American Journal of Law & Medicine

Clinical preventive services for adolescents: position paper of the society for adolescent medicine. (Symposium)


Over the past several years, new vaccines have become available to prevent serious illnesses and conditions in the adolescent population. Several have already been approved by the FDA for use in this age group; others are still in development. Recently, significant public attention has been focused on the availability of vaccines for several strains of HPV, to prevent both cervical cancer and genital warts. Prior to that, the vaccine for Hepatitis B was approved and recommended for the adolescent age group. Others currently available and recommended include vaccines for pertussis, meningitis, and influenza. In the future, additional vaccines are expected to become available for sexually transmitted and communicable diseases such as herpes simplex virus and HIV. Unfortunately, financial limitations and consent requirements can impede adolescents' access to the vaccines that are recommended for their age group. However, a variety of policy options exist for overcoming the barriers and expanding access. These policy options are grounded both in international principles of human rights and in the existing framework of laws in the United States, and can be enhanced by attending to variations in age and developmental status among adolescents.


First, this article reviews the health status and health care needs of adolescents, including their need for vaccinations recommended by the Advisory Committee of Immunization Practices of the Centers for Disease Control and Prevention. Part II of this article discusses the barriers related to financial access and consent requirements that can limit adolescents' access to recommended vaccines. Part III places the barriers that adolescents in the United States experience with respect to vaccine access in the context of international human rights principles for health care access. Part IV discusses the federal and state laws that can facilitate access to vaccines for adolescents. Finally, Part V offers policy options for improving access that are consistent with the developmental needs of adolescents.


Adolescents are often perceived as "healthy," and many are healthy. They also experience significant health concerns, which have been extensively documented. Moreover, even healthy adolescents need access to preventive services, such as immunizations and routine care, including health checkups.

The major health problems faced by adolescents have been described as "preventable health conditions with predominantly behavioral, environmental, and social etiologies." (1) They include injury, homicide, suicide, mental and emotional illness, chronic illness and disability, poor nutrition, eating disorders, dental problems, pregnancy, sexually transmitted disease ("STD"), human immunodeficiency virus ("HIV") infection, and substance abuse. (2)

The health problems and concerns of adolescents are more prevalent and more severe among those characterized as "vulnerable" or "special populations." Such groups include adolescents with a chronic illness or disability; pregnant and parenting teens; immigrant and migrant youth; gay, lesbian, bisexual, and transgender adolescents; homeless, runaway, and street youth; and adolescents living in state custody or out-of-home care. (3) Adolescents in these vulnerable groups are likely to need more intensive health services than other adolescents and to have greater difficulty accessing traditional sources of care. (4) Young adults also experience significant health concerns and encounter access barriers. (5) In addition, adolescents who are members of racial and ethnic minority groups are particularly affected by significant health disparities. (6)

The health concerns and problems of adolescents mean that this age group has a pressing need for a wide variety of health care and related services. (7) Many health care professional organizations and governmental agencies have issued recommendations on the health care services needed by adolescents. (8) Essential services include: comprehensive health assessments; immunizations; dental examinations and treatment; family planning and other reproductive health services; pregnancy related care, including prenatal and maternity care; STD and HIV prevention, diagnosis, and treatment; mental health services; substance abuse assessment, counseling, and treatment; treatment for acute and chronic illnesses and conditions; case management and coordination of care. (9)

Specifically, adolescents need access to immunizations for several vaccine preventable diseases. (10) In recent years, new vaccines have been developed and approved for the adolescent age group and other vaccines have been added to the list of vaccines recommended for adolescents. Recommendations of the Advisory Committee on Immunization Practices ("ACIP") of the Centers for Disease Control and Prevention ("CDC") now include a vaccination schedule for adolescents. (11)

Recently, considerable attention has been focused on the HPV vaccine now available and recommended for adolescents. In May 2006, the U.S. Food & Drug Administration ("FDA") licensed a vaccine to prevent HPV, and ACIP published recommendations for its use in March 2007. (12) The HPV vaccine provides protection against both cervical cancer and genital warts. (13) The FDA licensed the HPV vaccine for use in females ages 9 to 26, and ACIP recommended that all females in this age group receive the vaccine, preferably before the onset of sexual activity, at age 11 or 12. (14)


Adolescents encounter numerous barriers when seeking health care. (15) Noteworthy among these barriers are financial obstacles and consent requirements. (16) In a recent study related to immunization of adolescents that included interviews with key informants in ten states and four metropolitan areas, six themes emerged as barriers to high rates of adolescent vaccination. (17) These themes were related to the general public; health care practitioners; vaccine delivery; minor consent; vaccine cost and financing; and lack of coordination in timing of vaccine recommendations, supply, and financing. (18) Of these six themes, the two that most directly involve legal and policy issues are financial obstacles and consent requirements. (19)


At the core of the financial obstacles that limit access to health care, including access to vaccinations, are the rates at which adolescents lack health insurance coverage. (20) Adolescents are uninsured at higher rates than younger children. (21) Even those with health insurance are often underinsured, lacking adequate coverage for some of the benefits and services that are most important for this age group. …

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