What are the New Pneumococcal Vaccination Recommendations for Adults?

Jean Covino, DHSc, MPA, PA-C, is a clinical professor and director of didactic education at the Pace University-Lenox Hill Hospital PA Program-NYC in New York, New York.Jennifer Hofmann, MS, PA-C, is an associate clinical professor at the Pace University-Lenox Hill Hospital PA Program-NYC.

Pneumococcal vaccination is an important part of preventive health care in adults 65 years and older and in some younger adults with certain medical conditions.

Streptococcus pneumoniaeis a leading cause of pneumonia, and it is associated with other invasive diseases, including bacteremia, meningitis, and otitis media. Appropriate vaccination of adults effectively reduces invasive pneumococcal disease.

There are 2 types of vaccines: the pneumococcal conjugate vaccine (PCV) and the pneumococcal polysaccharide vaccine (PPSV). The PPSV vaccine contains 23 partially purified pneumococcal capsular polysaccharides serotypes, which are most commonly associated with invasive pneumococcal disease. The PPSV vaccine is recommended for all adults initially at 65 years and older. The PPSV is also indicated for certain adults younger than 65 years chronic medical conditions. Certain patients need both types of pneumococcal vaccines, and in these patients the PCV should generally be administered prior to the PPSV (seeTables 1and2). The PPSV protects 50% to 85% of relatively healthy adults from invasive pneumococcal disease.¹

The PCV vaccine contains 13 pneumococcal capsular polysaccharides covalently linked to a protein. This formulation increases mucosal immunity, which decreases nasopharyngeal carriage and increases antibody production in infants and young children. Specific indications for adults are based on age and medical indications (seeTables 1and2). In 2014, the Advisory Committee on Immunization Practices (ACIP) recommended the routine use of 13-Valent Pneumococcal Conjugate Vaccine(PCV13) in series with 23-valent pneumococcal polysaccharide vaccine(PPSV23) for all adults aged ≥65 years based on demonstrated PCV13 efficacy and safety against PCV13-type pneumonia among adults aged ≥65 years.^{2 The}ACIP recognized that there would be a need to reevaluate this recommendation, because it was anticipated that PCV13 use in children would continue to reduce disease burden among adults. Consequently, after having reviewed the evidence accrued during the preceding 3 years, in June 2019, the ACIP voted to remove the recommendation for routine PCV13 use among adults aged ≥65.³

Updated Recommendations for the 13-Valent Pneumococcal Conjugate Vaccine (PCV13) and the 23-Valent Pneumococcal Polysaccharide Vaccine (PPSV23) Among Adults

Table 1³

Aged 19-64

PCV13

PPSV23

No Medical Indication

No recommendations

No recommendations

Immunocompetent with comorbidities:

• Alcoholism
• Chronic heart disease
• Chronic liver disease
• Chronic lung disease
• Diabetes
• Smoking

No recommendation

1 dose

Immunocompetent with:

• Cerebrospinal fluid leak
• Cochlear implants

1 dose if not previously given

1 dose ≥ 8 weeks after PCV13

Immunocompromised:

• Acquired or congenital asplenia
• Acquired or congenital immunodeficiency
• Chronic renal failure
• Generalized malignancy
• HIV infection
• Hodgkin disease
• Leukemia
• Lymphoma
• Multiple myeloma
• Nephrotic syndrome
• People treated with immunosuppressive drugs, long-term systemic corticosteroids, and radiation therapy
• Sickle cell disease
• Solid organ transplant

1 dose if not previously given

2 doses:

• 1st dose ≥ 8 weeks after PCV13

• 2nd dose ≥ 5 years after first PPSV23 dose

Table 2³

Aged ≥ 65

PCV13

PPSV23

No medical indications

*Based on shared clinical decision making

1 dose

• If PCV 13 has been given, then given PPSV23 ≥ 1 year after PCV13

Immunocompetent with comorbidities:

• Alcoholism
• Chronic heart disease
• Chronic liver disease
• Chronic lung disease
• Diabetes
• Smoking

*Based on shared clinical decision making

1 dose

• If PCV 13 has been given, then given PPSV23 ≥ 1 year after PCV13 and ≥ 5 years after any PPSV23 at age < 65

Immunocompetent with:

• Cerebrospinal fluid leak
• Cochlear implants

1 dose if no previous PCV13 vaccination

1 dose ≥ 8 weeks after PCV13 and ≥ 5 years after any PPSV23 at < 65 years

Immunocompromised:

• Acquired or congenital asplenia
• Acquired or congenital immunodeficiency
• Chronic renal failure
• Generalized malignancy
• HIV infection
• Hodgkin disease
• Leukemia
• Lymphoma
• Multiple myeloma
• Nephrotic syndrome
• People treated with immunosuppressive drugs, long-term systemic corticosteroids, and radiation therapy
• Sickle cell disease
• Solid organ transplant

1 dose if no previous PCV13 vaccination

1 dose ≥ 8 weeks after PCV13 and ≥ 5 years after any PPSV23 at < 65 years

*Recommendations that changed in 2019 including risk of exposure

Conclusion

The pneumococcal vaccination is an essential component to preventive health care, specifically in adults ≥65 years old and in certain younger adults with medical conditions. The major change for 2019 is that PCV13 vaccination is no longer routinely recommended for adults aged ≥ 65 years. Shared clinical decision making for PCV13 use is recommended for those ≥65 years who do not have a cerebrospinal fluid leak, cochlear implant, or immunocompromising condition.

References

1. Moberley S, Holden J, Tatham DP, Andrews RM. Vaccines for preventing pneumococcal infection in adults.Cochrane Database Syst Rev.2013;(1):CD000422. doi: 10.1002/14651858.CD000422.pub3.

2. Tomczyk S, Bennett NM, Stoecker C, et al. Use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine among adults aged ≥65 years: recommendations of the Advisory Committee on Immunization Practices (ACIP).MMWR Morb Mortal Wkly Rep. 2014;63:822-825.

3. Matanock A, Lee G, Gierke R, Kobayashi M, Leidner A, Pilishvili T. Use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine among adults aged ≥ 65 years: 2019. Updated recommendations of the Advisory Committee on Immunization Practices.MMWR Morb Mortal Wkly Rep.2019;68(46):1069-1075. doi: 10.15585/mmwr.mm6846a5.