New Developments in Adult Vaccination: Challenges and Opportunities to Protect Vulnerable Veterans From Pneumococcal Disease

From the perspective of clinical providers, an additional pneumococcal vaccine complicating the vaccination schedule for adults represents an increased burden. Providers will need information to reach their own conclusions regarding the rationale behind the development and use of pneumococcal conjugate vaccines, the existing and evolving recommendations from public health authorities, and the strengths and limitations of the evidence supporting the use of pneumococcal vaccines. Otherwise, providers may find it difficult to incorporate new data and guidelines supporting pneumococcal vaccination into their decision-making (Boxes 1-4). An additional and formidable challenge is to carve out time during an already busy clinical encounter to discuss pneumococcal vaccines and other immunizations.³⁶

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Similarly, older adults or patients with chronic health conditions may not recognize the important role that vaccines can play in their health maintenance and are likely to prioritize other issues during medical visits. It is not obvious for patients that multiple vaccines may be necessary to prevent pneumococcal disease. Furthermore, many patients, not unreasonably, may assume that their yearly influenza vaccine is sufficiently protective against pneumonia. Therefore, patients need to be educated about the rationale behind pneumococcal conjugate vaccination. Ultimately, access to immunization—the opportunity for patients to have an encounter with their providers and with the health care system that results in the administration of an appropriate vaccine—will determine whether goals for pneumococcal vaccination are achieved.

The evolving landscape for the implementation of pneumococcal vaccines creates the need to develop, implement, and refine organizational changes to adhere to the new guidelines for the use of PCV-13 and PPSV-23 vaccines. These interventions, if effective, may help improve pneumococcal vaccination coverage among adults (Table 3).

Harnessing the Power of the EMR

Interventions to improve the adherence to pneumococcal vaccination guidelines begin by identifying persons eligible for vaccination based on their age, their vaccination status (ie, persons previously unvaccinated or due for vaccination according to the recommended schedule), or the presence of medical conditions conferring high risk for pneumococcal disease. This, in turn, depends on adequate documentation of patients’ underlying medical diagnosis, as well as up-to-date records of vaccine administration to patients.

Health care systems possessing a mature and sophisticated electronic medical record (EMR), such as the VHA Computerized Patient Record System (CPRS), are in a good position to wield such information to plan, implement, and assure the quality of activities designed to improve pneumococcal vaccination rates. An analysis of the proportion of veterans in VISN 10 who received pneumococcal vaccination revealed that even with the advantages of a robust EMR and a highly developed infrastructure devoted to primary care, pneumococcal vaccine coverage remains below the 60% target goal, although well above national averages (Figure 2).^37,38

Standing Orders

Standing orders make it possible for nurses and pharmacists to administer vaccines according to a preestablished protocol without a physician’s direct evaluation of each patient. Standing orders are a versatile intervention, with a record of effective implementation in both outpatient and inpatient facilities, in acute-care and long-term care facilities, and in most instances where patients interact with the health care system. Based on strong scientific evidence, ACIP recommends the adoption of standing-order programs to improve pneumococcal vaccination rates among adults.³⁹ Indeed, standing-order programs may prove a very effective intervention to fulfill the recommendation to administer PCV-13 to adults aged > 65 years.

The Virtual Vaccination Clinic

Unfortunately, with 2 vaccines that have to be administered at different times to various groups of patients at risk, the current state of pneumococcal vaccination may be too complex to be readily reduced to a comprehensible set of standing orders. An innovative way to realize the benefit of standing orders is to target high-risk groups for pneumococcal disease who are eligible for vaccination by selecting them using the EMR and entering standing orders tailored to their specific vaccination needs. The selection of patients according to comorbidities and vaccination status and the determination of the appropriate pneumococcal vaccine takes place in the context of a “virtual” vaccination clinic.⁴⁰

Enhancing Vaccinations


Further improvement in pneumococcal vaccination rates are likely to result from interventions that increase the demand for vaccines among patients and practitioners. Efforts to disseminate information and provide advice regarding pneumococcal vaccination are likely to result in patients seeking and clinicians offering the appropriate vaccine. Similarly, interventions to enhance the supply of vaccines at the point of care may reduce barriers that patients might encounter when attempting to receive vaccinations.

Another set of system-based interventions that can assist clinicians in making timely and appropriate vaccination decisions are EMR reminders, especially those targeting patients at high risk for pneumococcal disease because of underlying illnesses.⁴¹ Previous experience with pneumococcal vaccination in patients aged > 65 years indicates that EMR reminders facilitate improvements in vaccination. The involvement of a panel manager who coordinated with the primary care provider and contacted patients directly augmented the effect of the EMR reminder by 25%.⁴²