443 - Meningitis Vax, Vaping and Contraception, “Doctors Lounge”?

From the Advisory Committee on Immunization Practices (ACIP)

1)  Menquadfi for Meningitis Vaccination

Menquadfi (MenACWY-TT) – a new conjugated quadrivalent meningococcal vaccine – was approved in 2020 for use alongside the current available vaccines. Sanofi, the manufacturer of Menactra (MenACWY-D) and Medquadfi (MenACWY-TT), is discontinuing production of Menactra to focus on Menquadfi.

The recommended quadrivalent meningococcal vaccines – have different lowest ages at which they can be used:

·         Menveo (MenACWY-CRM) – as early as 2 months of age

·         MenQuadFi (MenACWY-TT) – as early as 2 years of age

·         Menactra (MenACWY-D) – as early as 9 months of age – being discontinued

Apart from the age issues, the difference in these vaccines are the proteins to which the meningitis saccharide is conjugated. The protein helps the vaccine be more immunogenic than the older polysaccharide-only vaccine (Menomune, no longer produced). The protein in MenACWY-D can interfere with DTAP and PCV 13, so MenACWY-CRM is recommended for high-risk indications prior to age 2. MenACWY-TT will avoid this issue due to a different conjugating protein as well as its different lower age. Both MenACWY-CRM and MenACWY-TT can used for the same indications over age 2 and can be interchanged.

Remember that MenACWY vaccines do NOT provide protection against Meningitis B – refer to the immunization schedules for MenB vaccine indications and information.

There are both routine and high-risk recommendations for the MenACWY vaccines:

Routine Recommendations:

·         MenACWY (either brand) – first dose at age 11 or 12, booster dose at age 16-18 (through age 21 is acceptable). While it is recommended to get two doses of the same product, interchanging them is OK.

High-Risk Recommendations:

·         Use MenACWY-CRM (Menveo) only prior to age 2, but either MenACWY-CRM or MenACWY-TT (Menquadfi) after that.

·         The dosing regimens vary by indication below – so refer to the immunization schedule and the MMWR reference (below) for specific guidance.

·         Indications:

o   medical conditions including anatomic or functional asplenia, complement component deficiencies, complement inhibitor use, or human immunodeficiency virus infection.

o   microbiologists with routine exposure to N. meningitidis in their work.

o   exposure during an outbreak

o   travel to or residence in countries where meningococcal disease is hyperendemic or epidemic.

o   unvaccinated or undervaccinated first-year college students living in residence halls.

o   military recruits

John’s Comments:

Here’s another plug for having up-to-date vaccine references available – the new immunization schedule comes out each February (and we cover the changes in Take 3), so make sure you get your copy each year. The schedules are always available online and the CDC Vaccine Schedules app is available for your phone. Best practice for vaccination includes the vaccinator checking doses and indications with a licensed provider– like a physician or advance care practitioner – prior to administration, so having a ready reference and embracing that opportunity to improve vaccine safety are key.

Reference:

Mbaeyi SA. Meningococcal Vaccination: Recommendations of the Advisory Committee on Immunization Practices, United States, 2020. MMWR Recomm Rep. 2020;69. Link

From the Literature and A Question From a Colleague

2)  Prescribing Contraceptives for Women Who Vape

Question: 

I recognize that prescribing of combination oral contraceptive pills (OCPs) is contraindicated for women older than 35 who smoke cigarettes, but is the same contraindication true for women who vape?

Answer:

According to the CDC and the American College of OB/GYN (ACOG), there are multiple contraindications for prescribing combination estrogen and progesterone hormone contraception (CHC) for women, including the CHC-containing vaginal ring and transdermal patch.  Some notable medical conditions that have an unacceptable risk include (abbreviated list):

·         Age ≥ 35 years and smoking ≥15 cigarettes per day

·         Two or more risk factors for arterial cardiovascular disease (such as older age, smoking, diabetes, and hypertension)

·         HTN with systolic 140–159 and/or diastolic 90–99 unless no other method is appropriate for or acceptable and no one with systolic > 160 mm Hg and/or diastolic > 100

·         Migraine with aura

·         History of venous thromboembolism

Under these circumstances, women should be counseled for nonhormonal or progestin-only contraceptives.

The combined risk of age > 35 and cigarette smoking can particularly increase a woman’s risk of cardiovascular events, including stroke, myocardial infarction, and venous thromboembolic disease.  The majority of this risk appears to be due to the interaction of nicotine with the CHC.  This is true not only

The use of both conventional and electronic (e-) cigarettes (vaping) deliver nicotine to the bloodstream, resulting in significant production of its primary metabolite – cotinine.  Similar to cigarettes, four mechanisms have been proposed by which e-cigarettes may increase the risk of cardiovascular disease: (i) sympathetic nerve activation; (ii) oxidative stress; (iii) endothelial dysfunction and (iv) platelet activation.  Thus, from that perspective, the risk would appear similar. 

Other constituents of e-cigarettes have raised more concern as well, including fine and ultra-fine particulate matter, which are thought to trigger vascular inflammation and platelet activation.  Thermal degradation of e-cigarette solvent carriers glycerol and propylene glycol can also produce carbonyls, such as formaldehyde, acetaldehyde, and acrolein.  E-cigarette liquids have also been manufactured with numerous flavorings.  The implications of many of these many potential toxicants is unclear.  Heavy metals such as cadmium and lead have been detected in certain e-cigarette aerosols, which have been associated with HTN and CAD respectively. 

Lack of research on the comparison of vaping with conventional cigarette smoking makes it difficult to conclude which is safer.

Mark’s Comments:

I found this to be both a wonderful and practical question, and one for which we have little direct evidence.   For that reason, I reached out to Isaiah Johnson, MD, the interim Chair for the Department of OB/GYN for Carilion Clinic and Medical Director for Women’s Quality and Patient Safety.  He replied:  “My personal practice is to not prescribe estrogen containing contraception to patients who vape.  While there is no direct evidence linking vaping to increased risk of thrombosis/cardiovascular events, in vivo studies suggest a possible increased risk (similar to smoking).  Another concern, I have is that patients may switch back and forth between vaping and cigarettes without provider knowledge.  Estrogen replacement therapy may be used in patients that smoke cigarettes and vape as the dose of estrogen is significantly lower.  This should be done balancing the risks and benefits of HRT and the patient's other cardiovascular risk factors.

References:

·         Kennedy C, et al.  The CV Effectss of Electronic Cigarettes: A Systematic Review of Experimental Studies. Preventive Medicine Volume 127, October 2019.  Link

·         ACOG Practice Bulletin No. 206: Use of Hormonal Contraception in Women With Coexisting Medical Conditions.  Obstetrics & Gynecology: February 2019; 33(3): e128-e150.  Link

From PeerRxMed ( www.PeerRxMed.org )

3)  Beyond the “Doctors Lounge”:  Upgrade 2022     

“Not valuing time with other physicians or allowing for informal conversations leads to a soulless efficiency and professional isolation.”   John Frey, MD (feel free to substitute your own profession or “colleagues” for “physicians”)

When I first started in clinical practice, most hospitals had a “Doctor’s Lounge.”  Ours was stuck in the far corner of the hospital and was connected with the medical records department.  There some physicians would gather to complete charting (yes, paper charts …), watch the news or read the paper, browse a medical journal, grab a caffeinated beverage, and if the timing was right, get a snack of some sort.   Though at times when I visited I would engage in a curbside consultation or informal conversation, in general the “culture” of doctors lounge (and its cousin, the physician’s dining room) mirrored the culture of medicine at that time in that it was stratified by specialty, age, gender, race, tenure, and social status.  Which made most interactions polite, superficial, and often guarded. 

Regardless of whether these spaces ever actually achieved their intended purpose, for the most part such professional physical gathering spaces have become long extinct, and attempts to revive them have been largely unsuccessful.   Yet the need for a space that encourages and enhances regular professional connection is perhaps even more relevant and important now than ever. 

If that is true, then what does an “evolved version” of the doctor’s lounge look like today?  For some, it is an online forum such as Sermo, Doximity, MomMD, or various Facebook groups.  Others are seeking such space through small gatherings such as Finding Meaning in Medicine or Balint groups.  Mayo Clinic has attempted to promote this connection through COMPASS dinner groups (COlleagues Meeting to Promote And Sustain Satisfaction), where small groups of physicians gather together for a meal and fellowship.   But for too many healthcare professionals, the answer is “there is nothing,” and we live for the most part in professional isolation, connecting very little even with those who work in our same physical space.  In the process, we find ourselves caught up in the “soulless efficiency and professional isolation” that Dr. Frey references above. 

And now that we have more insight into our professional past, we recognize that many of our predecessors and role models worked in relative emotional isolation as well, and that such an approach was never wise.  The work we do is too challenging, too taxing to not have others traveling with us who “get it” and “get us.”  We need those who can help us make sense of all we do, remind us of the reasons we do it, as well as support us as we weave it into the fabric of our lives.  

PeerRxMed was created to help address this void, and exists to provide both a platform and an ongoing process to facilitate intentional professional connection.  Many of us have never experienced this and there’s no better time to start than right now.  We don’t need a nostalgic revival of the physical “Doctor’s Lounge” to connect.  Instead, we need to embrace intentional professional connection in all the places and spaces in which we presently work.  Afterall, no one should care alone.  Thanks for helping to spread the word.

______________

Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org