Majority of U.S. Adults Are Missing Routine Vaccinations
Call to Action to Protect All Adults from Vaccine-Preventable Disease and Disability
From National Adult and Influenza Immunization Summit and partner organizations.
Call to Action
Given the tremendous health benefits of adult vaccinations and low rates of adult vaccination, made worse by the COVID-19 pandemic, the National Adult and Influenza Immunization Summit (NAIIS) members call on providers across the healthcare spectrum to take actions to improve routine vaccination of adults.
Specifically, NAIIS calls on all clinicians and other healthcare providers, such as pharmacists, occupational health, and clinical subspecialists, to follow the National Vaccine Advisory Committee (NVAC) Standards for Adult Immunization Practice including:
- Assess the vaccination status of patients at all clinical encounters, even among clinicians and other providers who do not stock vaccines.
- Utilize a jurisdiction’s immunization information system (IIS) to view patients’ prior vaccinations to support vaccine needs assessment.
- Identify vaccines patients need, then clearly recommend needed vaccines.
- Offer needed vaccines or refer patients to another provider for vaccination.
- Document vaccinations given, including in the jurisdiction’s IIS.
- Many electronic health record (EHR) systems already link to jurisdiction’s IIS – providers should check with their EHR administrators.
- Providers not already utilizing an IIS should contact their local or state immunization programs to inquire about enrolling in their jurisdiction’s IIS.
- Measure vaccination rates of providers’ patient panels; make changes to clinic patient flow and take other steps to address barriers to patient vaccination.
Taking these actions will help protect adults across the U.S. against preventable illness, disability, and death.
Vaccinations are critical components of routine healthcare for adults. They provide protection against severe illness, disability, and death from 15 different infectious diseases such as influenza, pneumococcal disease, herpes zoster (shingles), hepatitis A, hepatitis B, HPV-related cancers, tetanus, and pertussis (whooping cough).1 Time and again, vaccines have demonstrated their value in maintaining the health of individuals and their communities; vaccines are among the most effective and cost-effective preventive health interventions available.2,3,4 The enormous impact of COVID-19 vaccines on illnesses, hospitalizations, and deaths further demonstrates the immense value of vaccines.5,6,7
Despite tremendous benefit of vaccines, most adults in the United States are missing one or more routinely recommended vaccines.8 The most recent published data on all routinely recommended vaccines from the 2018 National Health Interview Survey (Table 1) found that at least 3 out of every 4 adults are missing one or more of four routinely recommended vaccines [influenza, pneumococcal, zoster (shingles), and tetanus toxoid-diphtheria (Td) or tetanus toxoid-diphtheria-pertussis (Tdap)].8 Many adults are missing other vaccines recommended for them based on their age, medical conditions, occupation, or other factors. In addition, many adults are also missing vaccines recommended ideally during childhood or adolescence; for example, nearly half of females and three-fourths of males age 19-26 years are missing HPV vaccination.8
Racial and ethnic disparities in adult vaccination coverage are also prevalent and have widened for some vaccines in recent years.8 For example, in 2019, while 29% of non-Hispanic White U.S. adults age 50 years and older had received a shingles vaccination, only 18% of non-Hispanic Black and 15% of Hispanic adults had been vaccinated.9
Further, routine vaccination of adults greatly declined during the COVID-19 pandemic as fewer people received preventive care, exacerbating already low adult vaccination rates.10,11
As U.S. communities reopen, people gather in large groups, and traveling resumes, non-COVID-19 infections that decreased during the pandemic – such as influenza, pertussis, pneumococcal pneumonia, bacterial meningitis, and other diseases – are likely to increase. Indeed, increases are already occurring for respiratory syncytial virus (RSV) and other viral infections.12 In addition, the occurrence of other vaccine-preventable infectious diseases continued during the pandemic, such as hepatitis B,13 hepatitis A,14 and herpes zoster (shingles).
A provider’s recommendation is a key predictor of adults’ decisions to get vaccinated.20 Yet, the majority of adults report that they did not discuss vaccinations with their providers at their most recent visits.21 In addition to provider recommendations, several other evidence-based strategies have been shown to improve vaccination rates, especially systems changes (e.g., routine incorporation of immunizations into patient flow, and evaluation of vaccination rates).19,22
Major challenges to adult vaccination include systematic incorporation of vaccination into the routine care of adults, many adults not having easy access to medical services or not having a primary care provider, out-of-pocket costs for certain adult vaccinations, and challenges with access to adults’ complete vaccination history.16-21 In addition, adult patients receive healthcare services from a variety of providers (compared to children, who generally have “medical homes” with only one provider). Seeing multiple providers (e.g., pharmacists, occupational health, specialty providers) can pose a challenge for having complete vaccination records available to all providers, but also provides an opportunity to have all providers recommend needed vaccines. Receiving vaccine recommendations from several different providers may help reinforce the importance of adult vaccines throughout the lifespan.
Critical to assessing patients’ vaccination needs is the ability for providers to have access to immunization records, including those reported to Immunization Information Systems (IIS). Ideally, all vaccinations should be reported to the IIS to facilitate having consolidated vaccination records for adults. Bi-directional sharing of immunizations between IIS and electronic health record systems will help increase the completeness of patient vaccination records in IIS and put vaccination records at provider’s fingertips.
Evidence-based strategies for improving immunization rates 22 include:
- Implementing healthcare system-based interventions to:
- Ensure vaccination needs assessments are routinely incorporated into patient flow and needed vaccines are identified and recommended to patients;
- Incorporate provider reminders about patients’ needed vaccines (e.g., enabling EHR pop-up reminders about needed vaccinations); and
- Provide feedback to providers regarding their patients’ vaccination rates.
- Increasing patient awareness of vaccines.
- Utilize the client/patient reminder and recall functions within IIS and electronic health record systems to send patients reminders about needed vaccines.
- Routinely utilizing IIS to assess vaccination needs and report vaccines administered to ensure patients have consolidated vaccination records.
- Utilizing standing orders, where appropriate, to give practitioners authority to give routinely recommended vaccinations as indicated in the standing orders.
- Enhancing access to vaccination services by offering vaccines at convenient times and at convenient locations, and by eliminating or reducing other barriers, such as out-of-pocket costs.
- Working with partners on community-based interventions to enhance vaccine access and awareness.
Improving and sustaining the adult immunization infrastructure to deliver recommended vaccinations consistently in the United States is also vital for preparing for the next major pandemic. Through implementation of the NVAC Standards for Adult Immunization Practices23 and the utilization of evidence-based strategies, we can close the gap in adult vaccinations missed during the COVID-19 pandemic and make progress in raising historically low vaccination rates among adults seen before the pandemic. These efforts will enable all patients to be informed about the vaccines they need, and to be protected from vaccine-preventable diseases, including COVID-19.
1. CDC/ACIP Adult Immunization Schedule. www.cdc.gov/vaccines/schedules/hcp/imz/adult.html (accessed June 18, 2021).
2. Whitney CG, et al., Benefits from Immunization during the Vaccines for Children Program Era — United States, 1994–2013. MMWR Weekly 2014;63(16);352–355. www.cdc.gov/mmwr/preview/mmwrhtml/mm6316a4.htm.
3. Dabestani NM, et al., A Review of the Cost-Effectiveness of Adult Influenza Vaccination and Other Preventive Services. Prev Med. 2019 Sep;126:105734. https://doi.org/10.1016/j.ypmed.2019.05.022
4. CDC. Ten Great Public Health Achievements—United States, 2001–2010 MMWR Weekly 2011:60(19);619–623. www.cdc.gov/mmwr/preview/mmwrhtml/mm6019a5.htm.
5. CDC. COVID-19 Vaccine ACIP Recommendations. www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/covid-19.html (accessed June 18, 2021).
6. Christie A, et al., Decreases in COVID-19 Cases, Emergency Department Visits, Hospital Admissions, and Deaths among Older Adults following the Introduction of COVID-19 Vaccine — United States, September 6, 2020–May 1, 2021. MMWR Morb Mortal Wkly Rep 2021;70:858–864. http://dx.doi.org/10.15585/mmwr.mm7023e2
7. CDC. When You Have Been Fully Vaccinated. www.cdc.gov/coronavirus/2019-ncov/vaccines/fully-vaccinated.html (accessed June 18, 2021).
8. Lu P, Hung M, Srivastav A, et al., Surveillance of Vaccination Coverage among Adult Populations—United States, 2018. MMWR Surveill Summ 2021;70(No. SS-3):1–26. http://dx.doi.org/10.15585/mmwr.ss7003a1.
9. CDC. Quickstats: Percentage of Adults >50 Years Who Ever Received a Shingles Vaccination, by Race and Hispanic Origin and Sex – National Health Interview Survey (NHIS), United States 2019. MMWR 2021;70:901. https://www.cdc.gov/mmwr/volumes/70/wr/mm7024a5.htm
10. Avalere. Updated Analysis Finds Sustained Drop in Routine Vaccines through 2020. Avalere Insight, June 9, 2021. https://avalere.com/insights/updated-analysis-finds-sustained-drop-in-routine-vaccines-through-2020 (accessed June 29, 2021).
11. Nyaku, Mawuli. Unpublished data. Presented to National Adult and Influenza Summit, July 15, 2021. https://www.izsummitpartners.org/weekly-update/#toc3
12. CDC. National Respiratory and Enteric Virus Surveillance System (NREVSS) www.cdc.gov/surveillance/nrevss/index.html (accessed June 18, 2021).
13. CDC. Nationally Notifiable Infectious Diseases and Conditions, United States: Weekly Tables. https://wonder.cdc.gov/nndss/static/2021/22/2021-22-table1p.html (accessed June 18, 2021).
14. CDC. Widespread person-to-person outbreaks of hepatitis A across the United States. https://www.cdc.gov/hepatitis/outbreaks/2017March-HepatitisA.htm (accessed June 18, 2021).
15. CDC. COVID-19 Data Tracker. https://covid.cdc.gov/covid-data-tracker/#vaccinations (accessed June 18, 2021).
16. Albright K, et al., Attitudes about Adult Vaccines and Reminder/Recall in a Safety Net Population. Vaccine 2017;35(52):7292–7296. https://doi.org/10.1016/j.vaccine.2017.11.001
17. Hurley LP, et al., Physician Attitudes toward Adult Vaccines and Other Preventive Practices, United States, 2012. Public Health Rep 2016;131(2):320–30. https://doi.org/10.1177/003335491613100216
18. Grande CJ, et al., Implementation of the Standards for Adult Immunization Practice: A Survey of U.S. Health Care Providers. Vaccine 2020; 38(33):5305–5312. https://doi.org/10.1016/j.vaccine.2020.05.073
19. Bridges CB, et al., Meeting the Challenges of Immunizing Adults. Vaccine 2015; 33 Suppl 4:D114–20. https://doi.org/10.1016/j.vaccine.2020.05.073
20. Winston CA, Wortley PM, Lees KA, Factors Associated with the Vaccination of Medicare Beneficiaries in Five U.S. Communities: Results from the Racial and Ethnic Disparities in Immunization Initiative Survey, 2003. J Am Geriatr Soc 2006;54:303–10. https://doi.org/10.1111/j.1532-5415.2005.00585.
21. Bridges CB, Presentation to National Adult and Influenza Summit, May 2016. www.izsummitpartners.org/content/uploads/2016/05/1a-3-Bridges-Making-Progress-Towards-Improving-Adult-Immunizations.pdf (accessed June 20, 2021).
22. The Community Guide. What Works: Increasing Appropriate Vaccination: Evidence-Based Interventions for Your Community. www.thecommunityguide.org/sites/default/files/assets/What-Works-Factsheet-Vaccination.pdf
23. National Vaccine Advisory Committee. Recommendations from the National Vaccine Advisory Committee: Standards for Adult Immunization Practice. Public Health Rep 2014;129(2):115–23.https://doi.org/10.1177/003335491412900203
|Table 1. Vaccination Coverage Estimates Using an Age-Appropriate Composite* Adult Vaccination Quality Measure and Individual Component Measures, by Age Group — National Health Interview Survey, United States, 2018. [Table reproduced from Lu P, et al., MMWR Surveill Summ 2021;70(No. SS-3):1–26.]|
|Characteristic||% (95% CI)|
|≥19 yrs||19–49 yrs||50–64 yrs||≥65 yrs|
|(n = 25,207)†||(n = 11,318)†||(n = 6,592)†||(n = 7,297)†|
|Includes influenza during preceding 12 months|
|Tdap only§||13.5 (12.7–14.3)||18.7 (17.4–19.9)||3.9 (3.2–4.8)||11.2 (10.0–12.5)|
|Td or Tdap¶||20.2 (19.4–21.0)||25.7 (24.5–26.9)||6.7 (6.0–7.6)||22.6 (21.2–24.0)|
|Does not include influenza during preceding 12 months|
|Tdap only**||24.0 (22.9–25.2)||36.9 (35.2–38.6)||4.8 (4.1–5.7)||12.1 (10.9–13.5)|
|Td or Tdap††||42.3 (41.3–43.3)||64.5 (63.1–65.8)||8.7 (7.9–9.7)||25.4 (23.9–26.8)|
|Influenza during preceding 12 months||44.7 (43.8–45.6)||34.2 (33.0–35.4)||46.9 (45.3–48.4)||68.8 (67.4–70.1)|
|Td or Tdap||62.9 (61.8–64.0)||64.5 (63.1–65.8)||62.8 (61.2–64.5)||58.9 (57.2–60.5)|
|Tdap||31.2 (30.0–32.5)||36.9 (35.2–38.6)||26.0 (24.2–27.9)||22.2 (20.5–24.0)|
|Herpes zoster¶¶||24.1 (23.1–25.1)||—||11.5 (10.5–12.5)||39.5 (37.9–41.1)|
|Pneumococcal***||69.0 (67.5–70.4)||—||—||69.0 (67.5–70.4)|
Abbreviations: CI = confidence interval; Td = tetanus and diphtheria toxoids vaccine; Tdap = tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine.
* Estimates using data from the 2018 National Health Interview Survey for age-based composite adult vaccination quality measure for tetanus toxoid-containing, pneumococcal, herpes zoster, and influenza vaccines. Influenza vaccination was measured as receipt during the preceding 12 months, in contrast to Table 1, where influenza vaccination coverage for July 2017–May 2018 was estimated using Kaplan–Meier survival analysis. Td/Tdap vaccination was measured as receipt during the preceding 10 years. Pneumococcal and herpes zoster vaccination were measured as ever receiving at least one dose of either kind of vaccine. Estimates for the composite measures (Source: Shen AK, Williams WW, O’Halloran AC, et al., Promoting Adult Immunization Using Population-Based Data for a Composite Measure. Am J Prev Med 2018;55:517–23) were calculated to include Tdap vaccine during the preceding 10 years (Method 1) or any tetanus-toxoid containing vaccine during the preceding 10 years (Method 2), and both with and without influenza vaccination during the preceding 12 months. Using Method 1, percent of respondents excluded in vaccination coverage estimation including influenza vaccination was 40.7% overall, ranging from 38.4% in adults age 19–49 years to 43.1% in adults age ≥65 years; percent of respondents excluded in vaccination coverage estimation excluding influenza vaccination was 40.6% overall, ranging from 38.2% in adults age 19–49 years to 43.1% in adults age ≥65 years.
† Total unweighted sample size for the overall age group. Denominators for each point estimate vary because persons who did not answer vaccination questions were excluded from analysis.
§ A composite estimate of overall vaccination coverage among adults age ≥19 years who received the selected vaccines recommended for their age group: for adults age 19–49 years, influenza and Tdap vaccines; for adults age 50–64 years, influenza, Tdap, and herpes zoster vaccines; for adults age ≥65 years, influenza, Tdap, herpes zoster, and pneumococcal vaccines. Estimates for each age group include adults who have received all of the selected vaccines for that specific age group.
¶ A composite estimate of overall vaccination coverage among adults age ≥19 years who received the selected vaccines recommended for their age group: for adults age 19–49 years, influenza AND Td or Tdap vaccines; for adults age 50–64 years, influenza, Td or Tdap, and herpes zoster vaccines; for adults age ≥65 years, influenza, Td or Tdap, herpes zoster, and pneumococcal vaccines. Estimates for each age group include adults who have received all of the selected vaccines for that specific age group.
** A composite estimate of overall vaccination coverage among adults age ≥19 years who received the selected vaccines recommended for their age group: for adults age 19–49 years, Tdap vaccines; for adults age 50–64 years, Tdap and herpes zoster vaccines; for adults age ≥65 years, Tdap, herpes zoster, and pneumococcal vaccines. Estimates for each age group include adults who have received all of the selected vaccines for that specific age group.
†† A composite estimate of overall vaccination coverage among adults age ≥19 years who received the selected vaccines recommended for their age group: for adults age 19–49 years, Td or Tdap vaccines; for adults age 50–64 years, Td or Tdap and herpes zoster vaccines; for adults age ≥65 years, Td or Tdap, herpes zoster, and pneumococcal vaccines. Estimates for each age group include adults who have received all of the selected vaccines for that specific age group.
§§ For influenza, respondents were asked if they received an influenza shot or nasal spray during the preceding 12 months.
¶¶ Herpes zoster vaccination coverage among adults age ≥50 years.
*** Pneumococcal vaccination coverage among adults age ≥65 years.