In 2014, the Advisory Committee on Immunization Practices (ACIP) recommended 13-valent pneumococcal conjugate vaccine (PCV13) in series with 23-valent pneumoccocal polysaccharide vaccine (PPSV23) for all adults aged 65 years and older.

The Morbidity & Mortality Weekly Report (MMWR) points out that PCV13 use in children has led to significant declines in pneumococcal disease among adults and children. Now, after review of accrued evidence, the ACIP has decided to change the recommendation for PCV13 use in adults.

According to the CDC, the ACIP advises a routine single dose of PPSV23 for adults aged 65 years and older, adding, “Shared clinical decision-making is recommended regarding administration of PCV13 to persons aged ≥65 years who do not have an immunocompromising condition, cerebrospinal fluid leak, or cochlear implant and who have not previously received PCV13.”

The CDC’s vaccine advisory group recommends that if a decision to administer PCV13 is made, PCV13 should be administered first, followed by PPSV23 at least 1 year later.

Two pneumococcal vaccines are currently licensed for use in adults in the United States: PCV13 (Prevnar 13, Pfizer, Inc.) and PPSV23 (Pneumovax 23, Merck and Co., Inc.). Routine use of PCV13 in series with PPSV23 for all adults aged 65 years and older was recommended based on demonstrated PCV13 safety and efficacy against PCV13-type pneumonia among older adults.

At that time, however, the ACIP said it recognized that there would be a need to reevaluate the recommendation because it was expected that PCV13 use in children would continue to reduce disease burden among adults through reduced carriage and transmission of vaccine serotypes from vaccinated children (i.e., PCV13 indirect effects). 

On June 26, 2019, after having reviewed the evidence accrued during the preceding 3 years, the ACIP voted to remove the recommendation for routine PCV13 use among adults aged 65 years and older and to recommend administration of PCV13 based on shared clinical decision making for adults in that age group without an immunocompromising condition, including cerebrospinal fluid (CSF) leak or cochlear implant, and who have not previously received PCV13. 

The second recommendation—for shared decision making—came about because the ACIP recognized that some older adults are potentially at increased risk for exposure to PCV13 serotypes, such as persons residing in nursing homes or other long-term care facilities and persons residing in settings with low pediatric PCV13 uptake or traveling to settings with no pediatric PCV13 program. It was determined that those patients might receive higher than average benefit from PCV13 vaccination. 

“When patients and vaccine providers engage in shared clinical decision-making for PCV13 use to determine whether PCV13 is right for a particular person, considerations might include both the person’s risk for exposure to PCV13 serotypes and their risk for developing pneumococcal disease as a result of underlying medical conditions,” noted the report.

The MMWR article emphasizes that all adults aged 65 years and older should continue to receive one dose of PPSV23. If the decision is made to administer PCV13, it should be given at least a year before PPSV23. The ACIP continues to recommend PCV13 in series with PPSV23 for adults aged 19 years or older with an immunocompromising condition, CSF leak, or cochlear implant.

Streptococcus pneumoniae can cause serious illness, including sepsis, meningitis, and pneumonia with bacteremia (invasive) or without bacteremia (noninvasive), according to the CDC. 

The decision came after a systematic review of scientific literature published from January 1, 2014, to July 3, 2018, was conducted to identify studies evaluating direct and indirect effects of vaccination with PCV13 on invasive pneumococcal disease, pneumonia (PCV13-type, all pneumococcal, and all-cause), and mortality (pneumococcal or all-cause). 

Researchers also evaluated PCV13 safety by looking for severe adverse events, including death, occurring after receipt of PCV13 in adults aged 65 years and older.

Out of 364 studies reviewed based on title and abstract screening, 20 studies were included in the GRADE tables. The policy question considered was whether PCV13 should be administered routinely to all immunocompetent adults aged 65 years and older in light of indirect effects from pediatric PCV use experienced to date.

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