Preventable Outbreak of Pneumococcal Pneumonia Among Unvaccinated Nursing Home Residents-- New Jersey, 2001 Tina Tan, MD CDC/EPO/State Branch New Jersey Department of Health and Senior Services

Nursing Home Outbreak April 24: New Jersey Department of Health and Senior Services notified 7 cases pneumococcal pneumonia with bacteremia 7 hospitalized, 4 deaths Illness onset April 3 – 24

Invasive S. pneumoniae Disease Bacteremia, meningitis or other infection of normally sterile site 30-40% case-fatality rate among elderly

Pneumococcal Polysaccharide Vaccine (PPV) ACIP guidelines: >65 years Residence in certain environments or social settings

Objectives Identify additional cases Investigate risk factors Implement control efforts Investigate why outbreak occurred

Case Finding Definition Febrile respiratory illness Requiring hospitalization Onset between April 1-26 Resident of nursing home

Case Finding Definition (cont’d) Radiographic findings consistent with pneumonia, and Blood cultures positive for S. pneumoniae, or Sputum specimens positive for diplococci

Case Finding Methods Residents transferred for treatment Nursing home medical charts Hospital discharge summaries

Case Finding Results 7 residents with pneumonia and bacteremia 2 additional residents identified

Laboratory Findings 7 blood culture isolates Serotype 14 Penicillin-sensitive Erythromycin-resistant only

Respiratory illnesses, February-April 2001

Nursing Home 114-bed facility Single-story building 2 wings Acute and rehabilitative care 200 staff, none with known illness

Hypotheses Risk factors Not vaccinated Compromised physical functioning Recent antibiotic use History of pneumonia Chronic medical conditions

Case-Control Study Cases Two unmatched controls per case –Selected randomly –Resided in north wing

Results

Cohort Analysis

Vaccine effectiveness = (risk unvaccinated – risk vaccinated ) / risk unvaccinated = (16% – 0) / 16% = 100%

Control Measures PPV offered to all 55 unvaccinated residents 37 (67%) received vaccine 18 (33%) refused vaccine

Reasons for PPV Refusal Concerns about costs and benefits of PPV

Additional Investigations To determine compliance with New Jersey’s immunization regulations Long-term care facilities (LTCF) Hospitals

Regulations Nursing homes required to assess for and offer PPV to residents >65 years at time of admission Hospitals required to offer PPV prior to discharging patients >65 years

LTCF Survey Results 361 (42%) of 853 LTCF responded 28 (8%) LTCF did not meet state regulation

Hospital Investigation Results

Summary Pneumococcal pneumonia associated with lack of PPV Serotype 14 included in PPV Limitations of regulations for ensuring vaccine coverage

Limitations Controls from north wing only Carriage study not conducted Limited LTCF and hospitals surveyed

Other LTCF Studies Outbreaks in LTCF with low PPV coverage 1997: 25% PPV coverage in nursing homes

Barriers to Vaccination Lack of physician emphasis Incomplete documentation Misconceptions –Adverse reactions after unintended revaccination –Vaccine benefits –Cost disadvantages

PPV Benefits Safe 56-81% effectiveness

PPV Cost Incentives Cost-effective Cost-saving Covered under Medicare State Medicaid plans cover vaccinations

Recommendations Multifaceted and integrated approach needed to increase vaccination rates Standing orders programs State regulations Vaccination history documentation Education

Acknowledgments NJDHSS E Bresnitz S Ostrawski C Morris J Calabria B Reetz E Fritz F Sorhage NJPHEL Hamilton Township DOH S Clugston CDC C Whitney R Dicker

Pneumococcal Disease Epidemiology Human carriers Respiratory, “autoinoculation” Communicability unknown

Transmission Respiratory and “autoinoculation” Serotypes frequently found in carriers Factors that influence spread –Crowding –Season –Upper respiratory infections –Pneumococcal disease

Pneumococcal Polysaccharide Vaccine (PPV) 23 capsular antigens of S. pneumoniae 85-90% of serotypes Protects against invasive disease

PPV Immunogenicity Induces type-specific antibodies Antigen-specific antibody response within 2-3 weeks Responses in elderly may be lower Responses may not be consistent among all 23 serotypes in vaccine

PPV Contraindications Severe allergic reaction to prior dose of vaccine or vaccine component Moderate or severe acute illness

PPV Duration of Immunity Protection for at least 9 years Antibody levels decline after 5-10 years Routine revaccination not recommended

Indications for Revaccination Persons >2 years of age at highest risk after 5 years since first dose Persons >65 years of age if vaccine received 5 or more years previously and <65 years of age at time Elderly persons with unknown vaccination status

Conjugate Vaccines Coupling of antigen to carrier protein Improves immunogenicity and protective efficacy

Drug-resistant S. pneumoniae Increasingly common in United States Treatment may require use of alternative antimicrobial agents May result in prolonged hospitalization and increased medical costs

Control Measures Implemented –Restricted transfers or admissions with no history of vaccination Not implemented –Cohorting ill patients and exposed staff –Closing facility to new admissions –Antibiotic prophylaxis

National Medicare Study Opportunities to provide PPV missed for up to 80% of eligible elderly persons hospitalized with pneumonia

Chronic Illnesses Cardiovascular disease Pulmonary disease (but not asthma) Diabetes mellitus Alcholism Liver disease

Immunosuppressive Conditions Congenital immunodeficiency HIV infection Leukemia Lymphoma Hodgkins disease Generalized malignancy Chronic renal failure Immunosuppressive therapy

Medical Risk Factors Cardiovascular disease Pulmonary disease (but not asthma) Liver disease Diabetes mellitus Renal disease

Healthy People 2010 Objective 90% pneumococcal vaccination coverage among nursing home residents and adults >65 years