The pneumococcal gauntlet has been thrown

The Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices has added the 13-valent pneumococcal conjugate vaccine to its protective roster for a subset of high-risk adults.

It’s wonderful to have a new prevention tool, but how can we ensure that it’s implemented when we are far from perfect in fulfilling adult vaccination recommendations for the 23-valent pneumococcal polysaccharide vaccine (PPSV23)? There are strategies that can help us.

The new recommendations call for one dose of 13-valent pneumococcal conjugate vaccine (PCV13), in addition to PPSV23, for adults with immunocompromising conditions (including HIV), functional or anatomic asplenia, cerebrospinal fluid leaks, or cochlear implants. ACIP did not change recommendations for other adults. Adults at least 65 who smoke or have chronic conditions such as alcoholism, asthma, diabetes, or heart disease should receive PPSV23 only.

Case fatality rates for pneumococcal bacteremia and meningitis are as high as 20%-30%.

Pneumococcal pneumonia has a mortality of 5%-7%, but it is much more prevalent, leading to 175,000 US hospitalizations annually.

Adults with chronic conditions such as diabetes and heart disease have up to 10 times as great a risk for invasive pneumococcal disease (IPD), compared with healthy individuals. For immunocompromised patients, such as those with HIV or cancer, the risk is 173 and 186 times greater, respectively.

Vaccination compliance is low. National Health Interview Survey data show that 64.7% of adults who are at least 65 have received a pneumococcal vaccination, up from 59.7% in 2010.

We are still a long way from reaching Healthy People 2020 goals. Rates among younger adults are even more disappointing. Only 18.5% of working-age adults with a pneumococcal vaccine indication have received it.

Secondary bacteremic pneumococcal pneumonia can be a major complication of flu. Pneumococcal vaccine, which can be administered at the same time as flu vaccine, may have an impact on this life-threatening complication.

There are many strategies that health care professionals can use to address this public health problem. A good place to start is to become familiar with the recommendations, educate caregivers, and engage clinical and ancillary staff in screening and vaccinating patients as appropriate.

The vaccination approach, including potential sequencing of PCV13 and PPSV23, varies depending on a patient’s risk condition and history. Vaccine-naive adults with an indication for PPSV23 should receive only a first dose immediately, with a second dose at age 65 (or later if less than 5 years has elapsed). Dosing for those with a PCV13 indication is more complicated, but the sequence is outlined in several resources, including an Adult Pneumococcal Vaccination Guide.

Every pneumococcal discussion opens the door for identifying other vaccination needs such as influenza, Tdap, and hepatitis B, now indicated for adults aged 19-59 years with diabetes (MMWR 2011;60:1709-11). Tools are available at the National Foundation for Infectious Diseases, the CDC, and the Immunization Action Coalition.