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Issues up close


With the persistent focus on maintaining high childhood immunization rates, it’s easy to lose sight of the importance of adult immunization. But nurses must not allow such lapses in prevention; tens of thousands of American adults suffer permanent disability or die from vaccine-preventable illnesses every year. Among the most common are influenza and pneumococcal disease. Despite its name, pneumococcal disease causes more than just pneumonia; it’s also responsible for thousands of deaths from meningitis and bacteremia annually.

Despite the serious impact of these infections and the availability of safe and effective vaccines, adult immunization rates fall well below national public health goals. Influenza vaccination gained widespread public attention amid last year’s H1N1 scare, and the vaccine is now recommended for everyone ages 6 months and older. Yet immunization rates continue to languish. As for pneumococcal diseases, the elderly and those with chronic conditions are especially vulnerable; an urgent need exists to raise vaccination rates among these populations.

Nurses working in hospitals, community clinics, and private practices are uniquely poised to help increase vaccination rates and put disease awareness and prevention firmly on the radar screen—where they belong. This means making use of standing orders in participating hospitals, ensuring that vaccinations are part of routine care, and educating the larger community about the impact of these infections and the importance of prevention. By taking these steps, nurses can help prevent serious illness, disability, and premature deaths among patients.

Serious and deadly impact

Influenza has serious consequences and can lead to severe illness in people of all ages. It causes more than 200,000 hospitalizations and up to 49,000 deaths in the United States annually. The disease can result in such complications as pneumonia, bronchitis, sinusitis, and ear infections. Also, it can worsen chronic conditions and cause serious health conditions, such as myocardial infarction.
Pneumococcal infection is a common complication of influenza, but pneumococcal disease occurs year-round. Pneumococcal bacteria strike quickly, with infection sometimes progressing to death within hours. These bacteria are a major cause of the more than 900,000 annual cases of community-acquired pneumonia (CAP) in Americans ages 65 and older. Bacteremia and meningitis are less common than pneumonia but far deadlier. Fatality rates are 30% for meningitis, 20% for bacteremia, and 5% to 7% for pneumonia.

Pneumococcal disease also is expensive. More than $8 billion dollars are spent every year on patients hospitalized with CAP. The cost is even higher if one considers outpatient CAP cases, invasive disease, and complications, such as cardiac events (in pneumonia) and blindness, hearing loss, and paralysis (in bacteremia and meningitis).

Vaccines are effective but underused

To counter the threat of these diseases, the American Nurses Association, Centers for Disease Control and Prevention (CDC), National Foundation for Infectious Diseases (NFID), and a host of other organizations emphasize the need to step up immunization efforts aimed at adults. CDC recommends annual influenza vaccination for everyone ages 6 months and older. Influenza vaccines are 70% to 90% effective in preventing infection in healthy young adults.

Pneumococcal vaccination is recommended for:

  • everyone ages 65 years and older
  • persons ages 19 to 64 who smoke cigarettes or have asthma
  • persons ages 2 and older with chronic heart or lung disease, diabetes, splenectomy, or immunocompromising conditions.

Pneumococcal vaccine is the most effective means of protection from pneumococcal disease. For most adults, one dose is 60% to 70% effective against the bacteria responsible for more than 90% of invasive pneumococcal disease cases.

Although both the influenza and pneumococcal vaccines are relatively simple interventions and their costs generally aren’t prohibitive, they are woefully underused. Alarmingly, millions of adults who should receive pneumococcal vaccination don’t; the number who don’t get influenza vaccination is even higher. Medicare plans provide first-dollar coverage for both vaccines, and most private insurance companies provide at least some coverage for CDC-recommended vaccinations.

How can nurses increase immunization rates?

Every nurse can take steps to raise disease awareness. In acute-care and hospital settings, nurses see patients with a range of pressing health problems that can draw their attention away from prevention. Nonetheless, they should be on the lookout for patients who would benefit from pneumococcal immunization, as well as those who haven’t yet received seasonal influenza vaccine. Tools exist to help them do this, such as computerized reminder systems and standing orders.

Standing-orders programs authorize nurses to administer vaccines by following a predetermined protocol (where state law permits). They provide nurses with an important opportunity to educate patients and caregivers and increase vaccination rates. The lives that could be saved are worth the additional but manageable paperwork these systems require. In addition to being inexpensive and increasing efficiency, these protocols have been shown to be among the most effective interventions to improve vaccination coverage. In one study, patients in facilities with standing-orders policies directed to nurses received the pneumococcal vaccine significantly more often (51%) than patients with reminders directed to physicians (32%). Sample standing-orders materials are available at www.immunize.org/standing-orders and www.immunizationed.org/standingorders/.

In community clinics and practices, nurses should consider using electronic medical record (EMR) systems, vaccine trackers, and other practice-based tools to make vaccinations a standard part of both sick and well visits. Making every encounter a potential vaccination visit is one of the best ways to heighten awareness among adults and increase immunization rates.

Pneumococcal vaccination can be given at any time throughout the year, and nurses should make it a priority to identify older patients and those with long-term health problems; they all need the vaccine. EMR systems can be particularly helpful because they can be programmed to flag patients with specific diagnosis codes (for example, diabetes, asthma, and smokers) that make them vulnerable. Once you know who these patients are, you can educate them about the dangers of pneumococcal disease and encourage them to get vaccinated.

During influenza season (October through May) nurses can use EMRs and other office tools to be vigilant about recommending the influenza vaccine to every adult patient who walks through the door. Mailed or electronic reminders also can help bring patients back to the office for an annual flu shot.
Also, be sure to discuss the importance of vaccination with colleagues. And of course, get vaccinated yourself as appropriate. By doing so, you can help protect yourself, your family, and your patients from serious illness.

Education and community outreach

Nurses also can make a difference by championing the issue outside their practice settings. This can take many forms, including talking with patients about the value of pneumococcal and influenza vaccinations and using such educational materials as waiting room posters or handouts. The National Foundation for Infectious Diseases (NFID) offers educational materials and tools at www.adultvaccination.org to help nurses educate patients about adult immunization.

Teachable moments in the community can increase the visibility of these diseases and make the case for vaccination. Most nurses have limited time, but finding even one opportunity to advocate at the community level can go a long way. For example, you might consider speaking at a local health fair, a library, a senior center, or your place of worship.

Setting nursing’s sights on achieving high levels of vaccine coverage is a significant challenge. The good news is that individual nurses can do many things to advance this effort. By taking the steps outlined here, you can be part of the solution to preventing unnecessary suffering and saving lives.

Selected references

Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine-Preventable Diseases. Atkinson W, Wolfe S, Hamborsky J, McIntyre L. (Eds.) 11th ed. Washington D.C.: Public Health Foundation, 2009.

Centers for Disease Control and Prevention. Updated recommendations for prevention of invasive pneumococcal disease among adults using the 23-valent pneumococcal polysaccharide vaccine (PPSV23). MMWR Morb Mortal Wkly Rep. 2010 Sep 3;59(34):1102-6.

Centers for Medicare and Medicaid Services. Adult Immunization Resources for Providers. https://www.cms.gov/AdultImmunizations/02_Providerresources.asp. Accessed December 9, 2010.

File TM Jr, Marrie TJ. Burden of community-acquired pneumonia in North American adults. Postgrad Med. 2010;122:130-141.

Rehm SJ, Farley MM, File TM Jr, et al. Higher pneumococcal disease vaccination rates needed to protect more at-risk US adults. Postgrad Med. 2009;121:101-105.

Tsai JC, Griffin MR, Nuorti JP, Grijalva CG. Changing epidemiology of pneumococcal meningitis after the introduction of pneumococcal conjugate vaccine in the United States. Clin Infect Dis. 2008;46:1664-1672.

Vaccine Preventable Diseases & Infections. AdultVaccination.org http://www.adultvaccination.org/vpd. Accessed December 9, 2010.

World Health Organization. 23-valent pneumococcal polysaccharide vaccine: WHO position paper. Wkly Epidemiol Rec. 2008;83:373-384.

World Health Organization. Immunizations, vaccinations and biological. http://www.who.int/rabies/vaccines/en/. Accessed December 9, 2010.

Barbara Chamberlain is program manager of Transforming Care at the Bedside, a joint initiative of the New Jersey Hospital Association and the Robert Wood Johnson Foundation. She is immediate past president of the New Jersey State Nurses Association and a member of ANA. Susan J. Rehm is a staff physician at the Cleveland Clinic in Cleveland, Ohio and vice chair of the Clinic’s Department of Infectious Disease. She also serves as medical director for the National Foundation for Infectious Diseases and as co-chair of NFID’s Pneumococcal Disease Advisory Board.

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