COMMENTARY

Pneumococcal Vaccination: Applying the ACIP Algorithms

Matthew R. Moore, MD, MPH

Disclosures

November 19, 2014

Editorial Collaboration

Medscape &

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Editor's Note: Since this commentary was published, the recommendations have been changed. Adults 65 years or older without immunocompromising conditions, cochlear implants, or cerebrospinal fluid (CSF) leaks should now get PPSV23 at least 1 year after PCV13 instead of 6 to 12 months later. The recommendation remains the same to administer PPSV23 at least 8 weeks after PCV13 to adults 65 years or older with immunocompromising conditions, cochlear implants, or CSF leaks.[1]

My name is Matt Moore. I'm an infectious disease physician and epidemiologist at CDC. Thanks for tuning in to this CDC Expert Video Commentary on Medscape. Today I would like to talk about how to protect your adult patients from pneumococcal disease.

Imagine that it is Monday morning. Your office is busy, as usual, and your first three patients have already arrived for their appointments. How are you going to make sure that all three are protected against pneumococcal disease?

Take the first patient. You walk in to the exam room and find a woman who has just turned 65 years old and is presenting for a routine check-up. You know her well and know that she has no underlying medical conditions. You also know that she has never received a pneumococcal vaccine. Which vaccine or vaccines should you give? In what order should you give them? How much time should be allowed to pass in between doses?

You will find answers to those questions in these recommendations from the Advisory Committee on Immunization Practices (ACIP). These recommendations were published on September 19[2] and are available on CDC's MMWR website.

Of importance, the recommendations cover not one but two different pneumococcal vaccines. The first is a vaccine that you have been giving your patients for many years, the 23-valent pneumococcal polysaccharide vaccine (PPSV23), which is sold under the trade name of Pneumovax® 23. The second vaccine is the 13-valent pneumococcal conjugate vaccine (PCV13), sold under the trade name of Prevnar 13®. It's extremely important to understand that, for all of your patients who are age 65 years or older, these two vaccines need to be used together for optimal patient care.

Prevnar 13 has recently been shown to protect against pneumococcal pneumonia even when blood cultures are negative. Pneumovax 23, on the other hand, covers 23 instead of 13 strains of pneumococcus. Both vaccines are safe and highly effective, so you should use them as a "one-two punch" combination.

But exactly how you use them together depends on the patient.

Let's go back to that 65-year-old patient. Which vaccines should you give? You should give both! In what order? We know from published literature that the immune response is always better when Prevnar 13 is given first, followed by Pneumovax 23. And, ideally, you should wait 6-12 months between doses. You should never give these two vaccines at the same time, although it is safe to give either pneumococcal vaccine with influenza vaccine at the same visit. So you should give pneumococcal and influenza vaccines together whenever possible and as long as there are no contraindications.

Now your second patient is ready for you. He is 67 years of age and is also quite healthy. You vaccinated him with Pneumovax 23 when he turned 65 because that has always been the age at which all adults have been recommended to receive that vaccine. Which vaccines should you give him now? In what order? And how long should you wait in between doses?

The ACIP recommendations also describe how to manage this patient. He has already had a dose of Pneumovax 23 and he had it at age 65 years, so he never needs another dose of Pneumovax 23. He only needs Prevnar 13. The key question is, how soon can you give it to him?

Based on their review of the available data, ACIP decided that 1 year is a reasonable amount of time to wait after giving Pneumovax 23 to ensure optimal immune protection.

Your patient is 67 years of age now and he received Pneumovax 23 at age 65 years. So it has been more than 1 year. You should vaccinate him with Prevnar 13 today!

Next, you walk in to find your third patient, a 65-year-old woman with diabetes. She received Pneumovax 23 at age 63 years. You ask yourself the same questions about which vaccines, in what order, and how long you need to wait in between doses. This is where things get a little more complicated.

Remember that, ever since 1997, the ACIP recommend-ations[3] have said that patients who are age 65 years or older, who received a dose of Pneumovax 23 before age 65 years, should wait at least 5 years before receiving the next dose. The new ACIP recommendations actually incorporate this older recommendation. They do that by linking the timing of the second dose of Pneumovax 23 to both the first dose of Pneumovax 23 and the dose of Prevnar 13. This graphic helps to explain how this would apply to your third patient of the day.

She received Pneumovax 23 at age 63 years and, now that she is 65, it has been more than 1 year, so you can and should vaccinate her with Prevnar 13 today.

But remember that the second dose of Pneumovax 23 needs to be given at least 5 years after the first dose of Pneumovax 23. So you should vaccinate her with Pneumovax 23 again in 3 years, when she is 68 years old.

To summarize, this patient also needs both vaccines. You can give her Prevnar 13 today because it has been at least 1 year since she received Pneumovax 23. To give her that second and final dose of Pneumovax 23, you will need to wait another 3 years because she only just received her first dose of Pneumovax 23 two years ago.

These new recommendations and the annual flu season provide great opportunities to talk to your patients about the importance of being fully immunized. Every clinical encounter offers a chance for you to assess the immunization status of your patients, to strongly recommend vaccines that patients need, to administer those vaccines or refer patients to a vaccinating provider, and to document vaccines received by your patients.

Last, I would like to point out some resources (also listed at the end of this transcript) that you may find helpful while implementing these new pneumococcal vaccine recommendations. Thank you for tuning in to this CDC expert video commentary on Medscape.

Web Resources

Adult Vaccination Information for Healthcare and Public Health Professionals

Standards for Adult Immunization Practice

Clinician Information on Pneumococcal Disease

Pneumococcal Vaccination Information

Recommendations, Scenarios and Q&As about PCV13 for Adults

Matthew R. Moore, MD, MPH, grew up in Ohio and completed medical school and internal medicine residency at Johns Hopkins University in Baltimore. After completing a postdoctoral fellowship in infectious diseases at the University of California, San Francisco, and a master's in epidemiology at Berkeley, he joined the Epidemic Intelligence Service (EIS) at CDC in Atlanta. His EIS work encompassed a variety of activities related to bacterial infections, including Legionnaires disease, neonatal sepsis, and pneumococcal disease. After EIS, his research focused on the epidemiology of foodborne infections until 2004, when he returned to the field of respiratory infections. Currently, Dr Moore leads epidemiology activities related to pneumococcal infections with CDC's Active Bacterial Core surveillance (ABCs) program, as a medical epidemiologist in CDC's National Center for Immunization and Respiratory Diseases.

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