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Immunization Practices in 2018: Challenges and Opportunities

The development of vaccines has been invaluable to global welfare.1 For example, childhood immunization prevents 2 million to 3 million deaths per year, according to the World Health Organization, and the Centers for Disease Control and Prevention (CDC) has reported that 16 diseases are under control or considered eradicated by vaccination.2,3 In the United States, among children within a recent 20-year birth cohort, vaccination will prevent an estimated 21 million hospitalizations and 732,000 deaths.3 From a financial burden perspective, this results in a net savings of $295 billion in direct costs and 1.38 trillion in total societal costs, according to a 2014 CDC report.3

By improving the health of the global population and saving millions of lives in a cost-effective manner, vaccines represent an important milestone in the trajectory of medicine and healthcare more broadly.4 However, despite the unmistakably positive impact that vaccines have had on public health, several notable gaps in knowledge and barriers to access limit their potential in the healthcare spectrum. Rates of adult vaccination are far below recommended levels, while community pharmacies, despite offering convenient and potentially cost-effective means for vaccination, remain underused sources of vaccine administration. Overcoming these challenges requires health systems, payers, and regulatory groups to take significant steps to boost education and awareness efforts and increase access to vaccine coverage. This article examines current reported vaccine rates and potential population health strategies to improve overall coverage.

Vaccine Rates and Recommendations

The CDC and other institutions recommend that individuals receive vaccines throughout life to prevent the incidence, prevalence, morbidity, and mortality of vaccine-preventable diseases. Serious diseases that occur in adults that can be prevented by vaccines include varicella, diphtheria, influenza, hepatitis A, hepatitis B, HPV, measles, meningococcal disease, mumps, pneumococcal disease, rubella, shingles/zoster, tetanus, and pertussis.5

The CDC’s Advisory Committee for Immunization Practices (ACIP) publishes recommendations for childhood and adult vaccinations (Table).6 Immunization recommendations are grouped according to age for adults 18 to 65 years old and adults 65 years old and above. The current recommendation lists vaccines against influenza; tetanus-diphtheria (Td); tetanus-diphtheria-acellular pertussis (Tdap); varicella; human papillomavirus (HPV); herpes zoster; measles, mumps, and rubella (MMR); and Streptococcus pneumoniae. Depending on the individual’s specific indications, other vaccines may be advised. These include vaccines against hepatitis A and B, meningococcus, and Haemophilus influenzae type b.7

Despite recommendations that adults receive routine vaccinations throughout their lives, rates of adult vaccination in the United States are low. Every year, at least 45,000 adults in the United States die from vaccine-preventable diseases.8 Patients who go without routine or recommended vaccinations cost the United States health system approximately $10 billion per year.8 Moreover, although the majority of people who die from vaccine-preventable infections had visited their healthcare provider in the year before their death, they still were not vaccinated.9 This finding further highlights the susceptibility of American adults to deadly diseases based on the inadequacy of the current vaccination rates. 

The CDC’s Healthy People project has set targets for adult vaccination rates based on various disease states and age groups. The target goal of 90% coverage was not met for influenza vaccination (67%) and pneumococcal vaccination (60%) were not met in 2010, despite gains over the previous decade.10 The target coverage rate for 2020 is 70 percent for influenza.11

Herpes Zoster

Herpes zoster results from the reactivation of varicella zoster virus through latent infection, causing a painful vesicular rash.12 The incidence rises significantly among patients aged 50 to 60 years and continues to escalate with age. The global incidence of herpes zoster is increasing due to prolonged life expectancy and the aging population.13 In 2012, approximately 20% of adults aged 60 years or older reported receiving a herpes zoster vaccination for the prevention of shingles, up from 15.8% the previous year.14

Following the October 2017 FDA approval of a recombinant zoster vaccine (RZV) to prevent shingles in adults aged 50 years and older, the ACIP began recommending RZV in individuals with competent immune systems, given as 2 doses. For individuals aged 60 years or older, RZV or zoster vaccine live can be given.15

Findings from a recent 10-year postmarketing safety review of the zoster vaccine live virus revealed a favorable safety profile, consistent with that seen in clinical trials and postlicensure studies.16 The review concluded that the zoster live virus vaccination is effective and offers protection against postherpetic neuralgia in older individuals. Additionally, a study in the United Kingdom showed that the zoster vaccine may be more cost effective than estimated previously.17


Adolescents should routinely receive the HPV vaccine at age 11 to 12 years, as per ACIP recommendations.18 The vaccine, which is indicated in males and females aged 9 to 26 years, is administered in 2 shots, with the second 6 to 12 months after the initial shot. For children aged 14 years or older, 3 shots should be given over 6 months.19

In 2016, CDC surveillance for HPV adolescent vaccination rates revealed that coverage of at least 1 dose among teens was 60.4%, and 43.4% were up to date with the recommended series for HPV.20 CDC experts note that although vaccination coverage among teens continues to improve overall, substantial opportunities exist to further increase prevention efforts for HPV-associated cancer. The Healthy People 2020 target is 80% coverage for the HPV vaccination (Figure).11

Importantly, 2 types of HPV are responsible for 70% of cervical cancers and precancerous cervical lesions,18 both of which can be prevented by the vaccine.

Influenza and Pneumococcal Disease

The ACIP recommends a yearly seasonal influenza vaccination for all individuals aged 6 months and older who do not have contraindications.21 Early surveillance from the 2017 influenza season revealed that, despite the recommendations, only approximately 40% of children and adults in the US had received an influenza vaccination.21 Even worse, the influenza vaccination coverage for adults aged 18 to 49 years decreased by 3.7% compared with the same time the previous season.21 Although researchers continue to emphasize that the annual influenza vaccination has a significant public health benefit and durable safety, many people are still unvaccinated.21  

Pneumococcal pneumonia—the most common form of pneumococcal disease in adults—is estimated to affect about 900,000 Americans each year.22 According to the CDC, approximately 5% to 7% of individuals who need care in a hospital because of the disease, end up dying from it.22 As many as 400,000 Americans are hospitalized annually from pneumococcal pneumonia, and about 90% of invasive cases are in adults. In 2013, the CDC reported an estimated 3700 deaths from pneumococcal meningitis and bacteremia.22 

In 2016, influenza and pneumonia together were the eighth leading cause of death for Americans 65 years of age and older,23 partially due to vaccine nonadherence; 90% of total deaths were among the elderly.24

The CDC’s recommendations for all adults aged 65 years and older to receive the pneumococcal vaccines, as these individuals are at increased risk for pneumococcal disease. In addition, some adults aged 19 to 64 years with certain medical conditions should receive the vaccine, such as chronic illnesses of the heart, liver, kidney, or lung, as well as conditions that weaken the immunize system, such as HIV/AIDS or cancer.25

In 2016, vaccination coverage among this group was 66.9%.26 A meta-analysis of 22 studies in adults found that the risk of invasive pneumococcal disease (and to a lesser extent, all-cause pneumonia) is reduced by pneumococcal vaccination, and a randomized, placebo-controlled study showed a 63.8% reduction in pneumococcal pneumonia in group of institutionalized elderly patients. A reduction in the incidence of all cases of bacteremic and nonbacteremic pneumococcal pneumonia was shown in adults older than 50 years in a 3-year cohort study.27

Measles, Mumps, and Rubella

The MMR recommendations can be confusing. The ACIP recommendations state that people born before 1957 are generally considered to be immune to measles and mumps.28 Adults born in 1957 or later should have documentation of 1 or more doses of the MMR vaccine unless they have a medical contraindication or evidence of immunity. Other guidelines regarding the MMR vaccine concern the patient’s age, occupation, and what type of vaccine they may have received earlier in life. The ACIP states that people vaccinated before 1980 with either inactivated mumps vaccine or mumps vaccine of an unknown type who are at high risk for mumps infection should be considered for revaccination.28

Rubella immunity should be determined for women of child-bearing age, according to the ACIP. The recommendations state that pregnant women should have an MMR vaccine upon completion or termination of the pregnancy and before leaving the hospital.28

Tetanus-Diphtheria and Tetanus-Diphtheria-Acellular Pertussis

The ACIP recommends all adults to get the Td vaccine with boosters every 10 years.28 People 11 years of age or older who have not received the Tdap vaccine, or with an unknown status, should receive 1 dose of Tdap followed by a Td booster every 10 years, the guidelines state.

The CDC reported in the 2016 vaccine surveillance that the percentage of adults who said they received any tetanus type vaccination during the past 10 years, for adults 19 years of age and older, was 62.2%. When broken down further by age group, the number was 62.8% for adults ages 19 to 49 years, 64.2% for adults ages 50 to 64, and 58.0% for adults 65 years of age and older. Researchers also assessed Tdap vaccination and found that coverage in the past 10 years was 26.6%, 28.0%, and 20.4%, in the consecutive age groups.26


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