Not enough patients receive vaccines and what doctors can do about it

Imagine a world where consumers all knew about the latest developments in preventive health.

Earlier this month the Advisory Committee on Immunization Practices (ACIP) released the 2010 immunization schedules. Revised annually, the immunization schedules are what doctors in the U.S. use to decide who should be immunized against what diseases. Far from esoteric, the schedules pertain to every single person living in the United States. If the H1N1 pandemic and subsequent mayhem over vaccination have taught us anything it’s that in the 21st century vaccines still matter.

Despite this, the release of the new guidelines was accompanied with little fanfare. Popular media mostly ignored the story. Even at my own academic medical center there has been little circulation or discussion of the new guidelines.

As individuals, we are generally of the belief that such information are more for doctors than for patients. After all, vaccines are not like healthy eating choices or the latest trends in fitness; they are prevention tools that require a health care provider to receive. As long as we show up for our doctor’s appointments, we think, we are doing our part to make sure we are taking advantage of all that medicine has to offer for preventing infectious illnesses.

Unfortunately, such is not the case. The data overwhelmingly shows that we are being under-vaccinated. A little over half of people eligible for the pneumonia vaccine receive it, about a third of those recommended to get the seasonal flu shot get it, and less than 5 percent of those who should receive the shingles vaccine have gotten it. Today, despite the initial public outcry over shortages of H1N1 vaccine, many people have not been immunized now that the vaccine is widely available. Each of these can be viewed as a missed opportunity to prevent illness, many of which have the potential to be life-threatening or disabling.

Looking at the guidelines, I suspect, would be highly instructive for many people. First, there are an astonishing number of vaccines available. Here is a partial list of diseases that vaccines protect against: chickenpox, croop, diphtheria, measles, hepatitis A, hepatitis B, HPV, influenza, meningitis, mumps, pertussis, pneumonia, polio, rotavirus, rubella, shingles, tetanus, and yellow fever.

Equally surprising to many people is that vaccines are not just for kids. (In fact, the immunization schedules are divided into ages birth to 6 years, 7 to 18 years, and ages 18 and older.) Nearly every age group is at risk for infectious illnesses for which vaccines are recommended. Children, of course, have a number of vaccines that are recommended to build their immunity, but so do adolescents.

Girls ages 11 to 12 should receive the human papillomavirus (HPV) vaccine to protect against early stages of cervical cancer; those who did not receive it earlier can get it up to 26 years of age. College students living in dorms are advised to get vaccinated against meningococcal meningitis, an infection of the covering of the brain. Adults who have young children at home, who are pregnant, or work in health care are recommended to receive the flu vaccine. People who travel to endemic countries (of which there are many) are advised to receive the hepatitis B vaccine, as is anyone who simply wants to be vaccinated because 40 percent of people with hepatitis B have no identifiable risk factors.

Beginning at age 50 all adults require vaccination against influenza annually; at age 60 a one-time vaccination against shingles; and at age 65 a one-time vaccination against pneumonia. And the above is just a partial list of vaccines and of those eligible for vaccination.

Given the above, it’s reasonable to consider vaccines as not only being in the medical domain. It’s just not doctors, hospitals, and the public health community that need to be apprised of the latest developments in infection prevention — the general public does too. Our experience with H1N1 shows that the public is a powerful driver for improvements in care delivery. One an individual level, too, people can advocate to receive vaccines that are recommended for them, but because of health care’s bias towards chronic and acute conditions, may escape their doctor’s attention.

Clearly we as health care providers need to do a better job vaccinating people. But there is a role for patients to advocate for themselves as well. You don’t need to be a doctor to get a sense of which vaccines are recommended for you. All you need is the latest ACIP guidelines, a working knowledge of your medical history, and ideally your vaccination history.

One day I would love to see Newsweek do a “by the numbers” about the low rates of vaccination, or for Steven Colbert to do a “report” on vaccine-preventable diseases, or for the release of the annual ACIP guidelines to be a highly anticipated and publicized event. Until then, it’s up to us to spread the word.

Shantanu Nundy is an internal medicine physician who blogs at

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