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Adult immunization rates fall far short of goals

From the April ACP Internist, copyright 2011 by the American College of Physicians

By Stacey Butterfield

It seems kids aren’t the only ones who need, and try to avoid, their shots. Rates of adult vaccination in the United States are falling short of goals set out by health authorities. For example, the CDC’s Healthy People 2010 campaign aimed to have 60% of high-risk patients under 65 vaccinated against pneumonia and influenza, yet actual rates may be as low as half of that.

William Schaffner, MACP, president of the National Foundation for Infectious Diseases, recently spoke with ACP Internist about issues surrounding adult immunization, including underuse of some recommended vaccines and obstacles to improving vaccination rates.

Q: Why does adult vaccination need attention?

A: The current vaccination rates of all adults—all immunization parameters, no matter how we measure them—clearly have not reached the Healthy People [2010] goals. The infant, childhood and adolescent immunization program that we have in this country is the most successful in the world, but once you cross the threshold of your 19th birthday, the public/private partnership that exists for infants, children and adolescents kind of dissolves. We don’t have the same commitment to a comprehensive adult immunization program. The goals have not been reached. We have a substantial way to go.

Q: What are the obstacles to greater uptake of adult vaccination?

A: There are several. As I like to quip, the first four are funding, funding, funding, and in case you didn’t get it, funding. We have had, until the recent enactment of health care reform, 40 million people in the United States who didn’t have any form of medical insurance. The two major public medical insurance programs, Medicaid and Medicare, both have substantial limitations in how easily practitioners who work with those programs can provide vaccines.

Even on the private side, there are insurance schemes that don’t cover all vaccines. There are many adults who have deductibles or have insurance programs that have copays. All of those financial reasons severely inhibit providing immunizations comprehensively to all adults. Beyond that, both patients and providers, including internists I’m afraid, can use more education and familiarity with adult immunizations and the adult immunization schedule. (The schedule is available online.)

Q: What kinds of education are needed?

A: Part of it happens through education of the general public. The best example is influenza vaccine. There’s a lot of information about influenza vaccine out there that’s revved up on an annual basis. People get, if you will, booster doses of information and there are many individuals now who entirely on their own motivation, because they have been informed through the public media, seek out influenza vaccination. We could obviously do that and more of it, both with influenza vaccine and other vaccines.

On the other side of the equation, the provider side, there have been a number of toolkits that have been provided so that providers know more about ordering vaccines, storing them, how to bill for them, what the proper adult immunization schedule is, and how to organize their practice so that the immunization status of their patients is reviewed on a regular basis, the gaps identified, and vaccines not only offered but actually delivered.

Q: What causes that gap between the offer of vaccination and delivery?

A: One example [is that] it is now recommended by the CDC’s Advisory Committee on Immunization Practices that every person age 60 and over receive the shingles vaccine. The majority of those people are 65 and over, so they are Medicare recipients. Trying to provide shingles vaccine under the Medicare program is a challenge. Unlike influenza vaccine and pneumococcal vaccine, which are in Part B of Medicare where they get first dollar coverage both for the vaccine and an administration fee, the shingles vaccine has been allocated to Part D.

A vaccine which is usually delivered in a physician’s office doesn’t fit into that program very well, although many pharmacists are participating and administering it. Here we have this really wonderful new vaccine and, at the moment, the maximum estimate I have seen of people age 65 and older who have received the vaccine is around 9% to 10%. That’s appallingly low. That’s similar to designing a fancy new Jaguar automobile and then leaving it in the garage.

We have to create not only good vaccines, but a smoothly functioning, coherent delivery mechanism and we’re still struggling with that. We had hoped—some of us—to have that included under health care reform, but we didn’t get that, so we have to keep working on it.

Q: How can individual internists improve vaccination rates?

A: I have an internist who is very interested in administering vaccines—he and everybody else in his practice. One of the things that they’ve done is organize this aspect of their practice to be very efficient. Much of it is out of [the physician’s] hands.

For example, the regular review of the immunization status, which happens every time I go into the office, that’s done by the nurses, before the physician sees me. If [the nurse has] put a tick next to something, the doctor knows right away as soon as he or she picks up the chart that ‘Oh, here’s an immunization gap.’ [The doctor] can say a few words about that and then the nurses will automatically offer me that vaccine, after the physician has made a very firm recommendation.

The recommendation of the doctor—explicit, firm, supporting and then quickly explaining why it’s important and that the vaccine is safe—remains the most powerful way to motivate patients to receive vaccines.

Q: Are there any other vaccines, like the shingles vaccine, that are underutilized?

A: Let me give you another example: hepatitis B. The Advisory Committee on Immunization Practices recommends that everyone who is not in a long-term monogamous relationship with an infection-free partner be vaccinated against hepatitis B. That’s simply a recommendation that is not well known by most internists. They think of hepatitis B as a vaccine that is relegated to relatively highly specialized groups of people. They haven’t realized that about three years ago, the CDC broadened that recommendation very substantially. There are many, many young adults who on the basis of that indication would be candidates for hepatitis B vaccine.

It’s also not been recognized very much yet, but this year for the first time, the Advisory Committee on Immunization Practices recommended that all adults in the United States—in fact everyone in the United States older than six months of age—be vaccinated annually against influenza. If you’re standing in front of me and you do not have genuine egg allergy (which is rare), you should be vaccinated. And oh, by the way, I should be, too.

The best data indicate that around half of health care providers get vaccinated each year against influenza. That’s our bad. We should do much better than that. We should make sure that not only we and our family members are vaccinated, but everyone who works in our office. How about the people who don’t see patients directly? The recommendation now is for all of us to be vaccinated and when patients come to us, we want them to enter an influenza-free zone.

Q: Any other vaccines you see as particular issues?

A: Pneumococcal vaccine has been with us for a very long time and it is recommended for everyone age 65 and older and for those younger than age 65 who have underlying conditions—heart disease, lung disease, diabetes, immunocompromise including AIDS, people who don’t have a spleen and, more recently, anyone with asthma and all smokers. In the under-65 age group, rates of people with these indications having received pneumococcal vaccine range from 10% to maybe 40% at the best. We haven’t put it all together.

The adult booster shot that protects against pertussis is also very important. We’re seeing more whooping cough infections in adults. And while whooping cough is very rarely deadly in adults, adults can pass it on to infants for whom it can have very tragic consequences. Whooping cough has been on the rise in pockets across the country, including California where 10 infants died from it last year alone. The vaccine is recommended once for all adults, including those 65 and older, which is a new recommendation that perhaps doctors haven’t caught up with yet.

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