Pamela G. Rockwell, DO

Food allergy is a complex condition that has become a growing concern for parents and an increasing public health problem in the United States. Food allergy affects social interactions, school attendance, and quality of life, especially when associated with comorbid atopic conditions such as asthma, atopic dermatitis, and allergic rhinitis.^1,2 It is the major cause of anaphylaxis in children, accounting for as many as 81% of cases.³ Societal costs of food allergy are great and are spread broadly across the health care system and the family. (See “What is the cost of food allergy?”².)

What a food allergy is—and isn’t

The National Institute of Allergy and Infectious Diseases ­(NIAID) defines food allergy as “an adverse health effect arising from a specific immune response that occurs reproducibly on exposure to a given food.”⁴ An adverse reaction to food or a food component that lacks an identified immunologic pathophysiology is not considered food allergy but is classified as food intolerance.⁴

The CDC estimates that 4% to 6% of children in the United States have a food allergy. Almost 40% of food-allergic children have a history of severe food-induced reactions.

Food allergy is caused by either immunoglobulin E (IgE)-mediated or non-IgE-mediated immunologic dysfunction. IgE antibodies can trigger an intense inflammatory response to certain allergens. Non-IgE-mediated food allergies are less common and not well understood.

© Joe Gorman

This article focuses only on the diagnosis and management of IgE-mediated food allergy.

The culprits

More than 170 foods have been reported to cause an IgE-­mediated reaction. Table 1^5-8 lists the 8 foods that most commonly cause allergic reactions in the United States and that account for > 50% of allergies to food.⁹ Studies vary in their methodology for estimating the prevalence of allergy to individual foods, but cow’s milk and peanuts appear to be the most common, each affecting as many as 2% to 2.5% of children.^7,8 In general, allergies to cow’s milk and to eggs are more prevalent in very young and preschool children, whereas allergies to peanuts, tree nuts, fish, and shellfish are more prevalent in older children.¹⁰ Labels on all packaged foods regulated by the US Food and Drug Administration must declare if the product contains even a trace of these 8 allergens.

How common is food allergy?

The Centers for Disease Control and Prevention (CDC) estimates that 4% to 6% of children in the United States have a food allergy.^11,12 Almost 40% of food-allergic children have a history of severe food-induced reactions.¹³ Other developed countries cite similar estimates of overall prevalence.^14,15

However, many estimates of the prevalence of food allergy are derived from self-reports, without objective data.⁹ Accurate evaluation of the prevalence of food allergy is challenging because of many factors, including differences in study methodology and the definition of allergy, geographic variation, racial and ethnic variations, and dietary exposure. Parents and children often confuse nonallergic food reactions, such as food intolerance, with food allergy. Precise determination of the prevalence and natural history of food allergy at the population level requires confirmatory oral food challenges of a representative sample of infants and young children with presumed food allergy.¹⁶

Continue to: The CDC concludes that the prevalence...

The CDC concludes that the prevalence of food allergy in children younger than 18 years increased by 18% from 1997 through 2007.^17,18 The cause of this increase is unclear but likely multifactorial; hypotheses include an increase in associated atopic conditions, delayed introduction of allergenic foods, and living in an overly sterile environment with reduced exposure to microbes.¹⁹ A recent population-based study of food allergy among children in Olmsted County, Minnesota, found that the incidence of food allergy increased between 2002 and 2007, stabilized subsequently, and appears to be declining among children 1 to 4 years of age, following a peak in 2006-2007.¹⁹

What are the risk factors?

Proposed risk factors for food allergy include demographics, genetics, a history of atopic disease, and environmental factors. Food allergy might be more common in boys than in girls, and in African Americans and Asians than in Whites.^12,16 A child is 7 times more likely to be allergic to peanuts if a parent or sibling has peanut allergy.²⁰ Infants and children with eczema or asthma are more likely to develop food allergy; the severity of eczema correlates with risk.^12,20 Improvements in hygiene in Western societies have decreased the spread of infection, but this has been accompanied by a rise in atopic disease. In countries where health standards are poor and exposure to pathogens is greater, the prevalence of allergy is low.²¹

A child is 7 times more likely to be allergic to peanuts if a parent or sibling has peanut allergy.

Conversely, increased microbial exposure might help protect against atopy via a pathway in which T-helper cells prevent pro-allergic immune development and keep harmless environmental exposures from becoming allergens.²² Attendance at daycare and exposure to farm animals early in life reduces the likelihood of atopic disease.^16,21 The presence of a dog in the home lessens the probability of egg allergy in infants.²³ Food allergy is less common in younger siblings than in first-born children, possibly due to ­younger siblings’ increased exposure to infection and alterations in the gut microbiome.^23,24

Diagnosis: Established by presentation, positive testing

Onset of symptoms after exposure to a suspected food allergen almost always occurs within 2 hours and, typically, resolves within several hours. Symptoms should occur consistently after ingestion of the food allergen. Subsequent exposures can trigger more severe symptoms, depending on the amount, route, and duration of exposure to the allergen.²⁵ Reactions typically follow ingestion or cutaneous exposures; inhalation rarely triggers a response.²⁶ IgE-mediated release of histamine and other mediators from mast cells and basophils triggers reactions that typically involve one or more organ systems (Table 2).²⁵

Cutaneous symptoms are the most common manifestations of food allergy, occurring in 70% to 80% of childhood reactions. Gastrointestinal and oral or respiratory symptoms occur in, respectively, 40% to 50% and 25% of allergic reactions to food. Cardiovascular symptoms develop in fewer than 10% of allergic reactions.²⁶

Continue to: Anaphylaxis

Anaphylaxis is a serious allergic reaction that develops rapidly and can cause death; diagnosis is based on specific criteria (Table 3).²⁷ Data for rates of anaphylaxis due to food allergy are limited. The incidence of fatal reaction due to food allergy is estimated to be 1 in every 800,000 children annually.³

Clinical suspicion. Food allergy should be suspected in infants and children who present with anaphylaxis or other symptoms (Table 2²⁵) that occur within minutes to hours of ingesting food.⁴ Parental and self-reports alone are insufficient to diagnose food allergy. NIAID guidelines recommend that patient reports of food allergy be confirmed, because multiple studies demonstrate that 50% to 90% of presumed food allergies are not true allergy.⁴ Health care providers must obtain a detailed medical history and pertinent family history, plus perform a physical exam and allergy sensitivity testing. Methods to help diagnose food allergies include skin-prick tests, allergen-specific serum IgE tests, and oral food challenges.⁴

General principles and utility of testing

Before ordering tests, it’s important to distinguish between food sensitization and food allergy and to inform the families of children with suspected food allergy about the limitations of skin-prick tests and serum IgE tests. A child with IgE antibodies specific to a food or with a positive skin-prick test, but without symptoms upon ingestion of the food, is merely sensitized; food allergy indicates the appearance of symptoms following exposure to a specific food, in addition to the detection of specific IgE antibodies or a positive skin-prick test to that same food.²⁸

Skin-prick testing. Skin-prick tests can be performed at any age. The procedure involves pricking or scratching the surface of the skin, usually the volar aspect of the forearm or the back, with a commercial extract. Testing should be performed by a physician or other provider who is properly trained in the technique and in interpreting results. The extract contains specific allergenic proteins that activate mast cells, resulting in a characteristic wheal-and-flare response that is typically measured 15 to 20 minutes after application. Some medications, such as H₁- and H₂-receptor blockers and tricyclic antidepressants, can interfere with results and need to be held for 3 to 5 days before testing.

A positive skin-prick test result is defined as a wheal ≥ 3 mm larger in diameter than the negative control. The larger the size of the wheal, the higher the likelihood of a reaction to the tested food.²⁹ Patients who exhibit dermatographism might experience a wheal-and-flare response from the action of the skin-prick test, rather than from food-specific IgE antibodies. A negative skin-prick test has > 90% negative predictive value, so the test can rule out suspected food allergy.³⁰ However, the skin-prick test alone cannot be used to diagnose food allergy because it has a high false-positive rate.

Continue to: Allergen-specific serum IgE testing

Allergen-specific serum IgE ­testing. Measurement of food-specific serum IgE levels is routinely available and requires only a blood specimen. The test can be used in patients with skin disease, and results are not affected by concurrent medications. The presence of food-specific IgE indicates that the patient is sensitized to that allergen and might react upon exposure; children with a higher level of antibody are more likely to react.²⁹

Food-specific serum IgE tests are sensitive but nonspecific for food allergy.³¹ Broad food-allergy test panels often yield false-positive results that can lead to unnecessary dietary elimination, resulting in years of inconvenience, nutrition problems, and needless health care expense.³²

It is appropriate to order tests of specific serum IgE to foods ingested within the 2 to 3–hour window before onset of symptoms to avoid broad food allergy test panels. Like skin-prick testing, positive allergen-specific serum IgE tests alone cannot diagnose food allergy.

Oral food challenge. The double-blind, placebo-controlled oral food challenge is the gold standard for the diagnosis of food allergy. Because this test is time-consuming and technically difficult, single-blind or open food challenges are more common. Oral food challenges should be performed only by a physician or other provider who can identify and treat anaphylaxis.

The presence of a dog in the home lessens the probability of egg allergy in infants.

The oral challenge starts with a very low dose of suspected food allergen, which is gradually increased every 15 to 30 minutes as vital signs are monitored carefully. Patients are observed for an allergic reaction for 1 hour after the final dose.

Continue to: A retrospective study...

A retrospective study showed that, whereas 19% of patients reacted during an open food challenge, only 2% required epinephrine.³³ Another study showed that 89% of children whose serum IgE testing was positive for specific foods were able to reintroduce those foods into the diet after a reassuring oral food challenge.³⁴

Other diagnostic tests. The basophil activation assay, measurement of total serum IgE, atopy patch tests, and intradermal tests have been used, but are not recommended, for making the diagnosis of food allergy.⁴

How can food allergy be managed?

Medical options are few. No approved treatment exists for food allergy. However, it’s important to appropriately manage acute reactions and reduce the risk of subsequent reactions.¹ Parents or other caregivers can give an H₁ antihistamine, such as diphenhydramine, to infants and children with acute non-life-threatening symptoms. More severe symptoms require rapid administration of epinephrine.¹ Auto-injectable epinephrine should be prescribed for parents and caregivers to use as needed for emergency treatment of anaphylaxis.

Team approach. A multidisciplinary approach to managing food allergy—involving physicians, school nurses, dietitians, and teachers, and using educational materials—is ideal. This strategy expands knowledge about food allergies, enhances correct administration of epinephrine, and reduces allergic reactions.¹

Avoidance of food allergens can be challenging. Parents and caregivers should be taught to interpret the list of ingredients on food packages. Self-recognition of allergic reactions reduces the likelihood of a subsequent severe allergic reaction.³⁵

Continue to: Importance of individualized care

Importance of individualized care. Health care providers should develop personalized management plans for their patients.¹ (A good place to start is with the “Food Allergy & Anaphylaxis Emergency Care Plan”^a developed by Food Allergy Research & Education [FARE]). Keep in mind that children with multiple food allergies consume less calcium and protein, and tend to be shorter⁴; therefore, it’s wise to closely monitor growth in these children and consider referral to a dietitian who is familiar with food allergy.

Potential of immunotherapy. Current research focuses on immunotherapy to induce tolerance to food allergens and protect against life-threatening allergic reactions. The goal of immunotherapy is to lessen adverse reactions to allergenic food proteins; the strategy is to have patients repeatedly ingest small but gradually increasing doses of the food allergen over many months.³⁶ Although immunotherapy has successfully allowed some patients to consume larger quantities of a food without having an allergic reaction, it is unknown whether immunotherapy provides permanent resolution of food allergy. In addition, immunotherapy often causes serious systemic and local reactions.^1,36,37

Is prevention possible?

Maternal diet during pregnancy and lactation does not affect development of food allergy in infants.^38,39 Breastfeeding might prevent development of atopic disease, but evidence is insufficient to determine whether breastfeeding reduces the likelihood of food allergy.³⁹ In nonbreastfed infants at high risk of food allergy, extensively or partially hydrolyzed formula might help protect against food allergy, compared to standard cow’s milk formula.^9,39 Feeding with soy formula rather than cow’s milk formula does not help prevent food allergy.^39,40 Pregnant and breastfeeding women should not restrict their diet as a means of preventing food allergy.³⁹

Diet in infancy. Over the years, physicians have debated the proper timing of the introduction of solid foods into the diet of infants. Traditional teaching advocated delaying introduction of potentially allergenic foods to reduce the risk of food allergy; however, this guideline was based on inconsistent evidence,⁴¹ and the strategy did not reduce the incidence of food allergy. The prevalence of food allergy is lower in developing countries where caregivers introduce foods to infants at an earlier age.²⁰

Multiple studies demonstrate that 50% to 90% of presumed food allergies are not true allergy.

A recent large clinical trial indicates that early introduction of peanut-containing foods can help prevent peanut allergy. The study randomized 4- to 11-month-old infants with severe eczema, egg allergy, or both, to eat or avoid peanut products until 5 years of age. Infants assigned to eat peanuts were 81% less likely to develop peanut allergy than infants in the avoidance group. Absolute risk reduction was 14% (number need to treat = 7).⁴² Another study showed a nonsignificant (20%) lower relative risk of food allergy in breastfed infants who were fed potentially allergenic foods starting at 3 months of age, compared to being exclusively breastfed.⁴³

Continue to: Based on these data...

Based on these data,^42,43 NIAID instituted recommendations in 2017 aimed at preventing peanut allergy⁴⁴:

• In healthy infants without known food allergy and those with mild or moderate eczema, caregivers can introduce peanut-containing foods at home with other solid foods.Parents who are anxious about a possible allergic reaction can introduce peanut products in a physician’s office.
• Infants at high risk of peanut allergy (those with severe eczema or egg allergy, or both) should undergo peanut-specific IgE or skin-prick testing:
  • Negative test: indicates low risk of a reaction to peanuts; the infant should start consuming peanut-containing foods at 4 to 6 months of age, at home or in a physician’s office, depending on the parents’ preference
  • Positive test: Referral to an allergist is recommended.

Do children outgrow food allergy?

Approximately 85% of children who have an allergy to milk, egg, soy, or wheat outgrow their allergy; however, only 15% to 20% who have an allergy to peanuts, tree nuts, fish, or shellfish eventually tolerate these foods. The time to resolution of food allergy varies with the food, and might not occur until adolescence.⁴ No test reliably predicts which children develop tolerance to any given food. A decrease in the food-specific serum IgE level or a decrease in the size of the wheal on skin-prick testing might portend the onset of tolerance to the food.⁴

CORRESPONDENCE
Catherine M. Bettcher, MD, FAAFP, Briarwood Family Medicine, 1801 Briarwood Circle, Building #10, Ann Arbor, MI 48108; [email protected].

Food allergy is a complex condition that has become a growing concern for parents and an increasing public health problem in the United States. Food allergy affects social interactions, school attendance, and quality of life, especially when associated with comorbid atopic conditions such as asthma, atopic dermatitis, and allergic rhinitis.^1,2 It is the major cause of anaphylaxis in children, accounting for as many as 81% of cases.³ Societal costs of food allergy are great and are spread broadly across the health care system and the family. (See “What is the cost of food allergy?”².)

What a food allergy is—and isn’t

The National Institute of Allergy and Infectious Diseases ­(NIAID) defines food allergy as “an adverse health effect arising from a specific immune response that occurs reproducibly on exposure to a given food.”⁴ An adverse reaction to food or a food component that lacks an identified immunologic pathophysiology is not considered food allergy but is classified as food intolerance.⁴

The CDC estimates that 4% to 6% of children in the United States have a food allergy. Almost 40% of food-allergic children have a history of severe food-induced reactions.

Food allergy is caused by either immunoglobulin E (IgE)-mediated or non-IgE-mediated immunologic dysfunction. IgE antibodies can trigger an intense inflammatory response to certain allergens. Non-IgE-mediated food allergies are less common and not well understood.

© Joe Gorman

This article focuses only on the diagnosis and management of IgE-mediated food allergy.

The culprits

More than 170 foods have been reported to cause an IgE-­mediated reaction. Table 1^5-8 lists the 8 foods that most commonly cause allergic reactions in the United States and that account for > 50% of allergies to food.⁹ Studies vary in their methodology for estimating the prevalence of allergy to individual foods, but cow’s milk and peanuts appear to be the most common, each affecting as many as 2% to 2.5% of children.^7,8 In general, allergies to cow’s milk and to eggs are more prevalent in very young and preschool children, whereas allergies to peanuts, tree nuts, fish, and shellfish are more prevalent in older children.¹⁰ Labels on all packaged foods regulated by the US Food and Drug Administration must declare if the product contains even a trace of these 8 allergens.

How common is food allergy?

The Centers for Disease Control and Prevention (CDC) estimates that 4% to 6% of children in the United States have a food allergy.^11,12 Almost 40% of food-allergic children have a history of severe food-induced reactions.¹³ Other developed countries cite similar estimates of overall prevalence.^14,15

However, many estimates of the prevalence of food allergy are derived from self-reports, without objective data.⁹ Accurate evaluation of the prevalence of food allergy is challenging because of many factors, including differences in study methodology and the definition of allergy, geographic variation, racial and ethnic variations, and dietary exposure. Parents and children often confuse nonallergic food reactions, such as food intolerance, with food allergy. Precise determination of the prevalence and natural history of food allergy at the population level requires confirmatory oral food challenges of a representative sample of infants and young children with presumed food allergy.¹⁶

Continue to: The CDC concludes that the prevalence...

The CDC concludes that the prevalence of food allergy in children younger than 18 years increased by 18% from 1997 through 2007.^17,18 The cause of this increase is unclear but likely multifactorial; hypotheses include an increase in associated atopic conditions, delayed introduction of allergenic foods, and living in an overly sterile environment with reduced exposure to microbes.¹⁹ A recent population-based study of food allergy among children in Olmsted County, Minnesota, found that the incidence of food allergy increased between 2002 and 2007, stabilized subsequently, and appears to be declining among children 1 to 4 years of age, following a peak in 2006-2007.¹⁹

What are the risk factors?

Proposed risk factors for food allergy include demographics, genetics, a history of atopic disease, and environmental factors. Food allergy might be more common in boys than in girls, and in African Americans and Asians than in Whites.^12,16 A child is 7 times more likely to be allergic to peanuts if a parent or sibling has peanut allergy.²⁰ Infants and children with eczema or asthma are more likely to develop food allergy; the severity of eczema correlates with risk.^12,20 Improvements in hygiene in Western societies have decreased the spread of infection, but this has been accompanied by a rise in atopic disease. In countries where health standards are poor and exposure to pathogens is greater, the prevalence of allergy is low.²¹

A child is 7 times more likely to be allergic to peanuts if a parent or sibling has peanut allergy.

Conversely, increased microbial exposure might help protect against atopy via a pathway in which T-helper cells prevent pro-allergic immune development and keep harmless environmental exposures from becoming allergens.²² Attendance at daycare and exposure to farm animals early in life reduces the likelihood of atopic disease.^16,21 The presence of a dog in the home lessens the probability of egg allergy in infants.²³ Food allergy is less common in younger siblings than in first-born children, possibly due to ­younger siblings’ increased exposure to infection and alterations in the gut microbiome.^23,24

Diagnosis: Established by presentation, positive testing

Onset of symptoms after exposure to a suspected food allergen almost always occurs within 2 hours and, typically, resolves within several hours. Symptoms should occur consistently after ingestion of the food allergen. Subsequent exposures can trigger more severe symptoms, depending on the amount, route, and duration of exposure to the allergen.²⁵ Reactions typically follow ingestion or cutaneous exposures; inhalation rarely triggers a response.²⁶ IgE-mediated release of histamine and other mediators from mast cells and basophils triggers reactions that typically involve one or more organ systems (Table 2).²⁵

Cutaneous symptoms are the most common manifestations of food allergy, occurring in 70% to 80% of childhood reactions. Gastrointestinal and oral or respiratory symptoms occur in, respectively, 40% to 50% and 25% of allergic reactions to food. Cardiovascular symptoms develop in fewer than 10% of allergic reactions.²⁶

Continue to: Anaphylaxis

Anaphylaxis is a serious allergic reaction that develops rapidly and can cause death; diagnosis is based on specific criteria (Table 3).²⁷ Data for rates of anaphylaxis due to food allergy are limited. The incidence of fatal reaction due to food allergy is estimated to be 1 in every 800,000 children annually.³

Clinical suspicion. Food allergy should be suspected in infants and children who present with anaphylaxis or other symptoms (Table 2²⁵) that occur within minutes to hours of ingesting food.⁴ Parental and self-reports alone are insufficient to diagnose food allergy. NIAID guidelines recommend that patient reports of food allergy be confirmed, because multiple studies demonstrate that 50% to 90% of presumed food allergies are not true allergy.⁴ Health care providers must obtain a detailed medical history and pertinent family history, plus perform a physical exam and allergy sensitivity testing. Methods to help diagnose food allergies include skin-prick tests, allergen-specific serum IgE tests, and oral food challenges.⁴

General principles and utility of testing

Before ordering tests, it’s important to distinguish between food sensitization and food allergy and to inform the families of children with suspected food allergy about the limitations of skin-prick tests and serum IgE tests. A child with IgE antibodies specific to a food or with a positive skin-prick test, but without symptoms upon ingestion of the food, is merely sensitized; food allergy indicates the appearance of symptoms following exposure to a specific food, in addition to the detection of specific IgE antibodies or a positive skin-prick test to that same food.²⁸

Skin-prick testing. Skin-prick tests can be performed at any age. The procedure involves pricking or scratching the surface of the skin, usually the volar aspect of the forearm or the back, with a commercial extract. Testing should be performed by a physician or other provider who is properly trained in the technique and in interpreting results. The extract contains specific allergenic proteins that activate mast cells, resulting in a characteristic wheal-and-flare response that is typically measured 15 to 20 minutes after application. Some medications, such as H₁- and H₂-receptor blockers and tricyclic antidepressants, can interfere with results and need to be held for 3 to 5 days before testing.

A positive skin-prick test result is defined as a wheal ≥ 3 mm larger in diameter than the negative control. The larger the size of the wheal, the higher the likelihood of a reaction to the tested food.²⁹ Patients who exhibit dermatographism might experience a wheal-and-flare response from the action of the skin-prick test, rather than from food-specific IgE antibodies. A negative skin-prick test has > 90% negative predictive value, so the test can rule out suspected food allergy.³⁰ However, the skin-prick test alone cannot be used to diagnose food allergy because it has a high false-positive rate.

Continue to: Allergen-specific serum IgE testing

Allergen-specific serum IgE ­testing. Measurement of food-specific serum IgE levels is routinely available and requires only a blood specimen. The test can be used in patients with skin disease, and results are not affected by concurrent medications. The presence of food-specific IgE indicates that the patient is sensitized to that allergen and might react upon exposure; children with a higher level of antibody are more likely to react.²⁹

Food-specific serum IgE tests are sensitive but nonspecific for food allergy.³¹ Broad food-allergy test panels often yield false-positive results that can lead to unnecessary dietary elimination, resulting in years of inconvenience, nutrition problems, and needless health care expense.³²

It is appropriate to order tests of specific serum IgE to foods ingested within the 2 to 3–hour window before onset of symptoms to avoid broad food allergy test panels. Like skin-prick testing, positive allergen-specific serum IgE tests alone cannot diagnose food allergy.

Oral food challenge. The double-blind, placebo-controlled oral food challenge is the gold standard for the diagnosis of food allergy. Because this test is time-consuming and technically difficult, single-blind or open food challenges are more common. Oral food challenges should be performed only by a physician or other provider who can identify and treat anaphylaxis.

The presence of a dog in the home lessens the probability of egg allergy in infants.

The oral challenge starts with a very low dose of suspected food allergen, which is gradually increased every 15 to 30 minutes as vital signs are monitored carefully. Patients are observed for an allergic reaction for 1 hour after the final dose.

Continue to: A retrospective study...

A retrospective study showed that, whereas 19% of patients reacted during an open food challenge, only 2% required epinephrine.³³ Another study showed that 89% of children whose serum IgE testing was positive for specific foods were able to reintroduce those foods into the diet after a reassuring oral food challenge.³⁴

Other diagnostic tests. The basophil activation assay, measurement of total serum IgE, atopy patch tests, and intradermal tests have been used, but are not recommended, for making the diagnosis of food allergy.⁴

How can food allergy be managed?

Medical options are few. No approved treatment exists for food allergy. However, it’s important to appropriately manage acute reactions and reduce the risk of subsequent reactions.¹ Parents or other caregivers can give an H₁ antihistamine, such as diphenhydramine, to infants and children with acute non-life-threatening symptoms. More severe symptoms require rapid administration of epinephrine.¹ Auto-injectable epinephrine should be prescribed for parents and caregivers to use as needed for emergency treatment of anaphylaxis.

Team approach. A multidisciplinary approach to managing food allergy—involving physicians, school nurses, dietitians, and teachers, and using educational materials—is ideal. This strategy expands knowledge about food allergies, enhances correct administration of epinephrine, and reduces allergic reactions.¹

Avoidance of food allergens can be challenging. Parents and caregivers should be taught to interpret the list of ingredients on food packages. Self-recognition of allergic reactions reduces the likelihood of a subsequent severe allergic reaction.³⁵

Continue to: Importance of individualized care

Importance of individualized care. Health care providers should develop personalized management plans for their patients.¹ (A good place to start is with the “Food Allergy & Anaphylaxis Emergency Care Plan”^a developed by Food Allergy Research & Education [FARE]). Keep in mind that children with multiple food allergies consume less calcium and protein, and tend to be shorter⁴; therefore, it’s wise to closely monitor growth in these children and consider referral to a dietitian who is familiar with food allergy.

Potential of immunotherapy. Current research focuses on immunotherapy to induce tolerance to food allergens and protect against life-threatening allergic reactions. The goal of immunotherapy is to lessen adverse reactions to allergenic food proteins; the strategy is to have patients repeatedly ingest small but gradually increasing doses of the food allergen over many months.³⁶ Although immunotherapy has successfully allowed some patients to consume larger quantities of a food without having an allergic reaction, it is unknown whether immunotherapy provides permanent resolution of food allergy. In addition, immunotherapy often causes serious systemic and local reactions.^1,36,37

Is prevention possible?

Maternal diet during pregnancy and lactation does not affect development of food allergy in infants.^38,39 Breastfeeding might prevent development of atopic disease, but evidence is insufficient to determine whether breastfeeding reduces the likelihood of food allergy.³⁹ In nonbreastfed infants at high risk of food allergy, extensively or partially hydrolyzed formula might help protect against food allergy, compared to standard cow’s milk formula.^9,39 Feeding with soy formula rather than cow’s milk formula does not help prevent food allergy.^39,40 Pregnant and breastfeeding women should not restrict their diet as a means of preventing food allergy.³⁹

Diet in infancy. Over the years, physicians have debated the proper timing of the introduction of solid foods into the diet of infants. Traditional teaching advocated delaying introduction of potentially allergenic foods to reduce the risk of food allergy; however, this guideline was based on inconsistent evidence,⁴¹ and the strategy did not reduce the incidence of food allergy. The prevalence of food allergy is lower in developing countries where caregivers introduce foods to infants at an earlier age.²⁰

Multiple studies demonstrate that 50% to 90% of presumed food allergies are not true allergy.

A recent large clinical trial indicates that early introduction of peanut-containing foods can help prevent peanut allergy. The study randomized 4- to 11-month-old infants with severe eczema, egg allergy, or both, to eat or avoid peanut products until 5 years of age. Infants assigned to eat peanuts were 81% less likely to develop peanut allergy than infants in the avoidance group. Absolute risk reduction was 14% (number need to treat = 7).⁴² Another study showed a nonsignificant (20%) lower relative risk of food allergy in breastfed infants who were fed potentially allergenic foods starting at 3 months of age, compared to being exclusively breastfed.⁴³

Continue to: Based on these data...

Based on these data,^42,43 NIAID instituted recommendations in 2017 aimed at preventing peanut allergy⁴⁴:

• In healthy infants without known food allergy and those with mild or moderate eczema, caregivers can introduce peanut-containing foods at home with other solid foods.Parents who are anxious about a possible allergic reaction can introduce peanut products in a physician’s office.
• Infants at high risk of peanut allergy (those with severe eczema or egg allergy, or both) should undergo peanut-specific IgE or skin-prick testing:
  • Negative test: indicates low risk of a reaction to peanuts; the infant should start consuming peanut-containing foods at 4 to 6 months of age, at home or in a physician’s office, depending on the parents’ preference
  • Positive test: Referral to an allergist is recommended.

Do children outgrow food allergy?

Approximately 85% of children who have an allergy to milk, egg, soy, or wheat outgrow their allergy; however, only 15% to 20% who have an allergy to peanuts, tree nuts, fish, or shellfish eventually tolerate these foods. The time to resolution of food allergy varies with the food, and might not occur until adolescence.⁴ No test reliably predicts which children develop tolerance to any given food. A decrease in the food-specific serum IgE level or a decrease in the size of the wheal on skin-prick testing might portend the onset of tolerance to the food.⁴

CORRESPONDENCE
Catherine M. Bettcher, MD, FAAFP, Briarwood Family Medicine, 1801 Briarwood Circle, Building #10, Ann Arbor, MI 48108; [email protected].

Food allergy is a complex condition that has become a growing concern for parents and an increasing public health problem in the United States. Food allergy affects social interactions, school attendance, and quality of life, especially when associated with comorbid atopic conditions such as asthma, atopic dermatitis, and allergic rhinitis.^1,2 It is the major cause of anaphylaxis in children, accounting for as many as 81% of cases.³ Societal costs of food allergy are great and are spread broadly across the health care system and the family. (See “What is the cost of food allergy?”².)

What a food allergy is—and isn’t

The National Institute of Allergy and Infectious Diseases ­(NIAID) defines food allergy as “an adverse health effect arising from a specific immune response that occurs reproducibly on exposure to a given food.”⁴ An adverse reaction to food or a food component that lacks an identified immunologic pathophysiology is not considered food allergy but is classified as food intolerance.⁴

The CDC estimates that 4% to 6% of children in the United States have a food allergy. Almost 40% of food-allergic children have a history of severe food-induced reactions.

Food allergy is caused by either immunoglobulin E (IgE)-mediated or non-IgE-mediated immunologic dysfunction. IgE antibodies can trigger an intense inflammatory response to certain allergens. Non-IgE-mediated food allergies are less common and not well understood.

© Joe Gorman

This article focuses only on the diagnosis and management of IgE-mediated food allergy.

The culprits

More than 170 foods have been reported to cause an IgE-­mediated reaction. Table 1^5-8 lists the 8 foods that most commonly cause allergic reactions in the United States and that account for > 50% of allergies to food.⁹ Studies vary in their methodology for estimating the prevalence of allergy to individual foods, but cow’s milk and peanuts appear to be the most common, each affecting as many as 2% to 2.5% of children.^7,8 In general, allergies to cow’s milk and to eggs are more prevalent in very young and preschool children, whereas allergies to peanuts, tree nuts, fish, and shellfish are more prevalent in older children.¹⁰ Labels on all packaged foods regulated by the US Food and Drug Administration must declare if the product contains even a trace of these 8 allergens.

How common is food allergy?

The Centers for Disease Control and Prevention (CDC) estimates that 4% to 6% of children in the United States have a food allergy.^11,12 Almost 40% of food-allergic children have a history of severe food-induced reactions.¹³ Other developed countries cite similar estimates of overall prevalence.^14,15

However, many estimates of the prevalence of food allergy are derived from self-reports, without objective data.⁹ Accurate evaluation of the prevalence of food allergy is challenging because of many factors, including differences in study methodology and the definition of allergy, geographic variation, racial and ethnic variations, and dietary exposure. Parents and children often confuse nonallergic food reactions, such as food intolerance, with food allergy. Precise determination of the prevalence and natural history of food allergy at the population level requires confirmatory oral food challenges of a representative sample of infants and young children with presumed food allergy.¹⁶

Continue to: The CDC concludes that the prevalence...

The CDC concludes that the prevalence of food allergy in children younger than 18 years increased by 18% from 1997 through 2007.^17,18 The cause of this increase is unclear but likely multifactorial; hypotheses include an increase in associated atopic conditions, delayed introduction of allergenic foods, and living in an overly sterile environment with reduced exposure to microbes.¹⁹ A recent population-based study of food allergy among children in Olmsted County, Minnesota, found that the incidence of food allergy increased between 2002 and 2007, stabilized subsequently, and appears to be declining among children 1 to 4 years of age, following a peak in 2006-2007.¹⁹

What are the risk factors?

Proposed risk factors for food allergy include demographics, genetics, a history of atopic disease, and environmental factors. Food allergy might be more common in boys than in girls, and in African Americans and Asians than in Whites.^12,16 A child is 7 times more likely to be allergic to peanuts if a parent or sibling has peanut allergy.²⁰ Infants and children with eczema or asthma are more likely to develop food allergy; the severity of eczema correlates with risk.^12,20 Improvements in hygiene in Western societies have decreased the spread of infection, but this has been accompanied by a rise in atopic disease. In countries where health standards are poor and exposure to pathogens is greater, the prevalence of allergy is low.²¹

A child is 7 times more likely to be allergic to peanuts if a parent or sibling has peanut allergy.

Conversely, increased microbial exposure might help protect against atopy via a pathway in which T-helper cells prevent pro-allergic immune development and keep harmless environmental exposures from becoming allergens.²² Attendance at daycare and exposure to farm animals early in life reduces the likelihood of atopic disease.^16,21 The presence of a dog in the home lessens the probability of egg allergy in infants.²³ Food allergy is less common in younger siblings than in first-born children, possibly due to ­younger siblings’ increased exposure to infection and alterations in the gut microbiome.^23,24

Diagnosis: Established by presentation, positive testing

Onset of symptoms after exposure to a suspected food allergen almost always occurs within 2 hours and, typically, resolves within several hours. Symptoms should occur consistently after ingestion of the food allergen. Subsequent exposures can trigger more severe symptoms, depending on the amount, route, and duration of exposure to the allergen.²⁵ Reactions typically follow ingestion or cutaneous exposures; inhalation rarely triggers a response.²⁶ IgE-mediated release of histamine and other mediators from mast cells and basophils triggers reactions that typically involve one or more organ systems (Table 2).²⁵

Cutaneous symptoms are the most common manifestations of food allergy, occurring in 70% to 80% of childhood reactions. Gastrointestinal and oral or respiratory symptoms occur in, respectively, 40% to 50% and 25% of allergic reactions to food. Cardiovascular symptoms develop in fewer than 10% of allergic reactions.²⁶

Continue to: Anaphylaxis

Anaphylaxis is a serious allergic reaction that develops rapidly and can cause death; diagnosis is based on specific criteria (Table 3).²⁷ Data for rates of anaphylaxis due to food allergy are limited. The incidence of fatal reaction due to food allergy is estimated to be 1 in every 800,000 children annually.³

Clinical suspicion. Food allergy should be suspected in infants and children who present with anaphylaxis or other symptoms (Table 2²⁵) that occur within minutes to hours of ingesting food.⁴ Parental and self-reports alone are insufficient to diagnose food allergy. NIAID guidelines recommend that patient reports of food allergy be confirmed, because multiple studies demonstrate that 50% to 90% of presumed food allergies are not true allergy.⁴ Health care providers must obtain a detailed medical history and pertinent family history, plus perform a physical exam and allergy sensitivity testing. Methods to help diagnose food allergies include skin-prick tests, allergen-specific serum IgE tests, and oral food challenges.⁴

General principles and utility of testing

Before ordering tests, it’s important to distinguish between food sensitization and food allergy and to inform the families of children with suspected food allergy about the limitations of skin-prick tests and serum IgE tests. A child with IgE antibodies specific to a food or with a positive skin-prick test, but without symptoms upon ingestion of the food, is merely sensitized; food allergy indicates the appearance of symptoms following exposure to a specific food, in addition to the detection of specific IgE antibodies or a positive skin-prick test to that same food.²⁸

Skin-prick testing. Skin-prick tests can be performed at any age. The procedure involves pricking or scratching the surface of the skin, usually the volar aspect of the forearm or the back, with a commercial extract. Testing should be performed by a physician or other provider who is properly trained in the technique and in interpreting results. The extract contains specific allergenic proteins that activate mast cells, resulting in a characteristic wheal-and-flare response that is typically measured 15 to 20 minutes after application. Some medications, such as H₁- and H₂-receptor blockers and tricyclic antidepressants, can interfere with results and need to be held for 3 to 5 days before testing.

A positive skin-prick test result is defined as a wheal ≥ 3 mm larger in diameter than the negative control. The larger the size of the wheal, the higher the likelihood of a reaction to the tested food.²⁹ Patients who exhibit dermatographism might experience a wheal-and-flare response from the action of the skin-prick test, rather than from food-specific IgE antibodies. A negative skin-prick test has > 90% negative predictive value, so the test can rule out suspected food allergy.³⁰ However, the skin-prick test alone cannot be used to diagnose food allergy because it has a high false-positive rate.

Continue to: Allergen-specific serum IgE testing

Allergen-specific serum IgE ­testing. Measurement of food-specific serum IgE levels is routinely available and requires only a blood specimen. The test can be used in patients with skin disease, and results are not affected by concurrent medications. The presence of food-specific IgE indicates that the patient is sensitized to that allergen and might react upon exposure; children with a higher level of antibody are more likely to react.²⁹

Food-specific serum IgE tests are sensitive but nonspecific for food allergy.³¹ Broad food-allergy test panels often yield false-positive results that can lead to unnecessary dietary elimination, resulting in years of inconvenience, nutrition problems, and needless health care expense.³²

It is appropriate to order tests of specific serum IgE to foods ingested within the 2 to 3–hour window before onset of symptoms to avoid broad food allergy test panels. Like skin-prick testing, positive allergen-specific serum IgE tests alone cannot diagnose food allergy.

Oral food challenge. The double-blind, placebo-controlled oral food challenge is the gold standard for the diagnosis of food allergy. Because this test is time-consuming and technically difficult, single-blind or open food challenges are more common. Oral food challenges should be performed only by a physician or other provider who can identify and treat anaphylaxis.

The presence of a dog in the home lessens the probability of egg allergy in infants.

The oral challenge starts with a very low dose of suspected food allergen, which is gradually increased every 15 to 30 minutes as vital signs are monitored carefully. Patients are observed for an allergic reaction for 1 hour after the final dose.

Continue to: A retrospective study...

A retrospective study showed that, whereas 19% of patients reacted during an open food challenge, only 2% required epinephrine.³³ Another study showed that 89% of children whose serum IgE testing was positive for specific foods were able to reintroduce those foods into the diet after a reassuring oral food challenge.³⁴

Other diagnostic tests. The basophil activation assay, measurement of total serum IgE, atopy patch tests, and intradermal tests have been used, but are not recommended, for making the diagnosis of food allergy.⁴

How can food allergy be managed?

Medical options are few. No approved treatment exists for food allergy. However, it’s important to appropriately manage acute reactions and reduce the risk of subsequent reactions.¹ Parents or other caregivers can give an H₁ antihistamine, such as diphenhydramine, to infants and children with acute non-life-threatening symptoms. More severe symptoms require rapid administration of epinephrine.¹ Auto-injectable epinephrine should be prescribed for parents and caregivers to use as needed for emergency treatment of anaphylaxis.

Team approach. A multidisciplinary approach to managing food allergy—involving physicians, school nurses, dietitians, and teachers, and using educational materials—is ideal. This strategy expands knowledge about food allergies, enhances correct administration of epinephrine, and reduces allergic reactions.¹

Avoidance of food allergens can be challenging. Parents and caregivers should be taught to interpret the list of ingredients on food packages. Self-recognition of allergic reactions reduces the likelihood of a subsequent severe allergic reaction.³⁵

Continue to: Importance of individualized care

Importance of individualized care. Health care providers should develop personalized management plans for their patients.¹ (A good place to start is with the “Food Allergy & Anaphylaxis Emergency Care Plan”^a developed by Food Allergy Research & Education [FARE]). Keep in mind that children with multiple food allergies consume less calcium and protein, and tend to be shorter⁴; therefore, it’s wise to closely monitor growth in these children and consider referral to a dietitian who is familiar with food allergy.

Potential of immunotherapy. Current research focuses on immunotherapy to induce tolerance to food allergens and protect against life-threatening allergic reactions. The goal of immunotherapy is to lessen adverse reactions to allergenic food proteins; the strategy is to have patients repeatedly ingest small but gradually increasing doses of the food allergen over many months.³⁶ Although immunotherapy has successfully allowed some patients to consume larger quantities of a food without having an allergic reaction, it is unknown whether immunotherapy provides permanent resolution of food allergy. In addition, immunotherapy often causes serious systemic and local reactions.^1,36,37

Is prevention possible?

Maternal diet during pregnancy and lactation does not affect development of food allergy in infants.^38,39 Breastfeeding might prevent development of atopic disease, but evidence is insufficient to determine whether breastfeeding reduces the likelihood of food allergy.³⁹ In nonbreastfed infants at high risk of food allergy, extensively or partially hydrolyzed formula might help protect against food allergy, compared to standard cow’s milk formula.^9,39 Feeding with soy formula rather than cow’s milk formula does not help prevent food allergy.^39,40 Pregnant and breastfeeding women should not restrict their diet as a means of preventing food allergy.³⁹

Diet in infancy. Over the years, physicians have debated the proper timing of the introduction of solid foods into the diet of infants. Traditional teaching advocated delaying introduction of potentially allergenic foods to reduce the risk of food allergy; however, this guideline was based on inconsistent evidence,⁴¹ and the strategy did not reduce the incidence of food allergy. The prevalence of food allergy is lower in developing countries where caregivers introduce foods to infants at an earlier age.²⁰

Multiple studies demonstrate that 50% to 90% of presumed food allergies are not true allergy.

A recent large clinical trial indicates that early introduction of peanut-containing foods can help prevent peanut allergy. The study randomized 4- to 11-month-old infants with severe eczema, egg allergy, or both, to eat or avoid peanut products until 5 years of age. Infants assigned to eat peanuts were 81% less likely to develop peanut allergy than infants in the avoidance group. Absolute risk reduction was 14% (number need to treat = 7).⁴² Another study showed a nonsignificant (20%) lower relative risk of food allergy in breastfed infants who were fed potentially allergenic foods starting at 3 months of age, compared to being exclusively breastfed.⁴³

Continue to: Based on these data...

Based on these data,^42,43 NIAID instituted recommendations in 2017 aimed at preventing peanut allergy⁴⁴:

• In healthy infants without known food allergy and those with mild or moderate eczema, caregivers can introduce peanut-containing foods at home with other solid foods.Parents who are anxious about a possible allergic reaction can introduce peanut products in a physician’s office.
• Infants at high risk of peanut allergy (those with severe eczema or egg allergy, or both) should undergo peanut-specific IgE or skin-prick testing:
  • Negative test: indicates low risk of a reaction to peanuts; the infant should start consuming peanut-containing foods at 4 to 6 months of age, at home or in a physician’s office, depending on the parents’ preference
  • Positive test: Referral to an allergist is recommended.

Do children outgrow food allergy?

Approximately 85% of children who have an allergy to milk, egg, soy, or wheat outgrow their allergy; however, only 15% to 20% who have an allergy to peanuts, tree nuts, fish, or shellfish eventually tolerate these foods. The time to resolution of food allergy varies with the food, and might not occur until adolescence.⁴ No test reliably predicts which children develop tolerance to any given food. A decrease in the food-specific serum IgE level or a decrease in the size of the wheal on skin-prick testing might portend the onset of tolerance to the food.⁴

CORRESPONDENCE
Catherine M. Bettcher, MD, FAAFP, Briarwood Family Medicine, 1801 Briarwood Circle, Building #10, Ann Arbor, MI 48108; [email protected].

Vaccines have been proven effective in preventing disease and are one of the most cost-effective and successful public health initiatives of the 20th century. Nevertheless, adult vaccination rates in the United States for vaccine-preventable diseases are low for most routinely recommended vaccines.¹ In 2013 alone, there were an estimated 3700 deaths in the United States (95% of which were adults) from pneumococcal infections—a vaccine-preventable disorder.²

Consider the threat posed by the flu. Annually, most people who die of influenza and its complications are adults, with estimates ranging from a low of 3000 to a high of 49,000 based on Centers for Disease Control and Prevention (CDC) data from the 1976-1977 flu season to the 2006-2007 season.³ Vaccination during the 2013-2014 season resulted in an estimated 7.2 million fewer cases of influenza, 90,000 fewer hospitalizations, and 3.1 million fewer medically attended cases than would have been expected without vaccination.⁴ If vaccination levels had reached the Healthy People 2020 target of 70%, an additional 5.9 million illnesses, 2.3 million medically attended illnesses, and 42,000 hospitalizations might have been averted.⁴

How are we doing with other vaccines? Based on the 2013 National Health Interview Survey, the CDC assessed vaccination coverage among adults ages ≥19 years for selected vaccines: pneumococcal vaccine, tetanus toxoid-containing vaccines (tetanus and diphtheria vaccine [Td] or tetanus and diphtheria with acellular pertussis vaccine [Tdap]), and vaccines for hepatitis A, hepatitis B, herpes zoster, and human papillomavirus (HPV). (With the exception of influenza vaccination, which is recommended annually for all adults, other vaccinations are directed at specific populations based on age, health conditions, behavioral risk factors, occupation, or travel conditions.)

Overall, coverage rates for hepatitis A and B, pneumococcal, Td, and human papillomavirus (HPV) for all adults did not improve from 2012 to 2013; rates increased only modestly for Tdap among adults ≥19 years, for herpes zoster among adults ≥60 years, and for HPV among men ages 19 to 26. Furthermore, racial and ethnic gaps in coverage are seen in all vaccines, and these gaps widened since 2012 for Tdap, herpes zoster, and HPV vaccination.¹

Commonly cited barriers to improved vaccine uptake in adults include lack of regular assessment of vaccine status; lack of physician and other health care provider knowledge on current vaccine recommendations; cost; insufficient stocking of some vaccines; financial disincentives for vaccination in the primary care setting; limited use of electronic records, tools, and immunization registries; missed opportunities; and patient hesitancy and vaccine refusal.⁵

Removing barriers to immunization. Several recommendations on ways to improve adult vaccination rates are made by many federal organizations as well as by The Community Preventive Services Task Force (Task Force), an independent, nonfederal, unpaid panel of public health and prevention experts. The Task Force—which makes recommendations based on systematic reviews of the evidence of effectiveness, the applicability of the evidence, economic evaluations, and barriers to implementation of interventions⁶—advocates a 3-pronged approach to improve adult vaccination rates: 1) enhance access to vaccination services; 2) increase community demand for vaccinations; and 3) incorporate physician- or system-based interventions into practice.⁷

Using your state’s immunization information system can help ensure accurate tracking of patients’ immunization status.

The CDC and other groups such as the National Vaccine Advisory Committee (NVAC) recommend that every routine adult office visit include a vaccination needs assessment, recommendation, and offer of vaccination.⁸ Additionally, the Task Force recommends 3 means of enhancing adult access to vaccination services: make home visits, reduce patient costs, and offer vaccination programs in the community.⁷

This article describes a number of simple steps physicians can take to increase the likelihood that adults will get their vaccines and reviews the literature on using new media such as smartphones and other Internet-based tools to improve immunization coverage.⁹

Increasing community demands for vaccinations

Physicians and other healthcare providers can increase community demand for vaccinations by improving their own knowledge on the subject, recommending vaccination to patients, and increasing their community and political involvement to strengthen or change laws to better support immunization uptake.

To increase awareness and education, keep abreast of the Advisory Committee on Immunization Practices (ACIP) recommendations and guidelines, which are updated annually and reported on in this journal’s Practice Alert column. Consider taking advantage of free immunization apps that are available from the CDC (“CDC Vaccine Schedules” http://www.cdc.gov/vaccines/schedules/hcp/schedule-app.html), the Society of Teachers of Family Medicine (STFM; “Shots Immunizations” http://www.immunizationed.org/Shots-Mobile-App), and the American College of Physicians (“ACP Immunization Advisor” http://immunization.acponline.org/app/).

Take steps to put guidelines into practice. Despite wide promulgation, clinical practice guidelines alone have had limited effect on changing physician behavior and improving patient outcomes. Interactive techniques are more effective than guidelines and didactic presentations alone at changing physician care and patient outcomes. Such techniques include audit/feedback (the reporting of an individual clinician’s vaccination rates compared with desired or target rates, for example), academic detailing/outreach, and reminders by way of electronic or other alerts.^10,11

Promote immunization to patients. Physicians are highly influential in determining a patient’s decision to vaccinate, and it is well documented that a strong recommendation about the importance of immunizations makes a difference to patients.^12,13

What you say and how you say it matters. A halfhearted recommendation for vaccination may result in the patient remaining unvaccinated.¹⁴ For example, “If you want, you can get your pneumonia shot today” is much less persuasive than, “I recommend you get your pneumonia vaccine today to prevent a potentially serious disease that affects thousands of adults each year.” Most adults believe that vaccines are important and are likely to get them if recommended by their health care professionals.¹⁵

At the time of a visit, chart reminders—electronic or paper—can keep the need for immunization visible amid competing priorities.

The CDC recommends that physicians encourage patients to make an informed decision about vaccination by sharing critical information highlighting the importance of vaccinations and reminding patients what vaccines protect against while addressing their concerns (www.cdc.gov/vaccines/adultstandards). Free educational materials for patients can be found at www.cdc.gov/vaccines/AdultPatientEd.

Draw on community resources. Laws and policies that require vaccinations as a prerequisite for attending childcare, school, or college increase coverage. Community and faith-based organizations are likely to play an important role in reducing racial and ethnic disparities in adult immunizations because they can deliver education that is culturally sensitive and tailored to specific subpopulations.^16,17 Physicians and other health care providers can get involved with community and faith-based groups and local and federal legislative efforts to improve immunization rates.

Consider implementing these system-based interventions

The following 6 system-based interventions can help improve adult immunization rates:

1. Develop a practice team. The practice team, based on the Patient-Centered Medical Home (PCMH), includes physicians, midlevel providers, nurses, medical assistants, pharmacists, social workers, and other staff. The PCMH team model can facilitate a shift of responsibilities among individuals to better orient the practice toward patients’ health and preventive services.^18,19 While physicians have traditionally held all of the responsibility for patient care, including screening for disease and prevention, shifting the responsibility of vaccine screening to nurses or medical assistants can free up time for longer physician/patient interactions.¹⁸

The creation of a practice champion within the PCMH team—a physician, midlevel provider, or nurse—to oversee quality improvement for vaccine rates and work to generate support and cooperation from coworkers has also been shown to improve vaccination rates.²⁰ The vaccine champion should keep abreast of new vaccine recommendations and relay that information to the practice through regular staff meetings, announcements, and office postings. The champion can also supervise pre-visit planning for immunizations.¹⁹

2. Use electronic immunization information systems (IIS). All states except New Hampshire have an IIS.²¹ Accurate tracking of adult immunizations in a registry provides a complete record and is essential to improving adult immunization rates,²² as does the use of chart notes, computerized alerts, checklists, and other tools that remind health care providers when patients are due for vaccinations.¹⁸ NVAC recommends that all physicians use their state IIS and create a process in their practice to include its use.

3. Incorporate physician feedback. Many health care systems and payers are using benchmarking and incentives to provide physician feedback on vaccination performance.²³ Using achievable benchmarks enhances the effectiveness of physician performance feedback.²⁴ The Task Force conducted a systematic review of the evidence on the effectiveness of health care provider assessment and feedback for increasing coverage rates and found that this strategy remains an effective means to increase vaccination rates.²⁵

4. Use reminders/alerts. Even though you may intend to routinely recommend immunizations, remembering to do so at the time of each visit can be difficult when there are so many other issues to address. Reminders at the time of the visit can help. Some electronic records have reminder prompts, or “best practice alerts” (BPAs), programmed into their systems.²⁶ These BPAs will prompt for needed immunizations whether the patient is being seen for a well, acute, or routine follow-up visit. These reminder/recall activities can be greatly simplified by participation in a population-based IIS.

Practices that don’t have an electronic health record can still improve vaccination rates by conveying the reminder with a brightly colored paper form attached to the front of a patient’s chart during the check-in process. One recent study showed that this approach increased rates of influenza vaccination in an urban practice by 12 percentage points.²⁷

Furthermore, simply reminding patients to vaccinate increases the vaccination rate.²⁸ Patient reminder/recall systems using telephone calls or mailings (phone calls are more effective than mailings) improve both childhood and adult vaccinations in all medical settings. More intensive systems using multiple reminders appear to be more effective than single reminders, and while costly, the benefits of increasing preventive visits/services and vaccine uptake help offset this cost.²⁸

5. Implement standing orders. Standing orders—which allow nurses and other appropriately trained health care personnel to assess immunization status and administer vaccinations according to protocol—help improve immunization rates.²⁹ ACIP advises that standing order programs be used in long-term care facilities under the supervision of a medical director to ensure the administration of recommended vaccinations for adults, and in inpatient and outpatient facilities. Because of the societal burden of influenza and pneumococcal disease, implementation of standing orders programs to improve adult vaccination coverage for these diseases is considered a national public health priority.³⁰

6. Develop an encouraging communication style. Studies show that how one communicates with patients is just as important as what one communicates. Certain communication styles and techniques may be more or less effective when discussing vaccination needs with some patients, especially those with vaccine hesitancy or low confidence in vaccine safety or effectiveness. For example, styles that are “directing” are usually unhelpful in addressing concerns about vaccination. These styles typically use information and persuasion to achieve change and may be perceived as confrontational. This approach can lead to cues being missed, jargon being used, and vaccine safety being overstated.

Styles shown to be helpful are those that elicit patient concerns, ask permission to discuss, acknowledge/listen/empathize, determine readiness to change, inform about benefits and risks, and give appropriate resources. These helpful forms of communication are more of a “May I help you?” style vs a “This is what you should do” style of communication.³¹

Telling a patient that vaccines are safe and, “You are silly not to get yours” is not as effective as saying, “What are your concerns about vaccines? Let’s talk about them.”

Assure patients that recommendations are based on the best interest of their health and on the best available science. Listen to a patient’s concerns and acknowledge them in a nonconfrontational manner, allowing patients to express their concerns and thereby increase their willingness to listen.³² Saying that there is “absolutely no need to worry—vaccines are safe and you are silly not to get yours” is not as effective as saying, “What are your concerns regarding vaccines? Let’s talk about them.”

For the vaccine-hesitant group, building trust is essential through a respectful, nonjudgmental approach that aims to elicit and address specific concerns. For those who refuse vaccines, keep the consultation brief, keep the door open for further discussion, and provide appropriate resources if the patient wants them.³³

Increase use of new media

Mass communication through smartphones and other Internet-based tools such as Facebook and Twitter brings a new dimension to health care, allowing patients and health professionals to communicate about health issues and possibly improve health outcomes.³⁴ The number of people using social media increased by almost 570% worldwide between 2000 and 2012 and surpassed 2.75 billion in 2013.³⁵

Sixty-one percent of adults in the United States look online for health information.³⁶ In a survey conducted in September 2014, the Pew Research Center found that Facebook is the most popular social media site in the United States. Seventy-one percent of online-knowledgeable adults use Facebook, and multiplatform use is on the rise: 52% of adult Internet users now use 2 or more social media sites, a significant increase from 2013, when it stood at 42%. (Other platforms such as Twitter, Instagram, Pinterest, and LinkedIn saw significant increases over the past year in the proportion of online adults who use them).³⁷

One RCT showed that patient access to a personalized Web-based portal increased influenza vaccination rates.

Health information provided by social media can answer medical questions and concerns and enhance health promotion and education.³⁵ A recent review of 98 research studies provided evidence that social media can create a space to share, comment, and discuss health information.³⁴ Compared with traditional communication methods, the widespread availability of social media makes health information more accessible, broadening access to various population groups, regardless of age, education, race, ethnicity, and locale.

New media platforms are proving effective. The first systematic assessment of available evidence on the use of new media to increase vaccine uptake and immunization coverage (a review of 7 randomized controlled trials [RCTs], 5 non-RCTs, 3 cross-sectional studies, one case-control study and 3 operational research studies published between 2000-2013) found that text messaging, accessing immunization campaign Web sites, using patient-held Web-based portals, computerized reminders, and standing orders increased immunization coverage rates.³⁵ However, evidence was insufficient in this regard on the value of social networks, email communication, and smartphone applications.

One RCT showed that having access to a personalized Web-based portal where patients could manage health records as well as interact with both health care providers and other members of the community through social forums and messaging tools increased influenza vaccination rates.³⁵

CORRESPONDENCE
Pamela G. Rockwell, DO, Department of Family Medicine, University of Michigan, 24 Frank Lloyd Wright Drive, P.O. Box 431, Ann Arbor, MI 48106-0795; [email protected].

Vaccines have been proven effective in preventing disease and are one of the most cost-effective and successful public health initiatives of the 20th century. Nevertheless, adult vaccination rates in the United States for vaccine-preventable diseases are low for most routinely recommended vaccines.¹ In 2013 alone, there were an estimated 3700 deaths in the United States (95% of which were adults) from pneumococcal infections—a vaccine-preventable disorder.²

Consider the threat posed by the flu. Annually, most people who die of influenza and its complications are adults, with estimates ranging from a low of 3000 to a high of 49,000 based on Centers for Disease Control and Prevention (CDC) data from the 1976-1977 flu season to the 2006-2007 season.³ Vaccination during the 2013-2014 season resulted in an estimated 7.2 million fewer cases of influenza, 90,000 fewer hospitalizations, and 3.1 million fewer medically attended cases than would have been expected without vaccination.⁴ If vaccination levels had reached the Healthy People 2020 target of 70%, an additional 5.9 million illnesses, 2.3 million medically attended illnesses, and 42,000 hospitalizations might have been averted.⁴

How are we doing with other vaccines? Based on the 2013 National Health Interview Survey, the CDC assessed vaccination coverage among adults ages ≥19 years for selected vaccines: pneumococcal vaccine, tetanus toxoid-containing vaccines (tetanus and diphtheria vaccine [Td] or tetanus and diphtheria with acellular pertussis vaccine [Tdap]), and vaccines for hepatitis A, hepatitis B, herpes zoster, and human papillomavirus (HPV). (With the exception of influenza vaccination, which is recommended annually for all adults, other vaccinations are directed at specific populations based on age, health conditions, behavioral risk factors, occupation, or travel conditions.)

Overall, coverage rates for hepatitis A and B, pneumococcal, Td, and human papillomavirus (HPV) for all adults did not improve from 2012 to 2013; rates increased only modestly for Tdap among adults ≥19 years, for herpes zoster among adults ≥60 years, and for HPV among men ages 19 to 26. Furthermore, racial and ethnic gaps in coverage are seen in all vaccines, and these gaps widened since 2012 for Tdap, herpes zoster, and HPV vaccination.¹

Commonly cited barriers to improved vaccine uptake in adults include lack of regular assessment of vaccine status; lack of physician and other health care provider knowledge on current vaccine recommendations; cost; insufficient stocking of some vaccines; financial disincentives for vaccination in the primary care setting; limited use of electronic records, tools, and immunization registries; missed opportunities; and patient hesitancy and vaccine refusal.⁵

Removing barriers to immunization. Several recommendations on ways to improve adult vaccination rates are made by many federal organizations as well as by The Community Preventive Services Task Force (Task Force), an independent, nonfederal, unpaid panel of public health and prevention experts. The Task Force—which makes recommendations based on systematic reviews of the evidence of effectiveness, the applicability of the evidence, economic evaluations, and barriers to implementation of interventions⁶—advocates a 3-pronged approach to improve adult vaccination rates: 1) enhance access to vaccination services; 2) increase community demand for vaccinations; and 3) incorporate physician- or system-based interventions into practice.⁷

Using your state’s immunization information system can help ensure accurate tracking of patients’ immunization status.

The CDC and other groups such as the National Vaccine Advisory Committee (NVAC) recommend that every routine adult office visit include a vaccination needs assessment, recommendation, and offer of vaccination.⁸ Additionally, the Task Force recommends 3 means of enhancing adult access to vaccination services: make home visits, reduce patient costs, and offer vaccination programs in the community.⁷

This article describes a number of simple steps physicians can take to increase the likelihood that adults will get their vaccines and reviews the literature on using new media such as smartphones and other Internet-based tools to improve immunization coverage.⁹

Increasing community demands for vaccinations

Physicians and other healthcare providers can increase community demand for vaccinations by improving their own knowledge on the subject, recommending vaccination to patients, and increasing their community and political involvement to strengthen or change laws to better support immunization uptake.

To increase awareness and education, keep abreast of the Advisory Committee on Immunization Practices (ACIP) recommendations and guidelines, which are updated annually and reported on in this journal’s Practice Alert column. Consider taking advantage of free immunization apps that are available from the CDC (“CDC Vaccine Schedules” http://www.cdc.gov/vaccines/schedules/hcp/schedule-app.html), the Society of Teachers of Family Medicine (STFM; “Shots Immunizations” http://www.immunizationed.org/Shots-Mobile-App), and the American College of Physicians (“ACP Immunization Advisor” http://immunization.acponline.org/app/).

Take steps to put guidelines into practice. Despite wide promulgation, clinical practice guidelines alone have had limited effect on changing physician behavior and improving patient outcomes. Interactive techniques are more effective than guidelines and didactic presentations alone at changing physician care and patient outcomes. Such techniques include audit/feedback (the reporting of an individual clinician’s vaccination rates compared with desired or target rates, for example), academic detailing/outreach, and reminders by way of electronic or other alerts.^10,11

Promote immunization to patients. Physicians are highly influential in determining a patient’s decision to vaccinate, and it is well documented that a strong recommendation about the importance of immunizations makes a difference to patients.^12,13

What you say and how you say it matters. A halfhearted recommendation for vaccination may result in the patient remaining unvaccinated.¹⁴ For example, “If you want, you can get your pneumonia shot today” is much less persuasive than, “I recommend you get your pneumonia vaccine today to prevent a potentially serious disease that affects thousands of adults each year.” Most adults believe that vaccines are important and are likely to get them if recommended by their health care professionals.¹⁵

At the time of a visit, chart reminders—electronic or paper—can keep the need for immunization visible amid competing priorities.

The CDC recommends that physicians encourage patients to make an informed decision about vaccination by sharing critical information highlighting the importance of vaccinations and reminding patients what vaccines protect against while addressing their concerns (www.cdc.gov/vaccines/adultstandards). Free educational materials for patients can be found at www.cdc.gov/vaccines/AdultPatientEd.

Draw on community resources. Laws and policies that require vaccinations as a prerequisite for attending childcare, school, or college increase coverage. Community and faith-based organizations are likely to play an important role in reducing racial and ethnic disparities in adult immunizations because they can deliver education that is culturally sensitive and tailored to specific subpopulations.^16,17 Physicians and other health care providers can get involved with community and faith-based groups and local and federal legislative efforts to improve immunization rates.

Consider implementing these system-based interventions

The following 6 system-based interventions can help improve adult immunization rates:

1. Develop a practice team. The practice team, based on the Patient-Centered Medical Home (PCMH), includes physicians, midlevel providers, nurses, medical assistants, pharmacists, social workers, and other staff. The PCMH team model can facilitate a shift of responsibilities among individuals to better orient the practice toward patients’ health and preventive services.^18,19 While physicians have traditionally held all of the responsibility for patient care, including screening for disease and prevention, shifting the responsibility of vaccine screening to nurses or medical assistants can free up time for longer physician/patient interactions.¹⁸

The creation of a practice champion within the PCMH team—a physician, midlevel provider, or nurse—to oversee quality improvement for vaccine rates and work to generate support and cooperation from coworkers has also been shown to improve vaccination rates.²⁰ The vaccine champion should keep abreast of new vaccine recommendations and relay that information to the practice through regular staff meetings, announcements, and office postings. The champion can also supervise pre-visit planning for immunizations.¹⁹

2. Use electronic immunization information systems (IIS). All states except New Hampshire have an IIS.²¹ Accurate tracking of adult immunizations in a registry provides a complete record and is essential to improving adult immunization rates,²² as does the use of chart notes, computerized alerts, checklists, and other tools that remind health care providers when patients are due for vaccinations.¹⁸ NVAC recommends that all physicians use their state IIS and create a process in their practice to include its use.

3. Incorporate physician feedback. Many health care systems and payers are using benchmarking and incentives to provide physician feedback on vaccination performance.²³ Using achievable benchmarks enhances the effectiveness of physician performance feedback.²⁴ The Task Force conducted a systematic review of the evidence on the effectiveness of health care provider assessment and feedback for increasing coverage rates and found that this strategy remains an effective means to increase vaccination rates.²⁵

4. Use reminders/alerts. Even though you may intend to routinely recommend immunizations, remembering to do so at the time of each visit can be difficult when there are so many other issues to address. Reminders at the time of the visit can help. Some electronic records have reminder prompts, or “best practice alerts” (BPAs), programmed into their systems.²⁶ These BPAs will prompt for needed immunizations whether the patient is being seen for a well, acute, or routine follow-up visit. These reminder/recall activities can be greatly simplified by participation in a population-based IIS.

Practices that don’t have an electronic health record can still improve vaccination rates by conveying the reminder with a brightly colored paper form attached to the front of a patient’s chart during the check-in process. One recent study showed that this approach increased rates of influenza vaccination in an urban practice by 12 percentage points.²⁷

Furthermore, simply reminding patients to vaccinate increases the vaccination rate.²⁸ Patient reminder/recall systems using telephone calls or mailings (phone calls are more effective than mailings) improve both childhood and adult vaccinations in all medical settings. More intensive systems using multiple reminders appear to be more effective than single reminders, and while costly, the benefits of increasing preventive visits/services and vaccine uptake help offset this cost.²⁸

5. Implement standing orders. Standing orders—which allow nurses and other appropriately trained health care personnel to assess immunization status and administer vaccinations according to protocol—help improve immunization rates.²⁹ ACIP advises that standing order programs be used in long-term care facilities under the supervision of a medical director to ensure the administration of recommended vaccinations for adults, and in inpatient and outpatient facilities. Because of the societal burden of influenza and pneumococcal disease, implementation of standing orders programs to improve adult vaccination coverage for these diseases is considered a national public health priority.³⁰

6. Develop an encouraging communication style. Studies show that how one communicates with patients is just as important as what one communicates. Certain communication styles and techniques may be more or less effective when discussing vaccination needs with some patients, especially those with vaccine hesitancy or low confidence in vaccine safety or effectiveness. For example, styles that are “directing” are usually unhelpful in addressing concerns about vaccination. These styles typically use information and persuasion to achieve change and may be perceived as confrontational. This approach can lead to cues being missed, jargon being used, and vaccine safety being overstated.

Styles shown to be helpful are those that elicit patient concerns, ask permission to discuss, acknowledge/listen/empathize, determine readiness to change, inform about benefits and risks, and give appropriate resources. These helpful forms of communication are more of a “May I help you?” style vs a “This is what you should do” style of communication.³¹

Telling a patient that vaccines are safe and, “You are silly not to get yours” is not as effective as saying, “What are your concerns about vaccines? Let’s talk about them.”

Assure patients that recommendations are based on the best interest of their health and on the best available science. Listen to a patient’s concerns and acknowledge them in a nonconfrontational manner, allowing patients to express their concerns and thereby increase their willingness to listen.³² Saying that there is “absolutely no need to worry—vaccines are safe and you are silly not to get yours” is not as effective as saying, “What are your concerns regarding vaccines? Let’s talk about them.”

For the vaccine-hesitant group, building trust is essential through a respectful, nonjudgmental approach that aims to elicit and address specific concerns. For those who refuse vaccines, keep the consultation brief, keep the door open for further discussion, and provide appropriate resources if the patient wants them.³³

Increase use of new media

Mass communication through smartphones and other Internet-based tools such as Facebook and Twitter brings a new dimension to health care, allowing patients and health professionals to communicate about health issues and possibly improve health outcomes.³⁴ The number of people using social media increased by almost 570% worldwide between 2000 and 2012 and surpassed 2.75 billion in 2013.³⁵

Sixty-one percent of adults in the United States look online for health information.³⁶ In a survey conducted in September 2014, the Pew Research Center found that Facebook is the most popular social media site in the United States. Seventy-one percent of online-knowledgeable adults use Facebook, and multiplatform use is on the rise: 52% of adult Internet users now use 2 or more social media sites, a significant increase from 2013, when it stood at 42%. (Other platforms such as Twitter, Instagram, Pinterest, and LinkedIn saw significant increases over the past year in the proportion of online adults who use them).³⁷

One RCT showed that patient access to a personalized Web-based portal increased influenza vaccination rates.

Health information provided by social media can answer medical questions and concerns and enhance health promotion and education.³⁵ A recent review of 98 research studies provided evidence that social media can create a space to share, comment, and discuss health information.³⁴ Compared with traditional communication methods, the widespread availability of social media makes health information more accessible, broadening access to various population groups, regardless of age, education, race, ethnicity, and locale.

New media platforms are proving effective. The first systematic assessment of available evidence on the use of new media to increase vaccine uptake and immunization coverage (a review of 7 randomized controlled trials [RCTs], 5 non-RCTs, 3 cross-sectional studies, one case-control study and 3 operational research studies published between 2000-2013) found that text messaging, accessing immunization campaign Web sites, using patient-held Web-based portals, computerized reminders, and standing orders increased immunization coverage rates.³⁵ However, evidence was insufficient in this regard on the value of social networks, email communication, and smartphone applications.

One RCT showed that having access to a personalized Web-based portal where patients could manage health records as well as interact with both health care providers and other members of the community through social forums and messaging tools increased influenza vaccination rates.³⁵

CORRESPONDENCE
Pamela G. Rockwell, DO, Department of Family Medicine, University of Michigan, 24 Frank Lloyd Wright Drive, P.O. Box 431, Ann Arbor, MI 48106-0795; [email protected].

Vaccines have been proven effective in preventing disease and are one of the most cost-effective and successful public health initiatives of the 20th century. Nevertheless, adult vaccination rates in the United States for vaccine-preventable diseases are low for most routinely recommended vaccines.¹ In 2013 alone, there were an estimated 3700 deaths in the United States (95% of which were adults) from pneumococcal infections—a vaccine-preventable disorder.²

Consider the threat posed by the flu. Annually, most people who die of influenza and its complications are adults, with estimates ranging from a low of 3000 to a high of 49,000 based on Centers for Disease Control and Prevention (CDC) data from the 1976-1977 flu season to the 2006-2007 season.³ Vaccination during the 2013-2014 season resulted in an estimated 7.2 million fewer cases of influenza, 90,000 fewer hospitalizations, and 3.1 million fewer medically attended cases than would have been expected without vaccination.⁴ If vaccination levels had reached the Healthy People 2020 target of 70%, an additional 5.9 million illnesses, 2.3 million medically attended illnesses, and 42,000 hospitalizations might have been averted.⁴

How are we doing with other vaccines? Based on the 2013 National Health Interview Survey, the CDC assessed vaccination coverage among adults ages ≥19 years for selected vaccines: pneumococcal vaccine, tetanus toxoid-containing vaccines (tetanus and diphtheria vaccine [Td] or tetanus and diphtheria with acellular pertussis vaccine [Tdap]), and vaccines for hepatitis A, hepatitis B, herpes zoster, and human papillomavirus (HPV). (With the exception of influenza vaccination, which is recommended annually for all adults, other vaccinations are directed at specific populations based on age, health conditions, behavioral risk factors, occupation, or travel conditions.)

Overall, coverage rates for hepatitis A and B, pneumococcal, Td, and human papillomavirus (HPV) for all adults did not improve from 2012 to 2013; rates increased only modestly for Tdap among adults ≥19 years, for herpes zoster among adults ≥60 years, and for HPV among men ages 19 to 26. Furthermore, racial and ethnic gaps in coverage are seen in all vaccines, and these gaps widened since 2012 for Tdap, herpes zoster, and HPV vaccination.¹

Commonly cited barriers to improved vaccine uptake in adults include lack of regular assessment of vaccine status; lack of physician and other health care provider knowledge on current vaccine recommendations; cost; insufficient stocking of some vaccines; financial disincentives for vaccination in the primary care setting; limited use of electronic records, tools, and immunization registries; missed opportunities; and patient hesitancy and vaccine refusal.⁵

Removing barriers to immunization. Several recommendations on ways to improve adult vaccination rates are made by many federal organizations as well as by The Community Preventive Services Task Force (Task Force), an independent, nonfederal, unpaid panel of public health and prevention experts. The Task Force—which makes recommendations based on systematic reviews of the evidence of effectiveness, the applicability of the evidence, economic evaluations, and barriers to implementation of interventions⁶—advocates a 3-pronged approach to improve adult vaccination rates: 1) enhance access to vaccination services; 2) increase community demand for vaccinations; and 3) incorporate physician- or system-based interventions into practice.⁷

Using your state’s immunization information system can help ensure accurate tracking of patients’ immunization status.

The CDC and other groups such as the National Vaccine Advisory Committee (NVAC) recommend that every routine adult office visit include a vaccination needs assessment, recommendation, and offer of vaccination.⁸ Additionally, the Task Force recommends 3 means of enhancing adult access to vaccination services: make home visits, reduce patient costs, and offer vaccination programs in the community.⁷

This article describes a number of simple steps physicians can take to increase the likelihood that adults will get their vaccines and reviews the literature on using new media such as smartphones and other Internet-based tools to improve immunization coverage.⁹

Increasing community demands for vaccinations

Physicians and other healthcare providers can increase community demand for vaccinations by improving their own knowledge on the subject, recommending vaccination to patients, and increasing their community and political involvement to strengthen or change laws to better support immunization uptake.

To increase awareness and education, keep abreast of the Advisory Committee on Immunization Practices (ACIP) recommendations and guidelines, which are updated annually and reported on in this journal’s Practice Alert column. Consider taking advantage of free immunization apps that are available from the CDC (“CDC Vaccine Schedules” http://www.cdc.gov/vaccines/schedules/hcp/schedule-app.html), the Society of Teachers of Family Medicine (STFM; “Shots Immunizations” http://www.immunizationed.org/Shots-Mobile-App), and the American College of Physicians (“ACP Immunization Advisor” http://immunization.acponline.org/app/).

Take steps to put guidelines into practice. Despite wide promulgation, clinical practice guidelines alone have had limited effect on changing physician behavior and improving patient outcomes. Interactive techniques are more effective than guidelines and didactic presentations alone at changing physician care and patient outcomes. Such techniques include audit/feedback (the reporting of an individual clinician’s vaccination rates compared with desired or target rates, for example), academic detailing/outreach, and reminders by way of electronic or other alerts.^10,11

Promote immunization to patients. Physicians are highly influential in determining a patient’s decision to vaccinate, and it is well documented that a strong recommendation about the importance of immunizations makes a difference to patients.^12,13

What you say and how you say it matters. A halfhearted recommendation for vaccination may result in the patient remaining unvaccinated.¹⁴ For example, “If you want, you can get your pneumonia shot today” is much less persuasive than, “I recommend you get your pneumonia vaccine today to prevent a potentially serious disease that affects thousands of adults each year.” Most adults believe that vaccines are important and are likely to get them if recommended by their health care professionals.¹⁵

At the time of a visit, chart reminders—electronic or paper—can keep the need for immunization visible amid competing priorities.

The CDC recommends that physicians encourage patients to make an informed decision about vaccination by sharing critical information highlighting the importance of vaccinations and reminding patients what vaccines protect against while addressing their concerns (www.cdc.gov/vaccines/adultstandards). Free educational materials for patients can be found at www.cdc.gov/vaccines/AdultPatientEd.

Draw on community resources. Laws and policies that require vaccinations as a prerequisite for attending childcare, school, or college increase coverage. Community and faith-based organizations are likely to play an important role in reducing racial and ethnic disparities in adult immunizations because they can deliver education that is culturally sensitive and tailored to specific subpopulations.^16,17 Physicians and other health care providers can get involved with community and faith-based groups and local and federal legislative efforts to improve immunization rates.

Consider implementing these system-based interventions

The following 6 system-based interventions can help improve adult immunization rates:

1. Develop a practice team. The practice team, based on the Patient-Centered Medical Home (PCMH), includes physicians, midlevel providers, nurses, medical assistants, pharmacists, social workers, and other staff. The PCMH team model can facilitate a shift of responsibilities among individuals to better orient the practice toward patients’ health and preventive services.^18,19 While physicians have traditionally held all of the responsibility for patient care, including screening for disease and prevention, shifting the responsibility of vaccine screening to nurses or medical assistants can free up time for longer physician/patient interactions.¹⁸

The creation of a practice champion within the PCMH team—a physician, midlevel provider, or nurse—to oversee quality improvement for vaccine rates and work to generate support and cooperation from coworkers has also been shown to improve vaccination rates.²⁰ The vaccine champion should keep abreast of new vaccine recommendations and relay that information to the practice through regular staff meetings, announcements, and office postings. The champion can also supervise pre-visit planning for immunizations.¹⁹

2. Use electronic immunization information systems (IIS). All states except New Hampshire have an IIS.²¹ Accurate tracking of adult immunizations in a registry provides a complete record and is essential to improving adult immunization rates,²² as does the use of chart notes, computerized alerts, checklists, and other tools that remind health care providers when patients are due for vaccinations.¹⁸ NVAC recommends that all physicians use their state IIS and create a process in their practice to include its use.

3. Incorporate physician feedback. Many health care systems and payers are using benchmarking and incentives to provide physician feedback on vaccination performance.²³ Using achievable benchmarks enhances the effectiveness of physician performance feedback.²⁴ The Task Force conducted a systematic review of the evidence on the effectiveness of health care provider assessment and feedback for increasing coverage rates and found that this strategy remains an effective means to increase vaccination rates.²⁵

4. Use reminders/alerts. Even though you may intend to routinely recommend immunizations, remembering to do so at the time of each visit can be difficult when there are so many other issues to address. Reminders at the time of the visit can help. Some electronic records have reminder prompts, or “best practice alerts” (BPAs), programmed into their systems.²⁶ These BPAs will prompt for needed immunizations whether the patient is being seen for a well, acute, or routine follow-up visit. These reminder/recall activities can be greatly simplified by participation in a population-based IIS.

Practices that don’t have an electronic health record can still improve vaccination rates by conveying the reminder with a brightly colored paper form attached to the front of a patient’s chart during the check-in process. One recent study showed that this approach increased rates of influenza vaccination in an urban practice by 12 percentage points.²⁷

Furthermore, simply reminding patients to vaccinate increases the vaccination rate.²⁸ Patient reminder/recall systems using telephone calls or mailings (phone calls are more effective than mailings) improve both childhood and adult vaccinations in all medical settings. More intensive systems using multiple reminders appear to be more effective than single reminders, and while costly, the benefits of increasing preventive visits/services and vaccine uptake help offset this cost.²⁸

5. Implement standing orders. Standing orders—which allow nurses and other appropriately trained health care personnel to assess immunization status and administer vaccinations according to protocol—help improve immunization rates.²⁹ ACIP advises that standing order programs be used in long-term care facilities under the supervision of a medical director to ensure the administration of recommended vaccinations for adults, and in inpatient and outpatient facilities. Because of the societal burden of influenza and pneumococcal disease, implementation of standing orders programs to improve adult vaccination coverage for these diseases is considered a national public health priority.³⁰

6. Develop an encouraging communication style. Studies show that how one communicates with patients is just as important as what one communicates. Certain communication styles and techniques may be more or less effective when discussing vaccination needs with some patients, especially those with vaccine hesitancy or low confidence in vaccine safety or effectiveness. For example, styles that are “directing” are usually unhelpful in addressing concerns about vaccination. These styles typically use information and persuasion to achieve change and may be perceived as confrontational. This approach can lead to cues being missed, jargon being used, and vaccine safety being overstated.

Styles shown to be helpful are those that elicit patient concerns, ask permission to discuss, acknowledge/listen/empathize, determine readiness to change, inform about benefits and risks, and give appropriate resources. These helpful forms of communication are more of a “May I help you?” style vs a “This is what you should do” style of communication.³¹

Telling a patient that vaccines are safe and, “You are silly not to get yours” is not as effective as saying, “What are your concerns about vaccines? Let’s talk about them.”

Assure patients that recommendations are based on the best interest of their health and on the best available science. Listen to a patient’s concerns and acknowledge them in a nonconfrontational manner, allowing patients to express their concerns and thereby increase their willingness to listen.³² Saying that there is “absolutely no need to worry—vaccines are safe and you are silly not to get yours” is not as effective as saying, “What are your concerns regarding vaccines? Let’s talk about them.”

For the vaccine-hesitant group, building trust is essential through a respectful, nonjudgmental approach that aims to elicit and address specific concerns. For those who refuse vaccines, keep the consultation brief, keep the door open for further discussion, and provide appropriate resources if the patient wants them.³³

Increase use of new media

Mass communication through smartphones and other Internet-based tools such as Facebook and Twitter brings a new dimension to health care, allowing patients and health professionals to communicate about health issues and possibly improve health outcomes.³⁴ The number of people using social media increased by almost 570% worldwide between 2000 and 2012 and surpassed 2.75 billion in 2013.³⁵

Sixty-one percent of adults in the United States look online for health information.³⁶ In a survey conducted in September 2014, the Pew Research Center found that Facebook is the most popular social media site in the United States. Seventy-one percent of online-knowledgeable adults use Facebook, and multiplatform use is on the rise: 52% of adult Internet users now use 2 or more social media sites, a significant increase from 2013, when it stood at 42%. (Other platforms such as Twitter, Instagram, Pinterest, and LinkedIn saw significant increases over the past year in the proportion of online adults who use them).³⁷

One RCT showed that patient access to a personalized Web-based portal increased influenza vaccination rates.

Health information provided by social media can answer medical questions and concerns and enhance health promotion and education.³⁵ A recent review of 98 research studies provided evidence that social media can create a space to share, comment, and discuss health information.³⁴ Compared with traditional communication methods, the widespread availability of social media makes health information more accessible, broadening access to various population groups, regardless of age, education, race, ethnicity, and locale.

New media platforms are proving effective. The first systematic assessment of available evidence on the use of new media to increase vaccine uptake and immunization coverage (a review of 7 randomized controlled trials [RCTs], 5 non-RCTs, 3 cross-sectional studies, one case-control study and 3 operational research studies published between 2000-2013) found that text messaging, accessing immunization campaign Web sites, using patient-held Web-based portals, computerized reminders, and standing orders increased immunization coverage rates.³⁵ However, evidence was insufficient in this regard on the value of social networks, email communication, and smartphone applications.

One RCT showed that having access to a personalized Web-based portal where patients could manage health records as well as interact with both health care providers and other members of the community through social forums and messaging tools increased influenza vaccination rates.³⁵

CORRESPONDENCE
Pamela G. Rockwell, DO, Department of Family Medicine, University of Michigan, 24 Frank Lloyd Wright Drive, P.O. Box 431, Ann Arbor, MI 48106-0795; [email protected].