Shopping Cart

INTRODUCTION

There are currently two vaccines to protect against pneumococcal disease: a 13-valent pneumococcal conjugate vaccine (PCV13) and a 23-valent pneumococcal polysaccharide vaccine (PPSV23).¹ The Advisory Committee on Immunization Practices (ACIP) is a committee within the Centers for Disease Control and Prevention (CDC), which provides recommendations on vaccine-preventable diseases. In November 2019, ACIP’s recommendations regarding the administration of PCV13 in adults aged 65 years and older was updated. It is now recommended that clinicians determine the appropriateness of PCV13 on a case-by-case basis instead of routine vaccination for all healthy seniors, an approach known as “shared clinical decision-making.”^1,2 Beyond vaccine administration, pharmacists are in a prime position to identify appropriate candidates for pneumococcal vaccination and work with patients to overcome barriers to vaccine acceptance.

PNEUMOCCOCAL DISEASE BACKGROUND

Pneumococcal disease is caused by Streptococcus pneumoniae, a gram-positive coccobacillus with a polysaccharide cellular capsule. Cellular capsules permit the bacteria to evade immune cells such as phagocytes and disrupt the immune response activation process. The immune system must be able to recognize the polysaccharide capsule and create antibodies directed against the polysaccharide capsule to prevent infection.³

Streptococcus pneumoniae colonizes the upper respiratory tract as part of normal flora of up to 90% of healthy individuals. At least 90 serotypes of S. pneumoniae have been identified to cause serious disease. Previous to the widespread use of the pneumococcal conjugate vaccine, ten common serotypes were responsible for about 62% of invasive pneumococcal disease.⁴

Streptococcus pneumoniae can be spread by air droplets and may be spread by asymptomatic carriers. It is a notable cause of illness in both adults and children. It is not only the most common cause of pneumonia, but also a major cause of sinusitis, otitis media, meningitis, and bacteremia.

Pneumococcal pneumonia accounts for about one-third of community-acquired pneumonias (CAP) and half of all hospital-acquired pneumonias (HAP). Although pneumococcal pneumonia is the most common type of pneumonia and occurs due to S. pneumoniae infiltration, pneumonia can also be caused by other bacteria, viruses, or fungi. Other bacterial causes of pneumonia include Haemophilus influenzae, Mycoplasma, and Chlamydia pneumoniae, while Staphylococcus aureus, Legionella, and H. influenzae are involved with more severe cases. Common viral pathogens include influenza and respiratory syncytial virus.⁵

Community-acquired pneumonia is a category of pneumonia in which the infection is acquired outside of a hospital, while HAP occurs after at least 48 hours of hospitalization. Ventilator-associated pneumonia (VAP) is a subset of HAP that affects patients receiving mechanical ventilation. Streptococcus pneumoniae causes between 9 to 46% of HAP and VAP cases, while this bacterium is the primary cause of CAP.^6,7 Health care-associated pneumonia is a historic designation that is no longer recognized by updated pneumonia treatment guidelines after the determination that these patients are not at an increased risk of multidrug-resistant pathogens.^5,7

In the United States, approximately 400,000 adults are hospitalized with pneumococcal pneumonia annually. Pneumococcal pneumonia has a brief incubation period of one to three days with a relatively quick onset of symptoms including fever, shaking, chills, productive cough, pleuritic chest pain, malaise, weakness, and difficulty breathing.⁴ Other pneumococcal infections, including bacteremia and meningitis, may occur despite the presence or absence of pneumonia and are collectively referred to as invasive pneumococcal disease.

Bacteremia occurs in at least one-quarter of patients who have pneumococcal pneumonia, but also accounts for more than 12,000 hospitalizations annually in patients without pneumonia. This alarming infection can cause sepsis and death in up to 20% of patients and is especially serious for elderly patients, with up to 60% of cases resulting in these complications.⁴

Streptococcus pneumoniae can also cause pneumococcal meningitis, which affects between 3,000 to 6,000 patients annually in the United States. This infection can lead to death in over 20% of adult cases. Signs and symptoms of pneumococcal meningitis include headache, lethargy, irritability, seizures, vomiting, and cranial nerve involvement. Patients who survive a case of pneumococcal meningitis may suffer lasting neurologic complications.⁴

In 2018, the CDC estimated S. pneumoniae was responsible for 31,400 cases of invasive pneumococcal disease and 3,480 deaths.⁸ Invasive pneumococcal disease caused significant morbidity and mortality in children younger than 5 years of age prior to the introduction of the pneumococcal conjugate vaccine. Before the vaccine, an estimated 17,000 cases of invasive pneumococcal disease occurred in children including approximately 200 fatal cases annually. Streptococcus pneumoniae also caused approximately 5 million acute otitis media cases annually.⁴

Pneumococcal pneumonia and invasive pneumococcal disease are mostly vaccine preventable. Since the first introduction of the pneumococcal vaccine, the rate of pneumococcal pneumonia and invasive pneumococcal disease has dropped dramatically.^9,10 This represents an extraordinary opportunity for pharmacists to intervene with vaccination guidance for patients.

PNEUMOCOCCAL VACCINES

Two vaccines are available for the prevention of disease caused by S. pneumoniae including a conjugate vaccine (PCV13) and a pure polysaccharide vaccine (PPSV23). The immune response to a pure polysaccharide vaccine involves stimulation of B cells without the assistance of helper T cells. This response does not trigger production of memory B and T cells. Antibodies induced by polysaccharide vaccines have less functional activity than those induced by protein antigens. The immune systems of children are too immature to produce an effective immune response to a non-protein-based antigen; therefore, polysaccharide vaccines offer minimal to no protection to children younger than 2 years of age.¹¹

Conjugate vaccines are protein-based and effectively produce an immune response in infants. These vaccines can also boost antibody responses on repeat vaccination, unlike polysaccharide vaccines. Conjugate vaccines involve combining (or “conjugating”) polysaccharides with proteins to elicit a protein-based immune response.¹¹ Conjugation is used for PCV13, in which a polysaccharide is linked to a diphtheria protein carrier, specifically diphtheria CRM₁₉₇ protein.¹²

There is also an adjuvant (aluminum) included in PCV13, which is included to produce a better immune response. Aluminum gels or aluminum salts represent the gold standard for vaccine adjuvants.¹³ The effectiveness of incorporating adjuvants into vaccines stems from their ability to stimulate an inflammatory response, which strengthens the response to the antigen.¹³ This inflammatory response can unfortunately also increase adverse events including injection site reactions, such as pain and swelling, malaise, and flu-like symptoms.¹⁴

23-Valent Pneumococcal Polysaccharide Vaccine

In 1977, the first pneumococcal vaccine was licensed. The vaccine consisted of purified capsular polysaccharide antigen from 14 types of pneumococcal bacteria.⁴ In 1983 a 23-valent polysaccharide vaccine (PPSV23) under the brand name Pneumovax 23 was licensed to replace the 14-valent vaccine.¹⁵ This vaccine contains polysaccharides from 23 strains of S. pneumonia, which cause 60% to 76% of invasive pneumococcal disease (1, 2, 3, 4, 5, 6B, 7F, 8, 9N, 9V, 10A, 11A, 12F, 14, 15B, 17F, 18C, 19A, 19F, 20, 22F, 23F, and 33F; see Table 1).⁴

Among healthy adults who are immunized with PPSV23, greater than 80% will develop antibodies within 2 to 3 weeks after vaccination. Although vaccine efficacy declines with advancing age and may be less effective in patients with underlying illness, the vaccine can still provide protection for these high-risk patients and should be administered.⁴

PPSV23 has been proven to reduce the risk of invasive disease caused by the serotypes included in the vaccine by 60% to 70%.⁴ Although results from studies have shown PPSV23 does not reduce the incidence of pneumococcal pneumonia, researchers have concluded that vaccination with PPSV23 can improve outcomes in patients with pneumococcal pneumonia including a decreased need for admission to the intensive care unit and reduced mortality.¹⁶

PPSV23 is available as a single-dose vial or prefilled syringe that should be stored upon receipt in the refrigerator between 2°C to 8°C (36°F to 46°F). The full contents of the vial or prefilled syringe (0.5 mL) should be administered either subcutaneously or intramuscularly in the deltoid muscle or lateral mid-thigh.¹⁷

13-Valent Pneumococcal Conjugate Vaccine

PPSV23 has been recommended for patients 2 years and older with certain underlying medication conditions and all adults age 65 years and older since the 1980s. In 2000, the 7-valent pneumococcal conjugate vaccine (PCV7) became available. The uptake of this vaccine resulted in a decrease in pneumococcal disease in all ages, which is thought to have resulted from herd immunity.⁴ In 2010, the FDA approved PCV13 (Prevnar 13), a 13-valent pneumococcal conjugated vaccine, which replaced PCV7. PCV13 added an additional six serotypes to those in PCV7 to provide improved coverage against invasive pneumococcal disease.¹

PCV13 contains 13 serotypes of Streptococcus pneumoniae (1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, and 23F; see Table 1). PCV13 is indicated for use in adults for the prevention of pneumonia and invasive disease caused by the S. pneumoniae serotypes covered by the vaccine; for use in children 6 weeks through 5 years of age for the prevention of invasive disease caused by the 13 serotypes in the vaccine and for otitis media caused by 7 of the 13 serotypes in the vaccine (4, 6B, 9V, 14, 18C, 19F, and 23F); and for children 6 years through 17 years of age for the prevention of invasive disease caused by the 13 serotypes in the vaccine.¹²

PCV13 is available as a single-dose prefilled syringe. Like PPSV23, it should be stored upon receipt in the refrigerator between 2°C to 8°C (36°F to 46°F); however, it is stable when stored for up to 4 days at temperatures up to 25°C (77°F). Immediately before administration, the syringe should be shaken vigorously to obtain a homogenous, white suspension since the solution contains an adjuvant. The full contents should then be administered intramuscularly in the deltoid muscle for all patients except infants, where the preferred site of administration is the anterolateral portion of the thigh.¹²

VACCINE RECOMMENDATIONS FOR CHILDREN AND ADOLESCENTS

PCV13 is recommended for use in all children aged 2 months to 59 months. The recommended routine vaccination schedule is a four-dose series administered at ages 2 months, 4 months, 6 months, and between 12 and 15 months.^12,18 Children 7 months of age and older who have not previously received PCV13 do not require a full series of 4 doses. The number of doses a child needs to complete the series depends on age, the presence of underlying health conditions, and previous PCV13 doses.

Unvaccinated children aged 7 to 11 months should receive 3 total PCV13 doses – 2 doses at least 4 weeks apart, followed by a booster dose at age 12 to 15 months. Unvaccinated children aged 12 to 23 months should receive 2 doses of PCV13 at least 8 weeks apart.^12,18

Previously unvaccinated 24 to 59 months of age should receive a single dose of PCV13 if they are otherwise healthy. If these patients have certain chronic medical conditions they should receive 2 doses of PCV13 separated by at least 8 weeks. These conditions include chronic illnesses (Table 2) or any immunocompromising condition (Table 3).^12,18

High-risk children 6 years to 18 years of age, including those with cerebrospinal fluid (CSF) leaks, cochlear implants, or immunocompromising conditions (Table 3) should receive a single dose of PCV13 up to the age of 18 years regardless of whether they have previously received PCV7 or PPSV23.^18,21

PPSV23 should be administered at least 8 weeks after PCV13 to children aged 2 years or older with any chronic illness (Table 2) or immunocompromising condition (Table 3). A second PPSV23 dose should be administered at least 5 years after the initial PPSV23 dose to children with an ongoing immunocompromising condition (Table 3). Immunocompetent patients without these conditions should not receive a second PPSV23 dose.^12,18,21

2019 UPDATES TO ACIP RECOMMENDATIONS

Since 2014, the CDC has recommended PCV13 to be administered to healthy adults aged 65 years and older followed by PPSV23 6-12 months later.²² In 2019, the ACIP removed the recommendation of routine PCV13 for patients at least 65 years of age based on new evidence. Shared clinical decision-making is now recommended for adults age 65 years and older who do not have immunocompromising conditions (Table 3), CSF leaks, or cochlear implants.¹

Why was this change made? In 2014, the ACIP revised previous recommendations to include the sequential administration of PCV13 followed by PPSV23 12 months after for all adults aged 65 years and older based on the results of the CAPiTA trial.²² The CAPiTA trial was a randomized placebo-controlled trial that evaluated the efficacy of PCV13 for preventing CAP among 85,000 adults aged 65 years and older with no prior pneumococcal vaccination history. This study demonstrated PCV13 was effective not only for invasive pneumococcal disease but also against non-invasive pneumonia.²³ From 2014 to 2017, there was no further decline in PCV13-type invasive pneumococcal disease incidence among adults aged 65 years and older and no reduction in the incidence of noninvasive pneumococcal pneumonia among adults despite widespread vaccine uptake. This data, combined with an economic analysis that suggested a high cost-effectiveness ratio of over $500,000 per quality-adjusted life year, implied that routine PCV13 vaccination was of limited value.¹

As a result, the guidelines shifted away from a universal PCV13 vaccination and moved toward shared clinical decision-making. This model requires health care providers, including pharmacists, to have more involved conversations with patients regarding their vaccine needs.² This approach is not new, but instead is recommended for other vaccines including the human papillomavirus (HPV) vaccine, hepatitis B virus vaccine, and meningococcal B vaccine. For example, HPV vaccination for adults aged 27 to 45 years of age provides minimal public health benefit and for that reason is not routinely recommended. However, some individuals within this age range may benefit and the decision to vaccinate must be individualized based on each person’s situation.²

Shared clinical decision-making for PCV13 vaccination of adults aged 65 years and older involves assessing each individual patient’s risk for exposure to the serotypes of PCV13 and any underlying medication conditions that may increase his/her risk for developing pneumococcal disease if exposed. Patients with immunocompromising conditions, CSF leaks, and cochlear implants should still receive PCV13 as described in more detail below.¹ Patients 65 years and older without these conditions who have not been previously vaccinated with PCV13 and may benefit from vaccination include:¹

• Patients residing in nursing homes or other long-term care facilities
• Patients residing in settings with low pediatric PCV13 uptake
• Patients traveling to settings with no pediatric PCV13 program 

These recommendations emphasize the opportunity for health care providers to recognize the benefits of a vaccine to an individual patient despite no impact at the population level.² The CDC’s recommendations to use shared clinical decision-making support how meaningful conversations are between pharmacists and patients or caregivers.² Pharmacists play a major role in administering immunizations, which is increasing on a daily basis with the ongoing novel coronavirus pandemic.²⁴

ADULT VACCINE RECOMMENDATIONS

Overall depending on patient risk and age at PPSV23 vaccination, it is possible for patients 19 years and older to receive 1 to 3 doses of PPSV23 throughout adulthood. Regardless of the situation, PPSV23 doses should be separated by at least 5 years from each other. If PCV13 is to be administered after PPSV23, it should be given no sooner than 1 year after the most recent PPSV23 dose.¹

The following recommendations encourage utilization of the pneumococcal vaccination unless there is a valid contraindication or precaution to receiving the vaccine. PCV13 and PPSV23 are contraindicated for patients who have had a severe allergic reaction to a previous vaccine dose or to a vaccine component. For PCV13, this includes a prior reaction to a diphtheria toxoid-containing vaccine given the presence of the adjuvant discussed earlier. Precautions to vaccination include moderate or severe acute illness with or without fever.²⁰

Patients with Immunocompromising Conditions

Patients 19 to 64 years of age with an immunocompromising condition (Table 3) should receive one PCV13 dose and two PPSV23 doses. The patient’s pneumococcal vaccine history will determine which of these vaccines the patient is eligible for, as well as the timing of each of these doses (Figure 1):²⁰

• If the patient is previously unvaccinated against pneumococcal infection, the patient should receive PCV13, followed by PPSV23 at least 8 weeks later, and a second PPSV23 at least 5 years after the first PPSV23 dose.
• If the patient has previously received a dose of PPSV23 but has not received PCV13, PCV13 should be administered at least 1 year after the previously administered PPSV23 dose, followed by a dose of PPSV23 at least 8 weeks after PCV13 and at least 5 years after the previous PPSV23 dose. A third PPSV23 dose is not required until age 65.
• If the patient has previously received PCV13 but has not received PPSV23, PPSV23 should be administered at least 8 weeks after the PCV13 dose, and a second PPSV23 at least 5 years after the first PPSV23 dose.
• If the patient has previously received 1 dose of PCV13 and 1 dose of PPSV23, PPSV23 should be administered at least 5 years after the prior PPSV23 and at least 8 weeks after PCV13.
• If the patient has previously received 2 doses of PPSV23, but has not received PCV13, PCV13 should be administered at least 1 year after PPSV23.

Figure 1. Advisory Committee on Immunization Practices Recommendations for PCV13 and PPSV23 Administration in Immunocompromised Adults 19-64 Years of Age²⁰

When individuals with immunocompromising conditions (Table 3) reach age 65, a final PPSV23 dose should be administered. However, if the patient has not previously received a dose of PCV13, this should ideally be administered first, followed by PPSV23 at least 8 weeks later. The final dose of PPSV23 should also come at least 5 years after the latest PPSV23 dose. If one of these patients receives PPSV23 at or after age 65 but has not received PCV13 or has an unknown PCV13 vaccine history, PCV13 should be administered at least 1 year after most recent PPSV23 dose.²⁰

Patients with Chronic Health Conditions

Adults 19 to 64 years of age with cochlear implants or CSF leaks are indicated to receive 1 dose of both PCV13 and PPSV23:²⁰

• Patients who have not received either vaccine in the past or for whom a vaccine history is unknown should be given PCV13 followed by PPSV23 at least 8 weeks later.
• If the patient has previously received PCV13 but not PPSV23, PPSV23 should be administered at least 8 weeks after the PCV13 dose.
• If PPSV23 has been given in the past but not PCV13, 1 dose of PCV13 should be given at least 1 year after PPSV23 administration. PPSV23 should not be administered again until age 65.

At age 65, guidance for these patients is identical to those with immunocompromising conditions as previously discussed.^1,20

Adults 19 to 64 years with chronic health conditions listed in Table 2 other than cochlear implants or CSF leaks are recommended to receive 1 dose of PPSV23 before age 65. PCV13 is not recommended in this population. These patients should receive PPSV23 if they have not received it before age 19 or if their vaccine history is unknown. Upon turning 65, shared clinical decision-making should be implemented to determine the appropriateness of PCV13 administration. If PCV13 is to be administered, it should be administered first followed by PPSV23 at least 1 year later. Notice that this differs from immunocompromised patients and those with cochlear implants or CSF leaks who should receive PPSV23 at least 8 weeks after PCV13. Regardless of PCV13 administration, 1 PPSV23 dose should be administered after the age of 65 and it should be at least 5 years after the previous PPSV23 dose. If, however, through shared clinical decision-making, the decision is made to administer PCV13 after PPSV23 is administered, PCV13 should be administered at least 1 year after the most recent PPSV23 dose.¹

Otherwise Healthy Individuals

All individuals over the age of 65 should receive one dose of PPSV23 regardless of vaccine history or underlying health conditions. Though these patients are not necessarily indicated for any pneumococcal vaccination prior to turning 65, if they have received any vaccination in the past, this should be considered when determining the timing of PPSV23 and, if jointly decided upon, PCV13. Timing should follow recommendations discussed in the previous paragraph. ^1,20

ADDRESSING BARRIERS

Pharmacists have the skills to address many of the barriers that may affect patient acceptance of the pneumococcal vaccine relating to vaccine hesitancy, patient safety, determination of patient vaccination history, sequencing of the vaccine, convenience with other vaccines, and costs. Pharmacists should engage in the process of shared decision-making with patients as part of the Pharmacist Patient Care Process and must proactively work to immunize patients. Failure to engage in these conversations can have consequences of poor outcomes.^3,25,26

Vaccine Hesitancy

Vaccine hesitancy is defined as “a delay in acceptance or refusal of vaccines despite available vaccination services,”²⁷ and is considered one of the top 10 threats to global health according to the World Health Organization (WHO).²⁸ Vaccine hesitancy arises for a number of reasons, including, but not limited to, negative media coverage and resulting distrust of the pharmaceutical industry; recommendations from influential anti-vaccination thought leaders (e.g., celebrities); religious, cultural, or socioeconomic factors; knowledge gaps regarding the risks and benefits of vaccines; and negative prior experiences with other vaccines.²⁹ Undoubtedly, hesitancy is playing a role in suboptimal pneumococcal vaccination rates. In 2017, 69% of adults aged 65 and older had received a pneumococcal vaccine, which was well below the Health People 2020 goal of 90%.³⁰

The American Society of Health-System Pharmacists encourages pharmacists to improve vaccination rates by examining the patient history and screening for immunization needs, providing counseling and education on guidelines, recommendations, and safety of vaccination, ensuring a sufficient stock of vaccines is available for the patient population to be served, promoting organizational vaccine initiatives through administrative measures, and educating the public through community outreach.²⁵

In addition to this generalized approach, it is beneficial for pharmacists to employ patient-specific counseling to illicit change. This technique, known as motivational interviewing, is based on three principles:³¹

1. Building a trusting relationship between the patient and pharmacist;
2. Engaging the patient in an ongoing dialogue about the proposed change; and
3. Helping the patient find their reasons for implementing the change

The principles of motivational interviewing align nicely with the suggested approach of shared clinical decision-making discussed previously.

Patient Safety

Patient concerns about the safety of vaccines are an important reason for vaccine hesitancy. Pharmacists should educate patients that the safety of vaccines is closely monitored by the CDC using 3 systems, including the Vaccine Adverse Event Reporting System, the Vaccine Safety Datalink, and the Clinical Immunization Safety Assessment Project. Additionally, the CDC and FDA inform health officials and the public of any problems found with a vaccine.³²

Patients should be educated that the pneumococcal vaccines are safe and effective at preventing pneumococcal disease. The most common side effects from pneumococcal vaccines are mild, lasting 1 or 2 days.³² Common adverse events reported with the PCV13 and PPSV23 are pain, redness, and swelling at the injection site; limited mobility of the injected arm; tiredness; headache; chills; decreased appetite; generalized muscle pain; and joint pain.^33,34 In one trial, reaction rates were similar between vaccines.³³ In a second trial that was done in patients 70 years of age or older, PPSV23 was associated with a statistically significantly greater proportion of adverse events compared to PCV13.³⁴ However, the majority of these adverse events were mild or moderate in severity.

Determination of Patient Vaccination History

A common challenge for health care providers is vaccinating adults with unknown vaccination records. Patients should be encouraged to reach out to previous employers, schools or colleges, or health care providers should contacted to determine which vaccines have been received in the past. State registries can help prevent unnecessary vaccination and billing and reimbursement problems, while also helping to avoid missed opportunities for vaccination. If reasonable attempts fail to produce a vaccination record, the CDC recommends vaccination for PCV13, but not for PPSV23.³⁵

Sequencing of the Vaccine

Vaccines administered in a multi-dose series that require patients to return to the site of care for follow-up visits can also be a barrier. Pharmacists are in a unique position as one of the most accessible health care providers to overcome the barrier of inconvenience. Approximately 90% of Americans reside within 2 miles of a pharmacy. Pharmacies provide increased access to vaccination administration with longer hours than physician offices, plus added weekend availability. Many primary care providers also do not regularly stock vaccines in their offices. Patients with chronic disease states who have frequent contact with a pharmacist present a great opportunity to increase vaccination rates.³⁶ Pharmacy technicians can also get involved in the process by tracking vaccine administration, scheduling future vaccination appointments, and reminding patients about follow-up visits. The Community Preventive Services Task Force (CPSTF) recommends home visits to increase vaccination rates in children and adults. The CPSTF does note, unfortunately, that home visits can be costly in comparison to other options.³⁷

Patients may have concerns about taking multiple trips to the pharmacy or to their provider to receive different vaccines for which they are indicated. Reassure patients that PCV13 and PPSV23 are both inactivated vaccines, and for that reason other vaccines can be given at the same time as either PCV13 or PPSV23 if indicated. Although PCV13 labeling suggests antibody response may be lower if it’s given with the influenza vaccine, this does not reduce vaccine efficacy and the CDC advocates giving both on the same day. Remember that PCV13 and PPSV23 should not be given together.¹⁹

Two notable exceptions with regard to concomitant non-pneumococcal vaccination exist. For patients with functional or anatomic asplenia or HIV infection, meningococcal ACWY vaccination, specifically with brand Menactra, was found to decrease the antibody response to certain serotypes in the PCV7 vaccine.³⁸ As a result, Menactra is recommended to be separated from PCV13, with PCV13 being administered at least 4 weeks before Menactra. This interaction is not a concern with the other brand meningococcal vaccination, Menveo.¹⁹ In addition, PPSV23 was found to reduce the immune response to the live zoster vaccine, Zostavax. Due to this interaction, PPSV23 should be administered at least 4 weeks before or after Zostavax immunization.¹⁷

Costs

Costs can serve as a barrier to vaccination rates. Changes in Medicare rules have made it easier for institutions to implement standing orders for the administration of pneumococcal vaccines to patients by nurses and pharmacists. There are many potential sources of reimbursement for immunization services, including Medicare Part B, Medicare Part D, Medicaid, private insurance, employer-provided coverage, and self-paying patients. All Medicare Part B enrollees 65 years of age or older have coverage for pneumococcal vaccination with no out-of-pocket expense. Medicare waives the costs to the patient for these immunizations, paying the entire cost of the vaccine and its administration fee, according to Medicare’s allowed rate.³⁹

Pneumococcal vaccines are also included on the Patient Protection and Affordable Care Act (PPACA) preventative services lists for adults and children. These services must be covered by all PPACA plans at no cost to enrolled patients.^40,41 Privatized insurance frequently covers the cost of preventative services, as well; however, individual patient benefits should be determined prior to administration. As of September 1, 2020, the private sector cost per dose of Prevnar 13 and Pneumovax23 were reported by the CDC to be $202.00 and $105.19, respectively.⁴²

In October 1994, the federal government began the Vaccines for Children (VFC) program to offer vaccination to children under the age of 18 years who meet at least one of the following criteria: the individual is eligible for Medicaid, is uninsured or underinsured, or is an American Indian or an Alaskan Native. The VFC program is federally funded and state operated. Pneumococcal vaccines are listed among those covered under the VFC program. Providers obtain vaccines for free through this program and pharmacists can become VFC program registered providers if allowed by their state.⁴³

Complacency

The current pandemic is helping to overcome another barrier to vaccines, complacency. The WHO designated COVID-19 a pandemic on March 11, 2020. One study found there were significant positive correlations between search volume indexes for coronavirus and search terms for pneumococcal and influenza vaccines.⁴⁴ The authors concluded the findings may predict changes in vaccination rates as online interest in the influenza and pneumococcal vaccines typically follow a seasonal pattern in September to November versus February and March as observed in the study.⁴⁴ As of September 2020, the CDC reports that the pneumococcal vaccines are widely available and no drug shortages have occurred secondary to the pandemic.⁴⁵ Pharmacists can continue to offer pneumonia vaccines to appropriate patients in light of this potential increase in demand.

5 Things Pharmacists Need to Know About Pneumococcal Vaccination

1. Pneumococcal infection can cause more than pneumonia and vaccination is the most important preventative measure.
2. Routine vaccination with PPSV23 continues to be recommended to all patients over the age of 65.
3. PCV13 vaccination for individuals over the age of 65 is no longer universally recommended, but instead shared clinical decision-making should be emphasized.
4. When administered in sequence, PCV13 should ideally be given before PPSV23. PPSV23 should be given at least 8 weeks after a PCV13 dose and PPSV23 doses should be separated by at least 5 years from each other. If PCV13 is given after a PPSV23 dose, there should be at least one year between vaccinations.
5. Pharmacists must actively encourage patients to take preventative steps to maintain their health while helping them overcome barriers, especially in the current environment where cautious behavior is scaling back preventative care.

CONCLUSION

Streptococcus pneumoniae can cause serious illness including sepsis, meningitis, and pneumonia with or without bacteremia. As a result of widespread use of PCV13 resulting in declines in pneumococcal disease among adults, shared clinical decision-making for PCV13 is now recommended for most adults age 65 years and older, while PPSV23 should continue to be used routinely in this population. Pharmacists play a major role in educating patients on vaccine eligibility and assisting them in overcoming barriers to care. It is important for pharmacists to stay up to date on this ever-evolving landscape, as guidance is updated frequently and new vaccines are under development, which may influence recommendations in the future.⁴⁶

REFERENCES

1. Matanock A, Lee G, Gierke R, et al. Use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine among adults aged ≥65 years: updated recommendations of the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep. 2019;68(46):1069-1075.
2. Hogue MD, Foster S, Rothholz MC. Shared clinical decision making on vaccines: nothing has really changed for pharmacists. J Am Pharm Assoc (2003). 2020:S1544-3191(20)30317-4.
3. Geno KA, Gilbert GL, Song JY, et al. Pneumococcal capsules and their types: past, present, and future. Clin Microbiol Rev. 2015;28(3):871-899.
4. Centers for Disease Control and Prevention. Pneumococcal disease. Accessed at: https://www.cdc.gov/vaccines/pubs/pinkbook/pneumo.html. Updated April 2019. Accessed September 28, 2020.
5. Lanks CW, Musani AI, Hsia DW. Community-acquired pneumonia and hospital-acquired pneumonia. Med Clin North Am. 2019;103(3):487-501.
6. Rotstein C, Evans G, Born A, et al. Clinical practice guidelines for hospital-acquired pneumonia and ventilator-associated pneumonia in adults. Can J Infect Dis Med Microbiol. 2008;19(1):19-53.
7. Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019;200(7):e45-e67.
8. Centers for Disease Control and Prevention. Active Bacterial Core surveillance report: Streptococcus pneumonia, 2018. Accessed at: https://www.cdc.gov/abcs/reports-findings/survreports/spneu18.html. Updated June 2020. Accessed September 28, 2020.
9. World Health Organization. Pneumococcal vaccines. WHO position paper. Wkly Epidemiol Rec. 2012:87(14);129-144.
10. Centers for Disease Control and Prevention. Pneumococcal disease: surveillance and reporting. Accessed at: https://www.cdc.gov/pneumococcal/surveillance.html. Updated September 2017. Accessed September 28, 2020.
11. Centers for Disease Control and Prevention. Principles of vaccination. Accessed at: https://www.cdc.gov/vaccines/pubs/pinkbook/prinvac.html. Updated June 2020. Accessed September 28, 2020.
12. Prevnar 13 [package insert]. Philadelphia, PA: Pfzier Inc.; July 2019.
13. HogenEsch H, O’Hagan DT, Fox CB. Optimizing the utilization of aluminum adjuvants in vaccines: you might just get what you want. NPJ Vaccines. 2018;3:51.
14. Centers for Disease Control and Prevention. Adjuvants and vaccines. Accessed at: https://www.cdc.gov/vaccinesafety/concerns/adjuvants.html. Updated August 2020. Accessed September 28, 2020.
15. Nuorti JP, Whitney CG; Centers for Disease Control and Prevention (CDC). Prevention of pneumococcal disease among infants and children - use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine - recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2010;59(RR-11):1-18.
16. Johnstone J, Marrie TJ, Eurich DT, Majumdar SR. Effect of pneumococcal vaccination in hospitalized adults with community-acquired pneumonia. Arch Intern Med. 2007;167:1938–1943.
17. Pneumovax 23 [package insert]. Whitehouse Station, NJ: Merk & Co., Inc.; December 2019.
18. Centers for Disease Control and Prevention. Pneumococcal vaccine recommendations. Accessed at: https://www.cdc.gov/vaccines/vpd/pneumo/hcp/recommendations.html. Updated November 2019. Accessed September 28, 2020.
19. Immunization Action Coalition. Ask the experts: pneumococcal vaccines (PCV13 and PPSV23). Accessed at: https://www.immunize.org/askexperts/experts_pneumococcal_vaccines.asp. Updated July 2020. Accessed September 28, 2020.
20. Immunization Action Coalition. Standing orders for administering pneumococcal vaccines (PPSV23 and PCV13) to adults. Accessed at: https://www.immunize.org/catg.d/p3075.pdf. Published February 2020. Accessed September 28, 2020.
21. Centers for Disease Control and Prevention (CDC). Use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine among children aged 6-18 years with immunocompromising conditions: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 2013;62(25):521-524.
22. Tomczyk S, Bennett NM, Stoecker C, et al. Use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine among adults aged ≥65 years: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 2014;63(37):822-825.
23. Bonten MJ, Huijts SM, Bolkenbaas M, et al. Polysaccharide conjugate vaccine against pneumococcal pneumonia in adults. N Engl J Med. 2015;372:1114-1125.
24. S. Department of Health & Human Services. HHS expands access to childhood vaccines during COVID-19 pandemic. Accessed at: https://www.hhs.gov/about/news/2020/08/19/hhs-expands-access-childhood-vaccines-during-covid-19-pandemic.html. Published August 2020. Accessed September 28, 2020.
25. American Society of Health System Pharmacists Council on Professional Affairs. ASHP guidelines on the pharmacist's role in immunization. Am J Health Syst Pharm. 2003;60(13):1371-1377.
26. American Journal of Managed Care. Addressing barriers to optimal community-based vaccination. Accessed at: https://www.ajmc.com/view/addressing-barriers-to-optimal-communitybased-vaccination. Published July 2018. Accessed September 28, 2020.
27. Marti M, de Cola M, MacDonald NE, et al. Assessments of global drivers of vaccine hesitancy in 2014 - looking beyond safety concerns. PLoS One. 2017;12(3):e0172310.
28. World Health Organization. Ten threats to global health in 2019. Accessed at: https://www.who.int/news-room/spotlight/ten-threats-to-global-health-in-2019. Accessed September 28, 2020.
29. World Health Organization. Summary WHO SAGE conclusions and recommendations on vaccine hesitancy. Accessed at: https://www.who.int/immunization/programmes_systems/summary_of_sage_vaccinehesitancy_2pager.pdf. Published January 2015. Accessed September 28, 2020.
30. Office of Disease Prevention and Health Promotion. Immunization and infectious diseases. Accessed at: https://www.healthypeople.gov/2020/topics-objectives/topic/immunization-and-infectious-diseases/objectives. Accessed September 28, 2020.
31. Gagneur A. Motivational interviewing: a powerful tool to address vaccine hesitancy. Can Commun Dis Rep. 2020;46(4):93-97.
32. Centers for Disease Control and Prevention. Pneumococcal vaccines – safety information. Accessed at: https://www.cdc.gov/vaccinesafety/vaccines/pneumococcal-vaccine.html. Updated September 2020. Accessed September 28, 2020.
33. Jackson LA, Gurtman A, van Cleeff M, et al. Immunogenicity and safety of a 13-valent pneumococcal conjugate vaccine compared to a 23-valent pneumococcal polysaccharide vaccine in pneumococcal vaccine-naive adults. Vaccine. 2013;31(35):3577-3584.
34. Jackson LA, Gurtman A, Rice K, et al. Immunogenicity and safety of a 13-valent pneumococcal conjugate vaccine in adults 70 years of age and older previously vaccinated with 23-valent pneumococcal polysaccharide vaccine. Vaccine. 2013;31(35):3585-3593.
35. Centers for Disease Control and Prevention. Vaccination programs. Accessed at: https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/programs.html. Updated July 2020. Accessed September 28, 2020.
36. Tak CR, Marciniak MW, Savage A, Ozawa S. The essential role of pharmacists facilitating vaccination in older adults: the case of Herpes Zoster. Hum Vaccin Immunother. 2020;16(1):70-75.
37. The Community Guide. Increasing appropriate vaccination: home visits to increase vaccination rates. Accessed at: https://www.thecommunityguide.org/sites/default/files/assets/Vaccination-Home-Visits_0.pdf. Accessed September 28, 2020.
38. Menactra [package insert]. Swiftwater, PA: Sanofi Pasteur Inc.; July 2019.
39. Adult Vaccine Access Coalition. Financial barriers to adult immunization. Accessed at: https://adultvaccinesnow.org/wp-content/uploads/2017/03/avac_financial_barriers_FINAL_.pdf. Published March 2017. Accessed September 28, 2020.
40. gov. Preventative care benefits for adults. Accessed at: https://www.healthcare.gov/preventive-care-adults/. Accessed September 28, 2020.
41. gov. Preventative care benefits for children. Accessed at: https://www.healthcare.gov/preventive-care-children/. Accessed September 28, 2020.
42. Centers for Disease Control and Prevention. CDC vaccine price list. Accessed at: https://www.cdc.gov/vaccines/programs/vfc/awardees/vaccine-management/price-list/index.html. Updated September 2020. Accessed September 28, 2020.
43. Centers for Disease Control and Prevention. Vaccines for Children program. Accessed at: https://www.cdc.gov/vaccines/programs/vfc/index.html. Updated April 2016. Accessed September 28, 2020.
44. Paguio JA, Yao JS, Dee EC. Silver lining of COVID-19: Heightened global interest in pneumococcal and influenza vaccines, an infodemiology study. Vaccine. 2020;38(34):5430-5435.
45. Centers for Disease Control and Prevention. Current vaccine shortages & delays. Accessed at: https://www.cdc.gov/vaccines/hcp/clinical-resources/shortages.html. Updated March 2020. Accessed September 28, 2020.
46. com. Pfizer announces top-line results from phase 3 study of 20-valent pneumococcal conjugate vaccine in pneumococcal vaccine-naïve adults aged 18 years or older. Accessed at: https://pipelinereview.com/index.php/2020031974055/Vaccines/Pfizer-Announces-Top-Line-Results-from-Phase-3-Study-of-20-Valent-Pneumococcal-Conjugate-Vaccine-in-Pneumococcal-Vaccine-Naive-Adults-Aged-18-Years-or-Older.html. Published March 2020. Accessed September 28, 2020.