1. Pneumococcal vaccination in adults: PCV13?.. PPSV23?.. both??
January 2016

2. Objectives Burden of Pneumococcal disease Pneumococcal vaccines
Vaccine recommendations
Contraindications/Adverse effects
Pneumococcal vaccination rates
Take home message

3. Burden of Pneumococcal disease (PD)
PD can be local or invasive
8th leading cause of death in US with influenza
kills more people yearly than all other vaccine-preventable diseases combined
more likely to get PD if smoke, have certain underlying conditions eg diabetes or heart disease, immunocompromised, ≥ 65 yrs
PD is caused by Streptococcus pneumoniae a Gram positive lancet-shaped bacterium  diplococci
– PD can be local – pneumococcal pneumonia- or invasive – bacteremia or meningitis
bacteremia and meningitis
1 in 20 die from pneumococcal pneumonia with 45,000 deaths
1 in 5 die from invasive disease with 3,600 deaths

4. Pneumococcal vaccines
Most effective way to prevent PD is vaccination 56-81% effective
Key virulence factors of Streptococcus pneumoniae :
polysaccharide capsule + >90 serotypes
vaccines aim to stimulate antibodies to this capsule and facilitate phagocytosis

5. Structure of S.pneumoniae
Source: Google Images at

6. Pneumococci in lobar pneumonia
Source: Google Images at

7. Pneumococcal polysaccharide vaccine (PPSV23)
Consists of capsular material from 23 pneumococcal serotypes which caused 85-90% of PD (now reduced to 50-60%)
Used principally in adults as poorly immunogenic <2yrs
Licensed in the US in 1983
Reduced to 50-60%
Stimulates B cell response

8. Pneumococcal conjugate vaccine (PCV13)
Consists of 13 capsular serotypes linked to a protein that is identical to diptheria toxin  immunogenic in <2yrs
Replaced PCV 7 for pediatric in 2010
Expanded to high-risk adults in 2012
Expanded to all adults > 65yrs in 2014
Expanded to all adults after CAPiTA trial in the Netherlands which showed its efficacy against vaccine-type pneumococcal pneumonia and vaccine-type invasive pneumococcal disease in adults>65yrs
ACIP (US Advisory Committee on Immunisation Practices) may reconsider recs for use of PCV13 in adults in 2018 as universal immunisation of infants with PCV13 may substantially reduce the potential benefit of PCV13 in adults
Stimulates T cell mediated B cell response with mucosal immunity  herd immunity

9. Vaccination recommendations from ACIP
Intermediate risk (19-64yrs)
High risk (19-64yrs)
All adults ≥ 65yrs
Revaccination
Advisory Committee on Immunization Practices

10. Intermediate risk for PD (19-64 yrs)
Intermediate risk 19-64yrs  PPSV23 alone
Smokers DM
Alcoholism
Chronic heart disease
Chronic lung disease (asthma, COPD, ILD)
Chronic liver disease

11. High risk for PD (19-64 yrs)
High risk (includes immunocompromised) 19-64yrs
 PCV13 and PPSV23 >8 weeks apart
Asplenic
HIV infection
Cancer
Renal failure
Nephrotic syndrome
On immunosuppressant therapy
CSF leak
Cochlear implant
PCV 13 then PPSV23 at least 8 weeks later and preferably 6-12 months later
Or PPSV23 and PCV13 one year later

12. All adults ≥ 65 yrs All adults ≥ 65 yrs  PCV13 and PPSV23
Give PCV13 first then wait 12 months before giving PPSV23 (minimum 8 weeks apart)
If PPSV23 already given then wait 12 months before giving PCV13
PCV13 followed by PPSV23 enhances immunogenicity with better antibody levels at one month

13. Revaccination Revaccination with PCV13 is not recommended
Revaccination needed for PPSV23:
- 5 years after first dose for high risk pts (except CSF leaks and cochlear implants)
AND
- if vaccinated before 65yrs will need single revaccination when ≥ 65 yrs that is 5 years after previous dose

14. Source: Google Images at http://www. cdc

15. Contraindications/Adverse effects
Previous allergic reaction to vaccine
Moderate or severe illness
Pregnancy
Adverse effects
Local inflammation
Fever, myalgia
Contraindications
Previous allergic reaction to vaccine components PCV7 or 13 or to diptheria toxoid
PPSV23
Previous allergic reaction to PPSV23
Moderate or severe illness
No studies showing pregnancy is CI and CDC recommends PPSV23 if pt meets criteria for vaccination
Local reactions:
PPSV %; PCV %
Fever, myalgia, arthralgia:
PPSV23 <1%; PCV %
Febrile seizures:
PCV /100,000
Serious rare adverse reactions:
PPSV23 rare; PCV13 8%

16. Room for improvement… Nationally
- Healthy People 2020: goal of 90% pneumococcal vaccination for >65 yrs
- CDC 2013 National Health Interview Survey: 59.7% overall: 63.6% white, 39.2% Hispanic, 48.7% African American
Locally – rate of pneumococcal vaccination for >65 yrs in local clinic [insert percentage vaccinated, if known]
Healthy People 2020 goal of 90% pneumococcal vaccination for >65 yrs

17. Take home message:
Follow pneumococcal vaccination guidelines and GET YOUR PATIENTS VACCINATED
Important that patients also get influenza vaccine every year as having flu increases chances of getting PD

18. References
Ask the experts: Diseases and vaccines CDC;
Vaccination coverage among adults, excluding influenza vaccination – United States , 2013;
National Committee for Quality Assurance. The State of Health Care Quality HEDIS Measures of Care

19. References
Use of pneumococcal vaccine in adults. Pisano J; Cifu AS. JAMA Vol 313 (7) MMWR, October 12, 2012, Vol 61, #40

CDC Leading causes of death in the US;