January 17, 2019

Don Wright, MD, MPH, FAAFP
Deputy Assistant Secretary for Health
Office of Disease Prevention and Health Promotion
Department of Health and Human Services
Tower Building 1101 Wootton Parkway, Suite LL100
Rockville, MD 20852

Re: Secretary’s Advisory Committee on National Health Promotion and Disease Prevention Objectives for Healthy People 2030

Dear Dr. Wright:

The Adult Vaccine Access Coalition (AVAC) greatly appreciates the opportunity to provide our comments on the Secretary’s Advisory Committee on National Health and Disease Prevention proposed Immunization and Infectious Disease (IID) objectives for Healthy People (HP) 2030.

AVAC consists of over 50 organizational leaders in health and public health that are committed to addressing the range of barriers to adult immunization and to raising awareness of the demonstrated benefits of adult immunization as a preventive measure that protects lives and avoids costly health care expenditures. AVAC works towards common legislative and regulatory solutions that will strengthen and enhance access to adult immunization across the health care system.

Over the past several decades, Healthy People immunization and infectious disease objectives have been a core benchmark for national efforts to improve and maintain immunization coverage across the lifespan. These federal objectives help to guide the actions of public and private stakeholders across the national, state and local landscapes who are committed to improving the health and wellbeing of our nation and provide a foundation for measuring progress.

We appreciated previous opportunities to offer comments to the Healthy People 2030 Framework and through the open comment period. We were grateful to have had the chance to meet with officials within the HHS Office of Disease Prevention and Health Promotion to learn more about the HP2030 process. At that time, AVAC shared recommendations, including our interest in the development of a Lifespan Immunization Objective as a Leading Health Indicator (LHI); strengthening and maintaining existing adult immunization measures (influenza, pneumococcal, shingles); incorporating the Adult Immunization Composite Measure in HP 2030 Objectives; broadening the Hepatitis B vaccine coverage measure to the full population (2020 objective only addresses coverage among health care personnel); encouraging the inclusion of lifespan immunization records in a fully operational, population-based immunization information system (IIS); and increasing the focus on addressing disparities in adult immunization rates.

We are disappointed that the proposed 2030 IID objectives deviated greatly from AVAC’s previous recommendations and are deeply concerned that the proposed 2030 objectives will significantly minimize and weaken immunization related activities over the coming decade. These proposed objectives fail to reflect the HHS Strategic Plan FY2018–2022, which acknowledges that “infectious diseases are a major health and economic burden for the United States.” Objective 2.1 of the Strategic Plan makes a commitment to “support access to preventive services including immunizations and screenings, especially for high-risk, high-need populations.”2 Yet, despite the availability of vaccines that protect adults against 14 different diseases, in addition to the well-known benefits of immunizations, more than 50,000 adults die from vaccine preventable conditions each year.

We wish to offer the following recommendations to the proposed Healthy People 2030 IID objectives so that they remain an important and meaningful benchmark in improving and maintaining immunization coverage across the lifespan:

We encourage the Committee to emphasize immunizations across the lifespan. We appreciate that the Committee maintained a lifespan seasonal influenza vaccination objective (IID-2030-13) that streamlines multiple age cohort objectives from Healthy People 2020. Coverage against seasonal influenza is an urgent public health priority. According to the Centers for Disease Control and Prevention, a 6.2 percent reduction in the adult immunization rate for flu during the 2017-18 influenza season was a contributing factor in the record number of deaths. The flu accounts for an estimated 8.95 billion, or 65% of the annual economic burden of adult vaccine-preventable diseases. The Healthy People 2020 target 70 percent vaccination rate is an appropriate and achievable goal for Healthy People 2030. We strongly urge the Committee to take a similar, consistent approach with regard to other ACIP- recommended vaccines. We understand and appreciate that a core aspect of the Healthy People 2030 process is to significantly reduce the number of objectives and to focus on objectives that can be reasonably and effectively measured and maintained. Federal leadership in immunization objectives to protect against vaccine preventable conditions across the lifespan can be effectively monitored through existing data sources and would yield important benefits across the health care system.

We ask that the Committee incorporate the new adult immunization composite measure (influenza, Td/Tdap, zoster and pneumococcal) as a Healthy People 2030 objective. The HHS National Vaccine Program Office (NVPO) and the Centers for Disease Control and Prevention (CDC) in collaboration with the National Adult Immunization and Influenza Summit have developed and tested a new composite measure for adult immunization which includes flu, Tdap, shingles, and pneumonia vaccines. It has been successfully utilized in the Indian Health Service program and is now being initially rolled out in HEDIS 2019.

Having a composite objective as part of HP2030 would put vaccination coverage rates into a larger context and encourage a more consistent approach for all vaccines. The composite is very much in line with the Healthy People 2030 plan to set national goals and measurable objectives to guide evidence-based policies, programs and other actions to improve health and well-being. An adult immunization composite objective would provide a single focal point to promote adherence to the adult immunization clinical standards of care. The addition of an adult composite would be complementary to similar composite objectives included for children and adolescent immunization status as part of Healthy People 2020, and would provide an efficient and robust means to monitor immunization coverage among specific populations at the national level.

At the same time, adopting the adult composite would align HP2030 objectives with external health care quality measurements tools, which in turn would help to streamline the patchwork of existing adult immunization measures, reduce the reporting burden, and provide a meaningful national picture of access to this important preventive service. An adult immunization composite objective would provide a clear national target for patients and providers on this important population health imperative.

AVAC advocates for the Committee to include a Hepatitis B vaccine coverage objective (proposed objective IID-2030-02). AVAC is deeply concerned about the recent rise in acute hepatitis B (HBV) infection rates in many parts of the U.S. as a result of the ongoing opioid crisis, with rates increasing by 100% to over 400% in some states. It is estimated that up to 2.2 million Americans are living with HBV. Chronic Hepatitis B increases the odds of liver cancer 50 to 100 times, and 1 in 4 individuals with chronic HBV will develop cirrhosis, liver failure and/or liver cancer. Despite the availability of current HBV vaccines to protect against this devastating condition and prevent its spread, there are up to 70,000 new infections each year. This number is exacerbated by the ongoing opioid epidemic affecting primarily young adults.

National survey data indicate only a quarter of adults age 19 and older are fully immunized, as adults aged approximately 25 years and older were not routinely vaccinated against hepatitis B at birth in the U.S. Recent studies also suggest that hepatitis B vaccine coverage is low among people with diabetes, HIV-infected individuals, hepatitis C-infected individuals, and individuals with chronic liver disease and chronic kidney disease, who are all at significantly increased risk of acquiring hepatitis B infection without completed immunization. The March 2017 report of the National Academy of Sciences, A National Strategy for the Elimination of Hepatitis B and C: Phase Two Report, recommended a series of actions across five areas that will help bring the elimination of viral hepatitis by 2030. The report found that a 50 percent reduction in mortality from chronic hepatitis B would result in 60,000 fewer deaths. The report also noted that hepatitis elimination requires coordinated action from federal and state agencies involved in this effort. Healthy People 2020 included a developmental objective to increase hepatitis B vaccine coverage among high-risk populations. Unfortunately, there is no Hepatitis B immunization objective as part of the HP2030.

AVAC urges the Committee to restore an immunization information system reporting objective (IID-20) and would encourage it be expanded to include reporting of immunization records across the lifespan (childhood/adolescent/adult). With the growing importance of health information technology, Immunization Information Systems (IIS) are an essential part of immunization infrastructure. IIS are confidential systems that allow real-time access to comprehensive, consolidated immunization records for individuals. Improving IIS and integrating them into the healthcare system is critical to expanding access to and utilization of immunizations and, in turn, will lead to a healthier future. IIS can be used by providers to help determine which recommended vaccines may be appropriate for a patient. IIS can also provide aggregate data on immunizations coverage (and gaps). This information is valuable for surveillance and program operations and guiding public health action. IIS serve as a vital link to responding to a vaccine-preventable disease outbreak or community or public health emergency.

Every state has an IIS, and although many people associate IIS with keeping track of childhood immunizations, at least 42 states maintain immunization records across patients’ full lifespans. Despite the benefits of IIS, several factors inhibit the use of IIS for adults, including: wide variations in use and capabilities for registries to accept adult immunization records, depending on the state, and the need for opt-in approval to roll childhood data into adult immunization registries; limited staff time and resources; the need for additional education and awareness; costs associated with EHR modifications; and technical interface challenges between a provider EHR and IIS. The fact that adults receive vaccinations in a variety of different settings (clinical practices, pharmacies, employer-sponsored health clinics, etc.) poses an additional challenge and supports IIS’ value to coordination of care. HP2020 included childhood (target 95 percent under age 6) and adolescent (80 percent between ages 11 and 18 with at least 2 records) immunization reporting objectives. AVAC recommends one lifespan IIS objective that would elevate immunization record capture into an IIS to be more of a national priority.

AVAC urges the Committee to increase the focus on addressing disparities in adult immunization rates. AVAC appreciates and supports the Advisory Committee’s commitment to better identify and target disparities in HP2030 objectives. Disparities persist in immunizations, with generally lower immunization coverage in certain racial and ethnic groups. AVAC coalition members are working on projects that seek to identify and enhance our understanding of coverage gaps and are developing pilot programs to test targeted solutions where these disparities currently exist. As such, AVAC supports the idea of stratification of Heathy People 2030 objective data by race, ethnicity, geographic area, sex, and disability as well as potential objectives to incorporate health equity. Maintaining a focus on addressing disparities will enable more accurate evaluation in coverage gaps and disparities, particularly among minority and vulnerable populations, and are essential to improving the impact of adult immunization efforts and expanding coverage.

AVAC urges the Committee to elevate infectious disease and immunization as a leading health indicator for (LHI) HP2030. The disparate nature of our health care system leads to a range of challenges and barriers to access across payers, providers and patients. The 2016 Department of Health and Human Services’ National Vaccine Program Office National Adult Immunization Plan, cites the following barriers to adult immunization: lack of information about recommended vaccines; financial hurdles; technological, logistical, linguistic and socioeconomic obstacles. Such barriers could be overcome by communicating immunization as a high-priority health issue. A strong emphasis on immunizing the American public would support healthy aging and would help to lessen the impact of vaccine preventable conditions and their complications, particularly among at risk populations such as the elderly, persons with chronic illness and pregnant women. At the same time, it would make economic sense by reducing avoidable health care costs, such as hospitalizations and other expensive medical interventions.

In addition to the above priorities, we wish to record our support for the following childhood and maternal IID Healthy People 2030 objectives.

  1. Expand the pregnancy immunization developmental measure (IID-2030-D01) to include all ACIP-recommended vaccines. We strongly encourage the Committee expand the parameters of the objective so it can reflect current maternal immunization composite that includes influenza. Beyond influenza, there is a strong indication that important vaccines, such as RSV and Streptococcal B, may become available and recommended for pregnant women in the coming decade. A composite objective that reflects ACIP-recommended vaccines would enable those new vaccines to be monitored.
  2. Including an objective to measure the number of adolescents who have received all ACIP-recommended vaccines by age 13. We commend the Committee’s inclusion of the objective IID-2030-12: Increase the percentage of adolescents aged 13 through 15 years who receive recommended doses of human papillomavirus (HPV) vaccine. Despite the disease prevalence, vaccination rates remain low so it is extremely important that HP 2030 encourage HPV vaccination. However, there are no proposed objectives related to receipt of other adolescent vaccines. HP2030 should seek to improve vaccination rates for adolescents, just as it does for young children, as both age cohorts are vulnerable to dangerous diseases that can be prevented by recommended vaccines. Given the very different vaccination rates between HPV and other immunizations recommended for adolescents, we believe a composite measure is very important for ensuring our children remain protected from tetanus, diphtheria, pertussis and meningococcal disease.
  3. Adding an objective to measure the number of children who have received all ACIP-recommended vaccines by age 6. We believe this measure is distinct from the currently proposed IID-2030-11, which would identify the number of children who have received no vaccines by age 2. Many children who are not fully immunized have missed only some vaccines, not all. By focusing on children who are simply missing some vaccine by age 6, we can better identify whether ongoing access issues or mistaken beliefs are affecting immunization levels.

Thank you again for this opportunity to offer our thoughts and recommendations on the proposed HP2030 objectives. Please contact an AVAC Coalition Manager at (202) 540-1070 or info@adultvaccinesnow.org if you wish to further discuss our comments. To learn more about the work of AVAC visit www.adultvaccinesnow.org.

Sincerely,

Alliance for Aging Research
American College of Preventive Medicine
American Immunization Registry Association
American Pharmacists Association
Asian & Pacific Islander American Health Forum (APIAHF)
Association of Asian Pacific Community Health Organizations (AAPCHO)
Biotechnology Innovation Organization (BIO)
Dynavax
Families Fighting Flu
GSK
Hep B United
Hepatitis B Foundation
Infectious Diseases Society of America (IDSA)
Immunization Action Coalition (IAC)
Immunize Nevada
Medicago
National Association of County and City Health Officials (NACCHO)
National Association of Chain Drug Stores (NACDS)
National Foundation for Infectious Diseases (NFID)
National Hispanic Medical Association (NHMA)
Novavax
Sanofi
Scientific Technologies Corporation
Seqirus
Takeda Vaccines
The Gerontological Society of America
Trust for America’s Health
University of Pennsylvania
Vaccinate Your Family
Walgreens