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Effectiveness in Disease and Injury Prevention Successful Strategies in Adult Immunization

MMWR 40(41);700-703,709

Publication date: 10/18/1991

Table of Contents


Editorial Note




Safe and effective vaccines are available to prevent pneumococcal disease and influenza and hepatitis B virus (HBV) infections among persons in the United States; however, a substantial number of adults at increased risk for these preventable infections remain unvaccinated. This report describes collaborative public and private efforts to increase the vaccination of adults and highlights National Adult Immunization Awareness Week, October 27-November 2, 1991.

Medicare Influenza Vaccine Demonstration Project

In October 1988, CDC, in collaboration with the Health Care Financing Administration, awarded demonstration grant funds to nine programs to assess the cost-effectiveness of providing influenza vaccine to Medicare part B beneficiaries and measure the impact of Medicare coverage on promoting the vaccine as a routine preventive health measure. The addition of a 10th program in 1990 increased the study population to more than 1.9 million Medicare beneficiaries.

Through a variety of promotional and educational efforts directed at providers and patients, the project substantially improved influenza vaccine delivery during the first 3 years of the 4-year study period. Vaccine doses administered increased from 481,000 the first full year to 786,000 the third, representing an overall increase in vaccine coverage of Medicare beneficiaries from 30% to 41%. Descriptions of the programs in Monroe County, New York, and Maricopa County, Arizona, illustrate the approaches that have been used to improve vaccine delivery and coverage.

Monroe County, New York. In 1989, a random sample of private-practice physicians identified all persons greater than or equal to 65 years of age (who should be vaccinated against influenza). In 28 (62%) of the 45 participating practices, a graph indicating the percentage of such patients in the practice who had been vaccinated was placed on a conspicuous wall in each office and updated weekly during the influenza season. Those practices achieved 30% higher vaccination levels than did those not using the graph (67% vs. 50% of patients vaccinated; p less than 0.01) (1). In 1990, this target-based system was expanded countywide and included an incentive of bonuses above the usual vaccine administration fees for practices that vaccinated 70% or more of their target population. Preliminary data indicate that one group of physicians vaccinated 72% of eligible Medicare patients (range: 44%-72% in the different physician practices).

Maricopa County, Arizona. As part of the Medicare demonstration project in Maricopa County, the county health department arranged for nine private-practice physicians to conduct influenza vaccination clinics for Medicare beneficiaries at shopping malls during October 1990-February 1991. Participating physicians were provided free vaccine and an administration fee for each vaccinee in the program. Billboards, newspaper advertisements, and public service announcements were used to promote the clinics. Of the 101,882 Medicare beneficiaries who were vaccinated through the project, 43,617 (43%) were vaccinated in nine mall clinics.

California Influenza/Pneumococcal Vaccination Program The California Influenza/Pneumococcal Vaccination Program was initiated in 1974 (2). Both influenza and pneumococcal vaccines are state-funded and are administered primarily at local health department clinics, community sites, and nursing homes. Local hospitals, senior citizen groups, and local American Red Cross chapters assist by providing facilities, nurses, and volunteers. Promotional efforts by local health departments include press releases, public service announcements, fliers, posters, and close coordination with senior citizen groups.

In fiscal year (FY) 1982, a total of 341,375 doses of influenza vaccine were administered, compared with 653,877 doses in FY 1991--an increase of 92%. In FY 1991, 16% of the total population aged greater than or equal to 65 years in the state were vaccinated against influenza. In FY 1987, a total of 23,753 doses of pneumococcal vaccine were administered (2), compared with 45,548 doses in FY 1990--also an increase of 92%.

Hepatitis B Vaccine in Sexually Transmitted Diseases Clinics In 1990, CDC initiated a demonstration project to assess the feasibility of offering hepatitis B (HB) vaccination in sexually transmitted diseases (STD) clinics to persons at high risk for sexually transmitted HBV infection. New patients who had no history of HBV infection or HB vaccination were offered vaccine. Patients accepting vaccination were tested for HB core antibody (a marker of past HBV infection) and given their first vaccine dose at their initial visit. Those with no evidence of past HBV infection were eligible for subsequent doses and were reminded by mail and telephone to return to complete their primary vaccination series.

During July 1990, in San Francisco, vaccine was offered to 1386 persons, of whom 611 (44%) accepted. Of these, 181 (30%) had prior evidence of HBV infection, and 430 (70%) were susceptible and eligible for subsequent doses. Of those eligible, 210 (49%) persons returned for a second vaccine dose, and 135 (31%) completed a three-dose series.

During a 3-week period in April 1991, in Birmingham, Alabama, vaccine was offered to 1079 persons, of whom 744 (69%) accepted. Of these, 638 (86%) were eligible for subsequent doses. Through September 1991, 249 (39%) of those eligible returned and received a second vaccine dose.

In both San Francisco and Birmingham, among participants having evidence of prior HBV infection, seropositivity was strongly associated with age (8% of persons less than 20 years of age had evidence of past infection, compared with 39% of persons aged greater than or equal to 30 years).

Reported by: FM LaForce, MD, WH Barker, MD, Univ of Rochester School of Medicine and Dentistry, Rochester, New York. P Lesniak, J Hartner, MD, Div of Public Health, Maricopa County Dept of Health Svcs, Phoenix, Arizona. M Fleenor, MD, J Hardin, Jefferson County Dept of Health, Birmingham, Alabama. F Taylor, GA Bolan, MD, San Francisco Dept of Public Health; GW Rutherford, III, MD, State Epidemiologist, California Dept of Health Svcs. Office of Research and Demonstrations, Health Care Financing Administration. Div of Viral and Rickettsial Diseases and Div of Bacterial and Mycotic Diseases, National Center for Infectious Diseases; Div of STD/HIV Prevention and Div of Immunization, National Center for Prevention Svcs, CDC.

Editorial Note

A substantial proportion of vaccine-preventable diseases occur among adults (Table 1) despite the availability of safe and effective vaccines. Reasons contributing to low vaccination levels among adults are that 1) no comprehensive vaccine delivery systems are available in the public and private sectors; 2) although statutory requirements exist for vaccination of children, no such requirements exist for all adults; 3) vaccination schedules are complicated because of the detailed recommendations that may vary by age, occupation, lifestyle, or health condition; 4) opportunities to vaccinate adults are frequently missed during contacts with health-care providers in offices, outpatient clinics, and hospitals (3); 5) vaccination programs have not been established in other settings where adults congregate (e.g., the workplace); and 6) patient and provider fears exist concerning adverse events following vaccination.

In the United States, influenza epidemics are often associated with more than 20,000 excess deaths annually, 80%-90% of which occur among persons greater than or equal to 65 years of age. Although influenza vaccine is estimated to be up to 70% effective in reducing deaths among high-risk elderly persons (3), findings from the 1989 National Health Interview Survey (NHIS) indicate that only 30% of persons aged greater than or equal to 65 years were vaccinated for influenza during the previous year (4). Disease caused by Streptococcus pneumoniae infection remains a problem in the very young, the elderly, and persons with certain high-risk conditions. Although pneumococcal vaccine is more than 60% effective in preventing invasive pneumococcal infections, data from the 1989 NHIS indicate that only 14% of persons aged greater than or equal to 65 years reported ever having received pneumococcal vaccine (4). The Medicare Influenza Vaccine Demonstration Project and the California Influenza/Pneumococcal Vaccination Program both illustrate how efforts to motivate providers and develop collaborative public and private delivery strategies can improve vaccination coverage against influenza and pneumococcal disease.

Each year HBV infection occurs in an estimated 300,000 persons, primarily young adults; 6%-10% of these persons become chronic HBV carriers. Heterosexuals with multiple sex partners are one category of persons at increased risk for HBV infection (5); the proportion of HBV infections in the United States accounted for by persons with only heterosexual activity as a risk factor increased from 14.7% in 1982 to 26.0% in 1988 (6). The findings in San Francisco and Birmingham, as well as in other sites (7), indicate that STD clinics may be opportune sites to vaccinate persons in this risk group against HBV infection. However, strategies to improve completion rates are needed: only half of susceptible persons have received at least two doses of vaccine through these programs, even though 70% or more of those receiving two doses will develop detectable protective antibody (8). Although universal vaccination of infants and adolescents is the optimal long-term strategy to prevent HBV infection, until then the continued targeting of high-risk groups is necessary to reduce disease incidence.

Of the 19 national health objectives for the year 2000 that target vaccination and infectious diseases, 10 are related to vaccination of adults (9). The objectives include 1) reduction of epidemic-related pneumonia and influenza deaths and provision of influenza and pneumococcal vaccines to at least 60% of noninstitutionalized high-risk populations and at least 80% of institutionalized chronically ill or older persons and 2) increasing HB vaccination among high-risk populations to at least 90%. The proportion of primary-care providers and public health departments that provide adult vaccinations for influenza, pneumococcal disease, and HBV should increase to 90% (9).

Vaccination programs have markedly reduced the incidence of vaccine-preventable diseases among children, but many adults remain susceptible because they are inadequately immunized. Improving vaccine use among adults and reaching the year 2000 national health objectives for immunization (9) require multifaceted strategies involving collaboration of public and private organizations to improve awareness and vaccine delivery, publicly supported delivery mechanisms that remove cost and accessibility constraints, and special surveys to assess current programs. The goal of National Adult Immunization Awareness Week is to emphasize the importance of appropriately vaccinating all adults by focusing attention on efforts that promote prevention and control of vaccine-preventable diseases. The National Coalition for Adult Immunization (telephone (301) 656-0003) and CDC offer more information on the week\'s activities.


1. Buffington J, Bell KM, LaForce FM, the Genesee Hospital medical staff. A target-based model for increasing influenza immunizations in private practice. J Gen Intern Med 1991;6:204-9.
2. CDC. Pneumococcal immunization program--California, 1986-1988. MMWR 1989;38:517-9.
3. Williams WW, Hickson MA, Kane MA, Kendal AP, Spika JS, Hinman AR. Immunization policies and vaccine coverage among adults: the risk for missed opportunities. Ann Intern Med 1988;108:616-25.
4. Rodgers DV, Strikas RA, Hardy AM, Park C, Zell ER, Williams WW. Influenza and pneumococcal vaccination in the elderly: results of the 1989 National Health Interview Survey (Abstract). In: Program and abstracts of the 119th annual meeting of the American Public Health Association. Washington, DC: American Public Health Association, 1991 (in press).
5. ACIP. Protection against viral hepatitis: recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR 1990;39(no. RR-2).
6. Alter MJ, Hadler SC, Margolis HS, et al. The changing epidemiology of hepatitis B in the United States: need for alternative vaccination strategies. JAMA 1990;263:1218-22.
7. Baddour LM, Bucak VA, Somes G, Hudson R. Risk factors for hepatitis B virus infection in black female attendees of a sexually transmitted disease clinic. Sex Transm Dis 1988;15:174-6.
8. Hadler SC. Vaccines to prevent hepatitis B and hepatitis A virus infections. Infect Dis Clin North Am 1990;4:29-46.
9. Public Health Service. Healthy people 2000: national health promotion and disease pre vention objectives. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991:121-3; DHHS publication no. (PHS)91-50213.


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