Vaccine administration just got more complicated!
Pneumococcal disease (caused by the bacterium Streptococcus pneumoniae) can result in three serious conditions: pneumonia, bacteremia, and meningitis. The bacterium has over 90 subtypes.
For many years, to protect adults against an illness with Streptococcus pneumoniae bacterium, we had only one pneumococcal vaccine approved by the FDA, the pneumonia polysaccharide vaccine PPSV23, brand name Pneumovax 23, protective against 23 serotypes. Almost everyone received this immunization, once, at age 65, with few exceptions. Many of us in travel health didn’t even view this vaccine as part of our pre-travel toolkit; rather, it was an immunization for seniors typically provided at a primary care visit.
Then this began to change:
- There were more indications for the use of pneumococcal polysaccharide vaccine
Starting in 2012, ACIP expanded indications for the use of the pneumococcal polysaccharide vaccine PPSV23 to include adults ages 19 and older who smoked, had asthma, or were at increased risk for invasive pneumococcal disease or its complications:
- Persons 2 years of age and older with a normal immune system who have a chronic illness, including cardiovascular disease, pulmonary disease, diabetes, alcoholism, chronic liver disease, cirrhosis, cerebrospinal fluid leak, or a cochlear implant.
In addition, the vaccine is also indicated for immunocompromised persons 2 years of age and older who are at highest risk of pneumococcal disease or its complications:
- Splenic dysfunction or absence either from disease or surgical removal).Cancer, including Hodgkin disease, lymphoma, and multiple myeloma, chronic renal failure or nephrotic syndrome, asymptomatic or symptomatic HIV infection., conditions such as organ transplant associated with immunosuppression, immunosuppression from chemotherapy or high-dose corticosteroid therapy 14 days or longer.
- PPSV23 also might be considered for persons living in special environments or social settings with an identified increased risk of pneumococcal disease or its complications, such as certain Native American (i.e., Alaska Native, Navajo, and Apache) populations.
- The FDA approved a second pneumococcal vaccine: PCV13, brand name Prevnar.
Licensed in 2010, it includes protection against 13 serotypes, including serotype 19A. Since 2007 serotype 19A has been the most common cause of invasive pneumococcal disease in all age groups. Indications include:
- All adults 65 years of age or older who have not previously received PCV13, or whose previous vaccination history is unknown, should receive a single PCV13 dose.
- Since June 2012, ACIP recommends a single lifetime dose for all PCV13-naïve adults 19 years and older with: Functional or anatomic asplenia (e.g., from sickle cell disease or splenectomy), HIV infection, leukemia or lymphoma, Hodgkin disease, multiple myeloma, or generalized malignancy, chronic renal failure or nephrotic syndrome, other conditions associated with immunosuppression (e.g., organ or bone marrow transplant), immunosuppressive chemotherapy, including long-term corticosteroids, cerebrospinal fluid (CSF) leak, and cochlear implants.
- There was new understanding of the importance of pneumonia immunization for international travel
Our recognition for the risk of pneumococcal infection for travelers changed. Worldwide, the number of resistant pneumococcal serotypes has increased. While there are just five serotypes of meningitis, there are more than 92 pneumococcal serotypes and resistance to the standard pneumococcal antibiotics is growing. Spread by respiratory droplets, pneumococcal infections pose a risk to anyone traveling by air or traveling to areas with congestion (the Hajj, large gatherings such as the Olympics, etc.).
Now In 2016 we have some good news, some not so good news, and some REALLY GOOD news:
The good news? Clinicians can now help protect their adult patients against a total of 32 serotypes of pneumonia by using the two available approved vaccines. As travel health nurses, we need to consider the administration of these vaccines as part of our pre-travel preparation for a growing number of adult travelers.
The not-so-good news? Unfortunately, the schedule for administering these two immunizations is not straightforward. The order in which these vaccines are given determines the minimal interval between doses. Contrary to the rule for all other inactivated vaccines, these two killed vaccines are not to be given together at the same visit.
The REALLY GOOD news? Recent CDC and IAC offerings can help make sense of this more complicated administration schedule.
The CDC chart Pneumococcal Vaccine Timing for Adults is a valuable tool for any travel health nurse scheduling either or both pneumococcal vaccines. It clearly spells out the administration schedule in a way that is quick and easy to interpret. Find it, and much more pneumococcal information, at: http://www.cdc.gov/vaccines/vpd-vac/pneumo/downloads/adult-vax-clinician-aid.pdf
CDC has also updated its CE series, You Call the Shots, to include a section on pneumococcal vaccination. Watch this February 2016 program to get a good overview of pneumococcal disease and approved vaccines. If you wish, you can skip the background content and go directly to the vaccine administration section. That is where you will find a chart that clearly shows the timing for the two different pneumococcal immunizations. http://www2.cdc.gov/nip/isd/YCTS/mod1/courses/pneumo/ce.asp
Immunization Action Coalition (IAC) Resources
IAC is always providing helpful clinical tools on their website. A recent addition is Pneumococcus: Q&A which gives a concise overview of the topic and the two vaccines. http://www.immunize.org/catg.d/p4213.pdf The March 2016 issue of Needle Tips also features an article on this topic https://mail.aol.com/webmail-std/en-us/suite
In addition, you can order free Pneumococcus Vaccine Pocket Guides that are an easy access resource for clinicians at http://www.immunize.org/pocketguides/pocketguide_pneumococcal_2016.pdf
While administering these two vaccines, remember some important health counseling points:
- Educate your travelers to use and understand the appropriate terminology when discussing these two vaccines. Since the Streptococcus pneumoniae causes three health conditions (pneumonia, bacteremia, and meningitis) the appropriate term to describe these vaccines is pneumococcal not the more commonly heard “pneumonia” vaccine.
- Explain the rationale for this schedule. You and your travelers may ask why can’t these two inactivated vaccines be administered together? In travel health, we are able to give all the other inactivated vaccines together. As described in the definitive ACIP Recommendation document, vaccine clinical trials demonstrated that if these two vaccines are given too closely together then the protective effect of PCV13 is reduced. http://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/pneumo.html
- Remind all travelers that flu vaccine is still considered the most important way to prevent respiratory illness during travel.
- Travelers who smoke should work to reduce this important risk factor for all pulmonary disease and seek smoking cessation counseling.
- Travelers who have underlying pulmonary health problems should talk to their primary care provider about all the ways they can reduce their personal risk for respiratory infections and complications.
- Every traveler should remember good respiratory hygiene- cough into a disposable tissue or your elbow, not your hand, wash hands frequently or use a 60% ETOH product, and know that paper masks are not protective.
Gail Rosselot NP, MPH, COHN-S, FFTM, RCPS (Glas), FAANP
Certificate in Travel Health (r)