CHILD, ADOLESCENT, ADULT IMMUNIZATIONS (Immunizations)
Clinical Preventive Service Recommendations
U.S. Preventive Services Task Force RecommendationNot Applicable — The U.S. Preventive Services Task Force (USPSTF) defers to the Advisory Committee on Immunization Practices (ACIP) and the Centers for Disease Control and Prevention (CDC) on recommendations for immunizations.
Advisory Committee on Immunization Practices (ACIP) and CDC RecommendationACIP and CDC recommend that all children and adolescents with no contraindications receive all routinely recommended childhood vaccinations. Children and adolescents who fall into high-risk groups because of health conditions, behaviors, or membership in certain communities should receive additional vaccines.1
ACIP and CDC recommend that all adults with no contraindications receive four routinely recommended vaccines (age-dependent). Adults who fall into high-risk groups because of health conditions, behaviors or exposures, as well as those without a history of immunization for certain diseases, should receive additional vaccines.1
Current ACIP recommendations are provided on the ACIP website (http://www.cdc.gov/vaccines/pubs/ACIP-list.htm).
The Value of Prevention
Economic Burden of Condition/DiseaseChildhood vaccine-preventable diseases were once extremely costly. For example, a large outbreak of rubella in 1964-1965 cost an estimated $840 million.15 Today, the lifetime cost to treat a single case of congenital rubella syndrome (CRS) is estimated to exceed $200,000.15 Using published studies and hospital discharge data, an economic analysis of the DTaP (diphtheria, tetanus, and acellular pertussis) vaccine showed that in the absence of immunizations, over $23 million dollars would be spent to treat disease among all the children born in a single year.16 In adolescents and adults, the direct costs (in 2002 dollars) to treat a case of pertussis was $242 and $326, respectively. The total societal costs of pertussis, including treatment of close contacts and indirect costs, are estimated at $804/adolescent case and $1952/adult case.17
Currently, direct medical costs for the prevention and treatment of anogenital warts and cervical HPV-related cancers is at least $4 billion annually. This figure does not include all diseases associated with HPV; if all diseases were included the number could be as high as $5 billion in direct medical costs annually.18
Among adults, influenza in particular results in large direct and indirect costs. For persons aged 18 to 64, 1,022,000 hospitalized days, 9.6 million outpatient visits, and 128,000 life years are lost as a result of seasonal influenza.19 Americans spend approximately $10.4 billion a year on direct medical costs related to influenza treatment (includes hospitalizations and outpatient visits).19
The economic burden of shingles in the elderly is substantial. About 32 percent of adults will get shingles at some point in their lives.13 Shingles necessitates 2.1 million doctors visits per year.20 Approximately 2.1 hospitalizations per 100,000 patient years are attributable to the illness. Average outpatient expenditure ranged between $112 and $287 per episode and treatment for an episode of postherpetic neuralgia between $566 and $1,914 in 2004 dollars.21 Costs for the average hospitalization for an acute episode of shingles ranged from $3,221 to $7,206 in 2004 dollars.21 The persistent pain associated with shingles costs employers approximately $4,917 (in 2004 dollars) over the first year.22
Workplace Burden of Condition/DiseaseThe workplace burden of vaccine preventable diseases and deaths vary by condition. Influenza is responsible for substantial indirect costs, which mainly result from lost productivity. Each year, among adults age 18 to 64 years, almost 17 million workdays are lost to influenza-related illness at a cost of $6.2 billion.19
Pain from herpes zoster can cause temporary or permanent disability resulting in lost work time. Persons with shingles and PHN lose an average of more than 129 hours of work per herpes zoster episode.23,24 Similarly, pertussis among adults results in an average of 9.8 missed work days per case.17
Childhood episodes of VPD also impact productivity, as parents may take time off from work to care for sick children.
Economic Benefit of Preventive InterventionChildren/Adolescents
Vaccines are cost-effective, and most child and adolescent vaccines are cost-saving. The routine childhood vaccination program saves nearly $10 billion in direct medical costs and $43 billion in societal costs for every birth cohort (all children born in one year).25 This cost-savings estimate includes reduced costs from lost productivity. The introduction of new vaccines has led to a substantial decline in medical spending for some conditions. For example, in 1995, a vaccine to protect against varicella (chickenpox) was added to the childhood schedule. In 1994-1995, the total estimated direct medical cost of varicella hospitalizations and ambulatory visits was almost $85 million; in 2002, after the vaccine was introduced, the cost declined to $22.1 million.26
Although not cost-saving, the 2005 recommendation for routine adolescent meningococcal vaccination is expected to prevent an estimated $18 million in direct costs and $50 million in lost productivity caused by meningococcal disease.27 Immunization of adolescents with Tdap vaccine is estimated to prevent 0.4-1.8 million cases of pertussis and to save $0.3-1.6 billion in a decade.28
A randomized controlled trial showed that healthy, working adults who received influenza shots (in a year when the vaccine was well matched to circulating influenza viruses) experienced significantly fewer days of influenza-like illness (ILI), made fewer doctor visits for such illnesses, and took fewer days off from work due to ILIs, compared with workers who were not vaccinated.30 Furthermore, among persons aged 65 to 79 years who were members of a Medicare managed care plan, influenza immunization was estimated to save about $80 per year, per person vaccinated by preventing hospitalizations from influenza-related illnesses.29 This is consistent with other studies showing economic benefits from vaccinating persons 65 and older against influenza.
Models estimating the impact of vaccinating one million people aged 60 and older against shingles show that over 300,000 outpatient visits, 375,000 prescriptions, 9,700 ER visits and 10,000 hospitalizations can be prevented. This translates into between $82 and $103 million in 2006 U.S. dollars in healthcare costs averted.23 Finally, immunization of adults with Tdap vaccine is estimated to prevent 0.9-4.7 million cases of pertussis and to save $1.3-6.4 billion in a decade.28
Table 1 details the direct and indirect savings (per dollar spent) of many vaccines routinely administered to children and adolescents.
Table 1: Direct and Indirect Savings per Dollar Spent on Select Vaccines
+ Includes second dose of MMR
# Includes recommended doses of DTaP, Td, Hib, IPV, MMR, HepB, varicella vaccines (completed series)
Sources: Ekwueme DU, Strebel PM, Hadler SC, Meltzer MI, Allen JW, Livengood JR. Economic evaluation of use of diphtheria, tetanus, and acellular pertussis vaccine or diphtheria, tetanus, and whole-cell pertussis vaccine in the United States, 1997. Arch Pediatr Adolesc Med 2000;154:797-803. (DTaP); Zhou F, Reef S, Massoudi M, Papania MJ, Yusuf HR, Bardenheier B, et al. An economic analysis of the current universal 2-dose measles-mumps-rubella vaccination program in the United States. J Infect Dis 2004; 189(Suppl 1):S131-45. (MMR); Zhou F, Bisgard KM, Yusuf HR, Deuson RR, Bath SK, Murphy TV. Impact of universal Haemophilus influenzae type b vaccination starting at 2 months of age in the United States: an economic analysis.Pediatrics 2002; 110(4):653-61. (Hib); Zhou F, Santoli J, Messonnier ML, Yusuf HR, Shefer A, Chu SY, et al. Economic evaluation of the 7-vaccine routine childhood immunization schedule in the United States, 2001. Arch Pediatr Adolesc Med 2005; 159:1136-44. (all routine); CDC unpublished data. (hepatitis B, varicella, IPV)
Estimated Cost of ImmunizationBased on catalog prices current as of 4/06/2009, the average private-sector cost to vaccinate a healthy child through adolescence with universally recommended vaccines is approximately $1,900 to $2,000, depending on the brand of vaccine given ($1,500 to $1,600 for male children, who do not receive HPV vaccine).30
Based on catalog prices current as of 4/06/2009, the average private-sector cost to vaccinate a healthy adult through age 74 with universally recommended vaccines is approximately $530 to $605, depending on the brand of vaccine given.31
In 2007, the median private-sector cost of vaccine administration was $15.32 Approximately 95% of paid claims fell within the range of $6 to $34.32
For children and adolescents (0 through 18 years), the median private-sector cost per dose of a routinely recommended vaccine (including combination vaccines) was $43 in 2007.32 Approximately 98% of paid claims ranged from $7 (influenza vaccine) to $162 (HPV vaccine).32
For adults (19 years and older), the median private-sector cost per dose of a routinely recommended vaccine was $15 (2007 dollars).32 Approximately 98% of paid claims ranged from $9 (influenza vaccine) to $179 (herpes zoster vaccine).32
Estimated Cost of TreatmentNot Provided
Cost-Effectiveness and/or Cost-Benefit Analysis of Preventive InterventionPlease refer to "Economic Benefit of Preventive Intervention" for information on the cost-effectiveness of immunizations.
Condition / Disease Specific Information
Epidemiology of Condition/DiseasePrevention of vaccine-preventable diseases is one of 10 great public health achievements of the 20th century.2 In 2006, Partnership for Prevention evaluated 25 clinical preventive services based on the clinical burden that could be prevented by the intervention and the cost-effectiveness of the intervention. Childhood immunization was one of three services to receive a perfect score, and adult influenza and pneumococcal vaccinations were also highly ranked.3 Today, most vaccine-preventable diseases (VPD) occur at record or near-record low levels. However, high rates of vaccination must be constantly maintained: countries that have reduced or discontinued use of certain vaccines have experienced large, costly outbreaks of VPD as a result of waning vaccination coverage.4
Approximately 11,000 babies born each day in the United States will need vaccination against 14 potentially deadly diseases before age two: diphtheria, hepatitis A, hepatitis B, invasive Haemophilus influenzae type b infection, influenza, measles, mumps, pertussis (whooping cough), polio, pneumococcal disease, rotavirus, rubella, tetanus (lockjaw), and varicella (chickenpox). Approximately 23% of toddlers have not completed the series of vaccinations that is recommended for all children before their second birthday.5
Traditionally, vaccines have been associated with protecting young children, but recently many vaccines targeted toward adolescents have been recommended. In 2005, the meningococcal conjugate vaccine (MCV4) was recommended for 11 to 12 year-olds at the pre-adolescent visit, and for older adolescents and college freshman in dormitories, as these groups experience higher rates of meningococcal disease than the general population.6 However, in October of 2010, the CDC reported evidence that the vaccine is actually effective for less than five years. Following this discovery, the CDC recommended that all teenagers should receive a bacterial meningitis booster shot at the age of 16.6,7 Also recommended in June 2005 was a new tetanus-diphtheria-acellular pertussis vaccine meant to combat waning immunity to pertussis in adolescents. Pertussis incidence among adolescents has been increasing since the 1908s, and nearly 9,000 cases of pertussis were reported among 11-18 year-olds in 2004.8 It is also important for adolescents to receive certain "catch-up" immunizations if they were not fully vaccinated in childhood (please refer to http://www.cdc.gov/vaccines/recs/schedules/child-schedule.htm#catchup for more information).
In June 2006, the ACIP recommended HPV vaccine for 11 to 12-year-old girls and also for teen girls and young women through age 26 who hadn't already received the vaccine. Catch-up vaccination was recommended for girls and young women 13-26 years of age. Clinical trials including approximately 20,000 adolescent girls and women showed that among those not previously infected, the vaccine prevented close to 100% of pre-cancerous lesions from the two types of HPV that cause the majority of cervical cancer in the United States.9 In October 2009, quadrivalent HPV vaccine was also approved for use in boys and young men.9
In October 2011, the ACIP expanded the HPV vaccination recommendation to include routine vaccination of males aged 11 or 12 years with three doses of quadrivalent HPV vaccine.9 Vaccination can begin as young as age 9, and boys and young men 13 to 21 years of age who haven't already received the vaccine should also be vaccinated. In addition to providing direct benefit to boys by preventing future genital warts or anal cancer there is also the potential that vaccinating boys will reduce the spread of HPV from males to females and reduce some of the HPV-related burden that women suffer from.9
The burden of vaccine-preventable disease in adults in the United States is substantial. Recent estimates indicate that an average of 36,000 deaths and over 200,000 hospitalizations associated with influenza occur each year in the United States, the majority among adults aged 65 years and older.11 When combined, pneumonia and influenza were the seventh leading cause of death in 2006 among all persons aged 65 years and older (estimate based on national mortality data).12 Among all age groups, influenza and pneumonia were the eighth leading cause of death in the United States in 2006, accounting for 56,326 deaths (2.3% of all deaths).12
In 2006, the FDA licensed the first vaccine to prevent herpes zoster (shingles). Shingles, also called herpes zoster or zoster, is a painful skin rash caused by the varicella zoster virus (VZV). VZV is the same virus that causes chickenpox. After a person recovers from chickenpox, the virus stays in the body. Usually the virus does not cause any problems; however, the virus can reappear years later, causing shingles.13 An estimated 1 million people are diagnosed with shingles annually.13 About 32 percent of adults will develop shingles at some point in their lives.13 More than half of people who develop shingles are over age 60.14 Shingles can be associated with a number of complications, most commonly long term pain known as postherpetic neuralgia (PHN). Up to 1 in 5 shingles sufferers experience persistent pain occurring weeks or months after the shingles rash has healed.14
Condition/Disease Risk FactorsRisk factors vary for each vaccine-preventable disease.
Preventive Intervention Information
Preventive Intervention: Purpose of ImmunizationsThe purpose of immunizing children, adolescents, and adults, is to prevent vaccine-preventable diseases.
All routinely recommended childhood vaccines have been demonstrated to be efficacious, and noticeable reductions in rates of disease have occurred following consistent, widespread use of vaccines.33 In each birth cohort (all children born in one year), the routine childhood immunization program prevents at least 13.6 million cases and 33,000 deaths from vaccine-preventable diseases.25 Influenza vaccination of healthy working adults younger than 65 years can reduce the rates of influenza-like illness, lost workdays and physician visits.34
Benefits and Risks of InterventionThe benefits of vaccination include partial or complete protection against the consequences of infection for the vaccinated person, as well as overall benefits to society as a whole through reduced transmission of disease. Individual benefits include protection from symptomatic illness, improved quality of life and productivity (fewer lost workdays), and prevention of death. Societal benefits include creation and maintenance of herd immunity against communicable diseases (which protects people who themselves are not able to be immunized), prevention of disease outbreaks, and reduction in healthcare-related costs.33
No vaccine is 100% effective or completely without risk. The risks of screening for susceptibility to VPDs are minimal for both examination of vaccination history and serologic testing, although false-positive or false-negative results are possible. Immunization risks range from common, minor, and local adverse effects to rare, severe, and life-threatening conditions. Thus, recommendations for immunization practices balance scientific evidence of benefits for each person and to society against the potential costs and risks of vaccination programs.33
The potential for significant adverse reactions to immunization can be minimized by adherence to the recommendations and contraindications for immunizations stipulated by ACIP. Information on vaccine contraindications is available online (www.cdc.gov/nip/recs/contraindications_guide.pdf).
Initiation, Cessation, and Interval of ImmunizationPatients of all ages, beginning at birth and throughout the lifespan, can benefit from screening and appropriate immunization. Screening for susceptibility to rubella should occur at the first clinical encounter with any woman of childbearing age.
All indicated vaccines should be offered at every visit to a healthcare provider. It is important for persons of all age groups who have not received all recommended vaccines to receive "catch-up" vaccinations.
One or more vaccinations may be deferred when medically contraindicated or when a parent, guardian, or patient refuses on religious, philosophical, or other grounds. Providers should document deferrals and exemptions in accordance with state and local requirements.
Intervention ProcessMost vaccines are administered via injection. There are several approved vaccine types and brands. Please refer to the accompanying SPD for more information.
Treatment InformationHealth benefits should include provisions for treatment services.
Other Important Information
For children, CDC's National Center for Immunization and Respiratory Diseases (NCIRD) provides an automatic scheduler that uses a child's birth date to calculate the appropriate dates of administration for each routinely recommended childhood vaccination. The scheduler is available online (www.cdc.gov/nip/scheduler_online_child.htm).
Strength of EvidenceThe level of evidence supporting the recommendations contained in this chapter is described below.
Summary Plan DescriptionScreening/risk assessment for vaccine-preventable disease (VPD) is a covered benefit for all beneficiaries. Screening may include counseling by the provider. Screening can be accomplished by a review of vaccination history, preferably documented history, or (when appropriate) serologic testing for antibodies to VPD using accepted laboratory tests.
Covered immunizations (children/adolescents): Single-antigen or combination vaccines as consistent with the most current ACIP recommendations. Currently included vaccines are: diphtheria, Haemophilus influenzae type b, hepatitis A, hepatitis B, human papilloma virus, influenza, measles, meningococcal disease, mumps, pertussis, pneumococcal disease, polio, rotavirus, rubella, tetanus, and varicella.
Covered immunizations (adults): Single-antigen or combination vaccines as consistent with the most current ACIP recommendations. Currently included vaccines are: diphtheria, herpes zoster (shingles), human papillomavirus, influenza, pertussis, pneumococcal disease, and tetanus. Also covered as necessary are: hepatitis A, hepatitis B, measles, meningococcal disease, mumps, rubella, and varicella.
Initiation, Cessation, and IntervalScreening/risk assessment and immunizations are covered whenever indicated by medical conditions or other risk factors. There are no age or frequency limitations.
Author(s)Lindley MC, Bhatt A. Child, adolescent, and adult immunizations evidence-statement. In: Campbell KP, Lanza A, Dixon R, Chattopadhyay S, Molinari N, Finch RA, editors. A Purchaser's Guide to Clinical Preventive Services: Moving Science into Coverage. Washington, DC: National Business Group on Health; 2006. Updated 2011.
Other Information and Resources
Business Group Resource(s)
CDC and ACIP Resources