Case Evaluating risk, assess needs
Ms. W, age 24, has bipolar I disorder, most recently manic with psychotic features. She presents for follow-up in clinic after a 5-day hospitalization for mania and comorbid alcohol use disorder. Her medical comorbidities include asthma and active tobacco use. She is taking lurasidone, 20 mg/d, and lithium, 900 mg/d. Her case manager is working to place Ms. W in a residential substance use disorder treatment program. Ms. W is on a waiting list to establish care with a primary care physician and has a history of poor engagement with medical services in general; prior attempts to place her with a primary care physician failed.
In advance of Ms. W’s transfer to a residential treatment facility, you have been asked to place a Mantoux screening test for tuberculosis (purified protein derivative), which raises the important question about her susceptibility to infectious diseases in general. To protect Ms. W from preventable diseases for which vaccines are available, you review the ARM SHOT mnemonic to broadly assess her candidacy for vaccinations.
Age
Age may be the most important determinant of a patient’s need for vaccination (Table 2). The CDC immunization schedules account for age-specific risks for diseases, complications, and responses to vaccination (Figure 1).6
Influenza vaccination. Adults can have an intramuscular or intradermal inactivated influenza vaccination yearly in the fall or winter, unless they have an allergy to a vaccine component such as egg protein. Those with such an allergy can receive a recombinant influenza vaccine. Until the 2016 to 2017 flu season, an intranasal mist of live, attenuated influenza vaccine was available to healthy, non-pregnant women, ages 2 to 49, without high-risk medical conditions. However, the CDC dropped its recommendation for this vaccine because data showed it did not effectively prevent the flu.7 Individuals age ≥65 can receive either the standard- or high-dose inactivated influenza vaccination. The latter contains 4 times the amount of antigen with the intention of triggering a stronger immune response in older adults.
Pneumonia immunization. All patients age ≥65 should receive vaccinations for Streptococcus pneumoniae and its variants in the form of one 13-valent pneumococcal conjugate vaccine and, at least 1 year later, one 23-valent pneumococcal polysaccharide vaccine (PPSV23). Immunization reduces the morbidity and mortality from pneumococcal illness by decreasing the burden of a pneumonia, bacteremia, or meningitis infection. Adults, ages 19 to 64, with a chronic disease (referred to as “special populations” in CDC tables), such as diabetes, heart or lung disease, alcoholism, or cirrhosis, or those who smoke cigarettes, should receive PPSV23 with a second dose administered at least 5 years after the first. The CDC recommends a 1-time re-vaccination at age 65 for patients if >5 years have passed since the last PPSV23 and if the patient was younger than age 65 at the time of primary vaccine for S. pneumoniae. This can be a rather tricky clinical situation; the health care provider should verify a patient’s immunization history to ensure that she (he) is receiving only necessary vaccines. However, when the history cannot be verified, err on the side of inclusion, because risks are minimal.
Shingles vaccination. Adults age ≥60 who are not immunocompromised should receive a single dose of live attenuated vaccine from varicella-zoster virus (VZV) to limit the risk of shingles from a prior chickenpox infection. The vaccine is approximately 66.5% effective at preventing postherpetic neuralgia for up to 4.9 years. Individuals as young as age 50 may have the vaccine because the risk of herpes zoster radically increases from then on,8 although most insurers only cover VZV vaccination after age 60.
Tetanus, diphtheria, and acellular pertussis (Tdap) vaccine. All adults should complete the 3-dose primary vaccination series for tetanus, diphtheria, and pertussis (also known as whooping cough) and this should include 1 dose of Tdap. Administration of the primary series is staged so that the second dose is given 4 weeks after the initial dose and the final dose 6 to 12 months after the first dose. After receiving the primary series, adults should receive a tetanus-diphtheria booster dose every 10 years. For adults ages 19 to 64, the Advisory Committee on Immunization Practices (ACIP) recommends 1 dose of Tdap in place of a booster vaccination to decrease the transmission risk of pertussis to vulnerable persons, especially children.