Adult Vaccinations in Primary
Care: Why They’re Important
and How to Improve
Kristin L. Nichol, MD, MPH, MBA
Professor of Medicine,
University of Minnesota Medical School
Associate Chief of Staff for Research,
Minneapolis Veterans Affairs Medical Center
Minneapolis, Minnesota
Disclosures (cont.)
[insert local practice presenter’s
name and disclosure]
 This presentation will not include any
non-FDA approved or investigational
uses of products or medical devices
[update if presentation has changed]
 Dr.
Learning Objectives

After reviewing this material, you should
be better able to
Identify which vaccines are indicated for
adult patients
 Summarize what the national vaccination goals
are and current national performance
 Describe barriers and strategies to enhancing
adult vaccination rates
 Propose 2 or more strategies that could enhance
vaccination rates in your practice

Impact of Vaccines During the
20th Century and Into the 21st Century
Reported Cases
(Year)
5796 (1950)
Reported Cases
(2009)
0
% Decrease in
Reported Cases
100%
486 (1950)
18
96%
Pertussis
120,718 (1950)
16,858
86%
Measles
319,124 (1950)
71
99%
Mumps
152,209 (1968)
1991
99%
Rubella
46,975 (1966)
3
99%
Hepatitis A*
32,859 (1966)
1987
94%
Hepatitis B*
26,611 (1985)
3405
87%
Disease
Diphtheria
Tetanus
*Underreporting estimated at a factor of 4.3 for hepatitis A and 2.8 for hepatitis B thus actual number of cases likely substantially higher
than reported numbers of cases.
CDC. Epidemiology and Prevention of Vaccine-Preventable Diseases: The Pink Book; 2011.
Available at: http://www.cdc.gov/vaccines/pubs/pinkbook/default.htm. Accessed June 15, 2011
Burden of Selected VaccinePreventable Diseases (VPDs)
VPD
Burden
200,000 excess hospitalizations annually (>40% in the elderly)
Influenza
~24,000 excess deaths annually (~90% elderly)
~50,000 cases of bacteremia each year
Invasive Pneumococcal
• Higher rates in elderly and persons with comorbidities
Disease (IPD)
• Case fatality rates ~20% (up to 60% in the elderly)
78,000 new infections annually (highest in young adults)
• 1 million with chronic hepatitis B virus infections
Hepatitis B
• Complications include cirrhosis and hepatocellular
carcinoma (80% of cases)
million new infections each year
Human Papillomavirus (HPV) 6.2
2 HPV strains cause 70% of cervical cancer
10,454 cases reported in 2007 (3152 in adults)
Pertussis
Most severe in infants
*Source often older child or adult
500,000 to 1 million cases annually; lifetime risk ~32%
Shingles
Shingles and postherpetic neuralgia increase with age
CDC. Epidemiology and Prevention of Vaccine-Preventable Diseases: The Pink Book; 2011.
Available at: http://www.cdc.gov/vaccines/pubs/pinkbook/default.htm. Accessed June 15, 2011
Vaccination Is the Best Way
to Prevent and Control VPDs
Recommended Adult Vaccines
by Age Group
Please see full reference for additional important footnote information.
CDC. Adult immunization schedule. Available at: http://www.cdc.gov/vaccines/recs/schedules/downloads/adult/adult-schedule.pdf.
Accessed February 6, 2012.
Recommended Adult Vaccines
by Condition
Please see full reference for additional important footnote information.
CDC. Adult immunization schedule. Available at: http://www.cdc.gov/vaccines/recs/schedules/downloads/adult/adult-schedule.pdf.
Accessed February 6, 2012.
Vaccination Rates Are Low
Vaccine
Influenza
Age 19-49, high risk
Age 50-64, total
Age 65
Healthcare workers (19-64 years old)
Pneumococcal
Ages 19-64, high risk
Age 65
Tetanus/pertussis since 2005 (19-64 years old)
Shingles (60 years old and older)
Hepatitis B (high risk, 19-49 years old)
HPV vaccine (women, 19-26 years old)
Vaccination Rate
33.4%
40.1%
65.6%
52.9%
17.5%
60.6%
50.8%
10.0%
41.8%
17.1%
CDC. 2009 Adult Vaccination Coverage, NHIS. Available at: http://www.cdc.gov/vaccines/stats-surv/nhis/2009-nhis.htm.
Accessed June 13, 2011
Baseline Vaccination Rates vs
Healthy People 2020 Goals: Gaps Persist
Vaccine and Target Group
Baseline Rate (Year)
Healthy People 2020 Goal
Influenza vaccine
Noninstitutionalized adults 18 to 64 years old
Noninstitutionalized high-risk adults 18 to 64 years old
Noninstitutionalized adults 65 years old and older
Institutionalized adults 18 years old and older
Healthcare personnel
Pregnant women
25% (2008)
39% (2008)
67% (2008)
62% (2006)
45% (2008)
28% (2008)
80%
90%
90%
90%
90%
80%
Pneumococcal vaccine
Adults 65 years old and older
High-risk adults under 65 years old
Institutionalized adults
60% (2008)
17% (2008)
66% (2006)
90%
60%
90%
Zoster vaccine
Adults 60 years old and older
7% (2008)
30%
Hepatitis B vaccine
Healthcare personnel
64% (2008)
90%
USDHHS. Healthy People 2020. Available at: http://www.healthypeople.gov/2020/default.aspx. Accessed June 13, 2011.
Disparities Also Persist: NHIS 2009
Vaccination
Rate,
Non-Hispanic
Whites
Vaccination
Rate,
Non-Hispanic
Blacks
Vaccination
Rate,
Hispanics
Influenza, 65 years old and older
68.6%
50.8%
50.6%
Pneumococcal, 65 years old and older
64.9%
44.8%
40.1%
Vaccine and Target Group
CDC. 2009 Adult Vaccination Coverage, NHIS. Available at: http://www.cdc.gov/vaccines/stats-surv/nhis/2009-nhis.htm.
Accessed June 13, 2011.
So, Why Are Vaccination Rates
So Low?
Determinants of Vaccination
Behavior Among Patients and
Providers Are Well Described
Critical Issues for Successful
Vaccine Delivery

Patient

Provider

Vaccine supply and reimbursement

Policy
Patient Issues for Vaccination

Awareness
Disease
 Vaccine
 Personal risk

Provider recommendation
 Misconceptions/fears

About vaccine
 About healthcare system


Access and ability to pay
Medicare Beneficiaries’ Reasons
for Not Getting Vaccinated

Lack of knowledge


Misconceptions


Personal risk and need for vaccination
About vaccines and VPDs
No recommendation from doctor
CDC. MMWR Morb Mortal Wkly Rep. 1999;48(39):886-890.
CDC. MMWR Morb Mortal Wkly Rep. 2004;53(43):1012-1015.
Medicare Beneficiaries’ Reasons
for Not Getting Vaccinated (cont.)
Didn't know
No doctor recommendation
Didn't remember
Shot causes diseases
Side effects
Pneumococcal (n=6926)
Influenza (n=4503)
Doesn't work
0
10
20
30
40
50
60
70
Percentage aged 65 years who reported reasons
for not receiving vaccinations1996
CDC. MMWR Morb Mortal Wkly Rep. 1999;48(39):886-890.
Consumers’ Reasons for
Not Getting Vaccinated

2006 survey of 2002 people
Random-digit dialing, weighted responses
to be representative of US population
 Vaccines: influenza, pneumococcal, tetanus


Commonly cited reasons
I’m healthy, I don’t need it
 My doctor hasn’t told me I need it
 May have side effects


The cost of vaccinations was cited less often
Johnson DR, et al. Am J Med. 2008;121(7 Suppl 2):S28-35.
Adults’ Main Reasons for
Not Being Vaccinated
Not needed
Didn't know*
No doctor recommendation
Tetanus
Tdap
Zoster
HPV
Side effects**
Cost
0
10
20
30
40
50
60
Percentage of US adults who reported reasons
for not receiving vaccinations2007
*Refers both to not knowing they should be vaccinated and not knowing enough about the vaccine.
**Includes concern about getting sick from vaccine.
Adapted from: Euler GL, CDC. Adult vaccination coverage, national immunization survey—adult, 2007.
Available at: http://cdc.confex.com/cdc/nic2008/webprogram/Paper15390.html. Accessed June 13, 2011
Consumer Misconceptions
About Vaccines
Category and Response
Vaccines and VPDs
Had vaccines as a child—don’t need them again
Vaccines not necessary for adults
Not concerned about catching VPDs
Not concerned about spreading illness to others
VPDs are not serious or life threatening
Vaccine safety/efficacy
Have heard vaccines are not safe
Vaccines don’t work
A vaccine made them sick
NFID. Saving lives: integrating vaccines for adults into routine care.
Available at: http://www.nfid.org/pdf/publications/adultimmcta.pdf. Accessed June 13, 2011.
% of Respondents
in Agreement
40%
18%
34%
32%
25%
35%
14%
25%
Who Most Influences Adults’ Decisions
to Get Immunized?
Ages 18-26
Age 65
and Older
All Adults
Personal physician
47%
82%
69%
Family member
33%
6%
19%
Celebrity physician,
public figure, other
11%
4%
7%
None of the above
7%
6%
4%
No answer
2%
1%
1%
NFID. 2009 National Adult Immunization Consumer Survey: Fact Sheet.
Available at: http://www.adultvaccination.com/doc/Survey_Fact_Sheet.pdf. Accessed June 15, 2011.
AMA. American Medical News. Physicians asked to persuade adults to get immunized.
Available at: http://www.ama-assn.org/amednews/2009/08/03/prsc0803.htm. Accessed June 13, 2011.
Inclination to Get Vaccinated Is Higher
if Physician Recommends
Physician
Recommendation? Impact on Vaccination
Yes
87% are very or somewhat likely to get vaccinated
No
55% would not get vaccine unless recommended
by doctor
CDC. Adult immunization coverage information from CDC’s National Immunization Survey.
Available at: http://www.nfid.org/pdf/pressconfs/adultimm08/cdcsurvey.pdf. Accessed June 15, 2011.
Provider Recommendation Translates
Into Higher Vaccination Rates
(Even for Patients With Negative Attitudes)
Vaccination Rates Among High-Risk* Patients With Negative Attitudes
Vaccination Rate (%)
100
80
No recommendation
82%
Recommendation
85.1%
60
40
27%
15.8%
20
0
Influenza
PPV
*High-risk patients were those ages 65 and older or those having heart disease, lung disease, diabetes,
or other serious illness.
Nichol KL, et al. J Gen Intern Med. 1996;11(11):673-677.
Disparities and Vaccination Barriers

Barriers
Health literacy
 Mistrust of system
 Language


Facilitators
Culturally appropriate education
 Leveraging communities/trusted leaders/
faith-based organizations
 Translated materials

Daniels NA, et al. J Natl Med Assoc. 2004;96(11):1455-1461.
Chen JY, et al. J Community Health. 2007;32(1):5-20.
Traeger M, et al. Am J Public Health. 2006;96(5):921-925.
Logan JL. J Natl Med Assoc. 2009;101(2):161-166.
What Can We Do to
Increase Vaccination Rates?
To Improve Vaccination Rates,
Providers Should …

Know the facts

Recommend vaccinations to your patients

Get organized and use systems approaches

Ensure offering and administration of vaccines


Automatic processes that empower nurses are effective
Address convenience, efficiency, and durability

Evaluate and improve processes

Consider new paradigms



New venues
Extend vaccination season
Practice what we preach (get vaccinated!)
Nichol KL. Cleve Clin J Med. 2006;73(11):1009-1015.
Know the Facts:
VPDs Are BAD,
Vaccines (as Recommended)
Are GOOD
Types of Vaccines

Inactivated (“dead”)

Inactivated whole cell
or subunit





Live

MMR

Varicella/zoster

LAIV/flu vaccine
nasal spray
Polysaccharide-based



TIV/flu shot
Hepatitis A and B
Acellular pertussis
HPV

Pneumococcal
Meningococcal
Toxoids

Td/Tdap
Avoid live virus vaccines for
pregnant women and patients with
severely compromised immune systems
CDC. Epidemiology and Prevention of Vaccine-Preventable Diseases: The Pink Book; 2011.
Available at: 12th:http://www.cdc.gov/vaccines/pubs/pinkbook/default.htm. Accessed June 15, 2011..
How Can Healthcare Providers
Keep Up on Adult Vaccinations?

www.cdc.gov/vaccines





Adult Immunization Schedule (updated annually)
ACIP recommendations for each vaccine
Vaccine information statements (VIS)
Lots of other information on VPDs, vaccine safety,
brochures, posters, and how to store and
administer vaccines
www.immunize.org

The Immunization Action Coalition has lots of useful
information for healthcare providers
Know Them,
Recommend Them
Do Primary Care Providers
Recommend Vaccines to Adults?
% of Surveyed Primary Care Providers Who Recommended
Influenza and Pneumococcal Vaccines
Patient Group
Influenza
Pneumococcal
Elderly
37%
65%
Lung disease
45%
68%
Diabetes
31%
44%
Heart disease
20%
29%
200 providers surveyed.
Johnson DR, et al. Am J Med. 2008;121(7 Suppl 2):S28-35.
Beware of Assumptions!
Reasons for Not Receiving Influenza
or Pneumococcal Vaccinations
Cited by HCPs
Cited by Consumers
Fear of needles
>65%
<20%
Cost
>60%
15%
Johnson DR, et al. Am J Med. 2008;121(7 Suppl 2):S28-35.
Get Organized to Get It Done
Missed Opportunities


Missed opportunities are common

More than 50% of patients needing an influenza
vaccine had at least one visit with a missed
opportunity to vaccinate

Among persons needing pneumococcal
vaccination, there were 10.7 missed opportunity
visits over 3 years
Patient refusals uncommon
Nowalk MP, et al. J Am Board Fam Pract. 2005;18(1):20-27.
Practical Barriers to Vaccinating
Adults in the Office Setting

Knowing what is recommended for whom

Having time to do it

Remembering to do it

Having adequate personnel to do it
Nichol KL, Zimmerman R. Arch Intern Med. 2001;161(22):2702-2708.
Szilagyi PG, et al. Prev Med. 2005;40(2):152-161.
Interventions That Improve
Vaccination Rates for Adults
Component
Odds Ratio (OR)
Organizational change
16.0
Provider reminder
3.8
Patient financial incentive
3.4
Provider education
3.2
Patient reminder
2.5
Patient education
1.3
Provider financial incentive
1.3
Feedback
1.2
Stone EG, et al. Ann Intern Med. 2002;136(9):641-651
Interventions That Improve
Vaccination Coverage:
Task Force on Community Preventive Services

Increase patient demand for vaccines




Enhance access




Patient reminder and recall systems
Clinic-based patient education
Manual outreach and tracking
Expanded access in healthcare settings
Reduced out-of-pocket costs to patients
Home visits
Address provider barriers



Provider reminders
Standing orders and policies
Provider assessment and feedback
CPS Task Force. Universally recommended vaccinations: health care system-based interventions implemented in combination.
Available at: http://www.thecommunityguide.org/vaccines/universally/healthsysteminterventions.html. Accessed June 13, 2011.
Case Example: A Multifaceted Program
Improved Success and Sustainability
Strategy
Tactics
Increase demand
Annual reminder to patients
Enhance access
Walk-in clinics
Address provider barriers
Institutional policy
Standing orders
Standardized forms
Efficient clinic flow
Ongoing measurement and evaluation
Nichol KL. Am J Med. 1998;105(5):385-392.
Case Example: Impact of Multifaceted
Program on Influenza Vaccination Rates
Influenza Vaccination Rate (%)
100
80
60
40
20
0
Baseline
After Provider
Multifaceted
Education (Standing Orders)
Nichol KL. Am J Med. 1998;105(5):385-392.
Multifaceted,
Year 10
Standing Orders Are Often
Key Components of Success

Consistently among the most effective kinds of
interventions to increase vaccination rates

Definition: policy/procedure/written order that allows
qualified nurses, pharmacists, and other healthcare
professionals (as allowed by state law) to assess and
vaccinate patients who meet certain criteria



Eliminate need for direct physician involvement with each patient
Eliminate need for individual physician’s order for each patient
Appropriate settings: outpatient, inpatient, emergency
department, long-term care, etc
McKibben LJ, et al. MMWR Recomm Rep. 2000;49(RR-1):15-16.
Standing Orders Are More Effective
than Provider Education or
Provider Reminders for Inpatients
Influenza Vaccine Offering Rates by Type of Intervention
100
Rates (%)
80
60
40
20
0
Provider Education
Provider Reminder
Crouse BJ, et al. J Fam Pract. 1994;38(3):258-261.
Standing Orders
Opportunities for
Improvement Abound
Use of Effective Vaccination Strategies by US Physicians
100
Generalists
Subspecialists
80
%
60
40
20
0
Influenza Pneumonia Influenza Pneumonia Influenza Pneumonia
Very Strongly Recommend Standing Orders
Patient Reminders
Nichol KL, Zimmerman R. Arch Intern Med. 2001;161(22):2702-2708.
Vaccination Strategies Used by
Subspecialists and Generalists
Strategy
Very strongly recommend for elderly patients
Increase demand
Patient reminders
Clinic-based patient education
Enhance access
Special clinics
Provider-oriented
Provider reminders
Standing orders
Assessment/feedback on vaccination rates
for elderly
Nichol KL, Zimmerman R. Arch Intern Med. 2001;161(22):2702-2708.
Influenza
75-86%
Pneumococcal
64-81%
14-24%
25-52%
9-14%
18-40%
10-27%
5-10%
26-39%
20-29%
20-38%
24-37%
13-19%
18-33%
Physician Practice and Interest in Selected
Strategies for Influenza Vaccinations
Doing Already
Would Try
Patient reminders
23%
53%
Walk-in clinic
67%
19%
Policy to assess status at each visit
48%
31%
Standing orders
33%
36%
Clearer vaccine guidelines
33%
51%
Registry
7%
56%
Szilagyi PG, et al. Prev Med. 2005;40(2):152-161.
Tips on How to Move Forward

Establish baseline rate

Chart audit, numbers of vaccine doses, etc

Inventory current strategies used

Identify where


Current strategies could be improved
New strategies could be added

Involve the clinic team in planning and implementation

Pay attention to work flow, efficiency, etc
Resources to Help

Immunization Action Coalition
(www.immunize.org)

Adult Vaccination Guide (complete “how-to”)
http://www.immunize.org/guide/
 Setting
up for adult vaccination services
 How to store and handle vaccines
 Documenting

Sample standing orders
 http://www.immunize.org/standing-orders/
Vaccine Information Statements (VIS)
from the CDC


Mandated by National Childhood Vaccine Injury
Act (NCVIA)
Must be used for all vaccines covered by the act
(regardless of age)




Includes most vaccines for adults
Strongly recommend for ALL vaccines
Obtain them from various Web sites
CDC, state health departments
Translations available in 30 different languages
(www.IAC.org)
CDC. Fact sheet for vaccine information statements. Available at: http://www.cdc.gov/vaccines/pubs/vis/vis-facts.htm. Accessed June 13, 2011.
Healthcare Workers:
Practice What We Preach!
Immunizations and Healthcare
Workers (HCWs)

“First do no harm”

Recommended vaccinations/immunity






Special situations


Influenza
MMR
Hepatitis B
Varicella
Tdap
Meningococcal for microbiologists with potential for exposure
Other vaccinations based on personal risk characteristics
Immunization Action Coalition. Healthcare personnel vaccination recommendations.
Available at: http://www.immunize.org/catg.d/p2017.pdf. Accessed June 15, 2011.
Summary

VPDs are an important cause of morbidity
and mortality in adults

We have safe and effective vaccines that
are underused

For patients, misconceptions about VPDs and
vaccines and lack of provider recommendation
are important factors in not being immunized

For providers, missing opportunities and failing to
recommend vaccination are important shortcomings
Summary (cont.)

Interventions to increase vaccination rates
should include efforts to enhance demand,
improve access, and address provider
and systems issues

In addition to vaccinating their patients,
providers should also be vaccinated

Lots of Internet resources are available
to help
Internet Resources

CDC’s National Immunization Program


Immunization Action Coalition


www.nfid.org
CMS


www.immunize.org
National Foundation for Infectious Diseases


www.cdc.gov/vaccines
www.cms.gov/AdultImmunizations/
State health departments