Current Trends Summary of the Second National Community Forum on Adult Immunization

From April 27-28, 1987, CDC sponsored the Second National Community Forum on Adult Immunization. Public health officials, private health-care providers, and representatives of professional medical associations participated. The main purpose of the forum was to assess progress since the first forum, held in January 1985. The following is a summary of the proceedings (1):

Current Status of Adult Vaccine-Preventable Diseases. Childhood vaccination programs have sharply reduced the occurrence of vaccine-preventable diseases in children. A substantial proportion of the remaining morbidity and mortality attributable to these diseases occurs among adults. The proportion of reported cases of certain vaccine-preventable diseases affecting adults ranges from 12% to 100% (Table 1). Thousands of patients with influenza or pneumococcal infection die annually. Ten thousand or more excess deaths, primarily among persons greater than or equal to65 years of age, were associated with 19 influenza epidemics from 1957 to 1986. About 40,000 pneumococcal disease-related deaths occur annually. Mortality is highest among patients with underlying medical conditions and among older persons.

Approximately 20% of persons at high risk for influenza-related complications are vaccinated each year. In 1985, less than 10% of the estimated 47.9 million persons in the United States at high risk for complications following pneumococcal infections had ever received pneumococcal vaccine. An average of no more than 30% (range, 2% to 90%) of those targeted to receive hepatitis B vaccine have been immunized. Serosurveys indicate that 49% to 66% of persons greater than or equal to60 years of age lack reliably protective levels of circulating antitoxin against tetanus, and 41% to 84% lack adequate protection against diphtheria. As many as 7 million young adults are susceptible to measles, and as many as 11 million women of childbearing age (15-44 years of age) are unprotected against rubella. The incidence, health consequences, and current protection levels of adults against these diseases illustrate the need for more prevention and control activities.

Provider Education. A supportive base of informed health-care providers is vital to establishing a system that will ensure adequate vaccination levels among adults. Representatives of the American Medical Association (AMA), American College of Physicians (ACP), American Academy of Pediatrics (AAP), American Academy of Family Physicians (AAFP), and American Dental Association (ADA) described their roles in both professional and public education.

In 1986, the AMA House of Delegates passed several resolutions that call for immunizing physicians and other adults, maintaining complete records and providing them to patients, promoting public and professional education on adult immunization, encouraging third-party payment for adult immunization, and promoting increased use of hepatitis B vaccine.

In 1985, the ACP published the Guide for Adult Immunization, referred to as the "Green Book" (2). The Green Book and the recommendations on adult immunization of the Immunization Practices Advisory Committee (3) have consolidated a vast amount of information into useful compendiums. The ACP plans to publish the second edition of the Green Book in early 1989.

The AAP has emphasized the need for students to be properly immunized before entering high school and college. The AAFP is preparing Immunization Guidelines, a reference source for its members that will provide information on appropriate vaccine usage in children and adults. The AAFP publishes articles on immunization in its monthly journal and updates its members about adult immunization and other topics in its monthly newsletter and a bulletin on preventive medicine and through workshops, annual meetings, and co-sponsorship of education conferences. The ADA has promoted improved infection control practices, including care of dental equipment, use of barrier techniques, and immunization of dental-care providers against hepatitis B infection.

Consumer Education. For 6 years, the National Foundation for Infectious Diseases (NFID) has conducted an annual fall public-awareness campaign supporting immunization against influenza and pneumococcal infections. NFID's executive director has defined four approaches to promoting adult immunization: 1) raise the consciousness of the entire nation by permanently establishing the last week of October as "National Adult Immunization Awareness Week"; 2) request financial support from other organizations for education, prevention, and control of adult vaccine-preventable diseases; 3) provide legislators with information on the cost-effectiveness of preventing influenza and other adult vaccine-preventable illnesses under Medicare and Medicaid; and 4) encourage private health insurers to cover adult immunization.

Voluntary organizations such as the American Lung Association contribute significantly to adult immunization by strongly recommending appropriate immunization to individuals they serve, by distributing educational materials and information to consumers and professionals, and through other activities.

Target Populations. While adult immunization programs encounter some of the familiar challenges faced by childhood immunization programs, they also face some unique problems: the higher cost of vaccine for adults and the lack of an easy method of identifying unprotected adults. Participants discussed ways of reaching college students, older people, and high-risk patients in health maintenance organizations (HMOs). In May 1983, the Council of Delegates of the American College Health Association adopted a pre-admission immunization policy recommending that colleges and universities require all students to present proof of immunity to measles, rubella, and other vaccine-preventable diseases as a prerequisite to matriculation or registration. Survey results in 1986 showed that 55% of responding institutions had a pre-admission immunization requirement (4,5). Even though the results represent significant progress, continued implementation and enforcement of matriculation requirements for immunization are essential.

The Office of Disease Prevention and Health Promotion (ODPHP), U.S. Department of Health and Human Services, has conducted a 3-year public education campaign entitled "Healthy Older People" (6). ODPHP pointed out that older people are willing to change their habits to maintain good health and will actively seek information on how to do so. A number of different media could be effective. These include daily newspapers (feature articles could reach the approximately 70% of older Americans who are subscribers); radio (news, talk, and call-in formats are preferred by older audiences); and television (older adults compose a large portion of the viewing audience for morning and evening news programs). Other possibilities include activities conducted by local organizations and medical institutions and health information pamphlets provided by local drugstores.

Because of their organizational structure, HMOs can determine the effectiveness of immunization coverage for their adult patients and can devise programs to improve vaccine utilization. Persons for whom vaccines are recommended can be systematically identified, sent messages recommending vaccination, and immunized during scheduled visits or at special clinics. However, successful activities may vary among HMOs with different organizational structures.

Forum participants also discussed immunization programs for health-care professionals, including those in training; patients in nursing homes and hospitals; adult clients in health department settings; and specific target groups for hepatitis B vaccine. Key suggestions for establishing effective programs included 1) obtaining administrative support, 2) devising systematic ways to identify potential vaccinees and offer them vaccine, 3) providing information on benefits and risks of vaccination, 4) delivering vaccine in ways convenient to providers and patients, and 5) keeping good records.

Future Activities. Improving immunization coverage for adults will require the development of 1) effective means of assessing both the patterns of vaccine usage and immunization coverage in target populations; 2) improved disease surveillance, particularly for influenza and pneumococcal disease; 3) improved influenza and pneumococcal vaccines; 4) effective public and professional education; 5) effective delivery systems; 6) increased resources for adult immunizations; and 7) strategies to fully implement current recommendations. Reported by: Div of Immunization, Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: Although much progress was described, the information presented at this forum highlights the need for continued efforts to improve immunization coverage among adults. The success of childhood immunization programs shows that current medical technology can control vaccine-preventable diseases; however, no such programs exist for adults. Significant improvements in the delivery of safe and effective vaccines to adults will take place only if changes occur in the practices of physicians and institutions caring for them. All

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