Carolyn B. Bridges, MD

Immunization Services Division National Center for Immunization and Respiratory Diseases

CDC

November 2012

Adult Immunizations

National Center for Immunization & Respiratory Diseases

Immunization Services Division

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 2009

43,500 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 2010

• 6,640 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. http://www.cdc.gov/abcs/reports-findings/survreports/spneu09.pdf

2. Huang et al . Vaccine 2011

3. 2009 NNDSS

4. Thompson AJPH 2009

5. CDC. Prevention of Herpes Zoster. MMWR 2008. 57(RR-5): p. 1-30

2012 ACIP Adult Immunization Schedule, Age-Based Recommendations --

Update anticipated early February 2013

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

Vaccination coverage for target groups by vaccine, age, and high-risk status, NHIS 2010*

*Data source: 2010 National Health Interview Survey. CDC. Adult Vaccination Coverage — United States, 2010. MMWR 2012; 61(04);66-72.

Age Based

Coverage for vaccines recommended for older adults, NHIS 2010*

*Data source: 2010 National Health Interview Survey. CDC. Adult Vaccination Coverage — United States, 2010. MMWR 2012; 61(04);66-72. ** Statistically higher than 2009 coverage rates

Vaccine Coverage %

Influenza (65+) 66.4% (CI 64.4 – 68.5)

Pneumococcal (ppv23) (65+) 59.7% (CI 58.0 – 61.4)

Zoster (60+) 14.4% (CI 13.7 – 16)**

1. BRFSS estimates, (19 states for children; 43 states plus DC for adults) online at:

http://www.cdc.gov/mmwr/PDF/wk/mm5839.pdf and CDC, unpublished

2. BRFSS and NHFS estimates, 2009-10; BRFSS and NIS estimates, 2010-11, both years for 50 states plus DC for

children, 43 states plus DC for adults. In press, MMWR, June 10, 2011

Seasonal Influenza Vaccination Coverage by Race/Ethnicity: 2008-09 -- 2010-11 Seasons, BRFSS and NIS

Group 2008-09 (%) 1 2009-10 (%) 2 2010-11 (%) 2

Race/ethnicity (adults)

White, non-Hispanic 39.7 43.8 43.3

Black, non-Hispanic 26.8 31.3 34.9

Hispanic 25.6 30.6 32.4

Race/ethnicity (children)

White, non-Hispanic 24.9 42.5 46.3

Black, non-Hispanic 20.0 35.5 47.9

Hispanic 18.4 43.9 55.3

Influenza Vaccination Coverage Among Adults 18-64 Years who Reported Selected Chronic Conditions,

BRFSS 2007–2011

CDC, Preliminary unpublished data, 2012

Summary: Effective Strategies to Increase Adult Vaccination Coverage

Intervention Population

Reducing client out-of-pocket costs for vaccinations Adults

Client reminder/recall systems Adults

Community-based interventions when implemented in combination

Adults

Provider reminder systems when used alone Adults

Provider assessment and feedback Adults

Standing orders Adults

Health care-based interventions when implemented in combination

Adults

Worksite interventions with on-site, reduced-cost, actively promoted influenza vaccinations

Adults, healthcare personnel

Summary from Megan Lindley, Jan 2012

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

Influenza vaccination coverage among pregnant women by provider recommendation and offer, mid-November 2011

75.0

37.5

10.1 0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

Offer No offer

Recommendation No recommendation

Pe

rce

nt

http://www.cdc.gov/flu/professionals/vaccination/pregnant-women.htm

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 3rd 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

Place of Influenza Vaccination Among Adults – United States, 2010-11 Season, BRFSS Survey

MMWR June 17, 2011

2011 & 2012 Prevention and Public Health Fund Program Area 5, Adult Immunization Awardees

ME

FY 2011 PPHF Program Area 5 Awardees (AR, CT, MA, MN, WA)

FY 2012 PPHF Program Area 5 Awardees (Chicago, IA, OR, UT, VA)

Total awardees funded: 10

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

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:

• Chicago, Iowa, Oregon, Utah, Virginia

Funding: ~$11M total (range ~$400K−$1.8M)

Emphasis on Promoting evidence-based interventions

Improving systems

Sustainable benefits

Overview by Initiative

Pharmacy: all 10 awardees

Employer: all 10 awardees

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)

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

Examples of NAIS Activities Underway

Inventory of adult immunizations educational materials from large number of sources On Immunization Action Coalition website at http://www.immunize.org/adult-vaccination/resources.pdf

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

http://flushot.healthmap.org/

Adult Immunizations Tear Sheets

http://www.cdc.gov/vaccines/hcp/patient-ed/adults/index.html

Adult Immunizations Tear Sheets

http://www.cdc.gov/vaccines/hcp/patient-ed/adults/index.html

Adult Immunizations Posters Adult Immunizations Prescription Pad

Available soon at Public Health Foundation online store (http://bookstore.phf.org/)

Adult and Influenza Immunization-related Activities

CDC

ISD NCIRD Vaccine SME’s

NCIRD/OD Influenza Coord Unit

NCHHSTP NCCDPHP - Chronic

OPHPR NCEZID

National Adult Immunization

Summit National Medical,

Pharmacy and Nursing

Organizations, e.g. AMA, ACP, AAFP,

ANA, APhA, NACDS, etc.

Vaccine manufacturers and distributors

Adult Provider Organization Coags n=2

State and local health department organizations,

e.g. Immunization programs, AIM, NACCHO, ASTHO, Adult

Coordinators

317 Grantee Adult Immunization-related

objectives

317 Pandemic Planning Grantees = 64

Advocacy Groups, e.g. IAC, NFID, IDSA, GSA, ADA, ACC NVPO

Adult PPHF Coags n=10

Hepatitis B Coags n=14

School-located vaccination coags n=6

Adult and Influenza Vaccine

Coverage Assessment and

Reporting

Standing Orders Project - HSREB

ACIP Adult Immunization

Schedule

Barcoding and IIS

Pandemic Preparedness and Exercises

Interagency Task Force on Adult Immunizations

Adult Provider Survey - HSREB

Economics of Adult

Immuniza-tion - HSREB

NQF HCP Flu Vaccine

Measure - HSREB

Affordable Care Act • First $ coverage for

ACIP rec vaccines • Meaningful Use • Health IT • Medicaid bump-up

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

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 cbridges@cdc.gov