Review and special article
Standards for adult immunization practices

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Abstract

Since the Standards for Adult Immunization Practices were first published in 1990, healthcare researchers and providers have learned important lessons on how to better achieve and maintain high vaccination rates in adults. The success rate of childhood immunization far exceeds the success rate of adult immunization. Thus, information and practices that will produce higher success rates for adult vaccination are crucial, resulting in overall societal cost savings and substantial reductions in hospitalizations and deaths. The Standards, which were developed to encourage the best immunization practices, represent the collective efforts of more than 100 people from more than 60 organizations. The revised Standards are more comprehensive than the 1990 Standards and focus on the accessibility and availability of vaccines, proper assessment of patient vaccination status, opportunities for patient education, correct procedures for administering vaccines, implementation of strategies to improve vaccination rates, and partnerships with the community to reach target patient populations. The revised Standards are recommended for use by all healthcare professionals and all public and private sector organizations that provide immunizations for adults. All who are involved in adult immunization should strive to follow the Standards in order to create the same level of success achieved by childhood vaccination programs and to meet the Healthy People 2010 goals.

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).

Section snippets

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,

References (24)

  • P.A. Briss et al.

    Review of evidenceinterventions to improve vaccination coverage in children, adolescents, and adults

    Am J Prev Med

    (2000)
  • U.S. Department of Health and Human Services. Healthy People 2010. Conference edition in 2 vols. Washington DC: U.S....
  • National Center for Health Statistics. Early release of selected estimates from the 2000 and early 2001 National Health...
  • W.W. Thompson et al.

    Mortality associated with influenza and respiratory syncytial virus in the United States

    JAMA

    (2003)
  • Prevention and control of influenzarecommendations of the Advisory Committee on Immunization Practices (ACIP)

    MMWR Morb Mortal Wkly Rep

    (2001)
  • A.M. Palache

    Influenza vaccinesa reappraisal of their use

    Drugs

    (1997)
  • J.P. Mullooly et al.

    Influenza vaccination programs for elderly personscost effectiveness in a health maintenance organization

    Ann Intern Med

    (1994)
  • K.L. Nichol et al.

    Benefits of influenza vaccination for low-, intermediate-, and high-risk senior citizens

    Arch Intern Med

    (1998)
  • J. Nordin et al.

    Influenza vaccine effectiveness in preventing hospitalizations and deaths in persons 65 years or older in Minnesota, New York, and Oregondata from 3 health plans

    J Infect Dis

    (2001)
  • Notice to readersupdated recommendations from the Advisory Committee on Immunization Practices in response to delays in the supply of influenza vaccine for the 2000–01 season

    MMWR Morb Mortal Wkly Rep

    (2000)
  • Centers for Disease Control and Prevention. Active Bacterial Core Surveillance (ABCs) Report, Emerging Infections...
  • D.R. Feikin et al.

    Mortality from invasive pneumococcal pneumonia in the era of antibiotic resistance, 1995–1997

    Am J Public Health

    (2000)
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