An Interdisciplinary Look at Strategies to Improve IMMUNIZATION RATES FOR OLDER ADULTS
[ WORKGROUP MEMBERS ]
R. Gordon Douglas, Jr., MD
Chairperson
Adjunct Professor of Medicine ❙ Weill Cornell Medical College ❙ New York, New York
Paul Etkind, DrPH, MPH
Senior Director of Infectious Diseases
❙ Community Health Team ❙ National Association of County and City Health Officials ❙ Washington, DC
Stefan Gravenstein, MD, MPH
Professor of Medicine ❙ Alpert Medical School of Brown University ❙ Clinical Director ❙ Healthcentric Advisors ❙ Providence, Rhode Island
Walter A. Orenstein, MD
Professor of Medicine ❙ Associate Director, Emory Vaccine Center ❙ Director, Emory Program for Vaccine Policy and Development ❙ Program Director for Operations Management and Initiatives, Influenza Pathogenesis and Immunology Research Center ❙ Emory University School of Medicine ❙ Atlanta, Georgia
Barbara Resnick, PhD, RN, CRNP, FAAN, FAANP
Professor of Nursing ❙ University of Maryland School of Nursing ❙
Adjunct Professor ❙ Department of Epidemiology and Preventive Medicine
❙ University of Maryland School of Medicine ❙ Baltimore, Maryland
William Schaffner, MD
Professor and Chair ❙ Department of Preventive Medicine ❙ Professor of Medicine (Infectious Diseases)
❙ Vanderbilt University School of Medicine ❙ Nashville, Tennessee
[ LEARNING OBJECTIVES ]
After reading this publication, the health professional will be able to:
[ ] List vaccines that are recommended for adults and describe progress toward public health goals for the use of these vaccines.
[ ] Describe barriers to immunizations for adults and strategies to address these barriers.
[ ] Locate national and state-specific information regarding initiatives to improve adult vaccination rates.
[ ] Recount examples of state-level activities designed to improve adult vaccination rates.
[ ] Dispel myths that impede the use of adult vaccines.
Vaccine-Preventable Diseases in Adults
Safe and effective vaccines are available to protect adults against many diseases, including influenza, pneumococcal infection, varicella, herpes zoster (shingles), tetanus, diphtheria, pertussis, hepatitis A and B, and human papillomavirus (HPV) infection (cervical and several other types of cancer). Each vaccine has a specific recommended patient population and immunization schedule. Recommendations for vaccines for adults are developed by the Advisory Committee on Immunization Practices (ACIP), which advises the Centers for Disease Control and Prevention (CDC).
The ACIP publishes an annual adult immunization schedule with a ge-based and underlying medical condition–based recommendations. In addition, the ACIP often publishes statements on individual vaccines, which provide comprehensive information on the disease to be prevented, risk groups, vaccine indications, vaccine precautions and contraindications, and other valuable information. The recommendations can be accessed at the ACIP website (www.cdc.gov/vaccines). The ACIP recommendations for adults for 2012 are shown in Figures 1 and 2. 1 Additionally, in February 2012, the ACIP voted that all adults 65 years and older should receive the tetanus, diphtheria, and acellular pertussis (Tdap) vaccine, effectively establishing a universal Tdap recommendation for all adults ages 19 years and older. 2
Adult immunization rates are still very low in comparison with the generally successful vaccination campaigns for children in this country. An estimated 40,000 to 50,000 adults die each year from vaccine-preventable diseases in the United States.3 Additionally, more than 1 million adults get shingles, an extremely painful condition.3 The direct health care costs associated with these diseases in adults is approximately $10 billion annually.3
In addition to the increased likelihood of becoming ill themselves, adults who are not immunized also are more likely to transmit the disease to others. For example, adults who
[ PRE-ACTIVITY QUESTIONS ]
Assess your baseline knowledge by answering the following questions:
[ 1 ] Which of the following statements best describes Medicare coverage for adult vaccines?
a ] All vaccines are covered through Medicare Part B.
b ] All vaccines are covered through Medicare Part D.
c ] Some vaccines are covered through Medicare Part B and some are covered through Part D.
d ] Vaccines are not covered by Medicare.
[ 2 ] Which of the following statements about vaccinations in long-term care facilities is true?
a ] Facilities are required to offer influenza and pneumococcal vaccines to residents, but residents are not required to accept them.
b ] All residents must be vaccinated annually against influenza unless they have medical contraindications or religious exemptions.
c ] Health care workers in these facilities must be vaccinated annually against influenza unless they have medical contraindications or religious exemptions.
d ] None of the above.
[ 3 ] Advantages to having vaccines administered by pharmacists include which of the following reasons?
a ] Pharmacists have an established infrastructure for billing Medicare Part D.
b ] Pharmacists are generally more accessible than physicians.
c ] Pharmacists generally have more convenient hours and scheduling than physicians.
d ] All of the above.
have not been immunized against pertussis can transmit the disease to children who are too young to be vaccinated. Such events have resulted in the deaths of infants.4
Current Vaccination Rates
The CDC website, Healthy People, provides science-based, 10-year national objectives for improving public health in the United States. Healthy People has established benchmarks and monitored progress over the past three decades.5
Healthy People 2020 objectives for adult vaccinations are shown in Table 1.6
Adult vaccination rates are well below national public health goals. For example, while a Healthy People 2010 objective was to vaccinate 90% of people over 65 years of age for influenza and pneumococcal infections, actual immunization rates fell far short of this goal. (In contrast, in the 2006–2007 school year, three-quarters of states met the Healthy People 2010 target of at least 95% coverage for all recommended vaccines for kindergarteners.7) Adult vaccination data as of 2009 are shown in Table 2.8
As shown in Table 2, in 2009, most adult vaccination coverage levels improved over previous years, but remained much lower than the Healthy People 2010 targets for pneumococcal disease, tetanus, Tdap, hepatitis A, hepatitis B, herpes zoster, and HPV. Furthermore, it is important to note that vaccination rates are lower for minorities than they are for whites. Vaccination coverage with two new vaccines primarily recommended to minimize long-term complications of infectious diseases—herpes zoster (shingles) and HPV infection—was particularly low. Although not shown in the table, vaccination rates also are notably low for health care workers, who are both at increased risk of contracting some of the vaccine-preventable diseases as well as passing some vaccine-preventable diseases on to others, including elderly adults and immunocompromised patients.
Barriers to Adult Vaccination
There are many reasons why vaccination rates for adults trail those for children. One important factor is the lack of a systemic infrastructure to support adult vaccinations. For example, in general, physicians who treat adults do not tend to champion immunizations to the same extent as pediatricians, and
TABLE 1. HEALTHY PEOPLE 2020 VACCINATION GOALS FOR ADULTS
Source: Reference 6.
adults do not access health care providers routinely at the same rates children do. Another systemic factor contributing to the discrepancy is that most schools, child care facilities, and summer camps require proof of immunization when children enroll; however, similar immunization requirements for adults are scarce. While a few employers may require immunizations (e.g., for health care workers or military personnel), there typically is no such incentive for adults and the impetus for vaccination of adults must come from health care providers or from patients themselves. (One exception is nursing homes, which must offer influenza and pneumococcal vaccines to residents, but residents are not required to accept them.)
Cost is an obstacle for many adults. For children, the Vaccines for Children Program is a federally funded program that provides vaccines at no cost to children who might not otherwise be vaccinated because of inability to pay. No analogous program exists for adults, and there is only a patchwork system for adult coverage. For example, only some recommended vaccines are covered
Source: Reference 1.
TABLE 2. PROPORTION OF ADULTS RECEIVING SELECTED VACCINATIONS
19–49 years, had traveled outside the United States to countries other than Europe, Japan, Australia, New Zealand, or Canada since 1995
19–49 years, had not traveled outside the United States to countries other than Europe, Japan, Australia, New Zealand, or Canada since 1995
(continued on next page)
TABLE 2. PROPORTION OF ADULTS RECEIVING SELECTED VACCINATIONS BY AGE GROUP AND HIGH-RISK STATUS, 2009
Human papillomavirus vaccination (at least 1 dose), ever
a Statistically significant difference from 2008 at P<0.05.
Source: Reference 8. (CONTINUED)
under Medicare Part B for eligible adults. Medicare Part D covers vaccines that are not covered by Part B, but there are logistical barriers to payment because physicians do not have the infrastructure to bill Part D. Furthermore, Medicare does not cover vaccines for most adults less than 65 years of age.
A growing number of pharmacists now administer vaccines (and can bill through Medicare Parts B and D), but patients may still encounter out-of-pocket costs due to co-pays and other cost-sharing requirements in Part D plans. Medicaid coverage for adult vaccines is inconsistent from state to state, and private insurance does not always pay for adult vaccines. Finally, some of the newer vaccines are expensive, with a complete course of vaccination costing hundreds of dollars.
Health Care Workers
Health care workers often do not receive recommended vaccines. Immunizations are particularly important for health care workers because of their frequent interactions both with patients who may be carrying the diseases as well as with those who may be more susceptible to diseases. This issue is compelling in long-term care facilities and hospitals where many elderly, frail, and medically fragile patients are susceptible to infection. Furthermore, undervaccinated health care workers can result in reduced staff during outbreaks—the times during which staff would be most needed.
The reasons health care workers give for not receiving vaccines include: thinking that they do not need the vaccine, getting the vaccine is inconvenient, having concerns about side effects, and believing that vaccines can cause the diseases they are intended to prevent.9 Such perceptions not only result in low vaccination rates for health care workers but can reduce the likelihood that they will promote vaccination to their patients.
Vaccines can cause the illness they are intended to prevent.
FACT: This myth is particularly common regarding influenza vaccine. However, the injectable influenza vaccine cannot cause influenza because the virus has been inactivated, split apart, and purified. In some other cases, it is possible for a person to develop a disease shortly after being vaccinated against it. For example, this can occur if a person is already incubating a disease before receiving the vaccination, but has not yet developed symptoms, or is exposed to the disease before full immunity develops. Experts concur that symptoms from full-blown disease dwarf the minor vaccineinduced symptoms.
Patients may develop an illness that has symptoms similar to the disease that they were immunized against. For example, influenza vaccinations are provided at the start of cold and flu season, and many people can develop a cold (unrelated to influenza virus) or influenza if the vaccine has not yet had time to take effect. Because of the timing, these people may blame the vaccine for their infection. Clinical trials show no greater incidence of colds or influenza infection in people who have just been vaccinated when compared with those who did not undergo vaccination. Studies also demonstrate that the frequency of influenza in vaccinated people is much lower, confirming the effectiveness of the vaccine.
The lack of a guaranteed source of payment for vaccines is a concern for providers who do not want to maintain an inventory of an expensive product with a relatively short shelf-life and that must be discarded if specific storage requirements are not maintained. Predicting demand is much more challenging for adult vaccines than it is for childhood vaccines.
The lack of a “medical home” for many adults is another barrier to adult immunizations. While most children have an established primary care provider and participate in regularly scheduled well-child visits, most adults do not have such a relationship. Adults generally go to the physician only when they are sick or to manage a chronic condition. Immunizations rarely take top priority during these office visits, which are often rushed. Thus, the fundamental infrastructure to support high immunization rates is insufficient. The Affordable Care Act of 2010 promotes integrated care models such as patient-centered medical homes, but such practice models are not yet widespread. It is anticipated that the full implementation of the law, planned for 2014, will lead to a more robust emphasis on preventive health, which may support increased adult immunization rates.
Another challenge is the lack of a central repository for information about which vaccinations patients have received. Most states have mandatory immunization registries for children, but adult registries are inconsistent and usually are optional for providers. Continuity of care among providers can be an issue for adults, particularly if the patient is sent to another location to receive a vaccine and/or if multiple vaccines are required to complete the immunization schedule. The development of state-wide immunization registries can help support adult
immunization programs, particularly if they are mandatory. Such registries help confirm whether a vaccine is needed for any particular patient.
Finally, the knowledge and beliefs of adults and health care providers about immunizations for adults remains an issue. As noted in the inset on page 5, many health care providers, as well as patients, have misperceptions about the benefits of vaccines for adults. Some vaccines for adults are relatively new and may not have been available at the time that practitioners received their professional training. In addition, numerous misperceptions about vaccines are perpetuated in the popular press and other forms of communication that can negatively impact the beliefs of patients and providers alike.
Initiatives to Improve Vaccination Rates
In addition to national public health initiatives such as Healthy People, numerous groups, coalitions, and task forces at federal, state, and local levels are working to improve adult immunization rates.
Federal Initiatives
The CDC has identified several activities that have demonstrated effectiveness for improving immunization rates among adults (Table 3).10 These initiatives are low-cost and straightforward for primary care providers to implement.
An overview of the research to support these strategies as well as steps to implement them are available at www.cdc.gov/vaccines/recs/ratestrategies/adultstrat.htm. Additionally, many national medical groups are working to increase awareness among providers and to include information about vaccination in medical school curricula.3
State-Based Immunization Initiatives
Although recommendations and policies for vaccination are set at the federal level, actual implementation occurs at state and local levels. State and local health departments organize, administer, and maintain vaccine campaigns and registries, and they run education and awareness campaigns.11 As shown in Table 4 and Figure 3, which provide recent data on rates of influenza and pneumococcal vaccinations, states have made varying progress toward increasing adult immunization rates.12
A number of organizations and coalitions are dedicated to assist state and local efforts to improve immunization rates. For example, the Association of Immunization Managers was created in 1999 to enable immunization managers located in state health departments to work together to effectively prevent and control vaccine-preventable diseases and improve immunization coverage in the United States. The organization strives to reduce vaccine-preventable diseases through promoting the allocation of resources for immunizations, supporting policies and programs that promote vaccinations, and allowing
groups to cross-pollinate information about effective strategies.13
Many state and local immunization coalitions have developed disease-specific task forces to address immunization needs in adults. These task forces aim to increase awareness and provide education about the vaccines that are recommended for adults. States also have been working to expand the number of vaccines that pharmacists are authorized to provide to adults. The ability of pharmacists to administer vaccines has helped to address some payment and accessibility issues because pharmacists have the infrastructure to bill Medicare Part D and they are often more accessible than physicians. Pharmacists also typically have more convenient hours than physicians, and a scheduled appointment is required less often.
Cost is commonly a barrier to the implementation of broader immunization programs. To address this issue, the 2009 American Recovery and Reinvestment Act (a.k.a. “the stimulus”) included funds to promote vaccinations. States and territories received almost $97 million
[ MYTH 2 ]
Vaccines are risky.
FACT: Because vaccines are given to healthy people to prevent disease in the future rather than to treat a current condition, vaccinations are expected to have a very high standard of safety. Almost all side effects are very minor, such as pain at the injection site of an injectable vaccine. Experts agree that side effects are almost always very minor and much better than coming down with the full-blown disease. Serious adverse events are very rare and the benefits of vaccines greatly outweigh any potential risks.3 Each vaccine, before it is licensed and approved by the Food and Drug Administration (FDA), undergoes very rigorous clinical testing with careful evaluation. This process often takes years until the FDA has information that it judges to demonstrate the vaccine is both safe and effective.
Strategy Definition
Standing orders A written order stipulating that all persons meeting certain criteria (i.e., age or underlying medical condition) should be vaccinated, thus eliminating the need for individual physician’s orders for each patient.
Computerized record reminders
Chart reminders
The computer can print a list of possible reminders that appear on a patient’s record. The software can be programmed to determine the dates that certain preventive procedures are due or past due and then print computer-generated reminder messages, usually overnight, for patients with visits scheduled for the next day.
Chart reminders can be as simple as a colorful sticker on the chart or can be a comprehensive checklist of preventive services including vaccinations. Reminders to physicians that patient vaccinations are due or overdue should be prominently placed in the chart. Reminders that require some type of acknowledgment, even a simple checkmark by the physician, are more effective.
Performance feedback
Provider assessment and feedback involves retrospectively evaluating the performance of providers in delivering one or more vaccinations to a client population and then reviewing their assessment data with providers.
Appropriate Settings Advantages
Private practice, managed care, hospitals including emergency departments, and long-term care facilities.
Private practice, managed care, hospitals, and long-term care facilities.
• The most consistently effective method for increasing adult vaccination rates.
• Easy to implement.
Private practice, managed care, hospitals, and long-term care facilities.
Computerized record reminders can be effective, efficient, and inexpensive once the computerized system is in place. Provider reminder strategies are so effective they have been demonstrated to improve rates both alone and in combination with other strategies.
Chart reminders are inexpensive and efficient. Reviewing health maintenance inventories with patients requires less than 4 minutes and can become part of the physician’s routine. Provider reminder strategies are so effective they have been demonstrated to improve rates both alone and in combination with other strategies.
Disadvantages
Only reaches patients already contacting the health care system.
Private practice and managed care.
• Competition increases physician compliance with vaccination recommendations.
• Immediate feedback on each physician’s performance.
• Easy to implement.
• Minimal disruption of office activity.
• Each physician can use his or her own approach for bringing patients into the office for vaccination (e.g., telephone reminders, informational brochures, personal encouragement).
• Motivating to physicians.
• Evaluation is built into this approach.
• Only reaches patients with office visits.
• May be less effective in fee-for-service practices since cost to the patient may be a barrier to vaccination in a fee-for-service practice.
• Only reaches patients with office visits.
• Chart reminders may be more effective in managed care organizations as compared with fee-for-service practices since cost to the patient may be a barrier to vaccination in a feefor-service practice.
• Time to train staff and implement strategy. However, less time is needed for evaluation since the poster is the actual evaluation tool.
• Can be difficult to continually track vaccination rates.
Home visits
Home visits involve providing face-toface services to clients in their homes. These services can include education about vaccine-preventable diseases and vaccines, assessment of need for or referral to vaccination services, and delivery of vaccinations. Home-visiting interventions also can involve telephone or mail reminders.
Private practice and managed care.
• Efficient, if using existing home health care delivery services.
• May help access lower income and other disadvantaged persons.
• Increased staff time, expense, and possible training requirements, particularly if implemented solely for vaccination services.
• Clients may lack records, or recall, of previous immunizations.
(continued on next page)
Strategy Definition
Mailed reminders and telephone scripts
To implement this reminder/recall strategy, medical staff either call the patient or send a letter reminding the patient that a vaccination is due (reminder) or overdue (recall) and offer the patient the opportunity to schedule an appointment.
Appropriate Settings Advantages
Private practice and managed care.
Expanding access
• Expanding access can include:
• Reducing the distance patients must travel to receive vaccination services.
• Increasing, or making more convenient, the hours during which vaccination services are provided.
• Delivering vaccinations in settings previously not used.
• Reducing administrative barriers to vaccination (e.g., drop-in clinics or express lane vaccination services).
Patient education Patients coming in for a scheduled appointment are handed an information sheet to review in the practice waiting room, prior to hospital discharge, or upon admission to a long-term care facility.
Private practice, managed care, and hospitals.
• Phone contact ensures that the message is understood and provides the opportunity to schedule an appointment.
• Reaches patients who otherwise may not have scheduled visits.
• Easy to implement, requiring minimal staff time.
• Regular use helps to increase vaccination rates.
• Mailed reminders work well for literate patients; telephone reminders may be more effective for less literate patients.
Disadvantages
• Reminders rely on patient to schedule and keep appointments.
• Not useful in practices with high patient turnover or with a population that changes residences frequently.
• May need bilingual reminders.
• Generating the list of patients who should receive reminders may be difficult in some practices (e.g., for those without computerized records).
• If baseline vaccination rates are high, the incremental increase in vaccination rate attained may not be worth the time and effort invested.
Personal health records
Personal health records are issued to patients (either given to patients at the time of a visit or mailed) and contain a preventive care schedule, including recommended times to receive vaccinations.
Private practice, managed care, hospitals, and long-term care facilities.
• Efficient.
• May help access lower income and other disadvantaged persons.
• Increase access to those not already in the system.
• Clearly effective when combined with other strategies.
• Increased staff time and expense.
• New clients may lack records, or recall, of previous immunizations.
• Inexpensive and easy to implement, requiring minimal staff time.
• Patients can ask questions and receive feedback.
• Does not require generating a patient list.
Private practice and managed care.
• Empowers patients and encourages them to be proactive in their own health care.
• Simple and inexpensive.
• Can and should be combined with other preventive health measures, such as cancer screening, to most efficiently use the advantages of the personal health record.
• Several are available (e.g., one-page sheet or wallet-size card).
• Patient has a record of preventive services received should they move or change providers.
• Only reaches patients already in contact with health care providers.
• Written materials are not as useful in practices serving those with low literacy levels; however, video and audio resources can sometimes be used.
• For minority populations, may need bilingual information sheets.
• Requires patient to take initiative (schedule and keep appointments) and remember to bring personal health record with them.
• Requires acceptance, promotion, and reinforcement of method by provider.
• Requires moderate level of literacy from patient.
• For minority populations, may need to translate card into another language.
• Not useful in populations with historically low compliance rates.
• If vaccination rates are already relatively high in this practice, the incremental increase in vaccination rate attained may not be worth the time and effort invested.
Source: Reference 10.
TABLE 4. SEASONAL INFLUENZA VACCINATION RATES FOR ADULTS, 2008
Source: Reference 12.
ALTHOUGH RECOMMENDATIONS and policies for vaccination are set at the federal level, actual implementation occurs at state and local levels.
for operations, infrastructure, and demonstration projects and more than $168 million for the purchase of vaccines through this law. Funds were used for state-level activities designed to support immunization programs and increase vaccination rates across a breadth of subpopulations. 14 State-specific information regarding how these funds were used is available from the Association of Immunization Managers at www. immunizationmanagers.org/
immunization/StateTerritorialLocal ImmunizationProjectAreas.phtml. Numerous other groups work to improve immunizations on a state level, including:
■ The national Immunization Action Coalition provides a list of state and local immunization coalitions and offers a wealth of patient and provider educational materials at www.izcoalitions.org.
■ The National Adult Immunization Coordinators Partnership has developed
FIGURE 3. PNEUMOCOCCAL VACCINATION RATES FOR ADULTS 65 YEARS AND OLDER, 2008
Source: Reference
[ MYTH 3 ]
Vaccines are just for kids.
FACT: Although many vaccines are recommended for adults, a 2007 study by the National Foundation for Infectious Diseases found that many people were unaware that vaccines were available for adults. Fully 40% felt that because they were vaccinated as a child, they did not need vaccines as an adult.3,15
Vaccines that are recommended for adults have been proven to reduce the disease burden and improve quality of life. Ongoing education and awareness campaigns are necessary to promote the importance of immunizations throughout the lifespan.
a list of adult immunization outreach materials by state/territory, which is available at www.cdc.gov/vaccines/ ed/adultimupdate/downloads/ naicp-outreach-materials.pdf. Finally, many state-level initiatives are run by state health departments. Links to all state health departments can be found at www.cdc.gov/mmwr/ international/relres.html.
Selected State-Based Initiatives
Virginia
In Virginia, a coalition of health care providers, business leaders, and community health care providers joined forces to run Project Immunize Virginia. This program has developed an array of resources to promote adult vaccinations, which are mostly targeted toward increasing awareness among health care providers and patients.
To increase influenza and pneumococcal vaccination rates in adults 60 years of age and older, Project Immunize Virginia has developed many resources. One toolkit, called Protecting Yourself for the Ones You Love, is designed to
educate older adults about vaccinepreventable diseases, focusing on influenza and pneumonia. Materials in the toolkit include activities and a timeline, messages for bulletins and newsletters, flyers and posters to promote vaccine awareness, and educational and marketing materials.
Other materials provided by Project Immunize Virginia include:16
■ A brochure describing all Project Immunize Virginia resources and tools
■ The Healthy Heath Care Workers Toolkit
■ Handouts about influenza
■ An influenza toolkit
■ Tdap flyers aimed and grandparents and caregivers of infants
These materials are available at www.immunizeva.org/tools.
Virginia also has both regional and state task forces working on pertussis prevention. Their focus is on “cocooning” babies by vaccinating the adults who care for them with Tdap. Thus, immunized adults will not transmit pertussis to vulnerable young infants, particularly in the first 2 months of life before they are old enough to be vaccinated. Another Virginia public health program, called Senior Navigator,
provides health and aging educational materials targeted to older adults at www.seniornavigator.org. The organization’s website provides comprehensive information to adults about many health-related topics, including the vaccines that they should receive.
Texas
Several initiatives have worked toward improving immunization rates in Texas. The Texas Department of State Health Services immunization program for adults maintains a robust informational website at www.dshs.state.tx.us/ immunize/adult.shtm, and has engaged in many activities to support adult immunizations. Texas runs a voluntary adult immunization registry, called the ImmTrac Texas Immunization Registry, which allows both patients and providers to view immunization histories. This registry is available at www.dshs. state.tx.us/immunize/immtrac/immtrac_ adult.shtm.
The immunization branch of the Texas health department used stimulus funds to purchase vaccine, increase immunization staffing capacity, and invest in infrastructure that will support ongoing immunization efforts. These funds paid for laptops and Internet use to allow local clinics access to the immunization registry. Additionally, funds were used to purchase upgraded refrigerators for vaccination clinics to increase storage capacity and reduce wasted vaccine.17
Another initiative, the Texas Immunization Stakeholder Working Group, was formulated as a recommendation of various studies and state legislation to increase partnerships across the state to raise vaccine coverage levels and improve immunization practices. The group provides a forum for diverse partners in the state immunization system (including state health care provider organizations, immunization experts, vaccine manufacturers, state and local
coalitions, state and local health officials, state health insurers, and community members) to share ideas, perspectives, best practices, and resources.18
Rhode Island
Rhode Island’s Immunize for Life program aims to increase immunization rates across the lifespan by implementing systems for vaccine purchase and distribution, quality assurance, public and provider education, information dissemination, surveillance, and community collaboration.
Insured adults (19 years or older) who live or work in Rhode Island are eligible to receive vaccinations for free at public flu clinics. Participating practices and facilities bill the insurers for the administration of vaccines using claims information provided by the insurers.
In 2006, Rhode Island became the first state to centralize distribution of influenza vaccine. This system is designed to be a cost-effective distribution system, modeled after Rhode Island’s childhood vaccination program. As part of this program, Rhode Island purchases influenza vaccine for the state, and providers order the vaccine from the state. The state’s willingness to take on this risk (cost) reduces waste and minimizes providers’ risk for unused doses.
The program has proven effective. Rhode Island has one of the best overall vaccination rates for influenza in the country and has been recognized for maintaining consistently high immunization rates.19
Michigan
To address immunization rates that were among the lowest in the country, Michigan created a partnership of public and private sector organizations, the Alliance for Immunization in Michigan, to focus on a broad spectrum of immunization issues.20 Their initial focus was to emphasize provider education.
[ MYTH 4 ]
I’m healthy, so I don’t really need a vaccine.
FACT: Perhaps because many years ago, adult influenza campaigns were targeted to older and sicker individuals, many relatively healthy adults feel that it is not important to be vaccinated. Although historically, elderly and frail populations were more likely to experience the most severe consequences of influenza, all adults are at risk for influenza as well as other vaccinepreventable diseases. Strikingly, in the 2009 influenza season, younger healthy adults were among those experiencing fatalities due to the circulating H1N1 strain.21
It is important to note that “herd immunity,” in which a high rate of vaccination prevents a disease from spreading through the community, is effective only when a very high percentage of the population is vaccinated. Becoming vaccinated can help protect individuals who are immunocompromised or others who are more likely to experience severe morbidity or mortality if they become ill.22 Furthermore, herd immunity provides no protection against a disease such as tetanus, which can be contracted from bacteria that can be found in the soil.
Finally, newer vaccines, now routinely given to children or teens, may not have been available to all adults when they were younger but could be beneficial to them now. Or, some of the protection from the disease may fade over time so an additional dose may be necessary.
[ MYTH 5 ]
Vaccines aren’t worth the money.
FACT: Although patients sometimes incur an out-of-pocket cost for a vaccine, the benefits of protection from a vaccine-preventable disease are considerable. For example, a vaccine against influenza or pertussis can prevent an infection that could lead to weeks of time off from work due to illness. Thus, vaccination can help patients avoid reduced quality of life during an illness and can save patients money.
To help put the cost of preventive medicine in perspective, consider that in 2008, Americans spent $2.1 billion on Halloween candy— the same amount required to provide influenza vaccine to approximately 160 million adults.23,24 The health and economic benefits of vaccinations are important factors when determining whether vaccines are a worthwhile expenditure.
The group created a provider toolkit, available at www.aimtoolkit.org, as a comprehensive resource for immunization management, parental education, and other resources.
The Alliance for Immunization in Michigan continues its focus on improving all facets of immunization services throughout the lifespan. Its ongoing goals include:
■ Raising the age-appropriate immunization levels of all Michigan children to at least 90%.
■ Raising awareness among health care providers and the public of the importance of immunization across the lifespan.
■ Promoting participation in the Michigan Care Improvement Registry by all health care providers.
■ Expanding the group’s education and development to include at least two presentations annually directed toward improving its proficiency and activities.
As part of its robust website, the Alliance for Immunization in Michigan presents a toolkit for adult immunizations at www. aimtoolkit.org/adults.php.
Conclusion
Improving immunization rates among adults is an important public health goal. Numerous barriers to adult vaccinations have been identified and many initiatives are underway to attempt to address these barriers. Some improvements in the infrastructure to support adult vaccinations are anticipated with the implementation of the Affordable Care Act, scheduled for 2014.
Other initiatives work to address barriers by improving access to vaccines, reducing costs, increasing patient and provider education, and improving the supporting infrastructure. Many resources, including those listed in this publication, are available for use in developing and promoting vaccine awareness and immunization campaigns. Multi-pronged efforts that address known immunization barriers have been proven to be effective at boosting state vaccination rates, and these successes can be used to inform future initiatives that ultimately improve the quality of life for older adults.
Association of Immunization Managers www.immunizationmanagers.org/index.phtml
Centers for Disease Control and Prevention Vaccines and Immunizations www.cdc.gov/vaccines/
Immunization Action Coalition www.immunize.org
List of state and local coalitions www.izcoalitions.org
References
1. Centers for Disease Control and Prevention. Recommendations and Guidelines: 2012 Adult Immunization Schedule. Available at: http:// www.cdc.gov/vaccines/recs/schedules/adultschedule.htm. Accessed March 16, 2012.
2. Fiore K. ACIP calls for universal Tdap vaccination. MedPage Today. February 22, 2012. Available at: http://www. medpagetoday.com/PrimaryCare/ Vaccines/31309. Accessed March 1, 2012.
3. Trust for America’s Health. Adult Immunization: Shots to Save Lives. February 2010. Available at: http://healthyamericans. org/report/73/adult-immunization-2010. Accessed March 1, 2012.
4. Winter K, Harriman K, Schechter R, et al. Notes from the field: pertussis—California, January-June 2010. MMWR Morb Mortal Wkly Rep. 2010;59:817.
5. Healthy People 2020. About Healthy People. Available at: http://healthypeople.gov/2020/ about/default.aspx. Accessed March 6, 2012.
6. Healthy People 2020. Immunization and Infectious Diseases. Available at: http://www.healthypeople.gov/2020/ topicsobjectives2020/objectiveslist. aspx?topicId=23. Accessed March 2, 2012.
7. Centers for Disease Control and Prevention. Vaccination coverage among children in kindergarten—United States, 2006-07 school year. MMWR Morb Mortal Wkly Rep 2007;56:819-21.
8. Centers for Disease Control and Prevention. Statistics and Surveillance: 2009 Adult Vaccination Coverage, National Health Interview Survey. Available at: http://www. cdc.gov/vaccines/stats-surv/nhis/2009-nhis. htm. Accessed March 2, 2012.
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For each question, circle the letter corresponding to the correct answer. There is only one correct answer to each question.
[ 1 ] Approximately how many adults in the United States die as a result of vaccine-preventable diseases every year?
a ] 10,000 to 15,000.
b ] 20,000 to 25,000.
c ] 30,000 to 40,000.
d ] 40,000 to 50,000.
[ 2 ] Of the following vaccines, the only one routinely recommended for adults 65 years of age or older is:
a ] Human papillomavirus.
b ] Herpes zoster.
c ] Hepatitis B.
d ] Meningococcal.
[ 3 ] Which of the following groups had the highest rate of influenza vaccination in 2008?
a ] Health care personnel.
b ] Noninstitutionalized adults aged 18 to 64 years.
c ] Noninstitutionalized high-risk adults aged 18 to 64 years.
d ] Noninstitutionalized high-risk adults aged 65 years and older.
[ 4 ] What is “herd immunity”?
a ] A situation whereby an infectious disease does not spread through a population due to high vaccination rates/immunity.
b ] The occurrence of a species that is immune to a virus.
c ] The term for when an infectious agent is eradicated.
d ] None of the above.
[ 5 ] Which state purchases all influenza vaccine in advance to reduce financial risk for health care providers?
a ] Virginia.
b ] Rhode Island.
c ] Texas.
d ] Michigan.
[ 6 ] Funds from the 2009 American Recovery and Reinvestment Act for promoting vaccines were used:
a ] Only by states that won them through a competitive bidding process.
b ] As an increase to health care providers providing immunizations through Medicare Part D.
c ] Only by the Centers for Disease Control and Prevention.
d ] By states for operations, vaccine purchases, infrastructure, and demonstration projects.
[ 7 ] Vaccine registries are generally used to:
a ] Allow patients to locate health care providers who administer particular vaccines.
b ] Manage vaccine inventory.
c ] Track which vaccines an individual patient has received.
d ] Facilitate billing for vaccine administration to multiple third-party payers.
[ 8 ] Regarding vaccination programs, what does “cocooning” mean?
a ] Vaccinating adults who care for infants to prevent disease transmission to the infant before the infant is old enough to be vaccinated.
b ] Using a modified vaccination schedule believed to enhance immunogenicity.
c ] Asking patients to reduce socialization during influenza season to decrease opportunities for disease transmission.
d ] Surrounding patients with multiple opportunities to receive vaccines.
[ 9 ] Why is it particularly important for health care workers to be vaccinated against diseases?
a ] To prevent them from becoming ill when treating infected patients.
b ] To prevent them from transmitting disease to other patients.
c ] To set a good example and promote vaccination to their patients.
d ] All of the above.
[ 10 ] In general, which ethnic group has the highest vaccination rates in the United States?
a ] Whites.
b ] Blacks.
c ] Hispanics.
d ] Asian.