https://orcid.org/0000-0003-1334-6783
ABSTRACT
Pneumococcal vaccination is recommended for chronic kidney disease (CKD) patients. We evaluated the impact of implementing a hospital vaccine consultation on their vaccination coverages. A sample was drawn from consecutive cases referred to our clinic between November 2014 and June 2018. 101 patients were analyzed: 4 had received the pneumococcal conjugated vaccine 13-valent at the time of the first appointment, whereas 93 had received it after being seen (RR (95%-CI) = 23.3 (8.88–60.85)). Moreover, 5 had received the pneumococcal polysaccharide vaccine 23-valent at the time of the first appointment, whereas 90 had received it after being seen (RR (95%-CI) = 18.0 (7.64–42.42)). Implementing a hospital-based vaccine consultation represents an effective intervention to improve pneumococcal vaccination coverage in these patients.
Introduction
Chronic kidney disease (CKD) patients have a 6.0–26.1 times higher risk of developing invasive pneumococcal disease (IPD) than the general population.Citation1 Therefore, internationalCitation2,Citation3 and nationalCitation4 organizations recommend vaccinating those at greatest risk (stage 4–5 CKD according to the KDIGO – Kidney Disease Initiative Global Outcomes – guidelinesCitation3) with a dose of pneumococcal conjugated vaccine 13-valent (PCV13)Citation2–4 and at least a dose of pneumococcal polysaccharide vaccine 23-valent (PPSV23).Citation2–4 However, the reported pneumococcal vaccination coverage in these patients in various countries, such as the United States, Citation5,Citation6 the United Kingdom, Citation7 and Germany, Citation8 is less than ideal, ranging from 5.7%Citation8 to 49.2%.Citation6
In Spain, this coverage was evaluated in patients with stage 4–5 CKD attended in primary care, and the vaccination rate was found to be 2.2% for PPSV23 and 2.2% for PCV13.Citation9 These results show that improvement interventions must be developed. One of the suggested measures to increase the vaccination rate is the implementation of recruitment strategies.Citation9
This research was carried out to evaluate the impact of implementing a hospital vaccine consultation on pneumococcal vaccination coverage in patients with CKD.
Materials and methods
A before/after type quasi-experimental study without a control groupCitation10 was carried out at the University Clinical Hospital of Zaragoza (UCHZ). This public hospital have 808 beds and it provides care to the 294,000 people living in Health Sector III of Aragon (Spain).
Until October 2014, patients with stage 4–5 CKD were vaccinated only in primary care. In November 2014, the UCHZ Preventive Medicine Service included these patients in its consultation for adult vaccines in risk groups. The following activities were carried out for this purpose: (a) the two Nephrology Services of our sector were invited to refer these patients for an assessment of their pneumococcal vaccination status, together with their vaccination status for and/or immunity to hepatitis B; (b) the pneumococcal vaccination program was confirmed with the Nephrology Services according to the recommendations of the Spanish Ministry of Health:Citation11 a dose of PCV13 is followed by a dose of PPSV23 at least 8 weeks later (patients vaccinated with PPSV23 before PCV13 require a minimum interval of 12 months between the two vaccines); after this, booster doses of PPSV23 is recommended at least five years after the first dose of this vaccine ;Citation11 (c) information was provided on the reasons to be vaccinated and the risks/benefits, and an individualized evaluation of the indication was undertaken according to the vaccination history of the patient, interactions, and contraindications; (d) a clinical report on vaccination was prepared and made available on the intranet of the Health Service of Aragon; and (e) a general clinical session was delivered in the hospital to disseminate information on our vaccine consultation to health professionals, affecting the vaccination program for patients with CKD.
A sample was drawn from consecutive cases of all patients with stage 4–5 CKD referred to our clinic for evaluation of their vaccination status between 1 November 2014 and 30 June 2018. The inclusion criteria were belonging to Health Sector III of Aragon and a diagnosis of stage 4–5 CKD before November 2013. The exclusion criterion was death during the period for which the administration of the vaccination program was planned.
Vaccine coverage at the time of the assessment appointment in our practice was compared with coverage after patients were attended in our practice. The chi-square test or Fisher’s exact test was used for the comparison; as a reference, figures were taken starting from the date of the first appointment. To quantify the magnitude of the associations, we calculated the Relative Risk (RR) with its 95% confidence interval (95%-CI).
The level of statistical significance considered was p < .05, and the statistical analysis program used was SPSS v25.0.
Results
Of the 101 patients who met the selection criteria, none of them had received a dose of PCV13 and at least one dose of PPSV23 at the time of their first appointment. After patients were attended at our clinic, 90 patients (89.1%) had received a dose of PCV13 and at least one dose of PPSV23 (p = .000) ().
Table 1. Vaccination coverage by type of vaccine and group
Discussion
This is the first study to analyze the impact of implementing hospital consultation regarding vaccines on pneumococcal vaccination coverage in patients with stage 4–5 CKD. A significant improvement was observed.
The observed increases in vaccine coverage after patients were attended in our consultation are greater than those described by other authors who carried out other types of improvement interventions. For example, DuvalCitation12 increased vaccination rates with PPSV23 by only 11.0 percentage points (from 54.5% to 65.5%) in dialysis patients after a project that provided training activities to patients to improve their acceptance of vaccines, in addition to providing training to healthcare personnel to improve their participation in quality improvement activities. KasperCitation13 reported that assessing candidates for kidney transplantation in an infectious disease consultation increased the receipt of both types of pneumococcal vaccines by up to 29 percentage points (from 4% to 33%).
The increase in coverage in this study exceeds that documented in CKD patients in other nationalCitation9 and international studies, Citation5–8,Citation12,Citation13 as well as those recently described in Spain in other patient groups for which vaccination against pneumococcus is recommended (such as cochlear implant carriers, with vaccination rates of 48.6%Citation14). Despite the promising results achieved, room and opportunities for improvement remain. Therefore, new actions must be developed, such as calling patients to remind them of their appointments, as this could help to minimize absenteeism in our practice and therefore improve vaccination coverage.Citation15 It is also necessary to develop future research in order to analyze the factors associated with non-vaccination, with the aim of being able to influence them and further improve vaccination coverage.
This work has some limitations. First, the sample size was not calculated beforehand, which may have contributed to relatively inaccurate results (with wide confidence intervals); however, our study was powerful enough to detect statistically significant differences. Second, limitations are derived from the design (a before/after type quasi-experimental study without a control group).
Our research shows that implementing a hospital-based vaccine consultation for patients, including people with stage 4–5 CKD, represents a useful and effective organizational strategy to improve their pneumococcal vaccination coverage, thereby reducing the risk of IPD.
Disclosure of potential conflicts of interest
Authors have no competing interests to declare.
Additional information
Funding
References
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