[CIS PIDD] [cis-pidd] Pneumococcal titers

[CIS-PIDD]

Ejaz:

I think your experience is the 'normal.'  The primary problem with repeating titers 6 months after the vaccine is that there are no age-appropriate "normal" data that I know of that address the issue.  It's difficult for immunologists to generate this information because we see patients for immune deficiency evaluations.

I have suggested to our Kaiser colleagues that this is the perfect study for them.  They have a superb infrastructure for vaccine studies in Northern California and they have a large "well" population.  I suspect a major problem is that there are no vaccine manufacturers willing to support such an effort.  My answers to your specific questions are below.

Joe Church
Children's Hospital Los Angeles

From: CIS-PIDD [mailto:cis-pidd at lists.clinimmsoc.org]
Sent: Tuesday, September 20, 2016 9:19 AM
To: CIS-PIDD
Subject: [cis-pidd] Pneumococcal titers

Dear colleagues
I would like take some  expert advice regarding a simple but consistent issue of obtaining pneumococcal titers.
It is our observation that whenever we order these titers in kids ages  5 to 18. They are almost always low and when we Immunized these kids with Pneumovax a significant majority show a robust response (10-20 serotypes show way above protective range) and then we check these levels again a significant majority show low titers within 6-12 months
I would like to share following  clinical observation  from our past experience
pneumococcal titers(23 serotype )obtained in 31 kids ages between 5-18.
28 of them showed titers <1.3 in 9-18 serotypes
27 received pneumovax and titers repeated in 4-5 weeks with following results:
18 showed great response with >70%  serotypes within protective range with 2-8 folds' response
6 showed 50% serotypes within protective range
2 showed 4-6 serotypes within protective range
Only in one kid there was no response and this was the only kid with low IgG for his age.
All other  kids had normal Quantitative Immunoglobulins with normal  Tetanus and Diphtheria titers
Out of 18 kids who had  great vaccine response only 12 were able to maintain these protective titers and when repeated within 6-12 months there was a significant drop in titers( It  went down in 6 kids almost to the base line levels within 6-12 months ( <1.3)
One of these kids (girl aged 14 with asthma was  recently diagnosed with bronchiectasis on CT scan but others have not had any significant clinical issues
My questions are:
Is this something unusual that we are observing?  No.
What to do with kids who dropped their titers? Especially when they are not that sick other than 2-4  "sinus or ear  infections"/year.
  Do they need IVIG ? prophylactic antibiotics ?   Not all, and maybe not most.  I have not been impressed with Ig replacement in this group.
Does every one repeat pneumococcal titers within 6-12 months after having a robust/ normal vaccine response ?  If infections continue I repeat at 4-6 months.  If there is a marked loss of antibody I may lean toward Ig, and if the patient has more serious infections I lean a bit harder.

Love to hear from the experts
Thanks
Ejaz  Yousef MD
Nemours Children Sociality Care
Jacksonville, FL


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