1. Immunizing Adults in Complementary (Non-Traditional) Settings
Litjen (L.J) Tan, MS, PhD
American Medical Association

2. Disclaimer…
The opinions expressed in this presentation are solely those of the presenter and do not necessarily represent the official position of the American Medical Association

3. Adult IZ Rates Are Poor!
69% and 66% respectively in influenza and pneumococcal rates in those over 65 years
2% of those over 60 years eligible for zoster
2% of those years for Tdap
44% over 65 years vaccinated against tetanus
10% of women between years for HPV
CDC, National Immunization Survey, 2008

4. Morbidity and Mortality due to Adult VPDs
At least 50,000 adults die annually from VPDs (pneumococcal disease, influenza, hepatitis B).
Hundreds of thousands more are hospitalized.
Significant cost burden to the US economy. For influenza alone:
Annual direct and indirect savings of $13.66 per person vaccinated
78% of all costs prevented are from lost work productivity
Nichol. Arch. Intern. Med. 2001;161:

5. Improving Adult IZ Rates
Increase Provider Awareness
No support to increase IZ efforts
Increase Public Awareness
Most adults cannot name more than one or two diseases that are vaccine preventable in adults
Improve Adult Vaccine Financing/Infrastructure
No VFC-similar program for adults
Improve Access to Vaccines
Traditional Health Care Providers
Complementary Health Care Providers
NFID National Survey, 2008

6. Complementary IZ Settings
Also called nontraditional immunization sites
Complement the primary care setting
Many Americans report having no personal health care provider
In schools, community centers, churches, stores.
Particularly relevant to adult immunizations
80% of pediatric vaccinations occur in primary care
But, complementary sites may be useful in reaching
Children with poor access to primary care (ethnic, socioeconomic reasons)
Implementing new influenza recommendations for children
CDC, BRFSS, 2006

7. Benefits of Complementary IZ Settings
Improved access for adults unable to reach a primary care provider
Eliminate barriers of primary care such as making an appointment, long wait times
Providing immunizations at generally lower costs
Increase access for those unwilling to pay, uninsured
Increased opportunities to increase public awareness
Build new alliances/partnerships to improve IZ
IDSA Immunization Guidelines, In Preparation

8. Comparison of Vaccination Rates When Pharmacists Vaccinate the Elderly
10.7%
Change
Vaccination Rates
3.5%
Change
This study, published in 2004, looked at influenza vaccination rates in 8 states that allowed pharmacists to vaccinate after 1997 compared with 8 states that do not allow pharmacists to vaccinate. The 1995 data show vaccination rates before pharmacist vaccination was allowed compared with 1999 when pharmacists were vaccinating in the 8 permitting states. A statistically significant increase in vaccination rates in the elderly was observed when pharmacists were vaccinating compared with the states that did not allow it.
Persons ≥65 y/o
Steyer TE et al. Vaccine. 2004;22:

9. Cost Effectiveness Non-traditional Settings for Influenza Vaccination
Mean cost (year 2004 values) of vaccination
Lower in mass vaccination ($17.04) and pharmacy ($11.57) settings than in scheduled doctor's office visits ($28.67).
Projected to be cost saving for healthy adults aged >/=50 years, and for high-risk adults of all ages.
Healthy adults (18-49 yo), preventing an episode of influenza cost:
$90 via the pharmacy setting
$210 via the mass vaccination setting
$870 via a scheduled doctor's office visit
Conclusion:
Using non-traditional settings to deliver routine influenza vaccination to adults is likely to be cost saving for healthy adults aged years and relatively cost effective for healthy adults aged years.
Prosser. Pharmacoeconomics. 2008;26(2):

10. Must Manage Challenges to Improve Success
Standards of Care
Management of Adverse Reactions
Continuity of Care and Recordkeeping
Legislative Barriers
Public motivation to seek vaccination
Improving acceptance by primary care
IDSA Immunization Guidelines, In Preparation

11. Maintain High Standards of Care
Standards from NVAC and AMA exist:
Assess for contraindications; deal with adverse events
Proper storage and handling of vaccines
Appropriate record keeping and reporting
Documentation of vaccination
Electronic health records; Registry
Adherence to regulatory standards
Privacy challenges; HIPAA
Use of evidence-based practice guidelines
Education on risks and benefits of vaccines
Patients should be encourage to see primary care for other preventive care measures – continuity of care
NVAC, MMWR, 49(RR01);1-13. AMA, Council on Medical Service, 2006

12. Pharmacists have extensive training prior to certification
CDC
Recognized
Pharmacists have extensive training prior to certification
Self-Study (0.8CEU)
Primer on immunology
Clinical disease review
Practice management
Regulatory roadmap
CDC resources
Seminar (1.2 CEUs)
Recap of vaccines, antibodies, diseases, microbes
Implementation
Record keeping
Public health collaboration
Cases and practicum
Also CPRP and OSHA Training

13. Legislative Barriers
Not all states authorize nontraditional providers to immunize
Liability concerns
This is changing – concerns are much reduced
Can use nurses, nurse practitioners, physicians and others to administer vaccines in complementary settings
Pharmacists?
Kamal, Am. J. Pharm. Edu. 2003; 67:1-10.

14. 47 states currently authorize pharmacists to administer immunizations
Over 30,000 pharmacists trained
Delivered over 2 million influenza vaccinations

15. Pharmacist Authority to Administer Immunizations

16. Increasing Public Demand for Adult Vaccines
Use complementary settings to target those who cannot access vaccines easily
Ethnic populations – religious gatherings, YMCAs
Economically disadvantaged – community centers, homeless shelters, battered women shelters
Secure important community role models for advocacy

17. Increasing Public Demand for Adult Vaccines
Consider immunizations in the school setting
Especially to implement new influenza recommendations, HPV vaccines
Relieve stressed primary care system
Need to secure immunizers, do not overly burden the school nurses
Acknowledge differences in immunizing adults versus children
Developmental and age considerations
Providing atraumatic care for children
Ability to PAY!
Role of occupational settings for immunizations
Insurance coverage?

18. Increasing Public Demand for Adult Vaccines
Use culturally appropriate and location-targeted messages to increase awareness of adult vaccines
Lack of knowledge and negative attitudes keep many African American adults from seeking vaccinations
Limited access to health care is a major impediment to improving Latino immunization rates
The most challenging Asian American populations are recent immigrants who are not well-assimilated into American culture
AMA, Improving Immunization: Addressing Racial and Ethnic Populations, 2007.

19. Improving Acceptance by Primary Care
The primary care provider typically has the first chance to immunize the patient
Complementary settings should catch those who slip through
Complementary settings are visible reminders to the public on importance of adult vaccines

20. Complementary Settings are Already in Play with Influenza
Source: Unpublished data from a Gallup telephone survey conducted on behalf of CDC in 2005.

21. A rising tide lifts all boats
Increased public awareness increases IZ rates for ALL providers
As all IZ providers work to increase awareness of adult vaccines, all providers will stand to benefit.
FYI Quote:
“I spent 20 years trying to convince doctors to give flu shots, and it was a big failure,” says Steven Mostow, MD, chairman of the Colorado [Influenza Alert] Coalition. He helped orchestrate the drug store clinics and public-education media blitz. “My first year, doctors wrote me nasty letters saying that I was taking their business away and sending it to grocery stores, but they were wrong,” says Dr. Mostow. “It increased overall awareness of immunization. There were 100,000 [doses] given in doctors’ offices when we started, and last year there were 700,000.”
Debrovner D. Colorado’s crusade. Am Druggist. 1994;(Dec):22-3.
Debrovner D. Colorado’s crusade. Am Druggist. 1994;(Dec):22-3.

22. What will it take to meet crisis or Universal Demand?
1947 New York Times photograph