Giving Vaccination Rates a Boost

When most people think of infectious diseases, maladies such as colds, influenza and even STDs come to mind. But few of us today have a solid frame of reference for diseases like mumps, measles or whooping cough, believing incidents to be rare or even obsolete. Unfortunately, this false sense of security and resulting complacency can lead to increased vulnerability when it comes to potential new outbreaks.

In 2006, the United States experienced its first mumps epidemic in 20 years. The outbreak was believed to have started on a college campus in Iowa. Later, infected airline passengers spread the disease to regions around the country. Eventually, the Centers for Disease Control and Prevention (CDC) documented more than 3,000 confirmed, probable and suspected cases of mumps in at least a dozen states.

Other diseases like measles have recently become more prevalent in Europe, as parents skip the vaccination due to autism concerns, a problem American public health officials have been dealing with for several years. In the last two years alone, more than 12,000 Europeans have contracted measles, according to a Lancet study, and many of them have been children.

Speaking at an international seminar in the Czech Senate, Zsuzsanna Jakab, director, European Centre for Disease Prevention and Control (ECDC), highlighted the importance of vaccines as one of the most important and effective tools for the prevention of infectious diseases in the EU, but cautioned that more work is needed to counter negative perceptions of vaccines. “As people think some infectious diseases are no longer a threat, they are more likely to question the value and safety of vaccination,” Jakab said.

A Generation-Spanning Concern

From a public health perspective, statistics show that stagnant vaccination rates are an issue impacting children and adults alike. The CDC currently recommends vaccinations from birth through adulthood to provide a lifetime of immunity.1 Unfortunately, few adults follow through with vaccinations as recommended, leaving them potentially at risk for unnecessary illness or even death. And since the healthcare model for adults in the U.S. is based primarily on acute care, many practitioners are either understocked with vaccines or not adequately trained on vaccination schedules for adult patients. In addition, for healthcare providers, there are valid concerns about possible financial losses due to excess vaccine inventory, or the high price tag associated with storing temperature- and time-sensitive vaccines.

Currently, nearly 95 percent of the 50,000 Americans who die every year from vaccine-preventable diseases are adults.2 Hundreds of thousands more are hospitalized annually. And while these cases represent worst-case scenarios, millions of others become ill, miss work or school and pass their infections on to others. The situation is a frustrating one for those in the healthcare profession; with so many safe and effective vaccines available, finding new and effective ways to address public concern, misinformation and apathy is essential.

“At the adult level, our current healthcare model does not stress preventive care,” says Litjen (L.J.) Tan, MS, PhD, director, medicine and public health at the American Medical Association. “We need to help providers become vaccinators by giving them the information, tools and resources necessary to succeed.”

While safety concerns get a lot of press when it comes to stagnant childhood vaccination rates, cost can be a factor as well. One possible reason is that vaccines are funded by a patchwork of public and private sources. While some private health insurance plans cover recommended vaccines for children, an increasing number of plans require patients to pay out of pocket for many of them. Unfortunately, the vaccines, especially newly recommended ones, can be very pricey.

“I think we have to develop a comprehensive strategy for communicating directly and honestly with parents,” adds Tan. “We need to train providers to engage with parents and address their concerns. Often, it is a time and staffing issue; in some cases, having a dedicated nurse practitioner on staff to offer vaccine consultations can help boost a practice’s vaccine rates.”

Understanding the Challenges

Vaccination barriers exist at all levels in the public and private sectors and among healthcare providers and delivery systems. Some key areas that could benefit from a communications and delivery booster shot include:

Boosting Awareness. Many adults, including healthcare workers, are unaware of the need to vaccinate adults. There may also be a lack of awareness regarding specific diseases vaccines are designed to prevent, such as meningitis, shingles and chickenpox. In other instances, patients may be somewhat aware of the need for vaccines, but have unanswered questions about safety and effectiveness that keep them from being immunized. For healthcare providers, having information readily available and being prepared to answer questions about various vaccines is a critical first step in increasing vaccination rates across population lines.

Boosting Influence. Healthcare providers play a significant role when it comes to influencing a patient’s decision to be vaccinated. A National Foundation for Infectious Diseases (NFID) survey reported that 87 percent of respondents claimed they were more likely to be vaccinated at a doctor’s recommendation, while only 41 percent said they would ask for a vaccine if their doctor did not bring it up. Unfortunately, many providers lack the resources to maintain an adequate supply of vaccine on hand and may be less-thanknowledgeable about vaccine guidelines, both deterrents to turning the tide on stagnant immunization rates. Looking at new and innovative business models and proactively planning vaccine clinics are two ways providers can reap the potential rewards within the vaccination market.

Boosting Infrastructure. With the exception of the influenza vaccination, there has been little emphasis on creating an infrastructure within the healthcare system to achieve consistently high immunization rates in adults. Issues surrounding distribution, supply and demand, delivery, availability and storage all combine to sabotage even the best-laid plans for a vaccination clinic.

Fighting the Flu: A Season-Long Approach

In 2007, the CDC began emphasizing the need to offer the influenza vaccine and schedule immunization clinics throughout the influenza vaccination season (October into January and beyond). This is an important message for practitioners, and one that has yet to be thoroughly embraced. A cross-sectional survey sent to a national, random sample of internists and general practitioners before this change in recommendation revealed that 43 percent of the respondents stopped vaccinating in December, and only 27 percent continued vaccinating into February and beyond. Furthermore, 43 percent of the physicians indicated that they were either neutral or hesitant to vaccinate after the onset of influenza activity in their community.³

Thinking Outside the Clinic: Exploring Non-Traditional Settings

According to a CDC-sponsored survey,⁴ the most common locations where patients received their influenza vaccine during the 2005-2006 season were physicians’ offices (39 percent), the workplace (17 percent) and community health clinics (10 percent). Providing influenza vaccination services at “non-traditional” sites that offer extended hours, are easily accessible or are frequently visited (e.g., grocery and other stores, malls, pharmacies, senior centers, churches) can increase access for those who might otherwise go unvaccinated. Other non-traditional settings where vaccine might be provided include adult day-care centers, casinos, bingo halls, major transit points, airports and polling stations on election days. Drive-through vaccination programs may also be a feasible alternative.

Thinking outside the “clinic” is essential if practitioners hope to boost vaccination rates. For one thing, traditional settings such as clinics and doctors’ offices may not offer sufficient infrastructure to handle increased demand. Development of alternative sites can also help establish the infrastructure that will be necessary to address increased vaccine demand in the event of an influenza pandemic.

Practice-Proven Methods: A Look at Successful Case Studies

Utilizing a season-long approach helped one practice in Clarks Summit, Pa., achieve high vaccination rates. With one physician and two nurses on staff, the practice takes a multipronged communication approach, routinely repeating its strong recommendation for vaccination at all visits during the influenza vaccination season. Educational posters placed in the waiting room urge annual vaccination. Vaccine-only clinics are offered weekly during the influenza vaccination season.⁵

A private pediatric group practice (12 pediatricians; 26,000 patients) in Nashville, Tenn., combines many interventions, with a goal of immunizing all children in recommended categories and any other patient desiring vaccines.⁶ Parents are educated about vaccination for preventable diseases at all well and sick visits. A patient reminder is mailed in September. During the influenza season, the practice’s on-hold message includes information about influenza vaccination, which also can be found on the practice’s website. To streamline vaccine delivery, multiple vaccine clinic days are offered, with nurses administering vaccine according to a standing order; the clinics allow for 10 appointments per hour. The vaccination program is evaluated at the end of every season, potential areas for improvement are discussed, and adjustments are made.

During the 2007-2008 influenza season, Arizona State University increased influenza vaccination among students, faculty and staff by 41 percent (from 2,343 to 3,980 vaccine doses), compared with the previous year.7 The improved vaccination rate occurred despite an increase in price from $10 per vaccination in 2006 to $18 for students and $20 for employees in 2007. A multifaceted program included convenient access to vaccinations and increasing demand through education and giveaways. Vaccine was made available during two week-long events at the student union. In addition, nurses visited residence halls. Education and awareness were enhanced through signage, advertising in the student newspaper and radio station, and free T-shirts given to persons who were vaccinated.

What Providers Can Do: A Strategies and Tools Checklist

After conducting a systematic review of published studies that looked at the effectiveness of various population-based approaches to increasing vaccination coverage for routinely recommended vaccines, the Task Force on Community Preventive Services and a diverse team of experts at the CDC identified a number of effective approaches.* Among them:

• Client Reminder/Recall Systems: Reminding members of a target population that vaccinations are due (reminders) or late (recall). Delivery method: telephone calls, letters or postcards.
• Assessment and Feedback for Providers: Retrospectively evaluating the performance of providers in delivering one or more vaccinations to a client population, and providing data back to providers. Delivery method: surveys, chart reviews, payment reviews.
• Provider Reminder/Recall Systems: Developing strategies to inform healthcare providers their patients are due or overdue for vaccinations. Delivery method: chart stickers, computer notification, vital sign stamps, medical record flow sheets and checklists.
• Standing Orders: Establishing protocols that enable nonphysician personnel to prescribe or deliver vaccinations to patients without direct physician involvement during patient visits. This is particularly effective for increasing flu and pneumococcal vaccination for adults age 65 and over. Delivery method: interaction with patients at time of visit in clinics, hospitals, nursing homes and other healthcare settings.
• Reducing Out-of-Pocket Costs: Providing insurance for, reducing co-payments associated with or offering free vaccinations. Delivery method: provision programs, insurance coverage or reduction of co-pays at the point of service.
• Expanding Access: Increasing availability of vaccinations in healthcare settings. Delivery method: increasing or changing the hours during which services are provided, reducing the distance from the client to the setting, delivering services where not previously provided (e.g., emergency rooms, inpatient clinics) or reducing administrative barriers to obtaining services within clinics (e.g., “express-lane” vaccination services).

The CDC recommends these findings be used by decision makers and clinicians in delivering and/or improving vaccine delivery.

The High Price of a Pound of Cure

At a White House summit on healthcare reform earlier this year, the administration stated that soaring medical costs present “one of the greatest threats not just to the well-being of our families … but to the very foundation of our economy.” That economic burden is only worsened when vaccine-preventable diseases are spread due to lack of awareness, apathy and misinformation. The reality is, the burden of many adult vaccine-preventable diseases in terms of cost and lives lost is high. Consider the following:

• Influenza kills an average of 36,000 people annually and is associated with more than $10 billion in costs with a moderately severe seasonal outbreak.
• Pertussis, with an estimated one to three million cases each year, can lead to pneumonia and exposure of infants, who are at greatest risk of death from pertussis.
• Pneumococcal disease, which causes pneumonia and invasive infections, kills approximately 5,000 annually.
• HPV infects more than 6 million females per year; two HPV strains included in the vaccine cause 70 percent of all cervical cancers.
• Shingles will affect one in three Americans in their lifetime. The accompanying severe pain syndrome (post-herpetic neuralgia) may last months or years after the shingles rash heals.
• Hepatitis B-related liver disease kills about 5,000 Americans and costs $700 million annually.

Clearly, finding ways to increase vaccination rates for preventable diseases across population lines can have a positive societal impact, from both a human and financial perspective. Is an ounce of prevention really worth a pound of cure? When it comes to vaccines for preventable diseases, the answer is a definitive “yes.”

*These findings and conclusions are those of the authors and the Task Force on Community Preventive Services and do not necessarily represent the official position of the CDC.