New data from the Centers for Disease Control and Prevention (CDC) show that adults remain largely unvaccinated against preventable infectious illnesses. At a news conference convened today by the National Foundation for Infectious Diseases (NFID), experts in public health, infectious disease, oncology and other medical specialties discussed the data and the health consequences for adults who skip vaccines. They collectively called on all adults and health care providers to improve vaccination rates.
"For more than six decades, vaccines have protected us from infectious illnesses that have a wide range of consequences, from lost work days and inability to meet our daily obligations, to pain, discomfort, hospitalization, long-term disability and death," said Susan J. Rehm, M.D., NFID medical director. According to Dr. Rehm, by foregoing needed vaccines, adults not only leave themselves vulnerable to sickness, but they expose those around them to unnecessary risks, too.
This problem is evident right now, as pertussis (whooping cough) continues to claim the lives of infants in California, while adults, who are frequently responsible for transmitting the disease to infants, fail to get the one-time pertussis booster vaccine. The impact of other vaccine-preventable infections may not be as immediately apparent, but they are no less important. Other vaccines for adults protect against viruses that cause several types of cancer, reactivation of the chickenpox virus that causes shingles later in life, and infection with bacteria that are the leading cause of community-acquired pneumonia.
New survey results from NFID suggest that doctor/patient communication challenges may be at least part of the problem. While physicians perceive they are encouraging their adult patients to be vaccinated, patients say the topic of vaccination rarely comes up during their doctor visits.
Vaccination rates highest among seniors; lowest among minority groups
In unveiling the adult vaccination data from the 2009 National Health Interview Survey (NHIS), Melinda Wharton, M.D., M.P.H., deputy director of the National Center for Immunization and Respiratory Diseases at the CDC, noted that the highest immunization rates are among older Americans, who tend to be vaccinated against influenza and pneumococcal infections. She suggested that one reason for this might be that older persons tend to have more routine visits with health care providers, providing more opportunities to learn about and adopt good preventive care behaviors.
"A good ongoing relationship with your medical provider is positive for so many reasons," said Dr. Wharton, "not least of which is that you will have an ongoing opportunity learn about the best ways to stay healthy, including the best preventive care choices like vaccines."
While adult vaccination rates are showing slow improvement overall, one vaccination trend Dr. Wharton specifically noted is the 7.4 percent decrease in pneumococcal vaccination rate in high-risk adults 19 to 64 years of age. She pointed out that this is not because people are suddenly foregoing this vaccine. Rather, the decrease reflects the recent addition of new risk groups -- namely smokers and people with asthma -- increasing the pool of people who should get the vaccine. Dr. Wharton called on smokers and people with asthma to check with their physicians or other health care providers about this vaccine.
In addition to generally low adult vaccination rates, Dr. Wharton touched on the problem of racial and ethnic vaccination disparities. While strides have been made to close racial and ethnic gaps, some significant vaccination gaps continue to exist among Whites, Blacks and Hispanics.
The NHIS survey also reported vaccination rates in health care professionals for influenza (up 7 percent, to 53 percent), hepatitis B (up 2.5 percent, to 65 percent) and Tdap (up 1.6 percent, to 58 percent). "It's gratifying to see health care worker vaccination rates continue to increase," said CDC's Melinda Wharton. "By modeling good preventive care behaviors our health care professionals are truly leading the way as good partners in their relationship with patients." The NHIS vaccination data include anyone employed in a health care occupation or setting. In contrast, physician-only vaccination rates are much higher (>90 percent for influenza) as reported in two separate NFID surveys fielded before and during the current influenza season.
Doctor/patient communication breakdown a factor in low vaccination rates
A dramatic physician-patient communication disconnect was revealed by new data from two NFID surveys. Nearly 90 percent of primary care physicians say they discuss vaccines with their patients, yet in a separate survey of consumers, almost half cannot recall ever discussing vaccines with their physicians. As further evidence of the communication gap between physicians and their patients, 99 percent of physicians say that they or their staff initiates vaccine discussions, but just 44 percent of patients say that is true.
"Busy primary care physicians think they're doing a good job recommending vaccines, but the survey indicates that patients aren't getting the message," suggested Dr. Rehm. "Consumers overwhelmingly said they look to physicians for vaccine recommendations and are likely to act on those recommendations, so it's clear that we physicians need to be more effective in communicating with our patients."
Among the positive findings, consumer familiarity with vaccine-preventable illnesses is rising, although still limited. Familiarity with specific vaccine-preventable diseases rose 4 to 12 percent compared with results from a 2009 survey, with the largest increase for pertussis vaccine. The only vaccine-preventable disease not to register an increase in familiarity is pneumococcal vaccine. Consumers also report that they rarely refuse vaccines if their physicians recommend them.
A realized consequence: disease resurgence
The ongoing pertussis epidemic in California demonstrates the danger still posed by diseases once thought to be gone in the U.S. There are reports of more than 6,400 cases so far in California this year, the most since 1958. While pertussis can affect people of any age and in fact, national rates have been rising in adults, it is the infants who adults pass this on to who bear the burden. Ten infants, all younger than three months, have died from whooping cough in California this year.
Patrick Joseph, M.D., a California infectious disease physician who is NFID's vice president, implored adults to get the one-time booster vaccine, "While the epidemic is in adults, the tragedy is in kids. The situation is grave when babies too young to be immunized are dying."
Dr. Joseph said this crisis means California doesn't have the luxury of bringing people along slowly. The time to increase vaccination rates for pertussis is now. The California Department of Public Health recommends pertussis boosters for all adults, including those over 65, a move supported by the CDC's Advisory Committee on Immunization Practices (ACIP). At its October meeting, ACIP voted to extend pertussis booster vaccination recommendations to include adults 65 and older nationwide.
While California has been hardest hit so far, many other areas have seen increased cases this year, including Ohio, South Carolina, Michigan, Texas, Idaho, upstate New York and the Philadelphia suburbs. Since pertussis knows no boundaries, Dr. Joseph voiced his hope that adults outside his home state would also take notice and seek a Tdap vaccine now to protect themselves and infants around them.
Importance of pneumococcal and influenza vaccines also highlighted
AARP board member Catherine Georges, R.N., Ed.D., reminded adults that the time to get an influenza vaccine is now. "We know it's important for Americans of all ages to go out now and get the flu vaccine, but it's even more critical for people 50-plus," said Dr. Georges, a registered nurse and professor and chair of the department of nursing at Lehman College and the Graduate Center at the City University of New York. "Older Americans are often caring for their children and for older loved ones. Getting vaccinated not only protects you, but also helps protect your family and friends." Dr. Georges echoed the universal recommendation from CDC for influenza vaccination of all Americans six months and older.
Since pneumococcal infection is an all too frequent complication of influenza, Dr. Georges reminded Americans that, "pneumococcal and influenza vaccines can be given at the same medical visit." Pneumococcal vaccine is recommended for everyone 65 and older and for younger adults with certain risk factors or conditions like asthma, smoking, heart disease and diabetes. For most people, pneumococcal is a one-time vaccination.
Alarmingly few Americans immunized against debilitating disease of shingles
The lowest vaccination rate for a routinely recommended vaccine is for the shingles vaccine, which is recommended for everyone starting at age 60. Only ten percent of eligible persons have received the shingles vaccine. Not only does the likelihood of getting shingles increase with age, so does the severity of shingles pain, which can last long after the shingles rash has disappeared (this pain is known as post-herpetic neuralgia, or PHN). This pain diminishes quality of life and functional capacity as much as congestive heart failure, a heart attack, type II diabetes or major depression.
Adults in the NFID survey say they are familiar with shingles, but further questioning reveals knowledge gaps; for instance, 42 percent do not know that anyone who has had chickenpox is at risk for shingles. Still, adults are aware of the pain of the disease; 55 percent say they "know someone who has had it and it was terrible." Unfortunately, only half of adults even know there is a shingles vaccine available and just 16 percent know it is currently recommended for everyone 60 and older.
"Shingles can be a terribly painful and debilitating disease, particularly in the elderly," said Jeffrey Cohen, M.D., chief of the Laboratory of Infectious Disease at the National Institute of Allergy and Infectious Diseases. "Shingles pain can be very difficult to treat. Current therapies are only somewhat effective and often associated with frequent and problematic side effects, especially in older people, which is why it is vitally important that we educate Americans about the vaccine."
Vaccines prevent cancer
"Human papillomavirus (HPV) not only causes cervical cancer, but also a growing portion of head and neck cancers," according to Maura Gillison, M.D., Ph.D, Jeg Coughlin Chair of Cancer Research at the Ohio State University College of Medicine. "Twenty years ago about 40 percent of these cancers were due to HPV; today that number is over 60 percent in the U.S. Even more alarming is that these cancers are happening in younger people without traditional risk factors—smoking and alcohol consumption."
The hepatitis B vaccine also protects against certain cancers. The hepatitis B virus causes 30 percent of all liver cancers in the U.S. and doubles the risk of non-Hodgkin's lymphoma. Both HPV and hepatitis B viruses are common. An estimated 70 percent of Americans will be infected with HPV in their lifetime and up to 1.4 million Americans have chronic hepatitis B infection.
CDC recommends HPV vaccine for all women 19 to 26 years of age if not previously vaccinated and recommends the hepatitis B vaccine for all sexually active adults who are not in a long-term, mutually monogamous relationship and others in more defined risk groups.
"I urge everyone to get the HPV and hepatitis B vaccines as recommended," said Dr. Gillison. "These vaccines are truly life-saving. As a cancer-specialist, I can tell you that prevention is a far better option than treatment. These are not cancers you want to have or want your kids to have."
National Foundation for Infectious Diseases