Case Study

JS is a 54-year-old white woman who comes to your office to establish herself as a patient. During a review of her medical history, several active medical problems come to light, including type 2 diabetes mellitus (formerly known as non–insulin-dependent diabetes mellitus) for 15 years, hypothyroidism and coronary artery disease with myocardial infarction 10 years earlier. She stopped smoking nine months ago after smoking one pack of cigarettes daily for 23 years. She underwent coronary artery bypass grafting eight years earlier. A review of medications reveals appropriate pharmacologic management of her medical problems. Papanicolaou test and mammography screenings are current. She has never received a pneumococcal vaccine.

Questions

1. Which one of the following factors contributes most to your decision to offer the pneumococcal vaccine?

   A. Her age.

   B. Her history of cigarette smoking.

   C. Her chronic medical problems.

   D. None of the above; this patient should not be offered a pneumococcal vaccine.

2. If JS receives the pneumococcal vaccine at this visit, when is revaccination indicated?

   A. In about four years.

   B. In about six years.

   C. In about eight years.

   D. In about 10 years.

   E. Revaccination is not recommended.

3. Which of the following side effects of the pneumococcal vaccine occur in one third to one half of patients?

   A. Erythema.

   B. Induration.

   C. Fever.

   D. Pain at injection site.

Answers

1. The answer is C: her chronic medical problems. Patients who are at increased risk of complications from pneumococcal disease include persons at the extremes of age (less than five years or more than 65 years); blacks, American Indians and Alaska Natives; residents in group homes and other institutional settings; persons with alcohol dependence; persons with chronic medical problems; and persons with immunodeficiency.^1–4 Invasive pneumococcal disease has produced case-fatality rates of 30 to 43 percent among the elderly and 25 to 27 percent among persons with chronic health conditions.^2,3

2. The answer is E: revaccination is not recommended. Routine revaccination for pneumococcal disease is not recommended. Although the total duration of antibody protection is unknown, sufficiently protective pneumococcal titers are thought to persist for at least five years following vaccination.⁵ In some individuals, antibody levels have been noted to fall to baseline levels within 10 years.⁵ Others, however, have reported that the clinical efficacy of pneumococcal vaccine lasts at least seven to 10 years.⁶ Revaccination with the current 23-valent vaccine (available since 1983) may be appropriate in high-risk persons who previously received the 14-valent vaccine, although this subset of patients is likely to be small. The potential benefits of revaccination might be considered in selected patients who are likely to demonstrate a low initial antibody response and/or a rapid decline in antibody levels following vaccination. The Centers for Disease Control and Prevention (CDC) guidelines specify high-risk groups for whom revaccination is recommended. The CDC's Web site is http://www.cdc.gov/nip/publications.

3. The answers are A, B, and D: erythema, induration and pain at the injection site. There is little evidence of serious adverse effects from the pneumococcal vaccine, although erythema, induration or pain at the injection site occurs in about one third to one half of patients. Fever, myalgia and severe reactions occur in no more than 1 percent of patients.^5,6 Most evidence indicates little difference in adverse reactions to revaccination, compared with initial vaccination.