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vaccines

Diseases and Conditions

Shingrix: The new shingles shot

May 8, 2018
Shingrix: The new shingles shot

Benjamin Bergen, Doctor of Pharmacy Candidate Class of 2018, Albany College of Pharmacy and Health Sciences

In Fall 2017, a new inactivated recombinant shingles vaccine, Shingrix, came to the market to help people better protect themselves against the herpes zoster (shingles) virus.1

What is shingles?

Shingles is a painful rash that usually develops on only one side of the body, caused by the chickenpox virus reactivating in the body years after initial infection. Since over 99% of people over 40 have had chickenpox, vaccination is recommended regardless of the person remembering if they had it. Blisters appear that scab over in 7 to 10 days and clear up within 2 to 4 weeks. Some people with shingles have a long-lasting burning sensation that can last for months or years after the rash goes away, called postherpetic neuralgia (PNH). The risk to get both shingles and PHN increases with age.1

Zostavax: The “old” shingles shot

Previously, the only available product for protection against shingles was Zostavax, Merck’s live vaccine which was approved in 2006. Zostavax was FDA approved for people over 50 years of age, but the Centers for Disease Control and Prevention (CDC) only recommended it for people 60 years of age and older. Zostavax should not be given to any person that has:1,2

  • An anaphylactic allergy to gelatin, neomycin, or any other component of the vaccine
  • Immunosuppression for any reason, including:
    • Primary or acquired immunodeficiency states
    • AIDs or other clinical manifestations of HIV
    • Leukemia or lymphoma, or any other malignant neoplasms affecting the bone marrow or lymphatic system
    • Receiving immunosuppressive therapy
      • Cancer treatment such as radiation or chemotherapy
      • Long-term steroids (ie: prednisone)
      • Biologic therapy such as adalimumab (Humira) or etanercept (Enbrel)
    • Women should not become pregnant for at least 4 weeks after receiving the vaccine

Shingrix: The new shingles shot

The CDC now recommends Shingrix over Zostavax for the prevention of shingles and related complications for all immunocompetent adults aged 50 and older:1,3

  • Regardless of having a history of shingles
  • Regardless of prior Zostavax vaccination. There should be at least 8 weeks between the vaccinations.
  • With chronic medical conditions such as diabetes, chronic kidney disease, or rheumatoid arthritis
  • At the same time as the flu or pneumonia vaccines

There are exceptions

The CDC still recommends Zostavax in certain cases, such as if Shingrix is unavailable or if a person is allergic to Shingrix.1 Shingrix has been shown to be much more effective than Zostavax for preventing shingles in different age groups, illustrated in the following table:2,3

Age Group Zostavax Efficacy Shingrix Efficacy
50-59 70% 96%
60-69 64% 97%
70-79 41% 91%
>80 18% 91%

 

Shingrix should not be given to any person that:1,3

  • Has a history of a severe allergies reaction to any component of the vaccine or after a previous dose of Shingrix.
  • Tested negative for immunity to varicella zoster virus (the chickenpox vaccine should then be given)
  • Currently has shingles
  • Is currently pregnant.

Possible side effects

The most common side effect with Shingrix is pain at the injection site. This is more common in younger people. Other side effects include muscle pain, fatigue, headache, shivering, fever, and gastrointestinal symptoms.

Head-to-head comparison

Shingrix is covered by Medicare Part D, the prescription drug plan, and may have a copay. A full comparison of the two vaccines is shown below:

Zostavax2 Shingrix3
Live attenuated vaccine Recombinant Inactivated Vaccine
Cannot be given to immunosuppressed patients Has not been studied in immunosuppressed patients
No longer CDC recommended CDC recommended for patients aged 50 or older
Single vaccination Two vaccinations, 2-6 months apart
Patients over 60: 39% decrease in postherpetic neuralgia Patients over 70: 88% decrease in postherpetic neuralgia

Call to action

If you are interested in learning more about vaccines and autoimmune disease, I encourage you to read our flu vaccine and pneumonia vaccine articles.

Medical Disclaimer

This information is offered to educate the general public. The information posted on this website does not replace professional medical advice, but for general information purposes only. There is no Doctor – Patient relationship established. We strongly advised you to speak with your medical professional if you have questions concerning your symptoms, diagnosis and treatment.

References:

  1. Herpes Zoster Shingrix Vaccine Recommendations. The Centers for Disease Control and Prevention. Cited 1 May 2018.
  2. Zostavax Prescribing Information. Food and Drug Administration 2006. Revised 2018.
  3. Shingrix Prescribing Information. Food and Drug Administration 2017. Revised Oct 2017.
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Diseases and Conditions

Pneumonia vaccines in people with autoimmune diseases

December 19, 2017
Pneumonia vaccines in people with autoimmune diseases

Do you need to get the pneumonia vaccine? Patients that have concurrent autoimmune diseases are at a higher risk of infection than others. In fact, infection is one of the most common causes of hospitalization in patients suffering from rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE); therefore, it is important to do everything possible to protect yourself from getting sick. The “pneumonia vaccine” or pneumococcal vaccine protects patients from pneumococcal diseases caused by the bacterium, Streptococcus pneumonia. Pneumococcal diseases can be serious and even fatal. Each year, in the United States alone, approximately 18,000 older adults die from pneumococcal diseases.

What is Streptococcus pneumoniae?

Pneumoniae is a gram-positive, spherical bacterium that has more than 90 known variations of the species, also known as serotypes. These bacteria typically group together in pairs or chains. They are the bacteria responsible for pneumococcal diseases including pneumonia, meningitis, bacteremia (infection of the blood), and many other severe illnesses. Pneumococcal pneumonia is the most common clinical presentation of a pneumococcal disease. It is a major cause for community-acquired pneumonia and results in about 400,000 hospitalizations every year. Pneumococcal meningitis can result in deafness and brain damage. It kills about 1 child in 10 who get it.

What are some signs and symptoms of pneumonia?

Pneumonia can look a lot like the common cold or the flu. Common symptoms include:

  • Abrupt onset of fever
  • Chills or rigors (uncontrollable shaking)
  • Chest pain
  • Productive cough
  • Trouble breathing
  • Malaise
  • Feeling of weakness

Which vaccine should I get?

Currently, there are two forms of pneumonia vaccine that is available in the US. Both forms of the vaccine are inactivated or “killed” vaccines.

Vaccine Brand Name Abbreviation
Pneumococcal conjugate vaccine Prevnar 13 PCV13
Pneumococcal polysaccharide vaccine Pneumovax PPSV23

The pneumococcal conjugate vaccine (PCV) 13, also known as Prevnar 13, covers 13 serotypes. The pneumococcal polysaccharide vaccine (PPSV) 23, also known as Pneumovax, covers 23 serotypes. Typically, both PCV13 are PPSV23 are required with PCV13 being given prior to PPSV23. The minimum interval between PCV13 and PPSV23 is 8 weeks. The table below shows the recommended vaccine schedule for immunocompromised people. Talk to your healthcare provider or pharmacist for more information about which vaccine would be most appropriate for you.

Pneumococcal vaccine status: Age FIRST give: THEN give: THEN give:
None/Unknown 19-64 years PCV13 PPSV23

(at least 8 weeks later)

 PPSV23

(at least 5 years after first PPSV23 dose)
None/Unknown 65+ years PCV13 PPSV23

(12 months after PCV 13)
PPSV23 65+ years PCV13

(at least 1 year after PPSV23)

 PPSV23

(6-12 months after PCV 13 AND 5 years after PPSV23)
PPSV23 Under 65 years PCV13

(at least 1 year after PPSV23)

 Second dose of PPSV23

(at least 8 weeks after PCV13 AND at least 5 years after first dose of PPSV23)

 Third dose of PPSV23

at age 65 (if at least 5 years have passed since last dose of PPSV23)
PCV13 No additional PCV13 doses are needed. At least 8 weeks must elapse before getting a dose of PPSV23.

What are some potential side effects?

These vaccines are normally well tolerated; however, side effects may still occur. Possible side effects may include

  • Injection site reactions including redness, pain, and swelling where the shot was given
  • Flu-like symptoms (mild fever, fatigue, headache, chills, or muscle pain)
  • Loss of appetite
  • Irritability
  • Life-threatening allergic reactions from this vaccine may also occur but are very, very rare

Where can I get the pneumonia vaccine?

Most doctor’s offices carry the pneumococcal vaccination. Call your primary care provider or specialist to see whether they can give you your pneumococcal vaccination. If not, most pharmacies also give this service as well.

Who should NOT get the vaccine?

Patients with a known hypersensitivity or allergy to any part of the vaccine should not receive the vaccine. Patients who have had allergic reactions to vaccines containing diphtheria (ex: Tdap, DTaP, tetanus vaccine) should tell their healthcare provider or pharmacist before receiving PCV13.

If you are feeling sick, wait until you feel better before getting the pneumonia vaccine.

Patients who are pregnant should not get the vaccine. Although there is no evidence of the vaccine being dangerous to the mother or the baby, as a precaution, it is recommended to receive the vaccine prior to conception.

Key points

  • The pneumonia vaccine can help protect you against serious or even fatal diseases.
  • Medications used in autoimmune conditions including RA, psoriatic arthritis, lupus, etc. can further weaken your immune system and predispose you to getting infections. Staying vaccinated can help keep you healthy and lower your risk of getting sick.
  • Pneumococcal diseases can spread from person to person through close contact.
  • Patients should receive up to 1 dose of PCV13 and up to 3 doses of PPSV23 in their lifetime. PCV13 and PPSV23 should not be administered on the same day.
  • The pneumonia vaccine can be given year-round. You can even get the flu shot on the same day. Just try to get one in each arm to reduce any pain associated with getting the vaccines.
  • When thinking about starting chemotherapy or other immunosuppressive therapy (ex. steroids, biologics, etc.), the interval between vaccination and initiation of immunosuppressive therapy should be at least 2 weeks.
  • You will not get sick after getting the vaccine; however, it is not uncommon to have flu-like symptoms that are caused by your body’s response to the vaccine.
  • It will take a couple weeks before the vaccine will take its full effect.

Final thoughts

For immunocompromised people, it is recommended to receive vaccination against the bacterium S. pneumoniae as outlined by the Center for Disease Control (CDC) vaccine schedule. Many studies and government organizations also support the use of the vaccination as the benefits outweigh the risks of this preventable infection. Other people who are also immunocompromised or over the age of 65 should also receive the vaccine. These patients may include those with congenital or acquired immunodeficiency, HIV infection, chronic renal failure, nephrotic syndrome, leukemia, lymphoma, Hodgkin disease, generalized malignancy, multiple myeloma, solid organ transplant, or iatrogenic immunosuppression. Iatrogenic immunosuppression is based on the use of immunosuppressive drugs, including long-term systemic corticosteroids (e.g., prednisone) and radiation therapy. Talk to your healthcare provider or pharmacist if you have any questions or concerns on the pneumonia vaccine.

 

Guest Authors: Yahya Rasoully, PharmD Candidate 2018; Stephanie Tchen, PharmD, PGY-1 Pharmacy Resident; and Jessica Farrell, PharmD

References

  • Pneumoccoal Disease. Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine-Preventable Diseases. Hamborsky J, Kroger A, Wolfe S, eds. 13th ed. Washington D.C. Public Health Foundation, 2015.
  • Rákóczi É, Szekanecz Z. Pneumococcal vaccination in autoimmune rheumatic diseases. RMD Open. 2017;3:e000484.
  • Nagel J, Saxne T, Geborek P, et al. Treatment with belimumab in systemic lupus erythematosus does not impair antibody response to 13-valent pneumococcal conjugate vaccine. Lupus 2017;26:1072–81.
  • Alten R, Bingham CO, Cohen SB, et al. Antibody response to pneumococcal and influenza vaccination in patients with rheumatoid arthritis receiving abatacept. BMC Musculoskelet Disord 2016;17:231.
  • Centers for Disease Control and Prevention. Pneumococcal Vaccines (PCV13 and PPSV23): Addressing Common Questions about Pneumococcal Vaccination for Adults. Available from https://www.cdc.gov/vaccines/hcp/adults/downloads/fs-pneumo-hcp.pdf

Medical Disclaimer

This information is offered to educate the general public. The information posted on this website does not replace professional medical advice, but for general information purposes only. There is no Doctor – Patient relationship established. We strongly advised you to speak with your medical professional if you have questions concerning your symptoms, diagnosis and treatment.

1 Comments
Overcoming Inflammation

Flu vaccines and autoimmune diseases

September 19, 2017
Should people with autoimmune diseases get a flu vaccine? If so which ones?

Have you received your annual flu vaccine?  Flu season is just getting started.  People who suffer from autoimmune diseases, like rheumatoid arthritis, lupus, and Sjogren’s syndrome, often have a weakened immune system, either from the disease itself or from the medications used to treat their disease.  Today I’d like talk about the flu also known as influenza, and discuss what steps you can take to protect yourself this season.

What is the flu or influenza?

The medical word for the flu is influenza.  Influenza is a type of virus that mainly attacks the respiratory system.  There are two general types of influenza: influenza A viruses and influenza B viruses.  Different components make up the flu virus: one hemagglutinin (H1, H2, H3) and one neuraminidase (N1, N2). There are many different strains of influenza and to make matters worse, it tends to mutate.

The stomach flu is NOT caused by influenza.  The stomach flu is a general word used to describe a gastrointestinal infection caused by other types of viruses like Norovirus, the most common cause of gastroenteritis in the United States.

What are some of the signs and symptoms of the flu?

The signs and symptoms of the flu vary widely and are rather nonspecific.  They can include:

  • High fever
  • Muscle pain
  • Rigors, uncontrollable shaking
  • Headache
  • Malaise
  • Sore throat
  • Nonproductive cough
  • Runny nose

Complicated cases

Sometimes the flu can morph into a much more serious illness.  It can cause viral pneumonia and then can lead into a secondary bacterial pneumonia, sinusitis, and/or an ear infection.  This tends to happen in people who have a weakened immune system like children and older adults.  People with autoimmune conditions and especially people taking medications that weaken the immune system also are at high risk.

How is the flu transmitted?

The flu spreads from person-to-person by large particle droplets.

  • Airborne droplets: Coughing and sneezing
  • Skin-to-skin: handshakes and hugs
  • Saliva: Shared drinks and kissing
  • Touching contaminated surfaces: Keyboard, doorknob

What are the best ways to prevent the flu?

The best ways to prevent the flu are first, by washing your hands and second, by getting vaccinated for the flu at the beginning of each flu season.  Choosing healthy lifestyle practices, like eating clean, exercising, and getting a good night’s sleep, are also important.

What are the most convincing reasons for getting vaccinated against the flu?

  • During the 2016 – 2017 flu season, it caused 5.1% of outpatient visits.
  • Pneumonia and the flu caused 2% of reported deaths.
  • There were at least 18,000 confirmed flu related hospitalizations, 60% of cases occurred in people aged 65 years and above.
  • There were 98 confirmed flu related pediatric deaths.[1]
  • Risks of complications, hospitalizations, and deaths from the flu are the highest among people age 65 and above, young children and people who have medical conditions that weaken the immune system.
  • If you end up getting the flu, the flu vaccination may make your flu illness milder
  • By getting the flu vaccine, you decrease the risk of passing it on to the people you love

Who should get a flu vaccine?

Everyone six months and older.  This is especially important for people who have a high risk of getting flu-related complications.  These include:

  • Children younger than five
  • Adults 65 years of age and older
  • Pregnant women, up to two weeks postpartum
  • People that live in a nursing home or another type of long-term care facility
  • People that have a medical condition that weakens the immune system, this includes almost everyone with an autoimmune disease

Medical conditions

  • People with weakened immune systems (autoimmune diseases, cancer, HIV or AIDS, people on chronic steroids and biologic medications)
  • Asthma
  • Neurological and neurodevelopmental conditions
  • COPD and cystic fibrosis
  • Coronary artery disease and heart failure
  • Diabetes mellitus
  • Blood diseases like sickle-cell anemia
  • Kidney disease
  • Liver disease
  • People with an extremely high body mass index (BMI) > 40

When is flu season and when should I get my flu vaccine?

In the United States, flu season occurs during the months of October into May.  Historically, the greatest number of cases occur during the month of February.  The CDC recommends that people get a flu vaccine by the end of October.  If you’ve missed the deadline, no worries, better late than never!

What viruses will the 2017 – 2018 flu vaccines protect against?

Every year, manufacturers must change the structure of the flu vaccine, because the virus is constantly changing.  Scientists use data from the previous year to try to guess which strains will be more problematic in the upcoming season.  Flu vaccines typically have 3 to 4 specific strains of influenza.  This year, the vaccinations that have three types of virus should contain the following:

  • A/Michigan/45/2015 (H1N1)pdm09-like virus (updated)
  • A/Hong Kong/4801/2014 (H3N2)-like virus
  • B/Brisbane/60/2008-like (B/Victoria lineage) virus

Vaccines that contain four strains should contain the above as well as the following:

  • B/Phuket/3073/2013-like (B/Yamagata lineage) virus

Where can I get a flu vaccine?

Most doctor’s offices carry the flu shot.  Call your primary care provider or specialist to see whether they can give you your flu shot this year.  If not, most pharmacies also give this service as well.

Still unsure, please follow this link to find a flu shot near you.

Which flu vaccine should I get?

According to the CDC’s of published guidelines for the 2017 – 2018 season, they recommend the use of the inactivated influenza vaccine or IIV, or the recombinant influenza vaccine (RIV).  These come as injections.  They recommend against vaccination with the nasal spray flu vaccine.  The latter is a live attenuated vaccine.  People who take biologic medications should not receive live attenuated vaccines.

Can I get a flu vaccine if I’m allergic to eggs?

The following are the CDC recommendations regarding egg allergies and the flu vaccine.

  • People who have experienced only hives after exposure to egg can get any licensed flu vaccine that is otherwise appropriate for their age and health.

  • People who have symptoms other than hives after exposure to eggs, such as angioedema, respiratory distress, lightheadedness, or recurrent vomiting; or who have needed epinephrine or another emergency medical intervention, also can get any licensed flu vaccine that is otherwise appropriate for their age and health, but the vaccine should be given in a medical setting and be supervised by a healthcare provider is able to recognize and manage severe allergic conditions. (Settings include hospitals, clinics, health departments, and physician offices). People with egg allergies no longer have to wait 30 minutes after receiving their vaccine.[2]

Disclaimer: I have some safety concerns about the latter.  I’m simply stating what the CDC has issued.  When in doubt, talk to your doctor.

Why does the flu vaccine sometimes cause flu-like symptoms?

Here are a few reasons.

You have the flu

The incubation period is between one and four days.  It also takes about two weeks for your body to build immunity after receiving the vaccine.  Therefore, you can get the flu after a flu shot if your body hasn’t had time to build immunity yet.

You have a cold

Rhinoviruses are a common culprit.  These are the viruses responsible for the common cold.  In severe cases, the common cold can feel like the flu and you can catch it the same way.

The vaccine failed

Last year, the vaccine was only 34% effective at protecting against influenza A (H3N2) and 56% against influenza B viruses.  Unfortunately, over the past six seasons, vaccines have been less and less effective.[3]  However, any immunity is better than no immunity.

The flu vaccine gave you the infection

This can occur if you’ve received a particular type of flu vaccine that uses a live attenuated virus.  This is the vaccine that comes as a nasal spray.  Live attenuated vaccines are vaccines that contain a less potent form of the real virus.  The immune system reacts to the virus and develops antibodies without causing the infection.  Sometimes the virus is stronger than the immune system.  The real infection can occur when this happens.

The CDC advised against the use of this particular type of vaccine.

Most common cause, your immune system is reacting to the vaccine

Scientists make injectable flu vaccines with inactivated virus or without any virus at all.  Therefore, by definition, these are not infectious.  You cannot get the real infection from them.

Some people may experience some soreness, redness or tenderness from the shot itself.  Some people actually develop a low-grade fever, headache, and muscle aches (i.e., flu-like symptoms).  These typically last about 2 days and resolve without any intervention.  This is your body’s way of telling you that it’s mounting an immune response to the vaccine.  This means your body is responding to the vaccine and making antibodies to protect you from the real infection, which is MUCH more severe.

Final thoughts

I know vaccines have received a bad reputation over the past few years.  However, when you look at the data, vaccination particularly for the flu, ultimately saves lives.  Let’s take example.

During the 1918 – 1919 flu season (i.e., the Spanish Flu), 1/3 of the world population experienced a terrible flu pandemic. About 50 to 100 million died.  Now this was a particularly bad season, “the mother of all flu seasons”, and the reason it was so deadly has to do with many factors that we have yet to confirm. The CDC has experimented with an influenza virus that has the genetic material from the 1918 virus.  Their results suggest that our modern-day vaccines and FDA-approved antiinfluenza medications like Tamiflu, would have worked against the 1918 virus.[4]

Bottom line, flu vaccines save lives.

If you want to learn more about the flu, please follow this link.

References

Fingers smiling against flu shot message image by wavebreakmedia via Shutterstock

[1] http://www.mdedge.com/jfponline/article/145540/vaccines/latest-recommendations-2017-2018-flu-season

[2] https://www.cdc.gov/flu/about/season/flu-season-2017-2018.htm

[3] http://www.mdedge.com/jfponline/article/145540/vaccines/latest-recommendations-2017-2018-flu-season

[4] https://wwwnc.cdc.gov/eid/article/12/1/05-0979_article

Medical Disclaimer

This information is offered to educate the general public. The information posted on this website does not replace professional medical advice, but for general information purposes only. There is no Doctor – Patient relationship established. We strongly advised you to speak with your medical professional if you have questions concerning your symptoms, diagnosis and treatment.

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