Board Review

A 59-year-old woman is evaluated in follow-up in November after being diagnosed with moderate COPD 3 months ago. She has never received the influenza or pneumococcal vaccine. She has no allergies. Her medications are a long-acting inhaled anticholinergic agent and an as-needed short-acting β₂-agonist inhaler.

On physical examination, vital signs and the remainder of the physical examination are normal.

Which of the following vaccinations are recommended for this patient?

A) Inactivated influenza vaccine and 13-valent pneumococcal conjugate vaccine (PCV13)

B) Inactivated influenza vaccine and 23-valent polysaccharide pneumococcal vaccine (PPSV23)

C) Inactivated influenza vaccine, PPSV23, and PCV13

D) Live attenuated influenza vaccine and PPSV23

E) Live attenuated influenza vaccine, PPSV23, and PCV13

Answer: B - Inactivated influenza vaccine and 23-valent polysaccharide pneumococcal vaccine (PPSV23)

Objective: Recommend appropriate influenza and pneumococcal vaccinations in a patient with COPD.

Key Point

Patients with COPD should receive inactivated influenza vaccination annually, and the 23-valent polysaccharide pneumococcal vaccine (PPSV23) should be given to all patients aged 19 to 64 years with COPD, with revaccination at age 65 years or older if 5 years have elapsed since the previous pneumococcal immunization; the 13-valent pneumococcal conjugate vaccine should also be administered at age 65 years or older if 1 year has elapsed since the last PPSV23 immunization.

This patient should receive inactivated influenza vaccine and 23-valent polysaccharide pneumococcal vaccine (PPSV23). Influenza vaccination has been shown to reduce serious illness (such as lower respiratory tract infections that require hospitalization) and death in patients with COPD. These vaccines should be administered annually in all patients with COPD. Pneumococcal vaccination with PPSV23 should be given to all patients aged 19 to 64 years with COPD, with revaccination at age 65 years if 5 years have elapsed since the previous pneumococcal immunization. All patients (with or without COPD) should also receive the 13-valent pneumococcal conjugate vaccine (PCV13) at age 65 years, although the polysaccharide and conjugate vaccines should be given sequentially rather than together for optimal effect. Ideally, PCV13 should be administered at least 1 year following PPSV23. PPSV23 and PCV13 are also indicated in patients with functional or anatomic asplenia, cochlear implants, persistent cerebrospinal fluid leak, and significant immunocompromising conditions. Preferably, these patients should receive PCV13 first followed by PPSV23 at least 8 weeks later. This patient will require another dose of PPSV23 at the age of 65 years. Patients with COPD who received their first PPSV23 dose at age 65 years or older do not require revaccination.

Because this patient is younger than 65 years, she does not require the PCV13 vaccination at this time.

The live attenuated influenza vaccination is recommended for healthy persons between the ages of 2 and 49 years. Because this patient has COPD and because she is older than 49 years, live attenuated influenza vaccination should not be administered.

Bridges CB, Coyne-Beasley T; Advisory Committee on Immunization Practices. Advisory committee on immunization practices recommended immunization schedule for adults aged 19 years or older: United States, 2014. . 2014 Feb 4;160(3):190. Link Out