Prevention

Approximately half of all cases of adult pneumonia can be prevented by annual administration of influenza vaccine, plus a one-time pneumococcal vaccine when indicated (Vu et al., 2002). Vaccination with inactivated influenza vaccine is appropriate for all age groups, but the live, attenuated influenza vaccine is approved for use only in healthy patients age 5 to 49 years. The CDC recommends that influenza vaccine be given to all children from 6 months to 18 years of age, all adults over age 50, and other persons at higher risk for complications of influenza (Box 18-4).

Health care workers are an important source of transmission of influenza from infected patients to other medically vulnerable patients. Therefore, they also should be immunized, preferably with inactivated vaccine if they have close contact with severely immunocompromised persons. Health care workers or family members vaccinated with live, attenuated influenza vaccine should avoid contact with severely immunosup-pressed patients for at least 7 days after vaccination.

Two types of vaccine are available for immunizing against invasive pneumococcal disease. For children younger than 2 years, universal vaccination with heptavalent (7 serotypes) pneumococcal vaccine is recommended. For other indications and age groups, pneumococcal polysaccharide vaccines currently cover 23 serotypes of the disease. ACIP recommends the pneumococcal polysaccharide vaccine for all patients older than 2 years with pulmonary, cardiac, immune, or other medical risk factors, immunocompromised persons, and those older than 65 years. Specifically, the indications for pneumococcal polysaccharide vaccine are as follows:

• Adults 65 years or older

• Immunocompetent adults or children 2 years or older who are at increased risk for illness and death associated with pneumococcal disease because of chronic illness

• Adults or children 2 years or older with functional or anatomic asplenia

• Adults or children 2 years or older living in environments in which the risk for disease is high

• Immunocompromised adults or children 2 years or older who are at high risk for infection

A systematic review suggests that pneumococcal vaccination does not significantly reduce all-cause mortality or overall rates of pneumonia, but it is specifically effective in preventing invasive pneumococcal disease (Dear et al., 2003).

Box 18-4. Groups Who Should Receive Seasonal Influenza Vaccine*

All children age 6 months to 18 years All persons age 50 years or older

Women who will be pregnant during the influenza season Persons who have chronic pulmonary (including asthma), cardiovascular (except hypertension), renal, hepatic, cognitive, neurologic/neuromus-cular, hematologic, or metabolic disorders (including diabetes mellitus) Persons who have immunosuppression (including medication induced or HIV)

Residents of nursing homes and other long-term care facilities Health care personnel

Household contacts and caregivers of children younger than 5 years and adults 50 years or older, with particular emphasis on vaccinating contacts of children less than 6 months

Household contacts and caregivers of persons with medical conditions that put them at higher risk for severe complications from influenza

*Centers for Disease Control and Prevention (CDC) recommendations, for all persons without contraindications in the groups listed.

Older patients should be revaccinated with pneumococcal polysaccharide vaccine after 10 years if the first pneumococcal vaccine was administered before age 65. Elderly persons with unknown vaccination status should be administered 1 dose of vaccine. Children older than 2 years at highest risk for serious pneumococcal infection and likely to have a rapid decline in pneumococcal antibody levels (asplenia, renal failure, HIV, cancer chemotherapy) should also be revacci-nated after 3 to 5 years.

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