How to Give a Strong Recommendation to Adult Patients Who Require Vaccination

Mary C. Anderson, MD; Marie T. Brown, MD; Marie-Michele Léger, MPH, PA-C; Aparna Ramakrishnan, MA, MSW

Disclosures

April 16, 2015

Case Presentation: The Older Adult

Ben is a patient who just turned 65 years old. He is coming in for his annual flu vaccine. His chart indicates that he received the tetanus-diphtheria-pertussis (Tdap) vaccine last year when his granddaughter was born and the pneumococcal polysaccharide vaccine about 10 years ago because of his smoking, but he has not yet received either the herpes zoster or pneumococcal conjugate (PCV13) vaccines. You recommend that he receive both along with the influenza vaccine at this visit. You also let him know that he should receive another type of pneumococcal vaccine, the pneumococcal polysaccharide vaccine (PPSV23), 6 months or more after the PCV13 vaccine.

Ben asked, "What is shingles? How likely am I to get it, and is it really serious?"

Patients are more willing to be vaccinated if they understand their risk of acquiring a particular vaccine-preventable disease and the potential consequences if they were to develop this infection. Share tailored information about why the vaccine is right for an individual patient, given that person's risk factors, and explain the potential costs of acquiring the disease.

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Herpes Zoster Vaccine

An estimated 1 million cases of herpes zoster occur in the United States annually, and almost 1 of every 3 people in the United States will develop shingles during their lifetime, with about half of the cases occurring among adults aged 60 years or older. Older adults are more likely to have postherpetic neuralgia and to have longer lasting and more severe pain. The Advisory Committee on Immunization Practices (ACIP) recommends that adults aged 60 years and older receive the zoster vaccine, even if they have had shingles before. Individuals who are pregnant, immunocompromised, or have HIV infection with CD4 counts < 200 cells/µL should not get this vaccine. For more information, visit CDC's shingles website.

Ben now asks you, "I thought I already got a pneumonia vaccine. Why do I need another? Is it safe for me, considering the prescription meds I'm taking?" Although older adults are more aware that they may need vaccines to help protect their health, they can still be reluctant to receive vaccines that they think might not be necessary, and they may have questions about how vaccines might interact with the medications they are taking. Explaining why each vaccine is important for the particular patient and answering questions in clear and simple language can help address reluctance.

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Pneumococcal Vaccines

The ACIP recommends that all pneumococcal vaccine-naive adults aged 65 years or older receive a dose of PCV13 followed by a dose of PPSV23 6-12 months later. If a dose of PPSV23 cannot be given during this time window, it should be administered later, during the next visit. PCV13 and PPSV23 should not be administered on the same day. Adults aged 65 years or older who have not previously received PCV13 and who have previously received one or more doses of PPSV23 should receive a dose of PCV13. The dose of PCV13 should be given at least 1 year after the most recent PPSV23 dose.

ACIP also recommends that adults aged 19 years or older with immunocompromising conditions, functional or anatomic asplenia, cerebrospinal fluid leaks, or cochlear implants, and who have not previously received PCV13 or PPSV23, should receive a dose of PCV13 first followed by a dose of PPSV23 at least 8 weeks later. Subsequent doses of PPSV23 should follow current PPSV23 recommendations for high-risk adults. The latest ACIP pneumococcal vaccination recommendations were published on September 28, 2014.

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