Audit of uptake of influenza pneumococcal vaccinations in patients attending RNHRD outpatients clinic

1. Audit of uptake of influenza & pneumococcal vaccinations in patients attending RNHRD outpatients clinic John Pauling SpR Rheumatology GP forum 24th February 2009

2. History of vaccinations

3. Variolation Buddhist nun practicing between 1022 and 1063 She would grind up scabs from a person with small-pox into a powder and blow the contents into the nostrils of a non-immune person.

4. Influenza Spanish flu 1918 – 20 million deaths 250,000 to 500,000 deaths every year worldwide (36,000 in US) Vaccines developed from hens eggs 1930’s Influenza vaccination for militrary personal WW2. Annually updated trivalent flu vaccine consisting of haemagluttinin (HA) components from 3 commonest viral strains (H3N2, H1N1 & Inflenza B in 2007/08)

7. Pneumococcal vaccination Invasive Pneumococcal Disease responsible for 800,000 to 1,000,000 paediatric deaths per year worldwide (WHO) Streptococcal pneumonia commonest cause of CAP in UK PCV (pneumococcal conjugate vaccine) & PPV (pneumococcal polysaccharide vaccine) Generally safe and well tolerated (very similar side effect profile to Influenza vaccination) Lifelong protection from single vaccination (except in asplenia etc when boosters every 5 - 10 years need to be given)

9. Rheumatoid Arthritis Rheumatoid arthritis is associated with approximately a two-fold risk of infection (particularly pulmonary) as compared with age-matched controls 1 Related to ill-defined immunoregulatory abnormalities ? Use of immunosuppressive medications eg antiTNFa

10. Are Vaccinations safe & effective in RA? Does the same mechanism that increases risk of infection also reduce their response to vaccines? Does the activation of the immune system, when responding to the immunizing antigen, induce a flare of the underlying rheumatic disease? Several case reports of such associations One small study observed lower rates of flares in RA following influenza vaccination (J Rheum 2000;27:553-4) No large scale studies performed to date to adequately address these questions

11. Use of Influenza vaccination in RA 2 studies have found antibody responses following influenza vaccination to be similar to those of normal controls 2, 3 Influenza vaccines generate a good humoral response in RA patients, although lower than healthy controls. The response was not affected by use of steroid, DMARDs or antiTNFa inhibitors 4

12. Use of Influenza vaccination in RA Other studies have suggested a reduced antibody response during antiTNFa therapy although still sufficient to offer protection 5 Significantly lower post vaccination titres and protection rates following influenza vaccinations found in 4 patients treated with rituximab 6 (Product literature advises vaccination 1/12 pre or 6/12 post infusion)

13. Use of pneumococcal vaccination in RA Immune responses to pneumococcal antigens of patients with RA were impaired by methotrexate but not antiTNFa therapy 7 This has also been observed in PsA patients treated with enbrel or MTX therapy 8 ? due to unselective inhibition of cell proliferation with MTX whilst TNFa doesn’t play important role in the induction of an immune response

14. Current National Guidance All patients with RA offered pneumococcal & annual flu vaccinations in US, Germany & Sweden Based on recommendations from the Joint Committee on Vaccination and Immunisation, the Department of Health (DoH) advises use of influenza and pneumococcal vaccines in: 9 All patients >65 years old <65 years old but with additional risk factors eg Use of immunosuppressive therapy Hyposplenism Diabetes CRF Chronic liver disease Chronic cardiovascular and pulmonary disease Long term care in nursing / residential home

15. Aim & Methodology 150 unselected patients attending RNHRD outpatient services between Aug & Nov 2007 Broad selection of clinic sub-specialties including general rheum, PsA, ESC, CTD, Osteoporosis service, AS course etc Use of self-reported questionnaire and scrutinization of medical notes to assess adherence with DoH guidance Assessment made of eligibility for vaccines, uptake of vaccinations and where indicated reasons for failure to receive vaccines explored

16. Patient Demographics 150 patients assessed 91/150 (60.7%) <65 years old 59/150 (39.3%) >65 years old Average age 59.9 years (range 24-87) 116/150 (77.3%) patients taking Immunosuppressive agents Other co-morbidities included respiratory disease (33/150, 22%), CVD (15/150, 10%), renal impairment (6/150, 4%), DM (4/150, 2.7%), and asplenia (1/150, 0.7%) 1 patient was living in a nursing home

17. Underlying Diagnoses

18. Results Vaccine indicated in 135/150 patients (90%) Vaccine indicated in all patients >65 yrs (59 patients) Vaccine indicated in 76/91 patients <65 yrs (83.5%) The vast majority of eligible patients <65 yrs (71/91, 92.1%) were taking immunosuppressant medications

19. Vaccine uptake in eligible patients

20. Reasons for non-uptake of Influenza vaccination in eligible patients

21. Reasons for non-uptake of Pneumococcal vaccination in eligible patients

22. Limitations Use of self reported questionnaires susceptible to recall bias Possible under reporting of pneumococcal vaccine uptake Under representation of soft tissue rheumatic conditions and OA in view of case mix attending RNHRD out patient services

23. Conclusions (1) Significant morbidity & mortality associated with Influenza & Pneumococcal vaccination Effective and well tolerated vaccines available Vaccines appear safe and sufficiently antigenic to induce an antibody responses in our patients even when receiving immunosuppressive therapy

24. Conclusions (2) Influenza vaccination uptake rates satisfactory for >65 yrs Significantly lower for <65 yrs and patients <65 yrs are significantly more likely to have never been offered vaccinations than refused Pneumococcal vaccination uptake lower than influenza vaccine uptake in all groups Uptake acceptable for >65 yrs but significantly lower in patients <65 yrs Patients who have not received pneumococcal vaccine more likely to have never been offered vaccine than refused, irrespective of age

25. Recommendations Increase awareness amongst local rheumatology healthcare providers and primary care “Reminder” notice on prescription pad Introduce vaccinations into our work-up policy for antiTNFa and Rituximab therapies Increase awareness for patients via RAISE meetings, posters in waiting areas etc Formation of steering group to seek solutions to how issues such as vaccinations, in addition to other key components of annual review can be best addressed Re-audit adherence to guidance in 2010

26. Any questions ?