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3.  A 50-year-old man with hypertension and stage 5 chronic kidney disease
(CKD) due to autosomal polycystic kidney disease is in your office to discuss
kidney replacement therapy (KRT) options.
 He thinks that preemptive kidney transplantation would be his preference.
He has 1 potential donor undergoing evaluation.
 If transplantation is not an option, he has decided on peritoneal dialysis (PD).

4.  Given the patient’s uremic symptoms and worsening kidney function, you
recommend that he can start KRT and refer him for PD catheter insertion
pending the donor’s workup.
 The patient states that he is up to date on childhood vaccinations but has
not had other immunizations in recent history.What vaccines would you
recommend at this time?

8. By

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11.  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.

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15.  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 .
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S. Pneumoniae: Transmission & colonization

19. Clinical Syndromes of pneumococcal disease

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

23. Everybody Is at Risk

24. The Very Young ≥65 Adults

25. 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

26. Smokers Asthma Sufferers

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

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34. + =
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

35.  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.
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Both of them elicit a B-cell-mediated immune response, but only
PCV13 produces a T-cell dependent response, which is essential for
maturation of the B-cell response and development of
immune memory.

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38. 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.
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How are the vaccines administered?
Pneumovax 23 can be administered either subcutaneously or intramuscularly,
while Prevnar 13 has to be administered intramuscularly.

44. Road Map

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48.  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.
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49.  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.
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59. Pneumococcal Immunization in Person ≥65 Years of Age
Source: ACIP. Recommended Adult Immunization Schedule. 2016.
PCV13
≥ 1
Year PPSV23
Pneumococcal Vaccine-Naïve
Age 65

60. PCV13
≥ 1
Year PPSV23
Pneumococcal Vaccine-Naïve
PCV13PPSV23
Has Already Received PPSV After Age 65
Age 65
≥ 1
Year
Received
Pneumococcal Immunization in Person ≥65 Years of Age

61. PCV13
≥ 1
Year PPSV23
Pneumococcal Vaccine-Naïve
PCV13PPSV23
Has Already Received PPSV After Age 65
Age 65
≥ 1
Year
Has Received Pneumococcal Polyasaccharide Vaccine Before Age 65
≥ 1
Year
PCV13
Received
Received
≥ 5 years
≥ 1
Year
PPSV23 PPSV23
Pneumococcal Immunization in Person ≥65 Years of Age

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72. 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.
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73. 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.
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91. PREDICT AND PREVENT
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94. 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.

95. 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.

96. 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.

97. 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.

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99. Q 3. 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

100. Q 3. 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

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104. Q 4. What is the maximum number of PPSV23 doses a patient with CKD
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.

105. Q 4. What is the maximum number of PPSV23 doses a patient with CKD
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.

107. Q 5 .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

108. 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.

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111. Q 6. 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.

112. Q 6. 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.

113. Q 7. 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.

114. Q 7. 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.

115.  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.

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Thank you