Download ADULT IMMUNIZATION An Unexploited Opportunity for Prevention

ADULT IMMUNIZATION
An Unexploited Opportunity for Prevention
William Schaffner, MD
Professor of Preventive Medicine
Department of Health Policy
Professor of Medicine (Infectious Diseases)
Vanderbilt University School of Medicine
Nashville, TN
It is better to avert the malady
by care than to have to apply
physic after it has appeared.
—Shao Tze
A.C.I.P.
CDC’s
Advisory Committee
on
Immunization Practices
Immunization Successes
Selected as one of 10 great public health
achievements of the 20th century
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•
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Smallpox eradication (globally)
Polio elimination (most of the world)
Measles elimination (western hemisphere)
Rubella elimination (western hemisphere)
CDC, MMWR 1999;48:241-243
Estimated Return on Investment of
Childhood Vaccines
• For each birth cohort vaccinated against 13 diseases in
accordance with the schedule of DTaP, Hib, IPV, MMR,
Hep B, Varicella, Hep A, Pneumo-7, and Rotavirus
vaccines:
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–
–
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42,000 lives are saved
20M cases of disease are prevented
13.6 billion dollars in direct costs are saved
68.9 billion dollars in direct plus indirect (societal) costs are saved
For each dollar invested in these vaccinations, $10.20 is saved
See presentation: by Fangjun Zhou – Tuesday Mar 29, Workshop D2 11:30am
Preliminary results of updated analysis from Zhou et al, Arch of Ped and Adolesc Med 2005
Invigoration of Adult Immunization
• Build on success of infant/childhood,
adolescent program
• New vaccines targeted at adults
• Recognition of the burden of adult vaccinepreventable disease – the majority of cases
and deaths due to vaccine-preventable
diseases now occur in adults
Adult Immunization Concepts
• The vast majority of vaccine-preventable diseases
occur in adults
• These diseases produce substantial morbidity and
mortality
• Vaccine coverage of adults is suboptimal, with
notable disparities of race/ethnicity and income
• Your advocacy for vaccines will benefit
your patients
Centers for Disease Control and Prevention (CDC). MMWR Morb Mortal Wkly Rep. 2012;61(04):66-72.
Immunization Contrasts - 1
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Pediatric
Diseases distinctive
Fabulous vaccines
Interrupt transmission
Eliminate disease
Universal coverage
Active programs: find
everyone
National/global vision
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•
•
•
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Adult
Diseases not as distinctive
Good vaccines
Personal protection
Reduce risk
Targeted populations
Passive: try to immunize
those presenting for care
Focus on practice
Immunization Contrasts - 2
Pediatric
• Create hurdles: “no
shots, no school
• Recommendations
clearly communicated
• Funding rather secure
Adult
• Averse to hurdles
• Recommendations
inadequately communicated
• Funding less certain
CORE ADULT VACCINES
INFLUENZA
PNEUMOCOCCAL
TDAP/TD
ZOSTER
HEPATITIS B
HPV
Burden of Vaccine-Preventable Diseases – 1
United States/Annual Rates
INFLUENZA
• 200,000 hospitalizations
• 36,000 deaths (>85% elderly)
• 44,000 cases
INVASIVE
• 4500 deaths
PNEUMOCOCCAL
• Higher rates in elderly, AA, persons
DISEASE
with comorbidities
HEPATITIS B
• 51,000 infections (>95% adults)
• 2000-3000 deaths
• 1.25 (m) chronic HBV infection
AA, African American; HBV, hepatitis B virus.
Centers for Disease Control and Prevention. http://www.cdc.gov/.
Burden of Vaccine-Preventable Diseases – 2
United States/Annual Rates
• 6.2 million new infections
HUMAN
• 2 HPV strains cause 70% of cervical
PAPILLOMAVIRUS
cancers and most anal, head and
(HPV)
neck cancers
PERTUSSIS
• Outbreaks throughout US
adolescents and young adults
• Most severe in infants
• Source is usually an adult or
older child
Centers for Disease Control and Prevention. http://www.cdc.gov/.
Burden of Vaccine-Preventable Diseases – 3
United States/Annual Rates
SHINGLES
• 1 (m) cases
• Lifetime risk 30%
• Incidence of shingles and postherpetic
neuralgia increases with age
Centers for Disease Control and Prevention. http://www.cdc.gov/.
Adult Vaccination Rates Too Low – 1
INFLUENZA
65
66%
50-64
40%
19-49
33%
HCW
65%
PNEUMOCOCCAL
HCW, health care
worker; TDAP,
tetanus,
diphtheria, and
pertussis.
65
AA
Hispanic
62%
48%
43%
19-64 (high risk)
20%
TDAP
19-64
13%
Centers for Disease Control and Prevention. National Health Interview Survey. 2011; Williams WW. Presented at: ACIP meeting;
February 21, 2013; Atlanta, GA. http://www.cdc.gov/ vaccines/acip/meetings/downloads/slides-feb-2013/02-Adult-Vax-Williams.pdf.
Accessed April 25, 2013
Adult Vaccination Rates Too Low – 2
HPV
Women, 19-26
(1 dose)
30%
HERPES ZOSTER (shingles)
60
AA
Hispanic
16%
8%
8%
Centers for Disease Control and Prevention (CDC). MMWR Morb Mortal Wkly Rep.
2013;62(4):66-72.
Conclusions: Coverage remaining very low –
tiny improvement since 2009
Racial/Ethnic disparities persist
An opportunity for improvement!
Reasons Why Patients
Not Vaccinated
• Healthy, don’t think they need it
• Didn’t know about disease
• Didn’t know about vaccine
• Doctor didn’t recommend it
When It Comes to Vaccines,
Doctors and Patients Aren’t Hearing One Another
Most physicians say,
“I talk to all of my patients
about vaccines”
87%
But few patients agree
“Yes, I regularly
discuss vaccines
with my health care
provider”
“I occasionally
discuss vaccines
with my health care
provider”
31%
21%
18%
Physicians
“I don't recall
ever discussing
vaccines”
Patients
Results are based on surveys by the National Foundation for Infectious Diseases. November 2010.
BE
AN ADVOCATE
FOR VACCINATING
YOUR ADULT PATIENTS!
When meditating over a
disease, I never think of finding
a remedy for it,
but instead, a means of
preventing it.
-Louis Pasteur