66yo M on dialysis comes for follow up of recent shingles diagnosis, doing well. He was vaccinated for Pneumovax and TDAP at age 62, but not zoster. What vaccine does he need?
a. Pneumovax, Prevnar
b. Pneumovax, Prevnar, Zoster
c. Prevnar, Zoster
d. Pneumovax, Zoster, Tdap
Prevnar is the pneumococcal 13-valent conjugate vaccine (PCV 13). The CDC has updated the recommended adult immunization schedule for 2013. There are new recommendations that Prevnar should be given to patients older then 19years of age with immunocompromising conditions, CKD, nephrotic syndrome, functional or anatomic asplenia, CSF leaks, or cochlear implants. Those previously vaccinated with Pnemovax (pneumococcal polysacchardie, PPSV 23) should still get the PCV 13 vaccine one year or more after their pneumovax vaccine. If your patient has not been vaccinated against either Pneumovax or Prevnar, then they should receive a single dose of Prevnar (PCV 13) followed by a dose of Pneumovax (PPSV 23) 8 weeks later.
Pneumovax should be given to all patients greater then 65years. A single vaccine is sufficiencent. There are a a few conditions that warrant vaccination under the age of of 65 and these include chronic lung diseases, chronic cardiovascular diseases, diabetes, CKD, nephrotic syndrome, chronic liver disease/cirrhois, alcohlism, cochlear impalants, CSF leaks, asplenia, nursing home residents, cigarrete smokers, and immunocompromised conditions. A "booster" shot of Pneumovax (PPSV 23) is required 5 years after the first dose for patients 19 through 64 years of age with chronic renal failure, nephortic snydrome, asplenia, or immunocompromising conditions. Regardless of vaccination status or booster status, all patients over 65 should be revaccinated with Pneumovax as long as it is 5 years past their prior vaccination. This patient had his vaccine 4 years ago so he should wait one additional year prior to revaccination.
Zoster should be given to all patients older then age 60years regardless of whether they have had zoster.
Other Interesting Pearls: Tdap shold be given to pregnant women 27 - 26 weeks gestation regardless of number of years from prior Td and Tdap vaccine to confer better immunity to the infant. Also HPV is recommended for boys starting at age 11 up to age 21.
