National Adult Immunization Plan

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES NATIONAL VACCINE PROGRAM OFFICE

THE NATIONAL VACCINE PROGRAM OFFICE

NATIONAL ADULT

IMMUNIZATION PLAN

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES NATIONAL VACCINE PROGRAM OFFICE

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EXECUTIVE SUMMARY

Vaccination is considered one of the most important public health achievements of the

20th century and continues to offer great promise in the 21st century. Vaccines save

lives and improve the quality of life by preventing serious infectious diseases and their

consequences. However, the benefits of vaccination are not realized equally across the

U.S. population. Adult vaccination rates remain low in the United States, and significant

racial and ethnic disparities also exist.

The U.S. Department of Health and Human Services National Vaccine Plan (NVP),

released in 2010, is a road map for vaccines and immunization programs for the

decade 2010–2020. While the NVP provides a vision for improving protection from

vaccine-preventable diseases across the lifespan, vaccination coverage levels among

adults are not on track to meet Healthy People 2020 targets. The National Vaccine

Advisory Committee and numerous stakeholder groups have emphasized the need for

focused attention on adult vaccines and vaccination.

1

The National Adult Immunization

Plan (NAIP) outlined here results from the recognition that progress has been slow and

that there is a need for a national adult immunization strategic plan.

As a national plan, the NAIP will require engagement from a wide range of stakeholders

to achieve its full vision. The plan emphasizes collaboration and prioritization of efforts

that will have the greatest impact. The NAIP also aims to leverage the unique

opportunity presented by the implementation of the Affordable Care Act.

The NAIP is intended to facilitate coordinated action by federal and nonfederal partners

to protect public health and achieve optimal prevention of infectious diseases and their

consequences through vaccination of adults. The NAIP includes indicators to draw

attention to and track progress against core goals. These indicators will measure

progress against set standards and inform future implementation and quality

improvement efforts. The plan establishes four key goals, each of which is supported

by objectives and strategies to guide implementation through 2020:

Goal 1: Strengthen the adult immunization infrastructure

Goal 2: Improve access to adult vaccines

Goal 3: Increase community demand for adult immunizations

Goal 4: Foster innovation in adult vaccine development and vaccination-related

technologies

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Achieving the goals of the NAIP is facilitated by agreement on plan priorities and

coordination of the wide range of programs that support them. The Assistant Secretary

for Health serves as the director of the National Vaccine Program and will lead the

NAIP and its implementation. In support of this mission, the National Vaccine Program

Office will facilitate collaboration and coordinate the monitoring of progress for

the NAIP.

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TABLE OF CONTENTS

Executive Summary ........................................................................................................... i

Tables .............................................................................................................................. iv

Abbreviations .................................................................................................................... v

Introduction ....................................................................................................................... 1

Barriers to Adult Immunization ...................................................................................... 4

Opportunities in the Changing Policy Landscape ......................................................... 4

Purpose and Leadership of the National Adult Immunization Plan .................................. 7

Development of the National Adult Immunization Plan .................................................. 11

Environmental Scan .................................................................................................... 11

Stakeholder Engagement ........................................................................................... 11

Measuring Progress: Indicator Development .............................................................. 12

Alignment with Existing HHS Programs and Plans ..................................................... 12

NAIP Goals, Objectives, and Strategies ......................................................................... 14

Goal 1: Strengthen the Adult Immunization Infrastructure .......................................... 15

Goal 2: Improve Access to Adult Vaccines ................................................................. 22

Goal 3: Increase Community Demand for Adult Immunizations ................................. 27

Goal 4: Foster Innovation in Adult Vaccine Development and Vaccination-Related

Technologies .............................................................................................................. 32

Monitoring and Evaluation .............................................................................................. 36

Appendix 1: Adult Immunization Schedule ..................................................................... 43

Appendix 2: Disparities in Adult Immunization Coverage by Race/Ethnicity .................. 44

Appendix 3: Federal Partner Efforts ............................................................................... 46

Appendix 4: Federal Roles and Responsibilities by Agency .......................................... 49

Appendix 5: Nonfederal Roles and Responsibilities ....................................................... 54

References ..................................................................................................................... 59

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TABLES

Table 1. Healthy People Objectives Specific to Adult Vaccination, 2013 Coverage and

2020 Targets …………………………………………………………………………………..2

Table 2. National Adult Immunization Plan: Federal and Nonfederal Stakeholders …..9

Table 3. Plan Priorities: Indicators for the Goals of the NAIP........................................38

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ABBREVIATIONS

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Abbreviation

ACF

ACIP

ACL

AHRQ

AITF

ASH

ASPE

ASPR

BARDA

CDC

CMS

DHS

DoD

EHR

FDA

FOH

HHS

HPV

HRSA

IHS

IID

IIS

IT

NAIP

NIH

NVAC

NVP

NVPO

OASH

OMH

ONC

OWH

RHA

Tdap

VA

VAERS

VFC

VICP

Definition

Administration for Children and Families

Advisory

Committee on Immunization Practices

Administration for Community Living

Agency for Healthcare Research and Quality

Interagency Adult Immunization Task Force

Assistant Secretary for Health

Assistant Secretary for Planning and Evaluation

Assistant Secretary for Preparedness and Response

Biomedical Advanced Research and Development Authority

Centers for Disease Control and Prevention

Centers for Medicare & Medicaid Services

U.S. Department of Homeland Security

U.S. Department of Defense

Electronic Health Record

U.S. Food and Drug Administration

Federal Occupational Health

U.S. Department of Health and Human Services

Human Papilloma Virus

Health Resources and Services Administration

Indian Health Service

Immunization and Infectious Diseases

Immunization Information Systems

Information Technology

National Adult Immunization Plan

National Institutes of Health

National Vaccine Advisory Committee

National Vaccine Plan

National Vaccine Program Office

Office of the Assistant Secretary for Health

Office of Minority Health

Office of the National Coordinator for Health Information Technology

Office on Women’s Health

Regional Health Administrator

Tetanus, Diphtheria, and Pertussis

U.S. Department of Veterans Affairs

Vaccine Adverse Event Reporting System

Vaccines for Children program

National Vaccine Injury Compensation Program

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INTRODUCTION

Despite the widespread availability of safe and effective vaccines, adult vaccination

rates remain low in the United States and far below Healthy People 2020 targets.

2,3

Vaccine-preventable diseases take a heavy toll on adults age 18 and older. The health

and productivity costs of influenza alone are estimated to be as high as $87 billion per

year.

4

The Centers for Disease Control and Prevention (CDC) estimates that, among

U.S. adults, each year there are roughly 40,000 cases and 4,000 deaths attributable to

invasive pneumococcal disease,

5

between 3,000 and 49,000 deaths due to seasonal

influenza,

6

9,000 reported cases of pertussis,

7

approximately 3,000 reported cases of

acute hepatitis B,

8

and about one million cases of herpes zoster.

9

Adults have been

directly affected in recent outbreaks of vaccine-preventable diseases, such as measles.

Unvaccinated adults have also unknowingly spread vaccine-preventable diseases (e.g.,

to small children who are too young to be immunized); thus, limited vaccination of adults

not only impacts adults directly but also has consequences for their families and

communities. With the aging of the U.S. population, the public health impact of vaccine-

preventable diseases and their complications in adults is likely to grow. The diminishing

function of the aging immune system reduces the immune response to vaccination and

underscores the need to develop more effective products for older adults.

10

The CDC and its Advisory Committee on Immunization Practices (ACIP) currently

recommend 13 different vaccines for adults age 18 and older to prevent a host of

diseases (Appendix 1).

10

The adult vaccine schedule, which was first published in 2002,

now includes vaccines that are universally recommended (e.g., influenza), those that

are recommended for certain age groups (e.g., human papilloma virus [HPV]), and

those that are targeted to individuals with specific risk factors (e.g., hepatitis A and

B).

1,10

The adult schedule also includes catch-up vaccinations for those adults who

never initiated or did not complete a multidose series when vaccination was first

recommended during childhood. Catch-up vaccinations include such vaccines as

measles, mumps, and rubella and varicella, which are routinely recommended for

administration during childhood.

As shown in Table 1, despite the health benefits that result from implementation of

ACIP/CDC recommendations, adults continue to be vaccinated at low and variable

rates. In contrast, childhood vaccination rates in the United States typically exceed 90

percent. The success of childhood vaccination can be attributed to many factors unique

to pediatric vaccination, such as state laws requiring vaccination for school entry and

the coordinated public health infrastructure established by the Vaccines for Children

program (VFC), a federally funded program to provide free vaccines to children who are

eligible for Medicaid, uninsured, under insured, or American Indian or Alaska Native.

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Another reason for the high rates of vaccination among children is that pediatricians and

family physicians, the primary providers of health care and preventive health services for

children, have long been committed to making immunization a core part of well-child

care. For adults, chronic diseases and screenings for cancer, blood pressure, and

cholesterol have historically been the primary focus of acute health care and preventive

health services, respectively.

1

As a result, vaccinations are emphasized less and are

underutilized in the adult population.

TABLE 1. HEALTHY PEOPLE OBJECTIVES SPECIFIC TO ADULT VACCINATION,

2013 COVERAGE AND 2020 TARGETS

2013

Percentage

2020 Target Percentage*

Adults age >18 years

39

†

70

Health care personnel

62

‡

90

Pregnant women

52

§

No target, in development

Objective IID-13: Increase the percentage

of adults who are vaccinated against

pneumococcal disease.

2013

Percentage

2020 Target Percentage**

Noninstitutionalized adults age >65 years

60

††

90

Noninstitutionalized high-risk adults age 18– 64

years

21

‡‡

60

Healthy People 2020.

2

† National Health Interview Survey, as reported by Healthy People 2020.

2

‡ National Health Interview Survey, as reported by Healthy People 2020.

2

§ Ding (2014).

12

The most recent published statistics are for the 2013–2014 influenza season; the

estimate is from an Internet panel survey. The study sample did not include women without Internet

access; results might not be generalizable to all pregnant women in the United States. Also, the

estimate might be biased if the selection processes for entry into the Internet panel and a woman’s

decision to participate in this survey were related to receipt of vaccination.

** Healthy People 2020.

2

†† National Health Interview Survey (2013).

3

‡‡ National Health Interview Survey (2013).

3

2

Objective IID-12: Increase the percentage of

children and adults who are vaccinated

annually against seasonal influenza.

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Objective IID-13: Increase the percentage

of adults who are vaccinated against

pneumococcal disease.

2013

Percentage

2020 Target Percentage

**

Institutionalized adults age >18 years in long-

term care or nursing homes

66§§

90

Objective IID-14: Increase the percentage

of adults age >60 who are vaccinated

against zoster (shingles).

2013

Percentage

2020 Target Percentage

***

Adults age >60 years

24†††

30

Objective IID-15: Increase hepatitis B

vaccine coverage among high-risk

populations.

2013

Percentage

2020 Target

Percentage

‡‡‡

Health care personnel age >19 years

64§§§

90

Notes: IID = Immunization and Infectious Diseases. The objective for influenza vaccination for

pregnant women is developmental, and no target has been set. Some, but not all, of the

ACIP/CDC-recommended vaccines are included in the Healthy People 2020 objectives.

In addition to achieving higher vaccination rates, the childhood vaccination program in

the United States has been largely successful at reducing or eliminating racial and

ethnic disparities in vaccination coverage. As a result of multiple interventions and

programs implemented over the past two decades, including the VFC, disparities in

vaccination coverage have dramatically declined between non-Hispanic white children

and children of other racial and ethnic groups.

11

In contrast, various racial and ethnic

minority adults (e.g., Blacks, Hispanics) receive recommended vaccinations at rates far

below those of whites.

13

Appendix 2 shows the disparities in immunization rates for

several racial and ethnic groups.

§§ Minimum Data Set data from 2005–2006, as reported by Healthy People 2020.

2

*** Healthy People 2020.

2

††† National Health Interview Survey (2013).

3

‡‡‡ Healthy People 2020.

2

§§§ National Health Interview Survey data from 2008, as reported by Healthy People 2020.

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Barriers to Adult Immunization

Numerous barriers must be addressed to make significant progress in adult vaccination,

meet Healthy People 2020 objectives, and eliminate disparities. Barriers that are

consistently highlighted by stakeholder groups and the research community include the

following:

•

Lack of coordination of adult immunization activities across all stakeholders,

including multiple health care providers for adults

1

•

Lack of integration of vaccines into adult medical care

1

•

Lack or underuse of administrative systems (e.g., immunization information

systems [IIS]) for documenting vaccination histories and identifying patients who

are due for vaccinations in medical records

14,15

•

Skepticism regarding vaccine safety and effectiveness

1

•

Inability to pay for vaccination as a result of lack of insurance or variable

coverage for recommended vaccinations across health plans

1,14

•

Provider concerns about reimbursement and vaccine administration fees paid by

health insurers, which discourages some providers from stocking all adult

vaccines

14,16,17

•

Lack of public knowledge regarding the adult immunization schedule and the

risks and consequences of vaccine-preventable diseases; lack of awareness that

adults are supposed to receive vaccines other than the influenza vaccine

1

•

Legal barriers at the state and federal levels (e.g., restricting which providers can

administer vaccines)

1

•

Lack of and/or weak recommendations by health care providers

1,14

•

Limited use of evidence-based strategies to improve vaccine uptake, such as

reminder-recall and related systems

18

19

•

Conflicting and inaccurate information about immunizations in mass media.

1,

The National Adult Immunization Plan (NAIP) was developed to help address these

barriers, as well as other persistent challenges, through coordinated actio n.

Opportunities in the Changing Policy Landscape

The NAIP builds on work that has been completed, or is under way, for adult

immunization and advances priorities that reflect the changing landscape of health care

and preventive health services as a result of Affordable Care Act implementation.

There have been several important developments in recent years that provide context

for the development and implementation of the NAIP at this time.

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vaccines.

to providers who administer vaccinations.

20

In 2012, the National Vaccine Advisory Committee (NVAC) published A Pathway to

Leadership for Adult Immunization, which outlined three recommendations to the Assistant

Secretary for Health (ASH) to support a NAIP: national leadership, allocation of resources,

and the development of a strategic plan for the adult immunization program.

1

•

In 2014, NVAC again served in an advisory capacity and published updated

Standards for Adult Immunization Practice to emphasize that all providers who care

for adults are responsible for assessing immunization needs at every clinical

encounter, strongly recommending needed vaccines, administering recommended

vaccines, and documenting receipt in a state immunization information system. The

standards, which have been endorsed by the U.S. Department of Health and Human

Services (HHS), also instruct providers who do not vaccinate to refer adult patients

•

In 2012, the first annual National Adult and Influenza Immunization Summit was

convened. The summit brings together public and private stakeholders involved in

adult immunization and provides a forum to share new ideas and information and

identify actions to increase adult vaccination rates for ACIP/CDC-recommended

In addition, passage of the Affordable Care Act in 2010 was an important mil

estone for

adult vaccination in the United States. The Affordable Care Act expanded access to

health insurance to millions of previously uninsured or underinsured Americans and

required that certain recommended clinical preventive services, including routi

ne

vaccines, be covered without cost

-sharing to individuals enrolled in most private health

insurance plans and those who obtained Medicaid coverage through Medicaid

expansion. Coverage of vaccinations did not change for individuals enrolled in Medicare

and traditional Medicaid plans. An estimated 17.6 million Americans have gained health

insurance since the first open enrollment period in the fall of 2013.

22

Furthermore, about

137 million individuals have private insurance coverage of preventive services w

ithout

cost-sharing.

23

At the state level, the Affordable Care Act also authorizes use of funds

for purchase of vaccines for adults at federally negotiated

prices. Although the full

impact of the Affordable Care Act is yet to be determined, it is

anticipated that it will

eliminate some of the financial barriers to adult vaccination.

While the Affordable Care Act represents an important step forward for adult

vaccination, some challenges remain. For example, people who continue to lack health

insurance (e.g., uninsured non-U.S. citizens, low-income individuals in states that have

not expanded Medicaid to cover people with annual incomes of up to 133 percent of the

federal poverty level) may continue to have difficulty accessing and paying for

recommended vaccinations.

21

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Furthermore, some Medicare beneficiaries may encounter financial barriers when

accessing vaccines covered by Medicare Part D (e.g., herpes zoster and tetanus,

diphtheria, and pertussis [Tdap] vaccines). Medicare Part B covers three preventive

vaccines without cost-sharing (influenza, pneumococcal, and hepatitis B vaccines), as

well as select vaccines directly related to the treatment of an injury or disease exposure;

however, cost-sharing for vaccines covered under Medicare Part D (e.g., herpes zoster)

varies widely from plan to plan and may discourage uptake among some beneficiaries.

In a 2011 report, the U.S. Government Accountability Office noted that some

stakeholders have raised concerns about the administrative challenges associated with

Part D and recommended actions to improve access to Part D vaccinations.

24

The

Centers for Medicare & Medicaid Services (CMS) has issued guidance on a number of

approaches to help address administrative challenges, but stakeholders report that

additional steps are needed.

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PURPOSE AND LEADERSHIP OF THE NATIONAL ADULT

IMMUNIZATION PLAN

To address ongoing barriers as well as new challenges, the NAIP is intended to promote

coordinated planning and action across all stakeholder groups, including those within and

outside the U.S. government. It provides direction by establishing a vision, four goals, 16

objectives, and numerous strategies to promote action through 2020.

The vision for adult immunization is to protect the public health and achieve optimal

prevention of infectious diseases and their consequences through vaccination of all adults.!

Under each goal is a set of objectives to steer improvement efforts within functional areas

critical to achieving each goal. Within these objectives, the NAIP identifies key strategies

to guide implementation through 2020. The strategies encourage focused attention on

areas that can have the greatest impact toward achieving the vision of a robust

immunization system that will improve adult health by protecting adults against vaccine-

preventable diseases and their complications. While the plan contains a list of strategies,

it should be noted that many of the strategies are interdependent, and, as such, the

appropriate sequencing of particular strategies is a key challenge for implementation. For

example, before generating community-wide demand (Goal 3), it will be necessary to

enhance the adult immunization infrastructure and remove access barriers (Goals 1–2) to

ensure that the delivery system has sufficient capacity to serve a larger number of adults.

While there is recognition of the challenges facing adult vaccination, NAIP goals can be

achieved through national leadership and collaboration among the many stakeholders

who comprise the adult immunization system. National leadership is critical to focus our

nation on disease prevention and to catalyze action to strengthen the vaccination

delivery system across the country. The Office of the Assistant Secretary for Health

(OASH), within HHS, is a strong advocate for the importance of adult immunization.

The goals are as follows:

Goal 1: Strengthen the adult immunization infrastructure.

Goal 2: Improve access to adult vaccines.

Goal 3: Increase community demand for adult immunizations.

Goal 4: Foster innovation in adult vaccine development and

vaccination-related technologies.

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The ASH serves as the director of the National Vaccine Program and will lead the NAIP

and its implementation. In support of this mission, the National Vaccine Program Office

(NVPO) within HHS will facilitate collaboration and coordinate the monitoring of

progress for the NAIP, which will be reviewed annually by the ASH and the National

Vaccine Advisory Committee (NVAC).

While federal leadership and the alignment of federal activities are critical to

implementing this plan, participation by diverse stakeholders is necessary for the NAIP

to realize its potential. The NAIP is a national rather than federal plan and thus calls for

the coordinated action of governmental and nongovernmental partners. The success of

this plan depends on state, local, territorial, and tribal governments; health care

providers; professional associations; advocacy groups; vaccine manufacturers;

academia and research organizations; payers and health plans; employers; and the

general public working together to overcome barriers and improve access to adult

vaccinations. Table 2 outlines some of the stakeholder groups that will be a part of plan

implementation.

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TABLE 2. NATIONAL ADULT IMMUNIZATION PLAN:

FEDERAL AND NONFEDERAL STAKEHOLDERS

Stakeholder Category Agency/Entity

Federal government, HHS agencies Administration for Community Living, Administration

for Children and Families, Agency for Healthcare

Research and Quality, Centers for Disease Control

and Prevention, Centers for Medicare & Medicaid

Services, U.S. Food and Drug Administration,

Health Resources and Services Administration,

Indian Health Service, National Institutes of Health,

Office of the Assistant Secretary for Public Affairs,

Offi

ce of the Assistant Secretary for Planning and

Evaluation, Office of the Assistant Secretary for

Preparedness and Response, Office of Global

Affairs, Office of Minority Health, Office of the

National Coordinator for Health Information

Technology, Partnership Center, Office of the

Assistant Secretary for Health, Office of Disease

Prevention and Health Promotion, Office on

Women’s Health, Office of Adolescent Health,

Regional Health Administrators

Federal government, other

departments/agencies

Department of

Defense, Department of Homeland

Security, Department of Veterans Affairs,

Department of Justice, Federal Occupational Health,

Office of Personnel Management

Government, nonfederal

State, territorial, tribal, and local public health

agencies and governments

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Nongovernmental stakeholders Academia/research organizations, health care

providers, vaccine industry, health care systems,

community immunizers, professional associations,

payers and plans, employers, foundations, schools

and training programs, community and patient

advocacy organizations, philanthropic organizations,

adult immunization coalitions, and the general public

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DEVELOPMENT OF THE NATIONAL ADULT

IMMUNIZATION PLAN

Lack of sufficient progress in increasing adult immunization rates coupled with the

ASH’s consideration of NVAC’s recommendation led to the development of the NAIP.

1

The plan was drafted after deliberation, analysis, and input from a broad range of

stakeholders, including health care providers; professional and advocacy organizations;

federal, state, local, tribal, and territorial governments; researchers; health insurers;

employers; vaccine manufacturers; and members of the general public. The RAND

Corporation was enlisted to conduct an environmental scan, engage stakeholders, and

collect data to identify plan priorities and key indicators.

Environmental Scan

The first step in developing the plan was to develop a comprehensive environmental

scan and review all prior recommendations and reports on adult vaccination from 2005

to 2015. Numerous stakeholder groups have issued reports in recent years calling for

action to improve adult vaccination.

14–16,25–31

These reports inventory past successes,

ongoing barriers, and potential opportunities to improve adult vaccination and

recommend actions to be taken by government agencies, health insurers, community

vaccinators, and others to raise adult vaccination rates. The environmental scan

identified both best practices and potential actions for strengthening adult vaccination.

These actions were assessed for continued relevance in the current policy environment,

and the chosen actions were organized by plan goal and objective.

Stakeholder Engagement

The second step in the process was robust stakeholder engagement. First, a survey

was fielded to 96 respondents representing a range of stakeholder groups, such as

health departments, payers, employers, research organizations, professional

associations, and health care providers. Then, eight focus groups with a total of 90

participants were convened to review survey results. Lastly, in-depth interviews were

conducted with dozens of governmental and nongovernmental subject matter experts.

Stakeholders were asked to assess and prioritize actions identified in the environmental

scan, as well as to identify any new actions.

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Measuring Progress: Indicator Development

Once a final set of actions was identified, stakeholders were also asked to identify and

prioritize indicators to track progress on plan goals and objectives and set ambitious yet

attainable milestones for 2020, using a target-setting method consistent with Healthy

People 2020. If a target had already been set by an existing policy or program, that

target was adopted. In cases in which no target existed, stakeholders discussed trend

data and determined target levels by consensus.

Following a number of stakeholder engagements, a draft plan was released for public

comment through a notice in the Federal Register. The final NAIP reflects the input of

the full range of stakeholders in the adult vaccine system in the United States.

Alignment with Existing HHS Programs and Plans

In developing the plan, care was taken to align with numerous HHS programs and

plans, including the National Vaccine Plan (NVP), Healthy People 2020, the National

Prevention Strategy, and the HHS Strategic Plan. These initiatives all contain specific

objectives and indicators related to strengthening adult vaccination, including the

following:

•

Healthy People 2020: Healthy People 2020 includes four objectives related to

improving vaccination coverage among adults within the topic of immunizations

and infectious diseases and one within the topic of older adults. The NAIP

supports the achievement of the adult vaccination targets specified in Healthy

People 2020.

•

National Prevention Strategy: The National Prevention Strategy emphasizes the

importance of adult vaccination and other preventive services for increasing the

number of Americans who are healthy at every stage of life.

•

HHS Strategic Plan: One of the objectives of the HHS Strategic Plan is to reduce

the occurrence of infectious diseases, including vaccine-preventable diseases.

The HHS Strategic Plan includes a specific strategy to remove financial and other

barriers to routine vaccination for adults, which is also a major focus of the NAIP.

•

National Quality Strategy: Established as part of the Affordable Care Act, the

National Quality Strategy focuses nationwide quality improvement and

measurement efforts on six priorities, including working with communities to

promote wide use of best practices to enable healthy living. This priority

encourages the adoption of recommended clinical preventive services for adults,

such as vaccination.

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•

HHS Action Plan to Reduce Racial and Ethnic Health Disparities: The HHS

Action Plan to Reduce Racial and Ethnic Health Disparities includes a measure

to increase the percentage of racial and ethnic minority populations who receive

the seasonal influenza vaccination.

•

National Vaccine Plan: The 2010 NVP provides a guiding vision for vaccination

for the decade 2010–2020 and strategic direction for coordination of the

immunization system in the United States. The NAIP supports and can be

described as being nested within the NVP, which is the road map for the broader

set of efforts seeking to prevent serious infectious diseases and their

complications through vaccination.

The NAIP was also designed to highlight areas of adult immunization that are

addressed in a more focused and detailed manner by other efforts. While the NAIP

provides a framework for approaching adult vaccination, there are unique issues for

certain populations, such as pregnant women, that require focused attention:

•

The NVAC Standards for Adult Immunization Practice, released in 2014, provide

guidance for health care providers representing both traditional and

complementary settings for vaccination of adults on how to implement many of the

priorities in the plan.

20

•

The Community Guide to Preventive Services reviews the evidence for potential

interventions and strategies to promote the use of screening, counseling, and

other preventive services typically delivered in primary care settings. The

Community Guide includes 13 recommendations on vaccination strategies and

identifies five areas in which there is insufficient evidence.

32

•

NVAC also advises the ASH regarding strategies to improve vaccination for

specific subgroups of adults, such as health care workers and pregnant women,

by offering evidence-based strategies for overcoming patient and provider barriers

that continue to hinder uptake of recommended vaccines in this population. In

addition, NVAC provides forward-looking analyses to identify barriers and

challenges to research and development of new vaccines specifically for pregnant

women.

33

These analyses and resulting recommendations help guide efforts to

expand the potential of vaccines to protect pregnant women and their infants.

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NAIP GOALS, OBJECTIVES, AND STRATEGIES

This section presents the goals, objectives, and strategies that compose the NAIP. The

activities outlined here will guide federal adult im munization efforts in collaboration with

nonfederal partners in the upcoming years to advance strategic goals and supporting

objectives. For each objective, the key federal agencies and nonfederal partners with

relevant roles and responsibilities are presented in Appendix 4 .

While all of the goals, objectives, and strategies are important for advancing adult

immunization, the NAIP’s priorities are captured by the plan performance indicators in

Table 3. In many cases, progress on the performance indicators (e.g., adult vaccination

rates) requires action on multiple objectives and strategies; thus, the indicators serve as

a barometer for what is happening across the adult immunization system .

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GOAL 1:

STRENGTHEN THE

ADULT IMMUNIZATION

INFRASTRUCTURE

The adult immunization infrastructure in the United States is complex and multifaceted,

consisting of numerous components with unique functions. While all the goals of the NAIP

feature objectives that impact critical aspects of the infrastructure or interdependencies

among system components, Goal 1 of the NAIP focuses on high level issues with the

potential to have significant impact on adult vaccination rates in the next several years.

One example is the increasing importance of health IT and the need for systems and

providers to be able to exchange accurate, timely information. Goal 1 represents a

commitment to strengthen the adult immunization infrastructure by improving and

leveraging elements that already exist, rather than creating new systems, programs,

and entities.

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GOAL 1 OBJECTIVES

GOAL 1

OBJECTIVE

1.1

GOAL 1

OBJECTIVE

1.2

GOAL 1

OBJECTIVE

1.3

GOAL 1

OBJECTIVE

1.4

GOAL 1

OBJECTIVE

1.5

GOAL 1

OBJECTIVE

1.6

Monitor and

r

eport trends in

adult vaccine-

preventable

disease levels

and vaccination

coverage data

for all

ACIP/CDC-

recommended

vaccines. In

cases where

there are

associated

Healthy People

2020 goals,

measure

progress toward

established

targets.

Enhance

current

vaccine safety

monitoring

systems and

develop new

methods to

accurately and

more rapidly

assess vaccine

safety and

effectiveness

in adult

subpopulations

(e.g., pregnant

women).

Continue to

analyze claims

filed as part of

the

National

Vaccine Injury

Compensation

Program

(VICP) to

assess whether

there was an

association

between

vaccines that a

claimant

received and

adverse events

experienced.

Incr

ease the

use of

electronic

health records

(EHRs) and

immunization

information

systems (IIS)

to collect and

track adult

immunization

data.

Evaluate and

advance

targeted

quality

improvement

initiatives.

Generate and

disseminate

evidence about

the health and

economic

impact of adult

immunization,

including

potential

diseases

averted and

cost-

effectiveness

with the use

of current

vaccines.

GOAL 1 INCLUDES SIX OBJECTIVES TO STRENGTHEN THE ADULT

IMMUNIZATION INFRASTRUCTURE:

Objective 1. 1:

Monitor and report trends in adult v accine-preventable disease lev els and

vaccination cov erage data for all A CIP/CDC-recommended vaccines. In cases

where there are associated Healthy People 2020 goals, measure progress toward

established targets.

Translating vaccination policy into health outcomes depends on strong public health

surveillance to evaluate the impact of adult vaccinations on vaccine-preventable

diseases. Surveillance also provides needed data to assess progress on plan indicators,

including the impact of activities on racial and ethnic disparities.

1.1.1 Evaluate the impact of adult vaccination on morbidity and mortality, with

special emphasis on vulnerable populations (e.g., older adults and

adults with chronic conditions, such as diabetes, heart disease, immune

compromising conditions, and stroke) where feasible.

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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES NATIONAL VACCINE PROGRAM OFFICE

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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES NATIONAL VACCINE PROGRAM OFFICE

1.1.2 Identify coverage gaps and disparities among racial and ethnic minorities

and develop targeted strategies to reduce disparities.

1.1.3 Improve methods to verify vaccination coverage status.

1.1.4 Identify efficiencies to improve adult immunization delivery by encouraging

greater use and increased functionality of existing systems (e.g., state and

local IIS).

Objective 1. 2:

Enhance current v accine safety monitoring sy stems and dev elop new methods

to accurately and more rapidly assess v accine safety and effectiv eness in adult

subpopulations (e.g., pregnant women).

Vaccines have a long track record of safety and effectiveness in adults, yet there is a

need to ensure that, when recommended and used broadly, vaccines perform as would

be expected from the clinical trials that led to their licensure. In addition, there is a need

to closely monitor vaccine safety and effectiveness in adult populations after new

vaccines are licensed, when licensed vaccines are recommended for new populations,

or when vaccines are used as part of the response to a public health emergency (e.g.,

an influenza pandemic). Vaccine safety and effectiveness monitoring is important not

only for public health, but also to ensure public confidence in vaccines.

The federal vaccine safety systems include, for example, the Vaccine Adverse Event

Reporting System (VAERS) co-sponsored by CDC and the Food and Drug

Administration (FDA), CDC’s Vaccine Safety Datalink (VSD) and Clinical Immunization

Safety Assessment, FDA’s Post-Licensure Rapid Immunization Safety Monitoring

System, and the Vaccine Injury Compensation Program and the Countermeasures

Injury Compensation Program, which are administered by the Health Resources and

Services Administration (HRSA). Vaccine safety monitoring is not limited to the federal

government, however, and a variety of nonfederal entities, including manufacturers and

academia, are active in this arena.

1.2.1 Increase awareness of the federal vaccine safety systems among adult

health care providers who vaccinate the public.

1.2.2 Increase the percentage of adult vaccination providers and patients that

report adverse events into VAERS.

1.2.3

Support improved online reporting interfaces (e.g., VAERS) to facilitate the

electronic submission of adverse event reports that occur after the

administration of vaccines.

1.2.4 Improve the timeliness and precision of vaccine effectiveness

assessments.

1.2.5 Encourage use of clinical research and population-based epidemiologic

studies for vaccine safety and effectiveness monitoring among

vaccinated adults.

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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES NATIONAL VACCINE PROGRAM OFFICE

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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES NATIONAL VACCINE PROGRAM OFFICE

1.2.6 Encourage greater use of EHRs and IIS to more rapidly identify persons

who may be impacted when a safety concern has been raised about a

particular vaccine or vaccine lot.

1.2.7 Determine the data needs to monitor vaccine safety and effectiveness in

pregnant women and newborns and the ability of these systems to capture

relevant data.

Objective 1.3:

Continue to analy ze claims files as part of the National Vaccine Injury

Compensation Program (VICP) to assess whether there was an association

between v accines that a claimant receiv ed and adv erse ev ents e xperienced.

The VICP was established in 1988 to provide compensation to individuals, including

adults, thought to have been injured or whose death was thought to have been related

to receiving certain vaccines. While adverse events following vaccination are extremely

rare, the VICP provides a no-fault alternative to the traditional tort system for resolving

vaccine injury claims. This program is instrumental in helping to ensure an adequate

supply of vaccines, encourage innovation, and stabilize vaccine costs by establishing

and maintaining an accessible and efficient forum for individuals thought to be injured by

select vaccines.

1.3.1 Review the latest medical and scientific literature for evidence of

associations between vaccines and adverse events when reviewing claims.

Objective 1.4:

Increase the use of electronic health records (EHRs) and immunization

information systems (IIS) to collect and track adult immunization data.

While IIS have the potential to act as a centralized repository of adult vaccination

records, the maturation of EHRs, IIS, and interoperability will also play a critical role in

ensuring coordination of adult vaccination activities and improving coverage.

34

A

centralized source of vaccination information is especially critical for adults who see a

variety of providers and receive vaccinations in a variety of settings (e.g., medical

settings, workplaces, schools, colleges, universities, pharmacies).

Many adult vaccination improvements are dependent on or would be accelerated by

better data exchange, and interoperability between EHRs and IIS facilitates better

health outcomes.

In order to achieve these outcomes, EHRs must be able to electronically send data to

IIS and to receive consolidated histories and forecasts from IIS in a secure manner.

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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES NATIONAL VACCINE PROGRAM OFFICE

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EHRs also must be able to reconcile a patient’s history and forecast what might be

needed to ensure that the appropriate vaccines are given at the right times. Information

technology enhancements can lead to better recordkeeping and submission to IIS that

addresses the barrier of unknown vaccination history, avoids the administration of

duplicate doses of vaccine, and helps ensure that opportunities for vaccination are not

missed. EHR and IIS-related strategies include the following:

1.4.1

Increase the ability of EHRs to generate a query using nationally accepted

standards and accept a standardized immunization history and forecast,

consistent with the objectives and measures set forth in rulemaking for the

Medicare and Medicaid EHR Incentive Programs.

1.4.2 Increase the ability of IIS to accept a query using nationally accepted

standards and respond with a standardized immunization history and

forecast to inform providers of needed vaccinations, consistent with the

objectives and measures set forth in rulemaking for the Medicare and

Medicaid EHR Incentive Programs.

1.4.3

Increase adoption of standardized transport methods, including use of the

CDC Web Services Definition Language (WSDL), by IIS and by EHRs to

allow for more consistent information exchange across all in the health

care system who provide vaccine services for adults.

1.4.4 Expand IIS and EHR functionality to facilitate interstate immunization data

exchange through a centralized hub.

1.4.5

Develop and disseminate “model agreements” to address the documented

legal and policy barriers that preclude data sharing between states and

systems.

1.4.6 Expand consumers’ access to their own vaccination data through secure

IIS and EHR consumer portals.

1.4.7 Develop and encourage adoption of standardized clinical decision support

tools for adult vaccination.

1.4.8 Encourage evaluation of IIS and EHR usage for adult vaccinations among

providers, facilities, and organizations delivering vaccines to adults.

1.4.9 Promote automation strategies for documenting adult vaccinations, such

as the inclusion of 2D barcode data from vials and syringes, and by

building IIS and EHR capacity to accept barcode data.

1.4.10 Encourage bidirectional exchange between EHRs and IIS for adult

vaccinations among clinics and health systems already entering pediatric

data (e.g.,federally qualified health, center–funded clinics, health

maintenance organizations).

1.4.11 Increase participation of federal agencies in IIS and the connectivity

between IIS and EHR in these organizations (e.g., federal occupational

health clinics, VA health systems, DoD-run clinics).

1.4.12 Promote the use of Clinical Decision Support for Immunizations (CDSi)

resources by IIS and EHRs to standardize vaccine recommendations for

adult populations

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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES NATIONAL VACCINE PROGRAM OFFICE

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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES NATIONAL VACCINE PROGRAM OFFICE

1.4.13 Increase the capability of IIS to onboard adult providers for bidirectional

data exchange between the provider and IIS.

Objective 1.5:

Evaluate and advance targeted quality improvement initiatives.

Targeted quality improvement efforts, such as the development and use of clinical

performance measures by providers and health plans, play an important role in helping

providers set priorities and establish practice patterns and, thus, can motivate providers

to improve adult vaccination rates. To ensure progress on plan goals and objectives, it

is helpful to encourage and incentivize providers to recommend, provide, and maintain

records of adult vaccinations. To date, there have been several efforts to assess current

performance measures, identify measurement gaps, and make recommendations

regarding the development and implementation of new measures. Most existing

measures focus on uptake of select vaccines (e.g., the percentage of health care

workers who receive an influenza vaccination); however, others also gather information

about processes of care (e.g., the percentage of nursing home residents assessed and

appropriately given the pneumococcal vaccine). Many future quality improvement

projects will be facilitated by strengthening the IT tools outlined in objectives 1.3

and 1.4.

1.5.1 Evaluate impact of current adult vaccination quality measures and the

feasibility of future quality measure development projects.

1.5.2 Disseminate best practices and lessons learned from successful and

unsuccessful adult quality measure and adult quality improvement pilot

projects.

1.5.3 Develop and validate new metrics to track progress on NAIP objectives.

Objective 1.6:

Generate and disseminate evidence about the health and economic impact of

adult immunization, including potential diseases averted and cost-effectiveness

with the use of current vaccines.

Generating information on the economic impact of adult immunization is a critically

important element of the plan. While economic evaluations of the childhood

immunization program in the United States have assessed the impact of all routinely

recommended vaccines on direct and indirect costs, no parallel research has been

published on adult immunization. Economic evaluations are critically important because

they help to inform policymakers, health insurance plans, providers, employers, and

the public about the value and importance of adult immunizations and can inform

decisions regarding promotion of and reimbursement for adult immunization services.

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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES NATIONAL VACCINE PROGRAM OFFICE

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1.6.1 Encourage the development and evaluation of models to estimate the

cost-effectiveness of adult immunization programs.

1.6.2

Encourage employers to offer and promote adult immunization using

evidence on economic impact.

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GO

AL 2:

IMPROVE ACCESS TO

ADULT VACCINES

The passage of the Affordable Care Act marked an important opportunity for adult vaccination,

with more consumers having improved access to preventive services. However, despite the

Affordable Care Act’s impact, critical challenges remain in achieving access to low cost, high

quality vaccination services. More than 17 million adults have gained health insurance coverage

since the beginning of open enrollment in October 2013 through September 12, 2015. Over that

period, the uninsured rate declined from 20.3 percent to 12.6 percent and a 38 percent (or 7.7

percentage point) reduction in the uninsured rate. Nonetheless, some adults will continue to be

uninsured or underinsured.

22

The NAIP aims to leverage the full potential of the Affordable Care

Act to improve access to adult vaccinations and to identify solutions to ongoing challenges.

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GOAL 2 OBJECTIVES

GOAL 2 INCLUDES FOUR OBJECTIVES TO IMPROVE ACCESS TO

ADULT VACCINES:

GOAL 2 OBJECTIVE 2.1

GOAL 2 OBJECTIVE 2.2

GOAL 2 OBJECTIVE 2.3

GOAL 2 OBJECTIVE 2.4

educe financial

Assess and improve

Expand the adult

Ensure a reliable supply

arriers for individuals

understanding of

immunization provider

of vaccines and the

ho receive

providers’ financial

network.

ability to track vaccine

ecommended adult

barriers to delivering

inventories, including

accines.

vaccinations, including

during public health

stocking and

emergencies.

administering vaccines.

R

b

w

r

v

Objective 2.1:

Reduce financial barriers for individuals who receive recommended adult

vaccines.

The inability of some individuals to pay for vaccines is a commonly cited barrier to

increasing adult vaccination. There is no adult program comparable to the VFC,

which offers free vaccines to eligible child populations and supports a robust delivery

infrastructure, including provider education. While the Affordable Care Act has

reduced financial barriers to vaccination for millions of Americans, certain segments

of the population (e.g., the uninsured) will continue to have out-of-pocket costs for

recommended vaccines. Thus, understanding and reducing financial barriers for

these segments of the population is an important objective of the NAIP.

2.1.1 Evaluate the impact of financial barriers, such as co-pays, on adult

vaccination uptake.

2.1.2 Advance efforts to have consistency in the individual state Medicaid

benefit for ACIP/CDC-recommended vaccines for adults.

2.1.3 Evaluate the impact of state Medicaid program approaches to cost sharing

for recommended adult vaccines on vaccination rates (e.g., compare

programs that elect to offer the same benefits for traditional and

expansion populations and those that maintain different benefits for

these populations)

.

2.1.4 Evaluate the advantages and disadvantages of novel state vaccine

financing pilot programs that provide vaccines to adults, including health,

economic, and innovation impacts.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES NATIONAL VACCINE PROGRAM OFFICE

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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES NATIONAL VACCINE PROGRAM OFFICE

Objective 2.2:

Assess and improve understanding of providers’ financial barriers to

delivering vaccinations, including stocking and administering vaccines.

Providers need to be educated about the importance of routinely assessing the

vaccine needs of their patients, strongly recommending needed vaccines, and either

vaccinating or referring patients to others who administer vaccinations. They also

must be empowered to pursue these activities with tailored guidance, education,

and tools.

Currently, many factors prevent providers from consistently vaccinating all patients

who could benefit, and providers in underserved and minority communities may face

unique challenges. The Affordable Care Act does not address providers’ financial

barriers to maintaining a vaccine inventory; thus, other policies and programs need

to focus on understanding these issues and work toward improving providers’

business practices when providing vaccination services.

2.2.1

Research the total costs of providing vaccination services in a provider

setting to improve understanding of costs associated with the range of

activities that are needed to ensure efficient and effective immunization

services (e.g., ordering, handling, storage, administration, patient

recall/reminders, and counseling).

2.2.2 Encourage the development of tools to improve immunization provider

business practices and work flow (e.g., practice efficiency and

inventory management), and assess the impact of these tools on adult

vaccination rates at the practice level.

2.2.3 Encourage vaccine manufacturers and third-party vaccine distributors

to build on existing work with providers to reduce the financial burden

of maintaining vaccine inventories (e.g., permitting providers to

purchase small quantities of vaccines).

2.2.4 Evaluate the impact of various methods to encourage and incentivize

provider recommendations for, provision of, and recordkeeping related

to adult vaccination (e.g., standing orders, IIS).

2.2.5 Evaluate the impact of various tools and other business models that

address financial risks associated with providing adult

vaccination services.

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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES NATIONAL VACCINE PROGRAM OFFICE

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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES NATIONAL VACCINE PROGRAM OFFICE

To ensure that vaccines are available at convenient locations and to expand the

capacity of the health care system to administer vaccines, the adult immunization

provider network should be strengthened. Adults frequently obtain recommended

vaccinations in complementary settings, such as workplaces, schools, community

health centers and pharmacies, so it is especially important for these providers to

have the capability to exchange information and document administration in

collaboration with physicians and patients’ medical homes. Pharmacists and others

can play an even larger role in adult vaccine delivery if they can offer the full range of

recommended vaccinations and bill for Medicare Part D vaccines. They are an

important resource in the immunization system, as more than 250,000 pharmacists

have been trained to administer vaccines in the United States, and nearly 95 percent

of Americans live within five miles of a community pharmacy.

The Affordable Care Act established an immunization coverage standard that

requires most new health plans to cover routine vaccines recommended by the

ACIP/CDC without cost-sharing when administered by an in-network provider. This

has led to questions about which providers are considered in and out of network and

whether the network is adequate to meet demand in all geographic settings.

1

Therefore, the plan’s goal of improving access to adult vaccination services includes

an objective to collect data to better understand and evaluate reported insurance

network provider adequacy concerns.

Another important element of the plan is to expand access through employers to

improve employee health and wellness and create healthier workplaces. The most

immediate impact from an employer perspective may be with seasonal influenza

immunization campaigns, but such efforts may offer the possibility of expanding to

other recommended adult vaccines.

2.3.1 Encourage in-network coverage of adult vaccinations administered in

accessible health care delivery settings (e.g., public health clinics,

pharmacies).

2.3.2 Identify and promote best practices related to collaborative models

among physicians and complementary settings (e.g., streamlined

referrals and information sharing).

2.3.3 Improve data collection efforts to support evaluation of reported in-

network adequacy concerns.

2.3.4 Identify, promote, and disseminate effective practices for billing private

health insurers (e.g., among health departments and others).

2.3.5 Continue to identify the barriers that prevent or discourage

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Objective 2.3:

Expand the adult immunization provider network.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES NATIONAL VACCINE PROGRAM OFFICE

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of the adult immunization provider network and communicate

challenges to policy makers.

2.3.7

Assess the impact of providing immunization services in

complementary settings on vaccination coverage, cost-effectiveness,

and health outcomes.

2.3.8 Increase the number of community health centers that routinely

administer vaccinations to adults and report vaccinations to IIS and

primary care providers.

2.3.9 Encourage on-site, occupational health vaccination clinics and

involvement of employers to increase employee vaccination rates and

reporting of vaccinations to IIS.

2.3.10 Conduct research on barriers and facilitators to delivering vaccines to

adults in pediatric settings.

Objective 2.4:

Ensure a reliable supply of vaccines and the ability to track vaccine

inventories, including during public health emergencies.

Many of the priorities described in the plan, if implemented, could result in

increased demand for adult vaccines and vaccination services. Thus, a reliable and

steady supply of adult vaccines is needed to realize the full benefit of the goals,

objectives, and strategies described in the plan. In addition, ensuring the functioning

of routine systems and engaging existing health care providers will be critical in

monitoring the response to public health emergencies requiring vaccines, such as

an influenza pandemic.

2.4.1 Increase the transparency of vaccine distribution strategies to public

and private entities to facilitate equitable distribution of vaccines in

times of shortage.

2.4.2 Develop and evaluate the impact of pilot projects designed to improve

supply and innovative inventory management (e.g., the use of 2D bar

coding on vaccine units of sale) to improve accuracy and timeliness of

vaccine distribution tracking.

2.4.3 Evaluate strategies that encourage multiple suppliers of vaccines for

adults.

2.4.4 Encourage manufacturers and public health authorities to work

collaboratively to develop contingency plans for the timing and

prioritization of vaccine supplies in case of shortages.

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2.3.6 Identify legal, practical, and policy barriers that may impede expansion

pharmacists and other providers in complementary settings from

accessing and entering vaccinations into state and local IIS and

reporting vaccinations to patients’ primary care providers.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES NATIONAL VACCINE PROGRAM OFFICE

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GOAL 3:

INCREASE COMMUNITY

DEMAND FOR ADULT

IMMUNIZATIONS

As described in the NVP, HHS is committed to providing accurate, timely, transparent, complete,

and audience appropriate information about vaccinations. Furthermore, communication activities

concerning vaccination should be strategic, evidence based, and culturally and linguistically

appropriate and should reflect the health literacy, language proficiency, and functional and

access needs of specific target populations. While the NVP includes a goal to support

communications to enhance informed vaccine decision making more broadly, Goal 3 of the

NAIP is intended to address the needs of adults and providers of adult vaccination services

specifically. Further, because adults make decisions for their children regarding vaccination,

education of adults and their health care providers is likely to have impacts beyond this

population.

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GOAL 3 OBJECTIVES

GOAL 3 OBJECTIVE 3.1 GOAL 3 OBJECTIVE 3.2 GOAL 3 OBJECTIVE 3.3

Educate and encourage Educate and encourage Educate and encourage other

individuals to be aware of and health care

providers to groups

(e.g., community and

receive recommended adult recommend and/or deliver faith-based groups, tribal

immunizations. adult vaccinations. organizations) to promote the

importance of adult immunization.

Objective 3.1:

Educate and encourage individuals to be aware of and receive recommended

adult immunizations.

Communications and outreach to the public are critical to address a lack of knowledge,

as well as common misconceptions and skepticism about adult vaccinations. Frequent

outreach raises awareness that vaccination is recommended across the lifespan and

helps establish vaccination as a routine part of preventive services and as a societal

norm. Although education alone is insufficient to increase vaccination rates, it can have

significant impact as a part of a number of broader, evidence-based strategies. Adults

are often unaware of their potential risk of acquiring diseases that can be prevented by

vaccination and of the availability of specific vaccines. This lack of knowledge may be

particularly acute among populations with limited English proficiency and persons with

disabilities.

36–38

While there are many existing materials that can be used to educate

the public and health care providers about adult vaccination, innovative strategies are

needed to address the lack of knowledge regarding the risk of vaccine-preventable

diseases and their consequences and the benefits of vaccines in preventing these

infections. In a digital age in which information travels rapidly and misinformation can

reach millions, novel outreach strategies that take into account patients’ preferences,

cognitive styles, literacy levels, preferred sources of information, and cultural

backgrounds should be tested, deployed, and broadly disseminated. Furthermore, these

strategies should recognize competing demands in providers’ office-based practices

that limit the length of provider-patient interactions about vaccination.

3.1.1 Conduct research on public awareness and acceptance of adult vaccines

(including vaccine financing, vaccine effectiveness, and vaccine safety

concerns) among the public, with a focus on racial, ethnic, and economic

disparities.

GOAL 3 INCLUDES THREE OBJECTIVES TO INCREASE COMMUNITY

DEMAND FOR ADULT IMMUNIZATIONS:

3.1.2 Conduct research on effective messaging and outreach strategies (e.g.,

social media) for different adult subpopulations to inform communication

efforts.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES NATIONAL VACCINE PROGRAM OFFICE

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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES NATIONAL VACCINE PROGRAM OFFICE

3.1.3 Develop and implement accessible and culturally and linguistically

appropriate communications and outreach strategies in multiple formats

for people with disabilities, including those who are deaf or hard of

hearing, people with limited English proficiency, people with co

gnitive

limitations, and people who do not use traditional media

.

3.1.4

Increase the public’s understanding of the presence and role of vaccine

safety monitoring systems and the meaning of reported data and how it is

used to assess vaccine safet

y.

Objective 3.2:

Educate and encourage

health care

providers

to recommend and/or deliv

er adult

v

accinations.

Health care providers are a highly influential source of information and advice about

vaccinations, and a strong recommendation about the importance of immunizations can

exert a strong influence over the vaccination decisions of patients, including those

patients who may have reservations about some or all vaccines.

39,40

However, adult

immunization status is not routinely assessed, and the rationale for evidence-based

vaccine recommendations is not always articulated from providers to patients. This is

one reason why NVAC issued the updated Standards for Adult Immunization Practice to

encourage assessment of vaccination needs at every patient encounter.

Many health care providers stock some, but not all, adult vaccines. Cost and

reimbursement concerns; competing clinical priorities, such as the management of

acute medical issues; and the complexities of vaccine storage and handling continue to

be reported barriers to providing office-based immunization services. While educational

outreach targeted at the public is important, health care providers also require the

knowledge and tools to recommend and either deliver vaccinations or to refer their adult

patients to others who administer vaccinations. Furthermore, increasing consumer

demand without simultaneously addressing health care provider vaccination barriers

could have a detrimental effect on efforts to improve adult immunization.

This NAIP objective focuses on activities that will have the most meaningful impact,

while also recognizing the existence and importance of addressing provider barriers that

may hinder uptake.

3.2.1 Encourage all providers, including providers in complementary settings, to

implement the NVAC Standards for Adult Immunization Practice, which

includes assessing patients’ vaccination status at every clinical

encounter, strongly recommending needed immunizations, and either

administering vaccines (including documentation in an IIS) or referring

patients to others who administer vaccinations.

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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES NATIONAL VACCINE PROGRAM OFFICE

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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES NATIONAL VACCINE PROGRAM OFFICE

3.2.2 Encourage health care providers to request immunization records from

patients to support vaccination status assessment and recommendations.

3.2.3 Encourage the incorporation of adult vaccine education into the training of

health care providers (e.g., medical, nursing, and pharmacist education

curricula; postgraduate training, certification, and board examinations; and

required continuing education credits).

3.2.4 Encourage integration of vaccination into the provision of other adult

preventive services and chronic disease management.

3.2.5 Encourage the incorporation of immunization status assessment into

comprehensive medication reviews in medical therapy management

programs.

3.2.6 Promote increased attention to vaccine-specific recommendations in

disease-specific clinical practice guidelines (e.g., diabetes, heart disease,

lung disease, and immunocompromising conditions).

3.2.7

Educate providers and health systems about evidence-based strategies

and existing tools within EHRs and IIS to support adult immunization:

standing orders, reminder and recall systems, clinical decision support for

immunizations into EHRs, and other tools.

3.2.8 Reduce vaccine storage and handling errors by improving provider

education and awareness of vaccine delivery best practices and the need

for standardized vaccine management plans.

3.2.9 Improve provider awareness of the Affordable Care Act’s impact on adult

vaccine insurance coverage in Medicare, Medicaid, and private health

insurance plans, both outside and inside the marketplaces.

3.2.10 Educate health care providers about the VICP.

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Objective 3 .3:

Educate and encourage other groups (e.g., community and faith-based groups to

promote the importance of adult immunization.

While health care providers are critical to promoting vaccination, they are not the only

influential source of vaccine-related information. Education through social and

community networks may help to increase adults’ knowledge of the risks of vaccine-

preventable diseases and the benefits of vaccination. A variety of networks can be

leveraged, including faith-based and community organizations, employers, and

individual trusted leaders.

Prior research has shown that outreach on preventive services through faith-based

organizations and individual faith communities is effective in increasing uptake of these

services.

1

Community and faith-based organizations are likely to play an especially

important role in reducing racial and ethnic disparities in adult immunization, as they can

deliver education that is culturally sensitive, linguistically appropriate, and tailored to

specific subpopulations.

3.3.1 Engage community leaders in reaching the public with information about

the importance of adult vaccination.

3.3.2 Encourage the development of adult immunization champions across all

sectors.

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-

GOAL 4:

FOSTER INNOVATION

IN ADULT VACCINE

DEVELOPMENT AND

One of the five goals of the NVP is to develop new and improved vaccines. The NVP, as well as

a myriad other policy documents, recognizes that vaccines have led to enormous reductions in

the incidence and impact of several once widespread infectious diseases. Goals 1 through 3 in

the NAIP focus on enhancing vaccine delivery. However, achieving these goals is dependent on

the existence of safe and effective vaccines. Goal 4 recognizes that there are opportunities for

the development of new vaccines, more effective versions of existing vaccines for adults, and

technological advancements to improve vaccine delivery.

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GOAL 4 OBJECTIVES

GOAL 4 INCLUDES TWO OBJECTIVES TO FOSTER INNOVATION AND

GOAL 4 OBJECTIVE 4.1

GOAL 4 OBJECTIVE 4.2

Develop new vaccines and improve the

Encourage new technologies to improve the

effectiveness of existing vaccines for adults.

distribution, storage, and delivery of adult

vaccines.

Objective 4.1:

Develop new vaccines and improve the effectiveness of existing vaccines for

adults.

While most existing vaccines are highly effective in children, vaccines recommended for

adults are generally less effective, especially older adults and those with immune systems

compromised by underlying diseases or medications. In general, the immune response of

currently recommended vaccines declines with advancing age and the onset of chronic

diseases. The perception that vaccines may have limited effectiveness in some adults

may, in turn, negatively influence demand and contribute to low vaccination rates.

However, the changing demographics of an aging society highlight the importance of

improving our understanding of the aging immune system and the development of next-

generation vaccines that can protect against serious infections that occur in this

population.

ADULT VACCINE DEVELOPMENT AND RELATED TECHNOLOGY:

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There are numerous challenges that must be overcome in developing new vaccines.

Bringing a new product to market can take ten or more years in development and can

require a significant financial investment on the part of manufacturers. The market is

also limited for special populations that are smaller in size than the general population of

adults, suggesting the need for targeted efforts to develop vaccines for use, for

example, in pregnant women and in immunocompromised individuals.

4.1.1 Encourage ongoing efforts to develop and license new and improved

vaccines, including support for research, development, and licensure of

vaccines; improved effectiveness; and longer duration of immunity. Ensure

that progress in these areas does not compromise the effectiveness of

vaccines or the rigorous, scientific standards used to evaluate vaccines

during the approval phase.

4.1.2 Encourage ongoing efforts to support the discovery, validation,

development, standardization and distribution of specialized reagents,

assays, technologies (i.e., genomic sequencing, bioinformatics, and

systems biology tools), and animal models needed to facilitate basic,

preclinical, and clinical research programs aimed at developing and testing

vaccine candidates.

4.1.3 Continue ongoing efforts to support research and advanced development

of vaccine adjuvants and formulations in order to enhance the immune

response.

4.1.4 Develop and encourage use of internationally adopted standards for

evaluating vaccine effectiveness that take into account diagnosis, study

design, and correlates of protection.

4.1.5 Optimize predictive values of vaccine effectiveness in animal models, and

develop and validate new analytical methods and biomarkers that will

establish early-phase correlates of protection.

4.1.6 Evaluate existing and identify new incentives to accelerate vaccine

development.

Objective 4.2:

Encourage new technologies to improve the distribution, storage, and delivery of

adult vaccines.

Numerous studies have highlighted the challenges that health care providers face in

storing and managing their vaccine inventories. New technologies are in development to

address these challenges and reduce the administrative burden on providers. New

technologies are also being developed to change the ways that vaccines are

administered (e.g., jet injector for select products and populations).

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These developments may further reduce barriers to adult immunization by

offering new solutions that appeal to both providers and consumers. The NAIP

encourages innovation in the realm of both new vaccine development and new

technologies to facilitate the management and administration of vaccines.

4.2.1 Apply new distribution tools and methods to strengthen the supply chain.

4.2.2 Improve the storage and handling of vaccines through the application of

new technologies.

4.2.3 Support and promote new technologies that improve the administration of

vaccines.

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MONITORING AND EVALUATION

Achieving the goals of the NAIP requires the collaboration of partners around a shared

vision and coordination of activities through focused implementation efforts. Meaningful

progress will be achieved only if stakeholders are engaged in shared, sustained,

focused, and coordinated actions. The strategies noted above operationalize the

objectives and goals laid out in the plan. However, these strategies are not intended to

be comprehensive; rather, they are focused on the areas of highest priority. The

strategies described in the plan are conditional and are subject to engagement by all

stakeholders and to the availability of resources to achieve them. To foster action and

accountability, federal stakeholders with leading or supporting roles have been identified

for each objective in the NAIP. Appendix 5 also offers recommendations regarding how

nonfederal stakeholders can play a role. All stakeholders are invited to review these

materials and identify novel ways that they can contribute.

An Adult Immunization Implementation Plan, which reflects available resources and

federal priorities, will be developed by the Interagency Adult Immunization Task Force

(AITF). The AITF was created to help improve coordination and collaboration across

HHS agencies and other federal groups during the 2009 H1N1 pandemic. The AITF

membership is composed entirely of HHS entities and representatives with a vested

interest in adult immunization.

Implementing the NAIP will require not just federal action, but also national action. The

success of the plan will require state, local, tribal, and territorial governments;

components of the health care delivery system; communities; manufacturers; and other

stakeholders to work together to ensure a coordinated and comprehensive adult

immunization program. The strategies identified here are intended to serve as a catalyst

for other stakeholders to develop their own plans for participation in adult immunization

activities.

The implementation of this plan demands regular monitoring and documentation of

progress, challenges, and opportunities—all of which provide transparency to

policymakers and the public. NVPO, in partnership with the AIT

F, will regularly track and

annually summarize progress on achieving the goals and priorities in the NAIP and

present them to NVAC and the ASH in an effort to highlight the impact of the

implementation of strategies outlined here, as well as to identify areas where progress is

lagging and propose corrective action where needed. An update on plan progress also

will be presented at an NVAC meeting, which is open to the public and is attended by

many stakeholders.

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A key feature of the NAIP is the indicators (Table 3) and accompanying milestones for

specific improvements to be achieved by 2020. These indicators reflect the priorities

within each goal of the plan. The indicators will be used to measure progress and inform

future implementation and quality improvement efforts. While many things could be

measured, a limited number of indicators—one or more for each plan goal—will be

tracked to monitor progress on priority issues. Indicators were selected to draw attention

to some of the most critical challenges within each goal of the plan and were drawn

primarily from existing measurement and data collection efforts, such as Healthy People

2020 and annual national surveys. In most cases, required data are already being

collected by partner agencies. A small number of developmental indicators have also

been included to shed light on key aspects of adult vaccination programs where ongoing

attention and improved data collection may be needed. NVPO has chosen to include the

developmental indicators to draw attention to these important areas of opportunity.

Research is planned to identify baseline levels for the developmental measures. The

data sources for the full set of indicators are listed in Appendix 3.

Target milestones for most indicators were identified by subject matter experts or

adapted from previously published goals. Certain developmental measures do not have

target milestones because trend data are not available to inform the target-setting

process. As data sources and indicators are developed or enhanced, the NAIP

indicators and accompanying milestones will be updated.

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TABLE 3. PLAN PRIORITIES: INDICATORS FOR THE GOALS OF THE

NAIP

Goal 1: Strengthen the Adult Immunization Infrastructure

****

Key Indicator

Baseline

(Year)

††††

2020

Milestone

Responsible for

Data Collection

(Data Source)

Adult vaccination coverage for

Healthy People 202

0 measures and

racial/ethnic disparities in coverage

CDC (National

Health Interview

Survey, CMS

Minimum Data

Set, Internet panel

surveys o

f

pregnant women

and health care

providers)

Percentage of adults age >18 years

who are vaccinated annually against

seasona

l influenza

39 (2013)

70

P

ercentage of health care personnel

w

ho are vaccinated annually against

s

easonal influenza

62 (2013)

90

Percentage of pregnant women who

are vaccinated annually against

influenza

52 (2013)

N/A

Percentage of adults age >65 years

who are vaccinated annually against

pneumococcal disease

60 (2013)

90

Percentage of noninstitutionalized

high-risk adul

ts age 18–64 years

who are vaccinated annually against

pneumococcal disease

21 (2013)

60

Entity

****

Items in italics are developmental.

††††

The baseline year is 2012 unless otherwise specific

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Percentage of institutionalized adults

age >18 years in long-term care or

nursing homes who are vaccinated

annually against pneumococcal

disease

66 (2006)

90

Percentage of adults age >60 who

are vaccinated agains

t zoster

24 (2013)

30

Percentage of health care personnel

age >19 years who are vaccinated

against hepatitis B

64 (2008)

90

Percentage of surveyed primary care

physicians who record information on

adult vaccinations in state or regional

IIS

8% of

internists; 36%

of family

physicians

50%

CDC

Percentage of surveyed pharmacists

who submit adult vaccination data to

IIS

28% (2013)

60%

CDC

Percentage of adults age >19 with

one or more immunizations recorded

in an IIS

25% (2012)

50%

CDC (IIS Annual

Report)

Developmental measure: (Amon

g

adult health care providers who have

identified an adverse event following

immunization) Percentage of

providers who have reported one or

more events to VAERS

41

17%

In

development

NVPO

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Goal 2: Improve Access to Adult Vaccines

Entity

Responsible for

Baseline

Key Indicator

‡‡‡‡

2020

Data Collection

(Year)

§§§§

Milestone

(Data Source)

85% (2013)

100%

American

Pharmacists

Association

Percentage of states and

territories that allow

pharmacists

to administer all routinely

recommended vaccines for adults

>19 without a patient-specific

prescription

Percentage of surveyed primary

20% of

60%

CDC

care providers who stock vaccines

internists;

routinely recommended for

31% of

adults

*****

family

physicians

20%

100%

CMS

Percentage of state Medicaid

programs that provide cover

age

of all ACIP/CDC-recommended

vaccinations for adults and

prohibit cost-sharing

‡‡‡‡

Items in italics are developmental.

§§§§

The baseline year is 2012 unless otherwise specified.

*****

The survey will capture stocking behavior for different adult vaccines, as well as provider-re

ported

rationale for not stocking some products.

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Goal 3: Increase Community Demand for Adult Vaccinations

Key Indicator

†††††

Baseline

(Year)

‡‡‡‡‡

2020

Milestone

Entity

Responsible for

Data Collection

(Data Source)

Percentage of surveyed adults who

believe that they are recommended

to receive a flu vaccine

45%

75%

CDC

Percentage of surveyed adults

who report receiving a provider

recommendation for flu vaccine

45%

90%

CDC

Percentage of surveyed adult health

29% of

60%

CDC

care providers who report assessing

internists;

vaccination status at every visit

32% of

family

physicians

Developmental measure:

Percentage of surveyed adults wh

are aware that certain vaccines ar

recommended for adults

§§§§§

o

e

In

development

In

development

CDC

Developmental measure:

Percentage of pregnant women who

reported receiving the following

immunizations during pregnancy:

1)

Influenza

2)

Tdap

In

development

In

development

CDC

‡‡‡‡‡

§§§§§

Items

in italics are developmental.

The baseline year is 2012 unless otherwise specified.

Research will capture data for selected adult subpopulations. However, this research is

not meant to beinclusive of every group, but to provide an estimate of adult vaccine

consumer awareness and areas of opportunity.

†††††

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Goal 4: Foster Innovation in Adult Vaccine Development and Vaccination-Related

Technologies

Key Indicator

******

Baseline

(Year)††††††

2020

Milestone

Entity

Responsible for

Data Collection

(Data Source)

Developmental measure: Number

In

Biotechnology

of vaccines in clinical development

development

industry

(Phase II or Phase III clinical trials)

organization

with an expected adult indication

(publicly available

data)

Developmental measure: Number

of vaccines on CDC-contracted

vaccine pricelist that include a 2D

barcode on unit of use or primary

vaccine product (e.g., vials,

syringes)

In

development

100%

CDC

******

Items in italics are developmental.

††††††

The baseline year is 2012 unless otherwise specified.

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http://www.cdc.gov/vaccines/schedules/easy-to-read/adult.html

APPENDIX 1: ADULT IMMUNIZATION SCHEDULE

Adult Immunization Schedule and Tools (CDC):

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APPENDIX 2: DISPARITIES IN ADULT IMMUNIZATION COVERAGE

BY RACE/ETHNICITY

Vaccine and Age Group

White

(%)

Black

(%)

Hispanic

(%)

Asian

(%)

Other

(%)

Pneumococcal vaccination, ever (age 19–64, high

risk)‡‡‡‡‡‡

22.3

21.2

17.9

11.0

19.8

Pneumococcal vaccination, ever (age ≥65)

§§§§§§

63.6

48.7

39.2

45.3

54.6

Tetanus vaccination, past - 19–49)

*******

69.0

54.1

52.5

52.7

66.0

Tetanus vaccination, past 10 years (age 50–

64)†††††††

67.3

54.4

55.0

53.4

69.7

Tetanus vaccination, past 10 years (age ≥65)

‡‡‡‡‡‡‡

59.6

40.3

45.3

42.8

72.4

Tetanus vaccination including pertussis vaccine, past

8 years (age ≥19)

§§§§§§§

19.7

12.6

10.2

15.5

22.4

Hepatitis A vaccination (≥2 doses), ever (age 19–

49)********

12.6

11.0

10.6

16.1

15.2

Hepatitis B vaccination (≥3 doses), ever (age 19–

49)††††††††

35.2

30.5

23.7

39.3

34.8

Herpes zoster (shingles) vaccination, ever (age

≥60)‡‡‡‡‡‡‡‡

27.4

10.7

9.5

22.6

24.5

HPV vaccination among females (≥1 dose), ever (age

19–26)

§§§§§§§§

41.7

30.6

30.3

19.8

43.1

Influenza vaccination, 2013–2014 season (age

≥18)*********

47.4

41.5

44.3

51.3

47.3

‡‡‡‡‡‡

National Health Interview Survey (2013).

3

§§§§§§

National Health Interview Survey

(2013).

3

*******

National Health Interview Survey

(2013).

3

†††††††

National Health Interview Survey (2013).

3

‡‡‡‡‡‡‡

National Health Interview Survey

(2013).

3

§§§§§§§

National Health Interview Survey (2013).

3

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********

National Health Interview Survey (2013).

3

††††††††

National Health Interview Survey (2013).

3

‡‡‡‡‡‡‡‡

National Health Interview Survey (2013).

3

§§§§§§§§

National Health Interview Survey (2013).

3

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*********

National Immunization Survey—Flu and Behavioral Risk Factor Surveillance System (2013–2014).

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APPENDIX 3: FEDERAL PARTNER EFFORTS

Agencies across HHS support a host of efforts that directly or indirectly support adult

immunization. The table below lists just a small sampling of agency efforts. These select

activities highlight how agencies across HHS advance adult immunization within their

respective organizations.

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Agency

Activities

Agency for Healthcare Research

and Quality (AHRQ)

AHRQ has developed a data management tool, or dashboard, to

depict Healthy People 2020 immunization data in a clear, easy-

to-view format. This dashboard highlights ongoing racial and

ethnic disparities in adult immunization and brings more attention

to key gaps in coverage.

Assistant Secretary for

Preparedness and Response

(ASPR)

ASPR, in conjunction with DoD, has supported the development

of Centers for Innovation in Advanced Development and

Manufacturing. These centers help to bolster the nation’s

existing manufacturing surge capacity and flexible

manufacturing of vaccines for pandemic influenza and other

therapeutic products in a health emergency.

Centers for Disease Control and

Prevention (CDC)

CDC has advanced new contracts with academic institutions and

health systems for vaccine safety and ongoing surveillance;

annually collects, analyzes, and disseminates influenza and

adult vaccination coverage estimates and conducts economic

evaluations for new vaccine recommendations; promotes

immunization information system improvements; expands public

and private sector partnerships; conducts research and

disseminates materials to increase awareness of adult

immunization; annually updates the adult immunization

schedule; and works with state immunization programs to

improve adult immunization infrastructure. CDC is also working

with ONC and other partners to develop Clinical Decision

Support for Immunizations (CDSi) tools.

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Agency

Activities

Centers for Medicare & Medicaid

Services (CMS)

CMS has encouraged states to expand coverage of ACIP/CDC-

recommended immunizations to all adults enrolled in the

Medicaid program and has included the HEDIS measure—Flu

Vaccinations for Adults Ages 18 to 64—in the core set of adult

health care quality measures for the Medicaid program.

Within the Medicare program, the CMS Quality Improvement

Initiative includes a number of quality measures relating to

immunizations for adults. In addition, CMS expanded coverage

of the adult pneumococcal immunizations so that adults enrolled

in Medicare can obtain them, as recommended by the ACIP.

Health Resources and Services

Administration (HRSA)

HRSA has announced the Health Center Patient-Centered

Medical Home and Quality Improvement Awards to recognize

health centers that have focused on practice transformation and

quality improvement, including efforts to strengthen adult

immunization.

HRSA also administers the VICP jointly with the Department of

Justice and the U.S. Court of Federal Claims. The VICP

provides compensation to individuals, including adults, thought

to have been injured or whose death was thought to have been

related to receiving certain vaccines covered by the program.

Indian Health Service (IHS)

IHS has implemented performance measures for adult

immunizations and partnered with NVPO to evaluate the

feasibility and usefulness of a composite adult immunization

measure to facilitate monitoring of vaccine coverage.

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Agency

Activities

National Vaccine Program Office

(NVPO)

NVPO led the development of the NAIP and chairs (with CDC

and the Immunization Action Coalition) the National Adult and

Influenza Immunization Summit. NVPO collaborated on the

advancement of a vaccine safety agenda, developed a tool kit

to increase influenza vaccination among health care personnel

in long- term care settings, published a report and

recommendations on reducing barriers to increased uptake of

recommended vaccines in pregnant women, co-authored an

article on the Affordable Care Act and its impact on

immunization insurance coverage for health care providers,

and collaborated with CMS on the development of a Medicare

claims data map for influenza.

Through its support of NVAC, NVPO has supported publication

of the 2011 report A Pathway to Leadership for Adult

Immunization: Recommendations of the National Vaccine

Advisory Committee and NVAC’s Standards for Adult

Immunization Practice.

Office of Minority Health (OMH)

OMH developed and maintains a co-sponsorship agreement

between HHS and Walgreens Inc. that provides $15 million in

free seasonal influenza vaccine annually to uninsured

individuals. Working with community and faith-based

organizations, this initiative has successfully vaccinated over

800,000 individuals.

Office of the National Coordinator

for Health Information Technology

(ONC)

ONC continues to advance pilot projects designed to improve

the exchange of vaccination data and improve access to

vaccination data by consumers. This includes the “data hub”

initiative that is being advanced in collaboration with NVPO,

CDC, and state and local partners. The data hub enables state

and local IIS to exchange data with each other through a

centralized model utilizing existing standards. By connecting to

the central hub, jurisdictions can then connect to any other

jurisdiction also connected to the central hub. ONC is also

working in close collaboration with CDC to specify CDC’s

Clinical Decision Support for Immunizations tools into sharable

clinical decision support artifacts.

Department of Veterans Affairs

(VA)

National Institutes of Health (NIH)

U.S. Food and Drug Administration

(FDA)

VA, NIH, and FDA have supported the development of new and

improved vaccines. They have engaged in activities related to

zoster vaccine research, maternal vaccination, and a host of

other initiatives. These agencies and other stakeholders are

working to advance adult vaccination safety, research, and

development needs.

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APPENDIX 4: FEDERAL ROLES AND RESPONSIBILITIES

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GOAL AND

OBJECTIVE

FEDERAL

Department of Health and Human Services

ACF

AHRQ

ASPR/BARDA

CDC

CMS

HRSA

IHS

NIH

NVPO

ONC

OWH

FDA

RHA

ACL

FOH

DHS

DOD

VA

OPM

Goal 1: Strengthen the adult immunization infrastructure

-

Objective 1.1:

Monitor and

report trends in

adult vaccine-

preventable

disease levels

and vaccination

coverage data

for all

ACIP/CDC

recommended

vaccines. In

cases where

there are

associated

Healthy People

2020 goals,

measure

progress toward

established

targets.

Objective 1.2:

Enhance

current vaccine

safety

monitoring

systems and

develop new

methods to

accurately and

more rapidly

-

assess vaccine

safety and

effectiveness in

adult

populations

(e.g., pregnant

women).

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GOAL AND

OBJECTIVE

FEDERAL

Department of Health and Human Services

ACF

QAHR

ASPR/BARDA

CDC

CMS

AHRS

IHS

NIH

NVPO

ONC

OWH

FDA

RHA

ACL

FOH

DHS

DOD

VA

OP M

Objective 1.3:

Continue to

analyze claims

filed as part of

the National

Vaccine Injury

Compensation

Program (VICP)

to assess

whether there

was an

-

association

between

vaccines that a

claimant

received and

adverse events

experienced.

Objective 1.4:

Increase the

use of EHRs

and IIS.

-

Objective 1.5:

Evaluate and

advance

targeted quality

improvement

-

initiatives.

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GOAL AND

OBJECTIVE

FEDERAL

Department of Health and Human Services

ACF

QAHR

ASPR/BARDA

CDC

CMS

AHRS

IHS

NIH

NVPO

ONC

OWH

FDA

RHA

ACL

FOH

DHS

DOD

VA

OP M

Objective 1.6:

Generate and

disseminate

evidence about

the health and

economic

impact of adult

immunization,

-

including

potential

disease burden

averted and

- cost

effectiveness

with the use of

current

vaccines.

Goal 2: Improve access to adult vaccines.

Objective 2.1:

Reduce

financial

barriers for

individuals who

-

receive

recommended

adult vaccines.

Objective 2.2:

Assess and

improve

understanding

of providers’

financial

barriers to

-

delivering

vaccinations,

including

stocking and

administering.

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GOAL AND

OBJECTIVE

FEDERAL

Department of Health and Human Services

ACF

QAHR

ASPR/BARDA

CDC

CMS

AHRS

IHS

NIH

NVPO

ONC

OWH

FDA

RHA

ACL

FOH

DHS

DOD

VA

OP M

Objective 2.3:

Expand the

adult

immunization

-

provider

network.

Objective 2.4:

Ensure a

reliable supply

of vaccines and

the ability to

track vaccine

inventories,

-

including during

public health

emergencies.

Goal 3: Increase community demand for adult immunizations.

Objective 3.1:

Educate and

encourage

individuals to be

aware of and

receive

recommended

adult

-

immunizations.

NATIONAL ADULT IMMUNIZATION PLAN

52

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES NATIONAL VACCINE PROGRAM OFFICE

Ā

GOAL AND

FEDERAL

Department of Health and Human Services

RQ

DA

C

PO

H

A

S

OBJECTIVE

ACF

AH

ASPR/BAR

CD

CMS

HRSA

IHS

NIH

NV

ONC

OW

FDA

RH

ACL

FOH

DH

DOD

VA

OPM

Objective 3.2:

Educate and

encourage

health care

providers to

-

recommend

and/or deliver

adult

vaccinations.

Objective 3.3:

Educate and

encourage other

groups (e.g.,

community and

- faith based

groups) to

-

promote the

importance of

adult

immunization.

Goal 4: Foster innovation in adult vaccine development and vaccination-related

technologies.

Objective 4.1:

Develop new

vaccines and

improve the

effectiveness of

-

existing

vaccines for

adults.

Objective 4.2:

Encourage new

technologies to

improve

distribution,

-

storage, and

delivery of adult

vaccines.

NATIONAL ADULT IMMUNIZATION PLAN

53

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES NATIONAL VACCINE PROGRAM OFFICE

Ā

APPENDIX 5: NONFEDERAL ROLES AND RESPONSIBILITIES

NATIONAL ADULT IMMUNIZATION PLAN

54

GOAL AND

OBJECTIVE

Health Care

Providers

Professional

Organizations

Public and

Private Health

Care Payers

and Plans

State, Local,

Territorial, and

Tribal

Governments

Academia and

Research

Organizations

Advocacy

Organizations

Employers

Vaccine

Manufacturers

Goal 1: Strengthen the adult immunization infrastructure

Objective 1.1:

Monitor and

report trends in

- adult vaccine

preventable

disease levels

and vaccination

coverage data

for all

- ACIP/CDC

recommended

vaccines. In

cases where

there are

associated

Healthy People

2020 goals,

measure

progress toward

established

targets.

-

Objective 1.2:

Enhance

current vaccine

safety

monitoring

systems and

develop new

methods to

accurately and

more rapidly

assess vaccine

safety and

effectiveness in

adult

populations

(e.g., pregnant

women).

-

NONFEDERAL

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES NATIONAL VACCINE PROGRAM OFFICE

Ā

GOAL AND

OBJECTIVE

Health Care

Providers

Professional

Organizations

Public and

Private Health

Care Payers

and Plans

State, Local,

Territorial, and

Tribal

Governments

Academia and

Research

Organizations

Advocacy

Organizations

Employers

Vaccine

Manufacturers

Objective 1.3:

Continue to

analyze claims

filed as part of

the National

Vaccine Injury

Compensation

Program (VICP)

to assess

whether there

was an

association

between

vaccines that a

claimant

received and

adverse events

experienced.

Objective 1.4:

Increase the

use of EHRs

and IIS to

collect and track

adult

immunization

data.

-

Objective 1.5:

Evaluate and

advance

targeted quality

improvement

initiatives.

-

NATIONAL ADULT IMMUNIZATION PLAN

55

NONFEDERAL

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES NATIONAL VACCINE PROGRAM OFFICE

Ā

GOAL AND

OBJECTIVE

Health Care

Providers

Profe ionass l

izatioOrgan

ns

Public and

thPrivate Heal

PayCare ers

and Plans

State

, Loc ,al

Territ

orial, and

Tribal

rnmenGove

ts

Aca

demia and

Research

izatioOrgan

ns

Advo y cac

Organizatio

ns

Employers

neVacci

Manufact urers

Objective 1.6:

Generate and

disseminate

evidence about

the health and

economic

impact of adult

immunization,

including

-

potential

disease burden

averted and

- cost

effectiveness

with the use of

current

vaccines.

Goal 2: Improve access to adult vaccines.

Objective 2.1:

Reduce

financial barriers

for individuals

who receive

recommended

adult vaccines.

-

Objective 2.2:

Assess and

improve

understanding

of providers’

financial barriers

to delivering

vaccinations,

including

stocking and

administering

vaccines.

-

NATIONAL ADULT IMMUNIZATION PLAN

56

NONFEDERAL

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES NATIONAL VACCINE PROGRAM OFFICE

Ā

GOAL AND

re

s

sional

tions

and Private

a

C re Payers

Local,

ial, and

o

G vernments

mia and

ch

tions

acy

tions

yers

a urers

OBJECTIVE

Health Ca

Provider

Profes

Organiza

Public

Health

and Plans

State,

Territor

Tribal

Acade

Resear

Organiza

Advoc

Organiza

Emplo

Vaccine

Manuf

ct

Objective 2.3:

Expand the

adult

immunization

provider

-

network.

Objective 2.4:

Ensure a

reliable supply

of vaccines and

the ability to

track vaccine

-

inventories,

including during

public health

emergencies.

Goal 3: Increase community demand for adult immunizations.

Objective 3.1:

Educate and

encourage

individuals to be

aware of and

receive

recommended

-

adult

immunizations.

NATIONAL ADULT IMMUNIZATION PLAN

57

NONFEDERAL

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES NATIONAL VACCINE PROGRAM OFFICE

Ā

GOAL AND

OBJECTIVE

Health Care

Providers

Professional

Organizations

Public and

Private Health

Care Payers and

Plans

State, Local,

Territorial, and

Tribal

Governments

Academia and

Research

Organizations

Advocacy

Organizations

Employers

Vaccine

Manufacturers

Objective 3.2:

Educate,

encourage, and

motivate health

care providers

to recommend

and/or deliver

adult

vaccinations.

-

Objective 3.3:

Educate and

encourage other

groups (e.g.,

community and

-faith based

groups, tribal

organizations)

to promote the

importance of

adult

immunization.

-

Goal 4: Foster innovation in adult vaccine development and vaccination-related

technologies.

Objective 4.1:

Develop new

vaccines and

improve the

effectiveness of

existing

vaccines for

adults.

-

Objective 4.2:

Encourage new

technologies to

improve

distribution,

storage, and

delivery of adult

vaccines.

-

NATIONAL ADULT IMMUNIZATION PLAN

58

NONFEDERAL

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES NATIONAL VACCINE PROGRAM OFFICE

Ā

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2.

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3.

Williams W, et al. Vaccination Coverage Among Adults, Excluding Influenza

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4.

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