Who Should Receive PCV13?

Who Should Receive PCV13?
Analisa Buysse, PharmD, Avera Marshall Regional Medical Center

Background: Since 2014, the Advisory Committee on Immunization Practices (ACIP) has recommended routine immunization with Prevnar13Ⓡ (PCV13) followed by PneumovaxⓇ23 (PPSV23) in one year for all patients ≥65 years old. At the time that this recommendation was established, ACIP recognized that routine use of PCV13 among adults ≥65 years old may not be recommended long term and opted to re-evaluate in four years. Standard pediatric immunization with PrevnarTM(PCV7) and PCV13 has decreased the prevalence of these pneumococcal strains and, as a consequence, there has been a notable decline in pneumococcal disease in children and adults over the past twenty years.

Evidence: From 2014-2018, there was a substantial increase in the administration of PCV13 among patients ≥65 years old (2018 coverage estimated at 47%). However, this increase in PCV13 use did not translate into decreased rates of invasive pneumococcal disease (IPD). Incidence of PCV13-type IPD remained stable from 2014 to 2017 both among adults ≥65 years old and among adults ages 19-64 who experience indirect protection from increased administration of PCV13. One cohort study found a reduction in all-cause pneumonia caused by PCV13-types when comparing 2014 to 2015-16 (10% in 2014 to 4% in 2015-16), suggesting that PCV13-types are not as often the cause of pneumonia cases.

To evaluate an economic perspective, two independent models were generated which predicted 76-175 cases of PCV13-type IPD and 4,000-11,000 cases of PCV13-type pneumonia over the lifetime of 2.7 million adults aged 65 years. Based on this data, the estimated cost effectiveness ratios were $200,000 to $560,000 per quality adjusted life year. When compared to the corresponding cost effectiveness ratio of $65,000 per quality adjusted life year in 2014, evidence suggests that the continued routine use of PCV13 in patients ≥65 years old may not be economically responsible. 

Discussion: Based on the aforementioned data outlining the decline in pneumonia cases caused by PCV13-types and the significant predicted economic burden, ACIP now recommends against the routine use of PCV13 in adults ≥65 years old. Instead, a shared clinical decision making process should be used for adults ≥65 years old without cochlear implant, an immunocompromising condition, or a CSF leak who have not previously received PCV13.

Clinical Impact: Pharmacists and other healthcare professionals will now have to use a higher level of clinical evaluation when considering the administration of PCV13 in adults. Patients who may be at an increased risk of pneumonia due to PCV13-types include those residing in long-term care facilities or those living in locations with low pediatric utilization of PCV13. Unfortunately, ACIP does not define a threshold for “low pediatric utilization,” however, according to the Minnesota Department of Health, the Minnesota PCV childhood immunization rate is 81.8%. Those also at increased risk of PCV13-type IPD include patients with chronic heart, lung, or liver disease, diabetes, alcoholism, and those who smoke cigarettes with more than one chronic medical condition. It may be noted, however, that the 2020 American Diabetes Association Standards of Medical Care in Diabetes Guidelines did not mention a recommendation for routine vaccination with PCV13 in adults ≥65 years old with diabetes. 

Overall, the decision to administer PCV13 in adults ≥65 years old will now be multifactorial and require consideration of patient social history, place of residence, medical history, and individual vaccination preferences. It is also currently unknown if PCV13 will continue to be covered by payers following the updated ACIP recommendation. Risks to the patient associated with administration of the immunization remain low, however pharmacists should also consider the potential negative economic impact when recommending frequent use of PCV13 in this population. The ACIP recommendation for administration of PPSV23 in all adults ≥65 years old remains in place and, if administration of PCV13 is indicated based on shared clinical decision making, PCV13 should continue to be administered at least one year prior to PPSV23. As ACIP continues to assess trends in pneumococcal disease, PCV13 and PPSV23 vaccination recommendations may continue to evolve.

References: 

  1. 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. 2019 Nov 22;68(46):1069-75.

  2. Minnesota Public Health Data Access. Minnesota Department of Health. [cited 12 Feb 2020]. Available from: https://mndatamaps.web.health.state.mn.us/interactive/immunizations.html.

  3. Standards of medical care in diabetes - 2020. Diabetes Care. 2020 Jan 1;43(Supplement 1).