ISSUE BRIEF Adult Immunization: Shots to Save Lives AN ISSUE BRIEF FROM TRUST FOR AMERICA’S HEALTH, THE INFECTIOUS DISEASES SOCIETY OF AMERICA, AND THE ROBERT WOOD JOHNSON FOUNDATION T he 2009 novel H1N1 flu outbreak has been a serious reminder that there is no strong mechanism in place for vaccinating adults in the United States. Public health departments are struggling with how to reach adults in communities around the country to encourage them to get vaccinated against H1N1, the seasonal flu, and, in some cases, pneumonia in a short period of time, without any real infrastructure in place. It is unfortunate, but not surprising, that be- these adult vaccines, immunization rates re- tween 40,000 and 50,000 adults die annually main low. Currently, there is no real system from vaccine preventable diseases in the or structure in place to ensure adults have United States. Millions of American adults go access to or receive the vaccines they need without routine and recommended vaccina- unless they are part of institutions that have tions because our medical system is not set up vaccine requirements, such as being en- to ensure adults receive regular preventive rolled in colleges or universities, serving in health care. The result is thousands of deaths the military, or working in health care set- from seasonal influenza, invasive pneumococ- tings. Significant numbers of adults do not cal disease, the effects of hepatitis B, and other have regular well care exams and switch infectious diseases that could have been pre- doctors and health plans often, which vented each year if more adults were vacci- makes it extremely difficult to set up ways nated.1 The U.S. Centers for Disease Control for people to know what vaccines they need and Prevention (CDC) has estimated the direct and for doctors to track and recommend health care burden of adult vaccine-pre- vaccines to patients. ventable diseases at about $10 billion annually.2 In addition, lack of health insurance cover- CDC recommends that adults should be vac- age and high costs can be an obstacle. Private cinated against a range of diseases, including medical insurance does not always pay for chickenpox, diphtheria, hepatitis A and B, adult vaccinations, and many patients can not human papillomavirus, influenza, measles, afford vaccines, some of which are expensive. meningococcal disease (meningitis), mumps, Even governmental program support is in- pertussis (whooping cough), pneumococcal consistent. Medicaid coverage varies among disease (pneumonia), rubella, shingles, and states, and the Medicare process for vaccine tetanus.3 Recommendations for some spe- payment is often bureaucratic and cumber- cific vaccines vary depending on an individ- some, and not all recommended adult vac- FEBRUARY 2010 ual’s risk factors and age. cines are covered under Medicare Part B, resulting in out-of-pocket costs that can be PREVENTING EPIDEMICS. Despite the recommendation of medical ex- prohibitive for some older Americans. PROTECTING PEOPLE. perts about the effectiveness and safety of According to the National Immunization Survey causes a blistering skin rash.6, 7 In addition, ap- released by CDC in 2007:4 proximately 20 million Americans ages 15 to 49 are currently infected with HPV and are at risk I Only 2.1 percent of eligible adults (18 to 64 for cervical cancer, and more than 800,000 to years old) had the tetanus, diphtheria, and 1.4 million Americans are estimated to have whooping cough vaccine in the previous chronic viral hepatitis B infection.8, 9 two years; I Just under two percent of older patients (60 According to the National Center for and over) had the shingles vaccine; Immunization and Respiratory Diseases, I Only 10 percent of eligible adult women (18 vaccine-preventable diseases kill more to 26 year olds) had the human papillo- Americans every year than traffic accidents, mavirus (HPV) vaccine; breast cancer, or HIV/AIDS.10 I Only 36.1 percent of all adults are vaccinated annually for the seasonal flu. Seniors, ages 65 Leading scientific and medical organizations, in- and older, are considered most at risk for cluding CDC and the Infectious Diseases Soci- complications from the flu, and the CDC rec- ety of America (IDSA), have called for the ommends all seniors receive a flu shot and the development of a strong adult immunization pneumonia vaccine. Yet only 69 percent of program to help prevent these unnecessary seniors, ages 65 and older, had the flu vaccine deaths and illnesses. Concerns about the need in 2008. Only 58 percent of Medicare bene- for an adult vaccine strategy have intensified ficiaries received flu vaccines; and with the novel H1N1 experience, and awareness of the importance of vaccines as a response to I Only 66.9 percent had the pneumococcal vac- many biological terrorism threats, such as small- cine, which is far short of the CDC’s goal of a pox or anthrax continues to grow. 90 percent vaccination rate for seniors.5 This paper reviews reasons why adult vaccination The consequences are severe in terms of deaths rates are so low and outlines a series of recom- and illnesses that could have been prevented. mendations for actions needed to develop and For instance, each year, approximately 36,000 implement an effective strategy to make sure Americans die of the seasonal flu, 5,000 die from American adults have the opportunity to receive pneumonia, and more than one million adults the vaccines recommended by medical experts. get shingles, an extremely painful condition that VACCINE SUCCESSES There is considerable evidence that immunizations are effective: I In the United States, mass vaccination has eliminated polio; I Smallpox has been eradicated worldwide through widespread immunization; I Among U.S. children, the recommended immunization series prevents approximately 10.5 million cases of infectious illness a year and 33,000 deaths;11 I An economic evaluation of the impact of seven vaccines -- diphtheria, tetanus, and pertussis (DPT), tetanus and diphtheria (Td), Haemophilus influenzae type b (Hib), polio, hepatitis B, and varicella (chicken pox), and measles, mumps, and rubella (MMR), routinely given to children found that these seven vaccines prevent more than 14 million cases of disease and more than 33,500 deaths during the lifetime of children born in any given year in the United States, and annually save $10 billion in direct medical costs and more than $40 billion in indirect societal costs.12 With widespread childhood hepatitis B vaccinations, experts predict there will be a dramatic decline in liver cancer cases among the next generation of adults; and I A report issued by the World Health Organization (WHO), UNICEF and the World Bank found that three million lives are saved worldwide each year through childhood immunizations, a number that could even be higher with more funding.13 2 ROUTINE PREVENTABLE DISEASES WITH ADULT VACCINES AVAILABLE TO PREVENT THEM14 Adults need vaccinations for new diseases and “booster” shots for diseases that they were vaccinated against as children, because their immunity may wane over time. In addition, new vaccines are being developed against old diseases, and adults can benefit from these vaccines as they become available. Vaccinations against diseases, such as pneumococcal and influenza, are especially important for people at high risk, including those suffering from chronic illnesses such as heart disease, pulmonary disease, diabetes, alcoholism or chronic liver disease (cirrhosis), and for health care professionals and care- givers. Also, Americans who travel to certain foreign countries may need vaccines to protect against diseases that exist in those regions but are not prevalent in the United States. Vaccines go through rigorous review and testing for effectiveness and safety by the U.S. Food and Drug Administration (FDA) before they are released to the market. The safety of vaccines is tracked through a monitoring system to keep track of potential patterns of adverse side effects. The Vaccine Adverse Event Reporting System (VAERS) is a joint CDC and FDA program that works with manufacturers, health care providers, and members of the public to report possible adverse events that people experience following vaccinations.15 In addition, the Vaccine Safety Datalink (VSD) project is a collaboration between CDC’s Immunization Safety Office (ISO) and eight large managed-care organi- zations to monitor safety and answer scientific questions about vaccine side effects.16 “ THERE’S A LEGITIMATE CONCERN IN THE PUBLIC ABOUT VACCINE SAFETY BECAUSE VACCINES ARE GIVEN TO HEALTHY PEOPLE. FOR THAT REASON, THERE IS A VERY HIGH LEVEL OF RESPONSIBILITY TO ENSURE THAT THEY ARE SAFE AND DO NOT CAUSE HARM. - EDWARD A. BELONGIA, MD, MARSHFIELD CLINIC RESEARCH FOUNDATION ” I Diphtheria: Diphtheria is a serious bacterial disease that frequently causes heart and nerve prob- lems. Without treatment, 40 to 50 percent of infected persons die, with the highest death rates oc- curring in the very young and the elderly. Diphtheria has largely been eradicated in the United States and other industrialized nations through widespread vaccination. There were only five re- ported cases of diphtheria between 2000 and 2007 in the United States.17 I Hepatitis A: Each year in the United States, hepatitis A infection sickens 125,000 to 200,000 peo- ple, resulting in 70 to 100 deaths. Hepatitis A disease tends to occur in outbreaks sometimes attrib- uted to many people having eaten from the same infected food source or transmission from person to person in family settings. I Hepatitis B: National studies show that about 12.5 million Americans have been infected with hep- atitis B virus at some point in their lifetimes. More than 10 percent of infected individuals develop chronic infection, increasing chances for chronic liver disease, cirrhosis and liver cancer. Hepatitis B- related liver disease kills about 5,000 people and costs $700 million annually in health care and pro- ductivity-related costs. I Human Papillomavirus (HPV): Approximately 20 million Americans currently are infected with HPV, and another 6.2 million people become newly infected each year. At least 50 percent of sexu- ally active men and women acquire genital HPV infection at some point in their lives. HPV can lead to cervical cancer. The HPV vaccine includes protection against the two HPV strains that cause 70 percent of all cervical cancers. I Influenza: Many illnesses are called “flu.” These include respiratory as well as gastrointestinal disorders and can be caused by a variety of infectious agents. Influenza is a specific respiratory infection caused by influenza viruses. Influenza vaccine protects against influenza, not the other disorders. In an average year, influenza causes approximately 36,000 deaths and 200,000 hospitalizations in the United States. 3 I Pertussis: Also known as whooping cough, pertussis is I Tetanus: Commonly known as lockjaw, tetanus is a severe highly contagious and can result in prolonged coughing disease that causes stiffness and spasms of the muscles, with spells that may last for many weeks or even months. Ap- approximately 30 percent of reported cases ending in death. proximately 50 out of every 10,000 people who develop Tetanus bacteria grow in soil and are an ongoing threat. In pertussis die from the disease. Since the 1980s, the number the United States, mortality due to tetanus has declined at a of reported pertussis cases has steadily increased, especially constant rate due to the widespread use of tetanus toxoid– among adolescents and adults.18 In 2004, a total of 25,827 containing vaccines since the late 1940s. According to CDC, cases of pertussis were reported to the CDC, the highest in 2005, a total of 27 tetanus cases and 2 deaths were re- number since 1959. Of these, 7,008, or 27 percent, oc- ported to the national tetanus surveillance system.19 curred among those between age 19 and 64. Young infants I Zoster (Shingles)20: Zoster (shingles) is a very painful nerve who die from pertussis often catch the infection from an infection caused by the same virus as chickenpox and is often adult or adolescent. accompanied by a localized skin rash with blisters. Anyone who I Pneumococcal disease: The pneumococcal bacterium is has had chickenpox can develop shingles because the virus re- spread by coughing and sneezing. It is the most common cause mains in the nerve cells of the body after the chickenpox infec- of pneumonia, inflammation of the coverings of the brain and tion clears and can emerge years later to cause shingles. The spinal cord (meningitis), bloodstream infection (sepsis), ear in- disease most commonly occurs in people 50 years and older, fections and sinus infections (sinusitis) in children under two and those with compromised immune systems. There are ap- years of age. The elderly are especially susceptible to this in- proximately one million zoster cases annually; one in three fection. In 2006, there were approximately 41,000 cases of in- Americans will get shingles in their lifetime; frequently shingles vasive pneumococcal disease, resulting in 5,000 U.S. deaths. and post-herpetic neuralgia increase with age. ADDITIONAL CHILDHOOD VACCINE-PREVENTABLE DISEASES In addition to the adult immunizations, there are also a in dormitories and military recruits living in barracks are number of other immunizations that are recommended especially vulnerable. during childhood, including: I Mumps: Prior to the mumps vaccine, the United States I Haemophilus influenzae type b (Hib): Prior to the vac- suffered approximately 200,000 cases of mumps per cine, Hib meningitis killed 600 children each year, and year with 20 to 30 deaths. Since a second dose of caused seizures among many survivors as well as perma- mumps vaccine was added to the standard childhood nent deafness, and mental retardation. Since the vaccine’s immunization series, annual cases are now in the introduction in 1987, the incidence of serious Hib bacteria hundreds rather than the thousands. infection has declined by 98 percent in the United States. I Rotavirus: Rotavirus is a disease of the digestive tract I Measles: As a result of widespread vaccination, measles caused by any one of three strains of rotavirus. Infection is no longer endemic in the United States. However, be- causes acute gastroenteritis (vomiting and diarrhea), and cause measles is still widespread in many countries, the humans of all ages are susceptible to rotavirus infection. United States is at risk of “importation” of the disease, According to CDC, each year rotavirus is responsible for and if high immunity is not maintained in adults and chil- more than 400,000 doctor visits; more than 200,000 dren, there is a risk of re-establishment of endemic trans- emergency room visits; 55,000 to 70,000 hospitalizations; mission. Measles is highly contagious. In the first half of and between 20 and 60 deaths in the United States. 2008, CDC received reports of 131 measles cases from I Rubella: Before the rubella vaccine was introduced, wide- 15 states and the District of Columbia -- the highest year- spread outbreaks mostly affected children in the 5-9 year to-date number since 1996.21 More than 90 percent of age group. Between 1962 and 1965, rubella infections dur- those infected had not been vaccinated or their vaccina- ing pregnancy were estimated to have caused 30,000 still tion status was unknown. In the United States, roughly births and 20,000 children to be born impaired or disabled. one in five people who develop measles require hospital- ization for one or more complications from the disease. I Varicella/Chickenpox: Although generally mild, vari- cella (chickenpox) is a highly contagious virus that can I Meningococcal disease: Meningococcal disease is a se- lead to severe illness with complications such as second- rious bacterial illness, and is a leading cause of bacterial ary bacterial infections, severe dehydration, pneumonia, meningitis in children two through 18 years old in the central nervous system deficits/disease and shingles. United States. About 1,000 - 2,600 people get meningo- Chickenpox has been reduced by 80 percent in the coccal disease each year in the United States and 10-15 United States since the introduction of the vaccine.22 percent of these people die. Young college students living 4 FUTURE POSSIBLE VACCINATIONS A number of additional vaccinations are in the research and development phase. Scientists hope that many additional vaccines are on the horizon for both infectious and chronic diseases. Most of the cur- rent vaccinations in wide use are focused on infectious diseases, but there are a number of potentially promising vaccines aimed at chronic disease issues and factors that contribute to chronic disease or be- havior health, including smoking, drug use, and obesity. A smoking vaccine is currently in clinical trials.23 CDC’S IMMUNIZATION RECOMMENDATIONS TO HEALTH CARE WORKERS24 INFLUENZA: Health care personnel need an influenza vaccination every year. Unvaccinated health care workers can spread influenza to patients and are a key cause of influenza outbreaks among pa- tients and long-term care residents. The vaccine does not cause influenza. HEPATITIS B: Five to 10 percent of acute hepatitis B infections lead to chronic infection, and these lead to liver damage (cirrhosis), liver cancer, or death. Hepatitis B vaccine should be given to protect individuals who are in contact with blood, body fluids, or used needles. MEASLES/MUMPS/RUBELLA (MMR): Health care workers who are not already immune to MMR should be vaccinated. Even mild or undetectable rubella disease can cause birth defects. TETANUS/DIPHTHERIA/PERTUSSIS (Td/Tdap): Health workers need a booster every 10 years for Td (tetanus-diphtheria) vaccine, and Tdap should replace a single dose of Td for adults who have not received a dose of Tdap previously. Persons may receive Tdap if it has been at least two years since the last Td vaccination. Health workers who are injured and/or who have direct patient contact should be especially vigilant about booster shots. VARICELLA (CHICKENPOX): Varicella can be transmitted in hospitals by patients, staff, and visi- tors. Health workers who are not already immune should be vaccinated. VACCINES FOR TRAVELERS25 Recommended: U.S. authorities recommend certain vaccines to protect travelers from illnesses present in other parts of the world and to prevent the importation of infectious diseases across international bor- ders. The vaccinations travelers need depend on several factors, including destination, whether the indi- vidual will be spending time in rural areas, the season of the year, age, health status, and previous immunizations. The CDC recommends travelers visit its destinations page at http://wwwn.cdc.gov/travel/ destinations/list.aspx to learn which vaccines they may need for specific countries. Required: The only immunization required by international health regulations is yellow fever vaccination for travel to certain countries in sub-Saharan Africa and tropical South America. Saudi Arabia requires meningo- coccal vaccination during the Hajj (the annual Muslim pilgrimage to Mecca) and documentation of polio vac- cination must be presented for children 15 years of age and younger. 5 VACCINES DURING PREGNANCY “ CHICKENPOX CAN MAKE YOU VERY SICK IF YOU ARE AN ADULT. ADULTS ARE 25 TIMES MORE LIKELY TO HAVE A SEVERE CASE OF CHICKENPOX THAN CHILDREN. THE DISEASE CAN RESULT IN DEATH. IN PREGNANT WOMEN, IT CAN CAUSE BIRTH DEFECTS. --ANNE GERSHON, MD, COLUMBIA UNIVERSITY COLLEGE OF PHYSICIANS, DEPARTMENT OF PEDIATRICS. ” Pregnant women have a higher risk of complications from influenza compared with the general popu- lation. Women who may become pregnant should consult with their health care providers to ensure they are current on routinely recommended vaccines. It is recommended that women who become pregnant should receive the inactivated seasonal flu shot and women should receive the Tdap vaccine before they become pregnant.26 In addition, the MMR vaccine can prevent birth defects due to infec- tion with rubella during pregnancy. Anyone receiving either the MMR or varicella (chickenpox) vac- cine should wait four weeks before becoming pregnant. If a woman is already pregnant, she should wait until after delivery to get either of these vaccines. The H1N1 outbreak demonstrated the need for pregnant women to receive flu vaccinations, as they suffered higher rates of severe reactions than the general population.27 I. PNEUMOCOCCAL AND SEASONAL INFLUENZA VACCINATIONS To illustrate the low rates of adult vaccinations, against the seasonal flu in each state. These rep- TFAH conducted an analysis of the number of resent the two most successful campaigns for seniors who have been vaccinated against pneu- adult immunizations, yet the number of adults monia and adults who have been vaccinated who get vaccinated is still relatively low. Pneumonia Vaccinations for Seniors CDC has recommended that all seniors, ages 65 chronic diseases), with a disease that lowers the and older, should be vaccinated against pneumo- body’s resistance to infection (such as Hodgkin’s nia, and HHS has set a national goal of immuniz- disease, or HIV/AIDS), who smoke, or who are ing 90 percent of seniors by the year 2010. This taking any drug or treatment that lowers the shot is only required once in a lifetime for most body’s resistance to infection (such as long-term people. As of 2008, only 66.9 percent of seniors steroids or radiation therapy), should get immu- have received the vaccine.28 Vaccination rates nized against pneumonia. range from a low of 55.4 percent in the District of People with flu, particularly seniors, are at risk for Columbia and a high of 73.2 percent in Oregon. developing pneumonia as a complication. Pneu- CDC also recommends that anyone over the age monia can be lethal, particularly in older adults. of two with underlying health problems (such as Together with flu, pneumonia is the eighth lead- asthma, heart disease, lung disease, sickle cell dis- ing cause of death in the United States. ease, diabetes, alcoholism, cirrhosis, and other 6 Pneumococcal Vaccination Rates for Adults Aged 65+ Percent Vaccinated Percent NOT Rank: 1= Lowest Vaccinated Vaccination Rate Alabama 64.0% (+/- 1.8) 36.0% 8 Alaska 64.0% (+/- 4.4) 36.0% 8 Arizona 68.2% (+/- 2.3) 31.8% 30 Arkansas 64.2% (+/- 1.5) 35.8% 12 California 61.0% (+/- 1.9) 39.0% 3 Colorado 72.6% (+/- 1.3) 27.4% 50 Connecticut 66.6% (+/- 1.4) 33.4% 22 Delaware 70.0% (+/- 2.1) 30.0% 38 D.C. 54.4% (+/- 2.3) 45.6% 1 Florida 62.4% (+/- 1.3) 37.6% 4 Georgia 64.0% (+/- 1.6) 36.0% 8 Hawaii 67.9% (+/- 1.8) 32.1% 27 Idaho 64.7% (+/- 1.8) 35.3% 14 Illinois 59.6% (+/- 1.7) 40.4% 2 Indiana 66.9% (+/- 1.7) 33.1% 24 Iowa 70.1% (+/- 1.5) 29.9% 40 Kansas 68.5% (+/- 1.2) 31.5% 32 Kentucky 65.2% (+/- 1.6) 34.8% 16 Louisiana 66.3% (+/- 1.7) 33.7% 21 Maine 70.5% (+/- 1.7) 29.5% 43 Maryland 66.1% (+/- 1.6) 33.9% 19 Massachusetts 69.6% (+/- 1.1) 30.4% 36 Michigan 65.8% (+/- 1.4) 34.2% 18 Minnesota 70.8% (+/- 1.7) 29.2% 45 Mississippi 66.8% (+/- 1.4) 33.2% 23 Missouri 67.3% (+/- 1.9) 32.7% 26 Montana 71.2% (+/- 1.5) 28.8% 47 Nebraska 70.2% (+/- 1.3) 29.8% 41 Nevada 66.1% (+/- 2.4) 33.9% 19 New Hampshire 71.2% (+/- 1.5) 28.8% 47 New Jersey 63.5% (+/- 1.4) 36.5% 6 New Mexico 64.6% (+/- 1.6) 35.4% 13 New York 63.3% (+/- 1.6) 36.7% 5 North Carolina 68.8% (+/- 1.0) 31.2% 33 North Dakota 69.4% (+/- 1.7) 30.6% 35 Ohio 68.4% (+/- 1.7) 31.6% 31 Oklahoma 71.1% (+/- 1.3) 28.9% 46 Oregon 73.2% (+/- 1.5) 26.8% 51 Pennsylvania 69.7% (+/- 1.4) 30.3% 37 Rhode Island 71.8% (+/- 1.6) 28.2% 49 South Carolina 64.0% (+/- 1.4) 36.0% 8 South Dakota 64.7% (+/- 1.4) 35.3% 14 Tennessee 65.4% (+/- 1.9) 34.6% 17 Texas 63.7% (+/- 1.6) 36.3% 7 Utah 68.0% (+/- 1.9) 32.0% 28 Vermont 69.0% (+/- 1.4) 31.0% 34 Virginia 68.1% (+/- 2.0) 31.9% 29 Washington 70.0% (+/- 0.8) 30.0% 38 West Virginia 66.9% (+/- 1.8) 33.1% 24 Wisconsin 70.5% (+/- 1.8) 29.5% 43 Wyoming 70.3% (+/- 1.5) 29.7% 42 U.S. Total 66.9% 33.1% N/A Source: Behavioral Risk Factor Surveillance System. 7 Seasonal Flu Vaccinations for Adults The annual vaccine for seasonal flu is the largest cinated. Seasonal flu vaccines have been largely existing program for adult vaccinations in the recommended for individuals above the age of 50, United States. However, only a fraction of adults since they are most at risk for health complications receive this vaccine. In some states, the rates of related to the flu. Even with targeted efforts to vac- adult vaccinations for the flu is as low as 25.5 per- cinate individuals above the age of 65, the rates of cent (Nevada), and even in the state with the high- annual flu vaccinations for seniors is as low as 61.3 est vaccination rate, South Dakota at 49.2 percent, percent in D.C and no state exceeds 80 percent. less than half of the state’s population has been vac- The highest rate is 78.1 percent in New Hampshire. SEASONAL FLU VACCINATION RATES FOR ADULTS, 2008 State 18-49 Year Olds 50-64 Year Olds 65 Years and Over Total Alabama 26.3% (+/- 2.8) 41.8% (+/- 2.8) 68.7% (+/- 2.7) 37.9% (+/- 1.9) Alaska 26.7% (+/- 3.5) 43.0% (+/- 4.9) 68.5% (+/- 6.3) 35.2% (+/- 2.8) Arizona 22.2% (+/- 3.6) 39.4% (+/- 4.6) 71.4% (+/- 3.2) 34.8% (+/- 2.6) Arkansas 27.7% (+/- 2.7) 44.9% (+/- 2.8) 70.5% (+/- 2.5) 40.1% (+/- 1.8) California 18.4% (+/- 1.5) 39.5% (+/- 2.2) 70.0% (+/- 2.2) 30.8% (+/- 1.1) Colorado 28.9% (+/- 1.6) 48.6% (+/- 1.9) 77.9% (+/- 1.7) 40.4% (+/- 1.2) Connecticut 28.3% (+/- 2.6) 45.7% (+/- 3.0) 74.6% (+/- 2.4) 41.1% (+/- 1.8) Delaware 26.1% (+/- 3.0) 46.7% (+/- 3.9) 69.6% (+/- 3.5) 38.8% (+/- 2.2) D.C. 30.3% (+/- 2.8) 44.2% (+/- 3.3) 61.3% (+/- 3.5) 38.2% (+/- 2.0) Florida 17.7% (+/- 2.5) 32.4% (+/- 2.8) 63.5% (+/- 2.5) 31.4% (+/- 1.7) Georgia 21.8% (+/- 2.3) 38.6% (+/- 2.8) 65.2% (+/- 2.9) 31.8% (+/- 1.7) Hawaii 31.9% (+/- 2.5) 47.4% (+/- 2.8) 77.1% (+/- 2.5) 44.2% (+/- 1.7) Idaho 20.8% (+/- 2.3) 39.5% (+/- 2.8) 68.4% (+/- 2.9) 33.0% (+/- 1.7) Illinois 20.8% (+/- 2.2) 38.6% (+/- 3.0) 63.2% (+/- 2.9) 31.9% (+/- 1.7) Indiana 21.5% (+/- 2.6) 39.9% (+/- 3.1) 68.6% (+/- 3.1) 34.1% (+/- 1.9) Iowa 32.7% (+/- 2.4) 48.2% (+/- 2.7) 76.5% (+/- 2.2) 44.8% (+/- 1.7) Kansas 26.9% (+/- 2.0) 43.5% (+/- 2.1) 72.0% (+/- 1.9) 38.9% (+/- 1.4) Kentucky 25.8% (+/-2.5) 43.6% (+/- 2.6) 73.6% (+/- 2.3) 38.6% (+/- 1.7) Louisiana 27.5% (+/- 2.3) 43.6% (+/- 2.6) 68.0% (+/- 2.8) 38.2% (+/- 1.6) Maine 25.0% (+/- 2.1) 47.3% (+/- 2.3) 74.6% (+/- 2.2) 40.6% (+/- 1.5) Maryland 26.8% (+/- 2.0) 46.3% (+/- 2.4) 69.8% (+/- 2.5) 38.5% (+/- 1.4) Massachusetts 28.5% (+/- 1.6) 45.8% (+/- 1.8) 72.0% (+/- 1.7) 40.5% (+/- 1.1) Michigan 23.0% (+/- 1.8) 41.8% (+/- 2.1) 70.0% (+/- 2.0) 35.7% (+/- 1.3) Minnesota 36.8% (+/- 2.9) 50.4% (+/- 2.9) 76.4% (+/- 2.6) 46.6% (+/- 2.0) Mississippi 24.7% (+/- 2.2) 38.4% (+/- 2.3) 67.5% (+/- 2.2) 35.5% (+/- 1.5) Missouri 26.5% (+/- 2.8) 45.1% (+/- 3.3) 71.3% (+/- 2.8) 39.2% (+/- 2.0) Montana 25.3% (+/- 2.6) 40.9% (+/- 2.5) 69.3% (+/- 2.4) 37.8% (+/- 1.7) Nebraska 33.0% (+/- 2.4) 51.3% (+/- 2.3) 75.7% (+/- 1.8) 45.2% (+/- 1.6) Nevada 15.4% (+/- 2.3) 29.6% (+/- 3.5) 57.1% (+/- 3.9) 25.5% (+/- 1.8) New Hampshire 28.9% (+/- 2.2) 49.4% (+/- 2.5) 78.1% (+/- 2.1) 42.6% (+/- 1.6) New Jersey 22.9% (+/- 1.9) 39.9% (+/- 2.2) 65.9% (+/- 2.2) 34.8% (+/- 1.3) New Mexico 28.0% (+/- 2.6) 42.3% (+/- 2.8) 69.7% (+/- 2.6) 38.6% (+/- 1.8) New York 24.8% (+/- 2.1) 43.9% (+/- 2.6) 70.9% (+/- 2.4) 37.6% (+/- 1.5) North Carolina 28.4% (+/- 1.7) 47.3% (+/- 1.9) 73.0% (+/- 1.6) 40.4% (+/- 1.2) North Dakota 30.0% (+/- 2.8) 45.4% (+/- 2.7) 73.2% (+/- 2.4) 42.1% (+/- 1.9) Ohio 24.2% (+/- 1.9) 42.0% (+/- 2.0) 70.3% (+/- 1.8) 37.1% (+/- 1.3) Oklahoma 27.8% (+/- 2.0) 51.3% (+/- 2.4) 73.2% (+/- 2.1) 41.8% (+/- 1.4) Oregon 20.7% (+/- 2.3) 43.2% (+/- 2.7) 70.1% (+/- 2.6) 35.3% (+/- 1.7) Pennsylvania 23.7% (+/- 2.0) 43.2% (+/- 2.3) 71.7% (+/- 2.0) 38.3% (+/- 1.4) Rhode Island 28.1% (+/- 2.8) 49.9% (+/- 3.0) 74.0% (+/- 2.6) 42.0% (+/- 2.0) South Carolina 23.6% (+/- 2.3) 42.9% (+/- 2.7) 68.0% (+/- 2.4) 36.3% (+/- 1.6) South Dakota 37.8% (+/- 2.7) 53.6% (+/- 2.6) 76.3% (+/- 2.1) 49.2% (+/- 1.8) Tennessee 29.0% (+/- 3.2) 42.7% (+/- 3.1) 70.8% (+/- 2.8) 39.5% (+/- 2.1) Texas 24.8% (+/- 1.9) 42.1% (+/- 2.5) 71.1% (+/- 2.2) 35.4% (+/- 1.5) Utah 30.7% (+/- 2.4) 48.6% (+/- 3.2) 73.3% (+/- 3.0) 39.8% (+/- 1.8) Vermont 26.1% (+/- 2.1) 46.9% (+/- 2.2) 73.4% (+/- 2.2) 40.2% (+/- 1.5) Virginia 29.3% (+/- 3.3) 48.0% (+/- 3.6) 73.1% (+/- 3.1) 40.7% (+/- 2.4) Washington 26.3% (+/- 1.3) 44.2% (+/- 1.4) 71.4% (+/- 1.4) 38.0% (+/- 0.9) West Virginia 23.5% (+/- 2.4) 46.5% (+/- 2.9) 71.1% (+/- 2.8) 39.1% (+/- 1.8) Wisconsin 28.9% (+/- 2.8) 44.4% (+/- 3.2) 73.0% (+/- 3.0) 40.5% (+/- 2.0) Wyoming 27.7% (+/- 2.0) 44.8% (+/- 2.1) 70.7% (+/- 2.1) 39.5% (+/- 1.4) National Totals 24.1% (+/- 0.5 ) 42.0% (+/- 0.5 ) 69.5% (+/- 0.5 ) 36.1% (+/- 0.7) Source: Behavioral Risk Factor Surveillance System. More information on the methodology for this analysis is available in Appendix D. 8 II. BARRIERS TO ADULT IMMUNIZATION Several barriers keep the numbers of adult vac- medical insurance that does not pay for cinations low. vaccines and their administration, so out-of- pocket costs may be prohibitive; I LIMITED ACCESS: Most adults are outside of institutionalized settings, like the military, I MISUNDERSTANDING AND MISINFOR- where vaccinations can be required; MATION: Many adults are misinformed about the safety and effectiveness of vaccines; I LIMITED CARE AND INSURANCE and COVERAGE: Primary and preventive care for adults is limited, particularly for the I LIMITED REARCH AND DEVELOPMENT: uninsured or underinsured; Vaccine research, development, and produc- tion have been limited in the United States I LIMITED FINANCING FOR for decades. IMMUNIZATIONS: Many adults have A. LIMITED ACCESS: FEW REQUIREMENTS FOR ADULT VACCINATIONS EXIST The United States has developed successful tain establishments like universities or the mili- childhood vaccination campaigns. To protect tary require some immunizations for adults who children from vaccine-preventable diseases, are affiliated with these institutions. For exam- states have enacted laws that require immuniza- ple, many colleges require new students to prove tion for the entry of children into the school sys- they have been immunized against MMR, tem and into child care facilities. In addition, a meningococcal disease and hepatitis B. Military Vaccines for Children (VFC) program was cre- personnel must also have certain vaccinations, ated to pay for vaccines for all children. Ac- and, depending on deployment, receive addi- cording to data from the 2006-2007 school year, tional immunizations to protect against such approximately three-quarters of the states al- bio-terror threats as smallpox and anthrax. ready have reached the national Healthy People Nursing homes that receive Medicare payments 2010 target of at least 95 percent coverage for are required to offer seasonal influenza and all vaccines recommended for children in pneumococcal vaccinations to their residents, kindergarten.29 The high nationwide coverage but residents are not required to accept them. underscores the value of school-entry require- Also, the requirement to offer the shots in nurs- ments in boosting vaccination coverage. ing homes does not extend to the facility’s health workers, staff, or visitors. Some hospitals Creating a program to reach all adults is more and other health care facilities require an im- complicated. For adults, there are no institu- munization review for specific vaccinations upon tions, such as schools, which could facilitate a admission of a patient or for new employees. broad immunization requirement, although cer- B. LIMITED CARE AND INSURANCE COVERAGE: ADULT CARE DOES NOT STRESS PRIMARY CARE OR PREVENTION The American health care system for adults is tion guidelines for adults, and many adult patients geared more toward treating illness than ensur- are unaware that they need vaccinations. And, a ing wellness. Many adults rarely see a primary significant number of adults -- an estimated 44 mil- care physician or only go to a doctor when they lion Americans -- lack access to primary health are sick or are managing chronic conditions. care altogether.30 And, many adults receive most of their medical Since vaccinations have not traditionally been care from sub-specialists who do not consider im- provided regularly as part of adult care, basic munizations their responsibility. In addition, systems are not well established for doctors to many doctors are unaware of specific immuniza- provide them. 9 “ I GET A CARD FROM MY VETERINARIAN WHEN IT’S TIME TO BRING MY DOG AND CAT IN FOR THEIR SHOTS. WHY DON’T I GET A CARD FROM MY DOCTOR WHEN IT’S TIME FOR ME TO GET MINE? ” --GREGORY A. POLAND, MD, DIRECTOR, MAYO CLINIC VACCINE GROUP. “ MANY DOCTORS ARE NOT VACCINE-SAVVY WITH RESPECT TO ADULTS, AND WE NEED TO EDUCATE THEM. PRACTICES SHOULD HAVE ‘STANDING ORDERS,’ SO THAT EVERY PATIENT WHO COMES IN IS SCREENED AND ASKED QUESTIONS ABOUT IMMUNIZATION -- AND THEN RECEIVES THE VACCINES IF THEY ARE NEEDED. ” --WILLIAM SCHAFFNER, MD, VANDERBILT UNIVERSITY SCHOOL OF MEDICINE, DEPARTMENT OF PREVENTIVE MEDICINE One problem for doctors is the difficulty in stor- tients are elderly and at increased risk for in- ing adult vaccines in their offices. Different vac- fluenza and pneumococcal disease. Vaccination cines have different temperature storage of health care personnel can reduce staff ill- requirements such as refrigeration or use of a nesses, absenteeism, and the likelihood of sick- freezer, and even a short power loss can ruin an ness and death among patients. entire inventory. Many small physician practices Studies have consistently shown several additional do not have the facilities for backup power. Also, reasons why health care workers do not get in- the administration fee provided by some payors fluenza vaccinations. The most frequent reason does not include the cost of purchasing refriger- unvaccinated workers gave for not getting the flu ators/freezers and other storage costs. And, even shot was that they thought that they did not need if a doctor’s office stores vaccine, it is hard to pre- it.32 Some expressed concern about vaccine side dict how much vaccine they will need or use, effects, including the erroneous belief that vac- since most adult vaccines are recommended over cine can cause the flu. Others perceived them- a period of 50 to 70 years, as compared to vac- selves to be at low risk for catching the virus or cines for children, which are mostly administered felt that getting vaccinated was an inconvenience. during the first six years of life. There is no guar- antee that the adults in any one practice will gen- In addition, despite the scientific evidence to the erate enough demand for a particular vaccine, so contrary, some doctors and medical providers vaccines may have to be discarded once their “use have unsubstantiated personal concerns about by” date expires, resulting in unreimbursed costs. vaccinations that cause them to dissuade patients from receiving vaccines or they pass along mis- In addition, many health care workers themselves information to their patients about vaccinations. do not get regularly recommended vaccinations. For instance, there were reports that a number A 2003 immunization survey conducted by CDC, of health providers counseled their patients not for example, showed seasonal influenza vaccina- to get the novel Influenza H1N1 vaccine in spite tion coverage of only 40 percent among health of the scientific evidence of the safety and effec- care workers.31 Experts say that immunizations tiveness of the vaccine. Many public health ex- are especially important for health care workers, perts recommend that increased education since they can transmit infections to their ill and about vaccinations should be included as part of immune-compromised patients and vice versa. nursing, medical, and other health professional This is considered an especially important issue educational curricula. in hospitals and nursing homes, where many pa- 10 “ HEALTH CARE WORKERS OFTEN [MISTAKENLY] THINK THEY’RE IMMUNE. THEY’VE BEEN WORKING IN THIS SETTING FOR A LONG TIME, HAVE BEEN AROUND SICK PEOPLE, AND [WRONGLY] THINK THEY HAVE NATURAL DEFENSES. ” -- PASCALE WORTLEY, MD, MPH, CHIEF, HEALTH SERVICES RESEARCH AND EVALUATION BRANCH, NATIONAL CENTER FOR IMMUNIZATION AND RESPIRATORY DISEASES, CDC. In an effort to increase the number of adults In addition, flu vaccination campaigns are mak- being vaccinated, a number of medical groups, ing vaccines regularly available to individuals in including the American College of Physicians alternative sites outside of the medical care set- and the IDSA, are trying to increase awareness ting, such as through drug stores and super- within medical school curricula and among cer- markets. During the novel Influenza H1N1 tain specialties, such as gynecology, which have vaccination campaigns, a number of non-tradi- regularized patient contact. So, for instance, tional sites were also used with success, includ- when women go for mammograms or Pap tests, ing airports, zoos, social service agencies, and they could also have access to vaccinations. baseball parks. Alternative sites could also be ex- plored for other vaccinations beyond influenza. KEEPING TRACK OF VACCINATIONS Effective tracking of adult immunization is important to help people avoid getting redundant or un- necessary vaccinations. Registries can maintain patient confidentiality while serving as good health records for individuals and as a means to track population vaccination trends.33 Forty-nine states have some form of childhood vaccination registry in effect. Approximately 20 percent of adults over 19 years of age have at least some immunization information in an immunization registry. The wider use of electronic medical records in the years ahead could make tracking vaccinations easier for individuals and providers. C. LIMITED FINANCING FOR VACCINES: LACK OF INSURANCE COVERAGE LIMITS VACCINATIONS One major obstacle to adult vaccinations is cost. Medicare Part B pays for influenza, pneumo- A number of insurance programs, including coccal, and hepatitis B vaccines, and covers some state Medicaid programs, do not cover the ac- other vaccines only when they are related to an tual costs for doctors to administer vaccines. Many injury -- tetanus, for example, or other direct ex- private insurers require patient co-payments for posure to a disease.37 As of 2006, Medicare Part vaccinations.34 Government programs cover ap- D pays for all current and future vaccines not proximately nine percent of adults younger than covered by Part B; however recipients confront 65 years of age. While federal funds from Section obstacles in obtaining vaccines through 317 of the Public Health Service Act given to states Medicare Part D, since the system is designed to can be used to help support adult vaccinations in reimburse pharmacies rather than physicians. public health clinic settings, most of these funds are Finally, the costs of several of the new adult vac- used to support childhood immunization pro- cines are relatively expensive and can be a disin- grams.35 The Section 317 program is a discre- centive to vaccinating adults. Zostavax®, the tionary federal grant program to all states, 6 cities, approved vaccine against shingles, is one of the territories and protectorates, which provides vac- most expensive vaccines on the market, as is Gar- cines to underinsured children and adolescents dasil®, an HPV vaccine. (The cost of Zostavax® not served by the VFC program, and as funding can be as high as $200 or more for a single shot; permits to uninsured and underinsured adults.36 Gardasil®, costs up to $175 or more per dose and In addition, Medicare coverage for vaccinations three doses are needed per individual.) for adults ages 65 and older is fragmented. 11 D. MISUNDERSTANDING AND MISINFORMATION: MISPERCEPTIONS AND MYTHS KEEP SOME ADULTS FROM GETTING VACCINATED Scientific research has shown that vaccines are Despite the evidence of safety and effectiveness very safe. While minor side-effects from vaccines of vaccines, many adults are unaware that they may develop, serious adverse events are ex- need certain vaccinations or are misinformed tremely rare, and some are so rare that risk can- about vaccines. not be accurately assessed. Most vaccine adverse According to the findings of a 2007 public opin- events are minor and temporary, such as a sore ion survey by the National Foundation on Infec- arm or mild fever, and can often be controlled tious Diseases, many adults did not know that by taking a pain reliever before or after vaccina- adult vaccinations were available that could pro- tion. There are so few vaccine-related deaths tect them from diseases for which they could be that it is impossible to assess the risk statistically.38 at risk.43 Forty percent of respondents reported The benefits of vaccines greatly outweigh the po- that they did not think they needed vaccines be- tential adverse effects. Diseases such as measles, cause they were vaccinated as a child, 34 percent mumps, and rubella have essentially been eradi- were not concerned about catching diseases that cated from the United States and Europe in the can be prevented by vaccines, 32 percent were past 40 years due to widespread vaccination ef- not concerned about spreading an illness to forts.39 Many adults in the United States or Europe friends, family, and co-workers, 25 percent have never even known anyone with a case of thought diseases prevented by vaccines are not se- measles, mumps, or rubella, yet these diseases con- rious or life-threatening, and 18 percent said they tinue to plague other parts of the world where vac- thought vaccines were not necessary for adults. cination campaigns and consistently available Despite the scientific evidence, a number of re- resources do not exist. Due to unsubstantiated spondents expressed concern about vaccine safety fear over vaccinations and a complacent attitude or efficacy. Thirty-five percent had heard or read towards diseases adults have not encountered in that vaccines are not safe, 25 percent reported modern times, some adults have chosen not to vac- that they thought a vaccine made them sick, and cinate their children and/or themselves, and in 14 percent felt that vaccines do not work. turn rates of certain vaccine-preventable diseases have increased in recent years, highlighting the im- About one-fourth of respondents expressed con- portance of continued efforts to vaccinate.40 cern about cost. Twenty-seven percent thought insurance would not cover vaccines, 26 percent With the current outbreak of 2009 novel H1N1 in- thought vaccines are too expensive, and 22 per- fluenza, many questions regarding the safety of vac- cent said they would not get vaccinated if they cines, specifically the H1N1 vaccines, have been had to pay for it. brought to the forefront of discussions. Two months after the first doses of the H1N1 vaccine Adult vaccination rates are particularly low for mi- became available to the public an extensive review nority groups. Researchers have found that of adverse effects indicated that the vaccine is safe.41 African Americans were significantly less likely No side effects beyond those typical of the seasonal than whites to have positive attitudes toward in- flu vaccine were reported, and a very small num- fluenza vaccination.44 According to 2008 data, 69 ber of serious adverse events have been reported. percent of older non-Hispanic whites received the seasonal influenza vaccination, compared to The importance of vaccinations cannot be over- only 53 percent and 51 percent of older African stated. According to the CDC: Americans and Hispanics, respectively.45 The gap Perhaps the greatest success story in public health is the for pneumococcal vaccination coverage was even reduction of infectious disease resulting from the use greater; vaccination rates were 61 percent for of vaccines. Routine immunization has eradicated non-Hispanic whites, compared to 45 percent for smallpox from the globe and led to the near elimina- African Americans and 29 percent for Hispanics. tion of wild polio virus. Vaccines have reduced some Researchers are trying to better understand the preventable infectious diseases to an all-time low, and reasons behind these disparities. Numerous stud- now few people experience the devastating effects of ies have shown that economics, education, and measles, pertussis, and other illnesses.42 discrimination all are factors.46 This study sug- gested that negative attitudes about vaccinations When used in conjunction with education and among African Americans had much more influ- other public health measures, vaccinations can ence over vaccination decisions than recommen- continue to increase the quality and length of dations from health care providers. life across the world. 12 Even some members of the medical community greater efforts be made to help provide in- express personal concern about vaccinations, de- creased education about the safety of vaccines to spite the scientific evidence of safety and efficacy, medical providers who may have concerns, par- which sometimes causes them to pass along mis- ticularly to encourage providers to provide the information to patients or even refuse to vacci- most up-to-date information to their patients. nate patients. Public health experts recommend E. RESEARCH AND DEVELOPMENT: RAMPING UP DISCOVERIES AND ADVANCES Vaccine research and development can be ex- phases, the first, a small trial to look at safety pensive for pharmaceutical companies, and it is and to see if there is an immune response; the often difficult for manufacturers to obtain the second, to assess dosage; and the third and development support needed to push a new vac- largest to document efficacy. cine toward profitability. Studies have shown Today, many experimental vaccines are in pub- that each new product reaching the market can lic and private sector vaccine development take up to a decade of development, and a fi- pipelines, aimed at routine use in healthy pedi- nancial investment of up to $1 billion.47 In ad- atric and adult populations, travelers, the mili- dition, the fact that the market for adult vaccines tary, and potential emerging biological threats.52 can be limited, since vaccination rates are so low, has discouraged many U.S. manufacturers from Recent years have seen the introduction of several major investment in vaccine development. important new vaccines, including those against zoster (shingles) and HPV, as well as improved In recent years, Congress has enacted legislation versions of existing vaccines, such as the meningo- that makes it easier and faster for the HHS to coccal conjugate vaccine and a pertussis vaccine fund the development and procurement of new that is effective in adolescents and adults (in- medical countermeasures against bioterrorism cluded in Tdap vaccine). Work is underway on and some naturally-occurring emerging infec- vaccines for cytomegalovirus (CMV), a common tious threats. Through the Biomedical Advanced virus that can be passed by a pregnant woman to Research and Development Authority (BARDA), her fetus, resulting in severe hearing, mental or the government has created measures to guar- movement impairments; and group B Strepto- antee that they will pay manufacturers for vac- coccus, a bacterium that can cause life-threaten- cines and drugs produced for the Strategic ing infections in newborns and illness among National Stockpile (SNS), once development is pregnant women, the elderly and those ill with complete.48 Unfortunately, since its creation, other conditions. BARDA has not been adequately funded to allow the program to achieve its mission. In fiscal year Scientists are always working on new vaccines, as (FY) 2010, BARDA received $305 million from well as trying to improve upon existing vaccines. Congress. Organizations such as the Center for Efforts to develop a single vaccine that would Biosecurity recommended BARDA receive $1.7 protect against all influenza viruses are under- billion in FY 2010 to successfully carry out its mis- way, as is an extensive global program to design sion and responsibilities.49 Furthermore, Con- and test candidate vaccines against HIV, which gress has authorized the HHS Secretary to causes AIDS, and for which there currently is no permit emergency use of critical products vaccine available. Also of global importance are through a streamlined, but temporary FDA li- new vaccines that could protect against Ebola censure procedure.50 This emergency authority and Marburg viruses, which cause hemorrhagic eases some of the regulatory burden of getting a fever; against malaria, a parasitic illness trans- new vaccine into the market. In December 2009, mitted by mosquitoes that causes one million HHS Secretary Kathleen Sebelius announced deaths every year, mostly in infants, young chil- she was ordering a major review of policies for dren and pregnant women, and most of them in developing medical countermeasures against Africa; and against tuberculosis (TB), which kills public health threats.51 approximately 2 million people worldwide an- nually. Scientists are also tackling non-infec- FDA’s Center for Biologics Evaluation and Re- tious conditions and are trying to develop new search (CBER) is responsible for regulating and vaccines that could prevent various types of can- licensing vaccines in the United States. Typi- cer as well as brain diseases that might result in cally, the development of a new vaccine follows substance abuse, such as cocaine, nicotine, and an approval process similar to the one used for methamphetamine addictions. drugs. Human studies are conducted in three 13 III. COORDINATION BETWEEN THE FEDERAL GOVERNMENT AND STATE AND LOCAL HEALTH DEPARTMENTS While the federal government sets the guidelines (NVAC) launched the Initiative on Immunization and many policies related to vaccinations, it is Registries to facilitate local and state based im- the state and local health departments that man- munization registries in the United States. One age both routine vaccination efforts on a regular of the national health objectives for 2010 is to in- basis and emergency vaccinations in the event of crease to 95 percent the proportion of children a new disease outbreak or bioterrorism event. In under 6 years of age who are part of a fully oper- addition, each state has vaccination laws and re- ational Immunization Information System (IIS).57 quirements, which the federal government sup- IIS are confidential, computerized information ports by setting policies and providing funding.53 systems that can record vaccination data about all children within a certain geographic area.58 State- The federal Advisory Committee on Immuniza- and locally-based immunization registries are crit- tion Practices (ACIP) determines which vaccines ical to effective documentation of vaccination cov- to recommend and approves the vaccines, and erage; they enable implementation of vaccination then state and local health departments organ- strategies, and they decrease resources needed to ize, administer, and maintain vaccine campaigns measure, achieve, and maintain increased levels and registries.54 Most health departments around of vaccination coverage.59 the country hold their own vaccination clinics and educate the public about the importance of As health information technology advances in the keeping up to date on immunizations.55 United States, many experts believe the inclusion of registry-like information in electronic health On a routine basis, public health departments records may facilitate public health department often administer childhood and adult vaccina- access to this information and make monitoring tions in public-private partnerships with health immunizations by providers easier as well. care providers. For instance, health depart- ments maintain clinics where children can come State and local health departments also play an for the vaccines they need for school as an al- important role in immunizing Americans dur- ternative to receiving the vaccinations from their ing new outbreaks and crises, such as bioterror- private pediatricians. In addition, health de- ism events. The federal government maintains partments administer adult vaccinations the SNS, which includes countermeasures and through clinics and often maintain flu vaccina- vaccines for emergencies, but state and local tion clinics. Being able to receive vaccinations health departments are responsible for the man- through health departments is particularly im- agement and administration of vaccinations in portant to have for individuals and families who their jurisdictions. State and local health de- are uninsured or underinsured. partments plan and train to: 1) receive SNS as- sets from the federal government; 2) distribute, For example, in an effort to improve preteen vac- or move, those assets from the storage facility to cination rates, California implemented Preteen the point-of-dispensing (POD); and 3) dispense, Vaccine Week in 2009.56 Through kits and plan- provide, or administer the medical counter- ning materials, educational materials, public serv- measure to the affected persons. According to ice announcements, and adolescent health the CDC, “preparedness to receive, stage, store, conferences, California raised awareness about and distribute SNS material is essential to saving the ACIP recommendations for preteens. Health lives at risk during a public health emergency.”60 departments are using many avenues such as schools, community centers, and local media to During the novel Influenza H1N1 outbreak, the improve vaccination rates in their communities. federal government purchased the vaccine and distributed it to designated vaccination sites in Another function of many state and local health states through public-private partnerships, so departments is to collect vaccination data and some vaccine went to the health departments, maintain immunization registries. These reg- some went to private health care providers, and istries are often used to help ensure children and some went to other health care entities, such as adolescents keep up-to-date with immunizations. pharmacies, as determined by the state or terri- In 1998, in an effort to facilitate community- and torial health department. Each state is respon- state-based immunization registry development, sible for conducting its own vaccination the federal National Vaccine Advisory Committee campaign. For instance, in Virginia, the state 14 and local government and health departments partments to directly administer vaccinations. are using advertisements on buses and in movie In Jackson County, Ohio, the local health de- theaters, television and radio ads, temporary tat- partment set up vaccination sites throughout toos, t-shirts and stickers as part of their media the county including a weekday and weekend campaign to encourage residents to get vacci- clinic at the health department as well as school- nated.61 Other states are using local health de- based clinics.62 IV. CONCLUSION AND RECOMMENDATIONS “ WE’VE HAD SIGNIFICANT IMPROVEMENT IN GETTING CHILDREN IMMUNIZED...BUT IT’S AN EMBARRASSMENT THAT WE HAVE DONE SO POORLY WITH ADULTS. --CONGRESSMAN HENRY A. WAXMAN, CHAIRMAN OF THE HOUSE ENERGY AND COMMERCE COMMITTEE ” Each year, hundreds of thousands of American TFAH and IDSA recommend a number of actions adults are hospitalized and tens of thousands be taken to increase adult immunization rates for die from diseases that could have been pre- vaccine-preventable illnesses. Many are based on vented by vaccination. CDC estimates that the IDSA’s 2007 statement, Actions to Strengthen Adult cost of the health burden to society from vac- and Adolescent Immunization Coverage in the cine preventable diseases is approximately $10 United States: Policy Principles of the Infectious Dis- billion annually. Initiating improvements in ease Society of America.63 These recommendations the nation’s ability to immunize adults will pre- reflect the views of TFAH and IDSA and do not nec- vent disease, mitigate suffering, and reduce essarily reflect the views of those consulted on this health care costs. paper or those who served as peer reviewers. 1. INCREASE DEMAND FOR ADULT VACCINES I If adult immunization coverage is to in- should expand curricula on vaccine-pre- crease, public and provider awareness must ventable diseases in adults. be improved. I With respect to providers, it should become a L With respect to public awareness, CDC standard practice to review patients’ immuniza- should receive additional resources to cre- tion histories and offer vaccinations at appropri- ate and manage a broad public education ate medical encounters. Providers should campaign targeted at improving adult im- consider routine preventive heath care visits, munization rates, with active participation such as cancer screenings and pre-natal visits, as by and collaboration with state and local an opportunity to discuss the patient’s immu- public health departments. Federal officials, nization needs. Providers and other parties in partnership with medical societies and should work to establish purchasing cooperatives public health departments, also must con- to lower costs and risks to individual providers. duct an assertive campaign to combat the Hospitals and medical practices should promote rise in “vaccine hesitancy.” Targeted infor- the use of standing orders for vaccinations. mation that is culturally-appropriate should I Providers should take advantage of advances in be made available to high-risk groups and electronic medical records or immunization racial and ethnic minority populations. registries to improve information-sharing State and territories should receive ade- about patients’ vaccination histories across dif- quate resources to tailor immunization cam- ferent providers and to generate reminders to paigns and approaches to their own unique providers and patients about recommended and diverse populations at local levels. vaccinations. Federal standards for meaningful L Professional medical societies (e.g., obstet- use of health information technology (IT), rics/gynecology and internal medicine) which will accompany health IT grants to should support ongoing education of their providers as part of the American Recovery members about the importance of adult im- and Reinvestment Act (ARRA), should also in- munization. Medical and nursing schools clude vaccine notification and tracking. 15 I All health care workers should play an in- transmission of seasonal and H1N1 influenza creased role in reducing transmission of dis- by [health care workers].”64 ease and set an example by complying with the I Mirroring the patient immunization offer man- immunization recommendations from ACIP dates at nursing homes, more hospitals and to protect themselves, their staffs, and their pa- health facilities should develop policies to offer tients. This includes receiving an annual in- vaccinations to eligible adult inpatients and out- fluenza vaccination to protect themselves and patients. There should be adequate payment their patients. IDSA supports “universal im- to hospitals for vaccine acquisition, storage, and munization of health care workers against sea- administration. The Joint Commission should sonal and 2009 H1N1 influenza by health care establish criteria for assessing influenza, per- institutions (inpatient and outpatient) tussis, and hepatitis B immunization rates in through mandatory vaccination programs as health care workers as a measure of institutional those programs are likely to be the most ef- compliance and performance. fective means to protect patients against the 2. EXPAND EXISTING FEDERAL IMMUNIZATION PROGRAMS AND CREATE A “VACCINES FOR UNINSURED ADULTS PROGRAM” I Congress should increase funding for the Sec- cines become a routine entitlement, similar to tion 317 Program. In March 2009, CDC pro- the VFC Program, should be created. Impor- vided Congress with a professional judgment tant legislation was introduced in the 110th estimate that the Section 317 Program would Congress to establish such a program (see Vac- require $1.6 billion in FY 2010 to fully protect cines for the Uninsured proposal text box). children who rely on this program and to ex- I Congress and HHS should act to ensure that tend the program to increase adult immu- Medicare beneficiaries receive coverage for all nization rates as well. FY 2010 funding for the preventive vaccines under Medicare Part B in- program is only $496.8 million. Congress al- stead of covering most vaccines under Part D. located an additional $300 million to the pro- Part B procedures are straightforward and al- gram as part of the ARRA, with those funds to ready cover influenza, pneumococcal and hep- be expended in FY 2009 and 2010, so that atitis B vaccines. Health reform legislation funding should be built into the FY 2011 base- passed by the U.S. House of Representatives in line. In addition, operations funding should 2009 includes a provision that would transfer be provided to cover physician’s expenses in Medicare-covered vaccines from Part D to Part administering the vaccines, which is not cur- B. Legislation was also introduced in the 110th rently covered by the 317 Program. TFAH Congress to transfer all Medicare-covered vac- and IDSA recommend at least $800 million in cines from Part D to Part B (see Vaccines for the funding for the 317 Program in FY 2011. Uninsured proposal text box). I Congress should build on the innovations that I The Centers for Medicare and Medicaid Serv- result from the one-time $300 million in sup- ices (CMS) should require institutions, as a plemental funding from ARRA and provide a condition of participating in the Medicare distinct funding stream to be used by states in program, to offer annual influenza vaccina- enhancing their outreach efforts to adults in tion to all health care personnel, report an- the FY 2011 budget. nual vaccination rates, and undertake I Congress should be commended for including vigorous promotional campaigns to increase a mandate for full coverage of all ACIP-recom- vaccine acceptance. Mandatory policies for mended immunizations for all insured Ameri- institutions receiving Medicare payments cans as part of the pending health reform should be considered. legislation. Regardless of the outcome of that I Congress should increase funding to permit debate, steps must be taken to provide funds CDC to increase its capacity to measure adult to cover immunizations for those who will re- immunization coverage rates and support en- main uninsured and to cover costs of immu- hanced development, interoperable functional- nizations during the time of transition where ity, and use of state and regional immunization benefits are being extended post-reform. A registries and/or take advantage of advances in Vaccines for Uninsured Adults (VFUA) Pro- electronic medical health records. gram that would help ensure that adult vac- 16 I Congress should provide the National Insti- to adult immunization within their own pro- tutes of Health (NIH), CDC and FDA with in- grams, collect data regularly about immuniza- creased support for vaccine-safety surveillance tion rates and practices within their settings, and research. conduct research to evaluate and eliminate barriers to immunization, and receive the re- I HHS agencies (CDC, the Agency for Health- sources to accomplish these goals. care Research and Quality, CMS, HRSA), the Department of Defense, the Department of I Medicare and Medicaid vaccine administra- Veterans Affairs, and the Federal Bureau of tion fees must be increased to cover Prisons should conduct assessments of barriers providers’ actual cost of administration. VACCINES FOR THE UNINSURED PROPOSAL In the 110th Congress, Representative Henry A. Waxman, (D-CA), chair of the House Energy and Commerce Committee, sponsored legislation to strengthen adult and adolescent immunization. One bill, H.R. 4933, would have established a Vaccines for Uninsured Adults program, modeled after the successful Vaccines For Children program. The measure proposed creating an entitlement program for all low income adults to receive free vaccines, and for physicians to receive a fee for providing the immunizations. The bill also proposed authorizing programs to educate the public about the impor- tance of adult immunization and permit grants to states to strengthen state adult immunization ef- forts. In addition, the legislation would require CMS, through increased research, to find more effective ways to encourage adults and, specifically, health care workers to get immunized. The measure would authorize $800 million annually for the first five years to implement these changes. Another bill, H.R. 4992 in the 110th Congress, focused on helping older Americans by moving vaccine coverage from Medicare Part D to Medicare Part B, thereby removing obstacles to vaccine delivery and providing administration fees to doctors for vaccinating patients. 3. STRENGTHEN PRIVATE INSURANCE COVERAGE OF ADULT VACCINES I Private payers should provide coverage for all I The National Committee on Quality Assur- ACIP-recommended adult vaccines and con- ance should work toward including every sider administration fees provided by Medicare adult vaccine recommended by ACIP in the Part B to be the minimal standard. If a federal Health Plan Employer Data and Information mandate does not occur as part of health re- Set (HEDIS), a set of measures that reflect form, states should require full coverage of quality of care in managed care and other ACIP-recommended vaccines. health care settings. 4. SUPPORT ADDITIONAL RESEARCH INTO ADULT VACCINES I Research supported by BARDA, NIH, CDC, munization rates, and to implement and eval- FDA, and other federal agencies must be uate interventions designed to eliminate un- funded sufficiently to support the develop- necessary concerns and disparities. ment of new adult vaccines, as well as im- I Congress should provide incentives that sup- provements in existing vaccines. Effectiveness, port vaccine development and production by safety and cost-benefit should be considered. industry within the United States to help assure I Congress should appropriate $1.7 billion for adequate supplies of vaccine, especially in times FY 2011 in the Public Health and Social Serv- of crisis. Steps should be taken to stabilize the ices Emergency Fund (PHSSEF) for BARDA’s vaccine market by assuring that vaccines will be advanced research and development mission. purchased once produced. The announced in- tent of governments to guarantee purchases of I Health services research should be funded to fixed amounts of vaccines has helped to stabi- study public and provider acceptance of vac- lize production in some cases and encourage cines, safety concerns among the public, and continued research and development. racial, ethnic, and economic disparities in im- 17 5. INCREASE RESOURCES FOR STATE AND LOCAL HEALTH DEPARTMENTS’ VACCINATION CAMPAIGNS I Sufficient resources must be provided to state In the first half of 2009, approximately 8,000 and local health departments to conduct suc- staff positions in LHDs were lost due to layoffs cessful vaccination campaigns. Such campaigns or attrition. An additional 12,000 LHD em- should reach out to adults to inform them ployees were subjected to reduced hours or about the availability, benefits, and safety of vac- mandatory furloughs. The response efforts to cines, as well as maintain vaccination clinics to the novel Influenza H1N1 outbreak would not administer vaccines to the general public, but have been possible without one-time and lim- particularly the uninsured and underinsured. ited federal funding and the shifting of staff re- Sufficient funding is an ongoing challenge. In sources from other programs. 2009, the National Association of County and I Ongoing support must be provided to ensure City Health Officials surveyed a sample of local that state and LHDs have continuous capacity health departments (LHDs) nationwide to to support vaccination and public health pro- measure the impact of current economic con- grams that help support vaccine efforts. Often ditions on LHDs’ budgets, workforce, and pro- vaccination campaigns are funded as “just-in- grams. The report found that LHDs had begun time” or one-time campaigns instead of an on- to eliminate or reduce vital programs and staff. going continued service. APPENDIX A: COMMUNITIES TAKING ACTION: SUCCESS STORIES AND INNOVATIONS Vax and Vote In an effort to increase the rates of those re- at-risk Americans. In recent years the efforts ceiving flu shots, the Robert Wood Johnson have been expanded, and in November 2008 Foundation (RWJF), together with Sickness Pre- Vote and Vax delivered 21,434 flu shots at 331 vention Achieved through Regional Collabora- locations in 42 states and the District of Colum- tion (SPARC), created the Vote and Vax bia.65 Almost half of those vaccinated reported initiative to provide flu vaccination clinics at or that they had either not received a flu shot the near polling centers across the country. previous year or would not have been vaccinated but for the Vote and Vax program. The program first started in 2004, and has helped to provide thousands of vaccinations to Colorado: A Decade of Targeting Adults Colorado places a special emphasis on adult im- to coordinate efforts. They also work with a local munization. For the past 10 years, the goal of the television station, which sponsors health fairs, to state’s Influenza and Adult Immunization Coali- distribute posters and brochures that encourage tion has been to decrease vaccine-preventable immunization. diseases through collaborative efforts in educa- “Originally we were mostly concerned with flu and tion and immunization. pneumococcal vaccination,’’ says Margaret Huff- Located within the state department of public man, ND, RN, the provider services unit manager health, the program uses, among other things, for Colorado’s immunization program. “Since the community outreach, media, and provider edu- introduction of the zoster vaccine, HPV and the cation to spread the message. The state does not Tdap recommendations, we highlight all the im- run immunization clinics, but provides vaccines munizations that adults should be considering.”66 to community clinics, such as church-based or The program uses money from Section 317 to mobile clinics, that deliver immunizations to un- fund its activities. Its greatest success has been derserved populations, such as the homeless. with the state’s elderly. “We really do well with Coalition officials meet monthly with commu- our seniors,” Huffman says. “We are one of the nity clinics, pharmacies (which under state law top states with flu and pneumococcal vaccines. can administer shots), vaccine manufacturers, We don’t do as well with our younger adults, but and local public health agencies, among others, we are working on it.”67 18 Howard County, Maryland: Drive-through Flu Shots Howard County, Maryland has a convenient and former Baltimore City Health Commissioner. relatively quick way to deliver seasonal flu shots: “People fill out consent forms while waiting in a drive-through clinic. People don’t leave their line, and then move on. We have about 10 or 12 cars -- they just roll up their sleeves, roll down lanes. People literally just drive by and hold out their windows, and stick out their arms. their arms. It’s extremely simple, and we can get a massive number of people through.”69 “It is just as easy as getting fast food, and a lot better for you,” says Peter Beilenson, MD, the This is not the only such drive-through opera- county’s health officer.68 tion in the country. The Department of Veter- ans Affairs, for example, also sponsors local During the three years the drive-through has drive-through immunization clinics in various been operating, the biggest challenges have been locations around the country. logistics and traffic control. Beilenson says the process has gotten better and faster each year. Public health experts recommend generally that This past fall, the county delivered shots to 4,000 a post-immunization waiting period be incorpo- people in five hours from a large parking lot that rated into drive-through clinic plans, to provide surrounds a local warehouse. The shots are free, protection against the possibility some people paid for by the county health department. may feel dizzy after receiving an immunization. “We set the clinic up in a huge circular driveway, with police directing traffic,’’ says Beilenson, the Immunize LA Families Immunize LA Families, part of the South Los South Los Angeles Health Projects. “We enroll Angeles Health Projects, successfully uses the 20,000 pregnant women every year. Now, let’s see federally funded Women, Infants and Children if we can get them to go get immunizations.”70 (WIC) nutrition program as a place to reach Immunize LA Families also hopes to initiate adult families in order to encourage pediatric immu- immunization outreach activities in churches, nization. It now plans to do the same with in- senior citizen centers and other sites, with sup- fluenza vaccination among adult pregnant port from the Racial and Ethnic Approaches to women who use WIC services. Community Health (REACH) program, created “WIC is one place where you can reach women by CDC to support community coalitions that and children, and we have one of the biggest WIC work to eliminate racial and ethnic health dis- programs in the country,’’ says Steve Baranov, parities. At present, Immunize LA Families re- Vice President for Community Health at the Los ceives less than $500,000 a year from CDC’s Angeles Biomedical Research Institute, Harbor- REACH program. “If we could double our UCLA Medical Center, and Executive Director of budget, we could do much more,” Baranov says.71 19 APPENDIX B Joint Statement of Medical Societies Regarding Adult Vaccination by Physicians Summary: It is proposed that: In an effort to emphasize the importance of (1) Primary and subspecialty physicians should adult vaccination against an increasing number conduct immunization review at appropriate of vaccine-preventable diseases, primary care adult medical visits to educate patients about the and many subspecialty physicians should take an benefits of vaccination and to assess whether the active role in the discussion and review of their patient’s vaccination status is current, referring adult patients’ vaccination status and in the ad- to the Advisory Committee on Immunization ministration of recommended vaccines. In- Practices Adult Immunization Schedule. creased consumer demand for quality care, and (2) When appropriate, physicians should provide guidelines and/or recommendations from the or refer patients for recommended immunizations. CDC and professional societies provide addi- tional impetus for a renewed and stronger em- (3) Physicians who administer vaccines should en- phasis on provision of vaccines. sure appropriate documentation in the medical record. In addition, documentation of vaccination The Potential Role of Subspecialists: in other settings, patient refusal, and any con- Primary care is the most convenient and ap- traindications is advisable. The use of immunization propriate setting for delivery of vaccines to registries and electronic data systems facilitates ac- most adult patients, since it serves as their cess to accurate and complete immunization data. “medical home.” However, many patients with chronic disease also have a “medical home” (4) Physicians who refer patients for vaccination with a subspecialist. For example, infectious also should review and document the vaccina- disease physicians often provide primary and tion status of their patients whenever possible. preventive care services for patients with HIV (5) Consistent with the CDC Advisory Commit- infection. Other subspecialists also may serve tee on Immunization Practices and multiple as the preferred source of care for their pa- subspecialty organizations, physicians and their tients with chronic disease, providing an op- staff should be immunized consistent with CDC portunity to serve as a source of vaccination recommendations, with particular attention to administration or referral. annual influenza immunization. Signed: American College of Physicians American Gastroenterological Association Infectious Diseases Society of America The Endocrine Society Society of Hospital Medicine The American Academy of Allergy, Asthma and Immunology American Association of Clinical Endocrinologists American College of Gastroenterology American Association for the Study of Liver Diseases American Society of Clinical Oncology Society of General Internal Medicine American Society of Nephrology American Society of Hematology American College of Cardiology Society for Adolescent Medicine American Thoracic Society American College of Chest Physicians The Society for Healthcare Epidemiology American College of Allergy, Asthma and of America Immunology 20 APPENDIX C: TYPES OF VACCINES AND VACCINE PRODUCTION Current Vaccines72 There are many different kinds of vaccines. They are made from pieces of the polysaccharide Live, attenuated vaccines contain a version of capsule that surrounds certain bacteria. Polysac- the living microbe that has been weakened in charide vaccines are generally less effective than the lab so it does not cause disease. This kind of live attenuated vaccines and inactivated vaccines vaccine is the closest thing to a natural infection; that are based on protein. They also are not very thus, it can elicit strong cellular and antibody re- effective in infants and children under two years sponses and produce lifelong immunity with of age. The pneumococcal vaccine for adults is a only one or two doses. Not everyone can safely polysaccharide vaccine. Conjugate vaccines are an- receive this kind of vaccine. People with weak- other type of subunit vaccine. They are made by ened immune systems, for example, should not joining the polysaccharide capsule that surrounds receive live vaccines. These vaccines need to be the bacterium to a protein carrier. This makes the refrigerated or frozen to keep their strength. vaccine effective in infants and young children. Ex- Vaccines against measles, mumps, chickenpox amples include Haemophilus influenzae type b (Hib) and shingles are live attenuated vaccines. and pneumococcal vaccines for children. Inactivated vaccines are those made by killing the Toxoid vaccines are used to prevent illness caused disease-causing organism with chemicals, heat, or by poisons developed by some bacteria. Scientists radiation. These are more stable than live vaccines inactivate these toxins by treating them with for- and may be safer. However, most of these vaccines malin, a solution of formaldehyde and sterilized stimulate a weaker immune system response than water. Such “detoxified” toxins, called toxoids, are do live vaccines, requiring several additional safe for use in vaccines. When the immune system doses, or booster shots, to maintain immunity. receives a vaccine containing a toxoid, it develops antibodies to fight off the natural toxin. The im- Subunit vaccines include only those parts (anti- mune system produces antibodies that lock onto gens) that best stimulate the immune system, and block the toxin. Vaccines against diphtheria rather than the entire microbe. The chances of ad- and tetanus are examples of toxoid vaccines. verse effects from these vaccines are generally lower than with other types. Once scientists iden- Chemicals commonly used in the production of tify which antigens are the most important in in- vaccines include a suspending fluid (sterile water, ducing infection, they may be able to either grow saline, or fluids containing protein); preservatives the microbe in the laboratory and use chemicals to and stabilizers (for example, albumin, phenols, break it apart, or manufacture the antigen mole- and glycine); and adjuvants, or enhancers, which cules from the microbe using recombinant DNA help improve the vaccine’s effectiveness. Vaccines technology. Vaccines produced this way are called also may contain very small amounts of the cul- recombinant subunit vaccines. The vaccine for ture material used to grow the virus or bacteria hepatitis B is a recombinant subunit vaccine. Poly- used in the vaccine, such as chicken egg protein. saccharide vaccines are a type of subunit vaccine. Vaccines of the Future73 DNA vaccines are still in experimental stages. In other words, the body’s own cells become vac- DNA vaccines use the genes that code for those cine-making factories, creating the antigens nec- all-important antigens. Researchers have found essary to stimulate the immune system. that when the genes for a microbe’s antigens are Recombinant vector vaccines are experimental introduced into the body, some cells will take up vaccines similar to DNA vaccines, but they use an that DNA. The DNA then instructs those cells to attenuated virus or bacterium to introduce mi- make the antigen molecules. The cells secrete crobial DNA to cells of the body. “Vector” refers the antigens and display them on their surfaces. to the virus or bacterium used as the carrier. 21 APPENDIX D: METHODOLOGY FOR PNEUMONIA AND SEASONAL INFLUENZA VACCINATIONS Data for this analysis was obtained from the Be- Omission of the primary sampling unit variable havioral Risk Factor Surveillance System implies one-stage sampling of elements and no (BRFSS) dataset (publicly available on the web clustering of sampled elements. Omission of the at cdc.gov/brfss).74 To conduct the analyses, sample weight implies equally weighted sample el- TFAH contracted with Edward N. Okeke, PhD, ements. Mean proportions for each variable were MBBS, MPH at the Department of Health Man- estimated using the svy: proportion command. agement and Policy at the University of Michi- For pneumococcal vaccination, the individual is gan School of Public Health. asked whether he/she has ever received a pneu- To account for the complex nature of the sur- monia shot. In all cases we exclude observations vey design and obtain estimates accurately rep- with missing data as well as observations where resentative at the state level, we used sample the individual either refused to answer, or weights provided by the CDC in the dataset. The replied, “Don’t know.” This never amounted to main purpose of weighting is to reduce bias in more than 5 percent of the observations. population estimates by up-weighting popula- For the seasonal influenza analysis, the variable tion sub-groups that are under represented and of interest was the FLUSHOT variable.76 Re- down-weighting those that are over represented searchers weighted data from 2008 using sample in the sample. Also estimation of variance, which weights provided by the CDC in the dataset and indicates precision and is used in calculating dropped observations where either the survey confidence intervals, needs to take into account participant answered, “don’t know” or refused to the fact that the elements in the sample will gen- answer. These accounted for less than 0.5 percent erally not be statistically independent as a result of all observations. Researchers then calculated of the multistage sampling design. influenza vaccination rates for three different We specified the sampling plan to STATA75 using population samples – individuals aged 18-49, in- the svyset command and the following set of dividuals aged 50-64, and individuals 65 and older weights: sample weight variable (FINALWT), first- – for each state. The research team reported 2008 stage stratification variable (STSTR), and primary influenza vaccination rates for each sub-sample, sampling unit variable (PSU). Omission of the along with standard errors and 95 percent confi- stratification variable in STATA implies no strati- dence intervals. Respective sample sizes for each fication of PSUs prior to first-stage sampling. sub-sample were 151,903, 130,713, and 121,459. 22 Endnotes 16 These include: Kaiser Permanente Medical Care Program of Northern California (Oakland), South- ern California Kaiser Permanente Health Care Pro- 1 National Foundation for Infectious Diseases. “Adult gram (Los Angeles), Group Health Cooperative of Vaccination Fact Sheet.” Puget Sound (Seattle), Kaiser Permanente North- http://www.adultvaccination.com/doc/Patient_ west (Portland, Ore.), Kaiser Permanente Colorado Fact_Sheet.pdf (accessed May 2009). (Denver), HealthPartners Research Foundation 2 Infectious Diseases Society of America. “CDC Finds Low (Minneapolis), Marshfield Clinic Research Founda- Rates of Adult Immunization.” http://idsociety.org/ tion (Marshfield, Wis.)and Harvard Pilgrim Health newsArticle.aspx?id=9510 (accessed May 2009). Care (Boston). 3 Paddock, C. “American Adults Not Getting Vacci- 17 W. Atkinson, Hamborsky J., McIntyre L., Wolfe S., nated.” Medical News Today. January 24, 2008. eds. Diphtheria. in: Epidemiology and Prevention of Vac- http://www.medicalnewstoday.com/articles/95049.p cine-Preventable Diseases (The Pink Book) (10 ed.). hp. (accessed September 2009). Washington DC: Public Health Foundation. 2007. http://www.cdc.gov/vaccines/pubs/pinkbook/dow 4 Ibid. nloads/dip.pdf. 5 Agency for Healthcare Research and Quality. “In- 18 U.S. Centers for Disease Control and Prevention. fluenza immunization: percentage of Medicare mem- “Preventing Tetanus, Diphtheria and Pertussis bers 65 years of age and older who received an Among Adults.” December 15, 2006. U.S. Depart- influenza vaccination.” U.S. Department of Health ment of Health and Human Services. and Human Services. http://www.cdc.gov/mmwr/pdf/rr/rr5517.pdf http://www.qualitymeasures.ahrq.gov/summary/sum (accessed May 12, 2009). mary.aspx?ss=1&doc_id=13095 (accessed June 2009). 19 U.S. Centers for Disease Control and Prevention. 6 U.S. Centers for Disease Control and Prevention. “Key “Tetanus Surveillance.” U.S. Department of Health Facts about Seasonal Influenza.” http://www.cdc.gov/ and Human Services. http://www.cdc.gov/vac- flu/keyfacts.htm. (accessed September 2009). cines/tetanus.htm. (accessed July 15, 2009). 7 Paddock, C. “American Adults Not Getting Vacci- 20 U.S. Center for Disease Control and Prevention. nated.” Medical News Today. January 24, 2008. “Shingles, Herpes Zoster Vaccination.” U.S. Depart- http://www.medicalnewstoday.com/articles/95049.p ment of Health and Human Services. hp. (accessed September 2009). http://www.cdc.gov/vaccines/vpd-vac/shingles/de- 8 U.S. Centers for Disease Control and Prevention. fault.htm (accessed May 15. 2009). “Human Papillomavirus: HPV Information for Clini- 21 U.S. Centers for Disease Control and Prevention. cians.” April 2007. http://www.cdc.gov/std/hpv/ “Update: Measles Outbreaks Continue in U.S.” U.S. common-clinicians/ClinicianBro-br.pdf. (accessed Department of Health and Human Services. September 2009). http://www.cdc.gov/Features/MeaslesUpdate/ (ac- 9 U.S. Centers for Disease Control and Prevention. cessed July 2009). “Hepatitis B FAQ for the Public.” U.S. Department of 22 Personal communication with Anne Gershon, MD. Health and Human Services. http://www.cdc.gov/ Columbia University College of Physicians Depart- hepatitis/B/bFAQ.htm#bFAQ05 (accessed October ment of Pediatrics, May 2009. 13 2008). 23 Painter, K. “Quitters get a shot in the arm with 10 Paddock, C. “American Adults Not Getting Smoking Vaccine. USA Today. November 16, 2009. Vaccinated.” Medical News Today. January 24, 2008. http://www.usatoday.com/news/health/2009-11-16- http://www.medicalnewstoday.com/articles/95049. Nicotinevaccine16_ST_N.htm (accessed December php. (accessed September 2009). 2009) 11 F. Zhou, et. al., “Economic Evaluation of Routine 24 U.S. Center for Disease Control and Prevention. Childhood Immunization with DTaP, Hib, IPV, “Vaccines/Publications and Flyers.” U.S. Depart- MMR and Hep B Vaccines in the United States,” ment of Health and Human Services. Pediatric Academic Societies Conference, Seattle, http://www.cdc.gov/vaccines/pubs/flyers- Washington, May 2003. brochures.htm#health (accessed May 2009). 12 U.S. Centers for Disease Control and Prevention. 25 U.S. Center for Disease Control and Prevention. “Program in Brief: Section 317.” U.S. Department of “Travelers’ Health.” Health and Human Services. http://www.cdc.gov/ http://wwwn.cdc.gov/travel/content/vaccinations.a NCIRD/progbriefs/downloads/grant-317.pdf (ac- spx#aware (accessed May 2009). cessed May 2009). 26 Children’s Hospital of Philadelphia and the Ameri- 13 Ibid. can Medical Association. Vaccines and Adults: A Life- 14 Every Child by Two. “History of Disease Eradica- time of Health. Philadelphia: Children’s Hospital of tion.” http://www.vaccinateyourbaby.org/why/his- Philadelphia. 2008. tory/index.cfm (accessed May 14 2009). http://www.chop.edu/vaccine/images/vaccines_ad 15 Vaers Overview, Vaccines, Blood & Biologics, Food ults.pdf (accessed May 2009). and Drug Administration web site at url 27 U.S. Centers for Disease Control and Prevention. http://www.fda.gov/BiologicsBloodVaccines/SafetyAv “2009 H1N1 Influenza Vaccine and Pregnant Women: ailability/ReportaProblem/VaccineAdverseEvents/Ov Information for Providers.” November 2, 2009. erview/default.htm accessed May 2009. http://www.cdc.gov/h1n1flu/vaccination/providers_ qa.htm (accessed December 2009). 23 28 U.S. Centers for Disease Control and Prevention. 43 National Foundation for Infectious Diseases. American Behavioral Risk Factor Surveillance System. 2008. adults’ awareness about immunization. CARAVAN® http://apps.nccd.cdc.gov/BRFSS/. (Accessed Oc- omnibus surveys, conducted October 25–28, 2007, by tober 2009). Opinion Research Corporation. Data on File. Tele- 29 U.S. Centers for Disease Control and Prevention. “Vac- phone interviews were conducted with a sample of cination Coverage Among Children in Kindergarten -- 1,005 adults (504 men, 501 women) and weighted by United States, 2006-07 School Year.” Morbidity and Mor- age, sex, geographic region, and race to ensure accu- tality Weekly, 56, no. 32 (August 17, 2007): 819-821. rate representation of U.S. adult population. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm 44 M.C. Lindley, Wortley, P.M., Winston, C.A., Barden- 5632a3.htm?s_cid=mm5632a3_e (accessed May 14, heier, B.H, “The Role of Attitudes in Understanding 2009). Disparities in Adult Influenza Vaccination.” American 30 Health Resources and Services Administration. “Pri- Journal of Preventive Medicine, 31, no. 4, 2006. mary Care.” U.S. Department of Health and Human 45 Office of Minority Health, Department of Health Services. http://ask.hrsa.gov/Primary.cfm. (ac- and Human Services website at url cessed May 2009). http://www.omhrc.gov/templates/browse.aspx?lvl= 31 “Prevention and Control of Influenza,” MMWR, 3&lvlid=60 (accessed May 2009). Centers for Disease Control and Prevention, July 29, 46 Fiscella, K., ``Commentary -- Anatomy of Racial Dis- 2005. http://www.cdc.gov/mmwr/preview/ parity in Influenza Vaccination,’’ HSR: Health Services mmwrhtml/rr5408a1.htm (accessed May 2009). Research 40:2, 2005. 32 Ibid. 47 “Crossing the Valley of Death: Bringing Promising 33 U.S. Department of Health and Human Services. Medical Countermeasures to Bioshield,” June 9, “Enhancing Participation in Immunization Informa- 2005 Senate hearing. http://help.senate.gov/Hear- tion Systems (IIS): Recommendations to the Na- ings/2005_06_09_a/Raub.pdf. (accessed May 2009). tional Vaccine Advisory Committee.” 2008. 48 Biomedical Advanced Research and Development http://www.hhs.gov/nvpo/nvac/IISRecommenda- Authority, Department of Health and Human Serv- tionsSep08.html (accessed June 2009). ices. http://www.hhs.gov/aspr/barda/ (accessed 34 Vaccine Education Center at The Children’s Hospi- May 2009). tal of Philadelphia and the American Medical Associ- 49 Center on Biosecurity, UPMC. “In letters to Senate ation. “Vaccines and Adults: A Lifetime of Health.” and House Appropriators, Center for Biosecurity rec- 2008. http://www.chop.edu/export/download/ ommends $1.7 Billion appropriation for BARDA for pdfs/articles/vaccine-education-center/vaccines- FY2010.” March 3, 2009. http://www.upmc-biosecu- adults.pdf. (accessed November 2009). rity.org/website/resources/commentary/2009-03-03- 35 Personal communication with Margaret S. Coleman, barda_fy10_senate.html (accessed December 2009). PhD, Senior Health Scientist, Health Services Re- 50 Project Bioshield: Purposes and Authority,’’ CRS Re- search and Evaluation Branch, National Center for port for Congress, June 12, 2007. http://www.fas.org/ Immunization and Respiratory Diseases, Centers for sgp/crs/terror/RS21507.pdf (accessed May 2009). Disease Control and Prevention, April 27, 2009. 51 U.S. Department of Health and Human Services. 36 U.S. Centers for Disease Control and Prevention. “The American Medical Association Third National “Program in Brief: Immunization Grant Program Congress on Health System Readiness.” December 1, (Section 317).” http://www.cdc.gov/NCIRD/prog- 2009. http://www.hhs.gov/secretary/speeches/ briefs/downloads/grant-317.pdf. (accessed Decem- sp20091201.html. (accessed December 2009). ber 2009). 52 Draft Strategic National Vaccine Plan, November 37 U.S. Centers for Medicare & Medicaid Services. “Adult 26, 2008, National Vaccine Program. Immunizations: Overview.” http://www.cms.hhs.gov/ http://www.hhs.gov/nvpo/vacc_plan/2008plan/dr adultImmunizations/ (accessed May 2009). aftvaccineplan.pdf (accessed May 2009). 38 Trust for America’s Health. “Closing the Vaccina- 53 National Vaccine Information Center. “State Vac- tion Gap: A Shot in the Arm for Childhood Immu- cine Requirements.” http://www.nvic.org/Vaccine- nization Programs.” Laws/state-vaccine-requirements.aspx (accessed 39 “Vaccine Coverage Among Adolescent Aged 13-17 December 2009). years – United States, 2007.” MMWR Morb Mortal 54 U.S. Centers for Disease Control and Prevention. Wkly Rep 2008: 57: 1100-1103. “Vaccines and Immunizations, Vaccines for Children: 40 “Vaccine Coverage Among Adolescent Aged 13-17 Frequently Asked Questions.” http://www.cdc.gov/ years – United States, 2007.” MMWR Morb Mortal vaccines/programs/vfc/projects/faqs-doc.htm#gen Wkly Rep 2008: 57: 1100-1103. (accessed December 2009). 41 Grady, D. “Review Shows Safety of H1N1 Vaccine, 55 Fielding JE, Cumberland WG, Pettitt L. “Immunization Officials Say.” The New York Times. December 5, 2009. Status of Children of Employees in a Large Corpora- tion.” JAMA. 1994;271:525-530. 42 Centers for Disease Control and Prevention. “His- tory of Vaccine Safety.” http://www.cdc.gov/vacci- 56 California Department of Public Health. “Preteen nesafety/Vaccine_Monitoring/history.html Immunizations: Your Best Shot.” (accessed January 11, 2010). http://www.cdph.ca.gov/programs/immunize/Pages /PreteenVaccines.aspx (accessed December 2009). 57 U.S. Centers for Disease Control and Prevention. “Vaccines and Immunizations, IIS: Frequently Asked Questions.” http://www.cdc.gov/vaccines/pro- grams/iis/faq.htm (accessed December 2009). 24 58 Ibid. 64 Infectious Diseases Society of America. “IDSA Policy 59 U.S. Centers for Disease Control and Prevention. “Ini- on Mandatory Immunization of Health Care Work- tiative on Immunization Registries.” MMWR ers Against Seasonal and 2009 H1N1 Influenza.” 50(RR17);1-17 October 5, 2001. http://www.cdc.gov/ http://www.idsociety.org/Content.aspx?id=15413 mmwr/preview/mmwrhtml/rr5017a1.htm (accessed (accessed November 2009). December 2009). 65 Sickness Prevention Achieved through Regional 60 U.S. Centers for Disease Control and Prevention. Collaboration. “Vote & Vax.” http://www.voteand- FY 2009 CDC Online Performance Appendix. Atlanta, vax.org/ (accessed December 10, 2009). GA: U.S. Department of Health and Human Serv- 66 Personal correspondence. ices, 2008. http://www.cdc.gov/fmo/PDFs/FY09_ 67 Ibid. CDC_Online_Performance_Appendix.pdf (accessed August 2008). 68 Personal correspondence. 61 Smith, T. “Virginia’s Health Department Rolls Out 69 Ibid. Swine-Flu Campagin.” Richmond Times-Dispatch. 70 Personal correspondence. October 16, 2009. http://www2.timesdispatch.com/ 71 Ibid. rtd/business/local/article/B-VFLU16_20091015- 72 National Institute of Allergy and Infectious Diseases, 214006/299601/ (accessed December 2009). vaccine website at url http://www3.niaid.nih.gov/ 62 Ervin, G. “Health Department Continues to Admin- topics/vaccines/understanding/typesVaccines.htm. ister H1N1 Vaccine to Protect Youth.” The Jackson (accessed May 2009). County Times-Journal. December 2009. 73 Ibid. http://www.timesjournal.com/articles/2009/12/08 /school/doc4b1e860e55f0a403279464.txt (ac- 74 Behavior Risk Factor Surveillance System is an an- cessed December 9, 2009). nual cross-sectional survey from the U.S. Centers for Disease Control and Prevention conducted in part- 63 Infectious Diseases Society of America. “Actions to nership with states designed to measure behavioral Strengthen Adult and Adolescent Immunization risk factors in the adult population (18 years of age Coverage in the United States: Policy Principles of or older) living in households. the Infectious Disease Society of America.” Clinical Infectious Diseases 44, no. 12( 2007): e-104 – e-108. 75 STATA Version 9.2 http://www.journals.uchicago.edu/doi/pdf/10.108 76 The specific question asked by the CDC was “During 6/519541?cookieSet=1 (accessed June 2009). the past 12 months, have you had a flu shot?” 25 GLOSSARY OF ACRONYMS ACIP: Advisory Committee on Immunization IIS: Immunization Information System Practices ISO: Immunization Safety Office AHRQ: Agency for Healthcare Research and LHD: Local Health Department Quality MMR: Measles, mumps, and rubella ARRA: American Recovery and Reinvestment Act NIH: National Institutes of Health BARDA: Biomedical Advanced Research and Development Authority NVAC: National Vaccine Advisory Committee BRFSS: Behavioral Risk Factor Surveillance PHSSEF: Public Health and Social Services System Emergency Fund CBER: Center for Biologics Evaluation and REACH: Racial and Ethnic Approaches to Research Community Health CDC: U.S. Centers for Disease Control and RWJF: Robert Wood Johnson Foundation Prevention SNS: Strategic National Stockpile CMS: Centers for Medicare and Medicaid SPARC: Sickness Prevention Achieved Services through Regional Collaboration Dtap: Diphtheria, tetanus and pertussis TB: Tuberculosis FDA: U.S. Food and Drug Administration Td/Tdap: Tetanus, diphtheria, and pertussis HEDIS: Health Plan Employer Data and TFAH: Trust for America’s Health Information Set VAERS: Vaccine Adverse Event Reporting HHS: U.S. Department of Health and Human System Services VFC: Vaccines for Children Hib: Haemophilus influenzae type b VFUA: Vaccines for Uninsured Adults HPV: Human Papillomavirus VSD: Vaccine Safety Datalink HRSA: Health Resources and Services Administration WHO: World Health Organization IDSA: Infectious Diseases Society of America WIC: Women, Infants and Children 26 TFAH AND IDSA WOULD LIKE TO THANK THE EXPERTS WHO HELPED PROVIDE INPUT TO THIS ISSUE BRIEF, INCLUDING: Faruque Ahmed, MD, PHD, MPH Margaret Huffman, ND, RN Team Leader for Adult Immunization Provider Services Unit Manager Health Services Research and Evaluation Branch, Na- Colorado Immunization Program, Colorado Depart- tional Center for Immunization and Respiratory Diseases ment of Public Health U.S. Centers for Disease Control and Prevention Amy Middleman, MD, MSEd Steve Baranov Director of Adolescent and Young Adult Immunization Vice President for Community Health Texas Children’s Hospital Center for Vaccine Aware- Los Angeles Biomedical Research Institute, Harbor- ness and Research UCLA Medical Center and Robert M. Pestronk, MPH Executive Director Executive Director South Los Angeles Health Projects National Association of County and City Health Officials Peter Beilenson, MD, MPH Gregory A. Poland, MD Health Officer Mary Lowell Leary Professor of Medicine, Infectious Dis- Howard County, Maryland eases, Molecular Pharmacology Edward A. Belongia, MD and Experimental Therapeutics; Director of the Mayo Vac- Senior Epidemiologist/Director cine Research Group; and Translational Immunovirology Marshfield Clinic Research Foundation, Epidemiology and Biodefense, Associate Chair for Research, Research Center Department of Medicine James S. Blumenstock Mayo Clinic and Foundation Chief Program Officer William Schaffner, MD Public Health Practice Professor and Chair Association of State and Territorial Health Officials Department of Preventive Medicine, Vanderbilt Uni- Anna DeBlois Buchanan, MPH versity School of Medicine Senior Director Raymond A. Strikas, MD Immunization and Infectious Disease Policy Capt. U.S. Public Health Service Association of State and Territorial Health Officials National Vaccine Program Office, U.S. Department Margaret S. Coleman, PHD of Health and Human Services Senior Health Scientist Gary A. Urquhart, MPH Health Services Research and Evaluation Branch, Na- Chief, Immunization Information Systems Support Branch tional Center for Immunization and Respiratory Diseases Immunization Services Division, National Center U.S. Centers for Disease Control and Prevention for Immunization and Respiratory Diseases, U.S. Sandra Adamson Fryhofer, MD, MACP Centers for Disease Control and Prevention Internist Timothy Westmoreland Member of the Adult Immunization Advisory Board Visiting professor of law and senior scholar in health law American College of Physicians Georgetown University; and Kathleen F. Gensheimer, MD, MPH Consultant Sanofi-Pasteur House Energy and Commerce Committee, U.S. House of Representatives Anne Gershon, MD Professor of Pediatrics and Director of the Division of Pascale M. Wortley, MD, MPH Pediatric Infectious Disease Branch Chief Columbia University College of Physicians Health Services Research and Evaluation Branch, Na- Department of Pediatrics tional Center for Immunization and Respiratory Diseases U.S. Centers for Disease Control and Prevention Claire Hannan, MPH Executive Director Special thanks to Gregory K. Folkers, MS, MPH, Chief Association of Immunization Managers of Staff, Immediate Office of the Director at the Na- tional Institute of Allergy and Infectious Diseases Alan R. Hinman, MD, MPH (NIAID), and Kristin M. Pope, Associate Director for Pol- Senior Public Health Scientist icy, National Center for Immunization and Respiratory Task Force for Global Health Diseases, U.S. Centers for Disease Control and Preven- tion, for their important contributions to this report. 27 ACKNOWLEDGEMENTS TRUST FOR AMERICA’S HEALTH IS A NON-PROFIT, NON-PARTISAN ORGANIZATION DEDICATED TO SAVING LIVES AND MAKING DISEASE PREVENTION A NATIONAL PRIORITY. The Robert Wood Johnson Foundation focuses on the pressing health and health care issues facing our country. As the nation’s largest philanthropy devoted exclusively to improving the health and health care of all Americans, the Foundation works with a diverse group of organizations and individuals to identify solutions and achieve comprehensive, meaningful and timely change. For more than 35 years the Foundation has brought experience, commitment, and a rigorous, balanced approach to the problems that affect the health and health care of those it serves. Helping Americans lead healthier lives and get the care they need -- the Foundation expects to make a difference in our lifetime. For more information, visit www.rwjf.org. TFAH BOARD OF DIRECTORS REPORT AUTHORS Lowell Weicker, Jr. Jeffrey Levi, PhD President Executive Director Former 3-term U.S. Senator and Governor of Connecticut Trust for America’s Health and Cynthia M. Harris, PhD, DABT Associate Professor in the Department of Health Policy Vice President The George Washington University Director and Associate Professor School of Public Health and Health Services Institute of Public Health, Florida A&M University William Schaffner, MD Robert T. Harris, MD Professor and Chair Secretary Department of Preventive Medicine, Vanderbilt Former Chief Medical Officer and Senior University School of Medicine and Vice President for Healthcare Chair, IDSA Immunization Work Group BlueCross BlueShield of North Carolina Marlene Cimons, PhD John W. Everets Freelance Writer and Treasurer Former Washington Health Policy Reporter, Los Angeles Times Gail Christopher, DN Vice President for Health Robert Guidos, JD WK Kellogg Foundation Vice President Public Policy and Government Relations David Fleming, MD Infectious Diseases Society of America Director of Public Health Seattle King County, Washington Laura M. Segal, MA Director of Public Affairs Arthur Garson, Jr., Trust for America’s Health MD, MPH Executive Vice President and Provost and the Robert C. Taylor Professor of Health Science and Public Policy CONTRIBUTORS University of Virginia Thomas M. Hall, MD, MIM Alonzo Plough, MA, MPH, PhD Internist and Occupational Medicine Specialist Director, Emergency Preparedness and Response Program Managing Director, Marrell Enterprises, LLC Los Angeles County Department of Public Health Rebecca St. Laurent, JD Theodore Spencer Health Policy Research Associate Senior Advocate Trust for America’s Health Climate Change Center PEER REVIEWERS Alan R. Hinman, MD, MPH Senior Public Health Scientist Task Force for Global Health 1730 M Street, NW, Suite 900 • Washington, DC 20036 (t) 202-223-9870 • (f) 202-223-9871 28