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Pneumococcal Vaccines (PCV13 and PPSV23)

Ask the Experts: Diseases & Vaccines

Pneumococcal Vaccines (PCV13 and PPSV23)

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Pneumococcal Vaccines (PCV13 and PPSV23)
Disease Issues Miscellaneous Vaccine Issues
Vaccine Recommendations (PCV13) for Children Scheduling and Documenting Vaccines
Vaccine Recommendations (PCV13) for Adults Administering Vaccines
Vaccine Recommendations (PPSV23) Storage and Handling
Boosters and Revaccination (PPSV23)  
Disease Issues
What causes pneumococcal disease?
Pneumococcal disease is caused by Streptococcus pneumoniae, a bacterium that has more than 90 serotypes. Most serotypes cause disease, but only a few produce the majority of invasive pneumococcal disease. The 10 most common types cause 62% of invasive disease worldwide.
How does pneumococcal disease spread?
The disease is spread from person to person by droplets in the air. The pneumococci bacteria are common inhabitants of the human respiratory tract. They may be isolated from the nasopharnyx of 5%-70% of normal, healthy adults.
How long does it take to show signs of pneumococcal disease after being exposed?
As noted above, many people carry the bacteria in their nose and throat without ever developing invasive disease.
What are the types of invasive pneumococcal disease?
There are two major clinical syndromes of invasive pneumococcal disease: bacteremia, and meningitis. They are both caused by infection with the same bacteria, but have different manifestations.
Pneumococcal pneumonia is the most common disease caused by pneumococcal infection. Pneumococcal pneumonia can occur in combination with bacteremia and/or meningitis, or it can occur alone. Isolated pneumococcal pneumonia is not considered invasive disease but it can be severe. It is estimated that 175,000 cases occur each year in the United States. The incubation period is short (1-3 days). Symptoms include abrupt onset of fever, shaking chills or rigors, chest pain, cough, shortness of breath, rapid breathing and heart rate, and weakness. The fatality rate is 5%-7% and may be much higher in the elderly.
Pneumococcal bacteremia occurs in about 25%–30% of patients with pneumococcal pneumonia. More than 50,000 cases of pneumococcal bacteremia occur each year in the United States. Bacteremia is the most common clinical presentation among children less than two years, accounting for 70% of invasive disease in this group.
Pneumococci cause 50% of all cases of bacterial meningitis in the United States. There are 3,000-6,000 cases of pneumococcal meningitis each year. Symptoms and signs may include headache, tiredness, vomiting, irritability, fever, seizures, and coma. Children less than one year have the highest rate of pneumococcal meningitis, approximately 10 cases per 100,000 population. The case-fatality rate of pneumococcal meningitis is about 8% among children and 22% among adults.
How serious is pneumococcal disease in the U.S?
Pneumococcal disease is a serious disease that causes much sickness and death. In fact, pneumococcal disease kills more people in the United States each year than all other vaccine-preventable diseases combined.
An estimated 28,000 cases and 2,900 deaths from invasive pneumococcal diseases (IPD-bacteremia and -meningitis) occurred in the United States in 2014. Young children and the elderly (younger than age five years and older than 65) have the highest incidence of serious disease.
Case-fatality rates are highest for pneumococcal meningitis and bacteremia, and the highest mortality occurs among the elderly and patients who have underlying medical conditions. Despite appropriate antimicrobial therapy and intensive medical care, the overall case-fatality rate for pneumococcal bacteremia is about 15% among adults. Among elderly patients, this rate may be as high as 60%.
Vaccine Recommendations (PCV13) for Children Back to top
When were the first conjugate vaccines licensed?
In 2000, the first pneumococcal conjugate vaccine (PCV) was licensed in the U.S. This vaccine contained seven serotypes (4, 6B, 9V, 14, 18C, 19F, and 23F) of Streptococcus pneumoniae and became known as PCV7 (Prevnar by Wyeth, now Pfizer). Ten years later in February 2010, a new 13-valent product was licensed — PCV13 (Prevnar 13, Pfizer) — which added 6 new serotypes (1, 3, 5, 6A, 7F, and 19A). Together, these 13 serotypes account for the majority of invasive pneumococcal disease (IPD) in the U.S., including serotype 19A, which is the most common IPD-causing serotype in young children. In February 2010 ACIP recommended that healthcare providers transition from use of PCV7 to use of PCV13 for routine vaccination of children.
PCV7 was initially recommended for routine use in infants and children ages 2 through 59 months. The recommendations were expanded with the licensure of PCV13 to include vaccination of children age 60 through 71 months with underlying medical conditions, and also recommendations to consider vaccination of older children, ages 6 through 18 years, with medical conditions placing them at increased risk of invasive pneumococcal disease.
What are the recommendations for routine vaccination of children with PCV13?
All infants should be given a primary series of PCV13, at ages 2, 4, and 6 months with a booster at age 12 to 15 months. Children who fall behind should be given catch-up vaccination through age 59 months, if otherwise healthy or, through age 71 months if they have certain underlying medical conditions.
A healthy child received only one dose of PCV at age 10 months. She is now 6 years old. Our state requires one dose of PCV13 after the first birthday for school attendance. Her physician says because she is older than 59 months, she does not need another dose of PCV13. What should we do in this situation?
ACIP does not recommend routine PCV13 vaccination of healthy children 60 months of age or older. If there is a school requirement, the simplest solution is to give the child one dose of PCV13. However, health insurance may not pay for this dose. For more information on the ACIP recommendations for pneumococcal vaccination of children, go to www.cdc.gov/mmwr/pdf/rr/rr5911.pdf.
What are the recommendations for vaccinating children who previously received PCV7?
The table below can help guide the vaccination of infants and children who are in various stages of PCV vaccination (i.e., unvaccinated, begun a series of PCV7 or PCV13 but not yet completed, or have completed a series of PCV7).
Recommended Schedules for Administering Pneumococcal Conjugate Vaccine (PCV) to Children
By PCV Vaccination History and Age
Child's age now Vaccination History of PCV7 and/or PCV13 Recommended PCV13 Schedule
(see footnote* below for minimum intervals between doses)
2 through 6 months 0 dose 3 doses, 8 weeks apart; 4th dose at age 12-15 months
1 dose 2 doses, 8 wks apart; 4th dose at age 12-15 months
2 doses 1 dose, at least 8 weeks after the most recent dose; dose #4 at age 12-15 months
7 through 11 months 0 doses 2 doses. 8 wks apart; dose #3 at age 12-15 months
1 or 2 doses before age 7 months 1 dose at age 7-11 months, with a second dose at age 12-15 months (8 wks later)
12 through 23 months 0 doses 2 doses, at least 8 weeks apart
1 dose before age 12 months 2 doses, at least 8 weeks apart
1 dose at or after age 12 months 1 dose, at least 8 weeks after the most recent dose
2 or 3 doses before age 12 months 1 dose, at least 8 weeks after the most recent dose
4 doses of PCV7 or other age-appropriate, complete PCV7 schedule 1 supplemental dose, at least 8 weeks after the most recent dose
24 through 59 months
(healthy)
Unvaccinated or any incomplete schedule 1 dose, at least 8 weeks after the most recent dose
4 doses of PCV7 or other age-appropriate, complete PCV7 schedule 1 dose, at least 8 weeks after the most recent dose
24 through 71 months
(with risk factor)
Unvaccinated or any incomplete schedule 2 doses, one at least 8 weeks after the most recent dose and another dose at least 8 weeks later
Any incomplete schedule of 3 doses 1 supplemental dose, at least 8 weeks after the most recent dose
4 doses of PCV7 or other age-appropriate complete PCV7 schedule 1 supplemental dose, at least 8 weeks after the most recent dose
* The minimum interval between doses of PCV7 or PCV13 administered at younger than 12 months of age is 4 weeks. The minimum interval for the next-to-last to last dose is 8 weeks.
Many children in my practice have received their complete series of PCV7. Would you please review the recommendations for which of them now need a supplemental dose of PCV13?
A single supplemental dose of PCV13 is recommended for all children ages 14 through 59 months who have received the complete 4-dose series of PCV7 or another age-appropriate, complete PCV7 schedule. For children who have underlying medical conditions, a single supplemental PCV13 dose is recommended through age 71 months. This also includes children who have previously received pneumococcal polysaccharide vaccine (PPSV23). Give the single supplemental dose of PCV13 no sooner than 8 weeks after the last dose of PCV7 or PPSV23 was given.
IAC has created a table that explains how to use PCV13 to catch up children who have fallen behind on their PCV7 doses. It is available at www.immunize.org/catg.d/p2016.pdf.
A 2-month-old was mistakenly given PPSV23 instead of PCV13. What should be done?
PPSV23 is not effective in children less than 24 months of age. PPSV23 given at this age should not be considered to be part of the pneumococcal vaccination series. PCV13 should be administered as soon as the error is discovered. Any time the wrong vaccine is given, the parent/patient should be notified.
There is a debate within my clinical department about not allowing influenza vaccine to be given with DTaP and PCV13. Are there data that state these should not be given concomitantly?
A CDC study has shown a small increased risk for febrile seizures during the 24 hours after a child receives the inactivated influenza vaccine at the same time as the PCV13 vaccine or DTaP vaccine. However, the risk of febrile seizure with any combination of these vaccines is small and ACIP recommends giving these vaccines at the same visit if indicated. See www.cdc.gov/vaccinesafety/concerns/febrile-seizures.html for more information.
Vaccine Recommendations (PCV13) for Adults Back to top
Please explain why pneumococcal polysaccharide vaccine is recommended for smokers or people with diabetes younger than age 65 but pneumococcal conjugate vaccine is not recommended for these groups.
The level of risk for pneumococcal disease in smokers and people with diabetes is not as high as in immunocompromised persons, and persons with asplenia, HIV infection, hematologic cancer, or with cochlear implant. Because of the lower risk, ACIP recommended that smokers and people with diabetes receive only pneumococcal polysaccharide vaccine (PPSV, Pneumovax 23; Merck) once before age 65 years, and the pneumococcal conjugate vaccine (PCV, Prevnar 13; Pfizer) at age 65 years or older. At this age, pneumococcal disease rates increase regardless of health status. More information on this issue is available at https://www.cdc.gov/mmwr/pdf/wk/mm6140.pdf and https://www.cdc.gov/mmwr/pdf/wk/mm5934.pdf.
Which adults are recommended to receive a dose of PCV13?
According to the ACIP recommendations published in September 2014, both pneumococcal conjugate vaccine (PCV13, Prevnar 13, Pfizer) and pneumococcal polysaccharide vaccine (PPSV23, Pneumovax, Merck) should be administered routinely in a series to all adults age 65 years and older. The two vaccines should not be given at the same visit.
In addition to adults age 65 years and older, adults age 19 through 64 years who have the conditions specified below and who have not previously received PCV13 should receive a PCV13 dose during their next vaccination opportunity.
Immunocompromising conditions (e.g., congenital or acquired immunodeficiency, HIV, chronic renal failure, nephrotic syndrome, leukemia, lymphoma, Hodgkin disease, generalized malignancy, immunosuppression by corticosteroids or chemotherapy, solid organ transplant, and multiple myeloma)
Functional or anatomic asplenia (e.g., sickle cell disease and other hemoglobinopathies and congenital and acquired asplenia)
Cerebrospinal fluid (CSF) leak
Cochlear implant
If a patient has a history of cerebrospinal fluid (CSF) leak but no current leak, is this a risk factor and a reason to administer PCV13 and PPSV23 to an adult?
No. If there is no longer a CSF leak, neither vaccine is recommended, unless there is another risk factor for invasive pneumococcal disease or an age-based indication.
Does an adult younger than age 65 years with beta thalassemia minor meet the criteria for a recommendation for vaccination with PCV13?
No. Beta thalassemia minor is a hemoglobinopathy, but compared to sickle cell disease, these patients have less risk for functional asplenia, and by extension a reduced risk for invasive pneumococcal disease.
PCV13 before PPSV23 to adults age 65 years and older? Wouldn't PPSV23 protect them against ten additional strains of the pneumococcal bacteria?
PCV13 is recommended to be given first because of the immune response to the vaccine when given in this sequence. An evaluation of immune response after a second pneumococcal vaccination administered 1 year after an initial dose showed that subjects who received PPSV23 as the initial dose had lower antibody responses after subsequent administration of PCV13 than those who had received PCV13 as the initial dose followed by a dose of PPSV23.
For adults without high-risk conditions, a 1-year interval is recommended between PCV13 and PPSV23 vaccines. What is the definition of a year? Does it need to be exactly one year? We have provided PCV13 to some individuals during flu season this year and told them to get the PPSV23 next year when they get their flu shot. What if they received their flu shot in November this year, but return for their flu shot in October next year?
What you describe is an excellent strategy for administration of PCV13 and PPSV23 to people age 65 years and older. ACIP does not define "one year" but this is assumed to be one calendar year. Receiving PPSV23 a few days or weeks earlier than one calendar year after PCV13 is not a medical problem. However, it could be a problem for reimbursement since Medicare will only pay for both vaccines if they are given at least 11 months apart. Private insurance may have similar rules. Here is the wording from the Centers for Medicare and Medicaid (CMS): "An initial pneumococcal vaccine may be administered to all Medicare beneficiaries who have never received a pneumococcal vaccine under Medicare Part B. A different, second pneumococcal vaccine may be administered 1 year after the first vaccine was administered (i.e., 11 full months have passed following the month in which the last pneumococcal vaccine was administered)."
If a provider does not yet stock pneumococcal conjugate vaccine (PCV13, Prevnar 13, Pfizer) for adults age 65 years and older but stocks pneumococcal polysaccharide vaccine (PPSV23, Pneumovax 23, Merck), should that provider refer patients to another provider to ensure they receive the PCV13 dose first? Or should the provider not miss an opportunity to give the PPSV23 and refer patients elsewhere for PCV13 in a year?
The Advisory Committee on Immunization Practices (ACIP) recommends that pneumococcal vaccine-naÔve people age 65 years and older should receive PCV13 first, followed by PPSV23 one year later. If the provider is unwilling to stock PCV13, then patients should be referred elsewhere to get PCV13 first. A solution to this problem is to stock PCV13 and PPSV23, both of which are covered by Medicare Part B.
I have a patient who takes adalimumab (Humira) for rheumatoid arthritis. Does a person who takes adalimumab meet the definition of immunosuppression for the purposes of PCV13 vaccination?
Adalimumab is a potent anti-inflammatory drug that blocks the activity of tumor necrosis factor (TNF). Adalimumab is considered immunosuppressive because serious infections have been reported in people taking the drug, including tuberculosis and infections caused by viruses, fungi, or bacteria. Consequently, a person taking adalimumab or other drugs that affect TNF activity (such as infliximab [Remicade], certolizumab pegol [Cimzia], golimumab [Simponi], or etanercept [Enbrel]) should be considered to have immunosuppression and receive PCV13.
We have a 19-year-old patient with a history of vasculitis, nephritis, and asthma. She is on azathioprine (Imuran) and is immunosuppressed. Her rheumatologist recommends she receive pneumococcal conjugate vaccine (PCV13, Prevnar 13, Pfizer) and meningococcal B vaccine. How often should these vaccines be given? Will she require a series of PCV13 doses or just a booster?
For people with iatrogenic immunosuppression, ACIP recommends 1 dose of PCV13 followed by a dose of PPSV23 at least 8 weeks later (see www.cdc.gov/mmwr/pdf/wk/mm6434.pdf, pages 944–7). Meningococcal serogroup B vaccine (MenB) is not specifically recommended for immunosuppressed people. However, people age 16 through 23 years who are not at increased risk may receive routine MenB vaccination (a category B recommendation) of either a 2-dose series of Bexsero (GSK) 4 weeks apart, or a 2-dose series of Trumenba (Pfizer) 6 months apart.
We have a 45-year-old patient taking Mesalamine for ulcerative colitis. Should he receive PCV13 and/or PPSV23?
Mesalamine (mesalazine) is a non-steroidal anti-inflammatory drug. It is not immunosuppressive, so its use would not be an indication for early pneumococcal vaccination with either of these vaccines (i.e., prior to the routine vaccination age of 65 years).
Can we administer either the pneumococcal polysaccharide or the pneumococcal conjugate vaccine to patients with multiple sclerosis?
Multiple sclerosis is not a contraindication to any vaccine, including either of the pneumococcal vaccines.
Vaccine Recommendations (PPSV23) Back to top
When were the first vaccines licensed for vaccination against pneumococcal disease?
The first pneumococcal vaccine, licensed in 1977, was a polysaccharide vaccine. It contained purified capsular polysaccharide antigen from 14 different types of pneumococcal bacteria. In 1983, a 23-valent polysaccharide was licensed (PPSV23; Pneumovax, Merck). It replaced the 14-valent vaccine.
For whom is PPSV23 recommended?
PPSV23 is recommended for all people who meet any of the criteria below:
1. All adults age 65 years and older
2. Age 2 through 64 years with any of the following conditions:
    a. cigarette smokers age 19 years and older
    b. chronic cardiovascular disease (e.g., congestive heart failure, cardiomyopathies; excluding hypertension)
  c. chronic pulmonary disease (including COPD and emphysema, and for adults ages 19 years and older, asthma)
    d. diabetes mellitus
    e. alcoholism
  f. chronic liver disease, cirrhosis
    g. candidate for or recipient of cochlear implant
    h. cerebrospinal fluid (CSF) leak
  i. functional or anatomic asplenia (e.g., sickle cell disease, splenectomy)
    j. immunocompromising conditions (e.g., HIV infection, leukemia, congenital immunodeficiency, Hodgkin's disease, lymphoma, multiple myeloma, generalized malignancy) or on immunosuppressive therapy
    k. solid organ transplantation; for bone marrow transplantation, see www.cdc.gov/vaccines/pubs/hemato-cell-transplts.htm.
  l. chronic renal failure or nephrotic syndrome
Public health authorities may also consider recommending PPSV23 for Alaska Natives and American Indians ages 50 through 64 years who are living in areas in which the risk of invasive pneumococcal disease is increased.
Is a patient younger than age 65 years who recently had a prostatectomy with lymph node dissection for prostate cancer a candidate for PPSV? The patient is believed to be cancer-free and is on no chemotherapy.
In the absence of "generalized malignancy" (which is generally considered to mean disseminated cancer) or immunosuppression, a recent history of prostate cancer surgery alone is not an indication for PPSV.
I have patients who are in their 70s and 80s and remember getting a pneumococcal vaccine a few years ago. Should we assume that this was PPSV? Should I assume that it was given before the 65th birthday?
You can accept a patientís verbal report of PPSV* and it is reasonable to assume that PPSV was the pneumococcal vaccine that was administered. If the patientís history suggests that this dose was given on or after age 65 years, it can be counted as the one dose recommended for this age group. If it has been a year or longer since this dose, pneumococcal conjugate vaccine (PCV, Prevnar 13, Pfizer) should be administered now. If there is any question about the age at which the dose was given, it is reasonable to give PCV now then give a dose of PPSV in 1 year.
*Note: a personal report (undocumented) of receipt of a vaccination is acceptable only for PPSV and influenza vaccines. All other vaccines must be documented with a written, dated record.
Which children should receive PPSV23 vaccine (in addition to PCV13)? At what age should they receive it?
PPSV23 is recommended for children with an immunocompromising condition, or functional or anatomic asplenia, and also for immunocompetent children with chronic heart disease, chronic lung disease, diabetes mellitus, cerebrospinal fluid leak, or cochlear implant. Administer 1 dose of PPSV23 to children age 2 years and older at least 8 weeks after the child has received the final dose of PCV13. Children with an immunocompromising condition, or functional or anatomic asplenia should receive a second dose of PPSV23 5 years after the first PPSV23.
Is PPSV23 contraindicated in pregnancy? Our patient has asthma and is pregnant.
No. PPSV23 is recommended in pregnancy if some other risk factor is present (for example, on the basis of medical, occupational, lifestyle, or other indication). For more information refer to the adult schedule available at www.cdc.gov/vaccines/schedules/hcp/adult.html.
Can you please explain when and why the recommendations for vaccination were changed for people with asthma and for cigarette smokers?
In 2008, the Advisory Committee on Immunization Practices (ACIP) reviewed information that suggests that asthma is an independent risk factor for pneumococcal disease among adults. ACIP also reviewed information that demonstrates an increased risk of pneumococcal disease among smokers. Consequently, ACIP recommends to include both asthma and cigarette smoking as risk factors for pneumococcal disease among adults age 19 through 64 years and as indications for PPSV23.
Since PPSV23 is recommended for all adults who smoke, should adults who use smokeless tobacco products (e.g., chewing tobacco) be vaccinated too?
No. ACIP does not identify people who use smokeless tobacco products as being at increased risk for pneumococcal disease or as being in a risk group for vaccination.
Currently, ACIP recommends PPSV23 for smokers age 19 through 64 years. Should we also vaccinate 16-year-olds who smoke?
No. Currently no data exist to indicate that people younger than 19 and smoke are at increased risk of pneumococcal disease.
Is PPSV23 indicated for former smokers?
PPSV23 is currently recommended for people age 19 through 64 years who actively smoke cigarettes (see www.cdc.gov/mmwr/preview/mmwrhtml/mm5934a3.htm). However, chronic lung disease is an indication for PPSV23, which could be applicable for former smokers.
Does a patient younger than age 65 years who smokes marijuana on a daily basis, but doesnít smoke cigarettes, need to receive pneumococcal polysaccharide (PPSV) vaccine?
No. ACIP does not identify people who smoke marijuana but not cigarettes as being at increased risk for pneumococcal disease or as being in a risk group for PPSV (Pneumovax 23, Merck) vaccination.
Is PCV13 recommended for adults age 19 through 64 years years who smoke?
No. PCV13 is only recommended for adults age 19 through 64 years at increased risk of invasive pneumococcal disease because of an immunocompromising condition, asplenia, cerebrospinal fluid leak or cochlear implant.
ACIP recommends vaccinating adult asthmatics with PPSV23. Should I give PPSV23 to people with mild, intermittent asthma or exercise-induced asthma? Why isn't PPSV23 recommended for asthmatic children?
PPSV23 (but not PCV13) is recommended for adults age 19 through 64 years with all types of asthma. Available data do not indicate that asthma alone increases the risk of invasive pneumococcal disease among people younger than 19 years, so PPSV23 is not currently recommended for people younger than 19 years with asthma. For more information, go to www.cdc.gov/mmwr/preview/mmwrhtml/mm5934a3.htm.
Would you include obstructive sleep apnea as chronic pulmonary disease which would require PPSV23 vaccination once for adults under the age of 65?
Obstructive sleep apnea alone is not an indication for vaccination with PPSV23 for persons 2 through 64 years of age. People with obstructive sleep apnea often have other pulmonary conditions (such as chronic obstructive pulmonary disease) that would put them at increased risk for invasive pneumococcal disease, for which they should be vaccinated. A table listing risk conditions and pneumococcal vaccine recommendations can be found at www.immunize.org/catg.d/p2019.pdf.
Should people who are HIV positive receive pneumococcal vaccines?
Yes. People with HIV infection should receive both PCV13 and PPSV23 vaccines as soon as possible after diagnosis. They should first be given PCV13, followed by PPSV23 at least 8 weeks later. If they are younger than age 65 years, they will need a second dose of PPSV23 at least 5 years after their initial dose and a third dose once they become age 65 years. If they are age 65 years or older when first diagnosed, they will need only one dose. The risk of pneumococcal infection is up to 100 times greater in HIV-infected people than in other adults of similar age. Although severely immunocompromised people may not respond well to the vaccine, and there is a chance that the vaccine may not produce an antibody response, the risk of disease is great enough to warrant vaccination.
Is systemic lupus erythematosus (SLE, lupus) a risk-based indication for pneumococcal vaccines?
Lupus per se is not an indication for either pneumococcal vaccine. However, immunosuppressive medication that may be used to treat lupus could create an indication for administering both pneumococcal vaccines. Also, if the patient has certain complications of lupus (such as nephrotic syndrome), the person would be a candidate for pneumococcal vaccines. Both immunosuppression and nephrotic syndrome are indications for administering both PCV13 (Prevnar, Pfizer) AND PPSV23 (Pneumovax, Merck). Administer PCV13 first, then PPSV23 8 weeks later. A handy document that summarizes indications for both pneumococcal vaccines is available at www.immunize.org/catg.d/p2019.pdf.
A child with selective IgA deficiency was sent by her physician to the health department to receive a dose of pneumococcal polysaccharide vaccine (PPSV23, Pneumovax; Merck). Does her illness fall under the criteria for administering PPSV23?
Selective IgA deficiency is a B-cell immunodeficiency, so PPSV23 is indicated if the child is age 2 years or older.
How often should diabetic patients receive PPSV23?
People with either type 1 or type 2 diabetes who are ages 2 through 64 years who have not already received a dose of PPSV23 should receive their first dose now. At age 65 years they should receive a one-time revaccination if 5 years have elapsed since the previous dose. PCV13 is not recommended for persons age 19 through 64 years whose only risk factor for invasive pneumococcal disease is diabetes.
PPSV23 is recommended for people with diabetes. Does this include gestational diabetes?
No.
How often should adult dialysis patients receive pneumococcal polysaccharide vaccine?
Adult dialysis patients age 19 through 64 years who have not previously received PCV13 or PPSV23 should receive a dose of PCV13 first, followed by a dose of PPSV23 at least 8 weeks later. A second dose of PPSV23 should be given 5 years after the first dose of PPSV23. Once they become 65, they will need another dose. If they were age 65 years or older when first vaccinated, only one dose of PPSV23 is recommended.
Adults age 19 years and older with immunocompromising conditions (including chronic renal failure), functional or anatomic asplenia, CSF leak, or cochlear implants, who previously have received 1 or more doses of PPSV23 should be given a PCV13 dose at least 1 year after the last PPSV23 dose was received.
Boosters and Revaccination (PPSV23) Back to top
Could you briefly summarize the recommendations for PPSV23 revaccination?
Revaccination 5 years after the first dose of PPSV23 is recommended for 1) children and adults younger than age 65 years at highest risk for serious pneumococcal infection or who are likely to have a rapid decline in antibody levels (see next Q&A) and 2) adults age 65 years and older who received their first dose for any indication when they were younger than age 65 years. Adults who receive PPSV23 at or after age 65 years should receive only a single dose.
Which adults ages 19–64 years should receive a second dose of PPSV23?
A second PPSV23 given 5 years after the first dose is recommended for people age 19 through 64 years who have functional or anatomic asplenia (including persons with sickle cell disease or splenectomy patients); chronic renal failure (including dialysis patients) or nephrotic syndrome; are immunocompromised, including those with HIV infection, leukemia, lymphoma, Hodgkin's disease, multiple myeloma, generalized malignancy; are receiving immunosuppressive therapy (including long-term systemic corticosteroids or radiation therapy); or who have received a solid organ transplant.
Do patients who were vaccinated with one or two doses of PPSV23 before age 65 need an additional dose of PPSV23 at age 65 or later?
Yes. Patients who received 1 or 2 doses of PPSV23 for any indication at age 64 years or younger should receive an additional dose of PPSV23 vaccine at age 65 years or older if at least 5 years have elapsed since their previous PPSV23 dose. Patients age 65 years and older who have not already received a dose of pneumococcal conjugate vaccine (PCV13) will need this as well. PCV13 is routinely recommended at age 65 and PPSV23 is administered one year later.
Should a healthy 75-year-old patient who was given PPSV at age 65 years be revaccinated?
No. Adults who were first vaccinated at age 65 years or older do not require revaccination. Make sure they have also received a dose of PCV13, which is routinely recommended at age 65 years.
Why is there no recommendation for patients older than 65 years to get a booster dose of PPSV23 if they first received it at age 65 years or older? It seems to me that their protection against pneumococcal disease would benefit from a booster dose of PPSV23 five or ten years after the first dose.
People age 65 and older should be given a second dose of PPSV23 if they received the first dose 5 or more years previously and were younger than 65 years at the time of the first vaccination. Protection from a single dose of PPSV23 at age 65 years or older is believed to persist for 5–10 years. The benefit and safety of a second dose given after age 65 years is uncertain. Until such data are available, ACIP recommends only a single dose at age 65 years or older.
Miscellaneous Vaccine Issues Back to top
I've heard that PPSV23 isn't very effective in older people. Should I still use it?
Yes. PPSV23 vaccine is 60%-80% effective against invasive pneumococcal disease when it is given to immunocompetent people age 65 years and older or people with chronic illnesses. The vaccine is less effective in immunodeficient people. So, although PPSV23 is not as effective as some other vaccines, it can significantly lower the risk of serious pneumococcal disease and its complications in most recipients.
My patient has had laboratory-confirmed pneumococcal pneumonia. Does he/she still need to be vaccinated with PCV13 and/or PPSV23?
Yes. There are more than 90 known serotypes of pneumococcus (13 serotypes in the conjugate vaccine and 23 serotypes in the polysaccharide vaccine). Infection with one serotype does not necessarily produce immunity to other serotypes. As a result, if the person is a candidate for vaccination, s/he should receive it even after one or more episodes of invasive pneumococcal disease.
If influenza vaccine is recommended for healthcare workers to protect high-risk patients from getting influenza, why aren't the pneumococcal vaccines also recommended?
Influenza virus is easily spread from healthcare workers to their patients, and infection usually leads to clinical illness. Pneumococcus is probably not spread from healthcare workers to their patients as easily as is influenza, and infection with pneumococcus does not necessarily lead to clinical illness. Host factors (such as age, underlying illness) are more important in the development of invasive pneumococcal disease than nasopharyngeal colonization with the organism. When you're giving influenza vaccine to your patients in the fall, don't forget to assess their need for pneumococcal vaccine as well as all other vaccines, including Tdap and zoster.
Why should we not give PCV13 vaccine to someone who has had a serious reaction to a diphtheria-containing vaccine in the past?
PCV13 vaccine is conjugated to a type of diphtheria-toxoid. So if someone has a past history of anaphylaxis following diphtheria-containing vaccine, it might be due to the diphtheria toxoid, and the cause of the anaphylactic allergy should be identified before the administration of PCV13 vaccine. This could be difficult since no single-antigen diphtheria toxoid is available in the U.S. Fortunately, true anaphylactic allergy to diphtheria-containing vaccine is rare.
Scheduling and Documenting Vaccines Back to top
Can we administer PCV13 and PPSV23 to a person 65 years of age or older at the same visit? If not, what is the recommended interval between doses?
PCV13 and PPSV23 should not be given at the same visit. Healthy people 65 years of age and older should receive PCV13 first, followed by a dose of PPSV23 one year later. If the patient has a high-risk medical condition (such as immunocompromised or asplenia) the first PPSV23 dose can follow the PCV13 dose by 8 weeks.
Rather than giving PCV13 first and waiting 8 weeks to give PPSV23 as recommended for an immunocompromised child (2 years or older) or adult patient, we inadvertently gave both vaccines at the same visit. We are looking for guidance.
Although PCV13 and PPSV23 should not be administered at the same visit, CDC does not recommend repeating either vaccine dose should this occur. You should inform the patient of the error and let them know that they will not need to repeat either dose.
Our patient is a 78-year-old female who received PCV13 (Prevnar13, Pfizer), then received PPSV23 (Pneumovax 23, Merck) approximately 10 weeks later. She had not received PPSV23 previously. Is the PPSV23 dose valid, or does it need to be repeated?
Even though the interval was shorter than the recommended 1 year, the dose of PPSV23 should be counted and does not need to be repeated. In the future, please note the ACIP recommendations for pneumococcal vaccine-naïve patients age 65 and older are as follows: The dose of PPSV23 should be given 1 year after a dose of PCV13. If PPSV23 cannot be given during this time window, the dose of PPSV23 should be given during the next visit. The two vaccines should not be administered at the same visit, and the recommended minimum interval between PCV13 and PPSV23 is 8 weeks. For more information, www.cdc.gov/mmwr/pdf/wk/mm6434.pdf#page=16.
We have a healthy 68-year-old male patient who received PCV13 (Prevnar13, Pfizer), then received PPSV23 (Pneumovax 23, Merck) approximately 5 weeks later. She had not received PPSV23 previously. Is the PPSV23 dose valid, or does it need to be repeated?
What to do when doses of PCV13 and PPSV23 are given without the recommended minimum interval between them is not spelled out in the ACIP pneumococcal recommendations. The CDC subject matter experts have provided the following guidance: in such a case, the dose given second does not need to be repeated. This is an exception to the usual procedure for a minimum interval violation (as described in ACIP's General Recommendations on Immunization). The recommended interval between the dose of PCV13 and PPSV23 is 1 year and the recommended minimum interval between doses is 8 weeks.
We have a healthy 66-year-old patient who received a dose of PPSV23 in January then received a dose of PCV13 five months later at a different facility. Should the PCV13 dose be repeated since it was given earlier than the 1-year interval recommended by ACIP?
ACIP recommends that healthy people age 65 years and older receive PCV13 first, then PPSV23 one year later. When PPSV23 has been given first, ACIP recommends an interval of one year before giving PCV13. What to do when doses of PPSV23 and PCV13 are given without the recommended minimum interval is not addressed in the ACIP recommendations. The CDC subject matter experts have advised that in such a case, the dose given second does not need to be repeated. This is an exception to the usual procedure for a minimum interval violation as described in ACIPís General Recommendations on Immunization (see www.cdc.gov/mmwr/pdf/rr/rr6002.pdf, page 5). There is no evidence to support that there are benefits to repeating the dose of PCV13. Information about the recommended intervals between pneumococcal vaccines can be found at www.cdc.gov/mmwr/pdf/wk/mm6434.pdf, pages 944—7.
What is the recommended interval between doses for adult patients who have already received one dose of PPSV23 and now need PCV13?
For patients who have already had one or more doses of PPSV23, it is recommended to wait at least 1 year after PPSV23 before administering PCV13. If the patient is recommended to receive a second dose of PPSV23, delay that second PPSV23 dose at least 8 weeks following PCV13 and 5 years or more following the first dose of PPSV23.
If patients who are in a recommended risk group for PPSV23 or PCV13 aren't sure if they have previously received these vaccines, should healthcare providers vaccinate them?
Yes. If patients do not have a documented vaccination history for these two vaccines and their records are not readily obtainable, you should administer the recommended doses. Extra doses will not cause harm to the patient.
I have patients who are in their 70s or 80s and remember getting a pneumococcal vaccine "a few years ago." Should I assume that this was PPSV23? Should I assume that it was given before the 65th birthday?
You can accept a verbal report of PPSV23. Since the recommendation for routine vaccination with PCV13 is relatively recent (November 2014) it is reasonable to assume that PPSV23 was the pneumococcal vaccine that was administered earlier. Try to ascertain how long ago it was given. If you think the dose was given after the 65th birthday and it has been a year since the dose was administered, give a dose of PCV13 now. If the dose was administered before the 65th birthday, administer a dose of PCV13 now, and then administer a dose of PPSV23 one year later, assuming that it has been 5 years since the first dose of PPSV23 was administered.
An 86-year-old patient came in today and stated he needed a pneumococcal vaccine booster. He reports receiving a dose of "pneumonia vaccine" when he was 77 years old. Which pneumococcal should he receive today, PCV13 or PPSV23?
It is unlikely that the previous dose of pneumococcal vaccine was PCV13, since this vaccine was not routinely recommended for any adult population nine years ago. The patient most likely received pneumococcal polysaccharide vaccine (PPSV23). A dose of PCV13 should be given now. People who receive PPSV23 after age 65 years are not recommended to receive additional doses of PPSV23.
We just gave PPSV23 to a 66-year-old patient who is newly diagnosed with a medical condition that places him at increased risk for pneumococcal disease and its complications. Should we give him a second dose in 5 years because of his underlying medical condition?
No. People who are first vaccinated with PPSV23 at age 65 years or older should receive only one dose, regardless of any underlying medical condition they might have.
When should I vaccinate children or adults who are planning to have either a cochlear implant or elective splenectomy?
It is preferable that the person planning to have the procedure have antibody to pneumococcus at the time of the surgery; if possible, administer the appropriate vaccine prior to the splenectomy or cochlear implant. Children 2 through 71 months of age should continue to receive PCV13 vaccine according to the schedule above. If the procedure is done on an emergency basis, vaccinate as soon as possible after surgery. Persons who have not previously received any pneumococcal vaccine should receive PCV13 first followed by PPSV23 at least 8 weeks later. Asplenic persons need a second dose of PPSV 5 years after the first PPSV23.
Do any of the bacterial vaccines that are recommended for people with functional or anatomic asplenia need to be given before splenectomy? Do the doses count if they are given during the 2 weeks prior to surgery?
Pneumococcal conjugate vaccine (PCV13), Haemophilus influenzae type b vaccine, meningococcal conjugate vaccine, and meningococcal B vaccine should be given 14 days before splenectomy, if possible. Doses given during the 2 weeks (14 days) before surgery can be counted as valid. If the doses cannot be given prior to the splenectomy, they should be given as soon as the patient's condition has stabilized after surgery. Pneumococcal polysaccharide vaccine should be administered 8 weeks after the dose of PCV13 for people 2 years of age and older.
How should we administer both pneumococcal vaccines (PCV13 and PPSV23) to our high risk pediatric patients?
All children with risk factors for pneumococcal disease or its complications should be vaccinated with PPSV23 beginning at age 2 years. If they are age-eligible and are due for a dose of PCV13, give that one first and then wait 8 weeks before giving PPSV23. For more information on vaccination of high-risk pediatric patients, see pages 26–27 of the ACIP statement at www.cdc.gov/mmwr/pdf/rr/rr5911.pdf. .
Some physicians in our area order PPSV23 every 5 years for their patients. Is this correct?
No. Only certain high-risk people who were vaccinated when younger than age 65 years will need a second dose 5 years later. At age 65 years, all adults (including people vaccinated when younger) will need to be vaccinated.
Can we vaccinate a 2-year-old boy with functional or anatomic asplenia against meningococcal disease if he has not completed a series of PCV13?
Possibly. If you are going to give him Menactra brand MenACWY, you need to wait at least 4 weeks after he completes the PCV13 series before giving him the Menactra. There is no similar space consideration if Menveo brand MenACWY is used; it may be given simultaneously with PCV13 or at any interval before or after receipt of PCV13.
We have a 10-year-old getting renal dialysis. The nephrologist will be starting her on a monoclonal antibody that interferes with C5 complement. If we administer a MCV4 and a PPSV23 now, and then give her a PCV13 in 8 weeks, will the PCV13 interfere with the efficacy of the PPSV23 or the MCV4?
Recommendations to separate MenACWY and PCV13 only apply to persons with functional or anatomic asplenia. So the best schedule is to give MenACWY (either brand) simultaneously with PCV13, and then PPSV23 in eight weeks. ACIP recommends giving PCV13 before PPSV23 in order to maximize the immune response from PCV13. PPSV23 may blunt the immune response to PCV13 if PCV13 is given after PPSV23, although in children there is a smaller effect than in adults. A 10 year-old with persistent complement component deficiency should also receive a 2 or 3 dose series (depending on brand) of meningococcal B vaccine.
Can I give other vaccines at the same time I give either PCV13 or PPSV23 to a patient?
Yes, with several exceptions. PPSV23 and PCV13 are both inactivated vaccines, which means you can give all other recommended vaccines at the same visit (using separate syringes) or at any later time with no waiting period following the vaccination. Here are the exceptions:
a. You cannot give both PCV13 and PPSV23 at the same time.
b. If the person has functional or anatomic asplenia, observe these rules:
  If using Menactra brand MenACWY vaccine, you should give PCV13 first with a 4 week separation between the final dose of PCV13 and Menactra.
  If using Menveo brand MenACWY give PCV13 at the same visit or at any interval before or after each other.
The pneumococcal conjugate vaccine (PCV13) package insert says that in adults, antibody responses to Prevnar 13 (Pfizer) were diminished when given with inactivated influenza vaccine. Does this mean we should not give PCV13 and influenza vaccine at the same visit?
No. The available data have been interpreted that any changes in antibody response to either vaccines' components were clinically insignificant. If PCV13 and influenza vaccine are both indicated and recommended they should be administered at the same visit. See the PCV13 ACIP recommendations, www.cdc.gov/mmwr/pdf/wk/mm6337.pdf, page 824.
What intervals should be observed between doses of PCV13 and PPSV23 for those children and adults who are recommended to receive both vaccines?
For PCV13-naïve adults ages 65 years and older, give PCV13 first followed by PPSV23 1 year later. For adults at increased risk of pneumococcal disease (such as immunocompromising conditions or asplenia) give PCV13 first followed by PPSV23 in at least 8 weeks. For adults age 19 years and older who have received one or more doses of PPSV23 previously, wait 1 year before giving PCV13 to avoid interference between the 2 vaccines. For children age 2 through 18 years who have not received PCV13 but who have received one or more doses of PPSV23 previously, wait 8 weeks before giving PCV13.
The Zostavax vaccine (Merck) package insert says that Zostavax should not be given simultaneously with pneumococcal polysaccharide vaccine (PPSV23). What does ACIP say about this?
ACIP has not changed its recommendation on the simultaneous administration of these two vaccines (i.e., they can be given at the same time or any time before or after each other).
Administering Vaccines Back to top
A dose of pneumococcal conjugate vaccine was administered into my patient's dialysis port. Does this dose count?
There are no data on the effectiveness of pneumococcal conjugate vaccine given by the intravenous route. The patient has renal disease, so it is important to ensure that the dose they receive is effective. CDC recommends repeating the dose.
What route and needle length is recommended for administration of pneumococcal polysaccharide vaccine?
Pneumococcal polysaccharide vaccine may be given either by intramuscular (IM) or subcutaneous (SC) injection. When administration is IM, choose needle length appropriate to the person's age and body mass: toddlers age 2 years: 1–1¼" (anterolateral thigh) or ⅝–1" (deltoid muscle); children ages 3–4 years: ⅝–1" (deltoid) or 1–1¼" (anterolateral thigh); adults, a 1–1½" needle. A ⅝" needle may be used in toddlers and children, adolescents and for adult patients weighing less than 130 lbs (60 kg) for IM injection in the deltoid muscle. For all of these age groups, a 5/8" needle can be used only if the subcutaneous tissue is not bunched and the injection is made at a 90-degree angle. When administration of PPSV23 is SC, a ⅝" needle is recommended.
What route and needle length should we use for administration of pneumococcal conjugate vaccine (PCV13)?
Pneumococcal conjugate vaccine (PCV13) should be administered by the intramuscular (IM) route. Choose needle length appropriate to the person's age and body mass: infants younger than age 12 months: 1"; toddlers 1–2 years: 1–1¼" (anterolateral thigh) or ⅝–1" (deltoid muscle); children ages 3–4 years: ⅝–1" (deltoid) or 1–1¼" (anterolateral thigh); adults, a 1–1½" needle. A ⅝" needle may be used in toddlers, children, adolescents, and for adult patients weighing less than 130 lbs (60 kg) for IM injection in the deltoid muscle. For all of these age groups, a 5/8" needle can be used only if the subcutaneous tissue is not bunched and the injection is made at a 90-degree angle.
Storage and Handling Back to top
How should pneumococcal vaccines be stored?
Both pneumococcal conjugate and pneumococcal polysaccharide vaccines should be refrigerated at temperatures between 35°F (2°C) and 46°F (8°C). Do not freeze either vaccine. Vaccine exposed to freezing temperature should not be administered.
 
This page was updated on December 15, 2017.
This page was reviewed on December 14, 2016.
 
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