What you can do to improve adult immunization rates

,

Applied Evidence

What you can do to improve adult immunization rates

J Fam Pract. 2015 October;64(10):625-626,628-630,633

By

Pamela G. Rockwell, DO

Easy-to-implement electronic or paper prompts and the system-based interventions outlined here can make a difference.

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References

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2. Centers for Disease Control and Prevention. Active bacterial core surveillance (ABCs) report, emerging infections program network, Streptococcus pneumoniae, 2013. Centers for Disease Control and Prevention Web site. Available at: http://www.cdc.gov/abcs/reports-findings/survreports/spneu13.pdf. Accessed August 20, 2015.

3. Centers for Disease Control and Prevention (CDC). Estimates of deaths associated with seasonal influenza --- United States, 1976-2007. MMWR Morb Mortal Wkly Rep. 2010;59:1057-1062.

4. Reed C, Kim IK, Singleton JA, et al; Centers for Disease Control and Prevention (CDC). Estimated influenza illnesses and hospitalizations averted by vaccination--United States, 2013-14 influenza season. MMWR Morb Mortal Wkly Rep. 2014;63:1151-1154.

5. Kimmel SR, Burns IT, Wolfe RM, et al. Addressing immunization barriers, benefits, and risks. J Fam Pract. 2007;56:S61-S69.

6. Briss PA, Zaza S, Pappaioanou M, et al. Developing an evidence-based Guide to Community Preventive Services—methods. The Task Force on Community Preventive Services. Am J Prev Med. 2000;18:35-43.

7. The Guide to Community Preventive Services. Increasing appropriate vaccination. The Community Guide Web site. Available at: http://www.thecommunityguide.org/vaccines/index.html. Accessed August 20, 2015.

8. National Vaccine Advisory Committee. Recommendations from the National Vaccine Advisory committee: standards for adult immunization practice. Public Health Rep. 2014;129:115-123.

9. Househ M. The use of social media in healthcare: organizational, clinical, and patient perspectives. Stud Health Technol Inform. 2013;183:244-248.

10. Bloom BS. Effects of continuing medical education on improving physician clinical care and patient health: a review of systematic reviews. Int J Technol Assess Health Care. 2005;21:380-385.

11. Cabana MD, Rand CS, Powe NR, et al. Why don’t physicians follow clinical practice guidelines? A framework for improvement. JAMA. 1999;282:1458-1465.

12. Rosenthal SL, Weiss TW, Zimet GD, et al. Predictors of HPV vaccine uptake among women aged 19-26: importance of a physician’s recommendation. Vaccine. 2011;29:890-895.

13. Zimmerman RK, Santibanez TA, Janosky JE, et al. What affects influenza vaccination rates among older patients? An analysis from inner-city, suburban, rural, and Veterans Affairs practices. Am J Med. 2003;114:31-38.

14. American Academy of Family Physicians. Strong recommendation to vaccinate against HPV is key to boosting uptake. American Academy of Family Physicians Web site. Available at: http://www.aafp.org/news/health-of-the-public/20140212hpv-vaccltr.html. Accessed August 20, 2015.

15. National Foundation for Infectious Diseases. Survey: adults do not recognize infectious disease risks. National Foundation for Infectious Diseases Web site. Available at: http://www.adultvaccination.org/newsroom/events/2009-vaccination-news-conference/NFID-Survey-Fact-Sheet.pdf. Accessed July 7, 2015.

16. Wang E, Clymer J, Davis-Hayes C, et al. Nonmedical exemptions from school immunization requirements: a systematic review. Am J Public Health. 2014;104:e62-e84.

17. National Vaccine Advisory Committee. A pathway to leadership for adult immunization: recommendations of the National Vaccine Advisory Committee: approved by the National Vaccine Advisory Committee on June 14, 2011. Public Health Rep. 2012;127:1-42.

18. Gannon M, Qaseem A, Snooks Q, et al. Improving adult immunization practices using a team approach in the primary care setting. Am J Public Health. 2012;102:e46-e52.

19. Bottino CJ, Cox JE, Kahlon PS, et al. Improving immunization rates in a hospital-based primary care practice. Pediatrics. 2014;133:e1047-e1054.

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PRACTICE RECOMMENDATIONS

› Recommend immunization to patients routinely. Most adults believe vaccines are important and are likely to get them if recommended by their health care professionals. C
› Consider implementing standing orders that authorize nurses, pharmacists, or other trained health care personnel to assess a patient’s immunization status and administer vaccinations according to a protocol. C
› Explore the use of Web-based patient portals or other new-media communication formats to engage patients. C

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

Vaccines have been proven effective in preventing disease and are one of the most cost-effective and successful public health initiatives of the 20th century. Nevertheless, adult vaccination rates in the United States for vaccine-preventable diseases are low for most routinely recommended vaccines.¹ In 2013 alone, there were an estimated 3700 deaths in the United States (95% of which were adults) from pneumococcal infections—a vaccine-preventable disorder.²

Consider the threat posed by the flu. Annually, most people who die of influenza and its complications are adults, with estimates ranging from a low of 3000 to a high of 49,000 based on Centers for Disease Control and Prevention (CDC) data from the 1976-1977 flu season to the 2006-2007 season.³ Vaccination during the 2013-2014 season resulted in an estimated 7.2 million fewer cases of influenza, 90,000 fewer hospitalizations, and 3.1 million fewer medically attended cases than would have been expected without vaccination.⁴ If vaccination levels had reached the Healthy People 2020 target of 70%, an additional 5.9 million illnesses, 2.3 million medically attended illnesses, and 42,000 hospitalizations might have been averted.⁴

How are we doing with other vaccines? Based on the 2013 National Health Interview Survey, the CDC assessed vaccination coverage among adults ages ≥19 years for selected vaccines: pneumococcal vaccine, tetanus toxoid-containing vaccines (tetanus and diphtheria vaccine [Td] or tetanus and diphtheria with acellular pertussis vaccine [Tdap]), and vaccines for hepatitis A, hepatitis B, herpes zoster, and human papillomavirus (HPV). (With the exception of influenza vaccination, which is recommended annually for all adults, other vaccinations are directed at specific populations based on age, health conditions, behavioral risk factors, occupation, or travel conditions.)

Overall, coverage rates for hepatitis A and B, pneumococcal, Td, and human papillomavirus (HPV) for all adults did not improve from 2012 to 2013; rates increased only modestly for Tdap among adults ≥19 years, for herpes zoster among adults ≥60 years, and for HPV among men ages 19 to 26. Furthermore, racial and ethnic gaps in coverage are seen in all vaccines, and these gaps widened since 2012 for Tdap, herpes zoster, and HPV vaccination.¹

Commonly cited barriers to improved vaccine uptake in adults include lack of regular assessment of vaccine status; lack of physician and other health care provider knowledge on current vaccine recommendations; cost; insufficient stocking of some vaccines; financial disincentives for vaccination in the primary care setting; limited use of electronic records, tools, and immunization registries; missed opportunities; and patient hesitancy and vaccine refusal.⁵

Removing barriers to immunization. Several recommendations on ways to improve adult vaccination rates are made by many federal organizations as well as by The Community Preventive Services Task Force (Task Force), an independent, nonfederal, unpaid panel of public health and prevention experts. The Task Force—which makes recommendations based on systematic reviews of the evidence of effectiveness, the applicability of the evidence, economic evaluations, and barriers to implementation of interventions⁶—advocates a 3-pronged approach to improve adult vaccination rates: 1) enhance access to vaccination services; 2) increase community demand for vaccinations; and 3) incorporate physician- or system-based interventions into practice.⁷

Using your state’s immunization information system can help ensure accurate tracking of patients’ immunization status.

The CDC and other groups such as the National Vaccine Advisory Committee (NVAC) recommend that every routine adult office visit include a vaccination needs assessment, recommendation, and offer of vaccination.⁸ Additionally, the Task Force recommends 3 means of enhancing adult access to vaccination services: make home visits, reduce patient costs, and offer vaccination programs in the community.⁷

This article describes a number of simple steps physicians can take to increase the likelihood that adults will get their vaccines and reviews the literature on using new media such as smartphones and other Internet-based tools to improve immunization coverage.⁹

Increasing community demands for vaccinations

Physicians and other healthcare providers can increase community demand for vaccinations by improving their own knowledge on the subject, recommending vaccination to patients, and increasing their community and political involvement to strengthen or change laws to better support immunization uptake.