Introduction
Two pneumococcal vaccines are currently licensed for use in adults in the United States:
a 13-valent pneumococcal conjugate vaccine (PCV13 [Prevnar 13, Pfizer, Inc.]) and
a 23-valent pneumococcal polysaccharide vaccine (PPSV23 [Pneumovax 23, Merck and Co.,
Inc.]). In 2014, the Advisory Committee on Immunization Practices (ACIP)* recommended
routine use of PCV13 in series with PPSV23 for all adults aged ≥65 years based on
demonstrated PCV13 safety and efficacy against PCV13-type pneumonia among adults aged
≥65 years (
1
). At that time, ACIP recognized that there would be a need to reevaluate this recommendation
because it was anticipated that PCV13 use in children would continue to reduce disease
burden among adults through reduced carriage and transmission of vaccine serotypes
from vaccinated children (i.e., PCV13 indirect effects). On June 26, 2019, after having
reviewed the evidence accrued during the preceding 3 years (https://www.cdc.gov/vaccines/acip/recs/grade/PCV13.html),
ACIP voted to remove the recommendation for routine PCV13 use among adults aged ≥65
years and to recommend administration of PCV13 based on shared clinical decision-making
for adults aged ≥65 years who do not have an immunocompromising condition,
†
cerebrospinal fluid (CSF) leak, or cochlear implant, and who have not previously received
PCV13. ACIP recognized that some adults aged ≥65 years are potentially at increased
risk for exposure to PCV13 serotypes, such as persons residing in nursing homes or
other long-term care facilities and persons residing in settings with low pediatric
PCV13 uptake or traveling to settings with no pediatric PCV13 program, and might attain
higher than average benefit from PCV13 vaccination. When patients and vaccine providers
§
engage in shared clinical decision-making for PCV13 use to determine whether PCV13
is right for a particular person, considerations might include both the person’s risk
for exposure to PCV13 serotypes and their risk for developing pneumococcal disease
as a result of underlying medical conditions. All adults aged ≥65 years should continue
to receive 1 dose of PPSV23. If the decision is made to administer PCV13, it should
be given at least 1 year before PPSV23. ACIP continues to recommend PCV13 in series
with PPSV23 for adults aged ≥19 years with an immunocompromising condition, CSF leak,
or cochlear implant (
2
).
Background
Streptococcus pneumoniae (pneumococcus) can cause serious illness, including sepsis,
meningitis, and pneumonia with bacteremia (invasive) or without bacteremia (noninvasive).
Since the early 1980s, PPSV23 has been recommended for persons aged ≥2 years with
certain underlying medical conditions, and all adults aged ≥65 years (
3
). 7-valent pneumococcal conjugate vaccine (PCV7) was introduced into the routine
pediatric immunization schedule in 2000 and was replaced by PCV13 in 2010 (
4
). In 2012, PCV13 was recommended in series with PPSV23 for adults aged ≥19 years
with immunocompromising conditions, CSF leaks, or cochlear implants (
2
). In 2014, PCV13 was recommended for all adults aged ≥65 years (
1
,
5
). Widespread use of PCV7 and PCV13 in children has led to sharp declines in pneumococcal
disease among unvaccinated children and adults by preventing carriage, and thereby
transmission, of vaccine-type strains (Figure). In 2014, ACIP recognized that, while
in the short-term, routine PCV13 use among adults aged ≥65 years was warranted, in
the long-term, continued indirect effects from PCV13 use in children might limit the
utility of this recommendation. In addition, models predicted limited public health
benefits in the long-term, given the relatively low remaining PCV13-type disease burden
(
1
). Therefore, ACIP proposed that the recommendation for routine PCV13 use among adults
aged ≥65 years be evaluated 4 years after implementation of the 2014 recommendation.
FIGURE
Invasive pneumococcal disease (IPD) incidence among adults aged ≥65 years, by pneumococcal
serotype* — United States, 1998–2017
Source: Active Bacterial Core Surveillance, unpublished data, 2019.
Abbreviations: PCV = pneumococcal conjugate vaccine; PCV7 = 7-valent PCV (serotypes
4, 6B, 9V, 14, 18C, 19F, and 23F); PCV13 = 13 valent PCV (PCV7 serotypes plus 1, 3,
5, 6A, 19A and 7F).
* Serotype 6C showed cross-protection from 6A antigen in PCV13 and was grouped with
PCV13 serotypes for IPD.
The figure is a line chart showing invasive pneumococcal disease incidence among adults
aged ≥65 years, by pneumococcal serotype, in the United States, during 1998–2017.
Methods
During 2016–2019, using the Evidence to Recommendations Framework, (https://www.cdc.gov/vaccines/acip/recs/grade/PCV13-etr.html)
the ACIP Pneumococcal Vaccines Work Group reviewed relevant scientific evidence regarding
the benefits and harms of PCV13 use among adults aged ≥65 years without an immunocompromising
condition, CSF leak, or cochlear implant, in the context of >5 years of pediatric
PCV13 use. The Work Group evaluated the quality of evidence for PCV13 efficacy, effectiveness,
safety, and population-level impact on pneumococcal-related disease using the Grading
of Recommendations Assessment, Development and Evaluation (GRADE) approach (https://www.cdc.gov/vaccines/acip/recs/grade/PCV13.html).
A systematic review of scientific literature published from January 1, 2014, to July
3, 2018, was conducted to identify studies evaluating direct and indirect effects
of vaccination with PCV13 on invasive pneumococcal disease (IPD), pneumonia (PCV13-type,
¶
all pneumococcal, and all-cause), and mortality (pneumococcal or all-cause). In addition,
PCV13 safety was evaluated by looking for severe adverse events, including death,
occurring after receipt of PCV13 in adults aged ≥65 years. Title and abstract screening
yielded 364 studies for in-depth review. Of these, 344 did not use PCV13 or did not
include an outcome or population of interest. Observational studies with <20% adult
PCV13 coverage and studies conducted in settings with low pediatric PCV13 coverage
were excluded, as were studies evaluating PCV13 safety if PCV13 was administered with
another vaccine, because severe adverse events could not be attributed to PCV13. The
remaining 20 studies were included in the GRADE tables. The policy question considered
was whether PCV13 should be administered routinely to all immunocompetent** adults
aged ≥65 years in the context of indirect effects from pediatric PCV use experienced
to date.
Summary of Evidence
PCV13 effectiveness and safety (individual-level benefits and harms). Before the 2014
recommendation, a randomized placebo-controlled Community-Acquired Pneumonia Immunization
Trial in Adults (CAPiTA) conducted in the Netherlands demonstrated 75% (95% confidence
interval [CI] = 41%–91%) efficacy against PCV13-type IPD and 45% (CI = 14%–65%) efficacy
against noninvasive PCV13-type pneumonia among adults aged ≥65 years (
6
). Postlicensure studies included in the GRADE tables in 2019 (https://www.cdc.gov/vaccines/acip/recs/grade/PCV13.html)
demonstrated PCV13 effectiveness against PCV13-type IPD (47%–59%) (
7
,
8
), noninvasive PCV13-type pneumonia (38%–70%) (
9
,
10
), and all-cause pneumonia (6%–11%) (
11
,
12
). PCV13 efficacy was not demonstrated against PCV13-type or all-cause mortality (
6
); no studies evaluating PCV13 effectiveness against mortality were identified. Three
randomized controlled trials (
6
,
13
,
14
) and six observational studies (
15
–
20
) that assessed harms were evaluated (https://www.cdc.gov/vaccines/acip/recs/grade/PCV13.html).
The rates of severe adverse events were similar among participants vaccinated with
PCV13 versus placebo or PPSV23 (https://www.cdc.gov/vaccines/acip/recs/grade/PCV13.html).
Common reported PCV13-associated adverse reactions included pain, redness, and swelling
at the injection site, limitation of movement of the arm in which the injection was
given, fatigue, headache, chills, decreased appetite, generalized muscle pain, and
joint pain (
21
). Overall, PCV13 was assessed to be safe and effective in preventing PCV13-type IPD
and noninvasive pneumonia.
PCV13 population-level impact (indirect and direct effects) on disease among adults
aged ≥65 years. The U.S. pediatric PCV program has been successful in preventing disease
among young children through direct protection of vaccinated children as well as in
unvaccinated populations through indirect effects (Figure). The incidence of PCV13-type
IPD among adults aged ≥65 years declined ninefold during 2000–2014, before the adult
PCV13 program was implemented (
22
). During the same period, indirect effects of similar magnitude were observed among
adults aged ≥65 years at increased risk for IPD because of either older age (≥85 years)
(
22
,
23
) or presence of underlying chronic medical conditions (
24
). Indirect effects on PCV13-type and all-cause pneumonia among adults have also been
demonstrated since 2000 (
25
–
27
). In 2014, additional reductions in disease incidence among adults aged ≥65 years
were expected to occur as a result of ongoing indirect effects of the pediatric PCV13
program, as well as through direct effects of PCV13 use among adults. PCV13 uptake
among adults aged ≥65 years increased rapidly, with coverage in 2018 estimated at
47%; coverage with any pneumococcal vaccine was 62%, with PPSV23 was 45%, and with
both PCV13 and PPSV23 was 30% (
23
). However, from 2014–2017, no further reduction in PCV13-type IPD incidence was observed
among adults aged ≥65 years, with the incidence stable at five of 100,000 population
(20% of all IPD) (
22
). Similarly, since 2014, no impact on PCV13-type IPD incidence has been observed
among adults aged 19–64 years, a population only experiencing indirect PCV13 effects
during this period. During 2014–2016, no reduction in the incidence of noninvasive
pneumococcal pneumonia (all serotypes combined) was observed among adults (
28
). One recent unpublished cohort study found a 31.5% reduction in PCV13-type pneumonia
and a 13.8% reduction in all-cause pneumonia between 2014–2015 and 2015–2016 (
29
). In this study, PCV13-types contributed to 4% of all-cause pneumonia among adults
aged ≥65 years during 2015–2016 (
29
) compared with the estimated 10% in 2014 (
1
). Overall, since the 2014 recommendation for PCV13 use among adults, minimal changes
in the incidence of pneumococcal disease among adults at the population-level were
observed, through both direct PCV13 effects from vaccinating older adults and continued
indirect effects from PCV13 use in children.
Economic analyses. Two independent economic models evaluated the expected public health
impact and cost effectiveness of continued PCV13 use in series with PPSV23 versus
use of PPSV23 alone. These models estimated that, over the lifetime of a single cohort
of 2.7 million adults aged 65 years, an expected 76–175 cases of PCV13-type IPD and
4,000–11,000 cases of PCV13-type pneumonia would be averted through continued PCV13
use in series with PPSV23, compared with PPSV23 alone (
30
). Applying the total costs to quality adjusted life years (QALY), the estimated cost
effectiveness ratios were $200,000 to $560,000 per QALY. In 2014, the estimated cost
per QALY for PCV13 use in series with PPSV23 was $65,000 (
31
). Considering the range of values for sensitivity analyses for key inputs in these
models, the results of the economic analyses were less favorable toward continued
PCV13 use for all adults aged ≥65 years compared with PPSV23 alone.
Rationale
Incidence of PCV13-type disease has been reduced to historically low levels among
adults aged ≥65 years through indirect effects from pediatric PCV13 use. Implementation
of a PCV13 recommendation for all adults aged ≥65 years in 2014 has had minimal impact
on PCV13-type disease at the population level in this age group. However, PCV13 is
a safe and effective vaccine that can reduce the risk for PCV13-type IPD and noninvasive
pneumonia among persons aged ≥65 years. Balancing this evidence and considering acceptability
and feasibility concerns, in June 2019 ACIP voted to no longer routinely recommend
PCV13 for all adults aged ≥65 years and instead, to recommend PCV13 based on shared
clinical decision-making for adults aged ≥65 years who do not have an immunocompromising
condition, CSF leak, or cochlear implant (Table 1) (Table 2).
TABLE 1
Recommendations for 13-valent pneumococcal conjugate vaccine (PCV13) and 23-valent
pneumococcal polysaccharide vaccine (PPSV23) among adults aged ≥19 years
Medical indication group
Specific underlying medical condition
PCV13 for persons aged ≥19 years
PPSV23* for persons aged 19–64 years
PCV13 for persons aged ≥65 years
PPSV23 for persons aged ≥65 years
None
None of the below
No recommendation
No recommendation
Based on shared clinical decision-making†
1 dose; if PCV13 has been given, then give PPSV23 ≥1 year after PCV13
Immunocompetent persons
Alcoholism
No recommendation
1 dose
Based on shared clinical decision-making†
1 dose; if PCV13 has been given, then give PPSV23 ≥1 year after PCV13 and ≥5 years
after any PPSV23 at age <65 years
Chronic heart disease§
Chronic liver disease
Chronic lung disease¶
Cigarette smoking
Diabetes mellitus
Cochlear implant
1 dose
1 dose ≥8 weeks after PCV13
1 dose if no previous PCV13 vaccination
1 dose ≥8 weeks after PCV13 and ≥5 years after any PPSV23 at <65 years
CSF leak
Immunocompromised persons
Congenital or acquired asplenia
1 dose
2 doses, 1st dose ≥8 weeks after PCV13 and 2nd dose ≥5 years after first PPSV23 dose
1 dose if no previous PCV13 vaccination
1 dose ≥8 weeks after PCV13 and ≥5 years after any PPSV23 at <65 years
Sickle cell disease/other hemoglobinopathies
Chronic renal failure
Congenital or acquired immunodeficiencies**
Generalized malignancy
HIV infection
Hodgkin disease
Iatrogenic immunosuppression††
Leukemia
Lymphoma
Multiple myeloma
Nephrotic syndrome
Solid organ transplant
Abbreviations: CSF = cerebrospinal fluid; HIV = human immunodeficiency virus.
* Only refers to adults aged 19–64 years. All adults aged ≥65 years should receive
1 dose of PPSV23 ≥5 years after any previous PPSV23 dose, regardless of previous history
of vaccination with pneumococcal vaccine. No additional doses of PPSV23 should be
administered following the dose administered at age ≥65 years.
† Recommendations that changed in 2019.
§ Includes congestive heart failure and cardiomyopathies.
¶ Includes chronic obstructive pulmonary disease, emphysema, and asthma.
** Includes B- (humoral) or T-lymphocyte deficiency, complement deficiencies (particularly
C1, C2, C3, and C4 deficiencies), and phagocytic disorders (excluding chronic granulomatous
disease).
†† Diseases requiring treatment with immunosuppressive drugs, including long-term
systemic corticosteroids and radiation therapy.
TABLE 2
Policy options* for use of pneumococcal vaccines in adults aged ≥65 years presented
for a vote and considerations by the Advisory Committee on Immunization Practices
(ACIP), June 2019
Proposed policy
Considerations raised at the June 2019 ACIP meeting
Outcome (votes in favor: against)
In favor
Against
ACIP recommends PCV13 for all adults aged ≥65 years who have not previously received
PCV13. PCV13 should be given first, followed by a dose of PPSV23
PCV13 is effective against invasive pneumococcal disease and pneumonia
Low burden of PCV13-type disease remaining
Rejected (6:8)
Changing the recommendation could negatively impact the perceived importance of adult
pneumococcal vaccine recommendations
Population-level impact from PCV13 use among older adults observed to date has been
minimal
Universal recommendations are easier for clinicians to understand and implement than
the recommendation based on shared clinical decision-making
Universal PCV13 recommendation for older adults are not a judicious use of resources
ACIP no longer recommends PCV13 for adults aged ≥65 years who do not have an immunocompromising
condition,† CSF leak, or cochlear implant. All adults aged ≥65 years should receive
a dose of PPSV23
Largest public health benefit for older adults is gained through indirect effects
from pediatric PCV13 use
PCV13 is effective against PCV13-type invasive pneumococcal disease and pneumonia
Rejected (1:13)
ACIP recommends PCV13 based on shared clinical decision-making for adults aged ≥65
years who do not have an immunocompromising condition,† CSF leak, or cochlear implant
and who have not previously received PCV13.All adults aged ≥65 years should receive
a dose of PPSV23
Balances the minimal population-level impact of a routine recommendation with the
potential for individual-level protection
—§
Affirmed (13:1)
PCV13 would remain available to patients who want this added protection
Abbreviations: CSF = cerebrospinal fluid; PCV13 = 13-valent pneumococcal conjugate
vaccine; PPSV23 = 23-valent pneumococcal polysaccharide vaccine.
* Policy options listed in the order they were presented to ACIP for a vote.
† Includes adults with chronic renal failure, nephrotic syndrome, immunodeficiency,
iatrogenic immunosuppression, generalized malignancy, human immunodeficiency virus,
Hodgkin disease, leukemia, lymphoma, multiple myeloma, solid organ transplants, congenital
or acquired asplenia, sickle cell disease, or other hemoglobinopathies.
§ No content for this cell.
New Pneumococcal Vaccine Recommendations for Adults Aged ≥65 Years Old
PCV13. PCV13 vaccination is no longer routinely recommended for all adults aged ≥65
years. Instead, shared clinical decision-making for PCV13 use is recommended for persons
aged ≥65 years who do not have an immunocompromising condition, CSF leak, or cochlear
implant and who have not previously received PCV13 (Table 1).
CDC guidance for shared clinical decision-making. When patients and vaccine providers
engage in shared clinical decision-making for PCV13 use to determine whether PCV13
is right for the specific individual aged ≥65 years, considerations may include the
individual patient’s risk for exposure to PCV13 serotypes and the risk for pneumococcal
disease for that person as a result of underlying medical conditions (Box).
BOX
Considerations for shared clinical decision-making regarding use of 13-valent pneumococcal
conjugate vaccine (PCV13) in adults aged ≥65 years
PCV13 is a safe and effective vaccine for older adults. The risk for PCV13-type disease
among adults aged ≥65 years is much lower than it was before the pediatric program
was implemented, as a result of indirect PCV13 effects (by preventing carriage and,
thereby, transmission of PCV13-type strains). The remaining risk is a function of
each individual patient’s risk for exposure to PCV13 serotypes and the influence of
underlying medical conditions on the patient’s risk for developing pneumococcal disease
if exposure occurs.
The following adults aged ≥65 years are potentially at increased risk for exposure
to PCV13 serotypes and might attain higher than average benefit from PCV13 vaccination,
and providers/practices caring for many patients in these groups may consider regularly
offering PCV13 to their patients aged ≥65 years who have not previously received PCV13:
Persons residing in nursing homes or other long-term care facilities
Persons residing in settings with low pediatric PCV13 uptake
Persons traveling to settings with no pediatric PCV13 program
Incidence of PCV13-type invasive pneumococcal disease and pneumonia increases with
increasing age and is higher among persons with chronic heart, lung, or liver disease,
diabetes, or alcoholism, and those who smoke cigarettes or who have more than one
chronic medical condition.* Although indirect effects from pediatric PCV13 use were
documented for these groups of adults and were comparable to those observed among
healthy adults, the residual PCV13-type disease burden remains higher in these groups.
Providers/practices caring for patients with these medical conditions may consider
offering PCV13 to such patients who are aged ≥65 years and who have not previously
received PCV13.
* Ahmed SS, Pondo T, Xing W, et al. Early impact of 13-valent pneumococcal conjugate
vaccine use on invasive pneumococcal disease among adults with and without underlying
medical conditions—United States. Clin Infect Dis 2019. Epub August 12, 2019.
If a decision to administer PCV13 is made, it should be administered before PPSV23
(
5
). The recommended intervals between pneumococcal vaccines remain unchanged for adults
without an immunocompromising condition, CSF leak, or cochlear implant (≥1 year between
pneumococcal vaccines, regardless of the order in which they were received) (
5
). PCV13 and PPSV23 should not be coadministered.
ACIP continues to recommend PCV13 in series with PPSV23 for adults aged ≥19 years
(including those aged ≥65 years) with immunocompromising conditions, CSF leaks, or
cochlear implants (Table 1) (
2
).
PPSV23 for adults aged ≥65 years. ACIP continues to recommend that all adults aged
≥65 years receive 1 dose of PPSV23. A single dose of PPSV23 is recommended for routine
use among all adults aged ≥65 years (
1
). PPSV23 contains 12 serotypes in common with PCV13 and an additional 11 serotypes
for which there are no indirect effects from PCV13 use in children. The additional
11 serotypes account for 32%–37% of IPD among adults aged ≥65 years (
22
). Adults aged ≥65 years who received ≥1 dose of PPSV23 before age 65 years should
receive 1 additional dose of PPSV23 at age ≥65 years (2), at least 5 years after the
previous PPSV23 dose (Table 1) (
5
).
Future Research and Monitoring Priorities
CDC will continue to assess the safety, implementation and the impact of shared clinical
decision-making regarding administration of PCV13 to adults aged ≥65 years; the indirect
effect of pediatric PCV13 vaccination on disease burden among older adults; and the
emergence of nonvaccine serotypes, to inform policy decisions for higher valency conjugate
vaccines currently in development. ACIP will continue to review relevant data as they
become available and update pneumococcal vaccination policy as appropriate.
Before administering PCV13 or PPSV23, health care providers should consult the relevant
package inserts (
21
,
32
) regarding precautions, warnings, and contraindications. Adverse events occurring
after administration of any vaccine should be reported to the Vaccine Adverse Event
Reporting System (VAERS). Reports can be submitted to VAERS online, by facsimile,
or by mail. More information about VAERS is available at https://vaers.hhs.gov/.
Summary
What is already known about this topic?
In 2014, the Advisory Committee on Immunization Practices (ACIP) recommended 13-valent
pneumococcal conjugate vaccine (PCV13) in series with 23-valent polysaccharide vaccine
(PPSV23) for all adults aged ≥65 years.
What is added by this report?
PCV13 use in children has led to sharp declines in pneumococcal disease among adults
and children. Based on a review of accrued evidence ACIP changed the recommendation
for PCV13 use in adults.
What are the implications for public health practice?
ACIP recommends a routine single dose of PPSV23 for adults aged ≥65 years. Shared
clinical decision-making is recommended regarding administration of PCV13 to persons
aged ≥65 years who do not have an immunocompromising condition, cerebrospinal fluid
leak, or cochlear implant and who have not previously received PCV13. If a decision
to administer PCV13 is made, PCV13 should be administered first, followed by PPSV23
at least 1 year later.