The “State” of
Adult Immunizations
Maria C. Lanzi, ANP, MPH
Impact of Vaccines in the
20th and 21st Centuries
Disease 20th C Annual
Morbidity
2010 Reported
Cases
% Decrease
Smallpox 29,005 0 100%
Diptheria 21,053 0 100%
Pertusus 200,752 21,291 89%
Tetanus 580 8 99%
Impact of Vaccines in the
20th and 21st Centuries
Disease 20th C Annual
Morbidity
2010 Reported
Cases
% Decrease
Polio
(paralytic)
16,316 0 100%
Measles 530,217 61 >99%
Mumps 162,344 2,528 98%
Rubella
47,745 6 >99%
Impact of Vaccines in the
20th and 21st Centuries
Disease 20th C Annual
Morbidity
2010 Reported
Cases
% Decrease
CRS 152 0 100%
H. Flu (<5
years of age)
20,000 (est) 270 99%
Pre-Vaccine versus Current Estimated
Annual Morbidity
Disease Pre-Vaccine Era
2008 Estimates
% Decrease
Hepatitis A 117,333 11,049 91%
Hepatitis B (acute)
66,232 11,269 83%
Varicella 4,085,120 449,363 89%
Pre-Vaccine versus Current Estimated
Annual Morbidity
Disease Pre-Vaccine Era
2008 Estimates
% Decrease
Pneumococcus
(invasive), All
ages
60,067 44,000 30%
Pneumococcus
(invasive), < 5yo
16,069 4,167 74%
Rotovirus
(hospitalizations
< 5 yo)
62,500 7,500 88%
Immunizations are recommended throughout life to prevent infectious diseases and their sequalae
Adult vaccines target different populations based on age, medical conditions, behavioral risk factors, occupation and travel.
Between 40,000 and 50,000 adults die in the United States annually from Vaccine Preventable Diseases
Direct health care burden of VPD, annually, $10 Billion
Kill more Americans each year than traffic accidents, breast cancer or HIV/AIDs
Adult Immunizations
• Each year, on average: – 36,000 Americans die of seasonal flu and it’s complications;
most are 65 or older • More than 200,000 hospitalizations
– 5,000 Americans die from invasive pneumonia (more than 50% of those are age 65 and over)
• Together, Influenza and Pneumonia are the 5th leading cause of adult deaths
Impact of VPD
– Approximately 20 million Americans 15-49 yo are currently infected with HPV • 6.2 million new cases year year
– More than 1 million adults get shingles each year • 1 in 3 Americans will get shingles in their lifetime
– More than 1 million Americans have chronic HBV infection • HBV related liver disease kills about 5,000 annually and costs
about $700 million annually in health care and productivity related costs
Impact of VPD
Incomplete Vaccination
Never completed series
New Vaccines that didn’t exist when child
Waning Immunity
Travel
Immigrants, including international adoptions
Refugees
Short Term Transit, including students (MMR)
Incidence Contributing Factors
Influenza Measles/Mumps/Rubella Hepatitis A Pneumococcal Hepatitis B
Tetanus/Diphtheria/Pertussis HPV Varicella Meningococcal Zoster
Adult Immunizations current CDC recommendations
Influenza 18-64yo; pregnant women 80%
18-64yo high risk; >=65 90%
HCP 90%
Pneumococcal persons >=65yo 90%
High risk persons 18-64yo 60%
Herpes Zoster 30%
HBV (for HCP) 90%
Healthy People 2020 Targets reduce incidence of VPD
Influenza “Old Man’s Friend”
•Overall 38.8% •HCP 66.9%
• Physicians: 85.6% • Nurses: 77.9% • All other: 62.8%
•Pregnant Women: 47% •New Jersey: 42.8%
Adult Vaccination Coverage 2011
“Captain of the Men of Death”
Pneumococcal: • High risk 19-64 year old: 20.1% overall
1.6% increase from 2010
• Adults aged >=65 year old: 62.3% overall 2.6% increase from 2010
New Jersey >=65 year old: 63.5%
Adult Vaccination Coverage 2011
Hepatitis B (2011: DM <60yo)
High risk adults’ data was not collected
Adults aged 19-49 not at high risk: 35.9%
Diabetics aged 19-59: 26.9%
Diabetics >=60 years: 12.4%
HCP overall: 63.8%
Adult Vaccination Coverage 2011
Herpes Zoster
Age >=60 years: 15.8%
Just under 2% of those 60 and older have had shingles
vaccine
Adult Vaccination Coverage 2011
• Tetanus (any tetanus toxoid –Td or Tdap) • Adults aged 19-64: 64.5% overall
• Age 50-64: 69.3%
• Age >=65: 54.4%
• Tdap specific: • Adults aged 19-64: 12.5%
• HCP 26.8% 2.1% of eligible adults had a Tdap in previous 2 years
HCP regardless of age, should receive a single dose Tdap if not previously had one
Adult Immunization Coverage 2011
Hepatitis A
Age 19-49: 12.5%
International Travel:
high endemic areas: 20.1%
low endemic areas: 8.4%
Chronic Liver Conditions: 17.1%
Adult Vaccination Coverage 2011
• HPV
• Women aged 19-26 >=1 dose: 29.5%
• Men aged 19-26 >=1 dose: 2.1%
• Only 10% of eligible adult women (18-26) had HPV vaccine
Adult Vaccination Coverage 2011
Difference between 2010 and 2011 overall
Non influenza adult vaccination coverage was similar to
2010 except for modest increase in Tdap vaccination
overall and HPV vaccination among women
Adult Vaccination Coverage
• MMR • Documented titers
• Meningococcal • Asplenia, persistent complement component deficiencies,
HIV, high risk exposure
• Varicella
• Written documentation of 2 doses
• most common VPD reported on cruise ships
Adult Vaccines
Special Populations - HCP
• MMR • Measles: Western Europe, Asia, Southeast Asia, the
South Pacific and Africa
• In 2011 40% of US measles cases resulted from international
travel
• Meningococcal • African meningitis belt
• Saudi Arabia: Hajj
• Poliomyelitis
• Nigeria, Pakistan, Afghanistan,
Adult Vaccines
Special Populations - Travel
Japanese Encephalitis
Rabies
Tick Borne Encephalitis (non US)
Typhoid
Yellow Fever
Adult Vaccines
Special Populations - Travel
Limited Access Adult Vaccines are not required (outside of institutions)
HCP: Influenza, Hepatitis B, Measles/Mumps/ Rubella, Tetanus/Diphtheria/Pertussis, Varicella
Limited Care Lack of stress on prevention/primary care/“well adult visits”
Limited Financing Insurance coverage
Medicare: Influenza, Pneumococcal, HBV (high risk)
Barriers to Increasing Immunization
Education Awareness
Reluctance to discuss Risk Behaviors and STD
Misinformation on safety and effectiveness
Cultural and unsubstantiated biases HCP, disparity between racial groups
Waning Immunity
Notification and Tracking Registry-like information
Information sharing across different providers
Barriers to Increasing Immunization
Patient Education Community Education
Standing Orders Hospital discharge Home visits
Reminders Computerized, phone, chart, mail
Expanding Access Increasing convenience, non traditional delivery
Personal Health Records
Strategies to Increase Rates
CDC: MMWR: Adult Vaccination Coverage – US, 2010; 2/3/2012 CDC: MMWR: Non-influenza Vaccination Coverage Among Adults – US 2011; 1/29/2013 CDC:MMWR: Influenza Vaccination Coverage Among Pregnant Women — 2011–12 Influenza Season, US; 11/28/12 CDC Health Information for International Travel 2012 CDC Adult Vaccination Resources for Healthcare Providers CDC Strategies for Increasing Vaccination Rates Adult Immunization: Shots to Save Lives 2010
Citations
New Jersey Behavioral Risk Factor Survey: Summary Report
“USE OF CLINICAL PREVENTIVE SERVICESIN NEW
JERSEY (2): IMMUNIZATION AND HORMONE
REPLACEMENT STATUS OF OLDER ADULTS. September
2000 Volume 4
Centers for Medicare and Medicaid Services: Immunizations
JAMA. 2007; 298(18):2155-2163
Forbes.com 2/19/2013: How Vaccines Have Changed Our
World In one Graphic
Citations
Super Storm Sandy:
Immunization Recovery
Suzanne Courtwright, MS, APRN-C
Director, New Jersey Immunization Network
Hurricane Sandy hits NJ Oct. 29,2012
www.abcnews.com
Trenton, NJ – Governor Chris Christie today announced a total assessment of the damage sustained from Hurricane Sandy to the State of New Jersey, which places the total cost at $36.9 billion.
Christie Administration Releases Total
Hurricane Sandy Damage Assessment
of $36.9 Billion
Wednesday, November 28, 2012
Health Care Costs: $291.8 million Businesses: $8.3 billion
American Academy of Pediatrics
New Jersey Chapter---
Membership Survey: “Sandy Recovery”
Goal:
• Assess affect on vaccine supply and loss
• Identify strategies used in 2012 to avoid vaccine loss
• Understand need for future comprehensive vaccine protection plan
• Identify best practices for vaccine
protection
Funded by the AAP Friends of Children Fund
American Academy of Pediatrics
New Jersey Chapter---
Membership Survey: “Sandy Recovery”
• 1,700 + members surveyed
• Survey Monkey
• 177 members responded
Survey Results:
Loss of childhood vaccines
• Nearly 20% practices who responded reported loss of vaccines 34/177 (19.2%)
• 7.4% practices who responded reported 100% loss of all vaccines (13/177)
Survey Results: Financial Hardship on Pediatric Practices
• 1 in 2 practices experienced financial hardship as a direct result of Hurricane Sandy (54.4%)
• Only 1 in 5 reported recovering financial losses as a result of adequate insurance (19.6%)
• 14 practices reported an actual dollar amount of estimated loss (totaling $409,600, approximately $30K on average)
Survey Results:
Disaster Preparedness in 2012
Plan # Practices % Practices
Vaccine Disaster Preparedness Plan 55 31
Generator 14 7.9
Off -Site Storage 17 9.6
Off-Site Storage (Professional) 9 5
Off-Site Storage (Home/Employee/Friend) 5 2.8
No Plan 3 1.6
Good Luck/Good Fortune 4 2.3
Survey Results:
Disaster Preparedness: Future
#Practices %Practices
Formal Vaccine Preparedness Plan 19 10.7
Generator in Office 55 31
Move Vaccines Off-Site 15 8.5
Not Sure 2 1.1
Nothing Different 20 11.2
Medical Building: Town should make it a priority to supply a generator
3 1.7
Demonstrated need for
Emergency Vaccine Management Plan
Vaccine Storage & Handling Toolkit
http://www.cdc.gov/vaccines/recs/storage/toolkit/storage-handling-toolkit.pdf
November 2012
Vaccine Storage & Handling Toolkit
http://www.cdc.gov/vaccines/recs/storage/toolkit/storage-handling-toolkit.pdf
Vaccine Storage & Handling Toolkit
http://www.cdc.gov/vaccines/recs/storage/toolkit/storage-handling-toolkit.pdf
CDC Recommended Best Practices:
Emergency Vaccine Retrieval &
Storage Plan
• Every site should have a written plan
• Provides up-to-date information on procedures to follow for vaccine protection
• Post near vaccines
• Ensure staff familiarity with it
• Review with staff quarterly
• Review the plan for updates at least annually
• Implement in advance of the event
http://www.cdc.gov/vaccines/recs/storage/toolkit/storage-handling-toolkit.pdf
CDC Recommended Best Practices:
Emergency Vaccine Retrieval &
Storage Plan Outlines:
• Personnel
• Equipment
• Information
• Protocols
http://www.cdc.gov/vaccines/recs/storage/toolkit/storage-handling-toolkit.pdf
CDC Recommended Best Practices:
Emergency Vaccine Retrieval &
Storage Plan 1. Designated primary & alternate vaccine
coordinators with emergency contact info 2. Emergency staff contact list in order of contact
preference 3. Vaccine storage unit specifications 4. Alternate vaccine storage facility(ies) 5. Written protocols, vehicles, & drivers for
transporting vaccines to and from alternate facility
http://www.cdc.gov/vaccines/recs/storage/toolkit/storage-handling-toolkit.pdf
CDC Recommended Best Practices:
Emergency Vaccine Retrieval &
Storage Plan
6. Written instructions for entering facility & vaccine storage spaces in an emergency if building is closed.
7. Appropriate packing materials to safely transport or temporarily store vaccines.
8. Written protocol for vaccine packing.
http://www.cdc.gov/vaccines/recs/storage/toolkit/storage-handling-toolkit.pdf
http://www.cdc.gov/vaccines/recs/storage/toolkit/storage-handling-toolkit.pdf
Thank you!