EXPERT ANALYSIS AT THE 2017 AAAAI ANNUAL MEETING
ATLANTA – In the opinion of John M. Kelso, MD, assessment of immunization status in older adults should be a routine part of all visits.
“Don’t assume that your patients are getting their vaccines someplace else,” he said at the annual meeting of the American Academy of Allergy, Asthma, and Immunology. “We should be taking advantage of the fact that these patients are in our offices.”
Dr. Kelso, of the division of allergy, asthma, and immunology at Scripps Clinic, San Diego, discussed the importance of four vaccinations in particular.
Inactivated influenza vaccine (IIV3)
For adults aged 65 and older, the high-dose, trivalent version of the flu vaccine (60 micrograms of hemagglutinin per strain, or IIV3-HD) may be preferable to the standard dose of 15 micrograms of hemagglutinin per strain (IIV3-SD). A study of nearly 32,000 patients found that IIV3-HD induced significantly higher antibody responses and provided better protection against laboratory-confirmed influenza, compared with IIV3-SD ( N Engl J Med. 2014;371:635-45 ). The relative efficacy of high dose vs. standard dose was 24.2%. “That means that one-quarter of all breakthrough influenza illnesses could be prevented if IIV3HD were used instead of IIV3-SD,” Dr. Kelso said.
Another approach is to use an adjuvanted influenza vaccine, which contains the standard 15 micrograms of influenza antigen but the adjuvant is MF59, a squalene-based oil-in-water emulsion. One small study of 282 patients aged 65 and older showed the adjuvanted vaccine to be more effective than the unadjuvanted vaccine ( Vaccine. 2013;51:1622-8 ).
The Centers for Disease Control and Prevention does not express a preference for the high-dose or adjuvanted vaccine, but rather stresses the importance of influenza vaccination with whatever age-appropriate IIV formulation is available at the time of the patient’s visit.
The 13-valent pneumococcal conjugate vaccine (PCV13) and the 23-valent pneumococcal polysaccharide vaccine (PPSV23)
All adults who turn 65 years of age should receive the PCV13, followed 1 year later by the PPSV23. For those who already received the PPSV23 after age 65 years of age, they should receive the PCV13 at least 1 year later. “The real bulk of hospitalizations and fatalities from invasive pneumococcal disease are happening to people over 65 year of age,” said Dr. Kelso, who is also a clinical professor of pediatrics and internal medicine at the University of California, San Diego “So there’s a real need here for vaccination.”
This should be administered to all adolescents and adults regardless of interval since their last tetanus-diphtheria vaccine. “This includes those age 65 years of age and older in whom the vaccine has been found to be equally safe and immunogenic,” Dr. Kelso said. “This is important not only to prevent pertussis in older adults, but also to prevent them from spreading the disease to infants where it can be fatal.”
One in three adults will develop zoster during their lifetime, he said, and one million episodes occur in the United States each year. Common complications include postherpetic neuralgia and eye involvement that can result in loss of vision. The CDC recommends routine vaccination of all immunocompetent persons over age 60 with one dose of zoster vaccine. “Persons who report a previous episode of zoster can be vaccinated but it is not indicated to treat acute zoster, to prevent persons with acute zoster from developing postherpetic neuralgia, or to treat ongoing postherpetic neuralgia,” Dr. Kelso said.
He reported having no relevant financial disclosures.