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