Daily Dose from Dr. John Spence

Dear Dr. Spence,

What are the advantages of getting a pneumonia vaccine? I have known people who get the shot but still end up getting pneumonia.

Signed,
Ms. J

Dear Ms. J,

The Advisory Committee on Immunization Practices recommends pneumococcal vaccinations for all adults over the age of 65. Despite this, it is speculated that only 50% of eligible patients actually receive the vaccine. Obvious blame can be placed on physicians who may fail to question patients about their immunization status given time constraints. Patients may also be hesitant to get the vaccine secondary to their lack of information regarding benefits and efficacy, or simply they fear the injection/needle itself.

The pneumovax  and prevnar vaccines protect against streptococcus pneumoniae, which remains the most common causative organism in bacterial pneumonia. There are probably 175,000 annual hospitalizations that can be linked to strep pneumonia and pneumococcal disease accounts for more than 6000 deaths per year. More than 50% of these cases are in patients whom vaccination was recommended based on age alone.


The vaccine is considered extremely efficacious. A three-year study of over 47,000 people over the age of 65 revealed that the pneumonia vaccine reduced the risk of serious pneumococcal disease by 44% and decreased the risk of mortality by 16%. It does not prevent the incidence of community-acquired pneumonia, but it does decrease the likelihood of more severe life-threatening infections that are associated with the bug. Rates of death or admission to the ICU were decreased from 21% to 10% when patients were vaccinated previously.

Again, the pneumovax and prevnar vaccines are recommended for any patient over the age of 65. For those less than 65, the vaccines may be indicated based on individual health risks and co-morbidities. For example, it is generally suggested that patients at increased risk of illness or death from pneumococcal pneumonia be immunized as well. This may include anyone suffering from chronic obstructive pulmonary disease (COPD), coronary artery disease, diabetes mellitus or others.


Vaccines are an important public health measure for disease prevention. Global success depends on patients and clinicians working together to adhere to published vaccination guidelines. Assuredly, this will help decrease morbidity from pneumococcal disease, which in turn will translate to saved lives.

-Dr. John Spence

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Dear Dr. Spence,

How important is vitamin D? Don’t I get enough from my diet?
Signed, 
JKL

Dear JKL,
Vitamin D is critically important in maintaining healthy bones, this much is clear. It is estimated that one billion people worldwide have a vitamin D deficiency. Amazingly, a study at a Boston hospital found a whopping 32% of healthy students, residents and physicians were vitamin D deficient despite intake of multi-vitamins and a glass of milk per day! Most vitamin D is obtained from sun exposure (3000 IU per exposure of 10 to 15 minutes) versus dietary sources (one cup of milk = 100 IU). Recent data suggests that most women should ingest 800 IU per day, whereas previous recommendations were set at 400.

Many patients diagnosed with osteoporosis actually have vitamin D deficiencies. Bisphosphonates like fosamax will not treat osteoporosis in these cases and may actually lead to severe low calcium levels. It becomes increasingly important that any patient diagnosed with osteoporosis be screened for vitamin D deficiency. Most patients can supplement with 800 to 1000 IU per day to help maintain normal levels, but those with malabsorption may require 25,000 to 50,000 IU per week.

So what? We know that supplementation of vitamin D may help prevent osteoporosis, but more recent studies show it may decrease the risk of falls in elderly populations and may decrease cancer rates. A study of 1180 women older than 55 years of age revealed that supplementation with 1000 IU of vitamin D plus calcium decreased the risk of cancer by roughly 35%. The number needed to treat to prevent one case of cancer is only 21 with an absolute risk reduction of 5%. Not bad for something as simple as vitamin D, which generally has minimal, side effects, even at massive doses.

Update on peripheral vascular disease (PAD): A German trial of 6880 patients greater than 65 years of age revealed a five year mortality rate of 19% in those with PAD. None of those patients had symptoms! The rate rose to 23% in those with symptoms; a very small, insignificant difference. The bottom line: PAD carries a poor prognosis regardless of whether a patient has signs or symptoms of leg pain or not. Mortality as a whole is increased by 60-80% in patients with PAD. Recommendations by the German authors are that all patients older than 70, or those aged 50-69 with cardiac risk factors, should be screened. Not a bad idea given the relative low cost, good insurance coverage, and ease of testing.

-Dr. John Spence