1. High Rates of Pneumococcal Vaccination in Alaska Native Adults
Rosalyn Singleton MD, Mary Krevans RN Alaska Native Tribal Health Consortium
Jay C. Butler, MD, FAAP, FACP, Lisa Bulkow MS, Debra Parks
Arctic Investigations Program – CDC

2. Pneumococcal Disease in Adults
Leading cause of
Adult pneumonia
Bacterial meningitis
Otitis and sinusitis
Common cause of
COPD Exacerbation
Primary peritonitis
Pericarditis
Conjunctivitis
Septic arthritis
Osteomyelitis
Pneumococcus or Streptococcus pneumoniae is one of the most common bacterial causes of serious infection in adults.

3. Invasive Pneumococcal Disease, Alaska, 1986-90 and 1991-97
This shows the rate of invasive pneumococcal disease by age from the AIP surveillance.
The yellow is the non-Native Alaskan rate. The dark blue is the rate in Alaska Natives between 1986 and 1990, and the light blue is the rate in Alaska Natives between During the latter period, the rate in elders >65 years decreased; however, the rate in younger Alaska Natives did not change.
Alaska Natives have a rate of pneumococcal disease 2-3 times that
of Alaska Non-Natives.
Parkinson, et al. ISPPD 1998

4. NARCH Pneumococcal Grant, 2002 SPECIFIC AIMS
Analyze pneumococcal disease in AN adults
Determine pneumococcal vaccine coverage in AN adults
Assess role of increased vaccine coverage on decreasing rate of pneumococcal disease in AN adults.
Evaluate barriers to pneumococcal vaccination
Develop strategies to increase immunization rates.

5. NARCH Pneumococcal Grant Methods
Chart review of adults with invasive pneumococcal disease,
Vaccine record review of a randomized sample of at-risk adults in 4 regions to document vaccine coverage
Interviews with community leaders, providers and Alaska Native adults

6. Incidence and Case-fatality of Invasive Pneumococcal Disease by Age, Alaska Natives, 1986-2000

9. Pneumococcal Polysaccharide Vaccine
How did we get to where we are today?

10. ACIP Recommendations for Pneumococcal Polysaccharide Vaccine
All persons aged 65 and older
Persons aged 2-64 years
Asplenia
Chronic illnesses: cardiopulmonary diseases (NOT asthma), DM, alcoholism, cirrhosis
Immunocompromising conditions: HIV infection, malignancy, immunosuppressive therapy
“Special environments”: long-term care facilities, “AK Native and certain American Indian populations”
MMWR 1997; 46:RR-8

11. ACIP Recommendations for Pneumococcal Revaccination
One-time revaccination after 5 or more years for:
Persons 2-64 years of age who are at highest risk for serious pneumococcal infection and those likely to have rapid decline in antibody levels (asplenia, HIV+, lymphoma, renal failure, organ transplant, immunosuppressive meds)
Persons 65 years of age and over who were first vaccinated before age 65
Alaska Recommendations
All Alaskans 55 years and older
Revaccination every 6 years.
MMWR 1997; 46:RR-8
Alaska Epi Bulletin 1994

12. Vaccine Uptake

13. Why Is PPV Uptake Not Better?
Adult Immunization Issues
Healthy adults often do not have regular clinic visits
Poor reimbursement; no “VFA”
Limited educational materials to physicians, subspecialists
Few age-specific benchmarks
Pneumococcal Disease Issues
Poor understanding of the burden of pneumococcal disease
“Old man’s friend”
PPV Issues
Confusion over what the vaccine does and does not do
Confusion over duration of protection, revaccination recommendations

14. NARCH Immunization Audit METHODS
Survey: Randomized sample of Alaska Native adults >54 years of age between 1986 and 2000 and registered at regional Tribal hospital
Four regions with regional Tribal hospital were surveyed
Method: chart review of hospital chart(s), PHN record and computerized immunization record(s)
Evaluated: immunization status, underlying conditions
Exclusion: persons who moved or had no visits at regional tribal hospital, died before study period

15. Proportion of pneumococcal immunizations documented in various record sources
PHN reviewed in 2/4 regions.RPMS is the computerized medical record.

18. Pneumococcal vaccination by high risk status, 55-64 year old Alaska Natives, 2000

19. Alaska Native pneumococcal immunization rates compared with BRFSS data, 2000

20. Interviews regarding Immunization Barriers METHODS
Indepth Interviews with 22 adults in one rural and one urban region:
Physicians
Health Aides
Nurses
Adults with “high risk” conditions
Adults with previous pneumococcal disease
State immunization program staff

21. What did we learn from interviews?
No problems with vaccine supply
Generally little resistance to Pneumovax
Some refuse because of stories about side effects
Difficult to obtain patient’s vaccination status
Time constraints prevent tracking vaccine hx.
Patients don’t actively seek Pneumovax but will get vaccinated if provider recommends
High risk patients access the health system sporadically – often in acute care settings.

22. Where Can We Improve? And How?
High-risk adults <65 years
55-64 year olds – Provider education, Standing orders, prompts
Alcoholics
Dept. of Corrections
Standing orders in Emergency Rooms, Inpatient Wards
Smokers
Recommendations at Smoking Cessation Intake
Provider Education
Standing orders for Clinics
Patient Understanding
Educational materials, Native translations
Grand Rounds, s, Presentations to Clinical Directors

23. Current Projects to Improve Adult Immunizations
Attach pneumococcal vaccination to “Flu campaigns”
Survey and promotion of the use of Standing Orders
Culturally-appropriate educational materials
Immunization brochure for AK Native Adults
Immunization brochure in Yupik translation
Adult Immunization Video

24. Acknowledgements: NARCH Research Staff Interviewees
Florence Burton RN
Anuska Tilden
Anna Angaiak
Barbara McCumber RN
Mary Krevans RN
Kim Waldrep
Debra Parks
William Doan
Interviewees
Tribal Health Boards and Clinical Directors
Arctic Investigations Program-CDC staff