Pneumonia in older adults remains a leading cause of morbidity, mortality, and increased healthcare costs. Streptococcus pneumoniae is a bacterium known to cause an array of illnesses in older adults, including pneumonia, meningitis, and bloodstream infections.1 Community-acquired pneumonia (CAP) is most commonly linked to S pneumoniae,and is associated with significant economic burden, hospitalization, and mortality rates.2,3 Approximately 5.6 million cases of CAP occur in the United States annually;of those cases, roughly 1.3 million lead to hospitalization.3 The mean age for CAP is 62.6 years, with direct costs exceeding $17 billion annually in the United States.3
In 2016, the Centers for Disease Control and Prevention (CDC) reported influenza/pneumonia as the eighth leading cause of death in those aged 65 years and older.4 Although pneumonia is considered a vaccine-preventable disease, the annual incidence of the disease remains high in the United States because of low vaccination rates. In 2016, the national pneumococcal vaccination rate for individuals aged 65 years and older was 66.9%,far under the goal of 90% set by Healthy People 2020.5,6
Preventing pneumonia by increasing vaccination rates begins with the primary care provider (PCP); however, providers are often managing urgent and chronic medical complaints, thus limiting prevention screening time during office visits.6 This article provides a quick reference guide informing the PCP about who should be vaccinated, what vaccines are available to reduce the incidence of pneumonia, and what barriers to vaccination uptake exist in this population.
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What Vaccines Are Available, and How Effective Are They?
Two vaccines are available to prevent pneumonia in this population: pneumococcal conjugate vaccine (PCV13 or Prevnar 13) and the pneumococcal polysaccharide vaccine (PPSV23 or Pneumovax 23). PCV13 reduces the risk for pneumococcal pneumonia, whereas both PCV13 and PPSV23 protect against invasive pneumococcal infections.7 Vaccinating adults aged 65 years and older with both PCV13 and PPSV23 is thought to give broader protection against invasive pneumococcal disease.7 The PCV13 vaccine contains 13 serotypes of S pneumoniae.8 According to the CDC, 1 dose of PCV13 protects 75 in 100 adults aged 65 years and older from invasive pneumococcal disease, and 45 in 100 from pneumococcal pneumonia.9 The PPSV23 vaccine covers 23 strains of pneumococcus, and is estimated to protect from 50 to 85 of 100 adults against invasive pneumococcal disease.9
Who Should Receive the Vaccine and When?
In the adult population, 2 target groups are recommended for the pneumococcal vaccine. The CDC recommends that all adults aged >65 years have both PCV13 and PPSV23 vaccines. 9 The pneumococcal vaccine is also recommended for adults aged 19 to 64 years who are considered at risk because of certain medical conditions or who have a history of smoking.10 In this at-risk age group, those with asthma; diabetes; heart, liver, lung, or kidney disease; HIV/AIDS; and certain medical conditions including any condition requiring immunosuppressant therapy, solid organ transplant recipients, cerebral spinal fluid leaks, cochlear implant recipients, and immunocompromising conditions should receive PPSV23 and/or PCV13.10 However, this article focuses on the 65-and-older population, as pneumococcal vaccination status is part of preventive measures set by the Centers for Medicare & Medicaid Services for the Medicare Shared Saving Program.11 The CDC recommends that whenever possible, PCV13 be administered before PPSV23 in those aged at least 65 years.10 Regardless of previous history of pneumococcal vaccines, the CDC recommends that after age 65 years, adults should receive only 1 dose of PPSV23, with no additional doses needed.10
Table. Time of Pneumococcal Vaccine Based on History in Adults Aged ≥65 Years10
| Never Received Either Pneumococcal Vaccine | Previously Vaccinated With PPSV23 and Not Dosed With PCV13 |
| • Administer 1 dose of PCV13 | • PPSV23 given at age ≥65 years, at least 5 years after any previous doses of PPSV23 before age 65 years |
| • Administer 1 dose of PPSV23 at least 1 year later | • Administer 1 dose of PCV13 at least 1 year after PPSV23 is given |
What Barriers Affect Vaccination Uptake in Primary Care?
The lack of vaccinations in this population is multifactorial. Patient-related barriers include lack of vaccine awareness, skepticism about vaccine effectiveness and safety,belief that the vaccine is unnecessary, fear of vaccine adverse effects, and lack of provider recommendation.6,12 Patients may also have a misconception that the vaccine will not be covered by insurance (private or Medicare), leaving them to pay out of pocket. These identified patient barriers often result from lack of education; therefore, patient outreach is essential and PCPs must raise awareness and offer vaccine recommendations at every patient encounter.
Practice-related barriers include lack of public knowledge regarding vaccinations, inaccurate vaccine information, gaps in regular screenings and recommendations during PCP visits, high costs of keeping vaccines in stock, and payment inconsistencies with either insured provider reimbursement or decreased funding for the uninsured patient population.7 Increasing vaccine access for the adult population can also be challenging because patient vaccine records can be difficult to access and patients and providers may not communicate effectively about vaccination history.7 Providers have a limited amount of time during patient encounters and are often treating acute and/or chronic health problems, reducing time spent discussing preventative measures such as immunizations.13 Identifying potential barriers in practice is vital to minimizing the effect of low vaccination rates. Strategies to overcome those barriers should be individualized for each organization, as it formulates a plan of action to increase the vaccine uptake in the population of adults aged ≥65 years.
How Can PCPs Overcome Barriers?
It is well-documented that provider recommendation continues to be an important factor linked to patient vaccination uptake.7 To increase vaccination rates in the population of adults aged ≥65 years, office staff members and providers require more education and encouragement to ensure that the unvaccinated patient population is engaged. Strategies to increase the uptake of pneumococcal vaccinations require organizational changes that include instituting standing order programs, provider reminders prompted by the electronic medical record, and patient outreach reminders.6,7
Increasing vaccination uptake starts with assessing vaccination status of all patients at every office visit, ensuring that the provider is recommending the pneumococcal vaccination and that any vaccine administered is documented in the electronic health record.7 In the event that an office does not stock the pneumococcal vaccines, providers should continue to assess vaccination needs and refer the patient to a provider or pharmacy that can provide the vaccine.7 If the patient is unsure of vaccine status, the provider, office staff, and/or patient can refer to the immunization information system or vaccine registry, a state-based registry that records all immunizations administered by participating providers.7 The immunization information system consolidates a patient’s vaccination record from varying participating providers into 1 record within a given geographical area.14
According to the CDC, most private healthcare plans must cover the pneumococcal vaccines if provided by an in-network provider.15 Medicare Part B will cover the first pneumococcal vaccine in the series, and the second vaccine as long as it is given 1 year after the initial one.15 The National Foundation for Infectious Diseases offers a variety of professional resources to help raise awareness and encourage the older adult population to receive the pneumococcal vaccine series. For more information or for tools to help raise patient awareness, visit the National Foundation for Infectious Diseases Web site.
Conclusion
Improvements in vaccination compliance should be made to prevent complications of pneumococcal disease, starting with increased awareness.16 Increasing vaccination awareness starts with provider recommendation, as there is a strong correlation between recommendation and patient uptake.7 To meet the Healthy People 2020 pneumococcal vaccination goal of 90% in the older adult population, PCPs should incorporate assessment of vaccination needs, provide necessary recommendations, and promote educational opportunities in the office setting.7 To continue making progress, office staff, including PCPs, must be engaged, implement practice changes, and frequently reevaluate the percentage of those unvaccinated.
Tara Caldwell, BSN, RN, DNP, APRN, FNP, is a registered nurse for Roper St Francis Healthcare in Charleston, South Carolina.
References
1. Jindracek L, Stark JE. Identifying missed opportunities for the pneumococcal conjugate vaccine (PCV13). J Pharm Technol. 2018;34(1):24-27.
2. Feldman C, Anderson R. The role of Streptococcus pneumoniae in community-acquired pneumonia. Semin Respir Crit Care Med. 2016;37(6):806-818.
3. Sato R, Rey GG, Nelson S, Pinsky B. Community-acquired pneumonia episode costs by age and risk in commercially insured US adults aged ≥50 years. Appl Health Econ Health Policy. 2013;11(3):251-258.
4. Health, United States, 2016: with chartbook on long-term trends in health. National Center for Health Statistics. Center for Disease Control and Prevention. https://www.cdc.gov/nchs/data/hus/hus16.pdf. Updated May 2017. Accessed May 31, 2018.
5. Vaccination coverage among adults in the United States, National Health Interview Survey, 2016. Centers for Disease Control and Prevention. https://www.cdc.gov/vaccines/imz-managers/coverage/adultvaxview/pubs-resources/NHIS-2016.html. Updated February 8, 2018. Accessed May 31, 2018.
6. Zimmerman RK, Brown AE, Pavlik VN, et al. Using the 4 pillars practice transformation program to increase pneumococcal immunizations for older adults: a cluster-randomized trial. J Am Geriatr Soc. 2017;65(1):114-122.
7. Williams WW, Lu P-J, O’Halloran A, et al. Surveillance of vaccination coverage among adult populations — United States, 2014. MMWR Surveill Summ. 2016;65(1):1-36.
8. About pneumococcal vaccines. Centers for Disease Control and Prevention. https://www.cdc.gov/vaccines/vpd/pneumo/hcp/about-vaccine.html. Published December 6, 2017. Accessed June 8, 2018.
9. Pneumococcal vaccination: what everyone should know. Centers for Disease Control and Prevention. https://www.cdc.gov/vaccines/vpd/pneumo/public/index.html. Published December 6, 2017. Accessed June 8, 2018.
10. Pneumococcal vaccine timing for adults. Centers for Disease Control and Prevention. https://www.cdc.gov/vaccines/vpd/pneumo/downloads/pneumo-vaccine-timing.pdf. Published 2015. Accessed June 2, 2018.
11. Accountable Care Organization 2015 program analysis quality performance standards narrative measure specifications. Center for Medicare and Medicaid Innovation. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/ACO-NarrativeMeasures-Specs.pdf. Published January 9, 2015. Accessed June 20, 2018.
12. National adult immunization plan. US Department of Health and Human Services. https://www.hhs.gov/sites/default/files/nvpo/national-adult-immunization-plan/naip.pdf. Published 2013. Accessed June 3, 2018.
13. Rehm SJ, File TM, Metersky M, Nichol KL, Schaffner W. Identifying barriers to adult pneumococcal vaccination: An NFID task force meeting. Postgrad Med. 2012;124(3):71-79.
14. About immunization information systems. Centers for Disease Control and Prevention website. https://www.cdc.gov/vaccines/programs/iis/about.html. Updated June 7, 2019. Published May 15, 2012.
15. Resources for adult vaccination insurance and payment. Centers for Disease Control and Prevention. https://www.cdc.gov/vaccines/hcp/adults/for-practice/insurance-payment.html. Published 2015. Accessed June 18, 2018. 16. Williams WW, Lu P-J, O’Halloran A, et al. Surveillance of vaccination coverage among adult populations — United States, 2015. MMWR Surveill Summ. 2017;66(11):1-28.
