Increasing pneumococcal vaccination rates among hospitalized patients.

OBJECTIVE: To increase the proportion of inpatients vaccinated against pneumococcal infection. DESIGN: Pre- and post-intervention study. SETTING: University medical center-affiliated, suburban community teaching hospital. PATIENTS: Unvaccinated inpatients 65 years and older and those 2 to 64 years old who had chronic medical conditions predisposing them to invasive pneumococcal infection. INTERVENTION: The nursing staff screened newly admitted patients for eligibility based on age, diagnosis, or medications from a computer-generated admissions list and placed a pre-printed order form for the pneumococcal polysaccharide vaccine (PPV) on the charts of eligible patients. Following the physician's order, the nursing staff administered the PPV and recorded it Ongoing quality improvements including admission vaccination screening and computer-based record keeping were initiated to identify unvaccinated eligible patients and track vaccination status. RESULTS: Efforts resulted in rates of in-hospital vaccination ranging from 3.1% to 7.9% (mean, 5.2% +/- 1.7% [standard deviation]) and significant improvements in the assessment of previous vaccination status, reaching 54% of eligible patients after 1 year. Ascertainment of a previous vaccination increased significantly following the initiation of the use of admission forms that specifically assessed vaccination status and a system to permanently record vaccination status in an electronic medical record (P < .05). CONCLUSION: Concerted efforts using electronic medical records significantly improved the assessment and documentation of inpatient vaccination status. Greater improvement of the rates of in-hospital vaccination will require healthcare system-wide efforts such as a standing order policy for vaccinating all eligible patients. Standing orders for inpatient immunization supported by effective assessment and tracking systems have the potential to raise vaccination rates to the goals of Healthy People 2010.     

Prevention of community-acquired pneumonia among a cohort of hospitalized elderly: benefit due to influenza and pneumococcal vaccination not demonstrated

Benefits from influenza and 23-valent pneumococcal polysaccharide (23vPPV) vaccines against invasive pneumococcal disease and laboratory confirmed influenza have been well documented. However, their effectiveness against pneumonia remains controversial for community-based elderly > or = 65 years. Using a case-cohort design we examined incremental VE of 23vPPV over and above influenza vaccine against hospitalization with community-acquired pneumonia (HCAP) in two large Australian hospitals. 1952 cases (ICD-10-AM codes for pneumonia: J10-J18) and 2927 randomly selected cohort subjects were studied. Vaccination status was confirmed by providers. Benefit against HCAP was not demonstrated in multivariate analysis for influenza vaccine compared with neither vaccine (RR 1.02, 95%CI 0.84-1.20) or for both vaccines compared with influenza vaccine (RR 0.98, 95%CI 0.81-1.18). The current program of funding these vaccines for the elderly is not having a discernable impact on HCAP in this setting.     

Validity of self-reported influenza and pneumococcal vaccination status among a cohort of hospitalized elderly inpatients

Use of self-reported vaccination status is commonplace in assessing vaccination coverage for public health programs and individuals, yet limited validity data exist. We compared self-report with provider records for pneumococcal (23vPPV) and influenza vaccine for 4887 subjects aged>or=65 years from two Australian hospitals. Self-reported influenza vaccination status had high sensitivity (98%), positive predictive value (PPV) (88%) and negative predictive value (NPV) (91%), but low specificity (56%). Self-reported 23vPPV (previous 5 years) had a sensitivity of 84%, specificity 77%, PPV 85% and NPV 76%. Clinicians can be reasonably confident of self-reported influenza vaccine status, and for positive self-report for 23vPPV in this setting. For program evaluation, self-reported influenza vaccination coverage among inpatients overestimates true coverage by about 10% versus 1% for 23vPPV. Self-report remains imperfect and whole-of-life immunisation registers a preferable goal.     

Cardioprotective effect of influenza and pneumococcal vaccination in patients with cardiovascular diseases

Due to the wide interaction between the respiratory and the circulatory systems, influenza and pneumococcal vaccinations are recommended in the prevention and treatment of cardiovascular diseases. The review summarizes the results of recent studies and meta-analyses demonstrating that in this group of high-risk patients both vaccinations have potentially beneficial properties. However, in the era of Evidence Base Medicine, there is still a lack of randomized prospective clinical trials, especially those evaluating the effect of pneumococcal vaccination. As the burden of cardiovascular diseases represents various pathologies, it is important to point that the beneficial effect of vaccination is more pronounced in the atherosclerotic etiology, especially in patients after recent coronary events. This information contributes significantly to the appreciation of the role of the adaptive and innate immunity in atherosclerosis, which is now considered as immuno-inflammatory process driven by LDL-cholesterol intimal infiltration and macrophages activation. The mechanism of the cardioprotective effect of vaccination may not only be associated with the elimination of infections and their complications, but also related to the modification of the immuno-inflammatory model of atherosclerosis.     

Status of influenza and pneumococcal vaccination among older American Indians and Alaska Natives

Objectives. We sought to estimate the influenza and pneumococcal vaccination coverage among older American Indian and Alaska Native (AIAN) adults nationally and the impact of sociodemographic factors, variations by geographic region, and access to services on vaccination coverage.Methods. We obtained our sample of 1981 AIAN and 179845 White respondents 65 years and older from Behavioral Risk Factor Surveillance System data from 2003 to 2005. Logistic regression provided predictive marginal vaccination coverage for each covariate and adjusted for demographic characteristics and access to care.Results. Unadjusted influenza coverage estimates were similar between AIAN and White respondents (68.1% vs 69.5%), but pneumococcal vaccination was lower among AIAN respondents (58.1% vs 67.2%; P<.01). After multivariable adjustment for sociodemographic characteristics, self-reported coverage for both vaccines was statistically similar between AIAN and White adults.Conclusions. Although there was no disparity in influenza coverage, pneumococcal coverage was lower among AIAN than among White respondents, probably because of sociodemographic risk factors. Regional variation indicates a need to monitor coverage and target interventions to reduce disparities within geographically and culturally diverse subpopulations of AIAN persons.Racial and ethnic disparities in influenza and pneumococcal vaccinations among older adults are well documented. In the 2005 National Health Interview Survey, 63% of Whites 65 years and older in the United States reported receiving an influenza vaccine in the last 12 months, compared with 42% of Hispanics and 39% of African Americans.1 For pneumococcal vaccination, gaps of similar or greater magnitude were observed.1 These disparities have persisted over time, even as overall influenza and pneumococcal vaccination coverage has increased.2American Indians and Alaska Natives comprise approximately 1.5% of the US population,3 but they experience a significant and disproportionate burden of poor health.4 American Indian and Alaska Native (AIAN) adults are more likely than are Whites to report risk factors for chronic disease including tobacco use, obesity, diabetes, and physical inactivity, and these disparities persist among adults 55 years and older.5^,6 Rates of infant mortality and deaths associated with alcoholism, tuberculosis, and accidents are all higher among AIAN populations than among Whites, and older AIAN adults experience higher rates of invasive pneumococcal disease than does the general US population.7^,8 Urban AIAN residents, who may live farther from health facilities designated specifically for American Indians, experience similar disparities compared with general urban populations.9^,10On the basis of county- and state-level assessments using various methodologies, estimates of influenza vaccination coverage among AIAN adults 50 years and older11^,12 or 65 years and older4 range from 30% to 70%, and pneumococcal vaccination estimates range from 21% to 67%. These data suggest that in some areas, older AIAN adults receive recommended vaccines at approximately the same rate as Whites nationwide. However, there are no published estimates of vaccination coverage among a nationally based sample of AIAN adults. We sought to provide a national estimate of influenza and pneumococcal vaccination coverage among older AIAN adults (≥ 65 years) in the United States and explored the impact of sociodemographic factors, variations by geographic region, and access to services on vaccination coverage.     

Cost-effectiveness of influenza vaccination in prior pneumonia patients in Israel

Pneumonia is a common complication of influenza infection, and accounts for the majority of influenza mortality. Both the WHO and the Ministry of Health in Israel prioritize seasonal influenza vaccination primarily on the basis of age and specific co-morbidities. Here we consider whether the targeting of individuals previously infected with pneumonia for influenza vaccination would be a cost-effective addition to the current policy. We performed a retrospective cohort data analysis of 163,990 cases of pneumonia hospitalizations and 1,305,223 cases of outpatient pneumonia from 2004 to 2012, capturing more than 54% of the Israeli population. Our findings demonstrate that patients infected with pneumonia in the year prior had a substantially higher risk of becoming infected with pneumonia in subsequent years (relative risk >2.34, p < 0.01). Results indicated that the benefit of targeting for influenza vaccination patients hospitalized with pneumonia in prior year would be cost-saving regardless of age. Complementing the current policy with the targeting of prior pneumonia patients would require vaccination of only a further 2.3% of the Israeli population to save additional 204–407 quality-adjusted life years (QALYs) annually at a mean price of 58–1056 USD/QALY saved. Global uncertainty analysis demonstrates that the cost-effectiveness of adding this policy is robust over a vast range of conditions. As prior pneumonia patients are currently not prioritized for influenza vaccination in Israel, nor elsewhere, this study suggests a novel supplement of current policies to improve cost-effectiveness of influenza vaccination. Future studies should use case–control study to further evaluate the effectiveness of vaccination in prior pneumonia patients.     

Cost-effectiveness of dual influenza and pneumococcal vaccination among the elderly in Shenzhen,China

ObjectiveTo assess the cost-effectiveness of dual influenza and pneumococcal vaccination for the elderly in Shenzhen, China.MethodsA Markov state-transition model with a weekly cycle was developed to compare the outcomes of dual influenza and pneumococcal vaccination for the prevention of influenza and pneumococcal infections compared with no vaccination among 70–74 years old people in Shenzhen over 5 years. The model allowed seasonal variation of influenza activity. We calculated the incremental cost-effectiveness ratio (ICER) with costs and quality-adjusted life years (QALYs) discounted at 5% annually from the societal perspective. The impact of parameter uncertainty on the results was examined using one-way and probabilistic sensitivity analyses (PSA).ResultsIn the base case, dual vaccination prevented 5042 influenza infections, 26 IPD cases, 3 disabilities, 34 deaths, and cost US$7.1 per person while resulting in a net gain of 0.0026 QALYs compared with no vaccination. Using once the Chinese gross domestic product per capita in 2019 (US$10,289) as the willingness-to-pay threshold, dual vaccination was cost-effective with an ICER of US$2699 per QALY gained. One-way sensitivity analyses showed that the ICER was relatively sensitive to changes in influenza attack rates and influenza vaccine effectiveness. Based on the results of PSA with 1000 Monte Carlo simulations, receiving both vaccines was cost-effective in 100% of the repetitions.ConclusionThe current study provides evidence that dual influenza and pneumococcal vaccination is a cost-effective disease prevention strategy for the elderly in Shenzhen, China.     

Economic evaluation of standing order programs for pneumococcal vaccination of hospitalized elderly patients.

BACKGROUND: Standing order programs (SOPs), which allow for vaccination without an individual physician order, are the most effective mechanism to achieve high vaccination rates. Among the suggested settings for the utilization of SOPs are hospital inpatient units, because they provide care for those most likely to benefit from vaccination. The cost-effectiveness of this approach for elderly hospitalized persons is unknown. The purpose of this study was to estimate the cost-effectiveness of SOPs for pneumococcal polysaccharide vaccine (PPV) vaccination for patients 65 years of age or older in 2 types of hospital. METHODS: In 2004, a 1,094-bed tertiary care hospital implemented a pharmacy-based SOP for PPV, and a 225-bed community hospital implemented a nursing-based SOP for PPV. Newly admitted patients 65 years of age or older were screened for PPV eligibility and then offered PPV. Vaccination rates before and after initiation of SOPs in the United States, incidence rates of invasive pneumococcal disease in the United States, and US economic data were the bases of the cost-effectiveness analyses. One-way and multivariate sensitivity analyses were conducted. RESULTS: PPV vaccination rates increased 30.5% in the tertiary care hospital and 15.3% in the community hospital. In the base-case cost-effectiveness analysis, using a societal perspective, we found that both pharmacy-based and nursing-based SOPs cost less than $10,000 per quality-adjusted life-year gained, with program costs (pharmacy-based SOPs cost $4.16 per patient screened, and nursing-based SOPs cost $4.60 per patient screened) and vaccine costs ($18.33 per dose) partially offset by potential savings from cases of invasive pneumococcal disease avoided ($12,436 per case). Sensitivity analyses showed SOPs for PPV vaccination to be cost-effective, compared with PPV vaccination without SOPs, unless the improvement in vaccination rate was less than 8%. CONCLUSION: SOPs do increase PPV vaccination rates in hospitalized elderly patients and are economically favorable, compared with PPV vaccination rates without SOPs.     

Intranasal vaccination with pneumococcal surface protein A plus poly(I:C) protects against secondary pneumococcal pneumonia in mice

Effective pneumococcal vaccines are required for preventing secondary bacterial pneumonia, a life-threatening condition, during epidemics of influenza. We examined whether nasal administration of a low dose of pneumococcal surface protein A (PspA) plus polyinosinic-polycytidylic acid (poly(I:C)) could protect against a fatal secondary pneumococcal pneumonia after influenza A virus infection in mice. PspA-specific IgG but not IgA level was higher in the airways and blood of mice nasally administered a low dose of PspA plus poly(I:C) than in mice nasally administered PspA alone or poly(I:C) alone. Binding of PspA-specific IgG increased C3 deposition on the bacterial surface. The survival rate during secondary infection was higher in mice immunized with PspA plus poly(I:C) than in mice immunized with poly(I:C) alone. The significant reduction in bacterial density in the lung and blood was associated with increased survival of immunized mice with secondary pneumonia. Passive transfer of sera from mice immunized with PspA plus poly(I:C) increased the survival of mice infected with secondary pneumonia. Our data suggest that an intranasal PspA vaccine has promising protective effects against secondary pneumonia after influenza and that PspA-specific IgG plays a critical role in this protection.     

No intention to comply with influenza and pneumococcal vaccination: behavioural determinants among smokers and non-smokers

OBJECTIVE: Smoking increases the risk for influenza and pneumococcal disease, but vaccination uptake is lower among smokers than non-smokers. We therefore aimed to determine reasons for not complying with vaccination among smokers and non-smokers. METHOD: In 2005 a self-administered questionnaire was sent to a random sample of Dutch patients (n=4,000) assessing medical, social and behavioural determinants. Independent factors associated with not complying with influenza and pneumococcal vaccination among smokers and non-smokers were assessed by multivariate logistic regression analysis. RESULTS: In all, 1,725 of 4,000 patients returned the questionnaire (response rate: 43%), 426 (25%) were smokers. Among smokers self-reported flu vaccine uptake was 42% and among non-smokers 52% among both only 0,2% received both vaccines. Most important predictors of not complying in smokers and non-smokers were patient's beliefs not to be susceptible to disease (odds ratio (OR) 4.0, 95% confidence interval (CI): 2.0, 8.0 and OR 2.8, CI: 2.0, 3.9), finding it difficult to go to the GP for vaccination (OR 2.5, CI: 1.3, 4.8 and OR 1.8, CI: 1.3, 2.6) and being against vaccination (OR 2.4 CI: 1.3, 4.4 and OR 1.8, CI: 1.3, 2.6), respectively. CONCLUSION: There are no substantial differences in determinants associated with not complying with influenza and pneumococcal vaccination between smokers and non-smokers but there is a trend towards stronger associations in smokers.     

Clinical pathway care improves outcomes among patients hospitalized for community-acquired pneumonia

PURPOSE: To examine the impact of a unique evidence-based clinical pathway on six outcomes of care in patients hospitalized for community-acquired pneumonia (CAP). METHODS: A retrospective cohort study of CAP patients discharged between January 1999 and December 2001, from 31 Adventist Health System institutions nationwide. A total of 22,196 records were available for multivariate analyses. Odds ratios (OR) for the outcomes were calculated and stratified by a unique severity score. The severity score ranged from 1 to 5, where 5 indicated the most severe condition. RESULTS: Pathway patients were significantly less likely to die in-hospital compared with non-pathway patients in four of the five severity strata (OR in severity level 1=0.37; 95% confidence interval [CI], 0.20-0.70). In all severity strata, pathway patients were approximately twice as likely as non-pathway patients to receive blood cultures and appropriate antibiotic therapy. Among patients who were classified as severity level 1, pathway patients experienced an 80% reduction in the odds of respiratory failure requiring mechanical ventilation (OR=0.20; 95% CI, 0.12-0.33). CONCLUSIONS: Patients who were placed on pneumonia clinical pathway care were much more likely than non-pathway patients to have favorable outcomes of care.     

Cost-effectiveness of dual influenza and pneumococcal vaccination in 50-year-olds

Influenza vaccination is now recommended for all ages; CDC pneumococcal polysaccharide vaccination (PPV) recommendations are comorbidity-based in nonelderly patients. We constructed a Markov model to estimate the cost-effectiveness of dual influenza and pneumococcal vaccination in 50-year-olds. Patients were followed for 10 years, with differing time horizons examined in sensitivity analyses. With 100% vaccine uptake, dual vaccination cost $37,700/QALY gained compared to a CDC recommendation strategy; with observed vaccine uptake, dual vaccination cost $5,300/QALY. Results were sensitive to shorter time horizons, favoring CDC recommendations. We found dual vaccination of all 50-year-olds economically reasonable. Shorter duration models may not fully account for PPV effectiveness.     

Cost-effectiveness of vaccination against pneumococcal pneumonia in The Netherlands

Because of the prevalence of pneumococcal pneumonia and thesubstantial morbidity and mortality associated with many pneumococcalinfections, considerable efforts have been made in disease prevention,using a polyvalent polysaccharide pneumococcal vaccine. Althoughthe WHO has endorsed a policy of universal vaccination of allelderly people, the economic aspects of such a policy have notbeen determined. Using a decision tree framework, this paperexamines the cost-effectiveness of various strategies of pneumococcalvaccination for the elderly in The Netherlands. For variousage categories, the economic attractiveness of the vaccinationof all individuals as well as the vaccination of only thoseindividuals with a specific disease has been calculated. Weconclude that, allowing for some uncertainty regarding key variablessuch as the vaccine efficacy and the hospital admission rate,the vaccination of all individuals above the age of 65 yearsis comparable in terms of cost-effectiveness to many existinghealth care interventions. The vaccination of individuals abovethe age of 55 years with chronic lung disease or chronic heartdisease is similarly attractive from an economic point of view,as is the vaccination of individuals above the age of 65 yearswith diabetes mellitus.     

Increasing influenza and pneumococcal vaccination and tuberculosis screening among residents of Colorado long-term care facilities

Persons residing in long-term care facilities are especially vulnerable to potentially preventable morbidity and mortality caused by influenza, S. pneumoniae, and tuberculosis. This project's objective was to increase the rates of pneumococcal vaccination, tuberculosis screening, and annual influenza vaccination. Intervention consisted of staff training videos, sample policies, and educational materials for residents and their families. At baseline during the 1995-1996 flu season, 84% of Colorado long-term care residents were vaccinated for influenza; 16% of residents had ever received pneumococcal vaccination; and 59% had been screened for tuberculosis. At remeasurement during 1997 to 1998, influenza vaccination rates were up to 89%, p = 0.006. The percentage of residents who had ever received pneumococcal vaccination increased to 48% at remeasurement, p < 0.001. Tuberculosis screening rates increased to 83%, p < 0.001. Following an educational intervention targeting both residents and staff, residents were significantly more likely to receive all three preventive services.     

Facilitating influenza and pneumococcal vaccination through standing orders programs

Influenza and pneumococcal vaccines are underused for persons in the United States aged > or = 65 years (66% receive influenza vaccine and 55% pneumococcal vaccine), even among patients in nursing homes (68% for influenza and 38% for pneumococcal vaccine). Systematic literature reviews by the Task Force on Community Preventive Services and the Southern California Evidence-Based Practice Center-RAND have shown that standing orders programs improve vaccination rates. Standing orders programs authorize nurses and pharmacists, where allowed by state law, to administer vaccinations according to an institution- or physician-approved protocol without the need for a physician's examination or direct order. Several studies have shown improved influenza and pneumococcal vaccination rates through standing orders programs specifically in long-term care facilities (LTCFs) and hospitals. Based on the strength of available evidence, the Advisory Committee on Immunization Practices recommends the use of standing orders programs in both outpatient and inpatient settings.     

Determinants of influenza and pneumococcal vaccination in elderly people: a systematic review

OBJECTIVES: Despite strong national and international recommendations on immunization practices, rates for influenza (IV) and pneumococcal vaccinations (PV) are low. We aimed to review international immunization rates and to analyze attitudes and beliefs regarding IV and PV. STUDY DESIGN: Systematic review. METHOD: The MEDLINE database search comprised articles from 1966 to October 2005. Fourteen surveys evaluating a total number of 49292 participants in nine different countries were included into the analysis. RESULTS: Vaccination rates among risk groups do vary significantly between different countries, reaching highest rates in the USA (IV, 82%; PV, 71%) and lowest in former West-Germany for IV (37%) and in Israel for PV (20%). Recommendations by doctors play a central role in promoting IV and PV. The main reason for not being vaccinated was lack of information. CONCLUSION: Specific strategies targeted at groups are needed to increase the knowledge of IV and PV, and thereby decrease incidences of acute lung diseases.     

北京市肺炎球菌疫苗免费接种政策对老年人肺炎住院的影响

目的  分析北京市肺炎球菌疫苗免费接种政策实施前后北京市老年人群肺炎住院情况的变化,评估该项政策对老年人肺炎防治的效果。方法  利用北京市城镇职工医疗保险数据库2014―2019年收集的老年人群住院数据,以2019年1月作为政策的干预分界点,应用中断时间序列模型(interrupted time series, ITS)分析政策实施前后北京市老年人群肺炎住院人次的变化。结果  免费接种政策实施前北京市≥65岁老年人因肺炎住院人次呈上升趋势(RR=1.019,P < 0.001),政策实施后上升趋势有所减缓(RR=0.971,P=0.013);敏感性分析中,≥65岁老年人因股骨骨折住院人次在政策实施前后则没有明显变化(RR=0.992,P=0.503)。结论  肺炎疫苗免费接种政策与老年人肺炎住院趋势减缓有一定关联,应进一步采取相关策略提高该疫苗的接种可及性。     

社区慢性阻塞性肺疾病患者流感和肺炎疫苗接种意愿及影响因素

[目的]了解慢性阻塞性肺疾病(COPD)患者流感、肺炎疫苗接种意愿和影响因素,为在COPD患者中开展相关健康教育和疫苗接种推广提供参考。[方法]以浙江省宁波市3个区的629名60~74岁COPD患者为调查对象,于2013年10-11月对调查对象进行问卷调查,内容包括个人基本信息、职业和收入、疫苗接种意愿与行为等。对疫苗接种意愿的影响因素进行多因素非条件logistic回归分析。[结果]5年内流感、肺炎疫苗接种率为10.49%,有意愿自费去社区医院自行接种流感、肺炎疫苗的比例为36.88%。有助于疫苗接种意愿的影响因素为个人收入高、5年内有疫苗接种史;阻碍疫苗接种意愿的影响因素为年龄大、认为流感疫苗接种后不良反应可能性高。[结论]应进一步开展成人疫苗接种的健康教育,对于老年人、COPD患者等特殊人群,政府应提供免费的流感、肺炎疫苗接种,提高此类人群的疫苗接种率。