Strategies for Public Health
Programs to Improve
Adult Immunization
Goals of Presentation
• Provide information on
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Adult immunization schedule
Burden of vaccine preventable diseases
Adult immunization coverage rates
Barriers and opportunities in adult immunization
• Discuss adult immunization practice standards
• Identify strategies by health departments to increase adult
immunizations
2
Burden of Disease Among U.S. Adults for
Diseases with Vaccines Available

Influenza disease burden varies year to year



Millions of cases and average of 226,000 hospitalizations annually with >75%
among adults
3,000-49,000 deaths annually, >90% among adults2
Invasive pneumococcal disease (IPD)1
 39,750 total cases and 4,000 total deaths in 2010
• 86% of IPD cases and nearly all IPD deaths among adults
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Pertussis (whooping cough)3
 >28,000 total reported cases 2013 and 2014
•

~9,000 among adults
Hepatitis B4
 3,350 acute cases reported 2010
• 35,000 estimated cases

Zoster (shingles)5
 About 1 million cases of zoster annually U.S.
1.
2.
3.
4.
5.
CDC. Active Bacterial Core Surveillance. http://www.cdc.gov/abcs/reports-findings/survreports/spneu10.pdf.
CDC. Estimates of deaths associated with seasonal influenza – United States, 1976-2007. MMWR. 2010;59(33):1057-1062.
CDC. Notifiable Diseases and Mortality Tables. MMWR 2013. 61(51&52): ND-719 – ND 732.
CDC. Viral Hepatitis Surveillance United States, 2010. National Center for HIV/AIDS, Viral Hepatitis, STD& TB Prevention/Division of Viral Hepatitis.
CDC. Prevention of Herpes Zoster. MMWR 2008. 57(RR-5): 1-30.
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Adult Immunization Coverage Rates
2010–2013
Tetanus past 10y, age ≥65
Tetanus past 10y, age 19-64
2013
2012
2011
Pneumococcal, age ≥65
2010
Pneumococcal, age 19-64 at high risk
0
10
20
30
40
50
60
70
80
90
100
Coverage rate (%)
Source: National Health Interview Surveys
: Healthy People 2020 target
Hepatitis B Vaccination (≥3 doses) for
Adults Living with Diabetes, 2010–2013
100
90
Coverage rate (%)
80
70
60
50
40
30
20
10
2010
2011
2012
2013
2010
2011
2012
0
19-59 yrs
≥60 yrs
Age
Source: National Health Interview Surveys
2013
Improvements in Some Adult Immunizations
2013
HPV (≥1 dose), Women 19-26 yrs
2012
2011
2013
Tdap, HCP 19-64 yrs
2012
2011
2013
2012
2011
2013
Zoster, age ≥60
2012
2011
0
10 20 30 40 50 60 70 80 90 100
Coverage rate (%)
Source: National Health Interview Surveys
Adult Immunization Rates Still Low
2013
2012
2011
HPV (≥1 dose), Women 19-26 yrs
2013
2012
2011
HPV (≥1 dose), Men 19-26 yrs
2013
2012
2011
Tdap, HCP 19-64 yrs
2013
2012
2011
Hep B ≥3 doses, HCP ≥19 yrs
0
10 20 30 40 50 60 70 80 90 100
Coverage rate (%)
Source: National Health Interview Surveys
: Healthy People 2020 target
Influenza Vaccination Coverage Among Adults
2011-12, 2012-13, and 2013-14 Seasons, United States
2011-12
(%)
2012-13
(%)
38.8
41.5
42.4
3.6
Persons 18-49 yrs, all
28.6
31.1
32.3
3.7
Persons 18-49 yrs, high risk
36.8
39.8
38.7
1.9
Persons 50-64 yrs
42.7
45.1
45.3
2.6
Persons ≥ 65 yrs
64.9
66.2
65.0
0.1
Group
Persons > 18 yrs
*
2013-14 Difference
(%)*
(%)
Estimates of the percentage of people vaccinated are based on interviews conducted beginning September (BRFSS) or October (NIS) 2013 through June
2014 and reported vaccinations from July 2013 through May 2014. For California, BRFSS interview data were only available for September-December
2013 and thus estimates for persons ≥18 years only reflect vaccinations during July-November 2013. For Mississippi, sample size was insufficient from
interviews conducted April-June 2014 to estimate vaccinations past the end of February, 2014 for persons ≥18 years.
http://www.cdc.gov/flu/fluvaxview/index.htm
Disparities in Adult Immunization
• Lower immunization coverage rates among1
– African Americans and Hispanics
– Uninsured
– Lower income
• Reduce disparities by
– Providers assessing for and recommending vaccination
– Promote immunization for people newly insured through Affordable
Care Act
1. Lu, P-J, et al. Am J Prev Med 2015 (in press)
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Reasons for Low Adult Immunization Rates
• Adults not aware of vaccines they need
• Healthcare providers for adults busy and often have
– Competing priorities
– Incomplete vaccination history
• Not all providers stock all vaccines for adults
• Adults frequently see multiple providers, so vaccine history
recordkeeping difficult
• Reimbursement for vaccines confusing, unclear
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Opportunities for Adult Immunization
• Adults not aware of vaccines they need… but most patients will
accept vaccines if recommended by trusted healthcare
provider
• Healthcare providers for adults are busy and have competing
priorities… but healthcare providers think immunizations are
important for their patients
• Not all providers stock all vaccines for adults… but access to
vaccines is increasing
• Adults frequently see multiple providers and recordkeeping is
difficult… but state vaccine registries include adult
immunizations
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Seize Opportunities to Improve
Adult Immunization
• Affordable Care Act (ACA)
– More adults insured
– Requires insurance for adults and children to include vaccination
– Improved access to vaccines through public and private insurance
• Since nearly all children covered through Vaccines for Children
or private insurance, more of available Section 317 vaccine
purchase funds can be used to vaccinate uninsured adults
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Use of Section 317 Funds
by Health Departments
• Utilization of Section 317 vaccine purchase funds for adult
immunization in 2015 among 55 immunization programs
– 23 state or city immunization programs allocated 100% of Section 317
vaccine purchase funds for adults
– 32 immunization programs allocated an average of 74% of Section 317
vaccine purchase funds for adults (4 programs used only state funds for
adults)
• [Optional: Add state’s use of 317 funds for adult immunization
activities]
Source: Program Operations Branch, Immunization Services Division, NCIRD, CDC
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Adult Immunization Priorities
• Strategies for Health
Departments to Increase Adult
Immunizations1 by National
Adult Immunization
Coordinators’ Partnership
(NAICP), 2014
• Based on Standards for Adult
Immunization Practice2,
National Vaccine Advisory
Committee, 2014
1.
2.
Available at: www.izsummitpartners.org/wp-content/uploads/2014/09/adult-tips.pdf
Public Health Reports, March–April 2014. Available at: www.publichealthreports.org/issueopen.cfm?articleID=3145
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Vaccination Coverage
by Provider Recommendation and/or Offer
Influenza vaccination before and during pregnancy overall and by provider
recommendation and offer* for influenza vaccination among women pregnant anytime
between October 2012 -January 2013, Internet Panel Survey, 2012-13 Influenza Season
Coverage estimates (%)
100
90
80
70.5
70
60
50.5
46.3
50
40
30
16.1
20
10
0
n = 1,702
n = 895
n = 270
n = 455
Overall
Reported a provider
recommendation and offer
Reported a provider
recommendation but no offer
Reported no provider
recommendation
*Women who didn't visit a provider since August 2012 (n=27) or women who didn't know whether
they received provider recommendation or offer (n=55) were excluded from this analysis.
What are Standards for
Adult Immunization Practice?
• All providers, including those who don’t provide vaccine services,
have role in ensuring patients up-to-date on vaccines
• Call to action for ALL healthcare professionals to:
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Assess immunization status of all patients at every clinical encounter
Strongly recommend vaccines that patients need
Administer needed vaccines or refer to a provider who can immunize
Document vaccines received by patients in state vaccine registries
www.cdc.gov/vaccines/hcp/patient-ed/adults/for-practice/standards/index.html
www.cdc.gov/vaccines/hcp/patient-ed/adults/for-patients/index.html
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Organizations Supporting Standards for
Adult Immunization Practice
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Association of Immunization Managers (AIM)
National Association of County & City Health Officials (NACCHO)
Association of State & Territorial Health Officials (ASTHO)
Centers for Disease Control and Prevention (CDC)
American Academy of Pediatrics (AAP)
American Academy of Physician Assistants (AAPA)
American Academy of Family Physicians (AAFP)
American College of Obstetricians and Gynecologists (ACOG)
American College of Physicians (ACP)
American Pharmacists Association (APhA)
Immunization Action Coalition (IAC)
Infectious Diseases Society of America (IDSA)
National Foundation for Infectious Diseases (NFID)
Others
To add your organization to those supporting the standards, go to…
http://www.izsummitpartners.org/support-adult-standards/
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Strategies for Health Departments to
Improve Adult Immunizations
• Determine community needs and vaccination capacity
• Identify and address barriers to adult vaccination
• Provide outreach and education to providers and the
public
• Develop and maintain partnerships with key
stakeholders
www.izsummitpartners.org/wp-content/uploads/2014/09/adult-tips.pdf
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Determine Community Needs
and Vaccination Capacity
• Designate adult immunization coordinator who spends
>50% of time on adult immunization activities
• Work with other health department services or clinics,
stakeholders to assess community vaccination needs
• Develop and maintain adult immunization coalition
• Include adult immunization activities in immunization
program’s priorities and planning
• Devise and apply targeted strategies to address
disparities in immunization coverage and access to
vaccines
www.izsummitpartners.org/wp-content/uploads/2014/09/adult-tips.pdf
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Identify and Address Barriers
to Adult Immunization
• Use available 317 funds to purchase vaccines for
uninsured adults
• Assist health department in becoming in-network
provider
• Develop reminder/recall functionality in state vaccine
registry
• Assist providers in utilizing patient assistance
programs offered by vaccine manufacturers for
uninsured adults
www.izsummitpartners.org/wp-content/uploads/2014/09/adult-tips.pdf
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Provide Outreach and Education
to Providers and Public
• Promote Standards for Adult Immunization Practice,
adult immunization schedule, and other updates to
partners, e.g., state chapters of medical, nursing, and
pharmacy professional organizations
• Urge use of state vaccine registry among adult vaccine
providers
• Provide annual state-level adult immunization
coverage rates to vaccine providers
• Distribute patient education and provider materials
www.izsummitpartners.org/wp-content/uploads/2014/09/adult-tips.pdf
www.cdc.gov/vaccines/adultstandards
www.cdc.gov/vaccines/adultpatiented
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Develop and Maintain Partnerships
with Key Stakeholders
• Partner with pharmacies and community vaccinators
to increase access to vaccines
• Establish relationships with employers to promote
vaccines to employees
• Collaborate with community and faith-based leaders
to promote immunizations for adults
• Collaborate with clinical public health programs, e.g.,
STD, substance abuse, chronic disease, to incorporate
vaccine assessment and administration into their
routine practices
www.izsummitpartners.org/wp-content/uploads/2014/09/adult-tips.pdf
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Using Adult Vaccination Records to
Improve Programs
• Include adult vaccination records in state vaccine registries
(immunization information systems, or IIS)
• Use IIS to develop programmatic initiatives to improve adult
immunization coverage and reduce disparities
• Ensure IIS meets new standards of interoperability with electronic
health records (EHR) to track adult immunization records
• Examples of activities at local health department
– Expand access to and provide training for IIS to adult healthcare providers
– Share information with providers on how to enroll and use IIS, produce
recruitment materials
– Disseminate vaccine coverage data in IIS to providers and public; identify
and address gaps in coverage
– Collaborate with state IIS managers to improve interoperability
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Summary
• Background and issues in adult immunization
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Adult immunization schedule
Burden of vaccine preventable diseases
Adult immunization coverage rates
Barriers and opportunities in adult immunization
• Promote adult immunization practice standards
– Assess, recommend, administer or refer, document (in IIS)
• Strategies for health departments to increase adult
immunizations
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Determine community needs and capacity
Identify and reduce barriers
Provide outreach and education to providers and public
Continue to develop partnerships, promote use of IIS
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Resources
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[Insert state immunization program]
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National Association of County & City Health Officials
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www.immunize.org/
National Foundation for Infectious Diseases (NFID)
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www.cdc.gov/vaccines/hcp/adults
www.cdc.gov/vaccines/adults/index.html
Immunization Action Coalition (IAC)
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www.immregistries.org/
Centers for Disease Control and Prevention (CDC)
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www.immunizationmanagers.org/
American Immunization Registry Association
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www.astho.org/Programs/Immunization/
Association of Immunization Managers
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www.naccho.org/topics/HPDP/immunization/
Association of State and Territorial Health Officials
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[Insert state immunization program URL]
www.adultvaccination.org/
American College of Physicians
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http://immunization.acponline.org/
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Thank You
• [Insert] state health department adult immunization
coordinator, IIS manager
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EXTRA SLIDES
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Call to Action for Public Health
• Determine community needs, vaccination capacity, and barriers to adult
immunization
• Provide access to all ACIP-recommended vaccinations for insured and
uninsured adults and work towards becoming in-network provider for
immunization services for insured adults
• Partner with immunization stakeholders and support activities and policies
to improve awareness of adult vaccine recommendations, increase
vaccination rates, and reduce barriers
• Ensure professional competencies in immunizations
Recommendations from the National Vaccine Advisory Committee: Standards for Adult Immunization Practice
Public Health Reports, March–April 2014. Available at: www.publichealthreports.org/issueopen.cfm?articleID=3145
31
Call to Action for Public Health (2)
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Routinely collect, analyze, and disseminate immunization coverage data
Provide outreach and education to providers and public
Work to decrease disparities in immunization coverage and access
Increase immunization registry access and use by adult vaccine providers
Develop capacity to bill for immunization of insured people
Ensure preparedness for identifying and responding to outbreaks of
vaccine-preventable diseases
• Promote adherence to applicable laws, regulations, and standards among
adult immunization stakeholders
Recommendations from the National Vaccine Advisory Committee: Standards for Adult Immunization Practice
Public Health Reports, March–April 2014. Available at: www.publichealthreports.org/issueopen.cfm?articleID=3145
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What are your community
needs, capacity, barriers?
• Work towards decreasing disparities in immunization access
based on race/ethnicity, insurance status, poverty, location
(e.g., rural, medically underserved), other factors
• Examples of activities at local health department
– Conduct needs assessment and use data in program planning
– Understand populations within community, e.g., diversity and insurance
status
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Promote system-based changes
• Develop policies and regulations that promote vaccination and
reduce immunization barriers for adult patients and their
providers.
• Examples of activities at local health department
– Work with providers in your area to do IIS onboarding, educate and
improve awareness
– Collaborate with existing public health clinical services (e.g., STI, HIV, TB
programs, substance abuse treatment service, chronic disease
programs) to include to do assessment
– Educate state legislatures and board of health regarding potential
barriers
– Incorporate vaccine assessments into routine care
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Effective Public Outreach
• Increase public awareness and knowledge of adult
immunizations through appropriate venues to
– Community organizations, business and civic groups
– Advocacy groups, e.g., mental health services, diabetes education,
correctional facilities
• Examples of activities at local health department
– Provide culturally-competent communications and outreach, including
social media and ethnic media
– Work with organizations associated with targeted population groups,
e.g., Hispanic and Asian-Pacific organizations
– Collaborate with healthcare coalitions to reach high-risk adults
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Outreach to Healthcare Providers
• Provide outreach and training to healthcare providers
– Professional organizations, e.g., medical, pharmacy, nursing
– Healthcare networks and systems
• Increase healthcare providers’ awareness and knowledge of
adult immunizations and training opportunities
• Examples of activities at local health department
– Share local adult immunization coverage information
– Distribute communications and outreach materials
– Assist providers with IIS on boarding and use of IIS
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General Communication
• Disseminate information on vaccines and vaccine preventable
disease outbreaks through press releases, social media, news
articles, other channels
• Examples of activities at local health department
– Communicate information on vaccine shortages, recalls, safety concerns
– Ensure professional competency by providing and supporting education
to providers about immunizations
– Distribute information to provider groups on ACIP recommendations
– Local access TV programs-newsletters
– Identify local champions/celebrities
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Education and Training
• Assist providers implement systems changes to routinely
assess adult vaccination, develop protocols for standing orders,
other changes to incorporate routine vaccine needs
assessment into patient flow
• Examples of activities at local health department
– Integrate services to deliver adult pneumococcal vaccinations in HIV
Clinics or chronic disease programs
– Provide examples of best practices to providers and collaborate with
them to implement changes
– Share successful practices with other health departments and
providers; submit for recognition at immunization coalition, NACCHO
Model Practices, National Adult and Influenza Immunization Summit
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Adult Immunization and
Public Health Preparedness
• Ensure preparedness for outbreaks of vaccine-preventable
diseases—create, maintain, practice emergency plans for
vaccine distribution and recordkeeping
• Participate in surveillance of state reportable disease system
• Maintain preparedness to investigate and control outbreaks
• Examples of activities at local health department
– Participate in and help develop pandemic
preparedness plans and exercises, ensure
inclusion of adult vaccination, vaccine storage
and handling practices, accountability
– Improve access to vaccines for adults
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What More Can We Do?
• Provide ACIP-recommended vaccines to insured and uninsured
adults
• Become in-network provider for immunization services for
insured adults
• Actively engage providers to disseminate vaccine
recommendations, storage and handling, administration
• Examples of activities at local health department
– Stock and dispense ACIP-recommended vaccines
– Develop billing capacity to become in-network provider
– Provide education, training, technical assistance to providers: healthcare
systems, education institutions, professional organizations, individuals
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