Geriatric Nursing 35 (2014) 333e334
Contents lists available at ScienceDirect
Geriatric Nursing journal homepage: www.gnjournal.com
From the Editor
Barbara Resnick, PhD, CRNP, FAAN, FAANP
It is that time of year again . immunization opportunities for older adults September/October is generally the time of year that older adults and their caregivers start thinking about vaccinations. The focus is on influenza as this vaccine is updated annually to ensure that antibodies to the relevant predicted strains of the influenza A/H3N2 and A/H1N1 subtypes and influenza B are stimulated. Immunization opportunities go beyond influenza and consideration should be given to vaccination of older individuals against pneumonia, tetanus, pertussis and herpes zoster. Unfortunately, however, current immunization rates among older adults range from 8 to 60%.1 The 2012 outcome data noted that the rate of influenza and pneumococcal vaccine among older adults across all races and ethnicities was approximately 60%. For tetanus the rate was similarly 55%, although for tetanus with pertussis the rate was only 8%. Lastly, the rate for herpes zoster vaccination was 20%. This is in contrast to the Healthy People 2020 adult goal of achieving immunization rates of 90%. Nursing colleagues we have a challenge ahead of us and I ask you this year to be a champion to improve the rate of immunizations to the older adults you care for. Although there is no immunization that is 100% effective in preventing the relevant disease, immunizations are effective in the majority of cases. The 23-valent vaccine containing pneumococcal capsular polysaccharide is estimated to be approximately 50% effective in preventing pneumonia.2 The Advisory Committee on Immunization Practices (ACIP) continues to recommend that all persons be vaccinated for pneumonia with PPSV23 at age 65 but that no revaccination is necessary for individuals who have received the vaccination at that time.3,4 All too often older adults do not know or do not remember if they have received a pneumococcal vaccine. In those situations, it is recommended to revaccinate. Immunizations for pneumonia and influenza have been shown to decrease hospitalizations among older adults5 and thus prevent the negative downward trajectory that often occurs post hospitalization and the long recovery period. The benefit of preventing a zoster infection with a vaccination for herpes zoster can have an even more direct impact on older 0197-4572/$ e see front matter Ó 2014 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.gerinurse.2014.08.001
adults than that received by influenza and pneumonia vaccinations. Zoster infection occurs at a prevalence rate of approximately 50% for those who are 85 years of age and older.6 The incidence of post-herpetic neuralgia and chronic pain is present in 15% of those 80 years of age and older.7 Fortunately, the vaccine against herpes zoster results in a 50% reduction in cases of herpes zoster and 66% reduction in the risk of having long term postherpetic neuralgia. Aside from the obvious negative impact of pain from a zoster infection, either acute or chronic, immunization will decrease the risk of having to isolate older adults from friends and family when actively infected with zoster. This is particularly true for those who live in institutional, communal settings. Given the significant implications of this disease, the benefits to vaccination are impressive. The incidence of tetanus among older adults is much lower than that of zoster. The cases that do occur, however, are in undervaccinated individuals.8 Currently, due to the reemergence of whooping cough, it is now recommended that acellular pertussis be included in one of the tetanus diptheria booster vaccinations to prevent both pertussis and tetanus. Vaccine coverage Just as a reminder, Medicare Part B covers most vaccines: influenza, pneumococcal, Tdap, and any vaccine directly related to the treatment of an injury (e.g., tetanus) or direct exposure to a disease or condition. The zoster vaccine, however, is covered by Part D. Part D coverage includes both the vaccine and the administration of the vaccine. If older individuals go to a pharmacy and get vaccinated they should make sure that the pharmacy is within their Part D network. If vaccinated in a provider’s office the individual and/or his or her caregiver should make sure that the provider can bill the drug plan. So, reimbursement is possible and getting some answers and clarity with the Med Part D plan prior to getting immunized is useful.
334
From the Editor / Geriatric Nursing 35 (2014) 333e334
Response to the challenge So as September rolls around I encourage you all to be champions in your settings of care. If it is primary care, capture the moment to encourage you patients to update all of their immunizations when they come in for their annual influenza vaccine. Assure your patients it is safe to get multiple immunizations all at once: influenza, pneumococcal and zoster for example. This year, if you administer influenza and pneumococcal vaccines in your settings . take on the challenge and ask ahead who might be interested in receiving a zoster vaccination at the same time. In so doing you could work with a local pharmacy (or your institutional pharmacy depending on what state you are in and what type of setting) and prearrange delivery, storage and reconstitution of the vaccine. Zoster vaccine must be stored frozen at minus 15 C and is then reconstituted with 0.7 mL of sterile water prior to administration. Maintenance of the frozen cold-chain is critical and the vaccine has to be used within 30 min of reconstitution. For those of you who are working in and/or see patients in assisted living settings nursing has a particularly important role in these settings as delegating nurses, nurse managers, operators and owners. I have yet to find a state that requires vaccinations of residents in assisted living prior to move-in. Of note, residents must be free of communicable disease and all have to be tested for tuberculosis. Conversely, children who start school and will be spending large amounts of time with other children must provide an up-todate immunization record. Consider doing the same for your assisted living residents at the time of move-in and updating this annually. If you do not have the resources to offer these vaccinations within your own setting, plan a field trip with residents to a local pharmacy or health department where immunizations are provided. Champions YOU ARE NOT ALONE! Vaccine Champions . you are not alone! Many groups are working to improve adult immunizations rates. Among these is the National Adult Vaccination Program (NAVP). NAVP includes a multistakeholder industry-supported collaboration spearheaded by The Gerontological Society of America (GSA). The goal of the NAVP is to develop a cohesive strategic and policy approach to improve adult vaccination aligned with the recommendations of the Centers for Disease Control Advisory Committee on Immunization Practices (ACIP). Over the past few years, using innovative approaches such as brain mapping, the NAVP has established a roadmap and key drivers for how to improve immunization rates for adult. Key drivers for improving uptake of immunizations focus on several themes: System, Framework and Process; Payers and Providers; and Patients and Caregivers. A key driver identified under Systems, Framework and Process includes establishing a culture supportive of adult immunizations. Social media, for example, might be a way to facilitate this process. A key driver for the theme of Payer and Providers is to provide some type of national leadership/champion for adult education related to immunizations. In addition, addressing quality improvement and wellness visits in an environment of increased
accountability and supported by resources for providers to reduce their financial risk will further drive the agenda to increase immunizations among adults. The Payer and Providers theme really focused on addressing the business of immunizations and the benefits to immunizations versus the cost of this service. Two drivers were identified as important to the Patient and Caregiver theme. One driver involves expanding policies and mandates to promote adult immunizations and the other focuses on incentivizing providers to immunize. As nurses I believe we are well suited to be useful champions in the immunization challenge. Work within your own settings to increase immunization rates. As health care providers we also need to be examples of appropriate health care practice and get immunized ourselves and encourage other providers and patients to do likewise. Remember nurses, zoster is now recommended for those age 50 and above! Take every opportunity to utilize the many available resources such as those on the NAVP webpage to keep yourselves and your patients educated about the benefits of immunizations, access and reimbursement. As noted above, no measure for prevention or treatment is ever 100% effective. Immunizations are our best approach to decreasing avoidable pneumonias, influenza, tetanus, pertussis and herpes zoster among older adults. We owe it to those for whom we provide care to assure that they have access to the opportunity for immunization and a chance of avoiding unpleasant symptoms, morbidity and potentially fatal disease. References 1. Williams WW, Lu PJ, O’Halloran A, et al. Noninfluenza vaccination coverage among adults-United States, 2012. MMWR. 2014;63(5):95e102. 2. Jackson LA, Janoff EN. Pneumococcal vaccination of elderly adults: new paradigms for protection. Clin Infect Dis. 2008;47:1328e1338. 3. Centers for Disease Control and Prevention. Prevention of pneumococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. 1997;46(RR-8). 4. Centers for Disease Control and Prevention. Updated recommendations for prevention of invasive pneumococcal disease among adults using the 23-valent pneumococcal polysaccharide vaccine (PPSV23). MMWR. 2010;59(34): 1102e1106. 5. Talbot HK, Griffin MR, Chen Q, Zhu Y, Williams JV, Edwards KM. Effectiveness of seasonal vaccine in preventing confirmed influenza-associated hospitalizations in community dwelling older adults. J Infect Dis. 2011;203:500e508. 6. Schmader K. Herpes zoster in older adults. Clin Infect Dis. 2001;32:1481e1486. 7. Oxman MN, Levin MJ, Johnson GR, et al. A vaccine to prevent herpes zoster and postherpetic neuralgia in older adults. N Engl J Med. 2005;352(22):2271e2284. 8. Kretsinger K, Broder KR, Cortese MM, Joyce MP, Ortega-Sanchez I, Lee GM, Healthcare Infection Control Practices Advisory Committee. Preventing tetanus, diphtheria, and pertussis among adults: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine recommendations of the Advisory Committee on Immunization Practices (ACIP) and recommendation of ACIP, supported by the Healthcare Infection Control Practices Advisory Committee (HICPAC), for use of Tdap among healthcare personnel. MMWR Recomm Rep. 2006;55(RR-17):1e37.
Barbara Resnick, PhD, CRNP, FAAN, FAANP University of Maryland, School of Nursing 655 West Lombard Street Baltimore, MD 21201, USA E-mail address: [email protected]
Contents lists available at ScienceDirect
Geriatric Nursing journal homepage: www.gnjournal.com
From the Editor
Barbara Resnick, PhD, CRNP, FAAN, FAANP
It is that time of year again . immunization opportunities for older adults September/October is generally the time of year that older adults and their caregivers start thinking about vaccinations. The focus is on influenza as this vaccine is updated annually to ensure that antibodies to the relevant predicted strains of the influenza A/H3N2 and A/H1N1 subtypes and influenza B are stimulated. Immunization opportunities go beyond influenza and consideration should be given to vaccination of older individuals against pneumonia, tetanus, pertussis and herpes zoster. Unfortunately, however, current immunization rates among older adults range from 8 to 60%.1 The 2012 outcome data noted that the rate of influenza and pneumococcal vaccine among older adults across all races and ethnicities was approximately 60%. For tetanus the rate was similarly 55%, although for tetanus with pertussis the rate was only 8%. Lastly, the rate for herpes zoster vaccination was 20%. This is in contrast to the Healthy People 2020 adult goal of achieving immunization rates of 90%. Nursing colleagues we have a challenge ahead of us and I ask you this year to be a champion to improve the rate of immunizations to the older adults you care for. Although there is no immunization that is 100% effective in preventing the relevant disease, immunizations are effective in the majority of cases. The 23-valent vaccine containing pneumococcal capsular polysaccharide is estimated to be approximately 50% effective in preventing pneumonia.2 The Advisory Committee on Immunization Practices (ACIP) continues to recommend that all persons be vaccinated for pneumonia with PPSV23 at age 65 but that no revaccination is necessary for individuals who have received the vaccination at that time.3,4 All too often older adults do not know or do not remember if they have received a pneumococcal vaccine. In those situations, it is recommended to revaccinate. Immunizations for pneumonia and influenza have been shown to decrease hospitalizations among older adults5 and thus prevent the negative downward trajectory that often occurs post hospitalization and the long recovery period. The benefit of preventing a zoster infection with a vaccination for herpes zoster can have an even more direct impact on older 0197-4572/$ e see front matter Ó 2014 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.gerinurse.2014.08.001
adults than that received by influenza and pneumonia vaccinations. Zoster infection occurs at a prevalence rate of approximately 50% for those who are 85 years of age and older.6 The incidence of post-herpetic neuralgia and chronic pain is present in 15% of those 80 years of age and older.7 Fortunately, the vaccine against herpes zoster results in a 50% reduction in cases of herpes zoster and 66% reduction in the risk of having long term postherpetic neuralgia. Aside from the obvious negative impact of pain from a zoster infection, either acute or chronic, immunization will decrease the risk of having to isolate older adults from friends and family when actively infected with zoster. This is particularly true for those who live in institutional, communal settings. Given the significant implications of this disease, the benefits to vaccination are impressive. The incidence of tetanus among older adults is much lower than that of zoster. The cases that do occur, however, are in undervaccinated individuals.8 Currently, due to the reemergence of whooping cough, it is now recommended that acellular pertussis be included in one of the tetanus diptheria booster vaccinations to prevent both pertussis and tetanus. Vaccine coverage Just as a reminder, Medicare Part B covers most vaccines: influenza, pneumococcal, Tdap, and any vaccine directly related to the treatment of an injury (e.g., tetanus) or direct exposure to a disease or condition. The zoster vaccine, however, is covered by Part D. Part D coverage includes both the vaccine and the administration of the vaccine. If older individuals go to a pharmacy and get vaccinated they should make sure that the pharmacy is within their Part D network. If vaccinated in a provider’s office the individual and/or his or her caregiver should make sure that the provider can bill the drug plan. So, reimbursement is possible and getting some answers and clarity with the Med Part D plan prior to getting immunized is useful.
334
From the Editor / Geriatric Nursing 35 (2014) 333e334
Response to the challenge So as September rolls around I encourage you all to be champions in your settings of care. If it is primary care, capture the moment to encourage you patients to update all of their immunizations when they come in for their annual influenza vaccine. Assure your patients it is safe to get multiple immunizations all at once: influenza, pneumococcal and zoster for example. This year, if you administer influenza and pneumococcal vaccines in your settings . take on the challenge and ask ahead who might be interested in receiving a zoster vaccination at the same time. In so doing you could work with a local pharmacy (or your institutional pharmacy depending on what state you are in and what type of setting) and prearrange delivery, storage and reconstitution of the vaccine. Zoster vaccine must be stored frozen at minus 15 C and is then reconstituted with 0.7 mL of sterile water prior to administration. Maintenance of the frozen cold-chain is critical and the vaccine has to be used within 30 min of reconstitution. For those of you who are working in and/or see patients in assisted living settings nursing has a particularly important role in these settings as delegating nurses, nurse managers, operators and owners. I have yet to find a state that requires vaccinations of residents in assisted living prior to move-in. Of note, residents must be free of communicable disease and all have to be tested for tuberculosis. Conversely, children who start school and will be spending large amounts of time with other children must provide an up-todate immunization record. Consider doing the same for your assisted living residents at the time of move-in and updating this annually. If you do not have the resources to offer these vaccinations within your own setting, plan a field trip with residents to a local pharmacy or health department where immunizations are provided. Champions YOU ARE NOT ALONE! Vaccine Champions . you are not alone! Many groups are working to improve adult immunizations rates. Among these is the National Adult Vaccination Program (NAVP). NAVP includes a multistakeholder industry-supported collaboration spearheaded by The Gerontological Society of America (GSA). The goal of the NAVP is to develop a cohesive strategic and policy approach to improve adult vaccination aligned with the recommendations of the Centers for Disease Control Advisory Committee on Immunization Practices (ACIP). Over the past few years, using innovative approaches such as brain mapping, the NAVP has established a roadmap and key drivers for how to improve immunization rates for adult. Key drivers for improving uptake of immunizations focus on several themes: System, Framework and Process; Payers and Providers; and Patients and Caregivers. A key driver identified under Systems, Framework and Process includes establishing a culture supportive of adult immunizations. Social media, for example, might be a way to facilitate this process. A key driver for the theme of Payer and Providers is to provide some type of national leadership/champion for adult education related to immunizations. In addition, addressing quality improvement and wellness visits in an environment of increased
accountability and supported by resources for providers to reduce their financial risk will further drive the agenda to increase immunizations among adults. The Payer and Providers theme really focused on addressing the business of immunizations and the benefits to immunizations versus the cost of this service. Two drivers were identified as important to the Patient and Caregiver theme. One driver involves expanding policies and mandates to promote adult immunizations and the other focuses on incentivizing providers to immunize. As nurses I believe we are well suited to be useful champions in the immunization challenge. Work within your own settings to increase immunization rates. As health care providers we also need to be examples of appropriate health care practice and get immunized ourselves and encourage other providers and patients to do likewise. Remember nurses, zoster is now recommended for those age 50 and above! Take every opportunity to utilize the many available resources such as those on the NAVP webpage to keep yourselves and your patients educated about the benefits of immunizations, access and reimbursement. As noted above, no measure for prevention or treatment is ever 100% effective. Immunizations are our best approach to decreasing avoidable pneumonias, influenza, tetanus, pertussis and herpes zoster among older adults. We owe it to those for whom we provide care to assure that they have access to the opportunity for immunization and a chance of avoiding unpleasant symptoms, morbidity and potentially fatal disease. References 1. Williams WW, Lu PJ, O’Halloran A, et al. Noninfluenza vaccination coverage among adults-United States, 2012. MMWR. 2014;63(5):95e102. 2. Jackson LA, Janoff EN. Pneumococcal vaccination of elderly adults: new paradigms for protection. Clin Infect Dis. 2008;47:1328e1338. 3. Centers for Disease Control and Prevention. Prevention of pneumococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. 1997;46(RR-8). 4. Centers for Disease Control and Prevention. Updated recommendations for prevention of invasive pneumococcal disease among adults using the 23-valent pneumococcal polysaccharide vaccine (PPSV23). MMWR. 2010;59(34): 1102e1106. 5. Talbot HK, Griffin MR, Chen Q, Zhu Y, Williams JV, Edwards KM. Effectiveness of seasonal vaccine in preventing confirmed influenza-associated hospitalizations in community dwelling older adults. J Infect Dis. 2011;203:500e508. 6. Schmader K. Herpes zoster in older adults. Clin Infect Dis. 2001;32:1481e1486. 7. Oxman MN, Levin MJ, Johnson GR, et al. A vaccine to prevent herpes zoster and postherpetic neuralgia in older adults. N Engl J Med. 2005;352(22):2271e2284. 8. Kretsinger K, Broder KR, Cortese MM, Joyce MP, Ortega-Sanchez I, Lee GM, Healthcare Infection Control Practices Advisory Committee. Preventing tetanus, diphtheria, and pertussis among adults: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine recommendations of the Advisory Committee on Immunization Practices (ACIP) and recommendation of ACIP, supported by the Healthcare Infection Control Practices Advisory Committee (HICPAC), for use of Tdap among healthcare personnel. MMWR Recomm Rep. 2006;55(RR-17):1e37.
Barbara Resnick, PhD, CRNP, FAAN, FAANP University of Maryland, School of Nursing 655 West Lombard Street Baltimore, MD 21201, USA E-mail address: [email protected]
