Vaccinations for Seniors: Addressing Compliance

IMMUNIZATION SCHEDULES for children are well-communicated, well-understood and, except for a small anti-vaccine contingent, largely adopted with more than 90 percent¹ of parents seeking to protect their children from vaccine-preventable diseases. On the opposite end of the age spectrum, however, adherence rates for seniors to their recommended vaccine schedule are significantly lower, causing concern not just due to the increased health risks for this older population, but for the potential health risks silent carriers pass on to others in their communities.

While some vaccines wear off over time, requiring boosters throughout life (tetanus, diphtheria and pertussis are three examples), others such as the shingles and pneumococcal vaccines are unique to the senior community with first administration given later in life. And, while with increasing age, immunosenescence causes vaccines to be less effective, they remain vital for reducing risk and severity of vaccine-preventable diseases. In fact, vaccinations are second only to clean water at improving health and quality of life, making compliance key. More than an individual responsibility, vaccines’ positive herd immunity makes them a civic responsibility.

Vaccine Noncompliance in an Aging Population

As the population ages, the number of people over 60 years of age is expected to double, reaching 2.1 billion by 2050. Additionally, the population of those age 80 and older is expected to increase by 309 million between the years 2015 and 2050.² Advances in healthcare and self-care have improved mortality and morbidity; however, without improved preventive strategies that vaccinations provide, the implications for older adults is staggering.

Cases in point: Approximately 36,000 people in the U.S. die of influenza (flu) annually, and 100,000 are hospitalized. Most of these are seniors. Over half of the viral reactivation of varicella zoster virus occurs in adults over 85 years old.² And, while invasive pneumococcal disease affects the young and old, community-acquired pneumonia mainly affects older adults. According to the National Foundation of Infectious Diseases, about one million U.S. adults get pneumococcal pneumonia every year, and tens of thousands die. About 18,000 of those deaths are adults age 65 and older.³ Lastly, tetanus and diphtheria antibody levels are lower than that considered to be protective for most adults, and this is particularly true for seniors.²

These numbers equate to exorbitant healthcare costs, according to the Alliance for Aging Research’s Silver Book statistics. Shingles, for example, costs patients $1 billion in direct and indirect medical expenses. More than half of hospitalizations and 65 percent of the economic burden of flu complications is attributed to those 65 years and older. And, Medicare patients who contract pneumonia can expect medical expenses nearly $16,000 higher during their illness and the year after than Medicare patients who do not contract the disease.⁴

Vaccines have proven to be effective and safe for the senior population. Even considering years when the flu vaccine is a mismatch to the predominate strain, the vaccine is considered largely safe, and even when it is not as efficacious, it is still beneficial. A flu vaccine can reduce the risk of illness by as much as 60 percent. The shingles vaccine, Shingrix, protects as many as 97 percent of people in their 50s and 60s, and as many as 91 percent of those in their 70s and 80s. A Tdap vaccine is effective in seven out of 10 patients in its first year. And, the pneumococcal conjugate vaccine is estimated to have prevented more than 30,000 cases of invasive pneumococcal disease and 3,000 deaths in its first three years of use.⁵

So, why the disconnect between these very effective and simple interventions and compliance in this vulnerable age group? While vaccination rates for infants and children have risen, the same cannot be said for seniors. By some estimates, one-third of older adults skip getting a flu vaccine, three quarters of seniors choose not to receive a shingles vaccination, and just under half do not get vaccinated for pneumonia or tetanus. This is in stark contrast to goals set by the Centers for Disease Control and Prevention, which is aiming for a 90 percent compliance rate for the flu vaccine by 2020.¹

Three challenges in particular plague progress of increasing vaccination compliance rates in the elderly:

• Varying degrees of vaccine effectiveness, particularly due to changes in immunity as one ages
• Noncommunication about which vaccines are recommended and when they are due
• Insurance coverage confusion, particularly for vaccines that fall under Medicare Part D

Challenge 1: Age-Related Immunity

With aging comes the inevitable changes to the immune system, making seniors more susceptible to a host of medical conditions, including vaccine-preventable communicable diseases. While this immune system decline can be observed in a laboratory, scientists are actively trying to understand how to apply that information so patients better understand their health index. “It is the next frontier of immunology research,” shares E. John Wherry, PhD, chair of the department of systems pharmacology and translational therapeutics at the Perelman School of Medicine at the University of Pennsylvania.

Unfortunately, this decreased immunity also means reduced impact of vaccines since studies show antibodies after vaccinations are lower in seniors. “There is a lot of attention being paid to different formulations which enhance a vaccine’s strength and potency,” says Dr. Wherry. By altering a vaccine’s formulation, it is hoped to better stimulate the immune system. One such example is the theory of original antigenic sin now being studied in flu vaccines. Original antigenic sin hypothesizes past exposure to flu strains throughout life impacts response to flu vaccines in the future. Studies are now looking at how information of past exposure can be captured and used for the benefit of future vaccinations.

While most vaccines are nearly 100 percent-effective, some are not, including the flu and pneumococcal vaccines. However, there are some options showing promise for seniors, including a high-dose flu vaccine, which has been approved for use in the U.S. since 2009 for those over 65 years old. The high-dose vaccine contains four times the amount of antigen as a regular flu shot, and results from a clinical trial of more than 30,000 participants showed adults 65 years and older who received the high-dose vaccine had 24 percent fewer flu infections compared to those who received the standard-dose flu vaccine.⁶

In addition, the use of adjuvants, alternate routes of administration such as nasal sprays, and live versus inactivated vaccines are being considered. At least one study has demonstrated an adjuvanted vaccine can lower the risk of hospitalizations for flu or pneumonia symptoms by 25 percent in seniors. And, inactivated vaccines are not only potentially safer and more effective for older adults, they are also safer for immunocompromised patients for whom a live attenuated vaccine is contraindicated.²

Challenge 2: What and When?

The second challenge to senior vaccine compliance is simply understanding which vaccines are needed and when, particularly when a booster is required. Healthcare settings experience good results with increasing frontline communications via nurses and medical assistants. One example is a University of Pittsburgh practice that saw a 40 percent improvement in vaccination rates by placing more emphasis on vaccines with this group. Another example, Mercy Care Alliance in Massachusetts, is having good results with identifying those for whom vaccinations are due using scans of electronic health records. It was able to identify 1,000 seniors who were due for the pneumococcal vaccine and facilitated outreach to those in need.¹

“Interestingly, the anti-vax movement does not seem to have influenced older adult attitudes,” says Susan Peschin, MHS, president and CEO of the Alliance for Aging Research. “In fact, a 2016 Pew Research Center survey showed 90 percent of adults ages 65 and older support a requirement that children be vaccinated against measles, mumps and rubella before they could be enrolled in school, compared to just 8 percent who said that parents should be able to decide whether or not to vaccinate their child — the lowest percentage of any age group.”

The Alliance for Aging Research believes older adults can play an influential role in increasing the immunity of their family members and social circles, particularly those who are vulnerable to infectious disease or who are too young to receive vaccinations themselves, by making sure their own vaccinations are up-to-date. They can also inject a dose of reality into the myth-driven debates around vaccines and lead their families by example.

It may also be effective to help seniors understand the very low cost of a vaccination compared to the potentially high costs of illness. For instance, it is estimated every dollar spent on vaccinations saves at least $18.40 in direct and indirect healthcare costs. The flu vaccine alone could save anywhere from $50 to $4,000 in prevention, and immunocompetent adults age 60 and older could save as much as $82 million to $103 million in healthcare costs by receiving a vaccine.⁴

Challenge 3: Insurance Confusion

Thankfully, private insurers are required by the Affordable Care Act to cover 100 percent of the cost for preventive vaccines. However, Medicare beneficiaries encounter cost-sharing for certain vaccines due to the lack of consistent coverage under Medicare Part D drug plans. Of the recommended vaccines for older populations, only flu and pneumococcal are included at no cost to patients under Medicare Part B. And, while Medicare Part D covers the cost of additional vaccines, including shingles and Tdap, there are generally co-pays. “Under Part D, nearly 24 million beneficiaries in stand-alone prescription drug plans are subject to cost-sharing requirements ranging from $14 to $103 per vaccine,” said Peschin. “Consequently, the higher the cost-sharing, the more likely it is that the beneficiary will not elect to receive the vaccine. As more vaccines reach the market, Part D cost-sharing will pose an increasing burden on Medicare beneficiaries seeking this important preventive medical care.”

More Work Is Needed

Clearly there is work to be done, from improving outcomes for older populations through new vaccine interventions and delivery, to helping seniors understand the benefits and timing of these potentially lifesaving interventions. Currently, 137 vaccines are being studied, according to the Alliance for Aging Research, with some of these studies focusing on improving outcomes for seniors. Researchers are also investigating how aging and chronic disease impacts the immune system so better vaccines that work optimally in older adults can be developed. Above all, says Dr. Wherry, as progress continues, the ability to quantify and define a person’s immune health will be of immeasurable benefit in the future.

August is National Immunization Awareness Month, offering an open opportunity to plan for and execute new initiatives that enhance communication with senior patients, helping them to increase their understanding and ownership of this crucial line of defense.