1. Chris Knefelkamp, PharmD PGY2 Internal Medicine Resident Richard L. Roudebush VA Medical Center September 17, 2015 A SHOT IN THE DARK: PNEUMOCOCCAL PNEUMONIA VACCINE ADMINISTRATION This speaker has no actual or potential conflicts of interest to disclose in relation to this presentation.

2. OBJECTIVES Describe the immunological responses of Prevnar and Pneumovax List the proper timeline for pneumococcal vaccine administration based on age and comorbidities Identify the laws governing pharmacist administration of pneumococcal vaccines

3. About 900,000 Americans get pneumococcal pneumonia each year with a 5-7% mortality rate 400,000 hospitalizations annually 90% of invasive pneumococcal disease cases in adults >95% pneumococcal deaths occur in adults Combination immunization therapy of Prevnar and Pneumovax Schedules based on: Age Prior vaccination status Immunocompetency BACKGROUND: PNEUMOCOCCAL DISEASE CDC. Pneumococcal Disease. Available at: http://www.cdc.gov/pneumococcal/about/facts.html. Accessed July 28, 2015.

4. PRODUCTS VaccineAttenuationType Unique Serotypes Common SerotypesCost* Pneumovax 23InactivatedPolysaccharide2,8,9N, 10A,11A,12F, 15B, 17F, 20, 22F, 33F 1, 3, 4, 5, 6B, 7F, 9V, 14, 18C, 19A, 19F, 23F $72.38 Prevnar 13InactivatedConjugated6A1, 3, 4, 5, 6B, 7F, 9V, 14, 18C, 19A, 19F, 23F $152.01 Prevnar 13 [package insert]. New York, NY: Pfizer Inc; 2015. Pneumovax 23 [package insert]. Kenilworth, NJ: Merck and Co; 2015. *AWP

5. Principles of vaccination. The Pink Book: Course Textbook. 12th Ed.http://www.nature.com/nri/journal/v9/n3/fig_tab/nri2494_F1.html

6. Principles of vaccination. The Pink Book: Course Textbook. 12th Ed.http://www.nature.com/nri/journal/v9/n3/fig_tab/nri2494_F1.html

7. All age groups Lateral thigh Deltoid Intramuscular OR subcutaneous Infants Lateral thigh Toddlers, Children, Adults Deltoid DO NOT administer in gluteal areas Intramuscular ADMINISTRATION TECHNIQUE PrevnarPneumovax Prevnar 13 [package insert]. New York, NY: Pfizer Inc; 2015. Pneumovax 23 [package insert]. Kenilworth, NJ: Merck and Co; 2015.

8. TIMELINE OF ADMINISTRATION Age GroupsUnderlying ConditionsPCV13 → PPSV23 PPSV23 → PCV13 24–71 mo Immunocompetent with underlying chronic conditions Functional or anatomic asplenia Immunocompromised ≥8 wks ≥8 wks 6–18 y High-risk immunocompetent (cerebrospinal fluid leaks, cochlear implants) Functional or anatomic asplenia Immunocompromised ≥8 wks ≥8 wks ≥ 19 y High-risk immunocompetent (cerebrospinal fluid leaks, cochlear implants) Functional or anatomic asplenia Immunocompromised ≥8 wks ≥1 y ≥ 65 y N/A≥1 y Foster, SL. American Pharmacists Association. 2011. http://www.pharmacist.com/updates-vaccine-recommendations-focus-acips-june-meeting

9. VACCINE – NAÏVE > 65 YEARS Prevnar> 1 YearPneumovax Tomczyk S, et al. MMWR Morbid Mortal Wkly Rep 2014;63:822-825.

10. PREVIOUSLY RECEIVED PNEUMOVAX Received Pneumovax at age > 65 > 1 yearPrevnar Tomczyk S, et al. MMWR Morbid Mortal Wkly Rep 2014;63:822-825.

11. PREVIOUSLY RECEIVED PNEUMOVAX Received Pneumovax at age < 65 >1 year Prevnar at age > 65 > 1 yearPneumovax 5 years Tomczyk S, et al. MMWR Morbid Mortal Wkly Rep 2014;63:822-825.

12. IMMUNOCOMPROMISING CONDITIONS Receive BOTH Prevnar and Pneumovax (with repeat) Asplenia Hemoglobinopathy (Sickle Cell) Complement deficiency B or T Cell deficiency Cancer HIV Chronic renal failure or nephrotic syndrome Organ transplant Iatrogenic immunosuppression (Chemotherapy, radiation therapy, systemic steroids for 14+ days) Centers for Disease Control and Prevention. 2012:61;816-819.

13. OTHER CHRONIC CONDITIONS (<65 YO) Risk groupUnderlying medical condition PCV13PPSV23 Recommended Revaccination 5 yrs after first dose Immunocompetent persons Chronic heart disease ✔ Chronic lung disease ✔ Diabetes mellitus ✔ Cerebrospinal fluid leak ✔✔ Cochlear implant ✔✔ Alcoholism ✔ Chronic liver disease, cirrhosis ✔ Cigarette smoking (age 19+) ✔ Heart disease – CHF and CM Lung disease – COPD, emphysema, asthma (age 19+) Centers for Disease Control and Prevention. 2012:61;816-819.

14. TIMELINE PEARLS DO NOT administer together Previously 6-12 month recommended interval PCV13  PPSV23 No data for shorter intervals No immunologic differences between 6 and 12 months Higher incidence of adverse effects with shorter (6 month) interval If Pneumovax is given at a shorter interval than 12 months, no need to repeat it Administer even if had previous pneumococcal pneumonia infection CMS will only cover 2 nd vaccine if 1 year has passed May be co-administered with Influenza vaccine Foster, SL. American Pharmacists Association. 2011. http://www.pharmacist.com/updates-vaccine-recommendations-focus-acips-june-meeting

15. Chris Knefelkamp, PharmD PGY2 Internal Medicine Resident Richard L. Roudebush VA Medical Center September 17, 2015 A SHOT IN THE DARK: PNEUMOCOCCAL PNEUMONIA VACCINE ADMINISTRATION