Vaccinating Adults: A Step-by-Step Guide - Step 1 Getting Started
step 1:Getting StartedIf you work in a setting that serves adults insome way – whether that be an internal medicine,family medicine, or ob-gyn practice, or a pharmacy,family planning clinic, homeless shelter, sexuallytransmitted disease clinic, correctional setting, ordrug treatment proYou could prevent serious gram – you coulddisease, and even death,prevent serious disby offering vaccinations to ease, and even death,by offering vaccinayour patients, clients, ortions to your patients,other adult populations.clients, or other adultpopulations. Increasingly, providing vaccinationservices in multiple types of healthcare settings isseen by public health and immunization experts asone of the best ways to deliver vaccines to adults.In 2004, the Immunization Action Coalition (IAC)first published Adults Only Vaccination: A Step-byStep Guide to help clinicians in a variety of adulthealthcare settings implement programs to vaccinate adults against infectious diseases. This 2017updated edition, Vaccinating Adults: A Step-by-StepGuide (“the Guide”), has been developed to incorporate current information with the expert advicefound in the original publication. But no guideor “how-to” manual is sufficient to train you to be afull-fledged vaccinator. You will need the assistanceof one or two well-trained and experienced healthcare professionals who might already be working inyour healthcare setting. You also can connect withexperienced staff at your state or local health department. A helpful list of state immunization programcoordinators is available through IAC’s website atwww.immunize.org/coordinators.We hope you won’t be intimidated by the seemingcomplexities of vaccination. While it’s true thatthe number of vaccines available and their dosingschedules can be a bit daunting, and official recommendations can change frequently, vaccinationmay be approached on many different levels. Inthe Guide, we address vaccination at its most basiclevel. As you gain experience, you will learn moreabout vaccine recommendations and schedulingintricacies.Print and Internet resources abound to help youkeep up to date with scheduling and other practicalissues. Some of the great resources available fromIAC include: IAC’s website for healthcare professionals atwww.immunize.org. Check this site often for thelatest information to help you stay current. TheClinic Resources web section at www.immunize.org/clinic is an excellent place to nating Adults: A Step-by-Step Guide Immunization Action Coalition www.immunize.org www.vaccineinformation.org
2 step 1:Getting Started Periodic IAC publications IAC Express at www.immunize.org/express.This publication, which is delivered directly toyour email box every week, features importantimmunization developments such as the latestvaccine recommendations and licensures,newly released information from theCenters for DiseaseControl and Prevention (CDC), including new and updatedVaccine Informationwww.immunize.org/expressStatements andpractical vaccination education materials likepatient handouts or staff materials, practicaljournal articles, and more. Be sure to subscribeto IAC Express at www.immunize.org/subscribe.These and other resources will serve you well onceyou are vaccinating, but they reflect a basic vaccination competence that we don’t want to assumehere. They tend to start “in the middle of things”because they are directed at established vaccinators.With the Guide, we want to start where you mightbe now – at the beginning.In this Guide, weassume that:This Guide strips essentialpreventive medicineintervention down to itsbasic steps. you don’t necessarily have thebasic vaccinationcompetencies (although you might); you don’t necessarily know how vaccination services will fit in with your other clinical or programofferings; you have: a community in need of more opportunities to bevaccinated against vaccine-preventable diseases;www.immunize.org/technically-speaking Technically Speaking, at www.immunize.org/technically-speaking, is a monthly columnwritten by IAC Executive Director Deborah L.Wexler, MD. The column is featured in TheChildren’s Hospital of Philadelphia VaccineEducation Center’s monthly Vaccine Update forHealthcare Providers. The content covers practical topics in immunization delivery that arerelevant to all patient ages. You’ll find guidanceabout topics such as needle length, vaccineadministration technique, cold chain issues,and immunization schedules. a motivated staff with at least one part-time orfull-time member who can make time to leadthe vaccination program, as well as one who canlegally (in your state) administer vaccines; and a healthcare setting willing to invest time andeffort to contribute to individual and communityhealth through vaccination.This Guide strips essential preventive medicineintervention down to its basic steps. You currentlyare reading the first of seven steps; subsequentsteps cover important “how to” practices such as: setting up for vaccination services; purchasing vaccines; storing and handling vaccine appropriately; deciding which people should receive whichvaccines; administering vaccines; and maintaining appropriate records.It will all come together – step by step!Vaccinating Adults: A Step-by-Step Guide Immunization Action Coalition www.immunize.org www.vaccineinformation.org
step 1:Vaccination definitely is one of our mostcost-effective medical interventions,generating cost savings through reducedtreatments for illness and hospitalizations.Step 7 of the Guide even provides information aboutthe complex topic of billing for vaccines. Offeringvaccinations may not be a huge income generatorfor your organization. But vaccination definitely isone of our most cost-effective medical interventions,generating cost savings through reduced treatmentsfor illness and hospitalizations. In the best-casescenario, if you complete the necessary paperworkGetting Started3Preventable Diseases (known informally as “ThePink Book”). This essential vaccine reference for allvaccinators can be accessedonline at www.cdc.gov/vaccines/pubs/pinkbook/index.html. The entirebook or individual chaptersmay be downloaded forfree. Soft-cover editions ofthe complete book may bepurchased (when in stock)www.cdc.gov/through the Public Healthvaccines/pubs/pinkFoundation website oductDetails.aspx?productId 27876.Why the emphasis on adult vaccination?and billing, you will receive appropriate reimbursement for vaccinating adults. Medicare has reimbursed providers for influenza and pneumococcalvaccines for many years. Even so, these vaccinesremain woefully underused nationwide, even byMedicare beneficiaries. For adults younger than 65years, most private insurance companies cover thecost of vaccines recommended by CDC’s AdvisoryCommittee on Immunization Practices (ACIP) atno cost to patients. Additionally, many state Medicaid programs cover adult vaccines, and some stateimmunization programs have special programs tosupport adult immunization activities.Need more help? You will want to obtain a copy ofCDC’s Epidemiology and Prevention of Vaccine-The simple answer to this In the U.S., fewer adultsquestion is that adult vacthan children are fullycination needs have suffered from inattention for vaccinated even thoughadults are much morefar too long. It’s time tocomplement our nation’s likely to die from vaccineexcellent immunizationpreventable diseasesinfrastructure for childrenthan are children.and teens with a similarimmunization landscape for adults.In the United States, fewer adults than children arefully vaccinated even though adults are much morelikely to die from vaccine-preventable diseases thanare children. According to the Recommendationsfrom the National Vaccine Advisory Committee: Standards for Adult ImmunizationPractice, available online 35491412900203, there are manyreasons for this oi/pdf/10.1177/003335491412900203Vaccinating Adults: A Step-by-Step Guide Immunization Action Coalition www.immunize.org www.vaccineinformation.org
4 step 1:Getting Started Healthcare providers as well as patients may lackknowledge about the need for vaccinating bothhigh-risk and healthy adults. All too often, adultsthink vaccines are “just for kids.” When adults receive care, medical managementof acute and chronic illnesses usually receivespriority over preventive services. Assessing thepatient for recommended vaccines may not evenbe considered. Many adults do not visit a clinician regularly, orthey do not have a primary care provider, or theychange providers often. As a result, their immunization status simply falls through the cracks.Even patients with chronic medical conditions thatplace them at high risk for complications fromvaccine-preventable diseases often see severaldifferent specialists, none of whom takes primary responsibility for immunization, and all ofwhom can mistakenly assume that vaccination issomeone else’s job. Some providers do not offer vaccines, or they maynot offer all the vaccines recommended for adults. Provider payment systems can be complicated,confusing, or inadequate.“Adult immunization rates in theUnited States are embarrassingly low. . . .We can and must do better.”– L.J Tan, MS, PhDChief Strategy Officer, Immunization Action CoalitionIn spite of these challenges, it is critical that weimprove our adult immunization levels. As notedby L.J Tan, MS, PhD, chief strategy officer, Immunization Action Coalition, “Adult immunization ratesin the United States are embarrassingly low. Asa result, thousands of adults will die from vaccinepreventable diseases this year, and hundreds ofthousands more will be hospitalized. We can andmust do better.” You and your healthcare setting canmake a difference by vaccinating adults.Indeed, in contrast to adult levels, vaccine coverage levels for children at kindergarten entry exceed90 percent in almost all places in the United States.Consequently, disease rates for almost all childhood vaccine-preventable diseases have decreasedby 95 to 100 percent. This includes rates for pneumococcal disease, for which the childhood vaccinehas been available since 2002. That is dramaticprogress in improving children’s health. We want tohave the sameeffective results foradults.It’s clear we haveour work cut outfor us. CDC’s 2 015adult immunizationcoverage estimates(released in 2017)indicate less thanone-half (44.8%) ofadults age 19 orolder have receivedtheir annual influenza vaccine, and less than onefourth (23.0%) of adults age 19 to 64 who are athigh risk for pneumococcal disease have ever beenvaccinated against pneumococcal infection. Similarly, only 3 in 10 (30.6%) of adults age 60 yearsor older have received herpes zoster (shingles)vaccine. Just 2 in 5 (41.6%) of young women age19 to 26 have received even one of the three recommended doses of human papillomavirus (HPV)vaccine, which can prevent cervical cancer. Finally,only 23.1% of adults age 19 and older for whomvaccination could be assessed have received theirrecommended dose of tetanus-diphtheria-pertussis(Tdap) vaccine. In addition, racial and ethnic disparities were apparent for all vaccines.Vaccinating Adults: A Step-by-Step Guide Immunization Action Coalition www.immunize.org www.vaccineinformation.org
step 1:Getting Started5Adults need different vaccines based on theirhealth, age lifestyle, and occupational factors– unlike most children, who need vaccinesbased on age alone.We must improve these rates. By picking up theGuide, you’ve already taken an important first stepin making a difference in adult vaccination coverage. With four simple actions, you can have a hugeimpact on adult vaccination rates:available online at lt-combined-schedule.pdf. Whenyou visit the site, you’ll see that there are two tablesof recommendations: one group of recommendations is based on age group, while the other is basedon the medical and other conditions of your patient.Multiple footnotes explain the details of the recommendations. This may look a little intimidating atfirst. However, after you take a few minutes to review theinformation, you’ll find it’s notas overwhelming as it mighthave first appeared. You’ll alsofind some great tools to helpwith your assessment of adultvaccinations needed, suchwww.immunize.org/as IAC’s Which Vaccines Do INeed Today? and other screen- catg.d/p4036.pdfing checklists, available at www.immunize.org/handouts/screening-vaccines.asp. And, as we willdiscuss later in the Guide, your state’s immunizationinformation system (registry) or your electronicmedical record system may include tools to help youdetermine whichYour state’s immunizationvaccinations yourinformation system or your patient needs.electronic medical recordAll of these toolssystem may include tools help with vaccinations neededto help you determinetoday and duringwhich vaccinations yourfuture visits.your name Assess the immunization status of all yourpatients during every clinical encounter; Provide a strong recommendation for vaccinesthat your patients need;date of birth month /day/yeartoday’s date month /day/year Which Vaccines Do I Need Today?Vaccines are an important part of helping you stay healthy. Which of these recommended vaccines doyou need? 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One size does not fit all.But the good news is that there are many resourcesavailable to help you assess your patient’s vaccineneeds.Each February, CDC announces the availability ofthe adult immunization schedule in the Morbidityand Mortality Weekly Report (MMWR). The currentrecommended adult immunization schedule isn , DP D ZRPDQ WKLQNLQJ DERXW D IXWXUH SUHJQDQF\ DQG GRQôW NQRZ LI ,ôP LPPXQH WR UXEHOOD n , DP D KHDOWKFDUH ZRUNHU , KDYH UHFHLYHG 005 RU , GRQôW UHPHPEHU LI , KDYH UHFHLYHG PRUH WKDQ DQG , GR QRW KDYH D ODE FRQƫUPHG UHSRUW VKRZLQJ WKDW , DP LPPXQH WR PHDVOHV PXPSV DQG RU UXEHOOD I was born in 1957 or later and:n , KDYH QHYHU UHFHLYHG 005 YDFFLQH RU , GRQôW UHPHPEHU LI , KDYH n , KDYH UHFHLYHG RQO\ 005 DQGn , DP HQWHULQJ FROOHJH RU DQRWKHU W\SH RI VFKRRO DIWHU KLJK VFKRRO n , DP SODQQLQJ RQ WUDYHOLQJ RXWVLGH WKH 8 6 continued on next page ľTHFKQLFDO FRQWHQW UHYLHZHG E\ WKH &HQWHUV IRU 'LVHDVH &RQWURO DQG 3UHYHQWLRQImmunization Action Coalition Saint Paul, Minnesota 651-647-9009 www.immunize.org www.vaccineinformation.orgZZZ LPPXQL]H RUJ FDWJ G S4 SGI ,WHP 34 patient needs.Vaccinating Adults: A Step-by-Step Guide Immunization Action Coalition www.immunize.org www.vaccineinformation.org
6 step 1:Getting StartedThe Guide does not discuss vaccinesfor children or travelersWe have limited the Guide to routine vaccinationsrecommended for adults, defined as people who areat least 19 years of age. We also have not includedinformation on vaccinations required for international travel. If your patient is traveling to differentcountries, immunization information can be foundon CDC’s travel website, wwwnc.cdc.gov/travel.Concluding thoughtsWith a little planning, vaccinatingadults is surprisingly manageable.With a little planning, vaccinating adults is surprisingly manageable – and not so surprisingly, thisplanning is extremely important. Now that you haveread this introduction and are motivated to becomea vaccinator or increase the number of vaccinesyou currently provide, you are ready to develop yourvaccination services program, one step at a time.Both you and the adults you protect from vaccinepreventable diseases in the months and years tocome will be glad you did.Vaccinating Adults: A Step-by-Step Guide Immunization Action Coalition www.immunize.org www.vaccineinformation.org
step 1:Getting Started7step ₁ : getting startedMaterials and Resources for You to Use Tools for ProvidersRecommendations from the National Vaccine Advisory Committee: Standards for Adult ImmunizationPractice (NVAC) – 491412900203Adult Vaccination Web Section (IAC)www.immunize.org/adult-vaccinationClinic Resources Web Section (IAC)www.immunize.org/clinicRecommended Adult Immunization Schedule, UnitedStates (CDC) – lt-combined-schedule.pdfConversations: Improving Adult ImmunizationsRates Using Simple and Strong Recommendations(AAFP) – ons/video.htmlStandards for Adult Immunization Practice standards/index.htmlEpidemiology and Prevention of Vaccine-PreventableDiseases (“The Pink Book”) Standards for Adult Immunization Practice standardsGuide to Adult Immunization to-adult-immunizationStrategies to Improve Adult Vaccination Coverage(IAC) – www.immunize.org/catg.d/p2050.pdfSuggestions to Improve Your Immunization Services(IAC) – www.immunize.org/catg.d/p2045.pdf Additional Provider ResourcesImmunizations (AAFP) – ons.htmlImmunizations: You Call the Shots dult Immunization n Webinar Series ation-webinar-seriesAdult Vaccination Information for Healthcare andPublic Health Professionals unizing Adult Patients: Standards of Practice(CDC) – s-immz-adults.pdfAdult Vaccination Resources: For Provider Practices(CDC) – .htmlNational Adult Immunization Plan al-adultimmunization-plan/naip.pdfnote: The publisher of each resource is shown as an acronymin the parentheses following the title. A key to these acronymsis included in Appendix A: Acronyms and Abbreviations.The Vaccine Handbook: A Practical Guide forPhysicians (“The Purple Book”) ed on next page Vaccinating Adults: A Step-by-Step Guide Immunization Action Coalition www.immunize.org www.vaccineinformation.org
8 step 1:Getting Startedstep 1: getting startedMaterials and Resources for You to Usecontinued from previous page Information for Patients General InformationFactsheets on Immunization Topics (NFID)www.nfid.org/publications/factsheetsAdult Vaccination Web Section (NFID)www.adultvaccination.orgHandouts for Patients and Staff (IAC)www.immunize.org/handoutsIAC Express (IAC) – www.immunize.org/expressVaccinate Your Family (ECBT)www.vaccinateyourfamily.org/adultsVaccine Information for the Public (HHS)www.vaccines.govVaccine Information for the Public (IAC)www.vaccineinformation.orgnote: The publisher of each resource is shown as an acronymin the parentheses following the title. A key to these acronymsis included in Appendix A: Acronyms and Abbreviations.Immunization Action Coalition (IAC)www.immunize.orgNational Adult and Influenza Immunization Summit(NAIIS) – www.izsummitpartners.orgState Immunization Program Manager Contacts(AIM) – www.immunizationmanagers.org/?MemPageSubscribe to IAC Express (IAC)www.immunize.org/subscribeTechnically Speaking ing Adults: A Step-by-Step Guide Immunization Action Coalition www.immunize.org www.vaccineinformation.org
step 1:Getting Started9To access issues of IAC Express, visitwww.immunize.org/expressFor a free subscription to IAC Express, visitwww.immunize.org/subscribeVaccinating Adults: A Step-by-Step Guide Immunization Action Coalition www.immunize.org www.vaccineinformation.org
10 step 1:Getting StartedTo access the current, ready-to-copy version of this piece, ndards-immz-adults.pdfImmunizing Adult Patients:Standards for PracticeYour patients trust you to give them the best advice on how to protect their health. Vaccinepreventable diseases can result in serious illness, hospitalization, and even death.Make adult vaccination a standard of care in your practice.Your patients have probably notreceived all the vaccines they need.Make Immunization a Standard ofPatient Care In Your Practice:Even though most insurance plans cover the cost ofrecommended vaccines, adult vaccination rates in the U.S. areextremely low. Each year, tens of thousands ofadults needlessly suffer, are hospitalized,and even die as a result of diseases thatcould be prevented by vaccines.1. ASSESS the immunization status of all your patientsat every clinical encounter. Stay informed about the latest CDC recommendationsfor immunization of adults. Implement protocols in your office to ensure thatpatients’ vaccine needs are routinely reviewed andpatients get reminders about vaccines they need.Your patients maynot even realize thatthey need vaccines.Many adults don’t know which vaccinesare recommended for them throughouttheir lives. Many also report notreceiving vaccine recommendationsfrom their healthcare professional.You can makea difference.Clinicians are the mostvalued and trusted sourceof health information foradults. Research showsthat most adults believevaccines are important and thata recommendation from theirhealthcare professional is a keypredictor of patients gettingneeded vaccines.Overview of Recommended Vaccines for Adults*2. Strongly RECOMMEND vaccines that yourpatients need. Address patient questions and concerns in clear andunderstandablelanguage.VACCINEWHO NEEDS IT Highlightexperiences with vaccinationALL AdultsSeasonal your positive(personalInfluenzaor in your practice).3. ADMINISTERneededvaccinesREFERyour a dose since age 11 or olderTdapALL Adultswhoorhavenot receivedpatients to a vaccination provider.Women should receive during every pregnancy For vaccines that you stock, make vaccination servicesasTdconvenient as possiblefor your patients.ALL Adults For vaccines that you don’t stock, refer patients toZoster in the areaAdultsyearsor older services.providersthat60offervaccinationCS HCVG15-ADU-129 07/26/20161 dose (All)1 dose each pregnancy1 dose every 10 years1 dose4. DOCUMENTvaccinesreceivedyour patients.Adult65 yearsbyor olderPneumococcalConjugate in your state’s immunization registry to Participatehelp your office, yourpatients,and yourwithpatients’otherAdults64 or youngercertainmedical conditions (HIV, asplenia, sickle cell disease,providers know whichvaccines yourhave had.cerebrospinalfluid patientsleaks, cochlearimplants, or conditions that cause weakening of the Follow up to confirmthat patientsimmunesystem) receivedrecommended vaccines that you referred them to getPneumococcal Adults 65 years or olderfromother immunization providers.PolysaccharideHPVStandards for Adult Immunization Practice emphasize the role of ALL healthcareprofessionals—whether they provide immunization services or not—in ensuringthat adult patients are fully immunized. These standards are published by theNational Vaccine Advisory Committee and supported by the Centers for DiseaseControl and Prevention as well as a number of national medical associations.NUMBER OF DOSES1 dose every year1 dose (if notpreviously received)1 dose (if notpreviously received)1 doseAdults 64 years or younger with certain medical conditions and who are at higher riskof infection1 or 2 dosesAdults 26 years or younger who have not started or finished the vaccine series3 dosesMeningococcal Adults who have not had the vaccine and are at risk for exposure or havedamaged spleen1 or more dosesMMRAdults born during or after 1957 who have not had the vaccine or do not havedocumented evidence of immunity1 or 2 dosesVaricellaAdults who have not had chickenpox or do not have documented evidence of immunity 2 dosesHep AAdults who are at risk and have not had the vaccine seriesHep BCentersfor DiseaseAdults who have nothadthe vaccine series and who are at risk, including adults withControl and Preventiondiabetes, end-stage kidney disease, chronic liver disease, or behaviors that increase risk3 dosesHibAdults with special health conditions (sickle cell disease, HIV/AIDS, removal ofthe spleen, bone marrow transplant, or cancer treatment with drugs) who havenot already had the vaccine1 doseDON’T WAIT.VACCINATE!U.S. Department ofHealth and Human Services2 doses*Visit www.cdc.gov/vaccines/schedules/ for a detailed schedule of recommended vaccines and guidelines for administration.Coverage of Adult VaccinesMost private health insurance plans cover the cost of recommended vaccines. If your patientsdo not currently have health insurance, refer them to www.HealthCare.gov to learn more abouthealth coverage options.For patients 65 years or older enrolled in Medicare, Medicare Part B covers the cost of influenzaand pneumococcal vaccines as well as Hep B vaccine for persons at increased risk of hepatitis.Those with a Medicare Prescription Drug Plan (Part D) or enrolled in a Medicare Advantage Plan(Part C) that offers Medicare prescription drug coverage may also have coverage for additionalvaccines like zoster, MMR, and Tdap. Visit www.Medicare.gov for more information.Vaccine coverage for Medicaid beneficiaries varies by state. Contact your State Medicaid Agencyfor more information.For additional information on adultimmunization and resources for patient education,visit: www.cdc.gov/vaccines/hcp/adults.In 2014: Only 20% of adults19 years or older hadreceived Tdap vaccine. Only 28% of adults60 years or older hadreceived zoster vaccine. Only 20% of adults19 to 64 years at highrisk had receivedpneumococcal vaccine.Source: National HealthInterview Survey, 2014.Last Updated May, 2016Vaccinating Adults: A Step-by-Step Guide Immunization Action Coalition www.immunize.org www.vaccineinformation.org
step 1:Getting Started11To access the current, ready-to-copy version of this piece, visitwww.immunize.org/catg.d/p2050.pdfStrategies to Improve Adult Vaccination CoverageMany vaccines are recommended for adults, but vaccines don’t work unless weget them into the arms of the people who need them. Despite the fact that thereDUH VDIH DQG HƪHFWLYH YDFFLQHV GLVHDVHV WKDW FDQ EH SUHYHQWHG E\ WKHVH YDFFLQHV continue to take a huge toll among adults in the United States.Low adult vaccination coverage rates occur for a variety of reasons, including lowcommunity demand for vaccines, lack of access to vaccination services, and systemand provider-related factors. Successful adult vaccination delivery depends onseveral patient and provider factors, aswell as system issues, such as vaccineeffective strategiessupply and reimbursement.Strategies to Improve Adult Vaccination Coverage (continued)Adults are unlikely to seek vaccination unless they believethat the disease is a threat to them and that there is avaccine that can prevent the disease. They need to knowthat they are personally at risk. Even if they know a vaccineis available, adults also may have misconceptions aboutpage 2the vaccine and inordinate concerns about vaccineadverse reactions.Unequivocal providerrecommendationStanding orders protocolsReminder and recallsystemsAssessment and feedback5HPL
first published Adults Only Vaccination: A Step-by-Step Guide to help clinicians in a variety of adult healthcare settings implement programs to vacci-nate adults against infectious diseases. This 2017 updated edition, Vaccinating Adults: A Step-by-Step Guide ("the Guide"), has been developed to incor-
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