Immunization is everyone's issue

Vaccination is an important part of preventive care, especially for patients with chronic diseases, yet adult immunization rates in the U.S. remain low.

In the most recent National Health Interview Survey from 2016, 43.5% of adults reported receiving a flu vaccine, with a decrease of 3.1% from 2010 among adults ages 65 years and older. Pneumococcal vaccination rates were 66.9% in those ages 65 years and older and 24% in those at high risk for infection. While rates of Tdap and zoster vaccination showed increases from 2010, they remained unimpressive: 26.6% among all adults for the former and 33.4% among those ages 60 years and older for the latter.

“These low coverage rates are disappointing, and we're failing our patients if we don't do as much as we can to get them vaccinated,” said Sandra Adamson Fryhofer, MD, MACP, an internist in Atlanta who serves as liaison to the Advisory Committee on Immunization Practices (ACIP). “But it doesn't have to be that way.”

ACP convened an Advisory Group in March to discuss barriers to adult immunization. Attendees from internal medicine, nursing, cardiology, endocrinology, pharmacology, behavioral health, and communications discussed burdens and challenges during the two-day meeting, with the goal of identifying potential ways for ACP to address them on a population health level. The Advisory Group and this article were supported by Sanofi Pasteur.

William Schaffner, MD, MACP, a professor of preventive medicine and infectious diseases at Vanderbilt University in Tennessee, who chaired the meeting, and group member Dr. Fryhofer each spoke recently to ACP Internist about the Advisory Group's findings.

Q: At the Advisory Group meeting, data were highlighted on the effectiveness of vaccination, specifically for flu, at decreasing mortality in older adults with chronic health conditions. How can awareness of this be raised?

A: Dr. Fryhofer: Information is golden, and if you don't have the information, you really don't have the tools to make the right decisions. We know that 6 in 10 U.S. adults have a chronic disease. Four in 10 U.S. adults have two or more chronic diseases. We also know that when you get infected with flu it triggers a robust inflammatory response. This can have both direct and indirect effects on people that have these chronic diseases. The greatest burden of influenza disease occurs in those 65 and older, and 90% of flu-related deaths occur in those 65 and older. This is definitely the population that we internists care for. Annual flu vaccination is integral to chronic disease medicine. It's just as important as getting your medicines refilled.

Q: Barriers identified during the meeting included clinicians' lack of engagement or recognition of their role in immunizing patients, and personal beliefs regarding the importance of vaccines. Why might some clinicians feel this way?

A: Dr. Schaffner: It may simply be that they haven't got the information about how powerful immunizations can be in protecting their patients against some of the effects or even ravages of chronic illnesses. We had cardiologists [at the Advisory Group meeting] who said giving influenza vaccine is as important or more important than prescribing statins in terms of the outcomes that you can have for your patients. That simple fact, I think, is not known. If you say that in a medical grand rounds, the internists almost literally sit up and say, “Really? Is that true? Wow!” A lot of that information is simply not out there. It hasn't sunk in.

Dr. Fryhofer: Those of us that live and breathe immunization see this data, but let's face it, there's a lot of information out there. We need to make sure our fellow internists and we as an organization, the American College of Physicians, are aware how important this is. Also, have a plan in your office, whether it be a flu vaccination prescription, having the vaccine available, having standing orders, motivating patients, motivating staff, having a designated vaccination champion, and just trying to make sure that your patients stay protected. At the Advisory Group meeting, we talked about setting up a target goal in an individual practice of at least 90%.

Q: The Advisory Group focused on subspecialists as partners in vaccination efforts. Why might subspecialists not see themselves that way? How can that be changed?

A: Dr. Schaffner: We're at the very beginning of a long journey, as I see it, in changing the culture. Trying to get a cardiologist to acknowledge that basically everyone in their practice should be vaccinated against, at the very least, influenza and pneumococcal disease is kind of a new idea. They really think of that as part of the role of the general internist, but a lot of patients have their subspecialist as virtually their main physician. At the very least, perhaps we could start to get them to say that you need to do this and go to the pharmacy and get it done and write them a little instruction, as though it were a script, and give it to them. Perhaps 10 years from now we'll actually have cardiologists ordering influenza vaccine and pneumococcal vaccine in their practices and actually giving it. But we're a long way from that.

Dr. Fryhofer: Not talking to a patient about vaccination, not immunizing, is a missed opportunity which for some of these high-risk patients with chronic disease could be like a death sentence. A nod from a specialist that this is important, that this can make a difference, that they're at risk because of their chronic disease, can be a motivating factor for patients. We know that a recommendation from a physician is the most powerful motivator for getting patients vaccinated. We want to encourage all generalists, specialists, and subspecialists to use their power to motivate patients to stay healthy in this way.

Q: The Advisory Group noted vaccine hesitancy among patients as a key barrier to improving vaccine rates. How can clinicians work to overcome this?

A: Dr. Schaffner: First of all, I think that if you ask internists whether they recommend vaccines, you know they all say, “Sure.” But if we were to go into their practice and kind of hide or have a little camera, you would see that their so-called recommendation is often a very offhanded statement, and it's not given with any force. “Uh, Tom, it's that time of the year. You ought to consider getting your flu shot.” What? That's not a recommendation. That opens the door for the patient to say no. And so I think first of all internists need to be trained on how to say, “Tom, it's that time of the year again. You'll get your flu shot—get that, your flu shot—on the way out.”

Whatever your personal style is, there are ways to enhance your own practice's immunization performance. But docs need to learn how to do that. They need to have it modeled. And they need, I think, to be shown that that casual statement that they've made … is not a recommendation. We don't make recommendations for the treatment of hypertension or diabetes that way. Why do we do that with flu vaccine?

Q: What else would you like to highlight about vaccination in particular or the Advisory Group's work as a whole?

A: Dr. Schaffner: From my point of view, we ought to be focusing on the doctor part of the equation. We ought to look to home and try to help docs both understand what the current recommendations are, why they are there, how important they are, and then help them in all the practical things, everything from ordering vaccines to stocking them, how to report if your state has an immunization registry, how to get that information into the immunization registry, and how to communicate with patients in a persuasive fashion.

Dr. Fryhofer: Adults with chronic disease are our patients. This is what internists do every day. We are the experts in chronic disease management. We need to be aware of the risks of low vaccination rates among people with these conditions. We need to make sure that subspecialists realize that they have a role. Flu season is around the corner, and October is the big month to vaccinate patients. I hope that all physicians will just put a little time into planning how they're going to handle their flu clinics, and get as many people protected as they can.