Pneumococcal Vaccine Recommendations

In this episode, TRC Healthcare editor, Vickie Danaher, PharmD, discusses Pneumococcal Vaccine Recommendations for Adults.

This is an excerpt from our December 2024 Pharmacy Essential Updates continuing education webinar series.

The clinical resources mentioned during the podcast are part of a subscription to Pharmacist’s Letter, Pharmacy Technician’s Letter, and Prescriber Insights: 

• Article: Prepare to Give More Adults a Pneumococcal Vaccine 
• Algorithm: Pneumococcal Vaccination in Adults
• Chart: Comparison of Pneumococcal Vaccines

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Transcript

This transcript is automatically generated. 

00:00:04 Narrator

Welcome to Clinical Capsules, where we bring you the same evidence-based insights you trust from TRC Healthcare, now in podcast form. We’re thrilled to launch this new series as we celebrate 40 years of keeping healthcare professionals ahead of critical medication updates and guidelines.

00:00:23 Narrator

Every 2nd and 4th Tuesday, our expert editors from Pharmacist’s Letter, Prescriber Insights, and Pharmacy Technician’s Letter will break down the most impactful clinical developments - giving you clear, actionable takeaways in just minutes.

00:00:38 Narrator

Today, in our very first episode, you'll hear an excerpt from our December 2024 pharmacy, essential updates, continuing Education Webinar series in this segment. Associate editor and pharmacist Vicky Danaher explains the latest changes to adult pneumococcal vaccine recommendations.

00:00:57 Narrator

With that, let's get started.

00:01:04 Vickie Danaher

Let's dive into what's going on with pneumococcal vaccines for adults.

00:01:09 Vickie Danaher

And we're talking about this because CDC has made some big changes to the recommendations regarding which patients need pneumococcal vaccination.

00:01:17 Vickie Danaher

We also have a new PCV 21 vaccine, which as in the mix of options that we have for vaccinating our patients and it's often confusing to know which vaccine to use.

00:01:28 Vickie Danaher

Plus, we've been getting lots of questions from you, our subscribers about how to incorporate all of these changes and updates into practice.

00:01:36 Vickie Danaher

So today we're going to answer your big questions and essentially go through The Who, what, when, where and why of pneumococcal vaccines.

00:01:43 Vickie Danaher

We'll talk about which adults need a pneumococcal vaccine and what's the right time for these patients to be vaccinated.

00:01:50 Vickie Danaher

We'll also talk about how the different pneumococcal vaccines compare and then if there's a preferred pneumococcal vaccine that adults should get.

00:01:58 Vickie Danaher

For example, if there's any vaccine, that's a better choice over another for particular patients.

00:02:05 Vickie Danaher

And this is especially important to discuss since the number of pneumococcal vaccines for adults keeps on growing.

00:02:11 Vickie Danaher

So like I mentioned, there is now a 21 valent pneumococcal conjugate vaccine, or PCV 21, which goes by the brand name catfaxiv.

00:02:20 Vickie Danaher

And this joins the other pneumococcal vaccines that were used to giving our patients, so PCV 20, which is Prevnar 20, PCV 15, which is VAX new Vance and then PSV 23, which is the pneumococcal polysaccharide vaccine, pneumovax 23.

00:02:39 Vickie Danaher

Another reason people's heads hurt to spin when we talk about pneumococcal vaccines is because the recommendations have evolved over the.

00:02:46 Vickie Danaher

Based on available evidence, we're not going to go through a full history lesson here, but even in the last five to 10 years, there's been multiple changes.

00:02:55 Vickie Danaher

For example, back in 2014, we were giving patients 65 and older a vaccine called Prevnar 13, or PCV 13 plus. Pneumovax 23A year later.

00:03:08 Vickie Danaher

And then a few years later, in 2019, we moved to mainly focusing on giving Pneumovax 23 to these patients because it was found that many older adults were already getting the benefits of Prevnar 13 indirectly through the use of Prevnar 13 in children.

00:03:25 Vickie Danaher

Then, in 2022, the recommendation shifted towards using the newer pneumococcal conjugate vaccines, Prevnar 20, or vaccine advance for at risk adults and adults 65 and older.

00:03:37 Vickie Danaher

And now, most recently, CDC has made changes to both the age at which older patients should be vaccinated, plus which vaccine should be used.

00:03:46 Vickie Danaher

So what is recommended?

00:03:47 Vickie Danaher

Which adults need a pneumococcal vaccine?

00:03:51 Vickie Danaher

And the big change here is that CDC has lowered the age at which adults should get vaccinated.

00:03:58 Vickie Danaher

So now we want to be recommending routine pneumococcal immunization for adults starting at age 50 years and older, instead of starting at age 65.

00:04:09 Vickie Danaher

And part of the reason why CDC is lowering the age for vaccination is because many adults aged 50 to 64 already have risk for pneumococcal disease.

00:04:17 Vickie Danaher

Which we know can cause pneumonia and ingredients and bloodstream infections.

00:04:22 Vickie Danaher

So, for example, at least 40 to 50% of these patients ready have conditions like diabetes, heart disease or weakened immune system, which puts them at increased risk of developing invasive or more severe illness.

00:04:35 Vickie Danaher

But in some cases, patients might not even know yet that they have these conditions or they don't realize that these conditions are a reason that they should get a pneumococcal vaccine.

00:04:45 Vickie Danaher

Plus, some patient populations have a higher rate of pneumococcal disease at an earlier age.

00:04:51 Vickie Danaher

For instance, serious cases peak and black or African American adults at age 55 to 59.

00:04:58 Vickie Danaher

So it makes sense that patients should be vaccinated sooner to prevent illness before it occurs.

00:05:05 Vickie Danaher

So in our daily workflow, we want to be watching out for our patients age 50 and older who are now recommended for pneumococcal vaccination by checking dates of birth or verifying their age.

00:05:15 Vickie Danaher

And starting a discussion or offering to provide information about immunization.

00:05:20 Vickie Danaher

In addition, we want to continue to stay alert for another group of adults that are also recommended to get a pneumococcal vaccine and those are patients aged 19 to 49 years old with immunocompromising conditions or risk factors.

00:05:37 Vickie Danaher

So we continue to look for patients who have immunocompromising conditions such as cancer or HIV or who are taking immunosuppressants such as methotrexate or adult libab.

00:05:50 Vickie Danaher

We also want to watch for those who have chronic health conditions, such as diabetes or heart, liver, lung disease, or who smoke, or who have alcoholism.

00:06:00 Vickie Danaher

And also listen out for other reasons that could make patients a candidate for pneumococcal vaccine, such as having a cochlear implant.

00:06:10 Vickie Danaher

Any of these things are a reason that patients should be vaccinated against pneumococcal disease.

00:06:17 Vickie Danaher

All right, so now that we know who should get a pneumococcal vaccine, let's stick into the actual vaccines and see how they compare.

00:06:26 Vickie Danaher

And like I alluded to earlier, there's two different types of pneumococcal vaccine for adults.

00:06:31 Vickie Danaher

So conjugate vaccines and polysaccharide vaccines, the pneumococcal conjugate vaccines or pcv are pcv 21 or cepacciv, pcv 20 or Prevnar.

00:06:45 Vickie Danaher

And PCV 15 or vaccine advance.

00:06:49 Vickie Danaher

And the way that these vaccines work is that they're conjugated or linked to a carrier protein, which Spurs production of memory cells.

00:06:57 Vickie Danaher

And this may lead to longer lasting and better immunity than polysaccharide vaccines or ppsv 23, which is pneumovax 23.

00:07:06 Vickie Danaher

Any of these options is a 0.5 ml dose given one time into the muscle. Although Ppsv 23 can also be given subcutaneously if desired.

00:07:20 Vickie Danaher

But a big difference with these vaccines is how their serotype coverage compares.

00:07:24 Vickie Danaher

Meaning, what strains they protect against?

00:07:28 Vickie Danaher

So for example, a PCV 21 helps protect against 21 specific stereotypes or strains of pneumococcal bacteria.

00:07:35 Vickie Danaher

PCV20 protects against 20 stereotypes and so forth.

00:07:41 Vickie Danaher

But point out that PCV 21 isn't just PCV 20 + 1.

00:07:45

Replay.

00:07:48 Vickie Danaher

Instead, PCV 21 covers 10 of the same serotypes as PCV 20 + 11 others.

00:07:56 Vickie Danaher

Npcv 21 protects against 8 stereotypes not included in any other pneumococcal vaccine.

00:08:05 Vickie Danaher

CDC estimates that PCV 21 targets serotypes that cause up to about 85% of invasive pneumococcal disease in adults.

00:08:14 Vickie Danaher

Whereas PCB20 targets up to about 65% of these strains.

00:08:20 Vickie Danaher

So overall PCV 21 has greater coverage of the strains causing invasive pneumococcal disease compared to PCB 20.

00:08:29 Vickie Danaher

On the other hand, PCV 21 is the only current pneumococcal vaccine that does not include coverage for STEROTYPE 4.

00:08:40 Vickie Danaher

And serotype 4 is responsible for causing over 30% of invasive pneumococcal disease in certain populations in the Western United States.

00:08:48 Vickie Danaher

Monitor this data so specifically Alaska, Colorado, New Mexico.

00:08:54 Vickie Danaher

Oregon and the Navajo Nation, which extends into parts of Arizona, New Mexico and Utah.

00:09:02 Vickie Danaher

Typically, patients who live in these conditions who develop serotype 4 disease are adults under age 65 who have specific risk factors such as alcoholism, chronic lung disease, smoking, homelessness and injection drug use.

00:09:20 Vickie Danaher

So, given the differences in the vaccines and the strains they cover, this leads us to the $1,000,000 question which pneumococo vaccine should adults get.

00:09:30 Vickie Danaher

And before I share our bottom line on this, I want to point out that you can use CDC's Pneumo Rex VAX advisor app or website to get the full recommendations and patient specific guidance.

00:09:41 Vickie Danaher

You're not already familiar with this tool. You basically enter a patients age.

00:09:45 Vickie Danaher

You answer some questions about their pneumococcal vaccine history and.

00:09:49 Vickie Danaher

Their underlying medical conditions and it's going to give you the full details and specifics from the CDC guidelines.

00:09:57 Vickie Danaher

But if you're looking for a simpler way to think about this, consider our practical approach.

00:10:03 Vickie Danaher

And rely on either PCD 20 or PCB 21 as your workhorse product.

00:10:09 Vickie Danaher

And that's because, for all patients aged 19 years and older who need a pneumococcal vaccine, 1 dose of PCV 20 or PCV 21 will get them up to date.

00:10:20 Vickie Danaher

So we can kind of think of these as a one and done at least for right now for any adult who needs a pneumococcal vaccine.

00:10:27 Vickie Danaher

Regardless of their age, risk factors or prior vaccine history.

00:10:32 Vickie Danaher

And to illustrate this further, let's take a minute now to walk through our pneumococcal vaccination in adults algorithm, which you can find in our website.

00:10:40 Vickie Danaher

This algorithm will help you select the recommended PNEUMOCO vaccine, including timing of doses in eligible adults based on their pneumococcal vaccination status.

00:10:52 Vickie Danaher

So, for example, eligible adults who have not had a pneumococcal vaccine before or whose history is unknown, should get PCV 21 or kept active or PCV 20 or Prevnar 20.

00:11:07 Vickie Danaher

In these patients PCV 15 or Dex Nuvance is another option.

00:11:12 Vickie Danaher

But this requires PPS V 23 or pneumovax. Usually a year later to complete the series.

00:11:19 Vickie Danaher

And we know that it can often be tricky to get patients to come back in for another vaccine.

00:11:23 Vickie Danaher

This approach also requires stacking multiple vaccines, which may not be practical.

00:11:30 Vickie Danaher

It's a similar story for adults who have just had ppsv 23 or pneumovax before.

00:11:36 Vickie Danaher

These patients should also get PCV 21 or PCV 1:20 year or they can get PCV 15. Alternatively, to complete the series.

00:11:48 Vickie Danaher

And then for patients who have only previously received Prevnar 13 or PCV 13, again we should recommend PCV 21 or PCV 20.

00:12:00 Vickie Danaher

This is also true for those patients who received PCV 13 at any age and who got ppsv 23 before their 65th birthday.

00:12:10 Vickie Danaher

But for those patients aged 65 and older who received PCV 13 at any age and who received PPV 23 after they turned 65, another pneumococcal vaccine is not automatically recommended.

00:12:27 Vickie Danaher

Instead, we want to use shared clinical decision making and work more closely with the patient to help them decide about getting PCV 20 or PCV 21 after five years.

00:12:38 Vickie Danaher

For example, we can help these patients weigh.

00:12:41 Vickie Danaher

Exposure risk.

00:12:42 Vickie Danaher

By considering if they live in a nursing home or another long term care facility, or if they're in an area with low vaccine uptake.

00:12:50 Vickie Danaher

We can also help them think about if they have any health issues that put them at a higher risk of developing severe pneumococcal disease.

00:12:57 Vickie Danaher

Such as having an immunocompromising condition, lung disease or diabetes.

00:13:03 Vickie Danaher

And then we also want to consider how long it's been since the patient's last pneumococcal vaccination.

00:13:08 Vickie Danaher

Since the benefit of Ppsv 23 wanes after about five years.

00:13:15 Vickie Danaher

Alright, so I know we breezed through that fairly quickly, but again, the goal here was to mainly highlight how again that we can use either PCV 20 or PCV 21 as the workhorse product since 1 dose of either product will get all adults in the pneumococcal vacc.

00:13:30 Vickie Danaher

Up to date.

00:13:33 Vickie Danaher

And when it comes down to choosing between PCV 20 or PCV 21, in general, we want to focus on getting eligible adults vaccinated with either option rather than worrying too much about which product they get.

00:13:47 Vickie Danaher

CDC hasn't expressed a particular preference for one product over another.

00:13:54 Vickie Danaher

But we do want to weigh nuances and consider our patient population location and so forth.

00:14:00 Vickie Danaher

For example, we want to go with PCV 21, which has better overall stereotype coverage but lean towards PCV 20 if invasive. Pneumococcal disease, due to serotype 4 is a concern such As for adults living in Alaska, Colorado, New Mexico and Oregon who have alcoholism or who are.

00:14:18 Vickie Danaher

Homelessness.

00:14:21 Vickie Danaher

Also keep in mind that PCV 21 is currently only approved for ages 18 years and up.

00:14:28 Vickie Danaher

The PCB 20 can be used to immunize both adults and children.

00:14:34 Vickie Danaher

So if you do stock both PCV 20 and 21, we want to make sure we use strategies to make sure that we're using the appropriate vaccine for the patients age.

00:14:39

Replay.

00:14:46 Vickie Danaher

Point out that PCV 21 costs about $290.00 per dose and PCV 20 costs about $265 per dose. Medicare Part B will cover any recommended option, but it may take other pairs time to align their coverage benefits to the updated C.

00:15:05 Vickie Danaher

So keep that in mind, especially when vaccinating younger patients.

00:15:12 Vickie Danaher

Now let's go through a couple patient cases to apply what we've learned.

00:15:17 Vickie Danaher

So here's our first patient, Joe.

00:15:19 Vickie Danaher

He's 22 years old.

00:15:21 Vickie Danaher

He doesn't have any allergies or medical conditions, but he does smoke and he has no history of pneumonia vaccines.

00:15:30 Vickie Danaher

Is a pneumococcal vaccine recommended for Joe, and if so, which one should he get?

00:15:38 Vickie Danaher

The answer here is yes, pneumococcal vaccination is recommended for Joe.

00:15:43 Vickie Danaher

He's between age 19 and 49 years old and smoking puts him at a high risk of pneumococcal disease.

00:15:52 Vickie Danaher

And since he has not had pneumococcal vaccine in the past, Joe should get one dose of PCV 21 or PCV 20.

00:16:01 Vickie Danaher

Like I said earlier, another option would be PCV 15.

00:16:05 Vickie Danaher

But then Joe would also need to come back for Ppsv 23 to complete the series.

00:16:12 Vickie Danaher

Let's move on to patient #2. This is.

00:16:15 Vickie Danaher

She's 85 years old and she also smokes, but she's already received Prevnar 13, or PCV 13 when she was age 69.

00:16:26 Vickie Danaher

And then she received Ppsv 23 one year later, when she was 70 years old.

00:16:32 Vickie Danaher

What do you think about this case?

00:16:37 Vickie Danaher

So this one's a little trickier, but Jane's case would be an example where that shared clinical decision making would be recommended so we can help Jane make a choice about getting either PCV 21 or PCV 20.

00:16:50 Vickie Danaher

Certainly, the fact that she smokes is a reason that would favor her getting vaccinated.

00:16:55 Vickie Danaher

We'd also want to weigh other things.

00:16:58 Vickie Danaher

Medical.

00:16:59 Vickie Danaher

Her life expectancy and her preferences and values.

00:17:05 Vickie Danaher

And then the last case that we have is our patient Barry.

00:17:09 Vickie Danaher

He is 66 years old and he has diabetes. Looking at his vaccine history, he last received PCV 13 when he was 62.

00:17:21 Vickie Danaher

That's about four years ago.

00:17:23 Vickie Danaher

Should Barry get another pneumococcal vaccine today?

00:17:29 Vickie Danaher

Patients who have a history of only PCV 13 should get PCV 21 or PCV 20 at least one year later.

00:17:39 Vickie Danaher

So yes, vaccination would also be recommended for Barry.

00:17:44 Vickie Danaher

So to close things out here, let's look at some practice pearls.

00:17:48 Vickie Danaher

So these cases were a good reminder for us to keep patient profiles updated with medical conditions and smoking status and previous vaccines, since this is going to help us identify candidates for pneumococcal vaccination.

00:18:01 Vickie Danaher

We also want to stay alert for confusion with vaccine abbreviations.

00:18:05 Vickie Danaher

You know, it was tricky for.

00:18:06 Vickie Danaher

Confusing all the different PCV products like PCV15PCV20PCV21 with each other.

00:18:15 Vickie Danaher

Last but not least, we want to continue to ask patients about other needed vaccines such as flu and RSV.

00:18:20 Vickie Danaher

Can be given at the same visit as pneumococcal vaccine.

00:18:26 Vickie Danaher

Alright, so I know there's a lot to sort through here, but we have lots of resources that can make it a lot easier for.

00:18:32 Vickie Danaher

And your.

00:18:33 Vickie Danaher

So feel free to save or print out that pneumococcal vaccination in adults algorithm and you can have copies in your pharmacy or in your practice to quickly and easily determine which vaccine a patient needs.

00:18:46 Vickie Danaher

And when we also have in our December 2024 article on our website and in the print issues we have this streamline table of our simplified.

00:18:57 Vickie Danaher

Approach to pneumococcal.

00:18:58 Vickie Danaher

So this is a quick and handy reference chart.

00:19:01 Vickie Danaher

You can also get our updated chart comparison of pneumococcal vaccines for a side by side look at products, dosing, serotype coverage and more.

00:19:14 Narrator

We hope you enjoyed and gained practical insights from listening to this presentation.

00:19:19 Narrator

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00:19:38 Narrator

Also in the show notes, we’ve linked directly to a few of the excellent resources mentioned today available to subscribers of Pharmacist’s Letter, Pharmacy Technician’s Letter, or Prescriber Insights. On those websites you’ll also find a lot more evidence-based, concise, yet comprehensive resources on this and other medication therapy topics. 

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00:20:15 Narrator

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00:20:25 Narrator

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00:20:29 Narrator

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00:20:39 Narrator

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