Update notice 2/2/16: Because of changed CDC ACIP recommendations in Sept 2015, this article has been updated to reflect the new recommendations. Essentially the 6 month interval between PCV13 and subsequent PPSV23 was extended to 12 months, so that it matched the interval necessary when PPSV23 had been given first. The reference for the updates is:
Kobayashi M, et al, Intervals between PCV13 and PPSV23 vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. 2015;64(34):944-7.
As of August 2014, the Centers for Disease Control’s Advisory Council for Immunization Practices (ACIP) has changed their 65 and over recommendations for pneumococcal vaccination.
The landscape of pneumococcal immunization continues to change. As you may know, there are two types of vaccine – the conjugate vaccine and the polysaccharide vaccine. You probably are familiar with the polysaccharide vaccine in the form of the 23 valent vaccine (Pneumovax®), referred to in the literature as PPSV23. While it protects against 23 different serotypes of the pneumococcus bacteria, studies have demonstrated in younger patients that the conjugate vaccine, first in PCV -7 and then in PCV-13 (also known as Prevnar 13®) vaccine achieve higher antibody response levels. Clinically, there has been a significant drop in pneumococcal pneumonia and invasive pneumococcal disease (IPD) in the younger population not only as a result of routine childhood immunization but also as a result of decreased pneumococcus carrier rates.
Studies have shown the PPSV23 has been effective in decreasing IPD rates among older patients, but the data on PPSV23 preventing noninvasive pneumococcal pneumonia has been inconsistent.
Comparative trials in older adults demonstrate that the conjugate vaccines stimulate as high or higher rates of antibody responses for almost all of the serotypes common to the two vaccines. In June of this year there was a study in The Netherlands demonstrating safety and clinical efficacy in PCV 13 vaccine in over 84,000 patients aged 65 and over in both preventing pneumococcal pneumonia and IPD.
Given this significant new evidence, ACIP has now recommended that we vaccinate our older adults with PCV 13 first. Because there are still important serotypes which PPSV23 includes which are not included in PCV13, the Council still recommends giving the PPSV23 later. They recommend a minimum spacing between vaccinations of six months if PCV13 is given first, or 12 months if PPSV23 already has been provided.
Essentially the CDC recommendations are as follows:
For patients <65 – no change in recommendations
For patients ≥65 years old
- If they have not received any pneumonia vaccination or cannot remember: Give PCV13 and then give PPSV23 six months later.
- If they have received PPSV23 already, but not PCV13:
Give PCV13 one year after the date of the PPSV23.NOTE: This has been changed as of September 2015. Give PCV 13 and then give PPSV23 12 months later.
The patient may need to get PPSV 23 again if the original PPSV23 was given before age 65. This vaccination will be needed five years after the date of the PPSV23 and still be spaced at least
six 12 months after the PCV13 dose.
- If they already have received PCV13: Find out if they’ve had PPSV23 already. If so, then it’s as above. If not, then just give PPSV23 a year later.
The minimal intervals between vaccines are not a safety issue. If by accident someone gets these vaccines closer together than recommended by CDC, they will not be harmed. It will just be that their antibody response will not be as good as if the intervals were done correctly. The CDC plans to re-evaluate their recommendation for possible adjustment in 2018.
Note: If a patient received their most recent PPSV23 before age 65, they will require an additional PPSV23, which must be given after age 65 at least 12 months since the PCV 13, and at least 5 years since the previous PPSV23.
Also, the ACIP recommends that certain immunocompromised patients have shortened intervals prior to this last dosage of PPSV23. See CDC website and reference for details.
What does this mean for Medical Directors and Attending Physicians?
The evidence supporting this recommendation was determined to be a type 2 (moderate level of evidence) and the recommendation was categorized as a Category A recommendation. If as a medical director you wish to give your patients PCV 13 first instead of PPSV23, you’ll need to work with your Director of Nursing to make sure that when patients are admitted that they are asked not only if a patient has received pneumococcal vaccine, but when and which type. You’ll also have to make sure that they don’t automatically get PPSV23 before you’ve reviewed the situation. Again, if patients cannot remember, then it’s all right to order PCV13. As you can see, the decision tree is a bit complex regarding timing, so you’ll need to make arrangements yourself as far as the best way to do this. Nurses routinely ask patients if they have received pneumococcal vaccine now as we track pneumococcal vaccination rates for both short and longer stay patients. While it’s best to follow the most up to date recommendations, the most important thing is that patients do not go unvaccinated for pneumococcus if they have indications and don’t refuse.
Tomczyk S, Bennett NM, Stoecker C, Gierke R, Moore MR, Whitney CG, 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) MMWR Weekly September 19, 2014 / 63(37);822-825