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Course: Immunization of Older Adults Return to Course Outline

Immunization of Older Adults

Practice standards can address this public health need

Learning Objectives
After reading this article, the learner will be able to:
1. Identify the need for older adults to receive four major vaccines recommended by national advisory guidelines and regulatory organizations.
2. Explain the adult immunization goals from the Healthy People 2020 initiative for at least two of the recommended vaccinations.
3. Delineate at least three reasons for low vaccination rates in older adults in the United States and identify solutions to mitigate these.

Age-related illnesses are a growing economic and societal burden within the United States and other developed countries. Approximately 40,000 to 50,000 Americans die annually from preventable illnesses related primarily to influenza and pneumonia.1,2 Approximately 95% of these deaths occur in the adult population, most often adults older than 65.3,4

Laws and policies related to pediatric immunization programs, such as Vaccines for Children, demonstrate the near universal agreement that children should be protected from diseases through private and public funding sources.5 These programs and others have led to a near 90% immunization rate among children entering school.5 While universal pediatric immunization is considered vital to public health, immunization of the adult population is not viewed with the same urgency. It should be.

Advancements in technology and specialized disease treatments have helped ensure an enhanced quality of life, increased life expectancy, and survival. Hand washing, perhaps the single most effective factor in disease control, is closely followed in importance by disease prevention through the use of vaccines. Economic benefits of these measures have demonstrated improved population health and are factors incorporated in the ongoing goals for the Healthy People 2020 initiative.

Additionally, the emergence of advanced practice providers and retail health clinics has made it easier to obtain vaccines. Why, then, are adults still not receiving vaccinations against preventable diseases?

Historical Perspective

Often in our nation's history, the need to address the health of the general public and future generations has led to significant alterations in healthcare delivery. The introduction of the Salk and Sabin polio vaccine in the 1960s significantly benefited the health of millions of children.6 Since that time, newer vaccination efforts have emerged to address different age groups and disease processes, saving billions in healthcare dollars and reducing disease burden.

When the Advisory Committee for Immunization Practices (ACIP) formed in 1964, its goal was to evaluate research evidence on immunizations and vaccines for prevention and disease control.6 Throughout its history, the ACIP has made vaccine recommendations for both children and adults. For years, emphasis has been on the benefits of immunization practices for the pediatric population. However, with the aging of Americans and results of the 2010 census highlighting the growth of the population older than 65, disease prevention in older adults has emerged as an important focus.

Healthy People 2020

The Healthy People 2020 goal for adult influenza immunization is at 90%.1,7,8 Currently, only 68% of adults 65 and older have received the vaccine, falling far short of the goal.5 Significant gaps remain in immunization rates for all 15 vaccines currently recommended by ACIP for adults, causing escalating concern among public health officials.5

Pneumonia, one of the most deadly preventable diseases among older adults, can be prevented with a number of available vaccines. However, only 60% of adults age 65 and older have received the vaccine (Healthy People 2020 goal is 90%).5 In 2010, the Centers for Medicare and Medicaid Services (CMS) identified the pneumococcal vaccine as a core measure for quality of care among hospitalized patients.2

Herpes zoster (shingles) affects millions of Americans aged 60 and older, with up to 32% experiencing post-herpetic neuralgia or chronic pain if left untreated.9,10 The CDC estimates that approximately 20% of adults 60 and older received the herpes zoster vaccine in 2012, far short of the need for universal protection.11

The recent results of the Northern Manhattan Study linking herpes with cognitive decline identified an inverse relationship with memory and executive function.12 An association with stroke and vascular decline was noted when a patient contracted herpes virus at some point. The outcomes noted that previous exposures to a number of common infections may contribute to cognitive decline, suggesting a need for further research. Another study noted an increased risk of stroke within 6 months of herpes zoster activation, emphasizing support of vaccination programs.13

Pertussis (whooping cough) can be deadly to infants and young children. However, the actual incidence of the burden of the disease among people older than 65 is unknown. In 2010, the ACIP recommended pertussis vaccination for all adults older than 65.14 Previously, the recommendation had only been for adults who are in close contact with infants. An ongoing work group evaluating the efficacy and safety of the vaccine demonstrated an economic benefit to the public with improving vaccination rates in elderly.14 In 2010, the cost of care for influenza, pneumonia, herpes zoster and pertussis was near $15 billion.5

Multiple Stakeholders

Vaccines are among the most effective vehicles for disease prevention and have demonstrated significant life-saving benefits, resulting in a reduction of more than 14 million diseases and direct care costs of more than $9 billion dollars.15 The intense disease surveillance system in the United States focuses on data collection processes that funnel to the CDC to assist in redefining vaccine recommendations for all ages. Emerging issues of immigration, international travel, bioterrorism and agricultural contamination support the need for intense monitoring of disease outbreaks and preventive methods to mitigate adverse outcomes.

In 2012, more than 1 million people were hospitalized for pneumococcal pneumonia, resulting in thousands of deaths.2 Adults 65 and older continue to obtain vaccination at low rates, with greater disparity noted in smokers and rural communities with significant numbers of black people.16 Between 2011 and 2012, disparities widened among racial and ethnic groups receiving the recommended adult vaccines.5 For instance, non-Hispanic white people achieved a vaccination rate of 67.5% for pneumococcal pneumonia while black people were around 52% and Asian people 42%.5

Research shows that both the influenza and pneumonia vaccines are cost effective and safe. Immunization against diseases such as pneumococcal pneumonia could help decrease the incidence of drug resistant bacteria and lower the costs of hospitalization and treatment.2,17

The herpes zoster vaccine has been recommended by the drug manufacturer for use in people older than 50. However, in a systematic review of the cost effectiveness and quality adjusted life years (QALY) associated with immunizations, the efficacy of the vaccine in ages 50 to 60 did not equate to a positive cost/benefit ratio.18 Best outcomes for vaccine effectiveness and long term coverage were associated with ages 60 and above. Still, the cost of the vaccine (approximately $220) can be prohibitive for seniors on fixed incomes who are struggling to decide whether food or needed medications are more important. Additionally, physicians may be reluctant to recommend the vaccine due to side effects from a modified live virus injection.

Recent legislative changes, such as the Affordable Care Act, may offer additional opportunities for adults to receive immunizations through insurance benefits and preventive care initiatives. However, some of these benefits may only be provided by in-network programs; out-of-network community services may not be covered. Even within some Medicare plans, barriers may prohibit access to needed vaccines.5 This adds to the confusion surrounding universal coverage for all vaccines.

Additionally, it is important to evaluate the public's perception of the cost and extent of diseases and the interventions used for prevention and treatment.19 The anti-vaccination movement has helped create outbreaks of diseases that had been eradicated. Many young parents today have never seen the effects of measles and chickenpox on children. While these cases are often mild in children, they can be deadly in older adults.

Additional costs of healthcare related services to hospitals, public health departments and school systems demonstrates the intense need to address and eradicate diseases that have associated vaccines available for administration. Visitors from other countries with less restrictive immunization practices can strain public health resources and put communities at risk for illness during communicability time frames when a population with lower immunity levels may be susceptible. Determining recent contacts, exposures and immune status is a time consuming and costly function for public health services.20

Lower vaccination rates often reflect a disparity in knowledge and understanding of disease prevention. Every day, our borders receive hundreds of immigrants from countries with less effective disease prevention methods. This places US citizens who are not immunized at a greater risk. Recent outbreaks of measles in California and mumps on a university campus in Illinois set the stage for stricter school admission enforcement policies.21 The outbreak in California led to passage of a state law that essentially negates religious or cultural exemptions for school age children receiving immunizations on entry into school.22

The costs of medications and treatments, as well as access to care, are frequent concerns among older adults. Factors associated with vaccine fears, understanding of the disease process, immunity, and cultural beliefs also influence immunization rates.

Goals and Barriers

Vaccines are among the most cost effective preventive care services available to improve survival and longevity. Among the barriers to adequate adult immunization rates are low or inaccurate public and provider knowledge about vaccinations; limited access to a supportive infrastructure; patterns of resource use by older adults; economic issues; and fragmented public health services.5 Additionally, inadequate stocking and distribution of vaccines and storage in primary care offices-as well as lack of incentives to provide them-become problematic.3 Adult immunizations are often undervalued by the public and their healthcare providers because of lack of knowledge or understanding about a confusing vaccination schedule.

Concerns about the administration of multiple vaccines indicated for adults may lead providers to schedule vaccinations at separate visits. This practice can place people at risk for contracting illnesses when prevention through administration of the recommended vaccines during the same visit can be the best strategy. Research has demonstrated that the practice of simultaneous administration of vaccines does not alter effectiveness or add undue risks.23

Recommendations

A strategy that incorporates a multifaceted approach to education and promotion of immunizations should be led by both federal and state governments, much like the massive undertaking in the 1950s and 60s that required pediatric vaccine distribution. Improving the demand for adult vaccinations through education utilizing celebrity spokespersons on television commercials or offering incentives through insurance benefits can promote an emphasis of the need and an awareness of the health and economic consequences of a compromised population.

Because many older adults are working beyond age 60, ensuring a healthy workforce decreases both direct and indirect costs due to absenteeism and increased workloads for other employees. Improving access to available vaccines through employee health services benefits employers through less work days lost.

Utilizing an integrated computerized decision support technology system to identify people within a healthcare setting who are eligible for vaccines can guide immunization delivery processes.8 Embedding a standing order protocol into the computerized documentation system can help decrease the fragmentation of care delivery and confirm vaccine administration documentation for retrieval at a later date and time.

Encouraging emergency department assessments and evaluation of adults to support vaccine administration prior to discharge should be a core focus and safety measure. Merely providing written discharge information is not enough. A thoughtful discussion is more effective at encouraging vaccination than a bundle of papers that may not be read.

Use of innovative resources, such as the SHOT LINE telephone assistance service provided throughout four counties in Idaho, can assist in providing information about specific vaccine issues.24 This service helps decrease errors in administration, timing of doses and missed vaccine opportunities. Additionally, the savings in time and dollars for parents, providers and the healthcare system, as well as addressing the impact of disease burden, can be significant.     

Ensuring a national payment structure for providers who offer vaccines can promote support for immunization and allow for the appropriate financing of their administration. Evidence has demonstrated that the No. 1 reason patients are vaccinated is provider recommendations.5

The National Adult Influenza and Immunization Summit (NAIIS) and the National Vaccine Advisory Committee (NVAC) developed practice standards for adult immunizations that incorporated the following: 25

  • Assess the immunization status of all patients in each encounter.
  • Recommend appropriate vaccines.
  • Administer or refer to a provider for immunizations.
  • Document administration of vaccines.

These simply stated practice guidelines can be incorporated through a multifaceted approach within communities and senior housing developments. Advanced practice providers can spearhead initiatives through the organization of public and private resources to prompt people older than 60 to become immunized to protect themselves, their loved ones, and friends. Nurses are integral in practice changes within organizations and can support processes that focus on appropriate administration of vaccines, not merely compliance with regulatory guidelines. Supporting immunization practices is economically judicious and a public health responsibility.

References

1. Locher J, et al. Influenza immunization in older adults with and without cancer. J Am Geriatr Soc. 2012;60(11):2099-2103.
2. Schurlknight M. Improving Pneumococcal Immunization Rates Among Hospitalized Adults. Nurs Econ. 2015;33(3):182-185.
3. Hurley LI, et al. U.S. physicians' perspective of adult vaccine delivery. Ann Intern Med. 2014;160(3):161.
4. A Pathway to Leadership for Adult Immunization: Recommendations of the National Vaccine Advisory Committee. Public Health Rep. 2012;127(Suppl 1):1-42.
5. Tan L. Adult vaccination: Now is the time to realize an unfulfilled potential. Hum Vaccin & Immunother. 2015;11(9):2158-2166.
6. Schwartz J, Mahmoud A. A half-century of prevention-The Advisory Committee on Immunization Practices. N Engl J Med. 2014;371(21):1953-1956.
7. Immunization and infectious diseases. Goal IID-13.1. http://www.healthypeople.gov/2020/topics-objectives/topic/immunization-and-infectious-diseases/objectives
8. Swenson C, et al. Using information technology to improve adult immunization delivery in an integrated urban health system. Jt Comm J Qual Patient Safety. 2012;38(1):15-23.
9. Le P, Rothberg M. Cost-Effectiveness of Herpes Zoster Vaccine for Persons Aged 50 Years. Ann Intern Med. 2015;163(5):489-497.
10. McLaughlin J, et al. Estimated Human and Economic Burden of Four Major Adult Vaccine-Preventable Diseases in the United States, 2013. J Prim Prev. 2015;36(4):259-273.
11. Williams W, et al. Noninfluenza Vaccination Coverage Among Adults-United States, 2012. MMWR. 2014;63(7):95-102.
12. Wright C, et al. Infectious Burden and Cognitive Decline in the Northern Manhattan Study. J Am Geriatr Soc. 2015;63(8):1540-1545.
13. Langan S, et al. Risk of stroke following herpes zoster: a self-controlled case-series study. Clin Infect Dis. 2014;58(11):1497-1503.
14. Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) in pregnant women-Advisory Committee on Immunization Practices. MMWR. 2013;62(7):131-135.
15. Understanding immunization and infectious diseases. http://www.healthypeople.gov/2020/topics-objectives/topic/immunization-and-infectious-diseases
16. Bennett K, et al. Receipt of influenza and pneumonia vaccinations: the dual disparity of rural minorities. J Am Geriatr Soc. 2010;58(10):1896-1902.
17. Kishel J, et al. Implementing an electronically based, nurse-driven pneumococcal vaccination protocol for inpatients. Am J Health Syst Pharm. 2009;66(14):1304-1308.
18. Szucs T, Pfeil A. A systematic review of the cost effectiveness of herpes zoster vaccination. Pharmacoeconomics. 2013;31(2):125-136.
19. Fine P. Science and society: vaccines and public health. Public Health. 2014;128(8):686-692.
20. Illinois Department of Public Health. Measles exposure in northern Illinois. 
 Communicable Disease Control Section. Memorandum. May 20, 2016.
21. Illinois Department of Public Health. Mumps cases in Illinois. Communicable Disease Control Section. Memorandum. Sept.18, 2015.
22. California Legislative Information Senate Bill 277. (2015). http://leginfo.legislature.ca.gov/faces/billCompareClient.xhtml?bill_id=201520160SB277
23. Golovyan D, Mossad S. Prevention and treatment of influenza in the primary care office. Cleve Clin J Med. 2014;81(3):189-199.
24. Strohfus P, et al. Effective and sustainable advice line promotes safe vaccine practices. Int J Evid Based Healthcare. 2016;April.
25. National Vaccine Advisory Committee. Recommendations from the National Vaccine Advisory committee: standards for adult immunization practice. Public Health Reports. 2014;129(2):115-123.  

Sue E. Durkin is an advanced practice nurse specializing in geriatrics at Advocate Good Samaritan Hospital in Downers Grove, Ill.




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