Background/Purpose:

The 2012 recommendations of the Centers for Disease Control (CDC) advise that adults aged ≥19 years with immunocompromising conditions including patients on iatrogenic immunosuppression should receive a dose of Pneumococcal Conjugate Vaccine (PCV13) first, followed by a dose of Pneumococcal Polysaccharide Vaccine (PPSV23) at least 8 weeks later (1). A second PPSV23 dose is recommended 5 years after the first PPSV23 dose for patients aged 19–64. Additionally, those who received PPSV23 before age 65 years for any indication should receive another dose at age of 65 years, or later if at least 5 years have elapsed since their previous PPSV23 dose. The preceding, 2008 recommendations suggested to vaccinate with PPSV23 alone (2). This project was initiated to evaluate compliance with the 2012 and 2008 guidelines at the Veteran’s Affairs (VA) Medical Center in Syracuse, New York.

Methods:

This study included patients with the diagnoses of rheumatoid arthritis, systemic lupus erythematosus, or granulomatosis with polyangiitis who were treated with methotrexate, azathioprine, adalimumab, tofacitinib, apremilast, rituximab, mycophenolate mofetil, anakinra, etanercept, sekukinumab, ustekinumab, certozilumab or cyclophosphamide. Compliance rate in our cohort was compared to previously published studies with chi-square test using GraphPad software (San Diego, CA). Two-tailed p <0.05 was considered significant.

Results:

The records of 3095 cases between 1/1/2014-1/1/2017 were examined. 414 of 3095 cases were treated with immunosuppressants. Only 138/414 (33%) of the patients were immunized appropriately following the 2012 guidelines (1). 155/414 patients (37%) received PPSV23 alone, which follows the 2008 guidelines (2). 271/414 patients (65%) received PCV13 alone, while 288/414 patients (70%) received PCV13 or PPSV23. As reference points for our study, we were unable to find publications that evaluated compliance with 2012 CDC recommendations. However, we found three studies that assessed pneumococcal vaccination in similar cohorts (Table 1). Compliance with 2008 CDC guidelines was significantly lower in study No. 1 but greater in studies No. 2 and 3 as compared to our cohort at 37%.

Table 1. Compliance rate of 37% at the Syracuse VA with 2008 CDC guidelines (2) is compared to three studies documented in the literature.

Conclusion:

This study demonstrates that the 66% majority of rheumatic disease patients on immunosuppressants at the Syracuse VA were not receiving adequate pneumococcal vaccination as recommended by the CDC (1). Therefore, quality improvement is necessary to enhance compliance with current CDC recommendations. Follow-up studies are warranted given the significant morbidity and burden to society inflicted by non-compliance with pneumococcal vaccination guidelines.

References:

1. Morb Mortal Wkly Rep. 2012 Oct 12;61(40):816-9.
2. Ann Intern Med 2008; 147: 725–9.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/compliance-with-pneumococcal-vaccination-in-rheumatic-disease-patients-on-immunosuppressive-medications/