Adult vaccination infrastructure faces growing pains

Developing new adult vaccines may have been the easy part.

Experts are now pointing out what is creating another level of difficulty: The structure to provide immunizations to adults is insufficient for delivering the shots that have long been available and woefully inadequate for incorporating new preventives.

"It's abysmal -- our ability to deliver influenza vaccines to young adults at high risk. We still need to immunize adults against pneumococcal disease, and we are doing a terrible job," said Neal A. Halsey, MD, director of the Institute for Vaccine Safety at Johns Hopkins Bloomberg School of Public Health in Baltimore. "And new vaccines are creating new opportunities and new challenges."

To address this issue, as well as others related to childhood vaccinations, the American Academy of Pediatrics and the American Medical Association organized the first National Immunization Congress, held Feb. 27 to March 1 in Chicago.

"Physicians find increasing challenges with immunization access and delivery," said AMA President-elect Ronald M. Davis, MD. And one of the tasks with which physicians and public health officials are struggling is how to overcome those trials to get the vaccines into the arms of grown-ups.

Among strategies offered by attendees was the establishment of a "Vaccines for Adults" program, much like the government-funded one for children, to provide shots to those who are uninsured and older than 18. Also, most agreed that insurance should always cover this preventive service.

Still, experts stress that increasing the number of adults who receive recommended vaccines is more than a financial issue.

A Sanofi Pasteur consumer survey, presented at the congress and due to be submitted for peer-reviewed publication, found that cost and insurance coverage were the least-cited reasons for not being fully vaccinated. The most common was that a physician or health care professional had not recommended it.

"This data point to the need for more consumer education about the value of vaccines, and the need for health care providers to be more active about delivering vaccines to their adult patients," said David R. Johnson, MD, MPH, lead author and Sanofi's director of scientific affairs.

This current missed connection in part can be accounted for by the reality that many adults see physicians only when they are sick -- a situation in which less time is usually available to discuss preventive care.

Experts also say, though, that this explanation does not account for every instance in which an indicated vaccine was not discussed during a health care visit. Many maintain that increased medical education would make such discussions more likely, too. The need is particularly acute for the many physicians who care for adult patients and are increasingly expected to administer such preventives, but who, unlike pediatricians and family physicians, have not traditionally been involved in doing so.

"Pediatricians and family physicians fully recognize that vaccines are a core part of their practice. That's not the case for internists and others providing care for adults. If it was, we would have much higher rates," said Dr. Halsey, who represented the Infectious Diseases Society of America at the meeting.

Focusing on physicians

As part of the education process, vaccine advocates are particularly interested in reaching and vaccinating health care workers. Low vaccination rates among this group can translate into a less-than-hearty encouragement to patients. "Health care workers need to be fully immunized not only to protect their patients but also to set an example to society that this is the right thing to do," Dr. Halsey said.

But it is a tough nut to crack. Though health care facilities where significant resources have been directed toward this goal have improved, it is rarely enough.

"Look at the uptake of influenza vaccine. In my own hospital we achieved 70% vaccination, which is substantially better than what we used to have. We bring carts to [nurses]. We have them sign declinations. But there's something missing. I don't know what that is," said Jon Abramson, MD, a member of the AAP's Task Force on Immunization.

While much talk involved ways to make vaccinations more likely in the health care setting, discussion also centered on how to make them available at other venues, too.

"Adults are too busy to run to their doctors' offices to get vaccine. We need to expand our vision," said Deborah L. Wexler, MD, executive director of the Immunization Action Coalition.

Those in favor hope that alternative venues can work in concert with physicians. This issue, though, has been particularly contentious in regard to flu vaccine because of many physicians' perceptions that retail venues receive preferential treatment when supplies are tight. This opinion continues despite community immunizers' statements that they also have been affected by supply disruptions.

According to an American Academy of Family Physicians study presented March 6 at the 41st National Immunization Conference hosted by the Centers for Disease Control and Prevention in Kansas City, Mo., only about 44% of family physicians support giving flu immunization in pharmacies. Even fewer, 27%, endorsed this practice at retailers. The often cited reasons are concerns that care could become fragmented and administration in these settings threatens the financial viability of area doctors.

"I don't think that we are opposed to having vaccines in nontraditional settings," said Andrew Eisenberg, MD, a family physician representing the Texas Medical Assn.

"The situation is that we work on such a small margin that any leftover vaccine impacts the ability to provide care at all," he said.