1. Carolyn B. Bridges, MD Associate Director for Adult Immunization Immunization Services Division National Center for Immunization and Respiratory Diseases Centers for Disease Control and Prevention March 26, 2012 Adult Immunizations Update, 2012

2. Adult Vaccine Preventable Diseases (VPD)  Vaccinations needed throughout lifespan to reduce burden of VPD  High burden of VPD remains among adults in the United States  From 3,000 to about 49,000 influenza-related deaths per year ~90% among adults 65 years and older  9,419 cases of acute hepatitis B in 2009  43,500 cases invasive pneumococcal disease (IPD) in 2009, including ~5,000 deaths 85% of IPD and nearly all IPD deaths among adults  Over 27,000 cases of pertussis reported in US in 2010 6,640 among adults, 4% of which are hospitalized  About 1 million cases of zoster annually U.S. 1.CDC. Active Bacterial Core Surveillance. http://www.cdc.gov/abcs/reports-findings/survreports/spneu09.pdf http://www.cdc.gov/abcs/reports-findings/survreports/spneu09.pdf 2.Huang et al. Vaccine 2011 3.2009 NNDSS 4.Thompson AJPH 2009 5.CDC. Prevention of Herpes Zoster. MMWR 2008. 57(RR-5): p. 1-30

3. Adult Immunization Schedule  Published at least annually since 2002  2012 published early February 2012 in o Annals of Internal Medicine o MMWR  Adult Schedule approved by :  American College of Physicians (ACP)  American Academy of Family Physicians (AAFP)  American College of Obstetrics and Gynecology  American College of Nurse-Midwives  Advisory Committee on Immunization Practices (ACIP) and CDC

4. 2012 ACIP Adult Immunization Schedule, Age- Based Recommendations

6. 2012 ACIP Adult Immunization Schedule, Medical, Occupational and Behavior-Based Recommendations

9. Flu season07/0808/0909/1010/11 ≥18 years 37.2 40.2 40.4 40.5 ±95% CI 0.4 0.6 0.4 0.4 18–64 years 30.5 33.4 34.4 34.8 ±95% CI 0.6 0.6 0.4 0.6 18–64 high-risk44.3 47.9 46.2 46.7 ±95% CI 1.4 1.4 1.0 1.4 18–49 years 25.4 28.2 29.9 30.5 ±95% CI 0.6 0.8 0.5 0.6 18–49 high-risk35.7 38.7 38.2 39.0 ±95% CI 2.2 2.0 1.3 2.2 >65 years 71.8 73.6 69.6 66.6 ±95% CI 0.8 0.6 0.6 0.6 U.S. Influenza Vaccine Coverage 2007-2011, BRFSS

10. 1. BRFSS estimates, (19 states for children; 43 states plus DC for adults) online at: http://www.cdc.gov/mmwr/PDF/wk/mm5839.pdf and CDC, unpublished http://www.cdc.gov/mmwr/PDF/wk/mm5839.pdf 2. BRFSS and NHFS estimates, 2009-10; BRFSS and NIS estimates, 2010-11, both years for 50 states plus DC for children, 43 states plus DC for adults. In press, MMWR, June 10, 2011 Seasonal Influenza Vaccination Coverage by Race/Ethnicity: 2008-09 -- 2010-11 Seasons, BRFSS and NIS

11. Influenza vaccination coverage estimates for pregnant women by mid-November 2010 and 2011 and by mid-April 2010 *Vaccinated as of mid-November based on women that were pregnant anytime between August- November. †Vaccinated as of end of season based on women that were pregnant anytime between October 2010 and January 2011 http://www.cdc.gov/flu/professionals/vaccination/pregnant-women.htm

12. Adult vaccination coverage estimates from the National Health Interview Survey (NHIS), United States, 2010 * Adults were considered at high risk for pneumococcal disease if they had ever been told by a doctor or other health professional that they had diabetes, emphysema, coronary heart disease, angina, heart attack, or other heart condition; had a diagnosis of cancer during the previous 12 months (excluding nonmelanoma skin cancer); had ever been told by a doctor or other health professional that they had lymphoma, leukemia, or blood cancer; or they had been told by a doctor or other health professional that they had chronic bronchitis or weak or failing kidneys during the preceding 12 months or had an asthma episode or attack; or they were current smokers. † Respondents were asked if they had ever had a pneumonia shot. § Respondents were asked if they had received a tetanus shot in the past 10 years. Respondents included adults who received tetanus-diphtheria toxoid (Td) during the past 10 years or tetanus, diphtheria, and acellular pertussis vaccine (Tdap) during 2005-2010. ¶ Respondents who had received a tetanus shot in the past 10 years were asked if their most recent shot was given in 2005 or later. Respondents who had received a tetanus shot since 2005 were asked if they were told that their most recent tetanus shot included the pertussis or whooping cough vaccine. Among 21,041 respondents aged 19-64 years, those without a "yes" or no" classification for tetanus vaccination status within the preceding 10 years (n = 1081 [5.1%], for tetanus vaccination status during 2005-2010 (n = 589 [2.8%], or Tdap status during 2005-2010 (n = 4,789 [22.8%] were excluded, yielding a sample of 14,824 respondents aged 19-64 years for whom Tdap vaccination status could be assessed. ACIP recommendations on use of Tdap in certain adults >65 were published January 14, 2011. ** p<0.05 by T test for comparisons between 2010 and 2009 within each level of each characteristic. Centers for Disease Control and Prevention. Adult Vaccination Coverage - United States, 2010. MMWR 2012;61, pages 66-72: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6104a2.htm?s_cid=mm6104a2_x Vaccination, age group, and high-risk (HR)* status Sample size % 95% CI (Confidence Interval) Difference from 2009 Pneumococcal vaccination, ever† 19-64 years, HR, total7,62418.5 (17.4-19.6)1.0 65 years and over, total5,20959.7 (58.0-61.4) Tetanus vaccination, past 10 years § 19-49 years, total13,94664.0 (63.0-65.0)0.9 50-64 years, total6,34963.4 (62.0-64.8)0.6 65 years and over, total5,06953.4 (51.5-55.2)0.6 Tetanus vaccination including pertussis vaccine, past 5 years ¶ 19-64 years, total14,8248.2 (7.6-8.8)1.6 **

13. Adult Vaccination Coverage from NHIS, 2010 * Adults were considered at high risk for hepatitis A or B if they had hemophilia and had received clotting factor concentrations, were a man who had sex with other men, had taken street drugs by needle, had traded sex for money or drugs, had tested positive for human immunodeficiency virus (HIV), or had sex with someone who would meet any of the previous criteria; considered themselves at high risk for HIV infection, or reported having a sexually transmitted diseases other than HIV or acquired immune deficiency syndrome (AIDS) during the previous 5 years. † Respondents were asked if they had ever received the hepatitis A vaccine, and if yes, were asked how many shots were received. § Respondents were asked if they had ever received the hepatitis B vaccine, and if yes, if they had received at least 3 doses or less than 3 doses. Centers for Disease Control and Prevention. Adult Vaccination Coverage - United States, 2010. MMWR 2012;61, pages 66-72: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6104a2.htm?s_cid=mm6104a2_x Vaccination, age group, and high-risk (HR)* status Sample size % 95% CI (Confidence Interval) Difference from 2009 Hepatitis A vaccination (at least 2 doses), ever † 19-49 years, total12,60710.7 (10.0-11.5)0.9 19-49 years, HR, overall98114.6 (12.1-17.6)0.4 19-49 years, with chronic liver conditions, overall10019.7 (11.8-31.1)-1.9 Hepatitis B vaccination (at least 3 doses), ever § 19-49 years, HR, total1,02342.0 (38.3-45.8)0.2 19-59 years, with diabetes, overall1,04522.8 (19.9-25.9)-0.3 60 years and over, with diabetes, overall1,48010.9 (9.2-13.0)0.8 19-49 years, non-HR, total11,94133.1 (32.0-34.3)-0.6

14. * Respondents were asked if they had ever received a shingles vaccine. † p<0.05 by T test for comparisons between 2010 and 2009 within each level of each characteristic. § Respondents were asked if they had ever received the HPV shot or cervical cancer vaccine. ¶ Data not applicable. Adult Vaccination Coverage from NHIS, 2010 Centers for Disease Control and Prevention. Adult Vaccination Coverage - United States, 2010. MMWR 2012;61, pages 66-72: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6104a2.htm?s_cid=mm6104a2_x Vaccination and age group Sample size % 95% CI (Confidence Interval) Difference from 2009 Herpes Zoster (shingles) vaccination, ever * 60 years and over, total 7,29014.4 (13.4-15.4) 4.4 † Human papillomavirus (HPV) vaccination among females (at least 1 dose), ever § 19-26 years, total 1,71820.7 (18.2-23.5) 3.6 † Human papillomavirus (HPV) vaccination among males (at least 1 dose), ever § 19-26 years, total 1,4740.6 (0.3-1.1) ¶ 19-21 years, total 5020.3 (0.1-1.0) ¶

15. Barriers to Adult Immunization  Lack of awareness of vaccine recommendations for adults by patients and providers  Many adults may not have regular healthcare provider or only see specialists  Preventive care may not be priority, especially among specialists  Out of pocket costs for vaccines for many adults

16. Barriers to Adult Immunization  Competing social and economic demands among adults  Adult vaccine schedule is complex  Especially for certain occupational and medical target groups  Limited public health resources expended on adult vaccines  Pediatric purchases on federal contracts in Dec 2010-Dec 2011: $3,535 billion (including both Vaccines for Children (VFC) and 317 program funds)  Adult vaccine purchases: $44 million (317 only)

17. Adult Vaccination – the Good News  Affordable Care Act expected to reduce the number of adults uninsured for vaccines  Efforts to enhance state and local health departments ability to bill for vaccines may provide opportunity to vaccinate high risk uninsured adults  317 funds can be used to address lagging vaccine coverage, including vaccination of uninsured adults  Medicare and Medicaid include coverage of vaccines for adults  Copayments can be a significant cost for vaccines covered by Medicare Part D covered vaccines such as Tdap and Zoster vaccines

18. Approaches to Reach Target Groups  Key drivers for improving adult coverage  Improve knowledge of adult vaccines among providers and patients  Increase provider recommendations to their patients for vaccination  Work with trusted intermediary organizations and leaders  Increase convenient access to vaccine  Repeated messages tailored to targeted groups  Individual immunization champions  Apply Community Guide recommendations to unique settings

19. Main Reason for Non-vaccination Adults 18 to 64 years: NIS-Adult 2007 Main Reason FluPneumococcalTetanus Vaccine cost4%2%1% Not needed28%19%41% Did not know4%25%10% Doctor did not recommend 7%30%17% Side-effects21%5%1%

20. Influenza vaccination coverage among pregnant women by provider recommendation and offer, mid-November 2011 http://www.cdc.gov/flu/professionals/vaccination/pregnant-women.htm

21. Meta-Analysis of Interventions to Increase Use of Adult Immunization InterventionOdds Ratio* Organizational change (e.g., standing orders, separate clinics devoted to prevention) 16.0 Provider reminder 3.8 Provider education 3.2 Patient financial incentive 3.4 Patient reminder 2.5 Patient education 1.3 *Compared to usual care or control group, adjusted for all remaining interventions Stone E. Ann Intern Med 136:641-51, 2002

22. Summary  Burden of vaccine preventable diseases remains high with lagging coverage for adult vaccines  Key steps to improve coverage  Increase provider and patient awareness of the burden of adult vaccine preventable diseases and vaccine recommendations  Increase providers recommending and offering vaccines to their patients  Increase monitoring and reporting on vaccine coverage  Partnering with vaccine provider groups, advocacy and community groups, public health and others to ensure sustained efforts and ensure progress

23. For more information please contact Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA 30333 Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348 E-mail: cdcinfo@cdc.gov Web: www.cdc.gov Lynda Anderson, CDC Helen Ding, CDC Gary Euler, CDC Susan Farrall, CDC Stacie Greby, CDC Erin Kennedy, CDC Megan Lindley, CDC Pengjun Lu, CDC Tammy Santibanez, CDC Abigail Shefer, CDC Jim Singleton, CDC Ray Strikas, CDC Walter Williams, CDC LaDora Woods, CDC Acknowledgements