Pneumonia Shots- Part 2: Immunocompromised Adults

Welcome back to Part 2 of the great Prevnar vs Pneumovax Update here at I Hate Rashes.

Last time, I talked about the differences between the two vaccines and the current recommendations for adults >65.  To recap, Pneumovax is a polysaccharide vaccine that covers 23 serotypes of S. Pneumoniae (PPSV23).  This is great because it is so broad.  Prevnar is a Conjugate polysaccharide vaccine that covers 13 serotypes (PCV13).  This is great because conjugating the pneumococcal polysaccharide to a diphtheria toxin boosts immunity and helps lead to herd immunity.  ACIP currently recommends that we give both PCV13 and PPSV 23 to our patients over 65. It is probably best to give PCV 13 first if the patient hasn’t had any pneumococcal vaccines. 
But what about all of those adults who get the pneumococcal vaccine BEFORE age 65? What should we do with them?  It is probably helpful to divide our recommendations between the immunocompetent vs immunocompromised conditions.

Those who are immunocompromised actually have long been recommended to get both PCV13 and PPSV23. This includes patients with asplenia, CSF leaks,  cochlear implants, HIV and other immunodeficiencies, nephrotic syndrome, leukemia/lymphoma, myeloma, transplants, and iatrogenic immunosuppression.  Iatrogenic immunosuppression includes chronic steroids, radiation therapy, and probably immunomodulators used in rheumatologic diseases. Most of these will need revaccination with PPSV23 5 years after their first vaccine: there is no need to revaccinate with the PCV13.

The immunocompetent patients continue to get just the PPSV23 prior to age 65.  This is for our patients with diabetes, COPD/Asthma/smoking, chronic heart disease, and chronic liver disease/alcoholism.  Once they turn 65, give them PCV13 and then repeat the PPSV23 about a year later.

Here’s a handy chart if you are more of a visual learner.

Risk group

Underlying medical condition

PCV13

PPSV23

Recommended

Recommended

Revaccination 5 yrs after first dose

Immunocompetent persons

Chronic heart disease

Chronic lung disease§

Diabetes mellitus

Cerebrospinal fluid leak

Cochlear implant

Alcoholism

Chronic liver disease, cirrhosis

Cigarette smoking

Persons with functional or anatomic asplenia

Sickle cell disease/other hemoglobinopathy

Congenital or acquired asplenia

Immunocompromised persons

Congenital or acquired immunodeficiency

Human immunodeficiency virus infection

Chronic renal failure

Nephrotic syndrome

Leukemia

Lymphoma

Hodgkin disease

Generalized malignancy

Iatrogenic immunosuppression**

Solid organ transplant

Multiple myeloma

Let’s practice some more:  For each patient, do you give PCV13 vs PPSV2, or both

  1. 55 newly diagnosed diabetic
  2. 60 year old with COPD, never had pneumococcal vaccine before
  3. 62 year old with COPD, had PPSV23 3 years ago, takes prednisone 5mg daily.
  4. 25 year old with coclear implants, never had pneumococcal vaccine before
  5. 35 year old with well controlled HIV, never had PCV13, had PPSV23 10 years ago, at diagnosis.

Let me know your answers or questions in the comments!

Here’s a link to the CDCs Adult Vaccine Schedule- note the new guideline for adults age 65 and over is not included here, yet.  There’s also an app for that.

 

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Pneumonia shots- part 1: Patients over 65

In my ever continuing struggle to stay up to date, i thought I’d post today about something that was big news back in the Fall: Two pneumonia shots for seniors.

The old news was that everyone needed a pneumonia shot at age 65- one and done, we always thought.  That “pneumonia shot” was really a vaccine against S. Pneumoniae, which causes meningitis, sepsis, along with the pneumonia that it was so nicely named for.  The standard vaccine that we used in adults was the 23-Valent polysaccharide vaccine (PPSV23), brand name Pneumovax.  This vaccine covers 23 serotypes of S. pneumoniae (that’s the 23 valent part of the name), and is made from polysaccharides found in the capsules of the bacterium (that’s the polysaccharide part of the name).  This shot is great because it covers so many different serotypes.  The downside of polysaccharide vaccines is that they can’t be given in children <2, they don’t provide lifelong immunity, and they don’t provide mucosal immunity (important because mucosal immunity promotes herd immunity). Studies on this vaccine show that it can prevent invasive pneumococcal disease, but may not be so great at preventing the noninvasive pneumococcal pneumonia.

These “polysaccharides” come from the S. pneumoniae capsule.

Enter the 13 Valent Conjugate Vaccine (PCV13), brand name Prevnar. This still uses polysaccharides from the pneumococcal bacteria, but attaches (conjugates) them to a “carrier protein”– in this case, a protein from diptheria. This carrier protein helps to rev up the immune system and induces mucosal immunity.  After several exposures, this kind of vaccine will induce lifelong immunity.  Before this year, we were commonly using this kind of vaccine in children (since the other one didn’t work), and in immunocompromised adults, but not in everyone.  We know from this vaccine, and another conjugate pneumonia vaccine (PCV7), that immunizing children reduces the prevalence of those particular serotypes in adults (remember, mucosal immunity is a key to creating herd immunity).

The new news is that the PCV13 is now recommended for all adults >65.  This recommendation came on the heels of a study performed by Pfizer (you can guess what they make) in the Netherlands.  They studied 85,000 adults >65 who had never had a pneumococcal vaccine, and compared PCV13 to Placebo.  There was a 75% reduction in vaccine-type pneumococcal disease in the vaccine group, and a 45% reduction in vaccine-type CAP.  This was convincing enough for ACIP (the group that makes vaccine schedule recommendations).  It is important to say again: participants in the study DID NOT have PPSV23 prior to the PCV13. Many of our patients have already had PPSV23.

We do know that PCV13 does induce an immune response in seniors, even if they have already had the PPSV23.  It seems to be a “higher” immune response than the PPSV23, indicating that it may be the better vaccine between the two.

So what to do?  Currently ACIP recommends that we give BOTH PCV13 and PPSV23 to our patients over 65.  The ideal scenario would be to give the PCV13 (Prevnar) first, and then the PPSV23 (Pneumovax) 6-12 months later. This is what you should do for patients who have never had any pneumococcal vaccination, as well as those who you are revaccinating because they have turned 65.  If your patient over 65 has already had PPSV23, then wait a year before giving the PCV13. See the handy chart below for potential scenarios

Pneumococcal vaccine status:

FIRST give:

THEN give:

None/Unknown

Prevnar 13
(≥ age 65)

Pneumovax 23

(6 to 12 months after Prevnar 13)

Pneumovax 23
Given AFTER 65
th birthday

Prevnar 13
(≥ 12 months after Pneumovax 23)

n/a

Pneumovax 23
Given BEFORE 65
th birthday

Prevnar 13

(≥ age 65 AND

≥ 1 year after Pneumovax 23)

Pneumovax 23
(6 to 12 months after Prevnar 13 AND
5 years after Pneumovax 23)

So what about paying for these vaccines?  That is another sticky situation. Medicare currently pays for ONE S. Pneumonia vaccine per lifetime– which now seems to run counter to ACIP guidelines.  It will take a year or two for Medicare to catch up, so don’t expect this to change until about 2016. *UPDATED INFO: Medicare, BCBS and Viva are in fact paying for the PCV13 vaccine.  My read of the Medicare website shows that the second pneumococcal vaccine will be covered if it is given 11 months after the first one.  If your patient is new to Medicare, or hasn’t had any S. pneumoniae vaccines yet, give them the PCV13– it is more immunogenic and is better to give first.  If your patient has already gotten a PPSV23 while covered by Medicare, they will likely have to pay out of pocket ($100-$150) to get the PCV13.  My advice is to wait until the Medicare guidelines catch up. After that, wait a year or so and give the PPSV23.  If they have already had the PPSV23, then give the PCV13 the next year.  It is safe to give the second shot as early as 8 weeks after the first one.

Here are some practice scenarios. Let me know which vaccine you would give, when, and why in the comments.

  1. 65 year old, no medical problems, never had a S. Pneumoniae vaccine
  2. 75 year old, Medicare patient, vaccinated with PPSV23 at age 65
  3. 65 year old with diabetes, new to Medicare, got PPSV23 at age 59 after diagnosis with DM

If you are ready to move on to Part 2, take a look at this post.

Here’s a link to the CDCs Adult Vaccine Schedule- note the new guideline for adults age 65 and over is not included here, yet.  There’s also an app for that.

Not what I was looking for: Incidental Findings

Just read this great article in The Atlantic by Danielle Ofri: The Ethical Implications of Incidental Findings  OK, so was posted over a month ago, but lots of things (like this) got in the way of reading it. Then suddenly, I had a lot of free time, and I found it.

I recently had a patient, whom I had not seen in over 2 years, call and ask to be put on prednisone due to an abnormality found on a chest CT ordered for a research study. Turns out she had bronchiectasis that was found “incidentally” during the study.  Clearly systemic steroids carry significant risk, and the patient was nearly asymptomatic, but worried about this finding. So this set off an avalanche of testing and referral to try to figure out what was going on. Of course, her insurance will pay for this, but should it?Should the study in question compensate her for this work-up? Thanks to the ACA, she shouldn’t be denied health insurance because of whatever we find, but she may be denied life insurance, or have other financial repercussions.  Alternatively, we may find something that we could intervene upon and extend her life.

I talk to patients about incidental findings quite frequently. It’s my mantra when trying to talk patients out of the “MRI of my whole body”, and various testing requests that are not indicated. As a primary care doctor, I’m often called upon to explain the scary/confusing findings that were uncovered by a study, the ER, or another physician. Sometimes I find a note in a radiology report that no one else mentioned. Or it might be buried in a discharge summary, but no follow-up was arranged. One study done at a trauma center estimates 1/3 of CT scans done on trauma patients had an incidental finding.  Nearly 2/3 of those were not mentioned in either the H&P or the discharge summary, just hidden in a radiological report.

So, how do you feel about these “incidental findings?” Who’s responsible for the follow-up and cost? For explaining things to the patient in the first place? How do you warn people about the potential for unintended consequences to testing?

Related content:

Another blog picks up this story (and thanks for the House GIF)

There was a Bioethics Commission report on this very topic released recently, here’s a summary from Science and here’s the whole report.