Association of standing-order policies with vaccination rates in dialysis clinics: a US-based cross-sectional study

Vaccination rates and the causes of vaccine hesitancy among patients with end stage renal disease

Aim: Chronic kidney disease creates a tendency to infections, and infections are the second most common reason for mortality following cardiovascular events in chronic kidney disease. Health authorities recommend vaccination against hepatitis B, annual influenza, pneumonia, zoster, tetanus, and new coronavirus disease for people with end-stage kidney disease. Vaccine-preventable diseases cause mortality in the adult population with chronic diseases. The primary purpose of this study is to investigate vaccination rates and awareness about vaccination among end-stage renal disease patients who were on renal replacement therapies in a single tertiary center in Turkey. Material and Method: 86 hemodialysis patients were included in this cross-sectional study. A questionnaire was used to investigate whether the patients were aware of the immunization schedule or not and whether they were vaccinated against hepatitis B virus, seasonal influenza virus, pneumonia, herpes zoster, tetanus, and SARS-CoV-2 or not. Results: Fifty-eight (67.4%) patients were vaccinated against SARS CoV2. 48(55.8%) patients were vaccinated against the Hepatitis B virus. 31 (36%) patients were vaccinated against Pneumococcus pneumonia. 48 (55.8%) patients have been vaccinated against the influenza virus annually. Only 14 (16.3%) patients were vaccinated against tetanus during the previous 10 years, and only 1 (1.2%) patient was vaccinated against Herpes zoster. Influenza vaccination rates were found to be higher in patients with a longer duration of hemodialysis when compared to the other group(p=0.03). SARS-CoV 2 vaccination rates were higher in patients who were older than 59 years of age when compared to the younger patients(p=0.03). Conclusion: Vaccination rates are far from the targets in patients with end-stage kidney disease. The most common reason to be unvaccinated is a lack of enough knowledge about the subject.

Comparative cost-effectiveness of a 2-dose versus 3-dose vaccine for hepatitis B prevention in selected adult populations

The hepatitis B virus is highly infectious and can cause incurable liver disease, leading to high morbidity rates, increased healthcare utilization, and high mortality. Multiple preventative hepatitis B vaccine options have been available for decades, but adherence to the traditional 6-month vaccine schedule for the approved 3-dose series remains low in adult populations at risk of hepatitis B exposure. A 2-dose hepatitis B vaccine (HEPLISAV-B) approved by the US Food and Drug Administration in 2017 induces rapid seroprotection within 1 month and has a safety profile comparable to a commonly used 3-dose vaccine. In a previous cost-effectiveness study, HEPLISAV-B had a favorable cost-effectiveness profile for multiple at-risk populations. The goal of the current analysis was to update and extend previous findings by evaluating cost-effectiveness of HEPLISAV-B compared with a 3-dose vaccine (Engerix-B) in selected adult populations, including patients with diabetes, chronic liver or kidney disease, end-stage renal disease, healthcare personnel, travelers to countries with endemic hepatitis B, and a public health population. Cost-effectiveness was measured as incremental cost-effectiveness ratios using a health economics Markov model that accounts for adherence rates, seroprotection rates, healthcare costs, and current pricing considerations. Patients progressed between a series of health states, and the difference in lifetime spending and survival for individuals receiving either HEPLISAV-B or Engerix-B was estimated from the perspective of a US managed care payer, HEPLISAV-B had favorable cost-effectiveness profiles for patients with diabetes, healthcare personnel, travelers, and patients with chronic liver disease and dominant incremental cost-effectiveness ratios for patients with chronic kidney disease and end-stage renal disease. A probabilistic sensitivity analysis supported the robustness of the cost-effectiveness profiles, and an additional analysis indicated that HEPLISAV-B was cost-effective in the general adult population. Overall, HEPLISAV-B was cost-effective in multiple adult populations recommended for HBV vaccination in the United States.

Improving influenza and pneumococcal vaccination uptake among incident peritoneal dialysis patients: a quality improvement initiative

INTRODUCTION

Influenza and pneumococcal vaccination rates among peritoneal dialysis (PD) patients remain suboptimal, despite availability of vaccinations and health recommendations.

AIM

The primary aim was to improve influenza and pneumococcal vaccination rates among incident PD patients at our center to 80%. A secondary aim was to develop a sustainable workflow for vaccination in PD patients.

DESIGN

A quality improvement (QI) initiative to increase vaccination rate among incident PD patients was conducted in a tertiary care hospital in Singapore from Jul 2017 to Dec 2018. Key drivers and barriers to success were identified through root cause analysis. Change ideas focusing on improving opportunities, access and enhancement of reminder systems were implemented using Plan-Do-Study-Act methodology. Vaccination rates were monitored at 3-month intervals.

RESULTS

Total of 249 patients were eligible for vaccination. The baseline vaccination rate for influenza, pneumococcal conjugate vaccine (PCV13) and pneumococcal polysaccharide vaccine (PPSV23) were 63%, 54% and 14%, respectively. Root-cause analyses revealed several practice-related barriers, including lack of physician recommendation, time constraints and ineffective reminder systems. Multifaceted interventions, such as the provision of vaccination at non-traditional clinical settings, physician audit and feedback, utilisation of reminder tools, successfully increased influenza, PCV13 and PPSV23 vaccination rates to 86%, 85% and 63%, respectively.

CONCLUSION

A robust influenza and pneumococcal vaccination program implemented using a standardized QI methodology and multidisciplinary approach is effective in improving and sustaining influenza and pneumococcal vaccination uptake among PD patients.

The coverage of influenza and pneumococcal vaccination among kidney transplant recipients and waiting list patients: A cross-sectional survey in Denmark

BACKGROUND

To characterize level and predictors of influenza and pneumococcal vaccine uptake among Danish kidney transplant recipients (KTR) and kidney transplant waiting list patients (WLP).

METHODS

A cross-sectional survey based on self-reported vaccine uptake including WLP and KTR ≤ 1½ years post transplantation. Descriptive statistics and logistic regression analyses identifying factors associated with influenza vaccine uptake in the latest season were performed.

RESULTS

A total of 220 participants were included in the study, 54% KTR and 46% WLP. Self-reported influenza vaccine uptake in the latest season was overall 41.8%. Uptake of influenza vaccine on any prior season apart from the latest season was 53.2% and significantly higher among WLP than KTR (P = .007). Pneumococcal vaccine uptake was only 4% overall. The only factor positively associated with influenza vaccine uptake in the latest season was any prior influenza vaccine uptake (OR 5.79, CI95 2.44-13.76) (P < .001). Recommendations given by other persons (non-physician) were negatively associated with receiving the influenza vaccination in the latest season (OR 0.34, CI95 0.13-0.92) (P = .03). Reasons for not being vaccinated were primarily lack of information, perception of own good health, and fear of adverse reactions.

CONCLUSIONS

Influenza and pneumococcal vaccine uptakes were suboptimal among Danish WLP and KTR. Increased awareness about guidelines and physicians´ education are warranted.

Barriers to Pretransplant Immunization: A Qualitative Interview Study of Pediatric Solid Organ Transplant Stakeholders

OBJECTIVES

To describe the experiences and beliefs of pediatric transplant stakeholders regarding factors that contribute to low pretransplant immunization rates.

STUDY DESIGN

Semistructured interviews were conducted with transplant team members (hepatologists, cardiologists, nephrologists, transplant nurse coordinators, and transplant infectious diseases physicians), primary care physicians, and parents of heart, liver, and kidney transplant recipients at 3 geographically diverse large pediatric transplant centers in the US. Interviews were conducted between July 2017 and February 2020 until thematic saturation was reached within each stakeholder subgroup. Content analysis methodology was used to identify themes.

RESULTS

Stakeholders participated in 30- to 60-minute interviews (16 transplant subspecialists, 3 transplant infectious diseases physicians, 11 transplant nurse coordinators, 12 primary care physicians, and 40 parents). Five central themes emerged: (1) gaps in knowledge about timing and safety of pretransplant immunizations, (2) lack of communication, coordination, and follow-up between team members regarding immunizations, (3) lack of centralized immunization records, (4) subspecialty clinic functioning as the medical home for transplant candidates but unable to provide all needed immunizations, and (5) differences between organ type in prioritization and completion of pretransplant immunization.

CONCLUSIONS

There are multiple factors that contribute to low immunization rates among pediatric transplant candidates. New tools are needed to overcome these barriers and increase immunization rates in transplant candidates.

Underimmunization of the solid organ transplant population: An urgent problem with potential digital health solutions

Solid organ transplant recipients are at risk for potentially life-threatening infections due to lifelong immunosuppression. Vaccine-preventable infections result in graft injury, morbidity, mortality, and significantly increased medical costs. Unfortunately, the majority of transplant recipients continue to be underimmunized at the time of transplant and thereafter. Given the rising rates of vaccine hesitancy and refusal in the general population, transplant recipients can no longer rely on herd immunity to protect them from vaccine-preventable infections. Novel tools are desperately needed to overcome transplant-specific immunization barriers to improve immunization rates in this high-risk population. Digital health technologies may offer a solution by addressing transplant-specific barriers: specifically, providing accurate information about vaccine safety, efficacy, and timing in the pre- and posttransplant periods; making a complete immunization record universally available and easily accessible; enabling communication between patients and multiple providers; and providing automated vaccine reminders to both patients and providers when vaccines are due using transplant-specific immunization guidelines. Digital health has transformed health care by empowering patients with their own health information and connecting patients, their providers, and public health officials. In doing so, it offers a potential platform to address and overcome the problem of underimmunization in the transplant population.

Practical Guide to Vaccination in All Stages of CKD, Including Patients Treated by Dialysis or Kidney Transplantation

Infection is a major cause of morbidity and mortality in patients with chronic kidney disease (CKD), including those receiving maintenance dialysis or with a kidney transplant. Although responses to vaccines are impaired in these populations, immunizations remain an important component of preventative care due to their favorable safety profiles and the high rate of infection in these patients. Most guidelines for patients with CKD focus on the importance of the hepatitis B, influenza, and pneumococcal vaccines in addition to age-appropriate immunizations. More data are needed to determine the clinical efficacy of these immunizations and others in this population and define optimal dosing and timing for administration. Studies have suggested that there may be a benefit to immunization before the onset of dialysis or transplantation because patients with early-stage CKD generally have higher rates of seroconversion. Because nephrologists often serve as primary care physicians for patients with CKD, it is important to understand the role of vaccinations in the preventive care of this patient population.

Vaccination practices in dialysis patients: A narrative review

In a period of turmoil concerning vaccination practices, there is a serious conflict between scientifically reasonable, evidence-based guidelines and the far-fetched rumors or misconceptions concerning the vaccination practices in the general population. When a significant portion of the medical and paramedical personnel may be deliberately unvaccinated against common biological agents, achieving effective vaccination rates in the dialysis population may be complicated. Vaccination rates are unacceptably low in dialysis patients and seroconversion rates are even lower; further, serological follow-up is generally poor. The particularly anergic immune system of the advanced chronic kidney disease patients is partly a cause of both high rates of infection and low rates of seroconversions. This narrative review is an effort to summarize current knowledge concerning the vaccination practices in dialysis patients with some specific recommendations based on these facts. Of particular interest is a new vaccine, the Zoster Recombinant, Adjuvanted Vaccine (Shingrix), which we will include in our discussion.

Immune response to hepatitis B vaccine among patients on hemodialysis

Infection with hepatitis B virus (HBV) poses a major health threat worldwide, where the magnitude and overburden of chronic carrier state approaches 150 million chronic carriers. The prevalence of HBV is greater among dialyzed patients compared to the general population owing to their increased vulnerability to blood and its products, along with hazards posed by contaminated hemodialysis tools and devices. An electronic systematic search of the published literature was carried and data on the immunological riposte to hepatitis B vaccination among hemodialysis patients was extracted from relevant studies. End stage renal disease patients on hemodialysis have a lower or an absolutely negative riposte to HBV vaccine. Several means have been tried to improve this response with some success, nevertheless none have been universally adopted. Genetic investigations are foreseen to make a break through concerning HBV vaccination.

Hospitalization and skilled nursing care are predictors of influenza vaccination among patients on hemodialysis: evidence of confounding by frailty

BACKGROUND

Observational studies of preventive medications, such as vaccinations, can suffer from the healthy-user bias because vaccinated patients may be healthier than unvaccinated patients. Indicators of health status and frailty suitable for attenuating this bias could be identified in administrative data.

OBJECTIVE

To examine the association of baseline variables and time-dependent hospitalization and skilled nursing care with the receipt of influenza vaccination in patients with end-stage renal disease.

RESEARCH DESIGN

Observational cohort study using United States Renal Data System files each year from 1999 to 2005.

SUBJECTS

Population-based cohorts that included >115,000 adult, hemodialysis patients each year.

MEASURES

We estimated hazard ratios for the association of baseline variables and time-dependent hospitalization days and skilled nursing days with influenza vaccination, controlling for demographic and baseline health status variables.

RESULTS

Vaccination coverage increased from 47% in 1999 to 60% in 2005. Patients with any length of hospitalization were less likely to be vaccinated, however, the association was stronger in patients with longer stays [15-25 d: hazard ratio=0.64 (95% confidence interval, 0.62-0.65); 26-30 d: 0.40 (0.38-0.42)]. Patients with any length of skilled nursing care of >1 day had similar estimates; these patients were also less likely to be vaccinated [26-30 d: 0.66 (0.64-0.69)].

CONCLUSIONS

Patients with long hospitalizations or skilled nursing stays were less likely to be vaccinated suggesting evidence of the healthy-user effect. These variables could be used to account for bias in studies of preventive services in patients on dialysis.

Immunization in end-stage renal disease: opportunity to improve outcomes

Infection is the second most common cause of death in patients with end-stage renal disease (ESRD), following cardiovascular causes. Immunization is a fairly simple, but underutilized, strategy for prevention of infectious morbidity and mortality in patients with kidney failure. It is imperative for nephrologists and primary care providers to have an understanding of immunization as an essential component of preventive healthcare measures in this high-risk population. Patients with ESRD represent a unique population due to their immunosuppressed state, dialysis-related exposures and suboptimal response to routine vaccines. While the Advisory Committee on Immunization Practices (ACIP) provides guidelines for vaccination of patients with renal disease against Hepatitis B, influenza and pneumococcal disease, the data on immunization against other commonly preventable infectious diseases are lacking. This article reviews the recent evidence on immunization in the ESRD population and synthesizes the related implications for maximizing prevention of infectious diseases in this high-risk population.

Knowledge, attitudes, and clinical practice of rheumatologists in vaccination of the at-risk rheumatology patient population

BACKGROUND

Patients with inflammatory arthritis are at increased risk of infection. Much of the burden of infection in this population is vaccine preventable. A number of international rheumatology organizations have published expert recommendations for vaccination in adult patients. Despite this, reported vaccination rates remain low among patients with inflammatory arthritis.

OBJECTIVES

We sought to establish the knowledge, attitudes, and clinical practice of rheumatologists with respect to vaccination.

METHODS

Rheumatologists practicing in Ireland in 2009 were surveyed by postal questionnaire. Data collected was entered into Microsoft Excel and statistical analysis was carried out using SPSS18 software.

RESULTS

Eighty (100%) practicing rheumatologists were surveyed. Response rate was 55% (44/80). Of those surveyed, 57% (25/44) had no written departmental vaccination guidelines. Although 90% of those surveyed agreed that the responsibility for ensuring vaccine compliance rests with health professionals, only 5% considered that the rheumatology clinic was the best setting in which to accomplish this. Half (50%, n = 22) of practicing rheumatologists do not inquire about vaccination history in the clinic, with a minority (9%, n = 4) recording vaccination history in their clinical notes. A significant percentage of rheumatologists do not perform screening about prior vaccination before initiation of either anti-tumor necrosis factor (34%) or disease-modifying antirheumatic disease (42%) therapy. Moreover, 57% (n = 25) considered the responsibility for vaccination the domain of the patients' general practitioners with the favored strategy to improve vaccine compliance being led by the primary care physicians (48%, n = 21).

CONCLUSIONS

The practice of Irish rheumatologists with regard to vaccination in this survey was suboptimal. Most neither recommend nor record vaccination history in their clinical notes, with the majority feeling that the rheumatology clinic is not the appropriate setting in which to target strategies to improve vaccine compliance. Although a more proactive role needs to be taken by rheumatologists as the principal prescribers of immunosuppressive therapy on this issue, our survey respondents suggest that strategies to improve vaccine uptake should be developed outside the rheumatology clinic and, in particular, involve primary care. The circulation of currently available international guidelines on vaccination specific for rheumatology patients to primary care physicians should be used to inform practices to ensure improved vaccine compliance.

Standing orders for influenza and pneumococcal polysaccharide vaccination: correlates identified in a national survey of U.S. Primary care physicians

BACKGROUND

Standing orders programs (SOPs) allow non-physician medical staff to assess eligibility and administer vaccines without a specific physician's order. SOPs increase vaccination rates but are underutilized.

METHOD

In 2009, correlates of SOPs use for influenza vaccine and pneumococcal polysaccharide vaccination (PPV) were assessed in a nationally representative, stratified random sample of U.S. physicians (n = 880) in family and internal medicine who provided office immunization. The response rate was 67%. Physicians reporting no SOPs, only influenza SOPs, and joint influenza and PPV SOPs were compared using multinomial and logistic regression models to examine individual and practice-level correlates.

RESULTS

23% reported using SOPs consistently for both influenza vaccine and PPV, and 20% for influenza vaccination only, with the remainder not using SOPs. Practice-level factors that distinguished practices with joint influenza-PPV SOPs included perceived practice openness to change, strong practice teamwork, access to an electronic medical record, presence of an immunization champion in the practice, and access to nurse/physician assistant staff as opposed to medical assistants alone.

DISCUSSION

Physicians in practices with SOPs for both vaccines reported greater awareness of ACIP recommendations and/or Medicare regulations and were more likely to agree that SOPs are an effective way to boost vaccination coverage. However, implementation of both influenza and PPV SOPs was also associated with a variety of practice-level factors, including teamwork, the presence of an immunization champion, and greater availability of clinical assistants with advanced training.

CONCLUSIONS

Practice-level factors are critical for the adoption of more complex SOPs, such as joint SOPs for influenza and PPV.

Immunogenicity of hepatitis B vaccine among hemodialysis patients: effect of revaccination of non-responders and duration of protection

BACKGROUND

Hepatitis B vaccination is recommended for patients on hemodialysis, however, seroprotection after a primary vaccine series is suboptimum. Limited data are available on the effect of revaccination of non-responders and on persistence of immunity in this population.

METHODS

Hepatitis B vaccine (40 μg/dose) was given to 77 susceptible patients on hemodialysis (0, 1, and 6 month schedule). Levels of hepatitis B surface antibody (anti-HBs) were tested ≥ 28 days after the third dose was administered, and non-responders revaccinated with an additional 3-dose series. Vaccine responders (anti-HBs ≥10 mIU/mL) were re-tested every 6 months and booster doses given as needed. Kaplan-Meier survival curve was used to estimate the probability of maintaining protective antibody level. Cox-proportional hazards models were used to assess the association between time to loss of protective antibody levels and certain explanatory variables.

RESULTS

Overall primary vaccine-induced response was 79.2% (95% CI 68.2%, 87.3%), including 49/77 (63.6%; 95% CI 51.8%, 74.7%) patients who received the initial primary hepatitis B vaccine series and 12/21 (57.1%; 95% CI 34.4%, 77.4%) non-responders who were revaccinated with an additional series. Among weak responders (anti-HBs level 10.0-99.9 mIU/mL), protective antibody levels persisted in 44% for 12 months post-vaccination; whereas among strong responders (anti-HBs level ≥100 mIU/mL), protective antibody levels persisted in 92% for 12 months, and 68% for 24 months post-vaccination. A weak post-vaccination response increased the risk of losing protective antibody levels (adjusted hazard ratio, 9.7; 95% confidence interval, 3.5-28.5; p<0.0001).

CONCLUSION

Revaccinating patients undergoing hemodialysis who do not respond to a primary vaccine series substantially increases the pool of protected patients. The threshold for defining hepatitis B vaccine-induced immunity should be revisited in this patient population to maximize the duration of protection.

Examining structural and clinical factors associated with implementation of standing orders for adult immunization

A proven method to increase vaccination rates in primary care is a standing orders program (SOP) for nonphysician staff to assess and vaccinate eligible individuals without a specific written physician order. This study describes a mixed methods approach to examining physicians' beliefs and attitudes about and adoption of SOPs for adult immunizations, specifically, influenza and pneumococcal polysaccharide vaccine. Focus groups and in-depth interviews of physicians, nurses, practice managers, and the medical director of a managed care health plan were conducted. Results were used to enrich a concise survey based on the Awareness-to-Adherence model of physician behavior and previous research, which was mailed to 1,640 general internists and family physicians nationwide. Barriers to SOPs identified through qualitative methods were lack of interest in changing the status quo, a physician-dominated hierarchy, and fear of malpractice. Facilitators included having an electronic medical record and a practice culture that was open to change. The survey (response rate 67%) confirmed the facilitators and further identified patient, physician, and practice factors that served as barriers to establishing and maintaining SOPs. This mixed methods approach provided the opportunity to develop a tailored and practice-oriented survey for examining the contextual factors influencing clinical providers' decisions to implement SOPs for adult immunization.

Prevention of infection in patients with chronic kidney disease. Part II: healthcare-associated infections

This second article, in a three-part CE series on the prevention of infection in patients with chronic kidney disease, focuses on healthcare-associated infections and blood borne viruses that are prevalent within the haemodialysis environment. It also informs the reader of the relevant infection and prevention precaution guidelines and their application within a haemodialysis setting.

Use of standing orders for adult influenza vaccination a national survey of primary care physicians

BACKGROUND

Influenza vaccination of adults remains below recommended levels. Standing orders programs (SOPs) that allow nonphysician medical staff to assess eligibility and administer vaccines without an individualized physician's order are a proven method to increase vaccination rates. However, recent data on their use are not available.

PURPOSE

Investigators surveyed primary care physicians nationwide in 2009 to assess factors related to awareness and use of SOPs.

METHODS

Using the AMA Master List, a stratified random sample of U.S. family physicians (n=820) and general internists (n=820) was selected to receive a mailed questionnaire. The inclusion criterion was providing primary care to adults in an office-based practice. The primary outcome measure, analyzed in 2010, was consistent use of SOPs.

RESULTS

The survey response rate was 67% (1015/1517). Forty-two percent of respondents who immunized adults in their practices reported consistent use of SOPs. Those physicians differed in several dimensions, including awareness of recommendations and regulations regarding SOPs for vaccines, size and type of practice, number and level of training of clinical staff, attributes of the staff. The two variables in logistic regression models that were associated with the highest likelihood of using SOPs were awareness of recommendations to use them (OR=3.0; 95% CI=2.2, 4.1) and agreement with their effectiveness (OR=2.7, 95% CI=1.9, 3.8).

CONCLUSIONS

Fewer than half of physicians report using SOPs for influenza vaccination, a number that is not much higher than it was about a decade ago. Approaches to increase use of SOPs are needed.