Download Optimising prevention of pneumococcal infection in HIV

Optimising prevention of pneumococcal
infection in HIV-infected patients
A Clinical Audit of Pneumococcal Vaccine Uptake in St. James’s Hospital
O. O’Brien, C. Sadlier, C. Dowling, A. Carr, C. Bergin, C. Bannan
26/11/2016
IPD in St. James’s Hospital
• IPD Incidence = 283/100,000 HIV+ patients vs 12/100,000 for all patients
• 212 cases of IPD in total presented to SJH between 2006 – 2015:
• 47 (22%) episodes occurred in 42 HIV-infected adults
 46 = bacteraemia of respiratory origin
 1 = meningitis
• Risk factors included:
 IV Drug Use = 36/42 (86%)
 Hepatitis C = 31/41 (76%)
• Overall mortality post-IPD = 7/47 (15%) HIV+ patients vs 7% of all cases
• 13/42 (31%) had received PPV23, compared to
 2% of non-HIV IPD cases
 84% of total HIV-infected cohort
• 8/13 (62%) infected with a PPV23 serotype
1) HPSC (2016)
2) Sadlier et al. (2016)
NIAC Guidelines
Pneumococcal Vaccination is indicated for:
• Routine Childhood Immunisation
PCV for all children <2 years
• Routine Adult Immunisation
PPV for all adults ≥65 years
.
• Clinical Risk Groups
Groups with a higher risk of IPD than
the general population
Chapter 16: Pneumococcal
Infection (since January 2014)
High Risk Groups
“Early studies of PCV13 indicate a more
immunogenic and durable response” and “HIVinfected IDUs represent a group that should be
prioritised”.
High Risk = PCV + PPV
Vaccination Schedule
• If PCV is given first, wait 2 months before giving PPV
If the patient has already received PPV, wait 1 year before giving PCV
• A PPV Booster should be given 5 years after first dose if:
Patient’s antibodies are likely to decline more rapidly (e.g. HIV)
OR
Patient is ≥65 and was <65 at time of first dose
• Those who received one dose of PPV at age 65 or older do not require any
further dose regardless of immune status.
HIV+
(Chapter 16, NIAC Immunisation Guidelines)
Audit
Methods
1) A list was compiled of HIV/HCV co-infected patients who have attended the
clinic (co-infection and IDU identified as risk factors for IPD)
2) Immunisation records were accessed to determine if patients had received
PCV, PPV or PPV Booster.
3) Dates of patients’ vaccinations were recorded in an Excel spreadsheet
(anonymised and encrypted).
4) Data Analysis was performed in Excel to see if vaccination schedules were
consistent with NIAC Guidelines.
Initial Audit = July 2015
1 Year Follow-Up = August 2016
Population
• N = 204
• HIV/HCV co-infected
• High Risk of IPD
• 76% Male, 24% Female
• Ages 24-65 years (Mean = 45, IQR = 39-50)
PPV23 (“Pneumovax”) Uptake
Booster >5
years
31 (15%)
• 23 (11%) received no vaccine
• 90 (44%) only received the first dose
 56 (27%) did not receive a booster at 5 years
 34 (17%) are too early to receive a booster
• 91 (45%) received a booster
 6 (3%) received a booster before 5 years
 54 (26%) received a booster at 5 years
 31 (15%) received a booster after 5 years
No Booster
56 (27%)
Booster at 5
years
54 (26%)
Of the 204 patients eligible for Pneumovax:
• 181 (89%) received at least one dose.
Of the 147 patients eligible for a Booster:
• 91 (62%) received it.
• 54 (37%) received it at the right time.
No Vaccine
23 (11%)
Booster <5
years
6 (3%)
Awaiting
Booster
34 (17%)
PCV13 (“Prevnar”) Uptake
Yes
8 (3.9%)
No
196 (96.1%)
Sadlier et al. (2014)
Integrated Vaccine Unit as a Model of Care
• The Integrated Vaccine Unit was established in the GUIDE Clinic in 2002
• Consists of:




Vaccine Nurse
Data Manager
Pharmacist
Vaccine Subgroup Committee
• Strategies employed:
 SMS texting
 Personal Vaccine Passports
 Reminders announcing availability
of seasonal influenza vaccine
• Factors affecting uptake:
“In the 2012/2013 active attending cohort
(n=1645) IDU was associated with
non-receipt of influenza vaccine
(67% vs 82%, p<0.01)”
Progress in vaccine coverage, 2003 vs 2012:
 Influenza = 47% vs 80% (p<0.01)
 Pneumovax = 34% vs 84% (p<0.01)
Proposals
For Patients
Raise Public Awareness with an advertising campaign (e.g. posters)
Educate Patients by counselling them on the importance of vaccines
Improve Access with home visits; convenient transport and clinic hours
(Busy clinics – perhaps make more rooms available to facilitate consultations?)
Encourage Adherence with reminders before next appointment
Utilise Inpatient Admissions as opportunities to vaccinate patients who do
not reliably attend clinic
For Staff
Emphasise Importance of vaccination in management protocols
Update Staff on pneumococcal vaccine guidelines
Ensure Availability of vaccination schedules in clinic
(i.e. hard copy or electronic access to national guidelines)
Incentivise staff vigilance towards vaccine provision
(electronic prescribing records could be used to monitor adherence to guidelines)
Electronic Notifications to remind staff when a vaccine is due
Standardise Documentation of vaccines in electronic patient records
1 Year Follow-Up
Improving Vaccine Uptake
Measures implemented:
 Reminder emails circulated to staff re: Pneumococcal vaccines
 Staff re-educated on updated immunisation guidelines
 Immunisation flowchart made clearly visible in clinic rooms
 Automated notifications in Electronic Patient Records
 Public Awareness Campaign (posters & leaflets)
 SMS reminders for patients
Immediate signs of improvement:
 In 12 months preceding these measures, 50 PCV doses were given (in the total HIV+ cohort)
 In 3 months following these measures, ~350 PCV doses were given (in the total HIV+ cohort)
Reflected in follow-up audit…
PPV23 (“Pneumovax”) Uptake (n=204)
100%
90%
Percentage of Patients
80%
44.6%
50.0%
70%
60%
50%
40%
30%
44.6%
40.7%
20%
10%
10.8%
9.3%
July 2015
August 2016
0%
% No Vaccine
% 1 Vaccine
% 2 Vaccines
PCV13 (“Prevnar”) Uptake (n=204)
100
3.9%
90
Percentage of Patients
80
54.4%
70
60
50
96.1%
40
30
45.6%
20
10
0
July 2015
August 2016
% No
% Yes
Limitations
Weaknesses:
• Some data may be missing
 Patients unaccounted for
 Vaccines given at other centres
(absence of “vaccine passport”)
 Failure to record vaccinations
• Results do not clarify the
cause(s) of suboptimal uptake
Strengths:
• Results clearly identify room for
improvement in an important
aspect of care for high risk
patient group
• Patients all attend the same clinic
(so should be relatively easy to
target and improve uptake)
Conclusions
 IPD is a significant cause of morbidity and mortality in HIV-infected
individuals, particularly in those with IV drug use and HCV co-infection.
 All HIV+ patients should receive both PCV13 and PPV23 vaccines.
 Of 204 HIV/HCV co-infected adults attending the GUIDE Clinic:
o 89% received PPV23, but only 62% of those eligible received a booster
o Only 4% received PCV13
 Measures were taken to improve provision by staff, uptake by patients, and
adherence to guidelines regarding schedules and precautions.
 Improvements seen after 1 year:
o PPV23 uptake increased from 89%  91%
o PCV13 uptake increased from 4%  54%
Future Work
• Extension of audit to all HIV+ patients attending SJH (& nationally)
• Re-evaluation of epidemiology of IPD in 2018
• Evaluation of implementation of national immunisation guidelines
Acknowledgements
- C. Sadlier
- C. Bergin
- C. Dowling
- A. Carr
- C. Bannan
Thank You
Any Questions?
References
•
Royal College of Physicians of Ireland. “Clinical Practice Audit for Professional Competence.” (Revised 1st May 2015)
•
Hibberd PL. “Pneumococcal immunization in HIV-infected adults.” In: UpToDate (Accessed on September 7th 2015)
•
National Immunisation Advisory Committee. “Pneumococcal infections.” Chapter 16, Immunisation Guidelines for Ireland (Updated August 2015)
•
Lynch JP & Zhanel GG. (April 2009). “Streptococcus pneumoniae: epidemiology, risk factors, and strategies for prevention.” In: Seminars in respiratory and critical care
medicine (Vol. 30, No. 2, pp. 189-209).
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Hirschtick RE, Glassroth J, Jordan MC, Wilcosky TC, Wallace JM, Kvale PA, ... & Hopewell PC. (1995). “Bacterial pneumonia in persons infected with the human immunodeficiency
virus.” New England Journal of Medicine, 333(13), 845-851.
•
Health Protection Surveillance Centre. “Invasive Pneumococcal Disease in Ireland: Quarters 3-4, 2015 & Annual Data provisional”. (19th April 2016)
•
Sadlier C, O'Connell S, Kelleher M, Bergin C. “Incidence and risk factors for invasive pneumococcal disease (IPD) in HIV-infected individuals 2006-2015.” (April 2016) HIV
Medicine (Vol. 17, pp. 38-38).
•
Sadlier C, Rock C, Kelleher M, Bergin C. “Factors Associated with Invasive Pneumococcal Disease in HIV-infected Adults in the Era of HAART.” (May 2015). Infectious Diseases
Society of Ireland 8th Annual Scientific Meeting.
•
Sadlier C, Carr A, Kelly S, O’Dea S, Bergin C. “Integrated vaccine unit as a model of care for vaccine delivery in a HIV-infected cohort.” (2014)