Overcoming Disparities In Pneumococcal ... - Adult Vaccination

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Pneumococcal Disease
Call to Action
Overcoming Disparities
in Pneumococcal Disease
Vaccination among US Adults
A Task Force Report
April 2012
Made possible by an unrestricted educational grant to the
National Foundation for Infectious Diseases from Pfizer Inc.
NFID’s policies prohibit funders from controlling program content.
Overcoming Disparities in Pneumococcal Disease Vaccination among US Adults
American and Hispanic adults, who are more likely to have
chronic medical conditions such as asthma, diabetes, and
cardiovascular disease and stroke.6-9 In addition, invasive
pneumococcal disease disproportionately affects African
Americans with a case rate of 21.6 per 100,000 compared to
12.8 for whites.10
Closing these gaps and increasing pneumococcal vaccination
rates among African American and Hispanic adults will
require multiple strategies involving the healthcare
community, public health advocacy, and grass-roots efforts
within these communities.
Disparities in vaccination coverage leave too many
African American and Hispanic adults at risk for
pneumococcal infection.
Pneumococcal disease can have a serious individual and
public health impact (see boxes for more information).1-3
Despite this, pneumococcal vaccination rates for all
indicated US adults fall well below public health goals. Gaps
in vaccination coverage coupled with a higher prevalence
of chronic medical conditions place a larger burden of
pneumococcal illness on African American and Hispanic
adults, which is of great concern.
Pneumococcal vaccination rates for African American and
Hispanic adults age 65 and older are 16 percent and 24
percent lower, respectively, compared with non-Hispanic
whites.4 There is also a considerable gap for younger at-risk
Hispanic adults where vaccine coverage is about 5 percent
lower than in age-matched whites (Figure 1).5
The reasons for gaps in vaccination coverage are complex.
Awareness of pneumococcal disease and vaccine availability
is low among all US adults. But some vaccination barriers
that exist in the general public may be heightened among
African American and Hispanic populations, including vaccine
or medical system distrust, and challenges in continuity of, or
access to, culturally competent care.
Lower vaccination rates are compounded by an increased
prevalence of pneumococcal risk conditions in African
Annual Public Health Burden
of Pneumococcal Disease in the US
• Pneumococcal bacteremia: 50,000 cases annually,
case-fatality rate about 20 percent.1
– Includes 25-30 percent of pneumococcal pneumonia
cases that progress to bacteremia.
• Pneumococcal meningitis: 3,000 to 6,000 cases annually;
case-fatality rate about 30 percent.1
• Pneumococcal pneumonia: 175,000 people hospitalized
each year; case-fatality rate of 5-7 percent.1
– Patients hospitalized with pneumococcal pneumonia
are at increased risk for concurrent cardiac events,
such as myocardial infarction, arrhythmia, or
congestive heart failure.2
The Considerable Costs of Pneumococcal Disease
• In 2004, pneumococci caused an estimated 4 million
illness episodes resulting in direct medical costs
(inpatient and outpatient) of $3.5 billion.3
– About half of these costs ($1.8 billion) were related to
care of patients age 65 years and older, many of whom
have chronic health problems.3
• Factoring in lost work and productivity, costs related to
pneumococcal infections in younger working adults nearly
equal those for the older population.319 18.6 14.3
White (not Hispanic or Latino)
Black (not Hispanic or Latino)
Hispanic or Latino
Pe rc en t Va cc in at ed 64.7 (AVG.)
18.5 (AVG.)
19-64 yrs
(with high-risk condition)
≥65 yrs
Figure 1
Pneumococcal Vaccination Rates in US Adults
Sources: CDC. National Health Interview Survey, 2011.4 CDC. Adult vaccination
coverage, 2010.5
Overcoming Disparities in Pneumococcal Disease Vaccination among US Adults
A multidisciplinary task force identified barriers to
better immunization in populations with disparities.
The National Foundation for Infectious Diseases (NFID) brought
together a task force of healthcare professionals, public
health officials, and consumer educators representing more
than 20 organizations to prioritize barriers to pneumococcal
vaccination among US adults and to identify solutions.
Attendees participated in large group discussions and smaller
working sessions that focused on specific patient populations.
One working group focused on defining and overcoming
barriers in populations with immunization disparities,
including Hispanic and African American communities. Task
force members identified the following key barriers to be
addressed in closing vaccination gaps:
• Lack of public awareness about pneumococcal disease
and available prevention
• General distrust of vaccines and government/medical
• Challenges in continuity of care and access to a primary
care provider
Many barriers and their solutions are issues for all adult
populations, but several may be of elevated importance
in some African American or Hispanic communities.
Strategies should be tailored by healthcare and public health
professionals according to the needs of their local community.
Lack of Public Awareness: Educating patients and
caregivers inside and outside the practice can help
increase vaccination rates.
Four out of five US adults don’t know about pneumococcal
disease.11 Clearly, more education about the disease is
needed if people are going to understand and accept the need
to protect themselves through vaccination. All healthcare
providers should assume responsibility for informing patients
and advocating strongly for vaccination and public health
officials need to reinforce the messages at the community
level. The following strategies can support increasing disease
and prevention awareness:
• Learn about the community you are trying to reach,
including language needs, health literacy-level
considerations, cultural sensitivities, and health
• Gain an understanding of how best to deliver disease and
prevention information for this community, eg, in-person
verbal vs. written communication; best modes of mass
communication, and use of social media; in collaboration
with trusted community leaders.
• Use culturally competent, strategically relevant messages
to educate patients and family members, developed in
conjunction with community members, if possible.
• Provide information to patients and the public in simple,
compelling, easy to understand language in written and
verbal communications.
• Tell stories that motivate patients and the community
to receive pneumococcal and other needed vaccines
by illustrating the impact of the diseases; consider the
messages that may be most meaningful within the culture
of the particular community.
• Provide information for non-English speakers in their
native language when needed.
• Inform vaccine recipients about Medicare and Medicaid
coverage of pneumococcal vaccine both individually and
through larger efforts if possible, such as posters that
are seen by everyone (placed on public buses, trains,
libraries, community-based organization bulletin boards/
websites, etc).
Patient education should consider language needs, cultural
sensitivities, and preferred mediums of communication
for the community being served. In addition, identifying
unique messages that motivate members of a particular
community can help ensure disease and prevention
messages resonate. For example, if commitment to family
is paramount in the community, providers and public health
officials could emphasize that pneumococcal vaccination
can help prevent serious disease that makes it difficult to
care for the family. A story about a patient who was sick
for weeks and could not take care of his or her children,
spouse, or elderly parents might be a strong motivator for
pneumococcal vaccination.
Pneumococcal disease and prevention messages can be
complicated and literacy-level considerations are important
when educating adults in any community. Keep information
simple and easy-to-understand and make recommendations
strong and direct. Consider delivering messages in bullet
format so that key points are easily seen and heard.
Overcoming Disparities in Pneumococcal Disease Vaccination among US Adults
In Hispanic communities where English is limited
among adults, it’s ideal for Spanish-speaking healthcare
professionals to serve the community and address
vaccination topics. When this is not possible, a
professional translator can provide assistance. However,
some healthcare professionals still report situations
where family members, including children, are asked to
interpret health information. Although this is not ideal, it
underscores the need to present information as simply
and directly as possible. Identify certified language
interpreters in the community or consider telephone line
interpreter services.
Adults with limited financial resources may hesitate to
accept vaccination if they are not aware that it is covered
by Medicare and Medicaid for those at risk, making it
important to include this information in discussions and on
posters viewed by all.12,13
Vaccine and Medical System Distrust: Resources
outside the medical setting can help with education
and vaccination efforts.
In some communities, there is a heightened sense of distrust
of vaccines or the medical system. The following strategies
can help alleviate distrust and reinforce the value of vaccines
for disease prevention:
• Discuss the importance of pneumococcal prevention
with patients, address any concerns about the
efficacy or safety of the vaccine, and provide a strong
recommendation for vaccination, providing studies to
patients where appropriate.
• At the community level, engage and educate trusted
community leaders (clergymen, disc jockeys, TV anchors,
local celebrities, community health workers, nurses,
teachers, etc) to help deliver messages in culturally
meaningful venues such as faith-based organizations,
community-based organizations, and community centers.
• Reach out to radio stations and other news outlets that
reach these community members and ask them to help
spread the word.
• Look for partnership opportunities with local initiatives
that reach adults with pneumococcal risk factors (senior
groups, youth groups that can spread the message to
relatives at risk, worksite wellness programs of large
employers in communities, etc).
Although distrust of the medical community at large exists,
studies suggest that African American adults value oneon-one discussion with their personal physicians when
considering health decisions, and physicians and other
medical professionals are the most common source of
health and medical information for Hispanics.14,15 Cultural
competency in providing care must go beyond providing
culturally sensitive, translated materials and include
discussion with the physician and/or other medical
professionals that reinforces the value of prevention.
Engaging community leaders to help share information can
bolster the strength of prevention messages. Where access to
healthcare is limited, a useful approach is to bring healthcare
information to the people. Information delivered by a trusted
member of the community in a culturally meaningful manner
might be an impetus for seeking vaccination.
Other opportunities within the community may exist through
partnerships with organizations that are addressing other
important healthcare issues. Examples include a diabetes
control or heart disease screening program centered within a
community that also has immunization rate disparities.
Continuity of Care and Access: Healthcare
professionals and public health departments can
increase their role in prevention efforts.
Healthcare professionals in all settings should do their
part to help at-risk patients (ie, those included in CDC
recommendations, Table 1 on next page)16,17 receive
pneumococcal vaccination. In communities where continuity
of care and access to primary care providers is an issue,
healthcare professionals need to be vigilant and see every
interaction with an at-risk patient as an opportunity to vaccinate
or refer them to sources where vaccination is available.
• All healthcare professionals can educate patients and
strongly urge them to receive pneumococcal and other
adult vaccines.
• Public health officials can educate community members,
and where possible, offer pneumococcal and other
adult vaccines or arrange for vaccination opportunities
elsewhere in the community.
• Physicians can drive implementation of systems in their
practices to promote vaccinating all at-risk patients.
Overcoming Disparities in Pneumococcal Disease Vaccination among US Adults
• Physician assistants and nurse practitioners can
prescribe and administer vaccines, and along with
nurses, they can identify and educate at-risk patients
and their families, anticipate and address questions or
concerns, and lead in-office efforts to use educational
materials like posters, signs, and flyers.
• Specialists can screen, educate, and vaccinate or refer
patients to venues for vaccination.
• Pharmacists, where authorized, can deliver
pneumococcal vaccine to recommended adults and
can mention or strongly urge patients to receive
pneumococcal vaccination based on their birth date, their
use of Medicare, or their need for medications commonly
used to treat chronic conditions.
• Support staff in any healthcare setting can be given
ownership of important prevention activities, particularly
patient screening, notification, and chart preparation with
reminder materials for clinical staff.
• Hospital staff can advocate for and/or implement
standing orders programs and make sure electronic
medical records (EMRs) reflect needed vaccines. The Joint
Commission has included pneumococcal vaccination as a
2012 performance measure,18 and the potential effect on
accreditation may be a strong motivator for compliance.
Multiple strategies will be needed to improve
pneumococcal vaccination rates; resources are
available to support these efforts.
NFID has a Pneumococcal Disease Professional Practice
Toolkit available with tools and materials to help practices
improve adult pneumococcal vaccination rates and promote
education among adults in their care. These include readyto-use and template resources for healthcare professional
and patient education, screening and tracking forms, and
links to information about standing orders programs.
Materials are available in English and Spanish, and language
is provided for professionals to tailor materials to address
specific risks and disparities in their communities. To access
the toolkit, visit: Adultvaccination.org/Pneumotools.
Table 1
Recommendations for Use of Pneumococcal
Polysaccharide Vaccine
All adults age ≥ 65 years
Adults 19 through 64 years with:
• Chronic medical conditions (eg, cardiovascular disease or stroke; liver, kidney or lung disease, including
asthma; diabetes; sickle cell disease; alcoholism)
• Immunocompromising conditions (eg, lymphoma or
leukemia, damaged or no spleen) or treatments (eg,
steroids, radiation therapy)
• Environments with increased risk (eg, nursing homes)
• Cochlear implant or leaks of cerebrospinal fluid
Adults age 19 through 64 years who smoke cigarettes
Most adults only need to be vaccinated once in their lifetime, but some
will need revaccination.
The US Food and Drug Administration recently approved a 13-valent
pneumococcal conjugate vaccine (PCV13) for use in adults age 50 years
and older. The CDC’s Advisory Committee on Immunization Practices has
not yet provided guidance for the use of PCV13 in adults.
Pneumococcal vaccines are contraindicated in anyone who has had a
severe (ie, anaphylactic) reaction to a previous dose or to any component
of the vaccine or to any diphtheria toxoid-containing vaccine (for
conjugate vaccine only).
For more information, visit www.cdc.gov/vaccines.
Sources: CDC. MMWR. 2010;59(34):1102-1106.16 CDC. Chart of
Contraindications and Precautions to Commonly Used Vaccines.17
More than 20 medical and health organizations served on
or supported the pneumococcal disease task force and
helped shape the content of the meeting described in this
document. Click here to see a full list.
Overcoming Disparities in Pneumococcal Disease Vaccination among US Adults
1. Atkinson W, Wolfe S, Hamborsky J, eds. Epidemiology and Prevention of Vaccine-Preventable
Diseases. 12th ed. CDC. Washington, DC: Public Health Foundation, 2011.
2. Musher DM, Ruedal AM, Kakal AS, Mapara, SM. The association between pneumococcal
pneumonia and acute cardiac events. Clin Infect Dis. 2007:45(2):158-165.
3. Huang SS, Johnson KM, Ray GT, et. al. Healthcare utilization and cost of pneumococcal
disease in the United States. Vaccine. April 2011:18;29(18):3398-3412.
4. CDC. Receipt of pneumococcal vaccination. Early release of selected estimates based on
data from the January – June 2011 National Health Interview Survey. http://www.cdc.gov/
nchs/data/nhis/earlyrelease/201112_05.pdf. Accessed March 20, 2012.
5. CDC. Adult vaccination coverage. http://www.cdc.gov/mmwr/preview/mmwrhtml/
mm6104a2.htm?s_cid=mm6104a2_w. Accessed March 20, 2012.
6. Agency for Healthcare Research and Quality. Diabetes disparities among racial and ethnic
minorities. 2001. AHRQ Pub. No. 02-P007. http://www.ahrq.gov/research/diabdisp.htm.
Accessed March 20, 2012.
7. Moorman JE, Zahran H, Truman BI, Molla MT. Current asthma prevalence—United States,
2006-2008. MMWR Morb Mortal Wkly Rep. 2011;60(1):84-86.
8. The Office of Minority Health. Heart disease and African Americans. http://minorityhealth.
hhs.gov/templates/content.aspx?ID=3018. Accessed April 5, 2012.
9. CDC. Prevalence of coronary heart disease - United States, 2006-2010. MMWR Morb Mortal
Wkly Rep. 2011; 60(40);1377-1381.
10. CDC. Active Bacterial Core Surveillance Report, Emerging Infections Program Network.
Streptococcus pneumoniae, 2009. http://www.cdc.gov/abcs/reports-findings/survreports/
spneu09.pdf. Accessed March 20, 2012.
11. NFID. Consumer Survey about Pneumococcal Disease. Data on File, 2011.
12. Centers for Medicare and Medicaid Services. Immunizations: overview. http://www.cms.gov/
Immunizations. Accessed March 20, 2012.
13. Preventive services covered under the Affordable Care Act. http://www.healthcare.gov/
news/factsheets2010/07/preventive-services-list.html. Accessed March 20, 2012.
14. Livingston G, Minushkin S, Cohn D. Hispanics and Health Care in the United States: Access,
Information and Knowledge. PEW Hispanic Center. August 2008.
15. Adult Immunization Consensus Panel. Increasing Immunization Rates Among African
American Adults. J Natl Med Assoc. April 2003;95(S4):37S-48S.
16. CDC. Updated recommendations for prevention of invasive pneumococcal disease among
adults using the 23-valent pneumococcal polysaccharide vaccine (PPSV23). MMWR Morb
Mortal Wkly Rep. 2010;59(34):1102-1106.
17. Guide to Contraindications and Precautions to Commonly Used Vaccines. http://www.cdc.
gov/vaccines/recs/vac-admin/contraindications-vacc.htm. Accessed March 15, 2012.
18. Specification Manual for National Hospital Inpatient Quality Measures. Oakbrook Terrace,
IL: Joint Commission. 2011. http://www.jointcommission.org/specifications_manual_for_
national_hospital_inpatient_quality_measures. Accessed March 20, 2012.

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