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Tactics for Increasing Immunization Coverage Among Adults

Educational Learning Objectives

At the conclusion of this presentation, the participant should be able to: • Acknowledge the indications and recommendations for current vaccines and vaccine schedules across adult populations • Address immunization barriers frequently encountered during patient/caregiver communications regarding safety, efficacy, and possible misinformation • Implement strategies for improving immunization rates within one’s clinical practice, taking into account current immunization schedules and guidelines

Adult Immunization Schedule: US 2011

CDC.

MMWR Morb Mortal Wkly Rep

. 2011;60(4).

Vaccines For Adults Based on Medical and Other Indications 2011

CDC.

MMWR Morb Mortal Wkly Rep

. 2011;60(4).

Recent Updates to the Adult Immunization Schedule

• Influenza • Pneumococcal • Tdap CDC.

MMWR Recomm Rep

. 2010;59(RR8):1-62.

CDC.

MMWR Morb Mortal Wkly Rep

. 2010;59(34):1102-1106.

ACIP. http://www.cdc.gov/vaccines/recs/default.htm. Accessed Nov 2010.

Adult Immunization Coverage National Health Interview Survey 2009

100 90 80 70 60 ≥ 65 yrs ≥ 65 yrs 50-64 yrs, HR 50 40 30 20 19-49 yrs, HR 19-64 yrs, HR 10 0 Sample size→ N = 1,067 Influenza N = 1,046 N = 2,444 Pneumococcal N = 8,070 N = 5,275

HR: High Risk CDC. http://www.cdc.gov/vaccines/stats-surv/nhis/2009-nhis.htm. Accessed Nov 2010.

Adult Immunization Coverage National Health Interview Survey 2009

100 90 80 70 60 50 40 ≥ 65 yrs 30 20 10 0 Tetanus, last 10 years Sample size→ N = 14,378 6,540 5,132 19-49 yrs Hep A (≥ 2 doses) N = 13,127 19-49 yrs, HR 19-49 yrs Hep B (≥ 3 doses) N = 1,052 12,454 ≥ 60 yrs 19-26 yrs Herpes Zoster HPV (at least 1 dose) N = 7,335 N = 1,785

HR: High Risk CDC. http://www.cdc.gov/vaccines/stats-surv/nhis/2009-nhis.htm. Accessed Nov 2010.

These new parents (age 30) both received Td vaccine 3 years ago prior to their marriage.

Should they be vaccinated with Tdap in order to protect their young son from pertussis?

Both parents should receive a single dose of Tdap promptly to protect their son from pertussis.

Tdap for Adults

• 19 to 64 years: single dose of Tdap in place of Td (if no previous Tdap received) • Especially important for adults around young infants – Parents, grandparents, nannies • ≥ 65 years (no previous Tdap) who have close contact with infants < 12 months* • Tdap can be administered regardless of interval since last Td *Off-label ACIP recommendation; Medicare Part D coverage CDC.

MMWR Morb Mortal Wkly Rep.

2009;58(14):374-375.

ACIP. http://www.cdc.gov/vaccines/recs/acip/slides-oct10.htm#adult. Accessed Nov 2010.

Self-reported Tetanus and Pertussis Coverage

Adults, National Health Interview Survey 100 100 Tetanus Preceding 10 years Adults ≥ 18 yrs Tdap 2008 Adults 18 –64 yrs 80 80

61,6 60,4

60 60 40 40 20 20 0 1999 2008

CDC.

MMWR Morb Mortal Wkly Rep

. 2010;59(40):1302-1306.

15,9 5,9

Total

Household Infant Contact HCW

Human Papillomavirus

25-year-olds

• Sexually active since age 13 • Multiple partners • Not previously vaccinated for HPV • Not previously sexually active • Now in a monogamous relationship • Not previously vaccinated for HPV

Should either of these women receive the HPV vaccine?

Licensed in the US

Available HPV Vaccines

Quadrivalent Merck - Gardasil ® Bivalent GSK - Cervarix ®

2006 2009 Virus-like Particle Types Protection against HPV 16/18 related CIN2+ Protection against HPV 6/11 related genital lesions HPV 6, 11, 16, 18 ≥ 98% ~99% HPV 16, 18 ≥ 93% -- Hypersensitivity-related contraindication Yeast Latex Licensed age range ACIP Recommendations 9 –26 yrs Routine 11 –12 yrs, catch-up 13 –26 yrs 10 –25 yrs Routine 11 –12 yrs, catch-up 13 –26 yrs Schedule 0, 2, 6 months 0, 1, 6 months CIN2+: cervical intraepithelial neoplasia grade 2 or higher and adenocarcinoma in situ Markowitz L. ACIP Meeting Oct 2009. http://www.cdc.gov/vaccines/recs/acip/downloads/mtg-slides-oct09/02-2-hpv.pdf. Accessed Nov 2010.

HPV – ACIP Recommendations

Quadrivalent HPV (HPV4) and Bivalent HPV (HPV2)

• Routine vaccination of females age 11 to 12 years – Catch-up 13-26 yrs (HPV4); 13-25 yrs (HPV2) • ACIP: no preference for either vaccine • HPV4 or HPV2 vaccination for prevention of HPV 16/18 related cervical cancers, pre-cancers, and dysplastic lesions • Vaccination with HPV4 for additional prevention against genital warts, pre-invasive and invasive lesions of the vagina and vulva ACIP Schedules. www.cdc.gov/vaccines/recs/schedules/default.htm. Accessed Nov 2010.

FDA. http://www.fda.gov/BiologicsBloodVaccines/Vaccines/ApprovedProducts/ucm172678.htm. Accessed Nov 2010.

HPV Vaccination and Pregnancy

• HPV vaccines are not recommended for use in pregnant women • Delay initiation of vaccination until after completion of pregnancy • If a woman is found to be pregnant after initiating the vaccination series, delay remaining doses until after the pregnancy • Two vaccine in pregnancy registries: – Quadrivalent HPV vaccine/pregnancy: 800-986-8999 – Bivalent HPV vaccine/pregnancy: 888-452-9622 CDC.

MMWR Morb Mortal Wkly Rep

. 2010;59:626-629.

HPV Quadrivalent Vaccine in Males

• FDA approved quadrivalent HPV vaccine for boys and men ages 9 through 26 • ACIP: Permissive HPV vaccine for males CDC.

MMWR Morb Mortal Wkly Rep

. 2010;59:630-631.

Quadrivalent HPV Vaccine for Women 27 to 45 years

Under FDA Review

ACIP Considerations

• As women age from their mid 20s, reduced prevalence and incidence of HPV • Disease outcomes (genital warts, CIN 2/3) peak among women in their mid to late 20s • Questions on natural history of incident infections in adult women • Greatest benefit from vaccinating females in early adolescence • Clinical trial data (women 24–45 years) – Efficacy against HPV 6/11/16/18-related persistent infection, CIN, external genital lesions – Well tolerated CIN: cervical intraepithelial neoplasia Dunne E. http://www.cdc.gov/vaccines/recs/acip/downloads/mtg-slides-feb10/02-3 hpv.pdf. Accessed Nov 2010.

Haupt R. http://www.cdc.gov/vaccines/recs/acip/downloads/mtg-slides-feb10/02-2 hpv.pdf. Accessed Nov 2010.

This 65-year-old recently recovered from a case of shingles.

Is he a candidate for the zoster vaccine?

If so, how long should he wait before receiving the vaccine?

Varicella-Zoster Vaccine Shingles Prevention Study

• Randomized, placebo-controlled, double-blind vaccine trial – Study population  38,546 volunteers at 22 sites; adults 60+ years  95% of volunteers completed study – Follow-up: median duration 3.12 years  Vaccine recipients:  Overall incidence of herpes zoster reduced by 51%  Incidence of postherpetic neuralgia reduced by 67%  Injection site reactions were more frequent in the vaccine group Oxman MN, et al.

N Engl J Med.

2005;352:2271-2284.

Varicella-Zoster Vaccine Shingles Prevention Study

Postherpetic Neuralgia Herpes Zoster

Oxman MN, et al.

N Engl J Med.

2005;352:2271-2284.

Zoster (Shingles) Vaccine

• Single-dose vaccine licensed for persons 60+ years of age • Shingles • Postherpetic neuralgia CDC.

MMWR Recomm Rep.

2008;57(RR5):1-30.

CDC. http://www.cdc.gov/vaccines/vpd-vac/shingles/photos.htm. Accessed Nov 2010.

Zoster Vaccine Contraindications and Precautions

• Contraindications – Previous severe allergic reaction to a vaccine component – Immunocompromised persons  HIV, AIDS, leukemia, lymphoma, or other malignant neoplasms  Persons on immunosuppressive therapy, including high-dose corticosteroids  Persons receiving immune mediators/modulators – Pregnancy or planned pregnancy within 4 weeks • Precautions – Moderate or severe acute illness CDC.

MMWR Recomm Rep.

2008;57(RR5):1-30.

A previous case of shingles is not a contraindication for the zoster vaccine.

The data are not definitive regarding how long to wait following a case of shingles to vaccinate with the zoster vaccine. Some professionals suggest 5 years.

Zoster Vaccine Cost Issues

• Routine vaccination not previously covered by Medicare part B – Eligible for reimbursement by Medicare part D • Patient assistance programs • With health care reform – Private sector health plans ‘1 st Dollar Coverage’ – Medicare personalized prevention plan Affordable care act. http://www.healthcare.gov/news/factsheets/affordable_care_act_immunization.html. Accessed Nov 2010.

AAFP. http://www.aafp.org/fpm/20070700/33bill.html. Accessed Nov 2010.

Seasonal Influenza Has a Huge Annual Impact in the United States

Variable

Cases Outpatient visits Hospitalizations Hospitalized days Days of productivity lost due to illness Deaths Life years lost Medical costs Lost earnings due to illness and loss of life Total economic burden

Estimated Annual Impact

24.7 million 31.4 million 334,185 3.1 million 44.0 million 41,008 610,656 $10.4 billion $16.3 billion $87.1 billion Based on 2003 US population demographics Molinari NA, et al.

Vaccine

. 2007;25:5086-5096.

Influenza Vaccination Coverage Levels

100 90 80 70 2006-2007 2007-2008 2008-2009 2009-2010* 2009 H1N1* 60 50 40 30 20 10 0 18-49 yrs 18-49 yrs HR 50-64 yrs 50-64 yrs HR ≥ 65 yrs ≥ 18 yrs 25-64 yrs 25-64 yrs HR

*Data from the Behavioral Risk Factor Surveillance System and National 2009 H1N1 Flu Survey CDC.

MMWR Recomm Rep

. 2010;59(RR8):1-62.

CDC. http://www.cdc.gov/flu/professionals/vaccination/coverage_0910estimates.htm. Accessed Nov 2010.

Annual Influenza Vaccine Is Recommended for

•

All people* age 6 months and older!

High risk groups include: • Adults > 50 yrs • Young children • Pregnant women • People with chronic comorbidities * Without contraindications CDC.

MMWR Recomm Rep

. 2010;59(RR8):1-62.

2010 –2011 Influenza Season

• 2010-2011 Trivalent Influenza Vaccines – A/California/7/2009(H1N1)-like virus – A/Perth/16/2009(H3N2)-like virus – B/Brisbane/60/2008-like virus • Current information from the CDC and FDA – http://www.cdc.gov/vaccines/vpd-vac/flu/default.htm#ref – http://www.fda.gov/BiologicsBloodVaccines/Vaccines/ApprovedProducts/ ucm094045.htm

CDC.

MMWR Recomm Rep

. 2010;59(RR8):1-62.

CDC. http://www.cdc.gov/vaccines/vpd-vac/flu/default.htm#ref. Accessed Nov 2010.

FDA. http://www.fda.gov/BiologicsBloodVaccines/Vaccines/ApprovedProducts/ucm094045.htm. Accessed Nov 2010.

Seasonal Influenza Vaccines

Factor

Route of administration Type of vaccine Number of included virus strains Vaccine virus strains updated Frequency of administration Approved age OK for persons with medical risk factors for influenza-related complications †

LAIV

Intranasal spray Live virus 3 (2 influenza A, 1 influenza B) Annually Annually* 2 –49 yrs

TIV

Intramuscular injection Killed virus 3 (2 influenza A, 1 influenza B) Annually Annually* ≥ 6 mos No Yes

†

Includes medical conditions such as chronic pulmonary, cardiovascular, renal, hepatic, neurologic, hematologic or metabolic disorders; those who are immunosuppressed; those who are or will be pregnant during influenza season; residents of nursing homes and chronic-care facilities *Children ≥ 6 mos–8 yrs without prior influenza vaccination or who only received 1 dose of seasonal influenza vaccine should receive 2 doses TIV: trivalent inactivated influenza vaccine; LAIV: live, attenuated influenza vaccine CDC.

MMWR Morb Mortal Wkly Rep

. 2010;59(RR8):1-62.

2010 –2011 Influenza Season

Vaccine

TIV TIV TIV TIV TIV TIV LAIV

Trade Name

Fluzone; sanofi Fluvirin; Novartis Fluarix; GSK FluLaval; GSK Afluria; CSL Fluzone High-Dose;* sanofi FluMist; MedImmune

Age Group

≥ 6 months ≥ 4 years ≥ 3 years ≥ 18 years ≥ 6 months ≥ 65 years 2 –49 years

Route of Administration

Intramuscular Intramuscular Intramuscular Intramuscular Intramuscular Intramuscular Intranasal TIV: trivalent inactivated influenza vaccine; LAIV: live attenuated influenza vaccine *Each 0.5 mL dose contains 60 μg each of the 3 influenza strains CDC.

MMWR Recomm Rep

. 2010;59(RR8):1-62.

CDC.

MMWR Morb Mortal Wkly Rep

. 2010;59(31):989-992.

100

Influenza Vaccination Coverage Levels Health Care Workers (HCW)

90 80 70 60 50 40 30 20 10 0

44,4 49 61,9 37,1 34,7

2006-2007 2007-2008 Seasonal 2009-2010 2009 H1N1 Both Seasonal + 2009 H1N1

CDC.

MMWR Recomm Rep

. 2010;59(RR8):1-62.

CDC.

MMWR Morb Mortal Wkly Rep

. 2010;59(12):357-362.

Nosocomial Influenza Is Well Documented

• Nosocomial outbreaks documented on – Solid organ transplant units – Oncology units – Neonatal ICU – Pediatric units – Long term care facilities – General medical wards • Results: morbidity for patients & staff, increased costs for institution & impaired capacity to provide care • Vectors for transmission include staff, visitors, patients Encourage hygiene etiquette amongst staff and patients Stott DJ, et al.

Occup Med (Lond).

2002;52:249-253.

Considerations for Those Morbidly Obese

High-risk Group for Influenza For Intramuscular (IM) Injections

22-25 gauge needle

Group

Adults Adults Women Men Women Men

Weight

< 130 lbs (< 60 kg) 130-152 lbs (60-70 kg) 152-200 lbs (70-90 kg) 152-260 lbs (70-118 kg) > 200 lbs (> 90 kg) > 260 lbs (> 118 kg)

Needle Length

5/8” 1” 1 1½” 1 1½” 1 ½” 1 ½” CDC.

MMWR Recomm Rep

. 2010;59(RR8):1-62.

Immunization Action Coalition. http://www.immunize.org/catg.d/p2020A.pdf. Accessed Nov 2010.

This woman is 6 months pregnant and would like to get an influenza vaccine.

Should she get the trivalent inactivated vaccine, the live attenuated influenza vaccine, or neither?

Influenza vaccination is recommended for all pregnant women, due to the increased risk for influenza-related complications.

She should receive the trivalent inactivated influenza vaccine. Live attenuated influenza vaccine is contraindicated during pregnancy.

Maternal Influenza Immunization and Protection of Infants

• Nonrandomized, prospective, observational cohort study • Navajo and White Mountain Apache Indian Reservations • N = 1160 mother infant pairs; birth–6 months Infants Born to Vaccinated Mothers vs Unvaccinated Mothers 41% ↓ in risk of laboratory confirmed influenza virus infection RR: 0.59; 95% CI, 0.37

–0.93

39% ↓ in risk of influenza-like illness hospitalization RR: 0.61; 95% CI, 0.45

–0.84

Higher hemagglutinin inhibition antibody titers at birth and 2 –3 months Eick A, et al.

Arch Pediatr Adolesc Med

. 2010 Oct 5. [Epub ahead of print]

Cumulative Cases of Laboratory-Confirmed Influenza in Infants of Moms Who Received Influenza Vaccine Compared with Controls; Bangladesh

N = 340 mothers randomized to either inactivated influenza vaccine or 23-valent pneumococcal polysaccharide vaccine Zaman K, et al.

N Engl J Med

. 2008;359:1555-1564.

Influenza Vaccination Coverage Levels Among Pregnant Women

100 90 80 70 60

50,7

50 40 30

24,2

20 10

11,3

Sample size→ 2007-2008 N = 113 NHIS 2008-2009 N = 177 NHIS 2009-2010 Seasonal N = 6,225 PRAMS NHIS: National Health Interview Survey PRAMS: Pregnancy Risk Assessment Monitoring System; 10 States 46,6 2009 H1N1 N = 5,112 PRAMS CDC.

MMWR Morb Mortal Wkly Rep

. 2010;59(47):1541-1545.

Influenza in the Elderly

• Serious complications from influenza – Secondary infections – Exacerbations of chronic diseases – Increased hospitalization and death • Influenza vaccination – Reduced hospitalizations and death CDC.

MMWR Recomm Rep

. 2010;59(RR8):1-62.

High-Dose Inactivated Influenza Vaccine for Adults ≥ 65 Years, 2010-2011 Influenza Season

• Rationale • Higher antigen content – Standard dose  TIV 45 μg total virus hemagglutinin antigen per dose – High-dose TIV  180 μg total virus hemagglutinin antigen per dose – Higher immune response; clinical ramifications unknown • ACIP: no preference for any specific inactivated trivalent influenza vaccine for use in adults ≥ 65 years CDC.

MMWR Wkly Rep

. 2010;59(16):485-486.

Risk Factors for Invasive Pneumococcal Disease

• Extremes of age • Comorbidities • Certain ethnic groups • Immune deficiencies Lynch J, Zhanel G.

Semin Respir Crit Care Med

. 2009;30(2):189-209.

S. Pneumoniae ABCs Data -2008

45 40 35 30 25 Cases Deaths 7 6 5 4 20 3 15 10 2 1 5 0 < 1 1 2-4 5-17 18-34 Age (years) 35-49 50-64 ≥ 65

CDC ABC Surveillance report. http://www.cdc.gov/abcs/reports-findings/survreports/spneu08.html. Accessed Nov 2010.

Invasive Pneumococcal Disease Among Adults ≥ 65 Years, 1998/99–2007 PCV7 introduced 40 35 30 *92% reduction in PCV7 serotypes, 2007 vs baseline 25 20 15 Serotype group PCV7 type Non-PCV7 type 19A 10 5 * 0 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Year

Pilishvili T, et al.

J Infect Dis

. 2010;201:32-41.

Pneumococcal Polysaccharide Vaccine (PPSV23) for Adults

• Vaccine contains 23 polysaccharide serotypes from

S. pneumoniae

• Single dose recommended for: – All ≥ 65 years – Asthmatics and smokers age 19 to 64 years – 19 to 64 years: chronic cardiovascular disease, chronic lung disease, diabetes, alcoholism, chronic liver disease, CSF leaks, asplenia, cochlear implants – Immunocompromised persons CDC.

MMWR Morb Mortal Wkly Rep

. 2010;59(34):1102-1106.

Revaccination with PPSV23

• 19 to 64 years: one-time revaccination after 5 years – Chronic renal failure or nephrotic syndrome – Functional or anatomic asplenia – Persons with immunocompromising conditions • ≥ 65 years: one-time revaccination if vaccinated ≥ 5 yrs previously and < 65 years at time of primary vaccination ACIP. http://www.cdc.gov/vaccines/recs/acip/slides-oct10.htm. Accessed Nov 2010.

Pneumococcal Polysaccharide Vaccine Coverage –Adults ≥ 65 Years, 1997–March 2010 100 90 80 70 60 50 40 30 20 10 0 1996 1998 2000 2002 2004

CDC/NCHS. http://www.cdc.gov/nchs/data/nhis/earlyrelease/201009_05.pdf. Accessed Nov 2010.

2006 2008 2010

Effectiveness of Pneumococcal Polysaccharide Vaccine in Older Adults: The VSD Cohort Study

• 3-year cohort study of 47,365 members of Group Health Coop (Seattle) • PPV was associated with lower rates of bacteremia: – HR 0.56 (95% CI 0.33 to 0.93) • PPV was not associated with lower rates of pneumonia – HR 1.07 (95% CI 0.99 to 1.14) HR = hazard ratio. Jackson LA, et al.

N Engl J Med.

2003;348:1747-1755.

• • •

Effectiveness of PPSV23 in Adults 2008 Meta-analysis

22 studies; 15 randomized controlled trials (RCTs), N = 48,656 patients; 7 non-RCTs, N = 62,294 patients Results from RCTs – Invasive pneumococcal disease (IPD)  Strong evidence of protection (74%); OR 0.26 (95% CI 0.15

–0.46);

< 0.00001

 No statistical heterogeneity – All-cause pneumonia  Inconclusive efficacy (29%); OR 0.71 (95% CI 0.52

–0.97);

= 0.029

 Substantial statistical heterogeneity – All-cause mortality  No evidence of protection; OR 0.87 (95% CI 0.69

–1.10);

= 0.25

– Adults with chronic illness  Evidence is less clear Results from non-RCTs – IPD  Evidence of protection (52%); OR 0.48 (95% CI 0.37

–0.61);

< 0.00001

Moberley S, et al.

Cochrane Database Syst Rev

. 2008;(1):CD000422.

PPSV23 and Prevention of Pneumonia in Elderly Patients

• Cohort studies suggest protection against IPD • Some cohort studies suggest protection against pneumonia, while others do not • No randomized trials have demonstrated efficacy against pneumonia in the elderly

Investigation of Pneumococcal Conjugate Vaccine for Adults

• Randomized, placebo-controlled clinical trial • 13-valent pneumococcal conjugate vaccine – Serotypes 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, 23F conjugated to CRM 197 • 85,000 adults ≥ 65 years – No prior vaccination with pneumococcal vaccine • Primary/Secondary endpoints: – Cases of 1 st episode vaccine-serotype specific pneumococcal community-acquired pneumonia – Cases of vaccine-serotype invasive pneumococcal disease, safety Hak E, et al.

Netherlands J Med

. 2008;66(9):378-383.

NCT00744263. http://www.clinicaltrials.gov/ct2/show/NCT00744263. Accessed November 2010.

Hepatitis A Vaccine International Travel

• For healthy persons 40 years of age or younger – 2 doses 6 months apart prior to departure – The first dose of Hepatitis A vaccine should be administered as soon as travel is considered – 1 dose of single-antigen vaccine administered at any time before departure • Consider both HAV and Ig for – Persons age > 40 with chronic illness traveling in less than 2 weeks and only receiving one dose of HAV – Persons at risk of severe disease from hepatitis A virus planning to travel in 2 weeks or sooner CDC.

MMWR Morb Mortal Wkly Rep.

2007;56(41):1080-1084.

Hepatitis A: Families of International Adoptees

• Hep A vaccination – All previously unvaccinated persons who anticipate close personal contact with an international adoptee from countries of high or intermediate endemicity during the first 60 days following arrival in the US • 1 st dose of Hep A vaccine – As soon as adoption is planned – Ideally at least two weeks prior to the arrival of the adoptee CDC.

MMWR Morb Mortal Wkly Rep

. 2009;58(36):1006-1007.

Hepatitis A Postexposure Prophylaxis

• For healthy persons 12 months through 40 years of age who have not previously received HepA vaccine • Immunoglobulin and/or single-antigen hepatitis A vaccine • Efficacy of Ig or HepA when administered > 2 weeks postexposure is unknown CDC.

MMWR Morb Mortal Wkly Rep

. 2007;56(41):1080-1084.

CDC.

MMWR Morb Mortal Wkly Rep

. 2009;58(36):1006-1007.

FACT: Hepatitis B virus infects over 40,000 Americans annually

CDC. http://www.cdc.gov/vaccines/vpd-vac/hepb/photos.htm. Accessed March 2010.

Hepatitis B Vaccine Adult Schedule

• 3-dose schedules for adults age ≥ 20 years – 0, 1, and 6 months* – 0, 1, and 4 months – 0, 2, and 4 months – 0, 1, 2, and 12 months** • 2-dose schedule for adolescents age 11 to 15 years – 0 and 4-6 mos using adult 10 ug formulation, Recombivax-HB • Behavioral, occupational, and medical indications; persons seeking protection from Hep B infection *Approved Twinrix schedule **A 4-dose schedule of Engerix-B is licensed for all age groups CDC.

MMWR Recomm Rep.

2006;55(RR16):1-25.

MMR Evidence of Immunity for Health Care Personnel: Mumps, Measles, & Rubella

• Born in 1957 or later – Laboratory confirmation of disease or immunity Or – Appropriate vaccination  2 doses of MMR, 4 weeks apart • Born before 1957 – Recommend 2 doses of MMR, 4 weeks apart to those unvaccinated without laboratory confirmation of disease or immunity  Stronger recommendation if there is an outbreak ACIP. http://www.immunize.org/catg.d/p2017.pdf. Accessed Nov 2010.

Identify and Address Barriers

Patient Issues for Vaccination

• Awareness – Disease – Vaccine – Personal risk • Provider recommendation • Misconceptions/fears – About vaccine – About health care system • Access and ability to pay

Main Reason for Not Being Vaccinated: NIS, Adult 2007

60 50 40 30 20 10 Cost 0 Sample size→ Tetanus N = 2,181 Not needed Didn't know Tdap N = 539 No MD Rec Side effects Zoster N = 843 HPV N = 221

Adapted from Euler GL. http://cdc.confex.com/cdc/nic2008/webprogram/Paper15390.html Accessed Nov 2010.

60 40 20 0

Cost Is Important, But….

Perceived cost as a significant barrier to patients being vaccinated

Consumers Physicians

Johnson DR, et al.

Am J Med.

2008;121:S28-S35.

Opportunities for Improvement Abound

100% 80% 60% 40% 20% 0% Use of Effective Vaccination Strategies by US Physicians Generalists Subspecialists Influenza Pneumo Influenza Pneumo Influenza Pneumo Very Strongly Recommend Standing Orders Patient Reminders Nichol KL.

Arch Intern Med

. 2001;161:2702-2708.

Improving Vaccination Rates – Provider Issues

• Know the facts • Recommend vaccinations to your patients • Get organized and use systems approaches – Ensure offering and administration of vaccine • Automatic processes that empower nurses are effective • Address convenience, efficiency, durability • Evaluate and provide feedback • Consider new paradigms – New venues – Extend vaccination season • Practice what we preach (get vaccinated!) Nichol KL.

Cleve Clin J Med.

2006;73:1009-1015.

Shots Immunization App -

Free

 For iPhone/iPod, iPad, Android, Blackberry, and PC  Select vaccine name for information on • • • • • • • High risk indications Adverse reactions Contraindications Catch-up Administration Risk communication Epidemiology   www.ImmunizationEd.org

Available at iTunes Store Content includes Childhood, Adolescent, and Adult Immunization Schedules for the US

Receive updates from the CDC via email:

http://www.cdc.gov/vaccines/pubs/default.htm

Email updates from the Immunization Action

Coalition - http://www.immunize.org/subscribe/

Provider Recommendation Can Overcome Negative Attitudes Among Patients

Vaccination Rates Among High Risk Patients With

Negative

Attitudes

100 80 60 40 20 0 Influenza PPV No MD Recommendation MD Recommendation

Nichol KL, et al.

J Gen Intern Med

. 1996;11:673-677.

Standing Orders Are Among the Most Effective Strategies

• Nonphysicians offer and administer vaccinations • Established with physician approved policies and protocols • • • Locations: – Clinics and hospitals www.immunize.org/standingorders www.immunizationed.org/standingorders CDC. http://www.cdc.gov/vaccines/recs/rate-strategies/adultstrat.htm. Accessed Nov 2010.

McKibbin LJ, et al.

MMWR Recomm Rep.

2000;49 (RR1):15-26.

Success of Standing Orders as Part of a Multifaceted Program

100 80

Influenza Vaccination Rates for Elderly Patients in General Medicine Clinics

Standing Orders 60 40 Education 20 0 83–84 84–85 86–87 87–88 89–90 91–92 92–93 93–94 96–97

Nichol KL.

Am J Med.

1998;105:385-392.

Patient and Provider Reminders

Vaccinations Due or Past Due

• Patient/parent – Telephone, letter/postcard • Provider – Computerized record reminders – Chart reminders Jacobson V, Szilagyi P.

Cochrane Database Syst Rev

. 2005;(3):CD003941.

Tailored Interventions for Inner-City Health Centers to Improve Vaccination Rates

90 80

** **

2000-2001 Preintervention 2001-2002 Nonintervention 2005-2006 Intervention 70 60 50

** **

40 30 20 10 0 White Non-White Influenza White Non-White Pneumococcal (≥ 65) **

< 0.001 vs 2000-2001 Nowalk M, et al.

J Am Geriatr Soc

. 2008;56:1177-1182.

Tailored Interventions Standing orders Provider and patient education Walk-in influenza clinics Electronic prompts Patient reminders

Provider Assessment and Performance Feedback

• Retrospectively assess the delivery of vaccine(s) • Incorporates principles of continuous improvement • AFIX – –

ssessment

eedback –

ncentives – e

change • Comprehensive Clinic Assessment Software Application (CoCASA) • Immunization Information System (IIS) CDC. http://www.cdc.gov/vaccines/programs/afix/overview.htm. Accessed Nov 2010.

The Community Guide. http://www.thecommunityguide.org/vaccines/universally/index.html. Accessed Nov 2010.

Expanding Access

• Consider new paradigms – New venues, walk-in clinics – Extended hours for vaccinations – Extend vaccination season Nichol KL.

Cleve Clin J Med.

2006;73:1009-1015.

Where Flu Shots Are Received (Often Not the Doctor’s Office)

100% 80% 60% 40% 20% 0% Age 18-49 Age 50-64 Age 65+ Other Workplace Hospital/ER Store Senior/Rec Center Other Clinic/Center Health Dept.

Medical Office

Singleton J, et al.

Am J Infect Control

. 2005;33:563-570.

Vaccinations in Nontraditional Settings

• Potential advantages – Cost – Access/convenience – Increased public awareness and demand – New providers and new strategies – For flu, pneumo, ??? other vaccines CDC.

MMWR Recomm Rep.

2000;49 (RR1):1-13.

Targeting Hospitalized Patients Makes Sense

• Hospitalization is a marker for increased risk • Hospitalized patients may be less likely to be immunized – Providers often miss opportunities to immunize • Organized programs work in the inpatient setting

Evidence-based Methods for Improving Immunization Rates

• Reducing client out-of-pocket costs • Client reminder and recall systems • Vaccination requirements for college attendance • Provider reminder systems when used alone • Standing orders when used alone • Provider assessment and feedback The Community Guide. http://www.thecommunityguide.org/vaccines/universally/index.html. Accessed Nov 2010.

Briss PA, et al.

Am J Prev Med.

2000;18(suppl 1):35-43.

Summary

• Critical patient issues for increasing adult vaccination rates – Knowledge / awareness – Provider recommendations • Critical provider issues for increasing adult vaccination rates – Stay current with the immunization schedule, recommendations – Identify and address barriers – Educate patients – Recommend vaccines to patients – Implement organizational and systems strategies – Ensure health care workers are vaccinated – Consider new paradigms

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Resources for Providers

Immunization Schedules

www.cdc.gov/vaccines/recs/schedules/ •

ACIP recommendations & provisional recommendations

www.cdc.gov/vaccines/pubs/ACIP-list.htm

www.cdc.gov/vaccines/recs/provisional/default.htm

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The Immunization Action Coalition: vaccine information for the public and health professionals

www.vaccineinformation.org

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The Guide to Community Preventive Services. Vaccine recommendations

www.thecommunityguide.org/vaccines/index.html

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Assessment, Feedback, Incentives, and Exchange (AFIX)

www.cdc.gov/vaccines/programs/afix/default.htm

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National Foundation for Infectious Diseases

www.nfid.org

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Centers for Medicare & Medicaid Services

www.cms.hhs.gov

Resources for Patients and Parents

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Guide to evaluating information on the web

www.cdc.gov/vaccines/vac-gen/evalwebs.htm

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CDC Vaccine Information Statements (VISs)

http://www.cdc.gov/vaccines/pubs/vis/default.htm

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Vaccine Safety

www.cdc.gov/Features/VaccineSafety •

National Network for Immunization Information (NNII)

www.immunizationinfo.org

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Allied Vaccine Group

www.vaccine.org

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Immunization Action Coalition (IAC)

www.immunize.org

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Vaccine Education Center at CHOP

www.vaccine.chop.edu

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TCH Center for Vaccine Awareness and Research