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Adult immunization rates still lagging
Systems-based approaches and nontraditional immunization settings can help increase adult vaccination rates.
Adult immunization rates have reached a plateau and are substantially below immunization goals, according to Kristin L. Nichol, MD, MPH.
Childhood immunization has been extraordinarily successful; 90% or more of children entering kindergarten have received recommended vaccinations. However, adult immunization rates with influenza and pneumococcal vaccine are far below the Healthy People 2010 goals, Nichol said.
“If we look at burden of disease only defined as death, 99% of vaccine-preventable deaths occur in adults, and most are due to pneumococcus or influenza,” Nichol, chief of medicine at the Minneapolis VA Medical Center and a professor of medicine at the University of Minnesota, said at the 41st Annual National Immunization Conference, held recently in Kansas City, Mo.
Suboptimal rates in adults
Mortality associated with vaccine-preventable illness remains high among adults. Nichol presented a summary of annual deaths in 2000 due to a variety of diseases. Vaccine-preventable illness topped the list, followed by colorectal cancer, breast cancer, prostate cancer, suicide, Parkinson’s disease, HIV and vaccine-preventable deaths in children.
She identified several challenges associated with adult immunization. Education is key, according to Nichol, and providers must make sure to recommend immunization to patients. Several studies found that recommendation by a health care provider can overcome a patient’s negative attitudes toward immunization, and the patient is more likely to receive vaccine when recommended.
“It is also important we all recognize how important provider recommendation is, even among patients who have negative attitudes toward immunization for influenza and pneumococcus. If the patients recalled provider recommendations, they were more likely to be immunized,” Nichol said. “If the patients didn’t receive recommendations, they were unlikely to be immunized. Provider recommendations can overcome negative attitudes.”
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Evaluating the system is also important, Nichol said. Feedback provides a way to monitor the quality of the setting providing immunization and the ability to improve upon it. Providers should also consider alternate settings to help increase immunization among adults.
Perhaps most importantly, according to Nichol, providers should be encouraged to implement strategies, approaches and systems for immunization in the clinic setting. In addition, providers should set an example by getting immunized as well.
“If we practice what we preach, not only do we protect ourselves and our patients, but we are more likely … to immunize our patients,” Nichol said.
Several evidence-based reviews analyzed the best strategies for enhancing adult immunization rates. Systems-based approaches, such as increasing immunization demand among patients, enhancing access with walk-in clinics and reduced-cost vaccines and patient reminders, can help increase community immunization rates, according to Nichol.
Determining systems approaches and strategies and then implementing them is a multifaceted approach, Nichol said. Increased vaccine demand, enhancing access and other barriers are usually addressed as a package.
Challenges and solutions
Nichols said that providers are not implementing these approaches as often as they should. In one survey, only 75% to 80% of providers acknowledged or indicated that they recommend immunization to their patients. She said that there is room for improvement, and there are opportunities to become involved with providers.
It is not easy to implement these systems-based approaches in the practice setting, according to Nichol. Vaccination requires time and resources, both of which are challenging for many providers. About one-third of patients visit a practitioner who has a solo practice, and another third of patients visit a small practice that has two to four physicians.
“I think as we work with groups working with systems-based aproaches, we need to be sensitive to this issue of size and [question whether] they in fact have the resources. Some [providers] do not have a [registered nurse] on site that can do the independent assessment and offer the vaccine,” Nichol said.
Another challenge remains, Nichol said. Although studies have shown that these systems-based approaches work for improving immunization rates in traditional settings, not all patients seek medical care in the traditional setting; 20% to 30% of adults do not have a personal provider.
Less than half of adults aged 18 to 49 receive influenza vaccine at a traditional physician’s office, and about half of people aged 50 to 65 receive vaccine at the physician’s office.
“All of the other places [where vaccines are administered] I would lump together as nontraditional,” Nichol said.
There are many places that are considered nontraditional settings, and they have a number of potential advantages, such as easy access for patients and inexpensive vaccines, she said.
Nontraditional settings are also very important in the delivery of vaccines to patients, and that is good news, according to Nichol. The health department in Minnesota recognized the importance of nontraditional settings and developed a mark of excellence program that certifies nontraditional providers that handle vaccination, she said. In addition, the American Medical Association has published guidelines for quality.
Another challenge is timing for immunization demand. The demand for vaccines tends to fall after the first few weeks of immunization and drops after Thanksgiving, according to Nichol, and it is important to sustain immunization into December.
It is also important to eliminate racial disparities, Nichol said. Racial disparities associated with immunization among children have been addressed, but the disparities still exist among adults.
“Remember, patients are the focus. We’ve heard about value-driven health care, and the value ultimately is defined by patients. We should be working to help empower them to go where it is convenient for them to go to get immunized and get high-quality, low-cost vaccine from a provider they trust,” Nichol said. – by Lauren Riley
For more information:
- Nichol K. Adult immunization strategies. Presented at: The 41st National Immunization Conference; March 5-8, 2007; Kansas City, Mo.