Optimal Administration Schedule for Pneumococcal Vaccinations for Older Adults: 2018 HEDIS and ACIP Updates

The Healthcare Effectiveness Data and Information Set (HEDIS), designed by the National Committee for Quality Assurance, is used by more than 90% of U.S. health plans to measure whether an institution is providing quality patient care. The data obtained through HEDIS are designed specifically to be able to compare performance both within a healthcare institution and among different institutions across the country. These data are readily available for all to review and for hospitals to focus on areas that require improvements. With the recent 2018 HEDIS update, seven new dimensions have now been implemented and are considered standards of care. This article focuses on HEDIS’s inclusion of pneumococcal vaccination for older adults.(1)

Despite the Advisory Committee on Immunization Practices’ (ACIP’s) revisions to pneumococcal vaccination schedules in 2014, the CDC reported that as of 2016, only 66.9% of adults 65 years and older had received a pneumococcal vaccination, an increase of only 7.2% from 2013.(2) However, the statistics failed to differentiate between those who had received a complete two-dose vaccination and those who had received a single-dose vaccination. In 2015, the CDC reported as many as 400,000 hospitalizations for pneumonia and estimated mortality rates to be between 5% and 7%.(3) In efforts to combat pneumococcal disease and encourage vaccination for high-risk individuals, ACIP has made additions to its previous recommendations, clarifying ambiguities and reiterating the importance of vaccination.

In earlier recommendations for pneumococcal vaccination schedules, ACIP stated the importance for all adults 65 years and older to receive pneumococcal vaccinations in a two-dose series (13-valent pneumococcal vaccine [PCV13] and 23-valent pneumococcal polysaccharide vaccine [PPSV23]). However, the recommendation addressed only vaccination schedules for adults 65 years of age and older who have previously received either a PPSV23 dose or none at all. This led to ambiguity for high-risk individuals under the age of 65 who had received or were indicated for a two-dose series of pneumococcal vaccines and “age-in” to the 65-years-and-up bracket. In addition, the previous recommendation failed to include data on same-visit administration of PCV13 with other routine adult immunizations such as tetanus and diphtheria (Td); tetanus, diphtheria, and pertussis (Tdap); and zoster. Since then, ACIP has included clarifications on these issues.

Recent updates from ACIP recommend that patients in the following groups are indicated to receive PCV13 at 19 years of age or older(4):

• Patients who have already received one dose of PPSV23 at before the age of 65 years should:

  • Receive a PCV13 dose at least one year after the last PPSV23 dose;

  • Then receive a PPSV23 dose at least 8 weeks after PCV13 and at least 5 years after the last PPSV23 dose; and

  • Then receive revaccination with PPSV23 after they reach the age of 65 years and at least five years after the last PPSV23 dose.

• Patients who have already received two doses of PPSV23 before the age of 65 years and one dose of PPSV23 at age 65 years or older should:

  • Receive a PCV13 dose at least one year after the last PPSV23 dose.

• Patients who have already received two doses of PPSV23 and one dose of PCV13 before the age of 65 years should:

  • Receive a PPSV23 dose at least eight weeks after the PCV13 dose and at least five years after the last PPSV23 dose when they are 65 years of age or older.

• Patients who have already received two doses of PPSV23 before the age of 65 years and one dose of PCV13 at or after the age of 65 years should:

  • Receive a PPSV23 dose at least eight weeks after the PCV13 dose and at least five years after the last PPSV23 dose.

The ACIP encourages individuals indicated for multiple vaccinations to receive those that are necessary on same-visit appointments. It previously was stated that trivalent inactivated influenza vaccine (IIV3) can be administered concurrently with pneumococcal vaccines. Since then, the CDC has announced that concurrent administration of Shingrix(5) and Zostavax(6) with PCV13 is safe, although studies are still ongoing regarding concurrent administration of zoster vaccinations with PPSV23. Data on the concurrent administration of pneumococcal vaccines with quadrivalent recombinant influenza vaccines (RIV), Td, and Tdap have yet to be announced.

According to the 2012 ACIP recommendations, PCV13 is indicated for individuals under the age of 65 if they are affected by immunocompromising conditions, anatomic or functional asplenia, or cerebrospinal fluid leak, or have cochlear implants. In 2018, the CDC added individuals who are affected by chronic heart, lung, or liver disease, as well as alcoholism, diabetes mellitus, and cigarette smoking to this population. After individuals in these groups receive a dose of PCV13, it is recommended that they follow the pneumococcal vaccination schedule as directed.

Certain immunocompromising conditions are indications for pneumococcal vaccination. These are: congenital or acquired immunodeficiency, including B- or T-lymphocyte deficiency, complement deficiencies, and phagocytic disorders excluding chronic granulomatous disease; HIV infection; chronic renal failure; nephrotic syndrome; leukemia; lymphoma; Hodgkin disease; generalized malignancy; multiple myeloma; solid organ transplant; and iatrogenic immunosuppression (including long-term systemic corticosteroids and radiation therapy).(7)

Conclusion

In summary, the new updates from ACIP now cover the optimal pneumococcal vaccination schedules for all individuals and can be used to increase pneumococcal vaccination rates and improve patient care and satisfaction.

As a reminder, for individuals for whom a dose of PCV13 is indicated, PCV13 should be administered first and at least eight weeks before a dose of PPSV23. In addition, it is recommended that doses of PPSV23 not be given within five years of the previous does of PPSV23. Both vaccines should be administered intramuscularly at a dose of 0.5 mL.

PCV13 contains serotypes 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, and 23F. The 13-valent vaccine was first approved in the United States in 2010, and it replaced the 7-valent pneumococcal conjugate vaccine on the childhood immunization schedule in 2011. The initial approval of Prevnar 13 was for children who are six weeks to five years old. In 2012, a recommendation for adults 50 years and older was added by the FDA, followed by the inclusion of an indication for 6- through 17-year-olds in 2013. The PCV13 vaccine is contraindicated in anyone who has had a previous severe or anaphylactic reaction to any component of the PCV7 or PCV13 vaccine or any vaccine that contains diphtheria toxoids.(8)

PPSV23 contains serotypes 1, 2, 3, 4, 5, 6B, 7F, 8, 9N, 9V, 10A, 12F, 14, 15B, 17F, 18C, 19A, 19F, 20, 22F, 23F, and 33F. The FDA approved indications for Pneumovax 23 use in patients who are 50 years or older and patients who are older than two years of age who are at increased risk of pneumococcal disease. The use of Pneumovax 23 is contraindicated in persons with severe allergic reaction to any component of the vaccine.(9)

References:

1. CQA Updates Quality Measures for HEDIS 2018. NCQA.org . www.ncqa.org/newsroom/details/ncqa-updates-quality-measures-for-hedisreg-2018?ArtMID=11280&ArticleID=85&tabid=2659 . Accessed August 8, 2018.

2. Early Release of Selected Estimates Based on Data From the National Health Interview Survey, January-June 2017. CDC.gov . December 2017; www.cdc.gov/nchs/data/nhis/earlyrelease/earlyrelease201712_05.pdf . Accessed August 11, 2018.

3. Pneumococcal Disease Fast Facts. CDC.gov . September 6, 2017; www.cdc.gov/pneumococcal/about/facts.html . Accessed August 11, 2018.

4. Pneumococcal Vaccine Timing for Adults. CDC.gov . November 30, 2015; www.cdc.gov/vaccines/vpd/pneumo/downloads/pneumo-vaccine-timing.pdf . Accessed August 9, 2016.

5. Administering Shingrix. CDC.gov . January 25, 2018; www.cdc.gov/vaccines/vpd/shingles/hcp/shingrix/administering-vaccine.html . Accessed August 8, 2018.

6. Administering Zostavax. CDC.gov . January 25, 2018; www.cdc.gov/vaccines/vpd/shingles/hcp/zostavax/administering-vaccine.html . Accessed August 8, 2018.

7. Recommended Immunization Schedule for Adults Aged 19 Year or Older, United States, 2018. CDC.gov . February 2018; www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf . Accessed August 11, 2018.

8. US Prescribing Information for PREVNAR 13. Pfizer.com . August 2017; labeling.pfizer.com/showlabeling.aspx?id=501 . Accessed August 8, 2018.

9. US Prescribing Information for PNEUMOVAX 23. Merck.com . May 2015; www.merck.com/product/usa/pi_circulars/p/pneumovax_23/pneumovax_pi.pdf . Accessed August 8, 2018.