Technically Speaking: ACIP Updates Its Pneumococcal Vaccine Recommendations for Adults 65 Years and Older

On Nov. 22, 2019, CDC published “Use of 13-Valent Pneumococcal Conjugate Vaccine and 23-Valent Pneumococcal Polysaccharide Vaccine among Adults Aged ≥65 Years: Updated Recommendations of the Advisory Committee on Immunization Practices (ACIP)” in Morbidity and Mortality Weekly Report (MMWR.68(46):1069).

This document updates ACIP’s 2014 statement which recommended routine use of pneumococcal conjugate vaccine (PCV13) in series with pneumococcal polysaccharide vaccine (PPSV23) for all adults in this age range. Since that time, the incidence of PCV13-type disease has been reduced to historically low levels among adults age 65 and older through indirect effects from pediatric PCV13 use. Because of this changing epidemiology, ACIP has updated its recommendations on PCV13 vaccine scheduling in older adults and incorporated the concept of shared clinical decision-making, as summarized below.

New pneumococcal vaccine recommendations for adults 65 years and older

• PCV13. PCV13 vaccination is no longer routinely recommended for all adults 65 years and older. Instead, shared clinical decision-making for PCV13 use is recommended for persons 65 years and older who do not have an immunocompromising condition, CSF leak, or cochlear implant and who have not previously received PCV13.
• CDC guidance for shared clinical decision-making*. When patients and vaccine providers engage in shared clinical decision-making for PCV13 use to determine whether PCV13 is right for the specific individual 65 years or older, considerations may include the individual patient’s risk for exposure to PCV13 serotypes and the risk of pneumococcal disease for that person as a result of underlying medical conditions.
  

  *Considerations for shared clinical decision-making.

  • Incidence of PCV13-type invasive pneumococcal disease and pneumonia increases with increasing age and is higher among persons with chronic heart, lung, or liver disease, diabetes, or alcoholism, and those who smoke cigarettes or who have more than one chronic medical condition. Although indirect effects from pediatric PCV13 use were documented for these groups of adults and were comparable to those observed among healthy adults, the residual PCV13- type disease burden remains higher in these groups. Providers/practices caring for patients with these medical conditions may consider offering PCV13 to such patients who are 65 years and older who have not previously received PCV13.
  • The following adults 65 years and older are potentially at increased risk for exposure to PCV13 serotypes and might attain higher than average benefit from PCV13 vaccination, and, therefore, providers/practices caring for many patients in these groups may consider regularly offering PCV13 to their patients 65 years and older who have not previously received PCV13:
    • Persons residing in nursing homes or other long-term care facilities
    • Persons residing in settings with low pediatric PCV13 uptake
    • Persons traveling to settings with no pediatric PCV13 program
  • PCV13 is a safe and effective vaccine for older adults. The risk for PCV13-type disease among adults 65 years and older is much lower than it was before the pediatric program was implemented, as a result of indirect PCV13 effects (by preventing carriage and, thereby, transmission of PCV13-type strains). The remaining risk is a function of each individual patient’s risk for exposure to PCV13 serotypes and the influence of underlying medical conditions on the patient’s risk for developing pneumococcal disease if exposure occurs.

• Scheduling when PCV13 is used — If a decision to administer PCV13 is made, it should be administered before PPSV23. The recommended intervals between pneumococcal vaccines remain unchanged for adults without an immunocompromising condition, CSF leak, or cochlear implant (≥ 1 year between pneumococcal vaccines, regardless of the order in which they were received). PCV13 and PPSV23 should not be coadministered. (Note: ACIP continues to recommend PCV13 in series with PPSV23 for adults 19 years and older [including those 65 years and older] with immunocompromising conditions, CSF leaks, or cochlear implants.)
• PPSV23 for all adults 65 years and older — ACIP continues to recommend that all adults 65 years and older routinely receive one dose of PPSV23. PPSV23 contains 12 serotypes in common with PCV13 and an additional 11 serotypes for which there are no indirect effects from PCV13 use in children. The additional 11 serotypes account for 32% to 37% of invasive pneumococcal disease among adults 65 years and older. Adults 65 years and older who received at least one dose of PPSV23 before turning 65 should receive one additional dose of PPSV23 at 65 years or older, at least five years after the previous PPSV23 dose.

Access the full MMWR article to review the updated recommendations in their entirety:

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