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Alaska Native and American Indian pneumococcal vaccine recommendations revised
Anticipated benefits of a mixed vaccine schedule do not outweigh potential risks and problems with implementation.
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ATLANTA — Revising vague language in the Advisory Committee on Immunization Practice’s recommendations for administering pneumococcal polysaccharide vaccine to otherwise healthy Alaska Native and American Indian children after they have previously received the seven-valent pneumococcal conjugate vaccine has been on the committee’s agenda since June. Proposals to clarify the recommendations were passed at the meeting in October.
“There are some considerable weaknesses in the recommendation. One is that the burden of decision making is on the individual provider, and many stress that they don’t have sufficient data to make these decisions,” Kate O’Brien, MD, MPH, associate professor at Johns Hopkins Bloomberg School of Public Health, Center for American Indian Health, said during a presentation of the working group’s activities.
After some deliberation, the committee tightened up pneumococcal vaccine recommendations for otherwise healthy children in these populations (recommendations for PPV23 use among children with underlying medical conditions, regardless of their ethnicity is already addressed in other parts of the ACIP PPV23 recommendation). Language that previously stated that physicians could consider revaccinating children of Alaska Native and American Indian descent who have already received the seven-valent pneumococcal (Prevnar, Wyeth) conjugate vaccine with the 23-valent pneumococcal polysaccharide vaccine (Pneumovax 23, Merck) at age 2 years has been redacted.
The committee no longer recommends routine revaccination with PPV23 for otherwise healthy children in this population; however, “health authorities may consider recommending” the additional vaccine in children aged 24 through 59 months “who are living in areas in which risk of invasive pneumococcal disease is increased,” the new recommendation states. This statement will allow the future use of PPV23 should the epidemiologic situation change.
Rationale behind the revisions
Changes in the ACIP recommendation stem from recognition that data on the increased risk of invasive pneumococcal disease exists among only a subset of Native American groups, rather than all Native Americans (ie Alaska Native, White Mountain Apache and Navajo populations); lack of a clear definition regarding American Indian descent; the observation of immune hyporesponsiveness; and the complexity of a two-product vaccine strategy.
“It is important to point out the perspective of the practitioners that are serving this population,” O’Brien said. “Routine use of polysaccharide vaccine has never been implemented in these populations, even when the rates were significantly higher in the preconjugate vaccine era, so there are no local data on safety or reactive immunogenicity in these populations.”
Furthermore, little is known about the efficacy of PPV23 in children aged younger than 5 years, according to O’Brien.
Although a disparity exists between incidence of invasive pneumococcal disease in the general U.S. population and some Alaska Native and American Indian populations, disease rates have decreased dramatically since the introduction of PCV7 in 1995, according to O’Brien. For some tribes rates remain higher than in similarly aged children in the general U.S. population. PPV23 serotypes account for between 80% and 90% of residual invasive pneumococcal disease cases in children aged between 2 and 5 years; however, the absolute rate differences are not large enough to warrant routine use of PPV23 among these children. “It is important to recognize that polysaccharide vaccine is routinely given to those children in these populations who have high risk conditions, but this is covered elsewhere in the ACIP recommendations,” O’Brien said. – by Nicole Blazek
For more information:
- O’Brien K. Proposed recommendations for use of PPV23 among American Indians and Alaska Natives. Presented at: the Advisory Committee on Immunization Practices Meeting; Oct. 22-23, 2008; Atlanta.