CDC hopes new immunization charts will give vaccines for adults a boost
By Deborah Gesensway
Earlier this fall, the federal government released new recommendations that public health officials hope will make immunizations as routine for adults as they are for children. For the first time, the CDC has compiled all of its recommendations on adult vaccines into two easy-to-use charts.
While most of the individual recommendations themselves are not new, public health officials hope that the new schedule will clear up many of physicians' questions about which adults should receive vaccinations, and when they should receive them. The charts were published in the Oct. 11 issue of Morbidity and Mortality Weekly Report.
To help physicians navigate vaccination recommendations, the schedules summarize current CDC recommendations through a simple color-coding scheme. The first schedule is organized by age.
Kathleen M. Neuzil, ACP-ASIM Member, assistant professor at the University of Washington in Seattle and the College's representative to the CDC work group that wrote the new schedules, explained how the age-based chart should be used. "A healthy 67-year-old is in my office," she said. "I look at the chart and ask, 'Does this patient need a tetanus booster? Does he need a flu vaccine? Is it recommended that he get a pneumococcal vaccine?'"
The second chart is organized by medical condition, which Dr. Neuzil said makes it particularly useful for internists: "Say the patient is 50 and diabetic. The recommendations tell us not only about tetanus and flu, but also about pneumococcal vaccine, and to give it only one time."
As can be seen from this example, she said, the chart aims to give clear advice on when patients need to be revaccinated for pneumococcal disease, which Dr. Neuzil said is a source of confusion for some physicians. (For excerpts of the chart, see this month's "Immunization Booster" on page 7.)
Dr. Neuzil said that the recommendations should be particularly helpful for individual practitioners who do not see much of any one chronic disease. "It can be very difficult to keep track of all recommendations for so many chronic diseases," she explained.
In this way, the recommendations should help internists do a better job of immunizing all patients who could benefit, not just the elderly. "We get into trouble when we see younger patients with high-risk conditions," Dr. Neuzil said. "In younger patients, immunization rates for influenza are about 40%, as compared to 65% in the elderly."
As that 65% figure denotes, compliance with even the easier-to-grasp age-based recommendations is less than optimal. According to the CDC, about 40,000 American adults die of vaccine-preventable diseases each year, about the same as die from traffic accidents.
Through the new charts, public health authorities hope to bring home the message that even healthy people should consider getting immunized for certain conditions. Public health authorities acknowledge, however, that the recommendations may be a tough sell for a medical culture that doesn't typically associate the word "adult" with "immunization."
Vishnu Sneller, PhD, an epidemiologist with the CDC's national immunization program, noted that one of her colleagues is undergoing dialysis. As a result, she said, everyone who works with that person "should be militant about getting an influenza vaccine every year."
Dr. Sneller explained that if she were to come down with the flu, she would probably recover with few problems. If her colleague on dialysis contracted the disease from her, however, it could prove deadly.
'We have the mentality that vaccinations are only for children.'—Vishnu Sneller, PhD
Dr. Sneller admitted that even at the CDC, many adults don't think about getting vaccinations. "We have the mentality that vaccinations are only for children," she said. "In addition, many physicians either don't think it's their job to give regular vaccinations, or if they want to, they are confused about the recommendations."
To make sure that the recommendations are up to date, public health officials plan to review them every year, much like the CDC reviews its childhood immunization schedule. The authors of the recommendations, including representatives from the College's Adult Immunization Initiative, hope all physicians will post copies on their office walls and use them as chart and patient reminders.
(The Adult Immunization Initiative is the College's campaign to improve adult immunization rates. More information is online.)
Concerns about evidence
The American Academy of Family Physicians and the American College of Obstetricians and Gynecologists have accepted the schedule, but ACP-ASIM declined to accept it based on concerns about evidence for some of the recommendations.
While the CDC is "the definitive source for vaccination policy" in the United States, explained Vincenza T. Snow, FACP, ACP-ASIM's Senior Medical Associate who oversees the Adult Immunization Initiative, not all of the recommendations are based on evidence from randomized, controlled trials.
While Dr. Snow acknowledged that ACP-ASIM has not officially endorsed the schedule, she noted that members of the College's Adult Immunization Initiative physician advisory board, as well as the Clinical Efficacy Assessment Subcommittee, reviewed the schedule positively. She also pointed out that the College is working with the CDC on next year's version and that ACP-ASIM will help publicize and distribute the schedule to internists.
Dr. Neuzil said that while not all the recommendations are based on randomized, controlled trials, there is a wealth of evidence supporting all of the CDC's vaccination guidelines. She also pointed out that most of the major recommendations, including the use of flu vaccines for patients under 50, are supported by evidence that includes top-quality data from randomized, controlled trials.
Dr. Neuzil said that an added benefit of laying out all the recommendations in one place is that the document shows where more research is needed. "It may have unveiled some controversies, but it represents the CDC's current recommendation," she said. "And I would hope that it will change every year. New vaccines may come on the market. An additional risk group may be identified for any one of these vaccines. Who knows, next year we may need to add smallpox vaccine to this list."
Deborah Gesensway is a freelance writer in Glenside, Pa.
The information included herein should never be used as a substitute for clinical judgment and does not represent an official position of ACP-ASIM.
"Recommended Adult Immunization Schedule" and "Recommended Immunizations for Adults with Medical Conditions" are online.
You can also access them though a link on ACP-ASIM Online.
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