An ASCP 2022 session presenter explains some recent updates on vaccination guidance for the older adult population.
Pharmacy Times® interviewed Crystal Hodge, PharmD, BCIDP, BCPS, associate professor of pharmacotherapy at the University of North Texas Health Science Center at Fort Worth, on her presentation at the American Society of Consultant Pharmacists (ASCP) 2022 Annual Meeting titled Vatfuls of Vaccines. The session provides an update on practical guidance for vaccinating the older adult population.
The ASCP 2022 Annual Meeting will be held at the JW Marriott San Antonio Hill Country Resort & Spa in San Antonio, Texas.
Pharmacy Times®: What are some of the new pneumococcal vaccines on the market for older adult patients?
Crystal Hodge: So on the market, in general, we've had 2 additional pneumococcal vaccines added. They are similar to some of the vaccines we've had before. So the new ones are the brand name Prevnar 20, generic name PCV20 or pneumococcal conjugate vaccine 20, and the Vaxneuvance vaccine, which is the [pneumococcal 15-valent conjugate vaccine (PCV15)].
On the market already, we had the Prevnar 13 and the Pneumovax, so, the 2 new products are both pneumococcal conjugate vaccines, which is similar to the Prevnar 13 that we have used previously. Really, the difference between these 4 vaccines that are available is going to be the serotypes that they cover of Streptococcus pneumoniae. So we've got multiple different serotypes that correlate with the number in the generic name. So for example, the polyculture of pneumococcal conjugate vaccine 20 covers 20 serotypes. This is an endeavor to try to increase the number of Streptococcus pneumoniae serotypes that we can protect our older adults against, since that is one of the primary causes of invasive strep pneumonia disease and, unfortunately, pneumonia.
Pharmacy Times®: What are some pneumococcal vaccination strategies for older adults that pharmacy professionals should consider when immunizing this patient population?
Crystal Hodge: So the primary thing that I would say is please always look at someone's immunization record. Most states will have some form of a database where they are able to look up immunization records. For someone in Texas, like me, that's going to be ImmTrac2. Our older adults may not have been opted into this already, but the more people that we can get registered into the system, the easier it'll be on all of our pharmacists to make sure our patients are up to date on vaccines.
When it comes to how to specifically immunize for pneumococcal disease, we have to look at which ones they've had before. So we know that there are certain indications that may have caused a person to get a pneumococcal vaccine before the age of 65. Then of course, when they turn 65, they will need to be vaccinated against streptococcus pneumoniae.
So if they've had the prior PCV13, you go ahead and finish the series with the PPSV23 once they turn 65. If they've had a prior PPSV23, after a year, you'll use one of the new products, either the PCV20 or the PCV15. Then if they've had the prior PCV13 and PPSV23, that's considered a full series—they don't need any more vaccinations. If they've received the prior PCV20, and then they become 65, then they also do not need any additional vaccines. So as long as they're able to complete 1 of 3 different regimens, either finishing a PCV13 plus PPSV23, a PCV15 plus a PPSV23, or a PCV20 by itself, they're good to go.
The other thing I would add to that is to make sure all of the visitors for older adults are up to date on their vaccinations. This is because we've seen an alarming trend in the pediatrics world where they are behind on their vaccines. A lot of our kids are having to use catch up schedules due to either not going to doctors’ offices or something along those lines. So we want to make sure that all of the kids that could potentially spread the pneumococcal disease to our older adults are also vaccinated.
Pharmacy Times®: What are some of the implications of the changes to hepatitis A and B virus indications of note for pharmacy professionals?
Crystal Hodge: Yeah, so I kind of love this one. So with hepatitis A and hepatitis B, what I think it really emphasized was how much time it takes to do an appropriate evaluation for vaccination because what they found is that, with hepatitis B in particular, the rates of hepatitis B actually stabilized. So even with updated indications, they weren't able to get that number down any further, which is why they conducted a survey and one of the biggest things in that survey that they found was that providers or pharmacists didn't have enough time to go through all of the indications or specific indications for hepatitis A and hepatitis B.
For example, and this is one of my pet peeves, is that with hepatitis B, anytime someone has a percutaneous exposure, they should be vaccinated against hepatitis B. So this meant that most of our diabetic patients or patients living with diabetes, who used insulin or GLP1 agonist, they had that percutaneous exposure, and they should have been getting the hepatitis B vaccine, and a lot of them weren't. A lot of our diabetics and a lot of our patients on dialysis weren't getting vaccinated. So ACIP, the governing body basically said, ‘Okay, all adults need to be vaccinated against these 2 hepatitis viruses.’ And that actually matches a little bit closer to what's been in the pediatric strict schedule.
So in the pediatric schedule, only within the last couple of decades have we started to include hepatitis A and hepatitis B. So using a more universal indication of all adults should get this vaccine, we're able to catch everyone else up.
Then in our older adults, there are a couple of instances, particularly with hepatitis A where they say it's a shared decision making based off of risk factors, but the incidence of side effects is so low that most older adults would also benefit from those vaccines.
Pharmacy Times®: What are some notable changes to shingles recommendations for older adult patients?
Crystal Hodge: So I absolutely love this one. With shingles—this is a painful disease, right? They get a rash, it's itchy, and then sometimes there's a neurologic pain that's associated with it. We have transitioned from a live shingles vaccine to a recombinant shingles vaccine, which is what we've been using for most adults greater than the age of 50.
However, they specifically went after the indication and are immunocompromised hosts, which I think is shouldn't be commended. The reason why is because most immunocompromised hosts or persons are excluded from vaccine trials. A lot of vaccine trials demonstrate efficacy by showing an immune response related to antibody. So if they can see that more antibodies are produced, they would correlate that to efficacy, and someone who's immunocompromised or immunodeficient, by the nature of that disease state, they're not going to be able to mount that response, so they're usually excluded.
The fact that we are able to show data that it works in this population is phenomenal, because we know, especially from COVID, sometimes they need an adjuvant, sometimes they need a higher dose, sometimes they need more doses. So being able to say, ‘Hey, we've done the trial in immunocompromised hosts,’ which is starting to include more and more of our older adults, older adults experience something called immunosenescence, where their immune system starts to not be as robust, and we're finding more and more targeted, immunocompromising medications, so the fact that we have data to support this population is a huge deal, and I absolutely love that they went after this indication.
Pharmacy Times®: Do you have any patient cases you could share showing immunization best practices pharmacy professionals should keep in mind for this patient population?
Crystal Hodge: So I'll be honest, I don't have a specific patient case. I would say that the one that speaks to me the most, and what I've encountered most in practice is persons living with HIV. There are huge—I'm in the south of in Texas, which we have a lot of persons living with HIV here—and I frequently see them not being up to date on their vaccines, particularly hep A and hep B. Then again, those patients that have some sort of percutaneous exposure—our diabetics, our patients on dialysis—like anybody really with any chronic disease state, which is going to include most of our older adults should be vaccinated against those. So I really think it's important that we're paying attention to those things. I love that they added the universal indication for adults.
Then just to mention with hep A, while they don't have a specific patient case, there have been recent outbreaks of hep A and different areas throughout the US in the last few years in this pandemic. So I know a lot of people have forgotten about it. But it even got so, so bad. And at one point that there was a city in California that had a huge hepatitis outbreak amongst the homeless population, and one of the strategies they employed was actually having to bleach the streets. So we are having outbreaks of vaccine preventable diseases and so being able to realize what our indications are and administer vaccines is something I'm very passionate about.