Preventable Outbreak of Pneumococcal Pneumonia Among Unvaccinated Nursing Home Residents New Jersey,

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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

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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

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Invasive S. pneumoniae Disease

• Bacteremia, meningitis or other infection of
  normally sterile site
• 30-40 case-fatality rate among elderly

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Pneumococcal Polysaccharide Vaccine (PPV)

• ACIP guidelines
• gt65 years
• Residence in certain environments or social
  settings

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Objectives

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

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Case Finding Definition

• Febrile respiratory illness
• Requiring hospitalization
• Onset between April 1-26
• Resident of nursing home

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Case Finding Definition (contd)

• Radiographic findings consistent with pneumonia,
  and
• Blood cultures positive for S. pneumoniae, or
• Sputum specimens positive for diplococci

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Case Finding Methods

• Residents transferred for treatment
• Nursing home medical charts
• Hospital discharge summaries

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Case Finding Results

• 7 residents with pneumonia and bacteremia
• 2 additional residents identified

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Laboratory Findings

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

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Respiratory illnesses, February-April 2001
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Nursing Home

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

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Hypotheses

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

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Case-Control Study

• Cases
• Two unmatched controls per case
• Selected randomly
• Resided in north wing

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Results
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Cohort Analysis
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Cohort Analysis

• Vaccine effectiveness
• (risk unvaccinated risk vaccinated) / risk
  unvaccinated
• (16 0) / 16
• 100

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Control Measures

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

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Reasons for PPV Refusal

• Concerns about costs and benefits of PPV

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Additional Investigations

• To determine compliance with New
• Jerseys immunization regulations
• Long-term care facilities (LTCF)
• Hospitals

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Regulations

• Nursing homes required to assess for and offer
  PPV to residents gt65 years at time of admission
• Hospitals required to offer PPV prior to
  discharging patients gt65 years

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LTCF Survey Results

• 361 (42) of 853 LTCF responded
• 28 (8) LTCF did not meet state regulation

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Hospital Investigation Results
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Summary

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

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Limitations

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

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Other LTCF Studies

• Outbreaks in LTCF with low PPV coverage
• 1997 25 PPV coverage in nursing homes

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Barriers to Vaccination

• Lack of physician emphasis
• Incomplete documentation
• Misconceptions
• Adverse reactions after unintended revaccination
• Vaccine benefits
• Cost disadvantages

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PPV Benefits

• Safe
• 56-81 effectiveness

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PPV Cost Incentives

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

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Recommendations

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

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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

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Pneumococcal Disease Epidemiology

• Human carriers
• Respiratory, autoinoculation
• Communicability unknown

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Transmission

• Respiratory and autoinoculation
• Serotypes frequently found in carriers
• Factors that influence spread
• Crowding
• Season
• Upper respiratory infections
• Pneumococcal disease

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Pneumococcal Polysaccharide Vaccine (PPV)

• 23 capsular antigens of S. pneumoniae
• 85-90 of serotypes
• Protects against invasive disease

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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

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PPV Contraindications

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

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PPV Duration of Immunity

• Protection for at least 9 years
• Antibody levels decline after 5-10 years
• Routine revaccination not recommended

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Indications for Revaccination

• Persons gt2 years of age at highest risk after 5
  years since first dose
• Persons gt65 years of age if vaccine received 5 or
  more years previously and lt65 years of age at
  time
• Elderly persons with unknown vaccination status

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Conjugate Vaccines

• Coupling of antigen to carrier protein
• Improves immunogenicity and protective efficacy

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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

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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

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National Medicare Study

• Opportunities to provide PPV missed for
• up to 80 of eligible elderly persons
• hospitalized with pneumonia

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Chronic Illnesses

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

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Immunosuppressive Conditions

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

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Medical Risk Factors

• Cardiovascular disease
• Pulmonary disease (but not asthma)
• Liver disease
• Diabetes mellitus
• Renal disease

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Healthy People 2010 Objective

• 90 pneumococcal vaccination coverage
• among nursing home residents and adults
• gt65 years