Pneumococcal Disease Pathogenesis

Dr Paul Auwaerter (Johns Hopkins University School of Medicine): We're going to delve into pneumococcal disease and then some preventative strategies. So I think most of us learned along the way in our medical training that Streptococcus pneumoniae is the most common cause of bacterial pneumonia and is a frequent colonizer in the upper airway tract, and is also responsible, at least in adults, but also for children, for a substantial amount of otitis media and also bacterial sinusitis.

Now we acquire this intermittently by colonization, breathing in droplets from others that could harbor the bacteria, and especially true if someone's a smoker. But what's more concerning and often life-threatening, although certainly pneumonia can be life-threatening, is if this particular bacteria gains access to the bloodstream and then spreads through the body. Which can result in a host of devastating complications, with perhaps meningitis being the most frequent, but also septicemia in the bloodstream and a host of other end-organ involvement. And we can also sometimes even see it as a cause of peritonitis, especially in people with liver disease.

[00:06:03]

Pneumococcal Virulence Factors

So there's a lot of reasons why this bacteria is common and so successful. First, there's a ton of different serotypes, although some are more common than others circulating amongst us humans. Perhaps most famous is the polysaccharide coat for those of you that might remember the Quellung test. This is a test that outlines the capsule, and that capsule is so important for inhibiting phagocytosis. But there's a host of other virulence factors that deal with facilitating adhesion. They're cytotoxic. They were responsible for immune evasion. So there's a lot of particular aspects of this bacteria that make it prone for not only causing disease but subsequently invasion.

[00:06:53]

IPD Incidence Rates by Age Group

Now, as many of you know, at least with the topic being vaccine, I know you had an earlier talk on this, too. There have been such a host of changes over the years about the immunizations, especially in children, where it has been changing, but also in adults to a degree. But what you can see in this graph is for invasive pneumococcal disease, or IPD, the most common group by far if you go back 20 years ago, was in older adults over 65. With the least common in the, you know, sort of young adult to middle age category. And then you had young children and those 50-64 in the middle.

But what's happened with the progressive immunizations are that the amount of disease in children is substantially declined. And it had an ancillary impact at the decreasing adult disease, even if they weren't immunized, interestingly. But you can certainly see the progressive trend here and some of the changes in the vaccine schedule to try to keep up with evolving serotypes that do change under the pressure of immunization.

[00:08:07]

Racial and Ethnic Disparities in Adult Invasive Pneumococcal Disease in the United States

Another aspect of at least invasive disease, because this is the easiest to track by the Centers for Disease Control, because you can do it through blood cultures. And, you know, sputum would not necessarily give you evidence that you have disease or not is the fact that certain groups seem especially prone to this serious complication. And they include Native American, Indian, and Alaskans, also Black non-Hispanics above the population average. Now, this is for a whole host of reasons, including barriers to seeking care, but also because they may have a higher rate of comorbidities.

[00:08:51]

Poll 2

Tracey Piparo: So guys, we want to know. Give us a little answer in the text box. What impact have the expanded age-based pneumococcal vaccine recommendations had on uptake in your practice? We'll give you a few seconds to answer that. And thanks for sharing. That's really super helpful info.

[00:09:40]

Pneumococcal Vaccine Uptake: Disparities

Dr Auwaerter: Okay. Thank you, Tracey, and everyone that put in that information. So this again will highlight a little bit about some of the issues with trying to help prevent invasive pneumococcal disease. And that is overall, you can see that even people at risk in that group between 18-64, which was sort of the older recommendation, which we'll get to, that regardless of where you were in terms of your ethnicities or races, the uptake was rather low in the 20% to 30% range.

Now, that did rise in the group of 65 and older, but you can see certain groups, including Blacks and Hispanics, certainly fell significantly below. So the thought is there's still substantial room to try to help improve coverage amongst many groups at probably all adults, but certainly those at risk, and especially in those in certain groups.

[00:10:42]

Impact of Invasive Pneumococcal Disease

So invasive pneumococcal disease probably accounts, and this is based on pre-COVID data for over 30,000 cases. And of course, that is not as much as just pneumococcal pneumonia per se. But importantly, whether you have pneumonia, which still has a substantial mortality, or the invasive disease probably ranges between 8% to 20%. So this is very serious and especially in older age groups. And the older you are seems to account for this. And this is also true for COVID, for influenza. So basically, as we get older, our immune system is just not as robust. And we have other frailties that make us prone to not having good outcomes.

[00:11:27]

Burden of CAP in US Adults, Pre-COVID

Now, at least for pneumonia, this is also true. And it's often been called the old man's friend or the captain of death for older adults. But you can see here the incidence rises substantially, especially as you get into the older age groups over 80. And importantly, if they do get ill and often they're admitted to hospital or even the ICU, they have substantial impact on their function afterwards. Often having to go to a rehabilitation facility. No longer able to return to home or have something that's substantially more long-lasting in terms of function, both mental and physical function afterwards, especially in critical illness.

[00:12:15]

Impact of Conjugate Vaccines on Shifting Pneumococcal Serotypes

The other landscape that's happening over time is, as we've been sort of clever and good at treating serotypes or preventing using the serotypes that are circulating are the organism, of course, shifts. And so when there's this so-called immune pressure for both colonization and prevention of disease, the nonvaccine stereotypes have generally risen up. And this is data from a few years ago, but you can see how those that aren't covered have gone on to have higher rates. And of course, it's a bit of an arms race here. So that's why you'll see vaccine manufacturers make vaccines that cover more and more serotypes. And this has been happening over time.

[00:13:02]

Serotypes Targeted by Pneumococcal Vaccines

So what's different a little bit just over the last year is the addition of a vaccine approved by the Food and Drug Administration last year, PCV21. Now, importantly, this is only for adults. It's not approved for pediatrics. So not part of the pediatric schedule, but importantly was really used and developed anticipating the serotypes that circulate in adults. So you can see here you have 8 other serotypes that are not covered by the other vaccines that were probably familiar with PCV13, 15, and 20, or even the older pneumovax or pneumococcal polysaccharide vaccine.

[00:13:46]

IPD Incidence Rates Among Adults Aged 50-64 Yr, by Vaccine Type, 2011-2022

And the reason this was developed is because of the green that you see here, is that the serotypes causing invasive disease have been substantial in terms of not being covered. So, PCV21 will now cover some of those green aspects there. In addition to what's also covered most frequently in the red as well. So, it's all in an effort to provide more protection, get ahead of the ones that are now more frequently circulating, at this time, among adult populations.

[00:14:26]

Proportion of IPD by Vaccine Type Among Adults With a Pneumococcal Vaccine Indication, 2018-2022

Shown by a bar graph here gives you a little idea of the differences that might be envisioned, whether you're in the younger or the older age group. You can see PCV has coverage in the 80% plus range, whereas PCV20, which is the older conjugate vaccine, covers in the 50% range. Then as always, there's some serotypes that are not covered by any vaccine.

[00:14:58]

STRIDE-3: Immunogenicity of PCV21 in Adults ≥50 Yr Against Common Serotypes

Now the PCV21, much like all vaccine studies, and I can't say this will be true moving ahead. We don't know what the FDA will do moving ahead, but has been based on immune bridging studies. Meaning you didn't need a randomized controlled trial to prove efficacy. You could just prove that you had substantial antibody production in a trial that both looked at efficacy by this method of antibody levels and also safety. And so here this was compared. And you can see at least in the cohorts with PCV21 and also PCV20 with common serotypes that noninferiority was reached, which meant this vaccine worked as well as the older one.

[00:15:48]

STRIDE-3: Immunogenicity of PCV21 in Adults ≥50 Yr

And this was also true when you looked at adults over 50 as well. And PCV21 does not have an immune adjuvant in it, interestingly. And yet develops nicely robust immune responses to serotypes.

[00:16:06]

STRIDE-3: Safety

In terms of safety, pretty much like all the pneumococcal vaccines, only a small percentage of people had any serious effect. Most of these are all local, along with some transient fatigue, headaches, and so on, almost all of which I advise my patients resolve within 3 days. I do not only infectious diseases, but I still do a bit of primary care, so I'm definitely in the middle of advising on vaccines frequently as well. But there are no new safety signals. And this would be anticipated given that these pneumococcal vaccines are iterative. You're adding serotypes. So it would be unusual to anticipate any major new problems even though you're expanding the repertoire.

[00:16:53]

CAP: Serotype coverage by PCV21

In terms of coverage, we don't have any direct prospective data, but some observational data out of health systems in the Southeastern United States, over 2000 patients showed that at least for people hospitalized, if you had serotypes responsible for the pneumonia that were included in PCV21, you saw that they still account for a substantial percentage. So basically, the PCV21 will cover a large percentage of the currently circulating serotypes, at least based on the years that were mentioned there.

[00:17:37]

Updated CDC PCV Recommendations for Adults

So what does all this mean when it comes to the current ACIP, CDC recommendations? And these were really developed last year. So these reflect the older panels and administration. And I think many of us were sort of frustrated by the frequent changes in pneumococcal recommendations, and this was in an effort to really accomplish 2 things. One is to provide simplification. And the second is to also recognize that there are people 50 and older that often have comorbidities that weren't getting the pneumococcal vaccine. So the thought was even if you did or didn't have comorbidities, the new recommendation is 50 and older with a single dose of any of the 3 conjugate vaccines 15, 20, or 21, and that's it. So it's simple. So you're moving it down to 50, an effort to capture more people that would be at risk. And therefore it becomes less complicated.

Now, the group that's younger of adults 18-49 still has the menu of which we're very familiar with here of certain complications. The ones that are a little unusual from the standard comorbidities are CSF leak, cochlear implant, which may not be immediately intuitive, but it's becoming more popular among our patients, along with some of the others listed here. So they're in that age group. You do need at least 1 of these indications to recommend pneumococcal immunization again with any of the 3 that are mentioned.

[00:19:16]

Updated CDC PCV Recommendations for Adults: PPSV 23 and Serotype 4

Now, there's 1 thing that's a little different, a couple of things that I would highlight. The pneumococcal polysaccharide vaccine, which we've used for years, is no longer recommended for the most part. There are a couple of maybe exceptions, which, if there are questions, we can delve into that deal with pregnancy and so on. But generally, it's been supplanted by the newer vaccines, either PCV20 or 21. PCV21 does not cover serotype 4. This is mainly only occurring in certain Native American populations. So if you're practicing in - with IHS or treating folks in those areas, you may want to use PCV20 or PCV15 because they do include serotype 4. So that's pretty special. So if you are practicing in those locations, you would want to take that under some advisement. And probably future vaccines like PCV30 and so on will likely include serotype 4.

[00:20:24]

Updated CDC PCV Recommendations for Adults: Prior Immunization

Now, where there's still shared decision making is in your patients that may have been previously immunized, especially for adults at 65 who may have gotten PCV13 and the pneumococcal polysaccharide vaccine. And then the question is, do they still benefit from some of the newer vaccines? And I think, well, there's a slide on this later, but I think that's something where you talk to your patients and judge, gosh, do you have risk factors, you know, or do you have terrible emphysema? Do you have diabetes? Do you have HIV? These sorts of things where they may benefit from getting the extra vaccine as a sort of booster, or for the other uncovered serotypes?

[00:21:11]

Posttest 1

Tracey Piparo: So let's see - yeah. Let's see if everyone was paying attention. So remember, your colleague would like to give the pneumococcal vaccine to a 50-year-old patient with hypertension and chronic kidney disease. Is this patient at risk for pneumococcal disease, and could they benefit from vaccination?

A. Yes, they are at risk based on age and comorbidities;

B. Yes, they are at risk based on comorbidities but not age;

C. No, they're too young for vaccination to have meaningful benefit;

D. No, they're not at risk based on age and comorbidities;

I think you guys are going to do great. I think everybody was listening. It looks like a great percentage got A, which is correct because, as of the October 2024 update, the CDC now recommends pneumococcal vaccination for all adults 50 or older regardless of risk factors.

Dr Auwaerter: Okay, I think there's another poll.

[00:22:33]

Poll 3

Tracey Piparo: Yep. So what's your confidence level now in making appropriate pneumococcal vaccine recommendations for patients with diverse vaccine histories?

A. Not at all confident;

B. Slightly confident;

C. Somewhat confident;

D. Confident; or

E. Very confident;

[00:23:14]

Individualizing Vaccine Choice

Dr Auwaerter: Okay. Well, thank you, Tracey. And for those of you, I mean, yes, there's certain aspects of pneumococcal disease that are still a little confusing. So I'm hoping to give you a little clarity and also a cheat as to how to make this easy. So, in terms of just individualizing choice, you might remember we talked about shared decision-making. How do we decide if someone's 65 and older who may have been previously immunized, should get reimmunized and so on? I think some of the things that bother me and are still placing people at risk are those in the green box, the teal box that you see here, or especially those, obviously, where they may be uncertain histories. I practice in Maryland, where we really have a statewide vaccine database, makes it very easy to see what people have gotten. But other states don't have that. And you may not be able to know offhand, and better to probably immunize rather than be left with uncertainty.

[00:24:17]

Incidence Rates for IPD Among US Adults With CDC-Indicted Medical Conditions From 2016 to 2019

But if we dive a little deeper, even though the ACIP recommendations aren't this specific, it gives you some insights as to who really is at risk for pneumococcal disease. And if you look on the left, I mean, gosh, any of your transplant patients, anyone that has a history of hematologic malignancy, splenic disease, immune deficiency, HIV, and then nephrotic syndrome where you're wasting protein and immune globulins look at that incident rate. It's, you know, huge compared to the healthy population, you know, up to 600X. It's really astounding. And then you can see on the right-hand side, it's still substantial but less than the healthy populations. And so these are the groups I would be especially nervous about.

[00:25:13]

Conjugate Vaccines for Adults With CKD

Now, the other aspect, which was sort of interesting with recent recommendations, are based on children. Studies of the PCV13, which is still widely used in the pediatric practices, showed that this vaccine works better if you give it to children with kidney disease, like polycystic kidney disease, and so on, earlier in illness than waiting till they're at end stage or stage IV kidney disease. And you got better immune responses. This is probably no surprise to anyone. I mean, with this, but based on this, they extrapolated to say that anyone with any renal dysfunction. So, you know, means that you'll get better immune response. So, you know, if you have your patients in 18 to 49, for example, and they have CKD3A or 2 even, you may want to immunize them before they progress for better immune response.

[00:26:12]

Prior Pneumococcal Immunization: Adults ≥50 yr

Now, 1 of the polling questions was how confident are you about vaccine recommendations? Well, gosh, you know, there's so many prior vaccines that people could have gotten. What do you do now, and so on and so forth, that it can get rather confusing? And there are actually 3 slides here that, if I went over these precisely, would spend probably too much time. But generally, the easiest thing to say is by giving PCV20 or 21, you're probably covered if you think that they would benefit or need from it.

[00:26:49]

Prior Pneumococcal Immunization: Adults With Comorbidities

But as you can see, there are a lot of potential scenarios here. Whether you have comorbidities or you're healthy and you are immunized and so on, as you go through.

[00:26:59]

Prior Pneumococcal Immunization: Adults With Chronic Conditions

So there are a lot of scenarios, but here's the cheat coming up.

[00:27:03]

Phoning a Friend for Vaccination Recommendations: Handy APP

This is what I have on my phone, and the Centers for Disease Control has done this both for the pediatric population, where they're always vaccine catch-up questions, but also for the adult population. And you just ask 4 simple questions that hopefully you have, or even if you don't know, you can leave it blank. It will give you a recommendation. So it makes it rather easy and targeted. But what you can see is they don't have PCV20 or 21, because if you got 20 or 21, you're done. You don't have to do anything more. It's easy. Although I know there might be some questions on this that will come up in Q&A. It's really if you're dealing with older vaccines like PCV13 and 23, which were the combo for quite a while.

[00:27:53]

Summary: When to Use Shared Clinical Decision-making

So returning to this shared decision-making, and this was 1 of the questions. If you're over 65 and that you got the older vaccine schedule, the 13 followed by the pneumococcal polysaccharide, you are eligible for potentially having a vaccine with better coverage of serotypes, but it's only 20 and 21. It's not 15. If you think about it, you're only getting 2 with 15, so that doesn't make a huge amount of sense. So it's 20 or 21, or if you don't think they're at particular risk or the patient is not terribly interested, definitely no immunization is also quite a satisfactory decision. And again, what would you weigh here? And it would be the degree of comorbidities. If you have someone with multiple myeloma, heck yeah, I would definitely want to immunize him. You know, if you had someone that just had hypertension, sure, you could offer it to them, but I don't think I would make a super strong recommendation on that group that we know it would benefit them.

[00:29:01]

Posttest 2

Tracey Piparo: So let's think about that 72-year-old patient who received a complete series of PCV13 and PPSV23 at age 65. If, after discussion and shared clinical decision-making, the patient agreed to an additional pneumococcal immunization, which choice would be most appropriate?

A. PCV15 only;

B. PCV20 or 21 only;

C. PCV15, 20, or 21; and

D. PPSV23 only;

I'll give you a few seconds. I think this one may have been a difficult one for folks. Do you want to touch on that, doc?

Dr Auwaerter: Yeah. So that was what I was trying to emphasize, that if you've had a 13 and a 23 and one of your patient's 65 and older, they have had it in the past, they are eligible. But it's only 20 or 21 that you would consider. You wouldn't reboost them with a pneumococcal vaccine, the 23, and you wouldn't choose the 15. So that really leaves you 20 or 21, and most practices will just stock 1 of them, not both. But you know, your pharmacies may have both and so on. So you could, you know, discuss that with them. But it's really B here. So that's - that's the key. And that's probably the real takeaway point that I would hope you would come from, because I think this is a group that would be most confusing there.

[00:30:51]

Take-home Points

So, in terms of take-home, we do have 21, which is a new—you know, been on the street now for a year plus. And it does cover serotypes that others don't. And it was really developed for use in adults to cover the most common circulating serotypes. And if you look at 20 and 21 together, they really cover most strains, at least, that have recently been described as causing invasive pneumococcal disease. And then lastly, remember the age has changed from 65 to 50, meaning everyone 50 and older in an effort to capture this greater group, gets one of the vaccines, which can be 15, 20, or 21.

[00:31:39]

Poll 4

Tracey Piparo: All right. So we have another question here. What is your confidence level in moving vaccine-hesitant patients toward acceptance?

A. Not at all confident;

B. Slightly confident;

C. Somewhat confident;

D. Confident;

E. Very confident;

Thanks for answering these guys.

[00:32:28]

Pneumococcal Vaccine Uptake Among Adults

Dr Auwaerter: Okay, so this again sort of touches on something we discussed earlier in the program is that the rate of pneumococcal immunization for those at risk is certainly not as high as we probably would hope to have, and especially for the younger age groups, which is 1 of the reasons that age was moved to 50, in effort to try to help those that clearly are more at risk, even that at 50 you start seeing the increase in pneumococcal disease.

[00:33:03]

Impact of Expanded Age-Based Indication

And so this age expanded indication there was also based also on groups such as Blacks, for example, and certain other groups that we already talked about that seem to have higher rates of invasive pneumococcal disease, poor outcomes, and death. So, this was all an effort to try to help prevent problems for those folks in those age groups.

[00:33:31]

Issues Impacting Vaccine Equity

Now, vaccine hesitancy. Vaccine issues have been in the news, and I think anyone that does primary care probably is fairly familiar with a lot of these issues. But there's certainly, I think, still a very solid basis for discussion about many of the factors that prevent patients that might be at most risk for developing a serious infections, where vaccines are an inexpensive way to prevent that. Yet they don't get them, and they are social factors. They may not be engaged with care, they may have limited opportunities for even discussing vaccine, and then sort of medical literacy as well. So, there's lots of things, and even of course, now there are issues with lots of internet information that may not be accurate, false, or misleading as well.

[00:34:32]

Factors That Influence Decisions About Vaccination

Many of the factors that I think influence, of course, are what you're find when you're scrolling on your phone there. And that's as many of us who haven't sworn it off, you know, will come across all sorts of information there from people that could be experts, but many of them have opinions and may be nonexpert. You also have certain health practices amongst family and friends that often influence. And then there's also the vaccine-specific recommendations as well. That, you know, can be often confusing for patients.

[00:35:09]

The Vaccine Hesitancy Spectrum

Now, if someone's actually anti-vax, as it were, that's going to be a tough 1. I mean, a lot of those folks, you know, you might bring it up. They'll may even bend your ear for a while about things. I always say it's at least something I would talk about and see whether they have any questions, but it's really the vaccine-hesitant group that probably where we can spend a little more time. And there are those that, you know, this slide calls fence sitters that are sort of plus, minus. And then the cautious acceptors, especially true, you know, if something has just come out, they may not want something that first year or 2. And then, as experience is gained and you can reassure them it's been used without problems, might go on to accept it. But the probability of success in getting a patient to take a vaccine in this group certainly is by offering a strong recommendation. That is, hands down, the best aspect to actually motivate a patient who might be a little hesitant. And then addressing their concerns as well.

[00:36:15]

Poll 5

Tracey Piparo: Yeah. So speaking about that, which of the following statements is the best way to use motivational interviewing to address vaccine hesitancy? I understand your hesitance, but

A. All the data show it is safe;

B. Can we talk about your concerns and what might make you feel more comfortable;

C. The benefits outweigh the adverse effects;

D. It is recommended to protect you from becoming hospitalized with pneumonia;

Dr Auwaerter: And Tracey, if we could just leave this slide. I forget. Leave this slide up for a second. I'll move on from it.

Tracey Piparo: Yep.

Dr Auwaerter: Does the polling stop?

Tracey Piparo: Yeah, I think we're good.

Dr Auwaerter: Okay. The point I want to make here is, if you look at A, C, and D, right? This is a clinician telling people something. And B is having the patient tell you, you know what their concerns are. And so I think that is certainly true for people that voice concerns. You're not going to probably get that far telling people things unless if they ask you. And this is what I sort of call unsolicited advice for people that are hesitant, right? So you'd rather have them voice what they're concerned about.

[00:37:54]

Promoting Vaccine Confidence

And I think you do it in an understanding way. You want to ask if it's okay to discuss vaccines? Some people may not even want to go into that area, and then this sort of motivational technique that is try to elicit from them what their concerns are if they seem to be in that hesitant group. And then trying to give them the information, and then, you know, some people are 2- or 3-meeting people, at least park that and then come back to it at a next visit if people need some time to think about it.

[00:38:28]

Tools to Address Vaccine Hesitancy in Older Patients

So there are lots of different ways to do this. Many of us have probably developed our own styles. You know, there are probably prompts to just remind you about best practices and other aspects that help fund vaccines at a federal level, especially for children. Also, primary care is 1 of the key places for people to get accurate vaccine information as well as reminders. And then there's also informational campaigns that you may see, although I think those have fallen off largely, since the start of the year, about getting your flu shots and so on and so forth, which used to be a typical fall campaign.

[00:39:13]

Successful Strategies for Building Vaccine Confidence in Older Adults

And then these strategies certainly can be customized to address concerns. For example, if you're practicing in a skilled nursing facility, there's usually less resistance to vaccines. But, you know, of course, if you're dealing with a family practice where you have both children and adults, you may have to address separate issues there. Or if you're taking care of transplant patients again, I think because of people's certain risks and their knowledge and acceptance, you really need to tailor those.

[00:39:46]

Motivating Interviewing: Strategies to Use

Returning to the motivational aspects, some of the keys here are those where you're soliciting open-ended questions. You're not trying to, you know, just spout information to people. You really try to validate what they're saying. You want to understand what they're saying and make sure they understand. And sometimes I ask people to repeat to me, like, "What's your understanding of what I said? Or is there something you're not quite understanding?"

[00:40:15]

Posttest 3

Tracey Piparo: So what's the best response to that 69-year-old who consistently refuses the pneumococcal vaccine because they believe it causes pneumonia?

A. Acknowledge the concern and explain how the vaccine works using simple, non-technical language;

B. Emphasize that declining vaccination puts others, especially immunocompromised individuals, at risk for disease;

C. State that you have studied the data, and your expert recommendation is that this vaccine is safe;

D. Tell them that most people their age have received the vaccine with no issue;

Take a few seconds to answer. I suspect folks did great with this one. A is obviously correct because according to the CDC recommendations, we should acknowledge vaccine hesitancy rather than confront it, and we should be providing that science-based answers, but in plain language, so that we can address concerns that the vaccine causes pneumonia.

[00:41:57]

Poll 6

So after all this, do you plan to make any changes in your clinical practice based on what you learned in today's program? Choose A for yes, B for no, and C if you're still uncertain.

[00:42:33]

Poll 7

I want to ask you 2 to just take a moment and share with us 1 key change that you do plan to make in your clinical practice based on this education. And I'll leave that up for a little bit while I start asking some of the questions that have come through, because we have some real good ones coming through that I think it's important to talk about. So - so lots of people were asking, how come you think there was such a drastic change in decreasing the age from 65 to 50 years old?

[00:43:04]

Questions and Answers

Dr Auwaerter: So the way I see that decision was, and it sort of reflects earlier aspects in a lot of vaccines to try to simplify things. because you might remember, the older pneumococcal vaccine in 65 was shared decision making and someone that's had prior vaccine and so on and so forth. But I think the key point was that there were still substantial people who were at risk for pneumococcal illness between 50 and 65 that you saw were very much lower than the 65 plus group. So the key way to do that is to buy lower the age group to 50. So those folks are at risk because so many people 50 and older have somsse of the comorbidities, and even if they don't, they are still at risk because of age. So that was the recognition that sort of demographics that still showed this was a group here that was under immunized and at risk.

Tracey Piparo: There's 2 questions here that came through that I think sort of complement each other. You know, I think folks in primary care are the real heroes. You guys are doing great work, and there's tons of vaccines out there that we're expected to talk about. So due to the increased amount of vaccines, excuse me, how do you decide which you want to focus that shared decision making and recommendations on, you know, thinking about influenza or RSV, pneumococcal, zoster? And how do you optimally integrate the pneumococcal in with the adult immunization schedule so that you make sure that you're getting the best coverage, the best long term effectiveness, and that it's feasible for everybody to - to kind of continue with.

Dr Auwaerter: What a great question, but it's a loaded one, isn't it?

Tracey Piparo: Exactly.

Dr Auwaerter: It's a great question. So I'll just tell you some quick thoughts that I have here. And they're by no means, you know, the be all and end all. The brilliance with pneumococcal immunization at the moment with PCV20 and 21 or even 15, it's 1 and done. You only have to give it once, right? So as opposed to some of the others. Clearly, some are time-based. RSV it'd be great to get that before the fall season in your at-risk patients. True for COVID often and certainly influenza. You know, shingles, for example, I find is maybe the more challenging because people, you know, there's a lot of talk because people have had side effects from the shingles vaccine and so on locally that persist for a while.

So the way I prioritize it is the ones that are most lethal are going to be of greatest concerns. And for me, it's usually seasonal influenza, pneumococcal, and COVID for your at-risk patients. So those are the ones I tend to emphasize RSV important, but I park that behind it. And shingles vaccine can be devastating of course, and I incorporate that. But it's not seasonal. So I sort of sneak that in at other times.

Tracey Piparo: Yeah, I think that's a good way to approach it. Again, I think primary care folks are superheroes for keeping this all straight and making the proper recommendations. It goes along with another question of how do you tailor that messaging when you're talking to patients who don't have any risk factors, and maybe they meet the age requirement? But, you know, say a 51-year-old who is doing great and doesn't have comorbidities as opposed to somebody with more comorbidities.

Dr Auwaerter: Yeah. So I think I introduced the fact that this is now recommended because they're gotten to the age where they're increased risk, but their risk isn't as high as if they're going to be, you know, later on. So, you know, if they're like, "Heck, doc, sure, I'll take the vaccine. You know, that's easy." If they ask more questions or so on, then I talk a little bit more, that, you know, they're at risk, but not as much as if they were to wait a while or if they, you know, so on. So I try not to twist arms for someone like that healthy patient, because certainly you don't want to feel like, "Oh my gosh, there's no flexibility here."

Then they just feel you're parroting whatever's, you know, guidelines say without really incorporating their concerns. So I certainly take a softer approach there, especially if I have a sense that they may not do it. I'll just tell you at the moment myself, I haven't gotten mine. I'm not quite 65 yet, but with the change in recommendations, you know, so it's something I probably have to go and talk to my doctor about too. So, you know, any new recommendation will take a few years to really get incorporated, get the knowledge out, but that's why these programs are important, because now you can begin that conversation with your patients.

Tracey Piparo: Yeah. So if you have that patient in your office who is, you know, really accepting of all your recommendations, and they're a little bit older, we're talking about above 65. Is it safe to recommend that they receive all of the vaccinations, maybe that they're due for at the same time, you know, maybe, for example, influenza, COVID, and then the PCV20 or 21? And would you have a preference over which pneumococcal vaccine you recommended?

Dr Auwaerter: So certainly I've had patients get 3 at a time. Some just want 2. One of the keys, I think most of you know, is if you give vaccines they have to be simultaneous or you have to at least spread them out by 2 weeks. Just so you're not having the immune system co-opted by a vaccine, and then you wait only 1 week. They won't respond to the second vaccine as much. I think a little bit just depends. I think most patients probably don't feel like getting 3 vaccines at once is their cup of tea. I usually find they're in the 2-group, but of course, it's an opportunity, especially in the office, where if they need 3, I usually say, "Well, how about it? Are you ready to get all 3 and get done?" And, you know, generally it's fine for most people. There's not additive side effects other than just the local sites of injection and so on. So that's sort of my approach. I don't know, Tracey, if you have any thoughts as well.

Tracey Piparo: Yeah. No, I think that's a great idea. Again, some people are just like, "I'm here and let me have it." I think it's really just talking through what they would like to do that day.

Dr Auwaerter: I was going to say the second part of the question was PCV20 or 21. So my feeling is, you know, either it's okay, there's no preference from ACIP. But my higher risk - now, for example, our facility only stocks at the moment PCV20. However, I do have some patients those with hematologic malignancies solid organ transplant. I've had patients with cochlear implants for example, who've already had pneumococcal disease. I've written prescriptions for PCV21 for them to go to the drugstore to get, and especially if you have pharmacists that are knowledgeable about what vaccines they've gotten, if they have gotten vaccines where they're not eligible, technically, you'll need to prescribe it off-label by a prescription for a drug to fill it.

Tracey Piparo: Interesting. I think that's where sometimes things get complicated.

Dr Auwaerter: They are, and I'm an ID physician, so, you know, probably I'm overthinking it. I think for my patients, you know, but I'm just - I wanted to let you know a little bit. And that's come up occasionally for some patients.

Tracey Piparo: So someone's asking, do you ever consider a booster when they've gotten the - I'm probably going to be wrong, the PPSV23?

Dr Auwaerter: Well, sure. So if someone's gotten the 13 and the 23 or they've gotten it years ago now, so if they've gotten to the 50 group, I would just give them 20 or 21, to be honest. I think that would be the thing to do in those cases. Technically, the advice is only if they've received 13 and 23, but there's probably other people, as you know, that could have gotten like PCV just 13 alone or just the pneumococcal vaccine. And I think even though there's no formal recommendations about that, if they're really in certainly in 1 of those risk groups, I would just give them 20 or 21.

Tracey Piparo: Yeah. From what I'm hearing you say, I think, you know, if someone came into the office and wasn't sure, maybe if they were a new patient or lost a follow-up and not sure what they've had in the past, it seems like maybe you can't go wrong offering 20 or 21.

Dr Auwaerter: That's right. That's why it's sort of simple, you know? Just 1 and you're done.

Tracey Piparo: Yep. Have in - let's see. We have time for a few more. Someone's asking. I know you were mentioning about cochlear implants being 1 of the risk factors that we should think of, because it's not something we see very commonly. Someone was wondering, what about a patient over 65 with a recently placed VP shunt? Should they be counseled to get the vaccine if they haven't had it already? And is there a waiting period?

Dr Auwaerter: Yeah. So VP shunt’s not an independent risk category, but maybe why they had the shunt potentially could be, but it's just the fact that at their age, they are at risk. And I think with the surgical procedure, there's technically no advice about that, but if they just had a shunt replaced, I - you know, I probably, you know - you know, there's older literature that, remember, in hospitalized patients, we used to give smokers pneumonia - pneumovax, right? Be prior to discharge because it was you capture them, right?

So I think it's the kind of thing. Are they up for getting a vaccine? I would say, I wouldn't do it too close because if there's postoperative fevers and so on, it gets cloudy. If someone's just had a surgery, so I - I probably wouldn't advise it right away. But you know, certainly within a week or 2 I wouldn't have any problem getting the vaccine.

Tracey Piparo: Oh, good to know. I think this is another question that a lot of people are probably thinking, and someone actually asked it. What is really the difference between 20 and 21 besides another serotype, I suppose?

Dr Auwaerter: Yeah. Well, I guess there's 2 things. The objective 1 is there's 8 serotypes that are not covered—that are covered, that aren't covered in 20 and obviously not in 15. The other aspect, I think, is that this was sort of formulated really for the adult population at the moment, right? I mean, they - they might be studying it in kids and whether it will be incorporated in the pediatric schedule per se, but it really covers, you know, that 85% of the circulating serotypes, whereas 20, for example, covers 58%, 54%. So you do get that extra advantage there. So those are the 2.