Pneumonia Vaccines: Current Recommendations and Advocacy Opportunities

Pneumonia is a bacterial, viral, or fungal infection of the lungs that can be mild to severe in presentation. Symptoms may include cough, fever, chills, and difficulty breathing. Pneumonia combined with influenza is the 8th leading cause of death in the United States, with pneumonia accounting for more than 50,000 annual deaths, 423,000 annual emergency department visits, and $16.2 billion in annual health care costs.^1-3

Although signs and symptoms may vary among individuals,certain patient populations are at greater risk for developing severe pneumonia and potentially fatal complications. Risk factors include age, environmental conditions, lifestyle habits, and comorbidities.⁴ Patients 65 years or older have a higher mortality rate compared with younger patients, with approximately 85% of all pneumonia deaths occurring in this older patient population.³

Currently, 2 types of pneumonia vaccine are available in the United States: the pneumococcal conjugate vaccine PCV13 (Prevnar 13) and the pneumococcal polysaccharide vaccine PPSV23 (Pneumovax). PCV13, which protects against 13 types of pneumococcal bacteria, is indicated for infants and young children, adults 65 years or older, and other patients at an increased risk for pneumonia. PPSV23, which protects against 23 types of pneumococcal bacteria, is indicated for adults 65 years or older and any individuals 2 years or older who are at an increased risk for pneumonia.⁵

Despite the demonstrated efficacy of these vaccines, only 66.9% of adults over age 65 years have ever received a pneumonia vaccine.¹ Given the consequences of acquiring pneumonia, there is both a need and an opportunity to improve vaccination rates. The pharmacist can play a valuable role in identifying high-risk patients, providing education on benefits and risks, and advocating for pneumonia vaccination when indicated.

INDICATIONS FOR PNEUMONIA VACCINATION

PCV13 is indicated for children 2 years or younger, adults 65 years or older, and patients aged 2 to 64 years who meet high-risk criteria for pneu- monia. PPSV23 is indicated for adults 65 years or older and patients aged 2 to 64 years who meet high-risk criteria for pneumonia.^5,6

For both vaccines, high-risk criteria for pneumonia include immunocompetent patients with chronic liver disease (including alcoholism), chronic heart disease (including congestive heart failure and cardiomyopathy), and chronic lung disease (including asthma, chronic obstructive pulmonary disease, and emphysema). Smokers, patients with diabetes mellitus, those with cochlear implants, and patients with a cerebrospinal fluid (CSF) leak are also at increased risk and have an indication for receiving pneumonia vaccination. Additionally, immunocompromised patients, including those with cancer, HIV infection, chronic kidney disease, asplenia, sickle cell disease, or a history of solid organ transplantation, should receive pneumonia vaccination.^7-9

DOSING AND VACCINATION SCHEDULES

Children

All children under age 2 years should receive 4 doses of PCV13 administered at 2, 4, 6, and 12 to 15 months of age. The first dose should be given no earlier than 6 weeks of age.¹⁰ Children with high-risk conditions should receive the full series of PCV13, as well as additional doses of PPSV23. If possible, all recommended doses of PCV13 should be administered prior to PPSV23.¹¹ The CDC provides specific recommendations for dosing schedules of PCV13 and PPSV23 in children and adolescents meeting high-risk criteria (table).¹¹

Children aged 2 to 5 years who are either immunocompromised or immunocompetent, with an underlying medical condition that classifies them as high-risk, should receive a dose of PPSV23 at least 8 weeks after their last dose of PCV13. If the dosing schedule for PCV13 was not completed, they should receive 1 to 2 additional doses of PCV13. If only 3 doses of PCV13 were previously administered, they should receive an additional dose of PCV13 before receiving PPSV23. If fewer than 3 doses of PCV13 were administered, they should receive 2 doses of PCV13, at least 8 weeks apart, before receiving PPSV23 at least 8 weeks after their most recent PCV13 dose.¹¹

In children aged 6 to 18 years who are immunocompromised, or have a cochlear implant or a CSF leak, a dose of PPSV23 should be administered at least 8 weeks after the most recent PCV13 dose. If PCV13 was not previously administered, then a dose should be administered before PPSV23 is given at least 8 weeks later. For patients who have already received PPSV23 but still require PCV13, wait at least 8 weeks after PPSV23 administration before administering PCV13. A second dose of PPSV23 should be administered no sooner than 5 years after the first dose in these patient populations.

In patients aged 6 to 18 years with chronic heart disease, chronic lung disease, liver disease, or diabetes mellitus, a single dose of PPSV23 should be administered if not already received. If PCV13 has been received previously, wait at least 8 weeks since the most recent dose.

Adults

Both PPSV23 and PCV13 are recommended in adults. Specific recommendations will vary based on age, immune status, and comorbidities.^8,10-12 PCV13 and PPSV23 should not be administered at the same time. When both vaccinations are indicated, PCV13 should be administered prior to PPSV23, whenever possible. Optimal interval between immunizations will vary based on the individual vaccine and patient characteristics.

In patients 65 years or older, both PCV13 and PPSV23 are indicated, regardless of immune status and comorbidities. All patients should receive a single dose of PPSV23, regardless of vaccination history. A dose of PCV13 may also be indicated in this population, if they have not previously received this vaccine. Patients who have not received any pneumonia vaccination or those with unknown vaccination history should receive a dose of both pneumonia vaccines. PCV13 should be administered first, and PPSV23 should then be administered at least 1 year later in most immunocompetent individuals. However, in immunocompromised patients, or those with cochlear implants or CSF leaks, the PPSV23 dose should be administered at least 8 weeks after the PCV13 dose, rather than waiting a full year. If patients have already received their dose of PPSV23 after age 65 years but have not received PCV13, a single dose of PCV13 should be administered at least 1 year after the PPSV23 dose, regardless of any current medical conditions.^8-10,12

In adults aged 19 to 64 years, PCV13 and PPSV23 may be indicated based on immune status and the presence of certain medical conditions. Immunocompetent individuals with high-risk medical conditions should receive 1 dose of PPSV23 during this time, with an additional dose after age 65 years. These doses should be administered at least 5 years apart. If patients are immunocompromised, they should receive 2 doses of PPSV23 between the ages of 19 and 64 years, with an additional dose after the age of 65 years. Each dose should be administered at least 5 years apart. PCV13 is indicated only in immunocompromised individuals and in those with cochlear implants or CSF leaks. PCV13 should be administered at least 8 weeks apart from PPSV23 and does not need to be readministered once a patient reaches age 65 years.^8-10,12

ROLE OF THE PHARMACIST

Pharmacists can play a vital role in identifying patients with an indication for pneumonia vaccination, simplifying and explaining the vaccination schedule, and advocating for vaccination by educating patients on the benefits of pneumonia immunization. The opportunity exists to improve vaccination rates; patients may be unaware of the risk factors for pneumonia, and of the potential complications and increased risk for morbidity associated with developing an infection. Pharmacists can interact with patients in the community, ambulatory care encounters, and hospital settings. Each individual encounter will provide the pharmacist with the chance to address the need for pneumonia vaccination, thus helping to reduce the complications and consequences of failure to vaccinate. In the community setting, pharmacist-based immunization services have demonstrated increased vaccination rates and advocacy.¹³ Across all health care settings and during transitions of care, pharmacists can become proactive regarding pneumonia vaccination and outcome optimization.

CONCLUSIONS

Pneumonia can be detrimental to the health of a patient, increasing both hospitalization and risk for mortality. PCV13 and PPSV23 are recommended in select patient populations, with dosing schedules varying based on age, immune status, and comorbidities. Despite demonstrated efficacy, the opportunity still exists to improve vaccination rates. Pharmacists can play a role in providing education and vaccine advocacy, to optimize outcomes in patients at risk for pneumonia.

LARESSA BETHISHOU, PHARMD, BCPS, is an assistant professor of pharmacy practice at Chapman University School of Pharmacy in Irvine, California.

References

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2. Deaths and mortality. CDC website. cdc.gov/nchs/fastats/deaths.htm. Updated May 3, 2017. Accessed October 20, 2017.

3. Trends in pneumonia and influenza morbidity and mortality. American Lung Association website. lung.org/assets/documents/research/pi-trend-report.pdf. Pub- lished November 2015. Accessed October 20, 2017.

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8. Recommended immunization schedules for adults. United States, 2017. CDC website. cdc.gov/vaccines/schedules/hcp/adult.html. Updated February 27, 2017. Accessed October 20, 2017.

9. Pneumococcal vaccine timing for adults. CDC website. cdc.gov/vaccines/vpd/ pneumo/downloads/pneumo-vaccine-timing.pdf. Published November 30, 2015. Accessed October 20, 2017.

10. Prevnar 13 [package insert]. Philadelphia, PA: Wyeth Pharmaceuticals Inc; 2017. Immunization: child and adolescent schedule. CDC website. cdc.gov/vaccines/ schedules/hcp/imz/child-adolescent.html. Updated February 6, 2017. Accessed October 20, 2017.

11. Pneumovax 23 [package insert]. Whitehouse Station, NJ: Merck Sharp & Dohme Corp; 2015.

12. Taitel M, Cohen E, Duncan I, Pegus C. Pharmacists as providers: targeting pneu- mococcal vaccinations to high risk populations. Vaccine. 2011;29(45):8073-8076. doi: 10.1016/j.vaccine.2011.08.051.