Pneumonia vaccine recommendations debated

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The latest pneumococcal vaccine guidelines for adults aged 65 or more years are “well intentioned but misguided, complex, and not ready for widespread adoption,” according to two physicians writing in the December issue of JAMA Internal Medicine. Another physician, however, calls for following the guidelines at least until they are reviewed in a few years.

In late 2014, the Advisory Committee on Immunization Practices recommended that older adults obtain both pneumococcal conjugate vaccine 13 (known as PCV13 or by the brand name Prevnar-13) and pneumococcal polysaccharide vaccine 23 (called PPSV23 and known by the brand name Pneumovax23).

“This new combination of pneumococcal vaccines is expected to reduce vaccine-type pneumonia in people aged 65 and older by about 45% and reduce invasive disease, the most deadly form, by 75%,” William Schaffner, M.D., professor of preventive medicine and infectious diseases at the Vanderbilt University School of Medicine and past president of the National Foundation for Infectious Diseases, said at a September 2014 press conference discussing the recommendation.

PPSV23 has been used in adults to protect against pneumonia for several years, and PCV13 “has been tremendously effective in kids, and we've seen the number of pneumococcal cases plummet in recent years,” Centers for Disease Control and Prevention Director Tom Frieden, M.D., M.P.H., said at the time. The CDC has endorsed the ACIP guideline.

In their JAMA Internal Medicine opinion piece, however, Michael Hochman, M.D., M.P.H. of the University of California, Los Angeles, and Pieter A. Cohen, M.D., of Harvard Medical School, question whether PCV13 “adds value when given instead of, or in addition to, PPSV23.” Limited research that is applicable to older adults in the United States is available, they say.

The ACIP and the CDC recommend that older adults not already vaccinated against pneumonia obtain PCV13 first. Regardless of the order in which the vaccines are received, however, people are advised to wait a year between receiving PCV13 and PPSV23, to maximize effectiveness. Hochman and Cohen say that following the recommended time schedule, however, is costly and complex for the medical offices that administer the vaccines and also may affect adherence by older adults. Improving pneumococcal vaccination among children and adults would be a simpler and less expensive approach to reducing the number of pneumonia cases, they argue.

In a related opinion piece in the same issue of the journal, Anne Schuchat, M.D., of the CDC's National Center for Immunization and Respiratory Diseases, writes that until the ACIP conducts a planned review of its recommendations in 2018, existing evidence suggests that widespread vaccination with PCV13 stops a high percentage of infection of the lower respiratory tract in which organisms appear not to have spread to the blood stream.

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