L.J Tan, PhD, MS, talks about a call to action to increase adult immunizations

AMA's Moving Medicine video series amplifies physician voices and highlights developments and achievements throughout medicine.

In today’s episode of Moving Medicine, L.J Tan, PhD, MS, chief policy and partnerships officer at the Immunization Action Coalition, discusses the importance of staying up-to-date on adult immunizations and a recent call to action that explains how physicians can help.

For additional background information on the Adult Immunization Call to Action, visit Immunization Action Coalition’s website.

Speaker

• L.J Tan, PhD, MS, chief policy and partnerships officer, Immunization Action Coalition

Unger: Hello, this is the American Medical Association's Moving Medicine video and podcast. Today we're talking with Dr. L.J Tan, chief policy and partnerships officer at the Immunization Action Coalition in St. Paul, Minnesota, about the importance of staying up-to-date on adult immunizations and how physicians can help.

Dr. Tan, who has a PhD in microbiology and immunology, is also the co-chair of the National Adult Immunization Summit and the National Influenza Vaccine Summit. I'm Todd Unger, AMA's chief experience officer in Chicago.

Dr. Tan, it's been a while since we saw you, welcome back to the update. Your organization, together with others has issued a call-to-action to increase vaccine coverage among adults. Can you tell us more about this call-to-action and who's it targeted for? Are we down to, for lack of better words, recalcitrant population or are there still people out there that we can move?

Dr. Tan: Oh, great question, Todd. And again, thank you to the American Medical Association for this opportunity. As someone who used to work there, AMA remains very close and dear to my heart. So again, thanks for the opportunity to come back. And I want to also thank the summit, the group, the partners that came together with a working group to create this call-to-action. And I want to also thank the Centers for Disease Control for signing on and supporting this call-to-action. And if you go and look at the call-to-action webpage, AMA has supported this, so also thank you. You'll see a link to the CDC's supporting materials for this call-to-action. So we're really not just calling to action, we're also providing a lot of tools to help providers and physicians, and actually implement this call-to-action.

Unger: What does the call-to-action mean?

Dr. Tan: I think what has happened and you pointed this out, you mentioned the word, the recalcitrant population, our challenge with adult vaccines even before COVID-19 was not necessarily recalcitrance but actually ignorance. And the fact that adult immunizations while recommended for many, many adults, many, many patients and indeed many physicians, many clinicians remained unaware, blissfully maybe, that there were recommendations that they could deliver to get people protected, adults protected, against these vaccine-preventable diseases. And so, it's not so much recalcitrance but just a lack of awareness, a lack of knowledge. And when you couple that with the fact that adults don't have the pediatric well care model, with kids, we go okay, they go in at two months, they go in at four months, they go in six months and then every one of these well care visits, there's immunizations that are considered and assessed and given as necessary.

We don't have that well care models for adults. Adults generally work on that acute care, you go in when something happens. You don't feel well and as a result, the vaccines get lost in the shuffle of dealing with all these other things. And even when someone comes in for a preventive care visit, if you remember back in 2008, when we talked about the Affordable Care Act and all the benefits that came with that, there's a whole bunch of preventive interventions that the physician needs to think about. So by the time they get down to the bottom of the list, they've spent 45 minutes talking about prevention for all these things, such as obesity, smoking cessation, mental wellness. By the time they get to the bottom list, they ran out of time to talk about these vaccines that are also recommended.

So I think those are the factors that have led to these poor adult immunization coverage rates, despite recommendations from the CDC that have been around for several years. And so, not so much recalcitrance, Todd, but more this idea that we now need to figure out how to drive this message home again. And this call-to-action is specifically to physicians and other clinicians, other providers of care to adults because the physician recommendation is one of the prime reasons an adult will actually get vaccinated. When a physician says, "I strongly recommend the flu vaccine, it will protect you against these conditions. Please get it," patients end up getting it. So this call-to-action is specifically to say, "Hey, you need to do this." And then it gives obviously, a lot of the background and the ways of doing it.

Unger: It's interesting because you mentioned there's a different kind of wellness model. I mean, it's well known that in adulthood it's more acute care and I'm very grateful. For instance, I went in to see my primary care physician about hypertension and in that conversation, he did see, however, it showed up in the EHR, whatever, that it was time for a tetanus shot for me. And thank goodness I did that because two weeks later I tripped on a nail and, thank goodness, I was covered for that. So, is that a systematic change? You mentioned it's down at the bottom in the list. I mean, is that something that the physician is being prompted on as part of a visit when someone's in there? There's a lot to ask, no?

Dr. Tan: Yes. Yes. So I think we're trying to routinize and make it part of the system a bit more for adults so that a lot of this work can be taken off the hands of the physician, if necessary. So for example, using electronic medical records and what we call standing orders, we can actually provide the vaccine to an adult, even if the physician hasn't seen the adult. And of course, if the patient says, "Oh, I really have some questions," the physician can then step in. But the situation that you talked about can even go out of the hands of the physician, where the physician actually signs off on a standing order and standing orders aren't new. We've used them for a long, long time. And what we're saying now is that a physician can sign off on a standing order and when that prompt comes off, the nurse in the clinician's practice, the physician's practice can actually now give the vaccine. And of course, again, as I said, if the patient says, "I have a question," then the physician steps in.

So it essentially tries to make the process a little more efficient. And I there's a lot of information out there on this. I think one of the things I just want to draw attention to this call-to-action, asks physicians to abide by actually a standard of care. It's called the Standards for Adult Immunization Practice. And it was issued by the National Vaccine Advisory Committee that advises the Department of Health and Human Services. I think this is one of the reasons why I think CDC was quick to sign on, was because it is based in a lot of data and science that shows that if we want to make a difference in these adult immunization rates, there are four things we have to do, physicians have to do.

They've got to assess the status of their patient because if you don't know what the patient's status is with vaccination, you can't make a recommendation, right? And this is where, what you talked about, the electronic medical records, those things come in. Then after you do that, you have to then identify the vaccines. And for you, Todd, he identified, "You are due for Tdap." And then he clearly recommended it to you, that's why you got it. If he didn't recommend it, the physician didn't recommend it to you, you probably wouldn't even think about getting the vaccine. Then best of all, if that physician can then offer the vaccine to you right on the spot, "By the way, when I step out of here, if you don't have any questions, the nurse is going to come in and give it to you right away."

And then finally, they document it, document it in the information systems of the state. So that when you now go and step on that nail two weeks later and you go into the emergency room, they can immediately look up your record and say, "He's had his Tdap. He's good." So those are the standards of care for adult immunization practice that this call-to-action refers to. And sometimes, I think in the busy physician life, hopefully this call-to-action will remind them that this exists and that they should go look at it.

Unger: This sounds really smart. And the timing couldn't be better for thinking about it this way because what are the vaccination numbers telling us now?

Dr. Tan: So the vaccination numbers before pre-COVID levels, they were already very, very low. We had numbers. And again, these are numbers anyone can look up. At least three out of four adults were missing, at least one routinely recommended vaccine. So the routinely recommended vaccines as many of your members, physicians will know, flu, pneumococcal, shingles, Tdap. Those are routinely recommended and at least three out of every four missing at least one of those. And as a result of that, what we know is that when we don't do everyone well, the people that really falls through the cracks and we've been talking a lot about equity, are the racial and ethnic disparities.

So racial and ethnic disparities in adult vaccination coverage have been prevalent and have continued to widen for some vaccines over the past few years. And then of course, when you take these low levels for the racial and ethnic minorities, the low levels in general, and then you put on top of that, COVID, when people didn't come in anymore. So physicians didn't even get a chance to talk to their patients. So as a result of COVID, those coverage rates dropped even more. So these are already low rates ... I'm sorry.

Unger: Could you give us some specifics, give me an example of that kind of disparity, where do we see that?

Dr. Tan: So let's start with shingles. In 2019, about 29% of non-Hispanic white U.S. adults, 50 and older had received the shingles vaccination. Now remember the recommendation that comes from CDC and the ACIP is that everyone, 50 years of age and older, should receive shingles vaccination. But again, as I said, 29% of non-Hispanic whites. So this is really, really low. But if you then look at the disparities, only 18% of non-Hispanic Blacks and only 15% of Hispanic adults have received shingles. So dramatically lower than the white levels, right?

Unger: So it's low to begin with, given, and you're talking about disparities even on the other side of that, that's terrible because I'm fortunately one of that 29%, because I've seen friends with shingles, I know what the pain associated with that is. And a lot of these illnesses are severe and preventable.

Dr. Tan: Exactly. And even if you look at shingles and say, "Hey, most people don't die from shingles," which is absolutely true, there are complications on shingles, such as post-herpetic neuralgia, which leads to chronic debilitating pain that totally destroys quality of life for the patient. And I think those are things that are ... sometimes we forget with adults. Often, when you talk to someone who's an older adult, when you talk to them about flu vaccine, for example, a lot of them aren't as worried about morbidity as they are, sorry, mortality, as they are about morbidity. A lot of the older folks will ask me and they'll say, "Hey, L.J, I've lived a long life. I'm not really that worried about death but I right now have quality of life. I cook for myself. I'm in an assisted living facility. I see my grandchildren. I love hopping onto that shuttle bus that takes me to Walgreens or takes me to a pharmacy. And I get to do my little shopping there. I love that."

But what I'll tell them is that if you catch flu and you don't have vaccine and you're not vaccinated, that quality of life could go away. You could lose mobility. You could end up being bedridden. You could end up needing a walker. And I think sometimes we lose track of this quality of life issue that adult vaccines protect us against as well.

Unger: Do you think that people just don't have familiarity with what shingles are and what they can cause or the impact of a flu or tetanus, and the risk that you're taking, essentially, by not thinking about these things? I mean, do you think that that's where the deficit is here, it's just on the patient understanding?

Dr. Tan: Absolutely. I think as we mentioned and talked about earlier, Todd, I think awareness of the patient for some of these vaccines that are recommended for them is poor. Flu may be the only one out there where patients generally say, "Yeah, I think I'm supposed to get that flu vaccine." But for the others, the awareness is poor. And part of that awareness is exactly what you said, it's also a lack of awareness of how severe some of these complications from these diseases can be. And I think that's incumbent on us as advocates for immunizations for adults to increase that awareness of not just the vaccines but the severity of the vaccine preventable diseases. So I think you're absolutely right.

Unger: Now, you mentioned also, this was a problem before COVID came along and then boom, we're in the middle of a pandemic, this is having a pretty significant impact now on immunizations. Can you just give us a little bit of detail on that?

Dr. Tan: Unfortunately, we don't have the actual data on that yet in terms of how much it's impacted, what we do have are data that's come from us from some of our partners at the summit. Like some of our manufacturing partners who have been tracking things like vaccines distributed. And what we do know is that there was a dramatic decline in vaccines that were being ordered as measured by claims data and by vaccines that were being distributed as measured by the distribution data from the manufacturers during COVID. And what we do know is that in this last few months, obviously prior to Delta, we have been seeing these increases back in the adult immunization coverage rates. But the challenge is that if we have a deficit, in order to cover all the people who missed the vaccines and catch them back up, we can't just return to where we were in the past. Todd, we've got to go above it to catch up all these other people.

And unfortunately, we're not even returning to previous levels before COVID, we're just slowly getting there. We're not even returning there yet, let alone getting above it so that we can catch up all these people who have missed it. So that's what we do know. And I think CDC is monitoring this. And hopefully, we'll have some actual data from some of our traditional surveillance systems that will continue to support our efforts in doing this.

Unger: We're in major catch-up mode and we know people look to and trust their physicians to outline a bit of a multi-step process. Can you give us some more practical guidance for physicians to help us rectify the situation?

Dr. Tan: Yeah, absolutely. So obviously, increasing the patient awareness, which we just talked about. So patients and physicians now have all these portals put this information out there, so patients can be aware of it. And as part of that, when a patient's about to come in, you need to use those immunization information systems to assess their needs. And let's say you find out that Todd needs a Tdap vaccine. Before you come in, maybe your physician can send to you, through the patient portal, a little snap sheet about tetanus, diptheria and whooping cough, and why you need the vaccine. So that's two strategies right there, using the immunization information system to assess needs and then using that information to increase patient awareness.

And then what we have found, is known in the aircraft industry, and what is known in the health care system industry is that if we implement system-based intervention, like what you've mentioned before, you come in, your electronic medical records pings up and says "You are due for..." If we incorporate those reminders, we call them provider reminders into the electronic health records, that is a wonderful way as an example of improving those immunization assessments and actually giving of vaccines as well.

So there's all this effort that we can do. And the final one before I stop is we also want to make sure that we continue to provide access to vaccination services for these. And we know that has been a challenge. We were exposed with the COVID-19. So my message is, now that we've got COVID-19 kind of under the belt, we know how to give COVID-19 vaccines, what we need to be saying is, "Hey, you got your COVID-19 vaccine. You're not done yet. Let me give you..." And then you can list all the vaccines you've assessed for.

Unger: Oh boy, we do have a challenge. If we don't correct this and we're on the trajectory that we're on right now, what's the outcome that we would expect to see?

Dr. Tan: Without having to go into numbers, we know that the average, you hear this bounced around all the time, now every year before COVID, so this does not include COVID numbers. About 50,000 adults passed away from a vaccine-preventable disease. That's annually. And then we know hundreds of thousands get hospitalized because of an adult vaccine-preventable disease. That's annually. So if that kind of morbidity and mortality doesn't scare you, and this was before COVID, before all this lost in coverage that we just talked about, Todd, if that's not enough, then you think about what that means in terms of cost to the health care system. And there are now two or three good papers out there that look at the cost of the health care system when we do not vaccinate. And we allow these vaccine-preventable diseases to persist. And the cost of the health care systems runs in the tens of billions of dollars annually. So morbidity, mortality, health care costs, all of them are already present and will continue to get worse if we do not turn this boat around.

Unger: Given the size of that number, shouldn't we be spending a lot more, and others call it for lack of better words, on marketing. It seems like there are a lot of voices out there that are talking about vaccinations but the deficit in terms of information and the ability to reach that patient, given the bombardment of other messages that are coming out there, do you see an opportunity for us to like market this better?

Dr. Tan: I think so. The whole concept of, "You've got your COVID-19, you're not done yet," I think that's something we can leverage because COVID has helped us in terms of helping the public understand the value of vaccines. I think that has really helped us. And I think what we need to continue to emphasize is that the value of vaccines are not just for pediatric populations but they're also for the adult population. So in other words, it's a lifespan value. We need to vaccinate our kids, our adolescents and our adults. So I think we need to leverage that and use that in our benefit. But the truth of the matter is, is that we as public health folks, you've heard this, the public health infrastructure is stretched. And so when we have to compete against some of the larger, as you say, marketing messages, the vaccinations tend to be the poor stepchild.

Unger: There's a lot of information out there, where are resources that physicians should look to about the call-to-action?

Dr. Tan: So the summit that I co-chair with the CDC and HHS has a webpage that's entirely dedicated to the call-to-action. It's www.izsummitpartners.org/call-to-action-adult-immunizations. And I think Todd, you're going to put that up for folks to look at. When you go to that site, you'll also be directed to all the other organizations that support that call-to-action, including the AMA, and you'll be able to link to their site as well as to that CDC site I mentioned at the very beginning, that has a lot of supporting infrastructure documents to help with that call-to-action.

Unger: Dr. Tan, thank you so much again. For those physicians out there that are interested in finding out more about the call-to-action, take a look down at the bottom here for that URL or search for that through Google. In the meantime, Dr. Tan, thanks so much for being here today. Really appreciate hearing from you as always. Again, call-to-action, please check that out. In the meantime, everybody out there, please take care and join us for another segment of Moving Medicine soon.

Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.