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Do standing orders help with chronic disease care and health maintenance in ambulatory practice?
RESULTS ARE MIXED. Studies of standing orders tend to examine their effect on compliance with preventive interventions for chronic disease rather than disease outcomes. In the ambulatory setting, they improve rates of influenza vaccination (strength of recommendation [SOR]: C, consistent cohort studies measuring vaccination rates), pneumococcal vaccination (SOR: C, consistent randomized controlled trials [RCTs] measuring vaccination rates), childhood immunizations (SOR: C, inconsistent RCTs measuring vaccination rates), and mammograms (SOR: C, RCT measuring screening rate).
Standing orders don’t improve screening rates for colorectal cancer (SOR: C, RCT measuring screening rate).
Evidence summary
Organizational changes in physician offices can improve delivery of services for preventing and controlling disease.1 Standing orders—typically defined as physician-approved protocols that authorize nurses or other staff members to perform procedures, such as immunizations without direct physician involvement1—are readily applicable in ambulatory settings. However, only 30% of physicians use standing orders in their practices.2
Research on standing orders in ambulatory care has focused on immunizations and cancer screening (TABLE). Interventions implementing standing orders typically have multiple components and include staff education, chart flow sheets, and recall-reminders for patients.
TABLE
Effect of standing orders in ambulatory practice
| Disease | Standing order | Improvement in vaccination or screening rate | NNT* |
|---|---|---|---|
| Pneumococcal disease3-5 | Pneumococcal vaccine | Baseline range: 5%-15%; Follow-up range: 25%-28.3% | 3.7-10 |
| Influenza6-8 | Influenza vaccine | Baseline range: 32%-51.4%; Follow-up range: 58%-74.6% | 3.8-4.3 |
| Cancer screening3 | Mammogram | Baseline: 33%; Follow-up: 60% | 3.7 |
| Childhood illnesses9 | Immunizations, ages 2-5 yr | Baseline: 14%; Follow-up: 29% | 6.7 |
| *Number needed to treat (NNT) is based on the number of additional patients who receive an intervention based on the number who may be exposed to the standing order. | |||
Improvement in pneumococcal and flu vaccine rates
Three multicomponent RCTs of outpatient standing orders reported improved pneumococcal vaccination rates.3-5 Similarly, 2 prospective, multicomponent cohort studies6,7 and 1 retrospective study8 found improved rates of influenza vaccination with standing orders.
Childhood vaccination rates also show positive trends
Two controlled trials (1 randomized3 and 1 nonrandomized9) that incorporated standing orders examined their use in childhood immunizations (measles, mumps, and rubella [MMR]; oral polio vaccine [OPV]; Haemophilus influenzae, type b [HIB]; diphtheria and tetanus toxoids with acellular pertussis [DTaP]; and hepatitis B). One trial reported increased use of acute care immunization opportunities;9 the other showed a nonsignificant positive trend in vaccination rates.3
Standing orders increase 1 form of cancer screening, not another
A multicomponent RCT of standing orders for mammography and colorectal cancer screening found a statistically significant increase in screening for mammography, but not colorectal cancer.3
Recommendations
The Society of Adolescent Medicine recommends standing orders for administration of influenza vaccine during flu season.10
The Task Force on Community Preventive Services recommends standing orders for adult vaccinations based on “strong evidence,” but states that insufficient evidence exists to recommend standing orders for childhood vaccinations.11 Vaccines examined include MMR, DTaP, HIB, hepatitis B, and varicella for young children; hepatitis B, varicella, MMR, and tetanus-diphtheria toxoids (Td) for adolescents; Td for adults up to 65 years of age; and influenza and pneumococcal vaccines for adults 65 years and older.
The Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention recommends standing orders for influenza and pneumococcal vaccines.12
1. Stone EG, Morton SC, Hulscher ME, et al. Interventions that increase use of adult immunization and cancer screening services: a meta-analysis. Ann Intern Med. 2002;136:641-651.
2. Nichol KL, Zimmerman R. Generalist and subspecialist physicians’ knowledge, attitudes, and practices regarding influenza and pneumococcal vaccinations for elderly and other high-risk patients: a nationwide survey. Arch Intern Med. 2001;161:2702-2708.
3. Mold JW, Aspy CA, Nagykaldi Z. Implementation of evidence-based preventive services delivery processes in primary care: an Oklahoma Physicians Resource/Research Network (OKPRN) study. J Am Board Fam Med. 2008;21:334-344.
4. Rhew DC, Glassman PA, Goetz MB. Improving pneumococcal vaccine rates. Nurse protocols versus clinical reminders. J Gen Intern Med. 1999;14:351-356.
5. Herman CJ, Speroff T, Cebul RD. Improving compliance with immunization in the older adult: results of a randomized cohort study. J Am Geriatr Soc. 1994;42:1154-1159.
6. Margolis KL, Nichol KL, Wuorenma J, et al. Exporting a successful influenza vaccination program from a teaching hospital to a community outpatient setting. J Am Geriatr Soc. 1992;40:1021-1023.
7. Nichol KL, Korn JE, Margolis KL, et al. Achieving the national health objective for influenza immunization: success of an institution-wide vaccination program. Am J Med. 1990;89:156-160.
8. Goebel LJ, Neitch SM, Mufson MA. Standing orders in an ambulatory setting increases influenza vaccine usage in older people. J Am Geriatr Soc. 2005;53:1008-1010.
9. Christy C, McConnochie KM, Zernik N, et al. Impact of an algorithm-guided nurse intervention on the use of immunization opportunities. Arch Pediatr Adolesc Med. 1997;151:384-391.
10. Kharbanda EO, Maehr J, Middleman AB, et al. Influenza vaccine: a position statement of The Society for Adolescent Medicine. J Adolesc Health. 2007;41:216-217.
11. Vaccine-preventable diseases: improving vaccination coverage in children adolescents and adults. A report on recommendations from the Task Force on Community Preventive Services. MMWR Recomm Rep. 1999;48(RR-8):1-15.
12. Harper SA, Fukuda K, Uyeki TM, et al. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2004;53 (RR-6):1-40.
RESULTS ARE MIXED. Studies of standing orders tend to examine their effect on compliance with preventive interventions for chronic disease rather than disease outcomes. In the ambulatory setting, they improve rates of influenza vaccination (strength of recommendation [SOR]: C, consistent cohort studies measuring vaccination rates), pneumococcal vaccination (SOR: C, consistent randomized controlled trials [RCTs] measuring vaccination rates), childhood immunizations (SOR: C, inconsistent RCTs measuring vaccination rates), and mammograms (SOR: C, RCT measuring screening rate).
Standing orders don’t improve screening rates for colorectal cancer (SOR: C, RCT measuring screening rate).
Evidence summary
Organizational changes in physician offices can improve delivery of services for preventing and controlling disease.1 Standing orders—typically defined as physician-approved protocols that authorize nurses or other staff members to perform procedures, such as immunizations without direct physician involvement1—are readily applicable in ambulatory settings. However, only 30% of physicians use standing orders in their practices.2
Research on standing orders in ambulatory care has focused on immunizations and cancer screening (TABLE). Interventions implementing standing orders typically have multiple components and include staff education, chart flow sheets, and recall-reminders for patients.
TABLE
Effect of standing orders in ambulatory practice
| Disease | Standing order | Improvement in vaccination or screening rate | NNT* |
|---|---|---|---|
| Pneumococcal disease3-5 | Pneumococcal vaccine | Baseline range: 5%-15%; Follow-up range: 25%-28.3% | 3.7-10 |
| Influenza6-8 | Influenza vaccine | Baseline range: 32%-51.4%; Follow-up range: 58%-74.6% | 3.8-4.3 |
| Cancer screening3 | Mammogram | Baseline: 33%; Follow-up: 60% | 3.7 |
| Childhood illnesses9 | Immunizations, ages 2-5 yr | Baseline: 14%; Follow-up: 29% | 6.7 |
| *Number needed to treat (NNT) is based on the number of additional patients who receive an intervention based on the number who may be exposed to the standing order. | |||
Improvement in pneumococcal and flu vaccine rates
Three multicomponent RCTs of outpatient standing orders reported improved pneumococcal vaccination rates.3-5 Similarly, 2 prospective, multicomponent cohort studies6,7 and 1 retrospective study8 found improved rates of influenza vaccination with standing orders.
Childhood vaccination rates also show positive trends
Two controlled trials (1 randomized3 and 1 nonrandomized9) that incorporated standing orders examined their use in childhood immunizations (measles, mumps, and rubella [MMR]; oral polio vaccine [OPV]; Haemophilus influenzae, type b [HIB]; diphtheria and tetanus toxoids with acellular pertussis [DTaP]; and hepatitis B). One trial reported increased use of acute care immunization opportunities;9 the other showed a nonsignificant positive trend in vaccination rates.3
Standing orders increase 1 form of cancer screening, not another
A multicomponent RCT of standing orders for mammography and colorectal cancer screening found a statistically significant increase in screening for mammography, but not colorectal cancer.3
Recommendations
The Society of Adolescent Medicine recommends standing orders for administration of influenza vaccine during flu season.10
The Task Force on Community Preventive Services recommends standing orders for adult vaccinations based on “strong evidence,” but states that insufficient evidence exists to recommend standing orders for childhood vaccinations.11 Vaccines examined include MMR, DTaP, HIB, hepatitis B, and varicella for young children; hepatitis B, varicella, MMR, and tetanus-diphtheria toxoids (Td) for adolescents; Td for adults up to 65 years of age; and influenza and pneumococcal vaccines for adults 65 years and older.
The Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention recommends standing orders for influenza and pneumococcal vaccines.12
RESULTS ARE MIXED. Studies of standing orders tend to examine their effect on compliance with preventive interventions for chronic disease rather than disease outcomes. In the ambulatory setting, they improve rates of influenza vaccination (strength of recommendation [SOR]: C, consistent cohort studies measuring vaccination rates), pneumococcal vaccination (SOR: C, consistent randomized controlled trials [RCTs] measuring vaccination rates), childhood immunizations (SOR: C, inconsistent RCTs measuring vaccination rates), and mammograms (SOR: C, RCT measuring screening rate).
Standing orders don’t improve screening rates for colorectal cancer (SOR: C, RCT measuring screening rate).
Evidence summary
Organizational changes in physician offices can improve delivery of services for preventing and controlling disease.1 Standing orders—typically defined as physician-approved protocols that authorize nurses or other staff members to perform procedures, such as immunizations without direct physician involvement1—are readily applicable in ambulatory settings. However, only 30% of physicians use standing orders in their practices.2
Research on standing orders in ambulatory care has focused on immunizations and cancer screening (TABLE). Interventions implementing standing orders typically have multiple components and include staff education, chart flow sheets, and recall-reminders for patients.
TABLE
Effect of standing orders in ambulatory practice
| Disease | Standing order | Improvement in vaccination or screening rate | NNT* |
|---|---|---|---|
| Pneumococcal disease3-5 | Pneumococcal vaccine | Baseline range: 5%-15%; Follow-up range: 25%-28.3% | 3.7-10 |
| Influenza6-8 | Influenza vaccine | Baseline range: 32%-51.4%; Follow-up range: 58%-74.6% | 3.8-4.3 |
| Cancer screening3 | Mammogram | Baseline: 33%; Follow-up: 60% | 3.7 |
| Childhood illnesses9 | Immunizations, ages 2-5 yr | Baseline: 14%; Follow-up: 29% | 6.7 |
| *Number needed to treat (NNT) is based on the number of additional patients who receive an intervention based on the number who may be exposed to the standing order. | |||
Improvement in pneumococcal and flu vaccine rates
Three multicomponent RCTs of outpatient standing orders reported improved pneumococcal vaccination rates.3-5 Similarly, 2 prospective, multicomponent cohort studies6,7 and 1 retrospective study8 found improved rates of influenza vaccination with standing orders.
Childhood vaccination rates also show positive trends
Two controlled trials (1 randomized3 and 1 nonrandomized9) that incorporated standing orders examined their use in childhood immunizations (measles, mumps, and rubella [MMR]; oral polio vaccine [OPV]; Haemophilus influenzae, type b [HIB]; diphtheria and tetanus toxoids with acellular pertussis [DTaP]; and hepatitis B). One trial reported increased use of acute care immunization opportunities;9 the other showed a nonsignificant positive trend in vaccination rates.3
Standing orders increase 1 form of cancer screening, not another
A multicomponent RCT of standing orders for mammography and colorectal cancer screening found a statistically significant increase in screening for mammography, but not colorectal cancer.3
Recommendations
The Society of Adolescent Medicine recommends standing orders for administration of influenza vaccine during flu season.10
The Task Force on Community Preventive Services recommends standing orders for adult vaccinations based on “strong evidence,” but states that insufficient evidence exists to recommend standing orders for childhood vaccinations.11 Vaccines examined include MMR, DTaP, HIB, hepatitis B, and varicella for young children; hepatitis B, varicella, MMR, and tetanus-diphtheria toxoids (Td) for adolescents; Td for adults up to 65 years of age; and influenza and pneumococcal vaccines for adults 65 years and older.
The Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention recommends standing orders for influenza and pneumococcal vaccines.12
1. Stone EG, Morton SC, Hulscher ME, et al. Interventions that increase use of adult immunization and cancer screening services: a meta-analysis. Ann Intern Med. 2002;136:641-651.
2. Nichol KL, Zimmerman R. Generalist and subspecialist physicians’ knowledge, attitudes, and practices regarding influenza and pneumococcal vaccinations for elderly and other high-risk patients: a nationwide survey. Arch Intern Med. 2001;161:2702-2708.
3. Mold JW, Aspy CA, Nagykaldi Z. Implementation of evidence-based preventive services delivery processes in primary care: an Oklahoma Physicians Resource/Research Network (OKPRN) study. J Am Board Fam Med. 2008;21:334-344.
4. Rhew DC, Glassman PA, Goetz MB. Improving pneumococcal vaccine rates. Nurse protocols versus clinical reminders. J Gen Intern Med. 1999;14:351-356.
5. Herman CJ, Speroff T, Cebul RD. Improving compliance with immunization in the older adult: results of a randomized cohort study. J Am Geriatr Soc. 1994;42:1154-1159.
6. Margolis KL, Nichol KL, Wuorenma J, et al. Exporting a successful influenza vaccination program from a teaching hospital to a community outpatient setting. J Am Geriatr Soc. 1992;40:1021-1023.
7. Nichol KL, Korn JE, Margolis KL, et al. Achieving the national health objective for influenza immunization: success of an institution-wide vaccination program. Am J Med. 1990;89:156-160.
8. Goebel LJ, Neitch SM, Mufson MA. Standing orders in an ambulatory setting increases influenza vaccine usage in older people. J Am Geriatr Soc. 2005;53:1008-1010.
9. Christy C, McConnochie KM, Zernik N, et al. Impact of an algorithm-guided nurse intervention on the use of immunization opportunities. Arch Pediatr Adolesc Med. 1997;151:384-391.
10. Kharbanda EO, Maehr J, Middleman AB, et al. Influenza vaccine: a position statement of The Society for Adolescent Medicine. J Adolesc Health. 2007;41:216-217.
11. Vaccine-preventable diseases: improving vaccination coverage in children adolescents and adults. A report on recommendations from the Task Force on Community Preventive Services. MMWR Recomm Rep. 1999;48(RR-8):1-15.
12. Harper SA, Fukuda K, Uyeki TM, et al. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2004;53 (RR-6):1-40.
1. Stone EG, Morton SC, Hulscher ME, et al. Interventions that increase use of adult immunization and cancer screening services: a meta-analysis. Ann Intern Med. 2002;136:641-651.
2. Nichol KL, Zimmerman R. Generalist and subspecialist physicians’ knowledge, attitudes, and practices regarding influenza and pneumococcal vaccinations for elderly and other high-risk patients: a nationwide survey. Arch Intern Med. 2001;161:2702-2708.
3. Mold JW, Aspy CA, Nagykaldi Z. Implementation of evidence-based preventive services delivery processes in primary care: an Oklahoma Physicians Resource/Research Network (OKPRN) study. J Am Board Fam Med. 2008;21:334-344.
4. Rhew DC, Glassman PA, Goetz MB. Improving pneumococcal vaccine rates. Nurse protocols versus clinical reminders. J Gen Intern Med. 1999;14:351-356.
5. Herman CJ, Speroff T, Cebul RD. Improving compliance with immunization in the older adult: results of a randomized cohort study. J Am Geriatr Soc. 1994;42:1154-1159.
6. Margolis KL, Nichol KL, Wuorenma J, et al. Exporting a successful influenza vaccination program from a teaching hospital to a community outpatient setting. J Am Geriatr Soc. 1992;40:1021-1023.
7. Nichol KL, Korn JE, Margolis KL, et al. Achieving the national health objective for influenza immunization: success of an institution-wide vaccination program. Am J Med. 1990;89:156-160.
8. Goebel LJ, Neitch SM, Mufson MA. Standing orders in an ambulatory setting increases influenza vaccine usage in older people. J Am Geriatr Soc. 2005;53:1008-1010.
9. Christy C, McConnochie KM, Zernik N, et al. Impact of an algorithm-guided nurse intervention on the use of immunization opportunities. Arch Pediatr Adolesc Med. 1997;151:384-391.
10. Kharbanda EO, Maehr J, Middleman AB, et al. Influenza vaccine: a position statement of The Society for Adolescent Medicine. J Adolesc Health. 2007;41:216-217.
11. Vaccine-preventable diseases: improving vaccination coverage in children adolescents and adults. A report on recommendations from the Task Force on Community Preventive Services. MMWR Recomm Rep. 1999;48(RR-8):1-15.
12. Harper SA, Fukuda K, Uyeki TM, et al. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2004;53 (RR-6):1-40.
Evidence-based answers from the Family Physicians Inquiries Network
Which asthma patients should get the pneumococcal vaccine?
ADULTS BETWEEN THE AGES OF 19 AND 64 YEARS who have chronic lung disease, including asthma, should get the vaccine, as should all patients 65 years and older (strength of recommendation [SOR]: C, consensus guidelines). Evidence doesn’t support routine vaccination of children with asthma or adults younger than 65 years who don’t have chronic lung disease to decrease asthma-related or pneumonia-related hospitalizations (SOR: B, 1 retrospective cohort study and 1 retrospective, case-controlled cohort study).
Evidence summary
A 5-year retrospective cohort study of 9170 patients evaluated the effect of pneumococcal vaccination on incidence and length of all-cause hospitalizations and hospitalizations related to respiratory and otorhinolaryngologic syndromes, including asthma and pneumonia.1 The vaccine was given to all patients older than 64 years (7834 patients [85%]) and any patient at risk for pneumococcal infection or complications, including patients with asthma, chronic obstructive pulmonary disease (COPD), bronchitis, chronic respiratory disease, cardiovascular disease, chronic renal failure, diabetes mellitus, immunodeficiency, and functional or anatomic asplenia (1336 patients [15%]).
The number of all-cause hospitalizations was reduced by 58% in patients who received the pneumococcal vaccine (relative risk [RR]=0.96; 95% confidence interval [CI], 0.94-0.98). In vaccinated patients with asthma (793 patients [8.7%]), asthma-related hospitalizations decreased by 78% (RR=1.82; 95% CI, 1.35-2.45; NNT=49) and average asthma-related length of hospital stay was shortened by about 2 days (P=.039). The study found no difference in pneumonia-related hospitalizations among all vaccinated patients.
Effect on younger patients is unclear
Because the investigators didn’t analyze asthma-related or pneumonia-related hospitalizations among asthmatic patients 64 years and younger, the effect of pneumococcal vaccination on this younger subgroup can’t be differentiated from the entire group of patients with asthma.1
What about pneumococcal hospitalization?
A retrospective, case-controlled cohort study examined the impact of pneumococcal vaccination on any pneumococcal-related hospitalization in patients with COPD or asthma.2 The study included 2746 adults with asthma (74.2% younger than 64 years) who were followed for about 2.1 years before and 2.6 years after vaccination.
Investigators found no significant differences in risk of pneumococcal-related hospitalization between asthma patients and controls throughout the study. They didn’t evaluate asthma-related hospital admissions.
Impact of vaccine on invasive disease in younger asthma patients?
A retrospective, nested, case-controlled study examined the relationship between asthma and invasive pneumococcal disease (IPD) in 6985 patients enrolled in Tennessee’s Medicaid program.3 Patients 2 to 49 years of age with any IPD diagnosis were identified using International Classification of Diseases (ICD-9-CM) codes and followed for 8 years.
Asthma patients without coexisting conditions that confer a high risk of IPD (such as diabetes, cardiac disease, and infection with human immunodeficiency virus) had a 14.7% risk of IPD compared with a risk of only 7.4% in age-matched controls (adjusted odds ratio=2.4; 95% CI, 1.7-3.4). The authors concluded that this Medicaid population with asthma had an increased incidence of IPD of 1 to 3 cases annually per 10,000 people. The effect of pneumococcal vaccination on the incidence of IPD in these younger asthma patients is unknown, however.3
Recommendations
The National Asthma Education and Prevention Program (NAEPP)4 and the Global Initiative for Asthma (GINA)5 make no recommendations regarding the administration of the pneumococcal vaccine.
The Advisory Committee on Immunization Practices (ACIP) recommends vaccination for all adults 65 years and older and adults 19 years and older with chronic lung disease, including asthma, or other chronic medical conditions such as cardiovascular diseases, diabetes, chronic liver diseases, chronic alcoholism, chronic renal failure, asplenia, and other immunocompromising conditions.6
The British Department of Health recommends vaccination with either the 7-valent conjugate or the 23-valent polysaccharide pneumococcal vaccine for all asthma patients taking systemic steroids longer than 1 month at a dose equivalent to prednisolone 20 mg daily and for children weighing less than 20 kg who take daily steroids at a dose of ≥1 mg/kg. Efficacy studies aren’t available to support this recommendation.7
1. Ansaldi F, Turello V, Lai P, et al. Effectiveness of a 23-valent polysaccharide vaccine in preventing pneumonia and non-invasive pneumococcal infection in elderly people: a large-scale retrospective cohort study. J Int Med Res. 2005;33:490-500.
2. Lee TA, Weaver FM, Weiss KB. Impact of pneumococcal vaccination on pneumonia rates in patients with COPD and asthma. J Gen Intern Med. 2007;22:62-67.
3. Talbot TR, Hartert TV, Mitchel E, et al. Asthma as a risk for invasive pneumococcal disease. N Engl J Med. 2005;352:2082-2090.
4. National Heart Lung and Blood Institute. Guidelines for the Diagnosis and Management of Asthma. Bethesda, Md: National Institutes of Health; 1991:11.
5. Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention. Available at: www.ginasthma.org/Guidelineitem.asp?l1=2&l2=1&intId=60. Accessed December 10, 2007.
6. Centers for Disease Control and Prevention. Recommended adult immunization schedule—United States, 2009. MMWR Morb Mortal Wkly Rep. 2008;57(53):Q1-Q4.
7. Department of Health. Immunisation Against Infectious Disease 2006: The Green Book. London, England: Department of Health; 2007. Available at: www.dh.gov.uk/en/Policyandguidance/Healthandsocialcaretopics/Greenbook/DH_4097254. Accessed December 10, 2007.
ADULTS BETWEEN THE AGES OF 19 AND 64 YEARS who have chronic lung disease, including asthma, should get the vaccine, as should all patients 65 years and older (strength of recommendation [SOR]: C, consensus guidelines). Evidence doesn’t support routine vaccination of children with asthma or adults younger than 65 years who don’t have chronic lung disease to decrease asthma-related or pneumonia-related hospitalizations (SOR: B, 1 retrospective cohort study and 1 retrospective, case-controlled cohort study).
Evidence summary
A 5-year retrospective cohort study of 9170 patients evaluated the effect of pneumococcal vaccination on incidence and length of all-cause hospitalizations and hospitalizations related to respiratory and otorhinolaryngologic syndromes, including asthma and pneumonia.1 The vaccine was given to all patients older than 64 years (7834 patients [85%]) and any patient at risk for pneumococcal infection or complications, including patients with asthma, chronic obstructive pulmonary disease (COPD), bronchitis, chronic respiratory disease, cardiovascular disease, chronic renal failure, diabetes mellitus, immunodeficiency, and functional or anatomic asplenia (1336 patients [15%]).
The number of all-cause hospitalizations was reduced by 58% in patients who received the pneumococcal vaccine (relative risk [RR]=0.96; 95% confidence interval [CI], 0.94-0.98). In vaccinated patients with asthma (793 patients [8.7%]), asthma-related hospitalizations decreased by 78% (RR=1.82; 95% CI, 1.35-2.45; NNT=49) and average asthma-related length of hospital stay was shortened by about 2 days (P=.039). The study found no difference in pneumonia-related hospitalizations among all vaccinated patients.
Effect on younger patients is unclear
Because the investigators didn’t analyze asthma-related or pneumonia-related hospitalizations among asthmatic patients 64 years and younger, the effect of pneumococcal vaccination on this younger subgroup can’t be differentiated from the entire group of patients with asthma.1
What about pneumococcal hospitalization?
A retrospective, case-controlled cohort study examined the impact of pneumococcal vaccination on any pneumococcal-related hospitalization in patients with COPD or asthma.2 The study included 2746 adults with asthma (74.2% younger than 64 years) who were followed for about 2.1 years before and 2.6 years after vaccination.
Investigators found no significant differences in risk of pneumococcal-related hospitalization between asthma patients and controls throughout the study. They didn’t evaluate asthma-related hospital admissions.
Impact of vaccine on invasive disease in younger asthma patients?
A retrospective, nested, case-controlled study examined the relationship between asthma and invasive pneumococcal disease (IPD) in 6985 patients enrolled in Tennessee’s Medicaid program.3 Patients 2 to 49 years of age with any IPD diagnosis were identified using International Classification of Diseases (ICD-9-CM) codes and followed for 8 years.
Asthma patients without coexisting conditions that confer a high risk of IPD (such as diabetes, cardiac disease, and infection with human immunodeficiency virus) had a 14.7% risk of IPD compared with a risk of only 7.4% in age-matched controls (adjusted odds ratio=2.4; 95% CI, 1.7-3.4). The authors concluded that this Medicaid population with asthma had an increased incidence of IPD of 1 to 3 cases annually per 10,000 people. The effect of pneumococcal vaccination on the incidence of IPD in these younger asthma patients is unknown, however.3
Recommendations
The National Asthma Education and Prevention Program (NAEPP)4 and the Global Initiative for Asthma (GINA)5 make no recommendations regarding the administration of the pneumococcal vaccine.
The Advisory Committee on Immunization Practices (ACIP) recommends vaccination for all adults 65 years and older and adults 19 years and older with chronic lung disease, including asthma, or other chronic medical conditions such as cardiovascular diseases, diabetes, chronic liver diseases, chronic alcoholism, chronic renal failure, asplenia, and other immunocompromising conditions.6
The British Department of Health recommends vaccination with either the 7-valent conjugate or the 23-valent polysaccharide pneumococcal vaccine for all asthma patients taking systemic steroids longer than 1 month at a dose equivalent to prednisolone 20 mg daily and for children weighing less than 20 kg who take daily steroids at a dose of ≥1 mg/kg. Efficacy studies aren’t available to support this recommendation.7
ADULTS BETWEEN THE AGES OF 19 AND 64 YEARS who have chronic lung disease, including asthma, should get the vaccine, as should all patients 65 years and older (strength of recommendation [SOR]: C, consensus guidelines). Evidence doesn’t support routine vaccination of children with asthma or adults younger than 65 years who don’t have chronic lung disease to decrease asthma-related or pneumonia-related hospitalizations (SOR: B, 1 retrospective cohort study and 1 retrospective, case-controlled cohort study).
Evidence summary
A 5-year retrospective cohort study of 9170 patients evaluated the effect of pneumococcal vaccination on incidence and length of all-cause hospitalizations and hospitalizations related to respiratory and otorhinolaryngologic syndromes, including asthma and pneumonia.1 The vaccine was given to all patients older than 64 years (7834 patients [85%]) and any patient at risk for pneumococcal infection or complications, including patients with asthma, chronic obstructive pulmonary disease (COPD), bronchitis, chronic respiratory disease, cardiovascular disease, chronic renal failure, diabetes mellitus, immunodeficiency, and functional or anatomic asplenia (1336 patients [15%]).
The number of all-cause hospitalizations was reduced by 58% in patients who received the pneumococcal vaccine (relative risk [RR]=0.96; 95% confidence interval [CI], 0.94-0.98). In vaccinated patients with asthma (793 patients [8.7%]), asthma-related hospitalizations decreased by 78% (RR=1.82; 95% CI, 1.35-2.45; NNT=49) and average asthma-related length of hospital stay was shortened by about 2 days (P=.039). The study found no difference in pneumonia-related hospitalizations among all vaccinated patients.
Effect on younger patients is unclear
Because the investigators didn’t analyze asthma-related or pneumonia-related hospitalizations among asthmatic patients 64 years and younger, the effect of pneumococcal vaccination on this younger subgroup can’t be differentiated from the entire group of patients with asthma.1
What about pneumococcal hospitalization?
A retrospective, case-controlled cohort study examined the impact of pneumococcal vaccination on any pneumococcal-related hospitalization in patients with COPD or asthma.2 The study included 2746 adults with asthma (74.2% younger than 64 years) who were followed for about 2.1 years before and 2.6 years after vaccination.
Investigators found no significant differences in risk of pneumococcal-related hospitalization between asthma patients and controls throughout the study. They didn’t evaluate asthma-related hospital admissions.
Impact of vaccine on invasive disease in younger asthma patients?
A retrospective, nested, case-controlled study examined the relationship between asthma and invasive pneumococcal disease (IPD) in 6985 patients enrolled in Tennessee’s Medicaid program.3 Patients 2 to 49 years of age with any IPD diagnosis were identified using International Classification of Diseases (ICD-9-CM) codes and followed for 8 years.
Asthma patients without coexisting conditions that confer a high risk of IPD (such as diabetes, cardiac disease, and infection with human immunodeficiency virus) had a 14.7% risk of IPD compared with a risk of only 7.4% in age-matched controls (adjusted odds ratio=2.4; 95% CI, 1.7-3.4). The authors concluded that this Medicaid population with asthma had an increased incidence of IPD of 1 to 3 cases annually per 10,000 people. The effect of pneumococcal vaccination on the incidence of IPD in these younger asthma patients is unknown, however.3
Recommendations
The National Asthma Education and Prevention Program (NAEPP)4 and the Global Initiative for Asthma (GINA)5 make no recommendations regarding the administration of the pneumococcal vaccine.
The Advisory Committee on Immunization Practices (ACIP) recommends vaccination for all adults 65 years and older and adults 19 years and older with chronic lung disease, including asthma, or other chronic medical conditions such as cardiovascular diseases, diabetes, chronic liver diseases, chronic alcoholism, chronic renal failure, asplenia, and other immunocompromising conditions.6
The British Department of Health recommends vaccination with either the 7-valent conjugate or the 23-valent polysaccharide pneumococcal vaccine for all asthma patients taking systemic steroids longer than 1 month at a dose equivalent to prednisolone 20 mg daily and for children weighing less than 20 kg who take daily steroids at a dose of ≥1 mg/kg. Efficacy studies aren’t available to support this recommendation.7
1. Ansaldi F, Turello V, Lai P, et al. Effectiveness of a 23-valent polysaccharide vaccine in preventing pneumonia and non-invasive pneumococcal infection in elderly people: a large-scale retrospective cohort study. J Int Med Res. 2005;33:490-500.
2. Lee TA, Weaver FM, Weiss KB. Impact of pneumococcal vaccination on pneumonia rates in patients with COPD and asthma. J Gen Intern Med. 2007;22:62-67.
3. Talbot TR, Hartert TV, Mitchel E, et al. Asthma as a risk for invasive pneumococcal disease. N Engl J Med. 2005;352:2082-2090.
4. National Heart Lung and Blood Institute. Guidelines for the Diagnosis and Management of Asthma. Bethesda, Md: National Institutes of Health; 1991:11.
5. Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention. Available at: www.ginasthma.org/Guidelineitem.asp?l1=2&l2=1&intId=60. Accessed December 10, 2007.
6. Centers for Disease Control and Prevention. Recommended adult immunization schedule—United States, 2009. MMWR Morb Mortal Wkly Rep. 2008;57(53):Q1-Q4.
7. Department of Health. Immunisation Against Infectious Disease 2006: The Green Book. London, England: Department of Health; 2007. Available at: www.dh.gov.uk/en/Policyandguidance/Healthandsocialcaretopics/Greenbook/DH_4097254. Accessed December 10, 2007.
1. Ansaldi F, Turello V, Lai P, et al. Effectiveness of a 23-valent polysaccharide vaccine in preventing pneumonia and non-invasive pneumococcal infection in elderly people: a large-scale retrospective cohort study. J Int Med Res. 2005;33:490-500.
2. Lee TA, Weaver FM, Weiss KB. Impact of pneumococcal vaccination on pneumonia rates in patients with COPD and asthma. J Gen Intern Med. 2007;22:62-67.
3. Talbot TR, Hartert TV, Mitchel E, et al. Asthma as a risk for invasive pneumococcal disease. N Engl J Med. 2005;352:2082-2090.
4. National Heart Lung and Blood Institute. Guidelines for the Diagnosis and Management of Asthma. Bethesda, Md: National Institutes of Health; 1991:11.
5. Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention. Available at: www.ginasthma.org/Guidelineitem.asp?l1=2&l2=1&intId=60. Accessed December 10, 2007.
6. Centers for Disease Control and Prevention. Recommended adult immunization schedule—United States, 2009. MMWR Morb Mortal Wkly Rep. 2008;57(53):Q1-Q4.
7. Department of Health. Immunisation Against Infectious Disease 2006: The Green Book. London, England: Department of Health; 2007. Available at: www.dh.gov.uk/en/Policyandguidance/Healthandsocialcaretopics/Greenbook/DH_4097254. Accessed December 10, 2007.
Evidence-based answers from the Family Physicians Inquiries Network