Pneumococcal disease causes

Transcription

1 52 Protocols for Pneumococcal Vaccination Subramanian Swaminathan 1, Dilip Mathai 2 Introduction Pneumococcal disease causes significant morbidity and mortality, especially in those aged > 50 years 1 and in younger adults who have chronic diseases. 2 In India, invasive pneumococcal disease is associated with highest case fatality rate (28%) among adults aged > 50 years. Moreover, mortality rate related to pneumococcal pneumonia has remained almost static around 12% during the past 6 decades. The availability of clear recommendations notwithstanding adult immunization coverage is still suboptimal in our country. The success of adult immunization in India depends on the physician s awareness of protocols and guidelines; recommendation of by the treating physician; and beliefs and attitudes of the patients. 3 Increasing pneumococcal coverage of all eligible and at risk patients involves multiple strategies. All healthcare professionals have a role in the prevention efforts, including screening patients; implementing protocols; prescribing and administering vaccine; and educating patients, caregivers, and community members. Pneumococcal vaccine can be administered during outpatient visits, or hospital stays. 2,3 Hospital Protocols At the global level, barriers for adult immunization include failure of the provider to check the patients status; difficulty in implementing mandatory adult ; and lack of authorization for medical technicians and nurses to vaccinate patients. 4 Difficulty in determining the patients status and lack of specialized centers are additional barriers encountered in India. 3 Vaccination protocols circumvent these issues and facilitate the standard delivery of quality care to the patient. Understanding the Term Protocol The term protocol may be defined as a set of written instructions that guide the patient care or aid the provider in performing a procedure. 4 What are Standing Order Protocols? Standing order protocols are medical therapeutic orders written by an authorized prescriber, identifying a medication to be administered or an action to be implemented. 4 With regard to, standing order protocols are written orders endorsed by a physician, an institution, or other authorized prescriber, which permit the pharmacists, nurses, or other healthcare personnel (where legally allowed) to evaluate the patient s immunization status and administer vaccines as per the protocol without the direct involvement of the attending physician at the time of interaction. 5 Standing order protocols can be implemented in different healthcare settings, such as hospitals, clinics, managedcare organizations, long-term care facilities, assisted living facilities, adult workplaces, pharmacies, home health care agencies, and correctional facilities. Numerous studies indicate that standing order protocols are more effective in increasing immunization coverage when compared to other strategies. Data from two studies show that standing order protocols achieved high pneumococcal rates, ranging from 78 94%. Moreover, studies on standing order protocols for pneumococcal or influenza did not report inappropriate or unnecessary. 6 Recommendations for standing order protocols: The Advisory Committee on Immunization Practices (ACIP) recommends standing order protocols for pneumococcal and influenza s, as well as for certain other vaccines, such as hepatitis B, when feasible. Based on the efficacy evidence, Community Preventive Services Task Force also recommends standing order protocols for adult in clinics, hospitals, and nursing homes. 6 Components of a standing order: Components of a comprehensive standing order (Figure1) include: 7,8 Targeted recipients of Factors determining the patient s need or requirement of Indications Contraindications Precautions Procedure for vaccine administration Name of the vaccine Vaccination schedule Dosage of vaccine Route of administration Legally required information if any Method of updating the patient s record Protocol for managing any medical emergency occurring secondary to Process of reporting possible post- adverse reactions Authorization by a physician, other authorized practitioner or an institution Also, standing orders should have an implementation date and an expiration date. They should also be reviewed periodically to 1 Senior consultant infectious diseases, Global Health City, Chennai, Tamil Nadu; 2 Dean and Professor of Medicine and Adult Infectious Diseases, Apollo Institute of Medical Sciences and Research, Apollo Institute of Medical Sciences and Research, Apollo Health City Campus Jubilee Hills, Hyderabad, Telangana

2 53 standing orders for Administering Pneumococcal Vaccines (PCV13 and PPSV23) to Adults Purpose Policy Procedure To reduce morbidity and mortality from pneumococcal disease by vaccinating all adults who meet the criteria established by the Centers for Disease Control and Prevention s Advisory Committee on Immunization Practices. Where allowed by state law, standing orders enable eligible nurses and other health care professionals (e.g., pharmacists) to assess the need for and to vaccinate adults who meet any of the criteria below. 1 Assess Adults for Need of Vaccination against Streptococcus pneumoniae (pneumococcus) infection according to the following criteria: Routine pneumococcal Assess adults age 65 years or older for need of pneumococcal. Pneumococcal conjugate vaccine (PCV13) should be administered routinely to all previously unvaccinated adults age 65 years and older. Pneumococcal polysaccharide vaccine (PPSV23) is recommended for all adults ages 65 years or older. For complete details, see section 5 (page 2). Risk-based pneumococcal Age 19 through 64 years with an underlying medical condition or other risk factor as described in the following table: category of underlying medical condition or other risk factor Standing orders for other vaccines are available at note: This standing orders template may be adapted per a practice s discretion without obtaining permission from IAC. As a courtesy, please acknowledge IAC as its source. recommended vaccines are marked x below PCV13 PPSV23 PPSV23 booster* Chronic heart disease, 1 chronic lung disease 2 x Diabetes mellitus x Chronic liver disease, cirrhosis x Cigarette smoking x Alcoholism x Cochlear implant, cerebrospinal fluid leak x x Sickle cell disease, other hemoglobinopathy x x x Congenital or acquired asplenia x x x Congenital or acquired immunodeficiency, 3 HIV x x x Chronic renal failure, nephrotic syndrome x x x Leukemia, lymphoma x x x Generalized malignancy, Hodgkin disease x x x Iatrogenic immunosuppression 4 x x x Solid organ transplant, multiple myeloma x x x * a second dose 5 years after the first dose of PPSV23 1 Excluding hypertension 2 Including asthma 3 Including B- (humoral) or T-lymphocyte deficiency, complement deficiencies (particularly C1, C2, C3, and C4 deficiencies), and phagocytic disorders (excluding chronic granulomatous disease) 4 Diseases requiring treatment with immunosuppressive drugs, including long-term systemic corticosteroids and radiation therapy 2 Screen for Contraindications and Precautions Contraindications Do not give pneumococcal vaccine (PCV13 or PPSV23) to a person who has experienced a serious systemic or anaphylactic reaction to a prior dose of the vaccine or to any of its components. For a list of vaccine components, refer to the manufacturer s package insert ( or go to Precautions Moderate or severe acute illness with or without fever continued on the next page Technical content reviewed by the Centers for Disease Control and Prevention Immunization Action Coalition Saint Paul, Minnesota Item #P3075 (11/15) Fig. 1: Standing order template for pneumococcal in adults Contd...

3 54 Standing Orders for Administering Pneumococcal Vaccine to Adults (continued) page 2 of 3 3 Provide Vaccine Information Statements Provide all patients with a copy of the most current federal Vaccine Information Statement (VIS). Provide non- English speaking patients with a copy of the VIS in their native language, if one is available and desired; these can be found at (For information about how to document that the VIS was given, see section 6 titled Document Vaccination. ) 4 Prepare to Administer Vaccine PCV13 must be given intramuscularly (IM). PPSV23 may be administered either IM or subcutaneously (Subcut). For vaccine that is to be administered IM, choose the needle gauge, needle length, and injection site according to the following chart: gender and weight of patient needle gauge needle length injection site Female or male less than 130 lbs ⅝"* 1" Deltoid muscle of arm Female or male lbs " Deltoid muscle of arm Female lbs ½" Deltoid muscle of arm Male lbs ½ Deltoid muscle of arm Female 200+ lbs ½ Deltoid muscle of arm Male 260+ lbs ½ Deltoid muscle of arm * A ⅝" needle may be used in patients weighing less than 130 lbs (<60 kg) for IM injection in the deltoid muscle only if the skin is stretched tight, the subcutaneous tissue is not bunched, and the injection is made at a 90 angle to the skin. If you prefer Subcut injection of PPSV23, choose a gauge, ⅝" needle for injection into the fatty tissue overlying the triceps muscle. 5 Administer PCV13 or PPSV23, 0.5 ml, according to the following dosing information and schedule: PCV13 must be administered by the IM route. PPSV23 may be administered either IM or Subcut. Routine for all adults ages 65 years and older age of patient vaccine(s) indicated (see table on page 1) history of prior schedule for administration of PCV13 and PPSV23 None or unknown Administer PCV13 followed in 1 year* by PPSV23. PPSV23 when younger than age 65 years; 0 or unknown PCV13 Administer PCV13 at least 1 year* after previous PPSV23. Administer another PPSV23 at least 5 years* after previous dose of PPSV yrs or older PPSV23 and 1-time dose of PCV13 PPSV23 when younger than age 65 years; PCV13 Administer another PPSV23 at least 5 years after previous dose of PPSV23 and at least 1 year* after previous dose of PCV13. PPSV23 when age 65 years or older; 0 or unknown PCV13 Administer PCV13 at least 1 year* after PPSV23 0 or unknown PPSV23; PCV13 Administer PPSV23 at least 1 year* after PCV13. * For adults age 65 years and older with immunocompromising conditions, functional or anatomic asplenia, cerebrospinal fluid leaks, or cochlear implants, the interval between PCV13 and PPSV23 should be shortened to 8 weeks. Risk-based for adults ages years (See next page.) continued on the next page Fig. 1: Standing order template for pneumococcal in adults Contd...

4 55 Standing Orders for Administering Pneumococcal Vaccine to Adults (continued) page 3 of 3 Risk-based for adults ages years age of patient years vaccine(s) indicated (see table on page 1) history of prior schedule for administration of PCV13 and PPSV23 For medical conditions in which only PPSV23 is indicated 1 dose PPSV23 None or unknown Administer PPSV23. For medical conditions in which both PCV13 and PPSV23 (1 or 2 doses) are recommended None or unknown Administer PCV13 followed in 8 weeks by PPSV23. 1 dose PCV13 and 1 dose PPSV23 0 or unknown PPSV23; Administer PPSV23 at least 8 weeks after PCV13. (i.e., cochlear implant; 1 dose PCV13 CSF leak) 1 dose PPSV23; 0 or unknown PCV13 Administer PCV13 at least 1 year after PPSV23. None or unknown Administer PCV13 followed in 8 weeks by PPSV23 #1. Administer PPSV23 #2 at least 5 years after PPSV23 #1. 1 dose PCV13 and 2 doses PPSV23 (e.g., immunocompromised) 1 dose PPSV23; 0 or unknown PCV13 0 or unknown PPSV23; 1 dose PCV13 1 dose PPSV23; 1 dose PCV13 2 doses PPSV23; 0 or unknown PCV13 Administer PCV13 at least 1 year after PPSV23 #1. Administer PPSV23 #2 at least 5 years after PPSV23 #1 and at least 8 weeks after PCV13. Administer PPSV23 #1 at least 8 weeks after PCV13. Administer PPSV23 #2 at least 5 years after PPSV23 #1. Administer PPSV23 #2 at least 5 years after PPSV23 #1 and at least 8 weeks after PCV13. Administer PCV13 at least 1 year after PPSV23 #2. 6 Document Vaccination Document each patient s vaccine administration information and follow up in the following places: Medical record: Document the date the vaccine was administered, the manufacturer and lot number, the site and route, and the name and title of the person administering the vaccine. You must also document, in the patient s medical record or office log, the publication date of the VIS and the date it was given to the patient. If vaccine was not administered, record the reason(s) for non-receipt of the vaccine (e.g., medical contraindication, patient refusal). Personal immunization record card: Record the date of and the name/location of the administering clinic. Immunization Information System (IIS) or registry : Report the to the appropriate state/local IIS, if available. 7 Be Prepared to Manage Medical Emergencies Be prepared for management of a medical emergency related to the administration of vaccine by having a written emergency medical protocol available, as well as equipment and medications. For IAC s Medical Management of Vaccine Reactions in Adults, go to To prevent syncope, vaccinate patients while they are seated or lying down and consider observing them for 15 minutes after receipt of the vaccine. 8 Report All Adverse Events to VAERS Report all adverse events following the administration of pneumococcal vaccine to the federal Vaccine Adverse Event Reporting System (VAERS) at Forms are available on the website or by calling (800) Standing Orders Authorization This policy and procedure shall remain in effect for all patients of the name of practice or clinic until rescinded or until. date Medical Director s signature Signature date Effective date Fig. 1: Standing order template for pneumococcal in adults

5 Non-SOP user, no plans to implement (%) Non-SOP user, would like to implement (%) incorporate updates on vaccine recommendations. 7 Implementation of standing order protocols: Assess the patient s need for pneumococcal : 8-10 Guidelines recommend the use of both pneumococcal vaccines, pneumococcal conjugate vaccine (PCV13) and pneumococcal polysaccharide vaccine (PPV23) in all adults aged > 50 years and in those who have risk factors. 9 In India, PCV 13 is approved for immunization of all healthy adults aged > 50 years. 10 Screen the potential recipient for: 8 Contraindications Previous anaphylaxis or serious systemic reaction to the vaccine or its components Precaution Acute illness of moderate-to-severe nature, with or without fever Provide information related to the vaccine 8 Administer the vaccine: 8 Intramuscularly (PCV13 and PPV23) using appropriate needle in the deltoid muscle of the arm Subcutaneously (PPV23) using appropriate needle into the fatty tissue over the triceps muscle Dose of PCV13 or PPV23 is 0.5 ml Document 1.2 Inconsistent SOP user (%) Abbreviation: SOP, standing order protocol Consistent SOP user (%) Unwilling to change the status quo Physiciandominated hierarchy Fear of malpractice Inadequate training of staff Fig. 2: Major barriers to implementing standing order protocol for adult pneumococcal information and update patient s medical/immunization records 8 Have written protocols to deal with medical emergencies resulting from vaccine administration ready, along with necessary equipment and medications; manage such eventualities as per the protocols 8 Administer the vaccine while the patients are lying down or seated, and keep them under observation for 15 minutes post 8 Vaccine reactions may include: 11 Localized itching, redness, swelling or bleeding at the injection site Psychological fright Syncope Anaphylaxis Factors affecting implementation of standing order protocols: A survey involving 1,640 providers with 67% response rate by Yonas et al. studied the factors impacting on the implementation of standing orders for adult. According to this study, the major barriers to standing orders include hesitancy in changing the status quo, medical hierarchy dominated by physicians, inadequate training of staff, and fear of malpractice (Figure 2). 12 On the other hand, facilitators for implementation of standing orders include ability to trust the Table 1: Different types of protocols General protocols Intensive care unit Discharge protocol Specialty related protocols Cardiology Diabetology Pulmonology (COPD discharge protocol) Nephrology (CKD, dialysis or RRT protocols) Oncology/hematology (BMT protocol) HIV patients on HAART Rheumatology Geriatrics Abbreviations: COPD - chronic obstructive pulmonary disease; RRT - renal replacement therapy; CKD - chronic kidney disease; BMT - bone marrow transplantation; HIV - human immunodeficiency virus; HAART - highly active antiretroviral therapy. support staff, availability of an electronic medical record (EMR), and openness to modernization and best practices as reported by those who consistently used standing orders. 12 A systematic review by Jacob et al. assessed the strategies that improved coverage. This review found that standing orders and reminder systems for the clients were the most cost-effective and least resource intensive strategies both for implementing and increasing coverage. 13 Different Types of Protocols Standing order protocols can be used in hospitals pertaining to various situations as outlined below in Table 1. 4 General protocols Discharging patients from the hospital is a complex process that is fraught with challenges. 14 Researchers are evaluating the effectiveness of different approaches for improving the discharge process. One classification to categorize these interventions is to consider them as pre-discharge approaches (patient education, discharge planning, scheduling a follow-up appointment); and post-discharge interventions (follow-up visits, home visits, patient-centered discharge instructions). 15 Preventing avoidable readmissions through during discharge can lead to profound improvement in both the quality of life of patients

6 57 and the healthcare systems financial well-being. Since a per protocol approach to a safe discharge can only cover the inpatients, who, nonetheless represent the most vulnerable population, an alternative way is needed to help the outpatient area. This could be addressed to a significant extent by the use of specialty based protocols to identify those who would benefit. Building these into the outpatient files or case records could ensure that this intervention is not lost in the vast array of issues that need to be addressed. Protocols as Per Specialty Recommendations for pneumococcal in adults pertaining to different specialties are given below. Protocols based on these recommendations facilitate implementation of pneumococcal. 1. Diabetology: The diabetic burden in India is estimated to be over 65 million patients, and around 80 million individuals are prediabetic. The risk of invasive pneumococcal disease is most among elderly diabetics with comorbidities and chronic diabetics with poor glycemic control. Considering the susceptibility of diabetic patients to pneumococcal infection and nasopharyngeal colonization, preventive pneumococcal may be offered to this group. One cohort study indicated the high efficacy (84%) of PPV23 in diabetic patients. Several case-control studies show high efficacy and safety (56 81%) of pneumococcal. 16 In India, PCV13 is approved for immunization of all healthy adults aged > 50 years. 10 Recommendations: In the Indian context, all diabetic patients should be counseled about the need for, and it should be strongly advocated for those aged > 60 years. Pneumococcal is recommended for: Diabetic patients with higher risk such as those: 17 Aged > 50 years Who have comorbidities (renal failure/nephropathy, malignancy etc.) Diabetic patients aged > 65 years (geriatric population) who: 16 Have chronic kidney disease Have chronic cardiopulmonary diseases Asthma Chronic obstructive pulmonary disease (COPD) Congestive cardiac failure Undergo transplantation Vaccination may also be considered for diabetic patients who have: 18 The condition for > 10 years Complications Poor glycemic control with glycosylated Hb > 7 Concomitant conditions causing immunocompromised state Smoking habit Guidelines recommend the use of both pneumococcal vaccines in all adults aged > 50 years and in those who have risk factors. 9 The Association of Physicians of India (API) recommends pneumococcal for all adults aged > 65 years and diabetic patients aged < 65 years Pulmonology: Pneumococcal pneumonia is a common complication of chronic pulmonary diseases, often leading to mortality. In India, the prevalence of COPD is around % in those aged > 60 years. Pneumonia and respiratory failure are the primary causes of mortality and morbidity in patients with severe to very severe COPD. Pneumococcal can decrease the mortality risk in both immunocompromised and immunocompetent patients. 3 Recommendations: Guidelines state that both PCV13 and PPV23 are indicated in all adults aged > 50 years and in those who have risk factors. 9 The National College of Chest Physicians (NCCP) and Joint Indian Chest Society (ICS) recommend pneumococcal for patients with chronic pulmonary diseases, including COPD. The Centres for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP) recommends pneumococcal for adults aged > 65 years and those aged years who: 19 Have chronic pulmonary diseases, such as COPD, asthma, and emphysema Are smokers The API recommends administration of PPV23 in all adults aged > 65 years, those aged < 65 years with chronic lung disease and bronchial asthma, as well as those who are smokers. 1 In India, PCV13 is approved for immunization of all healthy adults aged > 50 years Nephrology: In India, the prevalence of chronic kidney disease (CKD) is estimated to be around 17.2%, with diabetes being the most common cause. When compared to non-ckd subjects, the incidence of pneumonia is 5 times higher in dialysis patients and 3 times higher in CKD patients. 3 Recommendations: Guidelines recommend the use of both PPV23 and PCV13 in all adults aged > 50 years and in those who have risk factors. 9 In India, PCV13 is approved for the prevention of pneumococcal pneumonia and/or invasive pneumococcal disease in adults aged > 50 years. The Indian Society of Nephrology (ISN) recommends pneumococcal for immunocompetent adults aged > 65 years and those who have CKD or other comorbidities. 20 The Kidney Disease Improving Global Outcomes (KDIGO) recommends pneumococcal for 3 : All adults who have egfr < 30 ml/min/1.73 m 2 High-risk patients (nephrotic syndrome, diabetes, those undergoing immunosuppressive therapy) The ACIP recommends pneumococcal for adults aged > 65 years and those aged > 19 years who have nephrotic syndrome or chronic renal failure Oncology: In India, the crude mortality rate of cancer was estimated to be 49.1 per 100,000 by the year Infections form the leading cause of mortality and morbidity in cancer patients, particularly in those undergoing

7 58 Sample Patient Discharge Protocol Contd...

8 59 Sample Patient Discharge Protocol stem cell transplantation or chemotherapy. Nearly 50% of those with hematological malignancies develop pulmonary infection. Diagnostic or therapeutic splenectomy performed in these patients increases the risk of infections, with pulmonary infections being the most common complications. 3 Recommendations: National and international guidelines recommend pneumococcal for patients who have leukemia, Hodgkin s disease, lymphoma, multiple myeloma, and systemic malignancy, and in those undergoing splenectomy or hematopoietic stem cell transplantation. 3 Guidelines recommend the use of both pneumococcal vaccines in all adults aged > 50 years and in those who have risk factors. 9 The ACIP recommends pneumococcal for adults aged > 65 years and those aged > 19 years who have lymphoma, leukemia, Hodgkin s disease, multiple myeloma or generalized malignancy. 19 The API recommends pneumococcal for all adults aged > 65 years and in those aged > 19 years and < 65 years with immunosuppressive conditions and anatomic or functional asplenia. In India, PCV13 is approved for immunization of all healthy adults aged > 50 years. 10 Vaccination should be avoided during radiotherapy or chemotherapy; PPV23 should be given two weeks before elective splenectomy or cancer chemotherapy. One-time re with PPV23 may be considered in those with immunosuppressive conditions and anatomic or functional asplenia after 5 years Rheumatology: Rheumatoid arthritis (RA) is prevalent among million adults in India. Patients suffering from RA or other autoimmune rheumatic diseases (ARDs) are more susceptible to infections, including pneumonia and related morbidity and mortality. Immunosuppressive effects of corticosteroids, immunosuppressants, immunomodulators, and biologics used in these patients increase their vulnerability to infections. 3 Recommendations: The use of pneumococcal vaccines - PCV13 and PPV23 is recommended in all adults aged > 50 years and in those who have risk factors. 9 Most international guidelines recommend the pneumococcal for patients with rheumatic diseases. However, uncertainty prevails concerning the type of vaccine to be used. Though the current ACIP guidelines recommend pneumococcal with both PCV13 and PPV23 in immunosuppressed adults, the evidence did not cover patients with RA or those taking immunomodulatory drugs. Pneumococcal should be given minimum 2 weeks before commencing treatment with disease-modifying anti-rheumatic drugs (DMARDs), such as anti-tnf agents, tocilizumab, rituximab, and abatacept. Vaccination is also recommended for patients starting treatment with biologics. 3 In India, PCV13 is approved for immunization of all healthy adults aged > 50 years Human immunodeficiency virus infection: Recurrent and severe pneumococcal infection is often encountered in human immunodeficiency virus (HIV) infected patients owing to humoral immune dysfunction. An open-label study found PCV13 to be immunogenic and safe in HIV patients with CD4 count > 200 cells/mm 5. 3 Recommendations: Both pneumococcal vaccines are

9 60 Sample Nephrology Protocol for Vaccination in Chronic Kidney Disease/Dialysis Patients 21,22 Vaccine type Vaccination history First dose Second dose Third dose Pneumococcal vaccine Pneumococcal conjugate vaccine 0.5 ml (IM) No prior PCV13 PPV23 8 weeks after the last dose of PCV13 PPV23 after 5 years Pneumococcal polysaccharide vaccine 0.5 ml (IM) Influenza vaccine Inactivated influenza vaccine Yes/No 0.5 ml (IM) Hepatitis B Vaccine Recombinant hepatitis B vaccine 1 ml (IM) One dose of PCV13 PPV23 8 weeks after the last dose of PCV13 One dose of PPV23 PCV13 1 year after the last dose of PPV23 One dose each of PCV13 and PPV23 after 5 years PPV23 No history of exposure or Complete or incomplete or exposure PPV23 after 5 years PPV23 after 5 years Patients who have had prior with PPV23 at age 65 years should be given single dose of PPV23 Annual with single dose, unless contraindicated, in all individuals at risk, aged 6 months 0 month 1 month after the first dose 6 th month after the first dose Administer another dose if anti-hbsag is < 10 miu/ml at 1 2 months after the last vaccine dose For patients undergoing hemodialysis, perform annual anti-hbs testing and administer a booster dose if anti-hbs level is < 10 miu/ml Abbreviations: TIV - Trivalent influenza vaccine; HBs-Ag - Hepatitis B surface antigen; Anti-HBs - antibody to hepatitis B surface antigen. recommended for all adults aged > 50 years and in those who have risk factors. 9 The A PI recommends pneumococcal for all adults aged > 65 years and those aged > 19 years and < 65 years with symptomatic or asymptomatic HIV infection. 1 The ACIP recommends pneumococcal for adults aged > 65 years and those aged > 19 years who have HIV infection. 19 In India, PCV13 is approved for immunization of all healthy adults aged > 50 years Geriatrics: Elderly people constitute a high-risk group for contracting pneumococcal infection owing to the development of immunosenescence and increased prevalence of chronic diseases with advancing age. The incidence of pneumococcal disease is high among those aged > 50 years. 3 Recommendations: The Geriatric Society of India (GSI) recommends pneumococcal of the elderly population. Both vaccines are recommended for all adults aged > 50 years and in those who have risk factors. 9 Note: 21,22 1. All adults who have egfr < 30 ml/min/1.73 m 2 and those who are at high risk for pneumococcal infection, such as diabetes, nephritic syndrome, and immunosuppressive therapy are given polyvalent pneumococcal vaccine except when contraindicated. 2. All adults who have chronic kidney disease are offered annual influenza unless contraindicated. 3. All adults with high risk of CKD progression and have egfr < 30 ml/min/1.73 m 2 should be given hepatitis B and its serological response be confirmed. 4. The use of live vaccines should be considered based on the patient s immune status, according to recommendations. 5. Caution should be exercised while using live vaccines in CKD patients who are frequently immunocompromised. 6. Higher vaccine doses or more number of doses are recommended for hemodialysis patients and other immunosuppressed patients. Why Should Hospitals Use Protocols? At an organizational level, standing order protocols form an effective method for implementing adult. Around 60% patients, who have pneumococcal disease requiring in-patient care, were hospitalized within the past 4 years with the majority of them belonging to a high-risk category. Therefore, these protocols are particularly useful for carrying out pneumococcal in the hospital setting. 2 A systematic review of 29 studies evaluated standing orders for, either alone or combined with other preventive measures, such as patient/provider education, client/provider reminder-recall systems, and provider assessment/ feedback. Based on this review, the Community Prevention Services Task Force deduced that standing orders when used alone, improved the coverage in adults by a median of 17 pp (percentage points) and when combined with other measures, they improved the coverage by a median of 31 pp. This review also established the efficacy of standing orders pertaining to pneumococcal vaccine delivery to adults as well as in improving rates across different clinical settings and among several providers and patient groups. 23 Standing order protocols increase immunization coverage by 23 Decreasing missed opportunities for in clinical practice Making a routine process without a specific order from the physician for each dose of vaccine Authorizing nurses and other legally qualified healthcare personnel to vaccinate patients Freeing up the physician s time

10 61 Implementing standing order protocols can benefit hospitals by 4 Encouraging adherence to standards of care Reducing errors and improving safety of care Promoting quality of care Controlling medical costs Reducing litigation costs Recommendations for Formulation of Vaccination Protocols Standing order programs should document the infrastructure plan, important service-delivery factors, and quality parameters. Protocols should be formulated by a hospital committee comprising medical director, quality-control and infection-control personnel, nursing director, and representatives from medical or nursing staff and the protocols should cover following procedures 6 : Identifying eligible individuals for depending on their age, status or presence of risk factors Providing information regarding risks and benefits of the vaccine to the patients and their caregivers, and recording delivery of such information Documenting patient refusals or contraindications Documenting vaccine administration and post adverse reaction, if any, as per the approved protocol Providing record of to the patients and their primary care physicians Inappropriate can be avoided by ongoing communication between the program staff members, vaccine recipients and their respective primary-care physicians. 6 Standing order program should also have 6 Standard institutional as well as personal immunization records to check the patient s status and to avoid inappropriate re Quality assurance procedure for maintaining required standard of care Immunization coverage by institutional providers can be improved by the implementation of standing order protocols either alone or along with other preventive interventions. 6 Future Directions Indian Scenario In India, adult coverage is negligible and it should be increased with an aim to limit the consequences of preventable infectious diseases. Issues pertaining to safety, efficacy and cost of nationwide adult are yet to be resolved in the country. Nonetheless, India should urgently face up to the challenge of adult immunization by forming a national policy and national adult immunization schedule.24 Available evidence supports the use of pneumococcal vaccine in older adults aged 50 years.1,9,25 Hence, the national policy should cover the routine immunization of adults aged 50 years against pneumococcal infection to reduce pneumococcal disease burden, and the use of both PPV23 and PCV13 as per standard protocol may be considered in this age group.25 It is to be noted that in India, PCV13 is approved for use in those aged 50 years.3 Studies assessing the cost effectiveness of PCV13 in older adults and high risk patients have supported the vaccine use.3 Pneumococcal appears to be the lone public health tool for reducing pneumococcal disease burden in India. A study analyzing the cost-effectiveness of PCV13 in immunocompromised individuals including HIV infected patients found that a single dose of PCV13 is more cost-effective in the study population based on the life expectancy and vaccine efficacy in the immunocompromised group.26 Strategies to achieve pneumococcal of adults may include25 Improving awareness among medical professionals and other healthcare personnel on the benefits of adult immunization Administering pneumococcal vaccine routinely to older adults aged 50 years Devising protocols, guidelines and algorithms for pneumococcal that target high-risk patients: - At the out-patient department - Before discharge from the hospital Making immunization of high risk patients mandatory at diabetic clinics, and other specialty units such as oncology and nephrology/renal transplant units in tertiary care hospitals Using public-private partnership to develop community based interventions such as immunization camps or centres, so that adults aged 50 years belonging to low-and middle-income groups are immunized against pneumococcal disease Initiating patient/physician reminder programs or tracking systems at the practice level to ensure re of adults, who are already initiated on References 1. Muruganathan A, Mathai D, Sharma SK. The Association of Physicians of India. Adult Immunization New Delhi: Jaypee Brothers Medical Publishers Ltd.; Pneumococcal disease call to action Pneumococcal is everyone s responsibility. A Task Force Report. National Foundation of Infectious Diseases [Internet]. Available at: professional-resources/pneumococcal-cta/hcp. pdf. Accessed on Jul 19, The remaining challenge of pneumococcal disease in older adults. JAPI (Suppl) Apr;63. Available at: special_issue/contents.html phho/nursing_board/guidelines/ guidelinesforuseofmedicalprotocols.pdf, last accessed on Oct 27, The community guide. Increasing appropriate : Standing orders [Internet] [Updated May 26, 2016]. Available at: standingorders.html. Accessed on Jul 19, Advisory Committee on Immunization Practices. Use of standing orders programs to increase adult rates Recommendations of the Advisory Committee on Immunization Practices. MMWR 2000; 49: Immunization Action Coalition. Using standing orders for administering vaccines: What you should know [Internet]. Available at: immunize.org/catg.d/p3066.pdf. Accessed on Jul 19, Immunization Action Coalition. Standing orders for administering pneumococcal vaccines (PCV13 and PPSV23) to adults [Internet]. Available at:

11 62 Accessed on Jul 19, Sharma OP; expert comittee. Indian recommendations for in older adults Geriatric Society of India. Available at: html. Accessed on Jul 19, Prevenar 13 Summary of Prescribing Information adapted from LPDPRV version Immunization Action Coalition. Medical management of vaccine reactions in adult patients [Internet]. Available at: immunize.org/catg.d/p3082.pdf. Accessed on Jul 19, Yonas MA, Nowalk MP, Zimmerman RK, Ahmed F, Albert SM. Examining structural and clinical factors associated with implementation of standing orders for adult immunization. J Healthc Qual 2012; 34: Jacob V, Chattopadhyay SK, Hopkins DP, et al. Increasing coverage of appropriate s A community guide systematic economic review. Am J Prev Med 2016; 50: Hospital utilization (in non-federal short-stay hospitals) [Internet] [Updated Jul 6, 2016]. Available at: hospital.htm. Accessed on Oct 10, Hansen LO, Young RS, Hinami K, et al. Interventions to reduce 30-day re-hospitalization: A systematic review. Ann Intern Med 2011; 155: Joshi SR, Joshi SS, Shah SN. Pneumococcal vaccine in diabetes: Relevance in India. J Assoc Physicians India 2015; 63: Mohan V, Unnikrishnan R, Thomas N, et al. Pneumococcal infections and immunization in diabetic patients. J Postgrad Med 2011; 57: Kesavadev J, Misra A, Das AK, et al. Suggested use of vaccines in diabetes. Indian J Endocrinol Metab 2012; 16: Kim DK, Bridges CB, Harriman KH; Advisory Committee on Immunization Practices. Advisory Committee on Immunization Practices Recommended Immunization Schedule for Adults Aged 19 Years or Older: United States, Ann Intern Med 2016; 164: Indian Society of Nephrology guidelines for in chronic kidney disease. Indian Journal of Nephrology 2016; 26:S KDIGO guidelines 2012: Vaccination in CKD/ dialysis patients. practice_guidelines/pdf/ckd/kdigo_2012_ CKD_GL.pdf; last accessed on Oct 27, Guideline for vaccinating kidney dialysis patients and patients with chronic kidney disease Summarized from Recommendations of the Advisory Committee on Immunization Practices (ACIP). United States Department of Health and Human Services Centers for Disease Control and Prevention [Internet] [Updated Jul 2015]. Available at: pubs/downloads/dialysis-guide-2012.pdf. Accessed on Jul 19, Tan LJ. Immunization action coalition. Standing order protocols: How they work [Internet]. Available at: wp-content/uploads/2015/10/session_2_final_ Carrico.pdf. Accessed on 19 Jul, Verma R, Khanna P, Chawla S. Adult immunisation in India: Importance and recommendations. Hum Vaccin Immunother. 2015; 11: Mathai D, expert - committee members. Pneumococcal for adults An Indian perspective. Consensus recommendations National Expert Committee Smith KJ, Nowalk MP, Raymund M, et al. Costeffectiveness of pneumococcal conjugate in immunocompromised adults. Vaccine 2013; 31: