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pneumococcal polysaccharide vaccine, polyvalent (PneumoVax 23, Pnu-Immune 23, PPSV-23)

Indications: 1) primary immunization: immunity to pneumococcal lobar pneumonia & bacteremia in individuals >= 2 years of age who are at high risk of morbidity & mortality from pneumococcal infection a) all persons over 64 years of age b) persons aged 2-64 with chronic disease, especially: 1] chronic cardiovascular disease, including hypertension - congestive heart failure 2] pulmonary disease, including COPD, asthma & smoking [12] 3] renal failure including nephrotic syndrome 4] diabetes mellitus 5] malignancy 6] HIV infection 7] chronic liver disease (including cirrhosis) 8] alcoholism 9] CSF leak 10] cohlear implant 11] immunosuppression or immunodeficiency c) hyposplenism 1] splenectomy 2] autosplenectomy, i.e. sickle cell disease d) asbestosis (vaccination at diagnosis & 5 years later) 2) revaccination a) consider if >= 6 years since initial vaccination - asplenic patients who have received 14 valent pneumococcal vaccine b) recommended after 6 years in patients with nephrotic syndrome, renal failure or transplant patients c) recommended after 3-5 years in children with nephrotic syndrome, asplenia or sickle cell disease d) 3-4 months after completion of chemotherapy in patients with Hodgkin's disease who were vaccinated during chemotherapy e) a single revaccination is recommended in adults > 65 years of age >= 6 years since initial vaccination [7] f) revaccination 5 years after diagnosis & initial vaccination for asbestosis [3] * antibody levels remain at levels considered protective beyond 5 years in patients with autoimmune rheumatic disease [18] Contraindications: 1) active infections 2) Hodgkin's disease (within 10 days of chemotherapy or radiation therapy) 3) patients < 2 years of age 4) pregnancy 5) hypersensitivity to pneumococcal vaccine or any component Caution: 1) use with caution in individuals who have had pneumococcal infection within the past 3 years 2) may cause relapse in patients with stable idiopathic thrombocytopenic purpura (ITP) 3) have epinephrine available 4) considered safe if patients on warfarin, if INR is therapeutic [4] 5) considered safe in hospitalized patients with mild to moderate illness [3] pregnancy-category C safety in lactation ? Benefit/risk: - number needed to treat to prevent one case of invasive pneumococal pneumonia = 3,333 (range: 1429-12,500) [15] - NNT to prevent one case of pneumococal pneumonia = 38 [16] Dosage: - adults & children >= 2 years of age: 0.5 mL IM or SC - adults who have not previously received either vaccine should be given one dose of Prevnar followed by one dose of Pneumovax > 1 year later (CDC) [17] - CDC's Advisory Committee on Immunization Practices (ACIP) recommends - for all adults >= 65 years [19 - 20-valent (PCV20) pneumococcal conjugate vaccine by itself [19] or - 15-valent ( PCV15) vaccine followed by PPSV23 if not already received PPSV23 [19] - currently PPSV23 + PCV13 as a shared decision process [19] - Prevnar-13 prior to this recommended for at risk seniors - immunosuppression, CSF leak, or cochlear implant [19] - long-term care residemts [19] Injection: 1) 25 ug each of 23 polysaccharide isolates 2) 0.5 mL/dose (2.5 mL vials) Pharmacokinetics: 1) protective effects seen by the 3rd week after vaccination 2) antibody levels remain elevated for at least 5 years after vaccination 3) elimination: liver Adverse effects: 1) common (> 10%) - induration & soreness at the injection site (2-3 days) 2) ucommon (< 1%) - paresthesias, Guillain-Barre syndrome, low-grade fever, erythema, rash, myalgia, arthralgia, anaphylaxis 3) other - headache, photophobia Drug interactions: -> decreased effect with immunosuppressive agents, immune globulin, & other live virus vaccines within 1 month* * patients with lupus erythematosus or rheumatoid arthritis treated with immunosuppressive agents respond variably to the pneumococcal vaccine [5] Mechanism of action: 1) primary immunization with 23 polysaccharide isolates 2) reduces macrolide-resistant pneumococcal infections [6] 3) reduces mortality of hospitalized elderly [8] 4) reduces pneumococcal bacteremia, but not noninvasive pneumococcal pneumonia or bronchitis [9,11] Notes: introduced in 1983

Related

pneumococcal congugate vaccine (Prevnar, Prevnar 13, PCV13, Prevnar-20, PCV20, Prevnar-15, PCV15, Vaxneuvance, Capavaxive, PCV21, PHiD-CV10, PCV10, Synflorix) Streptococcus pneumoniae (pneumococcus)

General

pneumococcal vaccine

References

  1. Kaiser Permanente Northern California Regional Drug Formulary, 1998
  2. Drug Information & Medication Formulary, Veterans Affairs, Central California Health Care System, 1st ed., Ravnan et al eds, 1998
  3. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 16, 18. American College of Physicians, Philadelphia 1998, 2006, 2012, 2018.
  4. Prescriber's Letter 9(1):5 2002
  5. Journal Watch 22(4):30, 2002 Elkayam O et al Immunogenicity and safety of pneumococcal vaccination in patients with rheumatoid arthritis or systemic lupus erythematosus. Infect Dis 34:147, 2002 PMID: 11740700
  6. Journal Watch 25(9):70, 2005 Stephens DS, Zughaier SM, Whitney CG, Baughman WS, Barker L, Gay K, Jackson D, Orenstein WA, Arnold K, Schuchat A, Farley MM; Georgia Emerging Infections Program. Incidence of macrolide resistance in Streptococcus pneumoniae after introduction of the pneumococcal conjugate vaccine: population-based assessment. Lancet. 2005 Mar 2;365(9462):855-63. PMID: 15752529
  7. Centers for Disease Control and Prevention (CDC) Recommended adult immunization schedule, United States 2002-2003 MMWR Morb Mortal Wkly Rep 2002; 51:904 PMID: 12418546
  8. Fisman DN et al, Prior pneumococcal vaccination is associated with reduced death complications and length of stay among hospitalized adults with community-acquired pneumonia. Clin Infect Dis 2006; 42:1093 PMID: 16575726
  9. Musher DM et al, Effect of pneumococcal vaccination: A comparison of vaccination rates in patients with bacteremic and nonbacteremic pneumococcal pneumonia. Clin Infest Dis 2006, 43:1004 PMID: 16983612
  10. Prescriber's Letter 14(5): 2007 Revaccination With Pneumococcal Vaccine: Who Needs It? Detail-Document#: 230508 (subscription needed) http://www.prescribersletter.com
  11. Huss A et al Efficacy of pneumococcal vaccination in adults: A meta-analysis. CMAJ 2009 Jan 6; 180:48. PMID: 19124790 - Andrews R and Moberley SA. The controversy over the efficacy of pneumococcal vaccine. CMAJ 2009 Jan 6; 180:18. PMID: 19124781
  12. Advisory Committee on Immunization Practices. Recommended adult immunization schedule: United States, 2009. Ann Intern Med 2009 Jan 6; 150:40. PMID: 19124819 - Poland GA and Schaffner W. Immunization guidelines for adult patients: An annual update and a challenge. Ann Intern Med 2009 Jan 6; 150:53. PMID: 19124821
  13. Nuorti JP for the Centers for Disease Control and Prevention Updated Recommendations for Prevention of Invasive Pneumococcal Disease Among Adults Using the 23-Valent Pneumococcal Polysaccharide Vaccine (PPSV23) Morbidity and Mortality Weekly Report (MMWR) September 3, 2010 / 59(34);1102-1106 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5934a3.htm corresponding NGC guideline withdrawn Jan 2016
  14. Centers for Disease Control and Prevention (CDC) Recommended adult immunization schedule - United States 2012 MMWR Morb Mortal Wkly Rep 2012 / 61(04);1-7 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6104a9.htm
  15. Kelly H1, Attia J, Andrews R, Heller RF. The number needed to vaccinate (NNV) and population extensions of the NNV: comparison of influenza and pneumococcal vaccine programmes for people aged 65 years and over. Vaccine. 2004 Jun 2;22(17-18):2192-8. PMID: 15149776
  16. Moore RA et al Are the pneumococcal polysaccharide vaccines effective? Meta-analysis of the prospective trials. BMC Family Practice 2000, 1:1-1 http://www.biomedcentral.com/1471-2296/1/1
  17. Kobayashi M et al Intervals Between PCV13 and PPSV23 Vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Weekly. September 4, 2015 / 64(34);944-947 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6434a4.htm
  18. Broyde A et al. Longterm efficacy of an antipneumococcal polysaccharide vaccine among patients with autoimmune inflammatory rheumatic diseases. J Rheumatol 2016 Feb; 43:267. PMID: 26773117 http://www.jrheum.org/content/43/2/267
  19. Melville NA CDC Issues New Pneumococcal Vaccine Recommendations for Adults. Medscape. Feb 1, 2022 - Kobayashi M, Farrar JL, Gierke R, et al. Use of 15-Valent Pneumococcal Conjugate Vaccine and 20-Valent Pneumococcal Conjugate Vaccine Among U.S. Adults: Updated Recommendations of the Advisory Committee on Immunization Practices - United States, 2022. MMWR Morb Mortal Wkly Rep 2022;71:109-117 PMID: 35085226 Free article https://www.cdc.gov/mmwr/volumes/71/wr/mm7104a1.htm - Centers for Disease Control and Prevention. Pneumococcal vaccination: Information for healthcare professionals. CDC 2022 Jan 24 https://www.cdc.gov/vaccines/vpd/pneumo/hcp/index.html