INT J TUBERC LUNG DIS 19(6):735–741 Q 2015 The Union http://dx.doi.org/10.5588/ijtld.14.0480 E-published ahead of print 6 April 2015
Coverage of and factors associated with pneumococcal vaccination in chronic obstructive pulmonary disease ´ nez,* ´ † J. Astray-Mochales,† ˜ ˜ L. V. Carreno-Iba M. D. Esteban-Vasallo,† M. F. Dom´ınguez-Berjon, † R. Jimenez-Garc´ ´ ´ C. Gonza´lez del Yerro,† D. Iniesta-Fornies,† M. J. Gascon-Sancho, ıa‡ ´ de Promocion ´ de *Servicio de Medina Preventiva, Hospital Clinico Universitario San Carlos, Madrid, †Subdireccion ´ Consejeria de Sanidad, Comunidad de Madrid, Madrid, ‡Preventive Medicine Unit, Rey Juan la Salud y Prevencion, Carlos University, Madrid, Spain SUMMARY S E T T I N G : Patients aged 740 years with a diagnosis of chronic obstructive pulmonary disease (COPD; codes R95, R79 and R91 in the International Classification for Primary Care) registered in primary care clinical records in the Autonomous Community of Madrid, Spain. O B J E C T I V E : To assess pneumococcal vaccination coverage in patients with COPD and to analyse factors associated with vaccination uptake. D E S I G N : Population-based cross-sectional study in which data were collected in September 2010. R E S U LT S : We found that 93 797 patients (72.0% men and 28.0% women) had COPD. Overall coverage was 65.5% (67.5% men vs. 60.4% women, P , 0.001). In patients aged 40–59 years, coverage was 19.5%, reaching 75.8% in those aged 760 years. In patients
aged ,60 years, uptake was associated with a higher number of comorbidities and appropriate adherence to seasonal influenza and pandemic vaccination schedules. In patients aged 760 years, factors associated with uptake in both sexes were older age and appropriate adherence to seasonal influenza vaccination schedules. Factors associated with uptake in men were concomitant comorbidities and pandemic vaccination. C O N C L U S I O N : Vaccination coverage in individuals aged ,60 years with COPD is less than acceptable in Madrid. Coverage was higher in men and in patients with another chronic condition. K E Y W O R D S : lung disease; pneumococcal vaccines; primary care; Spain
PNEUMOCOCCAL DISEASE is a major public health problem worldwide. Although it affects all age groups, the highest rates are detected in young children and in the elderly. Persons with a wide range of chronic conditions and immune deficiencies are at increased risk. In the United States, approximately 43 500 cases and 5000 deaths were estimated in 2009.1 The mean annual incidence of invasive pneumococcal disease was 7.15 per 100 000 population in the Autonomous Community of Madrid (ACM), Spain, in 2010, reaching 15.14/100 000 in persons aged 760 years.2 The World Health Organization estimates that chronic obstructive pulmonary disease (COPD) will be the sixth most common cause of morbidity and the third cause of death in the world by the year 2020.3 In Spain, COPD was the fourth cause of years lost due to illness in 2008.4 A Spanish report established the relative risk of developing pneumonia in patients with COPD as being 4.7 times higher than in the general population aged .65 years.5 Smoking is also an important risk factor for pneumonia and invasive
pneumococcal disease.6 Streptococcus pneumoniae is the most common cause of pneumonia, and one of the most frequently isolated pathogens in cases of acute exacerbation of COPD.7 With the exception of vaccination, no public health interventions are likely to have any significant impact on the incidence of pneumococcal diseases.8,9 The COPD strategy of the Spanish National Health System and the Adult Vaccination Recommendations of the ACM consist of influenza and pneumococcal vaccination for COPD patients.2 The indication is by risk group in patients aged ,60 years and by age in patients aged 760 years. The two vaccines available for adults are the capsular pneumococcal polysaccharide vaccine 23 (PPSV23) and pneumococcal conjugate vaccine 13 (PVC13) (the latter since 2012 in Spain). PPSV23 covers 80–90% of the serotypes responsible for invasive pneumococcal disease in Europe,10 and its effectiveness against pneumococcal disease and at preventing invasive disease has been demonstrated.11,12 However, it fails to induce immune memory, and antibody levels decline with
Correspondence to: Mar´ıa D Esteban-Vasallo, Subdireccion ´ de Promocion ´ de la Salud y Prevencion, ´ Consejeria de Sanidad, Comunidad de Madrid, C/San Mart´ın de Porres 6, 28035 Madrid, Spain. Tel: (þ34) 91 370 08 25. e-mail: maria.estebanv@ salud.madrid.org Article submitted 30 June 2014. Final version accepted 12 January 2015.
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time.13 Studies on efficacy in patients with COPD are limited, and the effectiveness of vaccination remains controversial in this risk group.14 PVC13 generates a stronger response, immune memory and herd immunity, and reduces nasopharyngeal colonisation.13 PCV13 induces a greater functional immune response than PPSV23 for most serotypes covered by PCV13.15 PPSV induces a significant antibody response in elderly adults with COPD,16 and has proven to be cost-effective in the elderly.17 The objectives of the present study were to assess anti-pneumococcal vaccination coverage in individuals with COPD living in the ACM and to analyse factors associated with vaccination uptake.
POPULATION AND METHODS This was a population-based cross-sectional study of all adults with a previous diagnosis of COPD (chronic bronchitis or emphysema) registered in the primary care electronic clinical records (PCECR) of the public health system in ACM, Spain. Information sources Individual records were obtained from the PCECR of all patients aged 740 years with a registered episode of COPD (codes R95, R79 and R91 of the International Classification for Primary Care)18 at the end of September 2010. Duplicate information was detected and ruled out. Data were corrected according to updated death records. We obtained information about sex, date and country of birth, and presence of other chronic diseases likely to constitute an indication for pneumococcal vaccination, namely, conditions with the following codes: T90 (diabetes mellitus); K74, K75 or K76 (ischaemic heart disease); K77 (heart failure); K78, K82, K83 and K84 (other cardiovascular diseases); D97 (restricted to cirrhosis), B72, B73, B74, B76, B79 and B90 (immunosuppression); U88 (nephropathy); K90 (cerebrovascular disease) and R84, R85 and R89 (other pulmonary diseases). Individual records of anti-pneumococcal vaccinations registered were obtained from the Food and Public Health Information System (Sistema de informacion y alimentacion, ´ en salud publica ´ SISPAL), ´ which covers public and private centres. Although the database was created in 2005, it includes information on vaccines administered before this date. Most doses of the pneumococcal vaccine were administered after 2002. Records of the seasonal influenza vaccines administered in the previous four campaigns (2007– 2010) and the 2009 pandemic influenza vaccination (H1N1) were also obtained. All data were anonymised for analysis. Study variables The dependent variable was administration of at least one dose of PPSV23 until December 2010. Indepen-
dent variables included sex, age (as of 31 December 2010), origin (Spanish-born or immigrant), presence of each chronic condition selected according to the recommendations for pneumococcal vaccination established by the ACM,2 number of indications for vaccination, number of doses of influenza vaccine in the previous four campaigns and pandemic influenza vaccination (H1N1). Statistical analysis A descriptive analysis was performed. Pneumococcal vaccination coverage was assessed by estimating the proportion of individuals (stratified by sex) who had been vaccinated at any time, according to the independent variables. Factors associated with vaccination coverage against pneumococcus were studied separately by age (40–59 years and 760 years) and sex. Bivariate and multivariate analyses with logistic regression were performed. The multivariate model was constructed using variables that were statistically significant in the bivariate analysis. Crude and adjusted odds ratios (ORs) were calculated with their 95% confidence intervals (CIs). The analysis was performed using PASW Statistics 18 (Statistical Package for the Social Sciences, Chicago, IL, USA), and statistical significance was set at a two-tailed a , 0.05. Ethics The study was approved by the health authorities of the ACM and the person in charge of the SISPAL database, which is registered with the Data Protection Agency (Agencia Espanola de Proteccion ´ de Datos, ˜ Madrid, Spain).
RESULTS Study population The PCECR recorded 93 797 patients (72.0% men and 28.0% women) aged 740 years with COPD (Table 1). The mean age was 71.4 years (standard deviation [SD] 11.9), with the largest group comprising patients aged 775 years (43.1%). At least one other chronic condition was present in 46.7% of the men and 34.9% of the women, with diabetes mellitus being the most common (22.3% in men and 16.0% in women). Influenza vaccination coverage reached 60.0% in the last campaign analysed (2010). Of all the patients included, 40.3% had been vaccinated against seasonal influenza in the four seasons analysed (from 2007 to 2010), whereas 24.9% had never been vaccinated. Pneumococcal vaccination coverage Overall coverage was 65.5% (67.5% for men and 60.4% for women, P , 0.001, Table 2). Vaccination coverage in patients aged 40–59 years was 19.5% (19.4% in men and 19.7 in women), and reached 75.8% in patients aged 760 years (76.9% in men
Pneumococcal vaccination coverage in COPD patients
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Table 1 Distribution of study variables among subjects with COPD by sex, Autonomous Community of Madrid, Spain Variable
Total n (%) 93 797
Male n (%)
Female n (%)
67 491 (72.0)
26 306 (28.0)
2 804 8 166 7 715 19 841 28 965
1 855 4 190 2 860 5 964 11 437
Subjects with COPD Age group, years 40–49 50–59 60–64 65–74 775
4 659 12 356 10 575 25 805 40 402
Origin* Immigrant Spanish-born
3 044 (3.2) 90 582 (96.6)
1 826 (2.7) 65 571 (97.2)
Comorbidities Diabetes mellitus Other cardiovascular disease Ischaemic heart disease Heart failure Cerebrovascular disease Other pulmonary disease Immunosuppression Nephropathy
19 255 15 962 11 090 6 876 3 757 2 366 1 745 263
(20.5) (17.0) (11.8) (7.3) (4.0) (2.5) (1.9) (0.3)
(22.3) 15 056 (17.9) 12 105 9 335 (13.8) 4 577 (6.8) 3 016 (4.5) 2 156 (3.2) 1 344 (2.0) 212 (0.3)
Number of indications COPD COPD þ 1 COPD þ 2 or more
53 085 (56.6) 27 551 (29.4) 13 161 (14.0)
35 960 (53.3) 21 169 (31.4) 10 362 (15.3)
17 125 (65.1) 6 382 (24.3) 2 799 (10.6)
Influenza vaccination season coverage 2007 2008 2009 2010
52 810 55 610 58 992 56 249
(56.3) (59.3) (62.9) (60.0)
39 190 41 095 43 530 41 580
(58.1) (60.9) (64.5) (61.6)
13 620 14 515 15 462 14 669
(51.8) (55.2) (58.8) (55.8)
Number of doses of influenza vaccination 0 23 313 (24.9) 1 8 184 (8.7) 2 9 244 (9.9) 3 15 235 (16.2) 4 (all seasons) 37 821 (40.3)
15 966 5 624 6 425 10 983 28 493
(23.7) (8.3) (9.5) (16.3) (42.2)
7 347 2 560 2 819 4 252 9 328
(27.9) (9.7) (10.7) (16.2) (35.5)
Pandemic influenza vaccination uptake Yes 27 884 (29.7) No 65 913 (70.3)
21 666 (32.1) 45 825 (67.9)
(5.0) (13.2) (11.3) (27.5) (43.1)
(4.2) (12.1) (11.4) (29.4) (42.9)
(7.1) (15.9) (10.9) (22.7) (43.5)
1 218 (4.6) 25 011 (95.1) 4 199 3 857 1 755 2 299 741 210 401 51
(16.0) (14.7) (6.7) (8.7) (2.8) (0.8) (1.5) (0.2)
6 218 (23.6) 20 088 (76.4)
* Due to missing values, the sum of these numbers falls short of the overall total (,1%). COPD ¼ chronic obstructive pulmonary disease.
and 72.6% in women) (Figure). Coverage was 65.8% among Spanish-born subjects and 39.2% among immigrants (P , 0.001). As can be seen in the Figure, vaccination coverage increased significantly with the number of chronic conditions in both sexes, especially in those aged ,60 years, although coverage was much lower than in older patients despite the presence of other comorbidities indicating vaccination. In men, pneumococcal vaccination coverage was highest in those who had other cardiovascular diseases (78.6%) or heart failure (78.0%) as comorbid conditions. In women, the highest vaccination coverage was found in those who had other cardiovascular diseases (73.5%), followed by ischaemic heart disease (72.1%). For almost all comorbidities, vaccination coverage was significantly lower in women (P , 0.001). In people vaccinated against influenza in more than two campaigns, pneumococcal vaccination coverage was .80%, although it was always lower in women (P , 0.001).
Factors associated with pneumococcal vaccination In patients aged ,60 years, pneumococcal vaccination was associated with more comorbidities and appropriate adherence to both seasonal and pandemic vaccination schedules (Table 3). A gradient was observed in the probability of receiving anti-pneumococcal vaccination in relation to the number of campaigns in which the patient had been vaccinated against seasonal influenza. Compared with patients who were not vaccinated, the adjusted OR of being vaccinated against pneumococcus was 40.25 (95%CI 32.92–49.22) in men vaccinated in all four campaigns and 34.99 (95%CI 26.71–45.83) in women. In patients aged 760 years, vaccination against pneumococcus was associated with older age and appropriate adherence to the seasonal vaccination schedule. Increased likelihood of being vaccinated was also associated with pandemic influenza vaccination and the presence of more indications for the vaccine among older men. However, with both
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Table 2 Pneumococcal vaccination coverage among subjects with COPD by study variables and according to sex, Autonomous Community of Madrid, Spain Vaccination coverage Total n (%)
Male n (%)
Female n (%)
P value
Pneumococcal vaccine
61 482 (65.5)
45 583 (67.5)
15 899 (60.4)
,0.001
Age group, years 40–49 50–59 60–64 65–74 775
681 2 633 6 196 20 624 31 348
389 1 734 4 522 16 036 22 902
Origin Immigrant Spanish-born
1 194 (39.2) 59 585 (65.8)
729 (39.9) 44 397 (67.7)
Comorbidities Diabetes mellitus Other cardiovascular disease Ischaemic heart disease Heart failure Cerebrovascular disease Other pulmonary disease Immunosuppression Nephropathy
14 446 12 346 8 505 5 223 2 782 1 737 1 113 187
11 442 9 513 7 240 3 571 2 274 1 618 864 153
Number of indications COPD COPD þ 1 COPD þ 2 or over
31 139 (58.7) 20 057 (72.8) 10 286 (78.2)
Variable
Influenza vaccination season coverage 2007 46 464 2008 48 468 2009 50 307 2010 47 877 Number of doses of influenza vaccination 0 3 148 1 4 493 2 6 887 3 12 967 4 (all seasons) 33 987
(14.6) (21.3) (58.6) (79.9) (77.6)
(75.0) (77.3) (76.7) (76.0) (74.0) (73.4) (63.8) (71.1)
(13.9) (21.2) (58.6) (80.8) (79.1)
(76.0) (78.6) (77.6) (78.0) (75.4) (75.0) (64.3) (72.2)
21 724 (60.4) 15 655 (74.0) 8 204 (79.2)
292 899 1 674 4 588 8 446
(15.7) (21.5) (58.5) (76.9) (73.8)
0.077 0.776 0.940 ,0.001 ,0.001
465 (38.2) 15 188 (60.7)
0.635 ,0.001
3 004 2 833 1 265 1 652 508 119 249 34
(71.5) (73.5) (72.1) (71.9) (68.6) (56.7) (62.1) (66.7)
,0.001 ,0.001 ,0.001 ,0.001 ,0.001 ,0.001 0.566 0.436
9 415 (55.0) 4 402 (69.0) 2 082 (74.4)
,0.001 ,0.001 ,0.001
(88.0) (87.2) (85.3) (85.1)
34 907 36 321 37 698 35 943
(89.1) (88.4) (86.6) (86.4)
11 557 12 147 12 609 11 934
(84.9) (83.7) (81.5) (81.4)
,0.001 ,0.001 ,0.001 ,0.001
(13.5) (54.9) (74.5) (85.1) (89.9)
2 127 3 210 4 912 9 501 25 833
(13.3) (57.1) (76.5) (86.5) (90.7)
1 021 1 283 1 975 3 466 8 154
(13.9) (50.1) (70.1) (81.5) (87.4)
0.241 ,0.001 ,0.001 ,0.001 ,0.001
4 963 (79.8) 10 936 (54.4)
,0.001 ,0.001
Pandemic influenza vaccination uptake Yes 23 493 (84.3) No 37 989 (57.6)
18 530 (85.5) 27 053 (59.0)
COPD ¼ chronic obstructive pulmonary disease.
variables, the association was weaker than the association observed in patients aged ,60 years. These effects were not observed among older women.
DISCUSSION In this study, information from the PCECR and a specific vaccination registry was used to analyse pneumococcal vaccination coverage in patients with COPD. Overall coverage was 65.5%. The factors predicting vaccination included age, sex, number of chronic comorbid conditions that constitute an indication, and adherence to the influenza vaccination schedule in previous seasons. Pneumococcal vaccination in the ACM is indicated by age or risk group due to the high incidence of invasive pneumococcal disease in patients aged .60 years and the high percentage of cases associated with chronic diseases. Health care in the ACM is publicly funded, and the vaccines are free of charge. It is important to take into account the availability of free
health care when comparing vaccination uptakes with countries where medical care and prescriptions have to be paid for. The overall coverage in the present study (65.5%) was higher than in other European studies. A study in Germany that used a questionnaire administered to COPD and asthma patients aged 740 years reported that 14.6% of participants had received the pneumococcal vaccination.19 A Spanish questionnaire-based study performed in 2006 in patients with COPD showed a coverage of 32.5% (95%CI 31.6–33.4).20 It is important to remember that these findings are based on surveys, which could be subject to recall bias. Coverage among those aged 760 years was higher than reported elsewhere. In the United States, coverage was 59.7% among the general population aged 765 years.21 In a study of high-risk patients in Australia, coverage increased with age and was significantly higher for those aged 765 years (66.1% vs. 14.7% in patients aged ,50 years).22
Pneumococcal vaccination coverage in COPD patients
739
Figure Pneumococcal vaccination coverage among subjects with COPD by sex, age group and presence of other comorbidities indicating immunisation, Autonomous Community of Madrid, Spain.
The study from Germany revealed a significant trend toward higher vaccination rates with increasing age, reaching a maximum at age 70–80 years.19 Data suggest that a recommendation for vaccination based on age may help to achieve higher coverage than one based on risk groups. Other possible reasons for the lower coverage among younger patients include the following: 1) less severity and shorter disease duration resulting in fewer contacts with health care services; 2) provider bias, as professionals may be more persistent when recommending vaccination to older or more severely ill patients; and 3) younger patients may be less aware and knowledgeable of the effectiveness of or need for vaccination. Vaccination coverage was lower in women, and significantly so in those aged 765 years. A retrospective study of veterans in the United States showed that uptake rates were higher for men than for women aged 765 years (87% vs. 83%).23 In a study from Catalonia, Spain, vaccination coverage in COPD patients was significantly higher in men (67.0% vs. 59.2%),24 although no significant differences by sex were found at the national level.20 Previous Spanish studies also observed greater coverage of influenza vaccination among high-risk men.25–27 Jime´ nezGarc´ıa et al. suggest that explanations for the lower uptake among women could include less social support, differences in health status and provider bias.28 The higher number of women in institutions (nursing homes) could also account for the lack of completeness in the information registered. Another study in the United States found lower coverage for some racial/ethnic groups, both in highrisk populations aged between 19 and 64 years and in the general population aged 765 years.21 In the present study, differences by origin should be viewed with caution due to the small number of immigrants. The presence of concomitant comorbidities (diabetes or heart disease) was previously associated with significantly higher vaccination coverage in patients with COPD in Spain.20,24 The data provided in the
present study show that the effect of comorbidities is independent of age, although it is more evident in patients aged ,60 years. It is only logical to surmise that the higher coverage found among COPD patients with more chronic conditions could be a consequence of more frequent use of health care services. Such patients would be more likely to receive recommendations to be vaccinated by their medical practitioners. One of the conditions with the widest coverage (77.3%) was ‘other cardiovascular diseases’ (e.g., arrhythmia and valve disease), followed by ischaemic heart disease. In another Spanish study, the highest coverage was observed among patients with diabetes (65.9%).29 These differences could be due to different interventions by several specialists and health care levels in patient care. The factor most associated with pneumococcal vaccination was having been vaccinated in all previous seasonal influenza campaigns. This strong association has been reported elsewhere,20,26 and could be related to the fact that, since 2005, the ACM has promoted co-administration of the PPSV23 vaccine together with the influenza vaccine.2 Moreover, when administered together, the vaccines may have a synergistic effect and reduce the frequency of the most severe forms of pneumonia.2,30,31 Our results suggest that simultaneous vaccination is a good strategy for increasing coverage. In other published studies,8,19,22,24 influenza vaccine coverage in COPD patients was higher than that of the pneumococcal influenza vaccine. Although this finding was not observed in the COPD population in the present study, it seems unwise to compare both coverage rates directly: adherence to the pneumococcal vaccination schedule can be considered appropriate if the patient had a record of at least one dose at any time during the previous years, whereas influenza vaccination coverage is measured each year. The main strength of the present study is that we have reliable and exhaustive clinical information from the entire population of a large region of Spain (6.5
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The International Journal of Tuberculosis and Lung Disease
Table 3 Predictors of pneumococcal vaccination among subjects with COPD living in the Autonomous Community of Madrid, Spain: result of multivariate logistic regression analysis Male
Female
OR (95%CI)
aOR (95%CI)
OR (95%CI)
Age: 40–59 years Age group, years 40–49 50–59
1 1.67 (1.49–1.89)
1 1.19 (1.04–1.37)
1 1.46 (1.26–1.69)
Origin Immigrant Spanish-born
1 1.74 (1.38–2.21)
Number of indications COPD 1 COPD þ 1 2.10 (1.88–2.34) COPD þ 2 or over 3.11 (2.60–3.72) Number of doses of influenza vaccination 0 1 1 12.79 (10.38–15.77) 2 22.92 (18.59–28.25) 3 36.65 (29.78–45.11) 4 (all seasons) 51.31 (42.29–62.26) Pandemic influenza vaccination uptake No 1 Yes 5.26 (4.73–5.85) Age: 760 years Age group, years 60–64 65–74 775
1 2.98 (2.81–3.15) 2.67 (2.53–2.81)
Origin Immigrant Spanish-born
1 1.68 (1.46–1.92)
Number of indications COPD COPD þ 1 COPD þ 2 or over
1 1.42 (1.36–1.49) 1.62 (1.53–1.72)
Number of doses of influenza vaccination 0 1 1 8.13 (7.50–8.81) 2 21.08 (19.30–23.02) 3 37.17 (34.22–40.38) 4 (all seasons) 50.22 (46.95–53.72) Pandemic influenza vaccination uptake No 1 Yes 3.71 (3.52–3.90)
aOR (95%CI)
1 1.33 (1.03–1.73) 1 1.36 (1.20–1.55) 1.42 (1.15–1.74)
11.34 18.67 29.33 40.25
1 (9.18–14.01) (15.06–23.14) (23.67–36.33) (32.92–49.22)
1 1.85 (1.55–2.19) 2.82 (1.88–4.23)
10.53 21.07 31.78 41.93
1 (7.92–13.99) (15.92–27.90) (23.98–42.13) (32.29–54.45)
1 1.40 (1.15–1.72) 1.60 (1.01–2.54)
9.61 18.27 26.85 34.99
1 (7.22–12.79) (13.74–24.31) (20.13–35.81) (26.71–45.83)
1 1.48 (1.31–1.68)
1 4.69 (4.06–5.43)
1 1.48 (1.26–1.74)
1 2.28 (2.11–2.46) 1.48 (1.38–1.59)
1 2.36 (2.15–2.60) 2.00 (1.84–2.18)
1 2.07 (1.84–2.34) 1.49 (1.34–1.66)
1 1.45 (1.22–1.72) 1 1.10 (1.03–1.16) 1.02 (0.95–1.10)
8.30 21.22 36.02 47.46
1 (7.65–9.01) (19.38–23.23) (33.03–39.28) (44.09–51.09)
1 1.07 (1.01–1.14)
1 1.18 (1.10–1.27) 1.27 (1.16–1.40)
6.07 14.20 23.74 37.24
1 (5.38–6.85) (12.50–16.14) (21.04–26.78) (33.52–41.37)
6.21 14.41 23.68 36.71
1 (5.50–7.02) (12.67–16.39) (20.97–26.74) (33.01–40.82)
1 3.19 (2.92–3.48)
COPD ¼ chronic obstructive pulmonary disease; OR ¼ odds ratio; CI ¼ confidence interval; aOR ¼ adjusted OR.
million inhabitants) and almost 100 000 clinically diagnosed COPD patients. Although data from electronic clinical records are potentially limited by a lack of completeness and quality, the memory bias present in surveys is avoided, and it is possible to identify concomitant conditions that indicate vaccination. This study has several limitations. It was not possible to evaluate other relevant factors such as disease severity, smoking habits or exceptions to the indication. In addition, the databases used do not collect information on adverse reactions to vaccinations. New research is needed to identify factors such as sociodemographic characteristics and lifestyle variables, which can affect vaccination uptake. Special attention should be paid to patients aged ,60 years to identify barriers to access and reasons for nonadherence in this group, and thus enable interventions to improve coverage. Further investigations should be
undertaken to assess knowledge of and attitudes towards vaccination and awareness of the risk of pneumococcal infections in COPD patients. Interventions should be aimed at patients and health care professionals. Recent studies in the elderly demonstrate that attention to these factors can help to increase uptake.32,33
CONCLUSIONS Vaccination coverage in COPD patients aged ,60 years is less than acceptable in the ACM. Coverage was higher in men and in patients with at least one other chronic condition. Specific interventions are necessary to improve pneumococcal vaccination coverage in patients with COPD. Conflicts of interest: none declared.
Pneumococcal vaccination coverage in COPD patients
References 1 Centers for Disease Control and Prevention. Active Bacterial Core Surveillance (ABCs): Emerging Infections Program Network. ABCs Report: Streptococcus pneumoniae, 2010. Atlanta, GA, USA: CDC, 2010. 2 Servicio de Prevencion ´ de la Enfermedad, Direccion ´ General de Atencion ´ Primaria. Vacunacion ´ frente a la gripe estacional 2011. Vacuna de polisaca´ridos frente a neumococo. Madrid, Spain: Consejer´ıa de Sanidad, Comunidad de Madrid, 2011. [Spanish] 3 Fabbri L, Pauwels R A, Hurd S S. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary updated 2003. COPD 2004; 1: 105–141. ´ 4 Ge` nova-Maleras R, Alvarez-Mart´ ın E, Catala´-Lopez F, ´ Ferna´ndez de Larrea-Baz N, Morant-Ginestar C. [Burden of disease in the elderly population in Spain]. Gac Sanit 2011; 25 (Suppl 2): 47–50. [Spanish] 5 Vila Corcoles A, Ochoa Gondar O, Hospital Guardiola, I, ´ Marin Canseco M L. Chronic obstructive pulmonary disease and tobacco dependency: main risk factors in pneumonia in the over-65s. Aten Primaria 2003; 31: 272. [Spanish] 6 Vila-Corcoles A, Ochoa-Gondar O. Pneumococcal vaccination among adults with chronic respiratory diseases: a historical overview. Expert Rev Vaccines 2012; 11: 221–236. 7 Perez-Trallero E, Marimon J M, Larruskain J, Alonso M, Ercibengoa M. Antimicrobial susceptibilities and serotypes of Streptococcus pneumoniae isolates from elderly patients with pneumonia and acute exacerbation of chronic obstructive pulmonary disease. Antimicrob Agents Chemother 2011; 55: 2729–2734. 8 Influenza and pneumococcal vaccination levels among persons aged . or ¼ 65 years—United States, 2001. MMWR Morb Mortal Wkly Rep 2002; 51: 1019–1024. 9 Nichol K L. The additive benefits of influenza and pneumococcal vaccinations during influenza seasons among elderly persons with chronic lung disease. Vaccine 1999; 17 (Suppl 1): S91–S93. 10 Fedson D S, Nicolas-Spony L, Klemets P, et al. Pneumococcal polysaccharide vaccination for adults: new perspectives for Europe. Expert Rev Vaccines 2011; 10: 1143–1167. 11 Grabenstein J D, Manoff S B. Pneumococcal vaccines in adults: assessing the evolving evidence. Vaccine 2011; 29: 6149–6154. 12 Centers for Disease Control and Prevention. Pneumococcal disease epidemilogy and prevention of vaccine-preventable diseases. The Pink Book: Course Textbook. 12th ed. Atlanta, GA, USA: CDC, 2012. 13 Casas M F, Alfageme M I, Barchilon Cohen V S, Peis Redondo J I, Vargas Ortega D A. Pneumococcal vaccine recommendations in chronic respiratory diseases. Semergen 2014; 40: 313–325. [Spanish] 14 Vila-Corcoles A, Ochoa-Gondar O, Rodriguez-Blanco T, Gutierrez-Perez A, Vila-Rovira A. Clinical effectiveness of 23valent pneumococcal polysaccharide vaccine against pneumonia in patients with chronic pulmonary diseases: a matched case-control study. Hum Vaccin Immunother 2012; 8: 639–644. 15 Jackson L A, Gurtman A, van Cleef M, et al. Immunogenicity and safety of a 13-valent pneumococcal conjugate vaccine compared to a 23-valent pneumococcal polysaccharide vaccine in pneumococcal vaccine-naive adults. Vaccine 2013; 31: 3577– 3584. 16 Lai C C, Lee L N, Yu C J et al. Antibody responses to pneumococcal polysaccharide vaccine in Taiwanese patients with chronic obstructive pulmonary disease. J Formos Med Assoc 2007; 106: 196–203. 17 Lehmann D. Efficacy and effectiveness of pneumococcal polysaccharide vaccines and their use in industrialised countries. Med J Aust 2000; 173 (Suppl): S41–S44. 18 World Organization of Family Doctors. International
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classification of primary care. ICPC-2. 2nd ed. Barcelona, Spain: Masson, 2009. Schoefer Y, Schaberg T, Raspe H, Schaefer T. Determinants of influenza and pneumococcal vaccination in patients with chronic lung diseases. J Infect 2007; 55: 347–352. Arinez-Fernandez M C, Carrasco-Garrido P, Garcia-Carballo M, Hernandez-Barrera V, de Miguel A G, Jimenez-Garcia R. Determinants of pneumococcal vaccination among patients with chronic obstructive pulmonary disease in Spain. Hum Vaccin 2006; 2: 99–104. Centers for Disease Control and Prevention. Adult vaccination coverage—United States, 2010. MMWR Morb Mortal Wkly Rep 2012; 61: 66–72. Dower J, Donald M, Begum N, Vlack S, Ozolins I. Patterns and determinants of influenza and pneumococcal immunisation among adults with chronic disease living in Queensland, Australia. Vaccine 2011; 29: 3031–3037. Bean-Mayberry B, Yano E M, Mor M K, Bayliss N K, Xu X, Fine M J. Does sex influence immunization status for influenza and pneumonia in older veterans? J Am Geriatr Soc 2009; 57: 1427–1432. Jimenez-Garcia R, Arinez-Fernandez M C, Hernandez-Barrera V, Garcia-Carballo M M, de Miguel A G, Carrasco-Garrido P. Compliance with influenza and pneumococcal vaccination among patients with chronic obstructive pulmonary disease consulting their medical practitioners in Catalonia, Spain. J Infect 2007; 54: 65–74. Jimenez-Garcia R, Mayo-Montero E, Hernandez-Barrera V, Garrido P C, Martinez-Hernandez D, de Miguel A G. Influenza vaccination among diabetic adults: related factors and trend from 1993 to 2001 in Spain. Diabetes Care 2005; 28: 2031– 2033. Jimenez-Garcia R, Arinez-Fernandez M C, Garcia-Carballo M, Hernandez-Barrera V, de Miguel A G, Carrasco-Garrido P. Influenza vaccination coverage and related factors among Spanish patients with chronic obstructive pulmonary disease. Vaccine 2005; 23: 3679–3686. Jimenez-Garcia R, Hernandez-Barrera V, Carrasco G P, Del Pozo S V, de Miguel A G. Influenza vaccination among cardiovascular disease sufferers in Spain: related factors and trend, 1993–2003. Vaccine 2006; 24: 5073–5082. Jimenez-Garcia R, Hernandez-Barrera V, de Andres A L, Jimenez-Trujillo I, Esteban-Hernandez J, Carrasco-Garrido P. Gender influence in influenza vaccine uptake in Spain: time trends analysis (1995–2006). Vaccine 2010; 28: 6169–6175. Vila-Corcoles A, Ochoa-Gondar O, Ester F, Sarra N, Ansa X, Saun N. Evolution of vaccination rates after the implementation of a free systematic pneumococcal vaccination in Catalonian older adults: 4-years follow-up. BMC Public Health 2006; 6: 231. Ministerio de Sanidad, Politica Social e Igualdad. Estrategia en EPOC del Sistema Nacional de Salud. Madrid, Spain: Ministerio de Sanidad, Politica Social e Igualdad, 2009. Dominguez A, Castilla J, Godoy P, et al. Effectiveness of pandemic and seasonal influenza vaccines in preventing pandemic influenza-associated hospitalization. Vaccine 2012; 30: 5644–5650. Baig S A, Hassan M, Ahmed S M, Moazzam W, Inayat A. A cross-sectional study to investigate pneumococcal vaccination in the elderly in a low income county: patient knowledge, awareness, and attitudes of vaccination and prevalence rates by socioeconomic status. Hum Vaccin Immunother 2014; 10: 1024–1027. Schneeberg A, Bettinger J A, McNeil S, et al. Knowledge, attitudes, beliefs and behaviours of older adults about pneumococcal immunization, a Public Health Agency of Canada/Canadian Institutes of Health Research Influenza Research Network (PCIRN) investigation. BMC Public Health 2014; 14: 442.
Pneumococcal vaccination coverage in COPD patients
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RESUME C O N T E X T E : Des patients ag´ ˆ es de 740 ans avec un diagnostic de bronchopneumopathie chronique obstructive (BPCO ; codes R95, R79 et R91 d’apr`es la Classification internationale pour les soins de sant´e primaires) inscrits dans des registres de soins de sant´e primaires dans la communaut´e autonome de Madrid, Espagne. O B J E C T I F : Evaluer la couverture vaccinale antipneumococcique chez des patients porteurs de BPCO et analyser les facteurs associ´es a` la prise du vaccin. S C H E´ M A : Etude transversale en population. Les donn´ees ont e´ t´e recueillies en septembre 2010. R E´ S U L T A T S : Nous avons d e´ couvert que 93 797 patients (72,0% d’hommes et 28,0% de femmes) avaient une BPCO. La couverture vaccinale e´ tait de 65,5% (67,5% des hommes contre 60,4% des femmes ; ˆ es de 40–59 ans, la P , 0,001). Chez les patients ag´
couverture e´ tait de 19,5%, atteignant 75,8% chez ceux ag´ ˆ es de 760 ans. Chez les patients ag´ ˆ es de ,60 ans, la couverture e´ tait associ´ee a` un nombre plus e´ lev´e de comorbidit e´ s et d’adhe´ sion aux calendriers de vaccination saisonni`ere et e´ pid´emique contre la grippe. Chez les patients ag´ ˆ es de 760 ans, les facteurs associ´es a` la prise du vaccin dans les deux sexes e´ taient un age ˆ plus avanc´e et une adh´esion correcte aux calendriers de vaccination saisonni`ere contre la grippe. Les facteurs associ´es a` la prise du vaccin chez les hommes e´ taient des comorbidit´es concomitantes et la vaccination contre la grippe e´ pid´emique. C O N C L U S I O N : La couverture vaccinale chez les personnes ag´ ˆ es de ,60 ans avec une BPCO n’est pas acceptable dans notre r´egion. Cette couverture e´ tait plus e´ lev´ee chez les hommes et chez les patients porteurs d’une autre maladie chronique. RESUMEN
M A R C O D E R E F E R E N C I A: Pacientes de edad de 740 anos con diagn ostico ´ de enfermedad pulmonar ˜ obstructiva cronica ´ (EPOC; codigos ´ R95, R79 y R91 seg un ´ la Clasificaci on ´ Internacional de Atenci on ´ Primaria) registrado en la historia cl´ınica de Atencion ´ Primaria en la Comunidad Autonoma ´ de Madrid, Espana. ˜ O B J E T I V O: Valorar la cobertura vacunal frente a neumococo en pacientes con EPOC y analizar los factores asociados a su administracion. ´ M E´ T O D O: Estudio transversal de base poblacional. Los datos se recogieron en septiembre de 2010. R E S U LT A D O S: Se encontraron 93 797 pacientes (72,0% hombres y 28,0% mujeres) con EPOC. La cobertura global fue del 65,5% (67,5% en hombres vs. 60,4% en
mujeres, P , 0,001). En pacientes de 40–59 anos la ˜ cobertura fue del 19,5%, alcanzando el 75,8% a partir de 60 anos. Por debajo de 60 anos la vacunacion ´ se ˜ ˜ asocio´ con un mayor numero ´ de comorbilidades y con una adherencia adecuada a la vacunacion ´ frente a gripe estacional y pande´ mica. A partir de 60 anos la ˜ vacunacion ´ en ambos sexos se asocio´ a mayor edad y a una adecuada adherencia a la vacunacion ´ frente a gripe estacional. Los factores asociados en hombres fueron las comorbilidades y la vacunaci on ´ frente a gripe pand´emica. ´ N: La cobertura vacunal en individuos de CONCLUSIO edad de ,60 anos ˜ esta´ por debajo de lo aceptable en nuestra region. ´ La cobertura fue superior en hombres y entre pacientes con alguna otra patolog´ıa cronica. ´
Coverage of and factors associated with pneumococcal vaccination in chronic obstructive pulmonary disease ´ nez,* ´ † J. Astray-Mochales,† ˜ ˜ L. V. Carreno-Iba M. D. Esteban-Vasallo,† M. F. Dom´ınguez-Berjon, † R. Jimenez-Garc´ ´ ´ C. Gonza´lez del Yerro,† D. Iniesta-Fornies,† M. J. Gascon-Sancho, ıa‡ ´ de Promocion ´ de *Servicio de Medina Preventiva, Hospital Clinico Universitario San Carlos, Madrid, †Subdireccion ´ Consejeria de Sanidad, Comunidad de Madrid, Madrid, ‡Preventive Medicine Unit, Rey Juan la Salud y Prevencion, Carlos University, Madrid, Spain SUMMARY S E T T I N G : Patients aged 740 years with a diagnosis of chronic obstructive pulmonary disease (COPD; codes R95, R79 and R91 in the International Classification for Primary Care) registered in primary care clinical records in the Autonomous Community of Madrid, Spain. O B J E C T I V E : To assess pneumococcal vaccination coverage in patients with COPD and to analyse factors associated with vaccination uptake. D E S I G N : Population-based cross-sectional study in which data were collected in September 2010. R E S U LT S : We found that 93 797 patients (72.0% men and 28.0% women) had COPD. Overall coverage was 65.5% (67.5% men vs. 60.4% women, P , 0.001). In patients aged 40–59 years, coverage was 19.5%, reaching 75.8% in those aged 760 years. In patients
aged ,60 years, uptake was associated with a higher number of comorbidities and appropriate adherence to seasonal influenza and pandemic vaccination schedules. In patients aged 760 years, factors associated with uptake in both sexes were older age and appropriate adherence to seasonal influenza vaccination schedules. Factors associated with uptake in men were concomitant comorbidities and pandemic vaccination. C O N C L U S I O N : Vaccination coverage in individuals aged ,60 years with COPD is less than acceptable in Madrid. Coverage was higher in men and in patients with another chronic condition. K E Y W O R D S : lung disease; pneumococcal vaccines; primary care; Spain
PNEUMOCOCCAL DISEASE is a major public health problem worldwide. Although it affects all age groups, the highest rates are detected in young children and in the elderly. Persons with a wide range of chronic conditions and immune deficiencies are at increased risk. In the United States, approximately 43 500 cases and 5000 deaths were estimated in 2009.1 The mean annual incidence of invasive pneumococcal disease was 7.15 per 100 000 population in the Autonomous Community of Madrid (ACM), Spain, in 2010, reaching 15.14/100 000 in persons aged 760 years.2 The World Health Organization estimates that chronic obstructive pulmonary disease (COPD) will be the sixth most common cause of morbidity and the third cause of death in the world by the year 2020.3 In Spain, COPD was the fourth cause of years lost due to illness in 2008.4 A Spanish report established the relative risk of developing pneumonia in patients with COPD as being 4.7 times higher than in the general population aged .65 years.5 Smoking is also an important risk factor for pneumonia and invasive
pneumococcal disease.6 Streptococcus pneumoniae is the most common cause of pneumonia, and one of the most frequently isolated pathogens in cases of acute exacerbation of COPD.7 With the exception of vaccination, no public health interventions are likely to have any significant impact on the incidence of pneumococcal diseases.8,9 The COPD strategy of the Spanish National Health System and the Adult Vaccination Recommendations of the ACM consist of influenza and pneumococcal vaccination for COPD patients.2 The indication is by risk group in patients aged ,60 years and by age in patients aged 760 years. The two vaccines available for adults are the capsular pneumococcal polysaccharide vaccine 23 (PPSV23) and pneumococcal conjugate vaccine 13 (PVC13) (the latter since 2012 in Spain). PPSV23 covers 80–90% of the serotypes responsible for invasive pneumococcal disease in Europe,10 and its effectiveness against pneumococcal disease and at preventing invasive disease has been demonstrated.11,12 However, it fails to induce immune memory, and antibody levels decline with
Correspondence to: Mar´ıa D Esteban-Vasallo, Subdireccion ´ de Promocion ´ de la Salud y Prevencion, ´ Consejeria de Sanidad, Comunidad de Madrid, C/San Mart´ın de Porres 6, 28035 Madrid, Spain. Tel: (þ34) 91 370 08 25. e-mail: maria.estebanv@ salud.madrid.org Article submitted 30 June 2014. Final version accepted 12 January 2015.
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time.13 Studies on efficacy in patients with COPD are limited, and the effectiveness of vaccination remains controversial in this risk group.14 PVC13 generates a stronger response, immune memory and herd immunity, and reduces nasopharyngeal colonisation.13 PCV13 induces a greater functional immune response than PPSV23 for most serotypes covered by PCV13.15 PPSV induces a significant antibody response in elderly adults with COPD,16 and has proven to be cost-effective in the elderly.17 The objectives of the present study were to assess anti-pneumococcal vaccination coverage in individuals with COPD living in the ACM and to analyse factors associated with vaccination uptake.
POPULATION AND METHODS This was a population-based cross-sectional study of all adults with a previous diagnosis of COPD (chronic bronchitis or emphysema) registered in the primary care electronic clinical records (PCECR) of the public health system in ACM, Spain. Information sources Individual records were obtained from the PCECR of all patients aged 740 years with a registered episode of COPD (codes R95, R79 and R91 of the International Classification for Primary Care)18 at the end of September 2010. Duplicate information was detected and ruled out. Data were corrected according to updated death records. We obtained information about sex, date and country of birth, and presence of other chronic diseases likely to constitute an indication for pneumococcal vaccination, namely, conditions with the following codes: T90 (diabetes mellitus); K74, K75 or K76 (ischaemic heart disease); K77 (heart failure); K78, K82, K83 and K84 (other cardiovascular diseases); D97 (restricted to cirrhosis), B72, B73, B74, B76, B79 and B90 (immunosuppression); U88 (nephropathy); K90 (cerebrovascular disease) and R84, R85 and R89 (other pulmonary diseases). Individual records of anti-pneumococcal vaccinations registered were obtained from the Food and Public Health Information System (Sistema de informacion y alimentacion, ´ en salud publica ´ SISPAL), ´ which covers public and private centres. Although the database was created in 2005, it includes information on vaccines administered before this date. Most doses of the pneumococcal vaccine were administered after 2002. Records of the seasonal influenza vaccines administered in the previous four campaigns (2007– 2010) and the 2009 pandemic influenza vaccination (H1N1) were also obtained. All data were anonymised for analysis. Study variables The dependent variable was administration of at least one dose of PPSV23 until December 2010. Indepen-
dent variables included sex, age (as of 31 December 2010), origin (Spanish-born or immigrant), presence of each chronic condition selected according to the recommendations for pneumococcal vaccination established by the ACM,2 number of indications for vaccination, number of doses of influenza vaccine in the previous four campaigns and pandemic influenza vaccination (H1N1). Statistical analysis A descriptive analysis was performed. Pneumococcal vaccination coverage was assessed by estimating the proportion of individuals (stratified by sex) who had been vaccinated at any time, according to the independent variables. Factors associated with vaccination coverage against pneumococcus were studied separately by age (40–59 years and 760 years) and sex. Bivariate and multivariate analyses with logistic regression were performed. The multivariate model was constructed using variables that were statistically significant in the bivariate analysis. Crude and adjusted odds ratios (ORs) were calculated with their 95% confidence intervals (CIs). The analysis was performed using PASW Statistics 18 (Statistical Package for the Social Sciences, Chicago, IL, USA), and statistical significance was set at a two-tailed a , 0.05. Ethics The study was approved by the health authorities of the ACM and the person in charge of the SISPAL database, which is registered with the Data Protection Agency (Agencia Espanola de Proteccion ´ de Datos, ˜ Madrid, Spain).
RESULTS Study population The PCECR recorded 93 797 patients (72.0% men and 28.0% women) aged 740 years with COPD (Table 1). The mean age was 71.4 years (standard deviation [SD] 11.9), with the largest group comprising patients aged 775 years (43.1%). At least one other chronic condition was present in 46.7% of the men and 34.9% of the women, with diabetes mellitus being the most common (22.3% in men and 16.0% in women). Influenza vaccination coverage reached 60.0% in the last campaign analysed (2010). Of all the patients included, 40.3% had been vaccinated against seasonal influenza in the four seasons analysed (from 2007 to 2010), whereas 24.9% had never been vaccinated. Pneumococcal vaccination coverage Overall coverage was 65.5% (67.5% for men and 60.4% for women, P , 0.001, Table 2). Vaccination coverage in patients aged 40–59 years was 19.5% (19.4% in men and 19.7 in women), and reached 75.8% in patients aged 760 years (76.9% in men
Pneumococcal vaccination coverage in COPD patients
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Table 1 Distribution of study variables among subjects with COPD by sex, Autonomous Community of Madrid, Spain Variable
Total n (%) 93 797
Male n (%)
Female n (%)
67 491 (72.0)
26 306 (28.0)
2 804 8 166 7 715 19 841 28 965
1 855 4 190 2 860 5 964 11 437
Subjects with COPD Age group, years 40–49 50–59 60–64 65–74 775
4 659 12 356 10 575 25 805 40 402
Origin* Immigrant Spanish-born
3 044 (3.2) 90 582 (96.6)
1 826 (2.7) 65 571 (97.2)
Comorbidities Diabetes mellitus Other cardiovascular disease Ischaemic heart disease Heart failure Cerebrovascular disease Other pulmonary disease Immunosuppression Nephropathy
19 255 15 962 11 090 6 876 3 757 2 366 1 745 263
(20.5) (17.0) (11.8) (7.3) (4.0) (2.5) (1.9) (0.3)
(22.3) 15 056 (17.9) 12 105 9 335 (13.8) 4 577 (6.8) 3 016 (4.5) 2 156 (3.2) 1 344 (2.0) 212 (0.3)
Number of indications COPD COPD þ 1 COPD þ 2 or more
53 085 (56.6) 27 551 (29.4) 13 161 (14.0)
35 960 (53.3) 21 169 (31.4) 10 362 (15.3)
17 125 (65.1) 6 382 (24.3) 2 799 (10.6)
Influenza vaccination season coverage 2007 2008 2009 2010
52 810 55 610 58 992 56 249
(56.3) (59.3) (62.9) (60.0)
39 190 41 095 43 530 41 580
(58.1) (60.9) (64.5) (61.6)
13 620 14 515 15 462 14 669
(51.8) (55.2) (58.8) (55.8)
Number of doses of influenza vaccination 0 23 313 (24.9) 1 8 184 (8.7) 2 9 244 (9.9) 3 15 235 (16.2) 4 (all seasons) 37 821 (40.3)
15 966 5 624 6 425 10 983 28 493
(23.7) (8.3) (9.5) (16.3) (42.2)
7 347 2 560 2 819 4 252 9 328
(27.9) (9.7) (10.7) (16.2) (35.5)
Pandemic influenza vaccination uptake Yes 27 884 (29.7) No 65 913 (70.3)
21 666 (32.1) 45 825 (67.9)
(5.0) (13.2) (11.3) (27.5) (43.1)
(4.2) (12.1) (11.4) (29.4) (42.9)
(7.1) (15.9) (10.9) (22.7) (43.5)
1 218 (4.6) 25 011 (95.1) 4 199 3 857 1 755 2 299 741 210 401 51
(16.0) (14.7) (6.7) (8.7) (2.8) (0.8) (1.5) (0.2)
6 218 (23.6) 20 088 (76.4)
* Due to missing values, the sum of these numbers falls short of the overall total (,1%). COPD ¼ chronic obstructive pulmonary disease.
and 72.6% in women) (Figure). Coverage was 65.8% among Spanish-born subjects and 39.2% among immigrants (P , 0.001). As can be seen in the Figure, vaccination coverage increased significantly with the number of chronic conditions in both sexes, especially in those aged ,60 years, although coverage was much lower than in older patients despite the presence of other comorbidities indicating vaccination. In men, pneumococcal vaccination coverage was highest in those who had other cardiovascular diseases (78.6%) or heart failure (78.0%) as comorbid conditions. In women, the highest vaccination coverage was found in those who had other cardiovascular diseases (73.5%), followed by ischaemic heart disease (72.1%). For almost all comorbidities, vaccination coverage was significantly lower in women (P , 0.001). In people vaccinated against influenza in more than two campaigns, pneumococcal vaccination coverage was .80%, although it was always lower in women (P , 0.001).
Factors associated with pneumococcal vaccination In patients aged ,60 years, pneumococcal vaccination was associated with more comorbidities and appropriate adherence to both seasonal and pandemic vaccination schedules (Table 3). A gradient was observed in the probability of receiving anti-pneumococcal vaccination in relation to the number of campaigns in which the patient had been vaccinated against seasonal influenza. Compared with patients who were not vaccinated, the adjusted OR of being vaccinated against pneumococcus was 40.25 (95%CI 32.92–49.22) in men vaccinated in all four campaigns and 34.99 (95%CI 26.71–45.83) in women. In patients aged 760 years, vaccination against pneumococcus was associated with older age and appropriate adherence to the seasonal vaccination schedule. Increased likelihood of being vaccinated was also associated with pandemic influenza vaccination and the presence of more indications for the vaccine among older men. However, with both
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The International Journal of Tuberculosis and Lung Disease
Table 2 Pneumococcal vaccination coverage among subjects with COPD by study variables and according to sex, Autonomous Community of Madrid, Spain Vaccination coverage Total n (%)
Male n (%)
Female n (%)
P value
Pneumococcal vaccine
61 482 (65.5)
45 583 (67.5)
15 899 (60.4)
,0.001
Age group, years 40–49 50–59 60–64 65–74 775
681 2 633 6 196 20 624 31 348
389 1 734 4 522 16 036 22 902
Origin Immigrant Spanish-born
1 194 (39.2) 59 585 (65.8)
729 (39.9) 44 397 (67.7)
Comorbidities Diabetes mellitus Other cardiovascular disease Ischaemic heart disease Heart failure Cerebrovascular disease Other pulmonary disease Immunosuppression Nephropathy
14 446 12 346 8 505 5 223 2 782 1 737 1 113 187
11 442 9 513 7 240 3 571 2 274 1 618 864 153
Number of indications COPD COPD þ 1 COPD þ 2 or over
31 139 (58.7) 20 057 (72.8) 10 286 (78.2)
Variable
Influenza vaccination season coverage 2007 46 464 2008 48 468 2009 50 307 2010 47 877 Number of doses of influenza vaccination 0 3 148 1 4 493 2 6 887 3 12 967 4 (all seasons) 33 987
(14.6) (21.3) (58.6) (79.9) (77.6)
(75.0) (77.3) (76.7) (76.0) (74.0) (73.4) (63.8) (71.1)
(13.9) (21.2) (58.6) (80.8) (79.1)
(76.0) (78.6) (77.6) (78.0) (75.4) (75.0) (64.3) (72.2)
21 724 (60.4) 15 655 (74.0) 8 204 (79.2)
292 899 1 674 4 588 8 446
(15.7) (21.5) (58.5) (76.9) (73.8)
0.077 0.776 0.940 ,0.001 ,0.001
465 (38.2) 15 188 (60.7)
0.635 ,0.001
3 004 2 833 1 265 1 652 508 119 249 34
(71.5) (73.5) (72.1) (71.9) (68.6) (56.7) (62.1) (66.7)
,0.001 ,0.001 ,0.001 ,0.001 ,0.001 ,0.001 0.566 0.436
9 415 (55.0) 4 402 (69.0) 2 082 (74.4)
,0.001 ,0.001 ,0.001
(88.0) (87.2) (85.3) (85.1)
34 907 36 321 37 698 35 943
(89.1) (88.4) (86.6) (86.4)
11 557 12 147 12 609 11 934
(84.9) (83.7) (81.5) (81.4)
,0.001 ,0.001 ,0.001 ,0.001
(13.5) (54.9) (74.5) (85.1) (89.9)
2 127 3 210 4 912 9 501 25 833
(13.3) (57.1) (76.5) (86.5) (90.7)
1 021 1 283 1 975 3 466 8 154
(13.9) (50.1) (70.1) (81.5) (87.4)
0.241 ,0.001 ,0.001 ,0.001 ,0.001
4 963 (79.8) 10 936 (54.4)
,0.001 ,0.001
Pandemic influenza vaccination uptake Yes 23 493 (84.3) No 37 989 (57.6)
18 530 (85.5) 27 053 (59.0)
COPD ¼ chronic obstructive pulmonary disease.
variables, the association was weaker than the association observed in patients aged ,60 years. These effects were not observed among older women.
DISCUSSION In this study, information from the PCECR and a specific vaccination registry was used to analyse pneumococcal vaccination coverage in patients with COPD. Overall coverage was 65.5%. The factors predicting vaccination included age, sex, number of chronic comorbid conditions that constitute an indication, and adherence to the influenza vaccination schedule in previous seasons. Pneumococcal vaccination in the ACM is indicated by age or risk group due to the high incidence of invasive pneumococcal disease in patients aged .60 years and the high percentage of cases associated with chronic diseases. Health care in the ACM is publicly funded, and the vaccines are free of charge. It is important to take into account the availability of free
health care when comparing vaccination uptakes with countries where medical care and prescriptions have to be paid for. The overall coverage in the present study (65.5%) was higher than in other European studies. A study in Germany that used a questionnaire administered to COPD and asthma patients aged 740 years reported that 14.6% of participants had received the pneumococcal vaccination.19 A Spanish questionnaire-based study performed in 2006 in patients with COPD showed a coverage of 32.5% (95%CI 31.6–33.4).20 It is important to remember that these findings are based on surveys, which could be subject to recall bias. Coverage among those aged 760 years was higher than reported elsewhere. In the United States, coverage was 59.7% among the general population aged 765 years.21 In a study of high-risk patients in Australia, coverage increased with age and was significantly higher for those aged 765 years (66.1% vs. 14.7% in patients aged ,50 years).22
Pneumococcal vaccination coverage in COPD patients
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Figure Pneumococcal vaccination coverage among subjects with COPD by sex, age group and presence of other comorbidities indicating immunisation, Autonomous Community of Madrid, Spain.
The study from Germany revealed a significant trend toward higher vaccination rates with increasing age, reaching a maximum at age 70–80 years.19 Data suggest that a recommendation for vaccination based on age may help to achieve higher coverage than one based on risk groups. Other possible reasons for the lower coverage among younger patients include the following: 1) less severity and shorter disease duration resulting in fewer contacts with health care services; 2) provider bias, as professionals may be more persistent when recommending vaccination to older or more severely ill patients; and 3) younger patients may be less aware and knowledgeable of the effectiveness of or need for vaccination. Vaccination coverage was lower in women, and significantly so in those aged 765 years. A retrospective study of veterans in the United States showed that uptake rates were higher for men than for women aged 765 years (87% vs. 83%).23 In a study from Catalonia, Spain, vaccination coverage in COPD patients was significantly higher in men (67.0% vs. 59.2%),24 although no significant differences by sex were found at the national level.20 Previous Spanish studies also observed greater coverage of influenza vaccination among high-risk men.25–27 Jime´ nezGarc´ıa et al. suggest that explanations for the lower uptake among women could include less social support, differences in health status and provider bias.28 The higher number of women in institutions (nursing homes) could also account for the lack of completeness in the information registered. Another study in the United States found lower coverage for some racial/ethnic groups, both in highrisk populations aged between 19 and 64 years and in the general population aged 765 years.21 In the present study, differences by origin should be viewed with caution due to the small number of immigrants. The presence of concomitant comorbidities (diabetes or heart disease) was previously associated with significantly higher vaccination coverage in patients with COPD in Spain.20,24 The data provided in the
present study show that the effect of comorbidities is independent of age, although it is more evident in patients aged ,60 years. It is only logical to surmise that the higher coverage found among COPD patients with more chronic conditions could be a consequence of more frequent use of health care services. Such patients would be more likely to receive recommendations to be vaccinated by their medical practitioners. One of the conditions with the widest coverage (77.3%) was ‘other cardiovascular diseases’ (e.g., arrhythmia and valve disease), followed by ischaemic heart disease. In another Spanish study, the highest coverage was observed among patients with diabetes (65.9%).29 These differences could be due to different interventions by several specialists and health care levels in patient care. The factor most associated with pneumococcal vaccination was having been vaccinated in all previous seasonal influenza campaigns. This strong association has been reported elsewhere,20,26 and could be related to the fact that, since 2005, the ACM has promoted co-administration of the PPSV23 vaccine together with the influenza vaccine.2 Moreover, when administered together, the vaccines may have a synergistic effect and reduce the frequency of the most severe forms of pneumonia.2,30,31 Our results suggest that simultaneous vaccination is a good strategy for increasing coverage. In other published studies,8,19,22,24 influenza vaccine coverage in COPD patients was higher than that of the pneumococcal influenza vaccine. Although this finding was not observed in the COPD population in the present study, it seems unwise to compare both coverage rates directly: adherence to the pneumococcal vaccination schedule can be considered appropriate if the patient had a record of at least one dose at any time during the previous years, whereas influenza vaccination coverage is measured each year. The main strength of the present study is that we have reliable and exhaustive clinical information from the entire population of a large region of Spain (6.5
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The International Journal of Tuberculosis and Lung Disease
Table 3 Predictors of pneumococcal vaccination among subjects with COPD living in the Autonomous Community of Madrid, Spain: result of multivariate logistic regression analysis Male
Female
OR (95%CI)
aOR (95%CI)
OR (95%CI)
Age: 40–59 years Age group, years 40–49 50–59
1 1.67 (1.49–1.89)
1 1.19 (1.04–1.37)
1 1.46 (1.26–1.69)
Origin Immigrant Spanish-born
1 1.74 (1.38–2.21)
Number of indications COPD 1 COPD þ 1 2.10 (1.88–2.34) COPD þ 2 or over 3.11 (2.60–3.72) Number of doses of influenza vaccination 0 1 1 12.79 (10.38–15.77) 2 22.92 (18.59–28.25) 3 36.65 (29.78–45.11) 4 (all seasons) 51.31 (42.29–62.26) Pandemic influenza vaccination uptake No 1 Yes 5.26 (4.73–5.85) Age: 760 years Age group, years 60–64 65–74 775
1 2.98 (2.81–3.15) 2.67 (2.53–2.81)
Origin Immigrant Spanish-born
1 1.68 (1.46–1.92)
Number of indications COPD COPD þ 1 COPD þ 2 or over
1 1.42 (1.36–1.49) 1.62 (1.53–1.72)
Number of doses of influenza vaccination 0 1 1 8.13 (7.50–8.81) 2 21.08 (19.30–23.02) 3 37.17 (34.22–40.38) 4 (all seasons) 50.22 (46.95–53.72) Pandemic influenza vaccination uptake No 1 Yes 3.71 (3.52–3.90)
aOR (95%CI)
1 1.33 (1.03–1.73) 1 1.36 (1.20–1.55) 1.42 (1.15–1.74)
11.34 18.67 29.33 40.25
1 (9.18–14.01) (15.06–23.14) (23.67–36.33) (32.92–49.22)
1 1.85 (1.55–2.19) 2.82 (1.88–4.23)
10.53 21.07 31.78 41.93
1 (7.92–13.99) (15.92–27.90) (23.98–42.13) (32.29–54.45)
1 1.40 (1.15–1.72) 1.60 (1.01–2.54)
9.61 18.27 26.85 34.99
1 (7.22–12.79) (13.74–24.31) (20.13–35.81) (26.71–45.83)
1 1.48 (1.31–1.68)
1 4.69 (4.06–5.43)
1 1.48 (1.26–1.74)
1 2.28 (2.11–2.46) 1.48 (1.38–1.59)
1 2.36 (2.15–2.60) 2.00 (1.84–2.18)
1 2.07 (1.84–2.34) 1.49 (1.34–1.66)
1 1.45 (1.22–1.72) 1 1.10 (1.03–1.16) 1.02 (0.95–1.10)
8.30 21.22 36.02 47.46
1 (7.65–9.01) (19.38–23.23) (33.03–39.28) (44.09–51.09)
1 1.07 (1.01–1.14)
1 1.18 (1.10–1.27) 1.27 (1.16–1.40)
6.07 14.20 23.74 37.24
1 (5.38–6.85) (12.50–16.14) (21.04–26.78) (33.52–41.37)
6.21 14.41 23.68 36.71
1 (5.50–7.02) (12.67–16.39) (20.97–26.74) (33.01–40.82)
1 3.19 (2.92–3.48)
COPD ¼ chronic obstructive pulmonary disease; OR ¼ odds ratio; CI ¼ confidence interval; aOR ¼ adjusted OR.
million inhabitants) and almost 100 000 clinically diagnosed COPD patients. Although data from electronic clinical records are potentially limited by a lack of completeness and quality, the memory bias present in surveys is avoided, and it is possible to identify concomitant conditions that indicate vaccination. This study has several limitations. It was not possible to evaluate other relevant factors such as disease severity, smoking habits or exceptions to the indication. In addition, the databases used do not collect information on adverse reactions to vaccinations. New research is needed to identify factors such as sociodemographic characteristics and lifestyle variables, which can affect vaccination uptake. Special attention should be paid to patients aged ,60 years to identify barriers to access and reasons for nonadherence in this group, and thus enable interventions to improve coverage. Further investigations should be
undertaken to assess knowledge of and attitudes towards vaccination and awareness of the risk of pneumococcal infections in COPD patients. Interventions should be aimed at patients and health care professionals. Recent studies in the elderly demonstrate that attention to these factors can help to increase uptake.32,33
CONCLUSIONS Vaccination coverage in COPD patients aged ,60 years is less than acceptable in the ACM. Coverage was higher in men and in patients with at least one other chronic condition. Specific interventions are necessary to improve pneumococcal vaccination coverage in patients with COPD. Conflicts of interest: none declared.
Pneumococcal vaccination coverage in COPD patients
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Pneumococcal vaccination coverage in COPD patients
i
RESUME C O N T E X T E : Des patients ag´ ˆ es de 740 ans avec un diagnostic de bronchopneumopathie chronique obstructive (BPCO ; codes R95, R79 et R91 d’apr`es la Classification internationale pour les soins de sant´e primaires) inscrits dans des registres de soins de sant´e primaires dans la communaut´e autonome de Madrid, Espagne. O B J E C T I F : Evaluer la couverture vaccinale antipneumococcique chez des patients porteurs de BPCO et analyser les facteurs associ´es a` la prise du vaccin. S C H E´ M A : Etude transversale en population. Les donn´ees ont e´ t´e recueillies en septembre 2010. R E´ S U L T A T S : Nous avons d e´ couvert que 93 797 patients (72,0% d’hommes et 28,0% de femmes) avaient une BPCO. La couverture vaccinale e´ tait de 65,5% (67,5% des hommes contre 60,4% des femmes ; ˆ es de 40–59 ans, la P , 0,001). Chez les patients ag´
couverture e´ tait de 19,5%, atteignant 75,8% chez ceux ag´ ˆ es de 760 ans. Chez les patients ag´ ˆ es de ,60 ans, la couverture e´ tait associ´ee a` un nombre plus e´ lev´e de comorbidit e´ s et d’adhe´ sion aux calendriers de vaccination saisonni`ere et e´ pid´emique contre la grippe. Chez les patients ag´ ˆ es de 760 ans, les facteurs associ´es a` la prise du vaccin dans les deux sexes e´ taient un age ˆ plus avanc´e et une adh´esion correcte aux calendriers de vaccination saisonni`ere contre la grippe. Les facteurs associ´es a` la prise du vaccin chez les hommes e´ taient des comorbidit´es concomitantes et la vaccination contre la grippe e´ pid´emique. C O N C L U S I O N : La couverture vaccinale chez les personnes ag´ ˆ es de ,60 ans avec une BPCO n’est pas acceptable dans notre r´egion. Cette couverture e´ tait plus e´ lev´ee chez les hommes et chez les patients porteurs d’une autre maladie chronique. RESUMEN
M A R C O D E R E F E R E N C I A: Pacientes de edad de 740 anos con diagn ostico ´ de enfermedad pulmonar ˜ obstructiva cronica ´ (EPOC; codigos ´ R95, R79 y R91 seg un ´ la Clasificaci on ´ Internacional de Atenci on ´ Primaria) registrado en la historia cl´ınica de Atencion ´ Primaria en la Comunidad Autonoma ´ de Madrid, Espana. ˜ O B J E T I V O: Valorar la cobertura vacunal frente a neumococo en pacientes con EPOC y analizar los factores asociados a su administracion. ´ M E´ T O D O: Estudio transversal de base poblacional. Los datos se recogieron en septiembre de 2010. R E S U LT A D O S: Se encontraron 93 797 pacientes (72,0% hombres y 28,0% mujeres) con EPOC. La cobertura global fue del 65,5% (67,5% en hombres vs. 60,4% en
mujeres, P , 0,001). En pacientes de 40–59 anos la ˜ cobertura fue del 19,5%, alcanzando el 75,8% a partir de 60 anos. Por debajo de 60 anos la vacunacion ´ se ˜ ˜ asocio´ con un mayor numero ´ de comorbilidades y con una adherencia adecuada a la vacunacion ´ frente a gripe estacional y pande´ mica. A partir de 60 anos la ˜ vacunacion ´ en ambos sexos se asocio´ a mayor edad y a una adecuada adherencia a la vacunacion ´ frente a gripe estacional. Los factores asociados en hombres fueron las comorbilidades y la vacunaci on ´ frente a gripe pand´emica. ´ N: La cobertura vacunal en individuos de CONCLUSIO edad de ,60 anos ˜ esta´ por debajo de lo aceptable en nuestra region. ´ La cobertura fue superior en hombres y entre pacientes con alguna otra patolog´ıa cronica. ´
