INCREASING IMMUNIZATION RATES AMONG AFRICAN-AMERICAN ADULTS: PART II: REVIEW OF ADULT IMMUNIZATION ISSUES, BARRIERS AND OPPORTUNITIES
A. Burden of Adult Vaccine-Preventable Diseases
Vaccine-preventable diseases are responsible for as many as 39,000 adult deaths each year in the U.S. (20,000 from complications of influenza infection, 14,000 from pneumococcal disease, and 5,000 from chronic hepatitis В infection) (CDC, unpublished data). By comparison, childhood immunization programs have drastically reduced the number of vaccine-preventable deaths among children, with fewer than 500 deaths reported each year. Pneumonia and influenza together are the fifth leading cause of death in those aged 65 years and older.
During 11 of 23 annual influenza epidemics from 1972 through 1995 in the U.S., more than 20,000 deaths, 90 percent among persons aged 65 years or more, were attributed to complications of influenza infection such as exacerbation of underlying medical conditions or secondary pneumonia due to bacterium such as Streptococcus pneumoniae (S. pneumoniae). An estimated 110,000 hospitalizations a year are related to influenza. buy antibiotics amoxicillin
In addition to the human cost, the health care and lost productivity costs to society have been estimated at $3 billion to $5 billion for an average influenza epidemic, with direct medical costs accounting for 20 percent to 30 percent of the total cost. The estimated cost of pandemic influenza in the United States would be $71 billion to $167 billion.
S. pneumoniae causes 25-35 percent of hospitalizations for community-acquired bacterial pneumonia, and an estimated 50,000 cases of pneumococcal bacteremia and 3,000 cases of meningitis annually in the U.S. Among adults with pneumococcal bacteremia, 60 percent-87 percent also develop pneumonia, and up to 40 percent die. An estimated 14,000 deaths result from severe pneumococcal disease annually. The risk for invasive pneumococcal disease is higher among African Americans compared to Whites. African American adults have a threefold to fivefold higher incidence of bacteremia than Whites, and have twice the incidence of pneumococcal meningitis. Possible reasons for these higher rates among African Americans include lower levels of pneumococcal and influenza vaccination, higher prevalence of certain conditions (e.g., diabetes, heart disease, HIV infection) that are associated with higher risk for severe pneumococcal disease, delayed access to care, or higher chance of exposure associated with environmental conditions.
Estimates of influenza-associated hospitalizations and deaths have thus far not been computed by racial or ethnic group. However, higher rates of influenza complications are expected among African Americans compared to Whites because of lower vaccination levels among African Americans and the higher prevalence of certain conditions (e.g., diabetes, heart disease, HIV infection) among African Americans that are associated with higher risk for influenza complications. It is unlikely that there are racial differences in exposure, susceptibility and risk of complications from influenza, controlling for medical conditions. cialis canadian pharmacy
Influenza and pneumococcal vaccinations have become increasingly important for two reasons. First, prevalence of drug-resistant strains of S. pneumoniae have become more common in the
U.S., with 15 percent to 38 percent of isolates in selected sites nonsusceptible to penicillin in 1997. This emerging antimicrobial resistance further emphasizes the need for prevention of invasive pneumococcal disease by vaccination. Secondly, it is anticipated that another influenza pandemic will eventually occur. The influenza pandemic of 1918 caused 20 million deaths, many of them in younger adults. During this pandemic, the disease affected one in four adults. As a currently under-immunized group, African Americans lack the infrastructure support to promote widespread immunizations in the event of a pandemic. Additionally, existing community beliefs/attitudes about immunizations might hamper the acceptance of mass immunization campaigns for adults.
After influenza and pneumococcal infection, hepatitis В is the third major vaccine-preventable disease among adults. Annually between 19881994, an estimated average of 335,000 persons, primarily young adults, were infected with hepatitis В virus. Currently, annual incidence of the disease may be as low as 100,000. For those persons affected by hepatitis B:
♦ Between 8,400 and 19,000 require hospitalization,
♦ 6 percent to 10 percent become chronic carriers,
♦ About 25 percent of chronic carriers develop chronic active hepatitis,
♦ Each year in the U.S., about 4,000 persons die from hepatitis B-related cirrhosis, and
♦ 1,000 die from hepatitis B-related liver cancer.
During 1988-1994, the estimated average annual incidence rate of hepatitis В infections among African Americans was four times higher than the rate for Whites. tadalis sx 20
B. Immunization Recommendations
To reduce the burden of influenza, pneumococcal, and hepatitis В infections, specific immunization recommendations have been developed. For example, annual influenza vaccination and one dose of pneumococcal polysaccharide vaccine are recommended for persons at increased risk for complications from pneumococcal and influenza infections, including all persons aged 65 years or more and younger persons with chronic conditions such as heart disease, lung disease and diabetes. The American Academy of Family Physicians also has recommended annual influenza vaccination of all persons starting at age 50. The Advisory Committee on Immunization Practices (ACIP) is reviewing data on the risk of influenza-related complications among persons aged 50-64 years, the prevalence of high-risk medical conditions among persons in this age group, and the cost-effectiveness of this recommendation. The ACIP also recommends scheduling a prevention visit for every patient at the age of 50 years to assess vaccination status and take other preventive measures. Hepatitis В vaccination is recommended for adults at high risk for exposure through sexual contact, injection drug use, or occupations involving possible contact with human blood.
Additional disease burdens of importance for persons who were not infected or immunized during childhood may be at increased risk for measles, mumps, rubella, and varicella and their complications as adults. Other adults enter special high-risk groups as a result of disease, occupation, behavior, or increasing age; all require immunizations or booster doses not routinely provided in childhood. For example, a booster vaccination against tetanus and diphtheria is recommended every ten years for all adults.
