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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 # # # # # # # # # # # # # # # # # # # # # # # # # ## # # # ### # # # # ## ## # ## # # # # # # # # ## # # # # ## # # # # # # # # # # ## ## # # # ## # # # # # # # ## # # # # # # # # # # ## # # # # # # # ## # # ## # # # ## # # # # ## # # ## # # # # # # ### # #### #### # ## # # # # # # # ## # # # ## # # # # # # ## # ## # # # ## ## # ### # # ## # # # ## # # # ## # ## # # ## # # # # # ## # ## ## # ## # # # # # # # ## # # # ## # # # # # # # # # # # ## # ## # # # # # # # #### # # # # # # ## ## #### ## # ### # ## # # # # # # # # # # # # ### # # ## # # # # # ## # ### # # # ## # # # # # # # # # # # # # ## # ## ## # #### ## ## # # # # # # # # ## # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # ## # # # # # ## # # # ## # # # ## # # # ## # # # # ## # ## ### # # ## # ## # # # # # # # # ## ## # # # # # # # ## # # # # ## # # # ## ### # ## # # # # # # # # # ## # # ##### ## # # # # # # ## # # # # ## # ## # # # 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