Increasing Adult Immunization: Great Opportunities, Great Challenges

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By William Schaffner, M.D.


The following is a summary of the presentation I gave last month as the 2014 Jeryl Lynn Hilleman Lecturer at the 2014 National Immunization Conference in Atlanta, GA.

I cautioned the audience in advance about the strong opinions about adult immunization that I would be issuing, while “channeling” Dr. Maurice R. Hilleman, the passionate scientist and inventor of more than 40 vaccines — including the mumps vaccine he developed from his own daughter Jeryl Lynn’s case in 1963.[1] I also made it clear that, when it comes to adult immunization, it’s a “new game, with a new ball and new rules.” In fact, increasing adult immunization uptake presents great opportunities with great challenges. Vaccination for kids is a walk in the park compared to vaccination for adults, which may help explain why adult vaccination rates continue to remain far below public health goals.[2]

I then invited the audience to join me on a journey into the Twilight Zone beyond the 19th birthday…

First, imagine a pediatrician’s office waiting room. What do you see? Healthy children, parents, photos of babies, and posters about growth and development. Pediatricians are generalists whose practices focus mainly on developmental milestones and prevention of disease. In their offices, vaccination is a part of daily practice, and they are experts.

Now, imagine an internist’s office waiting room. What do you see now? Older, ill adults; caregivers; and brochures about diseases. Internists are focused on the treatment of diseases and management of medications, leaving little time to spare for prevention. Thus, vaccination is typically not a part of an internist’s practice, and they’re often not experts on vaccines. Of particular concern are anecdotal estimates that less than 5 percent of practicing internists are familiar with the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices (ACIP) that issues vaccine recommendations.

Adult vaccination is completely different from the fine-tuned machine of pediatric vaccination. It is much more disjointed, with certain vaccines needed at certain times, depending on age and health risk(s). For example, current pneumococcal vaccine recommendations are so complicated that a flow chart with footnotes is needed to determine who should get what type of vaccine and when![3] And only a select group of adults are mandated to receive certain vaccines, such as members of the military and some healthcare workers and college students.[4,5,6] Payment for adult vaccination is also uncertain and confusing. Beyond private insurance co-pays and deductibles, Medicare (Parts B and D), Medicaid, and the Affordable Care Act (ACA), there are also many adults who still have no health insurance.[7]

Now is a perfect time to issue a wake-up call to health care professionals who treat adult patients. Adults are not just grown up children, and they need vaccines, too. So what needs to happen to change this picture? If internists are being asked to integrate immunization into their clinical practices to increase vaccination rates for adults, I challenge the public health community to lead by example:

  • Public health clinics must integrate adult immunization into their practices.
  • Immunization standards should be met for the 1.5 million prisoners in the U.S. sentenced to more than one year. [8]
  • The 6.6 million U.S. veterans served by the U.S. Veterans Administration should also be receiving immunizations as part of their routine health care. [9]
  • The approximately 1.9 million American Indians and Alaska Natives who receive health care from the Indian Health Service. [10]
  • Members of the military are being vaccinated, but their dependents, including an estimated 750,000 spouses, should be as well. [11]

More can and must be done to increase adult vaccination. For more information and resources on increasing adult vaccination rates, visit


2. MMWR 62:66, 2013
3. ACIP, MMWR, 2014: 63(37);822-825

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