Update on Pneumococcal Vaccines Photo Credit: Content Providers(s): CDC/Dr. M.S. Mitchell - This media comes from the Centers for Disease Control and Prevention's Public Health Image Library (PHIL), with identification number #1003 CSF showing meningitis caused by S. pneumoniae

Objectives for Today Describe pneumococcal disease basics Identify which adults need both PCV13 and PPSV23 Indentify which adults age 19-64 need just PPSV23

Pneumococcal Disease Second most common cause of vaccine preventable death in the US Major clinical syndromes include Pneumonia Bacteremia Meningitis Streptococcus pneumoniae in spinal fluid. FA stain digitally colorized (direct fluorescent antibody). It is estimated that 18,000 people die annually from complications of pneumococcal disease. Infants and the elderly are hit the hardest. S. pneumoniae resides asymptomatically in the nasopharynx of healthy carriers. The respiratory tract, sinuses, and nasal cavity are the parts of host body that are usually infected. However, in susceptible individuals, such as elderly and immunocompromised people and children, the bacterium may become pathogenic, spread to other locations and cause disease. S. pneumoniae is the main cause of community acquired pneumonia and meningitis in children and the elderly, and of septicemia in HIV-infected persons. The methods of transmission include sneezing, coughing, and direct contact with an infected person. Despite the name, the organism causes many types of pneumococcal infections other than pneumonia. These invasive pneumococcal diseases include bronchitis, rhinitis, acute sinusitis, otitis media, conjunctivitis, meningitis, bacteremia, sepsis, osteomyelitis, septic arthritis, Streptococcus pneumoniae is a normal inhabitant of the human upper respiratory tract. The bacterium can cause pneumonia, usually of the lobar type, paranasal sinusitis and otitis media, or meningitis, which is usually secondary to one of the former infections. It also causes osteomyelitis, septic arthritis, endocarditis, peritonitis, cellulitis and brain abscesses. Streptococcus pneumoniae is currently the leading cause of invasive bacterial disease in children and the elderly. Streptococcus pneumoniae is known in medical microbiology as the pneumococcus, referring to its morphology and its consistent involvement in pneumococcal pneumonia.endocarditis, peritonitis, pericarditis, cellulitis, and brain abscess.[2] It is better to prevent than to try and fight pneumococcal disease with antibiotics that might not work. .

Pneumococcal Pneumonia Estimated 175,000 hospitalizations in U.S. Up to 36% of adult-community acquired pneumonia and 50% of hospital acquired pneumonia Common complication (bacterial) of influenza and measles Case fatality rate 5-7%, much higher in elderly Pneumonia of the right middle lobe

Pneumococcal Bacteremia More than 50,000 cases per year in the United States Rates higher among elderly and very young infants Case-fatality rate ~20%; up to 60% among the elderly Septi Chek Blood Culture Bottles

Pneumococcal Meningitis Estimated 3,000–6,000 cases per year in the United States Case-fatality rate ~30%, up to 80% in the elderly Neurologic sequelae common among survivors Increased risk in persons with cochlear implant Purulence covering the brain surface Photo courtesy of CDC

The following are at HIGH RISK for PNEUMOCCAL DISEASE: ●Those ≥ 65 Years of Age ●Persons 19-64 years with asthma or smokes cigarettes ●Persons 19-64 with chronic illnesses

Adult 65 and Older CDC recommends all adult ≥ 65 receive 2 types of pneumococcal vaccines One dose of PCV13 (first) One dose of PPSV23 ( 6 to 12 months after PCV vaccine) This age group requires both vaccines for the best protection against pneumococcal disease Vaccine Naïve *PCV13 and PPSV23 cannot be given at the same visit - See more at: http://www.adultvaccination.org/pneumococcal_vaccine_vaccination_adult_immunization.htm#sthash.ozMiqlpA.dpuf

Adult 19 to 64 Years Who Only Need PPSV23 Those with chronic conditions Asthma Diabetes Heart disease Alcoholism Liver disease Cigarette smokers Residents of nursing homes or other long-term care facilities When they turn 65 this group should receive a dose of PCV13

Adults 19 to 64 Who Should Receive both PCV13 and PPSV23* Functional or anatomic asplenia† Cochlear implants Cerebrospinal fluid leaks† Lymphoma, leukemia, Hodgkin disease,† Solid organ transplants† * PCV13 and PPSV23 cannot be given at the same visit † A second PPSV23 vaccine is recommended for these individuals five years after the first PPSV23 dose

Age 65 Years or Older This came from California Department of Public Health, Immunization Branch www.EZIZ.org

Age 19-64 Years with Underlying Conditions Prior doses count towards doses recommended in figure and do not need to be repeated If PPSV23 given previously- wait one year before giving PCV13 and if doses is indicated, wait at least five years before giving a second dose of PPSV23

The Centers for Medicare and Medicaid Services Update CMS is updating their coverage to align with the new ACIP Pneumococcal Vaccine guidelines An initial pneumococcal vaccine to who have never received the vaccine under Part B; and A different, second pneumococcal vaccine one year after the first vaccines was administered Effective dates of service on or after September 19, 2014 and does not require that a doctor of medicine or osteopathy order the vaccines.

Scenario 1 66 year old patient with a cochlear implant. Previously received a PPSV23 at age 55. What pneumococcal vaccine (s) does this patient need? Today he would receive a dose of PVC13, since it has been a year from PPSV23. Then 6-12 months later he should receivePPSV23 since he hasn’t received the dose at 65 years of age

Scenario 2 A 20 year old asthma patient shows at your clinic, asking for a shot of that” new pneumonia shot” (PCV13). Does this patient need a PCV13 or a PPSV23 today? This patient meets the criteria for a PPSV23 19-64 year old with a chronic condition. When the client turns 65 he will receive a PCV13 (Prevnar 13) and a 6-12 months later the second PPSV23.