Complications of Pneumonia in Elderly Prevented by Pharmacist Immunization Services
Hillary Clinton brought pneumonia into the headlines, creating a momentum and moment of public awareness that pharmacists can ride to promote the health benefits of vaccinations for older adults. This is an important campaign because a significant number of adults haven’t received the pneumococcal vaccinations.
As you develop an outreach plan, remember that you’ll do a better job of protecting older adults from pneumonia by creating opportunities to talk and educate. Whether you offer vaccinations by partnering with a physician or becoming certified to deliver vaccines, personal interaction is the key to promoting pneumococcal vaccination. Even if you do not offer vaccines on-site you can still be a powerful advocate.
Pneumonia in Adults Aged 65 and Over
Adults certainly recognize the danger of pneumonia, yet few realize that it kills one out of every 20 people it affects—and older adults bear most of the burden.1 Adults aged 65 and over are four times more likely to contract pneumonia, with an annual incidence of community-acquired pneumonia estimated at 18 cases per 1,000 persons in those aged 65 and increasing to 52 percent when they reach the age of 85.2
Complications of pneumonia in the elderly include bacteria in the bloodstream, pleural effusion, lung abscess, difficulty breathing and the worst possible outcome, death. In spite of such severe outcomes, only 61 percent of older adults have received pneumococcal vaccinations. With the increasing number of adults reaching the age of 65, it has become imperative to develop more effective immunization programs.
The risk factors responsible for greater susceptibility to pneumonia include:3
- Age – Being over 65 increases the risk, but once patients reach 70, age becomes an independent risk factor. Changes in basic lung physiology—decreased elasticity, increased air trapping and weaker respiratory muscles—factor into the risk.
- Comorbidities – Cardiovascular disease, lung disease, diabetes, dementia, HIV/AIDS and liver disease independently increase the risk not only for pneumonia but also for the risk of death from pneumonia.
- COPD – Chronic obstructive pulmonary disease and using inhaled corticosteroids more than six months
- Pharmacotherapy – Chemotherapy and long-term use of immunosuppressants
- Smoking – About one-third of cases are linked to smoking. Pharmacists should recommend a smoking cessation program.
- Alcohol abuse
- Surgery, injury, immobilization – Any condition that makes it difficult to cough and allows mucus to accumulate in lungs
- Hospitalization in ICU – increases risk of hospital-acquired pneumonia
Pneumococcal Vaccination Recommendations
The Centers for Disease Control and Prevention added a second pneumococcal vaccination to the immunization schedule in 2015. Their current recommendations say that all pneumococcal-naïve adults who are 65 years of age or older should receive a dose of the pneumococcal conjugate vaccine PCV13, followed by a dose of PPSV23 administered at least one year later. Experts have voiced their concern about the new vaccine, saying that the lack of evidence supporting its efficacy in adults combined with increased costs makes them wonder whether PCV13 should be removed from the schedule.
In JAMA Internal Medicine, Michael Hochman, MD, MPH and Pieter A. Cohen, MD suggested that the benefits of PCV13 are likely overstated and a simpler, less costly approach would yield better results.4 The CDC’s Advisory Committee on Immunization Practices will review the recommendations in 2018. Until then, health care providers should follow the current recommendations.
The CDC also recommends that anyone aged 19 or older with the following health conditions should get the two pneumococcal vaccines:
- Heart, lung or liver disease
- Cerebrospinal fluid leaks
- Cochlear implants
One last important word about PPSV23 comes from an article in US Pharmacist.5 More than 80 percent of healthy adults develop antibodies within two to three weeks after receiving PPSV23, but it’s not as effective in older adults with chronic health conditions. While it prevents invasive disease in 60 to 70 percent of patients, the PPSV23 does not provide reliable protection against pneumococcal pneumonia. The authors advise that pharmacists should avoid calling PPSV23 a “pneumonia vaccine.
Turning Your Pharmacy Into an Immunization Resource
In today’s environment of high healthcare costs, it’s no surprise that many industry resources associate immunizations with the need to lower costs. While preventing pneumonia eliminates higher costs down the road, don’t let the pervasive emphasis on cost become the focus when you interact with patients. Some experts have suggested that you can motivate older adults by telling them about the future costs they’ll save if they prevent pneumonia, but there’s a better chance that approach will fall flat. Adults without health insurance are significantly less likely to get any type of vaccination—they already struggle with paying for vaccines and don’t need additional cost-related guilt.
So what’s a better way to make your pharmacy a destination for older adults in need of vaccinations? A few studies offer some guidance on that issue:
Morbidity and Mortality Weekly Report (MMWR) published in February 2016 noted that herpes zoster vaccines were up among adults older than 60 years; otherwise, vaccination coverage was quite lacking across the board. In addition to only 61 percent receiving pneumococcal vaccines, a mere 43 percent got an influenza vaccination.6 Older adults just aren’t getting vaccinations, which could be due to:
- No health insurance – Be prepared to talk about assistance programs, for example, the Pneumovax 23 qualifies for the Merck Vaccine Patient Assistance Program.
- Lack of regular contact with a physician – Adults who report one or more physician contacts are more likely to get vaccinations. Pharmacists who reach out may replace lack of physician contact and boost compliance—routine counseling and offering the vaccine helps, according to the MMWR report.
- Lack of knowledge – They may not be aware of any immunizations other than those for flu.
BMC Public Health published a survey of Canadian adults, which found that they have about the same vaccination rate as the United States—58 percent of older Canadians have received the pneumococcal vaccine.7 Based on responses to the survey, they suggest that the following are important factors:
- Health care professional who provides the vaccine – Although 97 percent of the participants had contact with a physician, only half of them were ever offered the vaccine. Older adults are significantly more likely to get vaccinated when any health professional—including pharmacists—actually offers or suggests the immunization.
- Education and personal contact – Talking with patients about the risks of pneumonia and consistently reminding them about vaccinations improves the immunization rate.
Pneumococcal Vaccines as Part of Comprehensive Counseling
Take an inclusive approach to senior health care and simply add vaccinations to the package. Whether you put up posters suggesting they consult the pharmacist or include the topics during medication reviews, you can address multiple senior health concerns along with vaccinations, including polypharmacy, diabetes, weight, and hypertension. It’s even better if you offer pneumococcal vaccinations at your pharmacy, but even if you don’t, consistent personal contact promotes better compliance with pneumococcal vaccinations.
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- “Adults: Protect Yourself With Pneumococcal Vaccines,” September 2016, http://www.cdc.gov/features/adult-pneumococcal/ ↩
- “Community-Acquired Pneumonia in Elderly Patients,” August 2010, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2917114/ ↩
- “Preventing Pneumonia in Seniors,” October 2010, https://www.uspharmacist.com/article/preventing-pneumonia-in-seniors ↩
- “Pneumococcal Vaccine: Controversy Over CDC Recommendations,” March 2016, http://www.pharmacytoday.org/article/S1042-0991(16)00337-6/pdf ↩
- “Pneumococcal Vaccination: Optimizing Preventive Strategies and Reducing Disease Burden,” April 2014, https://www.uspharmacist.com/article/pneumococcal-vaccination-optimizing-preventive-strategies-and-reducing-disease-burden ↩
- “Surveillance of Vaccination Coverage Among Adult Populations – United States, 2014,” February 2016, http://www.ncbi.nlm.nih.gov/pubmed/26844596 ↩
- “Knowledge, Attitudes, Beliefs and Behaviours of Older Adults About Pneumococcal Immunization, a Public Health Agency of Canada/Canadian Institutes of Health Research Influence Research Network (PCIRN) Investigation,” May 2014, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4046143/ ↩