Adult Vaccinations in Primary Care: Why They’re Important and How to Improve

Kristin L. Nichol, MD, MPH, MBAProfessor of Medicine,University of Minnesota Medical SchoolAssociate Chief of Staff for Research,Minneapolis Veterans Affairs Medical CenterMinneapolis, Minnesota

Disclosures (cont.)

Dr. [insert local practice presenter’s name and disclosure]

This presentation will not include any non-FDA approved or investigational uses of products or medical devices [update if presentation has changed]

Learning Objectives

After reviewing this material, you should be better able toIdentify which vaccines are indicated for

adult patients Summarize what the national vaccination goals

are and current national performanceDescribe barriers and strategies to enhancing

adult vaccination ratesPropose 2 or more strategies that could enhance

vaccination rates in your practice

Impact of Vaccines During the 20th Century and Into the 21st Century

DiseaseReported Cases

(Year)Reported Cases

(2009)% Decrease in Reported Cases

Diphtheria 5796 (1950) 0 100%

Tetanus 486 (1950) 18 96%

Pertussis 120,718 (1950) 16,858 86%

Measles 319,124 (1950) 71 99%

Mumps 152,209 (1968) 1991 99%

Rubella 46,975 (1966) 3 99%

Hepatitis A* 32,859 (1966) 1987 94%

Hepatitis B* 26,611 (1985) 3405 87%

*Underreporting estimated at a factor of 4.3 for hepatitis A and 2.8 for hepatitis B thus actual number of cases likely substantially higher than reported numbers of cases.CDC. Epidemiology and Prevention of Vaccine-Preventable Diseases: The Pink Book; 2011. Available at: http://www.cdc.gov/vaccines/pubs/pinkbook/default.htm. Accessed June 15, 2011

Burden of Selected Vaccine-Preventable Diseases (VPDs)VPD Burden

Influenza200,000 excess hospitalizations annually (>40% in the elderly) ~24,000 excess deaths annually (~90% elderly)

Invasive Pneumococcal Disease (IPD)

~50,000 cases of bacteremia each year• Higher rates in elderly and persons with comorbidities• Case fatality rates ~20% (up to 60% in the elderly)

Hepatitis B78,000 new infections annually (highest in young adults)

• 1 million with chronic hepatitis B virus infections• Complications include cirrhosis and hepatocellular

carcinoma (80% of cases)

Human Papillomavirus (HPV) 6.2 million new infections each year2 HPV strains cause 70% of cervical cancer

Pertussis10,454 cases reported in 2007 (3152 in adults)Most severe in infants

*Source often older child or adult

Shingles 500,000 to 1 million cases annually; lifetime risk ~32% Shingles and postherpetic neuralgia increase with age

CDC. Epidemiology and Prevention of Vaccine-Preventable Diseases: The Pink Book; 2011. Available at: http://www.cdc.gov/vaccines/pubs/pinkbook/default.htm. Accessed June 15, 2011

Vaccination Is the Best Way to Prevent and Control VPDs

Recommended Adult Vaccines by Age Group

Please see full reference for additional important footnote information.CDC. Adult immunization schedule. Available at: http://www.cdc.gov/vaccines/recs/schedules/downloads/adult/adult-schedule.pdf. Accessed February 6, 2012.

Recommended Adult Vaccines by Condition

Please see full reference for additional important footnote information.CDC. Adult immunization schedule. Available at: http://www.cdc.gov/vaccines/recs/schedules/downloads/adult/adult-schedule.pdf. Accessed February 6, 2012.

Vaccination Rates Are Low

Vaccine Vaccination RateInfluenza

Age 19-49, high riskAge 50-64, totalAge 65Healthcare workers (19-64 years old)

33.4%40.1%65.6%52.9%

PneumococcalAges 19-64, high riskAge 65 17.5%

60.6%Tetanus/pertussis since 2005 (19-64 years old) 50.8%Shingles (60 years old and older) 10.0%Hepatitis B (high risk, 19-49 years old) 41.8%HPV vaccine (women, 19-26 years old) 17.1%

CDC. 2009 Adult Vaccination Coverage, NHIS. Available at: http://www.cdc.gov/vaccines/stats-surv/nhis/2009-nhis.htm. Accessed June 13, 2011

Baseline Vaccination Rates vs Healthy People 2020 Goals: Gaps PersistVaccine and Target Group Baseline Rate (Year) Healthy People 2020 Goal

Influenza vaccineNoninstitutionalized adults 18 to 64 years oldNoninstitutionalized high-risk adults 18 to 64 years oldNoninstitutionalized adults 65 years old and olderInstitutionalized adults 18 years old and olderHealthcare personnelPregnant women

25% (2008)39% (2008)67% (2008)62% (2006)45% (2008)28% (2008)

80%90%90%90%90%80%

Pneumococcal vaccineAdults 65 years old and olderHigh-risk adults under 65 years oldInstitutionalized adults

60% (2008)17% (2008)66% (2006)

90%60%90%

Zoster vaccineAdults 60 years old and older 7% (2008) 30%

Hepatitis B vaccineHealthcare personnel 64% (2008) 90%

USDHHS. Healthy People 2020. Available at: http://www.healthypeople.gov/2020/default.aspx. Accessed June 13, 2011.

Disparities Also Persist: NHIS 2009

Vaccine and Target Group

Vaccination Rate,

Non-Hispanic Whites

Vaccination Rate,

Non-Hispanic Blacks

Vaccination Rate,

Hispanics

Influenza, 65 years old and older 68.6% 50.8% 50.6%

Pneumococcal, 65 years old and older 64.9% 44.8% 40.1%

CDC. 2009 Adult Vaccination Coverage, NHIS. Available at: http://www.cdc.gov/vaccines/stats-surv/nhis/2009-nhis.htm. Accessed June 13, 2011.

So, Why Are Vaccination Rates So Low?

Determinants of Vaccination Behavior Among Patients and Providers Are Well Described

Critical Issues for Successful Vaccine DeliveryPatient

Provider

Vaccine supply and reimbursement

Policy

Patient Issues for Vaccination

AwarenessDiseaseVaccinePersonal risk

Provider recommendationMisconceptions/fears

About vaccineAbout healthcare system

Access and ability to pay

Medicare Beneficiaries’ Reasons for Not Getting VaccinatedLack of knowledge

Personal risk and need for vaccination

Misconceptions About vaccines and VPDs

No recommendation from doctor

CDC. MMWR Morb Mortal Wkly Rep. 1999;48(39):886-890.CDC. MMWR Morb Mortal Wkly Rep. 2004;53(43):1012-1015.

Medicare Beneficiaries’ Reasons for Not Getting Vaccinated (cont.)

CDC. MMWR Morb Mortal Wkly Rep. 1999;48(39):886-890.

Doesn't work

Side effects

Shot causes diseases

Didn't remember

No doctor recommendation

Didn't know

0 10 20 30 40 50 60 70

Pneumococcal (n=6926)Influenza (n=4503)

Percentage aged 65 years who reported reasons for not receiving vaccinations1996

Consumers’ Reasons for Not Getting Vaccinated2006 survey of 2002 people

Random-digit dialing, weighted responses to be representative of US population

Vaccines: influenza, pneumococcal, tetanus

Commonly cited reasonsI’m healthy, I don’t need itMy doctor hasn’t told me I need it May have side effects

The cost of vaccinations was cited less often

Johnson DR, et al. Am J Med. 2008;121(7 Suppl 2):S28-35.

Adults’ Main Reasons for Not Being Vaccinated

*Refers both to not knowing they should be vaccinated and not knowing enough about the vaccine.**Includes concern about getting sick from vaccine.Adapted from: Euler GL, CDC. Adult vaccination coverage, national immunization survey—adult, 2007. Available at: http://cdc.confex.com/cdc/nic2008/webprogram/Paper15390.html. Accessed June 13, 2011

Cost

Side effects**

No doctor recommendation

Didn't know*

Not needed

0 10 20 30 40 50 60

TetanusTdapZosterHPV

Percentage of US adults who reported reasons for not receiving vaccinations2007

Consumer Misconceptions About VaccinesCategory and Response

% of Respondents in Agreement

Vaccines and VPDs Had vaccines as a child—don’t need them again Vaccines not necessary for adults Not concerned about catching VPDs Not concerned about spreading illness to others VPDs are not serious or life threatening

40%18%34%32%25%

Vaccine safety/efficacy Have heard vaccines are not safe Vaccines don’t work A vaccine made them sick

35%14%25%

NFID. Saving lives: integrating vaccines for adults into routine care. Available at: http://www.nfid.org/pdf/publications/adultimmcta.pdf. Accessed June 13, 2011.

Who Most Influences Adults’ Decisions to Get Immunized?

Ages 18-26Age 65

and Older All Adults

Personal physician 47% 82% 69%

Family member 33% 6% 19%

Celebrity physician, public figure, other 11% 4% 7%

None of the above 7% 6% 4%

No answer 2% 1% 1%

NFID. 2009 National Adult Immunization Consumer Survey: Fact Sheet. Available at: http://www.adultvaccination.com/doc/Survey_Fact_Sheet.pdf. Accessed June 15, 2011.AMA. American Medical News. Physicians asked to persuade adults to get immunized. Available at: http://www.ama-assn.org/amednews/2009/08/03/prsc0803.htm. Accessed June 13, 2011.

Inclination to Get Vaccinated Is Higher if Physician Recommends

Physician Recommendation? Impact on Vaccination

Yes 87% are very or somewhat likely to get vaccinated

No 55% would not get vaccine unless recommended by doctor

CDC. Adult immunization coverage information from CDC’s National Immunization Survey. Available at: http://www.nfid.org/pdf/pressconfs/adultimm08/cdcsurvey.pdf. Accessed June 15, 2011.

Provider Recommendation Translates Into Higher Vaccination Rates (Even for Patients With Negative Attitudes)

Vaccination Rates Among High-Risk* Patients With Negative Attitudes

*High-risk patients were those ages 65 and older or those having heart disease, lung disease, diabetes,or other serious illness.Nichol KL, et al. J Gen Intern Med. 1996;11(11):673-677.

Influenza PPV0

20

40

60

80

100

27%15.8%

82% 85.1%No recommendationRecommendation

Vacc

inat

ion

Rat

e (%

)

Disparities and Vaccination Barriers

BarriersHealth literacyMistrust of systemLanguage

FacilitatorsCulturally appropriate educationLeveraging communities/trusted leaders/

faith-based organizationsTranslated materials

Daniels NA, et al. J Natl Med Assoc. 2004;96(11):1455-1461.Chen JY, et al. J Community Health. 2007;32(1):5-20.Traeger M, et al. Am J Public Health. 2006;96(5):921-925.Logan JL. J Natl Med Assoc. 2009;101(2):161-166.

What Can We Do to Increase Vaccination Rates?

To Improve Vaccination Rates, Providers Should … Know the facts Recommend vaccinations to your patients Get organized and use systems approaches

Ensure offering and administration of vaccines Automatic processes that empower nurses are effective Address convenience, efficiency, and durability

Evaluate and improve processes Consider new paradigms

New venues Extend vaccination season

Practice what we preach (get vaccinated!)

Nichol KL. Cleve Clin J Med. 2006;73(11):1009-1015.

Know the Facts:VPDs Are BAD, Vaccines (as Recommended) Are GOOD

Types of Vaccines

Inactivated (“dead”) Inactivated whole cell

or subunit TIV/flu shot Hepatitis A and B Acellular pertussis HPV

Polysaccharide-based Pneumococcal Meningococcal

Toxoids Td/Tdap

Live MMR Varicella/zoster LAIV/flu vaccine

nasal spray

Avoid live virus vaccines forpregnant women and patients with

severely compromised immune systems

CDC. Epidemiology and Prevention of Vaccine-Preventable Diseases: The Pink Book; 2011. Available at: 12th:http://www.cdc.gov/vaccines/pubs/pinkbook/default.htm. Accessed June 15, 2011..

How Can Healthcare Providers Keep Up on Adult Vaccinations? www.cdc.gov/vaccines

Adult Immunization Schedule (updated annually)ACIP recommendations for each vaccineVaccine information statements (VIS)Lots of other information on VPDs, vaccine safety,

brochures, posters, and how to store and administer vaccines

www.immunize.orgThe Immunization Action Coalition has lots of useful

information for healthcare providers

Know Them, Recommend Them

Do Primary Care Providers Recommend Vaccines to Adults?

Patient Group Influenza Pneumococcal

Elderly 37% 65%

Lung disease 45% 68%

Diabetes 31% 44%

Heart disease 20% 29%

200 providers surveyed.Johnson DR, et al. Am J Med. 2008;121(7 Suppl 2):S28-35.

% of Surveyed Primary Care Providers Who Recommended Influenza and Pneumococcal Vaccines

Beware of Assumptions!

Cited by HCPs Cited by Consumers

Fear of needles >65% <20%

Cost >60% 15%

Reasons for Not Receiving Influenza or Pneumococcal Vaccinations

Johnson DR, et al. Am J Med. 2008;121(7 Suppl 2):S28-35.

Get Organized to Get It Done

Missed Opportunities

Missed opportunities are commonMore than 50% of patients needing an influenza

vaccine had at least one visit with a missed opportunity to vaccinate

Among persons needing pneumococcal vaccination, there were 10.7 missed opportunity visits over 3 years

Patient refusals uncommon

Nowalk MP, et al. J Am Board Fam Pract. 2005;18(1):20-27.

Practical Barriers to Vaccinating Adults in the Office SettingKnowing what is recommended for whom

Having time to do it

Remembering to do it

Having adequate personnel to do it

Nichol KL, Zimmerman R. Arch Intern Med. 2001;161(22):2702-2708.Szilagyi PG, et al. Prev Med. 2005;40(2):152-161.

Interventions That Improve Vaccination Rates for Adults

Component Odds Ratio (OR)

Organizational change 16.0

Provider reminder 3.8

Patient financial incentive 3.4

Provider education 3.2

Patient reminder 2.5

Patient education 1.3

Provider financial incentive 1.3

Feedback 1.2

Stone EG, et al. Ann Intern Med. 2002;136(9):641-651

Interventions That Improve Vaccination Coverage:Task Force on Community Preventive Services Increase patient demand for vaccines

Patient reminder and recall systems Clinic-based patient education Manual outreach and tracking

Enhance access Expanded access in healthcare settings Reduced out-of-pocket costs to patients Home visits

Address provider barriers Provider reminders Standing orders and policies Provider assessment and feedback

CPS Task Force. Universally recommended vaccinations: health care system-based interventions implemented in combination. Available at: http://www.thecommunityguide.org/vaccines/universally/healthsysteminterventions.html. Accessed June 13, 2011.

Case Example: A Multifaceted Program Improved Success and Sustainability

Strategy TacticsIncrease demand Annual reminder to patientsEnhance access Walk-in clinicsAddress provider barriers Institutional policy

Standing ordersStandardized formsEfficient clinic flowOngoing measurement and evaluation

Nichol KL. Am J Med. 1998;105(5):385-392.

Case Example: Impact of Multifaceted Program on Influenza Vaccination Rates

Series10

20

40

60

80

100

Baseline After ProviderEducation

Multifaceted(Standing Orders)

Multifaceted,Year 10

Nichol KL. Am J Med. 1998;105(5):385-392.

Influ

enza

Vac

cina

tion

Rat

e (%

)

Standing Orders Are Often Key Components of Success Consistently among the most effective kinds of

interventions to increase vaccination rates

Definition: policy/procedure/written order that allows qualified nurses, pharmacists, and other healthcare professionals (as allowed by state law) to assess and vaccinate patients who meet certain criteria Eliminate need for direct physician involvement with each patient Eliminate need for individual physician’s order for each patient

Appropriate settings: outpatient, inpatient, emergency department, long-term care, etc

McKibben LJ, et al. MMWR Recomm Rep. 2000;49(RR-1):15-16.

Standing Orders Are More Effective than Provider Education or Provider Reminders for Inpatients

Crouse BJ, et al. J Fam Pract. 1994;38(3):258-261.

Series10

20

40

60

80

100

Provider Education Provider Reminder Standing Orders

Influenza Vaccine Offering Rates by Type of Intervention

Rat

es (%

)

Opportunities for Improvement Abound

Nichol KL, Zimmerman R. Arch Intern Med. 2001;161(22):2702-2708.

Influenza

Use of Effective Vaccination Strategies by US Physicians

0

20

40

60

80

100GeneralistsSubspecialists

Pneumonia Influenza Pneumonia Influenza PneumoniaVery Strongly Recommend Standing Orders Patient Reminders

%

Vaccination Strategies Used by Subspecialists and GeneralistsStrategy Influenza PneumococcalVery strongly recommend for elderly patients 75-86% 64-81%Increase demand

Patient remindersClinic-based patient education

14-24%25-52%

9-14%18-40%

Enhance accessSpecial clinics 10-27% 5-10%

Provider-oriented Provider remindersStanding ordersAssessment/feedback on vaccination rates for elderly

26-39%20-29%20-38%

24-37%13-19%18-33%

Nichol KL, Zimmerman R. Arch Intern Med. 2001;161(22):2702-2708.

Physician Practice and Interest in Selected Strategies for Influenza Vaccinations

Doing Already Would Try

Patient reminders 23% 53%

Walk-in clinic 67% 19%

Policy to assess status at each visit 48% 31%

Standing orders 33% 36%

Clearer vaccine guidelines 33% 51%

Registry 7% 56%

Szilagyi PG, et al. Prev Med. 2005;40(2):152-161.

Tips on How to Move Forward

Establish baseline rate Chart audit, numbers of vaccine doses, etc

Inventory current strategies used

Identify where Current strategies could be improved New strategies could be added

Involve the clinic team in planning and implementation

Pay attention to work flow, efficiency, etc

Resources to Help

Immunization Action Coalition (www.immunize.org)Adult Vaccination Guide (complete “how-to”)

http://www.immunize.org/guide/Setting up for adult vaccination servicesHow to store and handle vaccinesDocumenting

Sample standing ordershttp://www.immunize.org/standing-orders/

Vaccine Information Statements (VIS) from the CDC Mandated by National Childhood Vaccine Injury

Act (NCVIA) Must be used for all vaccines covered by the act

(regardless of age) Includes most vaccines for adults Strongly recommend for ALL vaccines

Obtain them from various Web sites CDC, state health departments

Translations available in 30 different languages (www.IAC.org)

CDC. Fact sheet for vaccine information statements. Available at: http://www.cdc.gov/vaccines/pubs/vis/vis-facts.htm. Accessed June 13, 2011.

Healthcare Workers: Practice What We Preach!

Immunizations and Healthcare Workers (HCWs) “First do no harm”

Recommended vaccinations/immunity Influenza MMR Hepatitis B Varicella Tdap

Special situations Meningococcal for microbiologists with potential for exposure

Other vaccinations based on personal risk characteristics

Immunization Action Coalition. Healthcare personnel vaccination recommendations. Available at: http://www.immunize.org/catg.d/p2017.pdf. Accessed June 15, 2011.

Summary

VPDs are an important cause of morbidity and mortality in adults

We have safe and effective vaccines that are underused

For patients, misconceptions about VPDs and vaccines and lack of provider recommendation are important factors in not being immunized

For providers, missing opportunities and failing to recommend vaccination are important shortcomings

Summary (cont.)

Interventions to increase vaccination rates should include efforts to enhance demand, improve access, and address provider and systems issues

In addition to vaccinating their patients, providers should also be vaccinated

Lots of Internet resources are availableto help

Internet Resources

CDC’s National Immunization Programwww.cdc.gov/vaccines

Immunization Action Coalitionwww.immunize.org

National Foundation for Infectious Diseaseswww.nfid.org

CMSwww.cms.gov/AdultImmunizations/

State health departments