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.

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

• 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.

PRODUCTS

Vaccine Attenuation TypeUnique

SerotypesCommon Serotypes Cost*

Pneumovax 23 Inactivated Polysaccharide 2,8,9N, 10A,11A,12F, 15B, 17F, 20, 22F, 33F

1, 3, 4, 5, 6B, 7F, 9V, 14, 18C, 19A, 19F, 23F

$72.38

Prevnar 13 Inactivated Conjugated 6A 1, 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

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

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

• All age groups• Lateral thigh• Deltoid

• Intramuscular OR subcutaneous

• Infants • Lateral thigh

• Toddlers, Children, Adults • Deltoid

• DO NOT administerin gluteal areas

• Intramuscular

ADMINISTRATION TECHNIQUE

Prevnar Pneumovax

Prevnar 13 [package insert]. New York, NY: Pfizer Inc; 2015.

Pneumovax 23 [package insert]. Kenilworth, NJ: Merck and Co; 2015.

TIMELINE OF ADMINISTRATION

Age Groups Underlying Conditions PCV13 → 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 ≥1 y

Foster, SL. American Pharmacists Association. 2011. http://www.pharmacist.com/updates-vaccine-recommendations-focus-acips-june-meeting

VACCINE – NAÏVE > 65 YEARS

Prevnar > 1 Year Pneumovax

Tomczyk S, et al. MMWR Morbid Mortal Wkly Rep 2014;63:822-825.

PREVIOUSLY RECEIVED PNEUMOVAX

Received Pneumovax at age > 65

> 1 year Prevnar

Tomczyk S, et al. MMWR Morbid Mortal Wkly Rep 2014;63:822-825.

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.

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.

OTHER CHRONIC CONDITIONS (<65 YO)Risk group Underlying

medical conditionPCV13 PPSV23

Recommended 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 CMLung disease – COPD, emphysema, asthma (age 19+) Centers for Disease Control and Prevention. 2012:61;816-819 .

TIMELINE PEARLS

• DO NOT administer together• Previously 6-12 month recommended interval PCV13PPSV23

• 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 2nd 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

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