SUPPLEMENT TO

the journal of

Free Family
1.0 CME
credit
Practice April 2008

Release Date: April 1, 2008 Available at jfponline.com

Update on vaccine-preventable
Expiration Date: April 1, 2009
Estimated Time To Complete Activity: 1.0 hour
Target Audience
This activity has been designed to meet the educa-
tional needs of primary care physicians and other
health care professionals who are interested in learn-
diseases: Are adults in your
ing more about the benefits of adult immunization.
Educational Objectives
At the conclusion of this activity, participants should
community adequately protected?
be better able to:
• E xamine clinical trial efficacy data regarding im-
munization against 6 vaccine-preventable diseases William Schaffner, MD
that commonly afflict adults Professor and Chair, Department of Preventive Medicine,
• R eview current adult immunization recommenda-
tions as issued by the Centers for Disease Control Vanderbilt University School of Medicine, Nashville, TN
and Prevention Advisory Committee on Immuniza-

T
tion Practices
•D  iscuss practical strategies to improve adult vac- he success of childhood vac- to missed opportunities to vacci-
cination rates in clinical practice
Accreditation Statement
cination programs and high nate, the lack of national programs
SciMed is accredited by the Accreditation Council for rates of immunization have that provide support for vaccine
Continuing Medical Education (ACCME) to provide
continuing medical education for physicians. made a major contribution to the administration in adults, and pub-
Credit Designation
SciMed designates this educational activity for a
reduction or elimination of many lic misconceptions about vaccines.
maximum of 1.0 AMA PRA Category 1 Credit™. Phy- childhood diseases in the United Increasing physicians’ awareness
sicians should only claim credit commensurate with
the extent of their participation in the activity. States. However, similar success about the impact of successful
Disclosure and Resolution of Conflicts of Interest has not been achieved in adults, adult immunization programs and
SciMed assesses conflicts of interest with its faculty
and all individuals who are in a position to control and vaccine-preventable diseases their responsibilities as vaccina-
the content of CME activities. All relevant conflicts of
interest that are identified are resolved by SciMed to continue to be a significant cause tors in the adult primary care set-
ensure fair balance and scientific objectivity.
When asked to report any potential conflict(s) of inter-
of morbidity and premature death ting can reduce the morbidity and
est, faculty reported the following: among adults.1 The Advisory Com- mortality associated with vaccine-
William Schaffner, MD, reports that he is a consul-
tant to GlaxoSmithKline, MedImmune, Merck & Co.,
mittee on Immunization Prac- preventable diseases in adults.
Inc., Novartis, and sanofi pasteur. tices (ACIP) Recommended Adult
Jenny Ko assisted in the development of this supple-
ment. Neither Ms Ko nor any SciMed personnel in- Immunization Schedule provides
volved in the development of content for this activity
vaccination recommendations for z Impact and
have relevant conflicts to report.
The materials for this activity were peer reviewed and 14 vaccine-preventable diseases recommendations
the reviewer had no relevant conflicts to report.
(Figure 1).2 This supplement re- Influenza
Disclaimer
The opinions or views expressed in this CME activity views the benefits of immuniza- In the United States, influenza ac-
are those of the presenters and do not necessarily
reflect the opinions or recommendations of SciMed tion against 6 vaccine-preventable counts for approximately 226,000
or the commercial supporter. Participants should
critically appraise the information presented and
diseases that physicians frequently hospitalizations and 36,000 deaths
are encouraged to consult appropriate resources encounter among their adult pa- annually among adults ≥50 years
for information surrounding any product or device
mentioned. tients: influenza, pneumococcal of age because of pneumonia or
Posttest and Evaluation infections, herpes zoster, human exacerbations of underlying cardio-
The posttest and evaluation appear on page S12.
Acknowledgement papillomavirus (HPV) infection, pulmonary diseases.6-9 The highest
Sponsored by pertussis, and hepatitis B. rates of serious illness and death
Rates of adult immunization associated with influenza are found
continue to fall short of the na- among individuals ≥65 years of age,
Supported by
an educational
tional Healthy People 2010 goals among whom more than 90% of in-
grant from established by the US Department fluenza-related deaths occur.7,8
This material was submitted by SciMed. It was
edited and peer reviewed by The Journal of Family
of Health and Human Services Vaccination prevents influenza-
Practice. (Table 1).3-5 The underutilization of triggered complications and exacer-
Copyright © 2008 Dowden Health Media
vaccines can be attributed in part bations of underlying comorbidities,

jfponline.com Supplement to The Journal of Family Practice / April 2008 S

 Vaccine-preventable diseases in adults

FIGURE 1

For further details, go to www.cdc.gov/vaccines/recs/schedules/adult-schedule.htm.

S April 2008 / Supplement to The Journal of Family Practice


thereby reducing morbidity and mortality. In a large
study cohort of adults ≥65 years of age during the
1999-2000 influenza season, influenza vaccination
reduced the risk of hospitalization due to infection
or cardiopulmonary conditions (number needed
to vaccinate [NNV]=154), influenza or pneumo-
nia (NNV=431), cardiac disease (NNV=376), or
cerebrovascular disease (NNV=621).10 Vaccinated
patients also had a noteworthy reduction in the
relative risk of death of 0.5 (P<.001; NNV=118).10
The ACIP adult guidelines currently rec-
ommend annual influenza vaccination for all
adults ≥50 years of age.2 However, individuals
<50 years who are at increased risk of serious
complications are also given high priority for
annual vaccination, including adults with car-
diopulmonary disease and other underlying
chronic comorbidities, residents of long-term
care facilities, and pregnant women.9
The Centers for Disease Control and Preven-
tion (CDC) estimates that for every 1 million indi-
viduals ≥65 years of age who are vaccinated each
year, approximately 1300 hospitalizations and 900
deaths can be avoided during a typical influenza
season.11 Influenza vaccine coverage in adults and
individuals at high risk, however, remains below
the national goal of 90% (Figure 2).3,9
Pneumococcal infections
The introduction of routine infant immunization
with the 7-valent conjugate pneumococcal vac-
cine has helped prevent pneumococcal disease
in older individuals by creating “herd immuni-
ty.” Despite the indirect protective effect in par-
ents and grandparents, pneumococcal infections
and disease are still common among adults.
Streptococcus pneumoniae remains the
most frequent causative agent of community-
acquired bacterial pneumonia. Approximately
175,000 hospitalizations can be attributed to
pneumococcal pneumonia annually.12 Pneumo-
coccal infections can also present as systemic
bacteremia or meningitis; more than 50,000
cases of bacteremia and up to 6000 cases of
meningitis are reported each year.12 Although
disseminated pneumococcal disease has a low
incidence rate, it is associated with a high
mortality rate (15% to 20%).13 Pneumococcal
disease accounts for more than 6000 deaths an-
nually; more than half of these deaths are in
jfponline.com Supplement to The Journal of Family Practice / April 2008
the journal of
Family
Practice
table 1
Vaccination coverage among adults falls
short of National Healthy People 2010 goals
Recent Healthy
Vaccination People
Vaccine Rate (%) 2010 Goals (%)
Influenza
≥65 years of agea,b 64 90
18 to 64 years of agea 31 60
Pneumococcala 57 90
Tetanus, diphtheria, pertussisc
Td 44 90
Tdap 2 —
Herpes zosterc 2 —
Human papillomavirus c
10 —
Hepatitis Ba
Long-term dialysis patients 56 90
Men who have sex with men 13 60
Health care workers 75 93
Singleton JA. Vaccination Coverage Among Adults. Presented at:
a
National Vaccine Advisory Committee Session on Adult Immuniza-
tion; Oct 22, 2007; Washington, DC; bPoland GA et al. Am J Prev
Med. 2003;25:144-150; cCenters for Disease Control and Preven-
tion, National Foundation for Infectious Diseases. Results of CDC’s
National Immunization Survey [press conference]. Washington, DC;
Jan 23, 2008.
adults for whom vaccination is recommend-
ed.12 In addition, the increase in antibiotic-re-
sistant strains of S pneumoniae underscores
the importance of vaccination for disease
prevention.14
In a large 3-year retrospective cohort study
of 47,365 individuals ≥65 years of age, the poly-
valent pneumococcal vaccine reduced the risk
of pneumococcal bacteremia by 44% (95% con-
fidence interval [CI], 7%-67%) and the risk of
all-cause mortality by 16%.15 Although vacci-
nation neither prevented community-acquired
pneumonia nor reduced the number of associ-
ated hospitalizations, a decrease in the inci-
dence of pneumococcal bacteremia as well as
improved outcomes were observed among hos-
pitalized patients who had previously been vac-
cinated.15,16 In a prospective study cohort (66%
of patients ≥65 years of age), vaccinated patients
were significantly less likely to develop pneu-
mococcal bacteremia (2% vs 5% for unvacci-
nated patients [P=.004 for the difference]; NNV=
36). Rates of death or admission to the intensive
care unit, the primary composite end point,
S
 Vaccine-preventable diseases in adults

FIGURE 2 adults <65 years of age, the vaccine is recom-

Self-reported influenza vaccination mended for immunocompetent persons with
in high-risk adult population groups comorbidities that increase the risk of illness or
death associated with pneumococcal infection,
100
90 Vaccine shortage: adults with functional or anatomic asplenia, in-
2004-2005 season
80 dividuals residing in long-term care facilities,
Vaccine coverage (%)

70 and immunocompromised adults at high risk of

60
pneumococcal disease.2
50
40
30 Herpes zoster
20 Approximately 1 million individuals in the
10
United States are affected each year by herpes
0
1990 1995 2000 2005
zoster, commonly known as shingles. Herpes
Year zoster, the late clinical manifestation of vari-
All ≥65 years High-risk 18-49 years cella-zoster virus (VZV), arises when cell-medi-
High-risk 50-64 years Pregnant women
ated immunity to VZV wanes. The risk of herpes
Healthy 50-64 years Health care workers
zoster increases markedly with advancing age.17
1989-2006 National Health Interview Survey. Singleton JA. Vac-
cination Coverage Among Adults. Presented at: National Vaccine The increased likelihood of herpes zoster is
Advisory Committee Session on Adult Immunization; Oct 22,  most apparent starting at 55 years of age and
2007; Washington, DC.
increases thereafter; more than 60% of affected
individuals are ≥50 years of age.18-20 Of those af-
fected, 9% to 34% will develop postherpetic
FIGURE 3
neuralgia (PHN), the most common complica-
Self-reported pneumococcal vaccination
tion of herpes zoster.21-23 Risk factors for PHN
in high-risk adult population groups
include severity of acute pain, severity of the
100 acute zoster rash, painful prodrome, and most
90 All ≥65 years
High-risk 50-64 years
importantly, increased age.23
Vaccine coverage (%)

80
70 High-risk 18-49 years Herpes zoster and PHN can produce sub-
60 stantial negative effects on quality of life, activi-
50
ties of daily living (ADL), psychological health,
40
30 and social functioning.24,25 The magnitude of
20 interference with quality of life and functional
10
status is directly related to pain intensity. In a
0
prospective observational study, it was noted
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006

Year
that the greater a patient’s pain, the greater the
negative impact on ADL; for every 1-point in-
1989-2006 National Health Interview Survey. Singleton JA. Vac-
cination Coverage Among Adults. Presented at: National Vaccine crease in pain on a 0-to-10 scale, there was a 0.5-
Advisory Committee Session on Adult Immunization; Oct 22,  to 1-point increase in ADL interference scores.24
2007; Washington, DC.
Moderate-to-severe pain was reported in 73% of
patients 7 days after rash onset.24 Of these pa-
tients, approximately 60% reported significant
were also reduced in vaccinated patients (10% interference with enjoyment of life, sleep, and
vs 21% for unvaccinated patients; NNV=9) (un- general activity.24 In a population study, pain
adjusted odds ratio [OR], 0.41 [P<.001]).16 associated with PHN had a moderate-to-severe
The ACIP recommends the polyvalent poly- impact on enjoyment of life in 48% of patients,
saccharide pneumococcal vaccine for all adults ability to carry out general activities in 40%,
≥65 years of age.13 Despite the recommenda- and a negative impact on mood in 45%.25
tion and the benefits of vaccination, only half Antiviral therapy, including acyclovir, fam-
of adults ≥65 years of age report ever receiving ciclovir, and valacyclovir, reduces the incidence
pneumococcal vaccination (Figure 3).3,12 Among and severity of herpes zoster when administered

S April 2008 / Supplement to The Journal of Family Practice

 the journal of

Family
Practice
Table 2
Treatments for postherpetic neuralgia and adverse event profiles
Medication Pain response and adverse event profile

Gabapentin, pregabalin a,b • 33% reduction in pain with gabapentin; 63% of patients receiving
pregabalin experienced clinically significant pain reduction.
•A
 dverse events include somnolence, dizziness, and peripheral edema.

Tricyclic antidepressants c • 47% to 67% of patients reported at least moderate pain relief.

•A
 dverse events include sedation, confusion, urinary retention,
dry mouth, postural hypotension, and arrhythmia.
Opioid analgesics d,e • 38% to 58% of patients report pain relief.

•A
 dverse events include constipation, nausea, vomiting, loss of appetite,
dizziness, and drowsiness.
Lidocaine patch 5% f •6
 0% efficacy (ie, at least moderate pain relief).

•N
 o systemic adverse events, but local reactions, including erythema and skin rash.

Topical capsaicin g • 19% reduction in pain.

• Burning elicited during its application was intolerable in up to two-thirds of patients.

Gabapentin, pregabalin, lidocaine patch 5%, and topical capsaicin are approved by the US Food and Drug Administration 
for the treatment of postherpetic neuralgia.
a
Rowbotham M et al. JAMA. 1998;280:1837-1842; bDworkin RH et al. Neurology. 2003;60:1274-1283; cPappagallo M, Haldey EJ. CNS
Drugs. 2003:17:771-780; dWatson CP, Babul N. Neurology. 1998;50:1837-1841; eRaja SN et al. Neurology. 2002;59:1015-1021; fDavies
PS, Galer BS. Drugs. 2004;64:937-947; gWatson CP et al. Clin Ther. 1993;15:510-526.

within 72 hours of rash onset.18 However, antivi-
rals do not reliably prevent PHN. The pain asso-
ciated with PHN is often severe and difficult to
manage. Although many agents, including anti-
convulsants, tricyclic antidepressants, opioids,
and topical agents, have some degree of efficacy
in the management of PHN, pain relief is almost
always only partial.26-32 In addition, these agents
are associated with troublesome adverse effects,
particularly in older patients (TABLE 2).26-32
Clinical trial data from the Shingles Preven-
tion Study (SPS) have shown that the herpes zos-
ter vaccine can reduce the incidence of herpes
zoster and PHN, as well as the severity and dura-
tion of the disease. The primary end point of the
SPS was the burden of illness of herpes zoster,
a measure based on the incidence and severity
of disease and duration of pain and discomfort.
Herpes zoster vaccination significantly reduced
the overall burden of illness by 61.1% (95% CI,
51.1-69.1) (Figure 4).33 The reduction in burden of
illness reflected an overall 51.3% decrease (95%
CI, 44.2-57.6; NNV=60) in the incidence of her-
pes zoster, which was observed to be significant-
ly greater in the 60- to 69-year-old age group than
in the ≥70-year-old age group (63.9% vs 37.6%
[P<.001]), and a drop in the average duration of
herpes zoster from 24 days to 21 days (P=.03).
The incidence of PHN—defined by the SPS as
pain ≥3 on a 0-to-10 scale, persisting or appear-
ing ≥90 days after rash onset—was evaluated as a
secondary end point. Herpes zoster vaccination
reduced the incidence of PHN by 66.5% (95%
CI, 47.5-79.2; NNV=364).
The herpes zoster vaccine is generally safe
and well tolerated; injection-site reactions were
the most commonly reported adverse events.
Based on clinical data from the SPS, a vaccine
was approved by the FDA in 2006 for the pre-
vention of herpes zoster in immunocompetent
individuals ≥60 years of age. The current ACIP
Recommended Adult Immunization Schedule,
updated for 2007-2008, recommends vaccina-
tion with the herpes zoster vaccine for all im-
munocompetent adults ≥60 years of age.2
A recent report by the CDC found that only
2% of adults ≥60 years of age received herpes
zoster vaccination in its first year of availabili-
ty.5 Rates of immunization often improve when
multiple vaccines can be administered during
the same visit to the clinic. Concomitant ad-
ministration of the herpes zoster vaccine with

jfponline.com Supplement to The Journal of Family Practice / April 2008 S

 Vaccine-preventable diseases in adults
FIGURE 4
Vaccine efficacy for herpes zoster
burden of illness
Efficacy 61.1% 65.5% 55.4%
(95% CI) (51.1-69.1) (51.5-75.5) (39.9-66.9)
9 FUTURE I study, vaccination was shown to be
8
P<.001
n Vaccine
burden of illness
7 n Placebo
Herpes zoster
6 HPV 6/11/16/18-associated genital warts and
5
4
3 against vulvar/vaginal intraepithelial neoplasia
2
1
0 The quadrivalent HPV vaccine is indicated
All 60-69 ≥70
Age (years)
CI, confidence interval.
Oxman MN et al. N Engl J Med. 2005;352:2271-2284.
a trivalent inactivated influenza vaccine in
adults demonstrated similar immunogenicity
to that of the herpes zoster vaccine adminis-
tered alone.34 Coadministration of the herpes
zoster and influenza vaccines may help ensure
that eligible patients receive the herpes zoster
vaccine.
Human papillomavirus
Human papillomavirus (HPV) is the most com-
mon newly acquired sexually transmitted infec-
tion, with an estimated annual incidence of 6.2
million cases.35 In the United States, approxi-
mately 27% of women and 65% of men are in-
fected with HPV.36,37
HPV is classified according to its cancer-
causing potential: high-risk (ie, oncogenic) types
and low-risk types. High-risk HPV types are es-
sential causes of cervical precancerous lesions
and cancer. The 2 most common types, HPV 16
and 18, are implicated in 70% of cervical squa-
mous cell carcinomas, 30% to 40% of other ano-
genital cancers (including vulvar, anal, and penile
cancers), and 20% to 75% of oropharyngeal can-
cers.38-40 The most common low-risk types, HPV 6
and 11, cause approximately 90% of genital warts
as well as low-grade cervical lesions.38
Two large phase 3 trials conducted in women
15 to 26 years of age have shown HPV vaccina-
tion with the quadrivalent HPV (types 6, 11, 16,
18) vaccine to be highly effective in prevent-
ing HPV-type–associated disease. The Females
United to Unilaterally Reduce Endo/Ectocervical
S April 2008 / Supplement to The Journal of Family Practice
Disease (FUTURE) II study found the quadriva-
lent HPV vaccine was 98% effective (95% CI,
86-100; NNV=148) against HPV 16/18-associ-
ated cervical intraepithelial neoplasia (CIN)
grade 2 or 3 and adenocarcinoma in situ.41 In the
96% effective (95% CI, 86-99; NNV=42) against
91% effective (95% CI, 37-100; NNV=269)
grade 2 or 3.42
in all girls and women 11 to 26 years of age for
the prevention of HPV 6/11/16/18-associated
diseases. Under special circumstances, the vac-
cine can be given to girls as young as 9 years
of age. The ACIP recommends vaccination for
all adult women aged 19 to 26 years who have
not yet been vaccinated or did not complete the
vaccination series.2 Sexually active mid-adult
women (ages 24 to 45) may also benefit from
HPV vaccination. Recent research has shown
HPV vaccination to be efficacious in mid-adult
women, as very few have been exposed to all
vaccine HPV types.43 The FUTURE III study
found the quadrivalent HPV vaccine to be 91%
effective (95% CI, 74-98; NNV=71) in reducing
the combined incidence of HPV 6/11/16/18-
associated persistent infection, CIN, or exter-
nal genital lesions among women aged 24 to 45
years.43 Licensing of the vaccine for use in this
older age group is anticipated in the future. De-
spite the benefits of HPV vaccination, a recent
CDC report found that only 10% of women 18
to 26 years of age had received at least 1 dose of
the 3-dose HPV vaccination course.5
Pertussis
Pertussis is an acute respiratory infection caused
by Bordetella pertussis, against which all chil-
dren are provided routine immunization. How-
ever, immunity to pertussis wanes 5 to 10 years
after vaccination, leaving adults susceptible to
infection.44 Adults affected with pertussis also
serve as a common source of infection and can
increase the rates of disease among young chil-
dren, who suffer greater morbidity.45-47 More
than 7000 cases of pertussis in adults are report-
ed annually; this represents approximately 30%
of all pertussis cases.48 Pertussis is associated

with a prolonged chronic paroxysmal cough
that disturbs ADL, including the ability to sleep,
concentrate, and eat. Complications of pertussis
can be debilitating and may require hospitaliza-
tion.48 Among older adults, common compli-
cations include rib fractures, cough syncope,
pneumothorax, aspiration, inguinal hernia, her-
niated lumbar disc, and subconjunctival hemor-
rhage.48 Pneumonia and other respiratory tract
illnesses can also complicate pertussis.48
Prevention by vaccination is the optimal
approach for reducing the health burden of per-
tussis. Acellular pertussis vaccines have been
shown to be highly efficacious against pertussis
infection in individuals 15 to 65 years of age. Re-
sults of a 2-year, double-blind study showed an
acellular pertussis vaccine to be 92% effective
(95% CI, 32-99; NNV=174) in reducing the inci-
dence of pertussis.49
The Tdap vaccine (an acellular pertussis
vaccine combined with tetanus and diphtheria
toxoids) was approved by the FDA in 2006 as a
one-time booster for the prevention of pertussis
in adults 19 to 64 years of age; data in individu-
als ≥65 years of age are expected. The 2007-2008
ACIP recommendations suggest the use of Tdap
in adults <64 years of age on a one-time basis
at the time of the next scheduled tetanus boost-
er.2 In a double-blind study of adults <64 years
of age, Tdap produced immunogenicity for teta-
nus and diphtheria comparable to Td (adult
tetanus and diphtheria toxoid vaccine), while
also producing high pertussis geometric mean
titers.50 Studies are now under way to determine
whether Tdap should be used routinely for de-
cennial boosting.
Hepatitis B
Hepatitis B is a bloodborne disease caused by
the hepatitis B virus (HBV); transmission can
occur through sexual contact, blood transfu-
sions, exposure to contaminated needles, needle
sharing by intravenous drug users, and vertical
transmission from mother to infant at or near
the time of birth.51,52 Thus, patients at high risk
of infection include heterosexuals with multiple
sexual partners, men who have sex with men,
intravenous drug users, and contacts of individ-
uals with chronic HBV infection.51 Worldwide,
2 billion people are infected and more than 400
jfponline.com Supplement to The Journal of Family Practice / April 2008
the journal of
Family
Practice
FIGURE 5
Self-reported hepatitis B vaccination
in high-risk adult population groups
100
90
Vaccine coverage (%)
80
70
60 57.4
53.4
48.3
50 42.5
40 35.1
30
20
10
0
18-20 21-25 26-30 31-40 41-49
Age (years)
2004 National Health Interview Survey. Singleton JA. Vaccination
Coverage Among Adults. Presented at: National Vaccine Advisory
Committee Session on Adult Immunization; Oct 22, 2007; Wash-
ington, DC.
million are carriers of HBV.53,54 Because of rou-
tine infant and childhood vaccination against
HBV, the highest incidence of infection in the
United States is among adults, who account for
95% of the 50,000 new cases estimated to occur
annually.55-58
HBV is a major cause of liver disease, in-
cluding chronic hepatitis, cirrhosis, and hepa-
tocellular carcinoma (HCC).54 There is no cure
for chronic hepatitis B disease, and treatment is
focused on the suppression of viral replication.59
Hepatitis B vaccination is the most effective
method to prevent HBV infection and its asso-
ciated complications, including HCC; hepatitis
B vaccine is considered the first anticancer vac-
cine.60 Completion of the 3-dose series is estimat-
ed to be more than 95% effective in preventing
hepatitis B infection.61
In 2004, the National Health Interview Sur-
vey reported that only 34.6% of adults aged 18
to 49 years had received hepatitis B vaccina-
tion. The immunization rate increases to 45.4%
when accounting for the subgroup of adults at
high risk, yet the numbers still fall short of the
national goals (Figure 5).3,57,58 Previously pub-
lished ACIP guidelines recommended hepatitis
B vaccination for adults at increased risk of in-
fection due to occupational or lifestyle hazards.
To improve rates of vaccination, ACIP recom-
mendations have been expanded and state that
a patient’s “acknowledgement of a specific risk
S
factor should not be a requirement for vaccina-
tion.”1,55 The ACIP now recommends hepatitis
B vaccination for all sexually active individuals
who are not in a long-term, mutually monoga-
mous relationship, as well as any adult request-
ing hepatitis B vaccination, without requiring
explicit acknowledgement of at-risk sexual or
drug-using behavior.1,2,55
z Practical considerations
Vaccine coverage
Effective January 1, 2008, vaccines for influen-
za, pneumococcal infection, hepatitis B for at-
risk patients, and tetanus (when administered
as part of treatment for a traumatic wound) are
covered by Medicare Part B for adults ≥65 years
of age. Adult vaccines, but not vaccine admin-
istration, that are not covered by Part B, includ-
ing the herpes zoster vaccine, may be covered
by Medicare Part D.62 Although in 2007, physi-
cians were permitted to submit claims to Part B
for the administration of vaccines covered un-
der Part D, the administration of these vaccines
is now also covered under Part D.62,63 However,
each prescription drug plan (PDP) or Medicare
Advantage prescription drug plan (MA-PD) de-
termines which vaccines will be covered under
Medicare Part D.
Vaccine access
Patients covered under Medicare Part D may re-
ceive vaccines in the physician’s office or clinic
and then pay the physician out-of-pocket for the
vaccine and its administration. The patient can
then seek reimbursement from the PDP or MA-
PD. Patients can also receive vaccines, with a
physician’s prescription, at community pharma-
cies in states that allow pharmacist administra-
tion of vaccines. Pharmacies can bill the plan
directly for both the cost of the vaccine and its
administration.62 Vaccine price lists are available
from the CDC.
Storage and handling
All vaccines currently marketed in the United
States must be stored either refrigerated or fro-
zen, depending on the specific product. Adult
vaccines, including the trivalent inactivated
influenza vaccine, pneumococcal, Td, Tdap,
S April 2008 / Supplement to The Journal of Family Practice
HPV, and hepatitis B vaccines must be refrig-
erated, whereas the live attenuated influenza
vaccine and herpes zoster vaccine must be fro-
zen.64 Proper vaccine handling and storage is of
utmost importance because vaccines exposed
to extreme fluctuations in temperature or not
stored appropriately will not be effective.
z Strategies for clinical practice
Effective patient education
As vaccinators, physicians can assist their pa-
tients with making informed decisions. Disease
education should be individualized to each
patient’s educational level and background.4
Adequate time should be allotted to appropri-
ately address any questions and concerns pa-
tients may have.65 In addition, it is important
for physicians to provide patients with written
information about each vaccine to be admin-
istered; printed versions of the CDC’s Vaccine
Information Statements (VISs) are available in
multiple languages from the CDC.65
Regular assessment of patient
vaccination status
Proper documentation and routine review of
patient immunization records during both
acute care and preventive visits ensures that a
patient’s vaccination status is up-to-date and
reduces or eliminates unnecessary immuniza-
tions. Written records of each immunization
should be provided to the patient; immuniza-
tion record forms are available at most state
public health departments at no cost.
Simultaneous administration
and missed doses
As stated in the CDC’s Standards for Adult Im-
munization Practices, when indicated, simulta-
neous administration of vaccines for adults is
recommended.4 Such administration will help
ensure adequate vaccine protection by requir-
ing fewer visits and reducing the potential for
missed doses.4 Examples include the safe and
effective administration of influenza and pneu-
monia vaccines at the same time, provided they
are not delivered in the same arm, as well as
the concomitant administration of the influenza
vaccine and herpes zoster vaccine.34,66

Physician reminders
Because patients may not remember when to
obtain their recommended immunizations, it is
useful for primary care physicians to provide
reminders and to ensure that their patients’
vaccination status is current.67 Data from a
meta-analysis demonstrated that patients who
received reminders (telephone calls, face-to-
face reminders) and recall interventions (post-
cards, letters) were more likely to have been
immunized and to be up-to-date with their vac-
cinations (OR, 1.66 [95% CI, 1.31-2.09]).67 The
implementation of physician reminders for im-
munization improved vaccine coverage by 5%
to 20%.67
Community-based vaccination
Adult immunization in nontraditional settings
increases patient convenience and access to
vaccination and has helped increase adult vac-
cination rates. Pharmacy immunization clinics
are increasing in the United States. By hosting
vaccination programs in their pharmacies, phar-
macists are expanding their role as health care
providers. Pharmacists function not only as vac-
cine advocates by providing patient education,
but also as administrators of vaccines; 26 states
currently permit pharmacists certified by the
jfponline.com Supplement to The Journal of Family Practice / April 2008
the journal of
Family
Practice
American Pharmaceutical Association’s Im-
munization Training Certification Program to
administer vaccines. Nurse practitioners and
visiting nurses are also actively involved in
adult immunization and often staff vaccina-
tion programs held in nontraditional settings
including pharmacies, senior citizen cen-
ters, grocery stores, churches, and the work
place.65 The provision of vaccines in nontradi-
tional settings contributes to the improvement
of vaccination coverage among all adult age
groups.
z Conclusion
Vaccines are among the most effective pub-
lic health measures for disease prevention.
Increased physician awareness of the impor-
tance of complete and timely immunization
of their patients, as well as their responsibili-
ties as clinicians who administer vaccines,
will positively affect the success of adult
vaccination in their clinical practices. Im-
proving vaccine coverage among individuals
from all adult age groups can significantly re-
duce the proportion of hospitalizations and
deaths caused by complications of vaccine-
preventable diseases. n
S
 Vaccine-preventable diseases in adults
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S11

the journal of
Family
Practice
Instructions for obtaining CME credit
There are no fees for participating in and receiving CME credit for
this activity. In order to obtain CME credit for participating in this
activity during the period April 1, 2008, through April 1, 2009,
participants must (1) read the educational objectives and disclo-
sure statements, (2) study the educational activity, (3) complete
the posttest by recording the best answer to each question, (4)
complete the evaluation form, and (5) fax the evaluation form with
answer key to SciMed per the instructions on this form.
A statement of credit will be issued only upon receipt of a com-
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Release date: April 1, 2008 Expiration date: April 1, 2009
Posttest questions
Please enter the correct answer for each question in the posttest answer key.
1. Which of the following adult vaccination rates continue(s) to fall
short of national immunization goals?
a. Influenza and pneumococcal vaccinations
b. Tetanus, diphtheria, pertussis vaccination
c. Herpes zoster vaccination
d. Human papillomavirus and hepatitis B vaccinations
e. All of the above
2. Based on estimates from the Centers for Disease Control, for every
1 million individuals ≥65 years of age who receive the influenza
vaccine, how many hospitalizations and deaths can be avoided
during an average influenza season?
a. 400 hospitalizations and 100 deaths
b. 700 hospitalizations and 300 deaths
c. 900 hospitalizations and 500 deaths
d. 1000 hospitalizations and 700 deaths
e. 1300 hospitalizations and 900 deaths
3. The Shingles Prevention Study has shown that the herpes zoster
vaccine significantly reduces the burden of illness by approximately
what percentage?
a. 20%
b. 30%
c. 40%
d. 50%
e. 60%
4. How many years after receiving childhood pertussis vaccination
does immunity to pertussis wane?
a. 5 to 10 years
b. 10 to 20 years
c. 20 to 30 years
d. 30 to 40 years
e. >40 years
5. Which of the following practical strategies can improve adult im-
munization rates?
a. Routine review of patient immunization status
b. Improving patient access to vaccines
c. Physician reminders (eg, telephone calls, postcards)
d. Community-based vaccination programs
e. All of the above
S12 April 2008 / Supplement to The Journal of Family Practice
Update on vaccine-preventable diseases:
Are adults in your community adequately protected? April 1, 2008
Evaluation form 0648
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Examine clinical trial efficacy data regarding immunization against 6 vaccine-
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