UPDATE ON THE RECOMMENDATIONS FOR THE USE OF PNEUMOCOCCAL VACCINES
Stanley A. Gall, MD
Pneumococcal disease is caused by Streptococcus pneumoniae for which there are 81 Serotypes. Pneumococcal disease is transmitted through respiratory droplets. Its most serious clinical manifestations are pneumonia and invasive disease( bacteremia and meningitis). Eighty-five percent of invasive pneumococcal disease occurs in adults.
Pneumococcal Disease Burden In The U. S. Clinical Presentation U. S Incidence Death Rate(%) Bacteremia 50,000 15-20 Meningitis 3,000-6,000 16-37 Pneumonia 1.6-2.0 Million 5-7
Pneumococcal disease has high associated morbidity:
-Meningitis: Can cause hearing loss, seizure, blindness and paralysis. Concurrent cardiac events are common among patents hospitalized with pneumococcal pneumonia. Symptoms may develop and may vary by clinical presentation. Classically seen in the alcoholic. Older series documented up to 80 percent mortality; better now with sophisticated ICU care.
-Pneumonia: fever, cough, shaking chills, shortness of breath, nausea, chest pain and particularly in the old, weakness and / or confusion as primary presenting symptoms without significant fever.
-Bacteremia: Similar to meningitis and pneumonia, with muscle and joint pain, metabolic acidosis, prerenal azotemia, hypoxia.
Two pneumococcal vaccines are approved for use in adults: a 23-Valent Pneumococcal polysaccharide vaccine( PPS23) and a 13-Valent Pneumococcal conjugate vaccine( PCV13). In August 2014, the advisory committee on immunizations practices( ACIP) recommended routine use of PCV13 among adults aged > 65 should be administered in series with PPSV23, the vaccine recommended for adults > 65 years series 1983.( 1)( 2)
Table 1 demonstrates the recommendations that will apply to most immunocompetent adult persons > 65 years of age or to those persons who received PPSV23 prior to age 65. Studies of the immune response of PCV13 à PPSV23 sequence among immune-competent adults suggest longer intervals(> 1yr) may lead to improved responses against serotypes present in both vaccines as compared to a single dose of PCV13 or PPSV23.( 3)( 4)( 5)
The recommended intervals for persons with cerebrospinal fluid leaks or sickle cell disease or other hemoglobinopathies and immuno-competent are reviewed in Table 2.
The interval for administration of PPSV23 after initial PCV13 is > 8 weeks. Durations of < 8 weeks are associated with increasing reactivity.
Table 3 emphasizes the need for PPSV23 and no PCV13 sequence for immuno-competent persons with the risks listed. This list includes many of the patients seen in the office every day and physicians need to be aware of the persons with these diagnosis.
TABLE 1
RECOMMENDED INTERVALS FOR SEQUENTIAL USE OF PCV13 AND PPSV23 FOR IMMUNO COMPE- TENT ADULTS AGED > 65 YEARS.
PNEUMOCOCCAL VACCINE-NAIVE PERSONS > 65
PCV13 at age ≥ 65 yr
≥ 1 yr
PPSV23
PERSONS WHO PREVIOUSLY RECEIVED PPSV23 AT AGE ≥ 65 YEARS
PPSV23 already received at age ≥ 65 yr
≥ 1 yr
PPSV13
PERSONS WHO PREVIOUSLY RECEIVED PPSV23 BEFORE AGE 65 YEARS WHO ARE NOW AGED > 65 YEARS
PPSV23 already received at < 65
≥ 1 yr
MMWR: 2015; 64:944-947
PCV13 at age ≥ 65 years
≥ 5 yr
TABLE 2
≥ 1 yr
PPSV23
10 LOUISVILLE MEDICINE