Adult Pneumococcal Vaccination: NAABI position paper 2016
 
 
Principle:
 

Streptococcus pneumoniae (S.pneumoniae) is a leading infectious cause of pneumonia and less often invasive pneumococcal disease worldwide. It causes significant morbidity and mortality in adults which might be reduced by vaccination.

Evidence from studies indicates that the vaccine may be more effective in preventing the rarer outcome of invasive pneumococcal disease than pneumonia (of all causes) or mortality in adults. Also vaccination might not afford as much protection in adults with chronic illness as it does for healthy adults. Current pneumococcal vaccines, even with added strain coverage, do not protect against all 90+ pneumococcal serotypes.

Vaccine recomendations are based upon epidemological evidences and immunogenicity studies; and are subject to revisions.

 
Types:
 
Two pneumococcal vaccines are currently available for use in adults in India: one 23-valent pneumococ­cal polysaccharide vaccine, PPSV23. The other is 13-valent pneumococcal conjugate vaccine, PCV 13. Both vaccines cover 12 of the same serotypes, plus PCV13 covers one more, and PPSV23 covers 11 others. PPSV23 is a polysaccharide 23 valent vaccine and may not induce a T-cell memory response. PCV13 is a conjugate vaccine which activates both B and T-cell and generates immunological memory. The act of conjugating or linking the polysaccharide vaccine to a carrier protein in PCV13 enhances immunogenicity. When both are indicated, PCV13 is advocated first for the best immune response. Either PCV 13 or PPSV23 can be given at the same visit as the influenza vaccine (live or inactivated), or other vaccines in adults, at separate injection sites.
 
Who need them:
 
Routine PPSV23 use is not recom­mended for subjects aged <65 years unless they have medical indications for PPSV23.
 
Immuno compromised Patients:
 
Advisory Committee on Immunization Practices (ACIP) recommends that adults aged =19 years with immunocompromising conditions, functional or anatomic asplenia, CSF leaks, or cochlear implants, and who have not previously received PCV13 or PPSV23, should receive both vaccines - a dose of PCV13 first, followed by a dose of PPSV23 at least 8 weeks later.
 
PCV 13-8 weeks later PPSV 23 - 5 years later PPSV 23
PPSV 23 - 1 year later PCV 13.
 
High-risk people younger than age 65 years need a second dose of PPSV23 5 years later (PPSV23 is not to be given every 5 years).
 
According to the present ACIP guideline, adults (19–64 years) needing PPSV23 include those with chronic heart disease/ chronic lung disease/ diabetes / asthma and also those who smoke (smoking is considered as an independent risk factor for pneumonia) ; PCV13 is not recommended for these conditions. However, PCV 13 is now FDA-approved for use in adults 50 years of age and older (condition unspecified). At age 65 years, all adults (including people vaccinated when younger) need to be vaccinated.
 
Immunocompetent Patients:
 
Who What and When
   
Immunocompetent adults 19 to 64 years of age or older with diseases, habits, or living conditions that put them at high risk of pneumococcal disease:
  • Heart disease (including heart failure or cardiomyopathy)
  • Pulmonary disease (including COPD, emphysema, or asthma)
  • Diabetes
  • Alcoholism
  • Cigarette smoking
  • Chronic liver disease
Single dose of PPSV23
Adults 65 years of age and older Single dose of PCV13 (if not previously given, or vaccination history is unknown), followed by PPSV23 at least one year later. If PPSV23 has been given first, PCV13 after one year.
 
Indian Recommendations
 

PPSV23 is recommended for adults over 50 years of age by the Geriatric Society of India. Pneumococcal vaccination is recommended for diabetes patients at an increased risk (older patients, nephropathy, renal insuffciency and malignancy) according to the Diabetic Association of India.

PPSV23 is recommended in pregnancy if some other risk factor is present (e.g., on the basis of medical, occupational, lifestyle, or other indications).

People with HIV infection should receive both PCV13 and PPSV23 vaccines as recommended after diagnosis.

Usual vaccination is recommended even after confirmed pneumococcal disease.

 
 
 
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