Issue
Number 360
January 16, 2003
UNPROTECTED PEOPLE: Stories of
people who have suffered or died from vaccine-preventable diseases
Story #53:
Outbreak of pneumococcal pneumonia
in a New
Jersey nursing home claims four lives
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The Immunization Action Coalition (IAC) publishes articles about people who
have suffered or died from vaccine-preventable diseases and occasionally
devotes an "IAC EXPRESS" issue to such an article. This is the 53rd in our
series.
The occurrence of a pneumococcal pneumonia outbreak in a New Jersey nursing
home in April 2001 caused the hospitalization of nine residents and the
death of four. Afterward, the New Jersey Department of Health and Senior
Services investigated the nursing home, surveyed other long-term care
facilities, and investigated hospitals to assess their compliance with the
state's vaccination requirements for residents age 65 and over.
The results of their investigations were reported in the "Morbidity and
Mortality Weekly Report" (MMWR) of August 24, 2001 (vol. 50, no. 33), under
the title "Outbreak of Pneumococcal Pneumonia Among Unvaccinated Residents
of a Nursing Home--New Jersey, April 2001." We are reprinting it now
as a timely reminder to health professionals to administer pneumococcal
vaccine to all their at-risk patients who need it. The complete text of the
report, excluding references, reads as follows:
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On April 24, 2001, seven cases of pneumococcal pneumonia with bacteremia
among residents of a nursing home were reported to the Hamilton Township
Department of Health, New Jersey; all seven diagnoses were confirmed with
blood cultures positive for Streptococcus pneumoniae. Illness onset
among the residents occurred during April 3-24; four residents died. The New
Jersey Department of Health and Senior Services (NJDHSS) was notified on
April 24 and initiated an investigation to identify additional cases
and implement control efforts. This report summarizes results of the
investigation, which underscore the importance of providing pneumococcal
polysaccharide vaccine (PPV) to elderly residents of long-term care
facilities (LTCFs).
The nursing home is a 114-bed facility that employs approximately 200 staff,
including nurses, restorative aides, and other administrative and support
personnel. None of the employees was known to have pneumonia or
laboratory-confirmed pneumococcal disease during this period.
On further investigation, two additional residents were identified to have
been hospitalized during April 3-24 with pneumonia. Seven of the nine
patients had blood cultures positive for S. pneumoniae, which were sent to
the New Jersey Public Health and Environmental Laboratory and CDC for
serotyping and susceptibility testing; pulsed-field gel electrophoresis was
performed. All isolates were serotype 14, belonged to the England 14-9
clonal group, and were penicillin-sensitive and resistant only to
erythromycin. Sputum specimens from the two remaining residents were Gram
stain positive for diplococci and findings from chest radiographs were
consistent with pneumonia. Seven of the residents lived in the same wing of
the nursing home.
A case-control study was conducted to determine risk factors for
pneumococcal pneumonia among residents of the nursing home. Cases included
the nine residents hospitalized with pneumonia. Two controls per
case-patient were selected randomly from among nursing home residents
without pneumonia symptoms who resided in the wing where most of the
case-patients resided during March 1-April 26. Nursing home medical records
of case-patients and controls were reviewed, and a standardized form was
used to abstract data.
Case-patients had a median age of 86 years (range: 78-100 years); seven
(78%) were women. Controls had a median age of 85 years (58-95 years), and
17 (94%) were women. Illness was strongly associated with lack of
documentation of receipt of PPV (none of nine case-patients versus nine of
18 controls; odds ratio=0; 95% confidence interval=0-0.7). Other exposures
assessed but not associated with disease included recent antibiotic therapy,
history of pneumonia, hospitalizations during the preceding year, medical
conditions that are risk factors for pneumococcal disease [chronic
cardiovascular disease, chronic obstructive pulmonary disease, chronic liver
disease, diabetes mellitus, and renal dysfunction], and physical functioning
(e.g., mobility and ability to eat and swallow).
At the time of the initial case of pneumococcal illness on April 3, 2001, 53
(49%) of the 108 residents had received PPV. When the outbreak was
recognized, PPV was offered to all 55 nonvaccinated residents; 37 (67%)
received vaccine. The remaining 18 were either ineligible for PPV or refused
the vaccine. The nursing home also restricted transfers or admissions of
patients with no history of having received PPV.
Following the investigation of the nursing home, the NJDHSS Division of Long
Term Care Systems surveyed 361 LTCFs during May 21-July 31 about their
vaccination policies. Of these, 28 (8%) did not meet the state regulation
that requires offering PPV to every resident of a LTCF.
During May 24-June 7, the NJDHSS Division of Inspections, Compliance and
Complaints investigated hospital compliance with the state regulation that
requires offering PPV to every hospitalized patient aged 65 years and older.
Hospitals were selected if they had admitted residents of the nursing home
before their long-term care placement or had admitted residents of this
nursing home during the preceding year. The selected hospitals' infection
control practitioners were interviewed to identify hospital policy on
offering the vaccine to PPV-eligible patients. NJDHSS staff reviewed medical
records of seven case-residents and randomly selected medical records of
patients aged 65 years and older to determine whether PPV was offered and
administered.
Four hospitals were identified, and medical records of 52 patients were
reviewed; at the time of the review, 49 of these 52 patients were
discharged, and three remained hospitalized. Each hospital had a form to
facilitate physician identification and documentation of PPV-eligible
patients; 35 (67%) of 52 medical records contained completed screening or
assessment forms. Of the 52 patients, 13 (25%) had received PPV before
hospital admission and 34 (65%) had no history of having received PPV and no
contraindications to the vaccine; none of these patients had documentation
of receipt of PPV while hospitalized.
Editorial Note:
The findings in this report suggest that lack of pneumococcal vaccine may
contribute to invasive pneumococcal disease in adults in LTCFs. Adults in
LTCFs are especially vulnerable to pneumococcal disease and death because of
their advanced age, the frequent presence of chronic illnesses, and
residence in a setting that might increase the risk for bacterial
transmission.
PPV is considered safe and is cost-effective and potentially cost-saving
among persons aged 65 years and older for prevention of bacteremia.
Pneumococcal vaccinations are covered by Medicare, and virtually all state
Medicaid plans cover vaccinations for high-risk groups (e.g., residents of
nursing facilities). However, PPV coverage among elderly adults in LTCFs
remains low, and outbreaks of pneumococcal pneumonia still occur in LTCFs
with low vaccine coverage. In 1999, PPV coverage among a sample of nursing
home residents in the United States was 38%. The low rate of PPV vaccination
among institutionalized elderly has been attributed, in part, to a lack of
physician emphasis on PPV administration. In addition, incomplete
documentation of vaccination history of nursing home residents and
misconceptions about adverse reactions after unintended revaccination with
PPV may discourage health-care providers from vaccinating those with unknown
vaccination history; however, the incidence of serious adverse events
following revaccination is low. A study of Medicare inpatients indicated
that opportunities to provide pneumococcal vaccines were missed for up to
80% of eligible elderly persons hospitalized with pneumonia.
One of the national health objectives for 2010 is to achieve 90%
pneumococcal vaccination coverage among nursing home residents and adults
aged 65 years and older (objective 14-29). Several methods have been
developed for improving vaccine delivery. Standing orders programs, which
authorize certain licensed health-care providers to administer vaccinations
according to institutional and physician-approved protocols, improve
vaccination rates in adults.
Regulations that mandate hospitals, adult day-care facilities, and LTCFs,
including nursing homes and assisted living facilities, to offer and
document pneumococcal vaccinations may improve vaccination coverage for LTCF
residents. However, this investigation highlights the limitations of
regulations for ensuring vaccine coverage. Better documentation would
facilitate tracking of the vaccination status of residents and provide
medical history information to other health-care facilities when a resident
is hospitalized or transferred or if an outbreak of pneumococcal illness
occurred.
For this report, only 361 of 853 LTCFs in New Jersey had been evaluated to
date for compliance with the state's vaccination requirements. These
facilities may not be representative of all LTCFs in New Jersey.
This outbreak underscores the importance of providing pneumococcal vaccines
to LTCF residents. The outbreak occurred in a setting of low vaccination
coverage despite state regulations designed to improve vaccine delivery. A
multifaceted approach that both facilitates delivery through standing orders
programs and increases awareness of the importance of preventing
pneumococcal disease may be needed to ensure optimal vaccine delivery to
LTCF residents.
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To access the article on the MMWR website, go to:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5033a3.htm
To access the entire MMWR issue in camera-ready (PDF) format, go to:
http://www.cdc.gov/mmwr/PDF/wk/mm5033.pdf
Additional information about influenza and pneumococcal vaccination is
available on the CDC website at
http://www.cdc.gov/nip
For pneumococcal vaccination articles from a variety of sources on
the IAC website, go to: http://www.immunize.org/pneumopoly
DISCLAIMER: The Immunization Action Coalition (IAC) publishes
Unprotected People stories for the purpose of making them available
for our readers' review. We have not verified this story's content,
for which the author(s) are solely responsible.
DO YOU KNOW OF STORIES OF UNPROTECTED PEOPLE? Please let us know if
you have personal stories of people who have suffered or died from
vaccine-preventable diseases or if you know of stories that have
appeared in the media describing suffering that occurred because
someone was not immunized. Send your stories or case reports to
"IAC EXPRESS" by email to admin@immunize.org
or by fax to (651) 647-9131.
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