An Update on Adult Immunizations

While there is a great deal of focus on childhood immunizations, the recommendations for adult vaccines receive less attention by patients, physicians and even the media. There are 17 vaccine-preventable diseases targeted by immunization recommendations across a person’s life span, with the majority of those vaccinations occurring in infancy and childhood; however, a fair number of vaccines require a new immunization or booster into and throughout adulthood. And, these adult recommendations are often overlooked or ignored.

One reason for this lack of emphasis is adults often (incorrectly) assume that the vaccines they received as children will carry over into adulthood. While in some instances this is true, in others, it is not. As we age, our immunity against some diseases for which we previously received vaccinations fades. Also as we age, we become more susceptible to and can become more seriously affected by some diseases. Add to this the fact that some of the newer vaccines, human papillomavirus, or HPV, for example, weren’t available when today’s adults were children (HPV only received the U.S Food and Drug Administration’s [FDA’s] approval in 2006), and the need for adults to continue receiving all recommended vaccines is well illustrated.

Still another barrier to adult immunization is the medical system itself — from healthcare providers not understanding that vaccines are needed by both healthy and unhealthy adults, to time constraints that prioritize treatment for acute and chronic illnesses over preventive care, and even insurance concerns. Medicare limits coverage for vaccines based on the type of plan, Medicaid vaccination coverage varies by state (with some states covering only a subset of recommended vaccines), some providers may not be eligible for reimbursement under some plans because they are not authorized as “in-network” providers for vaccination services, and until the Affordable Care Act (ACA) is fully implemented, many still don’t have insurance coverage.¹

Whatever the reasons, the vaccination rates for adults are too low. A recent Centers for Disease Control and Prevention (CDC) study that looked at six vaccines — pneumococcal, hepatitis A, hepatitis B, herpes zoster, HPV and tetanus antigen-containing vaccines — showed ranges of only an 18.5 percent vaccination rate for 18- to 64-year-olds for the pneumococcal vaccine to 64 percent for the tetanus antigen.²

“Generally when we think of vaccines, we tend to think of vaccines for children,” says Dr. Kristine Sheedy, communications director for the Immunization Center at CDC. “Most adults … aren’t aware that adults need vaccines too. Vaccines are needed throughout our lives based on age, health conditions, occupation, lifestyle and travel. Adult vaccines are safe and help prevent a number of common and serious diseases like pneumococcal disease, shingles and pertussis. Unfortunately, to some, adult vaccination isn’t viewed as ‘newsy.’ Adult immunization rates have been low for a number of years, and there haven’t been many changes in vaccines or new recommendations to the adult schedule. When it comes to adult vaccination, unfortunately, the story is one of lack of awareness.”

ACIP Updates

In February, CDC Advisory Committee on Immunization Practices (ACIP) announced its 2014 recommended adult immunization schedule. There are some key changes for flu, tetanus, diphtheria acellular pertussis (Tdap), HPV, zoster virus, pneumococcal disease and meningococcal disease vaccines.

Influenza. Five new flu vaccines have been approved for adult use. A live attenuated flu vaccine (LAIV4; Flumist Quadrivalent [MedImmune]) indicated for healthy, nonpregnant persons age 2 years through 49 years, replaces the trivalent (LAIV3) formulation. An inactivated flu vaccine (IIV4; FluLaval Quadrivalent [GlaxoSmithKline]), indicated for persons age 3 years and older, will be available in addition to the previous trivalent formulation. A quadrivalent inactivated influenza vaccine (IIV4; Fluzone Quadrivalent [Sanofi Pasteur]), indicated for persons age 6 months and older, will be available in addition to the company’s previous trivalent formulation. Also available are a trivalent cell culture-based inactivated influenza vaccine (ccIIV3; Flucelvax [Novartis]), indicated for persons age 18 years and older, and a recombinant hemagglutinin vaccine (RIV3; FluBlok [Protein Sciences]), indicated for persons age 18 years through 49 years.³

CDC recommends Flublok for those who have an allergy to eggs, as this vaccine contains no egg protein. Healthy People 2020’s target for flu vaccine administration to both noninstitutionalized adults age 18 years to 64 years and pregnant women is 80 percent, up from 24.9 percent for noninstitutionalized adults and 27.6 percent for pregnant women in 2008. The target for those 65 and older is 90 percent, up from 66.6 percent in 2008.⁴

Tetanus, diphtheria and acellular pertussis (Tdap). Adult immunization recommendations for the Tdap vaccine now match CDC’s pediatric immunization schedule, with a booster given every 10 years after initial vaccine administration.

HPV. It is no longer recommended that adult healthcare workers get an HPV vaccine. However, as a reminder, vaccination is encouraged for immunocompromised persons through age 26 if they did not receive all of the three-dose series of the vaccine when they were younger.⁵

Zoster virus. It also is no longer recommended for adult healthcare workers to receive a zoster virus vaccine; however, a single dose of the vaccine is recommended by ACIP for all those who are 60 years of age and older (FDA has approved the vaccine for those 50 years of age and older, but ACIP recommends vaccinations no earlier than 60 years).5

Healthy People 2020 suggests a 30 percent zoster virus vaccination rate goal for those age 60 and older, up from 6.7 percent in 2008.⁴

Pneumococcal disease. Clarifications on the order of which pneumococcal vaccines should be administered have been made, depending on whether people require both the pneumococcal conjugate (PCV13) and/or pneumococcal polysaccharide (PPSV23) vaccines. Persons with immunocompromising conditions are recommended to receive both PCV13 and PPSV23 vaccines.

A one-time revaccination five years after the first dose of PPSV23 is recommended for persons age 19 years through 64 years with certain immunocompromising conditions. Persons who received one or two doses of PPSV23 before age 65 should receive another dose of the vaccine at age 65 or later, provided that it has been at least five years since their previous dose. After age 65, no further dose is needed.⁵

Healthy People 2020 lists a target of no more than 31 diagnosed cases of invasive pneumococcal disease per 100,000 adults age 65 and older, down from 40.4 in 2008, and nine cases of antibiotic resistant pneumococcal disease, down from 12.2 in 2008.4

Meningococcal disease. Distinctions have been clarified as to who should receive the conjugate and the polysaccharide meningococcal vaccine. Also, the new recommendations clarify that the conjugate vaccine is not routinely recommended for those with HIV; however, should the patient receive this type of vaccine, two doses are recommended.

ACIP recommends to “administer two doses of quadrivalent meningococcal conjugate vaccine (MenACWY [Menactra, Menveo]) at least two months apart to adults of all ages with functional asplenia or persistent complement component deficiencies.” Also, “revaccination with MenACWY every five years is recommended for adults previously vaccinated with MenACWY or MPSV4 who remain at increased risk for infection.”⁵

Healthy People 2020 has a goal of no more than 1,094 cases of meningococcal disease, down from 1,215, which was the average annual infection rate between 2004 and 2008.⁴

A CDC Vaccine Schedules app is available for healthcare professionals who recommend or administer vaccines. The free tool visually mimics the printed schedules, which are reviewed and published annually, provides the most current version of the child and adolescent schedules with immunization recommendations from birth through age 18; the catch-up schedule for children 4 months through 18 years; the adult schedule, including recommended vaccines for adults by age group and by medical condition; and a contraindications and precautions table, with all footnotes that apply to schedules. The app can be obtained at www.cdc.gov/vaccines/schedules/hcp/schedule-app.html#download.

Improving Vaccination Administration

Improved availability and education about the recommended vaccines, as well as the frequency and severity of their associated diseases, is crucial to help reduce the incidence of disease. Every year, it is estimated that 30,0006 to 42,0004 people in the U.S. die of vaccine-preventable diseases, almost all of whom are adults. In addition, many thousands more become ill or die from complications related to those preventable diseases every year. For example:

• More than one million adults get shingles annually.
• 226,000 adults are hospitalized for the flu, and as many as 49,000 die from its complications.
• 175,000 adults are hospitalized for pneumonia, and nearly 4,000 die from invasive pneumococcal disease.
• As many as 1.4 million adults suffer from chronic hepatitis B and risk-associated liver cancer.
• 8,300 adults die annually of HPV-related cancers.⁷

What is interesting in comparison is that fewer than 1,000 American children die of vaccine-preventable diseases.² Clearly, there is a disconnect in the understanding and efforts between childhood and adult vaccinations. “It’s a social norm that children are vaccinated, but there is less awareness that adults need vaccines as well,” says Sheedy.

In September 2013, the National Vaccine Advisory Committee Standards for Adult Immunization Practice recommended expanding vaccine services by both pharmacists and community immunization providers, as well as increasing efforts of vaccine delivery in the workplace. However, before the reality of this expansion can happen, the financial barrier of these vaccines, particularly for smaller practices, must be overcome.

The ACA’s first dollar coverage provision of ACIP-recommended vaccines for those with certain insurance carriers or who are under the expanded Medicaid plans is expected to increase the number of adults who will be insured to receive vaccines. Also, the ACA requires vaccines, when delivered by in-network providers of private insurance companies, be administered with no co-pays.

One of the most important predictors of whether adults receive their recommended vaccines is that the vaccine is offered during doctor visits, so physicians play a key role in raising awareness. “Our research shows hands down that raising awareness is at the top of the list,” says Sheedy. “People are aware of the annual flu vaccine, and Merck has raised awareness of the shingles vaccine. We’ve got to talk to providers about best practices and push the tools that are available.”

Other successful opportunities for increasing vaccine coverage include worksite and community interventions, automatic reminder calls and standing orders in electronic health records. Providers are also encouraged to enter immunization information into the Immunization Information System (IIS), or immunization registries, via meaningful use incentives for both Medicare and Medicaid.¹

There is also hope for federal funding for adult immunization programs for those who are unable to afford them, much like Vaccines for Children. For instance, Oregon’s Special Immunization Project 2012-2013 sought to strengthen the adult immunization infrastructure and increase access to vaccines, particularly influenza and Tdap vaccines, by a rate of 10 percent by offering a weekly free Tdap clinic for those without health insurance.

Best Practices in Action

“Children’s vaccines are usually tied to a well-child exam, typically every few months during the child’s first two years of life,” says Alison Alexander, Immunize Oregon Coalition coordinator. “Since a child is closely monitored by a provider, the diligence is in part by the parent and reminder notices from the provider. Resources are limited for adults, generally speaking — nothing tied to well-visit exams.”

However, improving those educational resources and access was at the heart of Oregon’s Adult Immunization Project. Oregon is a great example of both state and counties working together to improve adult vaccination rates. With a $1.8 million grant awarded from CDC National Center for Immunizations and Respiratory Diseases through the Prevention and Public Health Fund (eight other states, as well as the city of Chicago, also received grants), participating counties (32 of Oregon’s 36 counties) got to work in partnering with providers and businesses to educate and vaccinate. “The goal of our project was to strengthen adult immunizations in Oregon, particularly influenza and Tdap,” says Kathy Scott, DrPH, assessment, readiness and epidemiology manager of the Oregon Immunization Program.

Some examples of Oregon’s objectives, all of which were on target or even exceeded by mid-term 2012, were partnering with pharmacies to increase the number of flu vaccine doses given to adults (322,150 by mid-term 2012, up from 286,548 doses in 2011), in part by updating pharmacy protocols to use the IIS to look at patient vaccine history and forecast what they would need. The counties also partnered with large nonhealthcare employers to encourage vaccinations either onsite or at a referring pharmacy, or to hold an educational campaign. “We had a goal of 116 employers, but everyone was engaged, and we had 170 participating at midpoint,” says Scott. They encouraged healthcare institutions to increase their workers’ vaccination rates (77 percent at midpoint), as well as those of long-term care facilities (57 percent) and ambulatory surgery centers (70 percent). Says Scott: “Our program was just one small part of this. Our project played a role, but there were lots of initiatives going on.”

“As a health department, we partnered with local organizations providing flu vaccines to local businesses and asked that they also add Tdap. It was a huge success, and the whole goal now is sustainability,” adds Heather Kaisner, MS, immunization coordinator and health communication specialist for Deschutes County Health Services, one of the participating counties. Of course, all those involved in not just Oregon’s Adult Immunization Project, but immunizations as a whole, must continually overcome obstacles to vaccinations such as time and budget constraints, as well as educating providers and patients. “The ideal time [to get vaccinated] is when adults go to their provider, but vaccines aren’t always talked about,” says Kaisner. However, those providers who do encourage vaccines tend to have patients who get vaccinated. Deschutes County created a two-page pamphlet geared toward barriers based on feedback from focus groups. “There are a lot of myths and misconceptions out there, and you can’t make assumptions,” says Kaisner. “The more awareness we bring to healthcare, the better. I think a great resource, personally, are pharmacists. They have a great opportunity for education. With healthcare providers, we go when we are sick, and hopefully we go to well visits too, and hopefully providers also encourage vaccines.”

Getting the word out plays an important part of all successful campaigns. Oregon utilized television, radio, newspapers and social media as part of its educational campaign. Sheedy says CDC is also using a mix of approaches to educate healthcare workers and patients about the new vaccine recommendations. “A core piece of that education is working with our partners,” she says. “We don’t have a lot of money to buy air time, so we count on our partners to get the message out to constituents. Pharmacists, private sector partners, healthcare professionals — all influential and trusted sources. If they make the recommendation, then patients are much more likely to get vaccinated. Part of what we want to do is raise awareness and create a new social norm.”