# Socioeconomic determinants of vaccination against pneumococcus in 763 945 patients with heart failure

François Roubille, B. Wyplosz, J. Fernandes, B. Grenier, F. Raguideau, E.

Blanc, G. Goussiaume

► To cite this version:

François Roubille, B. Wyplosz, J. Fernandes, B. Grenier, F. Raguideau, et al.. Socioeconomic determinants of vaccination against pneumococcus in 763 945 patients with heart failure. ESC Heart Failure, 2025, 10.1002/ehf2.15381. hal-05231038

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Distributed under a Creative Commons CC BY 4.0 - Attribution - International License
Socioeconomic determinants of vaccination against
pneumococcus in 763 945 patients with heart failure

F Roubille <fnref n="1" />, B Wyplosz <fnref n="2" />, J Fernandes <fnref n="3" />, B Grenier <fnref n="4" />, F Raguideau <fnref n="4" />, E Blanc <fnref n="5" />, G
Goussiaume <fnref n="5" />

**Keywords:**

Elderlies; Heart failure; Incentive campaign; Nationwide database; Pneumococcus; Social deprivation; Vaccination.

<footnote n="1">¹ PhyMedExp, Cardiology Department, University of Montpellier, INSERM U1046, CNRS UMR, Montpellier, France.</footnote>

<footnote n="2">² AP-HP, Hospitalisation à domicile, Institut Pasteur de Paris, Paris, France.</footnote>

<footnote n="3">³ CH Cote Basque, Bayonne, France.</footnote>

<footnote n="4">⁴ Epidemiology Department, Heva, Lyon, France.</footnote>

<footnote n="5">⁵ Pfizer, Paris, France.</footnote>
## Abstract

Respiratory infections are the leading cause of acute decompensation, hospitalization and higher mortality in heart failure (HF) patients. Despite recommendations, vaccination coverage against pneumococcus and influenza remains alarmingly low (3% and 50% in 2018, respectively). This study aimed to identify factors associated with vaccination among HF patients using data from the Nationwide Health Claims Database for 2020, in France. The patients were followed during the entire year 2020. At least one dose of PCV13 was considered as a proxy for vaccination. The model used was a multivariable logistic regression. Among 763 945 HF patients (mean age 76.7 years, 54.2% male), the mean annual visits were 7.0 with a general practitioner, 1.68 with a specialist and 70.0 with a nurse. Despite frequent healthcare contacts, vaccination coverage was only 12.6% for pneumococcus (PCV13) and 63.1% for influenza. In multivariable analyses, at least one dose of the PCV13 was less often received when patients were (1) older (odd ratio (OR): 0.71 [0.67; 0.74], P < 0.0001 and 0.48 [0.46; 0.51], P < 0.0001) in patients 76-85 and older than 85 years old, respectively, (2) women (OR: 0.916 [0.903; 0.929], P < 0.0001) or 3/when they presented social deprivation (for the quintile Q5 of deprivation index, OR was 0.893 [0.872; 0.914], P < 0.0001). Pneumococcus vaccination was associated with influenza vaccination or with better access to health services. We need to consider factors, such as age, sex and social deprivation, to adapt public health initiatives supporting a significantly and sustainably increase pneumococcal vaccination coverage in frail HF patients.

## Background

Respiratory infections are the primary cause of acute decompensation leading to hospitalization in heart failure (HF) patients. A sub-analysis of trials with sacubitril/valsartan reported a high incidence of pneumonia in these patients. Importantly, a first episode of pneumonia was associated with 4-fold higher mortality, which was confirmed in a prospective study.

Vaccination against preventable respiratory infections is crucial to limit this phenomenon. To this end, the 2021 European Society of Cardiology (ESC) guidelines recommend vaccination against influenza and pneumococcus. However, vaccination coverage remains alarmingly low among patients with HF.

## Aims

In this study, we aimed to identify the factors associated with vaccination among heart failure patients in France in 2020. This should pave the way for more tailored incentive campaigns and enable us to address specific limitations.
# Methods

The study design, data sources and study populations have been published elsewhere.4 Briefly, this was a retrospective cohort study based on claims data of the Système National des Données de Santé (SNDS), which contains data from all the population covered by health insurance (almost 100% of the French population), between 1 January 2020 and 31 December 2020.

All at risk patients, including HF patients, were included from index date (first time of
patients identification within the inclusion period or 1 January 2020 if prior to that date) and
followed until death, nursing home admission, or the end of the study period (31 December
2020). A 5 to 11-year follow-back period was used to capture the ‘at-risk’ status (HF was
identified by a dedicated algorithm based on hospitalizations, procedures, or medication
dispensings). Pneumococcus vaccinations were collected from 1 January 2009, until the end
of follow-up.

In France, at the time of the study, the vaccine pathway was as follows: (1) prescription by a physician; (2) dispensing by a pharmacists; (3) administration by a physician/nurse. In 2020, the recommended pneumococcal vaccine schedule comprised a 13-valent conjugate vaccine (PCV13), followed by a 23-valent unconjugated polysaccharide vaccine (PPVS23). Given that we worked on claims databases, we considered at least one reimbursement in community of PCV13 as a proxy for vaccination. Vaccination coverage was calculated in patients who were still alive at the end of the year. Influenza vaccine dispensing were collected between September 2020 and April 2021.

All reimbursed healthcare visits are recorded in the SNDS and were collected. Thanks to the SNDS, all reimbursed healthcare resource utilizations were identifiable. To assess the role of socioeconomic factors, we used the deprivation index (FDep),5 a composite indicator that characterizes the socioeconomic situation of families to reflect territorial disparities at the municipality level (variables taken from the population census and tax declarations: Q1 corresponds to the least deprived areas, and Q5 corresponds to the most deprived areas).

In a multivariable logistic regression model, factors associated with pneumococcal vaccination (at least one PCV13 dispensing) were analysed. Variables included were: age (the reference group was 18–45 years), sex, universal health coverage, access to GP index, influenza vaccine dispensing during the 2020–2021 season, other vaccines dispensing between 2009 and 2020 (meningococcal, hepatitis, diphtheria, tetanus, poliomyelitis and *Haemophilus*), number of GP/private specialist/nurse consultations, number of hospital admissions and FDep. Odds Ratio are given with 95% confidence intervals.

# Results

In 2020, we identified 924 048 patients with HF. A total of 763 945 (82.6%) were still alive at the end of the year, including 164 974 (21.6%) with newly diagnosed HF. For this patient groups (among the 763 945), the mean age was 76.7 years ± 13.2, 413 723 (54.2%) were male.
The pneumococcal vaccine coverage was 9.1% (both pneumococcal vaccines) and 12.6% received at least one PCV13. For influenza, the vaccine coverage was 63.1% (season 2020/2021).

The mean (SD) numbers of visits during the year were respectively: 7.0 ± 6.8 with a general practitioner (GP), 1.7 ± 6.4 with a specialist, including cardiologists, 70.0 ± 120.0 with a nurse. The patients were hospitalized 2.8 ± 12.6 times on average during 2020. They benefited more from vaccination against pneumococcus when they received vaccination against influenza during the following campaign (OR: 2.833 [2.786; 2.882] or when they had a better access to health services.

In multivariable analyses (Figure 1 and Figure 2), the patients received at least one dose of PCV13, less often when they were (1) older (OR: 0.71 [0.67; 0.74], *P* < 0.0001 and 0.49 [0.46; 0.51], *P* < 0.0001 in patients 76–85 and older than 85 years old, respectively) (Figure 1), (2) when they were women (OR: 0.92 [0.90; 0.93], *P* < 0.0001) (Figure 1), or (3) when they presented social deprivation (for the quintiles Q3, Q4 and Q5 of deprivation index, OR were as follows respectively: 0.94 [0.91; 0.96], 0.90 [0.88; 0.93], 0.89 [0.87; 0.91] all *P* < 0.0001), as shown on Figure 2.

<figure><img src="image_2.png" /><figcaption>**Figure 2** In multivariable analyses adjusted on age, sex, universal healthcare coverage, access to GP index, influenza vaccine dispensing during 2020–2021 season, dispensing of other vaccines between 2009 and 2020 (meningococcal, hepatitis, diphtheria, tetanus, poliomyelitis and Haemophilus), number of GP/Private specialist/nurse consultations, number of hospital admissions, and FDep, the patients received at least one dose of the PCV13, less often when they were when they presented social deprivation (for the quintiles Q3, Q4 and Q5 of deprivation index, OR were as follows respectively: 0.936 [0.914; 0.959], 0.903 [0.882; 0.925], 0.893 [0.872; 0.914] all *P* < 0.0001). OR, odd ratio.</figcaption></figure>

<figure><img src="image_3.png" /></figure>
Although the pneumococcal vaccination is provided free of charge, access to vaccination remains poor in this vulnerable HF population (probably because of less access, other personal priorities, ...). It has been established that incentive campaigns and communication efforts promoting vaccination are challenging to develop and often yield disappointing results.6 Targeting specific subgroups such as elderlies, could require adapted strategies.7 To develop a tailored approach and optimize efforts cost-effectively, it is crucial to understand the factors limiting awareness and accessibility to vaccination. This goes beyond the generally low initial uptake among the general population and the potential knowledge gaps on vaccination among some healthcare providers.

First, age acts as a double-edged sword. On one hand, younger and very old patients are likely to feel less concerned about vaccination due to a lower perceived risk.8 More importantly, elderly individuals likely have limited access to care,9 probably in some rural areas or, paradoxically, in institutions (one explanation could be that this vaccine is not reimbursed to the hospital when administered during hospitalization in France). Secondly, the lower coverage in women is in line with previous findings.10 Third, general awareness to benefits offered by vaccination could easily explain that patients already vaccinated against influenza are more likely to be protected against pneumococcus,11 which was expected.

Last but not least, social deprivation is a significant determinant, as already evidenced in the context of COVID-19 and influenza,12 in spite of reimbursement.

We should acknowledge some limitations. First of all, this study was conducted during the start of the Covid 19 pandemic (including the Covid vaccination programme) that should introduce a bias, such as interferences with Covid vaccinations and reduced access to healthcare services. However, partial results during other years seem similar. The choice was mainly due to the vaccination strategy regarding pneumococcus itself.

## Conclusions

In this nationwide exhaustive study of more than 760 000 patients with chronic HF in 2020, vaccination coverage against pneumococcus was found to be dramatically insufficient, around 10%. This is particularly surprising given that the vaccination is free of charge and is considered effective for more than 5 years, which should justify better coverage on contrary, compared with the annual influenza vaccination campaign.

This study has several major strengths, including a large national sample size. The study was based on the SNDS medico-administrative database, which provides comprehensive patient information, thereby minimizing missing data. By contrast, some limitations have to be acknowledged, especially the observational design.

Several factors are clearly associated with reduced likelihood of being vaccinated: age (a 52% decrease in patients older than 85 years), gender (8.2% lower in women) and socioeconomic status (up to 11% lower in the 20% most deprived patients).

We need to consider these factors to adapt our public health initiatives supporting a significantly and sustainably increase pneumococcal vaccination coverage. Identifying these
patient groups should enable us to tailor health policies more efficiently. For instance,
targeted communications for women, special efforts for socially deprived patients, and
specific information for geriatricians and general practitioners (GPs) caring for the elderlies.

These data urge us to make massive efforts to reinforce vaccination, a simple and validated
way to improve health in our frail patients. To this end, further studies are needed to develop
public health incentive campaigns or other healthcare programs and to evaluate their impact
on coverage, cost-effectiveness, and, above all, clinical outcomes. For instance, our group is
assessing the impact of a large, randomized trial that evaluates the effect of a letter
encouraging vaccination in patients with heart failure (HF) (NCT06360315). These
approaches are likely to decrease hospitalizations for acute HF, all-cause hospitalizations and
all-cause mortality.

Funding

This study was supported by Pfizer France. The sponsor contributed to the study design, the
interpretation of the data, and to the revision of the manuscript.
## Graphical Abstract

### Socioeconomic determinants of vaccination against pneumococcus in 763,945 patients with heart failure.

**Background:**

Respiratory infections :leading cause of acute decompensation, hospitalization, and higher mortality in heart failure (HF) patients.

Vaccination coverage against pneumococcus and influenza remains alarmingly low.

**Aim:** to identify factors associated with vaccination among HF patients using data from the Nationwide Health Claims Database for 2020, in France.

**Methods:** The patients were followed during the entire year 2020. At least one dose of PCV13 was considered as a proxy for vaccination. The model used was a multivariable logistic regression.

**Results**

* 763,945 HF patients (mean age 76.7 years, 54.2% male),

* mean annual visits were
  7.0 with a general practitioner,
  1.68 with a specialist,
  70.0 with a nurse.

Despite frequent healthcare contacts, vaccination coverage was only 12.6% for pneumococcus (PCV13) and 63.1% for influenza.

We need to consider factors such as age, sex, social deprivation, to adapt public health initiatives supporting a significantly and sustainably increase pneumococcal vaccination coverage in frail HF patients.

**Results**

In multivariable analyses, at least one dose of the PCV13 was less often received when patients were 1/ older (odd ratio (OR) : 0.71 [0.67;0.74], P<.0001 and 0.48 [0.46;0.51], P<.0001) in patients 76-85 and older than 85 years-old, respectively, 2/ women (OR: 0.916 [0.903;0.929], P<.0001)

<figure><img src="image_4.png" /></figure>

3/ when they presented social deprivation (for the quintile Q5 of deprivation index, OR was 0.893 [0.872;0.914], P<.0001).

<figure><img src="image_5.png" /></figure>

Pneumococcus vaccination was associated with influenza vaccination or with better access to health services.

Respiratory infections heighten risks for heart failure (HF) patients, yet 2020 data from France show low vaccination rates: 12.6% for pneumococcus and 63.1% for influenza. Using logistic regression on 763,945 HF patients, older age, female sex, and social deprivation were associated with lower pneumococcus vaccination, despite frequent healthcare visits. Vaccination was more common among those also vaccinated for influenza or with better healthcare access. Tailored public health efforts are needed to boost pneumococcal vaccination in this vulnerable population.

## References

1. Shen L, Jhund PS, Anand IS, Bhatt AS, Desai AS, Maggioni AP, et al. Incidence and outcomes of pneumonia in patients with heart failure. *J Am Coll Cardiol* 2021;77:1961-1973. doi:10.1016/j.jacc.2021.03.001

2. Drozd M, Garland E, Walker AMN, Slater TA, Koshy A, Straw S, et al. Infection-related hospitalization in heart failure with reduced ejection fraction: a prospective observational cohort study. *Circ Heart Fail* 2020;13:e006746. doi:10.1161/CIRCHEARTFAILURE.119.006746

3. McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Bohm M, et al. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. *Eur Heart J* 2021;42:3599-3726. doi:10.1093/eurheartj/ehab368

4. Wyplosz B, Fernandes J, Sultan A, Roche N, Roubille F, Loubet P, et al. Pneumococcal and influenza vaccination coverage among at-risk adults: a 5-year French national observational study. *Vaccine* 2022;40:4911-4921. doi:10.1016/j.vaccine.2022.06.071

5. Rey G, Jougla E, Fouillet A, Hemon D. Ecological association between a deprivation index and mortality in France over the period 1997-2001: variations with spatial scale, degree of urbanicity, age, gender and cause of death. *BMC Public Health* 2009;9:33. doi:10.1186/1471-2458-9-33
6. Jacobson VJC, Jacobson RM, CoyneBeasley T, Asafu-Adjei JK, Szilagyi PG. Patient reminder and recall interventions to improve immunization rates. *Cochrane Database Syst Rev* 2018;1: CD003941. doi:10.1002/14651858.CD003941.pub3

7. Buja A, Grotto G, Taha M, Cocchio S, Baldo V. Use of information and communication technology strategies to increase vaccination coverage in older adults: a systematic review. *Vaccines* 2023;11:1274. doi:10.3390/vaccines11071274

8. Nolte J, Hanoch Y. Adult age differences in risk perception and risk taking. *Curr Opin Psychol* 2024;55:101746. doi:10.1016/j.copsyc.2023.101746

9. Osborn R, Moulds D, Squires D, Doty MM, Anderson C. International survey of older adults finds shortcomings in access, coordination, and patient-centered care. *Health Aff (Millwood)* 2014;33: 2247-2255. doi:10.1377/hlthaff.2014.0947

10. Zintel S, Flock C, Arbogast AL, Forster A, von Wagner C, Sieverding M. Gender differences in the intention to get vaccinated against COVID-19: a systematic review and meta-analysis. *Z GesundhWiss* 2022;7:1-25. doi:10.1007/s10389-021-01677-w

11. Roy DN, Biswas M, Islam E, Azam MS. Potential factors influencing COVID-19 vaccine acceptance and hesitancy: a systematic review. *PLoS ONE* 2022; 17:e0265496. doi:10.1371/journal. pone.0265496

12. Giacomelli A, Galli M, Maggi S, Noale M, Trevisan C, Pagani G, et al. Influenza vaccination uptake in the general Italian population during the 2020-2021 flu season: data from the EPICOVID-19 online web-based survey. *Vaccines (Basel)* 2022;10:293. doi:10.3390/vaccines10020293
References

1. Shen L, Jhund PS, Anand IS, Bhatt AS, Desai AS, Maggioni AP, et al. Incidence and outcomes of pneumonia in patients with heart failure. J Am Coll Cardiol 2021;77:1961-1973. doi:10.1016/j.jacc.2021.03.001

2. Drozd M, Garland E, Walker AMN, Slater TA, Koshy A, Straw S, et al. Infection-related hospitalization in heart failure with reduced ejection fraction: a prospective observational cohort study. Circ Heart Fail 2020;13:e006746. doi:10.1161/CIRCHEARTFAILURE.119.006746

3. McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Bohm M, et al. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J 2021;42:3599-3726. doi:10.1093/eurheartj/ehab368

4. Wyplosz B, Fernandes J, Sultan A, Roche N, Roubille F, Loubet P, et al. Pneumococcal and influenza vaccination coverage among at-risk adults: a 5-year French national observational study. Vaccine 2022;40:4911-4921. doi:10.1016/j.vaccine.2022.06.071

5. Rey G, Jougla E, Fouillet A, Hemon D. Ecological association between a deprivation index and mortality in France over the period 1997-2001: variations with spatial scale, degree of urbanicity, age, gender and cause of death. BMC Public Health 2009;9:33. doi:10.1186/1471-2458-9-33

6. Jacobson VJC, Jacobson RM, Coyne-Beasley T, Asafu-Adjei JK, Szilagyi PG. Patient reminder and recall interventions to improve immunization rates. Cochrane Database Syst Rev 2018;1:CD003941. doi:10.1002/14651858.CD003941.pub3

7. Buja A, Grotto G, Taha M, Cocchio S, Baldo V. Use of information and communication technology strategies to increase vaccination coverage in older adults: a systematic review. Vaccines 2023;11:1274. doi:10.3390/vaccines11071274

8. Nolte J, Hanoch Y. Adult age differences in risk perception and risk taking. Curr Opin Psychol 2024;55:101746. doi:10.1016/j.copsyc.2023.101746

9. Osborn R, Moulds D, Squires D, Doty MM, Anderson C. International survey of older adults finds shortcomings in access, coordination, and patient-centered care. Health Aff (Millwood) 2014;33:2247-2255. doi:10.1377/hlthaff.2014.0947

10. Zintel S, Flock C, Arbogast AL, Forster A, von Wagner C, Sieverding M. Gender differences in the intention to get vaccinated against COVID-19: a systematic review and meta-analysis. Z Gesundh-Wiss 2022;7:1-25. doi:10.1007/s10389-021-01677-w

11. Roy DN, Biswas M, Islam E, Azam MS. Potential factors influencing COVID-19 vaccine acceptance and hesitancy: a systematic review. PLoS ONE 2022;17:e0265496. doi:10.1371/journal.pone.0265496

12. Giacomelli A, Galli M, Maggi S, Noale M, Trevisan C, Pagani G, et al. Influenza vaccination uptake in the general Italian population during the 2020-2021 flu season: data from the EPICOVID-19 online web-based survey. Vaccines (Basel) 2022;10:293. doi:10.3390/vaccines10020293