Vaccination strategies for high-risk and fragile populations in Lombardy (Italy): a region-wide assessment of hospital-based models and best practices
Keywords:
Hospital-based vaccinations; life-course immunization; high-risk subjectsAbstract
Background. Subjects with selected underlying medical conditions are at higher risk of infection and severe outcomes from vaccines preventable diseases. While most countries adopt life-course approaches to vaccination, high-risk group immunization programmes could maximize individual protection, while contributing to population health. The COVID-19 pandemic stimulated the planning and implementation of successful hospital-based high-risk groups’ immunization models. However, in Italy, high-risk subjects’ vaccine coverage is not actively monitored at the national or regional level, nor shared guidelines exist yet on hospitalbased immunization programmes.
Study Design. The study reports findings from a region-wide assessment of the availability, characteristics, and setting-specific features of hospital-based immunization programmes for high-risk subjects in the Lombardy region.
Methods. Fondazione The Bridge a not-for-profit organization based in Milan, in collaboration with the Prevention Unit of the Lombardy Region Directorate for Welfare, and the University of Pavia coordinated a project aimed at bringing together regional health institutions, key stakeholders, academic experts, scientific societies and patients’ associations to assess high-risk subjects’ barriers to vaccine uptake and inform preventive programmes and policies. In this context, we designed and implemented a survey to systematically map the existence and characteristics of hospital-based immunization programmes targeting high-risk subjects.
The survey was proposed to all 115 hospital medical directions of the Lombardy region.
Results. We collected data from 97 hospital medical directions, with a response rate of 85%. Among respondents, 24% were publicly managed hospitals, 17% were Scientific Institute for Research, Hospitalization and Healthcare (IRCCS) and 59% accredited
References
1. Kolobova I, Nyaku MK, Karakusevic A, Bridge D, Fotheringham I, O’Brien M. Burden of vaccine-preventable diseases among at-risk adult populations in the US. Hum Vaccines Immunother. 2022 Nov 30;18(5):2054602. doi: 10.1080/21645515.2022.2054602. Epub 2022 Apr 21. PMID: 35446725.
2. Centers for Disease Control and Prevention (CDC). Underlying Medical Conditions Associated with Higher Risk for Severe COVID-19: Information for Healthcare Professionals. 2023. Available from: https://www.cdc.gov/ coronavirus/2019-ncov/hcp/clinical-care/underlyingconditions.html [Last accessed: 2023 Dec 15].
3. Rosenthal N, Cao Z, Gundrum J, Sianis J, Safo S. Risk Factors Associated With In-Hospital Mortality in a US National Sample of Patients With COVID-19. JAMA Netw Open. 2020 Dec 10;3(12):e2029058. doi: https://doi.org/10.1001 %2Fjamanetworkopen.2020.29058. PMID: 33301018.
4. De Giorgi A, Fabbian F, Greco S, Di Simone E, De Giorgio R, Passaro A, et al. Prediction of in-hospital mortality of patients with SARS-CoV-2 infection by comorbidity indexes: an Italian internal medicine single center study. Eur Rev Med Pharmacol Sci. 2020 Oct;24(19):10258–66. doi: https://doi.
org/10.26355/eurrev_202010_23250. PMID: 33090437.
5. Dominguez-Ramirez L, Rodriguez-Perez F, Sosa-Jurado F, Santos-Lopez G, Cortes-Hernandez P. The role of metabolic comorbidity in COVID-19 mortality of middle-aged adults. The case of Mexico. Epidemiology; 2020 Dec. doi: https:// doi.org/10.1101/2020.12.15.20244160.
6. Rovida F, Esposito GL, Rissone M, Novelli V, Cutti S, Muzzi A, et al. Characteristics and outcomes of vaccinated and nonvaccinated patients hospitalized in a single Italian hub for COVID-19 during the Delta and Omicron waves in Northern Italy. Int J Infect Dis. 2022 Sep;122:420–6. doi: 10.1016/j.ijid.2022.06.028. Epub 2022 Jun 22. PMID: 35750265.
7. Poland GA, Hall LL, Powell JA. Effective and equitable influenza vaccine coverage in older and vulnerable adults: The need for evidence-based innovation and transformation. Vaccine. 2019 Apr;37(16):2167–70. doi: 10.1016/j.vaccine.2019.02.076. Epub 2019 Mar 20. PMID: 30902480.
8. World Health Organization (WHO). Influenza (Seasonal). 2023. Available from: https://www.who.int/news-room/ fact-sheets/detail/influenza-(seasonal) [Last accessed: 2023 Dec 15].
9. Centers for Disease Control and Prevention (CDC). Pneumococcal Disease: Risk Factors and How It Spreads [Internet]. 2023. Available from: https://www.cdc.gov/pneumococcal/about/risk-transmission.html#:~:text=Young%20 children%20and%20older%20adults,adults%2065%20 years%20or%20older [Last accessed: 2023 Dec 15].
10. Scognamiglio F, Fantini MP, Reno C, Montalti M, Di Valerio Z, Soldà G, et al. Vaccinations and Healthy Ageing: How to Rise to the Challenge Following a Life-Course Vaccination Approach. Vaccines. 2022 Feb 28;10(3):375. doi: 10.3390/ vaccines10030375. PMID: 35335007.
11. Tate J, Aguado T, Belie JD, Holt D, Karafillakis E, Larson HJ, et al. The life-course approach to vaccination: Harnessing the benefits of vaccination throughout life. Vaccine. 2019 Oct;37(44):6581–3. doi: 10.1016/j.vaccine.2019.09.016. Epub 2019 Sep 23. PMID: 31558327.
12. Philip RK, Attwell K, Breuer T, Di Pasquale A, Lopalco PL. Life-course immunization as a gateway to health. Expert Rev Vaccines. 2018 Oct 3;17(10):851–64. doi:
10.1080/14760584.2018.1527690. PMID: 30350731.
13. Burioni R, Odone A, Signorelli C. Lessons from Italy’s policy shift on immunization. Nature. 2018 Mar;555(7694):30–
30. doi: 10.1038/d41586-018-02267-9. PMID: 32094876.
14. Kang SJ, Jung SI. Age-Related Morbidity and Mortality among Patients with COVID-19. Infect Chemother. 2020;52(2):154. doi: 10.3947/ic.2020.52.2.154. PMID: 32537961.
15. Djaharuddin I, Munawwarah S, Nurulita A, Ilyas M, Tabri
NA, Lihawa N. Comorbidities and mortality in COVID-
19 patients. Gac Sanit. 2021;35:S530–2. doi: 10.1016/j. gaceta.2021.10.085. PMID: 34929892.
16. Colaneri M, Asperges E, Calia M, Sacchi P, Rettani M, Cutti S, et al. Despite Vaccination: A Real-Life Experience of Severe and Life-Threatening COVID-19 in Vaccinated and Unvaccinated Patients. Vaccines. 2022 Sep 16;10(9):1540.
doi: 10.3390/vaccines10091540. PMID: 36146618.
17. Cook TM, Roberts JV. Impact of vaccination by priority group on UK deaths, hospital admissions and intensive care admissions from COVID‐19. Anaesthesia. 2021 May;76(5):608–16. doi: 10.1111/anae.15442. Epub 2021 Feb 11. PMID: 33572007.
18. Perrone PM, Biganzoli G, Lecce M, Campagnoli EM,
Castrofino A, Cinnirella A, et al. Influenza Vaccination Campaign during the COVID-19 Pandemic: The Experience of a Research and Teaching Hospital in Milan. Int J Environ Res Public Health. 2021 May 30;18(11):5874. doi: 10.3390/ ijerph18115874. PMID: 34070763.
19. Freiser D, Roca M, Chung T, Bhakta T, Winston LG, Ortiz GM. The Evolution of a Hospital-Based Covid-19 Vaccination Program for Inpatients. NEJM Catal. 2022 Jan 19. Available from: http://catalyst.nejm.org/doi/10.1056/ CAT.21.0340 [Last accessed: 2023 Dec 15].
20. Lecce M, Biganzoli G, Agnello L, Belisario I, Cicconi G, D’Amico M, et al. COVID-19 and Influenza Vaccination Campaign in a Research and University Hospital in Milan, Italy. Int J Environ Res Public Health. 2022 May 26;19(11):6500. doi: 10.3390/ijerph19116500. PMID: 35682083.
21. Di Pietro A, Visalli G, Antonuccio GM, Facciolà A. Today’s vaccination policies in Italy: The National Plan for Vaccine Prevention 2017-2019 and the Law 119/2017 on the mandatory vaccinations. Ann Ig. 2019;31(2 Suppl 1):54–64. doi:
10.7416/ai.2019.2277. PMID: 30994164.
22. Odone A, Signorelli C. When vaccine hesitancy makes headlines. Vaccine. 2017 Mar;35(9):1209–10. doi: 10.1016/j.vaccine.2015.11.051. Epub 2015 Dec 2. PMID: 26657186.
23. Ferro A, Odone A, Siddu A, Colucci M, Anello P, Longone M, et al. Monitoring the web to support vaccine coverage: results of two years of the portal VaccinarSì. Epidemiol Prev. 2015;39(4 Suppl 1):88–93. PMID: 26499422.
24. Italian Ministry of Health. Italian influenza vaccination coverage. 2023. Available from: https://www.salute.gov.it/portale/ influenza/dettaglioContenutiInfluenza.jsp?id=679&area=inf luenza&menu=vuoto [Last accessed: 2023 Dec 15].
25. Italia Longeva. La mappa della fragilità in Italia. 2022; Available from: https://www.italialongeva.it/wp-content/ uploads/2022/04/indagine-2022_italialongeva.pdf [Last accessed: 2023 Dec 15].
26. Mihalek AJ, Russell CJ, Hassan A, Yeh MY, Wu S. National Inpatient Immunization Patterns: Variation in Practice and Policy Between Vaccine Types. Hosp Pediatr. 2021 May 1;11(5):462–71. doi: 10.1542/hpeds.2020-002634. Epub 2021 Apr 5. PMID: 33820809.
27. Bryan MA, Hofstetter AM, Ramos D, Ramirez M, Opel DJ. Facilitators and Barriers to Providing Vaccinations During Hospital Visits. Hosp Pediatr. 2021 Oct 1;11(10):1137–52.
doi: 10.1542/hpeds.2020-004655. PMID: 34556537.
28. Fedson DS, Houck P, Bratzler D. Hospital-Based Influenza and Pneumococcal Vaccination: Sutton’s Law Applied to Prevention. Infect Control Hosp Epidemiol. 2000 Nov;21(11):692–9. doi: 10.1086/501716. PMID: 11089652.
29. Anderson EJ, Kao C, Yildirim I. Hospitalization Is an Underutilized Opportunity to Vaccinate for Influenza.
Mayo Clin Proc. 2019 Mar;94(3):377–9. doi: 10.1016/j. mayocp.2019.01.012. PMID: 30832785.
30. Dexter PR, Perkins SM, Maharry KS, Jones K, McDonald CJ. Inpatient Computer-Based Standing Orders vs Physician Reminders to Increase Influenza and Pneumococcal Vaccination Rates: A Randomized Trial. JAMA. 2004 Nov 17;292(19):2366. doi: 10.1001/jama.292.19.2366. PMID: 15547164.
31. McFadden K, Seale H. A review of hospital-based interventions to improve inpatient influenza vaccination uptake for high-risk adults. Vaccine. 2021 Jan;39(4):658–66. doi: 10.1016/j.vaccine.2020.12.042. Epub 2020 Dec 21. PMID: 33357955.
32. Norman DA, Danchin M, Van Buynder P, Moore HC, Blyth CC, Seale H. Caregiver’s attitudes, beliefs, and experiences for influenza vaccination in Australian children with medical comorbidities. Vaccine. 2019 Apr;37(16):2244–8. doi: 10.1016/j.vaccine.2019.02.077. Epub 2019 Mar 15. PMID: 30885511.
33. McFadden K, Heywood A, Dyda A, Kaufman J, Seale H. Minimising missed opportunities to promote and deliver immunization services to middle and older age adults: Can hospital-based programs be a solution? Vaccine. 2021 Jun;39(26):3467–72. doi: 10.1016/j.vaccine.2021.05.027. Epub 2021 May 20. PMID: 34024659.
34. Joint Commission. Specifications Manuals. 2020. Available from: http://www.jointcommission.org/specifications_manual_for_national_hospital_inpatient_quality_measures. aspx [Last accessed: 2023 Dec 15].
35. Berger RE, Diaz DC, Chacko S, Louh I, Wheaton C, Ipolitti C, et al. Implementation of an Inpatient Covid-19 Vaccination Program. NEJM Catal. 2021 Sep 15;2(10):CAT.21.0235. doi: 10.1056/CAT.21.0235.
36. Odone A, Fara GM, Giammaco G, Blangiardi F, Signorelli C. The future of immunization policies in Italy and in the European Union: The Declaration of Erice. Hum Vaccines Immunother. 2015 May 4;11(5):1268–71. doi:
10.1080/21645515.2015.1019980. PMID: 25806425.
37. Shevlin J. A systematic approach for increasing pneumococcal vaccination rates at an inner-city public hospital. Am J Prev Med. 2002 Feb;22(2):92–7. doi: 10.1016/s0749-3797(01)00408-1. PMID: 11818177.
38. Gerard MN, Trick WE, Das K, Charles-Damte M, Murphy GA, Benson IM. Use of Clinical Decision Support to Increase Influenza Vaccination: Multi-year Evolution of the System. J Am Med Inform Assoc. 2008 Nov 1;15(6):776–9. doi: 10.1197/jamia.M2698. Epub 2008 Aug 28. PMID: 18756001.
39. Cohen ES, Ogrinc G, Taylor T, Brown C, Geiling J. Influenza vaccination rates for hospitalised patients: a multiyear quality improvement effort. BMJ Qual Saf. 2015 Mar;24(3):221–7. doi: 10.1136/bmjqs-2014-003556. Epub 2015 Jan 29. PMID: 25633277.
40. Peterson S, Taylor R, Sawyer M, Nagy P, Paine L, Berenholtz S, et al. The Power of Involving House Staff in Quality Improvement: An Interdisciplinary House Staff–Driven Vaccination Initiative. Am J Med Qual. 2015 Jul;30(4):323–7. doi: 10.1177/1062860614532682. Epub 2014 May 9. PMID: 24814939.
41. Gianfredi V, Pennisi F, Lume A, Ricciardi GE, Minerva M, Riccò M, et al. Challenges and Opportunities of Mass Vaccination Centers in COVID-19 Times: A Rapid Review of Literature. Vaccines. 2021 Jun 1;9(6):574. doi: 10.3390/ vaccines9060574. PMID: 34205891.
42. Smith JG, Metzger NL. Evaluation of Pneumococcal Vaccination Rates After Vaccine Protocol Changes and
Nurse Education in a Tertiary Care Teaching Hospital. J Manag Care Pharm. 2011 Nov;17(9):701–8. doi: 10.18553/ jmcp.2011.17.9.701. PMID: 22050395.
43. Lawson F, Baker V, Au D, McElhaney JE. Standing Orders for Influenza Vaccination Increased Vaccination Rates in Inpatient Settings Compared With Community Rates. J Gerontol A Biol Sci Med Sci. 2000 Sep 1;55(9):M522–6.
doi: 10.1093/gerona/55.9.m522. PMID: 10995050.
44. Middleton DB, Fox DE, Nowalk MP, Skledar SJ, Sokos DR, Zimmerman RK, et al. Overcoming Barriers to Establishing an Inpatient Vaccination Program for Pneumococcus Using Standing Orders. Infect Control Hosp Epidemiol. 2005 Nov;26(11):874–81. doi: 10.1086/502511. PMID: 16320983.
45. Bawa T, Smith D, Andreeva D, Vaidya S, Kruja B, Farrell T, et al. Inpatient COVID-19 vaccination rollout: Improving access to vaccination. Clin Med Lond Engl. 2022 Sep;22(5):461–7. doi: 10.7861/clinmed.2022-0132. PMID: 36507810.
46. Dallagiacoma G, Allora A, Salvati S, Cocciolo G, Capraro M, Lamberti A, et al. Type 1 Diabetes Patients’ Practice, Knowledge and Attitudes towards Influenza Immunization. Vaccines. 2021 Jun 29;9(7):707. doi: 10.3390/vaccines9070707. PMID: 34210044.
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Copyright (c) 2025 Anna Odone, Riccardo Vecchio, Luisa Brogonzoli, Elisa Sala, Giacomo Pietro Vigezzi, Alba Muzzi, Catia Rosanna Borriello, Danilo Cereda, Giuliano Rizzardini, Alessandro Venturi, Rosaria Iardino (Author)

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