If we look at vaccinepreventable diseases,

looking at the prevaccine

era and the year and
compare it to 1999, you
can see that virtually all of
the vaccine-preventable
diseases for which there
were current vaccines,
they have been decreased
by 99% to 100%.

Conventional wisdom is that

we should be congratulating
ourselves on a job well done.
After all, we've gone from
thousands, hundreds of
thousands in some cases, to
virtually nobody getting some
of these diseases. But for
adults I would put forward
that we have neither done it
well, nor are we done.
Conventional wisdom is an
illusion.

We all know that illusions

are simply the truths that
we live by until we know
better. And after this
program, you will know
better

The reality in the United

States is that vaccinepreventable diseases cause
untold human misery,
medical visits,
hospitalizations, and
complications. In fact, about
60,000 American adults die
each year and about 200 to
300 children. There is a 200fold greater mortality in
adults compared with
children. And I've often asked
the question: What would our
response be if 60,000 of
America's children were dying
each year of vaccinepreventable diseases?

This graphic makes the

point poignantly

If you look at 1989 to 1998,

and you look at the deaths
over that decade, you see that
we're talking about hundreds
of thousands of deaths. The
big 3 are influenza,
pneumococcal, and hepatitis,
particularly hepatitis B. And
90% of those influenza and
pneumococcal deaths are in
the elderly.

We also see and experience

considerable morbidity, not
just mortality, from vaccinepreventable diseases in the
form of excess hospitalizations,
lowered quality of life, missed
work, and the complications of
these diseases.

In fact, this might surprise you:

the number of deaths
prevented each year by
pneumococcal immunization
of adults, if we could really
accomplish that, would have
the same public health impact
as a discovery that would wipe
out all childhood leukemias,
and yet we don't equate the
two.

If you look at hepatitis

B in the age group 20
years to about 40
years, it is one of the
only age groups,
despite effective and
safe vaccines, where
the incidence of
hepatitis B continues
to rise; in fact, by 5%
in the last few years.

The main issue here is that the

Advisory Committee on
Immunization Practices (ACIP)
recommendations remain, for
adults, risk based. You basically
have to admit to bad behavior
unless you're a healthcare
worker before somebody thinks
to give you the vaccine. This
approach did not work in
children and adolescents and
was abandoned in favor of a
universal immunization
recommendation.

Why are immunization rates in

adults so low? A number of
reasons, including ignorance
and apathy regarding vaccinepreventable diseases among
clinicians. The other thing is
that compared with the
pediatric culture, adult
immunization is not a
significant part of internal
medicine culture or training.
And that's true, by the way, at
the federal level.
There are issues surrounding
reimbursement for adult
immunization, and particularly
the recent utilization of part D
has been problematic. Quality
and patient safety are not truly,
deeply ingrained yet in our
culture, or vaccines would be
one of the things that we
routinely do.

Remember, there is nothing else in

your medical practice that touches
every single patient other than
vaccines. There is nothing else in
our medical armamentarium that
we attempt to implement for
every human being.
There are also continuing
questions regarding efficacy and
safety of vaccines, and at the far
end of the spectrum, we see that
manifest as the antivaccine
movement.
But look back just a little bit in
history. A decade or so ago when
the US Government Accountability
Office (GAO) looked at this and
concluded that efforts to improve
healthcare providers' compliance
with adult immunization
guidelines were more promising
than attempts to try to influence
or increase consumers knowledge
and attitudes; it is not them, it is
us.

Let's go through a few of the

barriers that we see to adult
immunization. I've grouped 3
of them: pediatric bias and
ageism and politics

Here's the major myth you

hear, and certainly I heard as
a medical student:
"Pneumonia is the old man's
friend."

Every time I hear that, I feel ill,

particularly when you realize
what's demographically
happening, not only in this
country but all the developed
countries; a rapid rise in the
number of elderly.

We have also failed to force

change. As I've said, adult
vaccine-preventable disease
mortality is 200-fold higher in
adults than children, but the
Centers for Disease Control
and Prevention (CDC) spends
relatively little on adult
immunization activities.
Again, let's go back a little bit
in history. In 1994, the
National Immunization
Program received half a billion
dollars for immunization
programs. Less than 1% of
that went to adult programs.
So weigh this dramatic
discrepancy in morbidity and
mortality and where we put
our resources.

In 1987 to 1994, they had

278 full-time equivalent
employees; 5 of them
were devoted to adult
activities. Less than 2%
of the Section 317 funds
went to adult
immunization programs.
Over the last 7 years, the
CDC spent more than $200
million on childhood
immunization registries.
These are not bad things.
We celebrate that success,
but that was more than all
adult immunization
activities for the last
decade.
Reimbursement.

There is insufficient
Medicare reimbursement.
Most adult vaccines now
are under part D; this is a
disaster, and it is
counterproductive. There is
progress being made
though. We don't have what
the pediatricians very
successfully designed and
had, a "vaccines for
children" program. We don't
have the equivalent for
adults, particularly for
uninsured and underinsured
adults. There is a
hodgepodge of coverage by
private insurers, and we
lack public health and
legislative leadership on
something that's killing
60,000 of our citizens every
year.

There are also the issues of

the antivaccine movement,
and ignorance and fear.

When you look back in time,

all the way back to the
1700s, there has been a form
of antivaccine movement.
With smallpox, people were
afraid that if they got
immunized, a cow would
grow out of their arm or
similar such nonsense. Sir
William Osler was vilified by
his peers for supporting the
idea of typhoid immunization
during World War I. Influenza
and group B streptococcal
disease (GBS), had 1
reported association in 77.
Everybody knows about it,
yet we have spent 6 decades
trying to educate people
about the realities of the
safety and efficacy of
influenza vaccine.

Sudden infant death syndrome

(SIDS) and pertussis. There was the
concern that pertussis was
responsible for SIDS. They stopped
giving the vaccine in some
countries in Europe. Fortunately,
the epidemiologists didn't stop
their work, and what did they find?
The incidence of SIDS didn't change
at all, but the number of deaths
due to pertussis skyrocketed.
Similarly, with hepatitis B, in just
the last part of the last century,
developed European countries
banned the use of hepatitis B
vaccines in adolescent females
because we keep making the
mistake of assuming that
temporality is causality, and that is
rarely true in these sorts of
matters. Again, we found out the
hard way when the number of
demyelinating diseases didn't
change, but the number of
hepatitis B infections skyrocketed.
Similarly with Alum, one of our
only vaccines at the time in the
United States licensed as adjuvant
was being blamed for inclusion
myositis and thimerosal for a
variety of disorders.

More recently, and I'm sure

some of you have gotten
these sorts of questions
from your patients, there is
the idea that administering
multiple vaccines somehow
is responsible for a variety
of maladies: cancer,
asthma, diabetes, etc. Lyme
vaccine was actually
withdrawn from the market
because the manufacturer
couldn't withstand the class
action lawsuits despite the
lack of data suggesting that
there was any association
with autoimmune arthritis.
Measles and autism,
anthrax vaccine and Gulf
War Syndrome, and the list
goes on and on.

Finally, systems and

procedures is a real issue.

This is a summary slide from

the CDC on improving
vaccination coverage. It was
a task force on community
preventive services, and they
recommended a variety of
things. One is to increase the
demand for vaccines using
patient reminders,
multifaceted programs
including education, and
regulation. But again, I refer
you to that GAO report; the
issue is us. What the data
show, even in a patient who
comes into your office and
says, "I don't want this
vaccine", is that if you spend
the minutes required to tell
that patient why you
recommend it, why you
strongly recommend it and
what the data are, they are
highly likely to get the vaccine

Also recommended was

enhancing access by reducing
cost and walk-in clinics, and
addressing provider barriers
such as designing institutional
policies, standing orders,
standardized forms, and
efficient clinic flow. It is
frustrating if any of you have
been at institutions where you
have to make an appointment
to get influenza vaccine or
where you come in to get a
vaccine and you wait 30
minutes.

And then ongoing

measurement and
evaluation are
recommended. I've been
part of numerous surveys
where you ask physicians
through survey questions
what their level of
knowledge is about vaccines,
and they all understand it.
There is not that much
misinformation out there or
misunderstandings, but then
when you go into the clinic
and you measure their rate,
they'll tell you, "I give 90% of
my patients over the age of
65 years influenza vaccine
and pneumococcal vaccine."
But when you actually do a
chart audit, only 40% of us
are getting flu vaccine every
year.

They did some statistical

analyses on interventions
that improved vaccination
rates in adults (odds ratios
shown here). Head and
shoulders above all of
them are organizational
changes such as standing
order policies, whatever
you can do to make it
easy and efficient for the
patient to get the vaccine,
followed by provider
reminders, provider
education, and patient
education, which was way
down on the list compared
with our own education.

The major issues we face

include 60,000 deaths in
US adults each year due to
vaccine-preventable
diseases and an
inadequate federal and
public funding system for
adult vaccines. There is an
element of physician and
healthcare system
ignorance and passivity,
and I think overwhelming
demographic changes that
are going to force us to
confront this problem of
under-immunization,
particularly when we get to
diseases such as influenza
and pneumococcal disease,
if we're going to keep the
healthcare system solvent.
These are cost-saving
vaccines.

So we have significant challenges in

terms of ignorance and fear, in terms of
the anti-vaccine culture, and for
patients. We've done some work in this
area, and the only messages patients
get other than from their healthcare
providers are negative messages about
vaccines, particularly on the Internet.
Other challenges include
reimbursement issues for influenza and
occasionally for other vaccines, a fragile
vaccine supply that does make things
disruptive and difficult, and adult
immunization is not yet part of the
internal medicine or federal
government culture. It is interesting to
go on rounds with pediatricians vs going
on rounds with internal medicine
doctors. I've yet to see, in pediatrics,
where they don't ask the question: has
somebody reviewed the immunization
history? And it is usually on the inside
cover of the patient's chart. I rarely, if
ever, hear that on internal medicine
rounds. And it is somewhat of a mystery
to me. How can this be? Are we really
willing to ignore the data that 60,000
Americans are going to die next year of
diseases for which we have safe and
effective vaccines to protect them?

This is a patient safety and, in

my mind, a quality-of-care
issue and, indeed, systems are
being measured in terms of
their compliance with vaccine
recommendations, score
carded, and that information is
being put on the Web. We'll do
the right thing, but we'll end
up doing it for the wrong
reason, because we want to
look good on the score cards.
This is a chance for the health
profession to demonstrate that
we can and will do the right
thing for our patients, and that
the needs of our patients come
first.