Experts' Opinion for Improving Global Adolescent Vaccination Rates: A Call to Action

"The ultimate goal should be communicating successes achieved through vaccination programs, thereby counteracting, in real time, doubts regarding vaccine safety and efficacy that ultimately contribute to vaccine hesitancy."

Vaccine uptake among adolescents remains low compared with infant programmes. In May 2017, a multidisciplinary group of experts from around the world met in Amsterdam, Netherlands, to discuss adolescent vaccine uptake, as part of an educational initiative called the Advancing Adolescent Health Spring Forum. This article presents consensus opinions resulting from the meeting, which pertain to the burden of vaccine-preventable diseases (VPDs) among adolescents, reasons for low vaccine uptake, and common characteristics of successful strategies for improving adolescent vaccination. It serves as a "call to action" to global healthcare providers (HCPs) and public health administrators to prioritise adolescent vaccination as a central tenet of preventive healthcare for this age group.

Participants in the meeting explain that adolescents are at increased risk for some VPDs because of a variety of age-specific behavioural, environmental, and biological factors. For example, most of the recent outbreaks of invasive meningococcal disease in the United States (US) have occurred on college campuses, where young adults live in close quarters and socialise frequently. Despite such vulnerabilities, there is low adolescent vaccine uptake due to factors including:

• Lack of knowledge and poor communication among providers, parents, and adolescents (e.g., studies indicate that adolescents may not fully appreciate the risks posed by VPDs);
• Structural barriers in the health system (e.g., providers may have inadequate office resources to support adolescent vaccination);
• Lack of clarity regarding ownership of vaccination (e.g., adolescent vaccination introduces particular ethical challenges relating to adolescents' autonomy);
• Misinformation shared on the internet (e.g., adolescents may have difficulty distinguishing high- and low-quality source materials, potentially amplifying and reinforcing vaccine hesitancy); and
• Missed opportunities for vaccination (e.g., many adolescents do not have regular preventive care visits with a primary HCP).

Effective adolescent vaccination strategies tend to share several key features:

1. They are characterised by political will and strong leadership from a credible, well-known organisation.
2. They involve multiple stakeholders - adolescents, parents, educators, HCPs, public health agencies, schools and universities, public campaigns, and politicians.
3. They make benefits of vaccination clearly visible to the public through use of motivational drivers and rewards for achieving objectives.
4. They nuance messages and methods by age group (e.g., younger vs. older adolescents), recognising that barriers may differ between groups.
5. They focus on providing evidence-based information and education that are comprehensive but also youth friendly, in that they create a positive emotional connection to vaccination that is attractive to, and resonates with, adolescents and their parents.

While acknowledging that not all countries will have sufficient resources and coordination among groups responsible for new initiatives targeting adolescent and young adult vaccination, the group offers an example of a successful adolescent vaccination programme: the human papillomavirus (HPV)/cervical cancer vaccination programme in the United Kingdom (UK). Significant political support was evidenced by budgetary support: Vaccination was fully funded and free to recipients, and the full cost of programme implementation was covered, including, for example, preparation of national and local communication materials. In fact, targeted messaging was a central feature of the programme's rollout, and communication strategies and materials were reportedly developed based on extensive market research with multiple stakeholders, including parents, adolescents, and HCPs. Paper leaflets discussing the benefits of vaccination and containing consent forms were provided to all eligible participants, and newspaper and targeted magazine advertising were timed to coincide with the programme launch, with information about the vaccination programme also disseminated through television and radio advertising, public outdoor advertisements, and diverse social media platforms. This multichannel, targeted approach led to more than 2.3 million English girls receiving the HPV vaccine series from the programme's beginning in 2008 to 2015.

Considering that HCPs play a key role in encouraging and facilitating any opportunity for adolescent vaccination, the group of experts suggests that HCPs should take advantage of every visit to address vaccination with adolescents. They should keep up to date on VPDs and vaccination recommendations for adolescents, and take time to understand the perspectives of adolescents and their parents when discussing the benefits and risks of vaccination.

To bolster these discussions, educational campaigns through various channels, with targeted messaging to reach both parents and adolescents in the general public, are recommended. Specifically, consistent, lasting efforts should be made to use multiple media streams, including outdoor advertising, radio, television, video, and internet social media networks, to disseminate youth-friendly messages that present vaccination as part of a positive and healthy adult lifestyle.

In conclusion, the group suggests that "adolescent immunization should be undertaken as a local, regional, national, and global cause, with appropriate leaders appointed at each level. Finally, health authorities should continue to focus on successful vaccination strategies targeting adolescents, implement these strategies to successfully improve adolescent vaccination rates, and make these results transparently available to all stakeholders, particularly adolescents and the public."