Reports
Adult Immunization in Family Practice: Optimizing Opportunity at Each Clinic Visit
This report is based on medical evidence presented at sanctioned medical congress, from peer reviewed literature or opinion provided by a qualified healthcare practitioner. The consumption of the information contained within this report is intended for qualified Canadian healthcare practitioners only.
Primary Care Today
Toronto, Ontario / May 10-12, 2007
Family physicians need to both lay claim to and recruit patient participation in adopting a more proactive role in the promotion of adult immunization in their own practice. As discussed by researchers here, the first step towards achieving this goal is to recommend age-appropriate vaccination at every opportunity regardless of the reason for the medical appointment. “If we care about immunization, patients care about it. If we bring it up, they listen and if we do not, we have missed that opportunity,” Dr. Vivien Brown, Lecturer in Family and Community Medicine, University of Toronto, Ontario, told delegates here.
The Obstacles
As she and Dr. Allison McGeer, Professor of Laboratory Medicine and Pathobiology, University of Toronto, each described, there are good reasons why adult immunization is still underutilized. Keeping abreast of adult immunization is a significant task and one that has to be attended to in addition to everything else family physicians need to take care of. As Dr. Brown observed, the US Public Task Force estimated that the average family practitioner would have to spend 7.5 hours per day on preventive medicine alone in order to follow all of the guidelines that now exist.
Patients themselves can often complicate the task by going to the emergency department or walk-in clinic, getting an injection and not remembering what it was. Physicians have a very difficult time keeping track of what adults have been treated for and what they still require. “Patients are also often afraid of immunization,” Dr. Brown added, and of course there are barriers to getting immunized because not everyone has a family physician. Those who do may have problems securing an appointment, getting to the office and paying for the vaccine itself.
Patient barriers to vaccination help explain why adult immunization rates are below optimal levels but they are not the whole story. As discussed by Dr. McGeer, by the time children get to the age of nine or 10, “they have met all the big pathogens, they have memory cells and when they meet them again, they just deal with them.” Early childhood vaccination—an undisputed success here in Canada and elsewhere—primes infants to resist the major pathogens, thereby vanquishing serious illness and death among young children as well. By the time patients reach the age of 15 to 20, however, they start to accumulate exposure to new pathogens through occupational pursuits, travel and lifestyle behaviours. Though this exposure in general does not usually prove fatal, “you may get a substantial burden of illness,” Dr. McGeer observed, a significant proportion of which may have been prevented had adolescents and young adults been vaccinated with the appropriate vaccines. Compounding this is the significant immigrant population now residing in cities like Toronto, where over 40% of residents were born outside of Canada. As Dr. McGeer noted, many immigrants come from countries with inadequate childhood vaccination programs and may require a substantial “catch-up” to achieve protection against major pathogens encountered in their new home.
The Repercussions
Even previously vaccinated adults need certain boosters—tetanus and acellular pertussis are two such examples—and those at high risk to both contract and transmit vaccine-preventable diseases because of occupation, travel or lifestyle behaviours need to protect themselves against many pathogens including hepatitis A and B, typhoid, rabies, pertussis and influenza, but frequently do not. For example, only 57% of health care workers have had the hepatitis B vaccine, according to a 2006 Canadian National Immunization Survey, while only 36% of health care workers who have not had chickenpox have been tested for immunity.
The Elderly Population
The most important group in terms of vaccine preventable-morbidity and mortality are older adults who, despite prior exposure to all major pathogens, no longer can mount a robust enough immune response to rebuff infection when they meet these pathogens again. Regarding the incidence of invasive pneumococcal disease prior to the introduction of the pneumococcal vaccine in 1995, for example, there was a “dramatic increase” in illness and death starting at about the age of 50 and rates increase exponentially with advancing age, “so the big burden of disease and death is in older people,” Dr. McGeer confirmed.
Vaccines currently recommended for older adults or for those who are chronically ill include the influenza vaccine, the pneumococcal vaccine and, in the US, the herpes zoster vaccine. In Ontario, about 70% of adults over the age of 65 are vaccinated against the flu every year, as are about 60% of health care workers, “better than almost any other country in the world,” Dr. McGeer indicated, but still “disappointing,” she felt, in that only 14 health care workers need to receive the flu shot to prevent one death in elderly patients.
Uptake rates of the pneumococcal vaccine are similarly suboptimal at fewer than 40% in the well elderly (65 years of age or older), according to a Toronto-based survey. Nevertheless, the incidence of invasive pneumococcal disease has been cut by approximately 50% in the Toronto-Peel region since the introduction of the 23-valent vaccine in 1996.
The herpes zoster vaccine reduces the incidence of zoster illness by approximately 50% over a period of five years and the incidence of post-herpetic neuralgia by 67%, according to results from the Shingles Prevention Study (Oxman et al. N Engl J Med 2005;352(22):227-84). “The hope is that this vaccine will be efficacious for a lot longer than five years,” Dr. McGeer added.
Recommend Adult Vaccination
One way for physicians to convince adult patients to embrace immunization and take advantage of vaccines that are currently paid for by governments is to simply recommend that they be vaccinated. In one survey, for example, investigators found that approximately 80% of patients visiting an office or a clinic elected to have the flu shot when their health care provider recommended it compared with only about 25% of those when it was not recommended. A similar proportion of patients visiting emergency departments also chose to have the flu shot when it was recommended compared to about 40% of those when it was not.
In another survey of patients, almost 90% agreed to have the pneumococcal vaccine when it was recommended by their provider compared with only a small proportion of patients when it was not. “I also think that when you personalize what you are recommending—‘Yes, I gave my mother the pneumococcal vaccine and I am giving my daughter the human papillomavirus vaccine and I get the flu shot as well’—makes a huge impact on patients because they have confidence that you are comfortable with what you are advising and are doing it yourself,” Dr. Brown suggested.
Getting the Word Out
She also encouraged physicians to take advantage of posters, brochures and other educational material available from the Canadian Coalition for Immunization Awareness and Promotion (CCIAP) and display them prominently in their office. “We also have to encourage patients to become involved [in keeping track of their own immunization needs], because it is too big a job for just us,” she told listeners. Physicians also need to start creating accurate, updated records so that when patients move from one community or from one physician to another, “we have a record of what they had, when they had it and what they should be getting,” Dr. Brown advised.Ultimately, though, physicians need to stop downplaying the importance of adult immunization because vaccination is not 100% effective against infection. “We treat people with diabetes and hypertension because we know there is a benefit for patients and we need to do the same thing with adult vaccination. It is not about eradication of disease, it is about making things better,” Dr. McGeer concluded.
Note: At the time of printing, the herpes zoster vaccine is not available for use in Canada.