Pneumococcal and Herpes Zoster Vaccination Rates Among U.S. Veterans With Chronic Inflammatory Disease on Biologic Medications: A Quality Improvement Project

Introduction: Patients with chronic inflammatory diseases are often treated with pharmacologic therapies that target the immune system and have an increased risk of infection. These risks can be reduced by vaccination against common pathogens. This quality improvement project aimed to increase pneumococcal and herpes zoster vaccination rates in patients with chronic inflammatory disease on biologic immunosuppressive therapy.

Materials and methods: This quality improvement project was developed and implemented at the Veteran Affairs (VA) hospital in Memphis, TN. A VA data warehouse query was used to identify veterans with an active prescription for a biologic immunosuppressant over 2 phases (phase 1 and phase 2) of the project. Clinical pathway and VA electronic medical record, e.g., Computerized Patient Record System order set for various biological agents and vaccines, were developed by the investigators over a period of 3 months before the activation of phase 1 and was approved by the Memphis VA Medical Center Pharmacy and Therapeutics Committee. The pathway and the order set were developed for providers prescribing biologic therapies to include a review of patient immunization status and the option to order vaccines before initiation of biologics. When a provider used the order set to order the biologic, the appropriate vaccine and laboratory tests were recommended on the order set to educate the provider to take the appropriate actions necessary before the medication was started. Charts of Veterans included in the study were reviewed to assess vaccination rates before and after the QI project implementation for each phase. Phase 1 occurred over a 1-year period (October 2018 to October 2019) and sought to increase pneumococcal vaccination (PV) rates in patients on biologic therapies compared to the preintervention period. Recombinant zoster vaccine was not included in this phase as it was not readily available at the Memphis VA Medical Center at that time. Phase 2 (November 2019 to April 2022) sought to increase pneumococcal and herpes zoster vaccination rates.

Results: During phase 1, pneumococcal vaccination rates improved from a 41% preintervention rate to 66% (P < .01). During phase 2, 73% of patients completed their pneumococcal vaccination series and 58% received PCV13, PPSV23 and at least 1 dose of Shingrix, compared to 30% in the preintervention period (P < .01).

Conclusions: Provider education, clinical pathway, and Computerized Patient Record System order set can improve vaccination rates in patients with chronic inflammatory diseases on biologic immunosuppressive therapy.