Pneumococcal Vaccine – Types, Dosing And Schedule
PNEUMOCOCCAL VACCINE
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Last Updated : 2/29/2016
Sayenna Uduman
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Efficacy and added benefit of PCV13:
Since the PCV introduction in immunization practice, the incidence of all IPD decreased by 76% in children younger than 5 years, in US. This has also resulted reduction in adult cases 65 years and older indicates the significant indirect benefit (Herd immunity) of PCV by interruption of transmission of pneumococci from children to adults. Further PD reductions in children of all ages, have been demonstrated up to this date (CDC data, Redbook, 2015) and the same should be observed in Indian children. A recent study from India indicated that 73% of the pneumococcal isolates cover PCV13 containing ST’s. (J Infect Dev Ctries. 2013; 7:101–9)

PCV13 reduced IPD across all age groups when used routinely in children in the USA. These findings provide reassurance that, similar to PCV7, the PCVs with additional serotypes can also prevent transmission to unvaccinated populations.

PCV13 vaccination protects against serotype 19A infection which has emerged as the dominant penicillin resistant pneumococcus (PRP) strains causing invasive diseases.

Global evaluation studies demonstrated that PCV13 provided a wider coverage and more effective prevention against IPDs, mucosal pneumococcal diseases (otitis media, Pneumonia), and pneumococcal carriage.

Reduction of childhood nasopharyngeal colonization of PRP in the community; therefore PRP causing PDs are uncommon in PCV13 immunized children.

Immunization Schedules for Infants and Young Children < 2 years of age
IAP Guidebook on Immunization 2013–14 recommends:
• For routine immunization both PCV10 and PCV13 are licensed for children from 6 weeks to 5 years of age (although the exact labeling details may differ by country).
• Primary schedule (for both PCV10 and PCV13): 3 primary doses at 6, 10, and 14 weeks with a booster at age 12 through 15 months
• Additionally, PCV13 is licensed for the prevention of pneumococcal diseases in adults > 50 years of age.

CDC, ACIP Guidelines (North America, Mid East, most Euros’ countries):
• PCV13 is recommended for routine immunization for healthy children at 2, 4, 6, and 12 to 15 months of age.
• Children who miss their shots at these ages should still get the vaccine. The number of doses and the intervals between doses will depend on the child’s age. The recommended Schedule for number of doses of PCV13, Including Catch-up immunizations in previously unimmunized and partially immunized Children 24 through 71 Months of Age is shown in Table 1

Catch-up vaccination with PCV13
• Administer 1 dose of PCV13 to all healthy children aged 24 through 71 months who are not completely vaccinated for their age.(Redbook)
• Children with underlying medical conditions younger than 72 months of age who were previously fully immunized with PCV7 should receive one dose of PCV13.
• Older children with immune compromise and other specific high-risk conditions for invasive disease (e.g., cochlear implants, cerebrospinal fluid leaks, hemoglobinapathic and asplenia) should be immunized with two dose of PCV13 if not previously immunized ‘
• For high risk clinical condition, consider 2 doses of PCV13 at least 8 weeks apart if unvaccinated or any incomplete schedule of fewer than 3 doses of PCV that were received previously.

Capsular Polysaccharide vaccine (PPSV23):
• Not recommended for routine use in infant immunization & healthy individuals (not immunogenic < 2 years , T cell independent)
• Recommended only for the vaccination of persons with certain high-risk conditions.
• Single dose for all adults 65 years and older. People with certain chronic health conditions may be recommended to receive a second dose, five years after their first dose.
• If PPSV23 has been received but PCV13 has not, administer 1 dose of PCV13 at least 8 weeks after the most recent dose of PPSV23.
• Vaccination of persons with high-risk conditions: All recommended PCV13 doses should be administered prior to PPSV23 vaccination if possible.

When to use combined PCV13 and PPSV23
PPSV23 should never be used alone for prevention of PD’s amongst high-risk individuals. Children with following medical conditions for which PPSV23 and PCV are indicated in the age group 24 through 71 months:
• Children with anatomic or functional asplenia (including sickle cell disease and other hemoglobinopathies, congenital or acquired asplenia, or splenic dysfunction);
• Immune competent children with congenital heart disease (particularly cyanotic type and cardiac failure); chronic lung disease (including asthma if treated with high-dose oral corticosteroid therapy), diabetes mellitus; cerebrospinal fluid leaks; or cochlear implant.
• Children with immune compromising conditions: HIV infection, Nephrotic syndrome and chronic renal failure, diseases associated with treatment with immunosuppressive drugs or radiation therapy, including malignant neoplasms or solid organ transplantation, congenital immunodeficiency.

Immunization in adults
One dose of PCV13 is recommended for grown-up children 6 through 18 years of age and adults 19 through 64 years of age with the following medical conditions that put them at high risk for IPD’s.
Functional or anatomic asplenia/ Congenital or acquired immunodeficiency/ HIV infection/ Nephrotic syndrome & chronic renal failure/ chronic lung disease including asthma/ Cochlear implant(s)/ Sickle cell disease and other hemaglobinopathies/ malignant conditions & long-term immunosuppressive therapy/ Solid Organ transplant
• Adults 65 years of age or older with one of the above listed conditions who have not received any pneumococcal vaccine, should get a dose of PCV13 first and a dose of PPSV23 should be given 6 to 12 months later.
• For adults 65 years and older who have already received one or more doses of PPSV23, the dose of PCV13 should be given at least one year after receiving the most recent dose of PPSV23. Ask your health care provider for details.
Most healthy adults who get the vaccine develop protection to most or all of these types within two to three weeks of getting the shot. Very old people and people with some long-term illnesses might not respond as well, or at all.

Co-administration with Other Vaccines
• Pneumococcal containing combination (Combo’s) Vaccine are not manufactured and approved for clinical use.
• Concomitant administration of PCV13 and trivalent inactivated influenza vaccine (TIV) has been demonstrated to be immunogenic and safe.
The PCV13 can be coadministered with TIV in an adult immunization program. Currently, no data are available on co-administration with other vaccines (e.g, tetanus, diphtheria, and acellular pertussis vaccine or zoster vaccine) both among children and adults.

Summary
• PCV13 is ideal & recommended routinely for all children 2-71 months of age and should be the vaccine of choice in India, provided its cost gets lower in line with other vaccines.
• In healthy children 6 through 18 years of age due to their low risk of IPD, PCV13 is not recommended routinely. However, children with high risk conditions are eligible for vaccination; gets a single dose of PCV13 regardless of whether they have received before the PCV 7 or the PPSV23 vaccine
• Vaccine is indicated for 19 years of age and older with immunocompromising conditions
• For adults aged 50 through 64 years of age and older: both PCV13 and PPSV23 should be given. If the patient has already received PPSV23, administer PCV13 at least 1 year later
• Vaccination of persons with high-risk conditions is recommended with PCV13 and PPSV23: Almost 40% of IPD in these high risk person was cause by pneumococcal serotypes in PCV 13 and another 33% was caused by serotype in PPSV23 that are not in the PCV13.

References

Contributor Information and Disclosures

Sayenna Uduman
Sayenna A Uduman MD, FAAP
Visiting Professor, Infection Control Committee & ID Division of the KIMS
Thiruvananthapuram, Kerala, India


First Created : 1/10/2006
Last Updated : 2/29/2016

References

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