Guidelines for Prevention of Pneumococcal Disease in Long Term Care Facilities

Code of Maryland Regulations
Recommendations for Long Term Care Facilities

I. Introduction

Recent outbreaks of pneumococcal pneumonia in long term care facilities in the United States, including Maryland, have reinforced the need for pneumococcal vaccination in populations at risk of complications of Streptococcus pneumoniae. Several points are worth noting:

S. pneumoniae infections are among the leading causes of illness and death for persons who have underlying debilitating medical conditions and the elderly.
Because of their age and underlying health problems, nursing home residents are at high risk for developing serious complications or dying when they contract pneumococcal disease.
Because residents in long term care facilities are in close proximity to one another, S. pneumoniae can be passed among residents and staff.
Pneumococcal disease occurs most frequently during the winter months, both as a primary infection or as a secondary infection following an influenza infection.
S. pneumoniae has become increasingly resistant to penicillin and other commonly used antibiotics. This makes infections caused by this organism increasingly hard to treat. (Additional information about drug resistant Streptococcus pneumoniae can be found in the Morbidity and Mortality Weekly Report 1996; 45 No. RR-1: 1-20).

Therefore, prevention through proper immunization with pneumococcal vaccine is critical. The Advisory Committee on Immunization Practices (ACIP) recommends that the vaccine be administered to all persons 65 years or older and to any individual at increased risk of getting pneumococcal disease. ACIP recommendations for the use of pneumococcal vaccine can be found in the MMWR, Volume 38, No. 5, p. 64-68, 1989 (Attachment 5).

II. Code of Maryland Regulations

Code of Maryland Regulations (COMAR) 10.06.01.12-1 Pneumococcal Disease requires that residents of long term care facilities be vaccinated with pneumococcal vaccine. Residents' physicians shall educate the individual or the individual's legal guardian on the availability of the vaccine and administer the vaccine to a consenting individual who has no contraindications. The physician may refer the individual to another health care provider to administer the vaccine. Facilities are not the group that must comply with this regulation; the regulation requires the attending physician to educate and administer or refer the resident for pneumococcal immunization.

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Code of Maryland Regulations (COMAR) 10.06.01.12-1 Pneumococcal Disease requires the following: .

12-1 Pneumococcal Disease

A. There is no control of a case or contacts.

B. Vaccination of an Individual at Risk.

An individual at increased risk of pneumococcal disease includes an individual:

With anatomic or functional asplenia;
With sickle cell disease;
With human immunodeficiency virus infection;
With chronic heart, lung, liver, or renal disease;
With diabetes mellitus;
Who is 65 years old or older; or
Who is a resident of a long-term care facility.

A physician in attendance upon an individual at increased risk of pneumococcal disease shall:

Educate that individual or the individual's legal guardian on the availability of pneumococcal vaccine; and
Administer pneumococcal vaccine to a consenting individual who has no contraindications and who is at increased risk of pneumococcal disease, or refer the individual to a health care provider who has agreed to administer pneumococcal vaccine to an individual at increased risk of pneumococcal disease.

III. Recommendations for Long Term Care Facilities

Assure vaccination with 23-valent pneumococcal vaccine of all residents of long term care facilities. If the vaccination status is unknown to the facility, vaccinate the resident after obtaining appropriate consent.
- Survey your residents, their families or guardians, and/or their charts to assess which residents have had pneumococcal vaccine and which residents need vaccine
- Obtain consent from those residents who are able to give consent. If the resident is unable to give consent, send a letter to family or guardian with information about pneumococcal disease, asking them for vaccine status, and request permission to administer pneumococcal vaccine. You could include an Important Information Statement (IIS) about pneumococcal disease and the vaccine. (See sample letter, questionnaire, and IIS, Attachments 1, 2, and 3). If there is no response from the family, the medical director should order the vaccination.

Document in residents' chart the pneumococcal vaccine status, including the date administered (either date of past history of vaccination or the date when it is given at the facility), or declination for vaccination. (See Vaccine Administration Record, Attachment 4).
Assure that attending physicians comply with the Maryland regulation by establishing policies and procedures to accomplish pneumococcal vaccination on admission and on your current resident population.
Determine the agent(s) responsible for causing pneumonia in residents of your facility. This may require contacting the hospital if the information from a resident's hospitalization does not come back to the facility (especially if the resident died). Clearly, agents such as Legionella, Mycobacterium tuberculosis, and S. pneumoniae have different implications for control in your facility.
Report outbreaks of respiratory illness of any cause, with or without pneumonia to your local health department.

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Maryland's local health departments, the Epidemiology and Disease Control Program (410-767-6677) and the Licensing and Certification Administration (410-764-2770) of the Department of Health and Mental Hygiene are ready to provide consultation and assistance as needed.

We hope that these recommendations and materials will be helpful in your efforts to ensure that your attending physicians comply with the requirements of Code of Maryland Regulations 10.06.01.12-1 or in establishing policies of your own.

Download Attachment 2 in PDF format
Download Sample letter