that can result in abortions, miscarriages, andstillbirths. The risk of CRS is greatest in the firsttrimester of pregnancy, with defects rarely resultingfrom infection after the 20th week. Fetal infectionwithout clinical stigmata of CRS can occur at anystage of pregnancy. The main goal of rubellaimmunization programs is to prevent fetal infectionand CRS (7).The threat of CRS remains greatest among

religious groups like the Amish. Increased surveil-lance for adverse birth outcomes consistent withCRS is a challenge, because many births to Amishwomen occur at home and are not observed andreported. Cord-blood samples for rubella titerswould provide additional epidemiologic informa-tion and again are not likely to be available fromthis population. Health care providers who aretrusted by this community are encouraged to im-prove levels of rubella vaccine coverage amongchildren and adults, particularly women of child-

bearing age, perhaps by identifying missed orunderused opportunities for vaccination.

References..................................

1. Levinson, P. M., et al.: Behavioral risk factors in anAmish community. Am J Prev Med 5: 150-156 (1989).

2. Adams, C. E.: and Leaverland, M. B.: The effects ofreligious beliefs on the health care practices of the Amish.Nurse Pract 11: 58-60 (1986).

3. Hostetler, J. A.: Amish society. Ed 2. Johns HopkinsUniversity Press, Baltimore, 1980.

4. Sutter, R. W., et al.: Measles among the Amish: compara-tive study of measles severity in primary and secondarycases in households. J Infect Dis 163: 12-16 (1991).

5. Rubella and congenital rubella surveillance, 1983. MWWRMorb Mortal Wkly Rep 33: 237-242, 247, May 11, 1984.

6. Increase in rubella and congenital rubella syndrome-United States, 1988-1990. MWWR Morb Mortal Wkly Rep40: 93-99, Feb. 15, 1991.

7. Rubella and congenital rubella syndrome-United States,1985-1988. MMWR Morb Mortal Wkly Rep 38: 173-178,Mar. 24, 1989.

Pneumococcal Vaccinationin a Remote Population of High-Risk Alaska Natives

MICHAEL DAVIDSON, MD, MPHCAROL CHAMBLEE, RN, MPHHENRY G. CAMPBELL, RN, MPH,LISA R. BULKOW, MSGRADY E. TAYLORANNE P. LANIER, MD, MPHJAMES BERNER, MDJOHN S. SPIKA, MDWALTER W. WILLIAMS, MD, MPHJOHN P. MIDDAUGH, MD

Five authors are with the Public Health Service's Centers forDisease Control and Prevention (CDC). Dr. Davidson, Ms.Bulkow, and Mr. Taylor are with the National Center forInfectious Diseases, Arctic Investigations Program. Dr. Spika iswith the National Center for Infectious Diseases, Division ofBacterial Diseases. Dr. Williams is with the National Center forPrevention Services, Division of Immunization. Miss Chamblee,Mr. Campbell, Dr. Lanier, and Dr. Berner are with the PublicHealth Service's Indian Health Service, Alaska Area NativeHealth Service. Dr. Middaugh is with the State of Alaska,Department of Health and Social Services, Division of PublicHealth, Section of Epidemiology.

Tearsheet requests to Michael Davidson, MD; Alaska NativeMedical Center, Department of Medicine, 255 Gamble St.,Anchorage, AL 99501; tel.: (907) 279-6661; fax.: (907)257-1115.

Synopsis....................................

In response to an increasing prevalence of seriouspneumococcal disease among adult Alaska Nativesof northwest Alaska, a 3-year program was begunin 1987 to identify residents of that remote regionwho were at high risk for developing invasivepneumococcal disease, to determine their pneumo-coccal vaccination status, and to deliver vaccine toat least 80 percent of those at risk.

After reviewing public health nursing and IndianHealth Service data bases, the authors identified1,337 persons, 20 percent of the 6,692 residents ofthe region, at high risk for invasive pneumococcalinfection, defined either by having a specificchronic disease or by age criteria. Cardiovasculardisease and alcoholism were the two most commonchronic diseases. Only 30 percent of those deter-mined to be at high risk had received one or moredoses of pneumococcal vaccine previously. Half ofthose persons had received their most recent vacci-nation 6 or more years earlier.

The program used both customary and innova-tive methods to deliver 23-valent polysaccharide

July-August 1003, Vol. 106, No. 4 439

vaccine to 1,046 of those at high risk (78 percent),including 388 persons who were revaccinated. Atthe completion of the project, 1,123 persons, 84percent of those at high risk, had received at least Idose. They included 1,088 persons, 81 percent ofthose at high risk, with vaccination within theprevious 5 years as a result of the project, com-

pared with a 15-percent rate prior to the vaccina-tion phase of the project. The program demon-strated that high levels of vaccination againstpneumococcal disease, exceeding Year 2000 objec-tives of 60 percent, are attainable in a remote ruralAlaskan population.

A MONG THE 10 MOST COMMON CAUSES of hospi-talization and death, pneumonia and influenza arethe only disorders for which efficacious vaccinesare available. Besides causing both lobar and bron-chopneumonia, Streptococcus pneumoniae is a ma-jor cause of bacterial meningitis, otitis media, andsepsis ainong Native Aniericans of all ages.

Rates of confirmed pneumococcal bacteremiahave been documented to be 34 times higher amongAlaska Native children younger than 2 years and 6times higher among Alaska Native adults living inthe Yukon-Kuskokwim Delta than are found intypical U.S. populations (1). More than 96 percentof those infectiors were caused by pneumococcaltypes that are represented in the 23-valent pneumo-coccal polysaccharide vaccine currently available.The incidence of invasive pneumococcal disease (apositive culture from a normally sterile body site) ismore than four times higher among Alaska Nativesages 55-64 years than among non-Native Alaskanresidents of the same age and more than twice therate for persons 65 years and older of all racescombined and living in Charleston County, SC (2),for example. The rate of invasive pneumococcaldisease among Alaska Natives ages 55-64 yearswith no underlying conditions is equal to that of alladults 65 years and older residing elsewhere in theUnited States (unpublished data, Centers for Dis-ease Control and Prevention, National Center forInfectious Diseases, Arctic Investigations Program,1986-90).

Increased rates of invasive pneumococcal diseasein the Northwest Arctic Native Borough Associa-tion (NANA) region of northwest Alaska (figure 1)became evident to local health care providers dur-ing the period June 1986 through April 1987, when12 Alaska Native adults, 1 non-Native Alaskanadult, and 1 Alaska Native infant were diagnosed(figure 2). Four of the 12 Alaska Native adultsdied, 3 within 24 hours of admission to thehospital. The annual incidence rate for invasivepneumococcal disease during that period forAlaska Natives 60 years and older was almost 60times higher than rates available for other U.S.

population groups and 23 times higher than forresidents of all ages (3, 4). Of the pneumococcalserotypes isolated from nine patients, eight werevaccine types. Those high disease rates were docu-mented by sterile site isolates, despite the use of theempiric antibiotic therapy that is frequently neces-sary in rural Alaska. During the previous 30months, only two invasive pneumococcal infectionswere noted.The increase in morbidity and mortality from

pneumococcal disease in northwest Alaska was theincentive for a 3-year program from October 1987through September 1990 to assess pneumococcalvaccination levels as well as to vaccinate at least 80percent of those at high risk for developing seriousdisease. That objective was higher than the goal of60 percent established for the Year 2000 objectives(5). Beginning in 1976, vaccine supplied by theState of Alaska was limited to outpatient distribu-tion by public health nurses and community healthaides. However, because the regional provider ofprimary care and public health services, the Manii-laq Corporation, is operated by Alaska Natives, wesought support outside the Indian Health Service(IHS). Among the agencies that planned the collab-orative project were the State of Alaska's Depart-ment of Health and Social Services, the AlaskaArea Native Health Service, the Maniilaq Corpora-tion, and the Centers for Disease Control andPrevention (CDC).

In Alaska, from 1975 to 1987, the indications forvaccination with pneumococcal polysaccharide werethose recommended by CDC's Immunization Prac-tices Advisory Committee. The indications forvaccination included persons 2 years and older whohad conditions predisposing to serious infection,such as chronic cardiovascular, metabolic, pulmo-nary, and renal diseases; alcoholism; cancer; diabe-tes; immunosuppression; auto-immune disorders;and dysfunction of the spleen. In addition to theage criterion of 65 years and older, expandedindications for the vaccination of Alaska Nativesnow include all healthy persons 55 years and older,anyone 2 years and older with previously docu-

440 Public H"th Report

Figure 1. Location of region and communities in northwest Alaska in 3-year program to vaccinate Alaska Natives at high risk forpneuffoccal disease, 1987-90.

Pt. Hope

0 Noatak

0 Ambler

Shugnak *. KobukSelawik

mented invasive pneumococcal disease, and revacci-nation of high-risk or elderly persons whose lastvaccination was 6 or more years earlier. Theexpanded indications, developed by the AlaskaArea Native Health Service and CDC in 1987, werespecifically approved by the Immunization Prac-tices Advisory Committee.We considered the entire population in the

NANA region, 6,692 persons, to be at potentiallyhigh risk for invasive pneumococcal infection. Theprogram was directed to all eligible persons livingin the area: Alaska Natives and Eskimos (85.9percent of the population); Indians (1.6 percent);Aleuts (0.2 percent); non-Native Alaskans, includ-ing whites (9.6 percent); and persons of unknownethnicity (2.8 percent). The population is surpris-ingly mobile and lives in 10 small communities,plus the town of Kotzebue, which has 3,000 resi-dents and a regional medical center. One village,Point Hope, adjacent to the NANA region andincluded in the project, uses the medical center(figure 1). Except in Kotzebue, many adults in theregion maintain a subsistence lifestyle. Health carein smaller communities usually is provided by atrained community health aide or a visiting publichealth nurse, or both, some of whom are residents.

Methods

Patient selection. We identified persons residing inthe region who had previously diagnosed high-riskconditions and persons 55 years and older. We de-termined their vaccination status by matching in-formation from four data bases:

1. A computerized list of residents that originallyhad been compiled for a regional hepatitis Bvaccination program,

2. Recent and archival computer files from theIHS Patient Care Information System (PCIS) thatcontained information on diagnoses and vaccina-

July-August 1993, Vol. 108, No. 4 "1

Figure 2. Monthly Incidence and outcome of invasive pneumo-coccal infections, all ages, northwest Alaska, 1986-87, before

3-year vaccination program of high-risk population

Number.of cases4

* Alaska Native adult diedO Alaska Native adult survivedE3 Alaska Native infant survivedM Non-Native Alaskan adult survhred

3

2

1

0 1 I I I I I I I II I I- 1 I I I'J FMAMJ J ASOND J

1986 198

FMAM3 J ASOND

tions of about 12,000 patients seeking care withinthe region during the past 10 years.PCIS is a large-scale automated medical record

system that compiles the ambulatory, inpatient,and public health experience of Alaska Natives andthe State's rural health care delivery system andinvolves many facilities and agencies (6). When theproject was carried out, PCIS included data onmore than 476,000 patients and contained 3 timesas many health records. The system since has beenreplaced by an interactive computerized data base,the Patient Care Component (PCC) of the Re-source Patient Management System (RPMS).

3. A public health nurse card file of recordedvaccine administration, and

4. A computerized CDC demographic data baseof information on Alaska Natives, which we usedto identify deaths and resolve duplicate entries inthe other data bases that may have resulted fromname changes or inconsistencies.

Community health aides in each village con-firmed the census lists periodically throughout the3-year period. We removed from the working filesthe names of persons known to have died or movedaway.

Assessment of vaccination status. Considerableconsolidation of vaccination information was nec-essary. Vaccinations administered within 30 days atone location were considered identical and countedas a single event. Multiple vaccinations adminis-tered at different times or different places, morethan 30 days apart or located in different commu-nities, were independently recorded. A review of

medical records from clinics staffed by communityhealth aides in four NANA region villages revealedfew vaccinations not otherwise recorded, and thissource of information was not pursued.

Evaluation of high-risk conditions. The followingspecific high-risk conditions were considered to pre-dispose a person to severe pneumococcal infections-: chronic cardiovascular disease, chronic pulmo-nary disease, alcoholism, diabetes mellitus, chronicrenal failure, nephrotic syndrome, lymphoma, inva-sive cancer, multiple myeloma, severe connectivetissue disease, metabolic disorders, immune dys-function, disorders of the spleen, and HIV infec-tion.To validate the computer-listed diagnoses, we

reviewed hospital and clinic records from 250randomly selected persons with representative diag-noses. Records were searched for preestablishedclinical criteria based on hospitalization dischargediagnoses, clinic visits, laboratory data, and medi-cations prescribed. The total positive predictivevalue of these computer-listed diagnoses was only46 percent, because many represented inactive con-ditions, like benign cardiac murmurs, positive tu-berculin skin tests, obesity, and transient disorders,such as electrolyte abnormalities and anemia. Weeliminated these and other diagnoses, and achieveda refined definition of high-risk status, with anestimated overall positive predictive value of 90percent. High-risk status was assigned for thefollowing conditions and ICD-9 (7) codes.

Heart disease: 093, 391, 393-398, 401-405,410-414, 415-417, and 423-429.8, excluding424.9, 427.0-427.2, 427.6-427.9Lung disease: 490-496, 500-508, 510-519.7, ex-cluding 491.9

Connective tissue disease: 710, 714, 720-721Diabetes: 250-250.9Other metabolic disorders: 240-246.9, 251-277.8,excluding 276Renal disease: 581-589, 590.0-590.8Alcoholism: 303, 305.0, 331.7Cancer: 140-208, 235-239.9.

Additional codes defined other conditions withfew or no patients in the PCIS data base:

Acute and chronic liver disease (excludinghepatitis): 570-572.8HIV infection: 042-044Immune dysfunction and disorders of thespleen: 289.4-289.59, 865.

442 Public Health Reports

During the final 3 months of the project, amanual review of medical records of the remainingsubject population eliminated other noncontribu-tory diagnoses.

Vaccine administration. In the project, vaccinationwas administered largely by the customary provid-ers of this service. They included public healthnurses and health aides, as well as clinic and hospi-tal nurses in three settings:

1. An inpatient program, designed to query allphysicians regarding the administration of pneumo-coccal vaccination to their patients prior to dis-charge;

2. An outpatient facility program that providedsimultaneous pneumococcal vaccination to thoseadults receiving a tetanus and diphtheria toxoid(TD) booster; and

3. The coadministration of pneumococcal andinfluenza vaccines by community health providers,guided by the project's lists of high-risk persons.

Using a personal computer and the BorlandInternational relational data base Paradox, wegenerated a master list of all persons 2 years andolder who lived in the project area. The listincluded their risk status and pneumococcal vacci-nation history. Hospital staff members used themaster list in the clinic and inpatient settings tofind the vaccination status of outpatients andinpatients with high-risk diagnoses before dis-charge. Public health and primary care providers inthe field used shorter lists of high-risk personsrequiring vaccination. During the final 20 monthsof the project, we updated both the master list andthe short lists frequently as people were vaccinated.Both lists identified patients for simultaneous ad-ministration of influenza and pneumococcal vac-cines in the autumn and simultaneous doses oftetanus-diphtheria (TD) booster and pneumococcalvaccine during outpatient and emergency roomencounters.

Specific outreach programs were undertaken forhigh-risk persons within the town of Kotzebue.After sending letters encouraging appointments forvaccination, a student volunteer found many withdirect telephone calls. Public service announce-ments on a local radio station reached manypersons who were without telephone service. Listsof local utility customers helped in locating andreaching people without a telephone or postalservice. Pneumococcal vaccination was offered dur-ing a local health fair and by the health services of

Table 1. Prevalence of high-risk diagnoses in the generalpopulation and the population 20 years and older in northwest

Alaska, 1987-90

Patients 20 yearsAll patients and older

Diagnosis or category Number Percent Number Percent

Chronic cardiovascular ... 482 7 452 12Chronic lung ............ 296 4 252 17Connective tissue ....... 116 2 112 3Diabetes ................ 48 1 47 1Other metabolic ......... 164 3 148 4Renal ................. 15 < 1 14 <1Cancer ................. 80 1 78 2Alcohol abuse........... 334 5 337 955 years and older ...... 256 4 256 7All high risk patients..... 1,081 16 985 27

NOTE: Patients in multiple diagnostic categories were counted more than once.

a National Guard summer camp. The project nursemade many visits to a nursing home, a seniorcitizen center, and a regional jail to provide vacci-nation.

Results

When the project ended, the data base included6,692 current residents in northwest Alaska. Ofthem, 1,081 (16 percent) had specific high-riskdiagnoses, including 27 percent of all those 20years and older (table 1). Almost half of thehigh-risk persons were 20-49 years old, with anequal distribution of men and women (figure 3).The most prevalent high-risk conditions amongadults 20 years and older were cardiac disease (12percent), alcoholism (9 percent), and chronic lungdisease (7 percent) (table 1). We identified forvaccination an additional 256 persons, 4 percent ofthe total population, who were in good health, but55 years or older (table 1).

Previous pneumococcal vaccination was docu-mented for 9.5 percent of the population, including30 percent of all those 2 years and older withhigh-risk diagnoses, 68 percent of those 55-64 yearsold, 86 percent of those 65 years and older, and 64percent of those 55 years and older without anotherindication for vaccination (table 2).The information was collected largely from com-

puterized vaccination records. A review of publichealth nursing files identified an additional 10percent of vaccinations not recorded elsewhere.Categories of patients diagnosed with high-riskconditions, previously vaccinated one or moretimes, ranged from 15 percent of those withalcoholism to more than 68 percent of those withdiabetes (table 2). The most recent vaccination for

July-August 1993, Vol. 108, No. 4 443

Figure 3. Age distribution of residents of northwest Alaskapneumococcal disease vaccination project region with chronic

disease diagnoses, as of August 30, 1990

70+ 61 85

60-69 70 88

50-59 164 89

40-49 159 80

30-39 119 110

20-29 82 78

10-19 34 26

0-9 21 15

Age in years 510 men 571 women

NOTE: Patients with multiple diagnoses were counted once.

50 percent of those high-risk persons previouslyvaccinated had been administered 6 or more yearsearlier.The high-risk unvaccinated persons identified

included those from all diagnostic categories,mainly younger than 55 years, who lived in the 12communities. However, the community with thehighest proportion (83 percent) of high-risk personsrequiring vaccination or revaccination was the re-gional population center of Kotzebue.At the completion of the project, 1,123 persons,

84 percent of those at high risk, had received atleast 1 dose of the 23-valent polysaccharide pneu-mococcal vaccine (PNEU-IMMUNE (R)), and 81percent of the high-risk population had currentvaccinations, that is, within the previous 6 years,compared with only 15 percent at the beginning ofthe project's vaccination phase. Ten of the 12communities achieved a vaccination rate of morethan 90 percent, including 2 that achieved 100percent. During the project, 658 persons receivedtheir first pneumococcal vaccination and 388 wererevaccinated.

Discussion

The project demonstrated that a high level ofvaccination against pneumococcal disease, wellabove the Year 2000 objectives for the generalpopulation, can be achieved in a remote high-riskAlaska Native population. Estimates of existingvaccine coverage of high-risk candidates nationwidehave been cited as less than 10 percent (5, 8).We used a computerized health information sys-

tem (PCIS) that is no longer in use. Additionaldata bases, not generally available outside Alaska,

permitted a population-based, rather than clinic- orhospital-based, approach to identify those needingvaccination. That permitted precise calculation ofthe total number of high-risk persons and theirvaccination rates before and after the program.The total number of residents in the area calculatedby this project in 1990 was within 1 percent of the1990 census estimates, indicating the high degree ofaccuracy of the population-based methods.To validate the computerized source of diagnos-

tic and vaccination data (PCIS), we searched othersources of vaccination and clinical information. Bylimiting diagnoses to specific ICD-9 codes, high-risk diagnostic status was captured reliably fromcomputerized IHS data. Computerized vaccinationrecords appeared 90 percent complete, and weusually confirmed the date of vaccination by alter-nate sources. The expanded guidelines for pneumo-coccal revaccination of Alaska Natives required acorrect assessment of previous vaccination dates,and computerized IHS data appeared adequate forthis purpose.The current Immunization Practices Advisory

Committee recommendations for pneumococcalvaccination include the vaccination of "certainNative American populations with an identifiedincreased risk of disease" (9). Any extension of theguidelines should be based on high incidence ratesof disease determined by surveillance programs.Similarly, Immunization Practices Advisory Com-mittee guidelines currently restrict revaccination tothose at highest risk for fatal pneumococcal infec-tions or conditions such as renal disease withrapidly declining antibody levels. A forthcomingreport on the antibody levels achieved by partici-pants in our project will help in formulating futurerecommendations.The successful delivery of vaccinations in this

program depended largely upon three compo-nents: pneumococcal vaccination of patients beforetheir discharge from the hospital, simultaneouspneumococcal vaccination of those adults receivinga TD booster, and coadministration of pneumo-coccal and influenza vaccines. Because of a chronicshortage of outpatient clinic staff, we were unsuc-cessful in identifying persons 2 years and older inthis setting who required vaccination. However,even without the systematic outpatient screeningand outreach activities of the project, we believethat the Year 2000 health objective for pneumo-coccal disease prevention is attainable. A vaccina-tion level of 60 percent of high-risk adults wouldhave been achieved easily using only the threeproject components described.

44 Pubic Health Repors

Table 2. Vaccination status of population at high risk for pneumococcal disease before and after vaccination program, northwestAlaska, 1987-90

Porcent ever vaccinated

Before By end Percent revaccinated byRisk category program of program end of program

Chronic cardiovascular disease .49 93 38Chronic lung disease .41 89 30Connective tissue .55 91 41Diabetes . 68 100 56Other metabolic disease .37 92 26Renal disease .57 87 27Cancer .47 93 38Alcohol abuse .15 64 6Older than 54 years .64 84 27All high risk patients .30 84 25

NOTE: Patients in multiple diagnostic categories were counted more than once.

A pneumococcal vaccination level of 71 percentwas estimated for high-risk patients served by thePortland Area Indian Health Service in 1990,before computerized lists of high-risk persons weredistributed (10). However, the assessment includedonly clinic users more likely to have valid high-riskconditions and to comply with health providersoffering vaccination. Elsewhere, estimates of pneu-mococcal vaccination for older Navajo adults re-cently treated ranged from 36 percent to 63 percent(11). The 20 percent vaccination level estimated inhigh-risk users of urban Indian health clinics in1989 also exceeded current estimates of high-riskpersons (12). These methods for estimating vaccinecoverage appear useful and may be enhanced withthe refined ICD-9 codes used in the project.The current computerized data system, the Pa-

tient Care Component of the Resource and PatientManagement System, now operating at more thanhalf of the IHS and tribal health facilities, and itsquery system, Q-Man, could provide the basis forfacility- or community-based programs elsewhere.The multifacility integration of data (MFI) avail-able in the Tucson Area (13) could be used tocollect the entire immunization history of personsseeking care at several facilities. Such record link-ing could identify high-risk diagnoses not availablein any one medical record. The success of anyhealth maintenance reminder depends on the valid-ity of its information, whether automatically pro-duced by PCC for every patient encounter, orprovided on a list for community health workers.Health care providers quickly categorize all suchefforts as futile if they perceive outdated or inaccu-rate data. Before relying on this computer-basedstrategy to guide vaccination efforts, an assessmentmust be made of the computer system and data

base for local delays in the entry of recent vaccina-tions and diagnoses, as well as the incompleteretrieval of information regarding those personsrequiring vaccination.

Institutional-based immunization programs else-where have directed reminders for pneumococcalvaccination successfully to physicians. The remind-ers are inserted in the medical records of adultpatients (14, 15). Both outpatient chart remindersand computerized hospital discharge summarieshave improved vaccination rates of high-risk pa-tients, including alcoholics. More labor-intensiveprograms have used infection control nurses effec-tively in vaccinating inpatients (16).Although the project accessed a unique comput-

erized data base, its success is relevant to otherremote populations. Within IHS, PCC can be used.Since successful programs elsewhere (13-15) haveadministered pneumococcal polysaccharide vaccineto high-risk persons, even if prior vaccinationstatus was unknown and revaccination was notgenerally recommended, the effort expended by theproject to confirm prior vaccination status wasunnecessary. Current estimates of the cost of deliv-ery of the vaccine by public health providers inrural Alaska is almost $50 per dose. While the costper dose in this project was threefold higher, database development was responsible for at least halfthe increase.The design of the inpatient component of the

project reflected the observation of others, thatmost unvaccinated adults with serious or fatalpneumococcal infections have been hospitalizedwithin the previous 5 years (17). The programseized some frequently missed opportunities forpneumococcal vaccination, including the simulta-neous vaccination of appropriate persons who re-

July-August 1993, Vol. 108, No. 4 445

quired TD vaccine booster doses or influenzavaccine.A diagnosis of alcoholism and residence in Kot-

zebue characterized 41 percent of the remaining 248residents in the region who required vaccination atthe end of the project. Information on the immu-nogenicity of pneumococcal polysaccharide vaccineobtained during this study suggests that the totalantibody response of alcoholics equals or exceedsthat of patients with other chronic diseases. Fur-thermore, the total antibody response of alchoho-lics to type 12F, the most common serotype respon-sible for invasive disease in Alaska Native adults,was robust (18). The vaccination of high-risk alco-holics should be aggressively pursued in futurepneumococcal prevention programs.At the end of the project, all vaccination data

were entered into the local RPMS computer, themaster and the short lists were updated and givento primary and public health care providers, andmedical records were noted to show those requiringvaccination. Evaluation of those measures to deter-mine their duration and cost effectiveness is neces-sary.

References..................................

1. Davidson, M., et al.: Invasive pneumococcal disease in anAlaska Native population, 1980 through 1986. JAMA261: 715-718, Feb. 3, 1989.

2. Breiman, R. F., et al.: Pneumococcal bacteremia inCharleston County, South Carolina. A decade later. ArchIntern Med 150: 1401-1405 (1990).

3. Felice, G. A., Darby, C. P., and Fraser, D. W.: Pneumo-coccal bacteremia in Charleston County, South Carolina.Am J Epidemiol 112: 828-835 (1980).

4. Mufson, M. A., Oley, G., and Hughey, D.: Pneumococcaldisease in a medium-sized community in the United States.JAMA 248: 1486-1489, Sept. 24, 1982.

5. Public Health Service: Healthy people 2000: nationalhealth promotion and disease prevention objectives. DHHSPublication No. (PHS) 91-50212. Office of the AssistantSecretary for Health, Office of Disease Prevention andHealth Promotion. U.S. Government Printing Office,Washington, DC, 1990.

6. Brown, G. A.: Patient Care Information System. A de-scription of its utilization in Alaska. Proceedings of IVAnnual Symposium on Computer Applications in MedicalCare, Vol. 2, Nov. 2-5, 1980, Washington, DC, pp.873-881.

7. International classification of diseases: manual of the in-ternational statistical classification of diseases, injuries, andcauses of death. 9th revision. Clinical modification. DHHSPublication No. (PHS) 91-1260. Centers for Disease Con-trol, National Center for Health Statistics, and HealthCare Financing Administration, Hyattsville, MD, 1992.

8. Williams, W. W., et al.: Immunization policies and vac-cine coverage among adults. The risk for missed opportuni-ties. Ann Intern Med 108: 616-625 (1988).

9. Immunization Practices Advisory Committee: Recommen-dations for pneumococcal polysaccharide vaccine. MMWRMorb Mortal Wkly Rep 38: 64-76, Feb. 10, 1989.

10. Portland area documents achievement of 1990 objective forthe nation for adult immunization. IHS Primary CareProvider 16: 165-167 (1991).

11. Houck, P.: Vaccination status of Navajos over age 65.Encouraging results and missed opportunities during an-nual influenza vaccination. IHS Primary Care Provider14: 127-130 (1989).

12. Ruid, R. M.: Adult immunizations. Vaccine coverageagainst tetanus, diphtheria, pneumococcal disease, andinfluenza at American Indian Health Care Associationurban clinics. IHS Primary Care Provider 15: 104-109(1990).

13. Mason, W. B.: PCC update, 1992. IHS Primary CareProvider 17: 45-48 (1992).

14. Cheney, C., and Ramsdell, J. W.: Effect of medicalrecords' checklists on implementation of periodic healthmeasures. Am J Med 83: 129-136 (1987).

15. Clancy, C. M., Gelfman, D., and Poses, R. M.: Astrategy to improve the utilization of pneumococcal vac-cine. J Gen Int Med 7: 14-18 (1992).

16. Klein, R. S., and Adachi, N.: An effective hospital-basedpneumococcal immunization program. Arch Intern Med146: 327-329 (1986).

17. Fedson, D. S.: Influenza and pneumococcal immunizationstrategies for physicians. Chest 91: 436-443 (1987).

18. McMahon, B., et al.: Immunogenicity of the 23 valentpneumococcal polysaccharide vaccine in the Alaska Nativechronic alcoholics compared with non-alcoholic Native andnon-Native controls. Am J Med. In press.

446 Public Health Rports