ACIP releases 2014 adult vaccine recommendations; study identifies barriers in immunization delivery

Special Immunization Section

Vaccination rates among adults remain suboptimal, with thousands of adult patients every year suffering illness, hospitalization, and even death from vaccine-preventable diseases. Changing that situation is the goal of the Advisory Committee on Immunization Practices (ACIP), which released its 2014 recommendations for the adult immunization schedule in the February 4 Annals of Internal Medicine. Also published in that issue is an important study that sheds light on physicians’ perspective on barriers to vaccine delivery to adult patients.

Given the number of vaccines recommended for adults and the suboptimal vaccination rates that continue to result in substantial mortality, pharmacists need to understand barriers to adult vaccine delivery and implement measures to overcome some of these challenges in the most accessible health care setting in America: the community pharmacy.

Key updates for 2014

ACIP’s recommendations include key updates to the indications for Haemophilus influenzae type b (Hib) vaccine, information about the newly licensed recombinant influenza vaccine (RIV), clarification on use of the pneumococcal conjugate vaccine (PCV13) and pneumococcal polysaccharide vaccine (PPSV23), and clarification regarding the use of meningococcal vaccines among adults. Clinicians should access the complete update at 

Hib vaccine: The recommendations were updated to reflect that Hib vaccine is indicated for previously unvaccinated adults, including those with functional or anatomic asplenia (including sickle cell) and those planning elective splenectomy (preferably at least 14 days before surgery). The vaccine is also recommended for those who received it earlier but have had a successful hematopoietic stem cell transplant (a three-dose series of the Hib vaccine is recommended 6 to 12 months after such a transplant, regardless of Hib vaccination status). The revised recommendations also note that the Hib vaccine is not recommended for adults infected with HIV who were not previously vaccinated against Hib because of low risk of infection. 

RIV: RIV and the inactivated influenza vaccine may be used in patients who have a hives-only allergy to eggs, ACIP said. New recommendations note that since RIV contains no egg protein, it can be used in patients who have an egg allergy of any severity. 

PCV13 and PPSV23: Changes in the PCV13 and PPSV23 schedules remind vaccine providers that PCV13 should be administered first to previously unvaccinated adults who need to receive both vaccines. This applies to immunocompromised adults aged 19 and older, including those with chronic renal failure, nephrotic syndrome, functional or anatomic asplenia, cerebrospinal fluid leaks, or cochlear implants. In such cases, PPSV23 should be administered at least 8 weeks after PCV13. If patients in need of both vaccines are given PPSV23 first, a minimum of 1 year should pass before PCV13 is administered. 

Meningococcal vaccine: ACIP clarified which adults need one or two meningococcal vaccine doses and which specific vaccine should be given. The recommendations note that the conjugate vaccine (MenACWY) is preferred for adults aged 55 years and younger, while the polysaccharide vaccine (MPSV4) is preferred for those aged 56 years and older, but only if they are to receive a single dose. If more than one dose is needed or anticipated, the conjugate vaccine is preferred for adults of all ages. The revised recommendations note that HIV-positive patients should not be routinely vaccinated with meningococcal vaccines. However, those who do get vaccinated should receive two doses of the conjugate vaccine.

Other updates: Changes were made to the labeling for the tetanus, diphtheria, acellular pertussis (Tdap), and tetanus–diphtheria (Td) vaccines to be consistent with the language used in the pediatric immunization schedule. Information was added about the timing between the second and third human papillomavirus (HPV) vaccines. One other update notes that while working in health care is not a specific indication for either HPV or zoster vaccines, health care workers meeting age and other criteria should receive these vaccines.

Physicians’ perspective on vaccine delivery 

In the research study published in Annals, investigators reported results of a mail survey of 443 general internists and 409 family physicians throughout the United States that explored practices for assessing vaccination status among adult patients, stocking of recommended vaccines, potential financial barriers to delivering vaccines, and practices regarding vaccination by alternative vaccinators. 

The response rate for the survey was relatively high, with 79% of general internists and 62% of family physicians responding. The majority of physicians reported that vaccination status was most commonly assessed at annual or initial visits, with only one-third reporting that vaccination status was assessed at every visit. The most common means for obtaining vaccination information include evaluation of medical records or direct questioning of the patient. Only a minority of physicians said they used immunization information systems to access vaccination information.

The most commonly reported barriers to stocking and administering adult vaccines related to financial factors. These included being involved in a private practice setting or small practice (i.e., fewer than five physicians) and having a higher proportion of patients with the Medicare Part D drug benefit. Those physicians not stocking vaccinations reported they most often refer patients to a pharmacy/retail store or public health department. They also noted that if vaccinations were administered at these alternative sites, the preferred method of sharing data is to obtain the information directly from the vaccinator. Most physicians reported they feel it is their responsibility to see that patients receive all of the recommended vaccines, even if they are administered at alternative vaccination sites. In addition, most physicians agreed that it was helpful to have pharmacists share a role in vaccinating adults. (See Figure 1 for types of vaccines pharmacists can administer, by state.) 

Figure 1. Types of vaccines pharmacists are authorized to administer, by state, January 2014.

The authors of the survey results noted that missed opportunities for adult vaccinations are common and result from a variety of factors, including failure to assess vaccination status at every visit, lack of  vaccine availability at certain physician offices, and suboptimal communication between physicians and alternative vaccinators. 

 “Communication among providers is essential to avoid under- and over-vaccination of patients,” Carolyn B. Bridges, MD, told Pharmacy Today. An Associate Director for Adult Immunizations at the CDC, and an author on both the ACIP recommendations and the study, Bridges noted that the goal of up-to-date immunization records is to ensure that patients receive the correct vaccines and the correct number of recommended doses. “Submitting data to immunization registries places vaccination information in a central location and makes this information easily accessible to other providers,” she said.

The research study concluded that improving adult vaccination delivery will require increased use of evidence-based delivery methods and concentrated efforts to resolve financial barriers. They also noted the potential benefits of removing policy-related barriers and implementing such system changes as improving communication between providers and allowing for the more widespread use of effective tools (e.g., immunization information systems and clinical decision support systems). 

Talk with patients

“Adult vaccination rates are low, unacceptably low, and there is plenty of room for multiple providers such as pharmacists, physicians, physician assistants, and nurse practitioners to all play a key role in improving adult immunization rates,” said Bridges. “Patients are open to receiving recommended vaccinations. However, their awareness and knowledge on which vaccinations are low. Patients want to hear from their provider as to which vaccinations they need.”

Health professionals are encouraged to review their patients’ vaccination status at each patient encounter and to educate patients on which vaccines should be administered. In addition, all professionals need to be up to date with the 2014 adult immunization recommendations so that patients can be properly informed. The hope is that these measures, along with improved communication between vaccination providers and resolution of financial barriers, will improve adult immunization rates going forward.

This Special Immunization Section is supported by a contract provided by the National Vaccine Program Office (NVPO). The opinions expressed in this section do not represent the viewpoints of NVPO.