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CLINICAL MATTERS
Following the untimely demise of Meteor Garden actress Barbie Hsu from influenza, I got a deluge of inquiries from patients on how they could get the flu vaccine for added protection. In addition, they wanted to know what other vaccines were available for adults and what I would recommend. A common theme was that my patients (and a few doctor colleagues) didn’t know there were so many adult vaccines that were available on the market.
Vaccines, it is often said, are among the most important public health inventions ever devised. Vaccination is next only to clean drinking water in terms of impact on disease prevention. Vaccines save millions of lives every year and most recently enabled us to shorten the duration of the Covid-19 pandemic. Unfortunately, vaccines have been under attack by anti-vaxxers and vaccine skeptics in recent years, resulting in unnecessary outbreaks of vaccine-preventable diseases such as measles and chicken pox. It is difficult for laypeople to readily visualize the benefits of vaccines because the number of deaths prevented is an abstract concept. In contrast, many older people who were children before widespread vaccination became available can easily see the benefits. Before the polio vaccine, most parents dreaded summertime because this was when many children got infected and became disabled or died from the disease. In the Philippines, we still have occasional outbreaks, and people of my generation still have classmates who unfortunately got polio. I remember at least two of my classmates who each had a shrunken leg and had difficulty walking.
So, what vaccines should we get as adults? There are a lot, but we will focus on adult respiratory illnesses since these have the highest impact on the adult population. Some vaccines are only recommended for certain age groups and for those with specific comorbid conditions, but there are vaccines that are recommended for everyone.
Influenza vaccine
The flu vaccine is a yearly vaccine that is recommended for everyone. Even if you aren’t in the risk group, the flu can be pretty debilitating. While the vaccine doesn’t completely protect against acquiring infection, it does decrease the risk of severe disease and is life-saving in elderly and immunocompromised patients. Influenza has many strains, and these change each year. The current quadrivalent vaccines contain two strains each of influenza A and influenza B and represent the most likely predicted influenza subtypes that will circulate. Some years have a better match than others but because these change, a yearly vaccine schedule is recommended.
The best time to get a flu vaccine is before the flu season starts. This is because it takes six to eight weeks to make enough antibodies and T-cells for adequate protection. Since the Philippines is near the equator, it has access to both Northern Hemisphere and Southern Hemisphere flu vaccines. Flu season in the Northern Hemisphere and in the Philippines is from October to March, while in the Southern Hemisphere, it is usually from April to October. Some years, the strains for the Northern and Southern Hemisphere are the same, and sometimes they are different. Northern Hemisphere flu vaccines should be given around August to September, while Southern Hemisphere vaccines become available around late February to March. It doesn’t matter which flu vaccine version you take, but you only need one shot each year for adequate protection. There is no evidence that getting it every six months will increase its effectiveness.
Pneumonia (Pneumococcal) vaccine
This is perhaps the most confusingly named vaccine of all. The term “pneumonia” is used to refer to any kind of infection of the lungs, specifically the lower airways and the air sacs, or alveoli. Pneumonia can be caused by bacterial, viral or fungal pathogens. The “pneumonia” vaccine specifically protects against pneumonia caused by Streptococcus pneumoniae(also known as pneumococcal pneumonia) which is the most common cause of community-acquired bacterial pneumonia in the world. It does not protect against other bacterial causes of pneumonia like Haemophilus influenzae, Moraxella catarrhalis, Pseudomonas aeruginosa, or atypical organisms such as Mycoplasma pneumoniae, Chlamydophila pneumoniae or Legionella pneumophila. It does not protect against any viral or fungal agents either.
To add to the confusion, there are two kinds of pneumonia vaccines on the market: a polysaccharide vaccine (PPSV) and a conjugated vaccine (PCV). Polysaccharide vaccines were the first pneumonia vaccines to become available for adults and currently protect against 23 different strains of Streptococcus pneumoniae (PPSV23). Its major benefit is that it decreases the risk of invasive pneumococcal pneumonia, which can result in bacteremia and life-threatening meningitis. Conjugated vaccines, which elicit a stronger immune response, were invented to address the relatively lower efficacy of polysaccharide vaccines. They were the first effective pneumonia vaccines in children and they are now also given to elderly and immunocompromised adults. Conjugated vaccines have recently increased the number of strains included, and are currently available as PCV13, PCV15, and PCV20. There is a new PCV21 vaccine as well but it has not been introduced locally.
Recommendations for the pneumonia vaccine in the Philippines in adults are still evolving. Pneumococcal vaccination in non-immunocompromised adults is recommended for those aged 50 and older. Either PPSV23 or PCV13 was previously recommended by local guidelines prior to the availability of PCV15 and PCV20. Only one dose for either PPSV23 or PCV13 was needed with no recommendations for additional doses. A combination regimen of PCV13 or PCV15 followed by one dose of PPSV23 after one year has also been used with good safety and efficacy and may offer some advantages versus a single PCV13, PCV15, or PPSV23 dose. PCV20 is still new to the Philippines, and no local guidelines have been issued, but the US Centers for Disease Control (CDC) currently recommends PCV20 as a single dose for elderly or immunocompromised adults with no need for an additional PPSV23 dose. Since these recommendations are continually being refined, it is best to talk to your doctor if the pneumonia vaccine is right for you, and whether any you need just one type of vaccine or both.
Other adult respiratory vaccines
Covid-19 vaccines have had updated monovalent versions available yearly, but these have not made it to the Philippines aside from the bivalent vaccine that was last given in 2022. The original primary series of vaccines and boosters currently still protect against severe Covid-19, but protection from infection is waning. The US CDC recommends updated vaccines for everyone six months or older but is especially recommended for elderly patients above the age of 65 and those with comorbid conditions. The World Health Organization also recommends the updated vaccines but does recognize their limited availability globally. Talk to your doctor about getting an updated vaccine if you are in the high-risk group and have the chance to get it where it is available.
Two RSV vaccines against respiratory syncytial virus, which is a significant cause of severe pneumonia in young children and the elderly, have been approved in the Philippines for adults 60 years and older. Both vaccines significantly protect against hospitalization, especially in older adults with certain comorbid conditions such as chronic obstructive pulmonary disease and heart failure. In addition, one of the RSV vaccines can be given to pregnant women between 32 to 36 weeks of pregnancy, and this transfers the immunity to RSV from the mother to the infant in the first six months of life when RSV can be particularly deadly. Only one dose of RSV vaccine is currently recommended.
These are just some of the many effective and safe vaccines available for adults in our country. Talk to your doctor about decreasing your risk of severe respiratory disease at your next visit. It may save your life.
