[CIS PIDD] [cis-pidd] pneumococcal vaccine strategy in adolescents & adults with immune deficiency

[Boyce, Thomas G., M.D.]

Stan,

In studies of patients with HIV infection, which is all we have to go on until studies are done in other populations, PCV-13 primes the response to PPVS-23, providing higher titers to the extra serotypes in PPVS-23 than giving PPVS-23 alone.  If given in that order, the vaccines can be given 8 weeks apart (for a patient of any age).  One can still assess the polysaccharide immune response to those serotypes not in PCV-13.

Tom


Thomas G. Boyce, MD, MPH
Pediatric Infectious Diseases and Immunology
Mayo Clinic
email: boyce.thomas at mayo.edu
phone: 507-255-8464
fax: 507-255-7767


From: bounce-44233306-183824398 at lists.clinimmsoc.org [mailto:bounce-44233306-183824398 at lists.clinimmsoc.org] On Behalf Of Stan Ress
Sent: Thursday, December 12, 2013 2:42 AM
To: CIS-PIDD
Subject: RE: [cis-pidd] pneumococcal vaccine strategy in adolescents & adults with immune deficiency

I want to thank everyone that responded to my query on the most appropriate pneumococcal vaccine in a 15 year-old patient with severe IGA deficiency and low baseline IgG memory responses. The consensus was to use pneumovax23  for diagnosis & prevenar 13 for protection. My patient had never received any pneumococcal vaccines & I elected to administer pneumovax 23.

It is of interest that 2013 IDSA Clinical Practise Guideline for vaccination of the Immunocompromised Host has just been published as a CID advanced access paper on 4 December and is freely available, with similar recommendations. They also state that after PCV23 vaccination in age >19 years, Prevenar 13 should be administered ≥ 1 year later ( weak recommendation, low evidence).

This is a great forum in which to get good advice and also to debate difficult issues, because it is only by vigorous debate that one can get clarity where the issues are somewhat controversial.

Thanks again.

Stan
--
Stanley Ress
Associate Professor of Medicine
Head: Division of Clinical Immunology
Department of Medicine
H47 Old Main Building-room 26
Groote Schuur Hospital and UCT
Observatory 7925
Cape Town
South Africa
TEL:INTERN. + 2721-4066201 or 4066197
FAX:   "    + 2721-(0)865173095
Cell: 0833115482
email: stan.ress at uct.ac.za<mailto:stan.ress at uct.ac.za>



From: Laura Hoyt [mailto:Laura.Hoyt at childrensmn.org]
Sent: 06 December 2013 05:52 PM
To: CIS-PIDD
Cc: cis-pidd at lists.clinimmsoc.org<mailto:cis-pidd at lists.clinimmsoc.org>
Subject: Re: [cis-pidd] pneumococcal vaccine strategy in adolescents & adults with immune deficiency

We look at non-Prevnar serotypes for polysaccharide responses.
Laura Hoyt MD
ID and Immuno
Children's Hospitals and Clinics of Minnesota

Sent from my iPad

On Dec 5, 2013, at 11:57 PM, "Klaus Warnatz <klaus.warnatz at uniklinik-freiburg.de<mailto:klaus.warnatz at uniklinik-freiburg.de>>" <klaus.warnatz at uniklinik-freiburg.de<mailto:klaus.warnatz at uniklinik-freiburg.de>> wrote:
Hi,

we just wrote the recommendations for the German society of rheumatologists and discussed this with different authorities and the companies.
I don't think we know the ideal time point for booster vaccination with PPV23. We finally wrote that one should wait at least 8 weeks before booster and apply it within in the first year. It is also recommended to booster patients how have received PPV23 in previous years with PCV13 subsequently and I am not convinced that the response is so dramatically affected that we can not do this in our patients where we use PPV23 for diagnostics. So we decided to continue using PPV23 for diagnostic testing in patients with suspected humoral ID. There is no hint that the previous conjugated vaccine decreases subsequent encounters with the unconjugated polysaccharide (so I don't think that we should have problems in the field of HiB.).
The upcoming problem however will be that in Germany all kids are now vaccinated with the PCV and therefore it will become questionable whether we can use PPV23 anymore in the future as a test for pure PnPS responses. Helen Chapel has therefore promoted the Salmonella vaccine, but we have no experience with it , so I can't tell.

greetings

klaus
Prof. Dr. med. Klaus Warnatz

UNIVERSITÄTSKLINIKUM FREIBURG
University Medical Center Freiburg
Center for Chronic Immunodeficiency
Division of Rheumatology and Clinical Immunology

Tel: +49-761-270-77640 / FAX -71000 / Pager: 12-7100

Breisacher Str. 117, 79106 Freiburg, Germany
klaus.warnatz at uniklinik-freiburg.de<mailto:klaus.warnatz at uniklinik-freiburg.de>
http://www.uniklinik-freiburg.de/cci

Am 05.12.2013 um 22:43 schrieb Stan Ress:

Hi Jack,

I guess that ideally we hope to achieve both objectives! We do have adult patients with low baseline titres that responded well to pneumovax 23, in which case we would have shown B-cell competence and hopefully provided some extra protection against pneumococcal infection (admittedly they were not as severe as the 15 year-old girl with severe IgA deficiency & established bronchiectasis that I described). In patients that don’t respond, we will have added to the evidence of significant immune deficiency & helped to mount a case for funding for IVIG, although as you know, this conclusion seems to be controversial too.

Routine vaccination of children with prevenar 13 has only fairly recently been performed in SA, for the past couple of years only. I have no experience with this, which prompted my query about whether we could do more to stimulate an effective antibody response in adults by using the protein conjugated vaccine. I don’t fully understand the concept of immune tolerance & waning protection in this latter scenario. Does the same also apply to Haemophilus B vaccination? We don’t have access to unconjugated vaccine and use Glaxo Hiberix (tetanus toxoid-conjugated haemophilus B). By the same logic, is this also setting the patient up for tolerance & waning protection against future encounter with native unconjugated Haemophilus B antigens?

I’d really appreciate clarification on this as well.

Many thanks & Regards,

Stan

--
Stanley Ress
Associate Professor of Medicine
Head: Division of Clinical Immunology
Department of Medicine
H47 Old Main Building-room 26
Groote Schuur Hospital and UCT
Observatory 7925
Cape Town
South Africa
TEL:INTERN. + 2721-4066201 or 4066197
FAX:   "    + 2721-(0)865173095
Cell: 0833115482
email: stan.ress at uct.ac.za<mailto:stan.ress at uct.ac.za>




From: Bleesing, Jacob [mailto:Jack.Bleesing at cchmc.org]
Sent: 05 December 2013 10:43 PM
To: CIS-PIDD
Subject: RE: [cis-pidd] pneumococcal vaccine strategy in adolescents & adults with immune deficiency

Stan:

You write: “Our policy has been to vaccinate such patients with 23-valent pneumococcal polysaccharide vaccine.” What is the purpose of this vaccination in such patients – to test his immune response or to provide active protection? If the latter, what makes you think he is going to benefit – given the fact that he has low IgG ELIZA antibodies, recurrent infections and bronchiectasis?

I would just caution in following recommendations from  resources such as ACIP when we are dealing with patients with immunodeficiency disorders or suspected immunodeficiency disorders.

Regards,

JB



From: Boyce, Thomas G., M.D. [mailto:Boyce.Thomas at mayo.edu]
Sent: Thursday, December 05, 2013 3:19 PM
To: CIS-PIDD
Subject: RE: [cis-pidd] pneumococcal vaccine strategy in adolescents & adults with immune deficiency

This is true in adults.  In children, you only need to wait 2 months.

From: bounce-44205117-183824398 at lists.clinimmsoc.org<mailto:bounce-44205117-183824398 at lists.clinimmsoc.org> [mailto:bounce-44205117-183824398 at lists.clinimmsoc.org] On Behalf OfStan Ress
Sent: Thursday, December 05, 2013 2:11 PM
To: CIS-PIDD
Subject: RE: [cis-pidd] pneumococcal vaccine strategy in adolescents & adults with immune deficiency

Hi Laia,

I’d really like to hear what others think but what I understood from the ACIP statement is that, after PPSV23 vaccination, you need to wait at least one year before giving the 13-valent conjugate vaccine (Prevenar 13).

Regards,

Stan

--
Stanley Ress
Associate Professor of Medicine
Head: Division of Clinical Immunology
Department of Medicine
H47 Old Main Building-room 26
Groote Schuur Hospital and UCT
Observatory 7925
Cape Town
South Africa
TEL:INTERN. + 2721-4066201 or 4066197
FAX:   "    + 2721-(0)865173095
Cell: 0833115482
email: stan.ress at uct.ac.za<mailto:stan.ress at uct.ac.za>


From: Laia Alsina Manrique de Lara [mailto:lalsina at hsjdbcn.org]
Sent: 05 December 2013 09:29 PM
To: CIS-PIDD
Cc: CIS-PIDD
Subject: Re: [cis-pidd] pneumococcal vaccine strategy in adolescents & adults with immune deficiency

OK,
So how bad would it be to administer first Pneumovax23 to complete diagnosis, and if no response is observed, administer Prevenar13 for prophylactic purposes +/- IGRT?

Laia Alsina
Allergy and Clinical Immunology Department,
Hospital Sant Joan de Deu, Barcelona.

El 04/12/2013, a las 21:13, "John Ziegler" <j.ziegler at unsw.edu.au<mailto:j.ziegler at unsw.edu.au>> escribió:
Stan

 PPV23 as primary vaccine is still popular in this setting among my colleagues but I think it's unethical not to give PCV13 first.

John


_________________________
Professor John B. Ziegler, AM
Department of Immunology & Infectious Diseases
Sydney Children's Hospital
High St., Randwick NSW 2031
Australia
T: (02) 93821515
F: + 61 + 2 93821580
E: j.ziegler at unsw.edu.au<mailto:j.ziegler at unsw.edu.au>

On 5 Dec 2013, at 8:06 am, "Stan Ress" <stan.ress at uct.ac.za<mailto:stan.ress at uct.ac.za>> wrote:
Hi all,

I have been referred a 15 year-old patient with extremely severe IgA deficiency, recurrent respiratory infections, & bronchiectasis on CT chest. Her baseline vaccine status revealed low IgG ELIZA antibodies against 4/5 antigens, including S. pneumonia & H. Influenza B. Our policy has been to vaccinate such patients with 23-valent pneumococcal polysaccharide vaccine. However, I saw a reference to ACIP recommendation that children & adults with immune compromising conditions or asplenia, should receive 13-valent conjugate vaccine 1st, followed 8 weeks later by unconjugated PPSV23.

Is this the general current practise?

Thanks.
--
Stanley Ress
Associate Professor of Medicine
Head: Division of Clinical Immunology
Department of Medicine
H47 Old Main Building-room 26
Groote Schuur Hospital and UCT
Observatory 7925
Cape Town
South Africa
TEL:INTERN. + 2721-4066201 or 4066197
FAX:   "    + 2721-(0)865173095
Cell: 0833115482
email: stan.ress at uct.ac.za<mailto:stan.ress at uct.ac.za>

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