Continuing education

Can Increasing Adult Vaccination Rates Reduce Lost Time and Increase Productivity? Chad Rittle, DNP, MPH, RN, FAAOHN

ABSTRACT This article addresses limited vaccination coverage by providing an overview of the epidemiology of influenza, pertussis, and pneumonia, and the impact these diseases have on work attendance for the worker, the worker’s family, and employer profit. Studies focused on the cost of vaccination programs, lost work time, lost employee productivity and acute disease treatment are discussed, as well as strategies for increasing vaccination coverage to reduce overall health care costs for employers. Communicating the benefits of universal vaccination for employees and their families and combating vaccine misinformation among employees are outlined. [Workplace Health Saf 2014;62(12):508-515.]

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n June 2011, the Centers for Disease Control and Prevention (CDC) announced that “expanded vaccination coverage is one of the most cost-effective ways to advance global welfare” (CDC, 2011, p. 814). However, a significant cost burden remains for employers and employee families due to the incidence of influenza, pertussis, and pneumonia in the community. This article addresses the problem of limited vaccination coverage by providing an overview of the epidemiology of influenza, pertussis, and pneumonia, and the impact these diseases have on work attendance for the worker, the worker’s family, and employer profit. Second, studies focused on the cost of vaccination programs, lost work time, lost employee productivity, and acute disease treatment and strategies for increasing vaccination coverage to reduce overall health care costs for employers are discussed. Finally, strategies for communicating the benefits of universal vaccination among employees and their families and techniques for combating vaccine misinformation among employees are outlined. INFLUENZA According to the CDC, the influenza virus attaches itself to and penetrates respiratory epithelial cells in the trachea and bronchi. Its incubation period is 1 to 4 days ABOUT THE AUTHOR

Dr. Rittle is Assistant Professor, Chatham University, Pittsburgh, Pennsylvania. Submitted: February 17, 2014; Accepted: July 28, 2014; Posted online: September 16, 2014 The author has disclosed no potential conflicts, financial or otherwise. Correspondence: Chad Rittle, DNP, MPH, RN, FAAOHN, 1825 Foxcroft Lane, Unit 406, Allison Park, PA 15101. E-mail: [email protected] doi:10.3928/21650799-20140909-02

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(usually 2 days) and 50% of infected individuals develop symptoms, with viral shedding in respiratory secretions for 5 to 10 days. Although children transmit influenza for 10 or more days, it is typically contagious among adults from the day before symptom onset to approximately 5 days after symptoms begin (CDC, 2012a). The “classic” symptoms of influenza include abrupt fever (usually 101°F to 102°F), prostration, myalgia (mainly in back muscles), non-productive cough (the result of tracheal epithelial destruction), rhinitis, headache, sensitivity to light, and substernal chest burning. Symptoms generally last from 2 to 3 days but rarely more than 5 days. Although aspirin or acetaminophen may decrease symptoms, anti-viral medications are also often used. Recovery is usually rapid, but some workers may have lingering depression and asthenia and lack strength or energy for several weeks. The most common complications of influenza are secondary bacterial pneumonia, myocarditis, and worsening of chronic bronchitis and other chronic pulmonary diseases with death reported in 0.5 to 1 per 1,000 cases, the majority of deaths being among individuals 65 years of age and older. An association between influenza and morbidity in high-risk adult populations has been documented (CDC, 2012a). Hospitalization for adults with high-risk health conditions increases twofold to fivefold during major influenza epidemics (CDC, 2012a) (Table 1). Primary influenza viral pneumonia is an uncommon complication with a high fatality rate. The virus is transmitted via respiratory droplets, and disease activity has a “temporal pattern” peaking between December and March, although activity may occur earlier or later (CDC, 2012a) (Figure 1).

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TABLE 1

Hospitalization Rates (per 100,000) for Influenza by Age and Risk Groupa Age Group 0 to 11 months

High Risk

Not High Risk

1,900

496 to 1,038

1 to 2 years

800

186

3 to 4 years

320

86

5 to 14 years

92

41

15 to 44 years

56 to 110

23 to 25

45 to 64 years

392 to 635

13 to 23

≥ 65 years

399 to 518

125 to 228

a

Data from several studies, 1972 to 1995. Note: From Centers for Disease Control and Prevention. (2012a). Epidemiology and prevention of vaccine—Preventable diseases (12th Ed.). Atlanta: Author.

Influenza Vaccine Efficacy and Projected Cost Savings

Influenza vaccine efficacy often will vary depending on timing of administration and the match of the vaccine to viral strains in circulation (High, 2007). Although influenza vaccine has reduced all-cause mortality between 39% (95% confidence interval [CI]: 19 to 53) and 69% (95% CI: 56 to 79), if annual immunization is interrupted in older adults, the risk of death increased to 40% above baseline (High, 2007) with the reduction of risk returning upon resumption of annual vaccination. A more recent meta-analysis of influenza vaccine efficacy published in 2012 by Osterholm, Kelley, Sommer, and Belongia reported a pooled influenza vaccine efficacy of 59% (95% CI: 51 to 67) through eight studies over 12 influenza seasons. Osterholm et al. reported little evidence for efficacy in adults aged 65 years and older. Prosser et al. (2011) used a computer model to predict costs and health outcomes for a pandemic H1N1 vaccination campaign using inactive vaccine versus no vaccination. Cost-effectiveness ratios ranged from $8,000 to $52,000 per quality-adjusted life years (QALY), depending on age and risk status of individuals without high-risk conditions when vaccinated prior to an outbreak. Results were sensitive to the quantity of doses needed, costs to vaccinate, and the timing of vaccination delivery. Some other significant findings included: (1) the higher the attack rate, the more cost savings; (2) cost-effectiveness ratios were least favorable for those 65 years and older; and (3) the lowest cost-effectiveness ratios were impacted by lower attack rates, higher costs, timing of vaccination, and if the age group required one or two doses of vaccine (Prosser et al., 2011). The authors recommended early vaccination to promote better cost effectiveness. Indirect Costs of Influenza

Indirect costs associated with influenza are not readily defined. Appleby (2009) noted that many individuals

Figure 1. Month of peak influenza activity United States, 1976-2008. From Centers for Disease Control and Prevention. (2012a). Epidemiology and prevention of vaccine–Preventable diseases (12th Ed.). Atlanta: Author. Retrieved from: http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/flu.pdf

avoid influenza by staying home and avoiding contact with others, resulting in substantial indirect costs. These factors are rarely included in cost-benefit studies and may increase cost savings if considered in future studies. Similarly, a 2012 study conducted by Tora-Rocamora et al. in Spain could not tabulate worker absence costs due to the lack of information on duration of illness or individual worker base pay. Effectiveness of Influenza Vaccination Programs for Working Adults

In the population ages 50 to 64 years, Nichol, D’Heilly, Greenberg, and Ehlinger (2009) found, among unvaccinated participants, influenza-like illness was responsible for 45% of illness days during the influenza season, 39% of lost workdays, and 49% of illness-related reduced job productivity, resulting in on-the-job productivity losses. The researchers associated vaccination with a significant reduction in the rate of influenza-like illness (adjusted odds ratio: 0.48; 95% CI: 0.27 to 0.86), resulting in fewer days of illness and less absenteeism. They concluded the 50-to-64-year age group should be targeted as high priority in future vaccination programs. Cost Savings of Employer-Sponsored Influenza Immunization Clinics

Zimmerman et al. (2012) published an analytic modeling study and Monte Carlo simulation estimating the single-season costs associated with worksite influenza clinics. For a firm of 50 employees, cost savings for an inactivated vaccine versus no vaccine were $6.41 when vaccine effectiveness was 70% with intermediate transmissibility. In a scenario offering a choice of vaccines versus inactivated vaccine, the cost savings was $1.48. A third scenario evaluated the cost of vaccination if employees were offered vaccine choice plus an incentive versus an inactivated vaccine, and the cost savings was $1.84 for each dose given. In general, Zimmerman et al. reported that clinics offering a choice of

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Figure 2. Timeline of pertussis disease progression. From the Centers for Disease Control and Prevention website (http:// www.cdc.gov/pertussis/about/signs-symptoms.html).

ing adults younger than 65 can reduce the rates of influenza-like illness (ILI), lost workdays, and physician visits during years when the vaccine and circulating viruses are similar, but vaccination may not provide overall economic benefits in most years” (p. 1655). Newall, Kelly, Harsley, and Scuffham (2009) reviewed economic evaluations for the 50-to-64-year age group and found a lack of transparency in the cost effectiveness of influenza vaccine in the age group, concluding that cost effectiveness should be interpreted with caution. Gatwood et al. (2012) reported on a review of several studies that suggested seasonal influenza vaccination of healthy, working-age adults is generally not cost saving, requiring an investment to generate health benefits. They concluded that “the decision to vaccinate such a group will depend upon the societal and payer valuation of those benefits” (p. 36).

Figure 3. Changes in pertussis reporting by state from 2012-2013. From the Centers for Disease Control and Prevention website (http://www.cdc.gov/pertussis/outbreaks/ trends.html).

vaccines were slightly less costly under a number of scenarios and that incremental costs were “lower (1) in larger firms; (2) when influenza was assumed to be more contagious; and (3) when vaccine effectiveness was assumed to be higher” (p. 1107). The authors concluded that “employer-sponsored workplace vaccination is a cost-saving intervention with the potential to reduce the burden of influenza disease and its accompanying lost productivity in both small and large firms” (p. 1115). Zimmerman et al.’s team also noted that offering a choice of vaccines, with or without incentives, can result in higher employee vaccination rates and lower disease transmission rates, resulting in additional cost savings under many scenarios. Opposing Views

A few contrary views were also found. Bridges et al. (2000) noted that “influenza vaccination of healthy work-

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PERTUSSIS Pertussis, or whooping cough, is caused by the Bordetella pertussis bacterium. Pertussis is primarily a toxinmediated disease; the bacterium attaches to and invades the epithelial cells, the toxins paralyze the cilia, and inflammation interferes with clearing pulmonary secretions (CDC, 2012a). The incubation period is 7 to 10 days, and can range from 4 to 21 days but rarely longer than 42 days. Clinical features present in three distinct stages. The first (catarrhal) stage includes rhinitis, sneezing, lowgrade fever, and a mild, occasional cough lasting for 1 to 2 weeks. For many, the symptoms may mimic the beginning of a “cold.” The disease then progresses to the second (paroxysmal) stage; workers experience numerous rapid coughs, more frequently at night and with difficulty expelling thick mucus. Other symptoms include a long, inspiratory effort, usually with a high-pitched “whoop” (more frequent at night). Workers may become cyanotic with an average of 15 attacks during each 24-hour period. Vomiting and exhaustion commonly follow these attacks,

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Figure 4. Risk ratios and incidence rates for pertussis by year of follow-up post fifth-dose DTaP, Minnesota (MN) and Oregon (OR), 2010. Reproduced with permission from Tartof, S., Lewis, M., Kenyon, C., White, K., Osborn, A., Liko, J., . . . Skoff, T. (2013). Waning immunity to pertussis following 5 doses of DTaP. Pediatrics, 131, e1047-e1052. doi: 10.1542/peds.2012-1928 © 2010 by the AAP

which typically last from 1 to 6 weeks but may persist for up to 10 weeks. The third (convalescent) stage is a gradual recovery with the cough becoming less paroxysmal, often disappearing in 2 to 3 weeks. Respiratory infections may recur for many months, explaining the label, “the 100days cough.” Although pertussis is often milder in older age groups, infected adults often transmit the disease to susceptible family members, including unimmunized or incompletely immunized infants. Figure 2 is a timeline of pertussis disease progression (CDC, n.d.a). Pertussis cases reached a low between 1980 and 1990 when fewer than 2,900 cases per year were reported (CDC, 2012a). In recent years, adolescents (ages 11 to 18 years) and adults (ages 19 years and older) have accounted for an increasing proportion of pertussis cases, partially due to improved recognition and reporting for these age groups (CDC, 2012a). In 2012, 41,880 cases were reported, resulting from multiple outbreaks nationwide during the year (CDC, 2013b). Figure 3 graphically presents increases in reported pertussis cases from 2012 to 2013 (CDC, n.d.b). Complications of pertussis include secondary bacterial pneumonia for which young infants are at highest risk, difficulty sleeping, urinary incontinence, rib fracture, and neurological complications including seizures and encephalopathy caused by hypoxia from coughing and toxins (CDC, 2012a). Waning Pertussis Vaccine Effectiveness

Despite high coverage rates among children for the DTaP acellular pertussis vaccine, pertussis rates in the 7- to 10-years age group have increased substantially in recent years (Tartof et al., 2013). This higher rate may be due to waning efficacy from five doses of the DTaP vaccine. Tartof et al. suggested that waning pertussis vaccineinduced immunity is occurring before the recommended age of 11 to 12 years for an adolescent booster dose. Figure 4 details how risk ratios and incidence rates increase by the fifth year after the last dose of DTaP vaccine. Between the fourth and sixth year after administration of the

fifth dose of DTaP vaccine, a considerable increase in risk and incidence was documented in Minnesota and Oregon. Direct and Indirect Pertussis Outbreak Costs

Outbreaks of pertussis can be costly to U.S. employers. Baggett et al. (2007) estimated the cost of a 500-bed tertiary hospital-based pertussis outbreak was $195,342 in direct costs and $68,015 in indirect costs, totaling $263,357 for the six cases identified (i.e., $43,893 per case). The investigation noted that 738 individuals were potentially exposed, with a cost per person exposed of $357. Another 250-bed pediatric facility incurred $71,130 in direct costs and $50,000 in indirect costs, totaling $121,130 for a pertussis outbreak, with a cost-per-case of $30,282 for each of the four cases identified. The net number of exposures was 737 for a cost per individual exposed of $164. Cost differences were the result of higher personnel costs (Baggett et al., 2007). A similar study by Zivna et al. (2007) identified direct and indirect costs of a pertussis outbreak, including low and high estimates of investigation and management time from October 2003 to September 2004. Screenings were conducted on 353 medical center employees with 296 identified as having probable or definitive exposures and 287 health care workers receiving treatment or prophylaxis for pertussis infection. Direct costs totaled $13,416, personnel costs ranged from $19,500 to $31,190, and indirect costs ranged from $52,300 to $451,300. Total estimated costs for this outbreak ranged from $85,066 to $98,456. Clearly, pertussis outbreaks can result in significant costs to employers. Cost Effectiveness of Pertussis Vaccination Programs

In 2007, Lee et al. published a study using pertussis incidence data and a Markov model to evaluate the cost effectiveness of adult vaccination under three scenarios: no adult pertussis vaccination, one-time adult vaccination at 20 to 64 years of age, and adult vaccination with boosters every 10

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years. With an incidence of 360 cases per 100,000, the onetime strategy would prevent 2.8 million cases, vaccinate 106 million adults (64% of the cohort), and cost $2.1 billion. The 10-year booster strategy would vaccinate 335 million, prevent 8.3 million cases, and cost $6.7 billion. The researchers concluded that “vaccination of adults aged 20 years to 64 years would be cost effective with a pertussis incidence of greater than 120 per 100,000 population” (p. 186). Although the incidence of pertussis in the United States is rarely this high (e.g., 2012 incidence nationally was only 15.4 per 100,000 [CDC, 2013a]), incidence could be higher in individual states. In the 2012 CDC pertussis report, the incident rate was 120.2 per 100,000 in Wisconsin, 103 per 100,000 in Vermont, 77 per 100,000 in Minnesota, and 71.3 per 100,000 in Washington; these states had the highest incidence rates in 2012 (CDC, 2013a). Other Views on Pertussis Vaccination Programs

Public health officials are still recommending universal vaccination of adults, even though overall pertussis incidence rates in the United States are low. Factors considered in this decision include significantly high incidence rates in individual states, the potential costs of a pertussis outbreak for employers, and potential waning of child vaccine efficacy over time. A 2010 meta-analysis by Rittle noted that most cases of adult pertussis are not diagnosed, but many infants and children are infected by undiagnosed adolescents and adults. If a child misses a dose of the DTaP vaccine or receives a late dose, the risk of contracting pertussis increases 2.36 times (Rittle, 2010). All of these factors suggest that universal adult vaccination is desirable. PNEUMOCOCCAL DISEASE The bacterium Streptococcus pneumoniae is the cause of pneumococcal disease, with more than 90 serotypes identified. The 10 most common serotypes account for 62% of invasive disease worldwide (CDC, 2012a). Pneumococci are commonly found in the respiratory tract and may be isolated from the nasopharynx of 5% to 70% of healthy adults. Carriers will vary by population: 5% to 10% of adults without children, 27% to 58% of students and residents of schools and orphanages, and 50% to 60% of military personnel (CDC, 2012a). Clinical symptoms of pneumococcal disease include a 1- to 3-day incubation period with an abrupt onset of fever, chills or rigors, pleuritic chest pain, and a cough productive of rusty sputum. Other symptoms include dyspnea, tachypnea, hypoxia, tachycardia, malaise and weakness, nausea, vomiting, and headaches (CDC, 2012a). The CDC reported as many as 175,000 annual cases of pneumococcal pneumonia required hospitalization in 2011, accounting for up to 36% of adult community-acquired pneumonia, 50% of hospital-acquired pneumonia, and a common complication of influenza and measles. Although the casefatality rate is 5% to 7%, it may be much higher among elderly individuals (CDC, 2012a). Other complications of pneumococcal pneumonia include empyema, pericarditis, and endobronchial obstruction with atelectasis and lung abscess formation (CDC, 2012a). More than 50,000 cases

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of pneumococcal bacteremia are reported each year, occurring in 25% to 30% of individuals diagnosed with pneumococcal pneumonia. The case-fatality rate is 20% for the general population but as high as 60% among elderly individuals. Those workers with bacteremia and asplenia may experience a fulminant clinical course, a sudden intense development of symptoms, or pain that may rapidly lead to death (CDC, 2012a). Individuals with impaired immune function, functional or anatomic asplenia, chronic heart disease, chronic pulmonary disease, history of smoking, cerebrospinal leak, asthma, liver disease, or renal disease are at increased risk for developing invasive pneumococcal disease (CDC, 2012a). The overall incidence of pneumococcal disease in the United States during 1998 to 1999 was estimated to be 24 cases per 100,000 with variation according to age group. Highest rates historically are recorded among young children, especially those younger than 2 years. In 1998, the rate of invasive disease in this age group was estimated to be 188 per 100,000, with a corresponding incidence of 61 cases per 100,000 individuals 65 years and older (CDC, 2012a). In 2008, the United States incidence of invasive pneumococcal disease was 14.5 cases per 100,000. This rate reduction was attributed to the effectiveness of PCV7 pneumococcal vaccination for children, reducing the overall incidence of invasive disease among children younger than 5 years from approximately 99 cases per 100,000 from 1998 to 1999 to 21 cases per 100,000 in 2008 (CDC, 2012a). Current Pneumococcal Vaccination Rates

The CDC (2012a) estimated that 64% (p. 245) of adults 65 years and older have received the pneumococcal polysaccharide vaccine, a vaccination rate below the national goal of 90% coverage (Rehm et al., 2009). Vaccination rates for adults 19 to 64 years of age are even lower, approximately 25% (Rehm, 2009). To increase coverage rates, Rehm (2009) recommended providers integrate PPSV23 with their seasonal influenza program to reduce “missed opportunities” for clients to be vaccinated. Dual use of influenza and pneumococcal vaccines is encouraged by Gilchrist, Nanni, and Levine (2012), who reported that the cost-effective ratio for dual vaccination among elderly clients was $35,486 per QALY compared with $53,547 per QALY for PPSV23 and $130,908 per QALY for influenza vaccine given alone. Gilchrist et al. noted that “dual vaccination could control two co-occurring diseases, protect against secondary infections in the event of pandemic influenza, and possibly improve the cost-effectiveness of the PPV23 and influenza immunization programs” (p. 603). Two Types of Pneumococcal Adult Vaccines

Two pneumococcal vaccines are currently available for adults. The 23-valent pneumococcal polysaccharide vaccine (PPSV23) provides 60% protection against invasive disease in the elderly (Vila-Corcoles, 2007) and appears to be cost effective, especially for older adults with major comorbidities, even though its protection is incomplete. High (2007) reported PPSV23 efficacy limi-

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tations for immunocompromised adults because some serotypes are not included in the vaccine and efficacy wanes as workers age. The second vaccine approved for adults is a 13-valent pneumococcal conjugated vaccine (PCV13) approved for use among adults aged 50 years and older (Smith et al., 2012). Smith et al. (2012) reported that although PPSV23 covers 23 serotypes and could prevent more invasive disease than PCV13, the PCV13 vaccine can prevent “more pneumococcal disease than PPSV23, mainly nonbacteremic pneumococcal pneumonia (NPP)” (p. 810). Thus, Smith et al. (2012) recommended dual vaccination to protect against both invasive pneumococcal disease (PCV13) and non-bacteremic pneumococcal pneumonia (PPSV23). Administering PPSV23 and PCV13

Current CDC recommendations include administration of PCV13 at the earliest possible opportunity for those eligible, followed by PPSV23 eight weeks later, if PPSV23 was not already given. If PPSV23 has already been administered, PCV13 should be given 1 year after the last PPSV23 dose. If additional PPSV23 doses are needed, wait at least 8 weeks after administration of PCV13 and at least 5 years after the most recent PPSV23 (CDC, 2012b). Costs of Pneumococcal Disease

The clinical and economic burden of pneumococcal disease in the United States is significant. Direct health care costs associated with pneumococcal infection in 2004 totaled $3.5 billion (Huang et al., 2011). Those individuals 65 years and older had the most serious cases and the majority of direct health care costs ($1.8 billion annually). Correspondingly, costs associated with lost work time and resulting lost productivity losses for those 18 to 50 years of age nearly equaled costs for individuals 65 years and older (Huang et al., 2011). File and Marrie (2010) reported more than 60,000 pneumonia fatalities for those 15 years and older in 2005, with a hospitalization rate of 1,667 individuals per 100,000 and a 30-day mortality rate as high as 28%, resulting in an economic burden of more than $17 billion annually. Weycker, Strutton, Edelsberg, Sato, and Jackson (2010) estimated annual direct costs of $3.7 billion and annual indirect costs of $1.8 billion attributable to pneumococcal disease. These statistics support the report by Wroe et al. (2012) that estimated health care services to treat pneumococcal pneumonia will double in coming decades. Cost Effectiveness of Pneumococcal Vaccine

Two interesting perspectives about the cost effectiveness of pneumococcal vaccine were noted by High (2007) and Smith et al. (2012). High (2007) demonstrated that PPSV23 is cost effective and could save $8.27 per vaccination using typical assumptions and remained cost effective even when future health care costs were considered. Smith et al. (2012) concluded that substituting PCV13 for a dose of PPSV23 would cost $28,900 per QALY gained compared with no vaccination and would

be more cost effective than the currently recommended PPSV23 strategy. Smith et al. also noted that “while the routine administration of PCV13 between ages 50 and 65 would cost $45,100 per QALY” (p. 804), they concluded that substituting PCV13 vaccine for PPSV23 in the 50to 65-year age group could reduce pneumococcal disease burden. STRATEGIES FOR INCREASING EMPLOYEE VACCINATION RATES Although mandatory school requirements have resulted in excellent child vaccination rates, adult rates have lagged. Johnson, Nichol, and Lipczynski (2008) conducted a series of telephone interviews to determine adults’ attitudes and knowledge about adult vaccines along with other factors influencing immunization decisions. Seventy-nine percent to 85% of consumers (depending on the vaccine) were more likely to receive vaccines if recommended by their health care providers. Interestingly, 51% of study participants reported their physicians had not told them the vaccine was needed when they were asked about the tetanus booster. More than 60% of respondents, depending on the vaccine, reported they did not believe that a healthy individual needs vaccines. Many adults did not know when to get the vaccine: 27% for influenza, 37% for tetanus, and 26% for pneumococcal vaccine. Financial concerns were not a significant reason for being unvaccinated; only 14% to 17% of respondents reported not receiving one of the three vaccines because they lacked insurance coverage. Concerns about side effects were mentioned by several consumers: 43% from the influenza vaccine, 22% from the tetanus vaccine, and 40% from the pneumococcal vaccines. A majority of consumers (59%) also opted to “save” a vaccine in short supply (e.g., influenza) for others who might need it more, although no shortage of vaccine was evident at the time of the survey. Results of a Provider Survey

Of the 100 physician practices surveyed by Johnson et al. (2008), 90% of physicians and 94% of physician’s assistants, nurse practitioners, and registered nurses believed adults should be immunized and claimed to discuss recommended vaccines with their adult patients. However, physicians were less likely (29%, 95% CI: 20% to 38%) than the other health care providers listed above (42%, 95% CI: 32% to 52%, p ≤ .05) to discuss immunizations during acute care visits. Among physicians, 39% recommended influenza vaccination to all adults, 85% recommended tetanus vaccination to all adults, and 4% recommended pneumococcal vaccination to all adults 50 years and older and 65% to adults 65 years and older. When asked about the source of information about vaccines, 60% of physicians and 56% of other health care providers stated they use the official CDC Adult Schedule as a reference. Interestingly, only 33% of sampled offices had ever conducted an objective chart review to verify immunization rates among their clients (Johnson et al., 2008). Providers noted a number of barriers to increasing immunization rates among their clients, including failure to keep regular well care appointments, dislike of needles,

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zation rates were documented for influenza (24.1%), tetanus (28.5%), and pneumococcal (49.1%) vaccines. The researchers noted that “vaccination rates were higher if medical records included health maintenance flow sheets. Failure to discuss vaccination, to vaccinate at acute care visits, and low frequency of preventive visits resulted in missed opportunities to vaccinate” (p. 3457). Finally, High (2009) reported that “vaccine failures” (i.e., when the vaccination is given but the client becomes ill anyway) can result in client apathy. Vaccine failures occur when the pneumococcal vaccine is only effective against certain strains of the virus; the immune system of older patients is not robust enough to respond; older clients may have multiple comorbidities, including diabetes, that can affect vaccine response; obesity can impact vaccine efficacy when providers are using needles that are too short. High recommended the universal implementation of standing orders to improve vaccination rates and patient acceptance.

IN SUMMARY Can Increasing Adult Vaccination Rates Reduce Lost Time and Increase Productivity? Rittle, C. Workplace Health and Safety 2014;62(12), 508-515.

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All providers must educate the public about the need for adult vaccines. This should include the risks and benefits of vaccines, the risks of not vaccinating, and recommend all applicable vaccines at every opportunity.

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Providers should implement “reminder systems” to review vaccination status at each visit. Effective office reminder systems can increase vaccination rates.

Universal standing orders can also improve vaccination rates and patient acceptance.

and lack of an effective office reminder system. Non-physician providers were significantly more likely than physicians to discuss the consequence of missing vaccinations with their patients: 61% versus 47% for influenza (p = .02); 56% versus 34% for tetanus (p < .001); and 59% versus 40% for pneumonia (p = .004) (Johnson et al., 2008). Vaccine Costs

When questioned about the impact of cost on vaccine acceptance, 83% of consumers stated they would probably receive a vaccine to prevent missed days from work or hospitalization if the cost were between $25 and $30 (Johnson et al., 2008). Between 61% and 79% of providers believed their clients would likely accept a vaccine that cost between $25 and $30. Some providers were not aware that immunizations are covered by Medicare; pneumococcal vaccine has been covered since 1981 and influenza vaccine since 1993 (Johnson et al., 2008). Other Strategies

Older adults are more likely to be properly vaccinated because they see their providers regularly (Webb, 2011). However, many of the reported reasons for being unimmunized are similar to those found by Johnson et al. (2008), including client indifference, ineffective provider/client communication, ignorance of newer vaccines targeting adults, and failure to appreciate the public health benefit of vaccinations. According to Webb (2011), one of the most significant factors in increasing vaccine rates is the cost of vaccines and insurance coverage gaps. Missed opportunities were a significant factor as reported in a 2004 study by Nowalk, Zimmerman, and Feghali. They noted that missed opportunities to vaccinate occurred during 38.4% to 94.5% of office visits, depending on the vaccine. From a study of health records, immuni-

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IMPROVING VACCINATION RATES Public health officials are researching strategies to increase vaccination rates among adult clients. Fishbein et al. (2005) demonstrated that early in the influenza season missed opportunities to vaccinate are uncommon: “As the influenza vaccination progressed, attention to immunization status decreased and missed opportunities to vaccinate increased despite an abundant supply of vaccine” (p. 800). “Missed opportunities” to vaccinate increased steadily from October to January (p < .0001) and were more common when providers did not inquire about vaccination status or did not discuss vaccinations with their clients (p < .00001) (Fishbein et al., 2005). The authors concluded that to increase vaccination rates in adults, physicians and nurses “should include but not be limited to continued inquiry into vaccination status and discussion of the importance of vaccination with patients” (p. 801). Fishbein et al. also recommended that providers develop systems to remind clients and providers when vaccinations are due, routinely review vaccination status at each visit, and educate clients about the risks and benefits of vaccination. The researchers stated that “efforts to remind patients about vaccination . . . may be essential to achieving higher coverage in the U.S.” (p. 798). Although they were referring specifically to the influenza vaccine, this point is relevant to all adult vaccines. When discussing vaccines with adult clients, High (2009) noted that “for reluctant patients, physician attitude is extremely important and can overcome patient misperceptions regarding vaccine efficacy and safety” (p. S26). It is equally important for occupational health nurses to recommend applicable vaccines to their employees at every opportunity, a practice that can lead to increased vaccination rates. CONCLUSIONS Wolicki (2013) identified key messages that providers should communicate when discussing adult vaccines with their clients: 1. Vaccines are recommended throughout the lifespan. 2. An increasing number of vaccines are now available

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to protect adults from infectious diseases and their long-term consequences. 3. Vaccinating adults also protects others who are more vulnerable to infectious diseases and their sequelae, including infants and children. 4. More information can be found at the CDC’s website (http://www.cdc.gov/vaccines/adults/index.html). Practitioners can print and distribute “10 Reasons to be Vaccinated: Not Just for Kids” (http://adultvaccination.org/newsroom/10-reasons.pdf) as an informational brochure for clients. All providers, physicians, and nurses must educate the public about the need for and availability of adult vaccines and recommend all applicable vaccines at every opportunity. REFERENCES

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