Transcript 51st Annual Pincoffs Lecture

Adult Immunization
Do Disparities have Ethical Implications?
William Schaffner, MD
Professor of Preventive Medicine, Department of Health Policy
Professor of Medicine - Infectious Diseases
Vanderbilt University School of Medicine
Conflicts of Interest
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CDC: Co-PI, Cooperative Agreement
Emerging Infections Program
Merck: Member, Data Safety Monitoring Board
Sanofi-Pasteur: One lecture
Dynavax: Consultant
It is better to avert the malady
by care than to have to apply
physic after it has appeared.
—Shao Tze
Adult Immunization Concepts
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The vast majority of vaccine-preventable diseases
occur in adults
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These diseases produce substantial morbidity and
mortality
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Vaccine coverage of adults is suboptimal, with
notable disparities of race/ethnicity and income
Centers for Disease Control and Prevention (CDC). MMWR Morb Mortal Wkly Rep. 2012;61(04):66-72.
Infant, Childhood, Adolescent
Immunization
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One of the great clinical and public health
success stories of the 20th/21st centuries
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Disparities of income, race, urban/rural
eliminated
Comparison of 20th Century
Annual Morbidity and Current Morbidity:
Vaccine-Preventable Diseases
20th Century
Annual Morbidity
2010
Reported Cases
Percent
Decrease
Smallpox
29,005
0
100
Diphtheria
21,053
0
100%
Measles
530,217
61
>99%
Mumps
162,344
2528
98%
Pertussis
200,752
21,291
89%
Polio (paralytic)
16,316
0
100%
Rubella
47,745
6
>99%
Congenital Rubella
Syndrome
152
0
100%
Tetanus
580
8
99%
20,000
270
99%
Disease
Haemophilus influenzae
Centers for Disease Control and Prevention. Historical comparisons of vaccine-preventable disease
morbidity in the U.S. http://www.ct.gov/dph/lib/dph/infectious_diseases/immunization/
pdf/vpd_us_statistics_2010.pdf. Accessed April 9, 2013.
The Yearly Toll of
Vaccine-Preventable Diseases
HPV, human papilloma virus.
National Foundation for Infectious Diseases. Saving Lives: Integrating Vaccines for Adults into Routine Care.
Bethesda, MD: National Foundation for Infectious Diseases; 2008.
Burden of Vaccine-Preventable
Diseases – 1
United States/Annual Rates
INFLUENZA
• 200,000 hospitalizations
• 36,000 deaths (>85% elderly)
• 44,000 cases
INVASIVE
• 4500 deaths
PNEUMOCOCCAL
• Higher rates in elderly, AA, persons
DISEASE
with comorbidities
HEPATITIS B
• 51,000 infections (>95% adults)
• 2000-3000 deaths
• 1.25 (m) chronic HBV infection
AA, African American; HBV, hepatitis B virus.
Centers for Disease Control and Prevention. http://www.cdc.gov/.
Burden of Vaccine-Preventable
Diseases – 2
United States/Annual Rates
• 6.2 million new infections
HUMAN
• 2 HPV strains cause 70% of cervical
PAPILLOMAVIRUS
cancers and most anal, head and
(HPV)
neck cancers
PERTUSSIS
• Outbreaks throughout US
adolescents and young adults
• Most severe in infants
• Source is usually an adult or
older child
Centers for Disease Control and Prevention. http://www.cdc.gov/.
Burden of Vaccine-Preventable
Diseases – 3
United States/Annual Rates
SHINGLES
• 1 (m) cases
• Lifetime risk 30%
• Incidence of shingles and postherpetic
neuralgia increases with age
Centers for Disease Control and Prevention. http://www.cdc.gov/.
Adult Vaccination Rates – 1
Low and Disparate
Pneumococcal Vaccination
19 – 64 yrs high risk
White
20%
Black
22%
Hispanic
18%
Asian
12%
MMWR 62:66,2013
≥65 yrs
White
67%
Black
48%
Hispanic
43%
Asian
40%
Adult Vaccination Rates – 2
Low and Disparate
Tetanus Vaccination, past 10 years
50 – 64 years
White
Black
Hispanic
Asian
MMWR 62:66,2013
68%
54%
52%
45%
Adult Vaccination Rates – 3
Low and Disparate
Human papillomavirus (HPV), females, one or more doses
19 – 26 years
White
Black
Hispanic
Asian
MMWR 62:66,2013
33%
28%
20%
22%
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If the vaccine-preventable diseases cause
substantial illness and death as well as
large costs of medical care,
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If the vaccines are appropriately safe and
sufficiently effective,
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If vaccination rates are low and
racially/ethnicity disparate,
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Is that circumstance unethical?
Immunization Contrasts - 1
Pediatric
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Diseases distinctive
Fabulous vaccines
Interrupt transmission
Eliminate disease
Universal coverage
Active programs: find
everyone
National/global vision
Adult
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Diseases not as distinctive
Good vaccines
Personal protection
Reduce risk
Targeted populations
Passive: try to immunize
those presenting for care
Focus on practice
Immunization Contrasts - 2
Pediatric
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Create hurdles: ‘no shots,
no school”
CDC, ACIP: pediatricoriented
Strong involvement of
professional partners
(AAP, AAFP)
Recommendations clearly
communicated
Adult
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Averse to hurdles
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CDC, ACIP: adults of
marginal interest
Modest involvement of
professional group (ACP)
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Recommendations
inadequately communicated
Immunization Contrasts - 3
Pediatric
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“Well child” visit
scheduled
Adult
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No “well adult” schedule
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Doctors and staff
sophisticated about
vaccines
Included in medical
insurance
Public support for
underinsured
Specialist care
No care
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Doctors and staff need
education about vaccines
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Medical insurance
variable
Variable public support
for underinsured
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“Funding” Examples
Medicaid: Reimbursement payment varies by
state; provider barely breaks even or may
lose money
Medicare: Part A, first dollar coverage
influenza, pneumococcal
Part B, varies
shingles, Tdap
Increasing Adult Immunization
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Improve funding
Increase awareness of both providers and the
public – “Vaccination is not just for kids”
Standing orders
Knowledge of ordering, recording, refrigeration,
billing, etc.
Research to improve adult vaccines
Enlarge the “immunization neighborhood”
“Slices of the Pie”
Populations for which society is responsible
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US Military
Veterans Administration
Indian Health Service
Federal and State Prisons
When meditating over a
disease, I never think of
finding a remedy for it,
but instead, a means of
preventing it.
—Louis Pasteur