Should I continue to vaccinate my 65 years or older patients with pneumococcal conjugate vaccine (PCV13)?

The 2020 U.S. Advisory Committee on Immunization Practices (ACIP) has revised its previous 2014 guidelines from routinely vaccinating all adults 65 years or older with PCV13 to a more selective vaccination approach based on shared clinical decision-making in the absence of immunocompromising conditions, cerebrospinal fluid leak or cochlear implant. 1

More specifically, ACIP recommends that we “regularly” offer PCV13 for patients 65 years or older who have not previously received PCV13 in the following settings:

  • Residents of nursing homes or other long-term care facilities
  • Residents of settings with low pediatric PCV13 uptake
  • Travelers to settings with no pediatric PCV13 program

ACIP also recommends that we consider offering the PCV13 to patients with chronic heart, lung, or liver disease, diabetes, or alcoholism, those who smoke cigarettes, or those with more than 1 chronic medical condition.

Why the change in recommendations? The primary reason is sharp declines in pneumococcal disease in unvaccinated children and adults due to the widespread use of PCV7 and PCV13 in children, resulting in prevention of transmission of vaccine-type strains.  

These recommendations do not apply to the pneumococcal 23-valent polysaccharide vaccine (PPSV23), however. All adults 65 years or older should continue to receive a dose of PPSV23. 

Bonus Pearl: If a decision is made to administer PCV13 to an adult 65 years old or older, PCV13 should be administered first, followed by PPSV23 at least 1 year later.

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References

  1. Freedman M, Kroger A, Hunter P, et al. Recommended adult immunization schedule, United States, 2020. Ann Intern Med 2020; [Epub ahead of print 4 February 2020]. Doi: https://doi.org/10.7326/M20-0046.
  2. Matanock A, Lee G, Gierke R, et al. Use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine among adults aged ≥65 years: updated recommendations of the advisory committee on immunization practices. MMWR 2019;68:1069-75. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6871896/pdf/mm6846a5.pdf

 

Should I continue to vaccinate my 65 years or older patients with pneumococcal conjugate vaccine (PCV13)?

Should my hospitalized patient with ulcerative colitis flare-up receive pneumococcal vaccination?

There are at least 2 reasons for considering pneumococcal vaccination in hospitalized patients with ulcerative colitis flare.

First, these patients are often on immunosuppressants (eg, glucocorticoids) or biological agents (eg, infliximab) that qualifies them for both 13-valent conjugate (PCV13) and 23-valent polysaccharide (PPSV23) pneumococcal vaccines under the Advisory Committee on Immunization Practices (ACIP) Guidelines’ “Immunocompromised persons” risk group.1-4

Another reason is the possibility of  UC patients having coexisting hyposplenism, a major risk factor for pneumococcal disease. Although this association has been described several times in the literature since 1970s, it is relatively less well known.  In a study of patients with UC, hyposplenism (either by the presence of Howell-Jolly bodies in the peripheral blood smear or prolongation of clearance from blood of injected radioactively labelled heat-damaged red blood cells) was found in over one-third with some developing life-threatening septicemia in the early postcolectomy period.5

Another study found the majority of patients with UC having slow clearance of heat damaged RBCs despite absence of Howell-Jolly bodies in the peripheral smear.6 Fulminant and fatal pneumococcal sepsis has also been reported in patients with UC.7

Although the immunological response to pneumococcal vaccination may be lower among immunosuppressed patients in general, including those with UC, it should still be administered to this population given its potential benefit in reducing the risk of serious pneumococcal disease. 2,3  

References

  1. CDC. Intervals between PCV13 and PSV23 vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2015;64:944-47. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6434a4.htm
  2. Carrera E, Manzano r, Garrido. Efficacy of the vaccination in inflammatory bowel disease. World J Gastroenterol 2013;19:1349-53. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3602493/
  3. Reich J, Wasan S, Farraye FA. Vaccinating patients with inflammatory bowel disease. Gastroenterol Hepatol 2016;12:540-46. http://www.gastroenterologyandhepatology.net/archives/september-2016/vaccinating-patients-with-inflammatory-bowel-disease/
  4. Chaudrey K, Salvaggio M, Ahmed A, et al. Updates in vaccination: recommendations for adult inflammatory bowel disease patients. World J Gastroenterol 2015;21:3184-96. https://www.ncbi.nlm.nih.gov/pubmed/25805924
  5. Ryan FP, Smart RC, Holdworth CD, et al. Hyposplenism in inflammatory bowel disease. Gut 1978;19:50-55. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1411782/
  6. Jewell DP, Berney JJ, Pettit JE. Splenic phagocytic function in patients with inflammatory bowel disease. Pathology 1981;13:717-23. https://www.ncbi.nlm.nih.gov/pubmed/7335378
  7. Van der Hoeven JG, de Koning J, Masclee AM et al. Fatal pneumococcal septic shock in a patient with ulcerative colitis. Clin Infec Dis 1996;22:860-1. https://www.ncbi.nlm.nih.gov/pubmed/8722951

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Should my hospitalized patient with ulcerative colitis flare-up receive pneumococcal vaccination?