This transcript was automatically generated from the video recording and may contain inaccuracies, including errors or typographical mistakes.

Team Trivia! Are You Keeping Up With Pneumococcal Disease and Vaccine Developments?

So first, you have to select what team you're on.

1. Are you going to be a Pneumo Preventer, the orange block;
2. Are you going to be an IPD Interceptor in blue;
3. Are you going to be a Vaccine Vanguard in – in lavender.

So you have cubes on your tables that can be your team. Or if you want to be something else, that's fine too. But if you make your selection, please.

Round 1: Latest Developments in Pneumococcal Disease Epidemiology and Vaccines

All right. Well, thank you all for doing our login and for doing our start-up. I'm going to turn things over to my co-host, Nick, to – to do the first section of the program and be competitive. Win for your team.

Dr. Nicolas Issa (Dana-Farber Cancer Institute): Thank you, Dr. Hopkins. Welcome everyone. So I will be going over the latest development in pneumococcal disease epidemiology and vaccine.

Let’s Vote!

So let's vote first.

Pulse Check 1

So this is a pre-test question. For adults aged 65 years or older compared with PCV20, PCV21 has additional serotype that provide coverage for what additional percentage of invasive pneumococcal disease cases?

Please vote. All right. We'll go over this later. So let's go to the second question.

Pulse Check 2

Which pneumococcal vaccine include coverage for serotype four? Is it:

1. Only PCV21;
2. Only PCV20;
3. Only PCV15 plus PPSV23 one year later; or
4. Only PCV21 and PCV20;
5. Only PCV21 and PCV15 plus PPSV23 one year later; or
6. Only PCV20 and PCV15 plus PPSV23 one year later; or
7. All provide coverage for serotype four.

I know a lot of options here. Please vote.

All right. Excellent.

Burden of CAP and Invasive Pneumococcal Disease in US Adults

So let's talk first about the burden of community-acquired pneumonia and invasive pneumococcal disease in the US adults.

So for the community-acquired pneumonia, this is based on a study that was conducted by the CDC prior to the COVID-19 pandemic and found that the annual incidence of community-acquired pneumonia in adults was 243 per 100,000, but this increases to 60 – 634 if – per 100,000 if you're aged 65 to 79 and more, 16,430 per 100,000 adults for those aged 80 and above.

And of note is a pathogen was not found in these – most of these cases. In more than 62% of these cases, there was no pathogen identified. Viral was found in 23% and bacteria in 11%. And what they found also is duration of hospitalization is associated with decrease in quality of life and a decrease in functional status. But how about the invasive pneumococcal disease burden?

As a reminder, the definition of invasive pneumococcal disease is the isolation of strep pneumo in any sterile body fluids, including bloods, pleural fluid, CSF, joint fluid, or pericardial fluid. So based on this Active Bacterial Core surveillance data done by the CDC between 2018 and 2022, the annual incidence of invasive pneumococcal disease in those more than 65 years of age was 24 per 100,000. And this was associated with an increased mortality up to 20.8%.

Most of the risk factors associated with increased mortality included age greater than 65 years and older, or those who have chronic disease or immunosuppression, or are nursing home residence.

Streptococcus pneumoniae Serotypes

There are over 100 different serotypes of strep pneumo, but 23 serotypes are responsible for 80 to 90% of the invasive pneumococcal disease.

Now, with the advent of conjugated vaccine, there was a sharp decrease in the targeted pneumococcal serotype infection but also a rise in – in – in non-vaccine serotypes. However, these non-vaccine serotypes are less virulent and are not associated with as high of mortality as those included in the vaccination.

Serotypes Targeted by Pneumococcal Vaccines

So the current vaccine that we have for pneumococcal – for pneumococcus now are conjugated vaccines. And these are vaccines that has advantages over the polysaccharide vaccine. So as you know, conjugated vaccine trigger a T-cell-dependent immune response that leads to generation of memory B-cell. And this is more lasting immune – immune response compared to polysaccharide vaccine.

So we have PCV15, PCV20, and most recently, PCV21, which is not – PCV21 is not PCV20 plus one serotype. It’s actually a vaccine that has eight unique serotypes compared to other vaccinations.

The main thing to know about PCV21 is it does not cover serotype four, and serotype four is an important serotype in those who lives usually in the Western United States. So states such as Alaska, Colorado, New Mexico, Navajo Nation, Oregon. These were found to be responsible for more than 30% of invasive pneumococcal disease. So it's really important to consider this when choosing your vaccination.

It also were found that these are usually adults less than 65 who have one or more conditions such as smoking, alcoholism, they suffer from homelessness or they have COPD. So something to keep in mind when considering which conjugated vaccine you want to give.

IPD Vaccination Type Among Eligible Adults, 2018-2022

This is a study that was done between 2018 and 2022. And it looked at the percentage of invasive pneumococcal disease and the rate of coverage from PCV20 and PCV21 in two different groups of patients. The first one were those between 19 and 64 years old, and the other one for those aged more than 65.

And as you can see for PCV21 had 81% coverage compared to 58% coverage for PCV20 and a difference of 36% in 19 to 64 group. In the age more than 65 or equal to 65, PCV21 had 85% coverage compared to 54% coverage for PCV20 and a difference of 38%.

PNEUMO: Epidemiology of CAP

This is PNEUMO study, which is an epidemiological study looking at community-acquired pneumonia. It's a cross-sectional study that included 2016 adults hospitalized in three large Tennessee and Georgia hospitals from 2018 to 2022. In this study, the median age was 60.1. There were 60% White, 36% Black and 4% Hispanic.

So in this study, the highest burden of community-acquired pneumonia were in those greater than or equal to 65 year of age. And for those who have pneumococcal pneumonia, the incidence was 42 per 100,000. But for those serotypes involved, the PCV21 covered about 71% of those serotypes.

Now there are some limitations to this study. Not all serotypes were detectable. Also most pneumonia had unknown etiology. And also the study setting is not representative of the general US population.

Epidemiology of Pneumococcal Disease in the US

This is another study, but this one is a model-based analysis combining – combining the Active Bacterial Core surveillance data with the PNEUMO study and other epidemiologic data in the US to estimate the annual serotype specific pneumococcal disease burden.

So as you can see on this chart, it tracked how many of the serotypes would be covered by PCV15, PCV20 and PCV21. And for all spectrum of pneumococcal disease, you can see that PCV21 has the highest coverage.

Epidemiology of Pneumococcal Disease in the US

And this is also across all age group, and whether it's pneumonia or invasive pneumococcal disease.

Let’s Vote!

So let's vote.

Pulse Check 1

Now these are the same questions that we did for the pre-test. For adults aged 65 year or older, compared with PCV20, PCV21 has additional serotype that provide coverage for what additional percentage of invasive pneumococcal disease?

1. 27%;
2. 38%;
3. 47%; and
4. 58%.

Please vote, also including those who are joining us online.

All right. Great. Looks like you guys paid attention to the slides. All right, so next question.

Pulse Check 2

Which pneumococcal vaccine include coverage of serotype four? There are a lot of options.

1. Only PCV21;
2. Only PCV20;
3. Only PCV15 and PPSV23 one year later;
4. Only PCV21 and PCV20;
5. Only PCV21 and PCV15 plus PPSV23 one year later;
6. Only PCV20 and PCV15 plus PPSV23 one year later; and
7. All provide coverage of serotype four.

Please vote.

Okay, great. Very good audience.

Let’s Check the Leaderboard

All right, let's check the leaderboard and see who is winning. Wow. Very close.

Dr. Hopkins: Very close.

Dr. Issa: Excellent.

Round 2: Pneumococcal Vaccine Recommendations

All right. So let's talk – talk about the pneumococcal vaccine recommendations.

Let's Vote!

First, let's start with some pre-test.

Pretest 1

If following the current CDC recommendation, what age cut-off should you use for universal/routine pneumococcal vaccination? Is it:

1. 50 year or older;
2. 55 year or older;
3. 60 year or older; or
4. 65 year or older.

Please vote.

All right. Great. We'll cover that later.

Pretest 2

Okay. Pre-test question two. This is a hard one. A 67-year-old received PCV13 at age 62 five years ago, and PPSV23 at age 63, four years ago. Following CDC guidance, what would you recommend?

1. Give PCV20 or PCV21 now;
2. Give PCV20 or PCV21 in one year;
3. Give PPSV23 now;
4. Give PPSV23 in one year; or
5. Use shared clinical decision-making to determine whether to give PCV20 or PCV21 now or to give no additional pneumococcal vaccine.

Please vote.

All right. Okay, we'll cover this a little bit later.

Pulse Check 3

Okay. Another question. A 44-year-old patient with cochlear implant received PCV13 several years ago. Following CDC guidance, what would you recommend?

1. PPSV23 now;
2. PCV20 or PCV21 now;
3. PCV15 plus PPSV23 or PCV20 or PCV21 now; or
4. No further vaccination until age 50 year.

Please vote.

All right. Excellent. Okay.

Expanded Age-Based Indication for Pneumococcal Vaccination

All right. So let's talk about this new recommendation or fairly new, because this was in 2024 and based on an analysis of Active Bacterial Core surveillance data of invasive pneumococcal disease rate from any serotype between 2018 and 2009. This study looked at the incidence of invasive pneumococcal disease among Black versus non-Black adult patients.

And as you can see from this graph that the invasive pneumococcal disease rates among Black adults peaked at a younger age, 55 to 59 compared to non-Black adults. And this led to the revision of the CDC recommendation now, and with expansion of the age-based indication giving these data and also to improve health equity.

So from 2024, the current recommendation is to give pneumococcal vaccine for anyone aged 50 year and older.

Pneumococcal Vaccination Is Recommended for…

So the current recommendation, you have three choices. These are the available vaccines. You can either give PCV15 plus PPSV23 a year later, or PCV20 or PCV21. They're all are good options. If you don't have PPSV23, or you don't stock it, then you can use PCV20 or PCV21.

Pneumococcal Vaccination Is Recommended for…

So also the pneumococcal vaccine is recommended for younger adults aged 19 to 49 if they have risk factors. And these would include cerebrospinal fluid leak, any chronic condition involving heart, liver, kidney, or lung disease, asthma, diabetes, cochlear implant, alcohol use disorder, cigarette smoking, or if they have any of these immunocompromising conditions that include asplenia, immunodeficiency, cancer, HIV infection, sickle cell disease or other hemoglobinopathy.

Pneumococcal Vaccine Schedule: Age ≥50 Yr

So now we know that anyone above age 50 year and older should receive a pneumococcal vaccine. But what happened if they already received pneumococcal vaccines in the past? That gets to be a little bit confusing. And I have to reassure you that, later on, we can show you an easy – easier way of how to sort through all the different scenarios of what different vaccines were given before.

But for those who did not receive any prior vaccinations or those who received PCV7 at any age, then the recommendation is to give PCV20 or PCV21. The option B would be giving PCV15 and PPSV23 more than a year later.

If they gave – if they had PCV15 at any age, then you just give them PPSV23 a year later or if you're not – if you don't stock PPSV23 or not available, you can give PCV20 or PCV21 a year later. If they already got PCV15 and PPSV23 or PCV20 or PCV21 at any age, then the vaccination is complete.

So the goal here is the principal is to widen the coverage of the serotypes. Now there are different other scenarios that I won't be going over through, except to note that there's one thing for PCV13 and PPSV23 if they received it before age 65, then they would need to get PCV20 or PCV21 more than five years later. This was one of the questions in the pre-test.

But if they received PCV13 at any age plus PPSV23 at age more than 65 year of old, then it's a shared decision-making.

Pneumococcal Vaccine Schedule: Prior PCV13 + PPSV23

Dr. Hopkins: If you have a patient who's now over 65 that received PCV13 plus PPSV23 and it's now been five years or more, you should give PCV20 or PCV21 today. On the other hand, if that patient was given PCV13 plus PPSV23 at or after 65 years of age and it's now been at least five years, you should have a shared decision-making conversation about whether to give PCV20 or PCV21 or not give an additional dose of pneumococcal vaccine.

Pneumococcal Vaccine Schedule: Age 19-49 Yr With Immunocompromising Condition, Cochlear Implant, or CSF Leak

Now, same thing for those aged 19 to 49. If they have immunocompromising condition, cochlear implant or CSF leak, same thing as the previous one, except that here you can give PPSV23 after PCV15 in – after eight weeks, not a year. And also same thing for those who got PCV15 just to give them the broader coverage you would give PPSV23 more than eight weeks later, at least.

For those who already received PCV15 plus PPSV23 or PCV20 or PCV21 at any age than their vaccination is complete. Like I said, I'm not going to go read all of those. You'll have them in your slides and we'll show you later an easier way of how to figure out what the vaccine recommendation is for those patients.

Pneumococcal Vaccine Schedule: Age 19-49 Yr With Chronic Disease

Same here for the patients who are between the age 19 and 49 with chronic disease. But this one goes back to giving PPSV23 more than a year later.

My time is up. So I'm going to yield to Dr. Hopkins.

Updated Recommendations for PPSV23 in Adults

All right. So the updated recommendations. Well, flash. That was me. I must be electric. So PPSV23 has taken on a lesser role in pneumococcal protection in our population now. Really it should only be used in combination with PCV15 because you're covering the additional serotypes better with conjugate vaccine than you are with polysaccharide. The timing for when you're going to use PPSV23 is going to depend on immune status. If somebody has a normal immune system, you're going to wait a year after PCV15 to get PPSV23.

If somebody has, like many other patients that Dr. Issa treats, immune-compromised, then you're going to shorten that interval to provide that patient maximal protection as early as possible. So eight weeks or more after that dose of PCV15.

It's no longer recommended that those vaccinated that we use PCV13, we use PCV20 or PCV21 because we provide better protection across greater numbers of serotypes.

Your trivia point for the day. Our allergy immunology colleagues want to keep PPSV23 around because we use that to test the T-cell-mediated immunity. You give a dose of PPSV23 and then you assess for antibody production. So for our purposes in primary care, for our purposes in pneumococcal protection, conjugate vaccines provide better protection.

Updated Recommendations for Serotype 4 in Adults

Now serotype four. Dr. Issa mentioned earlier that serotype four disease cause – serotype four causes greater percentage over 30% of invasive pneumococcal disease in certain populations. Patients in the Navajo Nation, in Alaska, particularly among the Alaskan native population, Colorado, New Mexico and Oregon. And this has also been validated in patients who are homeless, who have additional risk factors.

If you live in an area where you're treating patients that have a high incidence of serotype four disease, PCV21 is a lesser – is – is an inferior vaccine to either PCV15 or PCV20 for protecting your patients.

So where I live in Arkansas, we don't have that much serotype four disease as far as we know. So we use more PCV21.

Phoning a Friend: PneumoRecs VaxAdvisor App

Now what Dr. Issa was referring to earlier. Here's where to phone a friend. Those patients who have had previous doses of pneumococcal conjugate vaccine can become very complex, very difficult to figure out what vaccine recommendations to use.

The PneumoRecs Vaccine Advisor is an application that was developed by CDC support a number of years ago. It's been updated recently. It can help us as healthcare professionals to quickly determine which pneumococcal vaccines our patients need and when to administer them.

You enter patient data on age, on risk factors and on pneumococcal vaccine history, and then it gives you what the current recommendations are for pneumococcal vaccine. So this is free to use. It's available for your phone app as well as a desktop application. I use it almost every day when I'm in clinic, and I'm sure Dr. Issa and all of you will find equal to value in using that.

My Recommendations for Pneumococcal Vaccine Stocking

So what do I do in Arkansas? I stock PCV21 for most qualifying patients. It provides better coverage for – versus the other vaccines for all pneumococcal conditions. There's really not good comparative effectiveness data on PCV21 versus PCV20 in healthy adults. We need that data. That's a – that's a research question going forward. But economic models suggest less cost per year of life gained for using PCV21 versus PCV20.

Now, for those of you that live in areas where you have increased serotype four disease – just of interest, could those of you raise your hands if you're in one of those states that has increased risk? Okay, so not a lot of us in here, but there may be some online.

For persons who are in areas where you have high amounts of serotype four disease – remember, this is Western states, homeless populations, Native American and Alaskan natives – then PCV20 or PCV15 plus PPSV23 is a better strategy. Remember, serotype four is not included in PCV21.

And the other piece I hate to tell you, the pneumococcal recommendations are complex. Guess what? There are at least four additional pneumococcal conjugate vaccines in the pipeline covering more strains. We'll get to have this talk again. Aren't you excited? More games.

Let's Vote!

All right. Let's vote.

Posttest 1

So post-test question number one. If following the current CDC recommendations, what age cut-off should you use for universal/routine pneumococcal vaccination? Is it:

1. Age 50 and older;
2. 55 and older;
3. 60 or older; or
4. 65 and older.

Let's show Dr. Issa that he did a good job getting you through this.

All right, 97.4. You hit it right the nail on the head. All right. Great job.

Posttest 1: Rationale

All right. So that's the correct answer, 50 and older for routine pneumococcal vaccination. I see many in this room are 50 and older. I hope that you're with me and you've had your pneumococcal vaccination.

Posttest 2

Post-test question number two. You've got a 67-year-old who got PCV13 at age 62 five years ago and PPSV23 at age 63 four years ago. If following CDC guidance, what would you recommend today?

1. Give PCV20 or PCV21 now;
2. Give PCV20 or PCV21 in a year;
3. Give PPSV23;
4. Give PPSV23 in a year; or
5. Use shared decision-making to determine whether or not to give PCV20 or PCV21, or to give no additional pneumococcal vaccine.

If you make your selections on your iPads and those online, do it as well.

I would jump up here, but I might break something. Okay. All right. So we got an increase there.

Posttest 2: Rationale

So the rationale here is, in patients over 65 years of age who previously had PCV13-based vaccination, we need to give a dose of PCV20 or PCV21 five years after their last dose of pneumococcal vaccination. Okay.

Pulse Check 3

So our third pulse check. 44-year-old patient with a cochlear implant got PCV13 several years ago. If following CDC guidance, what would you give today?

1. PPSV23 now;
2. PCV20 or PCV21 now;
3. PCV15 plus PPSV23; or
4. PCV20 or PCV21 now; or
5. No additional vaccination until age 50 and older.

Make your selection, please.

All right. A big increase. So I have to ask, did anybody in this room open up the Vaccine Advisor for those last two questions? Okay, good. All right.

Pulse Check 3: Rationale

So again, complex question. Remember, a cochlear implant is a highest risk situation. These folks are at very high risk for pneumococcal meningitis. And so they need PCV20 or PCV21 to give them broad serotype protection against invasive pneumococcal infections.

Let's Check the Leaderboard!

All right. Let's check the leaderboard. The IPD Interceptors are in the lead, following by a tie between the Pneumo Preventers and the Vaccine Vanguards. All right. Let's keep – keep voting. Let's keep doing well on these – on these tests.

Round 3: Vaccine Hesitancy Barriers to Pneumococcal Vaccines

All right. Let's now talk about barriers like vaccine hesitancy around pneumococcal vaccines.

Let's Vote!

Let's do a couple of baseline questions before we go.

Pretest 3

So first baseline question. I have evidence-based approaches to assess hesitancy around pneumococcal vaccines.

1. Strongly disagree;
2. Disagree;
3. You're neutral;
4. You agree; or
5. Strongly agree.

If you'd make your selection please on your iPads.

All right. You've got pretty good tool sets for about half of you. I'm going to give the rest of you some tools to use here in the next few minutes.

Pulse Check 4

All right. Next pulse check. Which of the following is not part of the CDC SHARE framework for vaccine recommendations?

1. Share personalized reasons why vaccination is right for this patient;
2. Highlight positive experiences that you have had or seen with vaccines to strengthen confidence;
3. Address the patient's questions and concerns in plain and understandable language;
4. Remind patients that vaccines protect them and others from serious illnesses and complications; and
5. Explain why a patient's risk factor make it important for them to receive the vaccine.

If you’d make your selections, please.

All right. Good.

The Vaccine Hesitancy Spectrum

All right. So as we think about the environment we're in today, we're seeing lots of vaccine hesitance. Studies show that individual awareness and strong recommendations for immunization are two of the most significant predictors of vaccine uptake.

We know that vaccine confidence falls along a spectrum. Many people are at varying degrees of confidence, hesitance, contemplation, pick your term, because they're all correct. It's really important for us to evaluate when you're talking to a patient, what their specific current concerns are and to create a safe space to ask questions. That doesn't mean that we need to have a long conversation about vaccines every time patients in.

But having brief conversations with patients who have doubts, who have questions is the most likely path to get us to a point where people get vaccinated. Most patients who are hesitant are not anti-vaccine. Most patients who are hesitant have questions. They have concerns. And we can answer those questions, concerns and get most of those patients vaccinated as long as we can have a mutually respectful conversation.

Tips on Making Vaccine Recommendations

So when we make – when we first encounter a patient to have a vaccine, we need to make a strong recommendation. I recommend Nick that you have a pneumococcal vaccine today, because I don't want to see you in the hospital with pneumococcal pneumonia. Strong recommendation and a reason why.

If he raises his eyes, if he looks down at the floor, if he shakes his head no. If he gives me any indication, any stop sign for that vaccine recommendation, we've got to stop. Our initial response as humans is, “What? Why don't you want this vaccine? It's the best thing you can do to stay out of the hospital.” If we do that, we've lost the battle. We can't doubt our patients. We can't scoff at them. We've got to be present them a face of acceptance, of trust and of conversation.

Not every patient is going to have an initial acceptance to every vaccine. We have to recognize that attitudes, behaviors and uptake are all contextual. Vaccination is a long game. It takes time for us to build trust and understanding with our patients. Even if you're in a situation like I have where I've got many patients I've treated for 20 and 25 and 30 years, there are still patients that have concerns and questions.

And if we can have a conversation, we're more likely to get them to acceptance than we are if we turn off the spigot. So we need to assess and address vaccination at every opportunity.

The PATHe to Vaccine Acceptance

So this is the – the method that I use when I have a patient that has questions or concerns. First, I prepare myself for an open and empathetic conversation. I'm going to lean into them. I'm going to – I'm going to make sure they know that I am here for them. I'm not going to judge them. I'm going to approach the patient by asking them, do you mind if I ask what your questions are or why you have concerns about pneumococcal vaccination?

I'm going to make sure that I don't pass any judgement on their response. I've got to be culturally humble. I may know a lot about this patient, but I don't necessarily know everything. I don't know that they're – they have a family member that potentially had a serious adverse event to a vaccine. That's not common, but it does happen.

We're going to provide brief positive messages about the vaccine, whether it be about safety, whether it be about disease risk. I'm going to identify misinformation, but I'm not going to rebut it because if you rebut misinformation, again, you solidify resistance to that vaccine. And I'm going to acknowledge when there are knowledge gaps. You know, we don't know the data about how much serotype four disease there is in Arkansas compared to Colorado.

We don't know that you, in particular, are going to get pneumococcal disease or invasive pneumococcal disease if we don't vaccinate you. But this gives us the best opportunity to reduce your risk. And humanizing your message so that the patient knows that they are important to you as an individual is really critically important. And then again, don't get hung up on whether I get them vaccinated today. Embrace the long game. If I get you vaccinated today, great. If I get you vaccinated next visit, it's not perfect but it's better than not getting vaccinated. So we need to come back to that conversation at each visit until we get people protected.

SHARE Framework: How to Make Clear Recommendations

This is the CDC's SHARE framework. It's essentially another way of that brief motivational interview that we use to get people to vaccination. You share personalized reasons why the vaccine is right for the person giving their specific attributes. You highlight positive experiences you've had with vaccines. You address the patient's questions. You remind the patient that vaccines are there to protect them and to protect others, and we explain the potential costs of what infectious diseases can result in for them.

Just again, there are multiple different ways. There are lots of tools out there for this many motivational interviews. Any of them is – is acceptable. You've got to find what fits your style. I'm a SHARE guy. Nick may be – or I'm a path guy. Nick may be a SHARE guy.

Maximize Vaccine Uptake With Staff Engagement

The other thing that's important is that we need to have everybody in the office on the same team. If I'm recommending a vaccine but the patient is roomed by a medical assistant that says, “Oh, Dr. Hopkins is going to want you to have pneumococcal vaccine today. I don't know about that.” You've lost, you know. So everybody in the office needs to be on the same page. You need to make sure that you, your nurse, the medical assistant, even the front desk clerk and the person doing the billing, all need to be on the same team.

So we train our staff. Gives us an opportunity to discover what concerns staff members may have, and it lets us know who may be the person that may start the conversation before the patient even gets to you.

We all are on the same page. We answer staff questions, and it allows us to better optimize the opportunity because our patients may relate more to people they know in the office from their community that they may not feel they can relate to you.

he Role of Social Media in Vaccination and Public Health

We have to remember we live in a world of social media. Social media algorithms can amplify emotionally charged content that can be misleading, that can reduce vaccine confidence. Misinformation often outpaces facts and corrections, so debunking and blanket bans that have been tried didn't work.

We have opportunities to meet people on social media where they seek information about vaccines. If you have the, shall we say, emotional tolerance to put up with that. Some do and some don't. It can be used to identify emerging concerns and, well – well-designed vaccine campaigns have been successful, but generally they take on the same approaches. Understanding where people are coming from and answering their questions, not putting out blanket statements that this person or this individual and government is wrong.

Key Takeaways

So the key takeaway is supportive vaccine conversations are really important to get your patients immunized. Pneumococcal vaccination is complex. It is underutilized. The PneumoRecs Vaccine Advisor can help get you through those difficult challenges and get our patients vaccinated and get them protected.

The other scenario we didn't talk about, Nick, that I think it's also important to recognize is that many of our patients don't know whether they previously had a pneumococcal vaccine. And if they don't know, assume no.

Let's Vote!

All right. Let's – let's vote on this last section.

Posttest 3

So post-test question number three. I have evidence-based approaches to assess vaccine hesitancy around pneumococcal vaccine.

1. Do you strongly disagree;
2. Do you disagree;
3. Are you neutral;
4. Do you agree; or
5. Do you strongly agree.

Make your selection on your iPads now. And online folks, vote please.

So I still haven't found what I'm looking for. Does that mean I didn't give you what you needed in that last section?

Posttest 3: Rationale

All right. So the – the agree and strongly agree were the vast majority. We had an uptick. Thank you all.

Pulse Check 4

All right. So next pulse check. Which of the following is not part of the CDC SHARE framework for vaccine recommendations?

1. Share personalized reasons why the vaccine is right for the patient;
2. Highlight positive experiences you've had or seen with vaccines to strengthen confidence;
3. Address patient questions and concerns in plain and understandable language;
4. Remind the patient that vaccines protect them and others from serious illnesses and complications; or
5. Explain why a patient's risk factor make it important for them to receive the vaccine.

Make your selection on your iPad please, and vote online.

All right. Pre 5.9%, up to 35% after. Okay. That's a – that's an improvement. Pneumococcal vaccination keeps you off the highway to hell.

Let's Check the Final Standings!

Okay. All right. Let's check the final standings. Well, look at that. So Pneumo Preventers win by one point. IPD Interceptors behind by one. And the Vaccine Vanguards in third place at 621. Let's give everybody a round of applause.

All pretty close. All pretty close.

Conclusions and Questions and Answers

All right. So conclusions and question and answer. Let's now answer some of your questions. Nick, since I've just been talking, you want to start with the first one?

Dr. Issa: Sure. But it's mostly related to what you just mentioned. How do we identify misinformation without rebuttal?

Dr. Hopkins: So – so that's really for me, that's pretty easy. Think back to the COVID-19 pandemic. How many times did I hear that if you get that shot, you're going to get a 5G chip. That is absolutely false. That's all you have to do is you can say that's false or that's – that's not true. That's not been shown in science.

If the patient wants to discuss it more, you can discuss it more. But don't go into active rebutting the information. You know, that's not true. There's – there are no chips in the vaccine. That's not a fact. Simple response.

Dr. Issa: Okay. All right. The second question is from people online. Are recommendation for serotype four applicable equally in native communities in Alaska as in larger cities?

I would say yes. And the reason is because it's not only native Alaskan, but also those in big cities who are experiencing like homelessness, have any of the other conditions, such as smoking, alcoholism, COPD. So I would say giving the geographic location, I would say, yes, you would need to cover serotype four independently.

Dr. Hopkins: All right. Our next question, if PCV20 or PCV21 is given at or after age 50, what's the recommendation for after they reach age 65?

Well, that's not one that we have a firm answer for right now. That's one of the reasons that we need some active surveillance and need some forward-facing epidemiologic data. Likely, we're going to have a recommendation for another dose of a high valency pneumococcal conjugate vaccine at some point. Current models estimate that PCV20 or PCV21 are likely to provide good protection for at least eight to 10 years, but we need some true surveillance data to answer that question rather than just relying on models. So stay tuned.

Dr. Issa: All right. Next question. Why was serotype four not included in PCV21? And I'm afraid I don't have an answer to this question.

Dr. Hopkins: You know, I – I don't know that there is a good answer for that. You know, when – when conjugate vaccines are constructed, they're faced with two pieces. Number one, you're trying to cover as many serotypes that cause significant invasive disease as possible. But the more serotypes you cover, the less of each of those antigens you can include in the vaccine construct. And so they – they had to draw a line at some point.

There was not a lot of serotype four disease that had been detected in active surveillance when the development process began for PCV21. And so that has emerged. We have seen this serotype replacement happen with pneumococcal vaccines over time. We've seen some serotype replacement in the haemophilus influenzae type B disease and other bacterial diseases we vaccinate children for.

And so that's part of the reason that we need to continue vaccine development if we're going to continue to respond to the bacteria and, frankly, the viruses that affect humans.

Dr. Issa: Next question is, what is the difference in polysaccharide versus conjugated vaccine?

So that's a good question. So polysaccharide vaccine just generate antibody and these are short-lived immune response because they don't involve the T-cell and generation of memory B-cell, versus conjugated vaccine, because they’re conjugated to a protein, they do stimulate T-cell-dependent immune response and therefore are much more immunogenic and much more long-lived compared to polysaccharide vaccine and definitely are preferred to polysaccharide vaccines.

Dr. Hopkins: Another point that's important for us to recognize is when you get a highly vaccinated population using conjugate vaccine, you also can develop some degree of community or population-level immunity to those pneumococcal serotypes. Polysaccharide vaccine doesn't reduce colonization over time like conjugate vaccines do, so you really get a community benefit from high levels of vaccination of children with pneumococcal conjugate vaccines.

PCV15 and PCV20 are the current pneumococcal vaccines recommended for our kids, so that can help us to reduce some of the burden of disease in adults. But we still need to respond with individual vaccination to reduce your risk for development of disease. So community immunity can lead to reduction in colonization. But your individual vaccine is what leads to reduction and you’re developing an invasive infection.

Dr. Hopkins: Okay. The next question I think is – is directly from one of the questions we asked a few moments ago during the presentation, are repeat PC – PCV20 and 21 recommended in immune-compromised patients and those who've got chronic medical conditions?

So in patients that have gotten PCV13, in patients that have just gotten pneumococcal polysaccharide vaccine, then yes, there's a recommendation to get PCV20 or PCV21 so that we give better, longer lasting protection with that conjugate vaccine if they have just gotten polysaccharide and broader protection to more serotypes if they've just gotten PCV13 plus the polysaccharide vaccine. That's the reason for giving those higher valency vaccines to people that have previously been vaccinated.

Dr. Issa: Excellent. The next question is, if patient already has gotten PPSV23 and PCV13, do they still need PCV20 or 21?

And this is again depends on the age. If it's less than 65 or not and also other medical conditions. I'm not sure Bob if you want to – yeah.

Dr. Hopkins: And the – and the five-year time interval between those previous vaccines. Now if your patient got PCV13 and PPSV23 after age 65, okay, now they're 70 years old. That's a situation where you can have a shared decision-making with that patient about whether they need PCV20 or PCV21. Most of the time, you know, if we look at the epidemiology of our patients when they get to their 70s and 80s, most of these patients have chronic medical conditions that put them at higher risk for pneumococcal infections.

And so the risk of giving PCV15 – or excuse me, PCV20 or PCV21 to these patients is very, very low. They've got significant potential benefit in reducing their risk for invasive pneumococcal infections. So most of the time that shared decision is going to be, yes, vaccinate them.

Now if I had a perfectly healthy 70-year-old who had no chronic medical conditions and had gotten those vaccines at age 65 and is now 70 or 72, I might wait a little bit, but those people are – they're kind of like the – the rare bird. We don't have too many – folks at least in my population that are 70-plus that don't have chronic health conditions and definitely not a mixed population.

Dr. Issa: All right. The next question. What about an elderly who doesn't know if she got vaccinated in young age, has past medical history of asthma, dementia and hypertension.

So for those who don't have a good history or they don't remember, you just give them PCV20 or PCV21.

Dr. Hopkins: Don't know means need vaccine, right? Okay. So ques – good question. Why are there different serotype prevalence in certain geographies than in others? You know, this is a – this is part of the challenge that we face with pneumococcal disease. Pneumococcal serotype distribution varies by geography. It varies by the patient population you're – you're dealing with.

Children – invasive pneumococcal disease in children has different serotype distribution than invasive pneumococcal disease in adults. If you look at pneumococcal serotypes in northern Europe as opposed to the US, they're significantly different, the serotypes that cause invasive disease. If you look at pneumococcal serotypes causing invasive disease in Africa, it's very different in northern Africa than in southern Africa.

So we see some of this may be pressure from previous vaccination. Some of it may be transmission within certain groups. There are multiple factors that go in and we know some of them, but we don't know all of them.

Dr. Issa: All right. The other question is probably for you, Bob.

Dr. Hopkins: Okay. All right. Do you have common vaccine hesitates – hesitation or concerns or questions that patients bring up regarding pneumococcal vaccines and how to address those?

You know, it's interesting. There are certain populations that are just hesitant to any vaccine you bring up. There are – I've had a number of patients in – in my communities raised the issue of, well, why should I get this pneumococcal vaccine? Isn't that something similar to what they did at Tuskegee? Or my sister or brother got a pneumococcal vaccine and they had a really red swollen arm and I don't want to take a chance on having that side effect with, you know, myself.

And so you're going to see different questions, different hesitation. And I try to talk patients through that situation. The red swollen arm does happen. It's not uncommon for you to have redness or swelling in the arm, particularly with repeated pneumococcal vaccine doses. We've known that going back to the polysaccharide vaccine days. And that's why that – I call it the great pneumococcal myth.

During the time of my training, up through about five or six years ago, for some reason, this myth seemed to be carried out that you needed PPSV23 every five years. That's never been a recommendation for – for wide population use. And if you had somebody getting pneumococcal vaccine every five years, they would get a red swollen arm because you're repeating that exposure and that immune response. So trying to address the specific questions of the patient and letting them whether – number one, is it real or not real? And number two, helping them understand why and to have a plan, you know.

So you've had previous pneumococcal vaccine. You may get a red swollen arm. I want you to make sure that you've got some ice packs ready, that you have some ibuprofen or acetaminophen, depending on what your risk factors are that you can take to help ameliorate those symptoms. So if you let them know what to expect and how to respond, your patient is going to be much more likely to accept the vaccine, even knowing that they may have what we would consider a minor side effect. But knowing how to respond to that in a positive way is much better than being left with the unknown of not knowing what to do about it.

Dr. Issa: All right. One question. You mentioned about having a limited number of antigen for PCV21 vaccine. Why is there a limit?

Dr. Hopkins: It really boils down to the – the chemistry of taking all those protein bound to a polysaccharide antigen. How many of those that you can put into a vaccine dose without all of those things – pardon my scientific expression – glomming on to each other and getting stuck together. You want to – the key is using enough protein to stimulate that T-cell-mediated immune response without using so much protein that you don't get a good, smoothly flowing liquid vaccine.

And so we've seen or we now are seeing development of PCV25, PCV24, PCV31 and others. And so what the scientists developing those vaccines are doing is they're trying to engineer that protein in a way that is giving you a T-cell-mediated response without being one that's going to react when put in larger quantities in the vaccine. Science is a wonderful thing.

If a patient had gotten PCV20 at a younger age, less than 50 due to a comorbidity, is a repeat PCV20 or 21 necessary later in life?

Well, we still don't know that. As we mentioned earlier, that – that – we will hopefully have more data to answer that question over the next few years with additional surveillance.

Dr. Issa: I think that's all the questions that we have.

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