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Publication: MMWR. Morbidity and Mortality Weekly Report
Author: Williams, Walter W
Date published: February 3, 2012

Immunizations are recommended throughout life to prevent infectious diseases and their sequelae. Adult coverage, however, remains low for most routinely recommended vaccines (7) and well below Healthy People 2020 targets. In October 201 1 , the Advisory Committee on Immunization Practices (ACIP) approved the adult immunization schedule for 201 2 (2). Apart from influenza vaccination, which is now recommended for all adults, other adult vaccines target different populations based on age, certain medical conditions, behavioral risk factors (e.g., injection drug use), occupation, travel, and other indications (2). To assess adult (>19 years) vaccination coverage for select vaccines, CDC analyzed data from the 2010 National Health Interview Survey (NHIS). This report summarizes the results of that analysis for pneumococcal, hepatitis A, hepatitis B, herpes zoster (shingles), and human papillomavirus (HPV) vaccines, as well as tetanus antigen- containing vaccines (including tetanus, diphtheria, and acellular pertussis vaccine [Tdap]), by selected characteristics (age, vaccination target group status, and race/ethnicity). Influenza vaccination coverage estimates for the 2010-11 influenza season have been published separately (3). Compared with results of the 2009 NHIS survey (i), increases in coverage were observed only for Tdap vaccination for persons aged 19-64 years (1.6 percentage point increase to 8.2%), zoster vaccination among persons aged >60 years (4.4 percentage point increase to 14.4%), and >1 dose HPV vaccination in women aged 19-26 years (3.6 percentage point increase to 20.7%); coverage for the other vaccines was unchanged at <70%. These data indicate only limited recent improvements in vaccination coverage among adults in the United States. Substantial increases are needed to reduce the occurrence of vaccine-preventable diseases among adults.

NHIS collects information about the health and health care of the noninstitutionalized, civilian population in the United States using nationally representative samples. Interviews are conducted in respondents' homes. Questions about receipt of recommended adult vaccinations are asked of a randomly selected adult within the household. Definitions of high risk conditions* are based on ACIP recommendations for each vaccine (2). Additional analyses were conducted to estimate baseline coverage of persons with diabetes who recently were recommended for hepatitis B vaccination and for males recommended for quadrivalent HPV vaccination if aged <21 years or aged 22-26 years and at higher risk for HPV infection (4,5). Weighted data' were used to produce national estimates. Point estimates and estimates of corresponding variances were calculated using statistical software to account for the complex sample design. Statistical significance was defined as ? <().() 5.

Pneumococcal Vaccination Coverage

Pneumococcal vaccination coverage among high-risk adults aged 19-64 years was 1 8.5% overall (Table 1). Coverage among high-risk non-Hispanic whites aged 19-64 years was higher (19.0%) compared with Hispanics (14.8%) and non-Hispanic Asians (11 .5%), but coverage was not significantly different for other racial/ethnic groups (Table 1). Among adults aged >65 years, coverage was 59.7% overall. Non- Hispanic whites aged >65 years had higher vaccination coverage (63.5%) compared with Hispanics (39.0%), non-Hispanic blacks (46.2%), and non-Hispanic Asians (48.2%). Neither overall coverage nor coverage for any specific age or racial/ ethnic group differed significantly from 2009 coverage.

Tetanus Vaccination Coverage

In 2010, the proportion of adults receiving any tetanus toxoid- containing vaccination (i.e., tetanus and diphtheria toxoid [Td] orTdap) during the past 10 years was 64.0% for adults aged 19-49 years, 63.4% for adults aged 50-64 years, and 53.4% for adults aged >65 years (Table 1). The proportion of adults receiving tetanus vaccination during the past 10 years across all age groups did not change compared with 2009 (1). Non-Hispanic whites had higher coverage across all age groups compared with non-Hispanic Asians, Hispanics, and non-Hispanic blacks.

Among adults aged 19-64 years for whom Tdap status specifically could be assessed, Tdap vaccination coverage was 8.2% (Table 1). Tdap coverage was estimated after excluding respondents without a "yes" or "no" classification for tetanus vaccination status within the preceding 10 years (n = 1,081 [5.1%] of 2 1,04 1) or tetanus vaccination status during 2005-2010 (n = 589 [2.8%] of 21,041), and those who reported tetanus vaccination during 2005-2010, but were not told (n = 4,124 [19.6%] of 2 1,04 1) or did not know the vaccine type (Td or Tdap) (n = 665 [3.2%] of 21, 041). Among 7,088 respondents who received a tetanus vaccination during 2005-2010, 58.9% reported that they were not informed of the vaccination type, and 9.6% could not recall what type of tetanus vaccination they had received (Table 2). Of the remaining respondents, 52.3% reported receiving Tdap (Table 2).

Compared with 2009, Tdap coverage increased for persons aged 19-64 years overall (1 .6 percentage point increase to 8.2%), and among non- Hispanic Asians (4.8 percentage point increase to 9.2%), non-Hispanic whites (1.7 percentage point increase to 9.1%), and persons without household contact with an infant aged <1 yearž (1 .7 percentage point increase to 8.1%); however, Tdap coverage remained low (Table 1). Non- Hispanic whites had higher Tdap coverage (9. 1 %) compared with non-Hispanic blacks (7.4%) and Hispanics (4.8%). Tdap coverage for persons with household contact with an infant aged <1 year (1 0.6%) was similar to coverage for non- Hispanic whites (Table 1).

During 2005- 20 10, Tdap vaccination of health-care personnel (HCP) overall (20.3%) was higher compared with the 2009 estimate (13.2%) (Table 3). Non-Hispanic white HCP had higher Tdap coverage (21.5%) compared with non-Hispanic black HCP (14.0%) and Hispanic HCP (13.8%). HCP were more likely to have received Tdap as a tetanus vaccination (63.2%) than adults who were not HCP (52.3%) (Table 2).

Hepatitis A Vaccination Coverage

Hepatitis A vaccination coverage (>2 doses) among adults aged 19-49 years was low overall (10.7%), and similar to the estimate for 2009 (9.8%). Vaccination coverage among adults aged 19-49 years was higher (16.6% versus 7.5%) among persons who traveled to countries of high or intermediate endemicity outside the United States (other than to Europe, Japan, Australia, New Zealand, or Canada) since 1995, compared with respondents who traveled only within the United States, Europe, Japan, Australia, New Zealand, or Canada (Table 1). Coverage was higher for non-Hispanic Asians (15.3%) and adults aged 1 9-49 years who indicated a race other than Asian, black or white and non-Hispanic ethnicity (16.5%) than for other groups (Table 1).

Hepatitis B Vaccination Coverage

In 2010, hepatitis B vaccination coverage (>3 doses) among adults aged 19-49 years at high risk for infection (42.0%) was similar to the 2009 estimate (41.8%) (Table 1). Vaccination coverage for persons aged 19-49 years at high risk for infection was 44.5% for non-Hispanic whites, 41 .6% for non-Hispanic blacks, and 40.2% for non-Hispanic Asians, but was lower for Hispanics (33.8%) compared with non-Hispanic whites. Overall, vaccination coverage was higher for adults aged 19-49 years at high risk for infection (42.0%), compared with adults aged 19-49 years not at high risk for infection (33.1%). Vaccination coverage for persons with diabetes aged 19-59 years and >60 years was 22.8% and 10.9%, respectively. Overall, hepatitis B vaccination coverage among HCP was 63.2%; coverage did not differ significantly across racial/ ethnic groups (Table 3) nor when compared with 2009 coverage.

Herpes Zoster Vaccination Coverage

In 2010, 14.4% of adults aged >60 years reported receiving herpes zoster vaccination to prevent shingles, an increase from the 10.0% reported in 2009 (Table 1). Non-Hispanic whites aged >60 years had higher herpes zoster vaccination coverage (16.6%) compared with all other race/ethnic groups (Table 1). Coverage for non-Hispanic whites and non-Hispanic Asians aged >60 years increased more than 5 percentage points compared with herpes zoster vaccination coverage estimates in 2009 (Table I)."

Human Papillomavirus (HPV) Vaccination Coverage

In 2010, 20.7% of women aged 19-26 years reported receipt of >1 dose of HPV vaccine, an increase from 17.1% reported for 2009 (Table 1), and a further increase from 10.5% reported for 2008 (1,6). Hispanics had lower coverage (15.1%) compared with non-Hispanic whites (22.4%), but coverage across racial/ethnic groups otherwise did not differ (Table 1). Fewer than 1% of males aged 19-26 years received >1 dose of HPV vaccine in 2010 (Table 1).

Editorial Note

In 2010, noninfluenza adult vaccination coverage was similar to 2009, except for modest increases in Tdap, HPV, and zoster vaccine coverage in certain groups. Many adults have not received one or more recommended vaccines. Vaccination coverage estimates for the three vaccines in this report that are included in Healthy People 2020 (pneumococcal, herpes zoster, and hepatitis B [for HCP] vaccines) are well below the respective target levels' of 90% for persons aged >65 years and 60% for persons aged 18-64 years at high risk (pneumococcal vaccine), 30% (herpes zoster vaccine), and 90% (hepatitis vaccine [for HCP]). These data indicate little progress was made in improving adult coverage in the past year and highlight the need for continuing efforts to increase adult vaccination coverage.

In October 201 1, ACIP recommended hepatitis B vaccination of previously unvaccinated adults aged <60 years who have diabetes as soon as possible after diabetes is diagnosed, and that adults aged >60 years with diabetes be considered for hepatitis B vaccination after assessing their risk and likelihood of immune response 2,4). The recommendations were based on findings from studies indicating increased risk for contracting acute hepatitis B among persons with diabetes (7,8) and a trend for higher mortality among acute hepatitis B virus- infected persons with diabetes compared with persons without diabetes (CDC, unpublished data, 2011).

Assisted monitoring of blood glucose and other procedures in which instruments or parenteral treatments are used in different persons sequentially without appropriate infection control procedures can result in percutaneous exposure to hepatitis B virus. Increasing hepatitis B vaccination among persons with diabetes and improving infection control practices during diabetes monitoring and care might decrease the occurrence of hepatitis B infection in this population. Diabetes will be included as a risk factor for hepatitis B infection in future determinations of overall coverage among persons with highrisk conditions.

Also in October 2011, ACIP recommended routine HPV vaccination for males aged 11-12 years and vaccination of males aged 13-21 years who have not been vaccinated previously; males aged 22-26 years also may be vaccinated against HPV. For immunocompromised males (including males with human immunodeficiency virus [HIV] infection), and for men who have sex with men, ACIP recommended routine vaccination through age 26 years for those not vaccinated previously (2,5). These recommendations replace the October 2009 ACIP guidance that HPV vaccine may be given to males aged 9-26 years. Since 2006, ACIP has recommended routine HPV vaccination for females aged 11-12 years and vaccination of females aged 13-26 years who previously have not been vaccinated against HPV (2). The percentage of age-eligible females administered HPV vaccine is low but increasing. The primary target group for HPV vaccine is girls and boys aged 11-12 years.

The findings in this report are subject to at least two limitations. First, the determination of vaccination status and identification of high-risk conditions in NHIS were not validated by medical records. Self- report of vaccination is subject to recall bias and might result in overestimation of rates. Adult selfreported pneumococcal vaccination status, however, has been shown to be sensitive and specific (9)- Second, theTdap estimate is subject to considerable uncertainty. Many respondents were excluded from estimations of Tdap coverage, creating a potential for bias. All respondents who reported a tetanus vaccination during 2005-2010, but were unable to say whether Td or Tdap was used, were excluded. Sensitivity calculations were conducted to assess the magnitude of potential bias. Depending on what proportion of excluded respondents actually received Tdap, actual Tdap coverage could fall within the range of 6.1%- 31.6%. Comparisons of Tdap coverage across years within subgroups might be affected by bias resulting from excluding persons who did not report the type of tetanus vaccine they received.

Substantial improvement in adult vaccination is needed to reduce the health consequences of vaccine-preventable diseases among adults. Successful vaccination programs combine education of potential vaccine recipients and publicity to promote vaccination, increased access to vaccination services in medical and complementary settings such as workplaces and commercial establishments (e.g., pharmacies), and use of practices shown to improve vaccination coverage, including remind er- re call systems, efforts to remove administrative and financial barriers to vaccination, use of standing order programs for vaccination, and assessment of practice-level vaccination rates with feedback to staff members (10). Annual publication of the adult immunization schedule (2) provides the most current recommendations for vaccinating adults and can provide a ready resource for persons who administer vaccine to adults in various settings.

* Adults were considered at high risk for pneumococcal disease if they had ever been told by a doctor or other health professional that they had diabetes, emphysema, coronary heart disease, angina, heart attack, or other heart condition; had a diagnosis of cancer during the previous 12 months (excluding nonmelanoma skin cancer); had ever been told by a doctor or other health professional that they had lymphoma, leukemia, or blood cancer; or they had been told by a doctor or other health professional that they had chronic bronchitis or weak or failing kidneys during the preceding 12 months; or had an asthma episode or attack; or were current smokers. Adults were considered at high risk for hepatitis A or B if they had hemophilia and had received clotting factor concentrations, were a man who had sex with other men, had taken street drugs by needle, had traded sex for money or drugs, had tested positive for human immunodeficiency virus (HIV), or had sex with someone who would meet any of the previous criteria; considered themselves at high risk for HIV infection, or reported having a sexually transmitted diseases other than HIV or acquired immunodeficiency syndrome (AIDS) during the previous 5 years.

[dagger]Additional information on NHIS methods is available at http://www.cdc.gov/ nchs/nhis/methods.htm.

žA single dose of Tdap is recommended for adults who have or who anticipate having close contact with an infant aged <1 year (e.g., parents, grandparents aged <65 years [adults >65 may receive Tdap] , child-care providers, and healthcare personnel) to reduce the risk for transmitting pertussis.

* Healthy People 2020 objectives and targets for immunization and infectious diseases are available at http://www.healthypeople.gov/2020/ topicsobjectives202 O/objectiveslist. aspx?topicid=2 3 .

References

1 . CDC. Adult vaccination coverage reported via National Health Interview Survey (NHIS). Atlanta, GA: US Department of Health and Human Services, CDC; 2011. Available at http://www.cdc.gov/vaccines/statS' surv/nh is/default. htm. Accessed January 9, 2012.

2. CDC. Recommended adult immunization schedule - United States, 2012. MMWR 2012;61:(4).

3. CDC. Final state specific influenza vaccination coverage estimates for the 2010-11 season - United States, National Immunization Survey and Behavioral Risk Factor Surveillance System, August 2010 through May 201 1 . Atlanta, GA: US Department of Health and Human Services, CDC; 2011. Available at http://www.cdc.gov/flu/professionals/ vaccination/ cove rage_l Oil estimates.htm. Accessed January 9, 20 1 2.

4. CDC. Use of hepatitis B vaccination for adults with diabetes mellitus: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2011;60:1709-11.

5. CDC. Recommendations on the use of quadrivalent human papillomavirus vaccine in males - Advisory Committee on Immunization Practices (ACIP), 2011. MMWR 2011;60:1705-8.

6. CDC. Vaccination coverage estimates from the National Health Interview Survey: United States, 2008. Atlanta, GA: US Department of Health and Human Services, CDC; 2009. Available at http://www.cdc. gov/ nchs/data/hestat/vaccine_coverage/vaccine_coverage.htm. Accessed December 12, 20 1 1 .

7. Reilly ML, Poissant T, Vonderwahl CW, Gerard K, Murphy TV. Incidence of acute hepatitis B among adults with and without diabetes, 2009-2010. Presented at the 49th Annual Meeting of the Infectious Disease Society of America and the HIV Medicine Association, October 20-23, 201 1; Boston, MA. Arlington, VA: Infectious Disease Society of America; 201 1.

8. CDC. Viral hepatitis surveillance - United States, 2009. Atlanta, GA: US Department of Health and Human Services, CDC; 201 1 . Available at http://www.cdc.gov/hepatitis/statistics/2009surveillance/index.htm. Accessed December 19, 2011.

9. Shenson D, DiMartino D, Bolen J, Campbell M, Lu PJ, Singleton JA. Validation of self- reported pneumococcal vaccination in behavioral risk factor surveillance surveys: experience from the sickness prevention achieved through regional collaboration (SPARC) program. Vaccine 2005;23:1015-20.

10. Task Force on Community Prevention Services. The guide to community preventive services. New York, NY: Oxford University Press; 2005. Available at http://www.thecommunityguide.org/library/book/index. html. Accessed December 19, 201 1.

Author affiliation:

Reported by

Walter W Williams, MD, Peng-Jun Lu, MD, PhD, James A. Singleton, MS, Carolyn B. Bridges, MD, Pascale M. Worthy, MD, Immunization Services Div, National Center for Immunization and Respiratory Diseases; Kathy K. Byrd, MD, Div o fViral Hepatitis, Lauri E. Markowitz, MD, Div of Sexually Transmitted Disease Prevention, National Center for HIVI AIDS, Viral Hepatitis, STD, and TB Prevention, CDC. Corresponding contributor: Walter W. Williams, wwwl @c dc.gov, 404-718-8734.

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