Immunization is a powerful tool for preventing public health disease outbreaks. Each year, vaccine-preventable diseases cause about 45,000 deaths in the United States and cost the health care system $10 billion.1,2 Vaccinations offer the potential to reduce related morbidity, mortality, and costs.3

The US Department of Health and Human Service’s Healthy People 2020 initiative establishes specific vaccination goals.4 Federal childhood immunization programs have successfully increased rates among children, but no similar adult vaccination programs exist.1,3

The CDC Advisory Committee for Immunization Practices (ACIP) publishes vaccination recommendations that differ based on age and medical, occupational, and lifestyle risks (table 15,6).5 However, adult vaccination coverage rates in the United States remain low, below Healthy People 2020 goals.1



ADULT IMMUNIZATION BARRIERS

In a survey of 512 people, 15.2% said they believed that adults do not need to be vaccinated.1 Knowledge gaps and misperceptions contribute to low coverage rates.1,5 Many adults are unaware of vaccine indications or benefits.5 In addition, they think that vaccinations are only for children and not for healthy adults.5,7

Adequate education about the benefits of adult immunization is scarce.3 The results of an Ohio study showed that nearly half of participants with diabetes or heart disease were unaware that immunizations can reduce disease complications, and 35.4% of those with small children in the home were unaware that immunizations reduce the risk of passing disease to children.7

People receive inaccurate information from the media, friends, family, and the antivaccine movement, leading them to believe that vaccines have dangerous adverse effects and cause illness.1,7 For example, some people may not comply with vaccine recommendations for fear of developing influenza from the flu shot.8

The CDC adult immunization schedule can be confusing. It includes routine vaccinations based on age and vaccinations for high-risk populations and specific disease states,5 making it difficult for patients to determine which immunizations they need.3 It also makes it less convenient and more time-consuming for providers to screen patients appropriately for immunization gaps.3

Adult primary care wellness visits are usually infrequent or shortened by time constraints, decreasing the opportunity for physicians to educate patients appropriately, address their concerns, and recommend vaccinations.1,9 Incomplete or missing immunization records may cause physicians to overlook important indications and inappropriately screen patients for vaccination.3 Similarly, community pharmacists often have access only to patient medication records, making it difficult to recommend needed vaccinations.8

Accessibility is one of the greatest vaccination barriers.2 Referrals to receive a vaccination at another location can deter patients from following through.9 Other factors that affect accessibility include immunization and office visit cost, insurance coverage, time constraints, transportation difficulties, and language barriers.5

POOR COVERAGE HAS NEGATIVE OUTCOMES ​​​

Low vaccination rates leave adults at greater risk of common infections and complications,10 potentially increasing inappropriate use of antibiotics and contributing to antibiotic resistance.11 Vaccination is important for individual and herd immunity (rates of natural- or immunization-induced immunity exceeding 90%, resulting in decreased circulating pathogen levels),11 which helps protects susceptible individuals who are unable to be immunized. ​​​​

Immunizations have an economic impact.3,11 Treating illness that could have been prevented is expensive for the health care system and individuals in terms of lost time, lost wages, and more health care bills.3,5,11 Low vaccine demand also affects vaccine supply; companies will not proceed with research and development of new vaccines without a good return on investment.3,11

SIMPLE SOLUTIONS

Patients report that the number one influence on immunization is a doctor’s recommendation.3,7 Immunization screening and recommendation must occur during hospital admission or discharge and at ambulatory care and primary care visits.2,12 Providers must review vaccinations when diagnosing new conditions and performing medical procedures.5

Ninety-three percent of Americans live within 5 miles of a community pharmacy.2 Community pharmacists are perfectly positioned to improve accessibility for patients who live far from or do not have primary care providers.2,10 Pharmacists can review immunization history, provide education and vaccine literature, and offer to give vaccinations to patients picking up prescriptions.2,5,13

Pharmacists possess ample training to be valuable, cost-effective patient educators and immunizers.2,5 They provide extended-hour walk-in clinics at community pharmacies or off-site clinics in community settings such as churches, malls, senior centers, colleges, and workplaces.2,5,13 Pharmacist-run clinics offer large-scale, reduced-cost immunization services that improve accessibility and adult vaccination rates.2,11,12

Physicians and pharmacists often lack complete up-to-date patient immunization histories.3 Electronic health records and immunization information systems need to be improved to track vaccinations better.13 A shared patient record system documenting immunizations would improve monitoring and screening convenience for physicians and pharmacists, increasing coverage rates and patient compliance.2,3

Because vaccine schedules can be complicated and sometimes require multiple doses, reminders are helpful for both patients and providers. Pharmacies can use electronic reminders to prompt technicians or pharmacists discuss vaccinations with patients picking up prescriptions.5 Other inexpensive patient notification methods exist that can successfully increase adult vaccine compliance (table 22,5,12,14,15).5,12


CONCLUSION

Adult immunization rates are very low, and the morbidity, mortality, and societal costs of vaccine-preventable diseases are high.3 Pharmacists and physicians must work together to recognize immunization barriers and educate patients to increase adult vaccination rates and improve public health.
 
Ms. Holveck is a 2018 PharmD Candidate at the University of Connecticut.

Ms. Wick is a visiting professor at the University of Connecticut schools of pharmacy and nursing.

References

1. Ozisik L, Basaran NC, Oz SG, Guven GS, et al. Perceptions and attitudes of patients about adult vaccination and their vaccination status: still a long way to go? Med Sci Monit. 2017;23(1):3178-3184. doi: 10.12659/MSM.901856.
2. Bach AT, Goad JA. The role of community pharmacy-based vaccination in the USA: current practice and future directions. Integr Pharm Res Pract. 2015;4(1):67-75. doi: 10.2147/IPRP.S63822.
3. Tan L. Adult vaccination: now is the time to realize an unfulfilled potential. Hum Vaccin & Immunother. 2015;11(9):2158-2166. doi: 10.4161/21645515.2014.982998.
4. Healthy People 2020. Immunization and infectious diseases. Healthy People website. healthypeople.gov/2020/topics-objectives/topic/immunization-and-infectious-diseases?topicid=23. Updated July 29, 2017. Accessed July 18, 2017.
5. Ventola CL. Immunization in the United States: recommendations, barriers, and measures to improve compliance: part 2: adult vaccinations. P T. 2016;41(8):492-506.
6. CDC. Immunization Schedules. CDC website. cdc.gov/vaccines/schedules/hcp/imz/adult.html. Updated February 6, 2017. Accessed July 18, 2017.
7. Sevin AM, Romeo C, Gagne B, Rodis JL. Factors influencing adults’ immunization practices: a pilot survey study of a diverse, urban community in central Ohio. BMC Public Health. 2016;16:424. doi: 10.1186/s12889-016-3107-9. 
8. Goad JA, Durham M. The anti-vaccine movement—a pharmacist’s view. In: Chatterjee A, ed. Vaccinophobia and Vaccine Controversies of the 21st Century. New York, NY: Springer; 2013:119-128.
9. Wright WL, Morrell E, Lee J, Cuellar NG, White P. Comparison of immunization rates of adults ages 65 years and older managed within two nurse practitioner-owned clinics with national immunization rates. J Am Nurse Pract. 2017;29(7):384-391. doi: 10.1002/2327-6924.12459.
10. Woods LO, Bridges CB, Graitcer SB, Lamont B. U.S. Immunization program adult immunization activities and resources. Hum Vaccin Immunother. 2016;12(4):1045-1050. doi: 10.1080/21645515.2015.1109756.
11. Luyten J, Beutels P. The social value of vaccination programs: beyond cost-effectiveness. Health Aff. 2016;35(2):212-8. doi: 10.1377/hlthaff.2015.1088.
12. American Society of Health System Pharmacists Council on Professional Affairs. ASHP guidelines on the pharmacist’s role in immunization. Am J Health Syst Pharm. 2003;60(13):1371–1377.
13. Islam JY, Gruber JF, Lockhart A, et al. Opportunities and challenges of adolescent and adult vaccination administration within pharmacies in the United States. Biomed Inform Insights. 2017;9:1178222617692538. doi: 10.1177/1178222617692538.
14. Kelley, H. The use of magnets as patient appointment reminders and HPV vaccination rates. DNP Projects. 148. uknowledge.uky.edu/dnp_etds/148. Published May 5, 2017. Accessed July 18, 2017.
15. Vilella A, Bayas JM, Diaz MT, et al. The role of mobile phones in improving vaccination rates in travelers. Prev Med. 2004;38(4):503-9. doi: 10.1016/j.ypmed.2003.12.005.