ATLANTA – Despite federal efforts to make adult immunization a higher priority, recent increases in use have been modest at best, according to Dr. Walter W. Williams an epidemiologist with the Centers for Disease Control and Prevention.
In a comparison of 2009 and 2010 data from the NHIS (National Health Interview Survey), an annual in-home survey that includes 7,624 noninstitutionalized adults aged 19-64 years, Dr. Williams found that the use of tetanus-diphtheria-acellular pertussis (Tdap) vaccination, for example, increased by almost 2%, rising to 8%. Herpes zoster vaccination rates among those aged 60 years and older increased by 4%, rising to 14%. And human papillomavirus (HPV) vaccination rates among women aged 19-26 years increased by nearly 4%, rising to 21%.
Racial disparities were seen for nearly all immunization rates, with non-Hispanic whites generally having higher rates than did black, Hispanic, or Asian adults. Pneumococcal vaccine coverage among adults aged 65 years and older was 64% for whites, compared with 46% for blacks and 39% for Hispanics/Latinos. Receipt of zoster vaccine among those at least aged 60 years was 17% for whites, compared with 5% for blacks and 4% for Hispanics/Latinos.
"These data highlight the problems that we have with our adult program or lack thereof," said Kristen R. Ehresmann, R.N., the director of the infectious disease epidemiology, prevention and control division of the Minnesota Department of Health, St. Paul.
Sara Rosenbaum, an attorney and a member of the CDC’s Advisory Committee on Immunization Practices, concurred. "I think these data are testament to the fact that we don’t really have an adult immunization program," she said, noting the lack of funding.
Ms. Rosenbaum, who teaches at George Washington University in Washington, also noted that "the zoster numbers tell us that there’s something terribly wrong right now with the way Medicare immunization coverage works for zoster," referring to the current system whereby Medicare covers Zostavax under Part D (prescription drug coverage), which physicians can’t bill directly.
But Dr. Anne Schuchat, director of the CDC’s National Center for Immunization and Respiratory Diseases countered that although the Medicare issue has been a "headache," the primary concern about Zostavax has been a supply problem, which is now resolved. Moreover, the vaccine is recommended for adults beginning at age 60, and most who are aged 60-65 are insured privately. "We actually have an opportunity now that the supply is good for every stakeholder to try to take advantage of a good vaccine for a very common bad disease, at least in the population that couldn’t access it because of supply, and now they can," she said.
Sandra A. Fryhofer, the ACIP liaison from the American College of Physicians (ACP), said that she found these latest data "very sobering. ... The excitement that we in this room share for adult vaccination has to go outside this room and out to our physicians and other providers."
Part of the problem for physicians in the trenches may be the failure of their reminder systems, said ACIP member Dr. Jonathan Temte, a family physician. "When I see children in my practice, it’s largely a well-care [visit] and vaccines are a big part [of those]. When I see my typical older adult for well care, I’m seeing six or seven or eight comorbid conditions at the same time. ... For adult immunizations, having reminder systems that are flawlessly built into your [electronic medical record] systems are so very important."
However, "most of us ... unfortunately have even learned how to ignore the warnings that pop up on our EMR screens because of all the chaos. We need to do a better job with those reminder systems," said Dr. Temte, professor of family medicine at the University of Wisconsin, Madison.
Signs that adult vaccination is moving up on the priority list include the fact it has gained increasing amounts of airtime at the thrice-yearly meetings held by ACIP. Back in the 1990s, the agendas for those meetings may have included one or two adult-focused topics amidst a much longer list of pediatric vaccine issues.
Today, some ACIP agendas are almost entirely geared toward adults. At the recent June meeting, topics included the use of the 13-valent conjugate pneumococcal vaccine for immunocompromised adults, hepatitis B vaccine for health care personnel in whom protection is uncertain, and postexposure prophylaxis with anthrax vaccine, as well as an entire session specifically focused on the woefully low rates of vaccine coverage for prevention of noninfluenza conditions among adults.
Dr. Carolyn B. Bridges, associate director for Adult Immunizations at the CDC’s Immunization Services Division, reported on the first-ever National Adult Immunization Summit, held May 15-17 in Atlanta. Sponsored by the American Medical Association, the National Vaccine Program Office, and the CDC, the meeting was patterned after the National Influenza Vaccine Summit (www.preventinfluenza.org).