Audit of uptake of influenza

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Audit of uptake of influenza pneumococcal
vaccinations in patients attending RNHRD
outpatients clinic

• John Pauling
• SpR Rheumatology
• GP forum
• 24th February 2009

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History of vaccinations
Edward Jenner, having first gained local R D
approval, inoculates 8 year old boy with cow pox
and exposes child to small pox without
complication
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Variolation

• Buddhist nun practicing between 1022 and 1063
• She would grind up scabs from a person with
  small-pox into a powder and blow the contents
  into the nostrils of a non-immune person.

• 2 to 3 of subjects died of small-pox but the
  practice
• reduced overall mortality by 10-fold

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Influenza

• Spanish flu 1918 20 million deaths
• 250,000 to 500,000 deaths every year worldwide
  (36,000 in US)
• Vaccines developed from hens eggs 1930s
• Influenza vaccination for militrary personal WW2.
• Annually updated trivalent flu vaccine consisting
  of haemagluttinin (HA) components from 3
  commonest viral strains (H3N2, H1N1 Inflenza B
  in 2007/08)

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(No Transcript)
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Concern 1976/77 regarding increased incidence of
GBS. Not seen since and increased risk considered
lt 1/1,000,000. Risk of anaphylaxis also
1/1,000,000.
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Pneumococcal vaccination

• Invasive Pneumococcal Disease responsible for
  800,000 to 1,000,000 paediatric deaths per year
  worldwide (WHO)
• Streptococcal pneumonia commonest cause of CAP in
  UK
• PCV (pneumococcal conjugate vaccine) PPV
  (pneumococcal polysaccharide vaccine)
• Generally safe and well tolerated (very similar
  side effect profile to Influenza vaccination)
• Lifelong protection from single vaccination
  (except in asplenia etc when boosters every 5 -
  10 years need to be given)

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Wyeth sponsored prevnar TV commercial banned in
Poland Saudi Arabia April 3rd 2007 as it showed
child dying in mothers arms and was deemed to
use fear to sell product. Wyeths share price
rose in response to widespread criticism.
Note prevnar sales worth 1.5
Billion to Wyeth 2005 !!!
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Rheumatoid Arthritis

• Rheumatoid arthritis is associated with
  approximately a two-fold risk of infection
  (particularly pulmonary) as compared with
  age-matched controls 1
• Related to ill-defined immunoregulatory
  abnormalities ?
• Use of immunosuppressive medications eg antiTNFa

1 Wolfe et al. The mortality of Rheumatoid
Arthritis. Arthritis Rheum 199437481-94
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Are Vaccinations safe effective in RA?

• Does the same mechanism that increases risk of
  infection also reduce their response to vaccines?
• Does the activation of the immune system, when
  responding to the immunizing antigen, induce a
  flare of the underlying rheumatic disease?
• Several case reports of such associations
• One small study observed lower rates of flares in
  RA following influenza vaccination (J Rheum
  200027553-4)
• No large scale studies performed to date to
  adequately address these questions

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Use of Influenza vaccination in RA

• 2 studies have found antibody responses following
  influenza vaccination to be similar to those of
  normal controls 2, 3
• Influenza vaccines generate a good humoral
  response in RA patients, although lower than
  healthy controls. The response was not affected
  by use of steroid, DMARDs or antiTNFa inhibitors
  4

2 Herron et al. Influenza vaccination in patients
with rheumatic diseases safety efficacy. JAMA
197924253-6 3 Chalmers et al. Immunisation of
patients with RA against influenza a study of
vaccine safety immunogenicity. J Rheumatol
1994211203-6 4 Fomin et al. Vaccination against
influenza in RA the effct of DMARDs including
antiTNFa
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Use of Influenza vaccination in RA

• Other studies have suggested a reduced antibody
  response during antiTNFa therapy although still
  sufficient to offer protection 5
• Significantly lower post vaccination titres and
  protection rates following influenza vaccinations
  found in 4 patients treated with rituximab 6
• (Product literature advises vaccination 1/12 pre
  or 6/12 post infusion)

5 Van der Bijl et al. AntiTNFa inhibits the
antibody response to influenza vaccination. Ann
Rheum Dis 2005(suppl III)181 6 Gellink et al.
Poor serological responses upon influenza
vaccination in patients with RA treated with
rituximab. Ann Rheum Dis 2007661402-3
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Use of pneumococcal vaccination in RA

• Immune responses to pneumococcal antigens of
  patients with RA were impaired by methotrexate
  but not antiTNFa therapy 7
• This has also been observed in PsA patients
  treated with enbrel or MTX therapy 8
• ? due to unselective inhibition of cell
  proliferation with MTX whilst TNFa doesnt play
  important role in the induction of an immune
  response

7 Kapetanovic et al. Influence of MTX, antiTNFa
blockers and prednisolone on antibody responses
to PPV in patients with RA. Rheumatology
200645106-11 8 Mease et al. Pneumococcal
vaccine response in psoriatic arthritis patients
during treatment with etanercept. J Rheumatol
2004311356-61
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Current National Guidance

• All patients with RA offered pneumococcal
  annual flu vaccinations in US, Germany Sweden
• Based on recommendations from the Joint Committee
  on Vaccination and Immunisation, the Department
  of Health (DoH) advises use of influenza and
  pneumococcal vaccines in 9
• All patients gt65 years old
• lt65 years old but with additional risk factors eg
• Use of immunosuppressive therapy
• Hyposplenism
• Diabetes
• CRF
• Chronic liver disease
• Chronic cardiovascular and pulmonary disease
• Long term care in nursing / residential home

9 Recommendations of the Joint Committee on
Vaccination and Immunisation Influenza and
pneumococcal vaccinations. Available at
http//www.immunisation.nhs.uk/
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Aim Methodology

• 150 unselected patients attending RNHRD
  outpatient services between Aug Nov 2007
• Broad selection of clinic sub-specialties
  including general rheum, PsA, ESC, CTD,
  Osteoporosis service, AS course etc
• Use of self-reported questionnaire and
  scrutinization of medical notes to assess
  adherence with DoH guidance
• Assessment made of eligibility for vaccines,
  uptake of vaccinations and where indicated
  reasons for failure to receive vaccines explored

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Patient Demographics

• 150 patients assessed
• 91/150 (60.7) lt65 years old
• 59/150 (39.3) gt65 years old
• Average age 59.9 years (range 24-87)
• 116/150 (77.3) patients taking Immunosuppressive
  agents
• Other co-morbidities included respiratory disease
  (33/150, 22), CVD (15/150, 10), renal
  impairment (6/150, 4), DM (4/150, 2.7), and
  asplenia (1/150, 0.7)
• 1 patient was living in a nursing home

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Underlying Diagnoses
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Results

• Vaccine indicated in 135/150 patients (90)
• Vaccine indicated in all patients gt65 yrs (59
  patients)
• Vaccine indicated in 76/91 patients lt65 yrs
  (83.5)
• The vast majority of eligible patients lt65 yrs
  (71/91, 92.1) were taking immunosuppressant
  medications

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Vaccine uptake in eligible patients
p 0.004 p lt 0.001
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Reasons for non-uptake of Influenza vaccination
in eligible patients
p 0.002
Patients gt 65 yrs significantly more likely to
have been offered but refused influenza vaccine
whereas patients lt 65 yrs more likely to have
never been offered the vaccination
NB 2 patients excluded from analysis as due to
have vaccination imminently
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Reasons for non-uptake of Pneumococcal
vaccination in eligible patients
No significant differences between different
cohorts. Patients in both cohorts more likely to
have never been offered the vaccine than refused
(p 0.064)
NB 2 patients excluded from analysis as due to
have vaccination imminently
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Limitations

• Use of self reported questionnaires susceptible
  to recall bias
• Possible under reporting of pneumococcal vaccine
  uptake
• Under representation of soft tissue rheumatic
  conditions and OA in view of case mix attending
  RNHRD out patient services

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Conclusions (1)

• Significant morbidity mortality associated with
  Influenza Pneumococcal vaccination
• Effective and well tolerated vaccines available
• Vaccines appear safe and sufficiently antigenic
  to induce an antibody responses in our patients
  even when receiving immunosuppressive therapy

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Conclusions (2)

• Influenza vaccination uptake rates satisfactory
  for gt65 yrs
• Significantly lower for lt65 yrs and patients lt65
  yrs are significantly more likely to have never
  been offered vaccinations than refused
• Pneumococcal vaccination uptake lower than
  influenza vaccine uptake in all groups
• Uptake acceptable for gt65 yrs but significantly
  lower in patients lt65 yrs
• Patients who have not received pneumococcal
  vaccine more likely to have never been offered
  vaccine than refused, irrespective of age

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Recommendations

• Increase awareness amongst local rheumatology
  healthcare providers and primary care
• Reminder notice on prescription pad
• Introduce vaccinations into our work-up policy
  for antiTNFa and Rituximab therapies
• Increase awareness for patients via RAISE
  meetings, posters in waiting areas etc
• Formation of steering group to seek solutions to
  how issues such as vaccinations, in addition to
  other key components of annual review can be best
  addressed
• Re-audit adherence to guidance in 2010

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Any questions ?