the HPV vaccine, according to the survey. In a public primary care setting, approximately half of 17-year-olds presenting for routine care and 65% of 12-year-olds would not get any vaccines if they were unaccompanied by a parent, she noted.
Between 30% and 50% of health care provider respondents said that an adolescent presenting to a public clinic for confidential services would not get the HPV vaccine and 60%–70% would not get Tdap or influenza vaccines, with variation by age, Dr. Ford said.
“We still have to think hard about how to get all teens vaccinated, but I think that this study really highlights the fact that there are a lot of missed opportunities among these older teens that we could be working on right now,” she said in an interview.
Interventions to increase adolescent vaccinations include strategies such as anticipatory consent for vaccinations at the time of school physical examinations; advance consent for additional doses, as with the three-dose HPV vaccine; and calling parents on cell phones.
Providers must work within the context of legal, ethical, and professional guidelines regarding minor consent, but hospitals and medical sites have a great deal of variety and flexibility regarding the process of documenting consent, Dr. Ford said.
Federal law requires that all heath care providers give vaccine information statements to parents or patients before administering each dose of the vaccines listed in the 2010 vaccine schedule.
The American Academy of Pediatrics believes that physicians have an ethical and legal obligation in most cases to obtain parental permission to undertake recommended medical interventions, and that in many circumstances they should also solicit patient assent when developmentally appropriate (Pediatrics 1995;95:314–7). The AAP also notes that physicians should seek informed consent directly from patients in cases involving emancipated or mature minors with adequate decision-making capacity, or when otherwise permitted by law.
During a discussion of the study, it was noted that most states require patient assent, not consent. Survey respondents would support efforts to allow minors to consent for vaccination at a mean of 14.26 years for Tdap, 14.08 years for influenza, and 13.81 for HPV, according to Dr. Ford.
Disclosures: None was reported.
My Take
A Time for Reflection
A common methodology for quality improvement involves identifying variations and reducing them. Sometimes, the variation is unimportant. Just about any choice of athlete's foot cream works. But pediatricians express passionate arguments in many directions when it comes to vaccines. So a survey showing that 50% of people do something, and 50% don't, should prompt deep reflection.
Surveys don't indicate which practice is better. That requires measuring outcomes. Surveys don't resolve barriers that impede effective care. But surveys can motivate change.
Vaccinating teenagers raises a complex multitude of ethical, legal, and practical problems. A 4-year-old may resist vaccination, but my nurse still administers the shots. Ethically, teenagers are different. Their assent is required. Ideally, both parent and teenager should be present in the office for this informed consent and assent to occur. An unaccompanied teenager in the office poses special problems. The history the teen gives may be incomplete and/or unreliable. Boosters need to be given but there are few well visits during which to accomplish them.