April 30th. 2020
In Collaboration with Immunization Action Coalition
Chronic care management has, at its core, the goal of reducing the risk of disease progression and the risk of complications. Effective and efficient management of chronic medical conditions are key components of population health and reducing healthcare costs overall. Many medical conditions increase the risk of severe disease from infections, including vaccine preventable diseases. And, conversely, infections can exacerbate chronic conditions like cardiovascular disease (CVD), congestive heart failure, diabetes, COPD and asthma.
The CDC recommends adults get certain vaccines based on their age, but also based on their medical conditions, such as chronic heart, lung, renal and liver disease, and having immunocompromising conditions such as HIV, malignancies, and treatment-related immunosuppression. The CDC’s adult immunization schedule, updated each year in early February, summarizes vaccine recommendations for adults based on their age, medical conditions and other considerations. The immunization schedule is annually reviewed and endorsed by American College of Physicians, American Academy of Family Physicians, American College of Obstetricians and Gynecologists, and American College of Nurse-Midwives.
Illness from infectious diseases, including vaccine preventable diseases like influenza, are known triggers of inflammation and worsening of underlying illnesses. The leading cause of death in the United States is cardiovascular disease, and respiratory infections have been associated with acute cardiovascular events such as acute myocardial infarction. A 2018 study published in The New England Journal of Medicine, found that the risk of acute myocardial infarction within seven days after detection of influenza A, influenza B, respiratory syncytial virus and other viruses were 5.2, 10.1, 3.5, and 2.8 (incidence ratios). Community-acquired pneumonia has also been associated with cardiac complications within a week of pneumonia diagnosis, according to a 2012 study published in the journal Circulation.
Influenza is the most common vaccine-preventable illness, resulting in millions of illnesses, 140,000-810,000 hospitalizations, and 12,000-61,000 deaths annually in the United States alone, according to the CDC. Among adults with known CVD, multiple studies have demonstrated the benefits of influenza vaccination in preventing subsequent major cardiac events, including stroke. A 2015 study published in the Cochrane Database of Systematic Reviews, estimated that influenza vaccination significantly reduced the risk of secondary CVD events with risk ratio (RR) of 0.45.
People with diabetes, asthma, COPD and other chronic lung disease are also at higher risk of more severe illness from influenza and from invasive pneumococcal disease. The American Lung Association and American Diabetes Association both recommend patients with chronic lung disease and diabetes, respectively, check to make sure they are up to date on their vaccines.
Patients with HIV and other immunocompromising conditions are also at increased risk of complications from vaccine-preventable diseases (VPD). For example, HIV infection is associated with a higher risk of invasive pneumococcal disease, HPV-related infections and HPV-related cancer, hepatitis A and B, influenza-related complications, and more severe illness and prolonged viral shedding of measles virus. For those with HIV and CD4 count <200 lymphocytes/mm3 or severe immunosuppression from HIV or other immunocompromising conditions, the measles, mumps and rubella (MMR) vaccine, as well as other live vaccines, are contraindicated.
The number and use of therapies which alter aspects of immunocompetence to effectively treat chronic conditions, such as rheumatoid arthritis, have rapidly expanded over recent years. Ensuring patients are up to date on all recommended vaccines is key to reducing the risk of infectious diseases complications for these patients. When feasible, vaccines should be up to date prior to initiating immunosuppressive treatments, according to a 2014 publication in the journal Clinical Infectious Diseases. Guidance on vaccination of persons with altered immunocompetence is available from CDC at: www.cdc.gov/vaccines/hcp/acip-recs/general-recs/immunocompetence.html.
Immune system competence declines with age (immunosenescence), increasing the burden and severity of outcomes from VPD. Shingles (herpes zoster) is a prime example. The risk of shingles and shingles-related complications, including post-herpetic neuralgia, increase dramatically with age and immunosuppression. The inactivated zoster vaccine, Shingrix, is approximately 90 percent effective in preventing shingles and its complications. While FDA has approved Shingrix for adults 50 and older without regard to immunocompetance, CDC currently recommends the vaccine for immunocompetent. Deliberations by CDC and its Advisory Committee on Immunization Practices regarding recommendations for the use of Shingrix in immunosuppressed persons are ongoing.
Multiple resources are available to assist healthcare professionals with implementing CDC’s immunization recommendations, including a CDC immunization app and CDC patient and provider communications, tools at www.immunize.org and the National Adult and Influenza Immunization (www.izsummitpartners.org), and through each state’s immunization program (www.immunizationmanagers.org/page/mempage.) Additionally, previous Becker publications exist to support the implementation of adult immunization programs within healthcare systems including:
Making Prevention the Priority, available at: https://www.izsummitpartners.org/content/uploads/2017/06/making-preventative-priority-becker-hospital-review-2017.pdf
A roadmap to better population health management through improved adult immunization, available at: https://go.beckershospitalreview.com/a-roadmap-to-better-population-health-management-through-improved-adult-immunization.
Overcoming challenges to providing adult immunizations in healthcare systems, available at: https://www.youtube.com/watch?v=BuhQmCVJ9Vs