More than 80% of healthy adults who receive the 23-valent polysaccharide pneumococcal vaccine develop antibodies against the serotypes contained in the vaccine, usually within two to three weeks after the vaccination. Older adults, those with chronic diseases, and the immunodeficient may not respond as well, and the immunity may not last the five to ten years that it does in normal adults. Nonetheless, one should vaccinate immunocompromised persons who are at increased risk of pneumococcal disease including those with asplenia, hypersplenism, Hodgkin disease, lymphoma, multiple myeloma, chronic renal disease, nephrotic syndrome, immunosuppression after transplantation, immunosuppression owing to chemotherapy or high dose corticosteroid therapy (14 days or longer). Steroid therapy is not a valid contraindication to the pneumococcal vaccine. There is insufficient evidence of improved protection with multiple doses of pneumococcal vaccine, so routine revaccination of immunocompetent persons is not recommended, but revaccination is recommended for those who are at highest risk for severe pneumococcal infection and for those who are likely to have a rapid decline in pneumococcal antibody titers. For those at high risk, the CDC recommends only one PPV23 revaccination five or more years after the first dose. I don’t think one dose of intravenous Solu-medrol® is likely to affect your patient’s response to the vaccine. She is certainly at high risk for the vaccine. I would give it to her. Reference: Epidemiology and Prevention of Vaccine-Preventable Diseases. January 2007. 10th Edition. Department of Health and Human Services. Centers for Disease Control and Prevention. As for influenza vaccine, I would give it, too, as your patient is at high risk of complications from influenza and might not get vaccinated if you delay it. I would give her the inactivated vaccine rather than the live, attenuated vaccine. I agree with the above, but we allergists do tend to hold off on vaccines when a patient is in the midst of an asthma exacerbation. I can’t give you a reference, but the “common knowledge” presented during my training was that it could further exacerbate the asthma. This patient’s asthma does not seem to be well controlled at present. If she is taking the Asmanex every day, she might need a higher dose, the addition of a LABA or an added leukotriene inhibitor. If on steroids I might hold off on live viral vaccines, particularly in the setting of an significant intercurrent illness (ie asthma exacerbation), due to immunosuppression. However, for killed vaccines this is less of a concern. Studies have shown that steroids do not affect the antibody response to immunizations: Ann Allergy. 1993 Apr;70(4):289-94.Links Antibody levels and response to pneumococcal vaccine in steroid-dependent asthma. Lahood N, Emerson SS, Kumar P, Sorensen RU. Pediatrics. 1996 Aug;98(2 Pt 1):196-200.Links Influenza vaccination of children during acute asthma exacerbation and concurrent prednisone therapy. Park CL, Frank AL, Sullivan M, Jindal P, Baxter BD. Arch Pediatr Adolesc Med. 1998 Dec;152(12):1191-5.Click here to read Links Effect of prednisone on response to influenza virus vaccine in asthmatic children. Fairchok MP, Trementozzi DP, Carter PS, Regnery HL, Carter ER. In summary, I would give killed vaccines to your patient, but would hold off on live viral vaccines until asthma flare is over and off prednisone.
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on July 27th, 2013
