Overcoming Challenges to Influenza Vaccination in Patients With CKD

Volume 54, Issue 1, Pages 6-9 (July 2009)

Overcoming Challenges to Influenza Vaccination in Patients With CKD

Alexander J. Kallen, MD, MPHCorresponding Author Informationemail address, Anthony E. Fiore, MD

Refers to article:
Decreased Antibody Response to Influenza Vaccination in Kidney Transplant Recipients: A Prospective Cohort Study , 30 January 2009
Kelly A. Birdwell, Mine R. Ikizler, Edith C. Sannella, Li Wang, Daniel W. Byrne, T. Alp Ikizler, Peter F. Wright
American Journal of Kidney Diseases
July 2009 (Vol. 54, Issue 1, Pages 112-121)
Abstract | Full Text | Full-Text PDF (457 KB) | Add-Ons
Immunogenicity of a Standard Trivalent Influenza Vaccine in Patients on Long-term Hemodialysis: An Open-Label Trial , 02 April 2009
Johan Scharpé, Willy E. Peetermans, Johan Vanwalleghem, Bart Maes, Bert Bammens, Kathleen Claes, André D. Osterhaus, Yves Vanrenterghem, Pieter Evenepoel
American Journal of Kidney Diseases
July 2009 (Vol. 54, Issue 1, Pages 77-85)
Abstract | Full Text | Full-Text PDF (301 KB)
Association of Standing-Order Policies With Vaccination Rates in Dialysis Clinics: A US-Based Cross-sectional Study , 06 April 2009
T. Christopher Bond, Priti R. Patel, Jenna Krisher, Leighann Sauls, Jan Deane, Karen Strott, Shelley Karp, William McClellan
American Journal of Kidney Diseases
July 2009 (Vol. 54, Issue 1, Pages 86-94)
Abstract | Full Text | Full-Text PDF (289 KB) | Add-Ons
Article Outline

• Acknowledgment

• References

• Copyright

Related Articles, pp. 77, 86, and 112

The prevention of infectious diseases in vulnerable populations, including patients with chronic kidney disease (CKD), is an important goal for clinicians and public health practitioners alike. Influenza, which is responsible for an estimated annual average of 226,000 excess influenza-related hospitalizations and 36,000 influenza-related deaths in the United States, is a prime example of a preventable infectious disease that has a significant public health burden.1, 2 CKD is among the comorbid conditions that confer an increased risk of influenza complications.3, 4 As a result, influenza vaccine is 1 of 3 vaccines (along with hepatitis B vaccine and pneumococcal polysaccharide vaccine) currently recommended for patients with CKD by the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC).5 In addition, the Centers for Medicare & Medicaid Services also considers influenza vaccination as a component of the quality assessment and performance improvement process in end-stage renal disease facilities.6

In observational studies, influenza vaccination is associated with decreased risk of influenza-related hospitalizations, deaths, and physician visits.7, 8 More specific to dialysis patients, Gilbertson et al,9 using data from the US Renal Data System (USRDS), showed that receipt of influenza vaccination was associated with decreased risk of hospitalization or death in a cohort of patients with end-stage renal disease.

In this issue, 2 clinical trials provide updated information about the immunogenicity of inactivated influenza vaccine in different groups of patients with CKD. Scharpé et al10 found that a high percentage of hemodialysis patients developed seroprotective levels of antibodies (defined as antibody titers ≥1:40 using the hemagglutinin inhibition [HI] test) to the influenza A (H1N1) virus (81.1%), influenza A (H3N2) virus (87.1%), and influenza B virus (86.4%) components of the vaccine, a rate similar to that in healthy controls. In addition, many patients had high HI titers even before vaccination, possibly from previous infections or vaccination during prior influenza seasons.

Other studies have found lower levels of immune response after influenza vaccination in patients undergoing hemodialysis. For example, Vogtlander et al11 found that significantly fewer hemodialysis patients than healthy staff members reached an HI titer of 1:40 or greater after influenza vaccination. Research has also suggested that the efficacy of influenza vaccine for clinical outcomes may be lower for patients with high-risk conditions, including CKD.12

In a second article, Birdwell et al13 found that the percentage of kidney transplant recipients developing an HI titer greater than 1:32 or having a 4-fold increase in HI titer after influenza vaccination was lower than the percentage of healthy adults who did so, particularly those within 6 months of transplantation. In this study, the percentage of patients who developed HI titers greater than 1:32 ranged from 70% for the influenza A (H3N2) and influenza A (H1N1) antigens to 86% for the influenza B antigen. Previous studies have shown that higher titers correlate with protection against influenza; however, the level of protection against influenza provided by lower HI titers is not clear.14

The results of these 2 studies are encouraging and provide additional evidence that annual influenza vaccination provides most patients with CKD with protection against influenza. However, in light of inconsistent data about influenza vaccine immunogenicity in patients on hemodialysis therapy and lower antibody responses in patients who have recently received a kidney transplant, clinicians caring for these patients must continue to consider the possibility of influenza in both vaccinated and unvaccinated patients with CKD with respiratory illness during influenza season. In addition, in certain situations or for certain patients, such as those who have recently received a transplant, consideration could be given to short-term prophylactic influenza antiviral medications after a discrete exposure or during influenza outbreaks when the influenza strains represented in the vaccine are not well matched to circulating viruses.15 Health care personnel (HCP) and family members who have regular contact with patients with CKD, particularly patients with a recent transplant, should be reminded consistently that reducing these patients' chances for exposure to influenza by vaccinating contacts is a critical component of influenza prevention efforts.

The encouraging news about vaccine immunogenicity for patients with CKD is tempered in this issue with additional evidence that levels of vaccination are less than stated targets. Healthy People 2010, an outline of national public health goals for 2010, has set 90% as its goal for the percentage of high-risk patients vaccinated against influenza.16 According to data from the USRDS, only about half the patients with end-stage renal disease were immunized against influenza from 2002 (54%) to 2007 (57%).17 In this issue, Bond et al,18 in their survey of vaccination practices in 3 networks, found greater rates of vaccination with influenza vaccine; an average of 76% across all centers. This is an improvement over previously documented levels; however, the reason for the difference is not clear. It may be related to differences in methods used to capture the data, different years of study, or differences in the facilities contributing data. In addition, to be included in the analysis of Bond et al,18 a facility had to meet several requirements, including completing a survey about vaccination and reporting the vaccination status of their patients. These requirements may have increased the proportion receiving vaccination by eliminating facilities that may be less rigorous about vaccination or less willing to report their information. In addition, this study took place in the context of an initiative designed to increase rates of vaccination. The levels of vaccination reported by Bond et al18 appear to be a positive step toward reaching the goals established in Healthy People 2010.

Bond et al18 note in their survey of vaccination beliefs that more than 95% of responding facilities reported that they believed influenza vaccine to be safe and important. Because influenza vaccination is widely viewed as necessary to prevent the excess morbidity and mortality associated with this disease, mechanisms are needed to facilitate vaccination. To improve vaccination rates, the ACIP has recommended the use of standing orders programs, in which nurses and pharmacists, where allowed by state law, are authorized to assess the immunization status of patients and administer vaccinations according to preapproved protocols without the need for a physician's examination or direct order at the time of vaccination.19 These programs have been associated with increased levels of vaccination in long-term care and inpatient settings.20, 21 However, it is possible that diversity among facilities makes a “one-size-fits-all” approach less effective than tailoring vaccination efforts to specific settings. In 2005, the CDC Task Force on Community Preventive Services reviewed methods to improve vaccination in high-risk adults.22 The Task Force recommended a broader approach to promoting vaccination by using 1 or more interventions from 3 separate intervention categories (Table 1). Although Bond et al18 found that influenza vaccination percentages did not vary significantly by the system used to order vaccination, it is interesting to note that most facilities reported some systematic method for offering influenza vaccination and only 10% of facilities required individual physician orders, perhaps the most cumbersome option, for a patient to receive influenza vaccination. In addition, although the article describes facility self-reports of the use of standing orders programs, assessment of how well the programs were implemented is not included.
Table 1.

Interventions to Increase Vaccination in High-Risk Populations

   Category   Examples
   Interventions to enhance access   Providing convenient access
      Reducing cost associated with vaccination
   Provider- or system-based interventions   Standing orders programs
      Reminder systems for providers
   Interventions to increase client demand   Reminder systems for clients
      Education programs


Adapted from the Centers for Disease Control and Prevention.22

Another important aspect of influenza prevention is the vaccination of HCP. Vaccination of HCP has been shown to decrease HCP absenteeism,23 transmission of influenza in health care settings,24, 25 and influenza-related morbidity and mortality in high-risk patients.24, 25 The percentage of HCP who are vaccinated has increased since 1989 from only about 10% to approximately 40%, a level that is still less than the Healthy People 2010 goal of 60%.26 A large number of barriers to HCP vaccination has been identified, including the misconception that the vaccine can cause influenza and the belief that the purpose of vaccination is to protect HCP and not their patients.26, 27 A number of interventions have been recommended to improve rates of HCP vaccination, including educational campaigns, using senior staff as role models, measuring rates of vaccination, and providing feedback to staff about levels of vaccination.26 However, ultimately, vaccination to protect vulnerable patients is a responsibility that all HCP need to take seriously.

If influenza vaccine is immunogenic, safe, and effective for the majority of patients with CKD, what needs to be done to further improve levels of vaccination in these patients and HCP? Understanding why some of these patients and many HCP are not being vaccinated is important because different reasons may require different solutions. Is vaccination simply not being recommended? If so, developing systematic ways to provide and encourage vaccinations may be useful. Are patients and staff refusing to be vaccinated? If so, educational interventions and incentives may be more important. More work is needed to understand these issues and develop and compare strategies for vaccination.
Acknowledgements
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The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. One coauthor (P. Patel) of 1 of the articles described in this report is a member of the same Division at the Centers for Disease Control and Prevention as Dr Kallen.

Financial Disclosure: None.
References
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Centers for Disease Control and Prevention, Atlanta, Georgia

Corresponding Author InformationAddress correspondence to Alexander J. Kallen, MD, MPH, 1600 Clifton Rd, MS A-35, Atlanta, GA 30333

PII: S0272-6386(09)00637-4

doi:10.1053/j.ajkd.2009.04.007

http://www.ajkd.org/article/PIIS0272638609006374/fulltext