By Dr. Geoffrey Modest
So, on rare occasions, there is news which makes life easier for primary care (sort of like the convergence of a lunar eclipse and a super moon).
- The CDC’s Advisory Committee on Immunization Practices (ACIP) has actually simplified the pneumococcal vaccine schedule (see http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6434a4.htm?s_cid=mm6434a4_w ). I have sent out prior blogs detailing the confusing administration of PCV-13 (the 13-valent vaccine which has been given to kids for years) and PPSV-23 (the old 23-valent vaccine for adults) in immunocompetent adults >65yo, highlighting that the dose of PCV-13 should be at least one year after PPSV-23; though if PCV-13 is given first, then the PPSV-23 could be given 6-12 months later. So, the new recommendation is to wait >= 1 year in either of the PPSV-23/PCV-13 sequences (note: there are no clinical data on the timing of the different vaccines, just immunogenicity studies which really do not even address these intervals directly, and one study finding more localized injection-site swelling if given at 2 month intervals vs 6 months apart). So, now, the common scenarios for an immunocompetent adult >65yo are:
- If never got vaccine, give PCV-13 at age 65, then wait a year and give PPSV-23
- If already given PPSV-23, then wait a year and give PCV-13 (no earlier than 65yo)
- But, if got PPSV-23 younger than age 65 (smoker, asthma, chronic lung disease, etc. etc.), then give PCV-13 at age 65 (if at least one year after the PPSV-23), and then can get their regular post-65 PPSV-23 if at least 1 year after the PCV-13 and 5 years after their last PPSV-23.
- If a dose of PPSV-23 is inadvertently given earlier than recommended, don’t repeat the dose.
- Remember that 40% of invasive pneumococcal infections occurring in those >65yo are caused by serotypes unique to PPSV-23: i.e., we should generally make sure that those >65 yo get both vaccines
Got it? (It actually is a slight bit simpler….)
But, for immunocompromised people (asplenia, HIV, nephrotic syndrome, chronic renal failure, congenital immunodeficiency, cancers, organ transplant), the interval for all patients above age 2 is PCV-13 followed by PPSV-23 after 8 weeks. If they got PPSV-23 first, they should wait 8 weeks for PCV-13 until they are 18yo, thereafter wait 1 year.
- So far, not a lot of influenza activity in the US (through 9/5/15), but the good news: all of the virus samples collected so far in the US and other countries have been “antigenically and/or genetically characterized as being similar to the influenza vaccine viruses recommended for inclusion in the 2015-2016 Northern Hemisphere vaccine” (see http://1.usa.gov/1VGKSHe). I.e., it seems like a good match. Which is, by the way, really different from last year, where there was really low vaccine effectiveness against the predominant influenza A (H3N2) virus, and the laboratory data showed a poor antigenic/genetic match. We’ll see….. But at least it looks good so far.
By the way, the breakdown for the first 1698 cases of influenza so far in the US is 54% influenza A (of which 5% were pH1N1, 93% H3N2), 46% influenza B. There have been a handful of variant viruses but of the H3N2 and H1N1 strains. All of the tested viruses were susceptible to neuraminidase inhibitors, but adamantanes (e.g. amanadine) does not work/lots of resistance.