Pneumococcal Vaccination in Nursing Homes

LETTERS TO THE EDITOR Pneumococcal Vaccination in Nursing Homes To the Editor: Once more we find that recommended strategies (with proven benefits) are underused in nursing home (NH) residents. This time, Marsteller et al1 have assessed the underuse of pneumococcal vaccination (PV) in American NHs using data from the National Nursing Home Surveys. The evaluation of 14,782 residents showed that only 27% of black residents and 34% of white residents were known to have ever received PV. Known that the highest mortality rates and acute care transfers of NH residents are related to pneumonia, and that the American and European regulatory agencies recommend NH residents to receive PV, one would expect to see higher rates of PV.2,3 We recently performed a study in French NHs assessing 4896 residents. The main aim of this cross-sectional survey was to identify major health problems in NHs to promote clinical research in this specific population and improve quality of care.4 A functional network, called REHPA (Recherche en Etablissements d’He´bergement pour Personnes Age´es) was established between the 240 participating NHs and the Geriatric Department of the Toulouse University Hospital to enhance future research in the specific NH community. One of the conclusions obtained was a selective underuse of specific treatments and preventive strategies like vaccinations with huge facility-based differences. Even if the French Regulatory Agency promotes the use of primary preventive strategies, enhancing the use of both PV and influenza vaccinations, the prevalence of residents receiving PV was as low as 13% (compared with the prevalence of influenza vaccination of 90%). The main issue that arises in the view of the present results is to know the reasons for the existing disparity of prevalence in 2 preventive strategies (that are equally recommended), the existing facility-based disparity (differences in prevalence from 0% to 100%), and the consistency and similarity of the results across Europe and the United States. In order to overcome these results, we can evoke 2 domains of intervention: 1. It could be that medical directors, in order to improve quality of care, need more specific studies on NH residents assessing the specific issues that are not present in the community-dwelling elderly population. Only by proving the benefits of treatments and prevention strategies in NH residents might we convince the NH health carers to change actual trends of underuse of preventive strategies. 2. As the results seemed facility based, there is an actual need for education and training in the field of preventive strategies. Specific training programs for NH health carers, based on the proven benefits of these strategies for NH residents, might increase the knowledge and the prescriptions. JAMDA – May 2009

In France, REHPA could enhance this research and provide evidence coming directly from NH field trials to suggest the areas where more research, education, or training is needed. Gabor Abellan van Kan, MD Department of Geriatric Medicine Toulouse University Hospital Toulouse, France Stephan Gerard, MD Department of Geriatric Medicine Toulouse University Hospital Toulouse, France Yves Rolland, MD, PhD Department of Geriatric Medicine Toulouse University Hospital INSERM U-558 University Toulouse III Toulouse, France Bruno Vellas, MD, PhD Department of Geriatric Medicine Toulouse University Hospital INSERM U-558 University Toulouse III Toulouse, France REFERENCES 1. Marsteller JA, Tiggle RB, Remsburg RE, et al. Pneumococcal vaccination in nursing homes: Does race make a difference? J Am Med Dir Assoc 2008; 9:641–647. 2. Centers for Disease Control and Prevention. Prevention of pneumococcal disease: Recommendations of the Advisory Committee on Vaccination Practices (ACIP). MMWR Morb Mortal Wkly Rep 1997;46:1–24. 3. Rapport du Comite´ technique des vaccinations (CTV) et du CSHPF. Conduite a` tenir devant des cas groupe´s d’infections invasives a` pneumocoque dans une collectivite´ (CSHPF: 14 janvier 2005-CTV :12 mai 2005). Available at: http://www.sante.gouv.fr/htm/dossiers/cshpf/a_mt_140105_ pneumo_collect.pdf. Accessed December 10,2008. 4. Rolland Y, Hermabessiere S, Abellan van Kan G, et al. REHPA: Research in nursing home residents. J Nutr Health and Aging 2009. In press.

DOI:10.1016/j.jamda.2008.12.054

Broken Ribs Following CPR or the Heimlich Maneuver To the Editor: I recently encountered a case that included a painful broken rib following the unnecessary application of the Heimlich maneuver. A 90-year-old female with congestive heart failure, prior deep venous thrombosis, and osteoporosis had a syncopal episode with loss of consciousness while eating breakfast. The episode was preceded by nausea and LETTERS TO THE EDITOR 283