What are the pneumococcal vaccine guidelines for older adults with chronic disease?

From the Guidelines

Adults aged 65 and older and those with chronic conditions should receive both the PCV20 (Prevnar 20) or PCV15 (Vaxneuvance) pneumococcal conjugate vaccine and, if PCV15 is given, the PPSV23 (Pneumovax 23) polysaccharide vaccine, as recommended by the most recent guidelines 1.

Key Recommendations

• For healthy adults 65+, a single dose of PCV20 is recommended, or alternatively, PCV15 followed by PPSV23 at least one year later.
• Adults 19-64 with chronic conditions like heart disease, lung disease, diabetes, alcoholism, or who smoke should follow the same schedule.
• Those with immunocompromising conditions, cochlear implants, or CSF leaks should receive PCV15 followed by PPSV23 at least 8 weeks later.

Rationale

These vaccines protect against invasive pneumococcal disease, which can cause serious infections including pneumonia, meningitis, and bloodstream infections. Pneumococcal disease carries significant mortality risk in older adults and those with chronic conditions. Side effects are generally mild and include injection site pain, fatigue, headache, and muscle pain. The vaccines can be administered during the same visit as other vaccines, including the flu vaccine, making it convenient to maintain protection.

Considerations

The Advisory Committee on Immunization Practices (ACIP) provides regular updates on pneumococcal vaccine recommendations, and the most recent guidelines should be consulted for specific guidance on vaccine administration 1. Additionally, shared clinical decision-making may be necessary for certain patients, taking into account individual risk factors and medical conditions 1.

From the Research

Pneumococcal Vaccine Guidelines for Older Adults with Chronic Disease

• The currently recommended single dose of the 23-valent pneumococcal free polysaccharide vaccine (PPSV23) for adults 65 years of age and older does not provide extended protection into older age 2.
• A 13-valent polysaccharide conjugate vaccine (PCV13) may provide alternative protection for older adults against pneumococcal infection 2.
• In adults aged 70 years and older previously vaccinated with PPSV23, PCV13 was significantly more immunogenic than PPSV23 for most of the common serotypes and for serotype 6A 2.
• Sequential PCV13/PPSV23 vaccination showed the highest adjusted vaccine effectiveness of 80.3% against pneumococcal community-acquired pneumonia (CAP) in adults aged 65-74 years 3.
• The Advisory Committee on Immunization Practices (ACIP) recommends a single dose of PCV for all PCV-naïve adults aged ≥50 years 4.
• Initial vaccination with PCV13 establishes an immune state that results in recall anti-pneumococcal responses upon subsequent vaccination with either conjugated or free polysaccharide vaccine 5.
• The 23-valent pneumococcal polysaccharide vaccine (PPSV23) is effective against vaccine-type invasive pneumococcal disease and vaccine-type pneumococcal pneumonia, but PPSV23-conferred protection may be lower in adults aged ≥75 years, those with certain underlying conditions, and individuals who were vaccinated >5 years before disease onset 6.

Vaccine Effectiveness and Recommendations

• The effectiveness of PCV13 and PPSV23 against pneumococcal CAP was statistically insignificant in adults aged ≥65 years, but sequential PCV13/PPSV23 vaccination was most effective in preventing pneumococcal CAP among adults aged 65-74 years 3.
• ACIP recommends a single dose of PCV for all PCV-naïve adults aged ≥50 years, and options include either 20-valent PCV (PCV20) or 21-valent PCV (PCV21) alone or 15-valent PCV (PCV15) in series with 23-valent pneumococcal polysaccharide vaccine (PPSV23) 4.
• Initial vaccination with PCV13 induces a T cell-dependent immune response and has the potential to provide an extended duration of protection with repeated vaccinations 5.

Special Considerations

• Adults with chronic disease may have a higher risk of pneumococcal infection, and vaccination with PCV13 or PPSV23 may provide protection against pneumococcal disease 2, 3, 6.
• The immune response to pneumococcal vaccination may be affected by the type of vaccine used, the age of the individual, and the presence of underlying medical conditions 2, 5, 6.