Healthcare Infection Prevention

Vaccine void: Confusion, inaction imperils LTC residents

Despite state shot reg, Strep pneumo kills four in nursing home outbreak

Vulnerable residents of long-term care facilities continue to die of invasive pneumococcal disease caused by Streptococcus pneumoniae because they have not been administered an available vaccine. Doubts about the efficacy of the vaccine and confusion about whether residents have previously been immunized appear to be contributing to a situation that leaves frail, elderly residents susceptible to a deadly infection.

The latest in a series of outbreaks reported over the years occurred in a New Jersey nursing home, where four unvaccinated residents died of invasive pneumococcal disease, the Centers for Disease Control and Prevention reported. A case-control study revealed that "illness was strongly associated with lack of documentation of receipt of pneumococcal polysaccharide vaccine (PPV), the CDC concludes.1 (See "Lack of vaccination prime risk factor," in this issue.)

The low rate of PPV vaccination among institutionalized elderly has been attributed, in part, to a lack of physician emphasis on PPV administration.2

"Some people don’t think it works, but the efficacy in general is good," says Chris Van Beneden, MD, medical epidemiologist with the CDC respiratory diseases branch. "The evidence is: It does provide protection. It is definitely worth giving it, but there are mixed opinions."

On the other side of the risk coin, adults in long-term care are especially vulnerable to pneumococcal disease and death because of at least three factors: advanced age, the frequent presence of chronic illnesses, and residence in a setting prone to secondary spread of an introduced pathogen. Looking at the fiscal considerations, for once money does not appear to be the problem.

Pneumococcal vaccinations are covered by Medicare, and virtually all state Medicaid plans cover vaccinations for high-risk groups (e.g., residents of nursing facilities), the CDC emphasizes. However, PPV coverage among elderly adults in long-term care remains low, and outbreaks of pneumococcal pneumonia still occur in facilities with low vaccine coverage. In 1999, PPV coverage among a sample of nursing home residents in the United States was 38%.3

Incomplete documentation of vaccination history of nursing home residents and misconceptions about adverse reactions after unintended revaccination with PPV may discourage health care providers from vaccinating those with unknown vaccination history. "Sometimes they think it has already been given to them," Van Beneden says. "The records can be hard to find."

In an attempt to overcome this barrier, the CDC is emphasizing that the serious adverse events following revaccination are low.4 Another confusing element is that revaccination is actually indicated for certain residents who received their original immunization before age 65.

"They are [all] not supposed to be revaccinated in general," Van Beneden says. "But if they were less then 65 when they received the vaccine, and now they are over 65, and it has been more then five years, then you give it to them. Unfortunately, people misinterpret this and say give it every five years or give it again in five years. That’s wrong."

Whatever the problem, the bottom line is that the vaccine is not being offered. A study of Medicare inpatients indicated that opportunities to provide pneumococcal vaccines were missed for up to 80% of eligible elderly persons hospitalized with pneumonia.5 One of the national health objectives for 2010 is to achieve 90% pneumococcal vaccination coverage among nursing home residents and adults aged 65 or older.

"Historically, people are not getting it that frequently," she says. "It is usually only about half the people above the age 65 have gotten it."

Several methods have been developed for improving vaccine delivery. For example, consider implementing standing orders authorizing health care workers to administer vaccinations according to institutional and physician-approved protocols. In addition, regulations that mandate hospitals, adult day-care facilities, and long-term care settings to offer and document pneumococcal vaccinations would seemingly be the answer.

However, the New Jersey outbreak occurred despite passage of such a regulation, which requires hospitals to offer PPV to admitted patients age 65 and older.

In a follow-up study to the outbreak investigation, researchers looked at hospitals that had admitted residents of the nursing home before their long-term care placement or during the preceding year. Infection control professionals at the selected hospitals — which were not identified by the CDC — were interviewed to clarify hospital policy on offering the vaccine to PPV-eligible patients. Investigators randomly selected medical records of patients aged 65 or older to determine whether PPV was offered and administered. The medical records of 52 patients from four hospitals were reviewed. Forty-nine of the patients already had been discharged at the time of review.

Each hospital had a form to facilitate physician identification and documentation of PPV-eligible patients. In all, 35 (67%) of 52 medical records contained completed screening or assessment forms. Investigators determined that 13 (25%) of the 52 patients had received PPV before hospital admission. Overall, 34 patients had no history of having received PPV and no contraindications to the vaccine. Despite the procedures in place, none of those 34 patients had documentation of receipt of PPV while hospitalized.

"The outbreak occurred in a setting of low vaccination coverage despite state regulations designed to improve vaccine delivery," the CDC concludes. "A multifaceted approach that both facilitates delivery through standing orders programs and increases awareness of the importance of preventing pneumococcal disease may be needed to ensure optimal vaccine delivery to long-term care residents."

References

1. Centers for Disease Control and Prevention. Outbreak of pneumococcal pneumonia among unvaccinated residents of a nursing home — New Jersey, April 2001. MMWR 2001; 50:707-710.

2. Sisk JE, Moskowitz AJ, Whang W, et al. Cost-effectiveness of vaccination against pneumococcal bacteremia among elderly people. JAMA 1997; 278:1333-1339.

3. CDC. Outbreaks of pneumococcal pneumonia among unvaccinated residents in chronic-care facilities — Massa-chusetts, October 1995, Oklahoma, February 1996, and Maryland, May-June 1996. MMWR 1997; 46:60-62.

4. Jackson LA, Benson P, Sneller VP, et al. Safety of revaccination with pneumococcal polysaccharide vaccine. JAMA 1999; 281:243-248.

5. CDC. Missed opportunities for pneumococcal and influenza vaccination of Medicare pneumonia inpatients — 12 western states, 1995. MMWR 1997; 46:919-923.