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Outbreaks of Pneumococcal Pneumonia Among Unvaccinated Residents in Chronic-Care Facilities -- Massachusetts, October 1995, Oklahoma, February 1996, and Maryland, May-June 1996

During October 1995-June 1996, CDC and state and local public health agencies investigated outbreaks of pneumococcal pneumonia with bacteremia at chronic-care facilities (CCFs) serving predominantly elderly populations in Massachusetts, Oklahoma, and Maryland. This report summarizes these investigations and identifies measures that may prevent such outbreaks.

In the investigation of these outbreaks, pneumonia was defined as a chest radiograph consistent with pneumonia and compatible clinical features. Control measures implemented in these outbreaks included restricting group activities and new admissions to the CCFs, cohorting of staff-resident assignments, and vaccination of all residents lacking documentation of pneumococcal polysaccharide vaccine (PV). In two of the outbreaks, antimicrobial prophylaxis was administered in conjunction with PV, after which no additional cases of invasive pneumococcal infection were identified.

Massachusetts. During October 5-14, 1995, a total of 10 cases of pneumonia occurred among 67 residents of a CCF (attack rate {AR}=14.9%); two cases were fatal. The median age of the residents was 90 years. Streptococcus pneumoniae serotype 14 was isolated from a blood culture obtained from one patient, and S. pneumoniae infection was confirmed by polymerase chain reaction during postmortem examination of lung tissue of another resident. Only three (4.5%) residents had documentation of vaccination with PV before the outbreak.

Oklahoma. During February 6-20, 1996, of 80 elderly residents at a CCF, 12 (15%) were hospitalized with pneumonia, and three residents with bacteremia died. The median age of residents was 85 years. Multidrug-resistant S. pneumoniae serotype 23F was isolated from blood cultures obtained from four residents and from sputum cultures from two others. The strain was resistant to penicillin, cefotaxime, cefaclor, chloramphenicol, erythromycin, trimethoprim-sulfamethoxazole, tetracycline, and clindamycin. S. pneumoniae serotype 23F with the same pattern of antimicrobial susceptibility also was isolated from the nasopharynx of 17 (23%) of 74 asymptomatic residents and two (3%) of 69 asymptomatic employees. Only three (3.8%) residents had documentation of previous vaccination with PV.

Maryland. During May 26-June 17, 1996, a total of 14 cases of pneumonia were identified among residents at a CCF with a census of 120 (AR=11.7%). The median age of patients was 86 years. S. pneumoniae serotype 4 was isolated from the blood of four residents with pneumonia. Four residents with pneumonia died, three of whom had pneumococcal bacteremia. Isolates were susceptible to the antimicrobials tested (penicillin, cefotaxime, chloramphenicol, erythromycin, trimethoprim-sulfamethoxazole, tetracycline, clindamycin, rifampin, ofloxacin, and vancomycin). Only two (1.9%) residents had documentation of previous vaccination with PV.

Reported by: P Kludt, MPH, SM Lett, MD, A DeMaria, Jr, MD, State Epidemiologist, Massachusetts Dept of Public Health. JM Crutcher, MD, State Epidemiologist, Oklahoma State Dept of Health. NM Curtis, CW Garvey, MD, LL Frank, Montgomery County Dept of Health and Human Svcs; A Danner, MPH, GC Benjamin, MD, D Dwyer, MD, State Epidemiologist, Maryland Dept of Health and Mental Hygiene. Adult Vaccine Preventable Diseases Br, National Immunization Program; Childhood and Respiratory Diseases Br, Div of Bacterial and Mycotic Diseases, National Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: Infectious diseases are the third leading cause of death in the United States, and respiratory infections account for nearly one half of these deaths (1). During 1980-1992, pneumonia accounted for 85% of fatal respiratory infections among persons aged greater than or equal to 65 years (1). S. pneumoniae is the most common cause of nursing-home-acquired pneumonia (2). Although PV is safe, efficacious, and cost-effective in reducing the incidence of bacteremic pneumococcal illness (3), only 30% of persons aged greater than or equal to 65 years have been vaccinated (4).

Positive blood cultures are found in 20% of persons hospitalized with cases of pneumonia attributed to S. pneumoniae (5). This, along with the common practice of treating pneumonia empirically without first obtaining cultures, contributes to the disparity between the number of clinical cases of pneumonia and the number of bacteriologically confirmed cases described in this report.

The death rate among those CCF residents with pneumonia described in this report ranged from 20% to 28%, and less than 5% of the residents aged greater than or equal to 65 years had documentation of previous vaccination with PV. The serotypes associated with disease in each outbreak are included in the 23-valent PV. Advisory Committee on Immunization Practices (ACIP) guidelines (6) recommend that all persons aged greater than or equal to 65 years or others at increased risk for pneumococcal disease receive PV. Although most residents at the CCFs involved in this report were eligible for vaccination based on their age, documented vaccine coverage at these CCFs ranged from 1.9% to 4.5%, substantially below national estimates for persons aged greater than or equal to 65 years and the national health objectives for the year 2000 (80%) (objective 20.11) (7). The recent emergence of antimicrobial resistance among S. pneumoniae (8) underscores the importance of PV use in accordance with ACIP guidelines, particularly among the institutionalized elderly.

At least two factors contribute to the low rate of PV vaccination among the institutionalized elderly. First, physicians for residents in CCFs usually do not emphasize administration of PV (9). Second, incomplete documentation of vaccination history for CCF residents and misconceptions about adverse reactions after unintended revaccination with PV may discourage health-care providers from vaccinating CCF residents with unknown vaccination history; however, the incidence of serious adverse events is as low following revaccination as it is following initial vaccination (10).

The risk for outbreaks of invasive pneumococcal infection in CCFs can be reduced by ensuring that all residents aged greater than or equal to 65 years have been offered PV. During outbreaks of respiratory illness in CCFs, febrile residents should have cultures conducted before starting antimicrobial therapy. New admissions to CCFs should be encouraged to receive PV before admission to the facility or be offered vaccination on admission. To decrease the administration of unnecessary doses of PV, vaccination status should be recorded for each resident. When eligible residents are uncertain about their vaccination history or the resident's medical record is incomplete, vaccine should be administered. PV can be administered simultaneously with influenza vaccine; during annual influenza vaccine campaigns at CCFs, records should be reviewed to verify documentation of PV, and PV should be offered to all residents lacking documentation. Administrative and legislative policies also may assist in requiring CCFs and other health-care institutions to offer PV and other vaccines to eligible adults.

References

  1. Pinner RW, Teutsch SM, Simonsen L, et al. Trends in infectious diseases mortality in the United States. JAMA 1996;275:189-93.

  2. Marrie TJ, Slayter KL. Nursing home-acquired pneumonia: treatment options. Drugs Aging 1996;8:338-48.

  3. Butler JC, Breiman RF, Campbell JF, Lipman HB, Broome CV, Facklam RR. Pneumococcal polysaccharide vaccine efficacy: an evaluation of current recommendations. JAMA 1993;270:1826-31.

  4. CDC. Influenza and pneumococcal vaccination levels among adults aged greater than or equal to 65 years -- United States, 1993. MMWR 1996;45:853-9.

  5. Musher DM. Pneumococcal pneumonia including diagnosis and therapy of infection caused by penicillin-resistant strains. Infect Dis Clin North Am 1991;5:509-21.

  6. CDC. Pneumococcal polysaccharide vaccine: recommendations of the Immunization Practices Advisory Committee. MMWR 1989;38:64-8,73-6.

  7. Public Health Service. Health people 2000 review, 1995-96. Washington, DC: US Department of Health and Human Services, Public Health Service, 1996.

  8. Butler JC, Hofmann J, Cetron MS, et al. The continued emergence of drug-resistant Streptococcus pneumoniae in the United States: an update from the Centers for Disease Control and Prevention's Pneumococcal Sentinel Surveillance System. J Infect Dis 1996;174:986-93.

  9. Quick RE, Hoge CW, Hamilton DJ, Whitney CJ, Borges M, Kobayashi JM. Underutilization of pneumococcal vaccine in nursing homes in Washington State: report of a serotype-specific outbreak and a survey. Am J Med 1993;94:149-52.

  10. Snow R, Babish JD, McBean AM. Is there any connection between a second pneumonia shot and hospitalization among Medicare beneficiaries? Public Health Reports 1995;110:720-5.




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