Adult vaccinations.

Adult vaccination saves lives and is cost-effective. During influenza epidemics, more than 20,000 estimated deaths occur in the United States. Despite the benefits of adult vaccination and the availability of usage guidelines, vaccination rates remain low. In 1999, only 67% and 55% of elderly persons reported receiving influenza and pneumoccal vaccines. Vaccination indications are categorized as age, health, occupation, lifestyle, and environment.

The vaccines for children program. Policies, satisfaction, and vaccine delivery.

OBJECTIVES: Characterize the Vaccines for Children (VFC) programs in Minnesota and Pennsylvania, assess providers' satisfaction with each state's program, and examine changes in doses administered in the public sector since implementation of the VFC. METHODS: Primary care providers participating in the VFC in Minnesota and Pennsylvania were surveyed. Doses administered were based on data from the National Immunization Survey. Outcome measures included satisfaction, ease of use of VFC, doses of immunizations administered through public health departments, and overall immunization coverage for the two states. RESULTS: Most participating providers in each state (80% to 94%) reported overall satisfaction with the VFC. Pennsylvania physicians were less satisfied with quarterly ordering of immunizations than were Minnesota providers with monthly ordering (56% vs 80%, p<0.05). The most common recommendation was to reduce paperwork. Doses administered in the public sector declined in Minnesota from approximately 146,000 in 1994 to 65,400 in 1999, and in Pennsylvania from approximately 250,000 to 79,300 during the same period. CONCLUSIONS: The VFC appears to increase the numbers of poor and uninsured children who receive necessary childhood immunizations within their medical homes. Providers are generally satisfied with the program.

Effect of the Vaccines for Children program on physician referral of children to public vaccine clinics: a pre-post comparison.

OBJECTIVE: Started in late 1994, the Vaccines for Children (VFC) program is a major entitlement program that provides states with free vaccines for disadvantaged children. Some evaluation studies have been conducted, but they do not include individually matched pre-post comparisons of physician responses. This project studied the effect of the VFC on the physician likelihood of referring children to public vaccine clinics for immunizations. DESIGN: In 1999, trained personnel conducted a survey of a cohort of physicians who previously participated in surveys on barriers to childhood vaccination conducted before VFC implementation. Responses were matched, and pre- versus post-VFC comparisons were made. SETTING AND PARTICIPANTS: Minnesota and Pennsylvania primary care physicians selected by stratified random sampling and initially studied in 1990 to 1991 and 1993, respectively. MAIN OUTCOME MEASURES: Likelihood of referral of a child to a public vaccine clinic. RESULTS: On a scale of 0 to 10, physician likelihood of referring an uninsured child decreased by a mean of 1.9 (95% confidence interval: 1.2-2.5) from pre- to post-VFC. Two fifths (45%) of physicians reported that the VFC decreased the number of referrals from their practice to public vaccine clinics and 50% gave intermediate responses. Among physicians who participate in VFC, only 9% were likely to refer a Medicaid-insured child in contrast to 44% of those not participating. CONCLUSIONS: Physicians' reported referral and likelihood of referring Medicaid-insured and uninsured children has decreased because of VFC in Minnesota and Pennsylvania.vaccination/economics, vaccination/legislation and jurisprudence, immunization programs/economics, immunization programs/utilization, vaccines/economics, Medicaid/economics, national health programs United States, child health services.

A comprehensive investigation of barriers to adult immunization: a methods paper.

OBJECTIVE: Immunization rates for influenza and pneumococcal vaccines among the elderly (especially minority elderly) are below desired levels. We sought to answer 4 questions: (1) What factors explain most missed immunizations? (2) How are patient beliefs and practices regarding adult immunization affected by racial or cultural factors? (3) How are immunizations and patient beliefs affected by physician, organizational, and operational factors? and (4) Based on the relationships identified, can typologies be created that foster the tailoring of interventions to improve immunization rates? STUDY DESIGN: A multidisciplinary team chose the PRECEDE-PROCEED framework, the Awareness-to-Adherence model of clinician response to guidelines, and the Triandis model of consumer decision making as the best models to assess barriers to and facilitators of immunization. Our data collection methods included focus groups, face-to-face and telephone interviews, self-administered surveys, site visits, participant observation, and medical record review. POPULATION: To encounter a broad spectrum of patients, facilities, systems, and interventions, we sampled from 4 strata: inner-city neighborhood health centers, clinics in Veterans Administration facilities, rural practices in a network, and urban/suburban practices in a network. In stage 1, a stratified random cluster sample of 60 primary care clinicians was selected, 15 in each of the strata. In stage 2, a random sample of 15 patients was selected from each clinician's list of patients, aiming for 900 total interviews. CONCLUSIONS: This multicomponent approach is well suited to identifying barriers to and facilitators of adult immunizations among a variety of populations, including the disadvantaged.

Pneumococcal conjugate vaccine for young children.

Streptococcus pneumoniae causes approximately 3,300 cases of meningitis, 100,000 to 135,000 cases of pneumonia requiring hospitalization and 6 million cases of otitis media annually in the United States. Pneumococcal conjugate vaccine, approved in 2000 for use in the United States, was designed to cover the seven serotypes that account for about 80 percent of invasive infections in children younger than six years. This vaccine demonstrated 100 percent efficacy against invasive pneumococcal disease in the primary analysis of a large randomized, double-blind, controlled trial. In the follow-up analysis, performed eight months after the trial ended, efficacy against invasive disease was found to be 94 percent for the included serotypes. When initiated during infancy, the four-dose vaccination schedule is set at two, four, six and 12 to 15 months of age. The American Academy of Family Physicians recommends routine vaccination of infants, catch-up vaccination of children younger than 24 months and catch-up vaccination of children 24 to 59 months of age with high-risk medical conditions such as sickle cell disease and congenital heart disease.

Haemophilus influenzae type B disease, vaccines, and care of exposed individuals.

Before effective vaccines became available, approximately 1 in every 200 children aged younger than 5 years had invasive Haemophilus influenzae type b (Hib) disease. Hib was the most common cause of bacterial meningitis and other invasive bacterial diseases in this age group. Rapid diagnosis and treatment are essential for Hib meningitis, because the mortality rate is 2% to 5%, even with antibiotic treatment--usually a third-generation cephalosporin, such as cefotaxime or ceftriaxone. Because of the use of Hib vaccines, the incidence of invasive H. influenzae disease in children younger than 5 years old declined by 97% between 1987 and 1997. Recent data indicate that the conjugate Hib vaccines given in infancy can be used interchangeably.

Child vaccination, part 1: routine vaccines.

Despite the success of the national childhood vaccination program in the United States in decreasing mortality due to vaccine-preventable diseases, vaccination rates remain suboptimal. Contributing factors include the failure to appreciate the hazards of vaccine-preventable diseases, concerns about adverse reactions associated with vaccine administration, and missed opportunities to administer vaccines. The 2 major types of indications for vaccinating children are age and presence of a medical condition that increases the risk of a vaccine-preventable disease. Hepatitis B virus (HBV) infection becomes chronic in 90% of those infected as infants, and 25% of those so infected will die of related chronic liver disease as adults. Routine infant vaccination against hepatitis B has been recommended since 1991. Approximately 69% of infants who develop pertussis require hospitalization. Acellular pertussis vaccines have been licensed for use in infancy. Starting in 2000, the all-inactivated poliovirus vaccine (IPV) schedule is recommended. IPV should eliminate vaccine-associated paralytic poliomyelitis. Pneumococcal conjugate vaccine was licensed in 2000 for routine use on a schedule of 2, 4, 6, and 12 to 15 months. The first dose of measles-mumps-rubella vaccine is now recommended at age 12 to 15 months, simultaneous with varicella vaccine administration.

Prevention of influenza by expanded ages for routine vaccination.

Influenza viruses are highly contagious and are transmitted from person to person, usually by the airborne route. Persons in semiclosed or crowded environments, such as students and residents of nursing homes, are at high risk for exposure. Fatality rates are highest in persons who have chronic medical conditions such as chronic obstructive lung disease and diabetes mellitus, particularly if they are elderly. When there is a good match between the vaccine and the circulating viruses, influenza vaccine has been shown to prevent illness in approximately 70% to 90% of healthy persons younger than 65 years. Despite the availability of an effective vaccine, it is underused. The Advisory Committee on Immunization Practices (ACIP) and the American Academy of Family Physicians (AAFP) now recommend that all persons aged 50 years and older receive annual influenza vaccination because of the suffering from influenza and the cost-effectiveness of vaccination. Reasons for lowering the recommended age for routine vaccination from 65 years to 50 years include reductions in office visits, hospitalizations, time taken off work, and costs. Persons younger than 50 years who have medical conditions that place them at risk for complications should also be vaccinated. If a vaccine shortage occurs, which may happen in the Fall 2000, then priority would be given to the elderly and those with high-risk conditions.

Child vaccination, part 2: childhood vaccination procedures.

In 1996, the Advisory Committee on Immunization Practices (ACIP), the American Academy of Family Physicians (AAFP), the American Academy of Pediatrics (AAP), and the American Medical Association recommended a well-child office visit at age 11 to 12 years to check vaccination status. Vaccination status should be assessed for varicella, hepatitis B, the second dose of measles-mumps-rubella (MMR) vaccine, and tetanus-diptheria (Td) toxoid if not given in the past 5 years. Adolescent patients should be screened for high-risk conditions indicating the need for influenza, pneumococcal, or hepatitis A vaccines. The Accelerated Immunization Schedule and Minimal Interval Table should be consulted for children who are behind schedule.

Adult vaccination, part 1: vaccines indicated by age. Teaching Immunization for Medical Education (TIME) Project.

The morbidity and mortality of vaccine-preventable diseases among adults are high, particularly among populations at high risk because of underlying medical conditions. Influenza vaccination is recommended annually, optimally during campaigns held between October and mid-November, for all persons 50 years and older and for younger persons with high-risk conditions. Because of production delays, influenza vaccination campaigns are delayed until November of this year. Pneumococcal polysaccharide vaccination is recommended for healthy persons 65 years and older and younger persons with high-risk conditions. A 3-dose series of adult tetanus and diphtheria toxoids (Td) is recommended for those who have not had a primary series or whose vaccination history is uncertain. Adults who have completed the primary vaccination series should receive a booster dose of Td vaccine every 10 years. Specific strategies for improving the rate of these vaccinations have been developed for medical offices and clinics, hospitals, and other health care institutions, and other settings where there is high risk of vaccine-preventable disease.

Adult vaccination, part 2: vaccines for persons at high risk. Teaching Immunization for Medical Education (TIME) Project.

The morbidity and mortality from vaccine-preventable diseases are high among adults with underlying medical conditions. Influenza vaccination is recommended annually, optimally between October and mid-November, for all persons 50 years of age and older and those with cardiac disease with potential for altered hemodynamics, diabetes mellitus, immunocompromising conditions, pulmonary disease, or renal disease. This season, because of production delays, influenza vaccination campaigns are planned for November. Pneumococcal polysaccharide vaccination is recommended for all persons 65 years and older and for those with alcoholism, asplenia, cardiac disease, cirrhosis, diabetes mellitus, immunocompromising conditions, pulmonary disease, or chronic renal disease. Indications for hepatitis B vaccination include chronic renal disease and hemodialysis, as well as employment in health care or employment as a mortician or public safety officer. It is also recommended for homosexual men, those who have multiple sex partners or a sexually transmitted disease, and injection drug users.

Does the Vaccines for Children program influence pediatric nurse practitioner referral of disadvantaged children to public vaccine clinics?

OBJECTIVE: Concerns about financial barriers to vaccination led to the creation of the Vaccines for Children (VFC) program, which provides free vaccines to states for disadvantaged children. Our objective was to understand the effect of free vaccine and insurance on pediatric nurse practitioners' (PNPs) likelihood of referring children to public vaccine clinics. Although referral from the medical home to public vaccine clinics is preferable to not vaccinating, there are disadvantages, including the potential for windows of inadequate protection and fragmentation of care. METHODS: A standardized survey was conducted by trained personnel using computer-assisted telephone interviewing. We interviewed a national random sample of primary care PNPs in 1997. RESULTS: In 1997, 252 of 271 (93%) directly contacted PNPs were interviewed. The percentage of respondents receiving free vaccines was 82%. Among PNPs not receiving free vaccines, the percentages stating that they were likely to refer insured, Medicaid insured, and uninsured children to public vaccine clinics were 7%, 27%, and 67%, respectively. In contrast, among PNPs receiving free vaccines, only 46% would refer an uninsured child and 10% a Medicaid child. CONCLUSIONS: Most respondents received free vaccine supplies in 1997. Based on current PNP data and previous physician data, most clinicians who do not receive free vaccine supplies are likely to refer uninsured children to public vaccine clinics. In contrast, clinicians who receive free vaccine supplies are much more likely to vaccinate uninsured and Medicaid-insured children.

Lowering the age for routine influenza vaccination to 50 years: AAFP leads the nation in influenza vaccine policy. American Academy of Family Physicians.

The American Academy of Family Physicians now recommends that all persons 50 years of age and older receive an annual influenza vaccination, because the rates of morbidity and mortality associated with influenza are high and vaccination is cost-effective. Reasons for lowering the recommended age for routine vaccination from 65 to 50 years of age include reductions in office visits, hospitalizations, time taken off work and associated costs. In working adults 18 to 64 years of age, the cost savings were estimated at $46.85 per person vaccinated. Furthermore, the fatality rate from influenza begins to rise at age 45 and is highest in persons with multiple chronic medical conditions. As in the past, recommendations target persons at high risk for complications, such as those with cardiac disease, lung disease and diabetes, as well as health care workers and residents of nursing homes. Severe allergy to eggs is a contraindication to influenza vaccination.

Relationship between primary payer and use of proactive immunization practices: a national survey.

OBJECTIVE: To quantify the national use and determinants of proactive immunization practices by examining the relationship to the primary practice payer. STUDY DESIGN: A standardized survey was conducted in 1995 by trained personnel using computer-assisted telephone interviewing. PATIENTS AND METHODS: A stratified random sample of family physicians, pediatricians, and general practitioners across the United States was selected from the American Medical Association master file of physicians list, which included nonmembers. The main outcome measures were use of reminder systems and assessment of immunization rates. RESULTS: Of the 1769 physicians who were contacted, 1236 participated. Use of reminder systems varied by the practice's primary payer: 31% of health maintenance organization (HMO), 41% of Medicaid, 27% of fee-for-service (FFS), and 28% of no predominant payment source physicians reported using a reminder system (P < 0.01). Use of computerized reminders also varied according to practice primary payer (HMO, 68%; Medicaid, 34%; FFS, 51%; and no predominant payment source, 42%; P < 0.01) as did assessment of immunization rates in the practice (HMO, 57%; Medicaid, 40%; FFS, 28%; and no predominant payment source, 30%; P < 0.01). A majority of Medicaid physicians (84%) required a physical examination before immunization, compared to 49% of HMO, 56% of FFS, and 63% of no predominant source physicians (P < 0.01). CONCLUSIONS: The primary payment source of a practice appears to influence use of proactive immunization practices.

Are vaccination rates higher if providers receive free vaccines and follow contraindication guidelines?

BACKGROUND AND OBJECTIVES: Economics has been suggested as a barrier to vaccination, but data that link clinician reports to actual immunization rates are limited. This study examined the relationship between clinicians' self-report regarding likelihood of vaccinating and actual age at vaccination from a registry of children seen by the clinicians. METHODS: Standardized telephone survey results of 29 providers were compared to the immunization records of children seeing these providers, using analysis of contingency tables (on time versus late) and conditional hierarchical linear models with log age at diphtheria-tetanus-pertussis (DTP)#3, DTP#4, and measles-mumps-rubella (MMR)#1 as the dependent variables. RESULTS: Children seeing providers likely to refer an uninsured child for immunization were vaccinated at a later log age at DTP#4 but not for DTP#3 or MMR#1 than children seeing providers unlikely to refer. Vaccination rates were higher for MMR#1 (77% versus 48%), DTP#3 (84% versus 71%), and DTP#4 (82% versus 66%) among providers who received free vaccine, compared with children seen by providers who did not receive free vaccine. These results remained significant in the hierarchical analyses. Providers likely to vaccinate an 18-month-old with watery diarrhea had higher vaccination rates than those unlikely to vaccinate for MMR#1, DTP#3, and DTP#4; the results were also significant in the hierarchical analyses. CONCLUSION: Children are vaccinated later in the practices of providers who are likely to refer uninsured children to a public vaccine clinic for vaccination, who do not receive free vaccine supplies, or who overinterpret contraindications.