Barriers to Immunizations and Strategies to Enhance Immunization Rates in Adults with Autoimmune Inflammatory Diseases




For as long as there have been immunizations, there have been barriers to them. Immunization rates in the United States are below target. Rheumatologists and rheumatology practitioners need to understand the issues of immunizations in patients with autoimmune inflammatory disease to identify and overcome barriers to immunization. Several strategies for overcoming these barriers are discussed.


Key points








  • Barriers to immunization have existed for as long as immunization.



  • Immunization rates in adults are below target.



  • Barriers to immunization must be identified and strategies developed to increase immunization rates.



  • All health care providers, both primary and specialty, should assess patients for immunization needs.



  • Specialty providers, including rheumatologists, should offer vaccines appropriate to immunocompromised patients.






Introduction and brief history of barriers to immunization


It seems that for as long as humans have practiced immunization, there have been barriers to it. Evidence suggests that immunizations have been used to prevent disease for almost 1000 years; the variolation technique, used to prevent smallpox, was likely developed in the 1100s and used in Turkey, Africa, China, and parts of Europe. In many of these areas those in favor of variolation were challenged by traditional healers who believed that smallpox was a natural way for the body to expel “bad humors” and religious leaders who believed that attempting to prevent smallpox would anger gods or goddesses. Nevertheless, the practice of variolation spread to Western Europe and North America in the 1700s, but there, too, it was not without controversy. Even then, when smallpox outbreaks routinely caused significant illness, disfigurement, and death, there were barriers to immunization of both children and adults. Some physicians saw the benefit of variolation but attempted to corner the market by intentionally making the process more difficult than it needed to be; by cultivating the belief that variolation required deep cuts and significant bloodletting, they ensured that those seeking immunization would have to pay for a major procedure versus the light scratch and inoculation that historically had been performed at times even by amateurs. The major objections to variolation in the Puritan colonies during the early to mid-1700s were on both medical and religious grounds; ministers weighed in on the debate and had significant influence over their congregations. Although many Puritan ministers supported variolation (including, most famously, Cotton Mather [ Fig. 1 ]), those who opposed it were often able to prevent their members from seeking immunization. One way to combat this barrier was to instruct nonphysicians on how to immunize themselves and their children (thereby overcoming 2 barriers: cost and stigma); Benjamin Franklin encouraged his friend, the English physician William Heberden, to write a pamphlet in 1759 entitled, “Some Account of the Success of Inoculation for the Small-Pox in England and America: Together with Plain Instructions, By which any Person may be enabled to perform the Operation, and conduct the Patient through the Distemper.” The pamphlets were distributed for free in the American colonies. By 1775 the benefit to national security seen by preventing smallpox was recognized, and George Washington ordered that all troops in the Continental Army be variolated. This helped spread acceptance of the practice until it was eventually replaced by the safer form of immunization, vaccination.




Fig. 1


Cotton Mather, FRS (1663-1728).


During the 1721 Boston smallpox epidemic, Puritan minister Cotton Mather urged a local physician to use variolation to prevent the spread of the epidemic. The practice, although successful, was not without controversy: a grenade was thrown through a window of Mather’s house. About the negative reaction, Mather wrote, “I never saw the Devil so let loose upon any occasion. The people who made the loudest Cry…had a very Satanic Fury acting them…. Their common Way was to rail and rave, and wish Death or other Mischiefs, to them that practis’d, or favour’d this devilish Invention.”


Since the transition from variolation to vaccination, the science of immunization has grown from the ability to prevent smallpox to the ability now to offer protection against 20 diseases. Despite advances made in vaccinology, however, barriers to immunization have prevented vaccines from being as protective as they could be. This article reviews topics relevant to immunizations in the adult autoimmune inflammatory disease population:




  • Recommended immunizations



  • The current status of immunization



  • Barriers to immunization



  • Possible strategies to overcome barriers to immunization





Introduction and brief history of barriers to immunization


It seems that for as long as humans have practiced immunization, there have been barriers to it. Evidence suggests that immunizations have been used to prevent disease for almost 1000 years; the variolation technique, used to prevent smallpox, was likely developed in the 1100s and used in Turkey, Africa, China, and parts of Europe. In many of these areas those in favor of variolation were challenged by traditional healers who believed that smallpox was a natural way for the body to expel “bad humors” and religious leaders who believed that attempting to prevent smallpox would anger gods or goddesses. Nevertheless, the practice of variolation spread to Western Europe and North America in the 1700s, but there, too, it was not without controversy. Even then, when smallpox outbreaks routinely caused significant illness, disfigurement, and death, there were barriers to immunization of both children and adults. Some physicians saw the benefit of variolation but attempted to corner the market by intentionally making the process more difficult than it needed to be; by cultivating the belief that variolation required deep cuts and significant bloodletting, they ensured that those seeking immunization would have to pay for a major procedure versus the light scratch and inoculation that historically had been performed at times even by amateurs. The major objections to variolation in the Puritan colonies during the early to mid-1700s were on both medical and religious grounds; ministers weighed in on the debate and had significant influence over their congregations. Although many Puritan ministers supported variolation (including, most famously, Cotton Mather [ Fig. 1 ]), those who opposed it were often able to prevent their members from seeking immunization. One way to combat this barrier was to instruct nonphysicians on how to immunize themselves and their children (thereby overcoming 2 barriers: cost and stigma); Benjamin Franklin encouraged his friend, the English physician William Heberden, to write a pamphlet in 1759 entitled, “Some Account of the Success of Inoculation for the Small-Pox in England and America: Together with Plain Instructions, By which any Person may be enabled to perform the Operation, and conduct the Patient through the Distemper.” The pamphlets were distributed for free in the American colonies. By 1775 the benefit to national security seen by preventing smallpox was recognized, and George Washington ordered that all troops in the Continental Army be variolated. This helped spread acceptance of the practice until it was eventually replaced by the safer form of immunization, vaccination.




Fig. 1


Cotton Mather, FRS (1663-1728).


During the 1721 Boston smallpox epidemic, Puritan minister Cotton Mather urged a local physician to use variolation to prevent the spread of the epidemic. The practice, although successful, was not without controversy: a grenade was thrown through a window of Mather’s house. About the negative reaction, Mather wrote, “I never saw the Devil so let loose upon any occasion. The people who made the loudest Cry…had a very Satanic Fury acting them…. Their common Way was to rail and rave, and wish Death or other Mischiefs, to them that practis’d, or favour’d this devilish Invention.”


Since the transition from variolation to vaccination, the science of immunization has grown from the ability to prevent smallpox to the ability now to offer protection against 20 diseases. Despite advances made in vaccinology, however, barriers to immunization have prevented vaccines from being as protective as they could be. This article reviews topics relevant to immunizations in the adult autoimmune inflammatory disease population:




  • Recommended immunizations



  • The current status of immunization



  • Barriers to immunization



  • Possible strategies to overcome barriers to immunization





Recommended immunizations


The Advisory Council on Immunization Practices (ACIP), a division of the Centers for Disease Control and Prevention (CDC), releases updates to both childhood and adult vaccine schedules annually. Diseases that are represented in the 2016 recommended vaccine schedule for adults are listed in Box 1 .



Box 1





  • Influenza



  • Tetanus



  • Diphtheria



  • Pertussis



  • Chickenpox



  • Genital warts and genital, anal, and oropharyngeal cancers



  • Shingles



  • Measles



  • Mumps



  • Rubella



  • Pneumonia



  • Hepatitis A



  • Hepatitis B



  • Meningitis



Diseases targeted in the 2016 Advisory Council on Immunization Practices adult vaccine schedule


Not every patient is a candidate for every vaccine; for example, patients who have been exposed to and developed a natural immunity for hepatitis A or hepatitis B do not require vaccination. Furthermore, not all of these vaccines are appropriate for adults with autoimmune inflammatory disease. The ACIP provides guidelines regarding timing, frequency, sequencing, contraindications, and special populations for each vaccine. Special attention must be given to the footnotes on each schedule, which provide further details and guidance for each vaccine and each special population. Patients with autoimmune inflammatory disease on greater than 20 mg prednisone per day (or the equivalent) or biologics are considered immunocompromised and should follow the schedule for adults with immunocompromising conditions. Table 1 is an abbreviated version of the 2016 ACIP recommendations for healthy adults and adults with immunocompromising conditions intended only to point out the differences between the 2 groups in the broadest sense; the full schedule with footnotes should always be referenced to ensure that the provider’s information is accurate and up to date. In addition, the ACIP frequently makes changes between yearly updates and communicates this to providers and the public via the Morbidity and Mortality Weekly Report , press releases, and the CDC Web site.



Table 1

Abbreviated 2016 Advisory Council on Immunization Practices recommendations































































Vaccine Frequency over Adult Years
Healthy Immunocompromised
Influenza 1 dose annually 1 dose annually
Tetanus/diphtheria/pertussis Substitute Tdap for Td once, then Td booster every 10 years Substitute Tdap for Td once, then Td booster every 10 y
Varicella 2 doses Contraindicated
Human papillomavirus 3 doses 3 doses
Zoster 1 dose Contraindicated
Measles/mumps/rubella 1–2 doses Contraindicated
Pneumococcal 13-valent conjugate 1 dose 1 dose
Pneumococcal polysaccharide 1–2 doses 1–3 doses
Hepatitis A 2–3 doses 2–3 doses
Hepatitis B 3 doses 3 doses
Meningococcal 4-valent conjugant or polysaccharide 1+ doses 1+ doses
Meningococcal B 2–3 doses 2 or 3
Haemophilus influenzae type B 1 or 3 doses 1–3 doses

Abbreviations: Td, tetanus/diphtheria; Tdap, tetanus/diphtheria/pertussis.

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Sep 28, 2017 | Posted by in RHEUMATOLOGY | Comments Off on Barriers to Immunizations and Strategies to Enhance Immunization Rates in Adults with Autoimmune Inflammatory Diseases
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