Pneumonia is a common disorder, with 4 to 5 million cases diagnosed each year in the United States, with approximately one quarter of patients requiring hospitalization (Papadakis et al., 2019). In the United States, pneumonia is the most common cause of hospital admission for adults (American Thoracic Society, 2018). For adults aged ≥65 years, hospitalization for pneumonia has a higher risk of death compared to any of the other top 10 reasons for hospitalization (American Thoracic Society, 2018). Pneumococcal pneumonia is the deadliest infectious disease in the United States and the eighth leading cause of death (Papadakis et al., 2019).
There are more than 100 pathogens known to cause pneumonia, including viruses, bacteria, and fungi (Centers for Disease Control and Prevention [CDC], 2018a). The most common bacterial pathogen is Streptococcus pneumoniae, which accounts for more than one third of all adult cases (CDC, 2018a). Risk factors for the development of pneumonia include advanced age, alcohol or tobacco use, and comorbid medical conditions, especially asthma, chronic obstructive pulmonary disease, and immunosuppression (Papadakis et al., 2019). To protect against pneumococcal pneumonia, adults aged ≥65 years should receive the pneumococcal conjugate vaccine (PCV13, Prevnar-13®) and the pneumococcal polysaccharide vaccine (PPSV23, Pneumovax23®) (CDC, 2018b).
Pneumonia has a 19.44% higher readmission rate in the Veterans Affairs Health System when compared to non–Veterans Affairs hospitals (Nuti et al., 2016). Mitigating the burden of pneumonia, especially in the wake of novel SARS-CoV-2, is important for the longevity of the health care system (Mendelson, 2020). Considering risk factors such as advanced age and comorbidities, the Veteran population is ideal to target for prevention of this deadly infection.
The intent of the current review is to explore the extent to which pneumonia impacts Veterans and potential benefits of the pneumococcal vaccination in this population. Organizational strategies to increase pneumococcal vaccination in Veterans should prove to be cost effective and decrease disease burden in a vulnerable population.
The current integrative review was conducted to explore strategies to increase pneumococcal vaccination in Veterans and was completed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for reporting systematic reviews (Moher et al., 2009). Covidence was used as evidence synthesis software. A systematic review of the literature was conducted using the following databases and the assistance of a medical librarian: CINAHL, PubMed, and Embase. The search strategy included a combination of medical subject headings (MeSH) keywords and related terms including “pneumococcal vaccine” OR “Pneumovax” AND “veteran” OR “veterans' health.” Related key words in titles and abstracts (ti/ab) were also included. Review of titles and abstracts was a single, non-blinded review. The search was limited with the following inclusion criteria: (a) article must be in the English language; (b) consist of Veterans aged ≥18 years; and (c) the article must not be older than 10 years. Exclusion criteria included full-text non availability and articles not peer reviewed. Further, articles excluded did not contain Veterans as the primary population focus or were the same study with a different title.
In total, 50 articles were considered for review after duplicates were removed. Sixteen full-text articles were assessed for eligibility, and nine were selected for final analysis. The search results are reflected in the PRISMA flow chart (Figure 1).
PRISMA flow diagram (Moher et al., 2009) of literature search and article inclusion.
Nine studies published between 2010 and 2019 were included in the final analysis. The Johns Hopkins Nursing Evidence-Based Practice model was used to evaluate the quality and strength of the articles (Dang & Dearholt, 2017). The nine articles selected were appraised as Levels III–V with quality ratings of A, B, or C. Study designs were primarily retrospective reviews, quality improvement initiatives, and case control studies. Four studies examined pneumococcal infection in adult inpatients, four studies assessed adult outpatients, and one study explored a quality improvement initiative for internal medicine residents (Table A, available in the online version of this article).
The primary theme that emerged from the evidence was the relationship between pneumococcal vaccination and Veterans with comorbid conditions (Case et al., 2015; Li et al., 2015; Morton et al., 2017; Wu et al., 2014). Of patients in the studies, 88.9% had at least one comorbid condition for which pneumococcal vaccination was indicated (Rueda et al., 2010). Risk of developing pneumococcal disease was shown to be highest in adults aged ≥65 years; immunocompromised individuals; and those with chronic illnesses including diabetes, chronic lung disease, and alcoholism (Morton et al., 2017). In individuals with comorbid conditions, pneumococcal vaccination was seen as a protective factor (Case et al., 2015; Li et al., 2015; Morton et al., 2017; Wu et al., 2014). In fact, two studies demonstrated statistically significant decreases in 1-year morbidity and mortality rates after receipt of pneumococcal vaccination (Case et al., 2015; Wu et al., 2014). In patients with heart failure, patients who received pneumococcal and influenza vaccinations demonstrated a 10% reduction in hospital length of stay (Wu et al., 2014).
A secondary theme described barriers to outpatient vaccination (Burns et al., 2018; Jindracek & Stark, 2018; Jolin et al., 2018; Wilson et al., 2019). Barriers included failure to offer pneumococcal vaccination during primary care visits (Jindracek & Stark, 2018), inability to document vaccinations received outside the facility (Jolin et al., 2018), lack of a streamlined workflow, and too much time wasted during the encounter (Wilson et al., 2019). The primary determinants of successful vaccination of Veterans with comorbid conditions were clinicians' knowledge of vaccine recommendations and vigilance following the guidelines (Case et al., 2015).
A third theme explored the spectrum of pneumococcal disease in Veterans (Jindracek & Stark, 2018; Rueda et al., 2010). The majority of patients were diagnosed with pneumonia during winter (Rudea et al., 2010). In fact, 66.2% of cases were diagnosed during a 5-month period, December through April (Rueda et al., 2010). There was also an increase of pneumococcal vaccinations during influenza season, often even administered concomitantly (Jindracek & Stark, 2018). Finally, African American patients were found to be at statistically significantly higher risk of developing pneumococcal pneumonia than White patients (Rueda et al., 2010).
Evidence supports the use of pneumococcal vaccination in adults with comorbidities and decreased overall mortality risk (Case et al., 2015; Li et al., 2015; Morton et al., 2017; Wu et al., 2014). Currently, there is a deficit in pneumococcal vaccination rates among Veterans (Performance Measures Report, 2019). The themes drawn from this sample of evidence can be used to guide current practice and direct future research.
Pneumococcal vaccination is a protective factor in adults with comorbid conditions (Case et al., 2015; Li et al., 2015; Morton et al., 2017; Wu et al., 2014). Outpatient clinic processes should support discussion of comorbid conditions, their impacts on morbidity and mortality, and the protection pneumococcal vaccination provides. The evidence recommends strict adherence to pneumococcal vaccination consensus guidelines (Case et al., 2015; Jindracek & Stark, 2018).
Identifying reasons for not following consensus guidelines is important for developing vaccination initiatives. The literature suggests that patients failed to receive indicated vaccinations due to lack of guideline awareness, failure to offer the vaccination (Jindracek & Stark, 2018), and lack of a streamlined workflow (Wilson et al., 2019). Educational initiatives would be beneficial if targeted toward those with direct patient influence (e.g., providers, nurses, medical assistants). Primary care clinics would benefit from a culture that emphasizes routine vaccinations and supports educational initiatives on consensus guidelines.
The evidence demonstrates the continued need for primary care providers to serve as active proponents for vaccination (Burns et al., 2018; Case et; al., 2015; Jindracek & Stark, 2018). One study found that of the 63% of eligible patients who did not receive PCV13, the main barrier was failure to offer the vaccination during the primary care visit (Jindracek & Stark, 2018). Specialty care providers also agree that the responsibility of vaccination should rest within the primary care office (Case et al., 2015). Due to the increase of pneumococcal vaccination during winter months, often concomitantly with the influenza vaccination (Jindracek & Stark, 2018), it is beneficial to provide staff with education to administer at any visit, when indicated. Future research exploring initiatives to increase awareness of vaccination guidelines in primary care is needed.
The current review has several limitations. The sample size was limited as few studies address vaccination strategies among Veterans. Among the nine articles analyzed, none were randomized controlled trials, suggesting the need for more rigorous research. Studies presented were also limited by demographics and only included the Veteran population, so generalizability to the U.S. population as a whole is limited.
The purpose of the current integrative review was to explore strategies to increase pneumococcal vaccination in Veterans. Pneumococcal disease causes significant morbidity and mortality, especially in older adults with comorbid conditions. Pneumococcal vaccination serves as a protective factor in these patients. Particularly considering the recent SARS-CoV-2 pandemic, pneumococcal vaccination may lessen the burden on primary care providers and potentially decrease hospital admission. Most of the studies reviewed are less rigorous, so conclusions should be drawn cautiously. However, results of this review suggest future process improvements should include staff education regarding administration of the pneumococcal vaccination and review of consensus guidelines.
- American Thoracic Society. (2018). Top 20 pneumonia facts. https://www.thoracic.org/patients/patient-resources/resources/top-pneumonia-facts.pdf
- Burns, C. M., Banks, R. E., Wilson, B. M., Carter, R. R., Jump, R. L. P. & Perez, F. (2018). A virtual clinic improves pneumococcal vaccination coverage among patients living with HIV at a veterans affairs medical center. AIDS Care, 30(2), 146–149 doi:10.1080/09540121.2017.1390542 [CrossRef] PMID:29052434
- Case, D. J., Copeland, L. A., Stock, E. M., Herrera, H. R. & Pfanner, T. P. (2015). Pneumococcal vaccination rates in VHA patients with inflammatory bowel disease. Medicine, 94(6), e417 doi:10.1097/MD.0000000000000417 [CrossRef] PMID:25674731
- Centers for Disease Control and Prevention. (2018a). Causes of pneumonia. https://www.cdc.gov/pneumonia/causes.html
- Centers for Disease Control and Prevention. (2018b). Pneumonia can be prevented— Vaccines can help. https://www.cdc.gov/pneumonia/prevention.html
- Dang, D. & Dearholt, S. L. (2017). Johns Hopkins nursing evidence-based practice: Model and guidelines (3rd ed.). Sigma Theta Tau International.
- Jindracek, L. & Stark, J. E. (2018). Identifying missed opportunities for the pneumococcal conjugate vaccine (PCV13). The Journal of Pharmacy Technology, 34(1), 24–27 doi:10.1177/8755122517740364 [CrossRef]
- Jolin, J., van Aalst, R., Volpp, B., Taylor, T. & Cohen, E. (2018). Using an inpatient quality improvement curriculum for internal medicine residents to improve pneumococcal conjugate vaccine administration rates. Joint Commission Journal on Quality and Patient Safety, 44(6), 328–333 doi:10.1016/j.jcjq.2017.12.005 [CrossRef] PMID:29793882
- Li, C., Gubbins, P. O. & Chen, G. J. (2015). Prior pneumococcal and influenza vaccinations and in-hospital outcomes for community-acquired pneumonia in elderly veterans. Journal of Hospital Medicine, 10(5), 287–293 doi:10.1002/jhm.2328 [CrossRef] PMID:25676363
- Mendelson, M. (2020). Could enhanced influenza and pneumococcal vaccination programs help limit the potential damage from SARS-CoV-2 to fragile health systems of southern hemisphere countries this winter?International Journal of Infectious Diseases, 94, 32–33 doi:10.1016/j.ijid.2020.03.030 [CrossRef] PMID:32194236
- Moher, D., Liberati, A., Tetzlaff, J. & Altman, D. G.the PRISMA Group. (2009). Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. PLoS Medicine, 6(7), e1000097 doi:10.1371/journal.pmed.1000097 [CrossRef] PMID:19621072
- Morton, J. B., Morrill, H. J., LaPlante, K. L. & Caffrey, A. R. (2017). Predictors of mortality among U.S. veterans with streptococcus pneumoniae infections. American Journal of Preventive Medicine, 52(6), 769–777 doi:10.1016/j.amepre.2016.10.023 [CrossRef] PMID:27988089
- Nuti, S. V., Qin, L., Rumsfeld, J. S., Ross, J. S., Masoudi, F. A., Normand, S.-L. T., Murugiah, K., Bernheim, S. M., Suter, L. G. & Krumholz, H. M. (2016). Association of admission to veterans affairs hospitals vs non-veterans affairs hospitals with mortality and readmission rates among older men hospitalized with acute myocardial infarction, heart failure, or pneumonia. Journal of the American Medical Association, 315(6), 582–592 doi:10.1001/jama.2016.0278 [CrossRef] PMID:26864412
- Papadakis, M. A., McPhee, S. J. & Rabow, M. W. (2019). Current medical diagnosis and treatment. McGraw-Hill Education.
- Rueda, A. M., Serpa, J. A., Matloobi, M., Mushtaq, M. & Musher, D. M. (2010). The spectrum of invasive pneumococcal disease at an adult tertiary care hospital in the early 21st century. Medicine, 89(5), 331–336 doi:10.1097/MD.0b013e3181f2b824 [CrossRef] PMID:20827110
- Wilson, J., Swee, M., Mosher, H., Scott-Cawiezell, J., Levins, L., Fort, K. & Kumar, B. (2020). Using lean six sigma to improve pneumococcal vaccination rates in a veterans affairs rheumatology clinic. Journal for Healthcare Quality, 42(3), 166–174 doi:10.1097/jhq.0000000000000218 [CrossRef] PMID:31385855
- Wu, W.-C., Jiang, L., Friedmann, P. D. & Trivedi, A. (2014). Association between process quality measures for heart failure and mortality among US veterans. American Heart Journal, 168(5), 713–720 doi:10.1016/j.ahj.2014.06.024 [CrossRef] PMID:25440800
Table of Evidence
|Article Number||Author and Date||Evidence Type||Sample, Sample Size, Setting||Key Findings||Observable Measures||Limitations||Evidence Level, Quality|
|1||Burns et. al., 2017||Prospective Cohort Study||99 Veterans living with HIV in Ohio
Increased vaccination rates after inception of virtual clinic
Relationship between a virtual clinical and vaccination rates in HIV (+) Veterans
Outcome was vaccination with the recommended pneumococcal vaccination within the 180- day observation period
Relatively small cohort at a single VA medical center
Level V, Quality B
|2||Case et. al., 2015||Cross-Sectional Study||All VHA patients over 18 diagnosed with Inflammatory Bowel disease
One-year mortality was lower for those vaccinated for pneumonia relative to the unvaccinated
|Pneumococcal vaccination in patients with IBD and the relationship of 1-year mortality rates|
Reliance on administrative extracts of the electronic health records system
Lack of clinical notes
Inability to capture out-of-system vaccinations
Level III, Quality A
|3||Jindracek et. al., 2017||Retrospective Review||150 outpatient Veterans age 65 or older who did not receive PCV13 at their primary care appointment, VA primary care system in Arkansas
Most common barrier was that the vaccine was not offered (92%), or patient declined vaccination (6.7%)
Even with a clinical reminder, only 37% of patients received indicated vaccination
Examines barriers to patients not receiving PCV13 when otherwise indicated
Single VA outpatient center
Level III, Quality A
|4||Jolin et. al., 2018||Quality Improvement Study||16 internal medicine residents at a VA Medical Center in White River Junction, Vermont
The percentage of veterans discharged with an up-to-date PCV13 vaccination on discharge increased from approximately 30% to 87% and was sustained.
Does a QI curriculum for inpatient medical residents improve PCV13 vaccination rates?
Small cohort at a single VA medical center
Multiple handoffs of the curriculum
Level V, Quality C
|5||Li et. al., 2015||Retrospective cohort study||6,723 elderly Veterans admitted for CAP between October 1, 2003 and September 20, 2003
Lower risk of bacteremia was associated with prior PV (odds ratio: 0.66; 95% confidence interval [CI]: 0.48–0.90).
The association of prior PV and/or FV with inpatient mortality and length of stay (LOS) (primary) and risk of any bacteremia and respiratory complications (secondary) were assessed
Almost exclusively male population (98%)
Cases were identified based on primary case of pneumonia, secondary cases may have been misidentified
Those hospitalized despite prior vaccinations may have more serious disease and/or be less responsive to vaccinations compared to unvaccinated
Level V, Quality A
|6||Morton et. al., 2017||Case control study|
Unvaccinated older Veterans (>50 years of age) admitted to Veterans Affairs medical centers from 2002 to 2011 with serious pneumococcal infections (n=9468)
Among adults >50 years with serious pneumococcal disease, mortality risk increased approximately 55% as vaccination indications present increased.
In addition to conditions already identified by ACIP, this study also revealed several other predictors of mortality that are not current recommendations for pneumococcal vaccination. These included neurologic disorders, fluid or electrolyte disorders, chronic pressure ulcers, and MRSA or Gram-negative infections. In particular, patients with neurologic disorders, including seizure disorders, multiple sclerosis, Parkinson disease, and ataxia, warrant consideration
This study identified independent predictors of 30-day all- cause mortality among unvaccinated adults aged 50 years and older with serious pneumococcal disease.
Study did not account for resistant S. pneumoniae isolates or the impact of antibiotic treatment on 30-day mortality.
The number of cases of pneumonia identified likely underestimates the actual number of cases, as the inclusion criteria for this study required both a diagnosis code and positive sputum culture.
It is possible that some patients did not report vaccinations received outside the VHA
Level IV, Quality A
|7||Rueda et. al., 2010||Retrospective cohort study|
136 Adult cases with a diagnosis of invasive pneumococcal disease at the VA Medical Center in Houston, TX (n=136)
Recommends the use of broader- spectrum conjugate pneumococcal vaccines13 or non- capsule-based vaccines for high risk populations
PPV23 alone is not fully protective
Examined the spectrum of pneumococcal disease at one tertiary care center
All patients who may have had invasive pneumococcal disease did not have blood cultures, so true numbers of patients with invasive pneumococcal disease may have been higher
Retrieval of cases in the first 2 years of the study were not as thorough as the last 7 years
Level III, Quality B
|8||Wilson et. al., 2019||Quality Improvement Initiative|
Large, midwestern VA Rheumatology Clinic
Adult outpatients seen in the rheumatology clinic (n=1,298)
Vaccination administration time decreased from 15 minutes to 7 minutes
Only 1 patient refused vaccination
Provider education led to the greatest increase in vaccination rates, but these improvements were transient.
Increase to 23% vaccination rate from 0%
Used Lean Six Sigma process to improve pneumococcal vaccination rates, goal of 70%
Single center intervention of one clinic
Intervention only lasted for 2 months, so unable to meet goal vaccination rate
Level V, Quality B
|9||Wu et. al., 2014||Retrospective Cohort Study|
107,045 patients with heart failure treated at 128 VHA hospitals (n=107,045)
|Inpatient/outpatient receipt of pneumococcal or influenza vaccinations were related to lower risks of 30-day and/or 1-year mortality (adjusted odds ratios 0.51–0.77 for vaccinations).|
Assessed the relationship between receipt of each HF care process and death at 30 days (inpatients only) and 1 year (all patients)
Sample size was predominantly male, so may not apply to women with heart failure
Receipt of care processes was not randomly assigned
Level III, Quality A