Pneumococcal Vaccine

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Continuing Education Activity

The advent of pneumococcal vaccines has proven to be a significant advancement in the treatment and prevention of a widespread and sometimes deadly disease process. Pneumococcal conjugate vaccine (PCV13) is recommended differently depending on the patient population. While both vaccine types are proven to stimulate long-lasting antibodies in immunocompromised adults, conjugate vaccines have been shown to provide some additional benefits, as will be covered here. This activity describes the mode of action of pneumococcal vaccines, including modes of administration, formulations, adverse event profiles, eligible patient populations, monitoring, and highlights the role of the interprofessional team in the management of these patients.

Objectives:

  • Identify the types of pneumococcal viruses requiring vaccinations.
  • Summarize the absolute and relative contraindications of the pneumococcal vaccine.
  • Review the methods of administering pneumococcal vaccination and eligible patients for each type of vaccine.
  • Explain interprofessional team strategies for improving care coordination and communication to advance pneumococcal vaccination and improve patient outcomes.

Indications

Pneumococcal vaccines are vaccines that work against the bacteria Streptococcus pneumoniae. These vaccines come in two formulations, polysaccharide vaccine, and conjugate vaccine.[1][2] The advent of pneumococcal vaccines has proven to be a significant advancement in the treatment and prevention of a widespread and sometimes deadly disease process.[3][4]

Pneumococcal conjugate vaccine (PCV13) is recommended differently depending on the patient population. In patients six weeks old through 6 years of age, PCV13 is recommended for active immunization for the prevention of diseases considered invasive and caused by Streptococcus pneumoniae serotypes 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, and 23F. It is also recommended for the prevention and active immunization of otitis media caused by S. pneumoniae serotypes 4, 6B, 9V, 14, 18C, 19F, and 23F. In patients aged 7 to 17 years old, it is recommended to prevent invasive disease in the subtypes mentioned above. In patients 18 years old and older, it is indicated for active immunization and prevention of pneumococcal pneumonia, caused by the subtypes of S. pneumoniae, as listed above.

Another pneumococcal vaccine, PPSV23, is indicated in the United States for all adults 65 years of age and older, as well as younger patients with conditions that increase the risk for developing pneumococcal pneumonia or invasive pneumococcal disease.[5] Conditions that would indicate PPSV23 in patients younger than 65 years of age are as follows: chronic heart disease excluding hypertension, chronic lung disease including asthma, diabetes mellitus, cerebrospinal fluid leak, cochlear implant, alcohol use disorder, chronic liver disease, cigarette smoking, hemoglobinopathy (including sickle cell disease), congenital/acquired asplenia, congenital/acquired immunodeficiency, human immunodeficiency virus infection, chronic renal failure, nephrotic syndrome, leukemia, lymphoma, Hodgkin disease, generalized malignancy, patients receiving immunosuppressive medications (anti-tumor necrosis factor [TNF], chemotherapy agents), solid organ transplant, and multiple myeloma. Recommendations are that all patients who received PPSV23 before the age of 65 years be revaccinated at age 65 unless the vaccine is given less than ten years before the patient turns 65 years old, in which case patients should be revaccinated ten years following the first dose. Recommendations are that patients with functional or anatomic asplenia or immunocompromised individuals receive repeat doses of the vaccination every ten years after the first dose.[6][7]

PPSV23 is also an important vaccine for HIV-positive and AIDS patients. A Canadian study showed a significant reduction in pneumococcal disease in this patient population.[8] However, the World Health Organization (WHO) considers the evidence of benefit to be insufficient and recommends indirect pneumococcal disease prevention using trimethoprim/sulfamethoxazole.[9] In the USA, the CDC recommends vaccination for all patients with HIV.

PCV13 and PPSV23 Together

While both vaccine types are proven to stimulate long-lasting antibodies in immunocompromised adults, conjugate vaccines are proven to provide some additional benefits. Benefits of polysaccharide conjugate vaccine over traditional polysaccharide vaccine include that conjugate vaccines stimulate the production of these antibodies in infants and toddlers, as opposed to only healthy adults, as seen with polysaccharide vaccines. Conjugate vaccines have also been demonstrated to stimulate mucosal immunity, which decreases colonization, as well as proving to provide herd immunity and prime the patient immunologically, for an enhanced host response, unlike traditionally polysaccharide vaccines.

The ACIP recommends that patients receive both vaccinations with any of the following: cerebrospinal fluid leak, cochlear implant, anatomic/functional asplenia, and immunocompromising conditions listed above.

Mechanism of Action

Both vaccines promote active immunization against the serotypes of the conjugate and capsular polysaccharides contained in the formulation of the vaccine. Immunity develops approximately 2 to 3 weeks after vaccination and lasts for five years. In children and the elderly, re-immunization may be necessary sooner.

PCV13

This vaccine formulation demonstrates improved antibody response compared to the pneumococcal polysaccharide vaccine because it contains purified capsular polysaccharides of pneumococcal serotypes conjugated to a carrier protein. PCV 13 actively immunizes against invasive disease caused by S. pneumoniae capsular serotypes 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, and 23F. All of the serotypes are individually conjugated to a CRM197 protein.[10]

PPSV 23

This vaccine formulation is the first pneumococcal vaccine formulated from a capsular polysaccharide. PPSV 23 contains 23 capsular polysaccharides types of S. pneumoniae, representing at least 85% to 90% of pneumococcal disease isolates in the United States. It has shown a 50% to 80% efficacy in preventing invasive pneumococcal disease in adults.[11]

S. pneumoniae serotypes: 1, 2, 3, 4, 5, 6B, 7F, 8, 9N, 9V, 10A, 11A, 12F, 14, 15B, 17F, 18C, 19F, 19A, 20, 22F, 23F, and 33F.

Administration

PCV13

Given as a single 0.5 ml injection, intramuscularly only. In patients six weeks through 5 years of age, it is administered as part of a 4-dose immunization series, administered as 0.5 mg intramuscular injections given at 2, 4, 6, and 12 to 15 months of age.[12][13] In all patients six years of age and older, it is administered at a single 0.5 ml intramuscular injection.[14][15]

PPSV23

Given as a single 0.5 ml injection, intramuscular/subcutaneously.[5]

PCV13 and PPSV23 Together

Patients of any age for whom it is recommended receive both vaccinations and should receive them as follows:

If the patient has had no prior vaccination with either vaccine, the patient should receive a single dose of PCV13. Eight weeks or more following this dose, PPSV23 should be given. PPSV23 should be given no sooner than eight weeks following the administration of PVC13.

If the patient has received PPSV23 in the past, a single dose of PCV13 should be given one year after the administration of PPSV23. PVC13 should be given no sooner than one year following the administration of PPSV23.

Adverse Effects

There are reports of the following adverse effects in different age groups. The list includes the most common side effects. However, it is not limited to all of the side effects. 

PCV13

Infants and Toddlers (most commonly reported reactions greater than 5%)

  • Irritability (greater than 70%)
  • Injection site tenderness (greater than50%)
  • Decreased appetite (greater than40%)
  • Decreased sleep (greater than 40%)
  • Increased sleep (greater than 40%)
  • Fever (greater than 20%)
  • Injection site redness ( greater than20%)
  • Injection site swelling (greater than 20%)

Children Aged 5 to 17 Years Old

  • Injection site tenderness (greater than 80%)
  • Injection site redness (greater than 30%)
  • Injection site swelling (greater than 30%)
  • Irritability (greater than 20%)
  • Decreased appetite (greater than 20%)
  • Increased sleep (greater than 20%)
  • Fever (greater than 5%)
  • Decreased sleep (greater than 5%)

Adults 18 Years and Older

  • Pain at the injection site (greater than 50%)
  • Fatigue (greater than 30%)
  • Headache (greater than 20%)
  • Muscle pain (greater than 20%)
  • Joint pain (greater than 10%)
  • Decreased appetite (greater than 10%)
  • Injection site redness (greater than 10%)
  • Injection site swelling (greater than 10%)
  • Limitation of arm movement (greater than 10%)
  • Vomiting (greater than 5%)
  • Fever (greater than 5%)
  • Chills (greater than 5%)
  • Rash (greater than 5%)

PPSV23

Common Reactions to PPSV23 (greater than 10% of patients)

  • Injection site pain/soreness/tenderness (60%)
  • Injection site induration/swelling (20.3%)
  • Headache (17.6%)
  • Injection site erythema (16.4%)
  • Fatigue/weakness (13.2%)
  • Myalgia (11.9%)

Concomitant administration of PPSV23 and live zoster vaccine showed a reduced immune response to live zoster vaccine. The recommendation is for administrations to be at least four weeks apart.[16]

PCV13

Studies done on animals have not shown fetal adverse effects or increased risk to the fetus. It is unknown if the vaccine is excreted with breast milk. Caution is necessary when administering this vaccine to breastfeeding women.

PPSV23

Animal reproduction studies have not been conducted. However, PPSV 23 is an inactivated vaccine, and studies of other inactivated vaccines have not shown to cause increased risk to the fetus. It is unknown if the vaccine is excreted with breast milk. Clinicians should exercise caution when administering this vaccine to breastfeeding women.

Contraindications

PCV13 and PPSV23 contraindications include severe allergic or anaphylactic reaction to any component of the formulation of the vaccine or any diphtheria toxoid-containing vaccine. Pregnancy is not a contraindication to vaccination. Recommendations are that pregnant women at high risk of infection should receive the vaccination.[17]

Monitoring

For the first 15 minutes following pneumococcal vaccine administration, patients require monitoring for an allergic reaction such as anaphylaxis and syncope.

Toxicity

There is no overdose risk with the administration of the vaccine. Careful dosing and administration and adherence to the vaccine guidelines should preclude any chance of overdosing the vaccines.

Enhancing Healthcare Team Outcomes

The pneumococcal vaccine is safe and effective and can help reduce the risk of infection with certain types of pneumonia, sepsis, and meningitis. All interprofessional healthcare team members, including clinicians (MDs, DOs, NPs, PAs), nursing staff, and pharmacists, should educate patients on the benefits of the pneumococcal vaccine, answer patient questions, allay any concerns they may have about the vaccine, and provide information for the patient in the unlikely event that they experience and adverse reaction. All healthcare team members also need to ensure the patient's medical record is updated to reflect the most recent vaccine administration, especially since clinicians, nurses, and pharmacists can all administer the vaccine in most states. This integrated teamwork and information sharing will help drive improved patient outcomes. [ Level 5] Over the years, the vaccine has proven to be safe and effective.[18]


Article Details

Article Author

Stela Tereziu

Article Editor:

David A. Minter

Updated:

1/21/2022 9:55:06 AM

PubMed Link:

Pneumococcal Vaccine

References

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