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Editorial Comment

Adult Immunizations and the Corner Drugstore

Lauter, Carl B. MD, MACP, FIDSA, FAAAAI; Written as an editorial commentary regarding Kulczycki et al. Practices, Challenges, and Opportunities to Improving Pneumococcal Immunization in Working-Age, At-Risk Adults Through Community Pharmacies on pages 23–28 of the Journal.

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Infectious Diseases in Clinical Practice: January 2017 - Volume 25 - Issue 1 - p 3-4
doi: 10.1097/IPC.0000000000000475
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Vaccines are safe and generally very effective in alleviating the burden that many infectious diseases have on individuals as well as society as a whole. The reductions in morbidity and mortality1 are well-documented benefits of the widespread application of vaccinations in children and adults. Recently, Ozawa and others2 have reported on their estimates of the economic burden of adult vaccine-preventable diseases in the United States.

Based on data from the Centers for Disease Control and Prevention, 58% of adults age eighteen and older did not receive an influenza vaccine in 2015 to 2016. Influenza was the most costly illness of the vaccine preventable diseases in that season, adding up to nearly 5.8 billion dollars in 2015. Pneumococcal infections accounted for 1.86 billion dollars in vaccine-preventable diseases in that same year. In all, 7.1 billion dollars of the total of 8.95 billion dollars was attributable to 10 vaccine-preventable diseases in the Ozawa article. These costs were estimated in terms of deaths, disabilities, doctor visits, hospital admissions and lost income. These estimates did not include the broader potential benefits to society, such as childhood development, household behavior, and macroeconomic indicators.3

Pneumococcal vaccination rates in adults in the United States are low, particularly in high-risk adults between 18 and 64 years of age (less than 22%) and far below the Health People 2020 targets of 60%.4,5

In this issue of Infectious Diseases in Clinical Practice, Kulczycki et al6 report on the results of a study carried out by using semistructured interviews with pharmacists at 12 independently owned community pharmacies (none were retail chains) in Alabama in the spring of 2015. Most of these pharmacies were in physician shortage areas of Alabama, and listed as underserved by primary health care providers by the Health Resources Service Administration.7 The authors explored, for the first time, the practice experiences, challenges, and potential opportunities of such pharmacists with the goal of improving pneumococcal vaccination rates in those adults, 18 to 65 years of age, who have comorbid conditions, as defined by the Advistory Committee on Immunization Practices.

When I originally read this article, I could not help recalling the picture of the small town “pharmacist” by Normal Rockwell on the cover of the March 18, 1939, Saturday Evening Post. Those were simpler times in pre–World War II America, and vaccinations for adults were essentially a nonissue.

In the current climate, multiple barriers to meeting population vaccination goals have been identified including cost, apathy, mistrust of authority (physicians, public health officials), accessibility, inconvenience, and denial of need.8–11 The expanding role of pharmacists in the past 20 years has helped to improve access to care for adults seeking vaccinations.12,13

Kulczycki et al, attempted to assess the knowledge and experience of these community-based pharmacists in regard to pneumococcal vaccinations of adults younger than 65 years, but their experience with adults older than 65 years raised additional concerns. Despite the fact that all of these pharmacists had completed immunization training with the American Pharmacists Association Pharmacy-Based Immunization Delivery Program14 (a program recommended by the Centers for Disease Control and Prevention), few of them had administered the PPSV-23 vaccine to adults, 18 to 64 years of age, 2 had never administered pneumococcal vaccine at all, 5 had never provided the PCV-13 vaccine, and only 1 of them used the Alabama State Immunization Registry. None of them routinely gave copies of vaccine records to the patients or sent reports to the primary care physicians.

Despite these shortcomings, the expanded hours of pharmacies compared to most physician offices, the convenient locations closer to home, the ability to avoid making an appointment with a physician and sitting in a crowded waiting room, at times with sick people, are all compelling arguments in favor of an expanded role for pharmacists as we attempt to improve vaccination rates in working, active non-Medicare and Medicare age adults in the United States.15

Education outreach campaigns to the public about the need for vaccines as well as to counter the powerful voices of antivaccine champions are needed. In addition, eliminating the economic barriers for those people not covered by the vaccine coverage mandates of the Affordable Care Act are also pieces of this complex puzzle that need to be put in place if we are to achieve the Healthy People 2020 vaccination goals. Perhaps, the economic implications of the health consequences of adult vaccine-preventable diseases in the United States will lead to a “tipping point” in our thinking and action in this important aspect of the health of our nation.

REFERENCES

1. Domestic Public Health Achievements Team, CDC. Corresponding contributor: Koppaka, Ram, MD, PhD, Epidemiology and Analysis Program Office, Office of Surveillance, Epidemiology and Laboratory Services, CDC. MMWR 201;60(19):619–623.
2. Ozawa S, Portnoy A, Getaneh H, et al. Modeling the economic burden of adult vaccine-preventable diseases in the United States. Health Aff (Millwood). 2016;35(11):1–8 DOI:10.1377/hlthaff.2016.042.
3. Jit M, Hutubessy R, Png ME, et al. The broader economic impact of vaccination: reviewing and appraising the strength of evidence. BMC Med. 2015;13:209 DOI 10.1186/s12916-015-0446-9.
4. Williams WW, Lu PJ, O'Halloran A, et al. Surveillance of vaccination coverage among adult populations—United States, 2014. MMWR Surveill Summ. 2016;65(1):1–36.
5. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Healthy People 2020. Available at https://www.healthypeople.gov/. Accessed Mar 4, 2016.
6. Kulczycki A, Wensel TM, Hogue M. Practices, challenges and opportunities to improving pneumococcal immunization in working-age, at-risk adults through community pharmacies. Infect Dis Clin Pract. 2016;25(1):23–28.
7. Alabama Department of Public Health. Primary Care Health Professional Shortage Areas. 2015. Available at: http://adph.org/ruralhealth/assets/primary_Care_HPSA_Map.pdf. Accessed April 30, 2016.
8. Johnson DR, Nichol KL, Lipczynski K, et al. Barriers to adult immunization. Am J Med. 2008;121(7suppl2):S28–S35.
9. Harris KM, Uscher-Pines L, Mattke S, et al. A blueprint for improving the promotion and delivery of adult vaccination in the United States, Santa Monica, CA: Rand Corporation. TF-1169-GSK. 2011.
10. Freed GL, Clark SJ, Cowan AE, et al. Primary care physician perspectives on providing adult vaccines. Vaccine. 2011;29:1850–1854.
11. Hurley LP, Bridges CB, Harpaz R, et al. U.S. physicians’ perspective of adult vaccine delivery. Ann Intern Med. 2014;160:161–170.
12. Health and Public Policy Committee, Pharmacists Scope of Practice. Position Paper of the American College of Physicians-American Society of Internal Medicine. Corresponding author: Keely, JL, MSS, MLSP. Ann Intern Med. 2002;136:79–85.
13. Ventola CL. Immunization in the United States: Recommendations, Barriers, and Measures to Improve Compliance: Part 2: Adult Vaccinations. P T. 2016;41(8):492–506.
14. American Pharmacists Association. Pharmacy-based immunization delivery. Available at: http://www.pharmacist.com/pharmacy-based-immunization-delivery. Accessed May 30, 2016.
15. Girotto JE. Expanding vaccination rates through pharmacist-initiated patient identification and assessment. DrugTopics July. 2016:58–67.
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