Have These Patients Been Immunized Appropriately?

A Case-Based Challenge

Robert H. Hopkins, Jr., MD


August 06, 2014

Assessing the Adult With Comorbidities

Mr. Roberts has diabetes, which places him at increased but not highest risk for pneumococcal disease; as a result, vaccination with PPSV23 is recommended. He also is at increased risk for hepatitis B, and vaccination is recommended. (A more detailed review of pneumococcal and hepatitis B vaccine recommendations for adults follows this section.) Finally, he should receive annual influenza vaccine when available in the fall because he is at increased risk for severe influenza. He does not need Td at this time because he has received a tetanus-containing vaccine in the past 10 years. It is important to note that a dose of Tdap should replace 1 dose of Td vaccine in all adults; and a dose of Tdap is recommended in all pregnant women during the late second or third trimester in order to provide passive immune protection against pertussis to infants who are too young to be vaccinated. Mr. Roberts is under age 60 years, so zoster vaccine is not recommended.

Pneumococcal Vaccine Recommendations

The ACIP defines varying levels of risk for pneumococcal disease (Figure 1).

Figure 1. Assessing need for pneumococcal vaccine. PCV13 = 13-valent pneumococcal conjugate vaccine; PPSV23 = 23-valent pneumococcal polysaccharide vaccine.

The highest risk category includes immunocompromised patients and those considered to be at anatomic risk, a group that includes patients with functional or anatomic asplenia, cerebrospinal fluid leaks, and cochlear implants. These highest-risk individuals should receive both PPSV23 and PCV13.

Figure 2. Highest risk categories for pneumococcal disease. CSF = cerebrospinal fluid. Data from CDC. www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/pneumo.html

Other adults considered to be at higher risk, requiring immunization only with PPSV23, include those listed in Figure 3.

Figure 3. Categories associated with elevated risk for pneumococcal disease. COPD = chronic obstructive pulmonary disease; ESRD = end-stage renal disease.


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