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There are several problems with the system for immunizing adults:
•Patients often do not request vaccinations. •Physicians do not aggressively promote their use. •Employers do not require proof of immunization as a condition of work. •Private insurance coverage is inconsistent. •Public sector financing often falls too low to be effective. •Production, particularly those for influenza vaccine, can be erratic. •Physicians often lack the facilities to store vaccines. •There is also substantial waste and discarding of existing supplies.
Get the story from The American Council on Science and Health
This brochure is based on the technical paper Adult Immunization: The Need for Enhanced Utilization by Steven Marks, available on our site, along with a shorter layperson–friendly booklet.
American Council on Science and Health 1995 Broadway, 2nd Floor, New York, NY 10023 – 5860
ACSH BOARD OF TRUSTEES
Nigel Bark, M.D. Albert Einstein College of Medicine Elissa P. Benedek, M.D. University of Michigan Medical School James E. Enstrom, Ph.D., M.P.H University of California, Los Angeles Robert Fauber, M.B.A. Moody’s Corporation Hon. Bruce S. Gelb New York, NY Elizabeth McCaughey, Ph.D. Committee to Reduce Infection Deaths Henry I. Miller, M.D. The Hoover Institution Rodney W. Nichols The New York Academy of Sciences, President Emeritus George F. Ohrstrom The Ohrstrom Foundation Kenneth M. Prager, M.D. Columbia University Medical Center Elizabeth Rose Aim High Productions Lee M. Silver, Ph.D. Princeton University Thomas P. Stossel, M.D. Harvard Medical School Harold D. Stratton, Jr., J.D. Dykema Glenn Swogger, Jr., M.D. The Menninger Clinic (ret.)
ACSH FOUNDERS CIRCLE
Christine M. Bruhn, Ph.D. University of California Taiwo K. Danmola, C.P.A. Ernst & Young Thomas R. DeGregori, Ph.D. University of Houston A. Alan Moghissi, Ph.D. Institute for Regulatory Science Albert G. Nickel LyonHeart (ret.) Stephen S. Sternberg, M.D. Memorial Sloan-Kettering Cancer Center Lorraine Thelian Ketchum Kimberly M. Thompson, Sc.D. Massachusetts Institute of Technology Robert J. White, M.D., Ph.D. Case Western Reserve University
A number of medical professional societies have endorsed programs and protocols to heighten awareness of the importance of adult immunization. New approaches under consideration include model insurance contracts providing payment for some vaccines, vouchers to patients, liability protection for pharmaceutical companies, new research on the true costs of vaccine delivery, deferred payment plans for vaccine purchasers, and manufacturer/government “buy–back” of unused influenza vaccine following flu season. These proposals also have a broader purpose – to shift our thinking about healthcare delivery from one grounded in acute–care treatment to one focused on disease prevention. Such a change in emphasis will undeniably contribute to lower rates of sickness and death. However, the short–term costs of such care may be considerable. Whether such an approach will prove viable may well depend on the contours of the debate on healthcare reform now underway and the priorities in any legislation that emerges.
Adult Immunization By Curtis Porter, from an ACSH report by Steven Marks © 2009 American Council on Science and Health
John Moore, Ph.D., M.B.A. Grove City College, President Emeritus
ACSH EXECUTIVE STAFF
Elizabeth M. WhelanScD., M.P.H., President
Judith A. D’Agostino Executive Assistant to the President Matt Johnston Manager of Individual Giving A. Marcial C. Lapeña Accountant Anthony Manzo Art Director Cheryl E. Martin Associate Director Curtis Porter Research Intern Gilbert L. Ross, M.D. Executive and Medical Director Todd Seavey Director of Publications Jeff Stier, Esq. Associate Director
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For more information, contact: American Council on Science and Health American Council on Science and Health, 1995 Broadway, 2nd floor, New York, NY 10023-5860 Tel: 212-362-7044 • Fax: 212-362-4919 • E-mail: ACSH@acsh.org • http://ACSH.org
The American Council on Science and Health
Dr. Elizabeth Whelan, President ACSH, 1995 Broadway 2nd ﬂoor, New York, NY 10023
RAISING AWARENESS, IMPROVING ACCESS
Why do so many adults remain unvaccinated against the most common VPDs? There are several barriers to immunization; they may best be grouped as financial, informational, and operational.
Financial. Payment for the cost and administration of adult vaccinations is frequently unavailable. Moreover, high deductibles and co–payments often discourage people from following the recommended schedules. Medicare does not pay for establishing or maintaining inventories, and physicians must purchase vaccines in advance. Informational. There is a general lack of awareness of the need for adult immunization. Physicians are often unaware of the recommendations, and patients are often surprised to learn that booster doses are required to maintain adequate protection.
By Curtis Porter from an ACSH report by Steven Marks
people with invasive pneumococcal disease die; experts estimate that vaccination could prevent more than half of those deaths. All adults above age 65 without evidence of previous infection should receive the Pneumovax 23 vaccine. Vaccination is also recommended for those under age 65 who are immunocompromised; residents of long–term care facilities; or people with chronic cardiovascular, liver, or pulmonary diseases, diabetes, diseases like sickle cell disease, or other immunocompromising conditions. Herpes Zoster Infection by the varicella zoster virus causes two different conditions, chickenpox and shingles. Chickenpox is typically manifested by a contagious rash that usually infects children, while shingles usually emerges in adults decades following an initial infection as the body’s natural immunity begins to wane. Shingles is characterized by a painful skin rash accompanied by blistering. Changes in pigmentation and scarring may be permanent. Shingles is estimated to affect about 1 million American adults each year. The vaccine Zostavax can reduce the risk of shingles as well as the severity and duration of the disease. All individuals age 60 or above should receive the vaccine, except for people who are immunocompromised, such as those with leukemia, lymphoma, or other bone–marrow conditions; people with AIDS; or individuals taking immunosuppressive drugs. Zostavax can be administered in conjunction with influenza vaccine without compromising the immune effect of either agent. Human papillomavirus Human papillomavirus (HPV) is the most common sexually transmitted infection in the US and the primary cause of cervical cancer in women. About 20 million Americans are already infected and, each year, about 6.2 million people acquire HPV. The infection is most common in adolescents and young adults, with up to 75% of new infections occurring among persons from 15 to 24 years of age. Overall, about 65% of women and 27% of men are infected with the virus, and about $4 billion a year is spent on managing the medical consequences of HPV infection. The two most common types of high–risk HPV trigger many cervical, vulvar, anal, penile, and oral cancers. For instance, the two leading types of cervical cancer are both caused by HPV, and 90% of anal cancers have been attributed to the virus. Lower–risk HPV strains are associated with the vast majority of cases of genital warts and other low–grade cervical abnormalities. Multiple large–scale clinical trials have shown that Merck’s HPV vaccine Gardasil is safe and highly effective in young, uninfected women. A three–dose course of HPV vaccine is approved for all girls and women between the ages of 11 and 26, although immunization can begin as early as age 9. The vaccine is also approved for males in the same age range. Another HPV vaccine, Cervarix, has proven effective and been approved as well.
Hepatitis B Hepatitis B is a leading cause of liver diseases, including chronic hepatitis, cirrhosis, and liver cancer. HBV is transmitted through the blood and bodily fluids via sexual activity, exposure to contaminated needles, transfusions, and from mother to child at birth. More than 1.25 million Americans are infected with HBV, with 5,000 to 8,000 new cases reported each year, and an estimated 1,000 to 1,500 chronic carriers of HBV die prematurely from either cirrhosis or liver cancer. About 5% of acute HBV infections develop into chronic hepatitis B, with the highest risk occurring in younger patients. There is no cure for chronic hepatitis B. Thus, completion of the three–dose HBV vaccination series is the best means of prevention. Tetanus, Diphtheria, and Pertussis Although unrelated, all of these bacterial diseases can be prevented by the same combination vaccine, “Tdap.” Tetanus (“lockjaw”) is an acute, often fatal illness caused by a toxin produced by a bacterium. The disease is characterized by generalized rigidity and convulsive muscle spasms. Tetanus can interfere with breathing, produce bone fractures from sustained convulsions, and lead to hypertension. Diphtheria is an acute illness provoked by another microbe, which is typically inhaled and absorbed into the bloodstream, then disseminated throughout the body. The third disease covered by the combination Tdap vaccine is pertussis (“whooping cough”). The bacteria bind with lung cells, leading to inflammation of the respiratory tract and impaired clearance of mucus. Pertussis is highly contagious and is most severe in younger adults and children. The incidence of tetanus and diphtheria in the US is very low due to the availability of effective vaccines. Since 2000, the number of cases of tetanus reported yearly has been about 30, 73% of which followed acute injury or wounds. There is only about one diphtheria case per year. In contrast, the annual incidence of pertussis reached a low of 2,900 cases during the period 1980–1990 and has been increasing since, reaching a high of 25,827 cases in 2004, the largest number since 1959. Vaccination with either Tdap vaccine–Boostrix or Adacel–is the best way to prevent these three bacterial infections. Adults aged 19 to 64 years should receive a single dose of Tdap for booster immunization against tetanus, diphtheria, and pertussis after a period of no more than 10 years following administration of the last tetanus vaccine. This schedule is especially important for adults who have close contact with infants, such as childcare or healthcare workers and parents. In sum, all adolescents and adults should have documented completion of at least three tetanus and diphtheria doses during their lifetime.
TOO FEW ADULTS ARE GETTING THEIR SHOTS Although vaccination is acknowledged to be one of the most cost–effective public health strategies available to prevent many communicable viral and bacterial infections, large numbers of Americans above the age of 18 remain vulnerable to vaccine–preventable diseases (VPDs). Upwards of 90% of children receive most of the recommended vaccines, but variable and generally low rates of coverage are the norm for adults. For example, only 10% of women in the target population of 18 to 26 years have been vaccinated against human papilloma virus (HPV), a major cause of cervical cancer. The rate is not much higher for tetanus and diphtheria toxioids; only 44% of American adults have been vaccinated. Even for influenza, the illness for which the value of immunization is best recognized by the public, and which annually takes the lives of over 30,000 Americans, coverage is erratic: rates of coverage range from 37% in younger adults to almost 70% of those age 65 or older. Despite the ready availability of clinically proven interventions to prevent a host of potentially life–threatening illnesses, utilization rates by adults continue to be disappointing. This brochure explains the current status of VPDs in the US. It explains the causes for low rates of vaccine use and continues with a description of the most common VPDs and their current immunization recommendations. As we shall see, the evidence is overwhelming that increasing adult immunization rates can improve public health, reducing the enormous expense of these serious, and preventable, diseases.
Operational. The American healthcare system, which emphasizes acute treatment, is poorly equipped to deliver preventive medicine to the population as a whole, especially to adults. Neither the government nor the private sector has been able to develop a sustained adult–vaccine delivery infrastructure.
VPDs: CHARACTERISTICS, IMPACT, VACCINATION SCHEDULES
What follows is a brief description of the 8 most common adult VPDs and the relevant vaccines for preventing them. Influenza In addition to the direct medical costs of more than $10 billion spent each flu season, another $16 billion in lost earnings due to illness has been attributed to influenza. Among adults over the age of 50, about 226,000 people are hospitalized, and somewhere between 30,000 and 40,000 Americans die as a result of pneumonia or other complications from the disease. All adults 50 years or older should receive an annual influenza vaccination. Yearly vaccination is also advised for individuals between 19 and 50 years at high risk due to medical, occupational, or lifestyle factors including those with pre–existing heart or lung conditions, household contacts of those at high risk, healthcare workers, residents of long– term care facilities, and pregnant women. Two types of vaccines are available: an injection containing the killed virus, and a nasal spray containing live, weakened influenza virus. Each vaccine is designed to protect against three influenza viruses, two type A and one type B. (The 2009 swine–origin influenza is a new strain of type A (H1N1) virus.) The precise formula varies from year to year. Pneumococcal Infections These infections are caused by bacteria that colonize the upper respiratory tract. They are the leading cause of community–acquired pneumonia, bacterial infections in the blood, meningitis, middle–earinfections, sinus infections, and other bacterial infections. Each year, about 6,000