2022 Updated CDC Recommendations for Pneumococcal Vaccination Lower Barriers to Assessing, Identifying Eligible Patients

For the pneumococcal vaccine, a 2022 update from the CDC defines who is immunocompromised for the purposes of vaccination assessment, explained Amanda Price, PharmD, BCACP, in a presentation at the American Society of Health-System Pharmacists 2022 Summer Meeting.

Some common patients considered immunocompromised for the purposes of assessing eligibility include those who are hematopoietic stem cell transplant recipients, have hematologic malignancies, are renal or other solid organ transplant recipients, have solid tumor malignancies, are living with HIV, and have primary immunodeficiencies, autoimmune conditions, or are taking immunosuppressive agents.

“For who’s considered immunocompromised, when you look at the information coming from the CDC and the [Advisory Committee on Immunization Practices], you’ll find that there is not necessarily broad consensus on the definition of this term. Depending on which vaccination you’re looking at, they will offer up [different] examples of patients who are immunocompromised, but in many cases, they also make the statement that the state of being immunocompromised is a spectrum,” Price said. “While you can certainly use that term, they urge clinicians to be doing an assessment of their patients and taking into account the level of immunocompromised state that the patient may have.”

The majority of the patients pharmacists may encounter will have at least 1 defined immunocompromised state, but some patients may have more than one of the defined states. The addition of multiple defined states can further influence the level of a patient’s immunocompromised state.

“With that in mind, one of the biggest changes that I think we’ve seen is going from the old recommendations to the new recommendations by eliminating the tiered-risk-based approach,” Price said. “The old guidelines actually had a universal age-based guideline that looked at patients who qualified for the pneumococcal vaccine based on their age. But even then, it got a little bit fuzzy, because they said you could receive a pneumococcal polysaccharide vaccine and, with shared clinical decision making, if you felt the risk was high enough, they might be eligible for the conjugate vaccine as well.”

In this tiered-risk-based assessment, the CDC placed patients into 2 tiers for assessment, including the immunocompromised patients, such as those with functional anatomic asplenia or patients with cochlear implants, that would receive a conjugate vaccine followed by the polysaccharide vaccine. In the other tier were patients with chronic medical conditions that would merit the polysaccharide vaccine, but not the conjugate vaccine.

“To be honest, this is one of the most challenging vaccination recommendations that I can think of, because it feels like you’re constantly playing those old nomadic puzzles from when you were in elementary school, where train A leaves the station here and train B leaves the station here, then when do you pass the playground? To be honest, I don’t know if I have enough information to know where the playground is,” Price said.

Instead, the new recommendations provide some harmonization around this to make it easier for clinicians to lower the barriers to assessing and identifying eligible patients, as well as to potentially tackle the disparities by eliminating the tier-risk-based assessment and replacing this with a risk-based assessment or an age qualification.

“Now, there is one point that the CDC went around and around about—whether or not to change that age-based recommendation down to 50 years from 65. Even listening to the evidence that they presented, it’s really interesting that the use of the PCV20 in the 50 to 65 universal age recommendation would be cost effective, but the same was not true of the PCV15 and 23 series,” Price said.

Price noted that the consensus became to leave the universal recommended age at 65 years. However, there were some internists that responded negatively to this recommendation, as they were concerned that this recommendation would risk losing the opportunity to catch patients before they got to those chronic medical conditions when their immune system could respond.

“As it stands though, the committee did vote to keep that universal age-based recommendation at 65, and then they put in immunocompromised and chronic medical conditions all into the same bucket. So for those who now qualify for the pneumococcal vaccination, they have their choice: They can receive the PCV20 as a single dose and be done, or they can receive the PCV15 plus the PPSV23 again in a year,” Price said. “But you’ll note that both regimens include a conjugate vaccine as the foundational vaccine.”

REFERENCE

Price A. Vaccination Updates 2022: COVID-19 and Beyond. Presented at: ASHP Summer Meeting 2022; June 12, 2022; Phoenix, AZ.