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Increasing Pneumococcal Vaccination Rates Among Patients of a National Health-Care Alliance -- United States, 1993

Streptococcus pneumoniae is the most common cause of bacterial pneumonia worldwide and a leading cause of sepsis and meningitis (1). In the United States, an estimated 40,000 persons die each year from pneumococcal infections (2). Since 1983, 23-valent pneumococcal polysaccharide vaccines have been licensed in the United States (2) and are 56%-57% effective in preventing invasive pneumococcal disease (3). However, the 1993 National Health Interview Survey documented that less than or equal to 28% of persons in high-risk categories, including all persons aged greater than or equal to 65 years, reported ever having received the vaccine (4). During 1993-1994, VHA Inc. (Irving, Texas) -- a national health-care alliance serving approximately 1200 health-care organizations nationwide (including 21% of all community hospitals in the United States) -- initiated efforts to improve pneumococcal vaccine delivery to and coverage among patients at increased risk for complications of pneumococcal infection. This report summarizes the program and an evaluation of its effectiveness in increasing vaccine coverage.

In August 1993, VHA conducted a telephone survey of a national probability sample about pneumonia and its prevention. * The survey indicated that, among participants aged greater than or equal to 65 years, 32% had read or heard about pneumococcal pneumonia, 27% were aware of pneumococcal vaccine, and 15% (or a member of their family) had ever been vaccinated. In comparison, the year 2000 national health objective for pneumococcal vaccine coverage for persons aged greater than or equal to 65 years is 60% (objective 20.11) (5). Based on these findings and recommendations from advisory councils of member health-care organizations, VHA developed the nationwide Pneumonia Pnockout{Registered} campaign. The goals of this program were to educate elderly and other high-risk persons about pneumococcal pneumonia and the need for pneumococcal vaccination and to encourage partnerships between VHA health-care organizations and public health departments, senior citizen centers, and community organizations. Overall, 355 (37%) of the 953 member organizations of VHA volunteered to participate.

The campaign was conducted October 25-November 19, 1993, and targeted persons aged greater than or equal to 65 years and those with high-risk conditions for pneumococcal disease as defined by the Advisory Committee on Immunization Practices (2). VHA provided each participating organization with a media kit containing public service announcements, sample press releases, and a national toll-free telephone number for patients listing VHA hospitals offering pneumococcal vaccination.

The campaign was evaluated by VHA in January 1994. Based on information provided by 221 (65%) of the 355 organizations, 82,562 persons received pneumococcal vaccine during the 4-week campaign. Of these, 21% were vaccinated in unspecified locations, 19% in hospital outpatient services, 18% in family practice centers or physicians' offices, 15% in public health departments, 15% in community sites, and 12% in other settings (e.g., hospital inpatient services {3%}, long-term-care facilities {2%}, and other sites {7%}). Examples of problems encountered during the program included the need for physicians' orders to vaccinate Medicare patients; hospital regulations requiring patient registration before administration of vaccine; assurance of adequate vaccine supplies; reluctance of physicians to participate; and the need to educate health-care providers and patients about vaccine benefits, safety, and effectiveness. Educational materials were provided to an estimated 288,000 persons, including the general public (58%), health-care staff (17%), physicians (4%), long-term-care staff (1%), and others (19%).

Evaluation of the impact of the campaign also included a follow-up survey in December 1993 that replicated the methods of the baseline survey. * Compared with August 1993, there were statistically significant increases in the prevalences of awareness of pneumococcal pneumonia (overall: from 26% to 31%; among persons aged greater than or equal to 65 years: from 32% to 40%) and pneumococcal vaccine (overall: from 16% to 24%; among persons aged greater than or equal to 65 years: from 27% to 44%), and of persons aged greater than or equal to 65 years reporting that they or a family member had been vaccinated (from 15% to 22%).

In September 1994, a year-round campaign was initiated to increase efforts of participating organizations to integrate pneumococcal vaccination into daily patient-care delivery systems; 216 organizations participated, of which 71 (33%) were new. Of the 216 organizations, 93 (43%) submitted preliminary evaluations of the 1994 program in January 1995. Based on this evaluation, 56 (60%) provided 36,450 doses of pneumococcal vaccine. An estimated 60% of doses were given in collaboration with public health departments and other community organizations, compared with 30% in 1993. Other patient-care settings (e.g., physician offices, outpatient and inpatient services, and home health care) accounted for 30% of vaccine doses delivered.

Reported by: DA Stewart, M Scovill, MS, C Aitches, JM Haning, DP Bourque, JS Roberts, MD, L Gentry, C Eddy, VHA Inc, Irving, Texas. DS Fedson, MD, Pasteur-Merieux MSD, Lyon, France. Adult Vaccine-Preventable Diseases Br, Epidemiology and Surveillance Div, National Immunization Program, CDC.

Editorial Note

Editorial Note: Based on national surveys, during 1989-1993, vaccination levels among adults increased substantially; for example, pneumococcal vaccination among persons aged greater than or equal to 65 years increased from 15% to 28% (4). However, these levels remain below the year 2000 national health objective of 60% vaccination levels for high-risk persons (objective 20.11) (5). Previously documented barriers to achieving high vaccination levels among adults include 1) missed opportunities to vaccinate adults during contacts with health-care providers in offices, outpatient clinics, and hospitals (6); 2) lack of vaccine-delivery systems in the public and private sectors that can reach adults in different settings (e.g., health-care, workplace, and college or university settings) (6); 3) patient and provider fears concerning adverse events following vaccination (7,8); and 4) lack of awareness among both patients and providers of the importance of vaccine-preventable diseases in adults (6). Two of the barriers identified during the VHA campaign are now being addressed: first, the Health Care Financing Administration has approved a regulation that enables the use of standing orders (rather than requiring a physician's presence) to administer pneumococcal vaccine to Medicare patients, and second, vaccine companies have initiated efforts to assure adequate supplies of pneumococcal vaccine. The number of VHA organizations participating in the campaign may increase by overcoming these barriers and others that may have limited participation (e.g., member agency interest and awareness of the problem in their communities and resources to address the problem).

Previous efforts to increase vaccination coverage levels among adults have involved collaborations between public and private health-care providers. For example, the Medicare Influenza Vaccine Demonstration and the Hawaii Pneumococcal Disease Initiative (9,10) both employed public-private partnerships to substantially increase vaccine delivery and improve vaccination levels among elderly persons. In comparison, the VHA campaign entailed minimal collaboration with public agencies during the development stage, although public health departments assisted with implementation. Important elements of the VHA campaign included collection of information about the target population and education of both the target population and health-care providers. More than 80% of the 1994 participants are continuing their efforts in 1995. Replication of the VHA campaign and similar efforts, in conjunction with public-sector support, will assist in achieving national health objectives for 1) reducing epidemic-related pneumonia and influenza-related deaths among persons aged greater than or equal to 65 years; and 2) increasing pneumococcal and influenza vaccination levels among noninstitutionalized, high-risk populations to at least 60% (5).


  1. Lederberg J, Shope RE, Oaks SC Jr, eds. Emerging infections: microbial threats to health in the United States. Washington, DC: National Academy Press, 1992.

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

  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 coverage levels among persons aged greater than or equal to 65 years -- United States, 1973-1993. MMWR 1995;44:506-7,513-5.

  5. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991:122-3; DHHS publication no. (PHS)91-50213.

  6. Williams WW, Hickson MA, Kane MA, Kendal AP, Spika JS, Hinman AR. Immunization policies and vaccine coverage among adults: the risk for missed opportunities. Ann Intern Med 1988;108:616-25.

  7. Pachucki CT, Lentino JR, Jackson GG. Attitudes and behavior of health care personnel regarding the use and efficacy of influenza vaccine {Letter}. J Infect Dis 1985;151:1170-1.

  8. Nichol KL, Lofgren RP, Gapinski J. Influenza vaccination: knowledge, attitudes, and behavior among high-risk outpatients. Arch Intern Med 1992;152:106-10.

  9. CDC. Final results: Medicare influenza vaccine demonstration -- selected states, 1988-1992. MMWR 1993;42:601-4.

  10. Campbell JF, Donohue MF, Nevin-Woods C, et al. The Hawaii Pneumococcal Disease Initiative. Am J Public Health 1993;83:1175-6.

Prevalence estimates have a standard error of plus or minus 2.2%.

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