As the U.S. population ages, increasing levels of adult immunization-particularly against influenza and pneumococcal disease-is taking on critical importance. Influenza and pneumonia combined remain the fifth leading cause of death among elderly persons. Both influenza and Streptococcus pneumoniae, the most common cause of pneumonia leading to hospitalization, may be preventable by vaccination. Indeed, the National Institute on Aging promotes the vaccine to prevent pneumococcal disease with this simple message: "It's Worth a Shot." The same can be said for other adult immunizations.
In its 1994 report on the status of adult immunization, the National Vaccine Advisory Committee (NVAC) cited the fewer than 500 deaths annually from vaccine-preventable diseases of childhood. By comparison, as many as 50,000 to 70,000 adults die each year of complications of influenza, pneumococcal infections, and hepatitis B.
Older Americans Need A Shot in the Arm
This Prevention Report draws attention to adult immunization before the start of the influenza season and the congressionally declared National Adult Immunization Awareness Week, October 12-18, 1997. The influenza vaccine generally is available to health departments and other providers in September. The influenza season may start as early as November, so now is a good time to plan. Expected to be available by this publishing date is the National Coalition for Adult Immunization's campaign kit, which can serve as a starting point for getting the adult immunization message to as many people as possible. (Note: Although immunization is best before influenza season, even after influenza starts in a community, CDC advises that it is still not too late to get an influenza shot. People who receive the influenza vaccine should be checked for pneumococcal vaccine status. Both shots can be administered at the same time--but in separate arms.)
According to the draft Adult Immunization Action Plan of the Department of Health and Human Services (HHS), the annual cost of complications due to influenza, pneumococcal infections, hepatitis B, and other vaccine-preventable diseases of adults tops $10 billion, not including the value of years of life lost. In sum, shots save lives. They can help avoid needless suffering and unnecessary costs caused by complications from various infectious diseases, and, as many family members and health care workers know, they can prevent infection of others. However, despite the availability of safe and effective vaccines, a substantial portion of susceptible adults are not being immunized.
For shots to work, however, people have to roll up their sleeves and get them. The Adult Immunization Action Plan, which follows the NVAC 1994 report cited above, will be coordinated by the HHS National Vaccine Program Office. The plan identifies five goals and specific action steps for HHS agencies to address the high mortality from vaccine-preventable diseases and the low immunization coverage levels among adults in the United States. The goals are to increase the demand for adult vaccination by improving provider and public awareness; increase the capacity of the health care delivery system to deliver vaccines effectively to adults; expand financing mechanisms to support the increased delivery of vaccines to adults; monitor and improve the performance of the Nation's immunization program; and enhance the capability and capacity to conduct research on vaccine-preventable diseases of adults, adult vaccines, adult immunization practices, new and improved vaccines, and international programs for adult immunization. HHS also emphasizes continued vigilance in childhood immunization (see Spotlight).
It's Never Too Late . To Immunize for Chickenpox
Adults who get chickenpox (varicella) are at much greater risk of complications and death than children. According to the Centers for Disease Control and Prevention (CDC), three women have died this year of chickenpox after being infected by young children. Although more than 95 percent of adult Americans have had this highly contagious disease, adults who are not sure should be tested and vaccinated.
CDC's Advisory Committee on Immunization Practices recommends that all children be vaccinated at 12 to 18 months of age. Vaccination also is approved for children under 13 who have not had chickenpox and for people over 13 who come in close contact with persons at high risk for serious complications (health care workers and family contacts of people whose immune systems are suppressed, such as AIDS and cancer patients).
For more information about vaccine-preventable diseases, contact CDC's National Immunization Hotline at (800)232-2522 (English) or (800)232-0233 (Spanish).
The plan's action steps will further recent and ongoing efforts of the public and
private sector, with emphasis on the collaborative achievement of shared goals. For
example, "Partners Promoting Adult Immunization" was the theme of the Health
Care Financing Administration's (HCFA) March Influenza and Pneumococcal Adult Immunization
Conference cosponsored by the Centers for Disease Control and Prevention (CDC) and the
National Coalition for Adult Immunization, an umbrella organization representing over 95
professional, medical, and health care associations, advocacy groups, voluntary
organizations, vaccine manufacturers, and government health agencies. In April, CDC
cohosted a satellite videoconference on "Adult Immunization: Strategies That
Work" and has changed its Federal grant guidance for State immunization programs to
invite specific proposals for adult immunization. Last year in its continuing efforts to
increase flu immunization rates, HCFA released the first-ever public service advertising
campaign through the World Wide Web. (Increasingly, the web is a rich resource of
immunization information: see Resources box.) HCFA
enlisted advice columnist Ann Landers' help to encourage older Americans to get their
annual flu shots. The agency addresses supply as well as demand strategies by providing
technical assistance for becoming a Medicare provider, thus enabling increasing numbers of
physicians to provide vaccinations free of charge to Medicare recipients.
Programs and Strategies
Successful immunization programs begin by defining objectives and designing strategies. Program planners need to set specific objectives for enhancing services to well-defined audiences and for filling information gaps. Providers need to become more aware of the vaccination needs of their adult patients. Because patients are concerned about potential complications from immunizations, providers and planners need to emphasize the safety and necessity of adult immunizations, as well as directly address misperceptions, such as "flu shots give you the flu." Planners also need to consider barriers, resources, and ways to measure results.
The CDC immunization teleconference covered successful strategies for practitioners in each of these settings: private practice, managed care, hospital, long-term care, and public health. Vaccinating medical staff is a strategy appropriate for every setting. Admission to a nursing home can include a review of the resident's pneumococcal vaccination status, as well as a standing order for the person's annual flu shot. Discharge planning in hospitals may include standing orders to assess vaccination status and to provide shots as needed. Emergency departments can do similar checking and immunization. Indeed, immunization record keeping is a key element in raising immunization levels among adults as well as children. Increasingly, medical settings and communities are using computerized tracking systems to help monitor immunization coverage.
Healthy People 2000 sets several objectives tied to adult immunization, including
pneumococcal disease. During the period 1980-1992, pneumonia accounted for 85 percent of
fatal respiratory infections among persons aged 65 and older. Although the pneumococcal
vaccine is safe, efficacious, and cost effective, only 30 percent in this age group have
been vaccinated. The Advisory Committee on Immunization Practices guidelines recommend
that all persons in this age group and others at increased risk for pneumococcal disease
receive the vaccination. (CDC published these revised recommendations in April. See In the Literature.) In the case of residents of
chronic-care facilities, vaccine coverage is well below the Healthy People 2000 objective
of 60 percent. Some of the reasons are tied to poor record keeping, a lack of emphasis on
the need for vaccination administration by health care providers, and incomplete
Who Should Get Shots?
Unlike childhood immunization, adult immunization has no statutory requirements. Different vaccines have different target groups among adults. From the annual flu shot to the once-in-a-lifetime pneumoccocal vaccine, shots for adults vary in terms of when they are given and how often (for the Adult Immunization Schedule, see http://www.cdc.gov/nip/adult.htm). The Guide to Clinical Preventive Services, 2nd edition, a report of the U.S. Preventive Services Task Force, provides recommendations covering adult immunizations against influenza, pneumococcal disease, tetanus, and diphtheria; measles, mumps, and rubella; hepatitis B; hepatitis A; and varicella. Other government and professional organizations have issued adult immunization guidelines. The Advisory Committee on Immunization Practices sets Federal vaccine policy, which differs very little from guidelines published by the American College of Physicians/Infectious Disease Society of America, the American Academy of Pediatrics, and the American Academy of Family Physicians. The American College of Obstetricians and Gynecologists has issued detailed guidelines on the use of vaccines during pregnancy.
Everyone aged 65 and older should get the pneumococcal vaccine once; some experts say anytime after age 50. Anyone over the age of 2 years with a chronic disease or a weak immune system also should get the vaccine. One shot lasts most people a lifetime although some people may need revaccination upon their physician's advice. The shot does not protect against viral pneumonia or other pneumonia-causing bacteria.
Influenza vaccine, unlike the pneumococcal vaccine, must be given every year: each season's vaccine is especially tailored to that season's viruses. Recommendations are essentially the same as the pneumococcal vaccination--everyone aged 65 and older and anyone over the age of 2 years with a chronic disease or weakened immune system. CDC also recommends the influenza vaccination for pregnant women and for residents of nursing homes, health care workers, nursing home staff, and volunteers who provide home care to people in the above groups; plus other at-risk groups.
Flu shots are free for beneficiaries who receive them from Medicare-participating
physicians. Medicare also covers a vaccination against pneumococcal disease. Public and
private groups urge all health insurance plans to include adult coverage for flu,
pneumococcal, and hepatitis B shots.
Progress in Flu Immunization
The rates for adult flu immunization are improving: The 1994 National Health Interview Survey, which reports the most recent data, indicates a 55 percent immunization rate, which is approaching the year 2000 target. Medicare reimbursement for flu vaccination, which began in 1993, has helped boost the immunization rate, putting the Nation close to the Healthy People 2000 objective of a 60 percent annual immunization rate for those 65 and older. Preliminary results from HCFA's Horizons Pilot Project, designed specifically to increase the flu vaccination rate among African Americans, indicate an increase in flu immunizations in such target areas as Mississippi. Horizon partners, including Historically Black Colleges and Universities, are using lessons learned from the 1996 flu shot season in their 1997 efforts.
In 1995, the Medicare reimbursement program paid for 11 million shots, resulting in an
estimated 5,000 fewer hospitalizations and $25 million in savings to the Medicare program.
Still, only half of the Medicare beneficiaries were immunized, with much lower rates among
African Americans. (See map.) HCFA has intensified efforts to reach underserved
1995 Influenza Immunizations Paid for by Medicare
|These data reflect claims paid by Medicare for non-HMO
Total immunization rates may be higher in those areas with free or publicly supported programs.
Source: Health Care Financing Administration, administrative claims data files, September 1 - December 31, 1995.
Information Is Prevention
Programs for childhood immunization have lowered health care costs and improved the well-being of the Nation's children. The same results can be realized for adults. Vaccine-preventable diseases are significant adult health problems, and vaccines for adults are available, safe, and effective.
As the HHS Adult Immunization Action Plan indicates, disseminating information in
print, on the air, and electronically is not the only strategy to be pursued. Changes in
clinical practice, increased financial support, improved surveillance, and support for
research are needed. Certainly, the programs under way prove, "It's Never Too Late To
|Adult Immunization Schedule
All Kids Count
American Academy of Pediatrics
Every Child by Two
Immunization Action Coalition
Manual for the Surveillance of
|Medicare Billing Made Easy for Influenza and
Pneumococcal Pneumonia Vaccinations Informational Kit
Health Care Financing Administration
Morbidity and Mortality Weekly Report
National Child Care Information Center
National Council of La Raza
National Immunization Program
National Institute on Aging
National Institute on Aging
Vacunas desde la cuna