Shoppers Drug Mart pharmacist/owner Allan Wong prepares a flu shot at his Surrey pharmacy. Immunization rates in older adults remains low across Canada, putting this population at risk for health complications.
Pharmacists need to become key drivers in the promotion of immunizations for adults
By Kane Larson, BSc, PharmD and Fawziah Lalji, BSc (Pharm), PharmD
Vaccines are essential health measures to protect patients from severe diseases that are preventable. While everyone is in agreement that communicable disease prevention is of utmost importance in children — leading to the virtual elimination of all immunization-related barriers for this age group — support for the immunization of older adults remains ineffectual. This results in considerable morbidity and mortality and directly contributes to tremendous health-care costs in Canada. In contrast to the childhood program, adult immunization rates are very low, resulting in social, racial and ethnic disparities.
It is imperative that health-care providers — including pharmacists — play a vital role in addressing the lack of importance placed on adult immunizations and the misinformation surrounding them, including the efficacy and safety of vaccines. Pharmacists, especially, are poised to take on this responsibility. Pharmacists are widely trusted by the Canadian public and are easily accessible compared to other health-care professionals.
According to the Canadian Pharmacists Association (CPhA), there are more than 42,500 pharmacists working in 10,000 pharmacies across Canada, providing advice on more than 625 million prescriptions per year. Pharmacists are well-positioned to educate and immunize the public against vaccine-preventable infections, and, in fact, a recent national survey showed that approximately 80 per cent of Canadians trust pharmacists to provide action on vaccinations and would consider going to their pharmacist for a flu shot or other vaccines.
Vaccination in adults is necessary
Canada’s National Advisory Committee on Immunization (NACI) conducts an evidence-based review on the efficacy and safety of newly marketed vaccines and provides their recommendation to health-care professionals. During the past decade a number of new vaccines have been marketed in Canada, and while most of these are publicly funded for childhood immunization programs in Canadian provinces, vaccines which are targeted specifically for adults, such as herpes zoster, conjugate pneumococcal and high dose influenza vaccines, are, for the most part, not publicly funded through our respective provincial governments, although a small number of Canadian provinces have provided limited funding to targeted immunization programs. For example, Ontario provides herpes zoster vaccine for individuals 65 to 70 years old, as well as the high dose influenza vaccine for patients in long-term care facilities.
Vaccination in adults is necessary for several reasons. The process of aging leads to waning of natural immunity, predisposing older adults to increased infections, and further to this, many studies have clearly shown that hospitalization, exacerbation of comorbidities, and death occurs more commonly in the older adult population, particularly for influenza, pneumococcal infection and herpes zoster. The process of immunosenescence — the gradual deterioration of the immune system due to aging — also means that even though individuals may have been vaccinated during childhood, immunity wanes over time, necessitating additional doses in adulthood (e.g., Td boosters — which protect against tetanus and diphtheria — every 10 years). Adults with chronic health conditions, such as cardiorespiratory illness, diabetes, chronic kidney or liver disease and immunosuppression, are particularly at risk for pneumococcal disease and influenza. Lifestyle factors such as homelessness, smoking or alcoholism also predispose adults to pneumococcal infections; individuals who have multiple sexual partners are at risk for hepatitis B an HPV; and men who have sex with men (MSM) may be at higher risk for HPV disease. Adults working in certain settings, such as health-care settings, corrections facilities or laboratories, are also at higher risk of acquiring infections. Finally, adults who are travelling internationally may be at risk for vaccine-preventable diseases such as typhoid, influenza, cholera, meningitis and hepatitis A and B.
Vaccines recommended by NACI for all adults include influenza, pneumococcal, herpes zoster, tetanus, diphtheria, and acellular pertussis, among others, depending on their age, level of immunosuppression and chronic medical conditions or whether they fit into special populations. Unfortunately, immunization rates in adults are very low and only 10 per cent of adults are up-to-date on immunizations required for their age, according to a 2014 national survey on adult immunization coverage by the federal government. For example, the national rate of influenza vaccine for adults between the ages of 18-64 years, with at least one comorbid condition, was only 37 per cent in 2015/16, far below the national goal of 80 per cent. Furthermore, adults at the age of 65 or older are often under-vaccinated as well for influenza (67%), tetanus (38%), pneumococcal (36%) and pertussis (9%) vaccines. It is clear that more work is required to increase the vaccination rates among Canadians, especially those at high risk for morbidity and mortality. There is no available study that provides a complete review of the economic impact of low immunization rates in Canada, but a U.S. study conducted by McLaughlin et al. estimated an annual cost for influenza, pneumococcal infection, zoster and pertussis to be $15.3B in individuals 65 years of age and older, representing 58 per cent of the total health-care costs related to patient care. But more importantly, vaccine preventable diseases are associated with significant morbidity, reduced quality of life and mortality. The best example of these statistics is influenza infection, which is associated with 3,500 deaths and 12,000 hospitalizations per year in Canada.
Barriers to vaccination
There are a significant number of barriers preventing patients from getting vaccines and recent articles by NACI and the Immunization Action Coalition (IAC) categorized the multitude of barriers into three distinct categories: undervaluation of adult immunization, inadequate infrastructure and payment for adult vaccinations.
The importance of adult immunization is under appreciated, both by the public and the provider. Traditionally, immunization campaigns have been piecemeal — targeted towards a specific vaccine, likely a newly marketed one or influenza — have not provided adequate information on safety of vaccines or have been kyboshed by the anti-vaccine movement that provides misinformation to the public. Further, campaigns have not focused on making the public understand the potential impact of low vaccination rates, in terms of lost wages (i.e., individual impact), and costs to the health-care system (i.e., to society as a whole). With respect to targeting campaigns towards providers, the IAC suggests it is important to make the health-care providers understand that the public values their recommendation greatly, given the multitude of studies that have shown that the public is more likely to get vaccinated when the advice comes from their health-care provider.
In Canada, the public health system provides a strong infrastructure to support the childhood immunization program, from birth to school-aged programs. In contrast, this infrastructure is not present for adult immunizations, with the exception of influenza and polysaccharide pneumococcal vaccines. As such, most of the adult vaccines are provided by either physicians or pharmacists, rather than public health, but in a system where there is a significant lack of infrastructure — lack of a comprehensive data system, missed opportunities, lack of clinical knowledge, complicated schedules, no provision of standing orders, underutilization of reminder systems, shortages and confusion about the vaccine supply, struggles with storing inventory and cultural and language barriers are not addressed. From the patient perspective, a Canadian survey conducted by the Canadian Immunization Research Network indicated the most common reason for vaccine hesitancy was due to misinformation, lack of knowledge, fears and mistrust about receiving the vaccine.
The third and final barrier that needs to be addressed is the lack of federal or provincial funding for adult immunizations in Canada. Unlike the childhood vaccines that are free for the public as they are on the provincial formulary, many of the adult vaccines are in the “recommended but not funded” category, resulting in considerable out-of-pocket expense for the patient. The expense of the new adult immunizations creates a significant barrier for patients, and in some cases, it is not a one-time cost, but needs to be born on a yearly basis (e.g., high dose influenza vaccine).
The shifting paradigm
In the United States, the National Vaccine Program Office of Department of Health and Human Services (DHHS) has recently created a new strategic plan for adult immunization — the National Adult Immunization Plan, which can be found at hhs.gov — that suggests that while barriers to vaccination have been addressed by different groups, the approach has been piecemeal, and has resulted in no real change with respect to immunization uptake. Thus, to increase immunization uptake rates and decrease the barriers, it will require a culture shift by providers and the public, as well as renewed commitment and leadership by all the stakeholders involved in adult immunizations — including pharmacists.
Part of the DHHS’ adult immunization plan includes the update of standards for adult immunization practice, to better reflect the changing landscape and inclusion of new immunization providers. The standards emphasize all providers embrace four fundamental actions:
- Assess immunization status of all patients at every clinical encounter;
- Recommend strongly the vaccines the patients need;
- Administer the vaccines needed (or refer to a provider); and
- Document vaccines administered to the patient.
The IAC has provided a step-by-step guide of this action plan that suggests the following:
(a) When carrying out the assessment for patients, health-care providers should determine the patient’s previous vaccination history and past diseases to which they may be immune. However, if the patient is unable to provide a written record (except for influenza and polysaccharide pneumococcal vaccine), and you have checked with the local health authority, pharmacy records, and/or physician’s office, the guide suggests administering the vaccine.
(b) In order to determine which vaccines are needed, one of the suggested tools to follow is the HALO approach — determine vaccine requirements based on your patient’s current Health condition, Age, Lifestyle, and/or Occupation. The tables provided in this article are helpful to determine the recommended vaccines for your patient, as the categories are listed across the top and/or in the footnotes.
(c) Screening for contraindications and precautions for the vaccines would be the next step, keeping in mind the most of them are temporary (e.g. pregnancy or illness) and the vaccine may be given at a later date.
(d) Finally, the provider should provide a strong recommendation as to which of the vaccines are to be administered, administer the vaccines and document.
It is essential that health-care providers — including pharmacists — assume a leadership role and help address undervaluation of adult immunizations, misinformation and lack of knowledge on the efficacy and safety of vaccines, and lack of access to vaccines. At the same time, our national health-care organizations need to engage the Canadian government to provide funding for many of these recommended but unfunded vaccines.
Kane Larson is a recent graduate of UBC’s Entry-to-Practice PharmD Program.
Fawziah Lalji is a professor in the Faculty of Pharmaceutical Sciences at UBC.