CDC Updates Pneumococcal Vaccine Recommendations

The United States Centers for Disease Control and Prevention (CDC) has updated pneumococcal vaccine recommendations, based on the Advisory Committee on Immunization Practices (ACIP’s) evaluation of their 2014 recommendation for Pneumococcal Conjugate Vaccine (PCV13) use among adults aged ≥65 years. The update was published in the CDC’s Morbidity and Mortality Weekly Report (MMWR).

The committee found that PCV13 use among children has indirectly helped reduce incidence of PCV13-type disease to historic lows among adults. As a result, they have removed the recommendation for routine PCV13 vaccination among adults aged ≥65 years. ACIP now recommends PCV13 administration in the aged ≥65 years population based on shared clinical decision-making which incorporates risk for exposure to PCV13 serotypes.

The committee continues to recommend PCV13 in series with Pneumococcal Polysaccharide Vaccine (PPSV23) for adults ≥19 years of age who have an immunocompromising condition, cochlear implants, or cerebrospinal fluid leaks.

Results were assessed through the 2016-2019 Evidence to Recommendations Framework. The ACIP Pneumococcal Vaccines Work Group conducted a systematic review of scientific literature published from January 1, 2014, through July 3, 2018, in order to identify studies that evaluated direct and indirect effects of vaccination with PCV13 on in invasive pneumococcal disease, pneumonia, and mortality.

While 364 studies were identified for in-depth review, 344 did not use PCV13 or did not include an outcome or population of interest. The remaining 20 studies were included in the analysis. The goal of the analysis was to assess whether PCV13 should be administered routinely to all immunocompetent adults aged ≥65 years in context of the indirect effects of pediatric PCV use.

During the 2000-14 period, incidence of PCV13-type invasive pneumococcal disease declined 9-fold among adults aged ≥65 years. From 2014-17, the period after the recommendation was made, no further reduction in PCV13-type invasive pneumococcal disease was observed in the ≥65 years adult population, with incidence remaining stable at 5 of 100,000 population.

Authors of the MMWR report did note a single unpublished cohort study that found a 31.5% reduction in PCV13-type pneumonia and a 13.8% reduction in all-cause pneumonia between 2014-15 and 2015-16. However, overall the authors concluded that since the 2014 recommendations were announced, minimal changes in incidence of pneumococcal disease among adults at the population-level were observed.

An economic analysis was also conducted, with 2 models that evaluated the expected public health impact and cost effectiveness of PCV13 use in series with PPSV23 compared to use of PPSV23 alone.

The models estimated that for a cohort of 2.7 million adults aged 65 years, an expected 76-175 cases of PCV13-type invasive pneumococcal disease and 4000-11,000 cases of PCV13-type pneumonia would be averted through continued PCV13 use in series with PPSV23, compared to PPSV23 alone.

Estimated cost effectiveness rations based on total costs to quality adjusted life years (QALY) were $200,000 to $560,000 per QALY. In 2014, at time of recommendation, the estimated cost per QALY for PCV13 use in series with PPSV23 was $65,000.

In making 2014 recommendations for routine PCV13 administration among adults aged ≥65 years, ACIP recognized that in the long-term, continued indirect effects of PCV13 use among children might limit the utility of the recommendation. Models at the time predicted limited long-term public health benefits due to an already relatively low remaining PCV13-type disease burden. Results appear to have confirmed this assessment.

While the report maintained that PCV13 is a safe and effective vaccine that can reduce risk for PCV13-type invasive pneumococcal disease and noninvasive pneumonia among persons aged ≥65 years, ACIP no longer recommends routine administration for all adults aged ≥65 years in favor of risk-based shared clinical decision-making. The decision, based on historically low levels of PCV13-type disease incidence, highlights the gains made by pediatric PCV13 vaccine uptake.