Health Objectives for the Nation Public Health Burden of Vaccine-Preventable Diseases among Adults: Standards for Adult Immunization Practice
The week of October 22-26, 1990, is National Adult Immunization Awareness Week. This event, observed annually during the last week in October, emphasizes the importance of appropriately immunizing all adults. Immunization programs in the United States have markedly reduced the occurrence of vaccine-preventable diseases in children; however, adults who were not infected or immunized during childhood may be at increased risk for these diseases and their complications (1). Adults may also be at increased risk for vaccine-preventable diseases because of advancing age, occupation, lifestyle, or development of certain chronic diseases. Some vaccine-preventable diseases (e.g., hepatitis B) primarily affect persons greater than or equal to 20 years of age (Table 1); for these diseases, most targeted risk groups for immunization are adults (2). Of the 19 national health objectives for the year 2000 that target infectious diseases, 10 are related to adult immunization (3). This report describes the public health impact of influenza, pneumococcal disease, hepatitis B, and measles on U.S. adults. Influenza and Pneumococcal Disease
Influenza. The impact of influenza is greatest in persons greater than or equal to 65 years of age. A typical influenza epidemic can cause greater than 20,000 excess deaths, 80%-90% of which occur among persons aged greater than or equal to 65 years. From January through March 1990, a major influenza epidemic was associated with a high proportion of pneumonia and influenza (P&I) deaths. Influenza A(H3N2), the predominant circulating subtype, accounted for 98% of the isolates reported to CDC. During the 1989-90 season, the proportion of all P&I deaths reported from 121 cities reporting regularly to CDC reached its highest level in 5 years. Persons greater than or equal to 65 years of age accounted for approximately 80% of P&I-related deaths during the epidemic.
Pneumococcal Disease. Disease caused by Streptococcus pneumoniae (pneumococcus) remains a problem in the very young, the elderly, and persons with certain high-risk conditions (4). Pneumococcal pneumonia accounts for 10%-25% of all pneumonia and an estimated 40,000 deaths annually (1,4). The estimated annual rate for pneumococcal bacteremia in 1984 was 15-19 per 100,000 population and in 1986-87 was 50 per 100,000 persons greater than or equal to 65 years of age, representing twofold to threefold increases over previously documented rates (5,6). In 1986 and 1987, the case-fatality rate for bacteremic patients was 18% in Charleston County, South Carolina; 91% of persons aged 19-64 years with bacteremia had underlying medical conditions for which pneumococcal vaccine is recommended (6).
The year 2000 health objectives include reduction of epidemic-related P&I deaths and provision of influenza and pneumococcal vaccines to at least 60% of high-risk populations. Hepatitis B
In 1989, 23,426 acute hepatitis B cases were reported in the United States. However, each year hepatitis B virus (HBV) infection occurs in an estimated 300,000 persons, primarily young adults, of whom 6%-10% become chronic HBV carriers. In addition, approximately 4000 persons die from HBV-related cirrhosis and 800, from HBV-related liver cancer (2). Surveillance data suggest a recent decrease in the incidence of HBV infections among homosexual men (7). From 1981 through 1988, however, hepatitis B cases in heterosexuals and intravenous (IV)-drug users increased by 76.9% and 77.1%, respectively (7).
HBV infection is an occupational hazard for health-care workers, in whom an estimated 6000-8000 new HBV infections occur annually. Because the risk for HBV infection for health-care workers may be highest during training, immunization should be completed during training in medical, dental, and other health profession schools before the first occupational exposure to blood. In 1988, of 115 medical schools in the United States and Canada, 22 (19%) required HBV immunization at any time during medical school; 33 (29%) of schools did not offer HBV immunization to students (8).
The year 2000 health objectives include increasing hepatitis B immunization levels to at least 90% of those at occupational risk for infection and at least 50% of those who use IV drugs. Measles
In 1989, 18,193 measles cases were reported in the United States, the highest number reported since 1978. Of these, 3104 (17%) occurred among adults greater than or equal to 20 years of age. From 1980 through 1989, 6% of all reported measles cases were transmitted in college settings. Of all persons who acquired measles in college settings from 1986 through 1989, 49% had no evidence of measles vaccination. In 1989, 41 measles-associated deaths were reported: 10 deaths occurred among persons aged 19-35 years, and nine of these persons had never been vaccinated. The year 2000 objectives target complete elimination of indigenous measles. Reported by: Div of Immunization, Center for Prevention Svcs; Div of Viral and Rickettsial Diseases, Div of Bacterial Diseases, Center for Infectious Diseases, CDC.
Editorial Note: Despite the continuing occurrence of vaccine-preventable diseases among adults in the United States, safe and effective vaccines recommended for adults (2,4,9,10) are not optimally used (1). For example, influenza vaccine is approximately 75% effective in reducing deaths in high-risk elderly persons (1); however, based on the 1985 United States Immunization Survey (USIS), only 20% of high-risk persons had received influenza vaccine in 1984. Moreover, CDC's Behavioral Risk Factor Surveillance System determined that the mean influenza vaccine coverage rate in 1987 was 32% among adults greater than or equal to 65 years of age in the 31 participating states and the District of Columbia.
Pneumococcal vaccine is greater than 60% effective in preventing invasive pneumococcal infections (4). Immunization against pneumococcal disease is recommended for persons aged greater than or equal to 65 years and for persons with underlying conditions, including many persons for whom influenza vaccine is recommended (4). Despite these recommendations, the 1985 USIS indicated that only 10% of high-risk persons had been immunized with pneumococcal vaccine.
For the current hepatitis B immunization strategy to succeed, high-risk populations and their health-care providers must recognize the role of heterosexual activity in the transmission of HBV (7). Moreover, IV-drug users and all sexually active adults with multiple sex partners should be immunized to prevent infection with HBV. Universal immunization of infants and/or adolescents represents the optimal strategy to prevent hepatitis B in all groups.
Recent declines in the incidence of HBV infections among health-care workers are probably due to both increased use of the hepatitis B vaccine in this population and increased adherence to universal precautions in the workplace. However, hepatitis B in health-care workers could be further reduced if medical, dental, and allied schools of health required all students to be immunized before they have contact with patients (2). Regulations proposed by the Occupational Safety and Health Administration may mandate availability of hepatitis B vaccine to all at-risk health-care personnel at the employer's expense. These regulations may accelerate and broaden the use of hepatitis B vaccine in health-care workers and assure maximal efforts to prevent occupationally acquired infection in the 1990s (11).
To prevent measles outbreaks and ensure high levels of immunity among young adults on college and university campuses, the American College Health Association has recommended that colleges and universities implement a Prematriculation Immunization Requirement (PIR). PIRs require that students present evidence of immunity to measles and other vaccine-preventable diseases as a condition for matriculation (12). As of March 1990, 22 states, the District of Columbia, and Puerto Rico have implemented PIR laws or policies for colleges and universities. However, of the five states in which large college outbreaks occurred in 1989, only one had a PIR in place. In addition, the Immunization Practices Advisory Committee (ACIP) now recommends a routine two-dose measles vaccination schedule. Colleges, technical schools, and other institutions for post-high school education should require that, at the time of school entry, students provide documentation of two doses of live measles-containing vaccines or other evidence of measles immunity (i.e., documentation of prior physician-diagnosed measles disease or laboratory evidence of measles immunity) (10). State and college PIRs can be used to enhance implementation of the ACIP recommendations and limit outbreaks in college settings.
In 1988, the National Coalition for Adult Immunization (NCAI) was formed to enhance efforts to immunize adults. The NCAI is a network of private, professional, and volunteer organizations and public health agencies. The goal of the NCAI is to reduce vaccine-preventable disease and death among adults in the United States by increasing the awareness of physicians, other health-care providers, and the general public about the need for and benefits of immunization. The NCAI supports the use of influenza, pneumococcal, hepatitis B, measles, mumps, and rubella vaccines and tetanus and diphtheria toxoids in adults.
To unify the diverse interests of the member organizations and offer a foundation of common goals among health-care providers, policy makers, and consumer interest groups, the NCAI has developed and adopted the "Standards for Adult Immunization Practice" (Table 2). The standards outline basic strategies that, if fully implemented, could markedly improve delivery of vaccines to adults and help achieve year 2000 national health objectives. Sustained collaborative efforts of the public and private sectors of health care are needed to decrease the public health impact of vaccine-preventable diseases.
AR. Immunization policies and vaccine coverage among adults: the risk for missed opportunities. Ann Intern Med 1988;108:616-25.
2. ACIP. Protection against viral hepatitis: recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR 1990;39(no. RR-2).
3. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives. Conference ed. Washington, DC: US Department of Health and Human Services, Public Health Service, 1990.
4. ACIP. Pneumococcal polysaccharide vaccine. MMWR 1989;38:64-8,73-6.
5. Istre GR, Tarpay M, Anderson M, Pryor A, Welch D, Pneumococcus Study Group. Invasive disease due to Streptococcus pneumoniae in an area with a high rate of relative penicillin resistance. J Infect Dis 1987;156:732-5.
6. Breiman RF, Navarro VJ, Darden PM, Darby CP, Spika JS. Streptococcus pneumoniae bacteremia in residents of Charleston County, South Carolina, a decade later. Arch Intern Med 1990;150:1401-5.
7. Alter MJ, Hadler SC, Margolis HS, et al. The changing epidemiology of hepatitis B in the United States: need for alternative vaccination strategies. JAMA 1990;263:1218-22.
8. Poland GA, Nichol KL. Medical schools and immunization policies: missed opportunities for disease prevention. Ann Intern Med 1990;113:628-31.
9. ACIP. Prevention and control of influenza: recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR 1990;39(no. RR-7). 10. ACIP. Measles prevention: recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR 1989;38(no. S-9). 11. Occupational Safety and Health Administration. Occupational exposure to bloodborne pathogens; proposed rule and notice of hearing. Federal Register 1989;54:23042-139. (29 CFR Part 1010). 12. American College Health Association. Position statement on immunization policy. J Am Coll Health 1983;32:7-8.
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