As the push gets under way to immunize Americans against swine flu and the seasonal flu, infectious-disease experts warn that many adults haven't received vaccinations for at least half a dozen other preventable diseases-some of which could put people who get influenza at even greater risk for complications and death.
Bacterial pneumonia is the most dangerous complication of the flu and a leading cause of death in previous flu pandemics. Yet only one in four adults under 65 who are considered by the Centers for Disease Control and Prevention to be at risk for the infection have been vaccinated against invasive pneumococcal disease, which causes bacterial pneumonia.
Adult-vaccination rates for other diseases also are dangerously low. Only half the people whom the CDC says should be vaccinated for whooping cough, which can also complicate the flu, have received the immunization. Those percentages are even lower for hepatitis B (32%), human papillomavirus (11%), which can lead to cervical cancer, and shingles (7%). Some adults need vaccinations because they never received them as children, or the immunity can fade over time. As people age, they also become more susceptible to infection. And some newer vaccines weren't available when many adults where children, while some have been improved on.
In all, more than 50,000 U.S. adults die from vaccine-preventable diseases annually-more than from breast cancer, AIDS, or traffic accidents. And hundreds of thousands of adults are sickened or suffer long-term problems from pneumococcal disease, meningitis, shingles and hepatitis, adding more than $10 billion annually to U.S. health-care costs.
"Vaccines have not been front and center in our national efforts for disease prevention as they should be," says Gregory A. Poland, director of the Mayo Clinic's vaccine-research group. "It's a collusion of ignorance-patients don't know to ask about vaccines, and physicians often don't have good mechanisms to screen patients and determine which vaccines they need."
A 2007 study by the CDC found that 78% of doctors either only occasionally ask or don't inquire at all about their patients' vaccination status. Doctors also reported that reimbursement for immunization is inadequate. While the federal vaccines-for-children program provides vaccines at no cost to underserved children, there is no national system to promote and monitor adult vaccination or pay for vaccines for those who can't afford them. Vaccines, which can range in price from $20 to nearly $300, often aren't covered or are only partly covered by insurance plans, including Medicare.
The National Vaccine Advisory Committee, which assesses federal immunization programs, is preparing several recommendations to improve vaccination rates and secure adequate federal funding for adult immunization. Vaccine-financing programs are also part of some health-reform proposals being considered by Congress. One proposal: a requirement that all insurance plans cover recommended vaccines for adults.
Unlike the flu shot, which is given annually and formulated to prevent specific strains of flu, adult vaccines are typically given once, with booster shots over time for some. And while children are typically followed by a pediatrician until they turn 18, "adults may see a lot of different doctors over their lifespan," which makes it harder to coordinate preventive care and keep track of which vaccinations have been received, says Carol Friedman, associate director for adult immunizations at the CDC's center for immunization and respiratory disease. Generally, if patients are unsure if they have been vaccinated, there is no harm in getting immunized again, or in receiving several shots at one doctor's visit.
A vaccine schedule for adults, updated annually, is available at CDC.gov/vaccines. The site also includes easy-to-understand vaccine fact sheets and an interactive quiz to help consumers determine which vaccines they need.
The CDC is urging state public health departments to encourage the use of the vaccine against pneumococcal disease, known as PSV, at the same time as vaccines for seasonal flu and the swine flu for those at risk. In addition to all adults over 65, those at risk include smokers and others aged 19 to 64 with asthma, heart disease, diabetes, or conditions that lower resistance to infection. Bacterial pneumonia has already been found in autopsies of 22 victims of swine flu who died in recent months, the CDC says.
A CDC national immunization survey conducted last year showed especially low rates for the vaccination for shingles, a reactivation of the childhood chickenpox virus. A vaccine was introduced three years ago, but only about 7% of adults over 60 who are recommended to get the vaccine have done so. Though not life threatening, shingles can cause a painful and disfiguring rash, and can involve nerves around the eye that can lead to blindness. Moreover, some patients experience severe nerve pain that can last for years, with little relief available from pain medications.
One barrier: The vaccine, which costs as much as $270, is covered by Medicare's part D drug benefit, not the Part B medical benefit. That means patients covered by the federal insurance program have to get a prescription from their doctor, take it to a pharmacy and then bring the vaccine back to their doctor for administration, unless they can find a drugstore-based clinic that will provide the vaccine on site.
Joan Ditcher, a New York City teacher, suffered excruciating pain after being diagnosed with shingles last fall at age 63, but says none of her doctors ever suggested the vaccine to her. "I believe in preventive care, as long as I'm aware of it," says Ms. Ditcher. "If I had known the vaccine was recommended for everyone my age, I would have gotten it." She has since received the vaccine, as shingles can recur, and convinced all of her friends to get it as well.
Only about half of adults have received the Tdap vaccine, which was licensed in 2005 as the first vaccine for adolescents and adults to combine a tetanus and diphtheria shot with pertussis, or whooping cough, which can cause violent coughing and pneumonia and presents a big risk when combined with influenza.
The CDC recommends that adults under 65 who have never received the Tdap vaccine substitute it for their next booster dose of tetanus, which should be received every 10 years. The most severe cases of disease and death linked to whooping cough have been in infants under six months of age, and the source of that infection is most often an older child or adult, so parents of newborns or women who plan to become pregnant are advised to get the vaccine.
Rates for vaccines against sexually transmitted diseases are also low. Only 11% of women between the ages of 19 and 26 have received the three-dose vaccine for human papillomavirus, or HPV, which prevents genital warts that can lead to cervical cancer. (The CDC's vaccine advisory committee is expected to vote at a meeting in Atlanta next week over whether to recommend that the vaccine be given to boys and young men as well.) The CDC also recommends that anyone who is not in a long-term, mutually monogamous sexual relationship and men who have sex with men to get a hepatitis B vaccination to prevent the infection that can cause liver cancer.
Making young adults more aware of vaccines is also crucial, experts say. A survey released this year by the National Foundation for Infectious Diseases, a nonprofit group funded by unrestricted grants from some vaccine makers, for example, shows only 49% of 18 to 26 year olds know that tetanus causes lockjaw, and that you should be vaccinated against it every 10 years.
Some patient advocacy groups are taking steps to raise awareness of vaccines for specific diseases, including Meningitis Angels (stompingoutmeningitis.com). The group was formed by Frankie Milley of Houston after her son Ryan died at 18 from bacterial meningitis, an infection that can lead to limb amputation, brain damage and death. Because it has been found to strike college students living in dormitories and frequenting crowded bars where smoking takes place, the CDC recommends that students get the meningococcal conjugate vaccine.
Leslie Meigs, a student at the University of St. Thomas in Houston, survived meningitis as a child but was left with chronic kidney disease that eventually required a transplant with a kidney donated by her father. She works with Ms. Milley's group.
"One of the things that young adults may not understand is this isn't a disease that you have and then go on normally with the rest of your life," says Ms. Meigs. "This is a disease that will leave you with after effects until the day you die."
From The Wall Street Journal by Laura Landro
Reviewed / Posted by: Scott W. Yates, MD, MBA, MS, FACP
