Pneumococcal vaccine recommendations are constantly evolving to respond to shifting patterns of infections, which is a good thing. However, it can be complicated to explain to patients. Listen in to learn how experts Richard Colgan, MD and Brenda L. Tesini, MD, discuss pneumococcal vaccine recommendations, including considerations such as vaccine serotype coverage.
Pneumococcal vaccine recommendations are constantly evolving to respond to shifting patterns of infections, which is a good thing. However, the nuances can be complicated to explain to patients. Listen in to learn how experts Richard Colgan, MD and Brenda L. Tesini, MD, discuss changing pneumococcal vaccine recommendations. Topics covered include:
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Presenters:
Richard Colgan, MD
Professor Emeritus
Department of Family and Community Medicine
University of Maryland School of Medicine
Medical Alumni Association
Carolyn Frenkil Selvin Passen History of Medicine
Scholar in Residence
Baltimore, Maryland
Brenda L. Tesini, MD
Associate Professor of Medicine, Pediatrics, and Community Health
Division of Infectious Diseases
University of Rochester Medical Center
Rochester, New York
Link to program page:
https://bit.ly/3RNHkHr
Links mentioned in this episode:
PneumoRecs VaxAdvisor App for Vaccine Providers | Pneumococcal | CDC
This transcript was automatically generated from the audio recording and may contain inaccuracies, including errors or typographical mistakes.
Clinical Conversations Podcast Episode 1
Dr. Richard Colgan (University of Maryland School of Medicine): Hi. My name is Richard Colgan. I'm a family physician, Professor Emeritus from the University of Maryland School of Medicine, Department of Family and Community Medicine. My clinical background has been both outpatient and, to a lesser extent, inpatient for close to 40 years.
Dr. Brenda Tesini (University of Rochester Medical Center): And hello, I'm Dr. Brenda Tesini. I'm an Adult and Pediatric Infectious Disease Physician at the University of Rochester Medicine, where I'm an Associate Professor of Medicine, Pediatrics and Community Health. My clinical practice is now predominantly inpatient. And I also focus on infectious disease surveillance trends in our region.
You know, I think what's interesting is that, you know, with changes in FDA and CDC and vaccine recommendations, you know, there's been this waxing and waning, you know, atmosphere about the desirability of getting vaccines. And – and fortunately, there are still, you know, new vaccines that are coming out that help us make up the deficit for where, you know, we need to acknowledge changing serotypes.
The pneumococcal vaccines are a great example of that. And what comes to my mind, you know, most recently, you know, we learned of the unfortunate death of – of Kyle Busch in his early 40s from – from pneumonia and sepsis. And, you know, that kind of made me think about, you know, how pervasive this problem is and, you know, how important immunization is even when – when one thinks they're young and healthy.
What do you think, Brenda?
Dr. Tesini: Yeah. Yeah, I completely agree. You know, I think that it speaks to our definition of – of healthy versus at-risk of these serious infections. You know, I also think back to patients I've seen recently relatively young adults, who, you know, themselves and their family considered healthy and are in the hospital with meningitis from pneumococcal infection.
And I think most people in this younger adult but – but – age group, but do you have underlying conditions that put them at high risk, have no idea. They really don't know that they're at risk for such a serious disease. So it is great to see ongoing attention to continue to address how pneumococcal disease changes in terms of the specific serotypes causing infection in different age groups, and that there still is robust research and development going into making new vaccines to match those.
Dr. Colgan: And, you know, kind of cutting to the – you know, the headline news here or the breaking news is I think the fact that with – with – with one of the newest pneumococcal vaccines, you know, it's directed more towards older adults, whereas previous pneumococcal vaccines have been almost a smattering of young and old. And I – I read with interest how, you know, the newer vaccine, you know, addresses specifically serotypes that are more important and prevalent in older individuals.
So yeah, there’s the PCV 21 isn't even approved and used in pediatrics. It's designed specifically at this point for older adults, because we were seeing a shift in new serotypes impacting this population. So majority infections – of infections in older adults were caused by serotypes not contained in the vaccine we were giving children and increasingly giving adults at risk as well. So this is really, I think changed how we can approach this issue of – of changing serotypes. And now gives us – you know, we have kind of two highly immunogenic vaccines that can be given to different populations.
And between the two of them cover really vast – vast array of serotypes that cause disease. I think the newest one, the PCV21 covers around 80% of serotypes that are currently causing disease in adults. Or as PCV20 still covers a fair bit, it still covers around 50% of those serotypes.
Dr. Colgan: You know, I'd like to bring up – for me what I think is the 800-pound gorilla in the room, at least as far as, you know, being a busy clinician in the outpatient setting. And that is when these new vaccines come out, you know, be it pneumonia or other vaccines, you know, the different COVID vaccines, influenza vaccines, for example, you know, it's – it’s very confusing to - to the – in the trenches clinician or at least maybe I'm just speaking of myself, but, you know, with the – with so many vaccines that are out there and with different indications and, you know, one is more so for this group and the others for that group.
What I was, you know, thinking about as being perhaps a great aid would be to, you know, install an application on your phone where you can easily look up what the latest recommendations are. And I know that – I believe that the CDC does have an app where you can look up what someone's desirable vaccine might be.
So I have used that the CDC. I think they call it the PneumoRecs, where you can walk through it. And they have an app that you can – you can download that specifically kind of goes into what's your patient's age? Do they have any of these conditions? What's their prior pneumococcal vaccine? And it will spit out what you should get. So I think that's – that is a – a great resource. And for me, so much easier than looking at those complicated big tables and trying to cross-reference, you know, when they get what.
You know, another thing that kind of surprised me. I was, I guess, a little bit surprised, but glad to see that the CDC has kind of listed specific risk factors for severe pneumococcal disease.
I mean, certainly you could – or I could guess, you know, COPD, asthma, diabetes, chronic heart conditions, immunocompromised state, etc.. But, you know, frankly, I didn't realize that, you know, young children under five attending group child care or, frankly, I didn't realize that, you know, even demographic factors like African American and Alaska Native people or those living in communal settings was a risk factor.
I mean, I think, you know, we can all understand that cigarette smoking and alcoholism isn't good for your health in general. But I didn't know that specifically it was a risk factor for severe pneumococcal disease.
But you know, a recent study showed that – that pregnant women are not getting vaccinated adequately against pneumococcal pneumonia. The study cited – looked at 492 pregnant women and observed that 1% of eligible women received pneumococcal vaccination during pregnancy and 7.7% were up to date with – with vaccination. So I thought that was, you know, interesting and important that pregnant women may be at a greater risk for severe pneumonia because of the immunologic and physiologic changes that occur during pregnancy
Dr. Tesini: Yeah. And I think that that really highlights how – I think the latest statistics are that only a third of people of adults at risk for severe pneumococcal disease have gotten the vaccination. And I think it's that they don't know and even their providers don't know.
Dr. Colgan: Yes.
Dr. Tesini: It is a really wide group of risk factors. It's not just your severely immunocompromised or, you know, severe heart and lung disease that – that put you at risk. And of the, you know, estimated 100 to over 200,000 hospitalizations of adults. We're not even talking kids – of adults hospitalized with pneumococcal pneumonia, 90% of them do have one of these risk factors identified. And that's what really drove the vaccine recommendations.
And lowering – one of the most recent changes to adult recommendations is also lowering the universal vaccination age – age-based vaccination recommendation down to 50.
Dr. Colgan: Yes.
Dr. Tesini: And yeah, I think that is fantastic and really meant to address some of the health disparities seen in pneumococcal disease. The peak rate of hospitalizations for adults who identify as Black was in the 50s.
Dr. Colgan: Yeah.
Dr. Tesini: As opposed to adults who identify as White just continue to increase with advanced age. And so it was really meant to help capture these high-risk groups and hopefully reduce some of the disparities we've seen.
Dr. Colgan: Yeah. That is kind of the breaking news, isn't it, that the – the vaccination is – pneumococcal vaccination is recommended now for adults 50 or older. And then like I mentioned, those risk factors, I noted two that the – the – the recommendations are that if you're between 19 and 49 with some of the risk factors that I mentioned, that's also another indication to be vaccinated for pneumonia – pneumococcal pneumonia.
Dr. Tesini: Yeah, yeah. And so I do think – getting back to the elephant in the room, I do think the recommendations now are a little bit easier to – you know, by reducing that age to, you know, universal vaccination over 50 and spelling out these risk factors, a lot of which now with electronic health records, can be pulled and primed for clinicians or office staff to kind of flag that, that these patients would likely benefit from pneumococcal vaccine. So I think that's helping a little bit.
And now with the, you know, just give like one and done conjugate vaccine of the – the PCV20 or 21. I think that's helping a little bit reduce that.
Dr. Colgan: Right. I would assume that – although we like to give, you know, shots in our own, you know, primary care office, I would assume that all of these newer vaccines are available in your big pharmaceutical – big pharmacy chains. Don't you think?
Dr. Tesini: Yeah, yeah, I would agree. And I love the – the concept of partnering with your local pharmacies. Because again, that trusted provider recommendation is the biggest factor associated with someone actually getting vaccinated. And that – so that still needs to be kind of bridged with getting the vac – even if they get the vaccine elsewhere, discussing it, recommending it is still what's going to promote that.
But yeah, the ease of just, you know, in our region, you're in your grocery store and you can just, while you're doing your grocery shopping, pop over and get your vaccine.
Dr. Colgan: Brenda, would you say that, you know, for older adults or those with some of the chronic health conditions we've talked about that the 21 would be more favorable than 20?
Dr. Tesini: I do think in most areas of our country the serotypes included in 21. So these are areas where we actually have active surveillance going on to know what serotypes are causing disease in different age groups. So it's not 100% across – across the country, but in majority of the country you are going to see more cost effectiveness and better health outcomes from giving the 21 because it's going to protect against the actual serotypes that are circulating and causing disease in older adults.
There are some interesting exceptions in areas of the West, where there is active surveillance, and particularly in Alaska and other areas that have active surveillance. Oregon, New Mexico, Colorado and the Navajo Nation are seeing high rates of a specific serotype that's in PCV20 and the previous iterations of PCV vaccines, that is, that serotype – serotype four is – is the specific one that that is causing high rates of disease. And so in those circumstances, you're probably going to get better bang for your buck using the PCV20.
There are also specific populations. Most notable is people experiencing homelessness that you see much higher rates of invasive bad pneumococcal disease from that serotype four. So certainly if you're – if you're coupling, you know, some sociodemographic risk factors and geographic risk factors for having high rates of serotype four, then you should – should use 20 if it's available. But unless that's present, 21 is probably going to do the best work for you because of the serotypes that are included in it.
Dr. Colgan: I have a question. Generally speaking, in another – in an otherwise fairly healthy older individual, if that person's already gotten the – the pneumococcal 20 and the pneumococcal PPV, is there any reason to get the 21?
Dr. Tesini: No, I really don't think so. I don't think you're going to get that incremental…
Dr. Colgan: Yeah.
Dr. Tesini: Increase. And so, if you use that, the kind of calculator guideline thing too, I think it'll say to not give it. The times where you do want to still give 21 or even 20 if you're in one of those scenarios or that's what's available to you is if you've only ever had the polysaccharide vaccine or you've only ever had the – what had previously been recommended conjugate vaccine, the PCV13. So if you've only had one of those, like one doesn't give you enough protection, you do still want a 21, you know, or a 20.
But if you've already had both of those, as was the recommendation for a while, but honestly was like hard to fit in all those doses for most people, then you don't need any more protection from the 20 or 21.
It sounds like the biggest news is the fact that there's additional pneumococcal vaccine – vaccines available. There's newer vaccines that address serotypes that heretofore we did not realize are as dangerous and illness producing than before. And that this – this – this advent – advance in pneumococcal vaccination is – is I guess so important that in part, the indications for vaccinating adults has now been lowered down to 50 and – and even lower than that 19 to 49, I think if somebody has some serious chronic health conditions.
So I think for me, those are the, you know, major messages on the most recent advances in pneumococcal vaccines. What do you think, Brenda? Anything to add to that?
Dr. Tesini: Yeah, I completely agree. We have an exciting new tool that – that really does target what's causing disease in older adults. You know, as well as a newer tool to use in pediatric patients. And between that coverage across, I think we're very hopeful to see a bigger reduction in disease, pneumococcal disease across the population again.
Dr. Colgan: But you know, a recent study showed that – that pregnant women are not getting vaccinated adequately against pneumococcal pneumonia. The study cited – looked at 492 pregnant women and observed that 1% of eligible women received pneumococcal vaccination during pregnancy and 7.7% were up to date with – with vaccination. So I thought that was, you know, interesting and important that pregnant women may be at a greater risk for severe pneumonia because of the immunologic and physiologic changes that occur during pregnancy.