Review and special articleStandards for adult immunization practices☆
Introduction
I n the United States, years of clinical and programmatic experience have been translated into successful childhood immunization practices. As a result, vaccination rates among infants and children are near or at all-time highs. Today, most childhood vaccine-preventable diseases rarely occur or are non-existent. However, similar success in vaccinating adults has not been achieved.
Goals for adult immunization feature prominently in Healthy People 2010,1 a comprehensive, nationwide health promotion and disease prevention agenda from the U.S. Department of Health and Human Services. The target is 90% coverage for annual influenza immunization among adults aged ≥65 years and 90% for one dose of pneumococcal vaccine. Success will require a dramatic increase from rates in 2000, which were only 66% for influenza vaccine and 50% for pneumococcal vaccine.2
Increasing the use of these two vaccines among older adults could have tremendous health impacts. Influenza and its complications kill approximately 40,000 individuals every year in the United States.3 Another 100,000 individuals suffer so severely from influenza that hospitalization is required.4 The overwhelming majority of these deaths and hospitalizations occur in the elderly. When vaccine viruses are well matched to circulating viruses, vaccination lowers the risk of infection among healthy adults by up to 90%.4, 5 Although influenza vaccination is somewhat less effective among the elderly, vaccination has been estimated to reduce their risk of influenza-related hospitalization and death by up to 70%.4, 6, 7, 8 The Centers for Disease Control and Prevention (CDC)9 estimate that for each additional 1 million elderly people vaccinated each year, 900 deaths and 1300 hospitalizations would be averted. Furthermore, economic studies find overall societal cost savings and substantial reductions in hospitalizations and deaths if people aged ≥65 years receive the influenza vaccine.4, 6, 7
In recent years, pneumococcal infections have accounted for >100,000 hospitalizations for pneumonia, >60,000 cases of bacteremia and other forms of invasive disease, and about 7000 deaths from invasive pneumococcal disease.10, 11, 12 In 1998, >50% of these deaths occurred among people aged ≥65 years. Overall, vaccine effectiveness against invasive pneumococcal disease among immunocompetent people aged ≥65 years is 75%,13 and the vaccine has been shown to be cost effective for people in this age group as well.14 Based on 1998 projections, annually 76% of invasive pneumococcal disease cases and 87% of resulting deaths occurred in people who were eligible for pneumococcal vaccine in the United States.12
Additional health benefits could also be gained by reaching immunization targets for younger high-risk adults. Healthy People 20101 targets are 60% coverage with influenza and pneumococcal vaccines among high-risk adults aged 18 to 64 years. In 1999, only 31% of these adults reported receiving influenza vaccine, and only 17% received pneumococcal vaccine (Centers for Disease Control and Prevention, unpublished data, 1999). In 1998, 41% of deaths attributed to invasive pneumococcal disease occurred among individuals aged 18 to 64 years who had a medical indication for the pneumococcal vaccine.12
Despite the availability of a vaccine that is >95% effective in preventing hepatitis B, approximately 80,000 individuals, mostly adolescents and adults, are infected annually in the United States.15, 16 About 6% of newly infected people become chronically infected and face a 15% to 25% lifetime risk of death from chronic liver disease. Annually, an estimated 4000 to 5000 chronically infected people die prematurely from chronic liver disease.17 Without an improvement in vaccinating adults at increased risk of hepatitis B infection, transmission of hepatitis B will continue for decades.
Vaccines also remain underutilized among other groups of adults, especially among certain racial/ethnic populations. For example, the rates of influenza and pneumococcal vaccination in African-American and Hispanic populations are significantly lower than those among whites.18 In addition, adult immunization is not limited to pneumococcal, influenza, and hepatitis B vaccines. All adults should be immune to measles, mumps, rubella, tetanus, diphtheria, and varicella, and adults who are susceptible to hepatitis A and polio should be vaccinated if they are at risk for exposure. Further, certain vaccines, such as travel vaccines or vaccines occupationally required, should be reviewed and provided if appropriate. The CDC’s Advisory Committee on Immunization Practices (ACIP) has recently published an Adult Immunization Schedule (http://cdc.gov/nip/recs/adult-schedule.htm).
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Revising the Standards
The Standards for Adult Immunization Practices, developed to encourage best practices, were first published in 1990.19 Since then, the healthcare system has changed dramatically. For example, there has been a shift toward managed care, resulting in a change in provider incentives and reimbursement for preventive services. Also in the past decade, healthcare researchers and providers have learned many valuable lessons about what is needed to achieve and maintain high vaccination rates among
Applying the Standards
Once the revised Standards are implemented on a practice-by-practice or program-by-program basis, immediate results can be expected for improved adult immunization. Long-term sustainable improvement in adult immunization necessitates an infrastructure to organize immunization efforts by providers and federal agencies, as well as state and local health departments. Such an infrastructure is lacking.24 Partnerships among healthcare professionals, state and local health departments, medical and
Standard 1: Adult vaccination services are readily available
Primary care healthcare professionals who serve adults should always include routinely recommended vaccinations as part of their care. Specialists, whose patients may be at increased risk of vaccine-preventable diseases, should also include routinely recommended vaccinations as part of their care. For selected vaccines (e.g., meningococcal vaccine for college entrants and vaccines for international travelers), patients may be referred to another provider.
Standard 2: Barriers to receiving vaccines are identified and minimized
Barriers to receiving vaccines may
Conclusion
The revised Standards for Adult Immunization Practices provide a concise, convenient summary of the most desirable immunization practices. The Standards have been widely endorsed by major professional organizations. This revised version of the Standards for Adult Immunization Practices is recommended for use by all healthcare professionals and payers in the public and private sectors who provide immunizations for adults. Everyone involved in adult immunization should strive to follow these
Acknowledgements
These Standards are approved by the National Vaccine Advisory Committee (NVAC), the National Coalition for Adult Immunization (NCAI), the Advisory Committee on Immunization Practices (ACIP), and the U.S. Public Health Service, and endorsed, as of December 1, 2001, by the American Medical Association, Infectious Diseases Society of America, American Academy of Family Physicians, American Academy of Pediatrics, American College of Obstetricians and Gynecologists, Society of Adolescent Medicine,
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2016, American Journal of Medicine
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