Missed opportunities to vaccinate a cohort of hospitalised elderly with pneumococcal and influenza vaccines
Introduction
Many countries recommend vaccination against influenza and S. pneumoniae among persons ≥65 years. The disease burden attributable to these organisms is high, and effectiveness of influenza vaccine and 23-valent pneumococcal vaccine (23vPPV) has been shown against laboratory confirmed influenza and invasive pneumococcal disease (IPD) [1], [2]. In Australia, free annual influenza vaccine has been provided in this age group since 1998 and five yearly 23vPPV since 2005, while in the state of Victoria, 23vPPV has been funded since 1998.
Every contact with a vaccine provider should be seen as an opportunity to update vaccinations. Hospitalisation in particular should prompt review of vaccination status since hospitalised persons are at increased risk of disease [3], [4], [5]. The American Advisory Committee on Immunization advises vaccination prior to discharge from hospital for both 23vPPV and influenza vaccine through the use of standing orders [6]. Assessment of missed opportunities for vaccination and risk factors for an incomplete vaccination status for hospitalised patients can assist future implementation strategies.
Studies from the United States show that elderly persons with an incomplete vaccination status for 23vPPV and influenza vaccine experience numerous missed opportunities to be vaccinated, and that hospital staff often do not document vaccination status or order vaccinations [7], [8], [9]. However, there is a paucity of data for elderly populations outside the United States. In Australia, no study has evaluated missed opportunities for vaccination with influenza vaccine or 23vPPV as its primary focus, and there are no data on the rate of recording of inpatient vaccination status or acceptability of 23vPPV or influenza vaccination among unvaccinated inpatients. We undertook to answer these questions for hospitalised elderly subjects participating in a large case-cohort study quantifying vaccine effectiveness against community-acquired pneumonia (CAP).
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Study subjects
The cases for the case-cohort study were persons aged ≥65 years with pneumonia (ICD-10-AM codes J10-J18) [10] identified from monthly discharge lists from two major teaching hospitals in Melbourne, Victoria, for the period April 2000–March 2002. As per a case-cohort design, cases were also eligible for selection in the cohort [11]. Nosocomially acquired pneumonia cases were excluded (diagnosis more than 48 h after hospital admission) [12]. The cohort was formed by randomly over-sampling 1.2
Subjects
4772/4887 (97%) subjects had medical records available for review and were eligible for inclusion. There were 1952 first presentation CAP cases and 2927 first presentation cohort subjects, including 107 also selected as cases. Subject mean age was 77 years and 2552 (54%) were male. At least one comorbid condition was present in 4273/4483 (95%) subjects, 1334 (28%) had a first language other than English, 722/4739 (15%) lived in their own home and 447/4749 (9%) died during admission.
Vaccination status
4166/4772
Missed opportunities to vaccinate prior to admission
While this study demonstrates that large numbers of elderly Victorian inpatients have received 23vPPV (53%) and influenza vaccine (71%) as recommended, these figures remain suboptimal. Virtually all (99.8%) incompletely vaccinated inpatients experienced at least one opportunity to be vaccinated prior to admission. The greatest number of opportunities occurred as doctor visits outside the hospital setting, and maximising opportunistic vaccination in primary care remains a priority. However, in
Conclusions
This study is the largest to date to quantify missed opportunities for vaccination with 23vPPV and influenza vaccine among hospitalised elderly patients with and without pneumonia. We found implementation of current recommendations to vaccinate patients aged ≥65 years with influenza vaccine and 23vPPV was suboptimal in both the hospital and primary care setting in Victoria. This was despite many opportunities for vaccination and relatively high acceptability of vaccination among unvaccinated
Acknowledgments
This study was supported by research assistants responsible for data collection: Anne-Marie Woods, Carol Roberts, Caroline Watts and Joy Turner, with data entry by Thao Nguyen and Jason Zhu. Graham Byrnes is supported by a National Health and Medical Research Council Capacity Building Grant in Population Health (251533). This study was jointly funded by the Victorian Government Department of Human Services and the National Health and Medical Research Council (grant number 146500). The sponsors
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