In baseball terms, vaccines for adults are like "minor leaguers"—not on the same high-profile playing field as the "major leaguers," vaccines for infants and toddlers. But the truth is that 50,000 US adults die every year from vaccine-preventable diseases. That's why the CDC, the National Foundation for Infectious Diseases (NFID), the AAPA, and other interested groups greatly emphasize adult immunization. Among the many underused vaccines for adults is one against pneumococcal disease. The time has come for PAs to step up to the plate to advocate for better vaccination coverage for this dangerous disease.


Pneumococcal disease has widespread impact. It is the most common cause of community-acquired pneumonia (CAP) in older Americans, and it also causes bacteremia and meningitis (so called "invasive pneumococcal diseases" or IPD). Pneumococcal disease is associated with substantial fatality rates: 5% to 7% for pneumonia, 20% for bacteremia, and 30% for meningitis.1 Costs are high for treatment of pneumococcal disease and its common complications. The yearly cost to our health care system from hospitalized cases of CAP among the elderly alone is $8 billion.2 That's about the same as NASA's annual budget for space exploration.3


Pneumococcal polysaccharide vaccine (PPSV23) is currently the best way to protect at-risk adults from pneumococcal disease. For most adults, one-time vaccination confers 60% to 70% protective efficacy against bacteria responsible for more than 90% of adult IPD cases. Data regarding PPSV23 effectiveness against pneumonia are less clear. The CDC recommends PPSV23 vaccination for all adults 65 years and older, those 19 to 64 years who smoke or have asthma, and those 2 to 64 years with chronic heart, liver, or lung disease; diabetes; immunocompromising conditions; chronic alcoholism; cirrhosis; asplenia; cochlear implants; or CSF leaks.4


Pneumococcal vaccine has first-dollar coverage from Medicare and Medicaid, and most private insurance companies cover CDC-recommended vaccines. Despite the general affordability of pneumococcal vaccine, its demonstrated long-term safety, and the incidence and severity of pneumo­coccal disease, vaccination coverage remains well below national goals of 90% for those 65 years and older and 60% for those younger than 65 with an immunization indication.5


Influenza vaccine is also important for people at risk of pneumococcal disease. Not only can influenza itself be deadly, but it is also a frequent precursor to pneumococcal disease. Staying current with both vaccines affords the best possible protection. The vaccines can be given during the same visit (in different arms). However, pneumococcal vaccine can be given at any time of year and should not be postponed to coincide with influenza vaccine. Of note is that influenza vaccination is now recommended for everyone at least 6 months of age.


PAs can take an active role in increasing adult pneumococcal vaccination rates. We can help by identifying patients in need of vaccination. A 2009 survey by NFID discovered that 13% of physicians did not know that everyone aged 65 years and older needs pneumococcal vaccination, and more than 40% did not know that smokers and alcoholics should be vaccinated.


We must be on the lookout for high-risk patients in our care who would benefit from immunization. We can reach patients through direct contact, but we should also consider in-office educational materials like posters, signs, and flyers. Standing orders, immunization registries, and reminder systems should be used to support our efforts to improve immunization rates. 


Even those of us without direct vaccination responsibility can do our part by urging patients and their families—and our friends and colleagues—to stay current on all vaccinations. We need to educate everyone about the serious medical risks associated with pneumococcal disease and the vaccine's long safety record. We can clarify misconceptions about side effects or risks of receiving more than one lifetime dose (which are low). NFID's Web site, www.adultvaccination.org, is an excellent source of information concerning pneumococcal disease and vaccination for patients and medical professionals. 


The PA community must partner with all health care professionals to improve our approach to pneumococcal disease prevention. Saying we know what to do and actually doing it are two different things. Positive change can start with one person taking action to raise awareness. Each of us must step up to the plate to make the necessary recommendations to ensure that people are optimally protected against this potentially deadly illness. JAAPA



Marie-Michèle Léger, MPH, PA-C, is the director of clinical and international affairs for the AAPA. Susan J. Rehm, MD, is a staff physician at the Cleveland Clinic, vice chair of the Clinic's Department of Infectious Disease, medical director for the National Foundation for Infectious Diseases, and co-chair of NFID's Pneumococcal Disease Advisory Board.

REFERENCES


1. Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine-Preventable Diseases. 11th ed. Atkinson W, Wolfe S, Hamborsky J, McIntyre L, eds. Washington DC: Public Health Foundation; 2009:217-230.


2. File TM, Marrie TJ. Burden of community-acquired pneumonia in North American adults. Postgrad Med. 2010;122(2):130-141.


3. Review of US Human Spaceflight Plans Committee. October 2009. http://legislative.nasa.gov/
396093main_HSF_Cmte_FinalReport.pdf. Accessed August 5, 2010.


4. Centers for Disease Control and Prevention. Pneumococcal vaccination. http://cdc.gov/vaccines/vpd-vac/pneumo/default.htm. Last modified May 11, 2010. Accessed August 5, 2010.


5. US Department of Health and Human Services. Healthy People 2010. www.healthypeople.gov. Accessed August 5, 2010.