Pneumococcal immunization of hospitalized patients

Pneumococcal immunization of hospitalized patients

Ordin, Dede

There is little controversy in the medical community over the importance of administering pneumococcal polysaccharide (PPV) and flu vaccine to high-risk populations. These immunizations are usually provided in outpatient settings, but immunization of hospitalized patients who have not been vaccinated previously can enhance immunization rates in a group at particularly high risk. Despite the demonstrated effectiveness of inpatient immunization programs (as described below), some Rhode Island physicians have expressed concern regarding immunization of vaccine-eligible patients hospitalized for surgery or an acute illness. Recently, discussion of this issue has become more prominent in many hospitals, since inpatient PPV immunization rates (at present calculated only for patients hospitalized for pneumonia) are included in Rhode Island’s publicly reported measures of hospital quality and will be reported nationally by the Centers for Medicare & Medicaid Services (CMS) later this year. In this article, I address some of the issues raised by Rhode Island physicians regarding administration of PPV to hospitalized patients.

Why do we need to provide PPV to patients in the inpatient setting? Shouldn’t they be getting the vaccine in their physicians’ offices?

Ideally, all persons eligible for the vaccine should be immunized in the outpatient setting, but this does not always happen. In a recent national study, only one-third of Medicare patients hospitalized for pneumonia, myocardial infarction, heart failure, or stroke in 1998-1999 had received PPV prior to admission. The situation is likely to be somewhat better in Rhode Island, where approximately 67% of those age 65 and older have received PPV. However, if 67% are immunized, this means that nearly one-third of this high-risk group has not been immunized in their physicians’ offices. In fact, 11% of Rhode Island adults, including 6% of people 65 years and older, report no regular source of primary care, and this proportion is even larger among Rhode Island’s minority populations.3 For these people a hospitalization (or emergency room visit) may afford the most expedient opportunity to provide the vaccine.

Does the Centers for Disease Control and Prevention (CDC) currently recommend inpatient administration of PPV to hospitalized high-risk patients?

Yes. CDC’s Advisory Committee on Immunization Practices encourages inpatient administration of PPV, noting that this strategy is effective and capable of reaching those patients most likely to develop pneumococcal disease.4 The target population (i.e., those at high risk for increased morbidity and mortality related to pneumococcal disease), is the same for inpatient and outpatient immunization and includes persons age 65 or greater, immunocompetent persons age two or greater at increased risk because of chronic illnesses, functional or anatomic asplenia, or living in environments in which the risk for disease is high (e.g., daycare centers), and immunocompromised persons age 2 or greater. CDC recommends onetime revaccination after five or more years for two groups: persons aged 65 or older vaccinated before the age of 65; and previously vaccinated persons aged 64 years or younger who are immunocompromised secondary to underlying medical conditions or medications. CDC notes that, for other high-risk populations, the need for subsequent doses of pneumococcal vaccine is unclear and will be assessed when additional data become available.

What are the potential adverse effects of inpatient administration of PPV?

Adverse reactions associated with inpatient PPV administration are similar to those in the outpatient setting and consist primarily of local reactions (i.e., pain, erythema, swelling) at the injection site. In a 1994 meta-analysis of nine randomized controlled outpatient trials of PPV efficacy, one-third of the 7531 patients receiving the vaccine had local reactions. There were no reports of severe febrile or anaphylactic reactions nor any reported neurologic disorders (e.g., Guillain-Barre syndrome).5

Which high-risk patients should NOT receive the vaccine in the hospital?

High-risk patients who have received the vaccine within the previous five years do not need to receive the vaccine. The manufacturer recommends that, if possible, patients undergoing splenectomy or receiving cancer chemotherapy or other immunosuppressive therapy should receive the vaccine at least two weeks before initiation of therapy. The safety of PPV during the first trimester of pregnancy has not been evaluated. At some hospitals, physicians have expressed concern over the theoretical possibility of an anaphylactic reaction to the vaccine and thus are reluctant to immunize patients who are hemodynamically unstable or in respiratory distress; some physicians have also questioned the efficacy of the vaccine in patients with febrile respiratory illness or other active infection. These precautions are noted in the Physicians’ Desk Reference, although I am aware of no published documentation that vaccine-associated adverse events have occurred in these situations. In any event, these concerns may be circumvented by immunizing patients at the time of discharge.

What should be done if a patient does not know whether he/she has previously received PPV?

According to current CDC recommendations, providers should not withhold vaccination in the absence of an immunization record or complete medical record. The patient’s (or family’s) verbal history should be used to determine prior vaccination status. When indicated, vaccine should be administered to patients who are uncertain about their vaccination history.4 Revaccination fewer than five years after initial PPV immunization results in a greater incidence of local reactions but has not been associated with any increased risk of systemic reactions.

How can busy physicians be expected to remember to order the vaccine for their hospitalized patients?

Immunization is seldom at the forefront of physician concerns during a patient’s hospitalization. Successful inpatient immunization programs utilize either standing orders or reminder systems, thus obviating the need to rely solely on physicians’ spontaneously remembering to order immunization for eligible patients. Standing orders for inpatient immunization are permissible under both Rhode Island law and Medicare regulations. In most standing order programs, a nurse screens patients to determine whether they meet the vaccine eligibility criteria. If the patient is determined to be eligible, the nurse activates the standing order and administers the vaccine, usually at discharge. Reminder systems involve screening for vaccine eligibility by nurses, pharmacists, or infection control practitioners, and placement of a highly visible reminder on the chart (or a message incorporated into a computerized order entry system) to remind physicians to order the immunization. These approaches have been reported to increase administration of PPV to vaccine-eligible patients by 29 to 78 percentage points.6,7,8,9

Is assistance available to Rhode Island hospitals working to increase their inpatient immunization rates?

Quality Partners of Rhode Island can provide literature, slide presentations, examples of standing orders, and general quality improvement consultation to help hospitals and physician offices increase patients’ PPV and influenza immunization rates.

REFERENCES

1. Bratzler DW, Houck PM, Jiang H, et al. Failure to vaccinate Medicare inpatients: A missed opportunity Arch Intern Med 2002;162:2349-56.

2. Influenza and Pneumococcal vaccination levels among persons aged >65 Yeats – United States, 2001. MMWR 2002;51:1019-24.

3. Behavior Risk Factor Surveillance System, Rhode Island, 2000. http://www.cdc.gov/brfss. Accessed 7/9/2003.

4. Prevention of pneumoccal disease: Recommendations of the Advisory Committee on Immunization Practices. MMWR 1997;46(RR-08):1-24.

5. Fine MJ, Smith MA, Carson CA et al. Efficacy of pneumococcal vaccination in adults: A meta-analysis of randomized controlled trials. Arch Intern Med 1994;154:2666-77.

6. Klein RS, Adachi N. An effective hospital-based pneumococcal immunization program. Arch Intern Med 1986;146:327-9.

7. Vondracek TG, Pham TP, Huycke MM. A hospital-based pharmacy intervention program for pneumoccal vaccination. Arch Intern Med 1998; 158:1543-7.

8. Lee DH, Sun T, Kemmerly S et al. Rapid implementation of a pneumococcal vaccine program in a multispecialty teaching hospital. JCOM 2002;9:141-5.

9. Bloom HF, Bloom JS, Krasnoff L, Frank AD. Increased utilization of influenza and pneumococcal vaccines in an elderly hospitalized population. J Am Geriatr Soc 1988;36:897-901.

Dede Ordin, MD, MPH

Dede Ordin, MD, MPH, is a Senior Medical Scientist at Quality Partners of Rhode Island and Medical Director for Quality Improvement at Rhode Island Hospital.

CORRESPONDENCE

Dede Ordin, MD, MPH

phone: (401) 528-3200

fax: (401) 528-3210

E-mail: dordin@riqio.sdps.org

Copyright Rhode Island Medical Society Aug 2003

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