1. 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

2. 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

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

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

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

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

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

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

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

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

11. Respiratory illnesses, February-April 2001

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

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

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

16. Results

17. Cohort Analysis

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

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

20. Reasons for PPV Refusal Concerns about costs and benefits of PPV

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

22. 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

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

24. Hospital Investigation Results

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

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

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

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

29. PPV Benefits Safe 56-81% effectiveness

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

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

32. 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

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

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

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

37. 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

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

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

40. 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

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

42. 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

43. 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

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

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

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

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

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