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High Rates of Pneumococcal
Vaccination in Alaska Native
Adults
Rosalyn Singleton MD, Mary Krevans RN
Alaska Native Tribal Health Consortium
Jay C. Butler, MD, FAAP, FACP, Lisa Bulkow
MS, Debra Parks
Arctic Investigations Program – CDC
Pneumococcal Disease in Adults
• Leading cause of
– Adult pneumonia
– Bacterial meningitis
– Otitis and sinusitis
• Common cause of
– COPD
Exacerbation
– Primary peritonitis
– Pericarditis
– Conjunctivitis
– Septic arthritis
– Osteomyelitis
Cases/100,000/yr
Invasive Pneumococcal Disease, Alaska,
1986-90 and 1991-97
500
450
400
350
300
250
200
150
100
50
0
Natives 1991-97
Non-Natives 1991-97
<2
2-9
10-19 20-39 40-54
Age (years)
55-64
>65
Alaska Natives have a rate of pneumococcal disease 2-3 times that
of Alaska Non-Natives.
Parkinson, et al. ISPPD 1998
NARCH Pneumococcal Grant, 2002
SPECIFIC AIMS
• Analyze pneumococcal disease in AN adults 1986-2000.
• Determine pneumococcal vaccine coverage in AN adults
1986-2000.
• Assess role of increased vaccine coverage on
decreasing rate of pneumococcal disease in AN adults.
• Evaluate barriers to pneumococcal vaccination
• Develop strategies to increase
immunization rates.
NARCH Pneumococcal Grant
Methods
1. Chart review of adults with invasive pneumococcal
disease, 1986-2000
2. Vaccine record review of a randomized sample of atrisk adults in 4 regions to document vaccine coverage
3. Interviews with community leaders, providers and
Alaska Native adults
Incidence and Case-fatality of Invasive
Pneumococcal Disease by Age, Alaska
Natives, 1986-2000
160
Incidence
35
Case-fatality
120
30
100
25
80
20
60
15
40
10
20
5
0
0
20-29
30-39
40-49
50-59
Age (years)
60-69
70-79
80+
Case-fatality
Cases/100,000/yr
140
40
Alaska Public Health Service Units
Alaska Villages
Rivers
Service Units
Anchorage
Barrow
Bristol Bay
Interior
Kotzebue
Norton Sound
Southeast
Yukon-Kuskokwim
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N
W
600
0
600
E
1200 Miles
S
Pneumococcal Polysaccharide
Vaccine
How did we get to where we are today?
ACIP Recommendations for
Pneumococcal Polysaccharide Vaccine
• All persons aged 65 and older
• Persons aged 2-64 years
– Asplenia
– Chronic illnesses: cardiopulmonary diseases (NOT
asthma), DM, alcoholism, cirrhosis
– Immunocompromising conditions: HIV infection,
malignancy, immunosuppressive therapy
– “Special environments”: long-term care facilities, “AK
Native and certain American Indian populations”
MMWR 1997; 46:RR-8
ACIP Recommendations for
Pneumococcal Revaccination
• One-time revaccination after 5 or more years for:
– Persons 2-64 years of age who are at highest risk for serious
pneumococcal infection and those likely to have rapid decline in
antibody levels (asplenia, HIV+, lymphoma, renal failure, organ
transplant, immunosuppressive meds)
• Persons 65 years of age and over who were first
vaccinated before age 65
Alaska Recommendations
• All Alaskans 55 years and older
• Revaccination every 6 years.
MMWR 1997; 46:RR-8
Alaska Epi Bulletin 1994
Vaccine Uptake
Why Is PPV Uptake Not Better?
• Adult Immunization Issues
– Healthy adults often do not have regular clinic visits
– Poor reimbursement; no “VFA”
– Limited educational materials to physicians, subspecialists
– Few age-specific benchmarks
• Pneumococcal Disease Issues
– Poor understanding of the burden of pneumococcal disease
– “Old man’s friend”
• PPV Issues
– Confusion over what the vaccine does and does not do
– Confusion over duration of protection, revaccination
recommendations
NARCH Immunization Audit
METHODS
• Survey: Randomized sample of Alaska Native adults >54
years of age between 1986 and 2000 and registered at
regional Tribal hospital
• Four regions with regional Tribal hospital were surveyed
• Method: chart review of hospital chart(s), PHN record
and computerized immunization record(s)
• Evaluated: immunization status, underlying conditions
• Exclusion: persons who moved or had no visits at
regional tribal hospital, died before study period
Proportion of pneumococcal immunizations
documented in various record sources
PHN record
34
Medical chart
23
Local RPMS
84
Any RPMS
91
0
20
40
60
80
% of pneumococcal immunizations
PHN reviewed in 2/4 regions.RPMS is the computerized medical record.
100
RESULTS:
Proportion of Alaska Native adults
55-64 years who had received
pneumococcal vaccine
% ever vaccinated
100
80
60
Region A
Region B
Region C
Region D
40
20
0
1986
1991
1996
Year
2001
Alaska Native Elders (age 65 or older)
who had ever received Pneumococcal
Vaccine
% ever vaccinated
100
80
60
Region A
Region B
Region C
Region D
40
20
0
1986
1991
1996
Year
2001
Pneumococcal vaccination by high risk status,
55-64 year old Alaska Natives, 2000
100
90
80
70
60
50
40
30
20
10
0
93
80
63
69
44
diabetes
chronic
lung
heavy
alcohol
any risk
no risk
Alaska Native pneumococcal
immunization rates compared with
BRFSS data, 2000
% ever vaccinated
100
80
86
61
63
60
40
24
20
0
55-64 y/o
Alaska Native
65+ y/o
U.S. total
Interviews regarding Immunization Barriers
METHODS
• Indepth Interviews with 22 adults in one rural
and one urban region:
–
–
–
–
–
–
Physicians
Health Aides
Nurses
Adults with “high risk” conditions
Adults with previous pneumococcal disease
State immunization program staff
What did we learn from interviews?
• No problems with vaccine supply
• Generally little resistance to Pneumovax
• Some refuse because of stories about side
effects
• Difficult to obtain patient’s vaccination status
• Time constraints prevent tracking vaccine hx.
• Patients don’t actively seek Pneumovax but will
get vaccinated if provider recommends
• High risk patients access the health system
sporadically – often in acute care settings.
Where Can We Improve?
And How?
• High-risk adults <65 years
– 55-64 year olds – Provider education, Standing orders, prompts
– Alcoholics
• Dept. of Corrections
• Standing orders in Emergency Rooms, Inpatient Wards
– Smokers
• Recommendations at Smoking Cessation Intake
• Provider Education
• Standing orders for Clinics
• Patient Understanding
– Educational materials, Native translations
• Provider Education
– Grand Rounds, E-mails, Presentations to Clinical Directors
Current Projects to Improve Adult
Immunizations
• Attach pneumococcal vaccination to “Flu
campaigns”
• Survey and promotion of the use of Standing
Orders
• Culturally-appropriate educational materials
– Immunization brochure for AK Native Adults
– Immunization brochure in Yupik translation
– Adult Immunization Video
Acknowledgements:
• NARCH Research Staff
–
–
–
–
–
–
–
–
Florence Burton RN
Anuska Tilden
Anna Angaiak
Barbara McCumber RN
Mary Krevans RN
Kim Waldrep
Debra Parks
William Doan
• Interviewees
• Tribal Health Boards and Clinical Directors
• Arctic Investigations Program-CDC staff