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Adult Immunization Physician Advisor Speaks on Pneumococcal Vaccinations

Gregory Poland, MD, FACP, chair of the ACP-ASIM Adult Immunization Initiative's Physician Advisory Board recently spoke on the current guidelines for pneumococcal vaccinations. Dr. Poland covered some of our members' frequently asked questions about the pneumococcal vaccine and shared ways for physicians to improve their pneumococcal vaccination practices.

Current guidelines by the Advisory Committee on Immunization Practices (ACIP) recommend pneumococcal vaccine for patients 65 years of age and older and others when indicated: Why do you feel 65 was chosen as the starting point?

Dr Poland: ACIP looked at the incidence of serious disease due to pneumococcus. Sixty-five was chosen because that's where the rate of incidence increases rapidly and because, at the time, the universal recommendation for influenza vaccine was 65. Now influenza vaccinations have been moved back to age 50, the time when other preventive health care interventions start.

Do you feel that change in the influenza recommendation will prompt a change in the pneumococcal recommendation?

Dr Poland: I think it could. The ACIP has not yet made that recommendation, but with routine health care maneuvers at age 50, such as colon cancer, prostate cancer, and breast cancer screening, that would be an opportune time.

One strong reason to move pneumococcal is that about a third of Americans already have risk factors for complicated pneumococcal disease by age 50. It's not as though you're at risk at age 65 when you weren't at risk at 64. It's just that when you graph out the number of cases by adult population, the slope of that line changes dramatically at about age 65.

So what's your recommendation to practicing physicians until the guidelines are addressed again? What do you do in your practice?

Dr Poland: I follow the ACIP guidelines - I recommend the immunization for patients over 65, and when I look at the person under age 65, I ask myself, "Is this person at high risk of pneumococcal infection and complications from that infection?" If the answer in my mind is yes, I give them the vaccine.

This guideline gets complicated by the fact that all we have is the 23 polysaccharide pneumococcal vaccine for adults, which requires a revaccination. As you know, this past year there was a pneumococcal conjugate vaccine released for children. Much thought is going into the need for a conjugate vaccine for adults too.

Why would a conjugate vaccine be good for adults?

Dr Poland: A conjugate vaccine gets hooked to a protein rather than just being a sugar molecule, which is what a polysaccharide is. By hooking it to a protein, you change it to a vaccine that becomes T-cell dependent. Meaning, after your body sees that vaccine, it develops long-term immune memory cells. This is why you don't have to give boosters for T-cell dependent vaccines. Right now, the only vaccine available for adults is a T-cell independent vaccine, so there are no long-term memory cells developed. It's totally dependent on antibody and requires revaccination.

Can you explain the distinction between booster and revaccination.

Dr Poland: What booster formally refers to is when you give an additional dose to someone who has immune memory to boost a memory response. Revaccination refers to giving another dose to develop an antibody response.

The question that remains with the pneumoccoccal revaccination is: how long does it last? People are living long enough now that we wonder, do you need a third dose, or a fourth? No one knows. The answer to that will be a conjugate vaccine, it's just not available yet.

Is that part of the confusion surrounding the pneumococcal revaccination?

The current guidelines for pneumococcal immunization say to administer the immunization at age 65 or between ages 2 and 65 when indicated. If somebody's received the immunization before age 65 and it's been five years or more, give a one-time revaccination.

This has been very, very confusing to physicians because of an initial report. The report showed that people who got a second dose of pneumococcal vaccine had a high rate of severe local and even systemic serum sickness-like reactions. Now, that was true, but those happened to be in a small group of people who had gotten their first dose of vaccine less than three years earlier and had high circulating antibody levels. That's why the current recommendation for adults is to get it five or more years after their first dose. Then we do not see any higher rate of local side effects than we would see after the first dose.

How quickly would they show a bad reaction if they had been vaccinated within three years?

Dr Poland: You would probably see one within a 24 to 72 hour time period. In that initial report there were both local and systemic reactions, the systemic reactions were almost a serum sickness-like picture. The local reactions were swollen, tender, hot arms, sometimes with fever and malaise. I've been doing vaccinations for 20 years and I've never seen anything that dramatic. I know they're out there, but I do all the vaccine consults at the Mayo Clinic and I haven't seen one, so I'm not too worried about it.

What do you do when the patient doesn't recall his or her immunization history?

Dr Poland: Okay, this is a very good question and often the case when dealing with elderly adults who may go to more than one place for their health care. The thing to keep in mind is that pneumoccoccal immunization rates are so low - the recommendation from ACIP is if you don't know and they don't know, give them a dose of vaccine. The consequence of not doing it is that millions go unimmunized and as a result 20,000 people or more die in the U.S. each year.

Part of the reluctance for the private practitioner is that, in the past, if they gave a dose of vaccine and it turned out that the patient did receive the vaccine before, Medicare would deny the claim and the doctor would have to pay.

So in the past Medicare would deny the claim if there was a previous claim?

Dr Poland: Correct. Medicare knows when the patient last received the vaccine, but the practicing physician doesn't. The good news is about three years ago Medicare pledged that they would not deny any reasonable claim that came in like that. Many private doctors out there may not realize this and still labor under that misconception that they might end up paying for the pneumococcal vaccination themselves.

The GAO recently released a report on the 2000-01 influenza shortage that mentioned if influenza vaccination is not available, to vaccinate patients for pneumococcal because it helps with some of the complications*. Do you feel this is the case?

Dr Poland: Yes, what the report was referring to is that one of the most common bacterial infections that occurs as a consequence of influenza infection is pneumococcal infection. But just to be clear, it's not saying that a 30 year-old healthy woman should receive the pneumococcal vaccine in the event of an influenza shortage. It is the 50 year-old smoker with heart disease or diabetes who should get a dose of pneumococcal vaccine.

* Review the GAO report at http://www.gao.gov/new.items/d01624.pdf

What can physicians do to improve their pneumococcal immunization practices?

Dr Poland: People don't think about pneumococcal vaccine; influenza vaccine is easier to remember because every year there's a campaign and it's always in the fall. We should hook up influenza campaigns with the pneumococcal vaccine. Pneumococcal vaccine can be administered at the same time as influenza vaccine, just inject it at a different site. Of course, the pneumococcal vaccine can be given year round, but matching it with influenza vaccination is a convenient time.

As you know, the new Healthy People 2010 goals have established a 90 percent rate of pneumococcal immunization; we're about 40 or 45 percent at best, in many populations, it's 20 to 30 percent. So we've got a long, long way to go. Improvements will only happen if there are processes in place.

And whether a physician is in some kind of organizational setting or a private practice setting, somebody in the office has to be the champion for immunization or rates will not improve. Physicians can use an office nurse with a standing order program. This has been demonstrated and works. Give the nurse the authority to ask about and administer vaccines without physician's orders. We do that in all the Mayo hospitals now.

If physicians don't want to do that, they should have some kind of process in place, electronic or otherwise, to measure and report immunization rates. If somebody measures that and feeds that information back to the practice or practitioner, immunization rates go up. So much the better if there's some kind of organized process that automatically happens in the office that the physician doesn't have to think of, that would be my advice.

Dr. Poland is the chair of the Adult Immunization Initiative's Physician Advisory Board and has been very active in ACP-ASIM and other organizations' efforts to promote adult immunization. A fellow of ACP-ASIM, Dr. Poland has been a contributing author to Guide for Adult Immunization and has served on the ACP-ASIM Adult Immunization Task Force. His faculty positions at the Mayo Clinic in Rochester, MN, include professor of medicine, Dept. of Internal Medicine, and chief of Mayo Vaccine Research Group, Clinical Pharmacology Unit.

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