Updated Pneumococcal Vaccine Guidelines - NPX Newsletter Summer 2022

By Nicole Glatz, PharmD Candidate, OSU 2023

Vaccine recommendations and products change frequently. It is important to frequently reference CDC’s website for the latest. Until recently, PCV13 and PPSV23 were the gold standard for pneumococcal vaccines. In October of 2021, CDC's Advisory Committee on Immunization Practices began to recommend the use of PCV15 or PCV20 for PCV naïve adults over the age of 65 or those from 19-64 years old with underlying conditions. PCV13 contains the pneumococcal polysaccharide serotypes of 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, and 23F. This differs from PCV 15 and PCV20 which contain 2 or 7 additional serotypes. Phase 3 trials of PCV15 and PCV20 compared to PCV13 showed noninferiority of the new vaccines for the 13 shared serotypes in adults ≥50 and ≥60, respectively. The table below further compares PCV15 and PCV20.

The new guidelines for the pneumococcal vaccines recommend that patients who are between 19-64 years old and have underlying conditions or over the age 65 receive either the PCV20 or the PCV15 vaccine with the PPSV23 vaccine one year after the PCV15 vaccine. The following diagrams depict the new vaccine guidelines.

Age 65+ or 19-64 years old with certain underlying medication conditions or risk factors†

†Alcoholism; chronic heart, liver, or lung disease; chronic renal failure; cigarette smoking; cochlear implant; congenital or acquired asplenia; cerebrospinal fluid leak; diabetes mellitus; generalized malignancy; HIV; Hodgkin disease; immunodeficiency; iatrogenic immunosuppression; leukemia, lymphoma, or multiple myeloma; nephrotic syndrome; solid organ transplant; sickle cell disease; or other hemoglobinopathies

*a minimum interval of 8 weeks can be considered for adults with an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak

Adults with previous PPSV23

The benefit of adding PCV15 or PCV20 to previous PCV13 or PCV13 and PPSV23 vaccination has not been studied. Thus, if a patient has already received the PCV13 vaccine with or without the PPSV23 vaccine, it is currently recommended to follow the older pneumococcal vaccine guidelines. The one exception to this is if PCV13 has been given and PPSV23 is due but not available, one dose of PCV20 may be used in place of PPSV23. Another aspect of the new vaccines that could use future studies is coadministration. PCV15, PCV20, and PPSV23 can be co-administered with QIV however slightly lower pneumococcal serotype specific OPA GMTs have been observed with co-administration. Currently, there is no data of the coadministration of these vaccines with Tdap, hepatitis B, or zoster vaccines. 

While a clear difference between the PCV vaccines and the PPSV23 vaccine is the number of serotypes that each vaccine covers, another important difference is in the formulation of the different vaccines. PPSV23 is a polysaccharide vaccine meaning that the pneumococcus is surrounded by a polysaccharide capsule. PPSV23 works by producing antibodies that boost the activity of phagocytic cells to kill the pneumococcus. Polysaccharide antigens do not induce a T-cell dependent response and therefore have an absence of memory B cells. Thus, antibodies to pneumococcus decline after 3-5 years and after 5-10 years, antibody titers usually show pre-vaccination levels. In contrast, the PCV vaccines are a protein-polysaccharide combination. These vaccines are T-cell dependent and can create a memory response giving them a longer duration. A benefit of PPSV23 is that it is cheaper than PCV13 and was cost effective in preventing invasive pneumococcal disease in immunocompetent older adults compared to PCV13. However, some cost effectiveness analyses of PCV20 or PCV15 and PPSV23 for adults at age 65 showed cost savings. Overall, PCV15 and PCV20 seem to be safe and effective vaccines that may help keep older and at-risk populations from contracting invasive pneumococcal infections better than previously studied vaccines. 

Reference
Kobayashi M, Farrar JL, Gierke R, et al. Use of 15-Valent Pneumococcal Conjugate Vaccine and 20-Valent Pneumococcal Conjugate Vaccine Among U.S. Adults: Updated Recommendations of the Advisory Committee on Immunization Practices — United States, 2022. MMWR Morb Mortal Wkly Rep 2022;71:109–117. DOI: http://dx.doi.org/10.15585/mmwr.mm7104a1

Vila-Corcoles A, Ochoa-Gondar O. Preventing pneumococcal disease in the elderly. Drugs & Aging. 2013;30(5):263-276. doi:10.1007/s40266-013-0060-5