Clinicians' and Pharmacists' Reported Implementation of Vaccination Practices for Adults

Infectious Disease Updates for Primary Care

This article summarizes the situation with public health threats for primary care patients as of early 2024 and provides updates on strategies for the prevention, diagnosis, and treatment of common infections where new treatments and vaccines are available. For flu and COVID, an update on treatment is also provided-along with pearls useful for the busy primary care provider. The authors also discuss a new treatment option for drug-resistant vulvovaginal candidiasis and provide a balanced view of the increasingly popular technique of preventing bacterial sexually transmitted infections using doxycycline after condomless sex among men who have sex with men.

Knowledge, Attitudes, and Practices Regarding Herpes Zoster Vaccination Among Specialists

Recombinant zoster vaccine has been recommended by the US Advisory Committee on Immunization Practices (ACIP) for the prevention of herpes zoster (HZ) in immunocompetent adults aged at least 50 years since 2018. In January 2022, this was extended to immunodeficient/immunosuppressed adults aged at least 19 years. Key study objectives were to assess specialists' knowledge of the ACIP HZ vaccination recommendations, their attitudes toward HZ vaccination, and HZ vaccination practices/barriers. This cross-sectional, web-based survey (conducted in March 2022) included US dermatologists, gastroenterologists, infectious disease specialists, oncologists, and rheumatologists who treat patients with psoriasis, inflammatory bowel disease, human immunodeficiency syndrome, solid tumors/hematological malignancies, and rheumatoid arthritis, respectively. Although most of the 613 specialists correctly identified the ACIP HZ vaccination recommendations for adults aged at least 50 years (84%) and immunodeficient/immunosuppressed adults aged at least 19 years (67%), only 29% knew that recombinant zoster vaccine is recommended for individuals who have previously received zoster vaccine live, and only 18% knew all current ACIP recommendations. For patients with the diseases listed, 84% of specialists thought that HZ is a serious risk, 75% that HZ vaccination is extremely/very important, and 69% were extremely/very likely to recommend HZ vaccination. Only 36% administer vaccines themselves, mainly because patients receive vaccinations from others. Barriers to vaccination included more urgent/acute issues, insufficient time, and lack of patient motivation/willingness. Full knowledge of the ACIP HZ vaccination recommendations among the surveyed specialists was low. There may be a need to educate specialists to improve adherence to these recommendations. [Figure: see text].

Clinical and economic implications of increasing access to herpes zoster vaccination rate in community pharmacies

BACKGROUND

A community pharmacist plays an important role in providing vaccination to the general public in the United States. No economic models have been used to assess the impact of these services on public health and economic benefits.

OBJECTIVE

This study aimed to estimate the clinical and economic implications of community pharmacy-based herpes zoster (HZ) vaccination services with a hypothetical scenario of nonpharmacy-based vaccination in the State of Utah.

METHODS

A hybrid model of decision tree and Markov models was used to estimate lifetime cost and health outcomes. This open-cohort model was populated based on Utah population statistics and included a population of 50 years and older who were eligible for HZ vaccination between the years 2010 and 2020. Data were derived from the U.S. Bureau of Labor Statistics, the Utah Immunization Coverage Report, the Centers for Disease Control and Prevention (CDC) Behavioral Risk Factor Surveillance System, the CDC National Health Interview Survey, and existing literature. The analysis was performed from a societal perspective. A lifetime time horizon was used. The primary outcomes were the number of vaccination cases increased and the number of shingles and postherpetic neuralgia (PHN) cases averted. Total costs and quality-adjusted life-years (QALYs) were also estimated.

RESULTS

Based on a cohort of 853,550 people eligible for HZ vaccination in Utah, an additional 11,576 individuals were vaccinated in the community pharmacy-based scenario compared with the nonpharmacy-based vaccination, resulting in 706 averted cases of shingles and 143 averted cases of PHN. Community pharmacy-based HZ vaccination was less costly (-$131,894) and gained more QALYs (52.2) compared with the nonpharmacy-based vaccination. A series of sensitivity analyses showed that the findings were robust.

CONCLUSIONS

Community pharmacy-based HZ vaccination was less costly and gained more QALYs and was associated with improved other clinical outcomes in the State of Utah. This study might be used as a model for future evaluations of other community pharmacy-based vaccination programs in the United States.

Pneumococcal vaccination uptake and missed opportunities for vaccination among Canadian adults: A cross-sectional analysis of the Canadian Longitudinal Study on Aging (CLSA)

Introduction

In Canada, pneumococcal vaccination is recommended to all adults aged ≥65 and those <65 who have one or more chronic medical conditions (CMCs). Understanding vaccine uptake and its determinants among eligible groups has important implications for reducing the burden of pneumococcal disease.

Methods

Using data from a large national cohort of Canadian residents aged ≥47 years between 2015–2018, we calculated self-reported pneumococcal vaccine uptake among eligible groups, estimated associations between key factors and non-vaccination, assessed missed opportunities for vaccination (MOV) and examined risk factors for MOV. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for relevant associations were estimated through logistic regression.

Results

45.8% (95% CI: 45.2–46.5) of 22,246 participants aged ≥65 and 81.3% (95% CI: 80.5–82.0) of 10,815 individuals aged 47–64 with ≥1 CMC reported never having received a pneumococcal vaccine. Receipt of influenza vaccination in the previous year was associated with the lowest odds of pneumococcal non-vaccination (aOR = 0.14 [95% CI: 0.13–0.15] for older adults and aOR = 0.23 [95% CI: 0.20–0.26] for those aged 47–64 with ≥1 CMC). Pneumococcal vaccine uptake was also more likely in case of contact with a family doctor in the previous year (versus no contact), increased with age and varied widely across provinces. Among individuals recently vaccinated against influenza, 32.6% (95% CI: 31.9–33.4) of those aged ≥65 and 71.1% (95% CI: 69.9–72.3) of those aged 47–64 with ≥1 CMC missed an opportunity to get a pneumococcal vaccine. Among individuals who had contact with a family doctor, 44.8% (95% CI: 44.1–45.5) of those aged ≥65 and 80.4% (95% CI: 79.6–81.2) of those aged 47–64 with ≥1 CMC experienced a MOV.

Conclusions

Pneumococcal vaccine uptake remains suboptimal among at-risk Canadian adults who are eligible for vaccination. Further research is needed to clarify the reasons behind missed opportunities for vaccination and adequately address the main barriers to pneumococcal vaccination.

The Awareness and Attitude of Physicians to Older Adult Routine Vaccination Scheme

Purpose

Immunization is one of the main components of preventive medicine measures. Influenza, pneumococcal, tetanus, and shingles vaccines are recommended for older adults routinely. This study aimed to show the knowledge and attitudes of the physicians to older adults’ vaccination schemes.

Patients and Methods

An electronic self-reported questionnaire was sent to physicians between March and July 2021 in Turkey. Sociodemographic characteristics, professional experience, area of expertise, and practice setting of the participants were recorded. As multiple-choice questions; the routinely recommended vaccines, and vaccines suggested in their daily practice before and after the COVID-19 pandemic were enquired.

Results

A total of 435 participants were included in the study. 43.9% of the patients were primary family physicians, and 36.8% were internists. 63.4% of the participants had reported reviewing the National Vaccination Scheme. 94.5% of the medical doctors indicated that they had recommended any vaccination to their patients. 20.9% of the practitioners could select four or five of the routinely recommended vaccines. Reviewing the National Adult Vaccination Scheme and being an internist were positively related to predicting the recommended vaccines. The recommendation rates of influenza and pneumococcal conjugate (PCV13) were seen at 88% and 78%, respectively. Except for PCV13, recommendation rates of other routine vaccines were decreased after the pandemic.

Conclusion

Awareness of routine vaccination schedules should be improved among health-care professionals, and reminders for immunization should be provided periodically in each health-care setting.

The Interface Between U.S. Primary Care Clinics and Pharmacies for HPV Vaccination Delivery: A Scoping Literature Review

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For HPV vaccine delivery to improve, shared knowledge about and comfort with HPV vaccine administration are needed for all stakeholders (clinicians, pharmacists, parents, and patients).

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Intervention studies were small with weak study designs, many of which revealed that pharmacists were not successful in integrating services into broader primary care systems.

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Challenges include getting physicians to sign standing order protocols, service delivery being poor due to engagement barriers, and low parental demand for pharmacists to administer the vaccine.

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Larger more discerning studies are needed to fully understand the potential of primary care and pharmacy interactions for HPV vaccination.

Completion of the Human Papilloma Virus (HPV) vaccine series remains low. Partnerships between primary care (PC) clinics and local pharmacies could boost vaccination rates. We conducted a scoping literature review to address what is known and what gaps exist on the interface between U.S. primary care clinics and pharmacies for HPV vaccination. We searched Ovid MEDLINE ALL file and Cumulative Index to Allied Health Literature for articles published between 1/1/2010 and 12/31/2020. Search subjects included: 1) Pharmacy HPV Vaccination, 2) Pharmacy/PC Collaboration, and 3) Pharmacy/PC Collaboration vaccination. We developed an abstraction form to collect information on research methods, settings, strengths, weaknesses and findings. We screened 407 articles for inclusion; 17 met inclusion criteria: 13 (76.5%) reported on observational/descriptive studies; 4 articles (23.5%) reported on intervention studies, none of which were conducted in rural areas. Observational studies focused on willingness to be vaccinated for HPV and facilitators and barriers for vaccination, especially at pharmacies. Many studies concluded that knowledge about and comfort with HPV vaccine administration were needed for all vaccination stakeholders (clinicians, pharmacists, parents, and patients). Intervention studies were small with weak study designs, many of which revealed that pharmacists were not successful in integrating services into broader primary care systems. Challenges included getting physicians to sign standing order protocols, poor service delivery due to engagement barriers, and low parental demand for pharmacists to administer the vaccine. In conclusion, larger more discerning studies are needed to fully understand the potential of primary care and pharmacy interactions for HPV vaccination.

Predictors of Influenza Vaccination in Early Rheumatoid Arthritis 2017-2021: Results From the Canadian Early Arthritis Cohort

Objective

Adults with rheumatoid arthritis (RA) are at a higher risk for infections, including influenza and related complications. We identified influenza vaccination coverage in adults newly diagnosed with RA and examined sociodemographic RA characteristics and attitudes associated with vaccination.

Methods

We used data from patients enrolled in the Canadian Early Arthritis Cohort between September 2017 and February 2021. At enrollment, participants reported their vaccination status in the previous year and completed the Beliefs About Medicines Questionnaire (BMQ). Clinical data were obtained from medical records. Logistic regression was used to identify predictors of vaccination in the year after RA diagnosis.

Results

The baseline analytic sample of 431 patients were mostly White (80%) women (67%) with a mean age of 56 (SD 14) years. Prediagnosis, influenza vaccine coverage was 38%, increasing to 46% post diagnosis in the longitudinal sample (n = 229). Participants with previous influenza vaccination (odds ratio [OR] 15.33; 95% confidence interval [CI] 6.37‐36.90), on biologics or JAKs (OR 5.42; 95% CI 1.72‐17.03), and with a higher change in BMQ Necessity‐Concerns Differential scores (OR 1.08; 95% CI 1.02‐1.15) had greater odds, whereas women (OR 0.32; 95% CI 0.14‐0.71), participants with a non‐White racial background (OR 0.13; 95% CI 0.04‐0.51), and participants currently smoking (OR 0.09; 95% CI 0.02‐0.37) had lower odds of influenza vaccine coverage.

Conclusion

Influenza vaccination coverage in patients with early RA remains below national targets in adults living with a chronic condition. Discussing vaccine history and medication attitudes at initial clinic visits with new patients with RA may enhance vaccine acceptance and uptake.

Real-world evidence on adherence and completion of the two-dose recombinant zoster vaccine and associated factors in U.S. adults, 2017-2021

INTRODUCTION

Poor compliance with adult vaccination recommendations contributes to substantial disease burden. Evidence on adherence, completion, and completion timeliness for the 2-dose recombinant herpes zoster vaccine (RZV) and factors associated with these outcomes is limited and not readily generalizable for the entire U.S.

METHODS

This retrospective, observational study examined adherence, completion, and the impact of sociodemographic, clinical and geographical factors among U.S. adults ≥ 50 years receiving RZV (4/20/2017 to 3/31/2021), using a large, geographically representative administrative claims database. Continuous enrollment in a medical benefit plan for six months prior to and following the index date (first observed vaccine dose) was required. Adherence was defined as receipt of the 2nd dose within 2-6 months, per label recommendation. Completion (receipt of all doses) was assessed at 6, 12, 18, and 24 months.

RESULTS

Among 726,352 adults included, the adherence rate was 71.8%. Among 208,311 adults with 24-month follow-up, the completion rate was 72.3% after 6 months and 86.2% after 24 months. Logistic regression showed low adherence/completion was associated with younger age, Black or Hispanic race/ethnicity, lower income, lower educational attainment, and possessing commercial rather than Medicare healthcare insurance. Recipients identified using pharmacy claims had much higher adherence (74.0%) than those identified using medical claims (48.0%).

CONCLUSIONS

Adherence and completion rates for RZV are suboptimal, especially for adults aged 50-64, racial/ethnic minorities, individuals with lower socio-economic status and those without Medicare insurance. More research and public health efforts are needed to understand and address potential barriers to RZV uptake, adherence and completion.

How colleges intervene to increase student body vaccination coverage

OBJECTIVE

The interventions colleges use to help students be compliant with vaccinations is unknown. This study describes colleges' use of practices consistent with Centers for Disease Control and Prevention (CDC) recommendations to encourage student body vaccination.

PARTICIPANTS

Participants were a convenience sample of 136 student health center (SHC) administrators from colleges across the U.S.

METHODS

An online survey assessed SHCs' use of various practices, policies and services to improve student body vaccination coverage.

RESULTS

There was wide variability in use of evidence-based interventions overall and with respect to specific vaccinations. While most SHCs (92.7%) coordinated vaccination outreach events on campus, only half (50%) accessed an immunization registry to verify vaccination histories. While 88.6% requested student vaccination histories for MMR, only 39.7% requested it for human papillomavirus (HPV).

CONCLUSIONS

The discrepancies in SHC implementation of interventions to increase coverage of the recommended vaccinations for students suggest that helping colleges expand their capacity to intervene may decrease coverage rate disparities.

Influenza Vaccine Uptake and Missed Opportunities Among the Medicare-Covered Population With High-Risk Conditions During the 2018 to 2019 Influenza Season : A Retrospective Cohort Study

BACKGROUND

Seasonal influenza causes substantial morbidity and mortality among older U.S. adults and those with comorbid health conditions.

OBJECTIVE

To describe seasonal influenza vaccine uptake and identify factors associated with missed opportunities for influenza vaccination.

DESIGN

Retrospective cohort study.

SETTING

Medicare fee-for-service claims.

PARTICIPANTS

31.6 million U.S. adults continuously enrolled under Medicare Parts A and B during the 2018 to 2019 influenza season.

MEASUREMENTS

Influenza vaccine uptake and missed opportunities by patient demographic characteristics, high-risk status (that is, ≥1 condition increasing influenza complication risk), Medicare-Medicaid dual-eligibility status, and health care provider visits (that is, vaccination opportunities).

RESULTS

Overall, 50.5% of beneficiaries aged 19 years or older had Medicare claims for influenza vaccination: 31.6% among people aged 19 to 64 years and 54% among people aged 65 years or older. More White beneficiaries were vaccinated (52.9%) than Black (34.9%) or Hispanic (30.4%) beneficiaries. Uptake was higher (56.1%) for beneficiaries with high-risk conditions than for those without (27.6%). Among unvaccinated beneficiaries overall, 77.4% visited a provider during influenza season; among unvaccinated beneficiaries with and without high-risk conditions, 91% and 43%, respectively, had seen a provider at least once. The proportion of beneficiaries with missed opportunities for influenza vaccination was 44.2% and was higher for beneficiaries in the non-high-risk group (59.1%) than those in the high-risk group (42.2%). Uptake was lower and proportions of missed opportunities were higher among beneficiaries in younger age groups, of Black and Hispanic race/ethnicity, without high-risk conditions, or with Medicare-Medicaid dual eligibility.

LIMITATIONS

Influenza vaccinations without claims could not be captured. Data on reasons for nonvaccination were unavailable.

CONCLUSION

Influenza vaccination coverage for Medicare beneficiaries continues to be suboptimal, with missed opportunities despite availability of influenza vaccination with no copayment. Disparities persist in vaccination uptake by race/ethnicity.

PRIMARY FUNDING SOURCE

None.

Insurance reimbursements for recombinant zoster vaccine in the private sector

A two-dose series of the recombinant zoster vaccine (RZV, Shingrix) was licensed by the Food and Drug Administration in 2017 and recommended by the Advisory Committee on Immunization Practices in 2018 for adults in the United States age 50 years and older. Despite the health benefits of shingles vaccination, coverage has remained low, with financial barriers among healthcare providers identified as one potential factor. This study estimates the reimbursement levels for RZV among a large sample of privately insured individuals in the US from the 2018 IBM® MarketScan® Commercial Claims and Encounters database. Of 198,534 claims for an RZV dose, the mean reimbursement was $149. Most claims (83%) exceeded $140, which was the private sector vaccine price reported on the CDC vaccine price list in April 2018. These results can be useful for providers considering procuring RZV and for state immunization programs considering ways to improve vaccination coverage.

Surveillance of Vaccination Coverage Among Adult Populations -United States, 2018

PROBLEM/CONDITION

Adults are at risk for illness, hospitalization, disability and, in some cases, death from vaccine-preventable diseases, particularly influenza and pneumococcal disease. CDC recommends vaccinations for adults on the basis of age, health conditions, prior vaccinations, and other considerations. Updated vaccination recommendations from CDC are published annually in the U.S. Adult Immunization Schedule. Despite longstanding recommendations for use of many vaccines, vaccination coverage among U.S. adults remains low.

REPORTING PERIOD

August 2017-June 2018 (for influenza vaccination) and January-December 2018 (for pneumococcal, herpes zoster, tetanus and diphtheria [Td]/tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis [Tdap], hepatitis A, hepatitis B, and human papillomavirus [HPV] vaccination).

DESCRIPTION OF SYSTEM

The National Health Interview Survey (NHIS) is a continuous, cross-sectional national household survey of the noninstitutionalized U.S. civilian population. In-person interviews are conducted throughout the year in a probability sample of households, and NHIS data are compiled and released annually. NHIS's objective is to monitor the health of the U.S. population and provide estimates of health indicators, health care use and access, and health-related behaviors. Adult receipt of influenza, pneumococcal, herpes zoster, Td/Tdap, hepatitis A, hepatitis B, and at least 1 dose of HPV vaccines was assessed. Estimates were derived for a new composite adult vaccination quality measure and by selected demographic and access-to-care characteristics (e.g., age, race/ethnicity, indication for vaccination, travel history [travel to countries where hepatitis infections are endemic], health insurance status, contacts with physicians, nativity, and citizenship). Trends in adult vaccination were assessed during 2010-2018.

RESULTS

Coverage for the adult age-appropriate composite measure was low in all age groups. Racial and ethnic differences in coverage persisted for all vaccinations, with lower coverage for most vaccinations among non-White compared with non-Hispanic White adults. Linear trend tests indicated coverage increased from 2010 to 2018 for most vaccines in this report. Few adults aged ≥19 years had received all age-appropriate vaccines, including influenza vaccination, regardless of whether inclusion of Tdap (13.5%) or inclusion of any tetanus toxoid-containing vaccine (20.2%) receipt was measured. Coverage among adults for influenza vaccination during the 2017-18 season (46.1%) was similar to the estimate for the 2016-17 season (45.4%), and coverage for pneumococcal (adults aged ≥65 years [69.0%]), herpes zoster (adults aged ≥50 years and aged ≥60 years [24.1% and 34.5%, respectively]), tetanus (adults aged ≥19 years [62.9%]), Tdap (adults aged ≥19 years [31.2%]), hepatitis A (adults aged ≥19 years [11.9%]), and HPV (females aged 19-26 years [52.8%]) vaccination in 2018 were similar to the estimates for 2017. Hepatitis B vaccination coverage among adults aged ≥19 years and health care personnel (HCP) aged ≥19 years increased 4.2 and 6.7 percentage points to 30.0% and 67.2%, respectively, from 2017. HPV vaccination coverage among males aged 19-26 years increased 5.2 percentage points to 26.3% from the 2017 estimate. Overall, HPV vaccination coverage among females aged 19-26 years did not increase, but coverage among Hispanic females aged 19-26 years increased 10.8 percentage points to 49.6% from the 2017 estimate. Coverage for the following vaccines was lower among adults without health insurance compared with those with health insurance: influenza vaccine (among adults aged ≥19 years, 19-49 years, and 50-64 years), pneumococcal vaccine (among adults aged 19-64 years at increased risk), Td vaccine (among all age groups), Tdap vaccine (among adults aged ≥19 years and 19-64 years), hepatitis A vaccine (among adults aged ≥19 years overall and among travelers aged ≥19 years), hepatitis B vaccine (among adults aged ≥19 years and 19-49 years and among travelers aged ≥19 years), herpes zoster vaccine (among adults aged ≥60 years), and HPV vaccine (among males and females aged 19-26 years). Adults who reported having a usual place for health care generally reported receipt of recommended vaccinations more often than those who did not have such a place, regardless of whether they had health insurance. Vaccination coverage was higher among adults reporting ≥1 physician contact during the preceding year compared with those who had not visited a physician during the preceding year, regardless of whether they had health insurance. Even among adults who had health insurance and ≥10 physician contacts during the preceding year, depending on the vaccine, 20.1%-87.5% reported not having received vaccinations that were recommended either for all persons or for those with specific indications. Overall, vaccination coverage among U.S.-born adults was significantly higher than that of foreign-born adults, including influenza vaccination (aged ≥19 years), pneumococcal vaccination (all ages), tetanus vaccination (all ages), Tdap vaccination (all ages), hepatitis B vaccination (aged ≥19 years and 19-49 years and travelers aged ≥19 years), herpes zoster vaccination (all ages), and HPV vaccination among females aged 19-26 years. Vaccination coverage also varied by citizenship status and years living in the United States.

INTERPRETATION

NHIS data indicate that many adults remain unprotected against vaccine-preventable diseases. Coverage for the adult age-appropriate composite measures was low in all age groups. Individual adult vaccination coverage remained low as well, but modest gains occurred in vaccination coverage for hepatitis B (among adults aged ≥19 years and HCP aged ≥19 years), and HPV (among males aged 19-26 years and Hispanic females aged 19-26 years). Coverage for other vaccines and groups with Advisory Committee on Immunization Practices vaccination indications did not improve from 2017. Although HPV vaccination coverage among males aged 19-26 years and Hispanic females aged 19-26 years increased, approximately 50% of females aged 19-26 years and 70% of males aged 19-26 years remained unvaccinated. Racial/ethnic vaccination differences persisted for routinely recommended adult vaccines. Having health insurance coverage, having a usual place for health care, and having ≥1 physician contacts during the preceding 12 months were associated with higher vaccination coverage; however, these factors alone were not associated with optimal adult vaccination coverage, and findings indicate missed opportunities to vaccinate remained.

PUBLIC HEALTH ACTIONS

Substantial improvement in adult vaccination uptake is needed to reduce the burden of vaccine-preventable diseases. Following the Standards for Adult Immunization Practice (https://www.cdc.gov/vaccines/hcp/adults/for-practice/standards/index.html), all providers should routinely assess adults' vaccination status at every clinical encounter, strongly recommend appropriate vaccines, either offer needed vaccines or refer their patients to another provider who can administer the needed vaccines, and document vaccinations received by their patients in an immunization information system.

Community chain pharmacists' perceptions of increased technicians' involvement in the immunization process

BACKGROUND

Over the past 2 decades, pharmacists have positioned immunization services as an important aspect of their expanding role in patient care.

OBJECTIVES

To examine how community chain pharmacists view time spent on immunization, available in-store resources and barriers, and pharmacy technician involvement in the context of their views about the achievement of key National Vaccine Advisory Committee (NVAC) Standards of Adult Immunization Practice in their workplace.

METHODS

A representative, nationwide survey was administered electronically to chain community pharmacists over a 4-week period. Community pharmacists offering year-round immunization in retail chain, supermarket, and mass-merchant settings, randomly sampled from a database maintained by the American Pharmacists Association. We examined several sets of interrelated relationships regarding pharmacists' perceived achievement of 3 key NVAC standards (assessment, recommendation and administration), time spent on the overall immunization process, the effectiveness of available in-store resources, immunization impediments, and the endorsement of increased technician involvement in community pharmacy-based immunization service (PBIS) delivery.

RESULTS

A sample of 590 survey responses was obtained from 9717 e-mails delivered, with 489 deemed eligible (5% response rate). Sizeable numbers of pharmacists acknowledged that several activities integral to achieving optimal immunization levels were not being addressed. Although pharmacists accepted that appropriately trained pharmacy technicians should be able to ask (77%) and assess (66%) patients, only 24% agreed that technicians should be able to administer vaccine doses. Pharmacists satisfied with in-store immunization resources and technicians' involvement were more likely to report achieving the 3 key NVAC standards. Paradoxically, how pharmacists viewed their immunization time expenditures was unrelated to whether they agreed that pharmacy technicians should have an expanded role in asking, assessing, or administering vaccines to their patients.

CONCLUSION

Overall, community pharmacies would likely better meet national immunization goals by achieving all 3 key NVAC standards and incorporating expanded roles for appropriately trained and supervised technicians in PBIS.

Implementation of the Standards for adult immunization practice: A survey of U.S. Health care providers

The revised Standards for Adult Immunization Practice ("Standards"), published in 2014, recommend routine vaccination assessment, strong provider recommendation, vaccine administration or referral, and documentation of vaccines administered into immunization information systems (IIS). We assessed clinician and pharmacist implementation of the Standards in the United States from 2016 to 2018. Participating clinicians (family and internal medicine physicians, obstetricians-gynecologists, specialty physicians, physician assistants, and nurse practitioners) and pharmacists responded using an internet panel survey. Weighted proportion of clinicians and pharmacists reporting full implementation of each component of the Standards were calculated. Adjusted prevalence ratio (APR) estimates of practice characteristics associated with self-reported implementation of the Standards are also presented. Across all medical specialties, the percentages of clinicians and pharmacists implementing the vaccine assessment and recommendation components of the Standards were >80.0%. However, due to low IIS documentation, full implementation of the Standards was low overall, ranging from 30.4% for specialty medicine to 45.8% in family medicine clinicians. The presence of an immunization champion (APR, 1.40 [95% confidence interval {CI}, 1.26 to 1.54]), use of standing orders (APR, 1.41 [95% CI, 1.27 to 1.57]), and use of a patient reminder-recall system (APR, 1.39 [95% CI, 1.26 to 1.54]) were positively associated with adherence to the Standards by clinicians. Similar results were observed for pharmacists. Nonetheless, vaccination improvement strategies, i.e., having standing orders in place, empowering an immunization champion, and using patient recall-reminder systems were underutilized in clinical settings; full implementation of the Standards was inconsistent across all health care provider practices.

Emerging Evidence for Infectious Causes of Cancer in the United States

Worldwide, infectious agents currently contribute to an estimated 15% of new cancer cases. Most of these (92%, or 2 million new cancer cases) are attributable to 4 infectious agents: Helicobacter pylori, human papillomavirus, and hepatitis B and C viruses. A better understanding of how infectious agents relate to the US cancer burden may assist new diagnostic and treatment efforts. We review US-specific crude mortality rates from infection-associated cancers and describe temporal and spatial trends since 1999. We review the US-specific evidence for infection-cancer associations by reporting available estimates for attributable fractions for the infection-cancer associations. Death due to cancers with established infectious associations varies geographically, but estimates for the US attributable fraction are limited to a few observational studies. To describe the burden of infection-associated cancer in the United States, additional observational studies are necessary to estimate the prevalence of infection nationally and within subpopulations. As infectious associations emerge to explain cancer etiologies, new opportunities and challenges to reducing the burden arise. Improved estimates for the United States would help target interventions to higher-risk subpopulations.

Does self-rated health status influence receipt of an annual flu vaccination?

Despite 79,400 deaths due to the influenza (flu) virus during the 2017-18 season, <50% of US adults receive an annual flu vaccination (AFV). Self-rated health status (SRH) is associated with health behavior utilization. The current study aims to determine if an association exists between an individual's SRH and their receipt of an AFV. In the 2017 US Behavioral Risk Factor Surveillance System survey, 39.1% of respondents had received a flu vaccination within the last 12 months. There was a statistically significant difference (p < 0.0001) between the vaccination rates of men (35.7%) and women (42.4%). There was a significant positive association between SRH and AFV for individuals who self-reported an SRH of either "Fair" (AOR 1.19; 95% CI 1.12-1.27) or "Poor" (AOR 1.24; 95% CI 1.14-1.35), compared to those reporting a status of "Excellent". For those reporting an SRH status of "Fair", there was a significant positive association for both men (AOR 1.20; 95% CI 1.10-1.32) and women (AOR 1.17; 95% CI 1.08-1.28). An association was also found for men (AOR 1.203; 95% CI 1.09-1.39) and women (AOR 1.23; 95% CI 1.09-1.399) who reported their SRH as "Poor". Only women showed a significant association (AOR 1.12; 95% CI 1.04-1.20) among those whose SRH was "Good". No association was found for individuals who reported SRH as "Very Good". These findings are of interest to health policy makers as they show there is still work required to convince individuals with a high SRH that they too need to receive an AFV.

Vaccination Capability Inventory of Community, Migrant, and Homeless Health Centers: A Survey Report

CONTEXT

Federally funded Community, Migrant, and Homeless Health Centers provide health services to the most vulnerable communities in the United States. However, little is known about their capabilities and processes for providing vaccinations to adults.

PROGRAM

We conducted the first national survey of health centers assessing their inventory, workflow, capacity for, and barriers to provision of routinely recommended adult vaccines. In addition, we asked health center leaders' perceptions regarding best practices and policy recommendations for adult vaccinations.

IMPLEMENTATION

A survey was developed on the basis of domains elicited from advisory panels and focus groups and was sent electronically to leaders of 762 health centers throughout the United States and its territories; data were collected and analyzed in 2018.

EVALUATION

A total of 319 survey responses (42%) were obtained. Health centers reported stocking most routinely recommended vaccines for adults; zoster vaccines were not stocked regularly due to supply and storage issues. Respondents most commonly reported adequate reimbursement for vaccination services from private insurance and Medicaid. Most vaccinations were provided during primary care encounters; less than half of health centers reported providing vaccines during specialist visits. Vaccines administered at the health center were most commonly documented in an open field of the electronic health record (96%) or in an immunization information system (72%). Recommendations for best practices related to better documentation of vaccinations and communication with immunization information systems were provided.

DISCUSSION

Health centers provide most adult vaccines to their patients despite financial and technological barriers to optimal provisioning. Further studies at point of care could help identify mechanisms for system improvements.

Assessment of the factors influencing primary care physicians' approach to vaccination of adult risk groups in Istanbul, Turkey

Background

We aimed to assess the factors influencing primary care physicians’ (PCPs) approach to adult vaccination in specific risk groups and evaluate the compliance to adult immunization guidelines.

Methods

This cross-sectional study performed between January 2016 and April 2016 in İstanbul, Turkey. A questionnaire designed to obtain physicians’ demographical data, experience, immunization status, and attitude on prescribing or recommending vaccines for adults in the risk group. Healthy individuals older than 65 and patients suffer from chronic diseases or had splenectomy before are considered as a risk group. The questionnaire was sent via email to a randomly selected group of 1,500 PCPs. The data of 221 physicians who responded emails were recorded for statistical analysis.

Results

Of the 221 participants (123 women, 98 men), the majority were aged 31–40 years. Their vaccination rates were 74.2% for hepatitis B, 54.3% for seasonal influenza, and 47.1% for tetanus. Among participants, the highest recommendation and prescription rate of adult vaccines was recorded in PCPs aged 31–40 years. In addition, PCPs with <10 years occupational experience were found to prescribe adult vaccines more frequently than PCPs with longer occupational experience.

Conclusions

Primary care physicians with lower age and relatively less experience are more intent to prescribe adult vaccines to patients that are in risk groups. This result may be due to increased awareness of adult immunization among PCPs who had more recent medical training. However, many other factors could have caused this difference, including physicians’ approach to primary medical care.

The essential role of pharmacists facilitating vaccination in older adults: the case of Herpes Zoster

Older adults share a disproportionately high burden of vaccine-preventable diseases. Despite recommendations from national and international health organizations, vaccination rates among older patients remain suboptimal, suggesting poor access and barriers to vaccination. Pharmacists are uniquely positioned to assist patients in overcoming many of these barriers. In this commentary, we describe some of the common barriers to vaccination that older adults encounter and the role pharmacists have in overcoming these barriers, in the US and abroad. We provide a case study of pharmacists' impact in supporting herpes zoster vaccination. We also identify areas of opportunities to promote further pharmacist involvement in vaccination efforts.

Randomized controlled trial of centralized vaccine reminder/recall to improve adult vaccination rates in an accountable care organization setting

Our objectives were to assess 1) effectiveness of using Colorado's Immunization Information System (CIIS) to send out vaccine reminder/recalls (R/Rs) centrally vs. usual care for adult vaccine delivery within an accountable care organization (ACO) and 2) practice staff's perception of centralized R/R. From 9/2016 to 4/2017, we conducted a randomized controlled trial among adults enrolled in a Medicaid ACO at six healthcare entities. Adults were divided into two strata: 15,153 age 19–64 and 616 age 65+. Adults age 19–64 who needed influenza and/or Tdap vaccine, and adults age 65+ who needed influenza, and/or Tdap, and/or a pneumococcal vaccine were randomized to receive up to 3 R/Rs by autodialed telephone and mail or usual care. Documentation of receipt of any needed vaccines in CIIS within six months was the primary outcome. We assessed intervention effectiveness using mixed effect logistic regression. Thirteen semi-structured exit interviews were conducted with staff from each healthcare entity. The intervention was not associated with the primary outcome for the age 19–64 population [OR 1.06 (95% CI 0.98–1.15)] or age 65+ population [(OR 0.96 (0.69–1.32)]. Practice staff perceived the intervention to be beneficial and not burdensome. Perceived barriers included lack of availability of appointments and adults receiving only influenza vaccine when other vaccines were needed. In conclusion, centralized R/R was not effective at improving adult vaccination rates in a Medicaid ACO. Future studies should consider better harmonizing vaccine centralized R/Rs with vaccine delivery efforts within the practice setting.

Clinical Trials Registration Number: NCT02133391.

Comparisons of immunization records between a community pharmacy, a regional registry, and a health system

OBJECTIVES

To compare the completeness of immunization records for 6 vaccines between a community pharmacy database, a regional immunization information system (IIS), and a health system's electronic health record (EHR).

METHODS

In a community pharmacy immunization program, 2 pharmacists and a community pharmacy resident performed a needs assessment for 6 vaccines (tetanus-diphtheria-acellular pertussis vaccine for adults or diphtheria-tetanus-acellular pertussis vaccine for children and adolescents, zoster vaccine live, 13-valent pneumococcal conjugate vaccine, 23-valent pneumococcal polysaccharide vaccine, hepatitis B vaccine series, and human papillomavirus vaccine) for more than 2400 patients from August 2016 to March 2017. This was a retrospective study to review immunization records for 243 patients. Inclusion criteria included patients from the community pharmacy immunization program who also had at least 1 medication prescribed by an academic health system provider. Immunization records for 6 vaccines were collected from the community pharmacy database, the regional IIS, and the EHR.

RESULTS

A total of 186 of 243 patients (77%) had additional immunization records in the regional IIS or EHR that were not found in the community pharmacy database. Among those 186 patients, 108 (58%) had additional immunization records for 2 or more unique vaccines. In total, 378 additional immunization records were identified for the 6 vaccines. For all 6 vaccines, the regional IIS and EHR possessed more complete immunization records than the community pharmacy database (P < 0.05 for HPV and P < 0.001 for the remaining 5 vaccines).

CONCLUSION

Our study showed that immunization records were more complete in a regional IIS and health system EHR compared with a community pharmacy database. If all 3 sources were used by the pharmacist during the needs assessment, the community pharmacy team would have made fewer vaccine recommendations, which would have reduced the potential for duplicate or inappropriate vaccines.

Logistical and structural challenges are the major obstacles for family medicine physicians' ability to administer adult vaccines

PURPOSE

This study was conducted to characterize the vaccination practices and challenges of family medicine physicians in Los Angeles County, California.

METHODS

The Los Angeles Academy of Family Physicians (LA AFP) sent out electronic surveys to all of their active members (N = 1121) between December 2017 and January 2018, and asked them to answer questions about themselves, their practice, their patient population, and their immunization practices and challenges. We then analyzed the results through basic statistical calculations and Pearson's chi-squared tests.

RESULTS

Seventy-four people (6.6%) responded to the survey, and 75% of responders stated that they administer all Advisory Committee on Immunization Practices (ACIP) recommended vaccines. The lowest vaccine administration rates were for the high-dose influenza vaccine, which 66.2% (n = 49) of respondents reported to administer, followed by the meningococcal B vaccine (68.9%; n = 51). The respondents who belonged to practices with more than 11 providers, were part of a large hospital or healthcare system, had electronic medical records (EMRs), and used the California Immunization Registry (CAIR) were more likely to report to vaccinate. The number one responding physician-reported challenge to vaccination was limited time and resources to address patient resistance followed by vaccine cost and lack of infrastructure to store vaccines.

CONCLUSIONS

In this pilot study, structural and logistical challenges appeared to make the biggest impact on adult vaccination for the responding family medicine physicians. Solutions addressing these challenges will help improve the adult immunization rates.

U.S. clinicians' and pharmacists' reported barriers to implementation of the Standards for Adult Immunization Practice

BACKGROUND

The Standards for Adult Immunization Practice (Standards), revised in 2014, emphasize that adult-care providers assess vaccination status of adult patients at every visit, recommend vaccination, administer needed vaccines or refer to a vaccinating provider, and document vaccinations administered in state/local immunization information systems (IIS). Providers report numerous systems- and provider-level barriers to vaccinating adults, such as billing, payment issues, lower prioritization of vaccines due to competing demands, and lack of information about the use and utility of IIS. Barriers to vaccination result in missed opportunities to vaccinate adults and contribute to low vaccination coverage. Clinicians' (physicians, physician assistants, nurse practitioners) and pharmacists' reported barriers to assessment, recommendation, administration, referral, and documentation, provider vaccination practices, and perceptions regarding their adult patients' attitudes toward vaccines were evaluated.

METHODS

Data from non-probability-based Internet panel surveys of U.S. clinicians (n = 1714) and pharmacists (n = 261) conducted in February-March 2017 were analyzed using SUDAAN. Weighted proportion of reported barriers to assessment, recommendation, administration, referral, and documentation in IIS were calculated.

RESULTS

High percentages (70.0%-97.4%) of clinicians and pharmacists reported they routinely assessed, recommended, administered, and/or referred adults for vaccination. Among those who administered vaccines, 31.6% clinicians' and 38.4% pharmacists' submitted records to IIS. Reported barriers included: (a) assessment barriers: vaccination of adults is not within their scope of practice, inadequate reimbursement for vaccinations; (b) administration barriers: lack of staff to manage/administer vaccines, absence of necessary vaccine storage and handling equipment and provisions; and (c) documentation barriers: unaware if state/city has IIS that includes adults or not sure how their electronic system would link to IIS.

CONCLUSION

Although many clinicians and pharmacists reported implementing most of the individual components of the Standards, with the exception of IIS use, there are discrepancies in providers' reported actual practices and their beliefs/perceptions, and barriers to vaccinating adults remain.