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Pneumococcal Immunization in Pediatrics: Updates and Recommendations

  • Authors: Todd Wolynn, MD, MMM; Dana DeShon, DNP, APRN, CPNP-PC
  • CME / CE Released: 1/5/2023
  • Valid for credit through: 1/5/2024
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  • Credits Available

    Physicians - maximum of 0.50 AMA PRA Category 1 Credit(s)™

    Nurses - 0.50 ANCC Contact Hour(s) (0.5 contact hours are in the area of pharmacology)

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Target Audience and Goal Statement

This activity is intended for pediatricians, primary care physicians, pulmonologists, nurses, and nurse practitioners.

The goal of this activity is for learners to be better able to recommend pneumococcal vaccination for their pediatric patients.

Upon completion of this activity, participants will:

  • Have increased knowledge regarding the
    • The CDC's Advisory Committee on Immunization Practices (ACIP) recommendations regarding standard and catch-up pneumococcal vaccinations
    • Serotypes most likely to cause invasive pneumococcal disease
    • Differences in serotype coverage among available pneumococcal vaccines
  • Demonstrate greater confidence in their ability to
    • Communicate with patients and caregivers about the importance of pneumococcal immunization in pediatric patients


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  • Todd Wolynn, MD, MMM

    CEO, Kids Plus Pediatrics
    Co-Founder, Shots Heard Round the World
    Pittsburgh, Pennsylvania


    Todd Wolynn, MD, MMM, has the following relevant financial relationships:
    Consultant or advisor for: Merck & Co., Inc.; Novavax, Inc.; Sanofi
    Speaker or member of speakers bureau for: Merck & Co., Inc.; Sanofi

  • Dana Deshon, DNP, APRN, CPNP

    OSF Morton Pediatrics
    Primary Care
    Morton, Illinois


    Dana DeShon, DNP, APRN, CPNP-PC, has no relevant financial relationships.


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    Senior Medical Education Director, Medscape, LLC


    Maria B. Uravich, BSc, ELS, has no relevant financial relationships.

  • Jennifer Gregg, PhD

    Medical Education Director, Medscape, LLC


    Jennifer Gregg, PhD, has no relevant financial relationships.

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  • Stephanie Corder, ND, RN, CHCP

    Associate Director, Accreditation and Compliance, Medscape, LLC


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Pneumococcal Immunization in Pediatrics: Updates and Recommendations

Authors: Todd Wolynn, MD, MMM; Dana DeShon, DNP, APRN, CPNP-PCFaculty and Disclosures

CME / CE Released: 1/5/2023

Valid for credit through: 1/5/2024


Activity Transcript

Todd Wolynn, MD, MMM: Hello, I'm Dr Wolynn. I'm the CEO of Kids Plus Pediatrics in Pittsburgh, Pennsylvania, and the co-founder of Shots Heard Round the World. I am thrilled to be able to welcome you to this Medscape program titled Pneumococcal Immunization and Pediatrics Updates and Recommendations. I'm very pleased to be joined today by Dr DeShon, who's from OSF Morton Pediatrics in Morton, Illinois. Welcome, Dana.

Dana DeShon, DNP, APRN, CPNP-PC: Hi, thank you. Glad to be here.

Dr Wolynn: Over the next 30 minutes, we're going to be discussing pneumococcal immunization with a focus on the pediatric population. But first, let's start off with a little background on the current pneumococcal disease burden and vaccination rates. So, Dr. DeShon, can you give us a little bit of insight into pneumococcal disease burden and what kind of numbers are we dealing with?

Dr DeShon: Thanks a lot. We know since we've had a vaccine available for pneumococcal disease since the 2000, that that has definitely made a huge impact on some of the pneumococcal things we see, especially with otitis medias and with pneumonias. But unfortunately, we are still seeing a huge burden in the United States, about two million infections of pneumococcal disease, over 150,000 hospitalizations, and over 6,000 deaths.

Dr Wolynn: I would agree that pneumococcal disease, particularly when we're looking at invasive pneumococcal disease, really still causes a lot of tragedy in our country. And can you take us into a little bit of breakdown of the types of infections that we're seeing caused by this bacterium?

Dr DeShon: Right. So we don't like to see any infections at all, but definitely those invasive pneumococcal diseases. So when we think about meningitis, pneumonia, bacteremia, those things that, you know, put kids in hospitals or worse is really those prevention we want.

So now, the beauty, when we saw the pneumococcal 13-valent vaccine on the market, well, seven first and then 13, is it made a huge impact on our kids with some of the otitis media and what we were seeing as organisms in the ear. Less of that streptococcus pneumonia related really to that vaccination, which has been huge... less pneumonias that we were seeing.

But unfortunately, we still have a ways to go with that. Personally in, in my practice, I work in a primary care pediatric office. When the original pneumococcal vaccine came out in 2000, I had a patient who was under a year of age. This was a new young mom, and this was a brand new vaccine.

She was a little leery about getting the vaccine, and at that point, they were only making recommendation for kids that had certain criteria that were more high risk at that point. So kids that were in daycare, kids that were low socioeconomic status, kids that had had frequent ear infections were the kids that we really targeted.

We decided not to get that vaccine. And unfortunately then her little one ended up getting pneumococcal meningitis. Thankfully did not die from it, but unfortunately did lose hearing forever -- the rest of her life related to that. So that was kind of an eyeopener to me, that that was really something significant with that vaccine really could have could have prevented that.

Dr Wolynn: I appreciate that, that story, because it really does drive home the point of the importance of immunizations. And as you can see on the slide, exactly what Dr. DeShon pointed out, there's a variety of different diseases that streptococcus pneumonia or pneumococcus causes, and as you see highlighted in the orange, these really represent invasive pneumococcal disease or IPD.

Which is really the kind of things that can really lead to tragedy, and obviously the kind of things that we would like to prevent. Now, Dr. DeShon, can you take us a little further into the symptoms of pneumococcal disease?

Dr DeShon: So when we look at the symptoms, I mean, we look at it and we're like, okay, this looks like many other things that we could also see when a kiddo comes into our office or into the ER setting, or to those prompt care. So headaches, fever, confusion, difficulty breathing, ear pain, cough, chest pain, sore throats. This is, you know, what I see every day in my office.

So then trying to figure out, is this going to be more invasive pneumococcal disease is kind of the challenging part with that as well. But symptoms can be very varied and can be very severe.

Dr Wolynn: I don't want to date myself here, but I will tell you that remembering in the days before we had to write these vaccines that everything was on the table. And while you still have to be pretty thorough in your differential when you see kids coming in with these symptoms, it's very reassuring when we know we have kids that are fully up to date.

That it's less likely that they will be suffering invasive pneumococcal disease. But then again, they have to be up to date and even then, we still need to be thorough. Now, something that's interesting that people need to be aware of are risk factors for pneumococcal disease. Can you talk a bit about that?

Dr DeShon: Yes. So we know that pneumococcal disease could really hit anybody healthy and those kids that do have those chronic health issues. But we know that there are some children that are more at risk. And so sometimes when we think about immunizing those kids or we might add on just like what we did with our great example is our COVID-19 vaccine, and if you have those risk factors, you might need a little extra boost in that immunity and protection against that.

So when we look at those kids, especially those kids under two, so we know pneumococcal disease hits hard under age two and over 65. So those kids that have those chronic heart, lung, kidney disease, those kids that have cerebrospinal fluid leak, those cochlear implants, diabetes, immunocompromising conditions, or kidney or spleen disorders.

And I used to think, I never am going see cochlear implants, and I think I have three kids that I see, on a regular basis. So, those rare things that we see. Also, any other sickle cell disease, we think of kids that have radiation or chemotherapy. So those kids with some of those cancer treatments as well, those are kids that are definitely more at risk of getting poor outcomes if they would get the pneumococcal disease.

Dr Wolynn: Absolutely. And to your point, knowing these risk factors really helps to what we think of as index of suspicion. If we know the kids have any of these conditions, it should be a red flag to be a little bit more on alert and work pneumococcal disease should be [in] your differential diagnosis, maybe a little higher than you would've thought, so absolutely. Thanks for going over those. So here's the big question. Why vaccinate against pneumococcal disease?

Dr DeShon: So we want to make sure that we are vaccinating and then making some of these diseases go away. But the huge issue also is just the whole antibiotic resistance, so those antibiotic resistance strains. So when we want to treat these diseases, and thankfully you can treat pneumococcal disease, but then we have this whole worry about bacterial resistance.

So about 30% of infections are resistant to more than one antibiotic when we think about pneumococcal disease. Thankfully since the introduction of that conjugate vaccine, the rate of antibiotic resistance infection has decreased about 97% in children less than or equal to five years of age. So that's totally a win-win with that.

Dr Wolynn: Absolutely. And this graph on the slide that you're looking at is just a great visual to show us how impactful vaccines can be if they're given. And then that, that extra benefit, as you pointed out of decreased antibiotic resistance.

And as we know, currently big quality measures are now being built around antibiotic stewardship, and this hopefully can reduce the amount of antibiotics that we have to use if you prevent the disease in the first place. So let's go on to talking about pneumococcal vaccination rates and, and where we're at with that.

Dr DeShon: So we know that the estimated vaccine coverage by age two is about 82%. I would say that's been a little challenging over the last couple years with the COVID-19 pandemic getting kiddos in to be seen and getting them back caught up on that. So it makes me wonder, if we would've been where we were two years ago, would our burden of disease be even a little bit less right now? We're doing pretty well. I mean, the nice thing is when you talk to parents about pneumococcal disease, they get it.

There's some diseases that [they] get a little more leery of, but you know, when you talk about meningitis and pneumonias, I mean, families know that they really want to prevent that with their little ones. So getting them in and getting those four vaccines is really crucial and it lines up very nicely for when the kids come in already for their checkups.

Dr Wolynn: I appreciate you bringing up the challenges that were presented by the pandemic because we know we lost ground and while we have caught up, I think the data still shows that we're still not where we were and we have room to still continue to make it better to really fully catch up.

As we know, a hundred percent of people can't get the vaccine, right, for whatever reasons, but we need to get into the nineties. That's always a goal, high nineties I always say. And so this is a good number, but could be better. And so thank you, thank you for covering that.

Well, now that we're talking about vaccination, I think this is a good time to transition into talking about the actual pneumococcal vaccines that are available in the United States. Can you walk us through that?

Dr DeShon: Thank you. There are two types of pneumococcal vaccines that are available in the United States. So we have the pneumococcal conjugate vaccine and the pneumococcal polysaccharide vaccine. So the conjugate vaccine, the ones that are currently in use is the pneumococcal conjugate vaccine 13-valent and a 15-valent.

Now those two can be used in the pediatric population and we'll talk about that again, more so in just a few minutes. And then there is the 20-valent, which currently at this point is approved for those that are over 18 years of age. And then we do use the pneumococcal polysaccharide vaccine, which is a 23-valent, but that does not work in young children. So they have to be at least two or older. And we use those with those kiddos that are at higher risk of complications.

Dr Wolynn: Absolutely. And as you said, I remember when the seven-type conjugate came out. So we are, we're making advances and we're certainly covering more types. So how about -- you made some reference to the polysaccharide vaccines not being particularly ideal for the youngest kids.

I know that we have a chart here that does a comparison between the polysaccharide vaccine and the conjugate, and you can see again that the conjugate certainly has some advantages there.

Dr DeShon: Right, right, right. So there is definitely differences. I say it's an old vaccine, it's still a good vaccine. Definitely some coverage for that. But there are definitely just some advantages of using the conjugate vaccine because of the way it joins in that protein to the antigen in order to improve the protection that the vaccine provides.

So when we think of comparing the two, that conjugate vaccine, as I said, can be used in those infants, those kids under age two. It provides herd immunity, so protecting those unvaccinated individuals and it also stimulates the mucosal immunity. So then we're going to have longer lasting immunity as well and not worrying about having to booster multiple times to continue to keep that same level of protection.

Dr Wolynn: All right. I'm going to throw the big old curve ball and say there's a slide up here with a ton of numbers and check marks and what are we looking at with serotype protection? Like what is this all about?

Dr DeShon: Right, right. So I can name them all off and see if you all can do a test at the end. It would be quite challenging doing that. I think the great thing is that we are continuing to add more and more protection.

So when we first started using the new, the conjugate vaccine, the pneumococcal conjugate vaccine, there was only seven serotypes. Then there's the 13 and then the 15 would include everything that was in the 13 valent but then add two more.

So for that one you could remember the 22[F] and 33F. So that's an easier one to remember. But then 20, it adds five more than what's in the 15, and then the 23 valence a little bit different. It doesn't have one of them that's in the 20, but then there's some additional ones on that one as well.

So lots and lots of numbers out there, but I think really, what we're looking at when we say all those serotypes is really look at all the protection and stuff that we're added, added benefit to hopefully preventing some of these invasive pneumococcal diseases that we are currently seeing.

Dr Wolynn: Great. And this kind of reminds me in the same vein as when we saw HPV vaccination coming along that they start with a smaller number of types. That they want to get the best that they can -- best bang for their buck -- but then obviously recognizing there's still a fair amount of burden of disease and they want to include additional types. And that's exactly what we see here with the pneumococcal vaccines.

And we know for instance, in this case, like with the 13 to the 15, the 22F and 33F are still really problems out there in causing a fair amount of disease and thus why you still see additional types and advances being made. So, let's go on to talking about the clinical significance of the PCV serotypes. Particularly again with regard to IPD or invasive pneumococcal disease.

Dr DeShon: Studies have shown one of those serotypes in the 13-valent conjugate vaccine causing about 21% of invasive pneumococcal disease. And those kids that were younger under five years of age.

And then those older kids between five and 18, it jumped to 34%. Interesting though with the serotypes unique just to the PCV 15, remember 22 and 33F so try to remember those two. The percentage causing additional invasive pneumococcal disease was about 15% for those kids under five years of age and 23% for those kids five to 18 years of age, which just means that we continue to add on some layered protection then with using the 22F and 33F serotype.

Dr Wolynn: Those are good to remember. Those are the two that they added to expand the coverage as you see represented here in this slide. Okay. So let's go on to talking about pneumococcal vaccine efficacy give us some of your insights on that.

Dr DeShon: We want to make sure that it works, right, that we want to make sure it's safe. And so we know with the pneumococcal 13 vaccine that we had about 75% efficacy against the serotypes. And then looking at the 15-valent pneumococcal vaccine, except for serotypes 6A, after dose three, the 15-valent met the criteria for non-inferiority to the pneumococcal 13. Four of those 13 shared serotypes regarding the response rate after dose three.

Additionally, the 15-valent pneumococcal vaccine elicits statistically significant higher immune response for serotype three than what was seen in the 13-valent.

And it met that non-inferior to criteria compared to the pneumococcal 13 for those two unique serotypes, remember 22 and 33.

And then when we look also at the 23 valent, then we have about 60 to 70% efficacy against serotype. Again, you get a couple few extra ones, but again, those are for the older individuals for sure, or kids over two.

Dr Wolynn: Makes total sense, right. If you're going to add these two additional serotypes, making sure it's working pretty much as well as the 13 matched serotype for serotype for serotype, and as you pointed out, three looked a little better and of course 22F and 33F were added too and provide even additional protection.

So, that expanded protection is exactly what we're looking for. So now the question comes down to the safety profile for the pneumococcal vaccines.

Dr DeShon: Right. And, and that's been really the great part that I've seen in the studies that I've looked at is really all of the reactions look about the same from what we've done from 2000 all the way now over two decades later with the current or new vaccines the reactions are pretty similar.

So when look at the conjugate 13, 15, and 20, I always tell my families and my moms, especially because those mommies want to make sure that they know what to do for their little one, that their little legs might be a little red, might be a little tender, they can expect some fever.

Usually if it's within 24 hours and we give them things that they can do for that. But also there might be a little loss of appetite, might be a little bit irritability, might be some fatigue. They might take an extra nap, some headaches, some myalgia and some chills. And the same thing with the 23-valent polysaccharide vaccine, you can also get those localized reactions. So the redness, the tenderness at the injection site, the fatigue, the fever, and the myalgia that also would go with that.

But the safety studies in the 15 conjugate vaccine that they did really were very similar than what they’ve seen in the 13 that we've been using for a very long time.

Dr Wolynn: I know when I've talked to our patients as well that, it's worrisome to parents to see their kids, as you said, acting fussier more tired fever, but that is a sign that the immunization is kind of doing what it should, which is getting your immune system kind of revved up to really prepare to be able to fight the real disease down the road.

Dr DeShon: Right. I always say if you see it, then that means that, you know it's working, your body is doing exactly what it needs to do to fight off that disease when it sees it. And I usually find if we prepare our families for potentially this is what's going to happen, it's so much easier than if they call 24 hours later and they're all upset because now their child has a 100, 101 fever.

Dr Wolynn: A hundred percent. That is good, efficient, awesome communication because you're preparing them. And when they're prepared and empowered, they oftentimes won't call the office unnecessarily nor worry unnecessarily. So I a hundred percent agree with you on that.

All right. So taking this all into effect and we have vaccines now that are coming to be able to work into our schedules. Tell us a little bit about the ACIP recommendation for the pneumococcal conjugate vaccines that were updated in 2022.

Dr DeShon: So the ACIP recommendation, and this will come out on the schedule for 2023, so you will see all this come out, which we know usually that schedule comes out around February or so, but the recommendation, you can start doing it now. So the, whether you use the 13 and the 15, you can use either one of those.

So they can be used interchangeably. They both are recommended. You can use one or the other for children age two to 15 nine months and then some of those older ones that we'll talk about that have some of those risk factors. They can be administered at the same time as other routine vaccines including COVID-19.

Obviously we'll be using different syringes and vaccine sites with that. And the conjugate 15 would follow the exact same schedule of what you would see currently right now for the 13 conjugate vaccine on the current 2022 immunization schedule.

Dr Wolynn: So let's go further and talk about the schedule itself. So the 2022 pneumococcal vaccination schedule.

Dr DeShon: Right, right. So we give the pneumococcal conjugate vaccine routinely to all children. Usually the schedule is two months, four months, six months, and then a booster dose between 12 and 15 [months]. It can be given as early as six weeks of age if we need to do that or want to do that added protection a little bit earlier. But that is a schedule that we do. Now we know that some kids need some catch-up vaccines as well. So for children between two and five that have any incomplete series, otherwise healthy children, then they would also need a dose, if they have not received it as of yet.

And then there's all sorts of parameters, like if you got your first vaccine and you were seven months of age, versus getting it when you were two months of age, it gets a little confusing. So you use those tables.

There's so many help things that you can get from the CDC immunization schedule and there's links on how then to decipher -- this is how many doses that they got at what age, and then this is what the recommendation would be with that. So that's pretty much all those children.

And then we start looking at those kids that have those underlying risk factors, so those kids that we talked about earlier. So those kids with those cochlear implants, those immunocompromising conditions. The kids that have asplenia or diabetes or chronic heart and lung disease, all those kids also are going to need doses of the conjugate vaccine as well as the polysaccharide vaccine. But again, that vaccine can't be given until after two years of age for that one.

So some of those kids may need then another booster dose of the 23-valent polysaccharide. We always want to give that conjugate vaccine first. And then usually it's eight weeks later, we give that 23-valent. We don't give those two together. Those two do need to be separated. And it says, like I said, those pretty clearly says all those on the vaccine schedule as well.

Dr Wolynn: You've made reference to the schedules and obviously the resources that are out there through CDC, AAP, we actually print them up in our office just so that they're there, like on the inside of some of our drawers that we open up and can reference them easily.

Dr DeShon: The nice thing is with the adults, when the 15 and 20 conjugate came out, they had the QR code, and so then you could go in and put the patient's age, what they've got and then what the recommendation is. And I have a feeling as we get more tech savvy, that's kind of what we're going to be doing. I think every provider should have the CDC on their phone or easy access because it really -- it can be confusing, but if you use those apps, it makes it so much easier to figure out what needs to be done.

Dr Wolynn: Combination of apps, your EMRs, your electronic medical records can do some forecasting and projections and you know, again, good old-fashioned printouts. All of those are good strategies or a combination of those are good strategies to have.

Dr Wolynn: Well, we've been talking about it. Let's dig a little bit deeper into these emerging vaccines for pneumococcal disease. So we do have a slide that kind of highlights the pneumococcal vaccines in clinical development.

Dr DeShon: That's just the exciting things that there's new vaccines coming down the pipeline. So right now, there is a 20-valent pneumococcal conjugate vaccine that's a four-dose series, as well as a 20-valent pneumococcal conjugate vaccine that's a three-dose series. In addition, there's the 15-valent, pneumococcal conjugate vaccine, the PNEU-DIRECT[ION] trial, and the 15-valent pneumococcal conjugate vaccine, the PNEU-PLAN trial, the catch-up study, and those are all phase 3 studies, ongoing. The polysaccharide pneumococcal 23-valent has a phase 4 study with ongoing safety data as well.

Dr Wolynn: Absolutely. So, you know, that's the one thing I always tell families is these vaccines -- and having been involved in clinical vaccine research for 14 years -- is fairly exhaustive, you know, from animal models to phase one, two, and three, and even phase four post-licensure studies.

So let's go on now and take a shot here at strategies to improve vaccination rates. Because we find ourselves in 2022 in a kind of a weird place right now where trusted information coming from authoritative and evidence-based resources are now being brought into question.

What are your thoughts here about using strategies to reach out to your families to get them good information and help them make good choices?

Dr DeShon: Right. So I think the first thing is we need to get to our patients, right. We want our patients to come in -- our children to come into the office and feel comfortable in doing that. We make every opportunity available, whether kids come in for checkups or they come in for illness visits or the other places that they might potentially get those vaccinations to make sure that there is different times of the day to do those.

I think we need to be working alongside with families instead of just dictating when you say, “Well, this is exactly what we -- what you're going to do -- and it's because I say so.” I think that we can say that, but we can say it in a very gentle, and really this is a team, like my best interest of your child is that it stays healthy.

Let's work on those things that are going to do that. We know that vaccines do prevent diseases and these are the vaccines. So if I have a 12-monther that comes in, I'm going to say, “Today we are going to be giving the pneumococcal vaccine, your Hepatitis A, your measles, mumps and rubella and your chickenpox vaccine. These are the side effects that you might see in the next seven to 10 days, potentially, or a few days if that. Do you have any questions with that?” And if they do, then you listen to that not trying to just interject. You just really need to listen what their concern is and then tell them. So, you know, the AIMS approach where we kind of mirror back, reflect what they said and then whether or not that you get parents to accept to get a vaccination.

I always find that...I never think it's terrible if I have a parent that's totally against vaccinations and they don't get the vaccine because I will have an opportunity again. But if I make that parent really upset with me, then there's no way that they're going to come back and we're going to have any sort of discussion with that.

But I always find, you just give gently, and you work along with them to make sure that they're feeling comfortable. We have the best interests, we're in this together and really we want our kids to be healthy.

Dr Wolynn: I entirely agree, right. The one thing we have as primary caregivers particularly is these longitudinal trusted relationships that are incredibly impactful. There's a lot of research to show that our recommendation is incredibly influential and building upon a trusted relationship is a great way to go.

I can't move on without saying that social media in 2022 and beyond I think will be starting to play a bigger role in delivering high quality healthcare. And I just want to give a shout out to that. I think that tool has been used for ill and I think we can do much better with it. So keep your eyes posted on that.

I think that addressing misinformation about vaccines -- you've said that you do tackle this. Can you give us a quick overview or just a thought on when you are faced with misinformation or disinformation?

Dr DeShon: Well first of all, you ask, “What is your concern?” So you ask where they got information and then you share with [them] your experiences. So, you know, for me I can say, well, I've been doing this for 24 years, I have five children of my own that have all been vaccinated.

This is as a whole group, we do support you and we want to come alongside you. With the [pneumococcal] conjugate vaccine, parents know what ear infections are, right? So we can say, this vaccine has helped with ear infections. And you know that these are the ones you're missing work, your kid is miserable, up through the night crying, so don't you want a vaccine that really is going to help them sleep better, right, and then keep them out of the hospital. They're not going to get, pneumonias or meningitis, so talk to where it's going to be personal to them.

Then give them that resources too.

Dr Wolynn: And just a tidbit that you don't amplify the myth. You start with the fact, you can address the myth and then end with the fact. That's called kind of sandwiching the answer in there in an effective way. Don't forget to use active listening. You can express empathy without magnifying a myth and letting people know that you still have this trusted relationship with them and you're there to help them.

Finally, I would say, how we talk with our patients is exactly as you pointed out, Dana. It's really using language that is accessible and trusted. Don't throw fear at people, don't throw data at people. But still make a good strong recommendation, but hear out the concerns and ask about the concerns when they're presented.

With that, I'm going to ask if you have any take home messages on pneumococcal disease and pneumococcal vaccination.

Dr DeShon: Right. So the best defense is vaccination, right. So that's what we want. We would like to eradicate as many diseases that we can. We have a vaccine that has been available since over two decades and we continue to make improvements and add more protection and just keep vaccinating.

Dr Wolynn: That's it. I mean, we are improving upon the great foundation that we already have for vaccination, but as Dr. DeShon is pointing out, we have to be diligent about keeping our patients up to date. That's the key. And remaining aware.

And also don't forget there is mis- and disinformation out there and be prepared to be able to handle that. Because that's much more likely, while most people will still accept your recommendation, it's always better to be prepared. Dana, I just want to thank you for joining me today for this important discussion.

This has been a great discussion and thank you for participating in this activity. Please continue on to answer the questions that follow and complete the evaluation.

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