Older Adult Vaccinations (flu, pneumonia, shingles, etc.)

Join Dr. Sharon Brangman, from SUNY Upstate Medical University and Dr. Ken Schmader, of Duke University Medical Center and the Director of Geriatric Research Education and Clinical Center at Durham VA Health Care System, as they discuss influenza, pneumococcal, and zoster vaccine recommendations.

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Transcript

Sharon Brangman, MD, AGSF: Hello, I'm Dr. Sharon Brangman. I'm a distinguished service professor and chair of the Department of Geriatrics at [SUNY] Upstate Medical University, and I also direct the [SUNY] Upstate Center of Excellence for Alzheimer's Disease. I'm here today with Dr. Kenneth Schmader, who's a professor of medicine. He's the director of the Pepper Older Americans Independent Center (OAIC) at Duke University Medical Center, and he is also the director of the Geriatric Research Education and Clinical Center at Durham VA Healthcare System.

We're gonna be discussing today some of the key points from the AGS Older Adult Vaccine Initiative module. We're gonna focus on Older Adults Vaccination. 

So thanks for joining us, Dr. Schmader. What I would like to do first is talk about the flu vaccine. Some of the changes that's been made in the last year are really important for clinicians who want to offer the flu vaccine to older adults.

So can you tell us what happened? [00:01:00] 

Kenneth Schmader, MD: Yeah, you bet. In the past there was no preference as to what influenza vaccine we would give older adults. So we used to say, "Any flu vaccine will do." But that changed to a preferential recommendation for either the high dose vaccine, or the adjuvanted vaccine, or the recombinant influenza vaccine.

And the reason for that is the evidence that these vaccines are better than standard dose has been accumulating over the past few years. As you know, Dr. Brangman, I represent the American Geriatrics Society on the Advisory Committee, on the Immunization Practices or ACIP at the CDC and I'm on the influenza work group.

So we did a massive systematic review of the literature and we found that in older adults, these, these vaccines, with as I mentioned, the higher dose flu vaccine, recombinant influenza vaccine, or the adjuvanted vaccine do have improved effectiveness compared to standard dose vaccines and also improved immunogenicity. 

Studies comparing those three with one [00:02:00] another are kind of few. We really don't have much evidence there to support the idea that any one of these vaccines is superior to the other. So, anyone is, is fine. Now, if none of these vaccines are available at the time, you know you want to vaccinate your older adult, then the standard dose is fine.

Sharon Brangman, MD: And what is the ideal time to give the influenza vaccine to our patient? 

Kenneth Schmader, MD: Yeah, that's a great question. 

There've been a number of studies that show decreases in vaccine effectiveness against influenza illness with increasing time after the vaccination, you know, within a season. And that waning is more pronounced even more in older adults. So the ideal time is October. You know, these flu vaccines will come out in August. They'll, they'll be in the pharmacies in August and they'll start offering it. But really that's a little too early for older adults. 

Sharon Brangman, MD: Okay. That's, that's important to remember. I'd like to shift now and talk about pneumococcal vaccines.

Now we know that the ACIP recommended that [00:03:00] various sequences of the pneumococcal polysaccharide vaccine and the pneumococcal conjugant vaccine for older adults have changed over the years. Can you tell us what is behind the evolution of changing the recommendations for the pneumo vax? 

Kenneth Schmader, MD: Yeah. I have to say that one thing that's behind it is these prior pneumococcal vaccine recommendations are so complex and hard to follow. I'm sure it was for you. It has been for me and many other clinicians. 

But what's happened over time is that the pneumococcal conjugate vaccines - and I'm gonna abbreviate that PCV - have improved in that the number of disease-causing serotypes that are covered by the newer PCVs are much better and help simplify the recommendation.

So now, instead of PCV -7 or -13, we have PCV15 and PCV20. And these target, the common serotypes that cause either invasive pneumococcal disease or [00:04:00] pneumococcal pneumonia in the United States. 

Now, the pneumococcal polysaccharide vaccine PPSV23 does that as well, but it induces a T-cell independent B-cell response that's just not as robust immunologically as the PCVs and PCVs have an extra protein on the capsule that induces a much more robust T-cell dependent response lasts longer. So we kind of prefer these vaccines. And, and part of that comes from a, a landmark trial called the CAPITA trial with PCV. That showed the benefit and quite a reduction in pneumococcal pneumonia, invasive pneumococcal disease with PCVs. That study was done with PCV13, but we know the PCV20, for example, covers many more serotypes, so that's why the FDA approved it.

So what this means for practice is it, it's a heck of a lot simpler now for older adults with no prior pneumococcal vaccine, or they don't know, or maybe they had [00:05:00] the polysaccharide in the past. The simplest option is just give one dose of PCV20 and you're done which is a heck of a lot easier than before.

Sharon Brangman, MD: So I think that's an important fact to remember. Cause yeah, it really does get confusing. So if you give one dose of PCV20 and you're done, that should be easy for most people to remember. 

And I'd also like to remind people that you don't have to memorize all this because we have it organized for you in our AGS Older Adult Vaccine Initiative. So that's an excellent reference point. So thanks for that update on the pneumococcal vaccine. 

And I'd like to now talk about the zoster vaccine, which we know it's had remarkable efficacy in clinical trials in older adults, and it can prevent zoster in over 90% of persons who are 70 years and older. So how are things working in clinical practice in your experience with that vaccine now that it's been approved for a few years?

Kenneth Schmader, MD: Yeah, this is interesting because [00:06:00] as we know that sometimes things are ideal in these phase three clinical trials, but you know, really what really happens in the real world. And just a reminder to the listeners, this recombinant zoster vaccine or RZV is really different than influenza pneumococcal vaccines.

It has a powerful novel adjuvant called AS01B, and it combined with an antigen from VZV, the varicella-zoster virus. And this adjuvant is an incredible, potent stimulator of the immune response and the main reason the efficacy was so high in the clinical trials, you know, over 90%, including an 80 year old. But recently there's been a real world Medicare study and what they found was over three or four years, the effectiveness of RZV was about 70% after two doses. But it was also effective against postherpetic neuralgia at about 76%. So even in real world practice, it's still quite a valuable vaccine. 

And kinda what was interesting in that study is that even in people [00:07:00] over the age of 80, it was still effective. And even in people who received two doses after 180 days it was effective. 

Which reminds me if I could point out a couple other things. Remember this is a two dose regimen with, you know, pneumococcal and flu. We just give one dose, but this is a two dose regimen. And. We're supposed to give it the second dose, two to six months after the first dose, but we know that people, they often don't make it back. Right? This happens quite a bit. So it's okay to administer the second dose any time after six months. You don't have to restart the series. And so there was a, a recent large study in geographically representative US population and looking at adherence rates in the real world, it was about 72% by six months and 86% after 24 months.

So people will in general come back to get the second dose. They may not get it at two months. 

Sharon Brangman, MD: This is one of the main vaccines that I've seen being given in pharmacies rather than in hospital settings. [00:08:00] Has that been your experience? 

Kenneth Schmader, MD: It absolutely has been. One- a main reason is that, It was not reimbursed for physicians to give the vaccine in their office until very recently with recent legislative changes now that is covered in physician's offices. But I think what's happened now is a pharmacist are so good at storing and handling this vaccine and they're so used to giving it now. That's become a great place to, to get the vaccine. 

Another thing I, I wanted to point out, I think maybe some people who've prescribed the vaccine will recognize it. This is more reactogenic than flu or pneumococcal vaccine. In other words, the frequency of injection site pain and redness or systemic symptoms is much higher with the RZV. Now, most of the symptoms resolve in one to three days, but you know about 15, 16% of people will develop pretty severe reactions, so-called grade three reactions that last for a couple days.

So [00:09:00] I think it's really important to counsel people ahead of time. You know, just take it easy a couple days after you get the vaccine and not, not try to do too much. You know, most people will do fine, but there is that 15% that might experience a, a pretty good reaction. 

Sharon Brangman, MD: That's so important to try to prepare patients because if they have a bad reaction, then they may be reluctant to try any other vaccine. So that's really important for us to remember as clinicians. 

Kenneth Schmader, MD: Yeah, absolutely. 

Sharon Brangman, MD: Is there anything else you'd like to say before we end today, Dr. Schmader? 

Kenneth Schmader, MD: Yeah, I'd just like to say that there's been incredible advances in vaccine science over the last decade that are really affecting our practice now, and that there's more research in this area that's gonna make our vaccines better.

There are mRNA influenza vaccines being developed. There are even higher serotype pneumococcal conscious vaccines being developed. There's probably some new vaccines for respiratory syncytial virus coming down the pike. And I, I think this is just [00:10:00] an amazing time for the use of vaccines in older people.

Sharon Brangman, MD: Thank you very much for talking with us today, and I would like to remind everyone that you can get a review of all of this information in the AGS' Older Adult Vaccine Initiative. And this is the module on older adult vaccinations. Thank you for joining us.