Changes apply to smokers, patients with asthma, and Alaska Natives/American Indians.
Advisory Committee on Immunization Practices (ACIP) recommendations for preventing invasive pneumococcal disease (IPD) via use of the 23-valent pneumococcal polysaccharide vaccine (PPSV23) now include (1) vaccinating patients who smoke and have asthma and (2) no longer routinely vaccinating Alaska Natives or American Indians younger than 65 years unless they have medical or other indications for PPSV23. These changes from the 1997 ACIP recommendations were recently reported in CDC’s Morbidity and Mortality Weekly Report (MMWR).
Recommendations for revaccinating adult patients at greatest risk for IPD (i.e., those with functional or anatomic asplenia, those with immunocompromising conditions) with PPSV23 remain unchanged.
Asthma. During meetings in 2008, ACIP concluded that asthma is an independent risk factor for IPD and should be included among chronic pulmonary diseases (e.g., COPD, emphysema) that are indications for PPSV23. ACIP recommended that patients 19 to 64 years of age with asthma should receive a single dose of PPSV23. In the recent MMWR report, CDC cited data from the Tennessee Medicaid database revealing that IPD was more common among adults aged 18 to 49 years with asthma compared with those without asthma, evidence suggesting that patients with high-risk asthma have nearly double the risk for IPD compared with those with low-risk asthma, and other reports.
Cigarette smoking. According to CDC, during 2001–03, 53% of IPD patients aged 18 to 64 years smoked cigarettes. Also, a study revealed that risk for IPD among immunocompetent cigarette smokers 18 to 64 years of age was four times that of control patients who reported never smoking. Risk for pneumococcal disease is reduced after quitting smoking, with one study showing reduction in IPD risk of about 14% each year after quitting smoking and a return to a risk similar to that for individuals who had never smoked in approximately 13 years. Guidance for quitting smoking cessation should be part of the therapeutic plan for smokers regardless of immunization status, according to ACIP. Professional organizations (e.g., Infectious Disease Society of America, American Thoracic Society) also recommend smoking cessation counseling and pneumococcal vaccination for smokers who are hospitalized with community-acquired pneumonia, and clinical practice guidelines for treating tobacco use and dependence are available from the U.S. Public Health Service.
Alaska Natives/American Indians. Although routine use of PPSV23 is no longer recommended for Alaska Natives/American Indians younger than 65 years without a medical condition or other indication for PPSV23, ACIP noted that in certain situations, public health authorities may recommend PPSV23 for Alaska Natives/American Indians 50 to 64 years of age who are living in areas with an increased risk for IPD.
General recommendations. ACIP recommends PPSV23 for all patients at 65 years of age. Anyone receiving PPSV23 before age 65 years for any indication should receive another dose of the vaccine at 65 years or older if at least 5 years have passed since their previous dose. Only a single dose is required in patients receiving PPSV23 at or after age 65 years.
According to CDC, since the infant 7-valent pneumococcal conjugate vaccine (PCV7) immunization program was introduced in 2000, indirect (i.e., herd) effects have reduced pneumococcal infections among unvaccinated patients of all ages, including those 65 years or older. CDC Active Bacterial Core surveillance data indicate that by 2007, the overall incidence rate of IPD among patients of all ages had decreased by 45% compared with 1998–99, before introduction of PCV7. Rates of IPD decreased by 40%, 18%, and 37% for patients aged 18 to 49, 50 to 64, and 65 or more years, respectively. The decreases resulted from reductions of 87% to 92% in cases of infection with serotypes covered in PCV7, the agency reported. However, despite the major direct and indirect effects of PCV7, IPD remains a major cause of illness and death: according to CDC, Streptococcus pneumoniae (pneumococcus) caused invasive disease resulting in an estimated 43,500 cases and 5,000 deaths in the United States in 2009. About 84% of IPD cases and nearly all deaths occurred in adults.