William Schaffner, MD, on the ACIP's Pneumococcal Recommendations

In this podcast, William Schaffner, MD, discusses the new recommendations for pneumococcal vaccination put forth by the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices.

William Schaffner, MD, is the medical director of the National Foundation for Infectious Diseases (NFID) and is a professor of preventive medicine in the Department of Health Policy and a professor of medicine in the Division of Infectious Diseases at Vanderbilt University School of Medicine in Nashville, Tennessee.

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William Schaffner:  This is Dr. Bill Schaffner. I am a Professor of preventive medicine and infectious diseases at the Vanderbilt University School of Medicine in Nashville, and I'm also the Medical Director of the National Foundation for Infectious Diseases.

Today we'll be talking primarily about the new recommendation made by the Advisory Committee on Immunization Practices about pneumococcal vaccination for people aged 65 and older.

In its June 2019 meeting, the CDC's Advisory Committee on Immunization Practices, the ACIP, made a change in its recommendations for who it is that should be receiving pneumococcal vaccine, and which vaccine among people who are aged 65 and older.

Now, before we get to that change, let's give you a little bit of background just so that we're all on the same page. You may remember that pneumococcal conjugate vaccine, PCV13, which protects against 13 different serotypes of pneumococcal disease is now being given universally to children in this country.

That's been a widely accepted, essentially universal, recommendation. Essentially every child is getting vaccinated. This not only had a profound effect on eliminating invasive pneumococcal disease, bacteremia and meningitis in young children, but it had an unanticipated, indirect effect. By that I mean, the vaccination of children also eliminated carriage of those 13 pneumococcal serotypes in the throats and the nasal pharynx of children. As it turned out children were the great distributors of pneumococci in our population.

They carried it and in hugging and kissing mom and dad, and Aunt Suzzie and Grandpa Tom, they would transmit those serotypes to those adults. Then, the adults would get sick with those serotypes. PCV13 not only protected the children, it eliminated carriage. Now, the children were no longer transmitting those serotypes to adults and as a consequence, the adults were protected against invasive pneumococcal disease caused by those serotypes. And the impact of that indirect effect was particularly notable among people aged 65 and older. That's the setup.

Four years ago, the ACIP recommended that everyone reaching age 65 and older, if they haven't received these vaccines in the past, should receive first PCV13 and then a year later followed by polysaccharide vaccine. Now, the ACIP kept looking at the indirect effect and discovered that this indirect effect was very profound among people who were aged 65 and older. They looked at that very carefully and on a population basis, voted that people aged 65 and older who are immunocompetent need no longer receive PCV13. They should still get polysaccharide vaccine but need not get PCV13.

They then had a second vote which said that there may be circumstances in which an individual physician and a patient may still elect to give an immunocompetent person PCV13 as well as polysaccharide vaccine once they reach age 65.

They had another vote that affirmed that in the circumstance of what they termed shared clinical decision‑making, it would be OK to give immunocompetent people both vaccines. What they didn't sell out was on what basis this shared clinical decision‑making should work. What are the kinds of circumstances?

As of this podcast recording, they still have not been explicit about that, but there's been enough discussion so that perhaps I can give you at least some previews of coming attractions. One of the things they said is, PCV13‑type invasive pneumococcal disease increases with increasing age. There may be some populations that are of substantially increased risk. For example, residents of nursing homes or other long term care facilities. It might be reasonable to give those folks both vaccines. You may not know that American Indian and Alaskan Native populations who are residing on tribal lands or in villages of those peoples are at increased risk of invasive pneumococcal disease. That's another set of populations where you might consider giving them both.

Then ‑‑ and this is a subtle thing ‑‑ people age 65 and older benefit if they're in the United States, of having children vaccinated and therefore you get this indirect effect.

But what if those people travel abroad? Where the children and whether it's Thailand or France or the Zambia or wherever you happen to be going, aren't receiving pneumococcal conjugate vaccine and you might have contact with children there and therefore you're at increased risk. So, travelers who are immunocompetent and age 65 and older, who are going around the world might be another population to consider giving both PCV13, and then a year later, polysaccharide vaccine.

I know that there's been some discussion about just recognizing that within increasing age, the proportion of the populations that has underlying illnesses ‑‑ heart disease, lung disease, diabetes, liver disease ‑‑ who might be alcoholic, or who smoke cigarettes, all of those circumstances increase the risk for invasive pneumococcal disease generally. Yet another set of circumstances that a doctor and a patient might talk about, and make them once they reach age 65, perhaps a population that you might consider giving both vaccines rather than just polysaccharide vaccine.

These are things that haven't been published yet by the Advisory Committee on Immunization Practices, but I know that those are the sorts of considerations that they are currently discussing, and I hope that that clarifies a little bit who ought to receive both vaccines.

Let me mention once again, if your patient is distinctly immunocompromised ‑‑ if they have chronic renal failure, if they have HIV infection, leukaemia, lymphoma, Hodgkin's disease, have generalized malignancy, they're receiving an immunosuppressive medication for example, or if they have sickle cell disease or congenital or acquired asplenia ‑‑ all those folks, if they haven't received a vaccine by the time they reach age 65, should get both vaccines.

It's a little complicated but I hope that I've helped you walk your way through that. Now, incidentally and perhaps not so incidentally, the question will come up, will Medicare under part B continue to pay for both vaccines? So far, representatives from Medicare have provided assurance that Medicare will continue to provide first dollar coverage under part B for both pneumococcal vaccines.

How will these changes affect practice? Number one, I think there'll be more internists having more conversations with people aged 65 and older, regarding whether or not they ought to receive both vaccines.

Mind you I'm going to say this again, if you're immunocompromised, if you have acquired congenital asplenia, if you have any other kind of hemoglobinopathy and as I said, if you're immunocompromised in any way, you should continue to get both vaccines. It's the otherwise healthy immuno‑competent 65‑year‑old and older, where you now have a choice.

Are you the belt and suspenders kind of doc, or are you the person who passes it a little more carefully? Another issue that will come up is ‑‑ and I've been asked this already ‑‑ our practice circumstance, whether in a hospital or a large group practice, has worked hard to put in electronic prompts to conform with the ACIPs previous recommendation that everyone receive two doses of vaccine.

Need we change those now? In the context of shared clinical decision making, if the provider group feels that it ain't broke, we don't need to fix it and we would like in general to give two doses of vaccine because our patient population is so enriched with people with underlying illnesses, we want to make sure that they are maximally protected. You'll be permitted to do that.

How carefully the ACIP finally addresses that circumstance, I'm not entirely sure. There will be a permissive path to continue doing what you're doing well, if that's what you choose to do.

I think the key take home message of these recommendations are that invasive pneumococcal disease is still a very important problem in this country. If it affects people aged 65 and older, it's often associated with a still fairly high mortality rate. Fairly high, 15 to 20 percent. People who recover from pneumococcal bacteremia or meningitis often have residual effects, afterwards disabilities. It's important to prevent these diseases if we can.

Just to reiterate, if you reach age 65 and your patient has not been previously vaccinated against pneumococcal disease, they ought to. Everybody should get polysaccharide vaccine certainly immunocompromised people and others like them, should get both conjugate and polysaccharide vaccine.

Conjugate first followed by polysaccharide a year later. Even healthy folks are worth a conversation to see whether they might fall into that group that would like, as I like to say, to take the belt and suspenders approach, concerning prevention and get both vaccines.

Well, it's that time of year, isn't it? It's soon going to be influenza vaccination season and I wouldn't want to live you without making the comment about that. The recommendations here are simple, everyone should receive influenza vaccine each and every year. That's every one of us who are healthcare providers, everyone in our offices, everyone in our families, and every single patient that walks through the door.

It's very simple. We acknowledge that influenza vaccine is far from perfect. Although we emphasize all the time, traditional vaccine effectiveness estimates and they were moderately low last year.

I think what we should remember is year‑in and year‑out, no matter what the vaccine effectiveness against preventing influenza completely is, it helps prevent the complications of influenza. It prevents the development of pneumonia. It prevents visits to the emergency room and hospital admissions. It prevents admissions to the intensive care unit, and it prevents deaths.

No matter how ineffective or effective the vaccine is, it always has some effect in modulating the severity of influenza. It's the best vaccine we have now. It's the vaccine we ought to use to maximize what we can do to prevent this illness in our patient population. As I like to say, if you're in doubt give it. When in doubt, immunize. Let's try to make sure that not only are we well vaccinated but all of our patients against influenza. It's the best that we can do for them, each and every influenza season.

Thanks for listening today. I hope you will join me in becoming an immunization insister, not just a recommender, but insist on vaccination of your patients. The immunization rate in your practice will increase and your patients will benefit.