COMMENTARY

Updated Pneumococcal Vaccine Recommendations for Older Adults

Miwako Kobayashi, MD, MPH

Disclosures

January 31, 2020

Editorial Collaboration

Medscape &

The Advisory Committee on Immunization Practices, or ACIP, voted in June 2019 to change the pneumococcal vaccine recommendations for older adults. Hello. I'm Dr Miwako Kobayashi, a medical epidemiologist at the Centers for Disease Control and Prevention (CDC). I hope to shed some light on what the new recommendation means and give you ideas on how to implement it in your practice.

Let's set the stage with some background information. CDC used to recommend routine use of two pneumococcal vaccines for all adults aged 65 years or older. The first is the 13-valent pneumococcal conjugate vaccine, PCV13, which is sold under the trade name of Prevnar 13. The second vaccine is the 23-valent pneumococcal polysaccharide vaccine, PPSV23, sold under the trade name of Pneumovax 23.

PCV13 is now recommended on the basis of shared clinical decision-making rather than routinely for all adults aged 65 years or older who have never received PCV13. This simply means that together, the patient and provider can decide whether PCV13 is right for that specific person. This change applies to older adults who do not have an immunocompromising condition, cerebrospinal fluid leak, or cochlear implant. PCV13 is still routinely recommended for older adults with those conditions who have never previously received a dose. In addition, CDC continues to recommend PPSV23 routinely for all adults aged 65 years or older.

PCV13 is a safe and effective vaccine, so this recommendation change might not make sense at first glance. The recommendation was changed to shared clinical decision-making because the incidence of the types of pneumococcal disease that the PCV13 vaccine can prevent has declined to historically low levels among older adults. This is because we've been giving PCV13 to children since 2010, which has worked well in reducing carriage of pneumococci. As a result, transmission of pneumococci from vaccinated children to unvaccinated individuals, including adults, has decreased, and CDC found that giving the vaccine to older adults had only a minimal impact on adult disease at the population level.

With all of this information in hand, you may be wondering what a shared clinical decision-making conversation about PCV13 sounds like. Here are some considerations for discussion with your patients:

  • Exposure risk: In most communities, the risk for exposure to the 13 pneumococcal strains covered by the vaccine is low. However, some groups are potentially at increased risk for exposure and thus might get more benefit from PCV13 vaccination. One example is people living in nursing homes or other long-term care facilities. Another example would be those planning to travel somewhere that doesn't have a pediatric PCV13 program or living in countries/settings with low PCV13 uptake among children.

  • Personal risk because of underlying medical conditions: Individuals who have a chronic medical condition like chronic heart, lung, or liver disease; diabetes; or alcoholism; and those who smoke cigarettes are at increased risk for pneumococcal disease if they are exposed.

For shared clinical decision-making, clinicians and patients need to consider both exposure and personal risk. For example, someone with many underlying medical conditions but low exposure risk might conclude that vaccination is beneficial to them. Conversely, a healthy patient with a higher risk for exposure might decide that vaccination is not right for them.

Considerations for Shared Clinical Decision-Making Regarding Use of PCV13 in Adults Aged ≥ 65 Years

  • PCV13 is a safe and effective vaccine for older adults. The risk for PCV13-type disease among adults aged ≥ 65 years is much lower than it was before the pediatric program was implemented, as a result of indirect PCV13 effects (reduced population carriage and transmission). 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 of developing pneumococcal disease if exposure occurs.

  • The following adults aged ≥ 65 years are potentially at increased risk for exposure to PCV13 serotypes and might attain higher-than-average benefit from PCV13 vaccination; providers/practices caring for many patients in these groups may consider regularly offering PCV13 to their patients aged ≥ 65 years 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

  • Incidence of PCV13-type invasive pneumococcal disease and pneumonia increases with increasing age and is higher among persons with chronic medical conditions like chronic heart, lung, or liver disease; diabetes; or alcoholism; and those who smoke cigarettes. While 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 aged ≥ 65 years and who have not previously received PCV13.

It is important to note that both routine immunizations, as well as those given to individuals consistent with an ACIP shared clinical decision-making recommendation, are generally required to be covered by private health insurance plans without cost-sharing requirements.

One important reminder: If a patient and a clinician decide that PCV13 is right for the patient, then it should be given first. Then, administer PPSV23 at least 1 year later so that the patient gets maximum benefit from both vaccines.

A resource that you may find helpful while implementing these new recommendations is CDC's mobile app, which provides patient-specific pneumococcal vaccination recommendations. Thank you for tuning in to this CDC expert video commentary on Medscape.

Miwako Kobayashi, MD, MPH, is a medical epidemiologist with the Respiratory Diseases Branch within the National Center for Immunization and Respiratory Diseases, where she works on pneumococcal and other bacterial respiratory diseases. She received her MD from the University of Tsukuba School of Medicine and completed a residency in internal medicine at Beth Israel Medical Center and an infectious diseases fellowship at Emory University. She received her master's degree in public health from Johns Hopkins Bloomberg School of Public Health.

Resources

Clinician Information on the Recommended Adult Immunization Schedule

PneumoRecs VaxAdvisor Mobile App (on iOS and Android devices)

Clinician Information on Pneumococcal Disease

Pneumococcal Vaccination Information for Healthcare Professionals

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