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Keeping Up With Adult Vaccinations

For pneumococcal disease, the 2015 rate of reported invasive disease was 29,500 cases (9.2/100,000), with 3350 fatalities (1.04/100,000).5 Recommendations for the use of the pneumococcal conjugate 13-valent vaccine (PCV13) and the polysaccharide 23-valent vaccine (PPSV23) were last updated in 2015. The complex decision-making algorithm for vaccine administration and timing is noted in Table 4. A recent study6 examined longer-term immunogenicity in immunocompetent patients 65 and older by measuring serial PCV13 serotype-specific opsonophagocytic activity titers and immunoglobulin G concentrations at 1 month, 12 months, and 24 months post immunization. A placebo comparison was able to be designed because the study was conducted in the Netherlands, where there is no mandate for PCV13 vaccination. Geometric mean titers were sustainably higher in the treatment group. A post hoc subgroup analysis demonstrated that in patients over 80, the titer response waned, bringing into question the relative influenza vaccine effectiveness (VE) with advanced age. Until that is determined, only a single dose is recommended for those over 65 currently.

Table 4: Pneumococcal Vaccine Preparations and Timing

For influenza, the rate of reported positive influenza swabs for the 2016-2017 season was 130,500, with the number of visits for influenza-like illness at 278,706 and reported mortality at 9788 cases.7 The majority of 2016 isolates were classified as H3N2. The recommendations for the 2017-2018 influenza season were just released at the end of this past August.8 The recommendations for vaccination of the entire population over 6 months unless contraindicated remain in place.

Regarding the choice of vaccine, the live attenuated vaccine is again not recommended because of concerns regarding effectiveness. This was supported by follow-up studies identifying lowered hemagglutinin activity of the attenuated strain from 2013-2014, leading to a lower replicative capacity and a subsequently lower immunogenic response to produce antibodies. Investigators are actively studying newer formulation strains so that the live product may become a viable alternative again. Trivalent and quadrivalent vaccines remain in equipoise, while standard dose (SD) versus high dose (HD) in select elderly patients is still a matter of ongoing debate. The prevailing public health goal is to improve vaccination rates, particularly in younger adults at higher risk.

According to the annual review by the ACIP regarding these vaccines, the overall VE across all strains of influenza vaccine for all ages was 48%. This was largely driven by lower effectiveness of the egg-based vaccine for H3N2. Administration of the higher-dose recombinant vaccine (RIV4), however, was found to result in an improved relative efficacy (compared with active comparator vaccine) against influenza A of 36% (95% CI, 14%-53%) (hazard ratio [HR], 0.64; 95% CI, 0.48- 0.86; P = .003) but no difference with respect to influenza B. Recombinant vaccine also contains no egg by-products, reducing the likelihood of a reaction in patients with a history of a truly severe egg allergy.

Want more information on this topic and the opportunity to ask questions of an expert? Register for a live, ACPE accredited webinar February 28th 8-9 PM EST at this link:
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