1. Implement a patient intake form to routinely assess vaccination status at every visit and identify which vaccines are needed.
2. Use standing orders and protocols to allow nurses and other staff to administer recommended vaccines.
3. Refer patients to pharmacies or health departments for vaccines not stocked in the practice and document referrals.
3. Enter administered vaccines and referrals into the state immunization registry to track rates and prevent missed opportunities.
2. Provide information on
Burden of vaccine-preventable disease and illness
Recommended adult vaccines
Current adult vaccination rates
Review “Practice Standards for Adult
Immunization”
Provide resources for implementing the “Practice
Standards”
2
Goals of Presentation
3. Burden of Disease Among U.S. Adults for
Diseases with Vaccines Available
Influenza disease burden varies year to year
Millions of cases and average of 226,000 hospitalizations annually with >75%
among adults1
3,000-49,000 deaths annually, >90% among adults2
Invasive pneumococcal disease (IPD)3
39,750 total cases and 4,000 total deaths in 2010
• 86% of IPD cases and nearly all IPD deaths among adults
Pertussis (also known as whooping cough)4
~28,000 cases per year for 2013 and 2014
• ~9,000 among adults
Hepatitis B5
3,350 acute cases reported 2010
• 35,000 estimated cases
Zoster (also known as shingles)6
About 1 million cases of zoster annually U.S.
1. Thompson WW, et al. Influenza-Associated Hospitalizations in the United States. JAMA 2004; 292: 1333-1340
2. CDC. Estimates of deaths associated with seasonal influenza – United States, 1976-2007. MMWR. 2010;59(33):1057-1062.
3. CDC. Active Bacterial Core Surveillance. http://www.cdc.gov/abcs/reports-findings/survreports/spneu10.pdf.
4. CDC. Notifiable Diseases and Mortality Tables. MMWR 2013. 61(51&52): ND-719 – ND 732.
5. CDC. Viral Hepatitis Surveillance United States, 2010. National Center for HIV/AIDS, Viral Hepatitis, STD& TB Prevention/Division of Viral Hepatitis.
6. CDC. Prevention of Herpes Zoster. MMWR 2008. 57(RR-5): 1-30.
3
4. Influenza costs lives and money
Direct medical costs in U.S.: ~$10.4 billion
Add in loss of work and life: ~$87 billion
Vaccination (41% in 2013-14) prevented:
• 7+ million illnesses
• 3+ million medically-attended illnesses
• 90,000+ hospitalizations
• Molinari, et al. The annual impact of seasonal influenza in the US: Measuring disease burden and costs. Vaccine 2007;25 :5086–5096.
• Reed, et al. Estimated Influenza Illnesses and Hospitalizations Averted by Vaccination — United States, 2013–14 Influenza Season MMWR
2014:63(49);1151-1154.
4
5. Impact of Vaccine Preventable Diseases in
People
[Speaker – insert personal stories on the
impact of vaccine preventable diseases or
consider using examples among extra
slides at the end of this slide set.]
5
6. Recommended Adult Vaccines
Vaccines are an important part of optimizing health
of the vaccinated person, and preventing infections
in others
Example: Vaccination against influenza and
pertussis reduces the risk in the person vaccinated
and also prevent someone from spreading these
diseases
6
9. Impact of Vaccination
Vaccine effectiveness varies by vaccine type, the disease
outcome, and the age or health of the person vaccinated
Zoster (Shingles) vaccine effectiveness: 51% against shingles, 66%
against post-herpetic neuralgia (PHN), and almost 80% against most
prolonged and extreme cases of PHN1
PCV13 (pneumococcal conjugate vaccine): 45% efficacy against
vaccine-type pneumococcal pneumonia, and 75% efficacy against
vaccine-type invasive pneumococcal disease among adults aged ≥65
years2
Influenza vaccine: varies annually based on antigenic match and also
age and health of person being vaccinated – about 60‒70% in
younger adults and about 30% in adults 65 years and older against
medically attended influenza when good match3
Hepatitis B vaccine: 90% effectiveness after completing a 3-dose
series, though lower in persons with diabetes, e.g. 90% with diabetes
and age <40 years, 80% with diabetes and 41‒59 years, 65% if 60‒69
years and <40% if 70 years or older4
9
1. Oxman MN, et al. NEJM 2005;352:2271-84.
2. Bonten MJ, et al. NEJM 2015;372:1114-25.
3. CDC. Prevention and Control of Seasonal Influenza: Recommendations of the ACIP – U.S., 2014-15 Influenza Season. MMWR 2014; 63(32); 691-697.
4. CDC. Use of hepatitis B vaccine for adults with diabetes mellitus. MMWR 2011;60:1709-1711.
10. Vaccination of Pregnant Women: Two-For-One
Influenza vaccination of pregnant women1
Reduce risk of influenza illness in pregnant women
Reduce risk of influenza illness, fevers and influenza hospitalizations in
infants during first 6 months of life
Vaccinate with inactivated flu vaccine (not live vaccine) during
pregnancy
Tdap vaccination of pregnant women
Vaccinate in 3rd trimester to transfer antibody to infant prior to birth
Prevents pertussis in mom and protects infant
• Tdap vaccination during pregnancy estimated to be 93% effective
in preventing pertussis in infants <4 months old2
Pregnant women should NOT receive any live vaccines
(e.g. live influenza vaccine, MMR, varicella or shingles
vaccines)
1. CDC. Prevention and Control of Seasonal Influenza: Recommendations of the ACIP – U.S., 2014-15 Influenza Season. MMWR 2014; 63(32); 691-697.
2. Dabrera G, et al. Case-control study to estimate the effectiveness of maternal pertussis vaccination in protecting newborn infants in England and Wales, 2012-
2013. Clin Infect Dis. 2015; 60 (3): 333-337.
10
12. Adult Immunization Coverage Rates 2010 -
2013
0 10 20 30 40 50 60 70 80 90 100
Zoster, age ≥60
Pneumococcal, age 19-64 at high risk
Pneumococcal, age ≥65
Tetanus past 10y, age 19-64
Tetanus past 10y, age ≥65
2013
2012
2011
2010
Source: National Health Interview Surveys : Healthy People 2020 target
Coverage rate (%)
12
13. 0 10 20 30 40 50 60 70 80 90 100
Influenza, ≥19 yrs, HCP
Influenza, ≥19 yrs
% Vaccinated
2013-14
2012-13
2013-14
2012-13
2011-12
Adult Influenza Vaccination Coverage, by Age,
United States
HP2020 Targets: 70% ≥19 years, 90% HCP ≥19 years
Data Source: 2011, 2012, 2013 and 2014 NHIS
2011-12
14. 0 10 20 30 40 50 60 70 80 90 100
Zoster, ≥60 yrs
Pneumococcal, ≥65 yrs
Pneumococcal, HR 19-64yrs
% Vaccinated
2014
2014
2014
2013
2012
2013
2012
2013
2012
Adult Immunization Coverage, Selected Vaccines by
Age and High-risk Status, United States
HP2020 Targets: 90% PPV ≥65 yrs, 60% PPV HR 19-64 yrs, 30% zoster ≥60 yrs
Data Source: 2012, 2013 and 2014 NHIS
16. Hepatitis B Vaccination for Adults Living
with Diabetes
0
10
20
30
40
50
60
70
80
90
100
19-59 yrs ≥60 yrs
2010 2011 2012 2013 2014
Adults with diabetes who received ≥3 doses hepatitis B vaccine
by age, National Health Interview Surveys, 2010-2014
Coverage
rate
(%)
Age
Source: National Health Interview Surveys
16
2010 2011 2012 2013 2014
17. Disparities In Adult Immunization Rates
Lower vaccine coverage among1
• Hispanics and African Americans compared to non-
Hispanic Caucasians
• Uninsured
• Lower incomes
Improve frequency of provider vaccine assessment and
recommendations may help reduce disparities
For newly insured adults
• Affordable Care Act (ACA) requires non-grandfathered
private plans to include coverage for ACIP-
recommended vaccines
• Especially important to conduct assessment among
newly insured
17
1. Lu, P-J, et al. Am J Prev Med 2015
18. Challenges
Vaccine coverage among adults is unacceptably low
Limited patient awareness about need for vaccines among
adults
Adult vaccinations less integrated into clinical practice
Opportunities
Most patients willing to get vaccinated when
recommended by medical providers
Primary care providers believe that immunizations are an
important part of the services they provide to patients
Systematic offering and recommendations from clinicians
result in higher uptake
• Hurley, et al. Annals of Internal Medicine, 2014.
• Guide to community preventive services: www.thecommunityguide.org/vaccines/index.html
• Adult non-influenza vaccine coverage: www.cdc.gov/mmwr/preview/mmwrhtml/mm6305a4.htm. 18
Key Adult Immunization Facts
19. Vaccination Coverage of Pregnant Women
by Provider Recommendation and/or Offer
*Women who didn't visit a provider since August 2012 (n=27) or women who didn't know
whether they received provider recommendation or offer (n=55) were excluded from this analysis.
50.5
70.5
46.3
16.1
0
10
20
30
40
50
60
70
80
90
100
n = 1,702 n = 895 n = 270 n = 455
Overall Reported a provider
recommendation and offer
Reported a provider
recommendation but no offer
Reported no provider
recommendation
Influenza vaccination before and during pregnancy by provider recommendation and offer* between
October 2012 -January 2013, Internet Panel Survey
Coverage
estimates
(%)
Your recommendation
is critical to ensure
your patients are up to
date on their vaccines.
19
20. NEW Adult Immunization Practice Standards
Stresses that all providers, including those that don’t
provide vaccine services, have a role in ensuring
patients are up-to-date on vaccines
Acknowledges that:
Adult patients may see many different healthcare
providers, some of whom do not stock some or all vaccines
Adults may get vaccinated in a medical home, at work, or
retail setting
Aim is to avoid missed opportunities and keep adult
patients protected from vaccine-preventable
diseases
20
21. Adult Immunization Practice Standards
Calls to action for healthcare professionals
Assess immunization status of all patients in every clinical
encounter.
Strongly Recommend vaccines that patients need.
Administer needed vaccines or Refer to a provider who can
immunize.
Document vaccines received by patients, including entering
immunizations into immunization registries.
http://www.publichealthreports.org
Even if you don’t
vaccinate, you still
need to recommend
vaccines to your
patients
21
22. Adult Immunization Practice Standards
Formally supported by healthcare organizations:
– American Academy of Pediatrics (AAP)
– American Academy of Physician Assistants (AAPA)
– American Academy of Family Physicians (AAFP)
– American College of Obstetricians and Gynecologists (ACOG)
– American College of Physicians (ACP)
– American Pharmacists Association (APhA)
– Association of Immunization Managers (AIM)
– Association of State & Territorial Health Officials (ASTHO)
– Centers for Disease Control and Prevention (CDC)
– Immunization Action Coalition (IAC)
– Infectious Diseases Society of America (IDSA)
– National Association of County & City Health Officials (NACCHO)
– National Foundation for Infectious Diseases (NFID)
To add your organization to those supporting the standards, go to…
http://www.izsummitpartners.org/support-adult-standards/
22
23. Example of Practice Standards Implementation
Assessment
Ask patients about their vaccinations during clinic visits
E.g. Include a form at check-in and communicate with patients before
seeing the provider about which vaccines might be needed
Strongly recommend vaccines
If you provide vaccines, be confident in your recommendation
Encourage your staff to use the same vaccine messages when caring for
patients
Share a personal story with hesitant patients, such as your family or staff
are up-to-date with their vaccines
Community partners, medical associations, and CDC has patient
education materials for your use
www.cdc.gov/vaccines/AdultStandards
23
24. Example of Practice Standards Implementation
Administer needed vaccines or refer
Develop standing orders or protocols for vaccine administration
Ensure practice is up-to-date with vaccine storage and handling
Develop relationships with pharmacies, health departments, and other
vaccination providers to refer your patients for vaccines you don’t stock
Document vaccines received by patients
Document receipt of vaccine in electronic medical records
Provide patients with vaccine documentation for their personal medical
records, e.g. shot card
Follow-up with patient or referring provider to document the vaccine
given
Enter immunization doses to state immunization registries (where
applicable)
www.cdc.gov/vaccines/AdultStandards
24
25. Examples of Assessment Tools
25
CDC forms:
• Online quiz for patients
• In-office 2- page intake form
http://www.cdc.gov/vaccines/hcp/patient-ed/adults/downloads/patient-intake-form.pdf
http://www2.cdc.gov/nip/adultimmsched/
26. Examples of Assessment Tools
26
Patient vaccine needs- assessment form from Immunization Action Coalition at immunize.org.
Consider Health, Age, Lifestyle and Occupation/Other Factors
H-A-L-O
27. Examples of Assessment Tools
27
Adult patient vaccine needs-
assessment form from National
Foundation for
Infectious Diseases at NFID.org
29. Components of Successful Vaccination Programs
Strategies shown to improve vaccine
uptake in healthcare settings:
Patient education (e.g. email reminders from
providers plus provider recommendations)
Use of standing orders
Use of reminder-recall systems
Efforts to remove administrative barriers
Provider and practice assessment of
vaccination and feedback
Use of immunization registries
http://www.thecommunityguide.org/vaccines/index.html.
29
30. Improving Use of Immunization Information
Systems (IIS – aka Vaccine Registries)
Increase use important for many reasons, including
Ensuring patients get the right vaccines at the right time
Tracking vaccination rates
Potential for use in quality measures and coverage tracking
• In pediatrics, use of IIS known to improve vaccination
Meaningful Use part 2 requirement to submit to IIS where available.
Improves readiness to respond to emergencies like 2009 H1N1
Challenge: limited use by adult providers (e.g. 8% internists)1
IIS contacts in each state can be found at:
http://www.cdc.gov/vaccines/programs/iis/contacts-
registry-staff.html.
1. Hurley, et al. Ann Intern Med 2014; 160(3):161.
30
31. Place of Vaccination by age group,
November 2012 NIS and NIFS*
*October 4 – November 17, 2012 National Immunization Survey (NIS) data for children 6 months through 17 years of age
November 2-15, 2012 National Internet Flu Survey (NIFS) data for adults ≥ 18 years of age
31
32. Example of Practice Standards Implementation
Osterhaus Pharmacy (Maquoketa, IA)
Eastern Iowa is a large rural area with limited access to health care
services and low vaccination rates
Osterhaus Pharmacy addressed the problem by identifying 272
patients with diabetes, and flagged them for outreach and
immunization with Tdap, zoster, pneumococcal, hepatitis B, and
influenza vaccines
Teamed with two local physicians to coordinate immunization
records, educate, screen and vaccinate patients
Among nearly 200 screened and vaccinated.
Only three of those screened were up-to-date on their
immunization.
32
http://www.izsummitpartners.org/immunization-excellence-awards/awards-2014/
33. Results with Implementation of Standards
Indian Health Service (IHS)
IHS is a federal agency charged with providing
healthcare to eligible American Indian/Alaska Native
people
Member of one of the 566 federally recognized tribes
Residence in the IHS catchment area
IHS provides services to approximately 2 million
patients each year
Network of IHS, Tribal, and Urban Indian health care facilities
in 35 states
33
34. Indian Health Service
Leveraging Technology
Use of EHR and provider reminder prompts focusing
on the following adult vaccinations:
Influenza for all ages
PPSV23 for 65 years+
PPSV23 for adults with high risk conditions
Tdap for everyone 19 yrs+
Td every 10 years
HPV
Females 19 – 26 years
Males 19 – 21 years
Zoster for 60 yrs +
Hepatitis A and B for patients who receive first dose
34
35. Indian Health Service
Leveraging Technology Data
81.5%
74.1%
49.5%
31.8% 27.4%
8.6%
38.8%
74.9%
87.1%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
IHS Adult Vaccination Coverage*
FY 2014 Q1 Reports
FY 2014 Q1
* Based on Active Clinical Users (2 visits in 3 years), N = 558,566
35
36. Results with Implementation of Standards
Outpatient Medical Practice
Clinics at University of Iowa wanted to improve pneumococcal
vaccination of their patients
Placed a two-question form on each chart asking about
Whether the patient got the pneumococcal vaccination
And, if no, why not.
Form also included indications for pneumococcal vaccination
Form completed for 75% of visits
Compared to baseline levels, 5-fold increase in pneumococcal
vaccinations
Returned to baseline levels when form not used
• Tobacman JK. Infect Control Hosp Epidemiol 1992;13:144-46.
36
37. Results with Implementation of Standards
Hospital and Pharmacy Collaboration
In 2000-2003, pneumococcal vaccine inpatient rates were 15-
31%
Pharmacy-driven standing orders program (SOP) developed by
multidisciplinary team after reviewing existing system challenges.
Pharmacists screened patients based on the SOP and, if appropriate,
added the vaccination order to the patient chart
Nurse reviewed with the patient and family their vaccination history and
allergies, gave the vaccine information statement (VIS), and obtained
verbal consent prior to administering the vaccine
Results
During 2005, pneumococcal vaccination increased to 69%
Influenza vaccination rate of 73%
• Sokos DR, et al. Am J Health-Syst Pharm 2007;46:1096-1102.
37
38. Patient check-in vaccine questionnaire to be used at
clinics: http://www.cdc.gov/vaccines/hcp/patient-
ed/adults/downloads/patient-intake-form.pdf.
H-A-L-O – vaccine needs questionnaire based on your
patient’s Health condition, Age, Lifestyle, and Occupation
at http://www.immunize.org/catg.d/p3070.pdf.
Patient on-line quiz – direct patients to complete the
quiz before coming to their appointment – gives them
and you a starting point for talking about which vaccines
they might need.
http://www2.cdc.gov/nip/adultimmsched/.
CDC adult vaccine schedule app at
http://www.cdc.gov/vaccines/schedules/hcp/schedule-
app.html.
Resources For Implementing New Standards
38
39. Resources For Implementing New Standards
CDC handouts for providers about how to implement the Standards
www.cdc.gov/vaccines/adultstandards and information about vaccine
recommendations at www.cdc.gov/vaccines/acip
National Adult and Influenza Immunization Summit and
Immunization Action Coalition (IAC)
www.izsummitpartners.org has information for providers on each vaccine and
vaccine administration, storage and handling at www.immunize.org.
National Foundation for Infectious Diseases
www.adultvaccination.org has tools for providers and information to help with
conversations with your patients about vaccines, including the top 10 reasons
to get vaccinated at http://www.adultvaccination.org/10-reasons-to-be-
vaccinated.
39
40. Resources From Professional Provider Organizations
on Adult Immunizations
American Academy of Family Physicians - http://www.aafp.org/patient-
care/immunizations/schedules.html for information on vaccinations plus CME
opportunities
American Assocation of Nurse Practitioners -
http://www.aanp.org/education/education-toolkits/immunizations. Includes tool kits
and other information.
American Academy of Physician Assistants – http://www.aapa.org. has information on
professional recommendations for immunization practice.
American College of Obstetricians and Gynecologists - www.immunizationforwomen.org
information about vaccines for pregnant and non-pregnant women, vaccine coding and
other business practices
American College of Physicians - http://immunization.acponline.org/ has information
about adult vaccinations, quality improvement, resources for practical application, and
information on special populations. Download the ACP Immunization Advisor App here:
http://bit.ly/ACPapp
American Pharmacists Assocation - http://www.pharmacist.com/immunization-
resources. Multiple resources, training and tools for pharmacists on immunizations.
Infectious Diseases Society of America - http://www.idsociety.org/Immunization/.
Provides multiple resources and also recommendations specifically for immune
compromised persons.
40
41. Series for Healthcare Providers on
Implementing Standards
www.cdc.gov/vaccines/AdultStandards
41
44. Medscape Module
Case Presentations and Videos
1. Older Adult
• Zoster
• PCV13
2. Adult with Diabetes
• Hep B
• Influenza
3. Pregnant Woman
• Tdap
• Influenza
45. For Providers That Need to Refer Patients for
Vaccinations
Providers and patients can find vaccine providers in their
area at http://vaccine.healthmap.org.
45
46. Conclusions
Substantial burden of disease in adults for which vaccines
available
Vaccination rates low among adults in U.S.
Adult Immunization Practice Standards updated and supported by
wide range of provider organizations
Implementation of standards is key to increasing awareness of
adult immunization, improving vaccine coverage, and reducing
racial and ethnic disparities in vaccine coverage
Many tools and resources available to:
Help providers implement practice standards
Educate patients on the importance of vaccination
46
49. Adult Immunization Practice Standards
Framework
• Incorporate IZ needs assessment into every clinical encounter.
• Recommend, administer needed vaccine or refer to a provider who can
immunize.
• Stay up-to-date on immunization recommendations and educate
patients.
• Ensure providers and their staff are up to date on their own vaccines
• Understand how to access registries.
All Providers
•Routinely assess immunization status of patients, recommend
needed vaccines and refer patient to an immunizing provider.
•Establish referral relationships with immunizing providers.
•Follow up to confirm patient receipt of recommended
vaccine(s).
Non-immunizing
Providers
•Observe and adhere to professional competencies regarding
immunizations.
•Assess immunization status in every patient care and counseling
encounter and strongly recommend needed vaccines.
•Ensure receipt of vaccination is documented.
Immunization
Providers
49
50. Adult Immunization Practice Standards
Framework
• Education and training of members, including trainees
• Resources and assistance to implement protocols, immunization
practices, immunization assessment, etc
• Encourage members to be up-to-date on own immunizations
• Assist members in staying up-to-date on IZ info & recommendations
• Partner with others immunization stakeholders to educate the
public
• Seek out collaboration opportunities with other immunization
stakeholders
• Collect and share best practices
• Advocate policies that support adult immunization standards
Professional healthcare
related organizations /
associations/healthcare
systems
•Determine community needs and capacity and community barriers to adult
IZ
•Support activities and policies to increase vaccination rates and reduce
barriers
•Ensure professional competency
•Collect, analyze and disseminate data
•Outreach and education to public and providers
•Work to decrease disparities
•Increase registry access and use
•Develop billing capacities
•Ensure preparedness, communicate vaccine information to providers and to
the public
•Promote adherence to laws and regulations pertaining to immunizations
Public Health
Departments
50
51. Meta-Analysis of Interventions to Increase Use
of Adult Immunization
Intervention Odds Ratio*
Organizational change
(e.g., standing orders, separate clinics devoted to
prevention)
16.0
Provider reminder 3.8
Patient financial incentive 3.4
Provider education 3.2
Patient reminder 2.5
Patient education 1.3
*Compared to usual care or control group, adjusted for all remaining interventions
Stone E. Interventions that increase use of adult immunization and cancer screening services. Ann
Intern Med. 2002; 136:641-51.
51
52. Influenza Vaccination Rates by Age Group and
Risk Group, BRFSS 2011-14
0
10
20
30
40
50
60
70
80
90
100
2011-12 2012-13 2013-14
18-49 yrs, all
18-49 yrs, high risk
50-64 yrs
≥ 65 yrs
Healthy People 2020 Goal
Adults 18 and older
52
53. Impact of Vaccine Preventable Diseases in People
Shingles: "I would rather have ten babies than the pain I've endured
for the past ten years," says 87-year-old Etta Watson Zukerman of
Bethesda, Md., who has lost partial use of her right arm and hand
due to nerve damage from postherpetic neuralgia (PHN).
Hepatitis B: “One day without warning, my brother, who was 18,
woke up with severe pain in his abdomen. When we took him to the
doctor, we were told that he and my mother were hepatitis B carriers.
My brother passed away a year later. One month after his death, my
mother was diagnosed with liver cancer.” Leslie D. Hsu
Testimonials from Immunization Action Coalition and CDC websites
Pertussis: Callie stopped breathing again. Family members watched
helplessly from behind a glass wall as doctors tried for 45 minutes to
revive her. Tragically, Callie could not be saved. She was only 5 weeks
old. "We never dreamed we'd lose her," Katie said. "Callie was a more
loved, more wanted baby than you'd ever find."
CDC website
CDC/ Patricia Walker, M.D., Regions Hospital, MN
53
Courtesy MN Oxman San Diego VAMC
54. Meet Joan:
Special Education Teacher
“The Pain of Shingles”
• Joan developed severe pain in her back
and the doctors could not initially figure
out what was wrong then the rash started
several days later.
• She had contracted shingles, but not the
traditional rash that is common to many at
disease onset.
– In some cases, rash happens after the pain
• The pain was so severe it kept her awake
at night. Joan says that she would have
sought vaccination if she had known it was
recommended.
For Joan’s full story, visit:
http://www.nfid.org/real-stories-real-people/joan-shingles.html
“If I had known that a
vaccine is recommended
for everyone my age, I
would have gotten it.
Believe me, if you could
understand the pain of
shingles, you’d get the
vaccine, too.”
54
55. Jacob Ryan Schmidt:
A competitive martial arts expert
“A Son’s Life Cut Short by Influenza”
• Jacob was strong as a bull and enjoying
life.
• In 2010, at the age of 27, he
succumbed to complications from
H1N1 influenza.
• His lungs collapsed; he developed an
infection. His organs were shutting
down. After about five weeks of
influenza ravaging his body, Jacob died.
For Jacob’s full story, visit:
http://www.nfid.org/real-stories-real-people/jacob-influenza.html#sthash.qbrBJ6AE.dpuf
“Jacob was not someone
you’d expect to fall ill to
influenza. He was healthy
and athletic, and built like
a freight train.”
55
56. Meet Dr. William Cochran:
A Pediatric Gastroenterologist
“A Doctor’s Personal Experience with
Whooping Cough”
• Dr. Cochrane came down with a severe
cough where he could not catch his
breath and would even pass out.
• He coughed so long and hard that he
cracked several ribs.
• He learned that he had pertussis or
“whooping cough”
• It took him three months to recover.
For Dr. Cochrane’s full story, visit:
http://www.nfid.org/real-stories-real-people/cochran-pertussis.html
“Anyone – doctor, parent,
grandparent, caregiver,
who comes into contact
with infants should be
sure they are up to date
on their immunizations to
spare those too young to
be protected through
vaccination .”
56
57. Overall coverage remains below HP2020 targets
• 90% for 65+ years for pneumococcal vaccine
• 60% for high risk 19-64 years for pneumococcal vaccine
• 30% for 60+ years for Zoster vaccine
• 90% for hepatitis B vaccine for healthcare personnel
Some improvement from 2013
– Tdap (≥19 year olds), and herpes zoster (≥60 year olds)
vaccines
– No improvements for other vaccines
Racial and ethnic disparities remain
Much remains to be done to increase vaccine utilization
among adults and to eliminate disparities
Raising awareness about disparities in adult
immunizations
57
58. *p<0.05 by T test for comparisons between HCP with direct patient care
responsibilities and HCP without direct patient care responsibilities.
Proportion of HCP >19 years of age who received
selected vaccines, by direct patient care
Group %
Influenza (2013-14 season), >19 years, with direct patient care 65
Influenza (2013-14 season), >19 years, without direct patient care 66
Tdap, >19 years, with direct patient care 48
Tdap, >19 years, without direct patient care 32*
HepB (>3 doses), >19 years, with direct patient care 68
HepB (>3 doses), >19 years, without direct patient care 48*
Data Source: 2014 NHIS
59. Partnerships to Raise Awareness and
Immunization Coverage
Professional medical, nursing, and pharmacist organizations
and their state or local chapters
Advocacy and education groups:
Association of Diabetes Educators, American Heart Association, etc.
Health departments and their clinics for HIV, STD, and TB, etc.
Community Health Centers
Corrections
Large healthcare systems
Occupational health
Private sector partners such as community organizations
including faith based partners, and others
59
Editor's Notes
[This slide set is intended to help speakers educate provider audiences about adult immunizations, current low levels of vaccination rates in the United States, and ways that providers can improve immunizations rates through implementation of the Standards for Adult Immunization Practice. These Standards were published in February 2014 in Public Health Reports. The main intended audiences for this slide set includes medical and pharmacist providers, including those that do and those that do not offer immunization services. Persons using this slide set are encouraged to modify the content to meet the specific needs of their audiences. Speakers may also modify this slide to add their name and organization. Suggested wording included in the speakers notes may also be changed to fit the speaker and audience.]
Speaker notes:
Hello. My name is ____________________ from [organization]. Today I will provide information about adult immunizations, current low levels of vaccination rates in the United States, and ways that providers can improve immunizations rates through implementation of the Standards for Adult Immunization Practice. I have [list potential conflicts of interest or if no have no conflicts] to disclose. [Mention also if your institution would allow medical education credits or other credits for this talk and how a participant would obtain credit. Such credit would need to be applied for by individual speakers and their institutions.]
The goals of today’s presentation are to [read slide wording above].
The burden of illness due to diseases for which vaccines are available is quite high. Many of the infections preventable through vaccination are also very common among adults in the United States. In fact, the vast majority of vaccine preventable illnesses in the US occur among adults. Most causes of vaccine preventable illness among children are relatively uncommon due to high rates of vaccination and very effective vaccines.
For influenza, the burden of illness varies from year to year.
There are millions of cases and an average of 226,000 hospitalizations annually, more than75% of which occur among adults.
Of the 3,000-49,000 deaths annually from influenza, >90% among adults. (2)
Invasive pneumococcal disease (IPD)1 is also common.
There were an estimated 39,750 total cases and 4,000 total deaths in 2010 from IPD.
86% of IPD cases and nearly all IPD deaths were among adults.
The US has seen an increase in pertussis (also known as whooping cough)3 in the last several years.
About 28,000 cases each year in 2013 and 2014
Hepatitis B4 also continues to occur with 3,350 acute cases reported in 2010 which is estimates to translate into an estimated 35,000 estimated cases, with more than 90% among adults.
Zoster (also known as shingles)5 is also common.
About 1 million cases of zoster annually in the U.S. with the risk increasing as adults get older.
INSTRUCTIONS: Persons giving this talk can insert slides or give verbal examples of cases of vaccine preventable illnesses that they have personal experience with. These are examples on the Centers for Disease Control and Prevention website and also the Immunization Action Coalition at immunize.org.
Speakers notes:
These are some personal examples of the impact of illness from some of the vaccine preventable illnesses that I mentioned. [read quotes from slide.]
See additional optional slides for other stories from patients with a vaccine preventable illness.
Vaccines are important for optimizing health, for protecting the person vaccinated, and also preventing the spread of illness to others.
E.g. Vaccination against influenza and pertussis reduces the risk in the person vaccinated and also prevents someone from spreading these diseases.
The adult immunization schedule is updated and published annually by the CDC’s Advisory Committee on Immunization Practices – also called the ACIP. The schedule is organized into two figures with detailed footnotes for each vaccine. The first figure includes commonly recommended vaccines on the left hand side. And age groups for adults are across the top. Yellow means that the vaccine is recommended for persons in that age group unless already immune or vaccinated. Purple means that the vaccine is recommended if in that age group and they have another reason to get the vaccine such as a high risk condition.
For example, influenza vaccine is recommended annually for all adults.
Varicella (the vaccine against chicken pox) is recommended for adults who are not immune due prior infection with varicella zoster virus or prior varicella zoster virus vaccination. Some adults would have been vaccinated during childhood. If vaccinated as a child, then they would not need to get varicella vaccination again. The footnote for this vaccine includes the definitions of who is considered immune.
Pneumoococcal polysaccharide vaccine is recommended for all persons 65 years and older. For persons 18-64, they should get this vaccine if they have another indication such as a person with asthma or chronic heart disease or diabetes.
Again, details for each vaccine are in the footnotes that accompany the figure.
Importantly, this schedule does not include all vaccines. In addition, providers and patients should go to www.cdc.gov/travel to find recommendations for vaccination for travelers. This website provides up to date information for vaccination and other health information based on the destination a person is traveling to.
This next figure also lists the commonly recommended vaccines on the left. Across the top it lists pregnancy, certain medical conditions, men who have sex with men, and healthcare occupation as different indications for vaccination. Not all indications are listed across the top and the footnotes provide additional details about indications for vaccination.
For example, pregnant women are recommended to receive influenza vaccination and Tdap vaccination during pregnancy. The live vaccines (MMR, varicella and zoster vaccines) are contraindicated during pregnancy. No information is available for vaccines where there is a white or blank space. Vaccines sicu as hepatitis B vaccine should be given if there is some other indication. For example, a women who is pregnant and traveling to an area where hepatitis B is more common or who lives in a household with a person who has an active infection with hepatitis B or who may be exposed to blood in a healthcare setting should be vaccinated against hepatitis B.
The impact of vaccination, or vaccine effectiveness, varies by vaccine type, the disease outcome being measured, and the age or health of the person vaccinated. I have listed some examples below. Please keep in mind that many of these diseases are common. So, while the vaccine effectiveness is modest for some vaccines when given to adults, the impact of vaccination overall is high given the high number of cases that can be prevented.
Zoster (Shingles) vaccine is 51% effective against shingles, 66% against post-herpetic neuralgia (PHN), and almost 80% against most prolonged and extreme cases of PHN.
PCV13 (pneumococcal conjugate vaccine) is 45% effective against vaccine-type pneumococcal pneumonia, and 75% effective against vaccine-type invasive pneumococcal disease among adults aged ≥65 years.
Influenza vaccine effectiveness varies annually based on antigenic match and also age and health of person being vaccinated – about 60-70% in younger adults and about 30% in adults 65 years and older against medically attended influenza when there is a good match.
Tdap vaccination of pregnant women is about 90% effectiveness in preventing pertussis (whooping cough) in their infants.
Hepatitis B vaccine is about 90% effectiveness after completing a 3-dose series, though lower in persons with diabetes, e.g. 90% with diabetes and age <40 years, 80% with diabetes and 41- 59 years, 65% if 60-69 and <40% if 70 years or older.
More information about vaccine effectiveness for all of these vaccines can be found at www.cdc.gov/vaccines and is detailed in the vaccine recommendations from the Advisory Committee on Immunization Practices. A link to these recommendations can be found at www.cdc.gov/vaccines.
As I mentioned in the prior slide, vaccination of pregnant women is an important way to decrease the risk of illness in the mother and also the infant during the first 6 months of life.
[READ SLIDE ABOVE]
So, as I have shown in the prior slides, many illnesses for which vaccines are available are common in adults. Vaccines are recommended based on age, immune status of the person, prior vaccinations, and certain health conditions and other factors. So, how are we doing as a country in getting adults vaccinated? I am going to show you some informaiton on vaccination rates from the 2012 National Health Interview Survey for selected vaccines and certain age and risk groups. More information on vaccination rates in the US can be found at www.cdc.gov/vaccines.
Our immunization program has been very successful with kids. So is there is a problem? Yes, there is. We’re not doing so well with adults.
Interviews from August through June of each season were used to estimate influenza vaccination coverage from July through May using Kaplan Meier survival analysis.
Influenza vaccination coverage among those aged ≥19 years was 39.6% during the 2011-12 season, 42.8% during the 2012-13 season, and 43.2% during the 2013-14 season. Coverage significantly increased from the 2011-12 season to the 2012-14 season, but coverage during all seasons was well below the Healthy People 2020 target of 70%.
Influenza vaccination coverage among health-care personnel aged ≥19 years was 61.5% in the 2011-12 season, 67.3% in the 2012-13 season, and 65.4% in the 2013-14 season. Coverage did not increase significantly from the 2011-12 season to the 2012-14 season, and coverage during all seasons was well below the Healthy People 2020 target of 90%.
Pneumococcal vaccination coverage among those aged 19-64 years with high-risk conditions was 20.0% in 2012, 21.2% in 2013, and 20.3% in 2014. Coverage during all years was well below the Healthy People 2020 target of 60%.
Pneumococcal vaccination coverage among those aged ≥65 years was 59.9% in 2012, 59.7% in 2013, and 61.3% in 2014. Coverage during all years was well below the Healthy People 2020 target of 90%.
Herpes zoster vaccination coverage among those aged ≥60 years was 20.1% in 2012, 24.2% in 2013, and 27.9% in 2014. Coverage significantly increased from year to year, as coverage approached the Healthy People 2020 target of 30%. The zoster estimate for non-Hispanic whites (32%) exceeded the Healthy People 2020 target.
At least one year-to-year increase in vaccination coverage occurred during the period of 2011 to 2014 for three vaccines: herpes zoster (≥60 years), HPV (women 19-26 years), and Tdap (19-64 years, and HCP 19-64 years).
The slide shows 2011-2014, although the trends analysis done for our report was on the period 2010-2014. Both influenza vaccination (> 19 years) and HPV vaccination of males (19-26 years) also had statistically significant increases during this period, but were not shown on the slide due to formatting issues (too many bars) and the much smaller scale for the increases. (In presenting this slide, both flu and HPV-males should also be noted.)
More detailed trend figures reporting the overall trend for the period of 2010-2014 will be presented in later slides.
Adults living with diabetes should get hepatitis B vaccine. How is the US doing in getting these patients vaccinated with hepatitis B vaccine?
Unlike for pediatric programs, lower vaccination rates are seen among non-Hispanic, non-white racial and ethnic groups. Multiple factors likely contribute to this. Lower coverage is also noted for uninsured persons and persons with lower incomes irrespective of race and ethnicity.
However, routine and systematic offering of vaccines has been shown to decrease gaps in vaccine disparities. The first step to get to vaccine recommendation and offer is doing a routine vaccine needs assessment.
Newly insured patients may not be aware that vaccines are included coverage. The ACA requires that private health plans include insurance coverage for ACIP recommended vaccinations. Since uninsured persons are statistically more likely to have lower vaccine coverage, newly insured persons may be one of the groups most likely not to be up to date on immunizations and to benefit from a vaccine needs assessment.
Now I wanted to review some key facts and observations about vaccination of adults. First, based on the information I just shared with you, I hope we all agree that vaccination rates among US adults are unacceptably low.
We also know that there is limited patient awareness about the need for vaccinations for adults.
Unfortunately, adult vaccination needs assessment and vaccination are too often not integrated into clinical practice
But, there are a number of opportunities to address these challenges.
First, research also shows that most patients are willing to get vaccinated when recommended by trusted healthcare providers.
Second, primary care providers believe that immunizations are an important part of the services they provide to patients.
And, systemic offering and recommendations for needed vaccines from clinicians result in higher uptake.
In the next slides, I will provide some examples of the impact of implementing means to take advantage of these opportunities in terms of increasing uptake of needed vaccines.
A key strategy for increasing the number of patients up to date on their vaccines is ensuring that providers make a strong vaccine recommendation for their patients. An example of the impact of the provider recommendation is this data from a survey of pregnant women. But the provider recommendation is not just impactful for pregnant women. Research shows that the provider recommendation is a key factor in getting vaccinated for flu and as well as for other vaccines.
In this example from a survey of pregnant women, you can see that coverage was 70.5% among those who received a provider recommendation and offer of vaccination. This example also demonstrates the importance of providers vaccinating at the time of the recommendation. When the vaccine was recommended, but vaccination was not offered, the coverage was substantially lower at 46.3%. Without a recommendation or offer, coverage was even lower at 16.1% among women who neither received a recommendation or offer.
This vaccination pattern was found in all demographic and other subgroups even among women who has a negative attitude toward the influenza vaccination, again demonstrating the importance of the provider recommendation.
Based on the facts we just reviewed and other factors, new practice standards for adult immunization practice were developed and approved by the National Vaccine Advisory Committee and published in Public Health Reports in February 2014.
The practice standards stress that all providers, including those that don’t provide vaccine services, have a role in ensuring patients are up-to-date on vaccines.
The standards acknowledges that:
Adult patients may see many different healthcare providers, some of whom do not stock some or all vaccines and that
Adults may get vaccinated in many different locations by different providers, including the medical home, at work, or retail settings like pharmacies.
The aim of the practice standards is to avoid missed opportunities and keep adult patients protected from vaccine-preventable diseases
The calls to action for healthcare professionals include:
Assess immunization status of all patients in every clinical encounter.
Strongly Recommend vaccines that patients need.
Administer needed vaccines or Refer to a provider who can immunize.
Document vaccines received by patients, including entering immunizations into immunization registries.
The recommendation to assess immunization status at every clinical encounter does not mean that this has to be done by the provider every time, but since adult patients see providers much less often than children and even less often for preventive services, providers should take advantage of those visits to incorporate vaccine needs assessment or review into their patient intake or patient flow. And, certain providers may assess only for certain vaccines. Primary care providers may assess for all vaccines. But, a cardiologist, for example, may just assess for influenza vaccination and pneumococcal vaccination of their patients since patients with cardiovascular disease are at increased risk of severe illlness from influenza and from pneumococcal disease.
The updates standards for adult immunization practice have been formally supported by a wide range of organizations. [highlight those organizations most pertinent to your audience.] If your organization wants to formally support the standards you can go to…. http://www.izsummitpartners.org/support-adult-standards/.
This slide discusses some of the that the first two parts of the practice standards may be implemented.
For vaccine needs assessment or vaccine needs review, this review may be done with a form at check-in and this form may be used to communicate with patients and the nurse before seeing the provider about which vaccines might be needed
Strongly recommending vaccines is important.
If you provide vaccines, be confident in your recommendation
Encourage your staff to use the same vaccine messages when caring for patients.
Share a personal story about an experience you know about of a person ill with a vaccine preventable illness with hesitant patients, or you can share that you, your family or staff are up-to-date with their vaccines.
You can also work with community partners, medical associations, and others to increase awareness about vaccines for adults. CDC also has patient education materials for your use.
This slide discusses ways that the last two parts of the practice standards may be implemented.
Administer needed vaccines or refer for vaccinations if there are vaccines you do not stock in your practice.
Develop standing order protocols for vaccine administration for vaccines you do stock.
And make sure your phe practice is up-to-date with regards to appropriate vaccine storage and handling procedures.
Develop relationships with pharmacies, health departments, and other vaccination providers to refer your patients for vaccines that you do not stock.
And, document vaccines received by your patients.
Document receipt of vaccine in your EHR
You can also provide your patients with vaccine documentation for their personal medical records. Some providers give patients “shot cards” for their patients to have as a record.
Follow-up with patients or referring providers to document that recommended vaccines were given for patients that were referred out for vaccination services.
Finally, also enter information about vaccines administered into state immunization registries that accept information on adult patients. This is helpful as it provides one location that all of a patient’s providers can go and see if a patient is up to date on their vaccines.
There are a number of different resources or tools available to help providers do vaccine needs assessments for their patients.
CDC has several tools that can help. One is to refer patients to the CDC website and the adolescent and adult vaccine quiz. Other tool is a 2-page patient handout that patients can fill out when they come for patient care.
Other partners also have tools as well. The H-A-L-O tool from Immunization Action Coalition can also be used and is publically available. This assesses a patient’s vaccine need based on their health conditions, age, lifestyly and occupation and other factors.
The National Foundation for Infectious Diseases also has an adult vaccine needs assessment tool available for providers.
Other partners and provider organizations have other tools as well that can help providers incorporate vaccine needs assessment and documentation of vaccination.
Your electronic health system may also help with provider reminders about needed vaccines.
[READ SLIDE]
Successful adult immunization programs use of combination of approaches to improve vaccination rates.
Based on the community guide: some techniques shown to improve coverage among adults includes efforts to remove administrative barriers, providing feedback to providers and their practices as to how they are doing, implementing use of standing orders, and use of reminder-recall systems.
The use of vaccine registries is also important for tracking your patients vaccinations and some have reminder capabilities that can help remind patients and providers about overdue vaccinations.
The use of Immunization Information Systems (IIS – aka Vaccine Registries) is important for a number of reasons including:
Ensuring patients get the right vaccines at the right time
Tracking vaccination rates
Potential for use in quality measures and coverage tracking – use of IIS has been shown to improve vaccination rates in children. No information is available for adults but it would be likely very helpful.
Meaningful Use part 2 requires that medical providers submit vaccinations into registries, where available for adults.
Use of IIS also helps with increase preparedness for a pandemic and other vaccine emergency responses so that patients and providers can make sure patients get the right dose at the right time.
A challenge is that there is currently limited use of IIS by adult providers (e.g. 8% internists), however many large chain pharmacies are increasing use of IIS.
For providers interested in finding out more about their state’s IIS, IIS contacts in each state can be found at the url listed here.
The benefits of using an IIS are illustrated in this slide showing the many different places that children and adults get influenza vaccination. In this slide, adults are red and children are in blue. The most common place of vaccination among both adults (32.5%) and children (65.4%) was a doctor’s office (Figure 2). These results are similar to results from the 2010-11 season when 31.6% of adults and 60.2% of children were vaccinated in doctor’s offices.
Other common places of influenza vaccination reported for adults during the 2011-12 season included medically related places besides doctor’s offices (24.7%), pharmacies or stores (19.7%), and workplaces (13.8%). The second most common places of influenza vaccination for children were medically related places other than doctor’s offices (22.7%).
This slide provides an example of successful Standards implementation.
Osterhaus Pharmacy (Maquoketa, IA)
Because eastern Iowa is a large rural area, people have limited access to health care services and local vaccination rates are some of the lowest in the state. Osterhaus Pharmacy initiated a process to address the problem by identifying 272 patients with diabetes, the largest at-risk group, in its system and flagged them for outreach and immunization with Tdap, zoster, pneumococcal, hepatitis B, and influenza vaccines. Nearly 200 of these patients were screened and vaccinated. Before this pharmacist intervention, only three of these patients were up-to-date on their immunization.
Osterhaus Pharmacy also teamed with the two local physician clinics to coordinate immunization records, screen and immunize patients, and educate patients on the importance of staying current with recommended immunizations.
An example of what can be accomplished in terms of vaccination rates comes from the Indian Health Service (IHS).
I.H.S. is federal agency charged with providing healthcare to eligible American Indian/Alaska Native people who are
Members of one of the 566 federally recognized tribes and who reside in the IHS catchment area
I.H.S. provides services to approximately 2 million patients each year through a network of I.H.S., Tribal, and Urban Indian health care facilities in 35 states.
So, they provide care in multiple locations to an underserved population.
What the I.H.S. did was to use their EHR and provider reminder prompts to focus on the following adult vaccinations:
Influenza for all ages
PPSV23 for 65 years+
PPSV23 for adults with high risk conditions
Tdap for everyone 19 yrs+
Td every 10 years
HPV
Females 19 – 26 years
Males 19 – 21 years
Zoster for 60 yrs + , and
Hepatitis A and B for patients who receive first dose.
What they were able to accomplish through E.H.R. prompts and through provider reminders was much higher vaccination rates than the national average.
This is an example from an internal medicine out patient practice at the University of Iowa.
[READ SLIDE]
This example illustrated the importance and effectiveness of a provider reminder about vaccination.
There are many different tools for providers and patients to help with vaccine needs assessment, including… [read resources on slide].
INSTRUCTIONS: Add your professional organization to this slide and a link to and description of resources available
Many professional medical and pharmacy organizations also have very helpful resources for providers. A few are listed here.
There are also other resources on the CDC website to help providers with implementation of the standards.
And CDC also has a number of patient education handouts that can be downloaded free of charge.
CDC also has some posters as well that are free to providers.
A Medscape Module as part of a series on the Standards was developed with case presentation and video examples of how to answer patient questions using SHARE in a quick and efficient way.
A vaccine finder, developed and managed by Harvard University, is available online to help patients or providers find a vaccine provider in your area. This site was launched in 2012 and helped provide the public with information about clinics in their area that had influenza and other vaccines for adults.
Any provider or clinic that wants for their site to be open to the public to get vaccinations can be added to this website. Prompts for how to list your location are included on the website.
In conclusion, there is a substantial burden of disease among US adults for which vaccines are available.
However, vaccination rates are low among adults in U.S.
The Adult Immunization Practice Standards have been updated and are supported by wide range of provider organizations.
Implementation of the standards is key to increasing awareness of adult immunizations, improving vaccine coverage, and reducing racial and ethnic disparities in vaccine coverage.
Many tools and resources are available to:
Help providers implement the practice standards and to
Educate patients on the importance of vaccination.
Final slide for speaker to add their contact information if they wish.
This slide demonstrates where the different age groups are with respect to the healthy people 2020 goal of 70% vaccination rate for all adults with influenza vaccine.
INSTRUCTIONS: Persons giving this talk can insert slides or give verbal examples of cases of vaccine preventable illnesses that they have personal experience with. These are examples on the Centers for Disease Control and Prevention website and also the Immunization Action Coalition at immunize.org.
Speakers notes:
These are some personal examples of the impact of illness from some of the vaccine preventable illnesses that I mentioned. [read quotes from slide.]
See additional optional slides for other stories from patients with a vaccine preventable illness.
(Note to speaker: click on the link to familiarize yourself with Joan’s full story)
(Note to speaker: click on the link to familiarize yourself with Jacob’s full story)
(Note to speaker: click on the link to familiarize yourself with Dr. Chochrane’s full story)
Adults were classified as HCP if they reported that they currently volunteer or work in a hospital, medical clinic, doctor’s office, dentist’s office, nursing home, or some other health care facility including part-time and unpaid work in a health care facility as well as professional nursing care provided in the home. HCP were classified as having direct patient care responsibilities if they reported providing direct patient care (physical or hands-on contact with patients) as part of their routine work.
Influenza vaccination coverage during the 2013-14 season was 65.1% among HCP with direct patient care, similar to the estimate among HCP without direct patient care (66.0%). Influenza vaccination coverage among HCP with and without direct patient care was similar to coverage during the 2012-13 season.
Tdap vaccination coverage was higher among HCP with direct patient care (47.5%) compared to HCP without direct patient care (31.6%), and coverage among both groups was similar to coverage in 2013.
Hepatitis B vaccination coverage was higher among HCP with direct patient care (67.7%) compared to HCP without direct patient care (47.6%), and coverage among both groups was similar to coverage in 2013.
Immunizaitons represents a great opportunity for collaboration among medical and pharmacy providers, state and local health departments, health systems and private sector partners in the community, State and local health departments can work with many different partners to ensure that their patients are up to date with vaccinations.