Schaffner, William, MD^*†; McElhaney, Janet, MD^‡; Rizzo, Albert A., MD^§∥; Savoy, Margot, MD, MPH^¶; Taylor, Allen J., MD^#; Young, Melissa, PharmD, CDE, BC-ADM^**

Influenza (flu) is a serious health concern in adults with certain chronic health conditions including diabetes, lung disease, and cardiovascular disease. These individuals are at increased risk of flu-related complications and exacerbation of underlying disease, even when the condition is well controlled, due to the effects of flu-related inflammation that may occur long after the acute infection.

Unfortunately, flu vaccination coverage rates remain suboptimal in adults, partly due to a lack of confidence in vaccine efficacy. However, strong evidence exists to support the benefits of flu vaccination in mitigating disease severity, reducing hospitalization rates, and disrupting viral transmission. Because of this gap in flu vaccination coverage, there is an urgent need to raise awareness of both the dangers of influenza infection and the benefits of vaccination in adults with chronic health conditions.

To help raise awareness, the National Foundation for Infectious Diseases convened a Roundtable to develop recommendations and strategies that highlight the importance of protecting vulnerable populations by emphasizing the benefits of flu vaccination to overall health, mitigation of illness severity and flu-related complications, and improved patient outcomes. This Call to Action summarizes key points and recommendations discussed at the Roundtable.

OVERVIEW: CONNECTION BETWEEN INFLUENZA AND EXACERBATION OF CHRONIC HEALTH CONDITIONS

Nearly 50% of US adults aged 45 to 64 years¹ have 2 or more chronic health conditions (Fig. 1).^2,3 As the US population ages, the proportion of adults with chronic health conditions will likely rise, as the prevalence of many chronic health conditions increases with age.^3,4

FIGURE 1

The high proportion of adults with chronic health conditions is of particular concern during flu season because of the potentially serious interaction between influenza virus and certain chronic health conditions including heart disease, lung disease, and diabetes. Influenza infection can exacerbate these conditions and may increase the risk of persistent catastrophic disability.⁵ Influenza can have direct effects, such as exacerbation of asthma or chronic obstructive pulmonary disease (COPD), and indirect effects that may trigger certain events or exacerbate conditions such as diabetes or heart disease (Fig. 2).

FIGURE 2

• Chronic Health Conditions and Increased Risk of Flu-Related Complications
• The Centers for Disease Control and Prevention⁶ have identified a long list of chronic health conditions that increase risk of flu-related complications, including the following:
• Asthma
• Neurologic and neurodevelopmental conditions, including cerebral palsy, epilepsy, stroke, muscular dystrophy, spinal cord injury, and more
• COPD and other chronic lung conditions, including cystic fibrosis
• Heart disease, including coronary artery disease, congestive heart failure, and congenital heart disease
• Sickle cell disease and other blood disorders
• Diabetes and other endocrine or metabolic disorders
• Kidney disorders
• Liver disorders
• People with HIV/AIDS, cancer, or other conditions that weaken the immune system
• Extremely obese individuals (body mass index ≥40 kg/m²)

Chronic health conditions may put adults at increased risk of flu-related complications.⁶ Estimates indicate that 31% of US adults aged 50 to 64 years and 47% of those 65 years and older are at high risk of flu-related complications due to certain chronic health conditions including cardiovascular and lung disease as well as diabetes or are likely to have decreased vaccination response because of immunocompromising conditions.⁷

Data from the 2017–2018 flu season show a disproportionate impact on adults 50 years and older with chronic health conditions. Among adults hospitalized due to flu for whom information on underlying medical condition was available, 92% had at least one reported underlying medical condition that placed them at high risk of flu-related complications, the most frequent of which included cardiovascular disease (46%), metabolic disorders such as diabetes (43%), obesity (37%), and chronic lung disease (30%).⁸

During the 2017–2018 season, flu-related hospitalizations were the highest since surveillance began in 2003. Adults aged 50 to 64 years had one of the highest cumulative hospitalization rates, second only to adults 65 years and older—surpassing the rate among infants and young children.⁸ This has significant implications for these vulnerable age groups that are a critical part of the work force, many of whom also have family commitments to children and/or older family members.

The serious consequences of flu in adults with chronic health conditions can be devastating and long term. In one study of hospitalized adults 65 years or older, patients with laboratory-confirmed influenza were more likely to experience persistent catastrophic disability versus controls, as shown by a significant decline in assessment of functional independence and activities of daily living 1 month after discharge.⁵

Ninety percent of flu-related deaths and most flu-related hospitalizations occur in older adults⁹—the very individuals most likely to be living with chronic health conditions.

Rather than chronological age, the concept of frailty as a measure of health and functioning may be a more accurate predictor of poor flu-related outcomes.⁵ For example, a middle-aged 53-year-old adult with diabetes and chronic lung disease may have the same risks of influenza-related hospitalization or disability as that of a 78-year-old patient with fewer comorbidities. Nonetheless, flu vaccination rates remain well below the Healthy People 2020 targets of 80% for adults aged 18 to 64 years and 90% for adults with high-risk conditions, including those 65 years and older (Fig. 3).^10,11

FIGURE 3

These suboptimal vaccination rates are partly due to a lack of confidence in flu vaccines. According to one study, 43% of adults 50 to 64 years old and 30% of those 65 years or older have no or low confidence in flu vaccines.¹² Alarmingly, 60% of US adults aged 31 to 49 years expressed that they have no or low confidence in the vaccine, which bodes poorly for this cohort as they advance in age.

Drivers of the low confidence include widespread misperceptions about the burden of flu and the benefits of vaccination. Among US adults aged 50 to 64 years, 47% believe that influenza infection would be “not very serious” or “not serious at all.”¹² These beliefs persist despite the known dangers of flu in this age group because of the significant prevalence of chronic health conditions¹ and potential for long-term consequences beyond acute infection.

In addition, nearly half of US adults aged 50 to 64 years admit that they are not well informed about the benefits of flu vaccination.¹² This may be attributed to misunderstanding the true benefits of flu vaccine—interruption of viral transmission and mitigation of disease severity.

Interruption of Viral Transmission

Prevention of influenza infection in vaccinated individuals—and unvaccinated individuals—guards against additional transmission of the virus into the community. Specifically, influenza vaccination can protect the community in 2 ways: first, by inducing active immunity in vaccinated individuals, which prevents infection, illness, and transmission, and second, through indirect protection by preventing susceptible persons from being exposed to the virus by breaking up human-to-human chains of transmission.¹³

The greater the number of vaccinated individuals, the greater the protection of the population. This is especially important in preventing transmission of the virus to those ineligible for flu vaccination, such as infants younger than 6 months, as well as to older adults who may not respond well to vaccination with standard flu vaccines because of advanced age (immunosenescence). In addition, community immunity may help protect those who forego annual immunization because they do not understand the full benefit of vaccination in reducing the severity of illness and lessening the chance of death.

Mitigation of Disease Severity

Recent studies show that flu vaccine may reduce the risk of severe disease among people who are infected despite vaccination. In one study of adults hospitalized with laboratory-confirmed influenza in the 2013–2014 season, vaccine was associated with a 52% reduction in flu-related deaths in adults aged 50 to 64 years and a 61% reduction in those 65 years and older compared with similar-aged unvaccinated adults. Vaccinated individuals were less likely to be admitted to the intensive care unit (ICU), and length of ICU stay was shorter.¹⁴ In addition, a recent study spanning multiple flu seasons (2012–2015) in New Zealand showed that receiving a flu vaccine reduced the odds of ICU admissions by 59% in hospitalized influenza-positive patients, with shorter length of stay and reduction in disease severity.¹⁵

Reducing the severity of disease is important not only for the general well-being of the infected individual and minimization of lost productivity but also to minimize the impact of inflammation. An often underrecognized danger of influenza is the resulting inflammatory reaction that may last for several weeks after acute influenza infection. This inflammation can worsen chronic health conditions and may trigger a heart attack or stroke.

Note that these 2010 data include any condition that lasted or was expected to last 12 or more months and resulted in functional limitations and/or the need for ongoing medical care. Chronic conditions exacerbated by flu—including heart disease, lung disease, and diabetes—comprise a substantial proportion of all chronic diseases.⁷

EXACERBATION OF HEART DISEASE

In the United States, 15.5 million people have heart disease,¹⁶ and it is the leading cause of death.¹⁷ Not surprisingly, the prevalence of heart disease increases with age, with the highest frequency in individuals 65 years or older. However, it is not solely a disease of older adults—more than half of individuals aged 45 to 64 years have some form of cardiovascular disease.¹⁸

The effects of flu on individuals with heart disease are well established, yet they remain underappreciated. A recent study noted that acute myocardial infarction is 6 times more likely within 7 days of laboratory-confirmed influenza infection than it is during an unrelated control interval.¹⁹

An increasing body of evidence points to inflammation as the mechanism by which flu exacerbates heart disease and other chronic health conditions (Fig. 4).²⁰ Exacerbation of existing cardiovascular disease may disrupt atherosclerotic plaques, resulting in arterial blockage and leading to a heart attack or stroke (Fig. 5).²¹ Influenza-associated inflammation can remain for weeks after viral symptoms have resolved, leaving patients vulnerable to disease exacerbation weeks after they have “recovered” from flu illness. The end result can be a potentially permanent loss of function and even catastrophic disability, particularly among frail older individuals with chronic health conditions.⁵

FIGURE 4

FIGURE 5

EXACERBATION OF LUNG DISEASE

Chronic lower respiratory diseases such as COPD and asthma are the third leading cause of death in the United States, and there are an estimated 11.3 million US adults living with COPD.²²

Flu is a major driver of mortality and morbidity in COPD.²³ It is well established that COPD increases susceptibility to flu-related complications,²⁴ and there is evidence that acute viral infections may alter the clinical course of the disease (eg, progressive loss of lung function) after acute exacerbation.²⁵ In a US study, influenza virus was detected in 25% of individuals hospitalized for COPD exacerbations.²⁶

In addition, the number of US adults with COPD is likely to be even greater than the official data indicate. More than 50% of US adults with impaired pulmonary function (likely due to COPD) have not been diagnosed^27,28 and consequently are less likely to take necessary precautions against flu infection.

Furthermore, individuals with asthma are at increased risk of severe disease and complications resulting from influenza infection.²⁹ Asthma, a lung condition caused by chronic airway inflammation, affects an estimated 18.7 million US adults, and in 2010, it was responsible for more than 14 million physician office visits, nearly 2 million emergency department visits, 439,000 hospitalizations, and more than 3400 deaths.²²

EXACERBATION OF DIABETES

In the United States, diabetes is widespread—affecting nearly one-quarter of adults aged 65 to 74 years and one-fifth of adults 75 years or older.⁴ Diabetes is the seventh leading cause of death in the United States and a leading cause of blindness, end-stage kidney failure, lower limb amputation, and cardiovascular disease.^30,31 Type 2 diabetes accounts for up to 95% of all diabetes cases.^32,33

Emerging data have identified probable links between obesity, chronic inflammation, and insulin resistance. Prospective studies have documented an association between insulin resistance and accelerated cardiovascular disease in individuals with type 2 diabetes.^34,35

Flu can cause significant and severe health complications for individuals with diabetes. The interaction of flu and diabetes is associated with significant morbidity and mortality attributed to metabolic complications.³⁶ In addition, the emerging data regarding inflammatory reactions to the flu and increasing cardiovascular risk must be considered when addressing flu risk in the diabetes population.³⁷

One study of individuals with diabetes found a 6-fold increased risk of hospitalization due to flu compared with people of similar age and sex distribution who did not have diabetes.³⁸ In addition, the frequency of comorbid conditions, such as renal disease and heart disease, complicates the impact of flu on this population and can leave individuals with long-term disability beyond acute flu infection.³⁹

BENEFITS OF INFLUENZA VACCINE FOR ADULTS WITH CHRONIC HEALTH CONDITIONS

Because of the serious complications of flu in individuals with chronic health conditions, it is critical to protect them from infection. Even during seasons when flu vaccines are not a good match with circulating virus strains, vaccination is still important in preventing serious outcomes.⁴⁰ In one study of adults hospitalized with influenza, vaccination during the 2013–2014 season was associated with a 52% reduction in flu-related deaths in adults aged 50 to 64 years and a 61% reduction in those 65 years and older, along with reduced ICU and hospital length of stay among older adults, compared with similar-aged unvaccinated adults.¹⁴ Another recent study showed that flu vaccines reduce the risk of cardiovascular events in individuals with preexisting heart disease by 53% among patients who had had a myocardial infarction in the previous year and 36% overall; in addition, the vaccine reduced the risk of death by 19% among all study participants.⁴¹

Several studies have demonstrated the efficacy of flu vaccine in preventing disease exacerbations and complications in people with chronic health conditions. In those with chronic heart disease, the flu vaccine compares favorably with other preventive measures such as smoking cessation and the use of statins and antihypertensive drugs.⁴² Among individuals with COPD, flu vaccine produces a significant drop in COPD exacerbations compared with a placebo,⁴³ is associated with lower risk of ischemic heart disease in older COPD patients,⁴⁴ and can reduce serious illness as well as death.⁴⁵

For individuals with diabetes, the American Diabetes Association has stated that annual flu vaccination is an important part of preventive care (see callout box, Statements on Flu Vaccine in Persons With Chronic Health Conditions).⁴⁶ In this population, flu vaccine significantly reduces admission rates for stroke, heart failure, and all other causes of death in older patients with type 2 diabetes.⁴⁷

It is also important to note that flu vaccination of household and community contacts greatly reduces transmission of flu virus to all in the community but most importantly to vulnerable individuals with chronic health conditions. High vaccination coverage across the population helps protect vulnerable individuals by greatly reducing the number of infected people overall, disrupting transmission, and providing indirect protection by preventing susceptible persons from being exposed to the virus (Fig. 6).¹³

FIGURE 6

CHALLENGES TO INCREASING INFLUENZA VACCINATION RATES IN ADULTS WITH CHRONIC HEALTH CONDITIONS

• Flu Vaccine Recommendations for 2018–2019 Season: Advisory Committee on Immunization Practices (ACIP) Recommendations ⁴⁸
• Routine annual influenza vaccination is recommended for all individuals 6 months or older who do not have contraindications.
• Influenza can cause serious illness and death, especially in older adults, very young children, pregnant women, and individuals with chronic health conditions.
• Vaccination is particularly important for persons at increased risk of severe complications and influenza-related outpatient/emergency department/hospital visits.
• When vaccine supply is limited, vaccination efforts need to focus on persons at high risk of flu-related complications:
• Children 6 to 59 months old
• Adults 50 years or older
• Chronic disease: pulmonary, cardiovascular, renal, hepatic, neurologic, hematologic, metabolic (including diabetes)
• Immunocompromised individuals
• Women who are or will be pregnant during flu season
• Residing in nursing home/long-term care facility
• Native American/Alaska Native
• Extreme obesity (body mass index ≥40 kg/m²)

Health Care Professional Challenges

Ownership/Accountability

Who should be responsible for ensuring and providing flu vaccination? Many specialists believe that it is the job of primary care providers. Consequently, specialists such as cardiologists and endocrinologists may not routinely stock flu vaccines. In fact, according to a joint publication of the American Heart Association and the American College of Cardiology, 50% of cardiologists do not stock the flu vaccine, although flu prevention is paramount to avoiding exacerbations of heart disease.⁴⁹ Pharmacists may stock and offer vaccines, but strong recommendations from other health care professionals (HCPs) help to increase patient interest in seeking vaccination at the pharmacy.

Limited Time and Resources

Time with patients is limited, constrained by practices and payers. Predetermined time limits are particularly challenging with patients who have multiple chronic conditions. Physicians—particularly specialists who do not typically administer flu vaccines—may be reluctant to add the service because of concerns that it may potentially increase the length of the visit. Patients may have questions about the effectiveness, necessity, and safety of a vaccine. Moreover, specialty medical office workflow often does not accommodate vaccination. A revised workflow would be required to determine who administers the vaccine, who provides the informed consent, who answers patient questions, and when in the workflow does this all happen. In addition, clinicians and office staff need to be trained on the various types of vaccines, indications and contraindications, and the importance of annual flu vaccination in mitigating severe illness.

Lack of Awareness

The relationship between acute flu infection, inflammation, and exacerbation of a patient's underlying disease, even if the disease is well controlled, is under appreciated by both primary care physicians and specialists. Beyond the acute infection, the potential effects of influenza illness in exacerbating chronic health conditions are not widely discussed or well known.

Patient Challenges

Myths and Misperceptions About Vaccination

In addition to misperceptions about and underappreciation of influenza infection, false notions about flu vaccine are also prevalent. It is not uncommon to hear individuals incorrectly state that flu vaccine “does not work,” that it “gives you the flu,” or even that it is “toxic.” Countering these false declarations with facts, even from credentialed HCPs and scientists, does not always overcome these ingrained beliefs.

Myths and misperceptions held by patients may stem from friends, family, or social cohorts such as parent groups or retirement communities. Social media posts against flu vaccine can exert influence over decision making, as can news reports with misleading information about low vaccine efficacy, despite various studies affirming the benefits of flu vaccination in mitigating disease.

Of particular concern, patients may assume that influenza vaccination is not necessary if HCPs are not strongly recommending it, which may, in part, be due to lack of awareness around the importance of annual flu vaccination for patients with chronic health conditions.

Misperceptions About the Burden of Flu

In addition to misunderstandings about the flu vaccine, false notions about influenza infection also present a challenge: “it's not so bad,” “having the flu builds your immune system,” and “I never get the flu” or “if I do get the flu, I'll recover.”

Eighty percent of unvaccinated adults believe that their likelihood of getting the flu is somewhat low or very low.¹² Among adults aged 50 to 64 years, 47% think the flu would not be serious for them personally, and fewer than half of 50- to 64-year-olds admit that they are “less than very well informed” about the impact of flu and the elevated burden and risks for adults with chronic health conditions.¹²

Lack of Awareness of Risks of Flu for Adults With Chronic Health Conditions

Information on the interactions between influenza infection and chronic health conditions is not widely available or understood by patients. This may well be due to lack of clear accountability (between primary care and specialty providers) and underappreciation of the impact of flu on these vulnerable populations.

RECOMMENDATIONS FOR INCREASING FLU VACCINATION RATES IN ADULTS WITH CHRONIC HEALTH CONDITIONS

• Statements on Flu Vaccine in Persons With Chronic Health Conditions
• American Diabetes Association: Position Statement ⁴⁶
• Vaccination should be recommended for patients with diabetes aged at least 6 months beginning each September.
• Intervention strategies strongly suggested for specific diabetes patients (eg, >64 years of age, those with chronic cardiopulmonary disorders, residents of nursing homes/chronic care facilities).
• Dosage and type of flu vaccine vary based on patient age.
• American Heart Association/American College of Cardiology: Science Advisory ⁴⁹
• Vaccination is recommended as a component of secondary prevention for persons with coronary disease and other atherosclerotic vascular conditions
• Vaccination should be administered to all persons with cardiovascular disease, unless they have a contraindication.
• Providers can increase influenza vaccination coverage by stocking the vaccine, and by promoting annual immunization with strong recommendations and standing orders.
• American Lung Association: Influenza ⁵⁰
• People with asthma or other lung diseases are at higher risk of developing complications from flu.
• Health officials recommend that everyone 6 months and older receive an influenza vaccination every year.
• Individuals are encouraged to speak to their health care providers to learn more about influenza and annual vaccination.

All Health Care Professionals Have a Role in Protecting Adults With Chronic Health Conditions From Influenza

• Both primary care providers and appropriate specialists should stock and insist upon annual flu vaccination—particularly for patients with known chronic health conditions and for all patients 50 years and older, who may have an undiagnosed chronic health condition or are likely to spread flu to those with chronic health conditions.
• Specialists, such as cardiologists, endocrinologists, and pulmonologists, who treat patients with chronic health conditions must routinely incorporate flu vaccine into fall visits.
• Health care providers should reach out to patients with chronic health conditions who do not have a scheduled early-fall visit and ask them to come in for flu vaccination.
• Health care providers who are unable to provide flu vaccination onsite should write a “prescription” for flu vaccine for patients with chronic health conditions. Although a prescription is not required to get a flu vaccine at a pharmacy or other health provider, a written “flu vaccine prescription” can help signal the importance and urgency of the recommendation. A strong health care provider recommendation is known to improve vaccination rates.

Identify/Assign a Flu Vaccine Champion in Your Medical Practice or Health System

• Educate all clinicians and office staff on current Centers for Disease Control and Prevention influenza vaccine recommendations.
• Clearly communicate that flu vaccine is an integral and important part of health care for adults with chronic health conditions. Emphasize the potential for disease exacerbation and continuous frailty that can result from influenza infection.
• Create a point in the workflow during the flu season (typically September to March) for vaccine administration.
• Establish a targeted goal of at least 90% vaccination coverage among patients in the practice and assess progress on an ongoing basis.

Reset Messages About the Value of Flu Vaccination

• Emphasize the benefits of flu vaccination not only for individuals but also for the whole community. Benefits include the following:
• Risk reduction. No vaccine is 100% effective but flu vaccination helps to reduce risk in individuals and reduces the amount of virus circulating in the community. Partial protection is the norm and the goal for flu vaccines.
• Mitigation of disease. Vaccination lessens the effect of influenza illness and reduces the risk of long-term consequences if an individual becomes infected despite having been vaccinated.
• Disruption of transmission. The more people who are vaccinated, the less influenza virus will be transmitted in the population, leading to a healthier community overall. Vaccination also provides indirect protection by reducing exposure of susceptible individuals to the virus.
• Community immunity. Getting a flu vaccine is the socially responsible thing to do to protect both healthy individuals as well as those with chronic health conditions.
• Motivate patients.
• Insist on flu vaccination for all adult patients with a strong recommendation.
• Inform adults with heart conditions, lung conditions, and/or diabetes that influenza infection could exacerbate their condition, or even worse, trigger an adverse cardiovascular event.
• Emphasize the importance of remaining vital and active, going to work, enjoying life, and spending time with family/friends.
• Explain the potential for post–flu frailty. A frail person may lose the ability to take care of him/herself and maintain independence without burdening younger family members. Individuals may never return to their pre–flu state.
• Integrate flu vaccine messages into overall wellness messages and programs. Eating healthfully, not smoking, exercising, and getting the flu vaccine every year are all part of maintaining a healthy lifestyle.
• Create a practical vaccination reminder tied to an annual fall ritual—Labor Day, the first day of school, and so on.

Reinforce Medical/Scientific Consensus Linking Improved Patient Outcomes With Annual Flu Vaccination

• HCP audience:
• Educate doctors, nurses, pharmacists, and other medical professionals via professional meetings, publications, and continuing medical education.
• Consumer/patient audience:
• Enhance point of care education, including waiting room videos and brochures, targeted signage, and direct conversations between patients and HCPs.
• Initiate public awareness campaigns to ensure that people can self-identify as having a health condition that may be exacerbated by flu. One way to do this is to associate flu vaccination with behaviors versus diagnosis. For example, instead of saying that patients with chronic heart or lung conditions or with diabetes should get a flu vaccine, say that those who take statins, those who use an inhaler, or those who take insulin should get a flu shot.

SUMMARY AND CONCLUSIONS

Flu is a dangerous and potentially deadly virus with impacts that extend beyond the initial acute infection. Flu is of particular concern for the millions of adults in the United States who have chronic health conditions such as diabetes, lung disease, and cardiovascular disease, which may increase the risk of infection and influenza-related complications including hospitalization, catastrophic disability, and even death. In particular, influenza-related inflammation can exacerbate chronic lung diseases and has been shown to increase the risk of myocardial infarction and stroke long after resolution of the acute illness.

For these reasons, annual flu vaccination is critical in adults with chronic health conditions to mitigate disease severity, reduce hospitalization rates, and disrupt viral transmission. Unfortunately, vaccination rates remain suboptimal in adults, and the severity and true impact of influenza infection are underappreciated and often misunderstood by both patients and HCPs.

There is an urgent need to raise awareness of the burden of flu in adults with chronic health conditions. Health care professionals must communicate the importance of protecting patients with chronic health conditions against flu and subsequent exacerbations and complications. They play a key role in communicating the known benefits of flu vaccine in mitigating these risks, and they must be prepared to recognize and address key barriers to vaccination, including lack of consumer confidence in vaccine efficacy, lack of HCP ownership in administering flu vaccines, and misperceptions about the impact of flu.

All HCPs have the opportunity to help reframe the conversation about the value of annual flu vaccination, not only for adults with chronic health conditions but also for the community as a whole. By following the recommendations outlined in this report, HCPs and health systems can significantly increase vaccination rates and improve patient outcomes in adults with chronic health conditions. Encouraging routine immunization behaviors in middle-age adults may also ensure that they continue to seek annual vaccination as they age into the 65-plus-year cohort, another group at particularly high risk of flu-related complications.

• Several influenza vaccine options are available specifically for older adults. Health care professionals should review available clinical evidence when making selections for their patients. To learn more, visit the Centers for Disease Control and Prevention Web site.

SUPPORTING ORGANIZATIONS

The following organizations participated in the Roundtable discussions:

Alliance for Aging Research

American Academy of Family Physicians

American Association of Diabetes Educators

American College of Cardiology

American College of Physicians

American Lung Association

American Medical Group Association

American Nurses Association

American Pharmacists Association

Centers for Disease Control and Prevention

Immunization Action Coalition

National Adult and Influenza Immunization Summit

National Association of Chain Drug Stores

National Foundation for Infectious Diseases

The Gerontological Society of America

REFERENCES

Self-Assessment Examination

A minimum assessment score of 80% is required.

1. Following adults 65 years and older, which age group had the highest cumulative flu-related hospitalization rate in the 2017–2018 influenza season?
1. 0–4 years
2. 5–17 years
3. 18–49 years
4. 50–64 years
2. The benefits of influenza vaccination include which of the following?
1. Mitigating disease severity
2. Reducing hospitalization rates
3. Disrupting viral transmission
4. All of the above
3. Which of the following is not an identified challenge to increasing influenza vaccination rates in adults with chronic health conditions?
1. Lack of ownership in administering influenza vaccines
2. There is no influenza vaccination recommendation for this population
3. Limited time during the medical visit
4. Lack of awareness of the potential effects of influenza illness in exacerbating chronic health conditions
4. How long can the inflammatory reaction caused by influenza last?
1. 2–3 days
2. Several weeks
3. 6 months
4. 1 year
5. Influenza vaccination has been associated with which of the following patient outcomes?
1. Reduced risk of cardiovascular events in individuals with pre-existing heart disease
2. Reduced risk of ischemic heart disease in older COPD patients
3. Reduced admission rates for stroke, heart failure, and all other causes of death in older patients with type 2 diabetes
4. All of the above

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