Notice to Readers Assessing Adult Vaccination Status at Age 50 Years

In January 1994, the National Vaccine Advisory Committee (NVAC) reported on the status of adult vaccination in the United States (1) and concluded that vaccine-preventable infections among adults are a continuing cause of morbidity and mortality, particularly among older persons. Missed opportunities to vaccinate adults during health-care visits have markedly influenced adult vaccination levels (2). To improve vaccination levels, the NVAC recommended changes in clinical practice, including systems for regularly offering vaccines to patients at risk. Consistent with the NVAC recommendations, the American College of Physicians Task Force on Adult Immunization and the Infectious Diseases Society of America have recommended linking the assessment of vaccination status and the administration of vaccinations at age 50 years to other established prevention measures (3).

At its meeting on October 19-20, 1994, the Advisory Committee on Immunization Practices (ACIP) adopted the recommendation that, for their patients aged 50 years, health-care providers 1) review adult vaccination status, 2) administer tetanus and diphtheria toxoids as indicated, and 3) determine whether a patient has one or more risk factors that indicate a need to receive one dose of pneumococcal vaccine and begin annual influenza vaccination. This recommendation is consistent with those of other groups that have recommended age 50 years as a time to assess important prevention measures, (e.g., screening for certain cancers that occur more commonly with advancing age or counseling of older women regarding estrogen replacement therapy) (4).

Establishing a routine vaccination status assessment at age 50 years provides an opportunity to improve the delivery of vaccination services to adults. ACIP recommends that all primary-care physicians schedule a prevention visit for their patients at age 50 years to assess vaccination status, provide recommended vaccines, and offer other prevention services that may be indicated.

In the United States, tetanus is primarily a problem among adults aged greater than 50 years (5) who never completed a primary vaccination series, never received appropriate treatment of a wound that could result in infection with Clostridium tetani, or both (5). Reviewing the need for either primary or booster tetanus toxoid administration at age 50 years would assure high levels of protection at an age when the incidence and the case-fatality rates of tetanus begin to increase. Although diphtheria has virtually disappeared from the United States, the re-emergence of diphtheria in the former Soviet Union (6) has heightened concerns regarding the low prevalence of protective antibody levels among adults in the United States. An age-based recommendation for tetanus and diphtheria toxoids (Td) vaccination should improve the use of Td among adults and decrease the risk for reoccurrence of widespread diphtheria in the United States.

Many persons aged 50-64 years have either cardiovascular or pulmonary risk conditions and are, therefore, candidates to receive pneumococcal and influenza vaccines (CDC, unpublished data, 1994) Table_1. The prevalence of these conditions is probably even higher among those who regularly seek medical care. Persons aged greater than or equal to 18 years for whom influenza and pneumococcal vaccines are recommended include all those aged greater than or equal to 65 years, those with chronic disorders of the pulmonary and cardiovascular systems, and those who have required regular medical follow-up or hospitalization during the preceding year because of chronic metabolic diseases (including diabetes mellitus), renal dysfunction, hemoglobinopathies, or immunosuppression (including immunosuppression caused by medications) (7,8). In addition, pneumococcal vaccine is recommended for persons with alcoholism, cirrhosis, cerebrospinal fluid leaks, and splenic dysfunction or anatomic asplenia (8). The rapid emergence of drug-resistant pneumococcal infections underscores the need for adherence to ACIP recommendations for pneumococcal vaccination (9).

Physicians should review a patient's vaccination status at every visit to identify these conditions in patients and provide the appropriate vaccines whenever indicated. In 1991, 9% and 15% of persons with cardiovascular or pulmonary high-risk conditions, respectively, in the 50-64-year age group reported having ever received pneumococcal vaccine, and 21% and 28%, respectively, reported having received influenza vaccine during the previous year (CDC, unpublished data, 1994;Table_1). In contrast, although still below the national health objective for the year 2000 (60% vaccination levels for these vaccines; objective 20.11) (10), a substantially higher percentage of persons aged greater than or equal to 65 years with these conditions reported receiving these vaccines than did persons aged 50-64 years Table_1. These data indicate that the recommendations to vaccinate persons aged less than 65 years based on the presence of certain chronic medical conditions have been inadequately implemented. A specific age-based standard should improve vaccination rates among those with high-risk conditions. Reported by: Advisory Committee on Immunization Practices. National Immunization Program, CDC.

References

1. Fedson DS, for the National Vaccine Advisory Committee. Adult immunization: summary of the National Vaccine Advisory Committee Report. JAMA 1994;272:1133-7.

2. Williams WW, Hickson MA, Kane MA, Kendal AP, Spika JS, Hinman AR. Immunization policies and vaccine coverage among adults: the risk for missed opportunities. Ann Intern Med 1988;108:616-25.

3. American College of Physicians Task Force on Adult Immunization/Infectious Diseases Society of America. Guide for adult immunization. 3rd ed. Philadelphia, Pennsylvania: American College of Physicians, 1994.

4. US Preventive Services Task Force. Guide to clinical preventive services: an assessment of the effectiveness of 169 interventions. Baltimore, Maryland: Williams and Wilkins, 1989.

5. CDC. Diphtheria, tetanus, and pertussis: recommendations for vaccine use and other preventive measures: recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR 1991:40(no. RR-10).

6. CDC. Diphtheria epidemic -- New Independent States of the former Soviet Union, 1990-1994. MMWR 1995;44:177-81.

7. CDC. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1995;44(no. RR-3).

8. CDC. Pneumococcal polysaccharide vaccine: recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR 1989;38:64-8,73-6.

9. Breiman RF, Butler JC, Tenover FC, Elliott JA, Facklam RR. Emergence of drug-resistant pneumococcal infections in the United States. JAMA 1994;271:1831-5.

10. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991:122-3; DHHS publication no. (PHS)91-50213.

TABLE 1. Prevalence of high-risk medical conditions and
influenza and pneumococcal vaccine coverage -- National
Health Interview Survey, United States, 1991
=========================================================
                                         Age group (yrs)
                                      -------------------
Conditions                              50-64       >=65
---------------------------------------------------------
Cardiovascular
  Percentage with conditions             36.1       45.2
  Percentage with conditions
    receiving pneumococcal vaccine        9.2       23.0
  Percentage with conditions
    receiving influenza vaccine          21.2       48.2

Pulmonary
  Percentage with conditions             12.4       12.0
  Percentage with conditions
    receiving pneumococcal vaccine       14.7       33.4
  Percentage with conditions
    receiving influence vaccine          27.8       52.3
========================================================

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