Everything You Need to Know About Adult Vaccinations
Rebecca Bakke was eight-and-a-half months pregnant with her first child when she came down with what she thought was a cold. She was 28 and working as a medical resident in a pediatric emergency room in wintry Ohio - germs came with the territory. In fact, she was so busy with work and so excited for the baby that she barely noticed her cough at all. Then, five weeks after Rebecca gave birth, her infant, Claire, started coughing. At first Rebecca assumed it was reflux, but she had cared for enough sick children to know after a few days that it was bad. Her mind started racing: How long have I been sick? By that point, it had been nearly two months. "Then I just knew," Rebecca says. "I knew I had whooping cough, and I knew I had given it to Claire."
Claire's pediatrician confirmed the diagnosis, and immediately put her on antibiotics, but there was no medicine that could soothe her symptoms. In the days that followed, Claire spiraled into hour-long coughing jags, stopping only to gasp for air. Sometimes she coughed so violently that her lips turned blue; she vomited so often that she struggled to gain weight. "It was terrifying," Rebecca says. She had seen infants with whooping cough in her hospital's intensive care unit - one, born just a few weeks before Claire, had even died. "I barely slept for weeks because I was afraid when I woke up that Claire would be gone too," Rebecca remembers.
Rebecca, now 35 and a pediatrician in Fargo, ND, recalls that time as the darkest of her life. Though Claire's health improved, the cough hung on for nine excruciating months. "The guilt made me crazy," she says. The most devastating blow: Rebecca learned that she could have protected her baby if only she had gotten a whooping cough booster. By the time she became pregnant, the vaccine she was given as a child had worn off. Now, every year when Claire blows out the candles on her birthday cake - seven this January - Rebecca says a prayer for the family of the newborn who died when her little girl was sick. "That could have been us."
Adult vaccination rates are even lower for some of the most contagious and deadliest - yet preventable - infections in our history.
As the temperatures begin to cool, we'll all be bombarded with reminders to get a flu shot. Most of us will ignore them. Only about 30 percent of adults under 50 got a flu shot last year, well below the 80 to 95 percent (depending on the disease) that epidemiologists say is needed to shield those who are most vulnerable: infants, the elderly, and patients with cancer or another illness that weakens their defenses. Adult vaccination rates are even lower for some of the most contagious and deadliest - yet preventable - infections in our history. As a result, diseases like whooping cough that were once considered rare are resurging in the United States, with cases among adults spiking 400 percent since 1990. Measles, still a leading cause of death for children around the world, has sickened more than 1,300 people in the last five years. Health officials say the trend among some parents to wait to vaccinate their kids or not to vaccinate them at all is partly to blame. But some of the worst outbreaks - like the one in Disneyland in 2014, in which measles quickly spread to seven states, Canada, and Mexico - also gain traction among adults. After all, once an illness is introduced into a community, anyone who isn't vaccinated can catch it and spread it, says David Kim, M.D., deputy associate director for adult immunizations at the Centers for Disease Control and Prevention (CDC): "Things can get out of control quickly."
In addition, experts say that the dismal rates of vaccination can also hamper medical advances. Drug manufacturers work quickly to develop a vaccine when faced with a threat like Zika, knowing it'll turn a profit, says Litjen Tan, Ph.D., chief strategy officer for the Immunization Action Coalition, which seeks to increase immunization through education. Less publicized viruses, like West Nile or chikungunya, are far less likely to get the funding it takes to bring a new vaccine to the market because, generally speaking, adults just won't get vaccines. "If you're on the board of one of these companies, your first thought would be, How are we going to get a return on our investment when we're covering adults at only 20 percent?" Tan says. "If we want to have continued research and development, we need to show that we as a culture value adult vaccines."
So much is at stake, and women can help solve this crisis. We're society's caregivers: the ones who are still most likely to work in schools and health-care settings, or in the home tending to those most vulnerable to disease. We wield a lot of influence. "Women are the driving force that ensures that their spouses, kids, and extended families take care of their health," says William Schaffner, M.D., a professor of preventive medicine at Vanderbilt University in Nashville. It's time to roll up our sleeves for vaccines.
First, What's Holding Us Back?
Incredibly, a discussion about vaccinations may never come up between a woman and her doctor. More than 40 percent of women depend on their ob/gyn for preventive care, where the focus tends to be on shots that are now recommended during pregnancy - specifically, the flu vaccine and the whooping cough booster Tdap. ("Both pass antibodies through the placenta, which helps protect babies during the first six months of life, when they're too young to be fully vaccinated," Schaffner says.) Many of the other specialists women frequent, like dermatologists, don't immunize as part of their care, Tan adds. But even when women do see a primary care physician, they may still face barriers: Roughly 40 percent of Americans skip an annual physical, and a 2014 study in the Annals of Internal Medicine found that only a third of doctors follow the CDC's guidelines to assess patients' vaccination status at every visit. It's likely a cost-cutting measure - it's expensive to keep vaccines in stock, and practitioners often aren't properly reimbursed for giving them. "Sometimes the compensation is so marginal that it's a barely break-even operation, which of course doesn't motivate the doctor," says Schaffner, who also serves as medical director of the National Foundation for Infectious Diseases.
If a patient isn't certain about what she's had in the past, she's out of luck, because record-keeping for adult vaccinations is spotty.
When doctors don't actively recommend vaccines, women might assume they don't need them, banking on the fact that they're young and healthy - and vaccines aren't always effective, anyway, right? They're not wrong, Schaffner says. The flu shot is only 50 to 60 percent effective, for example, while Tdap fully protects 7 out of 10 adults in the first year and begins to fade after that. Still, the reality is that vaccine-preventable illnesses can strike anyone at any age, and research shows that people who have been immunized are quicker to recover, and therefore less likely to spread disease. Gigi Bugsch of Woodland, CA, discovered this two years ago. She had never gotten a flu vaccine, figuring that as a teacher, she had been exposed to so many germs that her immune system was nearly infallible. Then, at age 45, she came down with H1N1. She was admitted to the hospital and, within 24 hours, put on a respirator, her lungs drowning in fluid. There were moments when her doctors didn't know if she'd make it. When she was finally discharged, a little over a month later, she had more than a million dollars in medical bills-yes, a million-and a fraction of the energy she'd had before she got sick. "Everybody thinks, It'll never happen to me," she says. "I had the same attitude, and it did."
The Cost Factor
A woman left on her own to decide what shots she needs faces a daunting maze, especially if she's not sure which vaccines she's already had. Even doctors think the CDC's adult vaccine schedule is complicated: Nearly 1 out of 3 physicians reported that many of the recommendations are difficult to follow, a study in Public Health Reports shows. Some shots are recommended for everyone, while others like pneumococcal, HPV, and hepatitis A depend on any number of things, from a woman's medical history to her travel plans. If a patient isn't certain about what she's had in the past, she's out of luck, because record-keeping for adult vaccinations is spotty - some states track them, some don't. With no documentation, a woman would have to dig out baby books, quiz her parents, or call health departments, previous schools, or doctors looking for answers. "No one has time to do that," Schaffner says. Blood tests can check immunity, but they're expensive and a hassle for doctors who have to send them out to labs. Fortunately, health officials say it's often safe to be re-immunized. The worst that can happen is your arm would be a little more red or sore afterward. "The reaction depends on which vaccine you're getting. Tdap is more painful, while the measles vaccine MMR doesn't feel as bad," Schaffner says. "In general, the longer it's been since you've had the previous shot, the smaller the reaction."
There's also the matter of how much a vaccine will cost. Prices range from just under $30 for a tetanus shot to nearly $200 for a zoster vaccine for shingles, and while the CDC says most insurers cover critical immunizations, some women may still have to fork over some cash. The Affordable Care Act guarantees full coverage for CDC-recommended vaccines as long as patients go to an in-network provider, but private insurance policies can vary. Depending on the plan, even a flu shot may carry out-of-pocket costs for those with co-pays or high deductibles. And without supplemental insurance, a woman on Medicare may not be fully covered for some suggested vaccines. Further, a woman with any insurance who wants a shot that isn't specifically recommended for her may have to foot the entire bill. Take the vaccine for HPV, the sexually transmitted infection that can cause cancer of the cervix, vagina, and vulva: It's only suggested for women up to age 26, because research has found that older women have likely already been exposed to the virus, rendering the vaccine less effective. But a newly single woman in her 40s may still want it, even if it doesn't work quite as well as it would have when she was 22. "Many women who are back in the dating game feel vulnerable and want some protection," Schaffner says. Still, most insurances would consider it optional, putting patients on the hook for $500 for the three-shot series. Travel vaccines, though recommended by the CDC, are also considered optional by most health plans. Kristin Meekhof, 42, went to a traveler's clinic two years ago before a trip to Kenya. Her vaccines for hepatitis A, typhoid, meningitis, and yellow fever totaled more than $400 - a cost she had to shoulder on her own. "I was surprised they weren't paid for by insurance, since it seems it would cost more if I caught one of these diseases and had to be treated with antibiotics and follow-up appointments," says Kristin, an author in Birmingham, MI. "You'd think they'd want to encourage safe travel." It's true: Illnesses are often traced to someone who traveled abroad.
Protecting Ourselves - And Everyone
It may feel like the obstacles are off-puttingly high, but it's important to remember that getting immunized is easier than most things we do for our health, like schlepping weekly to the gym. See your doctor once, and aside from your annual flu vaccine, you may not have to worry about shots again for another decade, when you're due for a tetanus booster.
Start by checking off the vaccines you need (see the schedule below), then call your insurance company to confirm what your plan will cover and whether you'll have to stick to a certain provider. If you don't have a primary care doctor, ask about pharmacists in your network who vaccinate. A call to the provider is next, to ensure they stock what you want. If they don't, ask for a referral, but double-check with your insurance company on how that impacts your coverage. Bring your checklist with you to the appointment, and be prepared to make your case if you fall outside the guidelines for any of the shots you want. The CDC recommendations carry the credibility of decades of research, so you'll want to explain why your situation is different, how the vaccine - though potentially less effective - will protect your health, and that you're willing to pay for it if necessary. "You may get some pushback, but if you're educated about the issues, you'll be fine," Tan says. Before you leave the doctor's office, ask for a printout of the vaccines to keep with your medical records, and bring it back each year when you return for your flu shot so you can review any new vaccines you may need. It'll vary as you age, and also as your circumstances (and even the CDC guidelines) change.
See your doctor once, and aside from your annual flu vaccine, you may not have to worry about shots again for another decade.
Since her daughter Claire's bout with whooping cough, Rebecca has made it her personal mission to ensure that no parent ever loses a child to a vaccine-preventable disease. "I should have known better," she says, noting that she was vaccinated with Tdap during her two subsequent pregnancies. "Now, as a pediatrician, I make sure that the families I take care of do know better." There are ways we non-doctors can help as well: After getting your vaccinations, tell anyone who notices your bandage about your appointment, and make copies of the checklist you brought to your doctor to hand out to your partner, parents, and friends. Bring up vaccinations if a neighbor tells you about her new teaching job or a cousin announces her pregnancy. At work, encourage your boss to sponsor an annual flu vaccination clinic, reminding them that it will cut down on sick days. And then work to ensure that everyone - even strangers - has equal access to basic health care: Write your congressperson and let him or her know that adult vaccination is important to you. "This preventive service should be available to everyone in the United States," Schaffner says. "Vaccinations for all makes the entire country healthier." That means your friends and family, and babies and grandmothers you haven't even met, will be safe. Because of you.
The Vaccine Schedule, Simplified
The Centers for Disease Control and Prevention recommends dozens of vaccines for adults, depending on your age, medical history, job, sex life - even your travel plans. You won't find them all here, but checking off the sections that apply to you can get the conversation started with your doctor. Print this page and bring it with you.
Influenza: It's a must-have every flu season, which starts in October.
Tetanus diphtheria (Td): Tetanus shots are recommended every 10 years, or after a bad wound.
Tetanus diphtheria pertussis (Tdap): Since 2005, the CDC has recommended that adults get a one-time Tdap booster, which protects against whooping cough.
Measles mumps rubella (MMR): Since 1989, children have gotten two doses of MMR. If you received only one dose before that, it has a slightly lower success rate, so get the second one if there's an outbreak in your area. Also, if you got the shot between 1963 and 1967, you may need to be revaccinated, as the formula was less effective those years.
Varicella (chicken pox): The two-dose chicken pox vaccine has only been given to children since 1995. If you had chicken pox, you're considered immune. Otherwise, you should get vaccinated - adults are more likely than kids to suffer serious complications.
Zoster (shingles): Zoster is essentially a chicken pox booster; it can prevent the virus from reactivating, causing painful shingles. The shot is only FDA-approved for ages 50 and up, but since it may only be effective for five years, the CDC suggests waiting until age 60, when the risk is greatest.
Major Factors
If you're pregnant: Be sure to get the flu shot, as well as Tdap. The CDC now recommends that women get a whooping cough booster during the third trimester of every pregnancy because of the protection it offers newborns. You should also insist that everyone who spends time with your baby - your partner, siblings, grandparents, caregivers - be current on both vaccines.
If you're dating: You may also want to be vaccinated for the sexually transmitted diseases human papillomavirus and hepatitis B. You can get the hep B vaccine at any age, and HPV up to age 26. Most older women have already been exposed to the virus, making the vaccine less protective. If you still want it, know that insurance probably won't cover the cost.
Also talk to your doctor if: You're planning to travel abroad or if you have any medical conditions that might up your risk for everyday infections. Some diseases, like hepatitis A and typhoid, are more common in other parts of the world, and it can take as long as four to six weeks for the vaccines to take hold. Meanwhile, people with long-term health problems like heart or lung disease may need to be immunized for risky illnesses they can catch at home, like pneumonia.
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