ACIP Recommends Pneumococcal Vaccines For Those 65+ and Immunocompromised Adults BY GINA SHAW
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moderately divided Advisory Committee on Immunization Practices (ACIP) recommended that adults 65 years of age and older, and those aged 19 years and older with certain underlying medical conditions or other risk factors, should receive a pneumococcal conjugate vaccine (either PCV20 or PCV15). If PCV15 is used, they recommended, the vaccine should be followed by a dose of pneumococcal polysaccharide vaccine (PPSV23). The risk factors in younger people include alcoholism, chronic heart, liver or lung disease, cigarette smoking, diabetes mellitus, chronic renal failure, nephrotic syndrome, immunodeficiency, iatrogenic immunosuppression, generalized malignancy, HIV, Hodgkin disease, leukemia, lymphoma, multiple myeloma, solid-organ transplants, congenital or acquired asplenia, sickle cell disease or other hemoglobinopathies, cerebrospinal fluid leak, or having a cochlear implant. At the Oct. 20 ACIP meeting, all panel members agreed that these two recommendations should go forward, but four of 15 voted yes on a prior recommendation that the age-based guideline should be brought down to age 50, noting that it could reduce disparities in disease burden in adults aged 50 to 64 years, and could open up opportunities to vaccinate adults before they develop underlying conditions. “This age group already has a lot of comorbid conditions, and it would be much easier to simplify the vaccination process to include this group,” said panel member Helen Keipp Talbot, MD, an associate professor of medicine at Vanderbilt University, in Nashville, Tenn. “This is an age group that will respond to a vaccine and create a lasting vaccine response much better than someone aged 70. The majority of physicians who
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take care of adults really were interested in starting at age 50. “While I do recognize that we do not know the duration of protection if we start at this age, as adult physicians, we are more than happy to evaluate a booster in the future because we hope that our patients live long enough to require that booster. We would like to capture people when they are most likely to respond to a vaccine and reduce current disease disparities,” Dr. Talbot said. But the ACIP found that placing the age-based recommendation for a PCV vaccine at 65 years of age consistently lowered the cost and provided better health outcomes, said Miwako Kobayashi, MD, MPH, a CDC epidemiologist in the Pneumococcal Vaccines Work Group, who presented the recommendations to the full panel. “When we reviewed the data for cost-effectiveness at 65 and older, there was consistent cost savings, which means lower cost and better health outcomes compared with current recommendations, in all costeffectiveness analyses,” she said. “Our analyses found that while recommending PCV20 at age 65 consistently showed that the intervention was cost-saving, PCV20 at age 50 resulted in worse health in some CDC scenarios.” Dr. Kobayashi noted that more than 90% of the infectious pneumococcal disease burden in the United States is in those who are 65 years of age and older, and in those who are 19 to 64 years of age with risk-based indications. After the unanimous vote to support the PCV vaccine in adults 65 and older and those aged 19 and older with certain underlying risk factors, members noted the importance of further data. “I do have some concerns that the disparities in outcomes related to invasive PCV disease may not be totally addressed by our vote,” said Oliver Brooks, MD,
the chief medical officer for the Watts HealthCare Corp., in Los Angeles, and a past president of the National Medical Association, who pointed out that hypertension and obesity were not included among the underlying risk factors. “Although there seems to be evidence suggesting that hypertension and obesity are not risk factors for PCV disease, I’d like to revisit these conditions at some time in the near future.” Many patients will still have invasive pneumococcal disease with serotypes that are not covered by the existing vaccines, noted Sarah Long, MD, a professor of pediatrics at Drexel University College of Medicine and the chief of the Section of Infectious Diseases at St. Christopher’s Hospital for Children, in Philadelphia. “It is increasingly important, in adults with invasive pneumococcal disease, that those isolates be saved and sent for serotyping. This is not a completely preventable disease, and in immunocompromised patients specifically, the likelihood that they have non-vaccine serotypes of invasive disease is quite high. Our clinical observations of what we are seeing, and how that is or isn’t covered by the vaccine, will only be relevant if we have ■ serotyping of those isolates.” The sources reported no relevant financial disclosures.
