ACIP: new recommendations for HPV and PCV-13 vaccines

The Advisory Committee on Immunization Practices (ACIP) of the CDC voted last week on 2 new vaccine recommendations: extending the age indication for the HPV vaccine and making the PCV-13 vaccine less clearly recommended. (There was no direct ACIP statement on these, just as reported by others. my info comes from STAT: https://www.statnews.com/2019/06/26/u-s-advisory-panel-stops-short-of-broad-recommendations-for-two-common-vaccines/
 ). In general the ACIP recommendations are followed by the CDC.

HPV vaccine (human papillomavirus):
--unanimous vote to equalize the recommended age for vaccination for women and men to age 26 (prior recommendation for men was til age 21)
--they did not recommend extending the age to 45, but left that to the patients and providers to decide.  This goes against the strong FDA recommendation to extend the age for all to 45 (of course, the patient still can decide….). see http://gmodestmedblogs.blogspot.com/2018/10/vaccine-approved-to-age-45-tdap-best.html for a review of the FDA proposal along with the studies they used to support this

PCV-13 (pneumococcal conjugate vaccine), this recommendation pertained only to adults over 65
--prior recommendation was for all adults 65 and oldePr
--new recommendation is for "shared clinical decision making", approved by a narrowish margin of 8 to 6
--it is notable that, though pneumococcal disease is not so common in adults, the vaccination of small kids with the original 7-valent PCV-7 vaccine (the precursor of PCV-13) decreased the incidence of pneumococcal disease in adults caused by the serotypes covered by PCV-7 from about 35 cases/100K population down to <5/100K.  (the vaccine in kids has had remarkable success, decreasing severe pneumococcal disease on the order of 50% against vaccine-type pneumococcal pneumonia, and 75% against vaccine-type invasive pneumococcal disease, per https://www.cdc.gov/vaccines/vpd/pneumo/hcp/about-vaccine.html. ) several of the ACIP members voted for the more watered-down recommendation because the incidence in adults has decreased so much in the vaccine-covered serotypes just by immunizing the kids
--there was a recent case-controlled study from Kentucky suggesting that immunizing patients >65yo with PCV-13 resulted in a major shift away from getting vaccine-specific serotypes (4.4% of those immunized had one of the serotypes, vs 14.5% in unimmunized, leading to an adjusted vaccine effectiveness of about 72%. See https://academic.oup.com/cid/article/67/10/1498/5000157 )
--and, as we know from the current measles epidemic, vaccination coverage in kids can be spotty, and exposure to disease overall is now more globalized with more travel to areas where kids are not so well immunized. so, relying on broad immunization of kids to protect adults may not necessarily be sufficient.

So, contrary to the above suggested changes, I do think that the current data are sufficient to continue with the old PCV13 recommendation for those >65, and extending the HPV til age 45.  These vaccines do have documented effectiveness in preventing serious diseases (especially invasive pneumococcal disease in adults and cervical cancer in women/likely oropharyngeal cancer in men and women).  On the other hand, It is good that they finally did increase the age for males at least to 26yo, as with females...

One potential concern is that down-grading the recommendations from Category A (a recommendation for all persons in an age- or risk-factor-based group) to Category B (individual clinical decision-making) is that there could be differences in the likelihood of insurance company coverage. At this time the Affordable Care Act (also known as “Obamacare”, which seems to be in the process of systematic deconstruction by Trump) requires coverage of both Categories A and B, as does the Vaccines for Children Program, Medicare and Medicaid. Of note, there is no legal imperative for private insurance companies to cover vaccines. So, a potential concern is that coverage may change and perhaps be different for Category A and B vaccines. we shall see how it all unfolds….

geoff

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