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 Pneumococcus or Streptococcus pneumoniae is one of the most common bacterial causes of serious infection in adults.

Invasive Pneumococcal Disease, Alaska, 1986-90 and 1991-97 This shows the rate of invasive pneumococcal disease by age from the AIP surveillance. The yellow is the non-Native Alaskan rate. The dark blue is the rate in Alaska Natives between 1986 and 1990, and the light blue is the rate in Alaska Natives between 1991-1997. During the latter period, the rate in elders >65 years decreased; however, the rate in younger Alaska Natives did not change. 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 Chart review of adults with invasive pneumococcal disease, 1986-2000 Vaccine record review of a randomized sample of at-risk adults in 4 regions to document vaccine coverage Interviews with community leaders, providers and Alaska Native adults

Incidence and Case-fatality of Invasive Pneumococcal Disease by Age, Alaska Natives, 1986-2000

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 reviewed in 2/4 regions.RPMS is the computerized medical record.

Pneumococcal vaccination by high risk status, 55-64 year old Alaska Natives, 2000

Alaska Native pneumococcal immunization rates compared with BRFSS data, 2000

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 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 Interviewees 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