Pneumococcal Immunization Program -- California, 1986-1988

Pneumococcal infections are an important cause of morbidity and mortality in the elderly. Many of these infections can be prevented through immunization with pneumococcal polysaccharide vaccine. In 1986, the Immunization Unit of the California State Department of Health Services (CSDHS) received state funding for a 2-year trial program of publicly funded pneumococcal immunizations for senior citizens and others at high risk for infection. This report summarizes the results of that program.

In the first year of the program, CSDHS distributed 58,060 doses of pneumococcal vaccine to 56 local health departments. To promote the vaccine, the local health departments were encouraged to use either of two strategies:

Provide the vaccine during scheduled fall influenza clinics. Each fall, up to 500,000 California residents (primarily persons greater than or equal to 65 years of age) receive publicly purchased influenza vaccine through local health department-sponsored outreach clinics, health-center clinics, and nursing and convalescent homes. Promoting and providing pneumococcal vaccine at these sites simultaneously with influenza vaccine would enable health-care providers to vaccinate optimal numbers of senior citizens.

Provide the vaccine through other scheduled health department clinics. Where pneumococcal vaccine could not be provided at influenza clinics (e.g., because adequate staff were not available), local health departments were encouraged to promote pneumococcal immunizations through leaflets, posters, and staff recommendations, with subsequent referrals either to a specific pneumococcal vaccine clinic held by the health department at a later date or to a publicly funded preventive health-care clinic for the aging.

From July 1986 through June 1987, the 56 participating departments administered 24,280 (41.8%) of the 58,060-dose inventory of pneumococcal vaccine.* Twenty of the departments administered 13,604 (60.9%) of 22,354 pneumococcal vaccine doses during their influenza clinics (Table 1). Twenty-four departments promoted pneumococcal immunization at their influenza clinics but referred patients to other locations, where 5982 (31.9%) of 18,756 doses were administered. Nineteen departments that neither provided nor promoted the pneumococcal vaccine at their fall influenza clinics administered 4694 (27.7%) of 16,950 doses (Table 1).

In the program's second year, the Immunization Unit developed special promotional materials to assist local health departments and emphasized administering pneumococcal vaccine at influenza clinics. From July 1987 through June 1988, 59 local health departments administered 44,257 (64.1%) of 69,054 doses of pneumococcal vaccine--an 82.3% increase over the number of doses administered in the first year. Sub sequently, the CSDHS secured an ongoing annual state appropriation to purchase pneumococcal vaccine. Reported by: DO Lyman, MD, State Epidemiologist, California State Dept of Health Svcs. Div of Bacterial Diseases, Center for Infectious Diseases; Div of Immunization, Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: Pneumococcal polysaccharide vaccine is recommended for

1. adults with chronic illnesses, especially cardiovascular and chronic pulmonary diseases; 2) adults with chronic illnesses (e.g., splenic dysfunction or anatomic asplenia, Hodgkin disease, multiple myeloma, cirrhosis, alcoholism, and renal failure) specifically associated with increased risk for pneumococcal disease or its complications; 3) adults with cerebrospinal fluid leaks and conditions associated with immunosuppression; and 4) otherwise healthy persons greater than or equal to 65 years of age (1).

Despite these recommendations, in 1985 less than 10% of the estimated 47.9 million persons considered to be at high risk for pneumococcal infections reported having ever received pneumococcal vaccine (CDC, United States Immunization Survey, unpublished data, 1985). The 1990 national objective for pneumococcal vaccine coverage in high-risk groups is 60%. Although vaccine and administration costs are reimbursed under the Medicare program, this objective is unlikely to be met nationwide (2).

Each year in the United States, pneumococcal infection causes an estimated 150,000-570,000 cases of pneumonia, 16,000-55,000 cases of bacteremia, and 2600-6200 cases of meningitis (3) and causes or contributes to 40,000 deaths. The 23-valent polysaccharide vaccine contains capsular types that cause 88% of bacteremic pneumococcal disease (1). Pneumococcal vaccine is estimated to be 60% efficacious in clinical groups at moderate to high risk for infection, although two recent studies in veterans' hospitals failed to demonstrate efficacy in high-risk veterans (1). Assuming an overall vaccine efficacy of 60% with 60% coverage, an estimated 12,000 deaths related to pneumococcal disease might be prevented annually (3).

The success in increasing pneumococcal vaccine coverage in California may be directly related to efforts to encourage local health departments to both offer and administer the vaccine at public influenza immunization clinics. This approach appears to be more effective than promotion of pneumococcal vaccine during influenza immunization clinics with subsequent referral of prospective vaccinees to other sites for vaccination. These findings are consistent with a previous study that indicated that influenza vaccination programs can be used to identify candidates for whom pneumococcal vaccine, other vaccines, and toxoids are recommended (4).

Recommendations for pneumococcal immunization from health-care providers can influence a patient's decision to be vaccinated, even when the patient initially has a negative perception of the vaccine or its benefits (5). Therefore, health-care providers should assess each patient's immunization status and, when indicated, provide influenza and pneumococcal vaccines as well as other vaccines recommended for adults (diphtheria and tetanus toxoids and measles-mumps-rubella and hepatitis B vaccines) (6,7).

References

1. ACIP. Pneumococcal polysaccharide vaccine. MMWR 1989;38:64-8,73-6.

2. CDC. Progress toward achieving the national 1990 objectives for immunization. MMWR 1988;37:613-7.

3. Williams WW, Hickson MA, Kane MA, Kendal AP, Spika JS, Hinman AR. Immunization policies and vaccine coverage among adults: the risk for missed opportunities. Ann Intern Med 1988;108:616-25.

4. Grabenstein JD, Smith LJ, Carter DW, et al. Comprehensive immunization delivery in conjunction with influenza vaccination. Arch Intern Med 1986;146:1189-92.

5. CDC. Adult immunization: knowledge, attitudes, and practices--DeKalb and Fulton Counties, Georgia, 1988. MMWR 1988;37:657-61.

6. ACIP. Adult immunization: recommendations of the Immunization Practices Advisory Committee. MMWR 1984;33(suppl 1S).

7. Committee on Immunization. Guide for adult immunization. Philadelphia: American College of Physicians, Council of Medical Societies, 1985. *Remaining doses were available for use in 1987-88; pneumococcal vaccine has a shelf life of 2 years from date of manufacture.

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