Adult Immunizations Carolyn B. Bridges, MD

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1 Adult Immunizations Carolyn B. Bridges, MD Immunization Services Division National Center for Immunization and Respiratory Diseases CDC November 2012 National Center for Immunization & Respiratory Diseases Immunization Services Division

2 Burden of Selected Diseases in Adults Vaccinations needed throughout lifespan to reduce burden of diseases for which vaccines are available High burden of these among adults in the United States 9,419 cases of acute hepatitis B in ,500 cases invasive pneumococcal disease (IPD) in 2009, including ~5,000 deaths 85% of IPD and nearly all IPD deaths among adults Over 27,000 cases of pertussis reported in US in ,640 among adults, 4% of which are hospitalized Currently in resurgence of pertussis About 1 million cases of zoster annually U.S. 1. CDC. Active Bacterial Core Surveillance Huang et al. Vaccine NNDSS 4. Thompson AJPH CDC. Prevention of Herpes Zoster. MMWR (RR-5): p. 1-30

3 2012 ACIP Adult Immunization Schedule, Age-Based Recommendations -- Update anticipated early February 2013

4 2012 ACIP Adult Immunization Schedule: Medical, Occupational and Behavior-Based Recommendations Update anticipated early February 2013

5 Vaccination coverage for target groups by vaccine, age, and high-risk status, NHIS 2010* Age Based *Data source: 2010 National Health Interview Survey. CDC. Adult Vaccination Coverage United States, MMWR 2012; 61(04);66-72.

6 Coverage for vaccines recommended for older adults, NHIS 2010* Vaccine Coverage % Influenza (65+) 66.4% (CI ) Pneumococcal (ppv23) (65+) 59.7% (CI ) Zoster (60+) 14.4% (CI )** *Data source: 2010 National Health Interview Survey. CDC. Adult Vaccination Coverage United States, MMWR 2012; 61(04); ** Statistically higher than 2009 coverage rates

7 Seasonal Influenza Vaccination Coverage by Race/Ethnicity: Seasons, BRFSS and NIS Group (%) (%) (%) 2 Race/ethnicity (adults) White, non-hispanic Black, non-hispanic Hispanic Race/ethnicity (children) White, non-hispanic Black, non-hispanic Hispanic BRFSS estimates, (19 states for children; 43 states plus DC for adults) online at: and CDC, unpublished 2. BRFSS and NHFS estimates, ; BRFSS and NIS estimates, , both years for 50 states plus DC for children, 43 states plus DC for adults. In press, MMWR, June 10, 2011

8 Influenza Vaccination Coverage Among Adults Years who Reported Selected Chronic Conditions, BRFSS CDC, Preliminary unpublished data, 2012

9 Summary: Effective Strategies to Increase Adult Vaccination Coverage Intervention Reducing client out-of-pocket costs for vaccinations Client reminder/recall systems Community-based interventions when implemented in combination Provider reminder systems when used alone Provider assessment and feedback Standing orders Health care-based interventions when implemented in combination Worksite interventions with on-site, reduced-cost, actively promoted influenza vaccinations Population Adults Adults Adults Adults Adults Adults Adults Adults, healthcare personnel Summary from Megan Lindley, Jan 2012

10 Meta-Analysis of Interventions to Increase Use of Adult Immunization Intervention Odds Ratio* Organizational change (e.g., standing orders, separate clinics devoted to prevention) 16.0 Provider reminder 3.8 Provider education 3.2 Patient financial incentive 3.4 Patient reminder 2.5 Patient education 1.3 *Compared to usual care or control group, adjusted for all remaining interventions Stone E. Ann Intern Med 136:641-51, 2002

11 Percent Influenza vaccination coverage among pregnant women by provider recommendation and offer, mid-november Offer 37.5 No offer 10.1 Recommendation No recommendation

12 Adult Vaccination Opportunities Even before Affordable Care Act (ACA), 80% of adults insured Medicare and Medicaid include coverage of some vaccines for adults Influenza, pneumococcal vaccine, Hepatitis B for high risk, Td as part of wound care management Medicaid varies by state ACA expected to reduce the number of adults uninsured for vaccines 317 Program Requirement to address lagging coverage among children, adolescents AND adults Funds previously used for insured children might be available for adult vaccine purchase AIM program committee taking up adult immunizations issues Increasing state coverage data to be come available for adults through BRFSS Influenza and pneumococcal vaccine every year Questions on Tdap vaccination, zoster vaccination, and place of influenza vaccination to be rotated every 3 rd year starting in 2013 Increased access to vaccines at workplaces, retail locations, pharmacies Adult PPHF cooperative agreements in 10 immunization programs Increasing interest in adult immunizations from private and public sectors

13 Place of Influenza Vaccination Among Adults United States, Season, BRFSS Survey MMWR June 17, 2011

14 2011 & 2012 Prevention and Public Health Fund Program Area 5, Adult Immunization Awardees ME Total awardees funded: 10 FY 2011 PPHF Program Area 5 Awardees (AR, CT, MA, MN, WA) FY 2012 PPHF Program Area 5 Awardees (Chicago, IA, OR, UT, VA)

15 Cooperative Agreements to Plan and Implement Adult Immunization Programs: PPHF Program Area 5 Focus: implementing adult immunization programs to improve transition to environment of expanded insurance coverage for adult immunizations Two required activities: Collaborate with employers to improve immunization among employees Collaborate with pharmacies to improve immunization among adult customers Two of five optional activities: Expand adult immunization at community health centers Improve health care worker immunization rates Promote hepatitis B immunization at local HD and STD clinics Ensure all adult ACIP-recommended immunizations are included as preventative benefits by state Medicaid offices Improve influenza and pneumococcal vaccination at hospital discharge among patients

16 PPHF Program Area 5: Plan and Implement Adult Immunization Programs Awardees: 2011 five awardees initially funded: Arkansas, Connecticut, Massachusetts, Minnesota, Washington 2012 five additional awardees funded: Funding: Chicago, Iowa, Oregon, Utah, Virginia ~$11M total (range ~$400K $1.8M) Emphasis on Promoting evidence-based interventions Improving systems Sustainable benefits

17 Pharmacy: all 10 awardees Employer: all 10 awardees Overview by Initiative Community Health Centers: 7 awardees (AR, Chicago, MA, MN, OR, UT, WA) Healthcare personnel: 6 awardees (AR, CT, MN, OR, IA, UT) Hepatitis B immunization: 3 awardees (CT, WA, VA) ACIP-recommended vaccines part of state Medicaid: 3 awardees (IA, MA, VA)

18 National Adult Immunization Summit (NAIS) Initiated in May 2012 to Provide forum for adult immunization stakeholder organizations to identify specific actions that will lead to improvements in adult vaccine uptake E.g. reducing barriers for payment, increasing access to vaccines and vaccinators, and increasing awareness of adult immunization recommendations Development of NAIS structure and agenda included AIM and several immunization programs and many other stakeholders Five working groups working on implementation of specific priority actions identified by the NAIS Patient Education Provider Education Access and Collaboration Quality and Performance Measures Education and promotion of adult immunization to decision-makers (no federal participants) HHS Interagency Adult Immunization Task Force, led by Dr. Howard Koh, Assistant Secretary for Health Same first 4 working groups as NAIS Share updates to ensure coordination Second NAIS planned for May 2013 in Atlanta

19 Examples of NAIS Activities Underway Inventory of adult immunizations educational materials from large number of sources On Immunization Action Coalition website at Working on a searchable database Developing adult immunization calendar Multiple pulse-points during the year to promote adult immunizations Drafting of a revision to the 2003 Adult Immunization Standards Recognizes change in adult immunization neighborhood, ACA, etc. and need for provider recommendation Compiling stories of people affected by adult vaccine preventable diseases Re-launch of new and improved influenza vaccine finder which will soon add adult vaccine finder anticipated January 2013 Led by Boston Children s Hospital Funding from NVPO Collaboration with NAIS and AITF on website content and provider group communications

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21 Adult Immunizations Tear Sheets

22 Adult Immunizations Tear Sheets

23 Adult Immunizations Prescription Pad Adult Immunizations Posters Available soon at Public Health Foundation online store (

24 Adult and Influenza Immunization-related Activities Affordable Care Act First $ coverage for ACIP rec vaccines Meaningful Use Health IT Medicaid bump-up 317 Pandemic Planning Grantees = Grantee Adult Immunization-related objectives Hepatitis B Coags n=14 School-located vaccination coags n=6 Interagency Task Force on Adult Immunizations Pandemic Preparedness and Exercises Barcoding and IIS Economics of Adult Immunization - HSREB Adult PPHF Coags n=10 NVPO CDC ISD NCIRD Vaccine SME s NCIRD/OD Influenza Coord Unit NCHHSTP NCCDPHP - Chronic OPHPR NCEZID NQF HCP Flu Vaccine Measure - HSREB National Adult Immunization Summit National Medical, Pharmacy and Nursing Organizations, e.g. AMA, ACP, AAFP, ANA, APhA, NACDS, etc. Adult Provider Organization Coags n=2 Vaccine manufacturers and distributors Advocacy Groups, e.g. IAC, NFID, IDSA, GSA, ADA, ACC State and local health department organizations, e.g. Immunization programs, AIM, NACCHO, ASTHO, Adult Coordinators Adult and Influenza Vaccine Coverage Assessment and Reporting ACIP Adult Immunization Schedule Standing Orders Project - HSREB Adult Provider Survey - HSREB

25 Conclusions Adults suffer a high burden from disease for which vaccines are recommended and coverage is low Adult immunization schedule and coverage estimates will be updated last week in January 2013y A number of opportunities exist to raise awareness of adult immunizations and increase provider recommendations for adult vaccination Ongoing, sustained, multifaceted effort needed with wide range of partners working together with public health

26 Thanks to many colleagues at CDC, HHS, NAIS, and State and Local Health Departments for their hard work on behalf of adult immunizations. Questions can be sent to