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Feature Article

Reducing pneumococcal risk in people aged 65 years and over

PAUL VAN BUYNDER
OPEN ACCESS

Adults without conditions associated with increased risk of IPD 

  • A single dose of 23vPPV is recommended for all non-Indigenous adults at 65 years of age. 
  • Adults aged over 65 years who did not receive a dose at 65 years of age are recommended to receive a single catch-up dose of 23vPPV as soon as possible. 
  • Aboriginal and Torres Strait Islander adults without medical conditions that are associated with an increased risk of IPD are recommended to receive:
    –  a dose of 23vPPV at the age of 50 years 
    –  a further dose of 23vPPV five years later.
The minimum interval between any two doses of 23vPPV is five years. Adults are recommended to receive no more than three doses of 23vPPV in their lifetime.
 

Adults with conditions associated with an increased risk of IPD

  • Adults with a newly identified or previously identified medical condition(s) associated with the highest increased risk of IPD (category A), except haematopoietic stem cell transplant recipients, are recommended to receive: 
    –  a single dose of 13vPCV at the time of diagnosis 
    –  a dose of 23vPPV at least two months after 13vPCV
    –  two further doses of 23vPPV at least five years apart.

Stem cell recipients should receive a course of three doses of 13vPCV over six months and then a follow-up dose of 23vPPV 12 months later.

  • Adults who have a newly identified or previously identified condition(s) listed in category B (increased risk of IPD) are recommended to receive:
    –  a dose of 23vPPV at diagnosis 
    –  two further doses of 23vPPV at least five years apart (see the case study in Box 2).

PneumoSmart vaccination tool

An online tool that can help identify the recommended pneumococcal vaccination regimen for individual patients is ­avail­­­­able at the PneumoSmart website (www.­pneumosmart.org.au/clinicians/vaccination-tool). The PneumoSmart vaccination tool also indicates which vaccines are funded under the NIP or PBS.

When would we use conjugated pneumococcal vaccine in older people?

The vaccine 13vPCV was licensed for older people in many countries after a Netherlands study provided evidence that this vaccine gives good protection against ­vaccine-type IPD and moderate protection against CAP.7 It was licensed for people aged over 50 years in Australia in 2011. 

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The role of 13vPCV in older people and the additional benefit over 23vPPV is ­contentious. Several countries, including Canada, the UK and Germany, assessed the possible cost versus benefit and decided against using 13vPCV in older ­people, ­staying with 23vPPV use. In the US, 13vPCV and 23vPPV are used sequentially in older people. An upcoming review may clarify the benefit of this approach ­compared with the use of 23vPPV alone.

Australia is still considering its position. Key issues are the degree of herd immunity provided by the childhood pneumococcal vaccination program and the question whether vaccine-type ­pneumococcal disease will continue to decline without a conjugate vaccine dose to older people. The Australian and New Zealand Society for Geriatric Medicine recommends that in unvaccinated older people, consideration should be given to first providing a dose of 13vPCV followed by 23vPPV two to six months later.12 However, 13vPCV is funded only for children up to 5 years of age. Offering 13vPCV to older people with a high risk of serious consequences of CAP may be worthwhile, but they will need to pay privately for it. 

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Several studies have shown that 23vPPV induces a state of immune tolerance or hyporesponsiveness to sub­sequent vaccination, where the response to revaccination does not reach the levels achieved with primary vaccination.13 The clinical significance of this is unknown, but if both 13vPCV and 23vPPV are to be given then 13vPCV should be given first, followed by 23vPPV at least eight weeks later. If 23vPPV has already been received then administration of 13vPCV should be delayed for 12 months. 

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