This Sunday, we bring to you from our archives, Dr. OP Sharma's article which explains adult vaccination in the elderly- focusing on the most important vaccines for preventing pneumococcal infection and influenza and how they are specifically relevant for high-risk patients.

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Vaccination in children has yielded excellent results by reducing the incidence and or severity of many vaccine preventable diseases in that age group. However, with age, particularly in older people, decreased immunity makes them more vulnerable to disease and hence vaccination in them is also relevant.

With crowding, rise in pollution, nutritional deficiencies, and comorbid conditions, respiratory infections are on the rise. The injudicious use of antibiotics and increasing drug resistance has led to preventive strategies gaining importance, vaccination being prime among them.

There are bacterial and viral respiratory infections involving both the upper and lower respiratory tract. Among the bacterial infections, the most common is community acquired pneumonia (CAP) caused by Streptococcus pneumoniae and among the viral the most common is the influenza virus.

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Pneumococcal infection

S. pneumoniae has 90 strains out of which 23 are responsible for most of the infections. Usually people affected are in the extremes of age group (less than 5 years and more than 60 years). Poor nutrition, tobacco usage, presence of comorbid conditions and compromised immunity increase severity of infection.

S. pneumoniae causes lower respiratory tract infections which manifests as otitis media, sinusitis, pneumonia, meningitis, or septicaemia. Symptoms include cough, fever, tachycardia and tachypnoea, and in the elderly- listlessness, decreased appetite, incontinence and falls.

Despite antibiotics and ICU care, invasive pneumococcal infections (severe pneumonia, bacteraemia and meningitis) cause fatality. The increasing drug resistance adds fuel to the fire. Hence there is a roll out of preventive strategies among which vaccination is prime.

Vaccines

PPSV23: A tetravalent pneumococcal polysaccharide vaccine, introduced in 1945 was further upgraded to 14-valent vaccine and then in 1983 upgraded to 23-valent formulation of a polysaccharide pneumococcal vaccine (PPSV23) containing long chains of polysaccharide molecules that make up the surface capsule of 23 types of pneumococci,30 which include 1, 2, 3, 4, 5, 6B, 7F, 8, 9V, 10A, 11A, 12F, 14, 15B, 17F, 18C, 19F, 19A, 20, 22F, 23F and 33F serotypes.

PCV13: A new pneumococcal conjugate vaccine (PCV7) was introduced in the year 2000 which was further upgraded to triskavalent vaccine containing capsular polysaccharides from 13 serotypes of pneumococcus (1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F and 23F) which are conjugated to a carrier protein containing a harmless variety of diphtheria toxin (Prevenar13, PCV13). It is recommended for prevention of IPD, pneumonia, and acute otitis media caused by the 13 pneumococcal serotypes included in the vaccine. The success has renewed interest in evaluating PCV in adults for prevention of invasive pneumococcal disease and pneumonia. The conjugate vaccine acts by binding to polysaccharide-specific B cells that communicate carrier protein antigen to T cells. There is T cell dependent immune response by release of cytokines that facilitate B cells to transform into plasma cells which in turn release antibodies.

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Indications

Both the vaccines are indicated in-

1. Persons aged 50 years and above.
2. Persons with certain underlying medical conditions such as coronary artery disease, congestive heart failure, cardiomyopathy, diabetes mellitus, bronchial asthma, chronic obstructive pulmonary disease, cirrhosis of liver, and chronic renal failure.
3. Immuno-compromised persons who are at high risk for pneumococcal infections, such as immunoglobin deficiency, human immunodeficiency virus (HIV) infection, leukaemia, lymphoma, multiple myeloma, Hodgkin’s disease, non-Hodgkin’s lymphoma, disseminated malignancy, who exhibit either a decreased responsiveness to vaccination or a greater decline in serum antibody concentrations.
4. Persons with organ or bone marrow transplantation.
5. Persons receiving long term therapy with corticosteroids or immunosuppressive agents.
6. Persons who have undergone splenectomy, or exhibit anatomic asplenia, or sickle cell disease as they exhibit reduced clearance of encapsulated bacteria from the blood stream.
7. Chronic smokers.
8. Persons suffering from sleep disorders.
9. Persons who are prone to nocturnal aspirations and severe GERD.

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Schedule of vaccination

PPSV23 is given only once as a single dose to elderly persons. PPSV is a sterile, clear, colourless liquid vaccine. One dose of (0.5 ml) of the vaccine contains 25 micrograms of each capsular polysaccharide antigen dissolved in isotonic saline solution with 0.25% phenol as a preservative.

Revaccination may be recommended for persons exhibiting an increased risk of pneumococcal infection and to those who are likely to have a rapid decline in pneumococcal antibody levels provided that 5 years have elapsed since getting the first dose of pneumococcal vaccine.

PCV13 is administered in a dose of 0.5 ml intramuscularly. The preferred site is the deltoid muscle of the upper arm.

• PCV 13 may have an edge in the elderly who have previously received PPV 23, to maintain protection
• PCV 13 may be the preferred vaccine in vaccine native or previously vaccinated adults
• In case both the vaccines are considered, PCV 13 should be administered first, followed by PPV 23
• For certain risk groups like individuals who are immunosuppressed or immunocompromised, if previously unvaccinated, a dose of PCV 13 is recommended, followed by a dose of PPV 23 eight weeks later

Common adverse events reported are pain, redness and swelling at the injection site, limitation of movement of the injected arm, fatigue, headache, chills, muscle ache and joint pain. These manifestations are short-lived.

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Concomitant vaccination

Concomitant vaccination with influenza vaccine can be done (by separate injection in the other arm) without an increase in side effects or decreased antibody response to either vaccine. The vaccine can be administered with combined diphtheria, tetanus, and pertussis (DTP) or other vaccines like polio. Neither increase in severity of reactions nor a decrease in antibody response is noted.

Contraindications: Administration of pneumococcal vaccine is not recommended to the following individuals:

1. Persons who had shown a severe hypersensitivity reaction to an initial dose of pneumococcal vaccine that they had received.
2. Persons who had shown severe hypersensitivity to any component of the vaccine or any vaccine containing diphtheria toxoid (PCV 13).
3. Persons undergoing chemotherapy or radiation therapy.
4. Persons who have to be vaccinated for zoster; the package insert advises that zoster and pneumococcal vaccine (PPV 23) should not be administered concurrently.

Precautions

1. As with all injectable vaccines, facilities for appropriate medical treatment and supervision must always be readily available in case of a rare anaphylactic event following the administration of the vaccine.
2. Minor illnesses, such as mild respiratory infection, with or without low-grade fever, are not generally contraindications for vaccination. The decision to administer or delay vaccination because of a current or recent febrile illness depends largely on the severity of the symptoms and their aetiology.
3. Caution and appropriate care should be practised when administering the vaccine to individuals with severely compromised cardiovascular and/or pulmonary function in whom a systemic reaction would pose a significant risk.
4. Administration  should be postponed in subjects suffering from acute, severe febrile illness.
5. As with any intramuscular injection, vaccines should be given with caution to adults with thrombocytopenia or any coagulation disorder, or to those receiving anticoagulant therapy.

Pneumococcal vaccines will only protect against Streptococcus pneumoniae serotypes included in the vaccine, and will not protect against other microorganisms that cause invasive disease, pneumonia, or otitis media. The safety of pneumococcal vaccine for pregnant women has not been studied.

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Influenza infection

Influenza or flu, is an acute, contagious viral respiratory illness, mostly ignored. Infection occurs in the upper respiratory tract- nose, throat, and at times descends to lungs. It can cause mild to severe illness, and when complicated with bacterial infection, particularly in high risk population, can lead to serious consequences including death.

The virus is prevalent all over the world. Overcrowding, congested population areas, sudden cold and humid climate favour the circulation of virus. Seasonal human Influenza outbreaks/epidemics are due to circulating influenza type A & B viruses undergoing drift. Epidemiological survey suggests the presence of influenza virus during all the 12 months of the year with two peak seasons; one, in and around rainy season and another during the winter months when there is sudden fall in the atmospheric temperature.

Vaccination

There are two types of vaccines:

• Killed vaccine
• Live attenuated vaccine

The seasonal influenza vaccine (LAIV) is a trivalent vaccine containing two influenza A strains: one H1N1 type, one H3N2 strain and one influenza type B strain (each 15 µg) decided by WHO on the epidemiologic and antigenic analysis of the currently circulating strains.

Indications

Annual vaccination against influenza is recommended to-

• All persons specially over 50 years of age
• Women who will be pregnant during the influenza season
• People with chronic pulmonary infection, renal, hepatic, haematological or metabolic disorders (including diabetes mellitus)
• Persons who have immune suppression
• Residents of nursing homes and other chronic-care facilities
• Healthcare personnel
• Household contacts and caregivers of children

Types of Vaccines

1. TIV: This contains an A/Brisbane/02/2018 (H1N1)pdm09-like virus, an A/South Australia/34/2019 (H3N2)-like virus, and a B/Washington/02/2019-like (B/Victoria lineage) virus.
2. Quadrivalent influenza vaccine: This contains an A/Brisbane/02/2018 (H1N1)pdm09-like virus, an A/South Australia/34/2019 (H3N2)-like virus, a B/Washington/02/2019-like (B/Victoria lineage) virus, and a B/Phuket/3073/2013-like (B/Yamagata lineage) virus.

Schedule of vaccination

Any of the above is given only once as a single dose. It is available as a 0.5 ml liquid in prefilled syringe. This is given as an intramuscular injection in the deltoid muscle. Yearly flu vaccination should begin in September, or as soon as the vaccine is available, and continue throughout the flu season which can last until as late as May. This is because the timing and duration of flu seasons vary. While flu season can begin as early as October, most of the time seasonal flu activity peaks in January, February or later. Revaccination needs to be done annually.

Common adverse events: The individual should be asked to disclose if they have egg allergy. The most common side effects of the injectable variety include soreness, redness, or swelling at the site of the injection.

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This article was originally published on 6 May, 2020.

Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.

The author Dr. O. P. Sharma is a Senior Consultant Geriatric Medicine at Indraprastha Apollo Hospitals, New Delhi.