McKnight's Long-Term Care News, October 2018, Feature 2, Medication Management

Vaccinations play a key role in preventing illnesses across all age groups, but their routine use in the elderly — including those in long-term care, of course— is especially critical.

A bout of the flu or pneumonia, for example, can be life-threatening in immunocompromised residents and may lead to secondary complications and community outbreaks. Beyond that, a case of herpes zoster (shingles) can prompt acute and debilitating nerve pain for months or even years after the blisters heal.

Despite the proven benefits of immunization and the fact that influenza and pneumococcal vaccines — the two most widely recommended for long-term care residents — are covered under Medicare Part B, many residents still aren’t getting them.

Lingering misconceptions about immunization, particularly that vaccines cause illness or are often ineffective, pose one of the greatest obstacles.

“This challenge is exacerbated by the fact that vaccines may not fully prevent infection or a disease in seniors,” says Joe Kramer, VP of sales for Geri-Care Pharmaceuticals Corp. Certain residents and their loved ones also may mistakenly believe vaccines are meant for those who are ill and not necessarily meant as part of a proactive wellness approach, he notes.

Beyond the personal pain and health concerns, a lack of vaccinations can bring havoc to facility operations.

Anti-vaxers’ effect

Some pharmaceutical experts say the anti-vaccine movement, which is largely targeted toward infant and child vaccinations, has begun infiltrating long-term care. In particular, healthcare workers’ negative beliefs about vaccines can have trickle-down effects on residents, says Marci M. Wayman, PharmD, a consultant pharmacist for Turenne PharMedCo.

“If vaccinations are not a priority for the nursing staff, perhaps the residents will not be offered vaccines or encouraged to take them,” she explains.

Even with a robust hygiene program, unvaccinated employees in nursing homes place residents at risk for infection, experts assert. When employees avoid shots for themselves or their children, they further increase the odds of disease transmission in the resident population.

Staffing shortages in the long-term care segment further compound the problem. Although some states and individual facilities require annual flu shots for employees, some operators in non-vaccine-mandated states fear vaccination requirements could pull qualified candidates from the hiring pool.

When it comes to long-term care resident immunization programs, pharmaceutical and clinical experts agree that influenza and pneumococcal vaccines are most vital. Appropriate administration of those vaccines is even used as a quality measure by the Centers for Medicare & Medicaid Services. The flu shot — either the recombinant or inactivated version — should be offered to residents each year.

The Centers for Disease Control and Prevention makes no recommendations for which type of influenza vaccine to give to seniors — standard dose or high dose, trivalent or quadrivalent, adjuvanted (a substance added to vaccines to boost immunity response that allows a smaller dose to be used) or unadjuvanted. But “there have been small differences seen in clinical trials that may suggest the high-dose version may provide superior effectiveness for some populations,” notes Mark Boe, president of Guardian Pharmacy of Minnesota.

This is the last season the trivalent flu vaccine will be offered, however, adds TJ
Griffin, RPh, chief pharmacy officer at PharMerica. “Only the quadrivalent vaccine will be available after this season and the price will go up as a result.”

What some might consider a “simple flu” can prove deadly in immunocompromised elderly. More than 20,000 people die annually from the flu and 90% are over age 65, Boe reminds.      

“Among the elderly, flu outbreaks in nursing homes can be deadly as the median infection rate in long-term care is 33 percent,” he explains. “Since the mortality rate among our elderly is about 6.5 percent, these risks are pressing matters.”

Double-whammy risk

Many residents who contact the flu end up with pneumonia, warns one clinician.

“One season, I had seventeen patients die from flu complications,” says Shari Carson, RN, BSN, chief clinical officer for Metron Integrated Health Systems.

With a well-matched flu vaccine, the shot will reduce the risk of flu illness by 40% to 60%, according to the CDC. When the flu is contracted in a vaccinated individual, the vaccine may still have triggered a positive immune response, so symptoms could be lessened, Griffin reminds. It’s a message that should be shared frequently with employees, residents and their family members.

Only about 10% of Metron Integrated Health residents refuse flu vaccine, and consistent vigilance can be largely credited to that success. The organization offers the influenza vaccine to every resident admitted from September through April. Those admitted outside those typical flu season months who will be staying in long-term are asked if they wish to receive the vaccine when it is given later that year.

“In October, all who have been signed consent are given the influenza vaccine once we go over the new year’s information,” Carson says. “Those who refused are offered again.”

The elderly also should receive the pneumococcal vaccine, administered in two different doses, and clinicians must follow proper dose timing intervals. The first dose, the PCV13, covers 13 strains of bacteria; the follow-up dose, the PPSV23, covers 23 strains and should be given at least one year after the PCV13. The CDC recommends this vaccine dosing/timing for most immunocompetent residents 65 years or older, including those who have not received any prior pneumococcal vaccines or have an unknown vaccination history.

Those age 65 or older who previously received a dose of PPSV23 but not the PCV13 dose should be given the PCV13 dose at least one year after the PPSV23 dose, regardless of medical conditions. The CDC does not generally recommend administering additional doses in seniors.

Beyond the Big 2

In addition to the flu and pneumococcal vaccines, many clinicians and pharmacists strongly recommend the shingles vaccine for senior residents. Many operators will be happy to learn that as of press time, the shingles vaccine shortage was easing, although its availability was still spotty, due to ongoing high demand and resulting waiting lists.

Even if the vaccine were readily available, some facilities aren’t pushing shingles vaccination due to reimbursement concerns and, perhaps, a lack of awareness on the vaccine’s benefits. 

“With the influenza and pneumococcal vaccines, it’s very clear that those are covered under Medicare Part B, but [the shingles vaccine] is covered under Medicare Part D,” explains Jennifer Hardesty, PharmD, FASCP, chief clinical officer for Remedi SeniorCare. “If you have a [resident] in a nursing home under a Part A stay, it could be a challenge getting the vaccine covered by Part D. You may need to pay and then get reimbursed.”

The intermittent shingles vaccine shortage shouldn’t keep operators from trying to access the shots and administering them whenever they become available, according to Griffin. Because the vaccine is administered in two increments — an initial dose, followed by an identical dose six months later. He recommends administering the first whenever possible.

“You’ll still have time for the supply to pick back up before that second dose is needed,” he explains.

The CDC assures there’s little cause for concern for residents who received the first dose nearly six months ago and may miss their second dose due to supply shortages — they’ll still be covered. Still, the agency recommends residents receive the second dose as soon as it becomes available, as it offers more than 90% immunity. 

Skilled nursing operators also should ensure residents are current on their tetanus-diphtheria-acellular pertussis (Tdap) boosters. Pertussis (whooping cough), has made a resurgence due to unvaccinated rates rising, and previously vaccinated adults who don’t get their booster shots are susceptible.

Setting records straight

Incomplete or altogether absent vaccination records for residents admitted to skilled nursing from hospitals, assisted living facilities or the general community leads to confusion and, perhaps, duplicated vaccines being administered unnecessarily.

“Since some vaccines aren’t supposed to be administered more than once, this is a big concern,” Hardesty notes.

When Amanda Kistler, RN, president of the National Association of Directors of Nursing in Long Term Care, worked in the skilled nursing environment, she says it was common for the hospital’s or discharging facility’s records to be incomplete.

The pneumococcal vaccine can be one of the most challenging when there is an unclear immunization history, according to Sarah Barker, PharmD, General Manager of Turenne PharMedCo-Montgomery. Having two vaccines that are given in separate years makes it more difficult.

Often, a resident or family member knows the resident received a pneumococcal vaccine but is unsure if it was PCV13 or the PPSV23, Barker explains.

“An incomplete history makes continuing the correct pneumococcal vaccination schedule more complicated,” she says.

Upon admission, vaccination history should be captured and documented, if possible, and any gaps in immunization should be addressed with an individualized vaccination plan. When a resident is transferred or discharged, it’s equally important that his or her immunization status is updated and included in the electronic medical record.

Beyond that, simple vaccination cards that identify the types and doses of vaccines received and the date they were administered also should be considered. These can be given to the resident or a family member and then handed off to the next doctor or stop in the care continuum, Hardesty says.

Experts agree community-wide education for staff, residents, family members and all other visitors remains the best approach for increasing vaccination awareness and participation and keeping more accurate immunization records.

“Staff members should be educated so they can educate residents on the usefulness of the vaccines,” says Julie Stafford, RN, CDP, CDONA, CADDCT, FACDONA, IP-BC, nursing home administrator at Genesis HealthCare-Alleghany Center in Sparta, NC.

Information tailored to skeptics often wins them over, she adds.