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Adult Immuniza-on Update

Maggie Zettle, PharmD Lieutenant, United States Public Health Service

Management Analyst, National Vaccine Program OfBice U.S. Department of Health and Human Services

Overview •  Adult vaccination coverage

–  Coverage by age group, race/ethnicity, vaccination indication

•  NVPO initiatives to improve adult immunization rates across the nation – NVAC Standards for Adult Immunization Practice – Draft National Adult Immunization Plan –  Interactive InBluenza Map – Vaccine Finder Tool

Data Source Na0onal Health Interview Survey, 2013

•  Annual in-‐home survey of U.S. non-‐institutionalized civilian population

•  Detailed health survey of one adult per family in each household sampled

•  Provides national coverage estimates •  Final sample of adult component:

– Response rate: 61% – N = 34,227

Na0onal Health Interview Survey, 2013 Vaccina0on Ques0ons

•  InBluenza (not reported here) •  PPSV or PCV13, Td/Tdap, HepA, HepB, Zoster, HPV

–  Proportion of pneumococcal vaccination by type not measured

•  High-‐risk status –  Limited information collected for Hep A and Hep B

•  Hep A (travel status & chronic liver disease) •  Hep B (travel status, chronic liver disease, & diabetes mellitus)

–  PPSV or PCV13 •  Health Care Personnel (HCP)

Defini0on of High-‐Risk for Pneumococcal Disease

•  Adults were considered at high risk for pneumococcal disease if they had been told by a doctor or other health care professional that they: –  Ever had:

•  Diabetes Mellitus •  Emphysema •  Coronary Heart Disease, Angina, Heart Attack, or other Heart Condition •  Lymphoma, Leukemia, or Blood Cancer

–  Had during the preceding 12 months: •  Cancer Diagnosis (excluding non-‐melanoma skin cancer) •  Asthma Episode or Attack •  Chronic Bronchitis •  Weak or Failing Kidneys

•  Or were Current Smokers

Adult Vaccina0on Coverage, Selected Vaccines by Age and High-‐risk Status, United States

24 (+4.1)

60

21

0 10 20 30 40 50 60 70 80 90

Herpes Zoster (Shingles), ≥60 yrs

Pneumococcal, ≥65 yrs

Pneumococcal, HR 19-‐64yrs

% Vaccinated

HP2020 Targets: 60% PPV HR 19-‐64 years, 90% PPV ≥65 years, 30% Shingles Data Source: 2013 NHIS

Adult Tetanus-‐containing Vaccina0on Coverage by Age and High-‐risk Status, United States

37 (+5.9)

29

17 (+2.9)

56

64

63

0 10 20 30 40 50 60 70 80 90

Tdap past 8 yrs, HCP ≥19 yrs

Tdap past 8 yrs, Living with infant <1 yr, ≥ 19 yrs

Tdap past 8 yrs, ≥19 yrs

Td past 10 yrs, ≥65 yrs

Td past 10 yrs, 50-‐64 yrs

Td past 10 yrs, 19-‐49 yrs

% Vaccinated

Data Source: 2013 NHIS

Poten0al for Bias in Tdap Es0mates

•  34% of respondents were excluded Those:

–  without a “yes” or “no” response for tetanus vaccination, past 10 years (5%)

–  without a response to tetanus vaccination during 2005-‐2013 (4%)

–  who reported tetanus vaccination but not told (21%) or did not know the vaccine type (4%)

•  Sensitivity analysis to assess magnitude of bias – Tdap coverage could range from: 13% -‐42% (adults 19-‐64 years); 9%-‐35% (adults >65 years)


*p<0.05 by T test for comparisons between HCP and non-‐HCP >19 years.

Propor0on of Adults >19 Years of Age who Received Tdap Vaccine

Group Not Told (%) Not Recall (%) Tdap/Td+Tdap

Adults, >19 years, Overall 51 11 68

HCP, >19 years 31 8 77*

Non-‐HCP, >19 years 54 11 67


Hepa00s A Vaccina0on Coverage by Age and High-‐risk Status, United States

12

13

6

16

9

0 10 20 30 40 50 60 70 80 90

HepA (≥2 doses), 19-‐49 yrs

HepA (≥2 doses), Chronic Liver Disease

HepA (≥2 doses), No Endemic Area Travel

HepA (≥2 doses), Travel Endemic Area

HepA (≥2 doses), ≥19 yrs

% Vaccinated


Hepa00s B Vaccina0on Coverage by Age and High-‐risk Status, United States

14

26

33 (-‐2.6)

62

34

21 (-‐2.3)

33

25 (-‐2.1)

0 10 20 30 40 50 60 70 80 90

HepB (≥3 doses), Diabetes ≥60 yrs

HepB (≥3 doses), Diabetes 19-‐59 yrs

HepB (≥3 doses), 19-‐49 yrs

HepB (≥3 doses), HCP ≥19 yrs

HepB (≥3 doses), Chronic Liver Disease

HepB (≥3 doses), No Endemic Area

HepB (≥3 doses), Travel Endemic Area

HepB (≥3 doses), ≥19 yrs

% Vaccinated

HP2020 Target: 90% HepB Healthcare Personnel (HCP) Data Source: 2013 NHIS

HPV Vaccina0on Coverage (≥1 dose ever), Adults 19-‐26 years of age by Sex, United States

5 (+2.7)

8 (+5.3)

6 (+3.6)

32

45

37

0 5 10 15 20 25 30 35 40 45 50

Males 22-‐26 yrs

Males 19-‐21 yrs

Males 19-‐26 yrs

Females 22-‐26 yrs



% Vaccinated


Age at First Dose of HPV Vaccina0on, Among Adults 19-‐26 years, NHIS 2013 – United States

Non-‐Influenza Adult Vaccina0on Coverage Rate Increases from 2012 to 2013

2.9

4.1

5.9

3.6

0 10 20 30 40 50

Tdap, ≥19 yrs

Herpes Zoster, ≥60 yrs

Tdap, HCP ≥19 yrs

HPV (≥1 dose), Men 19-‐26 yrs 6%

Data Source: NHIS 2012-‐2013

37%

24%

17%

Racial/Ethnic Vaccina0on Dispari0es Vaccination Group %

Vaccinated Whites

Disparity, Blacks

Disparity, Hispanics

Disparity, Asians

Pneumo. , HR 19-‐64 yrs 22 -‐1 -‐4 -‐11 Pneumo., ≥65 yrs 64 -‐15 -‐24 -‐18 Tetanus, 19-‐49 yrs 69 -‐15 -‐17 -‐16 Tetanus, 50-‐64 yrs 67 -‐13 -‐12 -‐14 Tetanus, ≥65 yrs 60 -‐19 -‐14 -‐17 Tdap, ≥19 yrs 20 -‐7 -‐10 -‐4 Tdap, 19-‐64 yrs 22 -‐8 -‐11 -‐5 Tdap, ≥65 yrs 13 -‐7 -‐6 -‐2 HepA, 19-‐49 yrs 13 -‐2 -‐2 +3 HepB, 19-‐49 yrs 35 -‐5 -‐12 +4 Herpes Zoster, ≥60 yrs 27 -‐17 -‐18 -‐5 HPV, Females 19-‐26 yrs 42 -‐11 -‐11 -‐22 Tdap, HCP ≥19 yrs 40 -‐8 -‐10 -‐7 HepB, HCP ≥19 yrs 63 -‐4 -‐9 +6

Racial/Ethnic Vaccina0on Dispari0es -‐-‐ NHIS 2013

Compared with 2012, racial/ethnic differences persisted for all six and widened for Tdap and herpes zoster: •  Non-‐Hispanic blacks, Hispanics, and Non-‐Hispanic Asians had lower vaccination coverage than that of non-‐Hispanic whites for all of the vaccines routinely recommended for adults, except for: –  PPSV/PCV13 19-‐64-‐HR -‐-‐ Blacks had coverage similar to whites

–  Tdap 65+ -‐-‐ Asians had coverage similar to whites –  Hep A 19-‐49 – Blacks had coverage similar to and Asians had coverage higher than whites

–  Hep B 19-‐49 – Asians had coverage higher than whites –  Herpes zoster 60+ – Asians had coverage similar to whites

•  Health Care Personnel (HCP) – Non-‐Hispanic black and Hispanic HCP had lower coverage than white HCP for Tdap, and Hispanic HCP had lower coverage than white HCP for Hep B.

Limita0ons of Findings

•  NHIS excludes persons in the military and those residing in institutions – results apply to the civilian, non-‐institutionalized population

•  Response rate 61.2% -‐-‐ low response rate can result in sampling bias if the nonresponse is unequal among participants regarding vaccination

•  Reported vaccination status and high-‐risk conditions not validated by medical records

•  Self-‐report of vaccination subject to recall bias •  Tdap estimates: potential bias due to exclusions

What We Learned •  Overall coverage remains below HP2020 targets

•  90% for 65+ years for pneumococcal vaccine •  60% for high risk 19-‐64 years for pneumococcal vaccine •  30% for 60+ years for Zoster vaccine •  90% for hepatitis B vaccine for healthcare personnel

•  Some improvement from 2012 – Modest increases for HPV (men, 19-‐26), Tdap (≥19 year olds), and herpes zoster (≥60 year olds) vaccines

– No improvements for other vaccines •  Racial and ethnic disparities remain •  Much remains to be done to increase vaccine utilization among adults and to eliminate disparities

Assess Recommend

Administer or Refer Document

Adult Immuniza0on Standards

Na0onal Adult Immuniza0on Plan

•  Protect public health through vaccination of all adults

•  5 year plan •  Diverse stakeholders (public and private) •  National scope •  Aligned with other HHS initiatives

Development of the Na0onal Adult Immuniza0on Plan

•  Environmental scan of literature over past 10 years •  Key stakeholders convened to provide high-‐level feedback •  Survey to generate feedback on possible plan priorities

–  96 respondents •  8 focus groups, 90 participants

–  Designed to reBlect diverse sectors •  One-‐on-‐one interviews with dozens of thought leaders •  Follow up meetings to discuss indicators and metrics •  Public comment period

–  Approximately 5,000 comments received

Goals of the Na0onal Adult Immuniza0on Plan

1.  Strengthen the Adult Immunization Infrastructure

2.  Improve Access to Adult Vaccines 3.  Increase Community Demand for Adult

Immunizations 4.  Foster Innovation in Adult Vaccine Development

and Vaccination Related Technologies

Goal 1: Strengthen the Adult Immuniza0on Infrastructure

Objective 1: Monitor and report trends in adult vaccine-‐preventable disease levels and vaccination coverage data for all ACIP recommended vaccines. Measure progress towards established targets in cases where there are HP2020 goals.

Objective 2: Enhance current vaccine safety monitoring systems and develop new methods to accurately and more rapidly assess vaccine safety and efBicacy in adult populations.

Objective 3: Continue to analyze claims Biled as part of the Vaccine Injury Compensation Program to identify causal links between vaccines and adverse events.

Objective 4: Increase the use of Immunization Information Systems and Electronic Health Records to collect and track adult immunization data.

Objective 5: Evaluate and advance targeted quality improvement initiatives.

Objective 6: Generate and disseminate evidence about the economic impact of adult immunization, including potential disease burden averted and cost effectiveness with the use of current vaccines.

Goal 2: Improve Access to Adult Vaccines

Objective 1: Reduce _inancial barriers for individuals who receive vaccines routinely recommended for adults. Objective 2: Assess and improve understanding of providers’ _inancial barriers to delivering vaccinations, including stocking and administering vaccines. Objective 3: Expand the adult immunization provider network. Objective 4: Ensure a reliable supply of vaccines and the ability to track vaccine inventories, including during public health emergencies.

Goal 3: Increase Community Demand for Adult Immuniza0ons

Objective 1: Educate and encourage individuals to be aware of and receive adult immunizations.

Objective 2: Educate and encourage healthcare professionals to recommend and/or deliver adult vaccinations.

Objective 3: Educate and encourage other groups (e.g., community and faith based groups) to promote the importance of adult immunization.

Goal 4: Foster Innova0on in Adult Vaccine Development and Vaccina0on Related

Technologies Objective 1: Develop new vaccines and improve the effectiveness of existing vaccines for adults. Objective 2: Encourage new technologies to improve the distribution storage, and delivery of adult vaccines.

Goal 1: Strengthen the Adult Immuniza0on Infrastructure

32

Indicator Baseline Data Source

Adult vaccination coverage levels for HP2020 measures CDC/AHRQ Dashboard CDC, CMS

Racial/ethnic disparities in adult vaccination coverage for HP2020 measures

CDC/AHRQ Dashboard CDC

Percentage of surveyed primary care physicians who record information on adult immunizations in a state or regional IIS

8% of internists 36% of family practitioners

CDC, NVPO

Percentage of surveyed pharmacies that submit adult vaccination data to an IIS 25% APhA

Percentage of surveyed providers who routinely query information on adult immunization from a state IIS In development ONC

Percentage of surveyed health care providers who have identiBied an adverse event following immunization and reported it to VAERS

17% NVPO

Goal 2: Improve Access to Adult Immuniza0ons


Percentage of states and territories that allow pharmacists to administer all routinely recommended vaccines for adults 19+

85% APhA

Percentage of surveyed primary care providers who stock adult routinely recommended vaccines


NVPO

Percentage of state Medicaid programs that include all recommended vaccinations for adults as a preventive beneBit for existing patients and prohibit cost sharing

33% CMS

33

Goal 3: Increase Community Demand for Adult Immuniza0ons


Percentage of surveyed adults who believe they are recommended to receive an inBluenza vaccine (within a speciBied year)

45% CDC

Percentage of adults who report receiving a provider recommendation for an inBluenza vaccine 45% CDC

Percentage of pregnant women who report receiving the following immunizations during pregnancy (inBluenza, Tdap)

In development CDC

Percentage of surveyed adults that are aware of the routinely recommended adult vaccines they are supposed to receive

In development NVPO

Percentage of surveyed adult healthcare providers who report assessing vaccination status at every visit


CDC

34

Goal 4: Foster Innova0on in Adult Vaccine Development and Vaccina0on Related Technologies


Number of vaccines in clinical development (Phase II or Phase III clinical trials) with an expected adult indication

In development BIO

Number of vaccines on CDC contracted vaccine price lists that include a 2D barcode 38 CDC

35

Interac0ve Influenza Vaccina0on Map

Na0onal Trend Data

National Demographic Disparity Week Hispanic Black Asian White

1 47.37 % -‐ 24.85 % 157.89 % -‐-‐

17 -‐ 40.34% -‐ 36.69 % -‐ 2.03 % -‐-‐

35 -‐ 37.68 % -‐ 34.09 % -‐ 1.44 % -‐-‐

National In_luenza Vaccination Rate By Race/Ethnicity

Week National Hispanic Black Asian White

1 0.15% 0.22% 0.11% 0.38% 0.15%

17 46.05% 28.82% 30.58% 47.27% 48.30 %

35 48.65% 31.69% 33.51% 50.11% 50.85%

4/13/15 http://www.hhs.gov/nvpo/Blu-‐vaccination-‐time-‐trends.html

HealthMap Vaccine Finder

Collaborators Peng-‐Jun Lu, MD, PhD Alissa O’Halloran, MSPH Carolyn B. Bridges, MD David K. Kim, MD

Tamara Pilishvili, MPH Craig M. Hales, MD

Lauri E. Markowitz, MD Walter W. Williams, MD

Bruce Gellin, MD Rebecca Fish

For Addi0onal Informa0on:

-‐  ACIP Recommendations for SpeciBic Vaccines http://www.cdc.gov/vaccines/hcp/acip-‐recs/index.html

-‐  Non-‐inBluenza Adult Vaccination Coverage http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6404a6.htm?s_cid=mm6404a6_e

-‐  Interactive InBluenza Map http://www.hhs.gov/nvpo/Blu-‐vaccination-‐map/index.html

-‐  Vaccine Finder http://www.vaccines.gov/

Thank you!

Extra Slides

Highlights: Non-‐Influenza Adult Vaccina-on Coverage – NHIS 2013

Compared with 2012 NHIS, modest increases only for : q  Tdap vaccination (17.2%) – ≥19 years (+2.9 percentage points)

q  Herpes zoster vaccination (24.2%) – >60 years (+4.1 percentage points)

q  HPV vaccination (> 1 dose) (5.9%) – men, 19-‐26 years (+3.6 percentage points)

q  No overall improvement in coverage for other vaccines

Tetanus Vaccina-on Including Pertussis Vaccine, Past 8 Years, ≥19 years, NHIS 2013 -‐-‐ United States

Group and Race/ethnicity 2012 (%) 2013 (%) Difference*

≥19 years, Overall 14.2 17.2 +2.9

White, non-‐Hispanic 16.1 19.7 +3.6

Black, non-‐Hispanic 9.8† 12.6† +2.7

Hispanic 8.7† 10.2†

Asian, non-‐Hispanic 14.7 15.5†

Others 21.4 22.4

Living with an infant aged<1 year 25.9 29.4

Not living with an infant aged<1 year 13.8 16.7 +2.9

*p<0.05 by T test for comparisons between 2013 and 2012 within each level of each characteristic. † p<0.05 by T test for comparisons with non-‐Hispanic white as the reference.

Herpes Zoster (shingles) Vaccina-on, 60 years and older, NHIS 2013 – United States

Group and Race/ethnicity 2012 (%) 2013 (%) Difference*

60 years and over, Overall 20.1 24.2 +4.1

White, non-‐Hispanic 22.8 27.4 +4.6

Black, non-‐Hispanic 8.8† 10.7†

Hispanic 8.7† 9.5†

Asian, non-‐Hispanic 16.9† 22.6

Others 19.7 24.5

*p<0.05 by T test for comparisons between 2013 and 2012 within each level of each characteristic. †p<0.05 by T test for comparison with non-‐Hispanic white as the reference.

Human Papillomavirus Vaccina-on Among Males (at least 1 dose), NHIS 2013 – United States

Age group 2012 (%) 2013 (%) Difference* 19-‐26 years, total 2.3 5.9 +3.6

19-‐21 years, total 2.4 7.7 +5.3

22-‐26 years, total 2.2 4.9 +2.7

*p<0.05 by T test for comparisons between 2013 and 2012 within each level of each characteristic.

Adult Vaccina-on Coverage, Selected Vaccines, by Age & High-‐risk Status, NHIS 2013 -‐-‐ United States

Group 2012 (%) 2013 (%) Difference*

Pneumococcal

19-‐64 years, HR, overall 20.0 21.2

>65 years, overall 59.9 59.7

Tetanus, Past 10 Years

19-‐49 years, overall 64.2 62.9

50-‐64 years, overall 63.5 64.0


Tetanus with Pertussis, Past 8 Years ≥19 years, overall 14.2 17.2 +2.9

Living w/ infant aged <1 year 25.9 29.4

*p<0.05 by T-‐test for comparisons between 2013 and 2012.


Group 2012 (%) 2013 (%) Difference* Hepatitis A (at least 2 doses)

≥19 yrs, overall 8.9 9.0

≥19 yrs, Chronic Liver Disease 13.1 13.3

Traveled to endemic area 16.1 15.9

No travel to endemic area 5.6† 5.7†

Hepatitis B (at least 3 doses) ≥19 yrs, overall 27.1 25.0 -‐2.1

≥19 yrs, Chronic Liver Disease 30.0 34.0

Traveled to endemic area 35.0 33.1

No travel to endemic area 23.2† 20.9† -‐2.3

19-‐59 yrs, with diabetes, overall 28.6 26.3

>60 years, w/ diabetes, overall 15.1 13.9

*p<0.05 by T-‐test for comparisons between 2013 and 2012. †p<0.05 by T-‐test for comparisons with had not traveled to endemic area as the reference.


Group 2012 (%) 2013 (%) Difference*

Herpes Zoster (Shingles)

>60 years, overall 20.1 24.2 +4.1

Human Papillomavirus, Females 19-‐26 years, overall 34.5 36.9

19-‐21 years, overall 44.3 44.7

22-‐26 years, overall 28.2 32.4

Human Papillomavirus, Males

19-‐26 years, overall 2.3 5.9 +3.6

19-‐21 years, overall 2.4 7.7 +5.3

22-‐26 years, overall 2.2 4.9 +2.7

*p<0.05 by T-‐test for comparisons between 2013 and 2012.

Health Care Personnel (HCP) Tetanus Vaccina-on Including Pertussis Vaccine, past 8 years, and Hepa--s B Vaccina-on, by

Age, NHIS 2013 – United States

Group 2012 (%) 2013 (%) Difference* HCP†, Tetanus with pertussis

≥19 years, overall 31.4 37.3 +5.9

HCP†, Hepatitis B


*p<0.05 by T test for comparisons between 2013 and 2012. †Adults were classi_ied as HCP if they reported they currently work in a hospital, medical clinic, doctor’s of_ice, dentist’s of_ice, nursing home or some other healthcare facility, including part-‐time and unpaid work as well as professional nursing care provided in the home.

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