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1 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


3 Disclosures (cont.) Dr. [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]


5 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

6 Impact of Vaccines During the 20th Century and Into the 21st Century
Disease Reported Cases (Year) Reported Cases (2009) % Decrease in Reported Cases Diphtheria 5796 (1950) 100% Tetanus 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 Hepatitis A* 32,859 (1966) 1987 94% Hepatitis B* 26,611 (1985) 3405 87% According to the Centers for Disease Control and Prevention, reported cases of many vaccine- preventable diseases (VPDs) decreased dramatically during the 20th century. This decrease in reported cases highlights one of the most important public health achievements of the last century—immunizations. As can be seen in this slide, the decrease in the number of reported cases of the VPDs shown ranges from 86% for pertussis to 100% for diphtheria. Vaccinations are, indeed, a major public health achievement. *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; Available at: Accessed June 15, 2011

7 Burden of Selected Vaccine-Preventable Diseases (VPDs)
Influenza 200,000 excess hospitalizations annually (>40% in the elderly) ~24,000 excess deaths annually (~90% elderly) Invasive Pneumococcal Disease (IPD) ~50,000 cases of bacteremia each year Higher rates in elderly and persons with comorbidities Case fatality rates ~20% (up to 60% in the elderly) Hepatitis B 78,000 new infections annually (highest in young adults) 1 million with chronic hepatitis B virus infections Complications include cirrhosis and hepatocellular carcinoma (80% of cases) Human Papillomavirus (HPV) 6.2 million new infections each year 2 HPV strains cause 70% of cervical cancer Pertussis 10,454 cases reported in 2007 (3152 in adults) Most severe in infants *Source often older child or adult Shingles 500,000 to 1 million cases annually; lifetime risk ~32% Shingles and postherpetic neuralgia increase with age Despite the major successes seen with immunizations in the last century, VPDs continue to cause substantial morbidity and mortality among adults. Influenza: complication rates are highest among the very young and the elderly. More than 40% of excess hospitalizations and about 90% of excess respiratory and circulatory deaths during influenza seasons occur among the elderly. Invasive pneumococcal disease: more than 50,000 cases of pneumococcal bacteremia occur every year, with highest rates in the very young and elderly. Pneumococci account for about 1/3 of community-acquired pneumonia and about half of hospital-acquired pneumonia in adults. Bacteremia occurs in about 25% to 30% of patients with pneumococcal pneumonia. Case fatality rates can be as high as 60% in the elderly. Hepatitis B: each year there are about 78,000 hepatitis B virus infections in the US. The incidence is highest among young adults, and the most common route of transmission is by sexual contact. While most adults with hepatitis B fully recover, complications can include fulminant acute hepatitis (occurs in 1% to 2% with acute hepatitis with case fatality rates of 63% to 93%). About 5% who become infected will progress to chronic hepatitis B that can cause cirrhosis and hepatocellular carcinoma. About 25% of persons with chronic hepatitis B will die prematurely from cirrhosis or liver cancer. HPV (human papillomavirus) is the most common sexually transmitted infection in the US. There are an estimated 20 million people infected, with about 6.2 million new cases occurring each year. Two high-risk HPV strains (16 and 18) account for 70% of cases of cervical cancer, as well as anal/genital cancers, in women and 70% of anal cancers in men. Two low-risk strains (6 and 11) are responsible for 90% of genital warts and 90% of recurrent respiratory papillomatosis in men and women. HPV is especially common among adolescents and young adults and is related to sexual behaviors such as number of sex partners and partners’ sexual history. Pertussis or whooping cough is an illness characterized by paroxysmal coughing. Since the 1980s, reported cases of pertussis have been on the rise. In 2008, more than 13,000 cases were reported across the US. In 2010, 9120 cases were reported in California alone; 9% of those cases were hospitalized, and 10 deaths were reported. Complications of pertussis can be serious, especially among infants, with the most common one being secondary bacterial pneumonia. While pertussis and its complications are most severe among the very young, adolescents and adults may also develop pertussis. Often the disease is milder than in the very young, but complications such as difficulty sleeping, urinary incontinence, pneumonia, and rib fracture can occur among older persons. Importantly, adolescents and adults can also transmit pertussis to infants and others who may be susceptible. Shingles (herpes zoster): an estimated 500,000 to 1 million cases of herpes zoster (shingles) occur in the US annually. The lifetime risk is at least 32%, with 50% of persons living to age 85 developing zoster. The risk for shingles increases with increasing age and immunosuppression. Postherpetic neuralgia and ocular or other organ involvement with zoster can occur and can be serious. CDC. Epidemiology and Prevention of Vaccine-Preventable Diseases: The Pink Book; Available at: Accessed June 15, 2011

8 Vaccination Is the Best Way to Prevent and Control VPDs
We have many safe and effective vaccines to prevent these and other diseases. Vaccination is, in fact, the best way to prevent and control VPDs.

9 Recommended Adult Vaccines by Age Group
Recommendations for the routine use of vaccines in adults are issued by the Centers for Disease Control and Prevention (CDC). The Advisory Committee on Immunization Practices (ACIP) was established in 1964 by the Surgeon General of the US Department of Health and Human Services (DHHS) as a federal advisory committee, and it provides expert advice and guidance to the Director of the CDC and the Secretary of the US DHHS on the use of vaccines. The ACIP makes policy recommendations, subject to the approval of the Director of the CDC, regarding the use of currently licensed vaccines in the US civilian population. In making policy recommendations, the ACIP reviews many factors, including disease burden in the US population; data on safety, efficacy, and effectiveness; cost-effectiveness of the vaccine; and other data. ACIP recommendations for adult vaccines are often harmonized with recommendations of other professional organizations, such as the American College of Obstetricians and Gynecologists, the American Academy of Family Physicians, and the American College of Physicians.1 Each year the ACIP reviews and updates the adult immunization schedule. The 2012 schedule was approved in October of 2011 and includes several changes and updates. It is important that the footnotes be read when using the schedule. This slide shows the part of the schedule that lists recommended immunizations by age group. Please see full reference for additional important footnote information. CDC. Adult immunization schedule. Available at: Accessed February 6, 2012. 1. Smith JC, et al. Ann Intern Med. 2009;150(1):45-49.

10 Recommended Adult Vaccines by Condition
This slide shows what immunizations are indicated for adults based on medical and other indications. For example, by using this figure a healthcare provider can easily see which vaccines are recommended for pregnant women, patients who are immunocompromised, or healthcare workers. Please see full reference for additional important footnote information. CDC. Adult immunization schedule. Available at: Accessed February 6, 2012.

11 Vaccination Rates Are Low
Vaccine Vaccination Rate Influenza Age 19-49, high risk Age 50-64, total Age 65 Healthcare workers (19-64 years old) 33.4% 40.1% 65.6% 52.9% Pneumococcal Ages 19-64, high risk 17.5% 60.6% Tetanus/pertussis since 2005 (19-64 years old) 50.8% Shingles (60 years old and older) 10.0% Hepatitis B (high risk, years old) 41.8% HPV vaccine (women, years old) 17.1% Adult vaccines are safe and effective, and we have clear recommendations for their use. Nevertheless, these vaccines are underused. Data from the 2009 National Health Interview Survey (a nation-wide survey conducted by the Centers for Disease Control and Prevention) show that vaccination rates for adults in this country are, indeed, too low. The highest vaccination rates are seen among the elderly for influenza (65.6%) and pneumococcal diseases (60.6%). Vaccination rates based on risk status (vs age-based) tend to be substantially lower. For example, where the vaccination rate for all persons 65 and older against pneumococcal disease is 60.6%, for high-risk persons younger than 65 it is only 17.5%. In addition, vaccination rates for newer vaccines such as shingles or HPV are also lower. CDC Adult Vaccination Coverage, NHIS. Available at: Accessed June 13, 2011

12 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% Pneumococcal vaccine Adults 65 years old and older High-risk adults under 65 years old Institutionalized adults 60% (2008) 17% (2008) 66% (2006) 60% Zoster vaccine Adults 60 years old and older 7% (2008) 30% Hepatitis B vaccine 64% (2008) For some routinely recommended adult immunizations, the US Department of Health and Human Services (DHHS), through the work of the Federal Interagency Workgroup, has identified a number of health goals for the US. As can be seen in this slide, there is a substantial gap between the baseline vaccination rates and the year 2020 goals for influenza vaccinations, as well as pneumococcal, zoster, and hepatitis B vaccines, across all of the specific groups identified. Adult vaccination rates are indeed too low, and they also lag behind our national goals. USDHHS. Healthy People Available at: Accessed June 13, 2011.

13 Disparities Also Persist: NHIS 2009
Vaccine and Target Group 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% Not only are vaccination rates for adults in general too low and short of national goals, but there are also significant disparities in vaccination rates by race and ethnicity. Data from the National Health Interview Survey show that vaccination rates for the elderly are lower among African-Americans and Hispanics than among Caucasians for both influenza and pneumococcal vaccines. CDC Adult Vaccination Coverage, NHIS. Available at: Accessed June 13, 2011.

14 So, Why Are Vaccination Rates So Low?

15 Determinants of Vaccination Behavior Among Patients and Providers Are Well Described

16 Critical Issues for Successful Vaccine Delivery
Patient Provider Vaccine supply and reimbursement Policy

17 Patient Issues for Vaccination
Awareness Disease Vaccine Personal risk Provider recommendation Misconceptions/fears About vaccine About healthcare system Access and ability to pay

18 Medicare Beneficiaries’ Reasons for Not Getting Vaccinated
Lack of knowledge Personal risk and need for vaccination Misconceptions About vaccines and VPDs No recommendation from doctor The CDC has published its findings addressing reasons reported by Medicare beneficiaries for not receiving influenza and pneumococcal (MMWR 1999) and influenza (MMWR 2004) vaccinations. These reports are based on data from the Medicare Current Beneficiary Survey (MCBS), which is an ongoing, nationally representative, longitudinal survey of Medicare beneficiaries. In 1996, the top reasons cited for not being vaccinated against influenza or pneumococcal disease were lack of knowledge, misconceptions about vaccines and vaccine-associated illnesses, and lack of provider recommendation. These findings are similar to findings published from other studies. For the years 1997 through 2002, the leading reasons given by Medicare beneficiaries for not receiving influenza vaccinations were consistently not knowing the vaccination was needed and concerns that vaccination might cause influenza or side effects. CDC. MMWR Morb Mortal Wkly Rep. 1999;48(39): CDC. MMWR Morb Mortal Wkly Rep. 2004;53(43):

19 Medicare Beneficiaries’ Reasons for Not Getting Vaccinated (cont.)
This graph summarizes the results of the 1996 survey of Medicare beneficiaries citing reasons for not receiving influenza or pneumococcal vaccinations. The roles of lack of knowledge, misconceptions about vaccines, and lack of provider recommendation are highlighted in these results. Percentage aged 65 years who reported reasons for not receiving vaccinations1996 CDC. MMWR Morb Mortal Wkly Rep. 1999;48(39):

20 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 In this study conducted in September and October of 2006, 2002 consumers and 200 healthcare providers completed structured telephone interviews concerning their knowledge and attitudes about adult vaccines. Among the most common reasons cited for not being vaccinated included lack of physician recommendation and mistaken assumptions (eg, healthy people don’t need vaccinations). Concerns about possible side effects were also common. In this study, costs were cited as a reason for not being vaccinated by only about 15% of consumers. Johnson DR, et al. Am J Med. 2008;121(7 Suppl 2):S28-35.

21 Adults’ Main Reasons for Not Being Vaccinated
These data are adapted from the results of the 2007 National Immunization Survey, a national telephone survey of a representative sample of US adults conducted by the Centers for Disease Control and Prevention. The top reasons given by the survey respondents for not being vaccinated were knowledge gaps (not needing the vaccine or not knowing about the vaccine), lack of provider recommendation, and concern about side effects. Cost was much less commonly cited as the main reason for not being vaccinated. *Included “Did not know about vaccine” and “Did not know I should get vaccinated”. **Included getting sick from vaccine, allergic reaction, etc. 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, Available at: Accessed June 13, 2011

22 Consumer Misconceptions About Vaccines
Category and Response % of Respondents in Agreement 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 40% 18% 34% 32% 25% Vaccine safety/efficacy Have heard vaccines are not safe Vaccines don’t work A vaccine made them sick 35% 14% In its Call to Action for Integrating Vaccines for Adults into Routine Care, the National Foundation for Infectious Diseases includes some data from a 2007 national consumer survey. In this telephone survey of 1005 adults (504 men and 501 women), respondents indicated their answers to questions about their knowledge and attitudes regarding vaccines and VPDs. These results show that many adults lack knowledge or have misconceptions about vaccines and VPDs for adults. This is clearly a common theme across studies. Cost was another category studied in this survey. 22% of respondents indicated that they would not get a vaccine if they had to pay for it, and 26% indicated that vaccines are too expensive. Thus, cost also seems to be important, though concerns about safety may be more important. NFID. Saving lives: integrating vaccines for adults into routine care. Available at: Accessed June 13, 2011.

23 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 No answer 2% 1% Results from a 2009 telephone survey of 1001 adults (500 men and 501 women conducted during February 2009) by the National Foundation for Infectious Diseases (NFID) shows the most important influencers of adults’ decisions to get immunized. Overall, physician recommendation was most often cited as the main reason that adults were vaccinated. However, responses varied somewhat by age group. For example, among young adults, while physician recommendation was most often cited at 47%, a family member was cited as a main reason by 33%. (Speculation— does this reflect the role of a parent among college-aged adults?) In contrast, among older adults, physician recommendation was cited as the main reason 82% of the time. All in all, these findings certainly highlight the importance of physician recommendation for getting adults vaccinated—a finding seen in other studies as well. NFID National Adult Immunization Consumer Survey: Fact Sheet. Available at: Accessed June 15, 2011. AMA. American Medical News. Physicians asked to persuade adults to get immunized. Available at: Accessed June 13, 2011.

24 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 In this slide, we illustrate in a somewhat different way the importance of provider recommendation for adult vaccination. In a 2007 national telephone survey of adults, the NFID found that the vast majority of respondents confirmed that interactions in their provider’s office were a key factor for their vaccination decisions; 87% reported that they would be very or somewhat likely to get vaccinated as long as their physician made the recommendation. On the other hand, 55% said they would not get vaccinated unless their doctor recommended it. (The survey was conducted on a sample of 1005 adults [504 men and 501 women] during October 2007.) CDC. Adult immunization coverage information from CDC’s National Immunization Survey. Available at: Accessed June 15, 2011.

25 Vaccination Rates Among High-Risk* Patients With Negative Attitudes
Provider Recommendation Translates Into Higher Vaccination Rates (Even for Patients With Negative Attitudes) Vaccination Rates Among High-Risk* Patients With Negative Attitudes Vaccination Rate (%) In this slide, we illustrate how provider recommendation can translate into actual (vs intended) vaccination behavior. 364 high-risk outpatients responded to a mail survey conducted in (High-risk patients were those ages 65 and older, or those having heart disease, lung disease, diabetes, or other serious illness.) Among those respondents who reported negative attitudes towards influenza or pneumococcal vaccination, vaccination rates were low if they did not receive a provider recommendation to get vaccinated. In contrast, even with their negative attitudes, if their physician or nurse recommended vaccination, then their vaccination rates were in excess of 80%. Provider recommendation makes a big difference! *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):

26 Disparities and Vaccination Barriers
Health literacy Mistrust of system Language Facilitators Culturally appropriate education Leveraging communities/trusted leaders/ faith-based organizations Translated materials Vaccination rates tend to be lower in certain racial and ethnic groups, and it is important to be aware of barriers as well as facilitators of vaccination that may be more common in certain groups. Some common barriers and facilitators are summarized in this slide. Daniels NA, et al. J Natl Med Assoc. 2004;96(11): Chen JY, et al. J Community Health. 2007;32(1):5-20. Traeger M, et al. Am J Public Health. 2006;96(5): Logan JL. J Natl Med Assoc. 2009;101(2):

27 What Can We Do to Increase Vaccination Rates?

28 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!) Healthcare providers are key people in ensuring that adults get vaccinated. In order to be effective in this role, healthcare providers should Ensure that they do know the facts—VPDs are bad for adults and vaccines (as recommended by ACIP) are good for adults. This includes being aware of the clinical manifestations and complications of VPDs, risk groups for the diseases, the target groups for vaccination, and the safety track records for the vaccines. Healthcare providers can keep up-to-date using a variety of resources, including materials available on the CDC’s Web site, as well as materials available on many state health department Web sites. In addition to being knowledgeable about adult VPDs and vaccines, healthcare providers should recommend these vaccines to their patients. Patients time and again report that a healthcare provider’s recommendation is among the most important reasons that they are vaccinated. Such recommendations should be clear and definite. “You are at risk for this disease. There is a safe and effective vaccine to help prevent this disease, and I recommend that you get vaccinated.” In addition to a provider’s recommendation, other office-based strategies that use systems-based approaches to automate processes and enhance efficiency can be highly effective. Evaluation and feedback within a practice are also important for quantifying just how well we are doing and for identifying gaps in our performance vs goals (eg, tracking numbers of vaccine doses used compared to numbers of patients seen, or conducting chart audits to identify how often vaccines are given). This is a key component of process improvement activities. It is also important to keep an open mind about new paradigms—if the logistics of vaccine delivery are too difficult for our practice, can we refer patients to another location? For seasonal vaccines such as influenza vaccination, can we extend the time period during which we offer vaccine? Finally, for providers it is important that we are vaccinated ourselves. This is important for the protection of our patients—for example, with influenza vaccination. It is also important because vaccinated healthcare providers are also more likely to vaccinate their patients. Nichol KL. Cleve Clin J Med. 2006;73(11):

29 Know the Facts: VPDs Are BAD, Vaccines (as Recommended) Are GOOD
Vaccines are safe and effective when used according to guidelines.

30 Types of Vaccines Inactivated (“dead”) Live
Inactivated whole cell or subunit TIV/flu shot Hepatitis A and B Acellular pertussis HPV Polysaccharide-based Pneumococcal Meningococcal Toxoids Td/Tdap Live MMR Varicella/zoster LAIV/flu vaccine nasal spray There are two basic types of adults vaccines available—inactivated and live attenuated—and it is important for healthcare providers to be aware of the differences between them. The inactivated (or “dead”) vaccines can be composed of either whole cells or fractions of them. Live attenuated vaccines contain modified and weakened organisms that retain the ability to replicate and induce immunity, but generally do not have the ability to produce illness. Both types of vaccines produce immune responses in the person being vaccinated, but the live attenuated vaccines may produce an immune response that is virtually identical to the immune response seen with natural infection. Live attenuated vaccines should generally be avoided in pregnant women or patients who are immunocompromised. However, inactivated vaccines are generally acceptable for immunocompromised patients. (See the adult immunization schedule including footnotes for more information.) 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: Accessed June 15,

31 How Can Healthcare Providers Keep Up on Adult Vaccinations?
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 The Immunization Action Coalition has lots of useful information for healthcare providers There are many online resources available to healthcare professionals to help them keep up-to- date on adult VPDs and vaccinations. Of course, the primary site for definitive information is the Centers for Disease Control and Prevention. On their Web site you can find current information including immunization schedules, detailed ACIP recommendations for each vaccine, vaccine information statements (VIS) that should be used to educate patients about the vaccines and any potential contraindications or side effects prior to vaccination, as well as a wealth of other useful materials on VPDs, vaccine safety, and how to store and administer vaccines. There are also downloadable brochures, posters, and other materials. In addition to the CDC, there are many other useful sites, including many state health departments. Another useful Web site for finding information on adult vaccinations is the Immunization Action Coalition (IAC) Web site, which prepares and publishes vaccination information specifically for healthcare professionals. The IAC receives funding from the CDC and works closely with various people at the CDC as they develop their materials.

32 Know Them, Recommend Them

33 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% We have already highlighted the importance of healthcare provider recommendations for adult vaccination. Data in this slide summarize the results of a nationwide survey of 200 healthcare providers (100 primary care physicians, 34 RNs, 33 PAs, and 33 NPs). In this study, 85% or more recommended tetanus vaccinations to all adults. But recommendations for influenza and pneumococcal vaccinations were much less common. These responses suggest a real opportunity for improvement. 200 providers surveyed. Johnson DR, et al. Am J Med. 2008;121(7 Suppl 2):S28-35.

34 Reasons for Not Receiving Influenza or Pneumococcal Vaccinations
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% HCPs should beware of assumptions about why patients may not be vaccinated. In a concurrent nationwide survey of healthcare professionals (N=200) and consumers (N=2002), both were asked about reasons for adults not being immunized. As can be seen here, HCPs much more often cited patients’ fear of needles or cost than the consumers reported (caveat: these data are from two different surveys; therefore, responses should be compared with some caution). These findings reinforce the importance of an HCP making that recommendation—even if they anticipate other concerns on the part of their patients. Johnson DR, et al. Am J Med. 2008;121(7 Suppl 2):S28-35.

35 Get Organized to Get It Done

36 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 It turns out that missed opportunities to vaccinate adults occur frequently within the healthcare setting. In this study, medical records for 217 elderly adult patients from 7 primary care practices were reviewed to assess adult vaccination rates for influenza and pneumococcal vaccines as well as missed opportunities to vaccinate patients. The results clearly demonstrate that missed opportunities are frequent and may contribute to low vaccination rates for adults. More than 50% of these patients who needed influenza vaccine had at least one healthcare provider visit with a missed opportunity. Among patients who needed pneumococcal vaccination, there were an average of 10.7 outpatient visits over a three-year period where an opportunity was missed to vaccinate. The reasons for these missed opportunities were not explored in this study, but they may have included the healthcare provider forgetting, a lack of time or resources, or poor records. Regardless of the reason for the missed opportunities, it is clear that vaccination rates could be higher if fewer opportunities to vaccinate at clinic visits were missed. Nowalk MP, et al. J Am Board Fam Pract. 2005;18(1):20-27.

37 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 There are a number of practical barriers that have been reported by primary care practitioners that undoubtedly contribute to missed opportunities. These include understanding the vaccine recommendations (what is recommended for whom), having sufficient time to assess and counsel patients, having sufficient personnel in the practice to vaccinate the patients, and simply remembering to address vaccinations when patients come in with other pressing acute or chronic medical conditions. Nichol KL, Zimmerman R. Arch Intern Med. 2001;161(22): Szilagyi PG, et al. Prev Med. 2005;40(2):

38 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 Feedback 1.2 Stone EG, et al. Ann Intern Med. 2002;136(9):

39 Interventions That Improve Vaccination Coverage: Task Force on Community Preventive Services
Increase patient demand for vaccines Patient reminder and recall systems Clinic-based patient education Manual outreach and tracking Enhance access 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 Oftentimes, interventions implemented in the healthcare setting involve more than one single tactic. They may include, for example, a combination of educational interventions for patients and providers along with standing orders or reminders. The Task Force on Community Preventive Services has conducted systematic reviews to identify interventions that are effective in increasing adult vaccination rates. They have found strong evidence that healthcare system- based interventions when used in combination can significantly improve vaccination rates. The interventions that they identified are summarized here. They recommend at least one intervention to increase demand along with one or more interventions to enhance access and/or interventions directed at vaccination providers or systems. CPS Task Force. Universally recommended vaccinations: health care system-based interventions implemented in combination. Available at: Accessed June 13, 2011.

40 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 The success of a long-term influenza vaccination program at one medical center highlights the success that can be achieved through the use of combination interventions that address patient demand, access, and provider barriers. At this medical center, influenza vaccination rates for elderly patients at baseline were less than 10% (measured in the early 1980s when national vaccination rates were very low). After an educational intervention directed at providers, vaccination rates increased to nearly 30%. But it wasn’t until a multifaceted program was implemented utilizing the elements listed above that vaccination rates increased to 61% in the first year of the multifaceted program and to almost 90% after the 10th year of the program. Nichol KL. Am J Med. 1998;105(5):

41 Influenza Vaccination Rate (%)
Case Example: Impact of Multifaceted Program on Influenza Vaccination Rates Influenza Vaccination Rate (%) Here is a graph depicting influenza vaccination rates for elderly outpatients followed at the medical center. In , the baseline vaccination rate was only 9%. After an educational intervention directed at providers in , the vaccination rate increased to 29%. But it was not until a multifaceted program including standing orders was implemented that vaccination rates really increased. In the vaccination rate increased to 61%, and after 10 years of the program, the vaccination rate was 89%. Baseline After Provider Education Multifaceted (Standing Orders) Multifaceted, Year 10 Nichol KL. Am J Med. 1998;105(5):

42 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 A critical component of the 10-year program just described was the implementation of standing orders that allowed nurses at the medical center to assess patients and then offer and administer vaccines to them without the direct involvement of a physician at the time of vaccination. This allowed for the systematic review and assessment of patients at the time of check-in, thereby avoiding the need for the provider to try to remember to address vaccination during the visit. Furthermore, the standing orders were used to allow nurses to staff the walk-in clinics (similar to a public health clinic model) without having to involve a physician with each patient. Standing orders have consistently been shown to be among the most effective interventions in other studies as well—including not only the outpatient setting, but also inpatient settings, emergency departments, and long-term care. They have also been successful for many different types of vaccines. McKibben LJ, et al. MMWR Recomm Rep. 2000;49(RR-1):15-16.

43 Influenza Vaccine Offering Rates by Type of Intervention
Standing Orders Are More Effective than Provider Education or Provider Reminders for Inpatients Influenza Vaccine Offering Rates by Type of Intervention Rates (%) As mentioned, standing orders can be highly effective in settings other than the outpatient clinic. This slide summarizes data from a pilot project involving 6 hospitals in northern Minnesota. Two of the hospitals chose provider education as their intervention of choice to increase influenza vaccine offering rates, two chose chart-based reminders to the providers to order the vaccine for their high-risk patients, and two chose to use standing orders. The standing order hospitals had the highest vaccine offering rates by far. Provider Education Provider Reminder Standing Orders Crouse BJ, et al. J Fam Pract. 1994;38(3):

44 Opportunities for Improvement Abound
Use of Effective Vaccination Strategies by US Physicians % Influenza Pneumonia Influenza Pneumonia Influenza Pneumonia Very Strongly Recommend Standing Orders Patient Reminders Nichol KL, Zimmerman R. Arch Intern Med. 2001;161(22):

45 Vaccination Strategies Used by Subspecialists and Generalists
Strategy Influenza Pneumococcal Very strongly recommend for elderly patients 75-86% 64-81% Increase demand Patient reminders Clinic-based patient education 14-24% 25-52% 9-14% 18-40% Enhance access Special clinics 10-27% 5-10% Provider-oriented Provider reminders Standing orders Assessment/feedback on vaccination rates for elderly 26-39% 20-29% 20-38% 24-37% 13-19% 18-33% Results of a nationwide survey of generalists and medical subspecialty physicians in illustrate how often these physicians use the kinds of strategies recommended by the Task Force. There were 1874 respondents to this survey. As can be seen, perhaps somewhat surprisingly, not all of them reported that they very strongly recommend influenza or pneumococcal vaccinations to their elderly patients—a group for whom both vaccines are recommended. The most commonly used interventions were patient education materials in the clinic. Fewer than 30% reported using standing orders. Nichol KL, Zimmerman R. Arch Intern Med. 2001;161(22):

46 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 51% Registry 7% 56% A national survey of PCPs conducted about a year (in 2000) later showed similar results for the use of patient reminders and standing orders. In this study, investigators asked whether the physicians were using the strategy already or would be willing to try the strategy. For standing orders, 33% were already using them and a further 36% would be willing to try them for a total of 69% either using or willing to try this effective strategy. Likewise, for patient reminders, 23% were already using them and an additional 53% would be willing to try for a total of 76% either using or willing to try patient reminders. These findings suggest that healthcare providers are often not opposed to using selected strategies even if they are not currently using them. Interestingly, however, another nationwide survey of primary care practitioners conducted about a decade later (2009) found that, by then, only 42% were consistently using standing orders for influenza vaccination of adults.1 There hasn’t been much progress over the past decade! Szilagyi PG, et al. Prev Med. 2005;40(2): 1. Zimmerman R, et al. Am J Prev Med. 2011;40:144.

47 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

48 Resources to Help Immunization Action Coalition (
Adult Vaccination Guide (complete “how-to”) Setting up for adult vaccination services How to store and handle vaccines Documenting Sample standing orders The IAC has many useful resources available online and for downloading, including an adult vaccination guide that gives information and advice on how to set up and run adult vaccinations in a practice setting. Also on their Web site are sample standing orders for the different adult vaccines.

49 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 ( Information from the CDC: Vaccine Information Statements are mandated by the National Childhood Vaccine Injury Act (NCVIA), and must be used for all vaccines that are covered by this law. Vaccines Covered by the National Childhood Vaccine Injury Act VIS for vaccines covered by the NCVIA (as of December 2010) and the dates they were issued are DTaP (includes DT): 5/17/07 Td/Tdap: 11/18/08 (Interim) Hib: 12/16/98 Hepatitis A: 3/21/06 Hepatitis B: 7/18/07 (Interim) Human papillomavirus (HPV): 3/30/10 (interim) Inactivated influenza: 8/10/10 (updated annually) Live, intranasal influenza: 8/10/10 (updated annually) MMR: 3/13/08 (interim) MMRV: 5/21/10 (interim) Meningococcal: 1/28/08 (interim) Pneumococcal Conjugate (PCV13): 4/16/10 (interim) Polio: 1/1/00 Rotavirus: 5/14/10 (interim) Varicella: 3/13/08 (interim) Multi-Vaccine VIS: 9/18/08 (interim); may be used for any combination of DTaP, polio, hepatitis B, rotavirus, PCV, and Hib. Note: when giving combination vaccines for which no separate VIS exists (eg, DTP/Hib, Hib/Hepatitis B), give out all relevant VIS. These VIS must always be used*. Every time one of these vaccines is given Regardless of what combination it is given in Regardless of whether it is given by a public health clinic or a private provider Regardless of how the vaccine was purchased Regardless of the age of the recipient The appropriate VIS must be given out at the time of the vaccination. (*Because “final” VIS have not yet been issued for rotavirus, HPV, Tdap, and meningococcal vaccines, their use is technically not mandated by the NCVIA, but it is strongly encouraged.) Vaccines NOT Covered by the National Childhood Vaccine Injury Act VIS also exist for vaccines not covered by the NCVIA. We encourage their use whenever the vaccine is given, but they must be used when the vaccine was purchased under CDC contract. The legal basis for this is not the NCVIA, but a “Duty to Warn” clause in CDC’s vaccine contracts. These VIS are identical to those for the NCVIA vaccines, except they do not bear a reference to the law (42 U.S.C.§300aa-26) and do not contain information about the National Vaccine Injury Compensation Program. VIS for vaccines not covered by the NCVIA (as of June 2009) and the dates they were issued are Anthrax: 3/10/10 Japanese Encephalitis (JE-VAX): 3/1/10;
Japanese Encephalitis (Ixiaro): 3/1/10 Pneumococcal Polysaccharide: 10/6/09 Rabies: 10/6/09 Shingles: 10/6/09 Smallpox: 1/16/03 Typhoid: 5/19/04 Yellow fever: 11/9/04 VIS were once available for these vaccines that are no longer used in the US Rotavirus (discontinued vaccine used in ) Lyme disease CDC. Fact sheet for vaccine information statements. Available at: Accessed June 13, 2011.

50 Healthcare Workers: Practice What We Preach!

51 Immunizations and Healthcare Workers (HCWs)
“First do no harm” Recommended vaccinations/immunity Influenza MMR Hepatitis B Varicella Tdap Special situations Meningococcal for microbiologists with potential for exposure Other vaccinations based on personal risk characteristics In addition to making sure our patients are vaccinated, it is also important for healthcare workers (HCWs) to ensure that they are also up-to-date on their vaccinations. For HCWs, it is especially important to have immunity to certain VPDs in order to protect our patients and avoid the possibility that we might expose vulnerable patients to a VPD. In addition, of course, vaccinations can help to reduce personal illness and reduce absenteeism. Finally, HCWs who are vaccinated may also be more likely to vaccinate their patients. Immunization Action Coalition. Healthcare personnel vaccination recommendations. Available at: Accessed June 15, 2011.

52 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

53 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

54 Internet Resources CDC’s National Immunization Program
Immunization Action Coalition National Foundation for Infectious Diseases CMS State health departments

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