Background: Immunization is one of the primary preventive services that influences the health and well-being of the adult. Health People 2010 includes immunization as one of the ten Leading Health Indicators for this decade. The 2010 targets are to have 90 percent of adults immunized for influenza and pneumococcal disease. In 1998 the influenza immunization level was 64 percent in adults aged 65 years and older. In 1998 only 46 percent of persons 65 years and older ever had received a pneumococcal vaccine. Despite these increases, coverage rates for certain racial and ethnic groups remain substantially below the general population (U.S. Department of Health and Human Services, 2000). Demographic realities dictate that providers be attentive to vaccine preventable disease to reduce health care costs while maintaining a desired quality of life. In addition, successful management of these diseases, should they occur, is threatened by the increasing appearance of antibiotic-resistant organisms and lack of effective therapies, thereby making vaccination even more crucial to maintaining optimal health.

Efficacy of adult vaccination is well-supported by numerous studies that suggest estimated disease incidence could be substantially reduced by vaccination. (Holt, 1992). Pneumonia and influenza deaths together constitute the sixth leading cause of death in the Us. Influenza causes an average of 110,000 hospitalizations and 20,000 deaths annually; pneumococcal disease causes 10,000 to 14,000 deaths annually (U.S. Department of Health and Human Services, 2000). More than 90% of deaths attributed to influenza and pneumonia occur in people 65 years and older. Cost-analysis studies demonstrate that pneumococcal vaccine improves the health of older persons at a reasonable cost and could be cost saving with public program administration (Riegelman, 1988). Although deaths related to tetanus and diphtheria are relatively low, an estimated 40-85% of persons over 60 years of age lack immunity and, in view of vaccine efficacy of almost 100%, should be immunized. The recent impetus for universal pediatric hepatitis B vaccine will not affect at-risk adult populations for decades. Since the majority of the estimated 300,000 annual hepatitis B infections occur among high-risk adult populations, such as heterosexuals with multiple sex partners, homosexuals, and intravenous drug users, efforts should focus on vaccinating these groups now. (Gardner & Tiru, 1996).

The Advisory Committee on Immunization Practices (ACIP) consists of 15 experts in fields associated with immunization who have been selected by the Secretary of the U.S. Department of Health and Human Services to provide advice and guidance to the Secretary, the Assistant Secretary for Health, and the Centers for Disease Control and Prevention (CDC) on the most effective means to prevent vaccine-preventable diseases. Current Advisory Committee on Immunization Practice (ACIP) adult immunization guidelines advise: 1) annual influenza vaccine and 2) pneumococcal vaccination for all adults over 65 years of age with revaccination at six years for populations at risk for pneumococcal disease, and 3) a combined tetanus-diphtheria (Td) toxoid for every 10 years after completion of a primary series. Additionally, Hepatitis B is recommended for certain high-risk populations. The ACO{ supports immunization recommendations of other professional groups such as the National Vaccine Advisory Committee, the American College of Physicians Task Force on Adult Immunization, and the Infectious Diseases Society of America. ACIP recommends linking assessment of vaccination status and administration of vaccinations at age 50 years to other established preventive measures, thus encouraging health care providers to schedule a prevention visit at this age (CDCb, July 28, 1995).

Reasons for vaccine underutilization are multiple and include:

Consumer and provider behavior attitudes. Misconceptions about vaccine safety, efficacy and inadequate knowledge of indications limit vaccine usage. Well adults often lack awareness of the need for immunization. A major factor contributing to low vaccination levels is simply that of "missed opportunities" at regularly scheduled clinic visits even when patient and provider attitudes support vaccination (Fedson, 1987)

Financial barriers. It has been suggested that simplifying the reimbursement process through Medicare could help reduce financial obstacles to vaccine delivery. (Holt, 1996). Current low mortality rates from tetanus and diphtheria infections as compared with other vaccine-preventable diseases may not appear to justify cost and practice of periodic Td vaccination. High costs of hepatitis B vaccine and the failure of most insurance companies to pay for its use makes the cost prohibitive in most settings. (Gardner & Tiru, 1996)

Access to health care. Disparities in adult vaccination levels exist among minority populations of varied socioeconomic status. Influenza and pneumococcal vaccination levels were reported higher among persons at or above poverty level and in those who had visited a physician in the previous year (influenza, 56%; pneumococcal, 30%), as compared with those who had not (influenza, 22%; pneumococcal,, 14%) (CDCa, July 14, 1995). Additionally populations at greatest risk for hepatitis B are often hard-to-reach populations who lack regular health care, such as, undocumented residents of the U.S.

Comprehensive Immunization Delivery and Role of The Registered Nurse

Nursing has taken a strong leadership role in promoting and realizing national health objectives for childhood immunization levels in the past decade. Likewise, registered nurses are in optimal positions to develop and participate in comprehensive vaccine delivery programs withing their own practices, collectively with other health care providers in the communities, and in clinical settings where they provide health care. (Holt, 1996). Some strategies for improving adult immunization levels include:

Organizational and administrative changes in clinical practice. Mailed patient reminders, provider reminders, provider performance feedback, activated sytem, medical record checklists of prevention services that include immunization, and standing order policies allowing nurses to administer vaccines have been shown in studies to boost immunization levels from 20% to 60%. Higher vaccination rates were demonstrated in those settings that combined several of the interventions. (Holt, 1992).

Educational programs targeting both providers and those at-risk. While providers and patients may be aware of the serious nature of these preventable diseases, greater emphasis must be placed on implementing prevention practices, such as immunization, in health provider education and in the routine care of adults. Collaborative program development with groups, such as the American Lung Association, the National Foundation for Infectious Disease, and the National Coalition for Adult Immunization, is indicated to improve consumer and provider awareness. Vaccine availability through ongoing efforts to improve vaccine financing and delivery is also needed.

Community-based interventions. Increasing the availability of immunizations at sites where adults congregate or reside may be helpful. Possible sites for consideration include institutional settings, such as long-term care facilities; outpatient facilities providing care to high-risk groups (e.g, hemodialysis units urgent care facilities, clinics for under-served populations, home health care agencies, retirement communities, senior centers, occupational health clinics, and fitness clubs).

Hospital-based interventions. Studies demonstrated that 50-60% of non-immunized older adults accepted pneumococcal and influenza vaccination as part of health care in the emergency department (Rodriques & Baraff, 1993). Hospitalized patients could receive needed vaccination before discharge. Approximately 20-30% of those who die of pneumococcal diseases and influenza are hospitalized within the last year of life (Fedson, 1985).

Recommendations

In view of the documented need for adult immunization and the potential for registered nurses to significantly improve the current low levels of adult immunization, the American Nurses Association supports:

1. Vaccine delivery strategies that remove barriers to access for all persons; regardless of ethnicity, socioeconomic status, immigration status or geography.
2. Public policy that removes barriers to access to immunization for all adults;
3. Research to evaluate consumer and professional attitudes and behaviors in regard to immunization delivery and to guide the design of evidence-based programs to improve vaccine acceptance and immunization levels;
4. Clinical practices linking assessment of vaccination status and administration of vaccines to other recommended preventive measures and strongly recognizing nursing's role in this process;
5. Forums for health care professionals to develop, share, disseminate and become educated about current information regarding indications, efficacy, safety, and delivery of adult immunization and consumer educational materials that reflect current research in these areas.
6. Collaborative and cooperative agreements and partnerships with private and public sector organizations to promote adult immunizations in a variety of settings and to advance ongoing vaccine research.

References

1. Centers for Disease Control (1995a). Assessing adult vaccination status at age 50 years. Morbidity and Mortality Week Report 44 (29), 561-563
2. Centers for Disease Control (1995b). Influenza and pneumococcal vaccination coverage levels among persons aged 65 years - United States, 1973-1993. Morbidity and Mortality Weekly Report 44 (27), 506-514.
3. Fedson, D.S. (1987). Influenza and pneumococcal strategies for physicians. Chest 91 (3), 436-443.
4. Fedson, D.S. (1985) Influenza and pneumococcal vaccine through a strategy of hospital-based immunization: A review of its rationale and implications. Journal of the American Geriatrics Society 33 (2), 142-149.
5. Gardner, P., & Tiru, C. (1996). Adult immunizations. Comprehensive Therapy 22(7), 440-448.
6. Holt, D. (1996). Immunizing older adults. In V.Burggraf & R.Barry(Eds.) Gerontological Nursing: current practice and research, (pp. 181-187). Thorofare, NJ:Slack
7. Holt, D. (1992) Recommendations, usage and efficacy of immunizations for the elderly. The Nurse Practitioner 17(3), 51-59
8. Rodiquez, R.M., & Baraff, L.J. (1993). Emergency department immunization of the elderly with pneumococcal and influenza vaccines. Annals of Emergency Medicine 22(11), 1729-1731.
9. Schoenbaum, S. (1987) Economic impact of influenza. American Journal of Medicine 82(6A), 26-30.
10. U.S. Department of Health and Human Services (2000) Healthy People 2010 Washington, DC: U.S. Government Printing Office.

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