Despite the longstanding recommendation of the CDC that adults aged at least 65 years receive the pneumococcal vaccine, coverage in this age group is lagging, with a rate of 59.7% overall, according to a February report in the Morbidity and Mortality Weekly Report.
Even more staggering is the 18.5% pneumococcal vaccine coverage rate among adults aged 19 to 64 years who are considered high risk — a group comprising those with chronic lung disease, chronic cardiovascular disease, diabetes, chronic liver disease and immunocompromising conditions, among others.
Pediatric vaccination programs have experienced overwhelming success rates, yet adult vaccination rates have been low for many years. Although the pneumococcal vaccine is a prime example of this, similar rates are seen for other types of vaccinations. According to the MMWR report, only 64% of adults aged 19 to 49 years reported receiving a tetanus vaccination within the past 10 years. This rate decreased with age: adults aged 50 to 64 years saw a 63.4% vaccination coverage rate and adults aged 65 and older saw a 53.4% coverage rate.
“Once you cross the threshold of the 19th birthday, which is how adults are defined in the immunization world, the proportion of people who are vaccinated is low,” William Schaffner, MD, a member of the Infectious Disease News Editorial Board and professor and chair of the department of preventive medicine at Vanderbilt University School of Medicine, told Infectious Disease News. “For infant, childhood and adolescent vaccinations, we have constructed a combined public and private mechanism that is successful in making vaccines available. There is no
comparable program for adults.”
Gregory Poland, MD, said the process to encourage physicians to incorporate adult immunizations begins in medical school.
Source: Mayo Foundation for Medical Education and Research
Infectious Disease News spoke with several experts in the field of adult immunizations to find out factors contributing to the low adult immunization rates and to identify what is needed to improve these rates.
Lack of knowledge
In December 2010, the US Department of Health and Human Services launched the Healthy People 2020 program, outlining its plans to improve health in the country. Among the goals of this initiative were to improve immunization rates for adults. They set a goal of 90% coverage of pneumococcal, herpes zoster and hepatitis B vaccines for adults aged at least 65 years and 60% coverage for adults aged 18 to 64 years.
The current vaccination coverage rates are falling significantly short. Some may be quick to place the blame on cost, but there are many other issues that come into play. One of the reasons is lack of knowledge.
“The public simply doesn’t know what to do regarding vaccination,” Deborah Wexler, MD, founder and executive director of the Immunization Action Coalition, told Infectious Disease News. “There is a lack of information available for adults about the vaccinations they need. In addition, the vaccination recommendations have been changing, so it is difficult to keep up with them.”
It is standard operating procedure for parents to bring their young children in to receive vaccinations. But there are not many adults who recognize that vaccination is not just for children. According to Schaffner, who is also the immediate past-president of the National Foundation for Infectious Diseases (NFID), the NFID has conducted surveys on the topic and found that adults are not familiar with the vaccines that are available and the diseases that they prevent.
However, Schaffner said the lack of knowledge does not just apply to patients.
“The same thing is true for medical providers,” he said. “Because of many financial barriers, providers who care for adults have not made themselves as familiar as they ought to be with vaccinations. There is a knowledge gap that we can fix if we eliminate the financial barriers.”
Differences in systems of care
According to L.J. Tan, PhD, director of medicine of public health at the American Medical Association, the system of care for adults is different from the system of care for pediatrics. Pediatricians focus on preventive care that makes vaccines a top priority, whereas adult physicians practice an acute care model. This model causes immunizations, as well as other preventive care measures, to take the back seat.
“What happens is that physicians, as well as patients, are not expecting immunizations, which results in an undervaluation of adult immunizations in the United States,” Tan said in an interview with Infectious Disease News. “Providers in the acute care model are not incentivized to offer vaccines. Their time is focused on acute care situations so they don’t value immunizations as much as they should. We are going to have to change that culture.”
In general, vaccines are not typically on the radar screens of adults, according to Carolyn Bridges, MD, associate director for adult immunizations at the CDC.
“Unlike children, adults aren’t typically going to see the doctor on an annual basis for preventive care visits,” Bridges said. “They visit their health care providers to take care of acute illnesses or manage chronic diseases. One of the things that we are trying to remind both patients and providers of is to work immunization assessment into office visits, just like they would for other preventive services like [assessing the need for] mammograms.”
For pediatric immunization, an infrastructure is in place to make sure that every child receives his or her vaccinations. For example, the Vaccines for Children program enables children who are underinsured or uninsured to receive their vaccines. There is collaboration between pediatricians and public health officials to create an infrastructure so that vaccines can be delivered to children.
“Someone needs to deliver these vaccines and you need an infrastructure to do that,” Tan said. “That infrastructure does not exist in the adult care model. There is no support for the delivery of adult vaccines, and there is no public health or federal engagement.”
There is no question that health care costs in the United States are significant. Many adults are without health insurance and may not be able to afford the cost of vaccinations out of pocket. However, both pneumococcal and influenza vaccines are fully covered by Medicare Part B, which should make coverage rates for adults aged at least 65 years a nonissue. Still, the coverage rates in this age group for these two vaccines remain in the 60% range.
It’s not as simple for the shingles (herpes zoster) vaccine or the tetanus-diphtheria-acellular pertussis vaccine, both of which are also recommended for adults aged at least 65 years. These are covered by Medicare Part D, but not every adult enrolls in a Part D plan. In addition, these plans often have co-pays and deductibles, representing significant out-of-pocket costs for those attempting to receive these vaccines. Also with Part D, the patient may have to pay upfront for the cost of the vaccine and the administration fee, and then submit the bill for reimbursement.
For adults aged younger than 65 years, insurance coverage also plays a key role. Most private insurers also have significant co-pays and deductibles that may deter adults from receiving their vaccines.
“With the exception of a few groups, such as the military and certain occupational groups, you will see that not all insurance programs cover vaccines optimally,” Schaffner said. “This is also true for the public programs like Medicaid and Medicare. Then there are those in the middle, who do not qualify for public insurance, nor do they have private insurance. Out-of-pocket expenses for vaccines, even for those who have some type of insurance, are a major barrier for those who wish to be immunized.”
There is hope that the Affordable Care Act will help alleviate some of the cost issues associated with receiving vaccines. According to Tan, vaccines will be covered 100% by insurance companies when the act completely comes to fruition by 2014. But this is not a complete solution because the payment issue with Medicare Part D will still exist.
Costs for physicians
Providers do not want to offer a vaccine that may end up being out-of-pocket for the patient. If the patient is not paying out-of-pocket, then they are concerned about receiving adequate reimbursement from the insurance companies.
When physicians recommend vaccines to their patients, the patients are several times more likely to receive the vaccinations than if their provider does not recommend the vaccine, Bridges said.
But the issue of reimbursement may deter some physicians from broaching the topic with their patients.
According to Wexler, reimbursement for vaccine cost and administration fees is typically low for adult providers. The shingles vaccine is not only expensive to buy but also expensive to store. If the physicians are paying more for the vaccine than they are getting paid, then there is a disadvantage to the physician.
“Physicians who provide care to adult patients often have concerns about carrying an inventory of such expensive vaccines,” Wexler said. “The work involved in monitoring the temperature and making sure they don’t expire, as well as the paperwork and keeping track of the vaccines, is a challenge for providers. There are many things that have to be balanced when deciding to vaccinate in your practice. Is there a financial cutoff point when it’s no longer a good idea to give this vaccine?”
Specialists vs. primary care
Typically, primary care physicians such as general internists and family medicine practitioners are the providers who carry the responsibility of educating their patients about vaccinations and providing vaccination. However, some patients bypass the PCP in favor of a specialist.
According to an article in the Archives of Internal Medicine, 9.8% of primary care visits were to an internal medicine subspecialist in 2007 and 27.8% of the primary care visits were to other specialist physicians. The researchers offer two possible explanations: First, patients prefer specialist care and believe they are better suited to treat specific conditions; second, a shortage of PCPs in the United States led patients to obtain primary care services from specialists.
By bypassing the PCP, these patients are often not getting the information they need about vaccine recommendations. What makes this so critical is that these patients are the ones who need the immunizations the most. For example, the CDC recommends that all high-risk adults receive a pneumococcal vaccine and an influenza vaccine yearly. Patients with diabetes and cardiovascular disease, who may routinely see endocrinologists or cardiologists, fall into this category.
“A primary care physician is more likely to assess the need for and to offer and recommend immunizations compared to most specialists,” Gregory Poland, MD, professor of medicine at Mayo Clinic in Rochester, Minn., told Infectious Disease News. “Most subspecialists don’t even think about it. They don’t stock vaccines and they don’t know where to refer the patients. It’s just not part of their culture. I’m not saying that oncologists have to carry tens of thousands of dollars worth of vaccines. But they, and other subspecialists, should be assessing patients and referring them for these services.”
Poland said, for young women, the OB/GYN is often the PCP, and the American College of Obstetricians and Gynecologists has taken a strong stand about immunization. OB/GYNs have especially taken charge of assessing for immunizations in pregnant women. The Archives of Internal Medicine article reported that 3.6% of primary care visits were made to OB/GYNs in 2007.
Because adults may see many different physicians during the year and may not have a PCP, it becomes the job of all physicians to make sure that their patients are up-to-date on their immunizations, Bridges said.
Tan said specialists not only need to recommend a vaccine and refer them to a provider who can administer it, but they also need to follow up with the patient and make sure he or she received the vaccine — to make sure that the loop of care gets closed.
A change of culture
The process to encourage physicians to incorporate adult immunizations into their practice begins in medical school.
“Residents in pediatric programs would never see a patient without assessing their vaccination status, but this assessment is never seen during rounds in an internal medicine program,” Poland said. “That needs to change. If this is the outcome we’re after, then the environment has to be arranged for it to happen. You arrange it by educating not only patients, but also doctors-in-training.”
Physicians already in practice must be educated as well. Patients need the education, too. But you cannot educate one and not the other, or the process will not work, Tan said. Patients must be educated on the vaccines they need. Physicians must be educated so that they are ready to provide the vaccines when their patients inquire about them. PCPs must be ready to give vaccines, and specialists must be ready to talk about the vaccines and refer their patients to receive vaccination.
“We can’t advance one outreach program and not the other,” Tan said. “If you educate the public and the doctors aren’t ready, then there will be a problem. If the doctors are ready and the patients aren’t coming in for the vaccines, then the doctors are going to lose money because the vaccines are biologic and they have a shelf life. They need to be educated at the same time.”
But outreach programs must also reach elected officials to make them aware of the circumstances so that they can introduce legislative solutions that will initiate a comprehensive national adult immunization program, Schaffner said.
Such a program will be the foundation of the infrastructure needed to make adult immunizations a priority, allowing physicians and the patients to be educated. It will also place value on adult immunizations, making insurance coverage better and increasing the knowledge of both patients and providers.
“We have been educating physicians about the importance of vaccines for a while and it hasn’t been receiving a lot of traction,” Tan said. “The reason it has not received a lot of traction is because we haven’t changed the culture. We seriously need to think about changing the culture of adult vaccinations. The pediatric vaccine model is down to a science, and there is no reason that an adult vaccination program can’t mimic that. Physicians and patients need to be convinced that it is important. If they believed it, it would happen.” – by Emily Shafer
For more information:
- CDC. MMWR. 2012;61:1-7.
- CDC. MMWR. 2012;61:66-72.
- Kale MS. Arch Intern Med. 2012;doi:10.1001/archinternmed.2012.3207.
Disclosure: Bridges, Schaffner, Tan and Wexler report no relevant financial disclosures. Poland reports financial relationships with Avianax, CSL Biotherapies, Dynavax, Liquidia Technologies Inc., Merck, NIH, Novartis Vaccines and Diagnostics, Ofstead and Associates, PaxVax Inc., Sanofi Pasteur, TapImmune and Theraclone Sciences.
Are retail-based clinics ideal places for adults to receive their vaccinations?
The array of services offered at retail-based clinics may allow the adult patient to have a better access to vaccinations.
Access to care is extremely important, particularly for those vaccines that would be impossible to give to every patient in a physician’s office, such as the influenza vaccine. The volume of people requiring an influenza vaccine over a short period of time is significant. The more venues available, the more opportunities you have to vaccinate as many people as possible.
The array of services offered at retail-based clinics may allow them to have a better ability to provide vaccinations to some groups of adults. For example, many doctors, particularly those who accept Medicare, may recommend the varicella vaccine, but do not carry the varicella vaccine. Pharmacies tend to have decent vaccine stocks and may be a place for people to receive newer vaccines that are not as familiar to the public. If patients come in for an influenza vaccine, they may receive recommendations for the pneumococcal vaccine or the varicella vaccine. To a certain extent, pharmacies are geared toward selling these vaccines, which isn’t always the case in many doctors’ offices.
The people who are most likely to receive vaccines in retail-based clinics are those who are generally self-motivated and are definitely going to be vaccinated no matter what. The large group of people who are hesitant, but who will be vaccinated if their doctor suggests it, is not the group that is easily reached at these clinics. We know from plenty of data that people actually do better with vaccinations when their doctors tell them to be vaccinated and the doctor is in the position to give the vaccination.
Andrew Eisenberg, MD, MHA, is a family physician, a county health officer and adjunct professor at the Texas A&M School of Rural Public Health. Eisenberg can be reached at email@example.com. Disclosure: Eisenberg reports no relevant financial disclosures.
As an internist, I believe that the medical home is the place to receive vaccinations.
Retail-based clinics are wonderful for giving influenza vaccines because everyone aged 6 months and older needs that vaccination every year, and they all need to be given within a short time frame. When the influenza vaccine is offered in places other than the doctor’s office, it increases the chance that we can get as many people as possible vaccinated before flu season hits.
Sandra Adamson Fryhofer
That said, as an internist, I really believe in the medical home and I believe that the medical home is the best place to receive vaccinations. The American Academy of Pediatrics and the American College of Physicians have argued that all children and adults should have a medical home. When you get your vaccinations at your medical home, you are able to take care of other issues as well. Retail-based clinics can potentially fragment medical care, as these providers don’t have the same relationship with patients as their primary care physicians do. They don’t provide the additional preventive, continuity of care and interventional services that might be needed at any given time.
Drug stores love it because it brings in more traffic into the pharmacy. If they get more people into their store, they are likely going to sell more items. This is not necessarily in the best interest of patients. Primary care physicians are focused on taking care of the patient — not selling — whereas a drug store is a business that is looking at the bottom line.
Sandra Adamson Fryhofer, MD, is an internal medicine physician in private practice and an adjunct associate professor of medicine at Emory University School of Medicine. Disclosure: Fryhofer reports no relevant financial disclosures.