Main findings of this study
Our results show that uptake of influenza vaccine among care homes with nursing in the Nottingham area is relatively high at 84%. The uptake of pneumococcal vaccine in the same care homes is however much lower. Moreover, our study suggests that homes with a policy for pneumococcal vaccination have higher uptake of the vaccine.
For influenza, the level of uptake in Nottingham's care homes is consistent with previous studies among the UK care home population which report coverage of 81–85% [
3,
5,
7], and represents a considerable improvement from the 39.6% uptake reported in Nottingham's care homes in 1992–1993 [
8]. It is reassuring that the reported influenza vaccine shortage of 2005/6 due to enhanced demand as a result of increased public awareness of pandemic influenza does not appear to have adversely affected uptake, in our study population or nationally [
9]. The upward trends observed in vaccine coverage are encouraging [
10], and have no doubt have been helped by financial incentives to GPs through the Quality and Outcomes Framework and locally enhanced service payments. Nevertheless further improvement would promote herd immunity amongst this vulnerable population, where rapid spread is likely to follow introduction of infection, and lead to high morbidity and mortality[
9].
As found by previous studies pneumococcal vaccination rates amongst our study population were low [
5,
11]. Although a number of studies have made recommendations for improving vaccine uptake in care homes, including joint policies between GPs and care homes [
8], organised vaccine delivery strategies [
5], and developing guidelines for care homes [
12], no UK intervention studies to increase pneumococcal vaccine uptake in care homes were identified from the published literature. One study in Trent found that educational outreach visits to 15 general practices were associated with a significant increase in pneumococcal, but not influenza vaccine uptake amongst high risk groups compared to controls. Whether this effect was sustained beyond the 6 month study period is unknown [
11]. A study of 133 long term care facilities in North America used a number of interventions including 'standing orders' (whereby nurses or pharmacists are authorised to administer vaccinations according to a pre-approved protocol), to increase pneumococcal vaccination rates from 40% to 75% [
13]. Likewise, in Canada a pharmacist-centred standing orders intervention increased pneumococcal vaccine uptake among residents in the two care homes studied from 4.2% to 83% and from 1.9% to 83% [
14]. As a result, the Centres for Disease Control and Prevention now recommend that standing orders be used in all long term care facilities [
15]. In view of the fact that Nottingham care home residents appear to be vaccinated by practice staff rather than nursing home staff, it is unclear whether these benefits are generalisable to the UK.
As would perhaps be expected from previous North American research [
16], the care homes in this study which had written policies for vaccination, had a higher vaccine uptake than homes which did not have such policies in place. In the case of pneumococcal vaccine this association was statistically significant on multivariate analysis. This may be a reflection of the quality of the care home and the importance placed on infection control procedures, equally it may be that policy directly affects uptake [
17].
Smaller homes had higher influenza uptake than did larger homes (see table
1) although the opposite was true for pneumococcal vaccine. It seems plausible that smaller homes might find it easier to ensure vaccination of its residents although our study may not be large enough to demonstrate this. We found that homes served by more than 5 GPs had higher pneumococcal vaccine uptake than those served by 5 or fewer (Table
1). As it would be more intuitive to suppose that homes served by fewer practices may have better uptake, this association may be due to chance, or alternatively there may be some other confounding factor involved, such as care home location.
Standards for care homes are currently enforced by the Commission for Social Care Inspection (CSCI), through a system of both planned and ad-hoc inspections. Currently, although their remit does include infection control, information pertaining to vaccine uptake and vaccination policy do not form part of such inspections. In view of the fact that our study and others suggest many long term care facilities still lack adequate policies to ensuring both residents and staff immunity against vaccine preventable diseases, perhaps this should be a consideration [
1,
5].
Failure to keep adequate records, particularly for pneumococcal vaccine which is required only once in a lifetime, often means that the vaccination status of an individual is unclear. Although vaccination is advocated in the event of uncertain vaccine status [
18], and although this may be desirable in improving vaccine uptake, the decision is not always straightforward due to the relatively high incidence of adverse reactions following repeat vaccinations [
19]. Although only one third of homes in our study kept a register of pneumococcal vaccination we did not find this to be associated with uptake.
Difficulty in obtaining consent in the care home setting where cognitive impairment is relatively common can be a barrier to vaccine uptake; indeed only 2 of the care homes we surveyed reported that they would vaccinate without expressed consent. Despite the potentially negative impact upon vaccine uptake, the alternative practice of vaccination without consent or by assuming tacit consent is ethically questionable [
20,
21]. Care home policy should therefore stipulate that consent for vaccinations should be obtained from residents, or their family if necessary, at the time of admission. This may minimise the likelihood that lack of consent will later act as a barrier to vaccination.
This study is, to the best of our knowledge, the first to report the uptake of pneumococcal vaccine in care homes with nursing following the extension of the UK pneumococcal immunisation programme to include people over 65 years of age. It shows that while influenza vaccine rates seem to be improving among care home residents, pneumococcal vaccine uptake remains low. This study also highlights the fact that most care homes in the Nottingham area do not have vaccination policies in place. This study supports the role of such policies and shows a positive association between having such a policy and vaccine uptake in the case of pneumococcal vaccine.