Adult vaccination: How to encourage uptake, overcome barriers

Jack Ende
Sandra A. Fryhofer

Strong encouragement from health care providers to adult patients to seek vaccinations as they age, particularly for vaccine-preventable diseases, such as shingles, pneumonia and influenza, is critical to improving uptake of immunizations.

“As we age, our immune system declines, making older adults more susceptible to serious conditions,” Jack Ende, MD, president of ACP, said in a press release. “Understanding the aging immune system is becoming increasingly important for clinicians because vaccination is an effective solution to overcoming some of this age-related decline in immunity.”

The ACP, along with the American Pharmacists Association and the Gerontological Society of America, recently released a guidebook for health care professionals on educating patients about vaccine-preventable diseases.

The organizations advocate for clinicians to recommend vaccination to adults based on the Advisory Committee on Immunization Practices (ACIP) schedule “at every opportunity.”

Healio Internal Medicine spoke with Sandra A. Fryhofer, MD, internal medicine physician in Atlanta and ACP liaison to ACIP, about the importance of vaccination in adults and how to encourage uptake and overcome barriers. – by Alaina Tedesco

Question: Why is it crucial for older adults to be vaccinated?

Answer: When we think about vaccines, childhood immunizations may first come to mind, but recent mumps outbreaks, such as the one in the National Hockey League, and recent measles outbreaks, such as the one in Disneyland, remind us what happens when kids and adults don’t get vaccinated. In July 2015, the first U.S. measles death in 12 years — in an adult woman — occurred in Washington State.

Each year, thousands of adult Americans get sick or die of vaccine-preventable diseases. As many as 40,000 adults develop, and as many as 4,000 adults die of, invasive pneumococcal disease, both bacteremia and meningitis. The annual death toll for influenza for adults ranges from 3,000 to 49,000 depending on the severity of the flu season.

Adults make up about 9,000 of the pertussis, or whooping cough, cases reported each year. Adults can pass pertussis to others, which can be a death sentence for infants. About 3,000 adults are diagnosed with acute hepatitis B each year. Approximately 1 million adults develop infection and pain from shingles each year.

All these diseases can be largely prevented with appropriate immunization.

Q: What should clinicians know about vaccines recommended in the adult population?

A: There are now at least 13 different vaccines recommended for adults by ACIP. ACIP’s recommendations have been evidence-based since October 2010. Each year, ACIP updates its adult immunization schedule by collating its latest recommendations into an easy-to-use reference guide.

The schedule includes color-coded graphics offering vaccine recommendations based on age, medical and “other indications.” There are special columns for pregnant patients, as well as for patients with immunocompromising conditions, HIV infection and those without a spleen.

It also includes specific recommendations for patients with diabetes, kidney disease, chronic heart, lung and liver disease. Health care personnel and men who have sex with men also have separate columns.

Each vaccine has a corresponding numbered footnote. Footnotes are even more concise this year. Read them slowly and carefully. They also contain electronic links to the more comprehensive ACIP vaccine recommendation statements.

Yellow bars on the graphics mean recommended for adults who meet age requirements, lack documentation of vaccination or lack evidence of past infection. The 2018 Adult Immunization Schedule was published in February in the Annals of Internal Medicine.

The new schedule also includes a preference for the new recombinant shingles vaccine (Shingrix, GlaxoSmithKline) for immunocompetent adults age 50 and older, including those who have received the older live zoster vaccine (Zostavax, Merck and Co.).

Unlike the older live zoster vaccine, the new recombinant zoster vaccine is not live. However, it does contain a brand new adjuvant to increase immune response. Since it is not a live virus vaccine, it may provide an option for immunocompromised patients at high risk for shingles: patients for whom the older live virus vaccine is contraindicated. The adjuvant in it is new and has only been studied in clinical trials, not out in the general population.

Two doses are recommended, at least 2 to 6 months apart. It is also very reactogenic, so patients should expect to get a significant local reaction. The most common reactions were fatigue, muscle aches and pain at the injection site — usually for just a few days.

For those aged 50 years and older, it cut risk of both shingles and post herpetic neuralgia by more than 90%. The vaccine also worked well in older patients and protection seems long-lasting. The major risk factor for shingles is getting older. Both risk and disease severity increase with age, starting at 50 years.

Q: What strategies can primary care providers use to educate their patients on vaccination?

A: Every ACIP recommendation has an accompanying Vaccine Information Statement (VIS) that reviews indications and precautions for each vaccine. Patients need to read them before receiving vaccination. I keep them in alphabetical order in a binder in each exam room. These are available for download at https://www.cdc.gov/vaccines/hcp/vis/current-vis.html.

Q: What are the risks associated with vaccination in older adults?

A: The major risk for adults is not being vaccinated. The ACIP Adult Schedule document in Annals of Internal Medicine also contains a list of contraindications and precautions for each vaccine. In general, live virus vaccines are not indicated for patients with immune system problems.

Q: What barriers come into play in adult vaccination? How can PCPs address these barriers?

A: As the number of new vaccines recommended has increased, so has vaccine price, which can be a financial barrier. Fortunately, ACIP recommendations do have coverage clout with insurance companies. The Affordable Care Act mandates insurance coverage, with no cost sharing, for all Category A and B ACIP recommendations within 1 year after the recommendation is made. This mandate does not apply to Medicare, however.

Current threats to ACA policy may jeopardize coverage of these expensive but lifesaving vaccines. Many pharmacies now offer immunization which helps increase access.

The single most important factor in promoting adult immunization is strong advocacy from a physician.

Disclosure: Fryhofer reports no relevant financial disclosures.

Jack Ende
Sandra A. Fryhofer

Strong encouragement from health care providers to adult patients to seek vaccinations as they age, particularly for vaccine-preventable diseases, such as shingles, pneumonia and influenza, is critical to improving uptake of immunizations.

“As we age, our immune system declines, making older adults more susceptible to serious conditions,” Jack Ende, MD, president of ACP, said in a press release. “Understanding the aging immune system is becoming increasingly important for clinicians because vaccination is an effective solution to overcoming some of this age-related decline in immunity.”

The ACP, along with the American Pharmacists Association and the Gerontological Society of America, recently released a guidebook for health care professionals on educating patients about vaccine-preventable diseases.

The organizations advocate for clinicians to recommend vaccination to adults based on the Advisory Committee on Immunization Practices (ACIP) schedule “at every opportunity.”

Healio Internal Medicine spoke with Sandra A. Fryhofer, MD, internal medicine physician in Atlanta and ACP liaison to ACIP, about the importance of vaccination in adults and how to encourage uptake and overcome barriers. – by Alaina Tedesco

Question: Why is it crucial for older adults to be vaccinated?

Answer: When we think about vaccines, childhood immunizations may first come to mind, but recent mumps outbreaks, such as the one in the National Hockey League, and recent measles outbreaks, such as the one in Disneyland, remind us what happens when kids and adults don’t get vaccinated. In July 2015, the first U.S. measles death in 12 years — in an adult woman — occurred in Washington State.

Each year, thousands of adult Americans get sick or die of vaccine-preventable diseases. As many as 40,000 adults develop, and as many as 4,000 adults die of, invasive pneumococcal disease, both bacteremia and meningitis. The annual death toll for influenza for adults ranges from 3,000 to 49,000 depending on the severity of the flu season.

Adults make up about 9,000 of the pertussis, or whooping cough, cases reported each year. Adults can pass pertussis to others, which can be a death sentence for infants. About 3,000 adults are diagnosed with acute hepatitis B each year. Approximately 1 million adults develop infection and pain from shingles each year.

All these diseases can be largely prevented with appropriate immunization.

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Q: What should clinicians know about vaccines recommended in the adult population?

A: There are now at least 13 different vaccines recommended for adults by ACIP. ACIP’s recommendations have been evidence-based since October 2010. Each year, ACIP updates its adult immunization schedule by collating its latest recommendations into an easy-to-use reference guide.

The schedule includes color-coded graphics offering vaccine recommendations based on age, medical and “other indications.” There are special columns for pregnant patients, as well as for patients with immunocompromising conditions, HIV infection and those without a spleen.

It also includes specific recommendations for patients with diabetes, kidney disease, chronic heart, lung and liver disease. Health care personnel and men who have sex with men also have separate columns.

Each vaccine has a corresponding numbered footnote. Footnotes are even more concise this year. Read them slowly and carefully. They also contain electronic links to the more comprehensive ACIP vaccine recommendation statements.

Yellow bars on the graphics mean recommended for adults who meet age requirements, lack documentation of vaccination or lack evidence of past infection. The 2018 Adult Immunization Schedule was published in February in the Annals of Internal Medicine.

The new schedule also includes a preference for the new recombinant shingles vaccine (Shingrix, GlaxoSmithKline) for immunocompetent adults age 50 and older, including those who have received the older live zoster vaccine (Zostavax, Merck and Co.).

Unlike the older live zoster vaccine, the new recombinant zoster vaccine is not live. However, it does contain a brand new adjuvant to increase immune response. Since it is not a live virus vaccine, it may provide an option for immunocompromised patients at high risk for shingles: patients for whom the older live virus vaccine is contraindicated. The adjuvant in it is new and has only been studied in clinical trials, not out in the general population.

Two doses are recommended, at least 2 to 6 months apart. It is also very reactogenic, so patients should expect to get a significant local reaction. The most common reactions were fatigue, muscle aches and pain at the injection site — usually for just a few days.

For those aged 50 years and older, it cut risk of both shingles and post herpetic neuralgia by more than 90%. The vaccine also worked well in older patients and protection seems long-lasting. The major risk factor for shingles is getting older. Both risk and disease severity increase with age, starting at 50 years.

PAGE BREAK

Q: What strategies can primary care providers use to educate their patients on vaccination?

A: Every ACIP recommendation has an accompanying Vaccine Information Statement (VIS) that reviews indications and precautions for each vaccine. Patients need to read them before receiving vaccination. I keep them in alphabetical order in a binder in each exam room. These are available for download at https://www.cdc.gov/vaccines/hcp/vis/current-vis.html.

Q: What are the risks associated with vaccination in older adults?

A: The major risk for adults is not being vaccinated. The ACIP Adult Schedule document in Annals of Internal Medicine also contains a list of contraindications and precautions for each vaccine. In general, live virus vaccines are not indicated for patients with immune system problems.

Q: What barriers come into play in adult vaccination? How can PCPs address these barriers?

A: As the number of new vaccines recommended has increased, so has vaccine price, which can be a financial barrier. Fortunately, ACIP recommendations do have coverage clout with insurance companies. The Affordable Care Act mandates insurance coverage, with no cost sharing, for all Category A and B ACIP recommendations within 1 year after the recommendation is made. This mandate does not apply to Medicare, however.

Current threats to ACA policy may jeopardize coverage of these expensive but lifesaving vaccines. Many pharmacies now offer immunization which helps increase access.

The single most important factor in promoting adult immunization is strong advocacy from a physician.

Disclosure: Fryhofer reports no relevant financial disclosures.