Burden of suffering
Vaccines are available to prevent a number of illnesses that contribute to morbidity and mortality in adults in the United States. Influenza is responsible for 20,000 to 40,000 deaths annually, and up to 50,000 deaths and an estimated 200,000 excess hospitalizations at a cost of $750 million to $1 billion during epidemic years. (1-3) Mortality from all pneumococcal disease is estimated at 40,000 deaths annually, with morbidity estimated at 500,000 cases of pneumonia, 50,000 cases of sepsis, and 3,000 cases of meningitis. (1,2) Hepatitis B infections occur in 200,000 to 300,000 people per year and result in 10,000 to 15,000 hospitalizations and 250 deaths due to fulminant hepatitis. (2-4) Approximately 1 million people are carriers of the hepatitis B virus; 25% have chronic active hepatitis, 4,000 die annually from HBV-related cirrhosis, and 800 die annually from HBV-related liver cancer. (4)
Adults older than 20 years of age represented 95% of tetanus cases and 100% of deaths due to tetanus during 1991-1994 (5) more than 60% of cases of diphtheria during 1985-89, (4) and 33% of measles cases during 1996. (6) In 1993, 20% of reported mumps cases for which age was known occurred among persons 20 years of age or older. (7) An estimated 6% to 11% of younger adults are unprotected against rubella; 85% of cases with known age in 1994-1996 were 15 years of age or older. (8) Congenital rubella syndrome is a very rare but serious event and remains a threat for the offspring of unimmunized women.
Description of Preventive Measures
Adult immunizations are administered in primary series (in previously unimmunized persons), booster doses, and periodic doses. Agents include toxoids (diphtheria and tetanus), live virus vaccines (measles, mumps, and rubella), inactivated virus vaccine (influenza), inactive viral particles (hepatitis B), and inactivated bacterial polysaccharide vaccine (pneumococcal). (4) This policy statement does not discuss either immune globulins for passive prophylaxis (against tetanus, hepatitis B, and other infectious diseases) or recommendations for adults with special risks, such as immune deficiency and other medical conditions, travel, and occupation.
Evidence of Effectiveness
Influenza Vaccine
In uncontrolled studies of influenza vaccination, the incidence of clinical illness in vaccinated persons has been 70% to 90% less than expected in healthy adults <65 years of age. (2) Among the elderly in nursing homes, vaccinated persons experienced a 30% to 40% reduction in the incidence of illness, a 50% to 60% reduction in hospitalization and pneumonia, and a 70% to 100% reduction in mortality. (2,9)
Pneumococcal Vaccine
The estimated effectiveness of the vaccine in preventing morbidity is 60% to 64% overall, but 44% to 61% in persons > 65 years of age. (4) It is not known how long vaccine-induced immunity persists.
Hepatitis B Vaccine
The overall effectiveness of the vaccine in preventing infection is 80% to 95%; it is 70% in persons 50 to 59 years of age and 50% in those > 60 years of age. (1) The duration of protection is uncertain. but is at least 7 years among healthy adults. (1,4)
Tetanus-Diphtheria Toxoid
When used properly, the vaccine is nearly 100% effective in preventing tetanus and at least 85% effective in preventing diphtheria. (4)
Measles-Mumps-Rubella Vaccine
A single dose of appropriately timed live measles vaccine will provide long-lasting immunity to measles in at least 95% of recipients. A second dose of vaccine will provide immunity in more than 90% of persons who fail to respond to the first dose and will decrease the percentage of nonimmune persons to a level too low to sustain transmission of the disease. Mumps vaccine will reduce the incidence of clinical illness by 75% to 95%. Rubella vaccine has demonstrated a similar effectiveness to that of measles in assuring immunity. (4)
Side effects to the above vaccines are generally mild, consisting of local redness and/or induration and/or tenderness at the injection site. There might also be febrile or dermatologic reactions (measles), arthralgias (rubella), parotitis and fever (mumps), malaise and myalgias (influenza), and rare allergic reactions. (4)
Public Policy Considerations
Although every visit to a health professional provides an opportunity for immunization, the proportion of the target population that is adequately vaccinated is only about one-half for influenza vaccine and one-fourth for pneumococcal vaccine. (2) Coverage for hepatitis B vaccine varies from 1% to 60% (average 10%) depending on the population. (1) Adequate antibody titers against tetanus and diphtheria are present in approximately 40% of adults.
Reasons for underutilization of vaccines in adults are outlined in the National Vaccine Advisory Committee (NVAC) report. (3) They include under appreciation of the importance of adult vaccine-preventable diseases; uncertainty or lack of knowledge about the safety and efficacy of adult vaccines; confusion related to differing vaccination schedules for various subpopulations rather than universal recommendations for all adults; few organized programs for vaccine delivery; and lack of reimbursement for the cost of adult vaccinations. Strategies to improve adult vaccination rates include improving provider and public awareness of indications for and contraindications to vaccine use; adequate vaccine delivery capacity; financial support for the provision of vaccine to adults from public and private insurers; and support for research on adult vaccine-preventable diseases and vaccines.
Based on evaluation of quality-adjusted life years gained, vaccination has been shown to be cost-effective and possibly cost-saving for influenza vaccination and highly cost-effective for pneumococcal vaccination. (10) Controversy currently exists as to whether tetanus-diphtheria should be administered at 10-year intervals throughout adulthood or if one booster dose at age 50 or 65, following a complete primary series earlier in life, would provide the same protection at a lower cost. (11)
Recommendations of Other Groups
The Advisory Committee on Immunization Practices (ACIP) recommends that adults be immunized according to the schedule in Table l. (4) Similar recommendations have been issued by the American College of Physicians (ACP), the National Vaccine Advisory Committee, the National Coalition for Adult Immunization, and the U.S. Preventive Services Task Force. (2,3,12,13) ACIP and ACP also recommend that adult vaccination status be reviewed at age 50, with Td administered at that time if needed and assessment made for the presence of any risk factors that indicate the need for pneumococcal and annual influenza vaccines. (14) Recommendations for other vaccines to be used in highrisk adults have also been issued. (15,16)
Rationale Statement
Appropriately timed adult immunizations can reduce or prevent morbidity and mortality related to influenza, pneumococcal infection, hepatitis B, diphtheria, tetanus, measles, mumps, and rubella. Influenza and pneumococcal disease, which cause considerable morbidity and mortality in the ever-increasing population over age 65, can be reduced through vaccination with little associated harm or net cost. Vaccination of adults at risk for hepatitis B infection can reduce the expenses of perinatally acquired chronic hepatitis B infection in their offspring as well as the cost of adult morbidity and mortality. (17) Diphtheria, tetanus, measles, mumps, and rubella affect small numbers of adults, but morbidity and mortality attributable to these preventable illness can be reduced substantially by selective immunization of at-risk adults.
Recommendations of the American College of Preventive Medicine
Adults aged 18 years of age and older without contraindications should receive immunizations for influenza, pneumococcal disease, hepatitis B, tetanus-diphtheria, and measles-mumps-rubella as outlined in the ACIP's Update on Adult Immunization (Table 1). (4) Priorities should include efforts to improve provider and public awareness of the safety and efficacy of adult vaccination; to avoid missed opportunities for vaccination, such as visits to health care providers for other problems, entry into school or employment situations, or travel; to use reminder systems for patients and providers; to have adequate supplies of vaccine; to improve mechanisms for financing and delivery of vaccine; and to assure support for research on better vaccines. (3) Individuals with special risk factors might require additional immunizations.
Table 1. ACIP recommendations for adult immunizations
| Age Group (years) |
Td (every 10 years) |
Measles | Mumps | Rubella | Influenza (annual) |
Pneumococcal polysaccharide |
Hepatitis B (series) |
| 18-24 | X | (1) | (2) | (3) | - | - | (4) |
| 25-64 | X | (1) | (2) | (3) | - | - | (4) |
| > 65 | - | - | - | - | (5) | (6) | (4) |
(1) Indicates for persons born after 1956 and for health care workers even if born before 1957; two doses recommended for individuals in college settings and among health care workers.
(2) Indicated for all adults believed to be susceptible.
(3) Especially indicated for nonpregnant women of child-bearing age.
(4) Indicated if not previously immunized and at increased risk of occupational, social, family, environmental, or illness-related exposure to HBV.
(5) Also indicated for younger persons at high risk of lower-respiratory-tract complications and death (i.e., chronic disorders of the cardiovascular, pulmonary, and/or renal systems; metabolic diseases; severe anemia; and/or compromised immune function); persons in nursing homes.
(6) Indicated for younger persons at high risk of pneumococcal disease (i.e, chronic disorders of the cardiovascular or pulmonary systems; metabolic diseases; alcoholism; cirrhosis; and/or compromised immune function); persons in special environments or social settings.
References
2. American College of Physicians Task Force on Adult Immunization/Infectious Diseases Society of America. Guide for adult immunization. 3rd ed. Philadelphia: American College of Physicians; 1994.
3. Fedson D. Adult immunization: summary of the National Vaccine Advisory Committee report. JAMA. 1994;272: 1133-7.
4. Centers for Disease Control. Update on adult immunization: recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR 1991;40(RR-12):1-94.
5. Centers for Disease Control and Prevention. Tetanus surveillance-United States, 1991-94. MMWR 1997;46 (SS-2):15-25.
6. Centers for Disease Control and Prevention. Measles-United States, 1996, and the interruption of indigenous transmission. MMWR 1997;46(11):242-6.
7. Centers for Disease Control and Prevention. Mumps surveillance-United States, 1988-1993. MMWR 1995; 44(SS-3):1-14.
8. Centers for Disease Control and Prevention. Rubella and congenital rubella syndrome-United States, 1994-1997. MMWR 1997;46(16):350-4.
9. Centers for Disease Control and Prevention. Prevention and control of influenza: recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR 1995;44(RR-3):1-22.
10. Fedson DS. Clinical practice and public policy for influenza and pneumococcal vaccination of the elderly. Clin Geriatr Med 1992;8:183-99.
11. Balestra D, Littenberg B. Should adult tetanus immunization be given as a single vaccination at age 65? J Gen Intern Med 1993;8:405-12.
12. National Coalition for Adult Immunization. Standards for Adult Immunization Practice. Bethesda, Maryland; 1990.
13. U.S. Preventive Services Task Force. Guide to clinical preventive services. 2nd ed. Alexandria, Virginia: International Medical Publishing; 1996.
14. Immunization Practices Advisory Committee. Assessing adult vaccination status at age 50 years. MMWR 1995;44: 561-3.
15. Centers for Disease Control and Prevention. Prevention of varicella: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1996;45(RR-11):1-36.
16. Centers for Disease Control. Recommendations of the Advisory Committee on Immunization Practices (ACIP): use of vaccines and immune globulins for persons with altered immunocompetence. MMWR 1993;42(RR-4):1-18.
17. Immunization Practices Advisory Committee. Hepatitis B Virus: a comprehensive strategy for eliminating transmission in the United States through universal childhood vaccination. MMWR 1991;40:1-25.
1. Gardner P, Schaffner W. Immunization of adults. N Engl J Med 1993;328:1252-8.
Address reprint requests to ACPM, 1660 L Street, NW, Suite 206, Washington, DC 20036
Published: American Journal of Preventive Medicine February 1998; 14(2):156-158
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