Pneumococcal vaccine in adults “Clinical Scenarios”

 Streptococcus pneumoniae, also called pneumococcus are lancet-shaped, gram-
positive diplococci.
 The pneumococcal cell wall surface is covered by a polysaccharide capsule .
 The polysaccharide capsule is an essential virulence factor and means of evading
the immune system by resisting phagocyte killing.
 Type-specific antibody to capsular polysaccharide is protective.

 Colonization:
o S. Pneumoniae is common inhabitant of the respiratory tract and may be
isolated from the nasopharynx.
o Humans may carry the bacteria without being infected (asymptomatic carriers)
, but may still pass on the bacteria to others .
 Transmission:
Person-to-person via respiratory droplets/secretions OR Autoinoculation in
asymptomatic carriers .
10
S. Pneumoniae: Transmission & colonization

Clinical Syndromes of pneumococcal disease

Pneumonia
1 in 20
deaths
Bacteremia
1 in 5
deaths
Meningitis
3 in 10
deaths
Clinical Syndromes –case fatality Rates

Underlying Conditions
Long-Term Health Problems Weakened Immune System
Heart or lung disease, sickle cell, diabetes,
alcoholism, cirrhosis, leaks of cerebrospinal
fluid, cochlear implant
Hodgkin’s lymphoma, leukemia, kidney failure,
multiple myeloma, nephrotic syndrome, HIV or
AIDS, damaged or no spleen, organ transplant

Pneumococcal Vaccines
Vaccine Trade Name
Pneumococcal Polysaccharide Vaccine
(PPSV23) Pneumovax
Pneumococcal Conjugate Vaccine (PCV13) Prevnar 13

+ =
Conjugate vaccine
The conjugation of a polysaccharide to a carrier protein leads to the interaction with
T cells resulting in the release of functional antibodies and production of
memory B cells
Polysaccharide antigens Immunogenic
carrier protein
B cell
Plasma cell
T-independent
Presentation
T cell B cell
Memory B cell
T-dependent
Plasma cell

 The main difference between Pneumovax 23 and Prevnar 13 is how many
different types of bacteria they target.
 Pneumovax protects against 23 serotypes types of pneumococcal bacteria,
while Prevnar 13 protects against 13 seotypes.
 In most cases, the CDC recommends that you get both vaccines at some
point in your life.
30

How effective is each vaccine?
 Vaccines help protect against disease, but no vaccine is 100% effective.
 Studies show that at least 1 dose of Prevnar 13 protects 80% of babies
from serious pneumococcal infections, 75% of adults age 65 and older
from invasive pneumococcal disease& 45% of adults age 65 and older
from pneumococcal pneumonia.
 Studies show that 1 dose of Pneumovax 23 protects 50% to 80% of
adults against invasive pneumococcal disease.
31

36
How are the vaccines administered?
Pneumovax 23 can be administered either subcutaneously or intramuscularly,
while Prevnar 13 has to be administered intramuscularly.

 The recommendations for the use of pneumococcal vaccines vary
based on your age and health conditions.
 For example, if you are 65 years or older, you should have one dose
of each vaccine.
 If you are between the ages of 19 and 64 years and have certain
health conditions, you may need one dose of PCV13, and one or
two doses of PPSV23 before you turn 65 years old.
41

 The maximum number of PPSV23 doses recommended in a lifetime is
three doses, which includes up to two doses before 65 years of age
for certain high-risk people plus one dose for everyone 65 years of
age and older.
42

Pneumococcal Immunization in Person ≥65 Years of Age
Source: ACIP. Recommended Adult Immunization Schedule. 2016.
PCV13
≥ 1
Year PPSV23
Pneumococcal Vaccine-Naïve
Age 65

PCV13
≥ 1
Year PPSV23
PCV13PPSV23
Has Already Received PPSV After Age 65
Age 65
≥ 1
Year
Received

PCV13
≥ 1
Year PPSV23
PCV13PPSV23
Age 65
≥ 1
Year
Has Received Pneumococcal Polyasaccharide Vaccine Before Age 65
≥ 1
Year
PCV13
Received
Received
≥ 5 years
≥ 1
Year
PPSV23 PPSV23

Can I get both vaccines at the same time?
No. The administration of the two vaccines should be separated by a
minimum of 8 weeks. In some cases, you should wait at least 1 year
between both vaccines.
65

Flu and pneumonia shots at the same time?
 Yes. These vaccines can be given at the same time, as long as they
are given in different arms.
 In fact, pneumonia can be a complication of influenza, so getting
both vaccines is a smart choice.
66

Q 1 . I've heard that PPSV23 isn't very effective in older people.
Should I still use it?
 Yes. PPSV23 vaccine is 60%-80% effective against invasive pneumococcal
disease when it is given to immunocompetent people age 65 years and
people with chronic illnesses.
 The vaccine is less effective in immunodeficient people. So, although
not as effective as some other vaccines, it can significantly lower the risk of
serious pneumococcal disease and its complications in most recipients.

Q 2 . Some physicians in our area order PPSV23 every 5 years for their
patients. Is this correct?
 No. Only certain high-risk people who were vaccinated when younger
than age 65 years will need a second dose 5 years later.
 At age 65 years, all adults (including people vaccinated when
will need to be vaccinated.

Q 3 . Which vaccine is indicated for a healthy 66-year-old
man?
a) PCV13
b) PPSV23
c) PCV13 and PPSV23
d) Neither vaccine is recommended

Q 4. Which vaccine is indicated for a 28-year-old woman who has been
diagnosed with breast cancer and will be undergoing surgery, followed
by radiation and chemotherapy in a few weeks?
a) PCV13
b) PPSV23
c) Both PCV13 and PPSV23

 Both PCV13 and PPSV23 are recommended for adults 19 years and
older with immunocompromising conditions, including those resulting
from cancer or cancer chemotherapy.
 A dose of PCV13 should be administered first, followed by a dose of
PPSV23 8 weeks later.
 When possible, administer these vaccines at least 2 weeks before a
patient starts chemotherapy or other therapies that can suppress the
immune system.

 Q 5. A patient with human immunodeficiency virus infection received a
dose of PCV13 at age 53. Does this patient need any additional doses
of PCV13 after age 65?
 A: No. If the patient already received one dose of PCV13 before age
65, no additional doses of PCV13 are needed, when he/she reaches
65 years of age .

Q 6. Three months ago, a 20-year-old man with sickle cell disease
received PPSV23. Is he eligible to receive PCV13 at today’s office visit?
A : No. If PPSV23 is given first, PCV13 can be given no sooner than 12
months later in immunocompromised patients.

Q 7. A 28-year-old patient on hemodialysis presents to the clinic. Which
pneumococcal vaccine or vaccines is this patient eligible for?
 A: End-stage renal disease places this patient in the
immunocompromised risk category.
 She should therefore receive one dose of PCV13 followed by two doses of
PPSV23

Q 8. Should we vaccinate 16-year-olds who smoke with a
pneumococcal vaccine?
 No. Currently no data exist to indicate that people younger than 19 and
smoke are at increased risk of pneumococcal disease.
 Currently, ACIP recommends PPSV23 for smokers age 19 through 64
years.

Q 9. Should a healthy 75-year-old patient who was given PPSV 23 at
age 65 years be revaccinated?
 No. Adults who were first vaccinated at age 65 years or older do not
require revaccination.
 Make sure they have also received a dose of PCV13, which is
recommended at age 65 years.

Q 9. Should a healthy 75-year-old patient who was given PPSV 23 at
age 65 years be revaccinated?
 No. Adults who were first vaccinated at age 65 years or older do not
require revaccination.
 Make sure they have also received a dose of PCV13, which is
routinely recommended at age 65 years.

Source: ACIP. Recommended Adult Immunization Schedule. 2016.
PCV13
≥ 1
Year PPSV23
PCV13PPSV23
Age 65
≥ 1
Year
Received

Q 10. What is the maximum number of PPSV23 doses a patient with a
leukaemia aged 35 years can receive in a lifetime?
 A: Immunocompromised patients are at risk of invasive pneumococcal
disease and can receive up to 3 doses of PPSV23.
 They would first receive PCV13, the first dose of PPSV23 8 weeks later, and
second dose of PPSV23 5 years after the first dose.
 The final dose of PPSV23 would be given after age 65 and at least 5 years
the second dose of PPSV23.

Q11. How often should diabetic patients receive PPSV23?
 People with either type 1 or type 2 diabetes who are ages 2 through
64 years who have not already received a dose of PPSV23 should
receive their first dose now.
 At age 65 years they should receive a one-time revaccination if 5
years have elapsed since the previous dose.
 PCV13 is not recommended for persons age 19 through 64 years
whose only risk factor for invasive pneumococcal disease is diabetes

Q 11. How often should diabetic patients receive PPSV23?
 People with either type 1 or type 2 diabetes who are ages 2 through
64 years who have not already received a dose of PPSV23 should
receive their first dose now.
 At age 65 years they should receive a one-time revaccination if 5
years have elapsed since the previous dose.
 PCV13 is not recommended for persons age 19 through 64 years
whose only risk factor for invasive pneumococcal disease is diabetes

Q 12. Mrs. Suzan is 47 years old and was recently diagnosed with HIV.
Assuming she has not previously received any pneumococcal vaccines,
which pneumococcal vaccine(s) should she receive, and when?
 A: Both PCV13 and PPSV23 are indicated for Mrs. Jones, according to the
following schedule:
 She should receive one dose of PCV13 now.
 Because she is immunocompromised, she should receive PPSV23 8 weeks
administration of PCV13.
 A second dose of PPSV23 should be administered 5 years after the first
dose.
 A third dose of PPSV23 should be administered at age 65 years (at least 5

Q 12. Mrs. Suzan is 47 years old and was recently diagnosed with HIV.
Assuming she has not previously received any pneumococcal vaccines,
which pneumococcal vaccine(s) should she receive, and when?
 Both PCV13 and PPSV23 are indicated for Mrs. Suzan, according to the following
1) She should receive one dose of PCV13 now.
2) Because she is immunocompromised, she should receive PPSV23 8 weeks after the
administration of PCV13.
3) A second dose of PPSV23 should be administered 5 years after the first PPSV23 dose.
4) A third dose of PPSV23 should be administered at age 65 years (at least 5 years after
second PPSV23 dose).

 Of note, Mrs. Suzan will not need PCV13 when she reaches 65 years of
age because she will already have received a dose of this vaccine as an
adult.

Q 13. When should I vaccinate an adult 35 years old, who is planning to
have either a cochlear implant or elective splenectomy?
 It is preferable that the person planning to have the procedure have
pneumococcus at the time of the surgery; if possible, administer the
vaccine prior to the splenectomy or cochlear implant.
 If the procedure is done on an emergency basis, vaccinate as soon as possible
after surgery. Persons who have not previously received any pneumococcal
vaccine should receive PCV13 first followed by PPSV23 at least 8 weeks later.
Asplenic persons need a second dose of PPSV 5 years after the first PPSV23.

Q7. When should I vaccinate an adult 35 years old, who is planning to have
either a cochlear implant or elective splenectomy?
 It is preferable that the person planning to have the procedure have
pneumococcus at the time of the surgery; if possible, administer the
vaccine prior to the splenectomy or cochlear implant.
 If the procedure is done on an emergency basis, vaccinate as soon as possible
after surgery. Persons who have not previously received any pneumococcal
vaccine should receive PCV13 first followed by PPSV23 at least 8 weeks later.
Asplenic persons need a second dose of PPSV 5 years after the first PPSV23.

Q 14 .Is systemic lupus erythematosus (SLE, lupus) a risk-based
indication for pneumococcal vaccines?
 Lupus per se is not an indication for either pneumococcal vaccine. However,
immunosuppressive medication that may be used to treat lupus could create
indication for administering both pneumococcal vaccines.
 Also, if the patient has certain complications of lupus (such as nephrotic
syndrome), the person would be a candidate for pneumococcal vaccines.
 Both immunosuppression and nephrotic syndrome are indications for
administering both PCV13 AND PPSV23. Administer PCV13 first, then
weeks later

Q 14 .Is systemic lupus erythematosus (SLE, lupus) a risk-based
indication for pneumococcal vaccines?
 Lupus per se is not an indication for either pneumococcal vaccine. However,
immunosuppressive medication that may be used to treat lupus could create
indication for administering both pneumococcal vaccines.
 Also, if the patient has certain complications of lupus (such as nephrotic
syndrome), the person would be a candidate for pneumococcal vaccines.
 Both immunosuppression and nephrotic syndrome are indications for
administering both PCV13 AND PPSV23. Administer PCV13 first, then
weeks later.

Q 15. How often should adult dialysis patients receive pneumococcal
polysaccharide vaccine?
 Adult dialysis patients age 19 through 64 years who have not
received PCV13 or PPSV23 should receive a dose of PCV13 first,
by a dose of PPSV23 at least 8 weeks later.
 A second dose of PPSV23 should be given 5 years after the first dose
PPSV23. Once they become 65, they will need another dose

Q 16. My patient has had laboratory-confirmed pneumococcal pneumonia.
Does he/she still need to be vaccinated with PCV13 and/or PPSV23?
 Yes. There are more than 90 known serotypes of pneumococcus (13 serotypes
the conjugate vaccine and 23 serotypes in the polysaccharide vaccine).
 Infection with one serotype does not necessarily produce immunity to other
serotypes. As a result, if the person is a candidate for vaccination, s/he should
receive it even after one or more episodes of invasive pneumococcal disease.

Q 18. A 64-year-old man, recently received a diagnosis of chronic obstructive
pulmonary disease (COPD) and wants to make sure he is doing everything he
can to reduce his chances of complicating or exacerbating his condition.
Which of the following vaccinations are recommended for this patient?
A) Inactivated influenza vaccine and 13-valent pneumococcal conjugate vaccine
(PCV13)
B) Inactivated influenza vaccine and 23-valent polysaccharide pneumococcal
(PPSV23)
C) Inactivated influenza vaccine, PPSV23, and PCV13
D) Live attenuated influenza vaccine and PPSV23

Q 18. A 64-year-old man, recently received a diagnosis of chronic obstructive
pulmonary disease (COPD) and wants to make sure he is doing everything he
can to reduce his chances of complicating or exacerbating his condition.
Which of the following vaccinations are recommended for this patient?
A) Inactivated influenza vaccine and 13-valent pneumococcal conjugate vaccine
B) Inactivated influenza vaccine and 23-valent polysaccharide pneumococcal
(PPSV23)
C) Inactivated influenza vaccine, PPSV23, and PCV13
D) Live attenuated influenza vaccine and PPSV23

Q19. Is PPSV23 indicated for former smokers?
 No, PPSV23 is currently recommended only for people age 19 through
years who actively smoke cigarettes.
 However, chronic lung disease for example. COPD is an indication for
PPSV23, which could be applicable for former smokers.

Q 21. 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 12
months later the second PPSV23.

Q 21. 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
12 months later the second PPSV23.

Q 22. A 50-year-old man has an exacerbation of COPD and is prescribed
prednisone 20 mg daily for 7 days, then 10 mg daily for 7 days, then 5
mg daily for 7 days, then 5 mg every other day for 14 days.
 He has never received a pneumococcal vaccine , Which pneumococcal
vaccine should he receive?
 A: COPD (Chronic obstructive pulmonary disease ) falls into the at-risk
category for patients ages 19 to 64 with comorbidities. This patient is a
candidate for PPSV23.
 The ACIP guidelines are silent on the additional need for PCV13 for
short courses of corticosteroids.

Q 22. A 50-year-old man has an exacerbation of COPD and is prescribed
prednisone 20 mg daily for 7 days, then 10 mg daily for 7 days, then 5 mg
daily for 7 days, then 5 mg every other day for 14 days.
 He has never received a pneumococcal vaccine , Which pneumococcal
should he receive?
 A: COPD (Chronic obstructive pulmonary disease ) falls into the at-risk
category for patients ages 19 to 64 with comorbidities. This patient is a
candidate for PPSV23.
 The ACIP guidelines are silent on the additional need for PCV13 for
short courses of corticosteroids.

Q 23: Mr. Faysal is 30 years old and smokes 1 pack of cigarettes per
day. The pharmacist recommends that he enroll in a tobacco cessation
program, but he remains resistant to change. Which pneumococcal
vaccine(s) should he receive, and when?
A: Mr. Fayasl is an appropriate candidate for pneumococcal vaccination
according to the following schedule:
 One dose of PPSV23 now.
 When he reaches 65 years of age, he should receive one dose of PCV13.
 A second dose of PPSV23 should be administered at least 1 year
the PCV13 (at least 5 years after the first dose of PPSV23).

Q 23: Mr. Fysal is 30 years old and smokes 1 pack of cigarettes per
day. The pharmacist recommends that he enroll in a tobacco cessation
program, but he remains resistant to change. Which pneumococcal
vaccine(s) should he receive, and when?
A: Mr. Fyasl is an appropriate candidate for pneumococcal vaccination
according to the following schedule:
 One dose of PPSV23 now.
 When he reaches 65 years of age, he should receive one dose of PCV13.
 A second dose of PPSV23 should be administered at least 1 year
the PCV13 (at least 5 years after the first dose of PPSV23).

Q 24: If influenza vaccine is recommended for healthcare workers to
protect high-risk patients from getting influenza, why aren't the
pneumococcal vaccines also recommended?
 Influenza virus is easily spread from healthcare workers to their patients,
infection usually leads to clinical illness.
 Pneumococcus is probably not spread from healthcare workers to their
patients as easily as is influenza, and infection with pneumococcus does
necessarily lead to clinical illness.

 Host factors (such as age, underlying illness) are more important in the
development of invasive pneumococcal disease than nasopharyngeal
colonization with the organism.
 When you're giving influenza vaccine to your patients in the fall, don't forget
to assess their need for pneumococcal vaccine as well as all other vaccines,
includingTdap and zoster.

Q 25: Which vaccine is indicated now for a 38-year-old woman who
received a cochlear implant and a dose of PPSV23 at 36 years of age?
a) PCV13
b) PPSV23
c) Both PCV13 and PPSV23

 A single dose of PCV13 should be administered now since more
than a year has elapsed since the dose of PPSV23.
 This woman does not need a second dose of PPSV23 now, but she
will need a dose at 65 years of age.

Q 28. 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 8 weeks later he should receivePPSV23 since he hasn’t
received the dose at 65 years of age

Pneumococcal vaccine in adults “Clinical Scenarios”

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