Pneumococcal Vaccination in Adults: Who Gets What and When?

Full update September 2019

Prevnar 13 is often thought of as a childhood vaccine, but it is also FDA-approved for use in adults 18 years of age and older (condition unspecified).2 The CDC recommends its use in adults 65 years and older and in younger adults with immunocompromising conditions, cerebrospinal fluid (CSF) leak, or cochlear implant, in addition to Pneumovax 23.1 Both vaccines cover 12 of the same serotypes, plus Prevnar 13 covers one more, and Pneumovax 23 covers 11 others.5 Immune response to Prevnar 13 (a conjugate vaccine) is as good as or better than Pneumovax 23 (a polysaccharide vaccine).5 The act of conjugating or linking the polysaccharide vaccine to a carrier protein enhances immunogenicity.6 When both are indicated, give Prevnar 13 first for the best immune response.5 There is a slightly lower immune response to Prevnar 13 when it is given at the same visit as the influenza vaccine in the elderly.5 However, either Prevnar 13 or Pneumovax 23 can be given at the same visit as the influenza vaccine (live or inactivated), or other vaccines in adults, at separate injection sites.3,4,8 Although Prevnar 13 and Pneumovax 23 should not be given at the same visit, they should not be repeated if accidentally given sooner than the recommended interval.1 The CDC’s recommendations for pneumonia vaccination in adults are summarized in the table below. If the following recommendations are followed correctly, no adult will receive more than three doses of 23-valent pneumococcal vaccine, and not more than one dose of Prevnar 13, in their lifetime.1

Information in the table below is from reference 1 unless otherwise noted.

Who

What and When

Immunocompromised adults 19 to 64 years of age:

  • Asplenia (functional or anatomic)b
  • Hemoglobinopathy (e.g., sickle cell disease)
  • Congenital or acquired immunodeficiency (includes complement deficiency, B- or T-cell deficiency, and phagocytic disorders [excluding chronic granulomatous disease])
  • Cancer (e.g., leukemia, lymphoma, Hodgkin’s disease, multiple myeloma)
  • HIV
  • Chronic renal failure or nephrotic syndrome
  • Organ transplantb
  • Iatrogenic immunosuppression (e.g., systemic corticosteroids 14 days or longer,4 radiotherapy, chemotherapy)b

Single dose of Prevnar 13 (if not previously given),a followed by Pneumovax 23 at least eight weeks later.

Wait until at least one year has passed since any previous Pneumovax 23 dose to give Prevnar 13.

A second Pneumovax 23 should be given at least five years after the first, but at least eight weeks after Prevnar 13.

Immunocompetent adults 19 to 64 years of age with CSF leak or cochlear implantb

Single dose of Prevnar 13 (if not previously given),a followed by Pneumovax 23 at least eight weeks later.

Wait until at least one year has passed since any previous Pneumovax 23 dose to give Prevnar 13.

Immunocompetent adults 19 to 64 years of age or older with diseases, habits, or living conditions that put them at high risk of pneumococcal disease:

  • Heart disease (including heart failure or cardiomyopathy)
  • Pulmonary disease (including COPD, emphysema, or asthma)
  • Diabetes
  • Alcoholism
  • Cigarette smoking
  • Chronic liver disease

Single dose of Pneumovax 23.

Adults 65 years of age and older

Single dose of Prevnar 13 (if not previously given, or vaccination history is unknown),a followed by Pneumovax 23 at least one year later (at least eight weeks later for adults who are immunocompromised, with functional or anatomic asplenia, or who have CSF leak or cochlear implant).1,4,7 Wait until at least one year has passed since any previous Pneumovax 23 dose to give Prevnar 13.

ACIP recommendation, 2019 (final CDC guidance pending): Pneumovax 23 is recommended. For patients 65 years of age and older without an immunocompromising condition, Prevnar 13 (if not previously given), based on shared clinical decision-making.9 The addition of Prevnar 13 prevents one case of outpatient pneumonia for every 2,600 immunocompetent seniors and one case of invasive pneumococcal disease for every 26,300 immunocompetent seniors vs giving Pneumovax 23 alone.10

Those who received one or more doses of the 23-valent vaccine before age 65 for any indication should receive another dose at age 65 or older after at least five years have elapsed since their previous Pneumovax 23 dose.

  1. Any dose of Prevnar 13 counts if given at younger ages.1
  2. If elective splenectomy or cochlear implant is being considered, the vaccine should be given at least 2 weeks before the procedure. If vaccination prior to the procedure is not feasible, the vaccine should be given as soon as possible after surgery. Similarly, there should also be a 2-week interval between vaccination and initiation of cancer chemotherapy or other immunosuppressive therapy, if possible.4

Project Leader in preparation of this clinical resource (350901): Melanie Cupp, Pharm.D., BCPS

References

  1. CDC. Pneumococcal vaccine timing for adults. November 30, 2015. https://www.cdc.gov/vaccines/vpd/pneumo/downloads/pneumo-vaccine-timing.pdf. (Accessed August 1, 2019).
  2. Product information for Prevnar 13. Wyeth Pharmaceuticals, Inc. Philadelphia, PA 19101. August 2017.
  3. CDC. General recommendations on immunization. In: Epidemiology and prevention of vaccine-preventable diseases. The Pink Book: Course Textbook. 13th Ed. 2015. https://www.cdc.gov/vaccines/pubs/pinkbook/downloads/genrec.pdf. (Accessed August 1, 2019).
  4. CDC. Pneumococcal disease. In: Epidemiology and prevention of vaccine-preventable disease. The Pink Book: Course Textbook. 13th Ed. 2015. https://www.cdc.gov/vaccines/pubs/pinkbook/downloads/pneumo.pdf. (Accessed August 1, 2019).
  5. Tomczyk S, Bennett NM, Stoecker C, 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 Morb Mortal Wkly Rep 2014;63:822-5.
  6. CDC. Principles of vaccination. In: Epidemiology and prevention of vaccine-preventable diseases. The Pink Book: Course Textbook. 13th Ed. 2015. https://www.cdc.gov/vaccines/pubs/pinkbook/downloads/prinvac.pdf. (Accessed August 1, 2019).
  7. Kobayashi M, Bennett NM, Gierke R, et al. Intervals between PCV13 and PPSV23 vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep 2015;64:944-7. Erratum in: October 30, 2015;64:1204.
  8. CDC. Influenza. In: Epidemiology and prevention of vaccine-preventable diseases. The Pink Book: Course Textbook. 13th Ed. 2015. http://www.cdc.gov/vaccines/pubs/pinkbook/flu.html#schedule. (Accessed August 1, 2019).
  9. ACIP Recommendations. June 2019 meeting recommendations. https://www.cdc.gov/vaccines/acip/recommendations.html. (Accessed August 1, 2019).
  10. Foster S, Goad J. Your guide to the latest in immunization practice. Annual Meeting and Exposition. Seattle, WA. March 22 to 25, 2019. https://aphameeting.pharmacist.com/sites/default/files/slides/Your%20immunization%20update%202019%20HO%20pgs%201-60.pdf. (Accessed August 8, 2019).

Cite this document as follows: Clinical Resource, Pneumococcal Vaccination in Adults: Who Gets What and When? Pharmacist’s Letter/Prescriber’s Letter. September 2019.

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