ACIP Streamlines Pneumococcal Vaccine Recs

Streamlined pneumococcal vaccine recommendations, and recombinant zoster vaccine (Shingrix) for immunocompromised adults, were endorsed by the CDC's Advisory Committee on Immunization Practices (ACIP) in unanimous votes on Wednesday.

ACIP voted 15-0 for a revised age-based recommendation and 15-0 for a revised risk-based recommendation for pneumococcal vaccines. All adults ages 65 and up and adults ages 19-64 with certain underlying medical conditions or other risk factors who have not previously received a pneumococcal conjugate vaccine or in whom previous vaccine history is unknown should receive one of the pneumococcal vaccines, PCV20 (Prevnar 20) or PCV15 (Vaxneuvance). If PCV15 is used, this should be followed by the polysaccharide vaccine, PPSV23 (Pneumovax 23).

However, an amendment proposed earlier in the meeting to knock the age-based recommendations down to 50 did not pass in a 4-11 vote.

The rationale for rejecting the amendment was the lack of efficacy data on the pneumococcal conjugate vaccines, as well as the idea that since children are now being immunized with pneumococcal conjugate vaccine, the landscape of disease has the potential to change.

Current CDC recommendations are for PPSV23 for adults ages 65 and up, people ages 2-64 with certain medical conditions, and adults ages 19-64 who smoke cigarettes, and for PCV13 (Prevnar 13) in children younger than 2 years, people older than 2 years with certain medical conditions, and for adults ages 65 and older through shared clinical decision making.

Amanda Cohn, MD, of the CDC, said of the separate age-based and risk-based votes, "discussions occurred at CDC among the workgroup [that] two age-based recommendations would be confusing."

Helen Keipp Talbot, MD, MPH, of Vanderbilt University in Nashville, was the committee member who proposed moving the age recommendations down to 50, speaking from her experience as an adult internist.

"The majority of physicians who took care of adults really wanted the age ... starting at age 50," she said, adding that while they do not know the duration of protection, she would be "more than happy to evaluate a booster in the future."

Beth Bell, MD, MPH, of the University of Washington in Seattle, pointed out that three-quarters of adults ages 50-64 already have chronic conditions, potentially making them eligible to receive the vaccine anyway, and questioned what the "incremental benefit would be dropping the age limit down to 50."

While those in favor of starting universal vaccination at age 50 also pointed out it would best address concerns about equity, ACIP chair Grace Lee, MD, of Stanford University School of Medicine in California, said that the most effective intervention is arguably the pneumococcal conjugate vaccines delivered in childhood.

"I would argue that childhood vaccination programs are going to address equity at a population level more than individual vaccines," she said.

After the vote, Oliver Brooks, MD, of Watts Healthcare Corporation in Los Angeles, noted that obesity and hypertension are not among the chronic conditions covered by a risk-based recommendation among younger adults, adding that he was concerned that "the disparities in outcomes related to pneumococcal disease may not totally be addressed by our/my vote." He proposed revisiting these conditions in the future.

Camille Kotton, MD, of Massachusetts General Hospital in Boston, added that these decisions were being made largely based on immunogenicity, and it would be important to "accumulate clinical data" and "monitor the situation" to ensure they "continue to see robust clinical protection" from the vaccines.

The other vote about the two-dose recombinant zoster vaccine for adults ages 19 and up who are immunodeficient or immunosuppressed due to disease or therapy also passed 15-0, with little fanfare. CDC staff noted that the dosing schedule would be at month 0 followed by a second dose 2 to 6 months later; however, if immunocompromised individuals would benefit from a shorter immunization schedule, the second dose could be 1 to 2 months later.

All recommendations from ACIP are not considered final until they are published in the Morbidity and Mortality Weekly Report.

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