|Pneumococcal Vaccine Recommendations
With the release of a new pneumococcal vaccine preparation, deciding who to immunize and how to immunize them has become a bit more complicated. In the following essay, Dr. Scully sorts this all out.
New recommendations for the use of the 13-valent pneumococcal conjugate vaccine (PCV13) in immunocompromised adults have been published in the MMWR.1 This includes patients over the age of 19 with problems such as HIV, malignancies, leukemias, and patients on immunosuppressive drugs or with functional or anatomic asplenia. Before the 7-valent conjugate vaccine (PCV7) as added to routine childhood immunization in 2000, Streptococcus pneumoniae was estimated to cause over 17,000 cases of invasive pneumococcal disease (IPD), including 800 cases of meningitis and 200 deaths.2 But the routine use of PCV7 essentially eliminated IPD due to vaccine serotypes, not only in children but also in adults (herd immunity). Although the subsequent years saw an increase in IPD due to non-vaccine serotypes (replacement strains) there was none-the-less a significant overall decline in IPD in both children and adults. In 2010, PCV13 replaced PCV7 in the routine childhood schedule and includes serotypes like 19A that had emerged post PCV7 use and was the cause of multi-drug resistant otitis media.
The thought now behind the use of PCV13 and the pneumococcal polysaccharide vaccine (PPSV23) in immunocompromised adults, is that the combination of the two vaccines will provide better coverage than either one of the vaccines could achieve on their own. The recommendations are divided into vaccine naïve patients and those previously vaccinated adults.
Here’s how it goes:
If a patient has yet to be vaccinated with any pneumococcal vaccine, PCV13 should be initiated first, followed by PPSV23 at least 8 weeks after PCV13. Another dose of PPSV23 can then be given 5 years later. For those who received PPSV 23 before the age 65 for any indication, they should receive another dose of the vaccine at age 65 years, or later if at least 5 years have elapsed since the previous PPSV 23.
For patients previously immunized with one or more dose of PPSV23, PCV13 can be given at least 1 or more years after the last PPSV23. For patients needing additional doses of PPSV23 according to previous guidelines, the next dose of PPSV23 should be at least 8 weeks after PCV13 and at least 5 years since the most recent PPSV23 dose.
Not exactly an easy schedule to remember if you ask me. I assume we’ll get used to it, and just when we do, the ACIP will likely change it again!
The PCV13 vaccine was licensed in December 2011 for adults over age 50 and previously licensed for ages 6 weeks to 6 years of age. So the use of the vaccine in patients aged 19-49 with immune compromise will technically be “off label” use of the vaccine until that formal approval comes through.
So far, the use of the PCV13 vaccine has been well received by my patients and without any adverse side effects. Remember though these new recommendations pertain only to immune compromised adults.
Mary-Louise Scully M.D.
1. CDC. Use of 13-Valent Pneumococcal Conjugate Vaccine and 23-Valent Pneumococcal Polysaccharide Vaccines for Adults with Immunocompromising Conditions: Recommendations of the ACIP . MMWR 2012;61 (40):816-819.
2. CDC. Direct and Indirect Effects of Routine Vaccination of Children with 7-Valent Pneumococcal Conjugate Vaccine on Incidence of Invasive Pneumococcal Disease – US- 1998-2003. MMWR 2005;54(36):893-897.
Posted by DrSugar on 12/17/2012 at 11:28 AM