Putting Prevention into Practice

Adult Immunization—Pneumococcal Vaccine



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Am Fam Physician. 2000 Apr 1;61(7):2239-2240.

Case Study

JS is a 54-year-old white woman who comes to your office to establish herself as a patient. During a review of her medical history, several active medical problems come to light, including type 2 diabetes mellitus (formerly known as non–insulin-dependent diabetes mellitus) for 15 years, hypothyroidism and coronary artery disease with myocardial infarction 10 years earlier. She stopped smoking nine months ago after smoking one pack of cigarettes daily for 23 years. She underwent coronary artery bypass grafting eight years earlier. A review of medications reveals appropriate pharmacologic management of her medical problems. Papanicolaou test and mammography screenings are current. She has never received a pneumococcal vaccine.

Questions

  1. Which one of the following factors contributes most to your decision to offer the pneumococcal vaccine?

    • A. Her age.

    • B. Her history of cigarette smoking.

    • C. Her chronic medical problems.

    • D. None of the above; this patient should not be offered a pneumococcal vaccine.

  2. If JS receives the pneumococcal vaccine at this visit, when is revaccination indicated?

    • A. In about four years.

    • B. In about six years.

    • C. In about eight years.

    • D. In about 10 years.

    • E. Revaccination is not recommended.

  3. Which of the following side effects of the pneumococcal vaccine occur in one third to one half of patients?

    • A. Erythema.

    • B. Induration.

    • C. Fever.

    • D. Pain at injection site.

Answers

1. The answer is C: her chronic medical problems. Patients who are at increased risk of complications from pneumococcal disease include persons at the extremes of age (less than five years or more than 65 years); blacks, American Indians and Alaska Natives; residents in group homes and other institutional settings; persons with alcohol dependence; persons with chronic medical problems; and persons with immunodeficiency.14 Invasive pneumococcal disease has produced case-fatality rates of 30 to 43 percent among the elderly and 25 to 27 percent among persons with chronic health conditions.2,3

2. The answer is E: revaccination is not recommended. Routine revaccination for pneumococcal disease is not recommended. Although the total duration of antibody protection is unknown, sufficiently protective pneumococcal titers are thought to persist for at least five years following vaccination.5 In some individuals, antibody levels have been noted to fall to baseline levels within 10 years.5 Others, however, have reported that the clinical efficacy of pneumococcal vaccine lasts at least seven to 10 years.6 Revaccination with the current 23-valent vaccine (available since 1983) may be appropriate in high-risk persons who previously received the 14-valent vaccine, although this subset of patients is likely to be small. The potential benefits of revaccination might be considered in selected patients who are likely to demonstrate a low initial antibody response and/or a rapid decline in antibody levels following vaccination. The Centers for Disease Control and Prevention (CDC) guidelines specify high-risk groups for whom revaccination is recommended. The CDC's Web site is http://www.cdc.gov/nip/publications.

3. The answers are A, B, and D: erythema, induration and pain at the injection site. There is little evidence of serious adverse effects from the pneumococcal vaccine, although erythema, induration or pain at the injection site occurs in about one third to one half of patients. Fever, myalgia and severe reactions occur in no more than 1 percent of patients.5,6 Most evidence indicates little difference in adverse reactions to revaccination, compared with initial vaccination.

REFERENCES

1. Haglund LA, Istre GR, Pickett DA, Welch DF, Fine DP. Invasive pneumococcal disease in central Oklahoma: emergence of high-level penicillin resistance and multiple antibiotic resistance. J Infect Dis. 1993;168:1532–6.

2. Breiman RF, Spika JS, Navarro VJ, Darden PM, Darby CP. Pneumococcal bacteremia in Charleston County, South Carolina. A decade later. Arch Intern Med. 1990;150:1401–5.

3. Bennett NM, Buffington J, LaForce FM. Pneumococcal bacteremia in Monroe County, New York. Am J Pub Health. 1992;82:1513–6.

4. Sims RV, Boyko EJ, Maislin G, Lipsky BA, Schwartz JS. The role of age in susceptibility to pneumococcal infections. Age Aging. 1992;21:357–61.

5. Centers for Disease Control and Prevention. Prevention of pneumococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. 1997;46(RR-8):1–24.

6. Butler JC, Breiman RF, Campbell JF, Lipman HB, Broome CV, Facklam RR. Pneumococcal polysaccharide vaccine efficacy. An evaluation of current recommendations. JAMA. 1993;270:1826–31.

The case studies and answers to the following questions on administering the pneumococcal vaccine are based on the 1996 recommendations of the United States Preventive Services Task Force (USPSTF), part of the Put Prevention into Practice program of the Agency for Healthcare Research and Quality (AHRQ), formerly the Agency for Health Care Policy and Research. The answers appear on the following page. The evidence on the efficacy of the pneumococcal vaccine and other USPSTF topics will be reviewed over the next four years; therefore, some of the recommendations may change.

The 1996 recommendations and other information are contained in the “Guide to Clinical Preventive Services,” 2d ed, chapter 66: Adult Immunizations. For more information, also consult the “Clinicians Handbook of Preventive Services,” 2d ed, chapter 50: Pneumococcus. The guide and handbook can be viewed on the Web site of the AHRQ at http://www.ahrq.gov/clinic. Specific journal references cited in the answers are provided in the discussion.


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