The Advisory Committee on Immunization Practices (ACIP) in November 2019 again updated its recommendations for pneumococcal vaccination among adults aged ≥65 years.
The update amends the ACIP’s 2014 statement that recommended routine use of the pneumococcal conjugate vaccine (PCV13) in series with pneumococcal polysaccharide vaccine (PPSV23) for all adults in this age range.
Brief history
The initial recommendation set back in the 1980s was for all adults aged >65 years to receive a single dose of the 23-valent polysaccharide vaccine (PPSV23) Pneumovax.
In 2000, PCV7, a 7-valent conjugate vaccine (Prevnar 7), was introduced for use primarily in children because the polysaccharide vaccine was not as effective in children aged <2 years who are at highest risk of invasive pneumococcal disease (IPD).
In 2010,the pneumococcal-13 conjugate (PPV13) Prevnar 13 was introduced adding another 6 pneumococcal strains to the vaccine; the ACIP recommended transition from Prevnar 7 to Prevnar 13 for routine vaccination of children.
In 2012 ACIP recommended routine use of Prevnar 13 for adults aged≥19 years with immunocompromising conditions, functional or anatomic asplenia, cerebrospinal fluid (CSF) leaks, or cochlear implants.
In 2014, the CDC recommended expanding routine use of the more immunogenic Prevnar 13 to all adults at age 65 years. It was observed that since the addition of the conjugate Prevnar 7 to the childhood vaccination schedule in 2000, the incidence of IPD in adults caused by those strains had decreased 9-fold by 2014. It was clear that the high rate of pneumococcal carriage in children (20% to 90% depending on socioeconomic status) had led to transmission to older family members and provided a level of herd immunity following the introduction of Prevnar 13.
It was observed that since the addition of the conjugate Prevnar 7
to the childhood vaccination schedule in 2000, the incidence of IPD in
adults caused by those strains had decreased 9-fold by 2014.
Additional risk factors for pneumonia
(PCV13) vaccination to consider
in shared decision-making
• Certain medical conditions (ie, chronic heart, liver, or lung disease [including asthma]; diabetes mellitus; history of aspiration, dysphagia, or esophageal motility disorders; inflammatory bowel disease)
• Group living situation, such as nursing homes, assisted living facilities, jails, shelters, or homelessness
• Prior pneumonia
• Racial/ethnic groups with higher burden of illness (African Americans, Alaska Natives, and American Indians)
• Residing in or traveling to settings with low rates of childhood PCV13 immunization
• Substance abuse, including alcohol, smoking, crack cocaine, and opioids
• The “oldest old” or other individuals who have immunosenescence, frailty, or decreased functional status
• Use of medication that may increase pneumonia risk, such as proton pump inhibitors, antipsychotics, opioids, or sedatives
The CDC was aware of this at the time and knew that this new recommendation would need to be re-evaluated in 4 to 5 years to see if a further reduction in IPD would be achieved by giving Prevnar 13 to adults aged >65. It did not, according to studies done from 2014-2017.
In June 2019, the ACIP voted 8:6 to no longer routinely administer Prevnar 13 to those over 65 years of age (PPSV23, Pneumovax is still recommended for this age group). They also voted 13:1 to permit use of Prevnar 13 based on a “shared” decision making process, thereby ensuring Medicare and insurance companies would pay for it if it is given.
So, what goes into the “shared decision making”process?
The CDC suggests 2 factors should be considered by the patient and provider.One is increased risk of exposure due to living in or traveling to an area with a low pediatric use of routine Prevnar 13 immunization.Residing in a nursing home or other long-term facility might fall in this category as well.The second factor to consider is whether the adult is at increased risk due to underlying, heart, lung, or liver disease.Diabetes, alcoholism, and smoking are also risk factors.
In a 6-year period the CDC recommendations essentially returned to what they had been before.It reminds me of that old Clint Eastwood movie, “The Good, the Bad, and the Ugly.”
The good: CDC is applying scientific reasoning to their recommendations as we acquire new data.
The bad: The extra burden placed on providers who will need to spend precious time in the patient visit trying to explain the difference between optional and recommended.
The ugly: This “flip-flop” in guidance may contribute to the anti-science bias of many; why listen to the scientists and experts since they are just going to change their mind in a few years?
Prevnar use is still recommended in adults with CSF leaks, cochlear implants, and some immunocompromised persons.A Prevnar 20 vaccine is in phase 3 trials.Will the ACIP change its recommendations again in a few years back to a 2-dose regimen for those over 65?Time will tell.
Let's see how you do on a brief quiz on the use on pneumococcal vaccines in adults.
