Introduction

Every year, tens of thousands of adults die and hundreds of thousands more are hospitalized due to diseases that could have been prevented by vaccination. The cost of this health burden to society, according to the Centers for Disease Control and Prevention (CDC), is roughly $10 billion per year. This failure stands in stark contrast to the success of childhood immunization. By integrating vaccinations into regular early-childhood health care visits—and by supporting them through public programs, for those who cannot afford to pay—many vaccine-preventable diseases are now nearly nonexistent among children aged <5 years in this country. Many of the lessons learned from developing a highly effective pediatric immunization program can be applied to the problem of underimmunization in adults (see the editorial commentary by Hinman and Orenstein [1] in this issue of the journal).

The nation has before it a major opportunity to improve immunization for adults. Newly licensed adult vaccines can prevent shingles (the zoster vaccine) and cervical cancer (the human papillomavirus vaccine). Other vaccines already recommended for many adults can prevent liver cancer (the hepatitis B vaccine) and complications of infections caused by influenza virus and pneumococci. Yet our track record in assuring that adults receive the vaccines recommended for them is poor. Although >90% of young children have received the individual vaccines recommended for them, coverage for adult vaccines can range from 26% to 65%, depending on the vaccine and the target population. For example, <60% of persons aged ⩾50 years have received a dose of tetanus toxoid in the past 10 years [2], and <50% of persons aged 50–64 years at high risk of influenza receive the annual influenza vaccine [3]. Coverage rates are even lower for the pneumococcal vaccine in high-risk groups [4]. Racial and ethnic disparities compound the problem.

Strengthening adult immunization coverage will require significant improvements in the health care system's ability and willingness to provide and deliver vaccines to adults. Policymakers, the public, providers, insurers, employers, and employees need to become more aware of the value of adult immunization. Providers often lack the technical expertise and resources to acquire certain vaccines and to keep them on hand. The infrastructure to deliver vaccines to underinsured and uninsured adults must be significantly bolstered. Vaccine payment in both private and public health sectors must be sufficient to cover costs and to serve as an incentive to make adult immunization a prominent part of the practices of physicians who care for adults. Health care quality measures, surveillance, and research are additional areas that are in need of improvement.

Most vaccines in use today have been recommended for young children or adults. Recently, several new vaccines targeted for adolescents have been licensed and recommended, including vaccines against meningococcal meningitis and cervical cancer and boosters against pertussis ("whooping cough"). Delivery, payment, monitoring, and support systems to vaccinate adolescents also need to be bolstered.

The Infectious Diseases Society of America (IDSA) offers the following principles as a blueprint for action and urges all health care providers, health officials, and policymakers to participate in the solutions. These principles may be further modified as new developments emerge. Improvements in the national capacity to immunize adults and adolescents can help to prevent disease, save lives, and ensure an effective system for the delivery of vaccines now in development. Importantly, this goal should be pursued in a manner that enhances rather than compromises pediatric immunization programs.

These principles are, in part, adapted from ideas contained in several past reports on adult immunization financing and access [5,6,7,8–9].

Policy Principles

I. Increase demand for adult and adolescent immunization by improving public and provider awareness. Targets and collaborators include the public, media, Congress, the CDC, the Department of Health and Human Services (HHS), IDSA members, other primary care and subspecialty societies, and other provider groups.

Provider Awareness

A. All medical providers should be encouraged to review immunization histories and offer immunization at appropriate medical encounters. The medical encounters that are most appropriate for providing adult and adolescent immunization need to be defined. At a minimum, all providers should counsel patients to seek immunization from their primary care providers.

B. Providers should address adult immunization needs during routine preventive health care visits, including visits for cancer screening. The development of age-based visits for immunization review is encouraged and should be integrated into other preventive health care visits.

C. Increased efforts must be made to enhance provider emphasis on the 11–12-year-old well visit promoted by the American Academy of Pediatrics. Similar well visits should be instituted to include visits at 14–15 years old (high school entry) and 17–18 years old [10].

D. Professional societies representing family practice, pediatrics, adolescent medicine, obstetrics/gynecology, internal medicine, and adult subspecialities should engage in increased and ongoing education of their members about the importance of adult and adolescent immunization. Additional activities may include instituting standards, incentives, and performance benchmarks.

E. Medical and nursing schools and postgraduate educational programs should support and expand curricula on vaccine-preventable diseases in adolescents and adults.

F. All medical providers should be encouraged to use systems, including Electronic Medical Records and Immunization Information Systems (IIS) or “immunization registries,” that remind providers and patients about vaccination recommendations and requirements.

G. All health care workers should be fully immunized according to recommendations from the Advisory Committee on Immunization Practices (ACIP) to protect themselves and their patients and to set a positive example.

Public Awareness

H. Mass public health education campaigns should be launched to promote messages about the availability and the importance of adult and adolescent vaccinations.

I. It is also important to launch education campaigns that target specific vaccines and high-risk groups, racial and ethnic minority populations, and adolescents and their parents.

II. Strengthen the health care system's capacity to deliver vaccines to adults and adolescents. Targets and collaborators include Congress, HHS, the CDC, Centers for Medicare and Medicaid Services (CMS), state and local public health agencies, and the Joint Commission.

A. The CDC and HHS, with appropriate outside support, should develop and implement a plan to finance and deliver existing and new adult vaccines through the public sector by enhancing the Section 317 Program, a CDC-run program that distributes funds to immunization programs.

i. Within the Section 317 Program, develop a vigorous adult immunization program that receives annual sustainable and dependable funding to provide grants to states and localities for adult immunization infrastructure and purchase.

ii. A full-time adult immunization coordinator position should be made available for each of the 64 immunization programs.

iii. The CDC needs strengthened adolescent and adult immunization units with levels of personnel that are adequate to manage a national program, including regional public health advisors, a national education/promotion program, increased capacity to measure coverage, and dedicated funds to strengthen use of state and regional IIS.

iv. Congress should provide significantly increased annual appropriations for Section 317, to include separate annual funding for adult vaccine purchase and infrastructure. As a start toward full funding of a national adult immunization program, Congress should provide $88 million for the purchase of adult vaccines and $45 million for adult infrastructure for fiscal year 2008 [11]. Funds must represent new monies and must not be taken from existing and needed increases for childhood immunization.

v. Funds should be sufficient to cover all vaccines recommended by the ACIP and should be distributed among the states and territories to cover the majority of uninsured and underinsured adults.

vi. Congressional appropriations for Section 317 should be increased each time that the ACIP recommends a new vaccine for children, adolescents, or adults.

B. Adolescent coverage must be strengthened in several ways.

i. The Vaccines for Children program is an entitlement program through which the CDC provides government-purchased vaccine to providers serving eligible children, including Medicaid-eligible, uninsured, underinsured, and American Indian or Alaska Native children. The number of Vaccines for Children program providers who serve adolescents should be increased. Mechanisms need to be developed to finance immunization in nontraditional settings, including school-based health clinics and obstetrics and gynecology providers' offices and clinics.

ii. National and state authorities should consider broadening minor consent laws to include consent for immunizations to prevent sexually transmitted infections.

C. State and local public health agencies must strengthen financial and programmatic investments in adolescent and adult immunization coverage.

i. State budgets should provide strengthened support for adolescent and adult vaccines and immunization, including through coverage by state Medicaid programs.

ii. Patient and physician reminder systems, as a component of IIS and Electronic Medical Records, should receive state support.

iii. States should develop standing-order policies that allow nonphysicians to administer vaccines in certain circumstances, such as at schools, pharmacies, and walk-in clinics.

iv. The informal networks known as Adult Immunization Coalitions (and related public-private partnerships) should receive enhanced state support as a means for improving awareness and coverage.

D. Hospitals should increase their attention to adult and adolescent immunization with policies to offer vaccination to eligible inpatients and outpatients; this builds on existing precedent for similar mandates regarding inpatients at nursing homes and limited CMS and Joint Commission standards. There should be financial incentives (through adequate payment) for vaccine acquisition, storage, and administration.

E. Use of IIS for adult and adolescent populations must be heightened.

i. States should require and further promote the use of state-based IIS.

ii. Increased outreach to adult and adolescent providers, nursing homes, and other adult facilities regarding IIS is needed.

iii. Promotion of IIS must also reach immunization providers in nontraditional locations (retail and community settings) to increase participation in IIS; information about immunizations administered in nontraditional settings should be conveyed to patients' primary care providers.

F. The National Vaccine Injury Compensation Program, a program of the Health Resources and Services Administration (HRSA), which provides federal compensation to people who are found to be injured by certain vaccines, should cover all vaccines recommended by the ACIP for routine administration to adults.

G. Financial and administrative obstacles to providing immunization to parents who bring children to a pediatric visit need to be overcome.

H. Efforts need to be made to determine appropriate opportunities for immunization outside of the medical system.

III. Expand provision of vaccines to adults and adolescents in public and private health insurance programs. Targets and collaborators include Congress, the CMS, the HRSA, the Department of Veterans Affairs (VA), private insurance companies, managed care organizations, other third-party payers, and state governments.

A. Public and private payers should offer coverage for all adult and adolescent vaccines recommended by the ACIP. Legislation should be enacted to allow for the development of standards for the coverage of immunization benefits by all insurers, including those covered by the Employee Retirement Income Security Act of 1974.

B. Insurance coverage must be accompanied by adequate payment for provider administration services and associated carrying costs. Medicaid and private insurance policies should view Medicare payments for influenza vaccine administration under Part B as a minimal standard.

C. Congress should ensure adequate payment under Medicare for all recommended adult vaccines indicated for all eligible populations, including vaccine administration costs. To this end, Congress should provide coverage for all appropriate preventive vaccines under Medicare Part B instead of Part D, because Part B procedures are straightforward and are also consistent with the current coverage of influenza and pneumococcal vaccines.

D. The CMS should work with the provider community to review the resource-based values for existing Current Procedural Terminology codes for vaccines and vaccine administration, and they should make appropriate changes that would encourage all insurers to provide at least a minimum level of coverage.

E. Other measures to promote insurance coverage for adolescent and adult vaccines should be considered and implemented. Coverage should include both product cost and vaccine administration fees.

IV. Promote adult and adolescent immunization as an important measure of health care quality in managed care and other health care organizations. Targets and collaborators include the National Committee for Quality Assurance (NCQA), the HHS, Congress, and state governments.

A. The NCQA should revise the Health Plan Employer Data and Information Set (HEDIS) measure on Adolescent Immunization Status to include recommended use of conjugate meningococcal vaccine; tetanus, diptheria, and pertussis vaccine; and human papillomavirus vaccine. Current adolescent HEDIS measures address only measles, mumps, and rubella vaccination; hepatitis B vaccination; and varicella vaccination.

B. The National Committee for Quality Assurance should establish a new measure of pneumococcal vaccine use for older adults in commercial plans. (A similar measure already exists for Medicare.)

C. Every ACIP-recommended adult and adolescent vaccine eventually should be included within HEDIS quality measures.

D. The Joint Commission should establish criteria for assessing influenza, pertussis, and hepatitis B immunization rates in health care workers as a measure of institutional compliance and performance.

V. Monitor and improve the performance of the nation's vaccine delivery and safety monitoring systems for adults and adolescents. Targets and collaborators include Congress, the CDC, HRSA, the Agency for Healthcare Research and Quality (AHRQ), and state and local public health agencies.

A. The CDC needs to expand and improve national surveillance for vaccine-preventable diseases in adults, adolescents, and children.

B. Ongoing surveillance of immunization coverage levels and immunization practices is needed for adolescents and adults, including expansion of existing national surveys, such as the National Immunization Survey.

C. Systems should be established for assessing coverage in high-risk patients, including pregnant women and persons with renal failure, diabetes, cardiac disease, chronic lung disease, cancer, and other disorders associated with immune deficiency.

D. Continued financial support for monitoring and improving postlicensure vaccine-safety surveillance must be ensured.

E. State-based quality collaboratives should include performance measures relating to adult and adolescent immunization.

F. Congress should provide sufficient funding to support these activities.

VI. Assure adequate support for research regarding adult and adolescent vaccine-preventable diseases and vaccines. Targets and collaborators include Congress, the National Institutes of Health (NIH), the CDC, the US Food and Drug Administration (FDA), HRSA, the AHRQ, VA, and vaccine companies.

A. Research supported by the CDC, the NIH, the FDA, and other federal agencies must be adequately funded to address the effectiveness, efficacy, safety, and cost-benefit/cost-effectiveness of existing and new adult and adolescent vaccines and to pursue cost-benefit research.

B. Adequate funding must also be provided for health services research. Studies should focus on public and provider acceptance of vaccines, including evaluation of safety concerns and other underlying factors that contribute to delays in the acceptance or refusal of recommended vaccines. Studies addressing the elimination of racial and ethnic disparities, use of vaccines during pregnancy, and use in other specific populations should be encouraged. Operations research to determine optimal strategies for vaccine delivery should also be supported.

Members Of The Immunization Work Group

Members of the Immunization Work Group include Neal A. Halsey (Chair), Edward A. Belongia, Gail A. Bolan, Walter A. Orenstein, Andrew T. Pavia, William Schaffner, and Bonnie M. Word, with additional author Julie Hantman. Donna Ambrosino and Kathleen Neuzil contributed to early drafts of the document.