Updated Recommendations for Pneumococcal Vaccination of Adults
Abstract & Commentary
By Stan Deresinski, MD, FACP, Clinical Professor of Medicine, Stanford, Associate Chief of Infectious Diseases, Santa Clara Valley Medical Center, is Editor for Infectious Disease Alert.
Synopsis: Recommendations for the vaccination of adults against invasive pneumococcal disease have been updated.
Source: CDC. Prevention of invasive pneumococcal disease among adults using the 23-valent pneumococcal polysaccharide vaccine (PPSV23). MMWR. 2010;59:1102-1106.
The advisory committee on immunization practices (APIC) and the CDC have updated for the use of the 23 valent pneumococcal polysaccharide vaccine (PPSV23) for the prevention of invasive pneumococcal disease in adults. The changes reflect improved knowledge of risk factors for such infections. Thus, targeted populations for PPV23 administration now include adults of any age who are tobacco smokers, as well as those with asthma. On the other hand, the previous recommendation for vaccination of Alaskan natives < 65 years of age without relevant comorbidities has been deleted.
The introduction of routine vaccination of infants with a 7-valent conjugated vaccine in 2000 has been associated with a decrease of invasive pneumococcal disease in individuals of all ages, including those > 65 years. The reduction in incidence is overwhelmingly the result of prevention of infections by pneumococcal serotypes contained in that vaccine. Despite this remarkable herd effect, there were an estimated 43,000 cases of invasive pneumococcal disease and 5,000 associated deaths in the United States in 2009. It can be hoped that the introduction of the 13-valent vaccine (PCV13), which supplants use of the older vaccine in 2010 for use in children, may provide further herd benefit to adults. Recommendations for vaccination with PCV are: 1) routine vaccination of all children aged 2-59 months with PCV13, 2) vaccination with PCV13 of children aged 60-71 months with underlying medical conditions that increase their risk for pneumococcal disease or complications, and 3) PCV13 vaccination of children who previously received one or more doses of PCV7. While not undisputed, the bulk of studies indicate that the 23-valent pneumococcal vaccine, which is not a conjugate, exerts preventive efficacy in many adult populations.
Individuals at the extremes of age are at increased risk of invasive pneumococcal disease, as are those with a variety of immune impairments and comorbidities (see Table 1). These include individuals with congenital or acquired immunodeficiency, functional or anatomic asplenia, HIV infection, various malignancy, and immunosuppressive therapy; individuals without systemic immunodeficiency but with a variety of comorbidities, such as chronic cardiac, liver, or pulmonary disease, diabetes mellitus, tobacco smoking dependency; and individuals with cerebrospinal fluid leaks and those with cochlear implants also are at increased risk.
Table 1. Underlying medical conditions or other indications for administration of 23-valent pneumococcal polysaccharide vaccine (PPSV23) among adults aged 19-64 years, by risk group Advisory Committee on Immunization Practices, (ACIP) 2010 |
|
Risk group |
Underlying medical condition or other indication |
Immunocompetent persons |
Chronic heart disease (excluding hypertension)* |
Chronic lung disease |
|
Diabetes mellitus |
|
Cerebrospinal fluid leaks |
|
Cochlear implant |
|
Alcoholism |
|
Chronic liver disease, including cirrhosis |
|
Cigarette smoking |
|
Persons with functional or anatomic asplenia§ |
Sickle cell disease and other hemoglobinopathies |
Congenital or acquired asplenia, splenic dysfunction, or splenectomy |
|
Immunocompromised persons§ |
Congenital or acquired immunodeficiencies¶ |
HIV infection |
|
Chronic renal failure |
|
Nephrotic syndrome |
|
Leukemias |
|
Lymphomas Hodgkin's Lymphoma Generalized malignancy Diseases requiring treatment with immunosuppressing drugs, including long-term systemic corticosteroids or radiation therapy Solid organ transplantation Multiple myeloma |
|
|
* Including congestive heart failure and cardiomyopathies. Including chronic obstructive pulmonary disease, emphysema, and asthma. § A second dose of PPSV23 is recommended 5 years after the first dose for persons with functional or anatomic asplenia and for immunocompromised persons. ¶ Includes B- (humoral) or T-lymphocyte deficiency, complement deficiencies (particularly C1, C2, C3, and C4 deficiencies), and phagocytic disorders (excluding chronic granulomatus diseases) |
|
In summary, everyone should be vaccinated with PPSV23 at age 65 years, and vaccination is also indicated for younger individuals at increased risk of pneumococcal infection (see Table 2). Those who had 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 five years have passed since their previous dose. Those who receive PPSV23 at or after age 65 years should receive only a single dose. Routine vaccination (i.e. revaccination) for most individuals is not recommended. A second dose of PPSV23 is recommended five years after the first dose for persons aged 19-64 years with functional or anatomic asplenia and for persons with immunocompromising conditions (see Table). ACIP does not recommend multiple revaccinations because of insufficient data regarding clinical benefit, particularly the degree and duration of protection and safety. It should also be remembered that smoking cessation is an important component of a program to prevent invasive pneumococcal disease.
Table 2. Updated recommendations for administration of 23-valent pneumococcal polysaccharide vaccine (PPSV23) among adults aged ≥ 19 years Advisory Committee on Immunization Practices (ACIP), United States |
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