Technically Speaking: Pneumococcal Vaccination of Children

Pediatric pneumococcal vaccination recommendations (updated September 2023) are complex because of differences for healthy children, those with immunocompromising conditions, and those with other chronic conditions. The schedule also changes as the vaccine recipient ages. There are so many variables to juggle, so if you are like me, you need an up-to-date forecasting system in your electronic health record (EHR) and, ideally, a good job aid if you are not certain that the EHR is correct.

Immunize.org offers a helpful set of tables on a single sheet, Recommendations for Pneumococcal Vaccines Use in Children and Teens. Bookmark it now or find it at Immunize.org by using the "Clinical Resources" tab. Click on "Search All Clinical Resources." Use the “Vaccine or Disease Name” filter and type in “PCV.” Scroll down to see the recommendations sheet. Please use this resource to answer the following questions.

Questions

Scroll down for answers.

Question 1: A healthy 10-month-old child received one dose of PCV15 at the 6-month visit. How many doses of pneumococcal conjugate vaccine (PCV) are still needed? Would this be different if the child had an immunocompromising condition?

Question 2: A healthy 5-year-old child received only one dose of PCV15; this was given at the 6-month visit. How many doses of PCV are needed? Would this be different if the child had an immunocompromising condition?

Question 3: Table 3 shows risk conditions for which additional doses of PCV15, PCV20, or pneumococcal polysaccharide (PPSV23) vaccines are indicated for children 24 months through 18 years of age. It divides these into immunocompromising (IC) and non-immunocompromising (non-IC) risk conditions. For the purpose of pediatric PCV recommendations, which of the following are considered IC and which are considered non-IC conditions?

1. Sickle cell disease
2. Diabetes mellitus
3. Asplenia
4. Cerebrospinal fluid leak
5. Cochlear implant

Question 4: A 17-year-old with nephrotic syndrome had four doses of PCV13 in the first two years of life but received no subsequent doses. How many doses of pneumococcal vaccine are still needed, if any? (See Table 4.)

Question 5: A fully immunized 6-year-old undergoes a hematopoietic stem cell transplant (HSCT). After the transplant, are any additional doses of pneumococcal vaccine recommended?

Answers

Answer 1: This child is in the “7 through 11 months” age category with one vaccine dose before 7 months of age. As shown on Table 1, she needs two additional doses: one dose eight weeks after the most recent dose and then the last dose at least eight weeks later, at 12 through 15 months of age. The recommendations for children 2 months through 23 months are the same for healthy children and those with immunocompromising or other chronic conditions.

Answer 2: This child is 5 through 18 years of age with an incomplete PCV series. As shown on Table 2, no additional doses are needed. Table 4 shows that for a child 24 months through 71 months (i.e., 2 years to less than 6 years of age) with any risk condition and any incomplete schedule, the recommendation would be for two doses of PCV20 or PCV15, given at least eight weeks apart.

Answer 3: IC conditions include sickle cell disease (A) and asplenia (C). Non-IC conditions include diabetes mellitus (B), cerebrospinal fluid leak (D), and cochlear implant (E).

Answer 4: This patient had no PCV20 to date. Either of the following options would be acceptable:

• One dose of PCV20 at least eight weeks after the most recent PCV dose.
• One dose of 23-valent pneumococcal polysaccharide vaccine (PPSV23) at least eight weeks after the most recent PCV dose. Then at least five years later, they would need one dose of PCV20 or a second dose of PPSV23.

Answer 5: (Hint: See Table 5.) The recommendation is for four doses of PCV20, beginning three to six months after the transplant. Give three doses, each separated by four weeks, followed by a fourth dose at least six months after the third dose and at least 12 months after the HSCT.

Vaccination of adults is much simpler. If you want more information on this, please see Standing Orders for Administering Pneumococcal Vaccines (PCV15, PCV20, and PPSV23) to Adults. This clinical resource includes tables that highlight the recommendations for adults 65 years and older (Table 1) and for adults 19 through 64 years of age with an immunocompromising condition (Table 2), a cochlear implant or cerebrospinal leak (Table 3), or a non-immunocompromising chronic health condition (Table 4).

Until the year 2000, pneumococcal infections caused 60,000 cases of invasive pneumococcal disease (IPD) each year. A seven-valent pediatric conjugate vaccine was first introduced in 2000. Since then, the recommendations have expanded to include adults, and the number of types of pneumococcus that the vaccines protect against have expanded, too. In 2019, there were fewer cases of IPD (~ 30,300), but 30% were resistant to one or more antibiotics. The effort to prevent pneumococcal disease is not over and continues to be of great importance.

CDC resources

• ACIP Updates: Recommendations for Use of 20-Valent Pneumococcal Conjugate Vaccine in Children ― United States, 2023. MMWR Morb Mortal Wkly Rep 2023;72:1072.
• PneumoRecs VaxAdvisor Mobile App for Vaccine Providers was updated in September 2023 to reflect CDC’s updated pediatric pneumococcal vaccination recommendations. This mobile app helps vaccination providers quickly and easily determine which pneumococcal vaccines a patient of any age needs and when.