Background/Purpose: Immunosuppressive agents have changed the course of debilitating autoimmune conditions. Despite their advantages, these agents come with risk of vaccine preventable infections.¹ Multiple organizations recommend scheduled influenza and pneumococcal vaccinations in all patients on chronic immunosuppression.^2,3

Clarity regarding indication and timing of vaccinations has been problematic as new biologic therapies enter clinical practice. A 1996 Medicare survey of 16,000 patients on biologics showed a common reason for low adherence is not knowing the indications or vaccine schedules.⁵ While physician specialists often initiate biologic therapy, primary care physicians typically have more access to vaccines. As a result, according to the Center for Disease Control (CDC) in 2014, vaccination adherence remains low amongst high-risk persons aged 19-64 years.⁴

In an outpatient primary care setting, we implemented a protocolized vaccination program for patients on immunosuppressive medications to increase influenza and pneumococcal vaccination adherence by at least 15% for each vaccine. 

Methods: A retrospective, chart analysis identified 756 patients on biologic agents in Internal Medicine and Rheumatology practices. From this population, each patient was evaluated for compliance with CDC guidelines for immunocompromised patients for Influenza, Pneumococcal 13-Valent Conjugate and Pneumococcal Polyvalent vaccines. After data was collected, each practice received educational outreach and resources to serve as reminders to improve vaccination adherence. After the completion of the subsequent influenza season, the same patients were reviewed to obtain adherence data after the intervention. 

Results: Of the patients studied, a majority of patients 65.2% (n=493) had rheumatoid arthritis, 19.6% had psoriatic arthritis, 7.0% had ankylosing spondylitis, and 8.1% had other conditions. The most common medications used were etanercept (35.5%, n=268) and adalimumab (35.1%, n=265). Prior to the educational program, 62.0% (n=469) received influenza vaccinations, 34.0% (n=257) received pneumococcal 13-valent conjugate and 51.9% (n=392) received pneumococcal 23 vaccination. After the program, 65.1% (n=487) received influenza, 49.9% received pneumococcal 13-valent conjugate and 59.8% (n=447) received pneumococcal 23 vaccine. Overall, adherence to vaccination schedule increased from 18.9% (n=143) to 29.9% (n=224). 

Conclusion: Patients on biologic therapies remain vulnerable to vaccine preventable illnesses such as Pneumococcal Pneumonia and Influenza. Based on our quality improvement initiative, there was an increase in overall vaccination adherence by 11% (n=81) in an at risk patient population. Despite this, inadequate resources and communication issues still remained an obstacle for primary care providers and specialists. In response to feedback from clinicians, a vaccination clinic is being developed in order to improve access to patients requiring vaccinations. Additionally, we have been working to optimize our best practice alert advisory through EMR, to improve communication between providers for our at risk population.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/practice-based-education-program-to-increase-vaccination-rate-in-patients-on-immunotherapeutic-agents/