By Marie Rosenthal, MS
In a 14-1 vote, the Advisory Committee on Immunization Practices (ACIP) recommended lowering the age recommendation for all pneumococcal conjugate vaccines (PCVs) to people 50 years of age and older, regardless of their risk.
In addition, vaccination is recommended for adults ages 19 to 49 years with certain underlying conditions or risk factors who have not received a PCV or whose vaccination history is unknown.
The one person who voted against the recommendation was the chair of the ACIP’s Pneumococcal Vaccines Work Group, James Loehr, MD, FAAFP. Dr Loehr said he thought the new recommendation should only apply to PCV21 (Capvaxive, Merck), which was approved by the FDA earlier this year.
“This is just a difference in priorities. I’m weighing different values in the ETR [evidence to recommend] system than other people are weighing. And it doesn’t mean that I’m right and they’re wrong. I totally respect the work group recommendation.
“I’m simply saying that my values are different, and so I’m voting differently based on those relative prioritization of the values,” said Dr. Loehr, a family medicine specialist at Cayuga Health, in Ithaca, N.Y.
Dr. Loehr mentioned several “uncertainties” with a general lowering of the age recommendation:
- the indirect effects from pediatric PCVs that are coming;
- higher-valency vaccines for adults that are being developed; and
- the duration of protection from adult vaccination, and that people who receive a vaccine at 50 are likely to see waning immunity and will need a second vaccine at 65.
The work group, however, agreed that having different age-based recommendations according to which PCV vaccine is being administered would be too much of a challenge to implement.
The work group considered many other issues, including the fact that an age-based recommendation, rather than a risk-based recommendation, is likely to see higher vaccination rates, and that the current recommendation already includes many adults in that age group: 33% to 54% of adults 50 to 65 years of age have an indication for risk-based pneumococcal vaccination.
In fact, 88% of adults 50 to 64 years who were hospitalized with pneumococcal disease had at least one condition that was included in the risk-based pneumococcal vaccine indication, according to Miwako Kobayashi, MD, MPH, of the CDC’s National Center for Immunization and Respiratory Diseases.
The vaccine is also an equity issue, according to the work group, because Blacks have a higher risk for disease.
Other considerations were concerns about the variability of health insurance coverage that might keep PCV20 (Prevnar 20, Pfizer) as the only practical option for people since PCV21 is a newer vaccine, and the cost-effectiveness of the vaccines versus the overall health benefits to society.
The 20 serotypes contained in Prevnar 20 are estimated to cause more than 2,000 deaths and more than 65,000 cases of invasive pneumococcal disease, including bacteremia and meningitis, and community-acquired pneumonia annually in adults 50 to 64, according to Pfizer. They include the 13 serotypes Prevnar 13 plus an additional seven serotypes: Streptococcus pneumoniae serotypes 1, 3, 4, 5, 6A, 6B, 7F, 8, 9V, 10A, 11A, 12F, 14, 15B, 18C, 19A, 19F, 22F, 23F and 33F.
Capvaxive contains 21 serotypes more likely to be of concern for adults: S. pneumoniae serotypes 3, 6A, 7F, 8, 9N, 10A, 11A, 12F, 15A, 15B, 15C, 16F, 17F, 19A, 20A, 22F, 23A, 23B, 24F, 31, 33F and 35B.
“PCV21 is not PCV20 plus an additional serotype. This was developed to target serotypes that commonly cause disease in adults, and the manufacturer does not have plans to seek an indication for routine use in infants. They will seek an indication for children with a risk condition, and there is a phase 3 trial currently in progress,” Dr. Loehr said.
CDC Director Mandy Cohen, MD, MPH, endorsed the ACIP’s recommendation. Lowering the age for pneumococcal vaccination gives more adults the opportunity to protect themselves from pneumococcal disease at the age when risk of infection substantially increases. S. pneumoniae can cause serious illnesses, including pneumonia, meningitis, and bloodstream infections, and older adults are at increased risk for pneumococcal disease, the CDC said in a statement announcing the endorsement.
