1. Presentation Outline Introduction Reasons to Immunize Adults: Make the Case Myths vs. Facts Barriers to Adult Immunization The Ask Adult Immunization Resources Making the Case for Adult Immunization Washington Academy of Physician Assistants January 27, 2013 Maxine Hayes, MD, MPH

2. Vaccine Preventable Diseases

3. “ Vaccines are one of the greatest achievements of biomedical science and public health.” Sandra Roush et al, CDC. 26 diseases are now vaccine preventable.

4. Tetanus (lockjaw), Diphtheria, and Pertussis (whooping cough) Human papillomavirus (HPV) Zoster Measles, Mumps, and Rubella (MMR) Influenza: a serious lung infection Pneumococcal Pneumonia: serious blood, lung, and brain infection Hepatitis A: a serious liver disease Hepatitis B: a serious liver disease Meningococcal Disease List of Adult Vaccine Preventable Diseases

5. 2012 ACIP Immunization Schedule Adults 5

6. Yet adult immunization rates remain low… 2.1 percent eligible adults had TDaP in previous 2 years. Less than 2 percent 60+ had shingles vaccine. 10 percent women 10-26 had HPV vaccine. 36.1 percent adults had seasonal flu vaccine. 42 percent of health care workers and caregivers got flu vaccine.

7. Making the Case Contrary to popular belief, Vaccine Preventable Diseases do occur among adults… Why Immunize?

8. Vaccine Preventable Diseases Cost the Economy… The CDC estimates that the direct health care burden of adult vaccine preventable diseases is approximately $10 billion annually. The annual economic burden of influenza in the US is estimated to be $87 billion. Lost productivity because of work absenteeism and premature mortality comprised the bulk of the economic burden. Adults with pertussis may undergo extensive medical evaluation (35% had three or more medical visits) and miss work (an average of 9.8 days).

9. Vaccinating Adults Saves Dollars When the VA put performance measures in place for flu and pneumococcal, vaccination rates jumped from 27 percent and 26 percent to 80 percent and 77 percent, respectively. Pneumonia hospitalization rates decreased 50 percent. The VA system saved $117 for each vaccine administered. “Harvard study” on cost effectiveness

10. Adult Immunization Challenges Access Misinformation Insurance and Financing Vaccine Program Funding Standards of Practice

11. Access Most adults are outside of institutional settings (e.g., schools, colleges) where requirements can be applied. limited access to primary/preventive care. Many adults lack a “medical home”. Logistical & administrative barriers for HCP. Many physicians do not take responsibility for immunizing patients BUT. Public health safety net is disappearing.

12. Misinformation Need for, and benefits of, adult vaccination not appreciated. Complex recommendations. Unfounded vaccine safety concerns. Healthcare provider lack of ownership. Example: dismal healthcare provider influenza coverage rates.

13. Insurance and Financing Many adults lack health insurance. Many who are insured have co-pays and deductibles for vaccinations. Medicare coverage is fragmented and complicated (Part B vs. Part D). Medicaid reimbursement is very low. New vaccines are EXPENSIVE (recent vaccines costing $175-$200 per shot).

14. Vaccine Program Funding Federal Vaccines for Children (VFC) program budget in 2010 - $3.3 billion. Discretionary Section 317 program budget ($558 million) provides funds to support: State immunization infrastructure & operational costs. Vaccines public health departments provide to individuals not eligible for VFC, including adults. In contrast – in 2009, Americans spent $4.2 billion on Halloween & Easter candy!

15. Adult vaccination and health insurance, NIS-Adult 2007 Health Insurance No Health Insurance

16. Lack of Understanding, Misinformation Major Barriers to Adult Vaccination Main Reason FLUPPV Tetanus 10 Tdap SHIN GLES HPV Summary Score § n362418122181539843221-- Vaccine cost 4%2%1%1%1%3%12 Not needed 28%19%41%42%48%29%207 Did not know…* 4%25%10%22%13%17%91 Doctor did not recommend 7%30%17%2%3%3%62 Side-effects † 21%5%1%9%8%3%47

17. Doctors May Not Know all Recommendations… Only 35 percent of primary care physicians know there is an Adult Immunization Schedule recommendation for TDaP.

18. Bugs rule! Vaccine-Preventable Diseases are only a plane ride away. There are people who cannot be immunized. To protect yourself. And Vaccine-Preventable Diseases cost the economy. Why Immunize?

19. Vaccination Myths Myth Vaccines don't work. Fact Vaccines do work.

20. Vaccination Myths Myth It's better to get the disease than the vaccine. Fact The risk of serious complications, including permanent disability or death, following natural disease is much higher than that from the vaccine.

21. Vaccination Myths Myth Vaccines aren't safe. The side effects they cause are worse than the diseases they prevent. Fact The risk of serious side effects or death from vaccines is far less than the risk from the disease.

22. Debunking the Myths: “I got sicker from the vaccine than when I actually got the flu” NEJM 345:159; 2001 SYMPTOMSVACCINEPLACEBO Rhinitis44.8%45% Sore throat28.328.7 Cough46.145.7 Headache39.637.8 Myalgia25.120.8 Chills12.211.1 Fever5.15.0 Fatigue27.928.6

23. Doctors may not know all recommendations….. Only 35 percent of primary care physicians know there is an Adult Immunization Schedule recommendation for TDaP.

24. Adult Immunization Web Resources

25. DOH Web Resources Washington State Department of Health (DOH) http://www.doh.wa.gov/ CDC http://www.cdc.gov/vaccines/spec-grps/adults.htm Adult Vaccination http://www.adultvaccination.com/index.htm

27. Questions