Vaccinations in Adults: Missed Opportunities


Am Fam Physician. 1998 Sep 15;58(4):850-854.

Mortality and morbidity from vaccine-preventable diseases remain high in adults, despite the development and dissemination of vaccine recommendations for this age group. It is estimated that each year, vaccination could prevent 8,260 deaths related to influenza and 19,200 deaths related to pneumococcal infection.1 In 1995, only 58 percent and 36 percent of persons 65 years of age or older reported receiving influenza and pneumococcal vaccines, respectively,2 despite national recommendations that they and younger persons with high-risk medical conditions be vaccinated. Vaccination rates were even lower among blacks, adults younger than 65 years of age with high-risk medical conditions, and persons below the poverty level. Why, when so many deaths could be prevented by compliance with vaccination recommendations, does the rate of vaccination remain so low?

Missed opportunities to vaccinate adults seen at acute care visits, chronic care visits and hospital discharge are one reason for low immunization rates. For instance, one retrospective study3 of patients discharged with a diagnosis of pneumonia showed that 61 to 62 percent had been hospitalized within the four preceding years and that 87 percent of these patients had one or more high-risk conditions recognized during the previous admissions that indicated the need for pneumococcal vaccine. Some medical practices may not stock certain vaccines for adult immunizations, particularly the more expensive vaccines. The cumulative effect is missed opportunities with the result that many high-risk adults who access medical care are not immunized.

Many patients who are aware of the need for vaccinations are hesitant to be vaccinated because of concerns about adverse events, although, for example, most adverse events after influenza vaccination are mild, local reactions at the injection site4 and, occasionally, fever. Media attention to adverse events increases public awareness and may even further decrease receptivity to vaccination.

Reimbursement issues related to underimmunization in adults include cost and the lack of insurance coverage for adult immunizations. Medicare now covers the cost of influenza and pneumococcal vaccines, thereby reducing the financial barriers to vaccination for elderly persons. However, many younger adults do not have insurance coverage for needed vaccines, and some vaccines (e.g., hepatitis B) are expensive.

With the goal of improving adult vaccination practices in the United States, there are steps that health care professionals can take to make an impact. We recommend proactive office systems, such as patient-oriented reminder and recall systems, provider-oriented prompts and standing orders for nurses, which have been proved to increase the use of preventive services, including immunizations.5 In addition, we recommend the establishment of systems for vaccination at hospital discharge, and target-based incentive programs that have physicians set a goal for influenza vaccination rates and regularly monitor progress.6

The classic meta-analysis on immunization delivery methods was conducted by Gyorkos and colleagues.5 They found that standing orders to administer vaccine increased pooled influenza vaccination rates by 39 percent and pneumococcal rates by 45 percent. They also found that provider-oriented strategies, primarily chart reminders, increased pooled influenza vaccination rates by 18 percent and pneumococcal vaccination rates by 7.5 percent. In addition, patient-oriented strategies, such as reminder letters or telephone calls, or educational pamphlets, increased pooled influenza vaccination rates by 12 percent.

The use of multiple strategies has been found to be beneficial. The multimodal Medicare Influenza Vaccine Demonstration Project increased rates from 26 percent in 1989–90 to 48 percent in 1991–92.7 A multimodal program in a Veterans Affairs institution including standing orders, a “walk-in” influenza vaccination clinic, patient mailings and clinician reminders achieved a 78 percent vaccination rate for elderly persons.8

Clinicians who are unaware of current guidelines may obtain them through the AAFP's Web site (https://www.aafp.org/clinical/) or the Centers for Disease Control and Prevention Web site (http://www.cdc.gov/). To increase vaccination rates, guidelines must be both adopted in practice and actually followed.9

The opportunity to reduce thousands of deaths through adult vaccination makes implementation worthwhile.

Dr. Zimmerman is assistant professor in the Department of Family Medicine and Clinical Epidemiology at the University of Pittsburgh School of Medicine and is a member of the AAFP Commission on Clinical Policies and Research. He is the AAFP Liaison to the Advisory Committee on Immunization Practices. Ms. Ball is project administrator, Immunizations Research Group, Department of Family Medicine and Clinical Epidemiology, University of Pittsburgh.


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1. Adult immunization: a report by the National Vaccine Advisory Committee. Atlanta: U.S. Department of Health and Human Services, 1994....

2. Pneumococcal and influenza vaccination levels among adults aged > or = 65 years—United States, 1995 [published erratum appears in MMWR Morb Mortal Wkly Rep 1997;46:974]. MMWR Morb Mortal Wkly Rep. 1997;46:913–9.

3. Fedson DS, Harward MP, Reid RA, Kaiser DL. Hospital-based pneumococcal immunization. Epidemiologic rationale from the Shenandoah study. JAMA. 1990;264:1117–22.

4. Margolis KL, Nichol KL, Poland GA, Pluhar RE. Frequency of adverse reactions to influenza vaccine in the elderly. A randomized, placebo-controlled trial [published erratum appears in JAMA 1991; 265:2810]. JAMA. 1990;264:1139–41.

5. Gyorkos TW, Tannenbaum TN, Abrahamowicz M, Bedard L, Carsley J, Franco ED, et al. Evaluation of the effectiveness of immunization delivery methods. Can J Public Health. 1994;85(Suppl 1):S14–30.

6. Buffington J, Bell KM, LaForce FM. A target-based model for increasing influenza immunizations in private practice. Genesee Hospital Medical Staff. J Gen Intern Med. 1991;6:204–9.

7. Final report: Medicare influenza vaccine demonstration—selected states, 1988–1992. MMWR Morb Mortal Wkly Rep. 1993;42:601–4.

8. Nichol KL. Improving influenza vaccination rates for high-risk inpatients. Am J Med. 1991;91:584–8.

9. Pathman DE, Konrad TR, Freed GL, Freeman VA, Koch GG. The awareness-to-adherence model of the steps to clinical guideline compliance. Med Care. 1996;34:873–89.



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