Vaccines are among the simplest, most effective, and least expensive ways to prevent serious, and often deadly, diseases. Yet vaccination seems to be an afterthought for many adults.
It’s time to shift that thinking and elevate vaccines to the scientific and technological zenith they deserve as one of the greatest advances of the 20th century, one that now has the potential to prevent some types of cancer. Such a shift would align scientific fact and medical expertise with public health policies and practices.
For many adults — especially those who are older, those with other significant medical conditions, or those who are pregnant — vaccination should be a cornerstone of preventive health care. Yet adult immunization rates in the U.S. are low: Under half of adults receive most vaccines recommended for them, and rates have been relatively steady since 2010.
There are several reasons for this. Many adults aren’t aware they need vaccines. Health care providers often don’t routinely assess their patients’ vaccination status or clearly communicate national recommendations for vaccination. Common adult vaccines often aren’t stocked in clinical offices. And as is true with so many other facets of health care in the United States, non-Hispanic black, Asian, and Hispanic adults have lower immunization rates than whites.
When it comes to adult immunizations, recommendations from the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices (ACIP) or from the myriad of respected professional medical societies, including the American Cancer Society, the American Medical Association, and the American Academy of Pediatrics, are not sufficient to improve adult vaccination rates. We need to see a broad shift in culture and policy at local, state, and federal levels.
This shift must start with policies around childhood vaccines, because these lay the groundwork for adult vaccinations. We have seen gains in this area with the establishment of the CDC’s Vaccines for Children program to address socioeconomic barriers to vaccination for those under 18 years of age. Vaccine proponents have advocated for commonsense legislation around school-based requirements for vaccines that include tightening vaccine exemption rules in many states. In addition, some states permit adolescent minors to make independent decisions to consent to vaccination.
Similar advances are needed for adult immunizations. For example, catch-up vaccination against the human papillomavirus (HPV), which can cause cancers of the cervix, vulva, vagina, penis, anus, and throat, could be included in the federally funded National Breast and Cervical Cancer Early Detection Program. This program, developed in the 1990s to reduce deaths from breast and cervical cancer, has provided access to cervical cancer screening for thousands of women since its inception. It is remiss for it not to incorporate HPV immunization.
In many states, this program provides access to Pap screens and HPV testing for uninsured women, some of whom are undocumented. They can benefit tremendously from HPV immunization, especially if they are within the catch-up immunization ages of 13 to 26 years, and even if they are between 27 and 45 years of age. Inclusion of the HPV vaccine for uninsured adults, who are not eligible for the Vaccines for Children program, would ultimately save money by reducing the number of abnormal cervical cancer screening results later on that require follow-up and procedures.
Paying for adult immunization is fraught with challenges.
Many medical practices cannot afford to stock and manage vaccine supplies. State purchasing of ACIP-recommended vaccines could help alleviate that burden.
Pharmacies can also play a role. Many pharmacies currently administer the flu vaccine. Embracing a broader spectrum of ACIP-recommended vaccines, including the HPV vaccine, could improve adult vaccination rates. For that to happen, though, resources must be provided to shore up state immunization information systems, also known as vaccine registries. These confidential, population-based computerized databases record vaccine administrations and consolidate immunization information from different locations.
In many states, the structure of Medicaid impedes adult vaccination. Although the Affordable Care Act requires Medicaid to cover all ACIP-recommended vaccines, the system for administering them is fragmented. In some situations, vaccines are considered a pharmacy prescription benefit, so administering them using supplies stocked by a clinician’s office will be reimbursed at a lower rate than if the vaccine was given by or obtained from a retail pharmacy.
Many vulnerable or sick patients end up in the emergency department or are admitted to the hospital. This should be seen as an opportunity to help them get back on track with preventive care, everything from blood pressure or diabetes management to needed vaccinations. Yet it often isn’t possible to access recommended vaccines from inpatient hospital formularies because they tend not to reimbursed as part of inpatient care.
That leads to a broken cycle in which hospitals identify vaccines as “ambulatory care,” ambulatory care offices provide adult vaccines with great variability or identify them as “pharmacy care,” and pharmacy administration of a broad spectrum of vaccines remains tenuous. Where can an adult reliably go to access essential preventive health?
It is long past time that the U.S. invests in a modern-day immunization infrastructure. This would leverage advanced information technology for identifying children and adults needing vaccination and consolidate vaccination history across locations and delivery systems; create innovative ways to finance and supply vaccines; and use proven preventive health delivery programs to minimize missed opportunities to immunize individuals of all ages against vaccine-preventable diseases.
Sangini S. Sheth, M.D., is an assistant professor of obstetrics, gynecology, and reproductive sciences at Yale School of Medicine.