What physicians need to know to ensure simpler pneumococcal vaccine management

Key takeaways:

• To avoid uncertainty, an expert recommends physicians understand each vaccine’s serotypes and which ones are being phased out.
• The 20-valent pneumococcal conjugate vaccine may be preferable due to convenience.

Over the last decade, there have been several updates to pneumococcal vaccinations in adolescents and adults, often leading to confusion among health care providers.

Much of this confusion is due to the availability of both updated and past pneumococcal vaccinations, according to William Schaffner, MD, a professor of preventive medicine and infectious diseases at Vanderbilt University Medical Center and medical director of the National Foundation for Infectious Diseases.

“We have both conjugate vaccines, which are relatively new, and the now very traditional old polysaccharide vaccine. The very fact that they're both still around will lead to some inevitable confusion,” Schaffner, who is also a member of the Infectious Disease News Editorial Board, told Healio.

Currently, there are four pneumococcal vaccinations licensed for use, which include:

• 20-valent pneumococcal conjugate vaccine (PCV20; Pfizer);
• 15-valent pneumococcal conjugate vaccine (PCV15; Merck);
• 13-valent pneumococcal conjugate vaccine (PCV13; Wyeth Pharmaceuticals); and
• 23-valent pneumococcal polysaccharide vaccine (PPSV23; Merck).

The indications and schedules for the vaccines vary. All four vaccines are approved for adults. The PCV13 vaccine and, as of June 2021, the PCV15 vaccine are approved in children. In addition, Schaffner said the PCV20 is currently on track to be approved in youth.

Ultimately, “the advent of those newer vaccines will raise a lot of questions in physicians’ minds and lead to confusion,” he said.

Schaffner expanded upon each vaccine’s regimen and highlighted key factors to help providers determine which vaccine to use and when.

Recommendations for PCV13

The CDC recommends one dose of the PCV13 vaccine for children at four different ages: 2 months, 4 months, 6 months and 12 to 15 months.

If they do not receive the recommended doses at those intervals, children without medical conditions can finish their vaccine series up to 59 months.

For children and adolescents aged 5 to 18 years with certain medical conditions, a single dose of PCV13 is recommended if they have not received any doses already. According to Schaffner, these medical conditions include heart disease, lung disease and diabetes.

When determining which PCV to use in children, Schaffner explained one significant simplifying factor is that PCV13 “is being phased out.”

“It will likely be replaced by PCV20,” he said.

Schaffner added that PCV13 no longer has a role in adult immunization, “unless PCV15 and PCV20 are unavailable.”

Recommendations for PCV15

Like PCV13, one dose of PCV15 can each be given to infants at age 2 months, 4 months, 6 months and 12 to 15 months. Those without certain medical conditions can finish the series up to 59 months.

Varying doses of PCV13 can also be given to children aged 2 to 5 years with certain medical conditions. Additionally, both PCV13 and PCV15 can be used interchangeably for healthy children and those with underlying conditions, according to the CDC.

Children aged 6 to 18 years with specific medical conditions can be given a single dose of PCV15 if they did not receive any prior vaccinations.

For adult patients who have not received any prior vaccinations, the CDC recommends a single dose of PCV15, followed by a dose of PPSV23, for those aged:

• 19 to 64 years who have certain medical conditions or risk factors; and
• 65 years and older.

Recommendations for PCV20

For adult patients who have not received prior vaccinations, a single dose of PCV20 is recommended for those aged:

• 19 to 64 years who have certain medical conditions or risk factors; and
• 65 years and older.

Additionally, adults aged 65 years and older have the option to receive PCV20 if they have not received:

• PCV13, but not PCV15 or PCV20, at any age; or
• PPSV23 at or over age 65 years.

Recommendations for PPSV23

According to the CDC, PPSV23 is recommended for:

• youth aged 2 to 13 years at increased risk due to certain medical conditions or risk factors after they have been given a dose of PCV15 or PCV20; and
• adults aged 19 years and older who have received PCV15.

PCV20 may offer preferable convenience

Schaffner said the serotype coverage of each PCV is one way to determine which vaccine to administer.

“PCV20 obviously covers 20 serotypes of the pneumococcus, PCV15 covers 15, and that’s why the polysaccharide vaccine is also still recommended,” he said. “It covers 23 serotypes, so you will get some added benefit from that second vaccine.”

Regardless of the vaccine, “the important thing is that everyone in your practice aged 65 years and older who hasn’t received pneumococcal vaccines previously should receive a one of these new vaccines,” Schaffner said.

While the combined regimen of PCV15 and PPSV23 may be preferential over PCV20 due to the additional serotype protection received from both, PCV20 has demonstrated its own benefits in the way of simplified patient care.

“What the CDC simply says is they don’t make a preferential recommendation and will let you choose on your own,” Schaffner said. “I think it’s quite evident that just using PCV20 is simpler because it’s a one and done regimen. You don't have to worry about following it up with polysaccharide vaccine.”

After conversations with local internists, Schaffner observed that “so far, they're choosing the PCV20 route just for convenience.”

“Polysaccharide vaccine has been around for a long time. It's certainly a valid vaccine, but my general sense is that internists don't have quite the confidence in it that they have in the newer conjugate vaccines,” he said.

Schaffner also advised physicians to consult the CDC’s chart detailing vaccine timing for adults aged 19 years and older.

“Suppose you have a patient who's received just polysaccharide vaccine, or they’ve received PCV13 and now it's been over 5 years, should you get it updated? All of those nuanced issues are dealt with pretty clearly in the table. It will provide good guidance for any doctor,” he said.

References:

• Pneumococcal Conjugate VIS. https://www.cdc.gov/vaccines/hcp/vis/vis-statements/pcv.html. Accessed March 14, 2023.
• Pneumococcal vaccine timing for adults. https://www.cdc.gov/vaccines/vpd/pneumo/downloads/pneumo-vaccine-timing.pdf. Accessed March 9, 2023.
• Pneumococcal vaccination. https://www.cdc.gov/pneumococcal/vaccination.html. Accessed March 8, 2023.
• Pneumococcal vaccination: What everyone should know. https://www.cdc.gov/vaccines/vpd/pneumo/public/index.html. Accessed March 15, 2023.