See Related Article p. 133Since 2005, the number of vaccines routinely administered to adolescents has rapidly increased, with new recommendations for quadrivalent meningococcal conjugate vaccine (MCV4); tetanus toxoid, diphtheria, and acellular pertussis (Tdap) vaccine; human papillomavirus (HPV; quadrivalent [HPV4] and bivalent [HPV2]) vaccine; and seasonal influenza vaccine, as well as catch-up vaccination against hepatitis A for adolescents in states/communities with existing hepatitis control programs in place, those at increased risk, and those desiring to be protected [[1]Fiore A.E. Wasley A. Bell B.P. Prevention of hepatitis A through active or passive immunization: Recommendations of the Advisory Committee on Immunization Practices (ACIP).MMWR Recomm Rep. 2006; 55: 1-23Google Scholar]. Also, a second dose of varicella vaccine was recommended for adolescents without a history of varicella disease who have received only a single dose [[2]Marin M. Guris D. Chaves S.S. et al.Prevention of varicella: Recommendations of the Advisory Committee on Immunization Practices (ACIP).MMWR Recomm Rep. 2007; 56: 1-40PubMed Google Scholar].Data from the National Immunization Survey document substantial improvements in coverage rates for vaccines administered to adolescents, with significant increases in the vaccination rates for Tdap, HPV, and MCV between 2008 and 2009. However, coverage level is still far below that achieved for vaccines routinely administered in childhood, and as illustrated in Figure 1, it seems unlikely that ≥80% levels of coverage targeted by Healthy People 2020 will be achieved [3Centers for Disease Control and Prevention (CDC)Vaccination coverage among adolescents aged 13–17 years—United States, 2007.MMWR Morb Mortal Wkly Rep. 2008; 57: 1100-1103PubMed Google Scholar, 4CDCNational, state, and local area vaccination coverage among adolescents aged 13–17 years—United States, 2009.Morb Mortal Wkly Rep. 2010; 59: 1018-1023PubMed Google Scholar].As presented by Kaplan [[5]Kaplan D.W. Barriers and potential solutions to increasing immunization rates in adolescents.J Adolesc Health. 2010; 46: S24-S33Abstract Full Text Full Text PDF Scopus (8) Google Scholar], there are multiple potential barriers to adolescent vaccination, including uninsured/underinsured adolescents, less use of preventive health services/fewer office visits, missed opportunities to be vaccinated during acute care visits, challenges in locating immunization records, lack of awareness of new vaccine recommendations, and parental misperceptions about the importance of adolescent vaccination. Also, as adolescents age, they are less likely to access preventive health care, which may explain, in part, the lower rates of vaccination for Tdap and varicella noted among 16- and 17-year-olds [[4]CDCNational, state, and local area vaccination coverage among adolescents aged 13–17 years—United States, 2009.Morb Mortal Wkly Rep. 2010; 59: 1018-1023PubMed Google Scholar].Public funding for vaccines is essential to achieve high rates of adolescent vaccination because about one in three adolescents receives vaccination through public sector support. These sources include the Vaccines for Children (VFC) program; section 317 funding, a federal discretionary grant program to states; and/or state vaccination funds [[5]Kaplan D.W. Barriers and potential solutions to increasing immunization rates in adolescents.J Adolesc Health. 2010; 46: S24-S33Abstract Full Text Full Text PDF Scopus (8) Google Scholar]. The VFC program provides vaccine coverage to persons up to age 19 who are Medicaid recipients, lack adequate health insurance, or are American Indians or Alaskan Natives; VFC pays for approximately 43% of all vaccines administered to children through age 18 years in the United States. Thus, an additional pragmatic limitation to the use of alternative vaccination sites beyond the medical home is that few locations outside of medical offices and federally qualified health centers are aware of and have signed on as VFC distribution sites.Mandates for completion of childhood vaccines before school entry have driven vaccine coverage rates to high levels among grade school children. In this context, middle and high schools seem to represent the most viable approach to ensuring universal adolescent vaccination. Although alternative vaccine delivery sites mentioned in the article by Clevenger et al [[6]Clevenger L-M. Pyrzanowski J. Curtis C.R. et al.Parents' acceptance of adolescent immunizations outside of the traditional medical home.J Adolesc Health. 2011; 49: 133-140Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar] could certainly participate in state immunization information systems (IISs) as a means of ensuring accurate and accessible records, a recent report noted that few of these alternative sites were current IISs users [[7]Schaffer S.J. Fontanesi J. Rickert D. et al.How effectively can health care settings beyond the traditional medical home provide vaccines to adolescents?.Pediatrics. 2008; 121: S35-S45Crossref PubMed Scopus (52) Google Scholar].Although many believe that the medical home represents the optimal location of delivery of comprehensive, longitudinal, prevention-oriented health services, the fact remains that vaccination rates among adolescents remain far below the targeted levels. However, before alternative vaccine delivery sites can be more fully considered, the trade-offs of further fragmentation of healthcare delivery need to be taken into account. The article by Clevenger et al [[6]Clevenger L-M. Pyrzanowski J. Curtis C.R. et al.Parents' acceptance of adolescent immunizations outside of the traditional medical home.J Adolesc Health. 2011; 49: 133-140Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar] affirms the belief among parents that medical offices are the “best” alternative site for adolescent vaccination, although about one in four respondents endorsed either public health clinics or school health clinics as the “next best location.” However, parents express concerns regarding the ability of school-located vaccination sites to keep track of immunization administration [[8]Middleman A.B. Tung J.S. At what sites are parents willing to have their 11 through 14-year-old adolescents immunized?.Vaccine. 2010; 28: 2674-2678Crossref PubMed Scopus (20) Google Scholar]. Promoting the use of IISs in the community can be one way of addressing this concern. In addition, although most parents have experienced and feel comfortable receiving vaccines in the medical home, fewer parents have experienced accessing vaccines for their children at alternative sites. Additional education and experience with the use of alternative vaccine delivery sites, and increased understanding of the role of record-keeping through IISs, may help in shifting parental attitudes toward alternative sites. Moreover, responses to a survey, as described by Clevenger et al [[6]Clevenger L-M. Pyrzanowski J. Curtis C.R. et al.Parents' acceptance of adolescent immunizations outside of the traditional medical home.J Adolesc Health. 2011; 49: 133-140Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar], may not be reflective of actual vaccine acceptance by parents. For example, 44% of parents who participated in a middle school-located immunization program had indicated on a preprogram questionnaire that they would not be willing to consider that site for Tdap and MCV4 immunization [[9]Middleman A.B. Tung J.S. School-located immunization programs: Do parental preferences predict behavior?.Vaccine. 2011; 29: 3513-3516Crossref PubMed Scopus (20) Google Scholar], thereby suggesting that the advantages inherent in some of the strategies used to improve immunization rates often become overwhelmingly appealing when actually offered.There is no question that providing comprehensive preventive health care for adolescents remains an important objective. However, holding vaccination hostage to the delivery of comprehensive health screening is not in anyone's best interest. Recommendations have been in place for many years for adolescents to receive comprehensive health screening and anticipatory guidance, and the American Medical Association (authors of the Guidelines for Adolescent Preventive Services), the American Academy of Pediatrics, the Society for Adolescent Medicine, and the Maternal Child Health Bureau (Bright Futures) have all supported these recommendations. There has been some success in increasing preventive healthcare visits in the United States using strategies that promote vaccination, such as mandatory physical examinations of 11–12-year-olds for school entry (http://www.nhsd.org/HealthServices/docs/privatephysician.pdf, Accessed on May 26, 2011). Rather than viewing vaccination as a stick to bring patients to comprehensive health screening visits, a new model for more comprehensive screening for adolescents needs to be developed.By identifying untapped opportunities to increase adolescent vaccination rates, new paradigms for further outreach can be recognized and promoted. For adolescent vaccination rates to be optimized, multiple strategies supporting immunization efforts at multiple locations will likely be required. Mandates have been very successful at improving immunization rates among people of all ages. The availability and use of alternative vaccination sites for adolescents should be encouraged. Also, use of IISs must be expanded at these alternative immunization sites. Educational campaigns should reassure and encourage parents to consent to vaccine delivery in locations outside of the medical home. If multiple strategies are developed in concert with each other, the potential for successfully improving vaccination rates among adolescents will continue to grow. “A rising tide lifts all boats,” and efforts to increase rates of adolescent vaccination will yield benefits across the health system. See Related Article p. 133 See Related Article p. 133 See Related Article p. 133 Since 2005, the number of vaccines routinely administered to adolescents has rapidly increased, with new recommendations for quadrivalent meningococcal conjugate vaccine (MCV4); tetanus toxoid, diphtheria, and acellular pertussis (Tdap) vaccine; human papillomavirus (HPV; quadrivalent [HPV4] and bivalent [HPV2]) vaccine; and seasonal influenza vaccine, as well as catch-up vaccination against hepatitis A for adolescents in states/communities with existing hepatitis control programs in place, those at increased risk, and those desiring to be protected [[1]Fiore A.E. Wasley A. Bell B.P. Prevention of hepatitis A through active or passive immunization: Recommendations of the Advisory Committee on Immunization Practices (ACIP).MMWR Recomm Rep. 2006; 55: 1-23Google Scholar]. Also, a second dose of varicella vaccine was recommended for adolescents without a history of varicella disease who have received only a single dose [[2]Marin M. Guris D. Chaves S.S. et al.Prevention of varicella: Recommendations of the Advisory Committee on Immunization Practices (ACIP).MMWR Recomm Rep. 2007; 56: 1-40PubMed Google Scholar]. Data from the National Immunization Survey document substantial improvements in coverage rates for vaccines administered to adolescents, with significant increases in the vaccination rates for Tdap, HPV, and MCV between 2008 and 2009. However, coverage level is still far below that achieved for vaccines routinely administered in childhood, and as illustrated in Figure 1, it seems unlikely that ≥80% levels of coverage targeted by Healthy People 2020 will be achieved [3Centers for Disease Control and Prevention (CDC)Vaccination coverage among adolescents aged 13–17 years—United States, 2007.MMWR Morb Mortal Wkly Rep. 2008; 57: 1100-1103PubMed Google Scholar, 4CDCNational, state, and local area vaccination coverage among adolescents aged 13–17 years—United States, 2009.Morb Mortal Wkly Rep. 2010; 59: 1018-1023PubMed Google Scholar]. As presented by Kaplan [[5]Kaplan D.W. Barriers and potential solutions to increasing immunization rates in adolescents.J Adolesc Health. 2010; 46: S24-S33Abstract Full Text Full Text PDF Scopus (8) Google Scholar], there are multiple potential barriers to adolescent vaccination, including uninsured/underinsured adolescents, less use of preventive health services/fewer office visits, missed opportunities to be vaccinated during acute care visits, challenges in locating immunization records, lack of awareness of new vaccine recommendations, and parental misperceptions about the importance of adolescent vaccination. Also, as adolescents age, they are less likely to access preventive health care, which may explain, in part, the lower rates of vaccination for Tdap and varicella noted among 16- and 17-year-olds [[4]CDCNational, state, and local area vaccination coverage among adolescents aged 13–17 years—United States, 2009.Morb Mortal Wkly Rep. 2010; 59: 1018-1023PubMed Google Scholar]. Public funding for vaccines is essential to achieve high rates of adolescent vaccination because about one in three adolescents receives vaccination through public sector support. These sources include the Vaccines for Children (VFC) program; section 317 funding, a federal discretionary grant program to states; and/or state vaccination funds [[5]Kaplan D.W. Barriers and potential solutions to increasing immunization rates in adolescents.J Adolesc Health. 2010; 46: S24-S33Abstract Full Text Full Text PDF Scopus (8) Google Scholar]. The VFC program provides vaccine coverage to persons up to age 19 who are Medicaid recipients, lack adequate health insurance, or are American Indians or Alaskan Natives; VFC pays for approximately 43% of all vaccines administered to children through age 18 years in the United States. Thus, an additional pragmatic limitation to the use of alternative vaccination sites beyond the medical home is that few locations outside of medical offices and federally qualified health centers are aware of and have signed on as VFC distribution sites. Mandates for completion of childhood vaccines before school entry have driven vaccine coverage rates to high levels among grade school children. In this context, middle and high schools seem to represent the most viable approach to ensuring universal adolescent vaccination. Although alternative vaccine delivery sites mentioned in the article by Clevenger et al [[6]Clevenger L-M. Pyrzanowski J. Curtis C.R. et al.Parents' acceptance of adolescent immunizations outside of the traditional medical home.J Adolesc Health. 2011; 49: 133-140Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar] could certainly participate in state immunization information systems (IISs) as a means of ensuring accurate and accessible records, a recent report noted that few of these alternative sites were current IISs users [[7]Schaffer S.J. Fontanesi J. Rickert D. et al.How effectively can health care settings beyond the traditional medical home provide vaccines to adolescents?.Pediatrics. 2008; 121: S35-S45Crossref PubMed Scopus (52) Google Scholar]. Although many believe that the medical home represents the optimal location of delivery of comprehensive, longitudinal, prevention-oriented health services, the fact remains that vaccination rates among adolescents remain far below the targeted levels. However, before alternative vaccine delivery sites can be more fully considered, the trade-offs of further fragmentation of healthcare delivery need to be taken into account. The article by Clevenger et al [[6]Clevenger L-M. Pyrzanowski J. Curtis C.R. et al.Parents' acceptance of adolescent immunizations outside of the traditional medical home.J Adolesc Health. 2011; 49: 133-140Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar] affirms the belief among parents that medical offices are the “best” alternative site for adolescent vaccination, although about one in four respondents endorsed either public health clinics or school health clinics as the “next best location.” However, parents express concerns regarding the ability of school-located vaccination sites to keep track of immunization administration [[8]Middleman A.B. Tung J.S. At what sites are parents willing to have their 11 through 14-year-old adolescents immunized?.Vaccine. 2010; 28: 2674-2678Crossref PubMed Scopus (20) Google Scholar]. Promoting the use of IISs in the community can be one way of addressing this concern. In addition, although most parents have experienced and feel comfortable receiving vaccines in the medical home, fewer parents have experienced accessing vaccines for their children at alternative sites. Additional education and experience with the use of alternative vaccine delivery sites, and increased understanding of the role of record-keeping through IISs, may help in shifting parental attitudes toward alternative sites. Moreover, responses to a survey, as described by Clevenger et al [[6]Clevenger L-M. Pyrzanowski J. Curtis C.R. et al.Parents' acceptance of adolescent immunizations outside of the traditional medical home.J Adolesc Health. 2011; 49: 133-140Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar], may not be reflective of actual vaccine acceptance by parents. For example, 44% of parents who participated in a middle school-located immunization program had indicated on a preprogram questionnaire that they would not be willing to consider that site for Tdap and MCV4 immunization [[9]Middleman A.B. Tung J.S. School-located immunization programs: Do parental preferences predict behavior?.Vaccine. 2011; 29: 3513-3516Crossref PubMed Scopus (20) Google Scholar], thereby suggesting that the advantages inherent in some of the strategies used to improve immunization rates often become overwhelmingly appealing when actually offered. There is no question that providing comprehensive preventive health care for adolescents remains an important objective. However, holding vaccination hostage to the delivery of comprehensive health screening is not in anyone's best interest. Recommendations have been in place for many years for adolescents to receive comprehensive health screening and anticipatory guidance, and the American Medical Association (authors of the Guidelines for Adolescent Preventive Services), the American Academy of Pediatrics, the Society for Adolescent Medicine, and the Maternal Child Health Bureau (Bright Futures) have all supported these recommendations. There has been some success in increasing preventive healthcare visits in the United States using strategies that promote vaccination, such as mandatory physical examinations of 11–12-year-olds for school entry (http://www.nhsd.org/HealthServices/docs/privatephysician.pdf, Accessed on May 26, 2011). Rather than viewing vaccination as a stick to bring patients to comprehensive health screening visits, a new model for more comprehensive screening for adolescents needs to be developed. By identifying untapped opportunities to increase adolescent vaccination rates, new paradigms for further outreach can be recognized and promoted. For adolescent vaccination rates to be optimized, multiple strategies supporting immunization efforts at multiple locations will likely be required. Mandates have been very successful at improving immunization rates among people of all ages. The availability and use of alternative vaccination sites for adolescents should be encouraged. Also, use of IISs must be expanded at these alternative immunization sites. Educational campaigns should reassure and encourage parents to consent to vaccine delivery in locations outside of the medical home. If multiple strategies are developed in concert with each other, the potential for successfully improving vaccination rates among adolescents will continue to grow. “A rising tide lifts all boats,” and efforts to increase rates of adolescent vaccination will yield benefits across the health system.