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Many of the ills of childhood such as measles and polio have been vanquished by routine infant vaccination. Now, scientists and vaccine makers are turning their attention to diseases that strike teenagers and young adults.
''Adolescent vaccines are going to become a big deal,'' says Michael Decker, vice president of medical affairs for drug company Aventis Pasteur.
That will mean changes in the way doctors and patients interact. Parents are used to carting their babies to the doctor's office for visits every couple of months, but with the advent of new vaccines, likely to be available before the end of this decade, late-childhood and early-teen visits to the doctor also may become routine.
At present, Decker says, ''the only vaccine on the get-it list (for teens) is the adult diphtheria-tetanus vaccine,'' given at about age 13 and recommended as part of the vaccine schedule approved by the Centers for Disease Control and Prevention.
But by the end of the decade, he predicts, at least four new vaccines will be available for older children and teens.
All vaccine makers have products in the pipeline, but those closest to the finish line, Decker says, are a booster shot for whooping cough, an improved meningococcal vaccine and vaccines for herpes and human papillomavirus, a cause of cervical cancer.
''That is a sea change,'' Decker says. ''It represents a need to be prepared, to organize the health care system. (Insurers) need to be ready.''
Acknowledging the need for readiness, the Advisory Committee on Immunization Practices, a panel of vaccine experts that makes recommendations to the CDC, has appointed a subcommittee on adolescent immunization. The group will consider how to integrate new vaccines into the program and whether they should be recommended for all youngsters.
Walter Orenstein, director of CDC's National Immunization Program, says health officials long have recommended a regular exam for 11- to 12-year-olds. During that visit, doctors have a chance to bring their patients up to date on missed vaccines and offer others, including vaccines for flu, chickenpox and hepatitis B.
The vaccines now being developed will face hurdles to their acceptance, experts say.
''Parents of young children know very well about the importance of immunization at a very young age,'' he says. But teen vaccination is newer, and ''adolescents don't always go in for checkups.''
Only 5% of 15- to 19-year-olds see a doctor regularly, says pediatrician Paul Offit, chief of infectious diseases at the Children's Hospital of Philadelphia, in his book, Vaccines: What You Should Know (Wiley). ''Most teenagers (and adults) wrongly assume that the vaccines they got as children were all that they needed for the rest of their lives.''
Parents also may balk at vaccinating children for sexually transmitted diseases (STDs), which account for many of the vaccines now in development. ''One can imagine a whole family of vaccines focused on STDs,'' says Peter Paradiso of Wyeth, but there are ''societal issues'' that could make recommendation for their use controversial.
To be effective, vaccines have to be given before exposure to a disease-causing virus or bacteria, and that holds true for vaccines against diseases that spread via sex. ''It only works if you give it to people before their first sexual contact, and that means adolescence,'' Decker says.
More than 25% of women over the age of 12 have genital herpes, according to the National Institute of Allergy and Infectious Diseases, which is enrolling more than 7,500 women in a study to test the herpes vaccine being developed by GlaxoSmithKline.
Only women ages 18-30 can participate in the current study, says Martin Wasserman of GlaxoSmithKline, but ''we're hoping we'll eventually be able to test it in even younger women and be able to provide it to young girls,'' he says. ''The earlier you get it, the more protection it offers.''
One of the biggest hurdles to routine adolescent vaccination, Orenstein says, likely will be cost.
When the immunization advisory panel adds a vaccine to its recommended list, it is offered free through a federal program to children up to age 18 who are uninsured or whose insurance doesn't cover the cost.
''But certainly the newer vaccines are not going to cost the couple of dollars per dose we're used to in the past,'' Orenstein says.
Manufacturers spend tens of millions of dollars on research, clinical trials and production to bring a vaccine to market, and it's expected the new ones will cost $50 or more per dose. ''Those are the kinds of prices we need to be ready for,'' Orenstein says.
To begin to address these concerns, the Institute of Medicine on Monday will release a report offering recommendations to federal and state policymakers on vaccine purchasing and supply, disparities in insurance coverage and the effects of licensing procedures on costs.
It's crucial that the public health system get ''ahead of the curve,'' says Adel Mahmoud, president of Merck Vaccine Division. ''We can't just wait for the disease and expect to treat it with antibiotics or other drugs,'' because the bugs are becoming resistant to treatment.
It's not enough to prevent disease in children, he says. ''The whole concept of immunization is expanding to say, 'Let us cover all the susceptible populations in our community, not only children, but also adolescents and adults.' ''
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