PCV-13 for all seniors??

as mentioned in https://gmodestmedblogs.blogspot.com/2019/07/acip-new-recommendations-for-hpv-and.html, there are new recommendations, now formally accepted by the CDC, to not administer the anti-pneumococcal PCV13 vaccine routinely but instead to engage the patient in “shared decision-making” (see https://www.cdc.gov/mmwr/volumes/68/wr/mm6846a5.htm )

Details:

-- there was a dramatic decrease in invasive pneumococcal disease (IPD) in adults greater than 65yo, beginning with the introduction of the PCV7 to kids in 2000. This reduction continued to decrease for the 1^st 4 years or so, leveled off, and then plummeted further after the introduction of PCV13 (covering 6 more pneumococcal serotypes) to children in 2010. These decreases were found in the aggregate of IPD cases, as well as cases from PCV13 vaccine-specific serotypes. There was no change in the incidence of non-covered PCV13 serotypes

-- In 2014 the CDC recommended PCV13 for all adults over 65yo. In the subsequent 3 years there was no further decrease in invasive pneumococcal disease in those over 65. Specifically:

     -- there was a pretty strong uptake in PCV13 vaccination rates in adults: in 2018, 47% received PCV13, 45% got PPSV23, 30% got the combination, and 62% got some coverage by a pneumococcal vaccine

    -- overall there was a ninefold decrease in invasive pneumococcal infections from PCV13-specific serotypes

    -- BUT, immunizing those over 65yo did NOT lead to any further decrease in their already low numbers of vaccine-specific IPD cases (incidence was stable at 5 IPD cases per 100K population).

    --and, there was no further decrease in pneumococcal disease on the unimmunized 19-64 year olds by immunizing those >65yo with PCV13

-- the protective effects of immunizing kids is similar in magnitude in adults over 65 who are at increased risk of IPD either because of older age (> 85 years old) or presence of underlying chronic medical conditions

-- all adults should still get PPSV23 according to the routine immunization schedule

  

points for shared decision-making, for adults over 65 who do not have any known immunocompromising conditions (including HIV), CSF leak, or cochlear implants:

-- PCV 13 is safe (ie, severe reactions are no different from placebo) and very effective in older adults.

-- The IPD risk in those >65yo is much lower than it was before widespread PCV 13 immunization of kids, as a result of decreasing PCV 13 carriage and transmission to older people. However, there are some conditions where PCV 13 may still be appropriate because of the patients’ likelihood of attaining higher than average benefit from PCV13 vaccination:

    -- people residing in nursing homes or other long-term care facilities

    -- people residing in settings with low pediatric PCV immunization rates

    -- people traveling to settings with no pediatric PCV13 program

    -- also, people with underlying medical conditions where invasive pneumococcal disease from PCV serotypes is more likely: chronic heart, lung, or liver disease, diabetes, alcoholism, smokers, or those with >1 chronic medical condition

--but, all patients at >65yo should get PCV-13 if they are immunocompromised (including CKD, nephrotic syndrome, immunosuppression, malignancy, HIV, sickle cell), or have cochlear implants or CSF leaks

So, it does seem pretty clear that many patients older than 65 without significant comorbidities may not receive significant benefit from PCV13 immunization (they seem to get huge benefit by immunizing young kids, their pneumococcal vectors). However, many such people do travel to countries where PCV13 immunization programs do not exist for children. The clearest examples are people who come from those countries and go back to visit, or they entertain visitors from these countries who have never been immunized. It is even possible that people traveling for vacations may be infected from the high pneumococcal carriage rates in those countries (i have seen no data supporting  this contention, though there does seem to be lots of international travel these days; and, as noted above, the CDC does include travel to these countries as a discussion point with patients).

bottom line: i still think that PCV13 is a highly effective vaccine, with minimal adverse effects and low cost, and that those coming from countries without aggressive PCV13 immunization of kids should still get the vaccine. And, those traveling to those countries might well benefit…  the potential benefit in these cases (even if small) may outweigh the risks (negligible). And, as with pretty much any vaccine, there is “shared decision-making”: ie, the patients do have choices and can opt-out, even for infections with much higher mortality rates than currently with pneumococcal disease (eg flu: see http://gmodestmedblogs.blogspot.com/2018/10/80000-died-in-2017-18-flu-epidemic-in-us.html ). And, PCV13 is just one shot for life in those >65yo

geoff​

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