The challenge of vaccinating hospitalized patients for influenza and pneumococcus.

Each year, an estimated 35,000 older Americans die of pneumonia and influenza-like illness. (1) These figures have remained constant over the past several decades, despite the availability of vaccines to prevent both influenza and Streptococcus pneumoniae infections. Following reports of deaths due to influenza or pneumonia among older, previously hospitalized patients during their last year of life (ie, among those hospitalized in the prior year, but without vaccination for influenza and pneumococcus), initiatives to vaccinate hospitalized, older patients against influenza and pneumococcus were reported as early as 1983. Fedson and Kessler (2) reported that only 2 out of 112 older patients admitted for influenza, pneumonia, or chronic pulmonary diseases had been immunized against influenza or Streptococcus pneumoniae during hospitalizations in the previous 12 months. Subsequently, in 1986, the Centers for Disease Control and Prevention recommended that hospitals provide immunizations for influenza, and for Streptococcus pneumoniae in 1989, prior to discharge. (3,4) While physicians agreed in principle to the concept, this was a departure from the historical practice of the physician's office serving as the primary vaccination site for most patients.

Various challenges and obstacles for full implementation of these vaccination programs were described, including the need for a physician order for a vaccination, refusal by the patient, the availability of the vaccine from the pharmacy when a patient was unexpectedly discharged, among others. Secondly, mixed signals were sent from the payors: while both vaccines were recommended by CDC and the Health Care Financing Administration (HCFA), Medicare did not authorize reimbursement for the influenza vaccine; moreover, the authorization to provide Medicare reimbursement for the pneumococcal vaccine only covered the cost of the vaccine, not its administration, which served as a disincentive. HFCA received congressional approval to begin reimbursement in 1993 for both the cost and administration of both vaccines. (5) Subsequently, a Centers for Disease Control and Prevention review in 1997 found immunization rates among adults >65 years of age were only 45% for Streptococcus pneumoniae, and were less than 65% for those receiving an influenza vaccination in the past year.6 Various initiatives have subsequently been reported in the medical literature, including computerized records and order entry, campaigns to educate and motivate physicians to order the vaccinations, etc. Despite these initiatives, vaccination rates have fallen short of the goal. These latter data are of great concern, as the majority of reported cases of community-acquired Streptococcus pneumoniae in older and elderly Americans are from among strains included in the 24-valent vaccine. (7) Moreover, recent data from Europe have shown unanticipated additive effects of the dual vaccinations among older patients, in the form of both reduced hospital admissions for influenza, pneumonia, and invasive pneumococcal disease, as well as in-hospital mortality for pneumonia. (8) In this issue, Bakare and colleagues have provided us with insight on two contrasting models for providing these immunizations: physician-driven vs. nursing-driven initiatives. (9) In a retrospective analysis of two different models, several points were clear: when vaccination was assessed to be necessary and communicated by the nurse, more patients were discovered to be eligible. In contrast, with the physician-driven model, fewer candidates were recognized, but an equal number of patients received vaccination. As with many successful ventures, a partnering of the two approaches is recommended by the authors in order to increase vaccinations in the hospital setting. Successful approaches will be essential for us to both decrease vaccine-preventable deaths, and to meet the Centers for Disease Control's 2010 Goals of Healthy People Campaign. Interestingly, as we face the prospect of avian influenza and the potential need for a mass immunization program, the first initiative in vaccinating hospitalized patients for influenza and Streptococcus pneumoniae followed the swine influenza immunization program of 1976. (2)

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References

1. Thompson WW, Shay DK, Weintraub E, et al. Mortality associated with influenza and respiratory syncytial virus in the United States. JAMA 2003;289:179-186.

2. Fedson DS. Kessler HA. A hospital-based influenza immunization program, 1977-78. Am J Public Health 1983;73:442-445.

3. Centers for Disease Control. Prevention and control of influenza. MMWR Morb Mortal Wkly Rep 1986;35:317-326, 331.

4. Centers for Disease Control. Recommendations of the Immunization Practices Advisory Committee Pneumococcal Polysaccharide Vaccine. MMWR 1989;38(5):64-68, 73-76.

5. Fedson DS, Houck P, Bratzler D. Hospital-based influenza and pneumococcal vaccination: Sutton's Law applied to prevention. Infect Control Hosp Epidemiol 2000;21:692-699.

6. Centers for Disease Control and Prevention: Influenza and pneumococcalvaccination levels among adults aged >65 years--United States. MMWR 1998;47:797-802.

7. Robinson KA, Baughman W, Rothrock G, et al. Epidemiology of invasive Streptococcus pneumoniae infections in the United States, 1995-1998: Opportunities for prevention in the conjugate vaccine era. JAMA 2001;285:1729-1735.

8. Christenson B, Hedlund J, Lundbergh P, et al. Additive preventive effect of influenza and pneumococcal vaccines in elderly persons. Eur Respir J 2004;23:363-368.

9. Bakare J, Shrivastava R, Jeevanantham V, et al. Impact of two different models on influenza and pneumococcal vaccination in hospitalized patients. South Med J 2006;100:140-144.

Courage is not the absence of fear; it is the making of action in
spite of fear.
--M. Scott Peck

Nausheen Faruqi, MD, and Keith M. Ramsey, MD

From the Franklin Health Centers and the Division of Infectious Diseases, University of South Alabama, Mobile, AL; and the Brody School of Medicine at East Carolina University and the Department of Safety and Infection Control, Pitt County Memorial Hospital, Greenville, NC.

Reprint requests to Keith M. Ramsey, MD, Department of Safety and Infection Control, Doctor's Park 6B, Pitt County Memorial Hospital, Greenville, NC 27834. Email: [e-mail]

Accepted December 6, 2006.