Adult ImmunizationAdult Immunization

Do Disparities have Ethical Do Disparities have Ethical Implications?Implications?

William Schaffner, MDProfessor of Preventive Medicine, Department of

Health PolicyProfessor of Medicine - Infectious DiseasesVanderbilt University School of Medicine

Conflicts of InterestConflicts of Interest

CDC: Co-PI, Cooperative AgreementCDC: Co-PI, Cooperative Agreement

Emerging Infections ProgramEmerging Infections Program Merck: Member, Data Safety Merck: Member, Data Safety

Monitoring BoardMonitoring Board Sanofi-Pasteur: One lectureSanofi-Pasteur: One lecture Dynavax: ConsultantDynavax: Consultant

It is better to avert the malady It is better to avert the malady by care than to have to apply by care than to have to apply physic after it has appeared.physic after it has appeared.

——Shao TzeShao Tze

Adult Immunization ConceptsAdult 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

Centers for Disease Control and Prevention (CDC). MMWR Morb Mortal Wkly Rep. 2012;61(04):66-72.

Infant, Childhood, Infant, Childhood, Adolescent ImmunizationAdolescent Immunization

One of the great clinical and public One of the great clinical and public health success stories of the 20health success stories of the 20thth/21/21stst centuries centuries

Disparities of income, race, Disparities of income, race, urban/rural eliminatedurban/rural eliminated

Comparison of 20th Century Comparison of 20th Century Annual Morbidity and Current Annual Morbidity and Current

Morbidity: Morbidity: Vaccine-Preventable DiseasesVaccine-Preventable Diseases

Centers for Disease Control and Prevention. Historical comparisons of vaccine-preventable disease morbidity in the U.S. http://www.ct.gov/dph/lib/dph/infectious_diseases/immunization/pdf/vpd_us_statistics_2010.pdf. Accessed April 9, 2013.

Disease20th Century

Annual Morbidity2010

Reported CasesPercent

Decrease

Smallpox 29,005 0 100

Diphtheria 21,053 0 100%

Measles 530,217 61 >99%

Mumps 162,344 2528 98%

Pertussis 200,752 21,291 89%

Polio (paralytic) 16,316 0 100%

Rubella 47,745 6 >99%

Congenital Rubella Syndrome

152 0 100%

Tetanus 580 8 99%

Haemophilus influenzae 20,000 270 99%

The Yearly Toll of Vaccine-Preventable Diseases

National Foundation for Infectious Diseases. Saving Lives: Integrating Vaccines for Adults into Routine Care.Bethesda, MD: National Foundation for Infectious Diseases; 2008.

HPV, human papilloma virus.

Burden of Vaccine-Preventable Diseases – 1

United States/Annual Rates

INFLUENZA• 200,000 hospitalizations• 36,000 deaths (>85% elderly)

INVASIVE PNEUMOCOCCAL DISEASE

• 44,000 cases• 4500 deaths• Higher rates in elderly, AA, persons

with comorbidities

HEPATITIS B• 51,000 infections (>95% adults)• 2000-3000 deaths• 1.25 (m) chronic HBV infection

Centers for Disease Control and Prevention. http://www.cdc.gov/.

AA, African American; HBV, hepatitis B virus.

Burden of Vaccine-Preventable Diseases – 2

United States/Annual Rates

HUMAN PAPILLOMAVIRUS (HPV)

• 6.2 million new infections• 2 HPV strains cause 70% of cervical

cancers and most anal, head and 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 – 1Low and Disparate

19 – 64 yrs high risk19 – 64 yrs high risk

White White 20%20%

Black Black 22%22%

Hispanic Hispanic 18%18%

Asian Asian 12%12%

≥ ≥65 yrs65 yrs

White White 67%67%

Black Black 48%48%

Hispanic Hispanic 43%43%

Asian Asian 40%40%

Pneumococcal Vaccination

MMWR 62:66,2013

Adult Vaccination Rates – 2Low and Disparate

50 – 64 years50 – 64 years

WhiteWhite 68% 68%

BlackBlack 54% 54%

HispanicHispanic 52% 52%

AsianAsian 45% 45%

Tetanus Vaccination, past 10 years

MMWR 62:66,2013

Adult Vaccination Rates – 3Low and Disparate

19 – 26 years19 – 26 years

WhiteWhite 33%33%

BlackBlack 28%28%

HispanicHispanic 20%20%

AsianAsian 22%22%

Human papillomavirus (HPV), females, one or more doses

MMWR 62:66,2013

If the vaccine-preventable diseases cause If the vaccine-preventable diseases cause substantial illness and death as well as substantial illness and death as well as large costs of medical care,large costs of medical care,

If the vaccines are appropriately safe and If the vaccines are appropriately safe and sufficiently effective,sufficiently effective,

If vaccination rates are low and If vaccination rates are low and racially/ethnicity disparate,racially/ethnicity disparate,

Is that circumstance unethical?Is that circumstance unethical?

Immunization Contrasts Immunization Contrasts - 1- 1

Diseases distinctiveDiseases distinctive Fabulous vaccinesFabulous vaccines Interrupt Interrupt

transmissiontransmission Eliminate diseaseEliminate disease Universal coverageUniversal coverage Active programs: Active programs:

find everyonefind everyone National/global National/global

visionvision

Diseases not as Diseases not as distinctivedistinctive

Good vaccinesGood vaccines Personal protectionPersonal protection Reduce riskReduce risk Targeted populationsTargeted populations Passive: try to Passive: try to

immunize those immunize those presenting for carepresenting for care

Focus on practiceFocus on practice

Pediatric Adult

Immunization Contrasts Immunization Contrasts - 2- 2

Create hurdles: ‘no Create hurdles: ‘no shots, no school”shots, no school”

CDC, ACIP: CDC, ACIP: pediatric- orientedpediatric- oriented

Strong involvement of Strong involvement of professional partners professional partners (AAP, AAFP)(AAP, AAFP)

Recommendations Recommendations clearly communicatedclearly communicated

Averse to hurdlesAverse to hurdles

CDC, ACIP: adults of CDC, ACIP: adults of marginal interestmarginal interest

Modest involvement of Modest involvement of professional group professional group (ACP)(ACP)

Recommendations Recommendations inadequately inadequately communicatedcommunicated

Pediatric Adult

Immunization Contrasts Immunization Contrasts - 3- 3

““Well child” visit Well child” visit scheduledscheduled

Doctors and staff Doctors and staff sophisticated sophisticated about vaccinesabout vaccines

Included in Included in medical insurancemedical insurance

Public support for Public support for underinsuredunderinsured

No “well adult” No “well adult” scheduleschedule Specialist careSpecialist care No careNo care

Doctors and staff need Doctors and staff need education about education about vaccinesvaccines

Medical insurance Medical insurance variablevariable

Variable public support Variable public support for underinsuredfor underinsured

Pediatric Adult

““Funding” ExamplesFunding” Examples

Increasing Adult Increasing Adult ImmunizationImmunization

Improve fundingImprove funding Increase awareness of both providers and Increase awareness of both providers and

the public – “Vaccination is not just for the public – “Vaccination is not just for kids”kids”

Standing ordersStanding orders Knowledge of ordering, recording, Knowledge of ordering, recording,

refrigeration, billing, etc.refrigeration, billing, etc. Research to improve adult vaccinesResearch to improve adult vaccines Enlarge the “immunization neighborhood”Enlarge the “immunization neighborhood”

““Slices of the Pie”Slices of the Pie”Populations for which society is Populations for which society is

responsibleresponsible

US MilitaryUS Military Veterans AdministrationVeterans Administration Indian Health ServiceIndian Health Service Federal and State PrisonsFederal and State Prisons

When meditating over a When meditating over a disease, I never think of disease, I never think of finding a remedy for it, finding a remedy for it, but instead, a means of but instead, a means of preventing it.preventing it.

——Louis PasteurLouis Pasteur