Vaccines are the most cost-effective preventive service that we can provide to our patients, and prevention is considered essential to public health. Vaccines are recommended in an effort to prevent morbidity and mortality associated with various diseases among children and adults.

As providers, we need to focus our efforts on improving the sub-optimal adult vaccination rates. One of the strongest indicators of a patient receiving an immunization is the recommendation of his or her provider.

Assessing immunization status at every visit, identifying at-risk patients, implementing reminder systems, educating patients, using a team approach, and using an immunization registry system are all effective ways to improve vaccination rates in the adult population.

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The State of Adult Immunizations

The CDC’s Advisory Committee of Immunization Practices (ACIP) releases updates each year on recommended vaccines, but despite these recommendations, coverage for many adult vaccines remains below the Healthy People 2020 goal established by the CDC.15

The ACIP currently recommends 12 immunizations for adults aged > 19 years, but we continue to face growing health concerns due to low vaccination rates.1 The Healthy People 2020 has a goal to increase these rates and reduce preventable diseases.

The Healthy People 2020 program wants to increase the pneumococcal vaccination coverage to 60% among high-risk patients aged 19 to 64 years, and to increase the coverage among adults aged >64 years to 90%.

The most recent data reports that high-risk adults aged 19 to 64 years have 20% coverage and adults aged > 65 years are at 59%.1 Despite current vaccination recommendations, invasive pneumococcal disease (IPD) remains prevalent.

In 2009, an estimated 43,500 cases and 5,000 deaths were caused by IPD.2 Almost 90% of these cases were in the adult population. The estimated direct and indirect costs associated with pneumococcal disease were $3.7 billion and $1.8 billion dollars annually at the end of the previous decade.14

In late 2013, the National Advisory Vaccine Committee (NVAC) released standards for adult immunization practice. Some of the recommendations include assessing immunization status at all visits, recommending vaccines, administering vaccines or referring if the provider cannot immunize.

The Primary-Care Provider Role

Providers must remain knowledgeable in order to educate their patients regarding the need for recommended immunizations. The standards for adult immunizations include developing systems to ensure that vaccines become part of routine care.7

Research indicates, however, that various patient and provider barriers impact adult immunization rates.  Provider-related barriers included lack of knowledge regarding whom to vaccinate, more urgent concerns during visits, and patient refusal. 7 The most common barriers were lack of provider recommendation, and the assumption that healthy people did not need the vaccination.5

A barrier that I have witnessed as a nurse practitioner student is a patient’s uncertainty if he or she has already received certain vaccines from one of his or her many “specialists.”  This lack of communication among providers contributes to the fragmented care in our health care system.

Without proper guidance and effective communication, individuals may not realize how vulnerable they are to vaccine-preventable diseases, or they may lack awareness of the different vaccines that are currently recommended for adults. Barriers must be first identified so that interventions can be implemented to improve rates of adult immunization.

Although patients can receive immunizations in multiple health care settings, primary-care visits provide an opportune time to screen, educate, and administer vaccines to our patients. 

All providers must continue to stay abreast of the latest adult immunization recommendations. Assess the barriers in your individual clinical settings, utilize registry systems, and educate your patients about the importance of these immunizations. Do not miss an opportunity to vaccinate your patients.

Possible Solutions

Systematic reviews on interventions were conducted to improve vaccination rates and found strong evidence to support provider reminder interventions with a goal of decreasing missed opportunities to vaccinate. 9, 10 Reminders were directed at all staff, and they included notations in the charts, standardized checklists, and chart prompts or stickers at the time of patients visit.

These studies had a median improvement of 17.9% in coverage.9,10  Evidence was found to support provider reminders in combination with other interventions. The multicomponent interventions included patient reminders, patient education, provider education, provider feedback, and standing orders.10 When combined with provider reminders, multicomponent interventions had a median improvement of 14%.

Immunization Information Systems (IIS) is an effective technological solution that increases adult vaccination rates and improves communication among the various providers that have the ability to vaccinate.

These systems are confidential databases that record all vaccinations administered to patients. The Community Preventive Services Task Force recommends the use of these systems from evidence-based findings.3 Promising evidence was found in systematic review that supports the use of immunization registries.

Use of these registries can help to implement interventions such as provider and client reminders, recall systems, and provider assessment and feedback. The electronic storage of health information can help to lessen the disjointed care that results when patients have multiple providers, and it will allow us to determine current vaccination status of patients.4

The state of South Carolina for example, approved a mandatory immunization registry in 2013. This system will be phased in over a period of three years, and all immunizations must be reported beginning January 1, 2017.11 

The use of this registry will allow providers to focus their efforts on improving adult vaccination rates and reducing associated morbidity and mortality. The use of an immunization registry will be increasingly important as we continue to see a rise in individuals being vaccinated at their worksites, specialists, pharmacies, and retail health facilities.1

Can you name the recommended adult immunizations? The Centers for Disease Control and Prevention website, is an up-to date resource for all practitioners.


  1. Bridges CB, Coyne-Beasley T. Annals of Internal Medicine. 2014; doi:10.7326/M13-2826
  2. Centers for Disease Control and Prevention.Morbidity and Mortality Weekly Report. 62(3), 48-51.
  3. Community Preventive Services Task Force. Journal of Public Health & Practice. 2014; doi: 10.1097/PHH.0000000000000092
  4. Groom H, Hopkins DP, Pabst LJ, Morgan JM, Patel. Journal of Public Health Management & Practice, 2014; doi: 10.1097/PHH.0000000000000069
  5. Johnson DR, Nichol CL, & Lipczinski K. The American Journal of Medicine. 2014; doi: 10.1016/j.amjmed.2008.05.005
  6. Mieczkowksi, TA, Wilson SA. Vaccine. 2014; 20(9), 1383-1392.
  7. National Vaccine Advisory Committee (NVAC). Public Health Reports. 2014; 129, 115-123. Retrieved from
  8. National Vaccine Advisory Committee (NVAC). 2011. Adult immunization: Complex challenges and recommendations for improvement. Retrieved from
  9. Ndiaye, SM, Hopkins DP, Shefer AM, Hinman AR, Briss PA et al. American Journal of Preventive Medicine. 2014; doi:10.1016/j.amepre.2005.02.016
  10. Shefer A, Briss P, Rodewald L, et al. Epidemiologic Reviews. 2008; 21(1), 96-142. Retrieved from
  11. South Carolina Department of Health and Environmental Control (SCDHEC). 2013. Retrieved from
  12. Szilagayi PG et al. Preventive Medicine. 2014; 40(2), 152-161.
  13. United States Department of Health and Human Services (USDHHS). 2014. Retrieved from
  14. Weycker D, Strutton D, Edelsburg J, Sato R, & Jackson, LA. Vaccines. 2014; doi: 10.1016/j.vaccine.2010.05.030
  15. Williams WW, Lu PJ, O’Halloran A, Bridges C et al. Morbidity and Mortality Weekly Report. 2014. Retrieved from