Hepatitis B Vaccination Among Adolescents in 3 Large Health Maintenance Organizations Idalia M. Gonza ´lez, MD, MPH*; Francisco M. Averhoff, MD, MPH‡; Mehran S. Massoudi, PhD, MPH‡; Hussain Yusuf, MBBS, MPH‡; Frank DeStefano, MD, MPH‡; Piotr Kramarz, MD‡; Julie E. Maher, PhD, MS§; John P. Mullooly, PhD§; Colleen Chun, MD§; Robert L. Davis, MD, MPH; Steven B. Black, MD¶; Henry R. Shinefield, MD¶; and the Vaccine Safety Datalink Team ABSTRACT. Objective. In 1995, the Advisory Com- mittee on Immunization Practices (ACIP) recommended routine hepatitis B (HB) vaccination of all unvaccinated 11- to 12-year-old adolescents. Little is known about the implementation of these recommendations in a managed care setting. The objective of this study was to determine the impact of ACIP recommendations on HB vaccination among adolescents in 3 managed care settings. Methods. We assessed HB vaccination coverage among adolescents who were enrolled in 3 large health maintenance organizations (HMOs) and who turned 13 years old after the 1995 ACIP recommendations. Children who were 8 to 10 years of age during May 1993 and were continuously enrolled through December 1998 were eli- gible. We used the HMOs’ computerized immunization tracking system to collect HB vaccination dates. The per- centage of adolescents who received 3 doses of HB vac- cine was determined. Results. In HMOs A, B, and C, coverage levels for 3 doses of HB vaccine were 43.4%, 65.5%, and 25.7%, re- spectively, among 13-year-olds in 1998 compared with 26.1%, 50.4%, and 5.5% among 13-year-olds in 1996. Be- tween the ages of 11 and 13 years, coverage rates among adolescents aged 13 in 1998 rose more than the coverage among adolescents aged 13 in 1996. The proportion of 13-year-olds in 1998 who received the first dose of HB vaccine by December 1998 was much higher at 89.6%, 65.2%, and 56.6% in HMOs A, B, and C, respectively, compared with the proportion who completed the 3-dose series (43.4%, 65.5%, and 25.7%, respectively). Conclusions. After the 1995 ACIP recommendations, HB vaccination coverage levels among 13-year-olds in- creased in each of the HMOs, suggesting adherence with national recommendations. Differences among the 3 HMOs may reflect differences in internal policies. More effective strategies may be needed to achieve the Healthy People 2010 goal of 90% vaccination coverage rates among adolescents. Pediatrics 2002;110:929 –934; hepatitis B vaccine, adolescence, health maintenance organizations, managed care, vaccination, immunization. ABBREVIATIONS. HBV, hepatitis B virus; ACIP, Advisory Com- mittee on Immunization Practices; HB, hepatitis B; AAP, Ameri- can Academy of Pediatrics; VFC, Vaccines for Children; HMO, health maintenance organization; VSD, Vaccine Safety Datalink; CDC, Centers for Disease Control and Prevention. P revention of hepatitis B virus (HBV) infection through vaccination of adolescents before they enter adulthood is crucial because young adults have the highest incidence of HBV infection in the United States. 1 Once infected, 2% to 6% of older children, adolescents, and adults will develop chronic HBV infections, putting them at increased risk for developing chronic liver disease or, later in life, primary hepatocellular carcinoma. 2 In 1982, the Advisory Committee on Immunization Practices (ACIP) recommended hepatitis B (HB) vaccination of individuals who are at high risk for HBV infection. 3 This strategy proved unsuccessful in part because such individuals were difficult to reach with vaccine before they became infected and approximately 30% to 40% of adolescents and adults with acute HBV infection have no identifiable risk factors. 4 In 1991, the ACIP recommended universal vaccination of in- fants with the HB vaccine, a strategy to eliminate HBV transmission, and universal vaccination of ad- olescents who live in communities where injecting drug use, teenage pregnancy, and/or sexually trans- mitted diseases is common. 5 In 1992, the American Academy of Pediatrics (AAP) recommended the im- plementation of universal vaccination of adolescents where resources permit. 6 In 1995, the ACIP ex- panded its recommendations to include routine HB vaccination of all previously unvaccinated 11- to 12- year-old adolescents 7 and in 1997 to all unvaccinated children and adolescents 0 to 18 years of age. 8 In the past decade, substantial success has been achieved in universal childhood HB vaccination with coverage rates approaching 90% among children aged 19 to 35 months. 9 Available information about adolescent HB vaccination coverage suggests that coverage is substantially lower (50%) 9 ; however, the data are limited. There may be potential barriers for vaccinating adolescents, including insufficient health care visits; the failure of providers to assess adolescent vaccination status at illness-related visits, From the *Epidemiology Program Office, assigned to the National Immu- nization Program, Centers for Disease Control and Prevention, Atlanta, Georgia; ‡National Immunization Program, Centers for Disease Control and Prevention, Atlanta, Georgia; §Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon; Center for Health Studies, Group Health Cooperative of Puget Sound, Seattle, Washington; and ¶Di- vision of Research, Kaiser Permanente of Northern California, Oakland, California. Received for publication Feb 12, 2002; accepted Jun 13, 2002. Reprint requests to (M.S.M.) National Immunization Program, Centers for Disease Control and Prevention, 1600 Clifton Rd, Mail Stop E-52, Atlanta, GA 30333. E-mail: mmassoudi@cdc.gov PEDIATRICS (ISSN 0031 4005). Copyright © 2002 by the American Acad- emy of Pediatrics. PEDIATRICS Vol. 110 No. 5 November 2002 929