Preventable Outbreak of Pneumococcal Pneumonia Among Unvaccinated Nursing Home Residents-- New Jersey, 2001

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. Cohort Analysis 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. 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 Acknowledgments

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