1. Adult Immunization Do Disparities have Ethical Implications? William Schaffner, MD Professor of Preventive Medicine, Department of Health Policy Professor of Medicine - Infectious Diseases Vanderbilt University School of Medicine

2. Conflicts of Interest CDC: Co-PI, Cooperative Agreement CDC: Co-PI, Cooperative Agreement Emerging Infections Program Emerging Infections Program Merck: Member, Data Safety Monitoring Board Merck: Member, Data Safety Monitoring Board Sanofi-Pasteur: One lecture Sanofi-Pasteur: One lecture Dynavax: Consultant Dynavax: Consultant

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

4. Adult 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.

5. Infant, Childhood, Adolescent Immunization One of the great clinical and public health success stories of the 20 th /21 st centuries One of the great clinical and public health success stories of the 20 th /21 st centuries Disparities of income, race, urban/rural eliminated Disparities of income, race, urban/rural eliminated

6. Comparison of 20th Century Annual Morbidity and Current Morbidity: Vaccine-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. Disease 20th Century Annual Morbidity 2010 Reported Cases Percent Decrease Smallpox29,0050100 Diphtheria21,0530100% Measles530,21761>99% Mumps162,344252898% Pertussis200,75221,29189% Polio (paralytic)16,3160100% Rubella47,7456>99% Congenital Rubella Syndrome 1520100% Tetanus580899% Haemophilus influenzae20,00027099%

7. 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.

8. 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.

9. 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/.

10. 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/.

11. Adult Vaccination Rates – 1 Low and Disparate 19 – 64 yrs high risk White 20% Black 22% Hispanic 18% Asian 12% ≥65 yrs White 67% Black 48% Hispanic 43% Asian 40% Pneumococcal Vaccination MMWR 62:66,2013

12. Adult Vaccination Rates – 2 Low and Disparate 50 – 64 years White 68% White 68% Black 54% Black 54% Hispanic 52% Hispanic 52% Asian 45% Asian 45% Tetanus Vaccination, past 10 years MMWR 62:66,2013

13. Adult Vaccination Rates – 3 Low and Disparate 19 – 26 years White33% Black28% Hispanic20% Asian22% Human papillomavirus (HPV), females, one or more doses MMWR 62:66,2013

14. If the vaccine-preventable diseases cause substantial illness and death as well as large costs of medical care, If the vaccine-preventable diseases cause substantial illness and death as well as large costs of medical care, If the vaccines are appropriately safe and sufficiently effective, If the vaccines are appropriately safe and sufficiently effective, If vaccination rates are low and racially/ethnicity disparate, If vaccination rates are low and racially/ethnicity disparate, Is that circumstance unethical? Is that circumstance unethical?

15. Immunization Contrasts - 1 Diseases distinctive Diseases distinctive Fabulous vaccines Fabulous vaccines Interrupt transmission Interrupt transmission Eliminate disease Eliminate disease Universal coverage Universal coverage Active programs: find everyone Active programs: find everyone National/global vision National/global vision Diseases not as distinctive Good vaccines Personal protection Reduce risk Targeted populations Passive: try to immunize those presenting for care Focus on practice PediatricAdult

16. Immunization Contrasts - 2 Create hurdles: ‘no shots, no school” Create hurdles: ‘no shots, no school” CDC, ACIP: pediatric- oriented CDC, ACIP: pediatric- oriented Strong involvement of professional partners (AAP, AAFP) Strong involvement of professional partners (AAP, AAFP) Recommendations clearly communicated Recommendations clearly communicated Averse to hurdles CDC, ACIP: adults of marginal interest Modest involvement of professional group (ACP) Recommendations inadequately communicated PediatricAdult

17. Immunization Contrasts - 3 “Well child” visit scheduled “Well child” visit scheduled Doctors and staff sophisticated about vaccines Doctors and staff sophisticated about vaccines Included in medical insurance Included in medical insurance Public support for underinsured Public support for underinsured No “well adult” schedule Specialist care No care Doctors and staff need education about vaccines Medical insurance variable Variable public support for underinsured PediatricAdult

18. “Funding” Examples Medicaid: Reimbursement payment varies by state; provider barely breaks even or may lose money Medicare: Part A, first dollar coverage influenza, pneumococcal Part B, varies shingles, Tdap

19. Increasing Adult Immunization Improve funding Improve funding Increase awareness of both providers and the public – “Vaccination is not just for kids” Increase awareness of both providers and the public – “Vaccination is not just for kids” Standing orders Standing orders Knowledge of ordering, recording, refrigeration, billing, etc. Knowledge of ordering, recording, refrigeration, billing, etc. Research to improve adult vaccines Research to improve adult vaccines Enlarge the “immunization neighborhood” Enlarge the “immunization neighborhood”

22. “Slices of the Pie” Populations for which society is responsible US Military US Military Veterans Administration Veterans Administration Indian Health Service Indian Health Service Federal and State Prisons Federal and State Prisons

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