A summary of presentations from the weekly Summit partner webinars
August 26, 2021 – The latest Summit summary
- NAIIS Adult Immunization Call to Action Update – Carolyn Bridges (IAC)
- NAIIS Adult Immunization Call to Action Update – Chelsea Toledo (CDC)
- Cost-benefit Analysis of Vaccination Against Four Preventable Diseases in Older Adults: Impact of an Aging Population – Sandra Talbird (RTI Health Solutions) and Justin Carrico (RTI Health Solutions)
NAIIS Adult Immunization Call to Action Update – Carolyn Bridges (IAC)
Carolyn Bridges, MD FACP, Director of Adult Immunizations, Immunization Action Coalition (IAC), gave a presentation on the uptake of COVID-19 vaccine and routinely recommended adult vaccines, and the NAIIS Adult Immunization Call to Action.
The COVID-19 pandemic demonstrates the enormous impact of vaccines.
As of August 20, 2021, the U.S. had administered more than 362 million doses of COVID-19 vaccines. Among those age 18 years and older, 73% have had at least one dose and 60% are fully vaccinated. For adults age 65 and older, 91% have received at least one dose and 81% are fully vaccinated. We are currently still seeing a huge number of cases of COVID-19, but we are not seeing a corresponding large increase in hospitalizations and deaths, demonstrating that the vaccines are preventing serious outcomes from COVID-19. This vaccination rate is overall a great achievement, however, there are parts of the country that are doing much better than others and there are pockets of the county that still need a lot of effort to increase vaccination rates in their communities.
The COVID-19 vaccination effort is benefiting routine vaccination implementation infrastructure in several ways. First of all, there have been substantial improvements to expand the use of immunization information systems. This will help immensely with adult vaccination needs assessment if providers continue to access the IIS to identify vaccines given and to report vaccines administered. Secondly, there are new and expanding partnerships that have been developed across multiple agencies to help with vaccination rates in groups with greater challenges accessing vaccines. Finally, there is greater awareness of barriers faced by certain groups of disproportionately impacted adults that weren’t less of a focus prior to the pandemic.
There is a substantial burden of vaccine-preventable diseases among adults.
Many are not aware of the disease burden and risk of disease due to missed adult vaccinations to prevent shingles, tetanus, whooping cough, hepatitis A, hepatitis B, streptococcus pneumoniae, and human papilloma virus (HPV).
Influenza also causes a huge burden, with the most severe illness in older adults with chronic medical conditions. From 2010–2020 adults age 65 and older accounted for 45-67% of influenza-related hospitalizations and 62-87% of influenza-related deaths.
Routinely recommended vaccinations have fallen during the COVID-19 Pandemic, impacting already low adult vaccination rates.
Routinely recommended vaccines for adults have historically low uptake, leaving adults vulnerable to vaccine-preventable illness, disability, and death. A MMWR that looked at 2018 national health interview survey data showed that increases in vaccine uptake has been minimal over time except for shingles vaccine. However, even with shingles vaccine, only a third of people age 60 and older have gotten the vaccine. For flu vaccine, 42% of people age 18–64 and 70% of people age 65 and older were vaccinate during the 2019–2020 season. For pneumococcal, 69% of people age 65 and older reported vaccination, however only 23% of those 18-64 at high risk were vaccinated. Only 59% of adults 65 years and older have gotten Td/Tdap vaccine in the past ten years. In the 19–26 year old age group, only 53% have gotten the HPV vaccine. Finally, the rates of the hepatitis vaccines are also low, with 12% of persons age 19 and older and 16% of those with liver disease vaccinated against hepatitis A, and 30% age 19 and older and 33% of those with liver disease vaccinated against hepatitis B.
There has been a lot of work done to highlight the issues of falling immunization rates during the pandemic:
- Impact of the COVID-19 Pandemic on Adult HPV, Pneumococcal, and Zoster Vaccinations – Mawuli Nyaku, DrPH, MBA, MPH, (Merck)
- The COVID-19 Pandemic: Impact on US Adolescent and Adult Vaccine Utilization Across Markets – Loren Becker (Avalere Health)
The majority of U.S. adults are missing at least one recommended vaccine.
Data from the MMWR publication on adult vaccination also shows substantial disparities in vaccination rates by race, ethnicity, education, income, and insurance status. Data shows that at least 75% of adults are not up to date on these routinely recommended vaccines: flu, Td/Tdap, pneumococcal, and zoster (shingles).
Concrete steps needed to improve adult vaccination update:
In response to low adult vaccination rates, multi-sector partners developed, and National Vaccine Advisory Committee updated and published standards in 2014. This recognizes that not all of the medical providers stock all recommended vaccines, the importance of the provider’s recommendation to the patient, and the need to accurately track patient vaccinations in immunization information systems (IIS, aka vaccine registries).
Further reductions in already low adult vaccination prompted CDC and partner organizations to develop a Call to Action on Adult Immunizations released on Aug. 23, 2021.
National Adult and Influenza Immunization Summit (NAIIS) Call to Action
The call to action, issued by the National Adult and Influenza Immunization Summit (NAIIS), which is co-led by CDC, HHS’ Office of Infectious Disease and HIV/AIDS Policy, and the Immunization Action Coalition, aims to increase U.S. adult vaccination coverage.
The call to action highlights the tremendous benefits of adult vaccines, low levels of vaccination––made worse by the COVID-19 pandemic––and ongoing disparities in U.S. adult vaccination rates. The call to action prompts provider organizations to encourage implementation of the standards of adult immunization practice.
Additional strategies to promote adult vaccination that have proven to be effective include providing greater access to vaccination and provider and system-based interventions. This information can be found in the Community Guide. The guide provides guidance on which community-based health promotion and disease prevention intervention approaches work and which do not work, based on available scientific evidence.
Many organizations are signing up to support the NAIIS call to action. Summit member organizations are welcome to sign up to support the call to action on the NAIIS call to action webpage by clicking the “Support the Call to Action” button in the right column. The CDC also has a webpage for the call to action for adult immunizations and other resources of interest to help providers and patients understand which vaccines they may need:
- CDC: Patient check-in vaccine questionnaire to be used at clinics
- CDC: Patient on-line quiz used to direct patients to complete the quiz before coming to their appointment, which gives you a starting point for talking about which vaccines they might need.
- CDC: Adult vaccine schedule app
In addition, IAC has a number of resources for providers assessing adult vaccination, including the HALO screening tool at: https://www.immunize.org/catg.d/p3070.pdf.
Are there specific guidance/communication materials that are available for community-based partners, discussing influenza vaccination in the context of COVID-19 and COVID-19 vaccination?
There is some information on CDC’s Clinical Considerations for Use of COVID-19 Vaccines webpage. The prior initial guidance was not to give any other vaccine within 14 days of the COVID-19 vaccine. This is no longer the case. Now we have the ability to co-administer or get any other vaccines even within 14 days before or after the COVID-19 vaccine.
Chelsea Toledo, MA, MPH, Sr. Health Communications Advisor, Partnering for Vaccine Equity, CDC Contractor – ASR, gave a short presentation on the NAIIS Adult Immunization Call to Action.
The CDC has added a link to the NAIIS call to action on its Strategies for Increasing Adult Vaccination Rates web page to increase the call to action’s visibility.
To support the call to action, consider sharing this tweet from CDC.
Are there specific guidance/communication materials that is available for community-based partners, discussing influenza vaccination in the context of COVID-19 and COVID-19 vaccination?
You can go to CDC’s Frequently Asked Influenza (Flu) Questions: 2021–2022 Season for information on this season.
Cost-benefit Analysis of Vaccination Against Four Preventable Diseases in Older Adults: Impact of an Aging Population – Sandra Talbird (RTI Health Solutions) and Justin Carrico (RTI Health Solutions)
Sandra Talbird, senior director, health economics, RTI Health Solutions (RTI-HS), and Justin Carrico, senior research health economist, RTI Health Solutions (RTI-HS), gave a presentation on recently published studies of the cost-benefit analysis of vaccination against four preventable diseases in older adults: and the impact of an aging population.
One of RTI Health Solution’s most recent research projects is on the on cost-benefit analysis of adult vaccination against four preventable diseases in older adults and the impact of the aging U.S. population. This was research sponsored and funded by GlaxoSmithKline Biologicals S.A. (GSK) and the study was published as two separate publications.
RTI-HS collaborated with vaccine manufacturers on this study to establish a consortium to pursue above-brand health economics and outcomes research initiatives that are considered above brand or not specific to any one vaccine or brand in particular. These are often of mutual interest to multiple vaccine manufacturers.
The Summit has provided feedback to this new consortium on research priorities from the public health perspective specifically around adult vaccination.
This group had an opportunity last summer to present to the Access and Provider Work Group and get insightful feedback. One of the top priorities was the need to estimate burden of illness of adult vaccine preventable diseases and the economic value of adult immunization in the U.S.
Research questions the study aimed to answer:
- What is the economic burden of influenza, pertussis, herpes zoster, and pneumococcal disease in adults aged 50 years and older in the US?
- What is the return on investment for current and increased vaccination coverage against these four preventable diseases?
- For both research questions above, what is the impact of the US population shift towards older age groups over the next 30 years?
Methods: Economic Model
A population-based, economic model was constructed to project cases and vaccination program cost of flu, pertussis, pneumonia, and zoster over a 30-year period from 2017–2046 among adults. The projected population estimates used to account for changes in the U.S. population over time came from the US Census Bureau. Using these population projections, the model accounted for the shifting of the U.S. population towards older age groups over the next few decades, as well as projected changes across mortality and net migration in each year. This approach allowed for a new cohort of individuals who were 50 years old to age into the model in each year.
For each year of the model, disease incidence among unvaccinated individuals was considered. Vaccination coverage and effectiveness estimates were then used to calculate annual disease cases among the vaccinated and unvaccinated populations while also accounting for waning vaccine protection over time.
With this model two analyses were conducted.
Burden of Disease Analysis: The first model aimed to project the burden of disease incidence, vaccine coverage, and efficacy of the four vaccine preventable diseases over a thirty-year period assuming that vaccine coverage remained at the 2017 level over the entire study period. The baseline of disease incidence, vaccine efficacy, and waning were also held constant over time in order to explore the burden of disease expected over 30 years. For the clinical outcomes, cases, deaths, and cost of disease were projected.
Cost-Benefit Analysis: The second model aimed to estimate the economic value or return on investment of the current vaccination program for the four diseases, as well as the hypothetical increases to vaccination coverage. This was conducted by comparing outcomes from three vaccination coverage scenarios over the 30-year period. The first scenario assumed all individuals were not vaccinated. The second scenario was mirrored from the first analysis where vaccination coverage remained constant over time. The third scenario assumed vaccination coverage increased linearly over time. The return on investment (expressed as a benefit-cost ratio) was calculated for current vaccination coverage and increased vaccination coverage.
For both of these analyses, cost included direct medical costs and societal costs.
Results: Impact of Population Aging on the Burden of Four Vaccine-Preventable Diseases
For the burden of diseases analyses, population growth and shifting of the age distribution of the U.S. population toward older age groups resulted in growth in the annual societal burden of the four diseases over 30 years. The societal burden of these diseases was projected to increase from 35 billion dollars to 49 billion dollars annually, which resulted in a cumulative 1.3 trillion dollar increase in societal costs over the 30-year period and over one million deaths due to these diseases if vaccines remained at the level they were at in 2017.
Results: Cost-Benefit Analysis of Vaccination against Four Preventable Diseases in Older Adults
In the cost benefit analysis, when the unvaccinated scenario was compared to the current vaccination coverage, there were an estimated 65 million averted disease cases over the 30-year period, which resulted in 185 billion dollars in averted costs of disease. Incremental vaccination costs associated with maintaining current coverage over that timeframe were estimated to be 136 billion dollars.
When comparing increases in vaccination coverage to current coverage, 33 million addition averted disease cases were estimated over the 30-year period. This was associated with additional cost savings relative to the current vaccination coverage cost scenario.
For both of these coverage comparisons the benefit ratios were greater than one, which indicates the incremental costs associated with vaccination were outweighed by savings related to the avoidance of disease-related costs. Each dollar invested in maintaining and increasing vaccination coverage was associated with more than one dollar of disease-related cost savings.
For both analysis there were a number of notable key limitations:
- The four preventable diseases that were modeled over time were modeled separately, and therefore interventions across diseases could not be captured. For example, a death due to pneumonia was not accounted for in the model population for zoster.
- The projections of the U.S. population coverage did not account for extraordinary events such as the COVID-19 pandemic which caused the rates of adult vaccinations to fall.
- The long-term cost of disease complications was not considered. This only captured the cost of acute care.
- The population-based model structure and methods for calculating diseases did not include indirect effects of vaccination, including herd immunity and serotype replacement.
The analysis demonstrated that the maintenance of current vaccine levels among adults age 50 years and older would lead to increases of the four diseases. The annual cost benefit showed that efforts to increase vaccination coverage in older adults may be warranted and economically justifiable.
Links to the two studies:
Are the one million deaths over and beyond what would have been expected?
Yes, if vaccination coverage stays at current coverage levels.
The number would be over and above what is expected but we didn’t calculate a standardized mortality ratio or try to quantify how much more the number would be over expected mortality.
You used the term “maybe warranted and economically justifiable” which, based on your ratios, seems to be a very conservative statement. If it looks like it’s actually cost saving, could you make that a stronger statement?
I think as modelers at lot of times we talk in a certain level of uncertainty.
Maybe it is economically justifiable as it is projected to be cost saving.
L.J Tan (IAC)
1. The Immunization Action Coalition (IAC), with funding support from Seqirus, is offering a limited quantity of FREE Flu Vaccine buttons and stickers in English and Spanish to support your flu vaccine promotion efforts this season.
To receive these supplies at no cost, please PRE-ORDER your buttons and stickers now. Delivery (also at no cost) is anticipated by early October.
2. The Immunization Action Coalition (IAC) will be holding two interactive webinars in September to emphasize vigilance in preventing influenza in the midst of the COVID-19 pandemic:
Even as COVID-19 vaccination efforts continue, seasonal influenza vaccination remains essential to protect health and ease the burden on healthcare systems. IAC will host a webinar titled The Continued Threat of Influenza and How to Sustain Influenza Vaccination Effortson September 9 at 1:00 p.m. (ET). Topics will include:
- Influenza surveillance in U.S. and worldwide
- Changes in circulation of other common respiratory pathogens, e.g., RSV
- Changes in influenza vaccine strains and changes in influenza ACIP recommendations
- Communication issues providers may face regarding perceptions of the need for influenza vaccination
- A public perspective on the importance of influenza vaccination and advocacy for vulnerable populations (chronic issues)
These topics will be addressed by speakers:
- Alicia Budd, MPH, Influenza Division of CDC’s National Center for Immunization and Respiratory Diseases (NCIRD)
- Robert H. Hopkins Jr., MD, University of Arkansas for Medical Sciences
- Gary Stein, MBA, Families Fighting Flu
Register now to be sure you don’t miss this informative session.
3. The second hour-long webinar titled “Translating COVID-19 Strategies to Improve Influenza Seasonal Flu Efforts” will take place on Monday, September 20 at 1 p.m. (ET). The webinar will cover the following topics:
- Information to improve influenza immunization in communities of color
- Strategies to reach small communities from a public health perspective
- Information for providers on emphasizing a strong recommendation for influenza vaccination this season
- Information on vaccine equity issues, reaching underserved populations and utilization of mass vaccination successes seen with COVID-19.
These topics will be addressed by speakers:
- Laura Lee Hall, PhD, President, Center for Sustainable Health Care Quality and Equity, National Minority Quality Forum (NMQF)
- Amy Callis, BA, MPH, Principal and Owner, Devi Partners
- Sarah Price, Director of Public Health Integration, National Association of Community Health Centers (NACHC) and Jennie McLaurin, MD, Specialist, Child & Migrant Health, Bioethics, Migrant Clinicians Network
- Mitchel Rothholz, R.Ph, MBA, Chief of Governance & State Affiliates and Executive Director, American Pharmacists Association (APhA)
Following these presentations there will be an opportunity for you to ask your questions. This live question and answer session will include additional experts from the Immunization Action Coalition joining the speakers to answer your questions.
Register now to be sure you don’t miss this informative session.
Both webinars are supported by IAC and a vaccine education grant from Seqirus, Inc.
4. We would like to welcome having more NAIIS member organizations to add their support to the Call to Action on adult immunization. Access the call to action and click on the top righthand button to add your organization.