|
In 1907, pneumonia was the leading cause of death in the United States.1 In 2007, it was the eighth leading cause of death. 2 That year, pneumococcal infection caused 52,847 deaths in the United States, more than any other vaccine-preventable disease. The mortality rate associated with pneumonia and influenza is 17.5 per 100,000 people.3
Healthy People 2010 states that "vaccines are among the greatest public health achievements of the 20th century."4 But this achievement's potential is unrealized when it comes to the 23-valent pneumococcal polysaccharide vaccine (PPSV23), which prevents at least 85% of the serotypes that cause invasive pneumococcal infection. The Centers for Disease Control and Prevention (CDC) has estimated that half of these deaths would be prevented through vaccination.3
Streptococcus pneumoniae does not manifest as pulmonary disease alone. Its more than 90 serotypes cause an estimated 3,000 cases of meningitis, 50,000 cases of bacteremia, 500,000 cases of pneumonia and 7 million cases of otitis media annually.3 Eckrode et al label it one of the leading infectious diseases in the United States, killing more people annually than AIDS, tuberculosis, meningitis and endocarditis combined.5,6 The case-fatality rate of pneumococcal-related disease is high. For example, 1 in 5 adults who develop pneumococcal bacteremia dies.3
S pneumoniae is the leading culprit in community-acquired bacterial meningitis. Thus, the CDC has recommended administering the pneumococcal polysaccharide vaccine to people older than 65 who have not had the vaccine and for all others between ages 2 and 65 who have medical indications for the vaccine.3,7-9 NPs and PAs have a responsibility to take steps to increase screening and administration of PPSV23 in the recommended populations.
 Risk Factors
The CDC reports that 91% of adults with invasive pneumococcal infection have at least one of the risk factors to indicate vaccination.3 The CDC recommendations are categorized as strong, moderate and justified (see table). Strong evidence and clinical benefits exist for vaccination of patients older than 2 with the following risks: chronic cardiovascular or pulmonary disease, asthma, diabetes mellitus, tobacco use, sickle cell disease, or splenectomy. Moderate evidence and benefits exist for patients older than 2 with the following risks: chronic liver disease, cerebrospinal fluid leaks or alcoholism. Justified vaccination based on the high risk for disease and the potential benefits of vaccination exists for patients older than 2 with the following risk factors: HIV infection, leukemia, lymphoma, Hodgkin's disease, multiple myeloma, generalized malignancy, chronic renal failure, nephrotic syndrome, receiving immunosuppressive chemotherapy, long-term systemic corticosteroid therapy, organ/bone/cochlear transplantation and institutionalized status.3,7-9 Link to current adult immunization schedules at www.cdc.gov/vaccines/recs/schedules/adult-schedule.htm.
Vaccination Considerations
A few special considerations should be noted for the populations mentioned above. Patients older than 65 should be vaccinated unless they received PPSV23 within the last 5 years and were younger than 65 at the time. Patients at highest risk for serious infection should be revaccinated after 5 years. If vaccination status is unknown, inoculation is recommended. Patients with HIV should be vaccinated as soon as possible after diagnosis in order to prevent transient elevations of plasma HIV levels. Two weeks should lapse between vaccination and the start of immunosuppressive therapies such as chemotherapy.3,7-9
Reactions associated with PPSV23 are minimal. In a recent meta-analysis, less than one-third of patients had mild local effects (pain, swelling or erythema). Fever, myalgias and local induration are rare. No deaths or neurologic disorders have been recorded in conjunction with pneumococcal vaccination.3 The only contraindications to receiving PPSV23 are previous anaphylaxis upon receiving the vaccination or previous anaphylaxis to a vaccination component.3,7
The only precaution to receiving the vaccine is moderate or severe acute illness with or without fever.4,7 For this reason, in an inpatient setting, critically ill ICU patients or those allergic to thimerosol are often excluded from receiving the vaccination.5,10 Any adverse reaction should be reported to the federal Vaccine Adverse Event Reporting System at (800) 822-7967 or www.vaers.hhs.gov.3,7
A National Health Objective
Even with these established guidelines and effectiveness as high as 84%, the national health goal for immunization against pneumococcal disease remains unachieved.4 The Healthy People 2010 objective for pneumococcal vaccination among patients 65 and older was set at 90%; for patients younger than 65, the goal was 60% vaccination.2,3,10 In 2008, the actual inoculation rate for patients older than 65 was only 60%; for those younger than 65, it was 25%.3,10
Disparities exist in these rates according to gender and race.11 Due to the gap between potential and actual vaccination, Healthy People 2020 will continue to devote 10  objectives to pneumococcal vaccination and awareness.12
Rapidly rising healthcare costs have increased the interest in and necessity for preventive public health efforts. The PPSV23 vaccine is a cost-effective and efficient way to prevent illness and infection and reduce expenditures for treatment.3,4 In light of the unmet national health vaccination objective, the CDC, the Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics, the American College of Physicians, and the American Academy of Family Physicians recommend vaccinating high-risk patients in an inpatient or outpatient setting.3,4,7,10 The Shenandoah study found that of inpatients diagnosed with pneumococcal pneumonia, up to two-thirds had been admitted within the last 4 years but had not received the PPSV23 vaccine.7,13
An inpatient strategy is much more feasible than a national campaign because patients who meet high-risk criteria are more likely to be identified while they are inpatients.5,14,15 A recent study at an Oregon hospital found that of 5,000 inpatients screened, more than 50% met the criteria for receiving pneumococcal vaccination.5
Barriers to Inpatient Vaccination
Specific barriers to vaccination programs in tertiary care exist. But a federal regulation that approves the use of standing orders by nurses or pharmacists has helped increase the possibility for creative strategies. The Immunization Action Coalition has published a standing order that can be adapted for any institution.7 A standing order vaccination policy at a New York hospital increased the inoculation rate from 0% to 78%.4,16 But even successful inpatient initiatives have revealed much resistance to new interventions in inpatient settings.
Middleton et al have categorized patient, provider and institutional barriers to implementation of vaccination policies in two large tertiary hospitals and a community hospital.10 The most pertinent patient barriers were obtaining an accurate vaccination history and patient or family resistance related to side effects or lack of education about the vaccine.10 The ACIP recommends accepting adult patient reports of previous vaccination as accurate but also points out that revaccination has rare deleterious effects.4,9,10 The institutional barriers encountered included complex development, low cost-benefit ratios, and breakdowns in the process of vaccination from start to finish.10
Overcoming Barriers
The ability to overcome barriers requires dedicated ownership by clinician leaders. According to Middleton et al, the development and use of efficient electronic health records (EHR) and standing orders are essential.10 Some states are attempting to develop shared EHR databases across inpatient and outpatient facilities. Clear guidelines and thorough education of ancillary and clinical staff are imperative.
Middleton et al also found that giving staff feedback on weekly progress was helpful to continue motivating adherence to the new process and procedures. Designation of one discipline as the screening clinician helped reduce workload and role confusion. Facility rates of vaccination increased when a daily time of administration (e.g., between 6 p.m. and 7 p.m.) was established. Evening was advantageous because it reduced the chance of sequelae that may affect patient tests or procedures and the likelihood that the patient would be outside the unit. Preadmission screenings for history, shared information with outpatient facilities and permanent identification on a patient's chart were helpful in reducing revaccination rates upon readmission.10 In short, the authors concluded that clear, organized, detailed and thorough communication through the layers of a tertiary institution are essential to the implementation process.
Our Responsibility
Although we are living in the era of conjugate vaccines, pneumococcal illness is the leading infectious disease. Pneumonia still ranks among the top 10 causes of death, even though it is the most common vaccine-preventable illness. National and state support for increasing vaccine administration exists. An efficient vaccine campaign for patients at risk is appropriate for implementation in tertiary care settings. Although this process is complex, clinical leadership and good communication can overcome barriers and increase vaccination rates. We have a responsibility to follow evidence-based practice guidance and meet Healthy People 2020 objectives by increasing pneumococcal vaccination in the recommended populations.
Amy Painter is a family nurse practitioner who is a clinical instructor in the colleges of nursing and medicine at the Medical University of South Carolina in Charleston.
References
1. U.S. Public Health Service. Vital Statistics of the United States. Washington DC: Federal Security Agency; 1900-1940: Vol. I -II. National Vital Statistics System. http://www.cdc.gov/nchs/nvss/mortality_historical_data.htm. Accessed Sept. 23, 2011.
2. Kochanek K. Deaths: preliminary data for 2009. National Vital Statistics Reports. 2011;59(4):1-51.
3. Centers for Disease Control and Prevention; Advisory Committee on Immunization Practices. Updated recommendations for prevention of invasive pneumococcal disease among adults using the 23-valent pneumococcal polysaccharide vaccine. 2010;59(31):1102-1106.
4. U.S. Department of Health and Human Services. Healthy People 2010: Objectives for improving health. http://www.cdc.gov/nchs/healthy_people/hp2010.htm. Accessed Sept. 23, 2011.
5. Eckrode C, et al. Implementation and evaluation of a nursing assessment/standing orders-based inpatient pneumococcal vaccination program. Am J Infect Control. 2007;35(8):508-515.
6. Maki DB. Pneumococcal bacteremia: lessons learned, yet more to learn. Mayo Clinic Proc. 2004;79(5):599-603.
7. Immunization Action Coalition. Standing orders for administering vaccines: pneumococcal polysaccharide vaccine (PPSV). http://www.immunize.org/catg.d/p3075.pdf. Accessed Sept. 23, 2011.
8. Centers for Disease Control and Prevention. Recommended Adult Immunization Schedule - United States, 2011. http://www.cdc.gov/vaccines/recs/schedules/adult-schedule.htm. Accessed Sept. 23, 2011.
9. Advisory Committee on Immunization Practices. Supplemental and archived pneumococcal ACIP recommendations. http://www.cdc.gov/vaccines/pubs/acip-list-sup/acip-sup-pneumo.htm. Accessed Sept. 23, 2011.
10. Middleton DB, et al. Overcoming barriers to establishing an inpatient vaccination program for pneumococcus using standing orders. Infect Control Hosp Epidemiol. 2005;26(11): 874-881.
11. Schiller J, Euler G. Vaccination coverage estimates from the National Health Interview Survey: United States, 2008. Table 2. http://www.cdc.gov/nchs/data/hestat/vaccine_coverage/vaccine_coverage.pdf. Accessed Sept. 23, 2011.
12. Healthy People 2020 objectives. http://www.healthypeople.gov/2020/topicsobjectives2020/. Accessed Sept. 23, 2011.
13. Fedson DS, et al. Hospital-based pneumococcal immunization. Epidemiologic rationale from the Shenandoah study. JAMA. 1990;264(9):1117-1122.
14. Vondracek T, et al. A hospital-based pharmacy intervention program for pneumococcal vaccination. Arch Int Med. 1998;158(14):1543-1547.
15. Robinson KA, et al. Epidemiology of invasive Streptococcus pneumoniae infections in the United States. 1995-1998: Opportunities for prevention in the conjugate vaccine era. JAMA. 2001;285(13):1729-1735.
16. Klein RS, Adachi N. An effective hospital-based pneumococcal immunization program. Arch Intern Med. 1986;146(2):327-329.
|