Vaccination imperative: protecting residents from pneumococcal disease
From left: William Hall, MD, Susan J. Rehm, MD, and William Schaffner, MD
By: William Hall, MD, Susan J. Rehm, MD, and William Schaffner, MD
Pneumococcal bacteria–or Streptococcus pneumoniae –are nothing if not opportunistic. When these bacteria infect the lungs, their most frequent target, they cause pneumonia. Less often, but even more seriously, these bacteria can invade the bloodstream or the covering of the brain, causing bacteremia (sepsis) and meningitis–together known as invasive pneumococcal disease (IPD).
Adults living in long-term care facilities are at particular risk for pneumococcal disease, as advanced age and associated comorbidities contribute to susceptibility. It is therefore incumbent upon facility administrators and others in supervisory positions to recognize the severity of this disease and give serious thought to providing residents with optimal protection.Dangerous killer
Pneumococcal disease fatality rates in adults are high: 5% to 7% for pneumonia, 15% to 20% for bacteremia and 16% to 37% for meningitis; rates in elderly individuals are even higher. The disease can strike quickly and without warning, but symptoms are not always consistent among patients. For example, frail elderly patients with bacteremia may exhibit only weakness and mental confusion, but no fever.Depending on whether infection causes pneumonia, bacteremia or meningitis, patients may exhibit some combination of the following symptoms: abrupt onset of fever, shaking/chills, cough, shortness of breath, chest pain, stiff neck, disorientation and sensitivity to light. Complications in those with IPD are common, ranging from concurrent cardiac events to long-term effects, such as hearing loss, seizures, blindness and paralysis.
Underuse of shotsTwo vaccines are essential to protecting patients: pneumococcal polysaccharide vaccine (PPSV23) and influenza vaccine. Both are recommended by the Centers for Disease Control and Prevention for all long-term care facility residents. Because influenza so often precedes serious pneumococcal disease and because staff very easily can spread influenza to vulnerable patients, influenza vaccine needs to be given every year to all residents and staff.
PPSV23 is a one-time vaccine for most adults and provides 60% to 70% protective efficacy against the 23 types of Streptococcus pneumoniae bacteria responsible for more than 90% of adult invasive pneumococcal disease cases. But while Medicare and Medicaid plans provide first-dollar coverage of vaccination for high-risk groups (including residents of long-term care facilities), pneumococcal vaccination rates have not approached 2010 national health objectives of 90% coverage among nursing home residents.PPSV23 is the best means of protection available today and we advocate for its use, but we also acknowledge conflicting data regarding its effectiveness against pneumonia. In addition, it provides less robust protection against IPD in those who are very old or immunocompromised. Newer vaccines in development for use in adults are expected to have enhanced efficacy against pneumococcal disease.
Increasing coverageAs an administrator, you can help reduce the incidence of pneumococcal disease in your facility. Aim to increase pneumococcal vaccine coverage by following public health immunization recommendations that include virtually all residents of long-term care facilities.
Educate patients, families and staff about the prevalence and serious medical risks of pneumococcal disease, its association with influenza, and the importance of prevention with PPSV23, proven safe for over 25 years. Involve family members in immunization education efforts, particularly for residents unable or disinclined to make their own vaccination decisions.Bringing all populations up-to-speed regarding misconceptions about side effects (which are few) and risks of receiving more than one lifetime dose (which are low) also should help lower patient and family resistance, and increase staff cooperation with vaccination efforts.
Other disease reduction strategies include computerized vaccination record-keeping and use of stickers on patient charts to allow for easy identification of patients lacking immunization.Because PPSV23 can be administered at any time of the year, policies such as vaccination upon entry and simultaneous administration of pneumococcal and other adult vaccines should be considered to ensure coverage of all previously unvaccinated patients. Consideration should also be given to instituting standing orders, which allow certain healthcare professionals (other than physicians) to vaccinate patients based on physician and institutional instruction and protocol.
The authors are members of the National Foundation for Infectious Diseases Pneumococcal Disease Advisory Board. Hall is the Paul Fine Professor of Medicine, director, Center for Healthy Aging, University of Rochester School of Medicine and is a member of the board of directors, AARP. Rehm is a staff physician at the Cleveland Clinic and is vice chair of the clinic's Department of Infectious Disease. Schaffner is chair of the department of preventive medicine at Vanderbilt University Medical Center in Nashville, TN.