A Report of the National Vaccine Advisory Committee
National Vaccine Advisory Committee Membership List
CHAIRMAN Georges Peter, M.D.
Brown University School of Medicine
Providence, Rhode Island
ACTING EXECUTIVE SECRETARY Martin Meyers, M.D.
National Vaccine Program Office, CDC
Atlanta, Georgia
PAST CHAIRMAN Edgar Marcuse, M.D., M.P.H.
University of Washington
Seattle, Washington
PAST EXECUTIVE SECRETARY Robert Breiman, M.D.
National Vaccine Program Office, CDC
Atlanta, Georgia
MEMBERS
Michael Decker, M.D., M.P.H.
Vanderbilt University School of Medicine
Nashville, Tennessee
Mary des Vignes-Kendrick, M.D.
City of Houston
Department of Health and Human Services
Houston, Texas
Theodore Eickhoff, M.D.
University of Colorado Health Sciences Center
Denver, Colorado
Amy Fine, M.P.H.
Washington, D.C.
Virginia Galvin, M.D.
Cobb/Douglas Health District
Marietta, Georgia
Jerome Klein, M.D.
Boston University School of Medicine
Boston, Massachusetts
F. Marc LaForce, M.D.
BASICS 2
Arlington, Virginia
Myron Levine, M.D.
University of Maryland School of Medicine
Baltimore, Maryland
Yvonne Maldonado, M.D.
Stanford University School of Medicine
Stanford, California
Thomas Monath, M.D.
OraVax, Incorporated
Cambridge, Massachusetts
June Osborn, M.D.
Josiah Macy, Jr. Foundation
New York, New York
Peter Paradiso, Ph.D.
Wyeth-Lederle Vaccines
and Pediatrics
West Henrietta, New York
Stanley Plotkin, M.D.
Aventis Pasteur
Doylestown, Pennsylvania
Gregory Poland, M.D.
Mayo Clinic and Foundation
Rochester, Minnesota
Patricia Quinlisk, M.D.
Iowa Department of Public Health
Des Moines, Iowa
David Smith, M.D.
Texas Tech University
Lubbock, Texas
Marian Sokol, Ph.D.
Any Baby Can, Inc.
San Antonio, Texas
Daniel Soland
SmithKline Beecham
Pharmaceuticals
Belgium
Patricia Whitley-Williams, M.D.
University of Medicine and
Dentistry/Robert Wood Johnson
Medical School
New Brunswick, New Jersey
Donald Williamson, M.D.
Alabama Department
of Public Health
Montgomery, Alabama
EX OFFICIO MEMBERS
David Benor, J.D.
Office of General Counsel
Rockville, Maryland
William Egan, Ph.D.
Food and Drug Administration
Rockville, Maryland
Col. Renata Engler, M.D.
Department of Defense/Walter Reed Medical Center
Washington, D.C.
Geoffrey Evans, M.D.
Health Resources and Services
Administration
Rockville, Maryland
Ruth Frischer, Ph.D.
Agency for International
Development
Washington, D.C.
T. Randolph Graydon
Health Care Financing
Administration
Baltimore, Maryland
John LaMontagne, Ph.D.
National Institutes of Health
Bethesda, Maryland
Walter Orenstein, M.D.
CDC
Atlanta, Georgia
J.P. Passino, M.P.H.
Department of Agriculture
Alexandria, Virginia
William Robinson, M.D.
Health Resources and Services
Administration
Rockville, Maryland
LIAISON REPRESENTATIVES
James Foy, D.O.
American Association
of Health Plans
Columbus, Ohio
Mary Glode, M.D.
Advisory Committee for Immunization Practices
Denver, Colorado
Adele Young, Ph.D., P.N.P.
Advisory Commission
on Childhood Vaccines
Fairfax, Virginia
WORKSHOP PARTICIPANTS
American Academy of Nurse Practitioners
American Academy of Family Physicians
American Academy of Pediatrics
American Association of
Occupational Health Nurses
American Association of Retired Persons
American College of Nurse
Midwives
American College of Physicians
American Dental Association
American Health Care Association
American Medical Association
American Nurses Association/Foundation
American Osteopathic Association
American Pharmaceutical
Association
Association of State and Territorial Dental Directors
Association of State and
Territorial Health Officials
Aventis Pasteur
North American Vaccine
Clinical Directors Network
Council of State and Territorial
Epidemiologists
CVS/Pharmacy
Delmarva Foundation
Food and Drug Administration
Georgia Drug and Narcotics Agency/Georgia State Board
of Pharmacy
Health Care Financing
Administration
Health Resources and Services
Administration
Immunization Education and Action Committee, National Healthy Mothers,
Healthy Babies Coalition
International Health Corporation
Little Havana Activities and Nutrition
Centers of Dade County, Inc.
Merck & Company, Inc.
Mississippi Board of Pharmacy
Mollen Immunization Clinics
National Association of Boards
of Pharmacy
National Association of
Childbearing Centers Foundation/Maternity Center Association
National Association of
Community Health Centers
National Black Nurses Association
National Center for Infectious Diseases, CDC
National Coalition for Adult
Immunization
National Coalition of Hispanic Health and Human Services
National Council of La Raza
National Council on the Aging, Inc.
National Immunization Program, CDC
National Institute for Allergy
and Infectious Diseases
National Institutes of Health
National Medical Association
Office of Minority Health, CDC
SmithKline Beecham
Pharmaceuticals
Virginia State Health Department
Visiting Nurses Association
of America
Wyeth-Ayerst
The following CDC staff members prepared this report:
Alicia S. Postema, M.P.H.
Robert F. Breiman, M.D. National Vaccine Program Office
Office of the Director
Adult Immunization Programs in Nontraditional Settings: Quality Standards and Guidance for Program Evaluation
A Report of the National Vaccine Advisory Committee
Summary
This report provides a summary of the National Vaccine
Advisory Committee's (NVAC) workshop on adult immunization programs
in nontraditional settings, quality standards for such programs, and guidance
for program evaluation. Throughout the United States, an increasing number
of adults are receiving vaccine in nontraditional settings (e.g., pharmacies
and churches). Immunization programs in nontraditional settings are often
more accessible and convenient than a health-care provider's office or a public
health clinic, especially for medically underserved adults (e.g.,
economically disadvantaged, inner city, and minority populations). Medically
underserved adults might be at particular risk for undervaccination because they are
often without a medical home (i.e., a regular point of contact where their
health-care needs are met). Immunization programs in nontraditional settings
might enhance the capacity of the health-care system to effectively deliver vaccine
to adults by increasing the number and types of sites where adults can
receive vaccine. NVAC has recognized that strategies need to be developed to
make vaccines available to all adults and that the number of immunization programs
in nontraditional settings is increasing. Therefore, the Committee issues
the following report, including quality standards and guidance for
program evaluation.
BACKGROUND
Approximately 45,000 adults in the United States die annually of complications
from influenza, pneumococcal infections, and hepatitis B -- the primary
vaccine-preventable diseases affecting adults. The total economic cost of treating these vaccine-preventable diseases among adults, excluding the value of years of life lost,
exceeds $10 billion each year. Although effective vaccines to prevent these diseases are
available, they are widely underutilized
(1,2). This underutilization reflects a lack
of emphasis on vaccines for adults in comparison with the more substantial emphasis
on vaccines for children.
Influenza and pneumococcal vaccine coverage rates for adults aged
>65 years vary by race and ethnicity
(2). In 1997, influenza vaccine coverage rates ranged from
67.2% among non-Hispanic whites to 50.2% among non-Hispanic blacks
(2). Pneumococcal vaccine coverage rates were even lower: 47.3% of white adults aged
>65 years reported receiving pneumococcal vaccine compared with 34.1% of Hispanics and 29.7% of
blacks (2). Disease burden also varies by race and ethnicity. Blacks have a threefold to
fivefold increased risk for developing life-threatening invasive pneumococcal disease
compared with whites (3-5).
A recommendation by a health-care provider is a key factor determining whether
an adult patient will be vaccinated (6). Medically underserved adults (e.g.,
economically disadvantaged, inner city, and minority populations) might be at particular risk
for underimmunization because they are often without a medical home (i.e., a regular
point of contact where their health-care needs are met) and might not have regular access
to a health-care provider (7-10). Therefore, to reach medically underserved adults,
strategies to increase vaccine-seeking behavior are critically needed. One such
strategy involves offering vaccine to adults in nontraditional settings (e.g., pharmacies
and churches) that might be more accessible and convenient than the office of a
health-care provider or a public health clinic. Immunization programs in nontraditional
settings might enhance the capacity of the health-care system to effectively deliver vaccine
to adults by increasing the number and types of settings in which adults can receive
vaccine.
INTRODUCTION
Purpose of the National Vaccine Advisory
Committee Workshop
The National Vaccine Program Office sponsored a public meeting of the
National Vaccine Advisory Committee's (NVAC) Adult Immunization Working Group on
December 1-2, 1997, to explore adult immunization programs in nontraditional settings.
The purpose of the workshop was
to gain a better understanding of programs currently offering vaccines to
adults in nontraditional settings,
to identify potential benefits and challenges associated with
administering vaccines in nontraditional settings,
to identify additional nontraditional settings that could be explored
and potentially used,
to define areas where additional research is needed,
to develop an effective immunization strategy integrating
immunization programs in nontraditional settings with those in traditional settings, and
to develop quality standards for immunization programs in
nontraditional settings.
The workshop was limited to discussion regarding vaccines for adults because
national vaccine coverage estimates for adults are substantially lower than the
national goals established for this population, whereas coverage estimates for children
approach or exceed national goals (2,7,11).
The purpose of this report is to provide a summary of discussions at the
NVAC workshop so that persons who conduct or plan to conduct immunization programs in
a nontraditional setting will have guidance regarding how to safely operate such a
program. This report also highlights the importance of evaluating these programs by
collecting data regarding associated benefits (e.g., increases in the number of adults
vaccinated) and challenges (e.g., preventing fragmentation of care by reporting
administration of vaccine to the primary-care provider of the vaccinee).
Influenza and pneumococcal vaccines constitute the majority of vaccines
administered in nontraditional settings; therefore, this report focuses on these vaccines. If
the types of vaccines administered in nontraditional settings increase, both the
benefits and challenges could change.
Workshop Participants
Workshop participants included members of the NVAC Adult Immunization
Working Group and representatives from approximately 50 organizations, including
federal and state governments, community and professional organizations, and private
companies. Participants were identified through discussions with staff at CDC, the
Health Resources and Services Administration, the National Coalition for Adult
Immunization (NCAI), and other organizations. NCAI is composed of nearly 100 professional
medical and health-care associations, advocacy groups, voluntary organizations, vaccine
manufacturers, and government agencies. Workshop presenters were selected to ensure
that a spectrum of viewpoints was represented.
SUMMARY OF WORKSHOP PRESENTATIONS
Information regarding the U.S. Department of Health and Human Services'
Adult Immunization Action Plan (1), vaccine coverage rates, and incidence of morbidity
and mortality attributable to vaccine-preventable diseases among adults was
presented. The American College of Physicians (ACP) and the National Medical Association
provided physicians' perspectives of administration of vaccine in nontraditional
settings. The benefits and challenges highlighted by these physicians were similar to those
of other workshop participants. Benefits included increased access and convenience,
reduced cost for vaccination, and increased awareness of the importance of
vaccination. Challenges included ensuring that trained staff are available to treat potential
adverse reactions to vaccines, keeping effective records, protecting health-care providers
from liability, preventing fragmentation of care, and removing restrictive legal regulations.
NCAI and the National Council on Aging emphasized the importance of
collaboration between public and private sectors and community-based organizations. A
panel of representatives from community-based organizations providing services to
traditionally underserved populations presented ways in which their clients might be
more adequately cared for by the health-care profession (e.g., providing culturally and
linguistically appropriate materials and outreach programs). Organizations that
currently provide vaccines to adults in several nontraditional settings (including
pharmacies, nontraditional clinical settings, retail establishments, dental care facilities,
churches, the workplace, and the home) provided examples of the benefits and challenges
experienced in these programs.
Examples of Adult Immunization Programs
in Nontraditional Settings
The Health Care Financing Administration's (HCFA) Horizons pilot project, a
collaborative project between professional review organizations and nine historically
black colleges and universities in eight southern states, was presented as an example of
how the Federal government works with communities to provide vaccine in
nontraditional settings. The goal of the Horizons project is to produce effective
community-based interventions for increasing vaccine coverage rates among black
populations. Tennessee's Horizons project has provided vaccines to adults in approximately 14
nontraditional settings, including shopping malls, senior citizen centers, nutrition sites,
mobile units, grocery stores, voting sites, parks, and public housing projects.
Pharmacies in the United States are increasing their participation in
vaccination activities (12). Pharmacists are functioning as a) vaccine advocates, by educating
their clients about the importance of vaccines; b) vaccine facilitators, by hosting
vaccine clinics at pharmacies; and c) vaccine administrators, by vaccinating their clients.
The American Pharmaceutical Association and CDC's National Immunization Program
have developed a training course to prepare pharmacists for active participation in
immunization programs (13). Twenty-six states have statutes that permit pharmacists to
administer vaccine. Accessability of pharmacists and the degree of trust between
pharmacists and patients were suggested as factors that provide important
opportunities for pharmacists to educate adults about the benefits of vaccines and, in some
cases, administer vaccine.
Nurse practitioners, visiting nurses, and members of the National Black Nurses
Association (NBNA) also are involved in immunization programs in nontraditional
settings. Nurse practitioners, using mobile-community health centers, often provide
care to traditionally underserved homeless and migrant workers and a large population
of older adults who reside in rural or inner city areas. NBNA and the Visiting Nurses
Association often staff immunization programs operating in nontraditional settings,
including the workplace, pharmacies, and churches.
A representative from the American Association of Occupational Health
Nurses noted that employers can be involved in workplace immunization activities on
three levels: a) providing vaccines at the work site, administered by their own medical
staff; b) contracting with health-care providers to administer vaccine at the work site;
and/or c) including preventive care benefits (e.g., vaccinations) in health plans for
employees. Employers generally are interested in increasing employee productivity; therefore,
decreased employee absenteeism associated with receiving influenza vaccine should
be highlighted (14). Potential barriers to workplace vaccination programs include
employers being reluctant to disrupt work schedules or to offer vaccine to employees
covered by health plans. Workplaces with a small number of employees might not be able
to provide vaccination programs on their own but might be able to unite with other
offices and provide vaccines in a centralized site within an office park.
New Settings and Incentives for Immunization Programs
Several additional nontraditional settings in which vaccines might be provided
include soup kitchens, prisons, sheltered workshops for persons with disabilities,
casinos, bingo halls, adult day care centers, major transit points, and polling stations
on election days. Designation of mass immunization days (analogous to national
immunization days for polio vaccination in endemic areas
[15]) during which vaccinations are provided in several different settings was suggested. New incentive or
endorsement programs that might increase the demand for vaccinations were also presented.
For example, retail coupons and endorsement by sports teams were suggested as
potential ways to enhance vaccine-seeking behavior among adults.
BENEFITS OF ADULT IMMUNIZATION PROGRAMS
IN NONTRADITIONAL SETTINGS
Access and Convenience
The most common benefits of administering vaccine in nontraditional settings
noted by workshop presenters are increased access and convenience. Providing vaccines
in settings readily accessible to adults who are most in need of the services is critical.
For many adults, the need to use transportation to reach a health-care provider is a
barrier to receiving preventive services
(7,9). This barrier might be eliminated by offering
preventive services (e.g., administration of vaccines) in a neighborhood retail
establishment, church, or other convenient location. Eliminating the need for making an
appointment in advance and avoiding the waiting time often associated with a clinic
or office visit are factors that also might increase the vaccine-seeking behavior of
some adults (8,9).
Reduced Cost for Vaccinations
The reduced cost of receiving vaccines in nontraditional settings compared
with traditional settings is another potential benefit. The current cost of administering
influenza and pneumococcal vaccines in a nontraditional setting is $10-$15 and
$15-$20, respectively. Adults without health insurance might be willing to pay for a vaccine
administered in a nontraditional setting when they would be unwilling or unable to
pay the greater cost associated with a physician's office visit
(16,17). For adults who are covered by Medicare, HCFA has mandated reimbursement for health-care
providers who administer influenza vaccine, regardless of the setting, even if the health-care
provider is not a member of the vaccinee's health-care plan.
Increased Awareness for Vaccinations Among Adults
An indirect benefit of administering vaccine in nontraditional settings is
increased public awareness of the need for adult immunization. This benefit is realized in
two ways. First, many immunization programs operating in nontraditional settings use
direct marketing to inform the community about their services and why they are
important. Although marketing strategies might be directed toward promoting a specific
site, the actual benefit is likely a general increase in public awareness regarding the
importance and availability of vaccines for adults. Secondly, immunization programs in
nontraditional settings often elicit media attention, which might increase community
awareness of the need for vaccination of adults.
CHALLENGES OF ADULT IMMUNIZATION PROGRAMS
IN NONTRADITIONAL SETTINGS
Adverse Reactions to Vaccines
Vaccine providers should be trained to manage adverse reactions that might
occur. Concerns regarding postvaccination observation included: "Should direct
observation
of vaccine recipients be routine? If so, what is the duration of observation? If a
severe adverse reaction occurs, are trained and skilled personnel on site to respond
appropriately?"
Recordkeeping
Important factors regarding recordkeeping include how to determine which
adults are in need of vaccines and how to prevent inappropriate revaccination.*
Immunization registries might play a role in resolving this issue; however, most existing
immunization registries do not include information regarding adults. Until immunization
registries routinely include this information, the primary-care provider and/or health
department should be notified when a vaccine is administered in a nontraditional setting
so that patient immunization records can be updated. In addition, vaccinees should
be provided with wallet-sized vaccine records. These efforts will help ensure that
adults are offered appropriately timed vaccines and that their vaccination status is
accessible to their health-care provider in traditional or nontraditional settings and to other
health-care providers who might offer them vaccines in nontraditional settings.
Liability of Health-Care Providers
Many workshop participants considered liability protection for health-care
providers an important component of any adult immunization program. Health-care providers
might be more likely to promote and administer vaccines if they could be assured of not
being held liable for incidents of rare but serious adverse reactions to vaccines.
Legal Regulations
Workshop participants described several restrictive legal regulations regarding
the administration of vaccines. In many states, legislation restricts who can administer
vaccines and under what circumstances. In some areas, new immunization programs
that might reach populations at high risk for disease could be hampered by restrictive
legal regulations.
Integrating Vaccine Programs in Nontraditional
and Traditional Settings
One challenge of offering vaccines in a setting that does not provide other
preventive services is fragmentation of care. Workshop participants acknowledged the
importance of having a medical home to ensure appropriate and comprehensive
preventive care, early diagnosis, and optimal therapy. Immunization programs in
nontraditional settings should facilitate identification of medical homes for medically
underserved adults who need a health-care provider. To promote integration of preventive care
services when an adult with a regular primary-care provider is vaccinated in a
nontraditional setting, the primary-care provider should be notified by the vaccine provider
of the patient's vaccination status. Vaccination status is often a marker for other
health-care needs. Therefore, adults seeking vaccines in nontraditional settings also
might need other preventive health services (e.g., mammograms and lipid screenings).
In addition, these programs need systematic procedures (e.g., providing lists of
nearby physicians and offering to schedule appointments) to ensure that referrals to
primary- care providers are offered when appropriate and that relevant health promotion
and disease prevention literature are available on site.
Quality of Services
The mission of an immunization program and the motivation of the
health-care providers who operate the program might affect the quality of services provided.
Important components of quality care when administering vaccines in nontraditional
settings include a) ability to handle adverse reactions, b) notification of the
primary-care provider or health department when vaccines are administered, c) physician
referral services, and d) providing education regarding other key preventive health measures.
FUTURE CONSIDERATIONS AND PRIORITIES
The conclusions reached by workshop participants were based primarily on
expert opinion and anecdotal information. Both workshop participants and NVAC
recognize the need for research targeted at providing data that addresses the effectiveness
of immunization programs in nontraditional settings in reaching previously
unvaccinated adults.
NVAC recommends that program evaluation be conducted to determine the
impact of immunization programs in nontraditional settings on vaccine coverage rates and
vaccine-preventive disease rates among adults. Specifically, the following
concerns should be addressed:
Determine characteristics of persons receiving vaccine in nontraditional
settings, including demographic characteristics, previous vaccine-seeking behavior,
and previous and anticipated future use of the traditional medical system. A
survey of persons using nontraditional settings for vaccination could provide these data.
Determine characteristics of programs successfully reaching
hard-to-reach, previously unvaccinated adults. Demonstration projects, including various
types of programs (e.g., those operated by service versus for-profit organizations)
in different locations, including churches, work sites, and pharmacies, need to
be assessed to determine which combination of features creates the
most successful program.
Catalogue the types of services provided. The catalogue could include
the following features: reporting to primary-care physician, referral to
physician, provision of educational materials regarding the importance of other
preventive care measures, the number of programs offering each service, and the effect
of these services on program operating costs.
Determine if the nontraditional settings in which vaccines are administered
are accessible locations and settings in which medically underserved
populations feel comfortable receiving vaccine. This information could be obtained
by surveying these adults.
Determine the potential effect of liability protection on physician practice
patterns by surveying physicians.
Determine reasons nonphysician providers in some states are not allowed
to administer vaccines in nontraditional settings. These reasons could be
ad-dressed by surveying state legislators and health officials.
GUIDANCE FROM NVAC FOR CONDUCTING ADULT IMMUNIZATION PROGRAMS IN NONTRADITIONAL SETTINGS
Although no formalized, coordinated effort to provide vaccinations in
nontraditional settings exists at the national level, many adults are already receiving vaccine in
these settings. To ensure the safety of persons receiving vaccines in these settings, NVAC
has established seven quality standards for vaccine providers conducting or planning
to conduct adult immunization programs in nontraditional settings.
Quality standards for immunization programs in nontraditional settings
generally coincide with the quality standards for programs in traditional settings. NVAC's
quality standards for immunization programs in nontraditional settings are consistent
with existing adult immunization standards of the Advisory Committee on
Immunization Practices (ACIP) (20), ACP
(21), the Infectious Disease Society of America
(22), and NCAI (23), with additional caveats specific to nontraditional settings.
Standard 1: Information and Education for Vaccinees
Before receiving vaccine, the vaccinee must be given information about the
risks and benefits associated with vaccination, including the CDC-developed Vaccination
Information Statements that address the risks and benefits for 12 commonly
administered vaccines, including influenza and pneumococcal vaccines. This information
should be culturally and linguistically appropriate and written at a reading level that can
be easily understood. The vaccine provider should be available to accurately address
questions and concerns posed by the vaccinee.
Vaccinees should also be informed regarding the importance of having a
medical home and receiving other preventive medical services. In addition, health
promotion and disease prevention literature should be available on site and offered to the
vaccinee.
Standard 2: Vaccine Storage and Handling
Adherence to vaccine handling and storage recommendations included in
vaccine package inserts is critical because mishandling and inappropriate storage can
render vaccines ineffective. Influenza and pneumococcal vaccines are the primary
vaccines administered in nontraditional settings. These vaccines should be stored at
temperatures between 2 C and 8 C (38 F and 48 F), and records of storage temperature
should
be maintained. Temperatures below freezing destroy the potency of these
vaccines (24). Vaccine providers are responsible for ensuring appropriate storage of
vaccines and should be trained accordingly. Storage procedures will become more complex
if the types of vaccine offered in nontraditional settings increase.
Standard 3: Immunization History
Prevaccination screening interviews should be conducted and immunization
histories of vaccinees obtained before administering vaccines. At a minimum, the
following information should be obtained from the vaccinee: vaccines previously received,
preexisting health conditions, allergies, and adverse events that occurred after
previous vaccinations. Consulting the vaccinee's medical record is the most reliable method
of determining immunization status; however, this is not always feasible, especially
among adults receiving vaccines in nontraditional settings. In many cases, the medical
record might not be available or, if available, might not contain the most recent
information, particularly if a vaccine was not administered by the vaccinee's primary-care
provider. Although repeated pneumococcal vaccination (especially within 24 months) might
be associated with local adverse reactions more severe than those occurring after
initial vaccination (19,25), ACIP and ACP recommend that the vaccine be offered when
vaccination status cannot be determined
(19,21).
Standard 4: Contraindications
Before administering vaccine, vaccine providers must assess the presence
of contraindications. This assessment, part of the process of assessing the vaccinee's
immunization history (Standard 3), should be made during the prevaccination
screening interview. If a contraindication to immunization exists, this information should be
provided to the primary-care provider or local health department and the vaccinee.
Severe systemic hypersensitivity reactions (including anaphylaxis) to egg
protein, gelatin, neomycin, or streptomycin are contraindications for vaccines that contain
these products (e.g., influenza vaccines). Live virus vaccines are generally contraindicated
for adults who are immunocompromised and for women who are pregnant. These
important contraindications affect only a small number of adults. Adults who need
vaccine are more likely to not be offered it because of misconceptions
concerning contraindications (see Box).
Standard 5: Recordkeeping
Each time an adult receives a dose of vaccine, the following information should
be recorded: vaccinee's name, age, preexisting health conditions, type of vaccine,
dose, site and route of administration, name of the vaccine provider, date vaccine was
administered, manufacturer and lot number, and date that the next dose is due. If
possible, this information should be recorded in the vaccinee's medical file, sent to
their primary-care provider, and given to the vaccinee. Retrievable files also should be
maintained by the vaccine provider in compliance with general medical practice and
state requirements.
Many adults do not have a primary-care provider and, even if they do, vaccine
is often not administered by their primary-care provider. Geographic and
occupational
mobility, changes in sources of health care, and economic factors often cause adults
to see several health-care providers throughout their lifetime. As a result,
vaccination records are often dispersed among a number of health-care providers. When vaccine
is administered by a health-care provider other than the vaccinee's primary-care
provider (e.g., vaccine received in a nontraditional setting), a vaccine card with the
information noted in this standard should be provided to the primary-care provider or local
health department (if no such provider can be identified) and the vaccinee. When
possible, reminder notices should be sent to adults alerting them of when they are due for
another vaccination.
Standard 6: Vaccine Administration
Health-care providers who administer vaccine must have the legal authority to
do so and must be appropriately trained and licensed in all aspects of vaccine
administration, including a) proper storage and handling of vaccines, b) information to be
elicited from clients before vaccination (Standard 3), c) information to be given to clients
before vaccination (Vaccine Information Statements), d) techniques for vaccine
administration (20), and e) ability to handle adverse reactions.
Specific information regarding the recommended route of administration and
appropriate dose is included in the package insert of each vaccine. Most vaccines
are administered intramuscularly or subcutaneously. The dose indicated in the insert
should be the dose administered. Administering one half of the recommended dose to
potentially reduce the risk for adverse reaction has not been demonstrated to be an
effective method of reducing adverse reactions and could result in inadequate protection
against disease (26).
Standard 7: Adverse Events
Vaccine providers must be trained to recognize and treat adverse reactions, and
the equipment needed to do so must be available on site. Vaccines are safe and
effective; however, adverse events, ranging from minor, local reactions to severe systemic
illness, occasionally occur following vaccination. Although severe, systemic
reactions are rare, they can be life-threatening. Vaccine providers should be trained to use
medications (epinephrine, atropine, and sodium bicarbonate) and conduct procedures
necessary to maintain the airway and manage cardiovascular collapse (basic and
advanced cardiopulmonary resuscitation [CPR], operation of a defibrillator, and use of a self-
reinflating ventilating bag [Ambu bag] to provide positive pressure ventilation
during resuscitation). Vaccine providers must be in close proximity to a telephone so that
emergency medical personnel can be summoned immediately, if necessary.
Vaccinees should be monitored for adverse reactions after receiving vaccine. If
a severe adverse reaction occurs while the vaccinee is on site or any time after
receiving vaccine, the primary-care provider or local health department should be notified.
To improve knowledge about vaccines and vaccine-associated adverse
reactions, all serious adverse events should be reported to the Vaccine Adverse Event
Reporting System (VAERS) (21). VAERS reporting forms and assistance can be
obtained by telephone (1-800-822-7967) or through the CDC Internet site at
<http://www.cdc.gov/nip/vaers.htm>.
CONCLUSION
The ability of vaccines to save lives and prevent suffering extends beyond
childhood. As with childhood vaccines, adult vaccines are a cost-effective means of
preventing disease (27,28). To realize these benefits, vaccines must be made readily
available to the public. Although rates of vaccine coverage among adults are increasing,
many adults (especially among economically disadvantaged, inner city, and minority
populations) are not receiving appropriate vaccinations
(2). Enhancing educational efforts and increasing the number and types of programs (e.g., standing orders [29] and
nontraditional settings) safely administering vaccine to adults might increase the
number of adults receiving vaccines and the associated benefits.
Educating health-care providers and the public is the cornerstone of an
effective vaccination strategy. The Adult Immunization Action Plan
(1) emphasizes the need for physicians and other health-care providers to recognize both the severity of
influenza and pneumococcal disease and the safety and effectiveness of vaccines so they
consistently offer vaccines to their patients. Physicians' recommendations influence
patients' decisions to receive vaccine, regardless of the patients' initial attitude
(6). However, some adults who need vaccination receive medical care but are not offered
vaccine, whereas others might not have regular contact with traditional health-care settings.
For these reasons, increased efforts to educate the public as well as health-care
providers are needed. The 1994 NVAC report on adult immunization concluded
that "better public understanding of the seriousness of vaccine-preventable diseases
and the benefits of vaccination will be essential if there are to be improvements in adult
immunization" (30).
An essential step toward creating an effective immunization infrastructure
integrating traditional and nontraditional immunization programs is to determine the role
each type of program has in the overall immunization strategy. Data from
immunization programs in traditional and nontraditional settings are needed to assess who
receives vaccine in which settings and why they choose that setting. Data characterizing
persons who do not receive vaccine and their reasons for not getting vaccinated also
are needed. These data will facilitate the development of a comprehensive
immunization strategy to increase immunization coverage in all segments of the adult population.
Integration of nontraditional immunization programs with the existing
health-care infrastructure provides the potential to increase vaccine coverage rates and
decrease vaccine-preventable diseases among adults. To do so most effectively, the specific
contributions of immunization programs in traditional and nontraditional settings need
to be established, and the quality standards in this report need to be implemented.
The efforts that effectively lowered vaccine-preventable disease rates among children
now need to be targeted toward developing new and effective immunization programs
that will make appropriate vaccines readily accessible to adults.
References
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>65 years -- Los Angeles County, California, 1996. MMWR
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children. Am J Public Health 1991;81:1057-9.
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national certificate training program. 4th ed. Washington, DC: American Pharmaceutical
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in healthy, working adults. N Eng J Med 1995;333:889-93.
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CDC. Prevention and control of influenza: recommendations of the Advisory Committee
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* Influenza vaccine should not be routinely administered more than once during an
influenza season (18). Revaccination with pneumococcal vaccine one time, at least 5 years after
initial vaccination, is recommended for persons at highest risk for pneumococcal infection (e.g.,
persons who are immunocompromised or who are asplenic) and those most likely to have a
rapid decline in antibody concentrations. In addition, for persons vaccinated before age 65 years,
a second dose should be administered at age >65 years, provided that
>5 years have elapsed since the first dose
(19).
True Contraindications
(Do Not Administer Vaccine)
False Contraindications
(Vaccine May be Administered)
Anaphylactic reaction to a vaccine.
Mild to moderate local reaction
following a dosage of an injectable antigen.
Anaphylactic reaction to a vaccine component.
Low-grade or moderate fever following a previous vaccine dosage.
Moderate or severe illness with or
without fever.
Mild acute illness with or without fever.
Pregnancy.
Current antimicrobial therapy.
Compromised immune system.
Convalescent phase of illness.
Prematurity.
Recent exposure to an infectious
disease.
History of penicillin or other
nonspecific allergies or fact that
relatives have such allergies.
Pregnancy of mother or household
contact.
Unvaccinated household contact.
Breast-feeding.
* This table is a modified version of the National Vaccine Advisory Committee's Standards
for Pediatric Immunization Practices (CDC. Standards for pediatric immunization
practices: recommendations of the National Vaccine Advisory Committee. MMWR 1993;42[No.
RR-5]). Please consult with CDC's National Immunization Program for updates.
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