Does my healthy 65-year-old patient still need the 13-valent pneumococcal conjugate vaccine (PCV13)?

WHY CHANGE THE RECOMMENDATION?

In its 2014 recommendation for pneumococcal vaccination in all adults 65 and older, the ACIP noted that certain high-risk groups should be vaccinated earlier or receive additional doses.¹ Pallotta and Rehm outlined these recommendations and discussed the rationale for vaccinating against Streptococcus pneumoniae to prevent invasive pneumococcal disease.³

So why did the ACIP modify its recommendation? The primary reason is that the incidence of PCV13-type pneumococcal disease in adults had gone down to historic lows (Figure 1). A key to this reduction was that children started to be vaccinated in 2000, at first with PCV7 and then with PCV13, which replaced PCV7 in 2010.^1,2 This incidence leveled out from 2014 to 2018 despite the ACIP recommendation and data showing that about half the Medicare beneficiaries older than 65 received the vaccine.⁴ The decreased incidence of disease also has decreased the cost-effectiveness of vaccination. The cost of giving PCV13 and then PPSV23, compared with PPSV23 alone, is now estimated to be $200,000 to $560,000 per quality-adjusted life year,¹ whereas in 2014, it was only $65,000.⁵

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FIGURE 1

Incidence of invasive pneumococcal disease among US adults 65 and older by pneumococcal serotype, 1998–2017.

Matanock A, Lee G, Gierke R, Kobayashi M, Leidner A, Pilishvili T. Use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine among adults aged ≥ 65 years: updated recommendations of the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep 2019; 68(46):1069–1075. doi:10.15585/mmwr.mm6846a5

In light of these facts, the ACIP voted to remove the recommendation requiring older patients to receive the PCV13 vaccine.

SHARED CLINICAL DECISION-MAKING

But it is not that simple. In an attempt to balance “the minimal population-level impact of routine [vaccination] with the potential for individual-level protection,”¹ the ACIP added the principle of shared clinical decision-making to its recommendation.^1,2,4

The ACIP committee recognized that some immunocompetent patients at higher risk of invasive pneumococcal disease (or their physicians) may believe that PCV13 would still be worthwhile. This population includes patients with certain medical conditions (eg, alcohol or tobacco abuse; chronic heart, liver, or lung disease; diabetes) and patients living in nursing homes or other long-term care facilities.^1,4 By adding the concept of shared clinical decision-making, the ACIP committee ensured that “PCV13 would remain available to patients who want this added protection.”¹

A practical downside of this recommendation is that busy primary care practitioners may lack the time to effectively and efficiently review the potential benefit or lack of benefit of PCV13 for the individual. Also, universal recommendations (eg, vaccinate all patients over age 65) are generally easier to remember or implement than conditional recommendations (eg, vaccinate some patients over age 65). Strategies known to improve vaccination compliance rates include interventions such as electronic medical record reminders and direct patient outreach.

SUMMARY

The 2019 ACIP recommendations are to vaccinate all patients age 65 and older with PPSV23, but PCV13 can be used in shared clinical decision-making. The ACIP continues to endorse use of both PCV13 and PPSV23 in patients older than 19 (including those 65 and older) with immunocompromising conditions, cerebrospinal fluid leak, or cochlear implants.¹ These recommendations are summarized in Table 1.²