Dec 17 2013
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NewPublicHealth Q&A: Litjen Tan, Immunization Action Coalition

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A new report from Trust for America’s Health finds that despite recommendations by medical experts about the effectiveness and safety of vaccines, an estimated 45,000 adults and 1,000 children die from vaccine-preventable diseases each year in the United States.

NewPublicHealth spoke with Litjen (L.J) Tan, MS, PhD, chief strategy officer of the Immunization Action Coalition, to ask about ongoing efforts to improve immunization rates among all age groups across the nation. The Coalition works to increase immunization rates and prevent disease by creating and distributing educational materials for health professionals and the public and facilitates communication about the safety, efficacy, and use of vaccines within the broad immunization community of patients, parents, health care organizations, and government health agencies. The Coalition is supported by the U.S. Department of Health and Human Services.

NewPublicHealth: What are the critical gaps in immunization in the United States—for children and adults?

Litjen Tan: Immunization rates are really high in our childhood population, but generally not at all high in the adult population, though for some vaccines the rates are improving. We are also not doing very well for adolescents. On the broader level I think what the immunization rates reflect is the state of preventive care in the United States when you come out of childhood, which is why I think the Affordable Care Act really is a great boon. We’ve got this wonderful preventive care model for our kids; we take our kids in, we get them their shots, they get protected and we’ve got high coverage rates generally over 90 percent for all major vaccines. We have almost no vaccine-preventable disease in the United States except for instances linked to pockets of populations that haven’t been vaccinated—as we’ve seen recently with measles.

But then we get to adolescence we have this breakdown. Rates for HPV vaccination are not so good. Our meningococcal vaccination rates are not where they should be and neither are the tetanus, diphtheria and pertussis booster rates in adolescents. What happens with the adolescents is parents don’t necessarily bring them in for prevention checkups anymore. We bring them in when there’s a problem or when they need a school sports visit, and so we plant in adolescents this idea that care is no longer about prevention but care is now about acute care, and that persists into adulthood. This is the thinking that stops us from saying, “hey, do I need my vaccines? When should I get them?”

We need to make sure that our adolescents get the idea that vaccines prevent disease and that they actually do have vaccines that are recommended for them and then I think we’ll begin to see an appreciation of immunizations for adults as well.

NPH: Do we need to target both parents and the adolescents themselves?

Tan: Absolutely, but there’s a lot of discussion about how we do that. It gets a little tricky because we push autonomy of the adolescent, and we have a precedent in public health—discussions between providers and adolescents about sexually transmitted infections—but there are a lot of legislative and regulatory barriers against directly talking to an adolescent in the absence of a parent.

With immunizations we need to have both the adolescent and the parent in the room and

I also think we need to start thinking in the immunization world about how we can take some other health campaigns and messaging styles aimed at teens and reach out to the adolescents directly through those means while at the same time educating the parents about these important vaccines.

NPH: How aware are adults that they need vaccines like the flu shots, the pneumococcal vaccine, and the shingles vaccine? How well are they doing in uptake?

Tan: We’re not doing well with all adults. Shingles, in particular, we’re in the teens in terms of coverage, and if you think about Healthy People 2020, we’re nowhere near those goals.  

One area where we’ve especially fallen short is young adults who have chronic conditions and I think that’s an awareness issue. A lot of people think that even though they have diabetes they don’t need extra health help because they are living a normal life, when in fact they especially need certain vaccines such as an annual flu shot and the pneumococcal vaccine. What we have to do is emphasize to providers that they’ve got to be looking out for these patients. Patients look to [their provider for advice]. If they have a chronic condition there’s also a critical opportunity because they’re going to be interacting with the healthcare system a little bit more.

The National Vaccine Advisory Committee just issued a report in September, the Standards for Adult Immunization Practice, a revision of the standards from 10 years ago, and the big paradigm shift is the concept that all providers of care to adults, not just preventive care physicians, should do the following things:

  • Assess the patient for recommended immunizations, strongly recommend those immunizations and provide those recommendations if they can.
  • If they cannot provide those recommendations, refer these patients to an immunizing provider and ensure through follow-up that the patient got vaccinated.

The standards were revised with the participation with a lot of primary care provider groups. We may begin to see a little pushback with the specialty groups — the endocrinologists and cardiologists, for example. Personally I would argue that it is downright shameful if you, as a cardiologist, have patients with chronic heart disease and you are not even assessing their vaccination needs. We know, for example, that if you have a patient with chronic heart disease they’re at an eight-fold higher risk of a heart attack if they develop the flu. So why are they not assessing for that vaccine and providing it? If you don’t want to provide vaccines because you are a specialty practice and carrying vaccines may be tricky for you, it is still within your responsibly to make sure that your patient gets vaccinated. That pushback, though, will be a chance for education and messaging with providers.

NPH: What about an education campaign for adults on vaccines?

Tan: I personally believe that the country is ripe for a national campaign on adult vaccines. Unfortunately, when you talk about that kind of campaign you’re talking about resources that we just don’t have.

What we do is a lot of is targeted education and messaging to adults. For example, focusing on chronic disease is one way we’re working with a lot of groups such as the American Diabetes Association, to try to reach out to the patient advocacy groups and asking them to work with us to provide very targeted messaging to their specific population.

But we are also trying different approaches. Our coalition is co-sponsored by the Centers for Disease Control and Prevention and the National Vaccine Program Office of the U.S. Department of Health and Human Services and the three groups have brought together about 200 stakeholder organizations in adult immunizations to try to improve immunization rates. An important approach is working with providers of all kinds in order to get messages about vaccinations to adults. Those provider partners include pharmacists, home health care workers and long term care providers. There are so many places where we can try to interact with the health system in order to reach out to adults, but it is a challenge.

NPH: How are you dealing with some of the negative and often false messaging that has emerged about childhood vaccines?

Tan: We’ve learned that it is really hard to sell public health, but we’re beginning to do it. We have been living in this academic ivory tower and what we need to understand is that, first, a story doesn’t have to be factual to change minds, and second, a story does not have to be accurate to change emotions or behavior. And I think that for public health and for scientists and physicians to grasp that was a big turning point.

We have begun to recognize that you can talk about science all you want but a good story changes behavior sometimes much better than the science. We’ve recognized is it’s not always about the science anymore, it’s about risk management, it’s about risk communication, and physicians and public health staff are rarely trained in that.

So we’ve now started helping our physicians learn how to communicate and manage risk. There is a risk in any medical intervention but the provider needs to portray that risk in a picture that the parent can understand—the risk of harm is less than one in a million and that is the same risk as being stuck by lighting. So in the examination rooms, those conversations are now happening when they weren’t before. And I think that’s been extremely successful in combating the negative campaigns.

And, so importantly, we’re also engaging parents on social media about childhood vaccinations, which is exactly what the anti-vaccine forces have been doing.

We’re got a whole group out there, Voices for Vaccines, formed by parents whose kids were injured because they weren’t vaccinated and they got a vaccine-preventable disease. We’ve got parents out there now who are willing to come out fight negative stories with positive stories.

NPH: How will the Affordable Care Act help increase the uptake of immunizations?

Tan: Under the Affordable Care Act if there is a recommended vaccine all payers are supposed to provide that vaccine 100 percent free to the patient. Whether a physician or a provider gets reimbursed at an adequate level, that’s something we’ll have to work on as advocates, but for the patient it’s free. There are exceptions to that rule because we will still have some grandfathered plans and states that did not opt in to expand Medicaid, and in those states, there’s a co-pay. But in general most patients will have much better free access to vaccines.

I don’t think we’ve done a good job letting people know about that and about how important prevention is. Vaccines are an incredible prevention intervention that don’t cost you anything. We need to tell people that they’ve actually paid for these benefits through their premiums and it would be silly not capitalize on that.

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Tags: Infectious disease, Infectious diseases, Public policy, Q&A, Vaccines