If we look at vaccine-preventable diseases, looking at the prevaccineera and the year and compare it to 1999, you can see that virtually all of the vaccine-preventable diseases for which there were current vaccines, they have been decreased by 99% to 100%.

Conventional wisdom is that we should be congratulating ourselves on a job well done. After all, we've gone from thousands, hundreds of thousands in some cases, to virtually nobody getting some of these diseases. But for adults I would put forward that we have neither done it well, nor are we done. Conventional wisdom is an illusion.

We all know that illusions are simply the truths that we live by until we know better. And after this program, you will know better

The reality in the United States is that vaccine-preventable diseases cause untold human misery, medical visits, hospitalizations, and complications. In fact, about 60,000 American adults die each year and about 200 to 300 children. There is a 200-fold greater mortality in adults compared with children. And I've often asked the question: What would our response be if 60,000 of America's children were dying each year of vaccine-preventable diseases?

This graphic makes the

point poignantly

If you look at 1989 to 1998, and you look at the deaths over that decade, you see that we're talking about hundreds of thousands of deaths. The big 3 are influenza, pneumococcal, and hepatitis, particularly hepatitis B. And 90% of those influenza and pneumococcal deaths are in the elderly.

We also see and experience considerable morbidity, not just mortality, from vaccine-preventable diseases in the form of excess hospitalizations, lowered quality of life, missed work, and the complications of these diseases.

In fact, this might surprise you: the number of deaths prevented each year by pneumococcal immunization of adults, if we could really accomplish that, would have the same public health impact as a discovery that would wipe out all childhood leukemias, and yet we don't equate the two.

If you look at hepatitis

B in the age group 20

years to about 40

years, it is one of the

only age groups,

despite effective and

safe vaccines, where

the incidence of

hepatitis B continues

to rise; in fact, by 5%

in the last few years.

The main issue here is that the Advisory Committee on Immunization Practices (ACIP) recommendations remain, for adults, risk based. You basically have to admit to bad behavior unless you're a healthcare worker before somebody thinks to give you the vaccine. This approach did not work in children and adolescents and was abandoned in favor of a universal immunization recommendation.

Why are immunization rates in adults so low? A number of reasons, including ignorance and apathy regarding vaccine-preventable diseases among clinicians. The other thing is that compared with the pediatric culture, adult immunization is not a significant part of internal medicine culture or training. And that's true, by the way, at the federal level.There are issues surrounding reimbursement for adult immunization, and particularly the recent utilization of part D has been problematic. Quality and patient safety are not truly, deeply ingrained yet in our culture, or vaccines would be one of the things that we routinely do.

Remember, there is nothing else in your medical practice that touches every single patient other than vaccines. There is nothing else in our medical armamentarium that we attempt to implement for every human being.There are also continuing questions regarding efficacy and safety of vaccines, and at the far end of the spectrum, we see that manifest as the antivaccinemovement.But look back just a little bit in history. A decade or so ago when the US Government Accountability Office (GAO) looked at this and concluded that efforts to improve healthcare providers' compliance with adult immunization guidelines were more promising than attempts to try to influence or increase consumers knowledge and attitudes; it is not them, it is us.

Let's go through a few of the barriers that we see to adult immunization. I've grouped 3 of them: pediatric bias and ageism and politics

Here's the major myth you hear, and certainly I heard as a medical student: "Pneumonia is the old man's friend."

Every time I hear that, I feel ill, particularly when you realize what's demographically happening, not only in this country but all the developed countries; a rapid rise in the number of elderly.

We have also failed to force change. As I've said, adult vaccine-preventable disease mortality is 200-fold higher in adults than children, but the Centers for Disease Control and Prevention (CDC) spends relatively little on adult immunization activities.Again, let's go back a little bit in history. In 1994, the National Immunization Program received half a billion dollars for immunization programs. Less than 1% of that went to adult programs. So weigh this dramatic discrepancy in morbidity and mortality and where we put our resources.

In 1987 to 1994, they had

278 full-time equivalent

employees; 5 of them

were devoted to adult

activities. Less than 2%

of the Section 317 funds

went to adult

immunization programs.Over the last 7 years, the CDC spent more than $200 million on childhood immunization registries. These are not bad things. We celebrate that success, but that was more than all adult immunization activities for the last decade.

Reimbursement.

There is insufficient

Medicare reimbursement.

Most adult vaccines now

are under part D; this is a

disaster, and it is

counterproductive. There is

progress being made

though. We don't have what

the pediatricians very

successfully designed and

had, a "vaccines for

children" program. We don't

have the equivalent for

adults, particularly for

uninsured and underinsured

adults. There is a

hodgepodge of coverage by

private insurers, and we

lack public health and

legislative leadership on

something that's killing

60,000 of our citizens every

year.

There are also the issues of

the antivaccine movement,

and ignorance and fear.

When you look back in time,

all the way back to the

1700s, there has been a form

of antivaccine movement.

With smallpox, people were

afraid that if they got

immunized, a cow would

grow out of their arm or

similar such nonsense. Sir

William Osler was vilified by

his peers for supporting the

idea of typhoid immunization

during World War I. Influenza

and group B streptococcal

disease (GBS), had 1

reported association in 77.

Everybody knows about it,

yet we have spent 6 decades

trying to educate people

about the realities of the

safety and efficacy of

influenza vaccine.

Sudden infant death syndrome (SIDS) and pertussis. There was the concern that pertussis was responsible for SIDS. They stopped giving the vaccine in some countries in Europe. Fortunately, the epidemiologists didn't stop their work, and what did they find? The incidence of SIDS didn't change at all, but the number of deaths due to pertussis skyrocketed.Similarly, with hepatitis B, in just the last part of the last century, developed European countries banned the use of hepatitis B vaccines in adolescent females because we keep making the mistake of assuming that temporality is causality, and that is rarely true in these sorts of matters. Again, we found out the hard way when the number of demyelinating diseases didn't change, but the number of hepatitis B infections skyrocketed.Similarly with Alum, one of our only vaccines at the time in the United States licensed as adjuvant was being blamed for inclusion myositis and thimerosal for a variety of disorders.

More recently, and I'm sure

some of you have gotten

these sorts of questions

from your patients, there is

the idea that administering

multiple vaccines somehow

is responsible for a variety

of maladies: cancer,

asthma, diabetes, etc. Lyme

vaccine was actually

withdrawn from the market

because the manufacturer

couldn't withstand the class

action lawsuits despite the

lack of data suggesting that

there was any association

with autoimmune arthritis.

Measles and autism,

anthrax vaccine and Gulf

War Syndrome, and the list

goes on and on.

Finally, systems and

procedures is a real issue.

This is a summary slide from

the CDC on improving

vaccination coverage. It was

a task force on community

preventive services, and they

recommended a variety of

things. One is to increase the

demand for vaccines using

patient reminders,

multifaceted programs

including education, and

regulation. But again, I refer

you to that GAO report; the

issue is us. What the data

show, even in a patient who

comes into your office and

says, "I don't want this

vaccine", is that if you spend

the minutes required to tell

that patient why you

recommend it, why you

strongly recommend it and

what the data are, they are

highly likely to get the vaccine

Also recommended was enhancing access by reducing cost and walk-in clinics, and addressing provider barriers such as designing institutional policies, standing orders, standardized forms, and efficient clinic flow. It is frustrating if any of you have been at institutions where you have to make an appointment to get influenza vaccine or where you come in to get a vaccine and you wait 30 minutes.

And then ongoing measurement and evaluation are recommended. I've been part of numerous surveys where you ask physicians through survey questions what their level of knowledge is about vaccines, and they all understand it. There is not that much misinformation out there or misunderstandings, but then when you go into the clinic and you measure their rate, they'll tell you, "I give 90% of my patients over the age of 65 years influenza vaccine and pneumococcal vaccine." But when you actually do a chart audit, only 40% of us are getting flu vaccine every year.

They did some statistical

analyses on interventions

that improved vaccination

rates in adults (odds ratios

shown here). Head and

shoulders above all of

them are organizational

changes such as standing

order policies, whatever

you can do to make it

easy and efficient for the

patient to get the vaccine,

followed by provider

reminders, provider

education, and patient

education, which was way

down on the list compared

with our own education.

The major issues we face

include 60,000 deaths in

US adults each year due to

vaccine-preventable

diseases and an

inadequate federal and

public funding system for

adult vaccines. There is an

element of physician and

healthcare system

ignorance and passivity,

and I think overwhelming

demographic changes that

are going to force us to

confront this problem of

under-immunization,

particularly when we get to

diseases such as influenza

and pneumococcal disease,

if we're going to keep the

healthcare system solvent.

These are cost-saving

vaccines.

So we have significant challenges in terms of ignorance and fear, in terms of the anti-vaccine culture, and for patients. We've done some work in this area, and the only messages patients get other than from their healthcare providers are negative messages about vaccines, particularly on the Internet.Other challenges include reimbursement issues for influenza and occasionally for other vaccines, a fragile vaccine supply that does make things disruptive and difficult, and adult immunization is not yet part of the internal medicine or federal government culture. It is interesting to go on rounds with pediatricians vs going on rounds with internal medicine doctors. I've yet to see, in pediatrics, where they don't ask the question: has somebody reviewed the immunization history? And it is usually on the inside cover of the patient's chart. I rarely, if ever, hear that on internal medicine rounds. And it is somewhat of a mystery to me. How can this be? Are we really willing to ignore the data that 60,000 Americans are going to die next year of diseases for which we have safe and effective vaccines to protect them?

This is a patient safety and, in my mind, a quality-of-care issue and, indeed, systems are being measured in terms of their compliance with vaccine recommendations, score carded, and that information is being put on the Web. We'll do the right thing, but we'll end up doing it for the wrong reason, because we want to look good on the score cards. This is a chance for the health profession to demonstrate that we can and will do the right thing for our patients, and that the needs of our patients come first.