Pneumococcal disease is an infection caused by Streptococcus pneumoniae bacteria (also referred to as pneumococcus). These bacteria can cause many types of illnesses, including pneumonia, meningitis, and ear, sinus, and bloodstream infections. Pneumococcus is spread when people cough, sneeze, and/or are in close contact with others who are infected. Symptoms depend on the part of the body that is infected. They can include fever, cough, shortness of breath, chest pain, stiff neck, and confusion and disorientation. Symptoms may also include sensitivity to light, joint pain, chills, ear pain, sleeplessness, and irritability. In severe cases, pneumococcal disease can cause hearing loss, brain damage, and death.
Pneumococcal disease is a leading infectious cause of serious illness among older adults in the United States. Studies have identified certain patient groups that are more likely to become ill with pneumococcal disease. These high-risk groups include adults aged 65 and older and children younger than 2 years of age. People with weakened immune systems (eg, those with HIV/AIDS), those with chronic illnesses (eg, diabetes, heart disease, and asthma), and individuals who smoke cigarettes are at increased risk for getting pneumococcal disease.
Vaccines Have Helped
The incidence of pneumococcal infections among children and adults in the U.S. has dropped since a 7-valent pneumococcal conjugate vaccine (PCV7) was initiated for routine use among infants in 2000 and was later replaced by the 13-valent pneumococcal conjugate vaccine (PCV13) in 2010. “For decades, the 23-valent pneumococcal polysaccharide vaccine (PPSV23) has been recommended for use in adults aged 65 and older for the prevention of pneumococcal infections,” explains Tamara Pilishvili, MPH. More recently, the FDA approved PCV13 for use in adults aged 50 and older.
When compared with 2010 data, the incidence of invasive pneumococcal disease (IPD) caused by serotypes unique to PCV13 among adults aged 65 and older declined by about 50% in 2013, thanks in large part to PCV13 replacing PCV7 in the pediatric immunization schedule. Still, an estimated 13,500 cases of IPD occurred among adults aged 65 and older in 2013. Studies show that about 20% to 25% of IPD cases and 10% of community-acquired pneumonia cases in the older adult population are caused by PCV13 serotypes and are potentially preventable with the use of this particular vaccine.
Key Updates
In 2012, with the licensure of PCV13 for adults, the Advisory Committee on Immunization Practices (ACIP) revisited its recommendations and indicated that pneumococcal vaccine-naïve individuals aged 19 and older who are immunocompromised or have functional or anatomic asplenia, cerebrospinal fluid leaks, or cochlear implants should receive a dose of PCV13 first, followed by a dose of PPSV23 at least 8 weeks later.
“In 2014, results of a study involving about 85,000 adults aged 65 and older with no prior pneumococcal vaccination history evaluating efficacy of PCV13 in preventing community-acquired pneumococcal pneumonia were released,” says Dr. Pilishvili. “This trial found that PCV13 was effective against community-acquired pneumonia and led ACIP to recommend routine use of PCV13 followed by PPSV23 in this older patient population. ACIP indicated that both PCV13 and PPSV23 should be routinely administered in series to all adults aged 65 and older to achieve broader protection against IPD.”
Sequencing & Intervals
ACIP also provided guidance on the sequential administration and recommended intervals for PCV13 and PPSV23 for adults aged 65 and older (Figure). Older adults who have not previously received pneumococcal vaccines or whose previous vaccination history is unknown should receive a dose of PCV13 first, followed by a dose of PPSV23. “The dose of PPSV23 should be given 6 to 12 months after a dose of PCV13,” Dr. Pilishvili says. “If PPSV23 cannot be given during the 6-to-12-month window, the PPSV23 dose should be given during the patient’s next visit. The two vaccines should not be coadministered, and the minimum acceptable interval between PCV13 and PPSV23 is 2 months. Healthcare providers should be offering a dose of PCV13 to both vaccine-naïve adults aged 65 years and older as well as those who previously received one or more doses of PPSV23.”
The ACIP recommendations also note that older adults who previously received one or more doses of PPSV23 also should receive a PCV13 dose if they have not yet received it. A PCV13 dose should be given 1 or more years after receipt of the most recent PPSV23 dose. Among appropriate candidates for additional doses of PPSV23, the subsequent PPSV23 dose should be given 6 to 12 months after PCV13 and at 5 years or later after the most recent dose of PPSV23.
Important Considerations
According to Dr. Pilishvili, the recommendations for pneumococcal vaccination use among adults aged 65 and older will be reevaluated in 2018 and revised as needed. “The updated guidance from ACIP may be complicated for healthcare providers but allows for flexibility if doses are not given within the recommended window or if previous vaccination history is unknown,” she says. “It’s important to be vigilant about offering these vaccinations to adults as indicated. The better that healthcare providers are at adhering to these recommendations, the more likely we are to optimize protection against pneumococcus in older adults.”
TimH