A 62 year-old female comes to your ambulatory care clinic for her annual influenza vaccine. She is an every day smoker, and her past medical history includes hypothyroidism, hypertension, and osteoarthritis. You review her immunization history to see that she received a flu shot one year ago, Zostavax two years ago, and Tetanus-diphteria acellular pertussis (Tdap) eight years ago. In addition to the flu vaccine, which of the following vaccines would you recommend for this patient? Select all that apply.
A. Pneumococcal conjugate (PCV13)
B. Pneumococcal polysaccharide (PPSV23)
C. Tetanus-diphtheria acellular pertussis (Tdap)
D. Tetanus-diphtheria (Td)
E. Recombinant zoster (Shingrix)
Answer with rationale:
The correct answers are B and E.
Immunizations are an extremely important aspect of patient care for the prevention of certain diseases. As pharmacists, it is essential to be able to identify patients who qualify and/or have contraindications for particular vaccines. Recommendations for different vaccines vary based on age, comorbidities, and other patient-specific factors.
PCV13 is not indicated for this patient, making answer A incorrect. PCV13 for adults age 19-64 is only recommended in select patients: those who have cochlear implants, cerebrospinal fluid (CSF) leaks, asplenia, sickle cell disease, and immunocompromised persons (HIV, solid organ transplant, generalized malignancy, chronic renal failure, etc.). PCV13 can be considered for this patient after age 65. However, this should be based on clinical decision making with the patient. CDC recently updated recommendations for PCV13 in November 2019, and it is no longer recommended for all patients 65 years and older. If the decision is made to give PCV13, it should be administered at least one year after the most recent pneumococcal vaccine.
Answer B is correct. The Centers for Disease Control and Prevention (CDC) recommends that anyone age 19-64 who actively smokes or has a history of alcoholism, diabetes, chronic heart, liver, or lung disease and has not previously received the recommended pneumococcal vaccine should receive PPSV23. Once the patient turns 65 years old, it is recommended that a final dose of PPSV23 be administered at least 5 years after the most recent dose of PPSV23 and at least 8 weeks after administration of PCV13 if given.
Answer C is incorrect because patients should receive one dose of Tdap with administrations of Td every 10 years thereafter. It is important to note that there are actually four kinds of vaccines for prevention of tetanus. DTaP (diphtheria, tetanus, and pertussis) or DT (diphtheria and tetanus) is recommended for children < 7 years old, while older children and adults should receive Tdap and Td. For adults who have never received Tdap, a single dose should be given, regardless of when they last got Td.
Answer D is incorrect because the patient received Tdap 8 years ago. It is recommended to wait 10 years before giving the Td vaccine.
Answer E is correct. Shingrix (recombinant zoster vaccine) is recommended and indicated in patients age 50 and older. Zostavax (zoster vaccine live) is recommended in patients 60 and older by the CDC even though it is FDA-approved for patients 50 and older. However, Shingrix is preferred over Zostavax by the CDC, and it is recommended that patients receive Shingrix even if they have previously received Zostavax. Two doses of Shingrix should be given, separated by 2 to 6 months.
A nice reference for pneumococcal vaccines can be found here on the CDC website: https://www.cdc.gov/vaccines/vpd/pneumo/downloads/pneumo-vaccine-timing.pdf