Monday, April 9, 2018

Increasing pneumococcal vaccination rates

- Jennifer Middleton, MD, MPH

A Medicine by the Numbers feature on Pneumococcal Vaccines in Chronic Obstructive Pulmonary Disease (COPD), in the current issue of AFP, gives pneumococcal vaccination in persons with COPD a "green" rating, indicating that the benefits outweigh potential harms. Despite these benefits, too few adults with COPD are receiving pneumococcal vaccination.

To clarify, adults with COPD aged less than 65 years should receive Pneumovax 23 (PPSV23); Prevnar 13 (PCV13) is only indicated for adults aged 18-64 with immunodeficiencies, certain hemoglobinopathies, and other specialized conditions (for a full list, check out this CDC Summary). All adults, regardless of co-morbid health conditions, should receive Prevnar 13 at age 65 followed by Pneumovax 23 at least one year later.

The article describes the evidence base demonstrating that, in persons with COPD, the number needed to treat (NNT) for pneumococcal vaccination is 21 to avoid an episode of community-acquired pneumonia and 8 to avoid an acute COPD exacerbation. (The authors reviewed studies that included adults both under and over age 65 to reach these conclusions.) While pneumococcal vaccination might not prevent mortality from COPD, patients are likely to be pleased with the benefit of avoiding pneumonia and/or exacerbations, especially given the lack of reported harms with this vaccine.

The CDC found that, in 2015, only 23% of adults eligible for pneumococcal vaccination had received one (the number eligible includes diagnoses other than COPD). Nonwhite adults and adults without health insurance reported lower vaccination rates. A study of vaccination attitudes and knowledge in Germany found that patient knowledge that pneumococcal vaccination was recommended correlated with increased rates of vaccination among eligible adults; interestingly, for influenza and tetanus vaccines, knowledge alone in this same study did not predict vaccination (though attitudes about each vaccine did).

Increasing awareness of the indications for pneumococcal vaccination is one step to increase vaccination rates; physician reminders, patient letters, and nurse-driven vaccination when used together were also effective at increasing rates in ambulatory specialty practices. In primary care practices, the 4 Pillars Toolkit has been effective; the 4 Pillars Toolkit includes online resources for increasing convenience, patient communication, systems of care, and practice motivation.

Pharmacist-driven interventions to increase influenza and pneumococcal vaccinations in patients with COPD have had mixed success. One study found pharmacist-initiated interventions did not increase pneumococcal vaccination rates for those with COPD or asthma in community settings. Inpatient pharmacist-led patient education, however, may increase pneumococcal vaccination. Employee health screenings that include a pharmacist review of vaccinations may also increase vaccination rates.

Ideal strategies are likely to differ by practice and locale; resources to guide your practice include the AFP By Topic on Immunizations (excluding Influenza) that includes this editorial on Navigating the Changes in Pneumococcal Vaccinations for Adults as well as this overview of the 2018 Advisory Committee on Immunization Practices (ACIP) Adult Immunization Recommendations. From Family Practice Management comes this article providing an overview of practice strategies to both increase vaccination rates and minimize lost costs from storing vaccines.

What strategies have worked to increase pneumococcal vaccination rates in your practice?