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Quick Guide: Pneumonia Vaccination Update
Pneumonia is an infection in one or both lungs that can be caused by bacteria, viruses, or fungi. Transmitted via person-to-person contact with respiratory secretions, such as saliva or mucus, Streptococcus pneumoniae, or pneumococcus, are a common cause of pneumonia. The infection creates inflammation in the lungs, causing mild to severe symptoms such as cough, fever, chills, and difficulty with breathing. The presence of comorbidities, a weakened immune system, and being aged 65 years or older increase the risk of invasive pneumococcal disease, especially for those residing in long-term care settings. In fact, the mortality rate for nursing home residents requiring hospitalization for pneumonia has been estimated between 13% and 41%.1 If detected quickly, pneumonia is often treatable with antibiotics in older adults, but the Centers for the Disease Control and Prevention (CDC) strongly recommends prevention, especially in older adults and other high-risk individuals.
Current Recommendations for Pneumococcal Vaccination in Older Adults
Polysaccharide vaccines and conjugate vaccines are the two different types of pneumococcal vaccines that are used to prevent pneumococcal disease. On September 19, 2014, the CDC recommended that the 13-valent pneumococcal conjugate vaccine (PCV13) should be routinely used in adults aged 65 years and older in a series with pneumococcal polysaccharide vaccine (PPSV23), the vaccine currently recommended for adults aged 65 years and older. The CDC’s publication of this recommendation in Morbidity and Mortality Weekly Report (MMWR)2 is based on the consensus opinion of the CDC’s Advisory Committee on Immunization Practices (ACIP), which voted 13-2 in favor of these recommendations in August during a special meeting.
The CDC outlines the ACIP’s recommendations as follows:
1. Adults aged 65 years and older who have not previously received a pneumococcal vaccine or whose previous vaccination history is unknown should receive a dose of PCV13 first, followed by a dose of PPSV23. The dose of PPSV23 should be given 6 to 12 months after a dose of PCV13. If PPSV23 cannot be given during this time frame, the dose of PPSV23 should be given during the next visit. The CDC advises that the two vaccines should not be coadministered, and the minimum acceptable interval between PCV13 and PPSV23 is 8 weeks.
2. Adults aged 65 years and older who have previously received one or more doses of PPSV23 should receive a dose of PCV13 if they have not yet received it. A dose of PCV13 should be given at least 1 year after receiving the most recent PPSV23 dose. For those for whom an additional dose of PPSV23 is indicated, this subsequent PPSV23 dose should be given 6 to 12 months after PCV13 and at least 5 years after the most recent dose of PPSV23.
3. In 2018, the ACIP will re-evaluate the recommendations for routine use of PCV13 among older adults and revise, if needed.
These recommendations are supported by high-quality evidence gleaned from the results of CAPITA (The Community-Acquired Pneumonia Immunization Trial in Adults), a randomized placebo-controlled trial evaluating the efficacy of PCV13 for preventing community-acquired pneumonia among approximately 85,000 adults aged 65 years and older with no prior pneumococcal vaccination history. Residents of nursing homes or long-term care facilities, those who received previous pneumococcal vaccination, and those who were immunosuppressed were excluded from the CAPITA study. These results were released in June 2014 and discussed prior to the ACIP’s vote on August 13.
In February 2010, PCV13 was approved by the US Food and Drug Administration, replacing the 7-valent pneumococcal conjugate vaccine (PCV7) for use among infants and young children. In December 2011, PCV13 was approved for adults aged 50 years and older to prevent pneumonia and invasive disease caused by Streptococcus pneumoniae. The approval followed randomized multicenter studies in the United States and Europe showing that for the 12 common serotypes, PCV13 induced antibody levels that were either comparable to or higher than the levels induced by PPSV23.3
The ACIP’s recommendations for routine use of PCV13 in adults aged 19 years and older with immunocompromising conditions, functional or anatomic asplenia, cerebrospinal fluid leaks, or cochlear implants have not changed.4 These patients should receive PCV13 at their next vaccination opportunity, the ACIP advises; these patients who have not previously received PCV13 or PPSV23, should receive a dose of PCV13 first, followed by a dose of PPSV23 at least 8 weeks later. Subsequent doses of PPSV23 should follow current PPSV23 recommendations for adults at high risk. Specifically, a second PPSV23 dose is recommended 5 years after the first PPSV23 dose for persons aged 19 to 64 years with functional or anatomic asplenia and for persons with immunocompromising conditions. Additionally, those who received PPSV23 before age 65 years for any indication should receive another dose of the vaccine at age 65 years, or later if at least 5 years have elapsed since their previous PPSV23 dose.
Immunocompromised patients who have previously received one or more doses of PPSV23 should be given a PCV13 dose at least 1 year after the last PPSV23 dose was received. For those who require additional doses of PPSV23, the first such dose should be given no sooner than 8 weeks after PCV13 and at least 5 years after the most recent dose of PPSV23.
Annals of Long-Term Care: Clinical Care and Aging® (ALTC) discussed these recommendations and their potential impact with Tamara Pilishvili, MPH, Respiratory Diseases Branch, CDC National Center for Immunization and Respiratory Diseases, who co-authored the ACIP’s recommendations.
ALTC: What will be the impact of these new recommendations on the health of older adults in the United States?
Pilishvili: The impact that PCV13 will have on the health of older adults depends on how many adults receive the vaccine. If we can get as many as 30% of adults aged 65 years or older vaccinated during 2015, we estimate that around 500 cases of invasive pneumococcal disease (IPD) and 15,000 cases of community-acquired pneumococcal pneumonia can be prevented in 1 year.
What were the key findings of CAPITA that provided the basis for the ACIP’s recommendations regarding PCV13?
Among adults 65 years or older, PCV13 is estimated to be 75% effective at preventing vaccine-type IPD and 45% effective at preventing vaccine-type community-acquired pneumococcal pneumonia. The evidence supporting PCV13 vaccination of adults was evaluated using the GRADE framework and determined to be type 2 (moderate level of evidence); the recommendation was categorized as Category A.
To increase vaccination uptake in the future, what should healthcare providers stress to their older adult patients about these recommendations?
Older adults are at increased risk for pneumococcal disease, which can cause life-threatening infections, such as pneumonia and bloodstream infections. Now, ACIP recommends two pneumococcal vaccines to be used in sequence in adults to help protect them from pneumococcal infections. In 2013, 38% of IPD among adults aged 65 years and older was caused by serotypes unique to PPSV23. Given the high proportion of IPD caused by serotypes unique to PPSV23, broader protection is expected to be provided through use of both PCV13 and PPSV23 in series.
At the ACIP’s meeting in August, there were questions regarding optimal interval spacing of the two vaccines and the safety of coadministering PCV13 with other vaccines recommended for older adults. What guidance does the MMWR report provide on these questions?
Immunogenicity studies evaluating responses to PCV7 and PPSV23 administered in series showed a better immune response when PCV7 was administered first. An evaluation of immune response after a second pneumococcal vaccination administered 1 year after the initial study doses showed that subjects who received PPSV23 as the initial study dose had lower opsonophagocytic activity (OPA) antibody responses after subsequent administration of PCV13 than those who had received PCV13 as the initial dose followed by a dose of PPSV23, regardless of the level of the initial OPA response to PPSV23. Studies evaluating the immune response after a sequence of PCV7 or PCV13 followed by PPSV23 with intervals of 2, 6, and 12 months or 3 to 4 years demonstrated that after the PPSV23 dose, antibody levels were higher than the pre-PCV baseline, and a noninferior response was observed when compared with post-PCV antibody levels. None of the studies were designed to evaluate the optimal interval between vaccine doses.
Concomitant administration of PCV13 and trivalent inactivated influenza vaccine (TIV) has been demonstrated to be immunogenic and safe. PCV13 can be coadministered with TIV in an adult immunization program. However, a randomized double-blind trial found slightly lower pneumococcal serotype–specific geometric mean concentrations and lower proportion achieving at least a fourfold rise in hemagglutination inhibition assay titer for one of three influenza subtypes (influenza A[H3N2]) with PCV13 plus TIV compared with PCV13 alone or TIV alone among adults aged 65 years and older. Currently, no data are available on coadministration with other vaccines (eg, tetanus, diphtheria, and acellular pertussis vaccine or zoster vaccine) among adults.
References
1. Nursing home-acquired pneumonia. The Merck Manual Professional. bit.ly/1Bbumzp. Updated November 2013. Accessed August 27, 2014.
2. Tomczyk S, Bennett NM, Stoecker C, et al. Use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine among adults aged >65 years: recommendations of the Advisory Committee on Immunization Practices (ACIP). Morb Mortal Wkly Rep (MMWR). 2014;63(37):822-825.
3. FDA expands use of Prevnar13 vaccine for people ages 50 and older [news release]. https://bit.ly/FDA_Prevnar13. Published December 30, 2011. Accessed August 27, 2014.
4. Use of 13-valent pneumoccal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine for adults with immunocompromised conditions. Morbid Mortal Wkly Rep (MMWR). 2012;61(40):816-819.
