A good month to raise the rates

There are several important revisions for adult immunizations, including not using the live attenuated influenza vaccine for the 2017-2018 flu season.


It's now October. Memories of summer are shrinking in the rearview mirror. This was a busy summer at the College, particularly the month of August, which is National Immunization Awareness Month (NIAM), an annual observance sponsored by the CDC that is fully supported by ACP. NIAM 2017 was particularly noteworthy, as special attention was given to the revised immunization schedule for adults, approved several months earlier by the Advisory Committee on Immunization Practices (ACIP) and published in the Feb. 7 Annals of Internal Medicine. I will not provide the Annals acronym; NIAM, CDC, ACP, and ACIP is enough alphabet soup to fill anyone's bowl.

Much of the new schedule for adult immunizations will be familiar. There are, however, several important revisions.

For influenza, for the 2017-2018 flu season, the live attenuated influenza vaccine should not be used because it has proven ineffective. There also are modifications to the precautions for administering the flu vaccine to patients with a history of egg allergy. For patients whose allergic reaction is limited to urticaria, the inactivated influenza vaccine and, certainly, the recombinant influenza vaccine can be administered. Patients with a history of more severe allergic response can still receive the vaccine, but in appropriate, medically supervised settings.

Human papillomavirus (HPV) vaccine recommendations have been revised to reflect recent data on immunogenicity in young girls that show adequate responses after two doses, obviating the need in girls and boys younger than 15 for the third dose (however, the two doses should be given at least six months apart). When HPV immunization is started after age 15, the three-dose recommendation still stands.

The indications for hepatitis B vaccine have been expanded to include adults with several forms of chronic liver disease.

For meningococcal conjugate vaccination (MenACWY), new indications include adults with HIV. HIV is not currently an indication for meningococcal B vaccination. There have also been some dosing modifications for meningococcal B vaccination.

Finally, the new schedule is summarized in more readable tables, and the footnotes, which are more important than footnotes usually are, have been modified and made much more clear.

The recommended schedules for vaccination against tetanus and diphtheria/tetanus, diphtheria, and pertussis (Td/Tdap); measles, mumps, rubella (MMR); varicella; herpes zoster; pneumococcal pneumonia; hepatitis A; and Haemophilus influenzae type B remain the same.

What also remains the same, of course, are the challenges we face as internists getting our adult patients fully immunized. While rates for influenza and pneumococcal pneumonia have improved, neither are as close to 100% as we would like, particularly when one considers the potential severity of these infections.

Just in the case of influenza, recent morbidity and mortality estimates were 200,000 hospitalizations and 70,000 deaths each year. I can still remember the MKSAP question “Which of the following will offer a 69-year-old woman with coronary artery disease, already talking aspirin and a statin, exercising and following a healthy diet, the greatest reduction in risk of future cardiovascular events?”, to which the correct answer was “influenza vaccination.” Read Paul A. Offit's gripping biography, “Vaccinated: One Man's Quest to Defeat the World's Deadliest Diseases,” the story of Maurice Hilleman, a Lasker Award winner and the man responsible for nine of the vaccines used today, to appreciate how devastating these now preventable diseases once were and how grateful we should be that we can now protect our patients from them.

But if only they get immunized.

Explanations for our less than acceptable rates of immunization fall into three categories: those attributable to patients, to our practices, and to our public health policy. We all know only too well that many patients decline vaccines, particularly the influenza vaccine. “I had the flu shot a few years ago,” they say, “and I came down with the flu.” Or, “I don't take shots, never have and never will.” The antivaccine movement has only made matters worse. Medical blogger, columnist, and primary care physician Suzanne Koven, MD, reminds us that many patients just don't like being injected with foreign substances, let alone substances related to “germs,” while for other turning down a flu shot is a means of taking control.

Practice-related factors also account for lower than desired rates of immunization. We are busy, maybe too busy. Hectic office visits are dominated by acute and chronic problems. Our staff, our electronic medical records, and other office-based systems may not facilitate effective immunization practices as much as we would like.

Finally, systems of health insurance and policies for preventive services let us down. This becomes painfully evident when we look at disparities in vaccination rates across ethnic and racial groups and between the insured and the uninsured. Our nation came perilously close this past summer to adopting a health care bill that would have left millions uninsured and would have removed immunizations as an essential health benefit. One can only imagine the impact of such a step backward upon rates of influenza and pneumonia, no less childhood and adolescent diseases.

So with the “flu season” closing in, where do we start?

I am extremely proud of what ACP has done to address the complex challenge of improving rates of adult immunizations. The College's initiatives include patient education materials, quality improvement programs, and training programs for residents. My colleague Sandra Fryhofer, MD, MACP, provides an excellent video on ACPOnline.org at that summarizes the 2017 ACIP immunization schedule, calling attention to what is new. Also, the College maintains practice advisory programs devoted to immunization, including webinars and toolkits. Through an alliance with the National Foundation for Infectious Diseases, College members can access that organization's Campaign for Adult Immunization. These and other important resources are available at ACPOnline.org. Enter “adult immunization” in the Search box, and you'll find what you need. And do not miss the links to “I Raise the Rates,” which is an exciting initiative through the ACP Quality Connect program that is already achieving remarkable outcomes. The latest iteration of this program, “I Raise the Rates through the Promotion of Racial and Ethnic Equity in Primary Care,” developed in conjunction with the National Minority Quality Forum, QHC Advisory Group, and Louisiana State University Health Care Services Division, is designed to address disparities in immunization rates among some of our most disadvantaged populations.

I am grateful and honored to serve as your President and share my thoughts in this column. Please let me hear from you.