In a Roundtable Discussion, experts from the CDC and academia discuss best practices to increase clinicians' and patients' awareness of the importance of immunization throughout their life span, from pediatrics to geriatrics. The feasibility of applying previously successful strategies to overcome gaps in knowledge and increase immunization rates from across patient age-groups and different infectious diseases is explored. This activity focuses on practical recommendations that are in keeping with the latest updates from the Advisory Committee on Immunization Practices regarding new vaccines and indications, revaccination, safety, and storage. A team approach is provided to stimulate patient follow-up and help clinicians better educate their patients about the lifelong benefits of immunization, from generation to generation.

Vaccine-preventable diseases (VPDs) continue to take a toll across the life span of the population in the United States. The development of new vaccines within the past few years for children and adolescents has made the Advisory Committee n Immunization Practices (ACIP) recommended immunization schedules more complex and increased the challenge for clinicians to provide timely, complete immunization coverage. This extends to the adult and geriatric populations, with the need for booster does, annual influenza immunization, and recently available vaccines for young and older adults.

According to recent study by the Centers for Disease Control and Prevention (CDC), only 17% of children in the US aged 24 months to 35 months were immunized on time with six routinely recommended vaccines (DTaP, MMR, polio, pneumococcal conjugate, Hib, and varicella vaccines).¹ More than one-third were "severely" under-vaccinated (for more than 6 months) for at least one vaccine, allowing resurgence of VPDs that had been close to extinction or well-controlled. Pertussis, for example, is now at least well-controlled of any reportable bacterial disease for which childhood vaccination is recommended.^2,3 Reported cases of pertussis have increased markedly in the US, reaching a 45-year high of more than 25,000 in 2004-2005.^2,4 In 2004 through 2006, 69 of the 82 reported deaths from pertussis occurred in infants less than or equal to 3 months of age.⁵ In 2008, there were 17 reported deaths from pertussis in infants less than 7 months of age.^6,7

Adolescence is a time of heightened risk for VPDs. Immunity from childhood vaccinations may be waning⁴; new behaviors increase the likelihood of exposure to hepatitis and human papillomavirus (HPV); and dormitory life makes college students vulnerable to meningococcal meningitis. Among the main barriers to adolescent immunization are fewer well visits during the teenage years; lack of transportation; embarrassment and the need for parental consent; and ignorance of the importance of immunization. Immunization of adolescents not only prevents deaths and lifelong complications of disease for them, but also reduces transmission of infection to vulnerable populations at both ends of the age spectrum - young infants and the elderly.

Among senior citizens in the US, influenza and pneumococcal infections are responsible for more deaths than all other VPDs combined.⁸ Of the 36,000 deaths annually during the 1990 - 1991 through the 1998 - 1999 flu season, 90% of affected individuals were aged greater than or equal to 65 years.⁹ Healthcare workers who care for elderly people and immunosupressed patients are advised to receive vaccinations against influenza, pertussis, and other VPDs for their own protection and to prevent transmission to their patients.¹⁰

Education, awareness, funding, and insurance coverage of adult vaccinations are limited when compared with those of children.¹¹ Yet the number of adults in the US who die annually from VPDs is far greater than that of the number of children: 43,000 adults compared with 300 children. ^*12-14

Educational efforts geared to clinicians and their office personnel should increase awareness of the lifelong value of immunization, so they, in turn, can educate their patients about disease prevention through increased immunization utilization.

^{*Extrapolated estimates from reference 12 - 14.}

1. Luman ET, Barker LE, Shaw KM, et al. Timeliness of childhood vaccinations in the United States: days undervaccinated and number of vaccine delayed. JAMA. 2005;293:1204-1211.

2. Centers for Disease Control and Prevention (CDC). Final 2004 Reports of Notifiable Diseases. MMWR. 2005;54(31):777.

3. Centers for Disease Control and Prevention (CDC). Preventing tetanus, diphtheria, and pertussis among adults: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine. MMWR. 2006;55(RR-17):1-33.

4. Forsyth KD, Campins-Marti M, Caro K, et al. New pertussis vaccination strategies beyond infancy: recommendations by Global Pertussis initiative. Clin Infect Dis. 2004;39:1802-1809.

5. Centers for Disease Control and Prevention (CDC). Pertussis. In: Atkinson W, Wolfe S, Hamborsky J, McIntyre L, eds. Epidemiology and Prevention of Vaccine-Preventable Diseases. 11th ed. Washington, DC: Public Health Foundation; 2009:199-216.

6. Centers for Disease Control and Prevention (CDC). Pertussis Surveillance Report - 03/13/09. Weeks 1-53, 2008 (Provisional data).

7. Centers For Disease Control and Prevention (CDC). Notifiable diseases/deaths in selected cities: weekly information. MMWR. 2009;57(53):1402-1431.

8. Bratzler DW, Christiaens BF, Hempstead K, Nichol KL. Immunization for seniors. J Law Med Ethics. 2002;30(suppl 3): 128-134.

9. Institute of Medicine. Calling the Shots. Immunization Finance Policies and Practices. Washington, DC: National Academy Press; 2000.
Http://books.nap.edu/html/calling_the_shots/ch1.html Accesssed June 16, 2009.

10. Poland GA, Tosh P, Jacobson RM. Requiring influenza vaccination for health care workers: seven truths we must accept. Vaccine. 2005;23:2251-2255.

11. Wilson KA. Public policy largely ignores adult immunization needs. Managed Care. 2000. http://www.managedcaremag.com/archives/0010/0010.immunization.html Accessed June 16, 2009.

12. Centers for Disease Control and Prevention. Active Bacterial Core Surveillance (ABCs) Report, Emerging Infections Program Network, Streptococcus pneumoniae, provisional-2008. http://www.cdc.gov/abcs/survreports/spneu08.htm Accessed November 12, 2009.

13. Centers for Disease Control and Prevention. Statistics and Surveillance. http://www.cdc.gov/hepatitis/statistics.htm Accessed November 12, 2009.

14. Roush SW, Murphy TV; and the Vaccine-Preventable Disease Table Working Group. Historical comparisons of morbidity and mortality for vaccine preventable diseases in the United States. JAMA. 2007;298(18):2155-2163.

At the conclusion of this CME activity, participants should be better able to:

• Describe the prevalence, incidence, and consequences of disease for which the Center for Disease Control and Prevention's Advisory Committee on Immunization Practices (ACIP) recommends vaccinations specific to their patient populations
• Identify barriers to immunization among their patients
• Describe successful methods used to increase vaccination rates in a practice or institutional setting similar to their own
• Implement specific strategies to improve timely immunizations of their patients

This CME activity is intended for Primary Care Physicians, Pediatricians, Geriatricians, and Adolescent Medicine Practitioners.

Gregory A. Poland, MD
Mary Lowell Leary Professor of Medicine
Director
Mayo Vaccine Research Group
Mayo Clinic
Rochester, Minnesota

Carol Friedman, DO
Captain, US Public Health Service
Associate Director for Adult immunizations
Immunizations Services Division
National Center for Immunization and Respiratory Diseases
Centers for Disease Control and Prevention
Atlanta, Georgia

Andrew Kroger, MD, MPH
Medical Officer
Education, Information and Partnership Branch
Immunization Services Division
National Center for Immunization and Respiratory Diseases
Centers for Disease Control and Prevention
Atlanta, Georgia

Amy B. Middleman, MD, MPH, MSEd
Associate Professor
Department of Pediatrics
Adolescent Medicine Section
Texas Children's Hospital
Center for Vaccine Awareness and Research
Baylor College of Medicine
Houston, Texas

Raymond A. Strikas, MD
Captain, US Public Health Service
National Vaccine Program Office
Department of Health and Human Services
Washington, DC

Marguerite M. Mayers, MD (Course Director)
Consultant, Pediatric Infectious Diseases
Children's Hospital at Montefiore
Professor of Clinical Pediatrics
Albert Einstein College of Medicine
New York, New York

This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME). Albert Einstein College of Medicine is accredited by the ACCME to provide continuing medical education for physicians and other health-care providers.

Albert Einstein College of Medicine designates this educational activity for a maximum of 2.75 AMA PRA Category 1 credits^TM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Release Date: January 2010. Credit Available through January 31, 2011.

There are no fees for participating and receiving CME Credit for this activity. During the period January 2010 through January 31, 2011, participants must:

• Register for the program where prompted on the CD
• Complete the posttest by recording the best answer to each question in the answer key
• Complete the activity evaluation form
• Sumbit directly online

A statement of credit will be issued immediately online only upon receipt of a completed activity evaluation form and a complete posttest with a score of 70% or better.

Estimated time to complete the activity: 2.75 hours

Release date: January 2010
Expiration date: January 31, 2011

Conflict of Interest

The "Conflict of Interest Disclosure Policy" of Albert Einstein College of Medicine requires that faculty participating in any CME activity disclose to the audience any relationship(s) with a pharmaceutical or equipment company. Any presenter whose disclosed relationships prove to create a conflict of interest with regard to their contribution to the activity, or who refuses to provide all their conflict-of-interest information, will not be permitted to present.

Faculty Disclosures

Gregory A. Poland, MD (Chair) is a consultant for Novavax, Merck and Co., Wyeth, Avianax, GlaxoSmithKline, Nocartis Vaccines, Emergent BioSolutions, Theraclone Sciences, MedImmune LLC, and Liquidia Technologies. He also receives grant/research support from Merck and Co., and Wyeth. He services as Chair for Novel Vaccine DMSB for Merck and Co.
Carol Friendman, DO, has nothing to disclose
Andrew Kroger, MD, MPH, has nothing to disclose
Amy B. Middleman, MD, MPH, MSEd, she receives grant/research support from sanofi pasteur
Raymond A. Strikas, MD, FACP, has nothing to disclose
Marguerite M. Mayers, MD (Course Director) Children's Hospital at Montefiore has nothing to disclose
Suans Basilico, Liz Selkowe and Debbie Walsh of Haymartket Medical Education have nothing to disclose

This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of the patients' conditions, review of any applicable manufacturers' product information, and comparison with recommendations of recognized authorities.

The information in this program is provided to medical professionals for information purposes only.

The material contained herein is intended to be a faithful representation of the live presentations to the extent reasonable. The authors/presenters are exclusively responsible for the respective content. Accordingly, no responsibility is assumed by Merck & Co., Inc., Haymarket Medical Education LP, or Scientia MedMedia LLC, for any injury and/or damage to persons or property as a matter of product liability, negligence or otherwise; or from any use of diagnosis or treatment discussed or suggested. This activity should not be used by clinicians without medically appropriate (1) evaluation of (a) their patients' conditions and (b) indications and possible contraindications, warnings, and adverse effects or dangers in use; (2) review of any applicable manufacturers' prescribing and other product information; (3) comparison with recommendations of recognized authorities; and (4) independent verification of diagnostic methods, therapeutic methods, results of research, and measurement of medical doses.