Farah Alhalabi, 2022, PharmD Candidate
Heather Erwin, PharmD, MHA, BCPS
Pneumococcal disease, caused by Streptococcus pneumoniae, can cause many types of illnesses. Most of these are mild, but some are considered invasive and can be fatal, such as meningitis, bacteremia, and pneumonia.1 While pneumococcal disease is very common in children, certain adults can also be at a very high risk. In fact, one in every four to five patients who are 65 years and older die after contracting pneumococcal disease.2 There are two types of vaccines that help prevent pneumococcal disease: pneumococcal conjugate vaccine (PCV13) and pneumococcal polysaccharide vaccine (PPSV23).3
PCV13 helps protect against thirteen types of pneumococcal bacteria and is recommended for both children and some adults.3 Regardless of age, patients with immunocompromising conditions or treatment, (such as human immunodeficiency virus, malignancy, or organ transplant), cochlear implant, anatomic or functional asplenia, and sickle cell disease should receive the PCV13 vaccine. In addition, patients with certain higher risk chronic medical conditions, such as chronic renal failure, nephropathy, or cerebral spinal fluid leak, are eligible for the PCV13 vaccine.4
The recommendations for PCV13 in patients without immunocompromising conditions are less specific. In 2014, the Advisory Committee on Immunization Practices (ACIP) recommended routine administration of PCV13 in addition to PPSV23 for all patients 65 years of age or older.5 However, in 2019, ACIP changed its recommendation for patient eligibility in the 65 years of age or older group for PCV13 to a shared decision-making process between patients and healthcare providers. This was largely due to increased pediatric uptake of PCV13 leading to decreased population-based burden and transmission. As a result, providers may be faced with a challenge in determining the best candidates for this vaccination among their patients without immunocompromising conditions.
Per ACIP, herd immunity protecting older individuals is likely impacted by decreasing childhood immunization rates, inadequate access to care in certain communities, or lack of a childhood PCV13 program. Thus, a shared clinical decision is based on individual rather than population level benefits.4 Risk of exposure to PCV13 serotypes and underlying disease(s) that a patient has are important factors to consider when determining the benefit of PCV13 for that individual. The vaccine is indicated for adults 65 years of age or older with medical conditions that can make PCV13 type disease burden higher in this age group. These include chronic medical conditions, such as heart disease, liver disease, and lung disease; diabetes mellitus; and inflammatory bowel disease. In addition, the vaccine is recommended for patients who smoke regularly and drink excessive amounts of alcohol. Moreover, patients who are homeless, those who have had a prior pneumonia, or people living in areas where the risk is much higher (e.g., nursing homes, shelters, and jails) should receive the PCV13 vaccine per ACIP.4 In addition, certain types of medications, such as proton pump inhibitors, antipsychotics, opioids, and sedatives may increase a patient’s risk of contracting pneumonia, so individuals on one or more of these medications may also be candidates to receive the PCV13 vaccine if deemed desirable after a discussion between the clinician and the patient. Lastly, groups at a higher risk of contracting pneumococcal infection, such as frail patients, African Americans, Alaska natives, and American Indians, could also benefit from PCV13 vaccine.4
The CDC recommends that PCV13 be administered first when a patient is eligible. The timing of PPSV23 administration following PCV13 vaccination is age- and indication-dependent and detailed in Table 1. If a patient has received a dose of PPSV23 before and is due for another PPSV23 immunization, they should wait five years until receiving that subsequent dose.2 More guidance on PPSV23 eligibility and administration is available on the CDC website.
Because the changes to eligibility and dosing schedules of PCV13 can be complicated and providers may not always find the time to effectively review the benefits of PCV13 with every patient, pharmacists play a vital role in educating patients and providers about pneumococcal vaccines. Pharmacists can help in identifying patients who are candidates for PCV13, especially patients who are immunocompromised or have chronic health conditions that put them at a greater risk of getting pneumococcal disease. The CDC offers excellent resources for patients and healthcare providers to help guide them toward safe and appropriate vaccination decision-making. Pharmacists and healthcare providers should also involve the patients in making this decision by explaining the benefits of PCV13 based on their conditions or risk factors while taking into consideration values, preferences, and views toward vaccinations.