Should adult tetanus immunization be given as a single vaccination at age 65? A cost-effectiveness analysis

Variation in Receipt of Cancer Screening and Immunizations by 10-year Life Expectancy among U.S. Adults aged 65 or Older in 2019

IMPORTANCE

The likelihood of benefit from a preventive intervention in an older adult depends on its time-to-benefit and the adult's life expectancy. For example, the time-to-benefit from cancer screening is >10 years, so adults with <10-year life expectancy are unlikely to benefit.

OBJECTIVE

To examine receipt of screening for breast, prostate, or colorectal cancer and receipt of immunizations by 10-year life expectancy.

DESIGN

Analysis of 2019 National Health Interview Survey.

PARTICIPANTS

8,329 non-institutionalized adults >65 years seen by a healthcare professional in the past year, representing 46.9 million US adults.

MAIN MEASURES

Proportions of breast, prostate, and colorectal cancer screenings, and immunizations, were stratified by 10-year life expectancy, estimated using a validated mortality index. We used logistic regression to examine receipt of cancer screening and immunizations by life expectancy and sociodemographic factors.

KEY RESULTS

Overall, 54.7% of participants were female, 41.4% were >75 years, and 76.4% were non-Hispanic White. Overall, 71.5% reported being current with colorectal cancer screening, including 61.4% of those with <10-year life expectancy. Among women, 67.0% reported a screening mammogram in the past 2 years, including 42.8% with <10-year life expectancy. Among men, 56.8% reported prostate specific antigen screening in the past two years, including 48.3% with <10-year life expectancy. Reported receipt of immunizations varied from 72.0% for influenza, 68.8% for pneumococcus, 57.7% for tetanus, and 42.6% for shingles vaccination. Lower life expectancy was associated with decreased likelihood of cancer screening and shingles vaccination but with increased likelihood of pneumococcal vaccination.

CONCLUSIONS

Despite the long time-to-benefit from cancer screening, in 2019 many US adults age >65 with <10-year life expectancy reported undergoing cancer screening while many did not receive immunizations with a shorter time-to-benefit. Interventions to improve individualization of preventive care based on older adults' life expectancy may improve care of older adults.

Investigation of the baseline tetanus antibody level and its persistence in a military unit

OBJECTIVES

To determine tetanus antibody levels in army recruits and evaluate the persistence of immunity following tetanus booster immunization in adults.

METHODS

A total of 680 recruits were selected for observation of their tetanus antibody levels. From 2005 to 2015, 691 peacekeepers with tetanus vaccination were included in the questionnaire-based and serological survey based on cluster stratification. The tetanus antibody-positive rate, geometric mean concentration (GMC), and their respective changes over time were analyzed in different age groups, regions, and years after tetanus booster immunization.

RESULTS

The positivity rates of tetanus antibodies in the recruits and peacekeepers were 74.85% and 99.86%, respectively (χ² = 193.00, P < 0.05) and the antibody GMCs were 0.05 and 0.70 IU/mL (t = 15.73, P < 0.05). The antibody positivity rates of recruits from 12 provinces ranged from 47.62% (Hubei) to 100% (Inner Mongolia) (χ² = 37.24, P < 0.05) and the antibody GMCs ranged from 0.02 (Hubei) to 0.09 IU/mL (Heilongjiang) (F = 5.19, P < 0.01). Among the 691 peacekeepers, no statistically significant difference in antibody positivity rate was detected between men and women. After administration of one booster dose of the tetanus vaccine, a protective antibody level was calculated to persist up to 22 years; a significant difference in antibody levels was observed within 10 years between one and two or more booster doses.

CONCLUSION

The rate at which recruits tested positive for tetanus antibodies was low. Thus, it is necessary to screen for tetanus antibodies during military recruitment and implement a precision-based booster immunization protocol for tetanus vaccine. Moreover, one dose of the tetanus vaccine booster has been calculated to maintain a protective antibody level up to 22 years, without the need for repeated reinforcements during this period.

Cost-effectiveness of adult vaccinations: A systematic review

BACKGROUND

Coverage levels for many recommended adult vaccinations are low. The cost-effectiveness research literature on adult vaccinations has not been synthesized in recent years, which may contribute to low awareness of the value of adult vaccinations and to their under-utilization. We assessed research literature since 1980 to summarize economic evidence for adult vaccinations included on the adult immunization schedule.

METHODS

We searched PubMed, EMBASE, EconLit, and Cochrane Library from 1980 to 2016 and identified economic evaluation or cost-effectiveness analysis for vaccinations targeting persons aged ≥18 years in the U.S. or Canada. After excluding records based on title and abstract reviews, the remaining publications had a full-text review from two independent reviewers, who extracted economic values that compared vaccination to "no vaccination" scenarios.

RESULTS

The systematic searches yielded 1688 publications. After removing duplicates, off-topic publications, and publications without a "no vaccination" comparison, 78 publications were included in the final analysis (influenza = 25, pneumococcal = 18, human papillomavirus = 9, herpes zoster = 7, tetanus-diphtheria-pertussis = 9, hepatitis B = 9, and multiple vaccines = 1). Among outcomes assessing age-based vaccinations, the percent indicating cost-savings was 56% for influenza, 31% for pneumococcal, and 23% for tetanus-diphtheria-pertussis vaccinations. Among age-based vaccination outcomes reporting $/QALY, the percent of outcomes indicating a cost per QALY of ≤$100,000 was 100% for influenza, 100% for pneumococcal, 69% for human papillomavirus, 71% for herpes zoster, and 50% for tetanus-diphtheria-pertussis vaccinations.

CONCLUSIONS

The majority of published studies report favorable cost-effectiveness profiles for adult vaccinations, which supports efforts to improve the implementation of adult vaccination recommendations.

Durability of Vaccine-Induced Immunity Against Tetanus and Diphtheria Toxins: A Cross-sectional Analysis

BACKGROUND

Many adult immunization schedules recommend that tetanus and diphtheria vaccination be performed every 10 years. In light of current epidemiological trends of disease incidence and rates of vaccine-associated adverse events, the 10-year revaccination schedule has come into question.

METHODS

We performed cross-sectional analysis of serum antibody titers in 546 adult subjects stratified by age or sex. All serological results were converted to international units after calibration with international serum standards.

RESULTS

Approximately 97% of the population was seropositive to tetanus and diphtheria as defined by a protective serum antibody titer of ≥0.01 IU/mL. Mean antibody titers were 3.6 and 0.35 IU/mL against tetanus and diphtheria, respectively. Antibody responses to tetanus declined with an estimated half-life of 14 years (95% confidence interval, 11-17 years), whereas antibody responses to diphtheria were more long-lived and declined with an estimated half-life of 27 years (18-51 years). Mathematical models combining antibody magnitude and duration predict that 95% of the population will remain protected against tetanus and diphtheria for ≥30 years without requiring further booster vaccination.

CONCLUSIONS

These studies demonstrate that durable levels of protective antitoxin immunity exist in the majority of vaccinated individuals. Together, this suggests that it may no longer be necessary to administer booster vaccinations every 10 years and that the current adult vaccination schedule for tetanus and diphtheria should be revisited.

Immunogenicity and safety of the new reduced-dose tetanus-diphtheria vaccine in healthy Korean adolescents: A comparative active control, double-blind, randomized, multicenter phase III study

BACKGROUND/PURPOSE

A new reduced-dose tetanus-diphtheria (Td) vaccine was developed in Korea, and phase I and II clinical trials were successfully undertaken. We conducted this double-blind, randomized, multicenter phase III clinical trial to assess the immunogenicity and safety of the new Td vaccine.

METHODS

Healthy adolescents 11-12 years of age were enrolled and randomized to receive the new Td vaccine (study group) or a commercially available Td vaccine (control group). Blood samples were collected prior to and 4 weeks after the vaccination. Between the study and control groups, seroprotection rate, booster response, and geometric mean titer of antibodies against diphtheria and tetanus toxoids were compared after the vaccination. All solicited and unsolicited adverse events and serious adverse events during the 6-week study period were monitored.

RESULTS

A total of 164 adolescents received vaccination, and 156 of them were evaluated to assess immunogenicity. The seroprotection rate and geometric mean titer for antibodies against diphtheria were significantly higher in the study group, whereas those against tetanus were significantly higher in the control group. However, all seroprotection rates against diphtheria and tetanus in the study and control groups were high: 100% against diphtheria and tetanus in the study group, and 98.7% against diphtheria and 100% against tetanus in the control group. No significant differences in the frequency of solicited and unsolicited adverse events were observed between the two vaccine groups.

CONCLUSION

The new Td vaccine is highly immunogenic and safe, and this new Td vaccine can be effectively used for preventing diphtheria and tetanus.

Tetanus in Italy 2001-2010: a continuing threat in older adults

Despite being a completely preventable disease, tetanus cases continue to occur in Italy and notification and hospitalization rates have been reported to be higher with respect to European and other industrialized countries. We examined statutory notification, hospitalization, mortality and seroprevalence data to describe tetanus epidemiology in Italy from 2001 to 2010. A total of 594 tetanus cases were notified, with an average annual incidence of 1.0/1,000,000 population. Most cases were unvaccinated or incompletely vaccinated. Eighty percent of cases occurred in subjects aged >64 years and a higher proportion of females with respect to males were reported in this age group. The annual number of hospital admissions was 1.4-1.7 times greater than the number of notifications in the same year. The mean annual number of reported deaths was 21. Seroprevalence data show progressively higher susceptibility levels with increasing age. Over 50% of persons aged 45-64 years and over two thirds of subjects ≥65 years had tetanus antibody levels <0.01 IU/ml. Results show that tetanus is a continuing problem in Italy and, as in other countries, most cases occur in older adults, especially elderly women. The observed differences in notification and hospitalization rates suggest underreporting by physicians. In recent years, Italy has accounted for most cases reported annually in the European Union (EU) but different case definitions are used. In Italy, a confirmed case is one that meets the clinical case definition while the EU case definition classifies confirmed cases as those with laboratory confirmation of disease. The incidence of clinical tetanus in Italy is ten-fold higher than in other industrialized countries, like Australia and Canada, likely due to higher susceptibility levels in Italy. In view of the low prevalence of tetanus antibodies in adults ≥45 years, strategies to improve vaccine uptake in this population group need to be implemented.

Age-related decline in immunity: implications for vaccine responsiveness

Aging is associated with declines in immune system function, or 'immunosenescence', leading to progressive deterioration in both innate and adaptive immunity. These changes contribute to the decreased response to vaccines seen in many older adults, and morbidity and mortality from infection. Infections (e.g., influenza, pneumonia and septicemia) appear among the top ten most-common causes of death in adults in the USA aged 55 years and older. As immunosenescence has gathered more attention in the scientific and healthcare communities, investigators have demonstrated more links between immunosenescent changes and morbidity and mortality related to infections and declining vaccine responses. This review summarizes the recent literature on age-dependent defects in adaptive and innate immunity, data linking these defects to poor vaccine response and morbidity and mortality, current recommendations for vaccinations and potential strategies to improve vaccine efficacy in older adults.

Evaluation for tetanus antibodies in Korean-Americans living in the New York area: a pilot study

Public health initiatives to immunize children and adults have effectively reduced the number of tetanus cases in the USA. However, in the third National Health and Nutrition Examination Survey (NHANES III), immigrants from Mexico had a 67% non-protective anti-tetanus antibody (ATA) level. Less work has been conducted among other immigrant populations to determine the extent of this observation. Objective To measure ATA levels among the Korean-American immigrant population. Methods A convenience sample of 50 Korean Americans born outside the USA was recruited to determine the levels of ATA. A non-protective level of ATA was defined as below 0.15 IU/ml. Results The mean age was 59.5 years and 82% were female. There were 43/50 (86% (95% confidence limits 76, 96)) patients with a non-protective ATA level. Those between the ages of 50-59 years (94% were seronegative) and 60 years-highest age (92% were seronegative) were among the least likely to be protected. Neither gender nor a self-reported history of past tetanus immunization or military service predicted protection to tetanus. Discussion In this pilot study we found that 86% of Korean immigrants did not have protective ATA levels, with patients in the 50-59 year age range as unlikely to be protected as the older subjects. Patient reported history was unreliable in determining whether an individual had protective levels. Conclusion The vast majority of sampled Korean American immigrants lack protective ATA levels and are in need of immunization. Additional study is needed to determine the risk of other immigrant groups to tetanus.

Levels of diphtheria and tetanus specific IgG of Portuguese adult women, before and after vaccination with adult type Td. Duration of immunity following vaccination

BACKGROUND

The need for tetanus toxoid decennial booster doses has been questioned by some experts. Several counter arguments have been presented, supporting the maintenance of decennial adult booster doses with tetanus and diphtheria toxoids (adult formulation of the vaccine: Td). This study aimed to evaluate the use of Td in Portuguese adult women under routine conditions. For that purpose we selected a group of women 30+ years of age to which vaccination was recommended. We intended to know if pre-vaccination antibody concentrations were associated with factors as age at first and last vaccination, number of doses and time since last revaccination. We also intended to assess the serological efficacy of Td booster.

METHODS

Following the Portuguese guidelines 100 women were vaccinated with Td. Antitetanus toxin IgG (ATT IgG) and antidiphtheria toxin IgG (ADT IgG) levels were measured (mIU/ml) in 100 pre-vaccination and 91 post-vaccination sera. Detailed vaccination records were available from 88 participants.

RESULTS

Twenty-two women (Group A) began vaccination with DPT/DT in their early childhood and their pre-vaccination ATT IgG levels increased with the number of doses received (p = 0.022) and decreased with time since last vaccination (p = 0.016). Among the 66 women who began vaccination in adolescence and adulthood (Group B), with monovalent TT, ATT IgG levels decreased with age at first dose (p < 0.001) and with time since last vaccination (p = 0.041). In Group A, antidiphtheria toxin IgG kinetics was very similar to that observed for ATT IgG. Among women not vaccinated with diphtheria toxoid, ADT IgG levels decreased with age. Serological response to both components of Td was good but more pronounced for ATT IgG.

CONCLUSION

Our study suggests that, to protect against tetanus, there is no need to administer decennial boosters to the Portuguese adults who have complied with the childhood/adolescent schedule (6 doses of tetanus toxoid). The adult booster intervals could be wider, probably of 20 years. This also seems to apply to protection against diphtheria, but issues on the herd immunity and on the circulation of toxigenic strains need to be better understood.

Diagnosis of tetanus immunization status: multicenter assessment of a rapid biological test

Diagnosis of tetanus immunization status by medical interview of patients with wounds is poor. Many protected patients receive unnecessary vaccine or immunoglobulin, and unprotected patients may receive nothing. The aim of this study is to evaluate the feasibility and accuracy of the Tetanos Quick Stick (TQS) rapid finger prick stick test in the emergency department for determining immunization status. We designed a prospective multicenter study for blinded comparison of TQS with an enzyme-linked immunosorbent assay (ELISA). Adults referred for open wounds in 37 French hospital emergency departments had the TQS after receiving standard care (emergency-TQS). TQS was also performed in the hospital laboratory on total blood (blood/lab-TQS) and serum (serum/lab-TQS). ELISA was performed with the same blood sample at a central laboratory. We assessed concordance between emergency-TQS and blood/lab-TQS by the kappa test and the diagnostic accuracy (likelihood ratios) of medical interview, emergency-TQS, and lab-TQS. ELISA was positive in 94.6% of the 988 patients included. Concordance between blood/emergency-TQS and blood/lab-TQS results was moderate (kappa=0.6), with a high proportion of inconclusive blood/emergency-TQS tests (9.8%). Likelihood ratios for immunization were 3.0 (95% confidence interval [CI], 1.8 to 5.1), 36.6 (95% CI, 5.3 to 255.3), 89.1 (95% CI, 5.6 to 1,405.0), and 92.7 (95% CI, 5.9 to 1,462.0) for medical interview, blood/emergency-TQS, blood/lab-TQS, and serum/lab-TQS, respectively. The sensitivity of the blood/emergency-TQS was 76.7%, and the specificity was 98% by reference to the ELISA. TQS use in the emergency room could make tetanus prevention more accurate if its technical feasibility were improved, and our assessment will be supplemented by a cost effectiveness study.

Tetanus and trauma: a review and recommendations

BACKGROUND

This review covers the pathogenesis and treatment of the disease along with the reexamination of the current recommendations for prophylaxis against tetanus in the United States. Although tetanus is still a major problem worldwide, the incidence in North America has become almost negligible because of the highly effective primary immunization program. Recently, there have been no deaths reported attributable to tetanus in the United States in trauma patients who had received the primary childhood immunization. However, tetanus immunization and prophylaxis in the acute injury setting is frequently misused and misunderstood.

METHODS

A review of the literature regarding tetanus.

RESULTS

After review, the authors recommend tetanus toxoid in adults only if it has been more than 10 years since their last immunization. There is no urgency for the administration of tetanus toxoid in the acute setting, as it provides protection against the next injury and not the current injury. Tetanus-diphtheria toxoid is not required unless there are plans for the injured patient to travel to diphtheria-prone countries in the future, as the incidence of diphtheria is negligible in the United States.

CONCLUSION

The review of reported cases of tetanus demonstrates that it is not possible to clinically determine which wounds are tetanus prone, as tetanus can occur after minor, seemingly innocuous injuries, yet is rare after severely contaminated wounds. Tetanus immunoglobulin should be reserved for patients with wounds who had never received primary immunization against tetanus.

Tetanus immunity in nursing home residents of Bolu, Turkey

BACKGROUND

Tetanus is a serious but vaccine-preventable disease and fatality rate of the disease is high in the neonates and the elderly. The aim of this study was to detect the tetanus antibody prevalence in the over sixty-year age residents of the nursing homes in Bolu.

METHODS

A voluntary-based study was done in the residents of two nursing homes in Bolu, Turkey. Blood samples were taken from 71 volunteers residing in there nursing homes. Tetanus IgG antibodies were measured by a commercial ELISA kit.

RESULTS

Among overall subjects, only 11 (15.7 %) had the protective tetanus antibody titers at the time of the study. Totally, 10 subjects were examined in emergency rooms due to trauma or accidents within the last ten years and, four (40%) of them had protective antibody levels. Of the remaining 61 subjects only 7 (11%) had protective antibody levels (p < 0.05) [Relative Risk = 3.49, 95% Confidence Interval 1.24-9.77].

CONCLUSIONS

Tetanus antibody level is below the protective level in the majority of the over-sixty-year-age subjects residing in the nursing homes. Each over sixty-year age person in our country should be vaccinated. Until this is accomplished, at least, nursing home residents should be vaccinated during registration.

Vaccines for women age 50 and older

For older populations, most of whom are women, preventing illnesses and deaths through the use of vaccines is a leading public health challenge. Our understanding about how age and sex affect the immune system is limited, and basic and translational research aimed at improving vaccines and immune responses of older persons is needed. In the meantime, fully implementing current vaccine recommendations, particularly those for influenza and pneumococcal vaccines, can save thousands of lives and prevent illnesses in persons > 50 years of age.

Tetanus immunity in long-term care facilities

OBJECTIVES

To investigate the correlates of tetanus immunity in the elderly residing in a long-term care facility in Hawaii.

DESIGN

Cross-sectional.

SETTING

A nursing home in Honolulu, Hawaii.

PARTICIPANTS

Sixty subjects aged 65 and older: 30 men and 30 women.

MEASUREMENTS

The interview included demographic information, immunization history, military service information, and other potential risk factors for tetanus. Serum tetanus antibody titers were measured.

RESULTS

The data showed that 76.7% (46/60) had adequate tetanus titers. This is in stark contrast to previous studies, which have reported immunity rates of 27% to 46% in similar populations. There were significant associations between immunity and prior history of military service. There were no significant associations between immunity and past history of immunization, education, socioeconomic status, or sex.

CONCLUSION

History of immunization from patients, families, or medical charts may be unreliable indicators of tetanus immunity. Recognizing patterns of and barriers to immunization could have important consequences for public health policy in long-term care institutions.

An audit of the tetanus immunisation status of plastic surgery trauma and burns patients

This study audits the tetanus immunisation management of plastic surgery trauma patients by their referring Accident and Emergency departments, and compares this to nationally published guidelines. We assessed 269 burns and trauma patients, referred from across South Wales, using a questionnaire together with their Accident and Emergency notes or letter. The precise question(s) that had been asked regarding the tetanus immunisation status of the patient, and the immunisation management based on the results of those questions, were recorded. The accurate tetanus immunisation status of the patient was established, the wound was assessed and further management was given as indicated. Only 16 patients had been asked whether they had received a course of tetanus, and 41 patients were not questioned about their tetanus immunisation status by the referring Accident and Emergency department. As a consequence of more accurate questioning, 73 patients (27%) required further action after their arrival in the Plastic Surgery unit. This audit has demonstrated that the management of tetanus immunoprophylaxis in plastic surgery trauma patients cannot be confidently left to the referring Accident and Emergency department but should form an integral part of the treatment at the admitting unit.

Issues related to the decennial tetanus-diphtheria toxoid booster recommendations in adults

In terms of disease prevention, reduction of adverse reactions, and cost benefit studies, a strong case can be made for a policy that focuses on assuring high levels of primary immunization with tetanus and diphtheria (Td) toxoids and abandons the decennial Td booster in favor of a single midlife booster at age 50-65 years. The addition of acellular pertussis antigens to Td for routine use in adults has potential problems in terms of schedule, cost, and possible adverse reactions. Careful risk/benefit studies are necessary to evaluate its effectiveness and priority.

Implications of the diphtheria epidemic in the Former Soviet Union for immunization programs

The massive diphtheria epidemic in the former Soviet Union provides important lessons for all diphtheria immunization programs: It is important to achieve a high level of childhood immunization, maintain immunity against diphtheria in older age groups, and use anti-epidemic measures, including immunization, to control epidemics in the early phase. The immunization coverage among children should be at least 90%. Further studies are needed to elaborate the most effective strategy to maintain immunity against diphtheria in adults (periodic booster doses, immunization of selected age groups in health care settings, use of Td [tetanus-diphtheria toxoids with reduced diphtheria toxoid content] vaccine instead of monovalent tetanus toxoid whenever tetanus toxoid is indicated [e.g., in treatment of wounds or in school-based immunization programs]). Efforts should be undertaken to monitor diphtheria immunity in different groups by conducting age-specific serologic studies.

Aging and the immune response to tetanus toxoid: diminished frequency and level of cellular immune reactivity to antigenic stimulation

The period of efficacious immune reactivity afforded by tetanus immunization and the need for continuing some forms of tetanus vaccination programs have been the subjects of recent debates. Our studies demonstrate that the level of antitetanus immunity based on immunological memory (i.e., cellular immune responsiveness) varies dramatically as a function of age, with older individuals constituting a population which is increasingly susceptible to tetanus infection.

Delivery of vaccines to adults: correlations with physician knowledge and patient variables

Our objective was to explore reasons why vaccines are not provided to adult patients receiving primary health care. The study setting was a primary health care clinic in a urban hospital staffed primarily by residents and teaching faculty. The patients were identified as all continuity care patients with a scheduled visit to the clinic during the 4-week study period in April 1995. The providers were all primary care providers for the patients during the study period. The providers were given two surveys before the study: one to assess their knowledge of published preventive health care guidelines and one to assess their perspective of the guidelines. During the study period, the charts of the patients were reviewed for the services they had received. An assessment was placed in each patient's chart for the provider's completion during the visit. The assessment enabled the provider to explain why services had not been provided. The results showed that influenza, pneumococcal, and diphtheria-tetanus vaccines were provided at varying rates. Each vaccine had a different profile as to noncompliance with guidelines. Lack of provider knowledge of the guideline was most apparent with pneumococcal vaccine. Providers' ambivalence regarding the scientific basis and/or clinical importance was most apparent with influenza vaccine. Patient refusal was a prominent cause with influenza vaccine in the elderly. Patient appointment behavior (opportunity for care and compliance) also seemed to play an important role. We conclude that explanations for nondelivery of vaccines to adults seem to be multiple. Lack of physician knowledge and physician perception of the guidelines provide some explanations. Patient-related factors including refusal, decreased opportunity for care, and noncompliance also play important roles in why vaccinations are not provided. Improvement in the rates at which immunizations to adults are provided will require interventions in multiple areas.

Preventive medicine and screening in older adults

PURPOSE

To review important current issues, studies, recommendations and controversies relating to preventive medicine and screening in older people. STUDY SELECTION/DATA ABSTRACTION: MEDLINE searches for literature on prevention and screening with regard to older adults as well as each individual condition reviewed; bibliographical reviews of textbooks, journal articles, government and advocacy organization task force reports, and recommendations. Important information synthesized and discussed qualitatively.

DATA SYNTHESIS

Data and recommendations are presented for most common preventive services, including primary prevention and screening for cardiovascular diseases and risk factors, common malignancies, endocrine and infectious diseases, osteoporosis, sensory deficits, and dementia.

CONCLUSIONS

The goal of preventive medicine in older people should be not only reduction of premature morbidity and mortality but preservation of function and quality of life. Attempts to prevent diseases of old age should start in youth; the older the patient, the less likely the possibility or value of primary and secondary prevention, and the greater the stress must be on tertiary prevention. Age 85 is proposed as a general cutoff range beyond which conventional screening tests are unlikely to be of continued benefit; however, care must always be individualized. Emphasis should be on offering the best proven and most effective interventions to the individuals at highest risk of important problems such as cardiovascular diseases, malignancies, infectious and endocrine diseases, and other important threats to function in older people. Breast cancer screening, smoking cessation, hypertension treatment, and vaccination for infectious diseases are thus far among the most firmly proven and well accepted specific preventive measures, with physical exercise also being particularly promising. Although more research is needed, a current working approach is necessary and possible. A summary table of recommendations and information tools such as reminders or flowsheets may be valuable in helping the physician carry out prevention and screening programs.

Assessment of delivery of preventive health services

Our objective was to design and evaluate an instrument to assess the performance of a clinic in the delivery of preventive health services to a general medical clinic population. The patients were identified prospectively; data were obtained retrospectively with review of the charts. The study was conducted in a primary care clinic staffed primarily by internal medicine residents in an urban academic medical center. Patients who were receiving continuity care in the clinic and who were scheduled for an appointment during the 4-week study period were eligible for inclusion. Patients were identified by the appointment schedule. Charts were reviewed for the delivery of preventive health services. Data were abstracted utilizing a standard instrument. We found that the rate at which services were provided varied considerably by service and over time. The techniques used provided some insight into methods for the evaluation of the delivery of preventive services. It should be possible to assess a clinic's performance over a range of services over its entire population over time. An understanding of this more global performance may provide a better tool for managers and researchers addressing these issues. There may be legitimate reasons for services not being provided. These issues are complex and require sensitive, detailed investigation.

Tetanus immunity in an older Australian population

OBJECTIVE

To evaluate the effectiveness in older Australians of the current tetanus vaccination program.

DESIGN

A cross-sectional survey of tetanus immunity (enzyme immunoassay of serum samples) in an older population in New South Wales. Self-reported history of tetanus vaccination was compared with serologically measured immunity.

PARTICIPANTS

430 randomly selected adults, 49 years of age and older, from the Blue Mountains Eye Study population.

RESULTS

Fifty-two per cent (95% confidence interval [CI], 47%-57%) of adults 49 years of age and older had protective levels of tetanus antitoxin ( > 0.15 IU/mL). There was a significant decline in the prevalence of immunity with increasing age (chi 2 for linear trend, P = 0.036), and women were less likely to be immune regardless of their age (Mantel-Haenszel weighted odds ratio, 0.65; CI, 0.43-0.92). Thirty-five per cent (95% CI, 31%-40%) of all participants reported that they had been vaccinated in the preceding 10 years. Although self-reported tetanus vaccination history was associated with tetanus immunity, it was neither sensitive nor specific as a test for immunity.

CONCLUSIONS

About half the adults 49 years of age and older in the Blue Mountains area of New South Wales do not have protective levels of tetanus antitoxin because of inadequate vaccination coverage in this age group. Vaccination history is not a reliable indicator of tetanus immunity and a system is needed for accurate recording of adult vaccination.

Immunizations in long-term care facilities: policies and practice

PURPOSE

The present study was conducted to assess the policies and practices of nursing homes in regard to immunizations for residents and employees.

METHODS

A 20-item, cross-sectional survey was mailed to all 445 Minnesota nursing homes from May through July 1993. Questions asked were about facility characteristics and their policies, practices, and attitudes regarding immunizations for residents and employees. Second and third mailings were sent to nonresponding institutions.

RESULTS

The median size of 399 (90%) responding institutions was 88 beds and 110 employees. The median number of residents on December 1, 1992, was 84. Although 99% of the facilities had an influenza vaccination program, only 69.3% had written policies. The mean influenza vaccination rate for residents was 84%, with higher rates in institutions having written policies, facility-wide standing orders for vaccine administration, and in institutions that did not require written consent for vaccination. One-third of the facilities had written policies for pneumococcal vaccination, and 16.3% had policies for tetanus/diphtheria. Twelve-month immunization rates for these vaccines were 11.9% and 2.9%, respectively. Most facilities had an influenza vaccination program for employees with a mean vaccination rate of 33%. These rates were higher if the facility offered vaccine onsite, free of charge, and provided special inservice education to employees. Employee 12-month vaccination rates for hepatitis B and tetanus/diphtheria were 23.2% and 1.7%, respectively. Few of the institutions included evaluation of immunization activities in their quality assurance programs.

CONCLUSION

Many long-term care facilities have inadequate policies and practices for ensuring their residents and employees immunity to important vaccine preventable diseases. These institutions, as caretakers for a vulnerable population, should develop and implement organized programs to immunize their residents and employees. By doing so, they will be able to take advantage of important opportunities to prevent illness and protect the health of their residents and employees.

Geriatric health maintenance

OBJECTIVE

To highlight articles pertaining to geriatric health maintenance and provide clinicians with current evidence supportive of or opposed to screening or treatment for various diseases and conditions.

METHOD

We conducted a computer-assisted search of the relevant medical literature and summarized the results of pertinent studies in the elderly population.

RESULTS

The geriatric population is progressively increasing in numbers. Unfortunately, no consensus exists about health maintenance in this population. To date, the United States Preventive Services Task Force has made several recommendations about preventive services; however, they did not specifically focus on the geriatric age-group. We outline their guidelines and discuss our clinical practices in a wide variety of encounters with geriatric patients.

CONCLUSION

The efficacy of many screening tests and interventions for preventing illness in elderly patients is unclear. As the general population continues to age, further research in this area will be important.

A population-based serologic survey of immunity to tetanus in the United States

BACKGROUND

Vaccination rates are frequently considered a surrogate measure of protection. To provide more accurate estimates, serum levels of antibody against tetanus were measured as part of the third National Health and Nutrition Examination Survey (NHANES III), which studied a representative sample of the civilian, noninstitutionalized population of the United States.

METHODS

We measured tetanus antitoxin using a solid-phase enzyme immunoassay in serum samples from 10,618 persons six years of age and older who were examined during phase 1 of NHANES III in 1988 to 1991.

RESULTS

Overall, 69.7 percent of Americans six years of age and older had protective levels of tetanus antibodies (> 0.15 IU per milliliter). The rate decreased from 87.7 percent among those 6 to 11 years of age to 27.8 percent among those 70 years of age or older. Among children 6 to 16 years of age, 82.2 percent had protective levels of tetanus antibodies, with little variation according to race or ethnicity. More men than women were immune (79.0 percent vs. 62.4 percent). Mexican Americans had a significantly lower rate of immunity (57.9 percent, P < 0.05) than either non-Hispanic whites (72.7 percent) or non-Hispanic blacks (68.1 percent). Those with a history of military service, higher levels of education, or incomes above the poverty level were more likely to have protective antibody levels. Although the prevalence of immunity declined rapidly starting at the age of 40 years, most of the 107 cases of tetanus (with 20 deaths) reported in 1989 and 1990 occurred in persons 60 years of age or older.

CONCLUSIONS

Despite the fact that effective vaccines against tetanus have been available since the 1940s, many Americans do not have immunity to tetanus, and the rates are lowest among the elderly. There is an excellent correlation between vaccination rates (96 percent) and immunity (96 percent) among six-year-olds. However, antibody levels decline over time, and one fifth of older children (10 to 16 years of age) do not have protective antibody levels.