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May 2013
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EIN Update: 13-Valent Pneumococcal Conjugate Vaccine in the Hospital Setting
The Emerging Infections Network (EIN) is a forum for infectious diseases consultants and public health officials to report information on clinical phenomena and epidemiological issues with public health significance. Any diagnostic or therapeutic recommendations and all opinions presented are those of the individual contributor. They do not necessarily represent the views of EIN, IDSA (EIN’s sponsor), or the Centers for Disease Control and Prevention (CDC), which funds EIN. The reader assumes all risks in using this information. 

Members of EIN recently discussed the use of 13-valent pneumococcal conjugate vaccine (PCV 13) in the inpatient setting in light of 2012 recommendations from the federal Advisory Committee on Immunization Practices (ACIP).

“We’ve been following the ACIP recommendations in our office and our HIV clinic, but adding this in to the pneumococcal vaccine protocols in the hospitals seems very complicated, if not impossible, unless you have a unified [electronic medical record] for both the in- and outpatient locations,” a member in New Hampshire wrote.

“If you have [PCV 13] on your inpatient formulary, has it replaced the [23-serotype pneumococcal polysaccharide vaccine] in your protocols?” the member continued. “I’d really love to place this issue on hold, pending release of the efficacy studies, but our pharmacy staff and vaccine manufacturers have been asking.”

A member in Connecticut responded: “We have not added [PCV 13] to our inpatient formulary. Although we have been very successful administering both the [23-serotype pneumococcal polysaccharide vaccine] and influenza vaccine to our inpatients, both are out-of-pocket costs that we have not been billing for. I’m not anxious to add to these expenses by incurring the additional cost of PCV-13 in the absence of demonstrated better efficacy,” the member wrote.

In a joint response, several staff with the National Center for Immunization and Respiratory Diseases at Centers for Disease Control and Prevention (CDC) agreed “that the PCV13 recommendations for immunocompromised adults are complicated to implement, especially in the hospital setting. As more data become available, we will work with the ACIP Pneumococcal Work Group to simplify the recommendations as much as possible.

“In the meantime, CDC has been advising individual providers to treat patients with unknown or uncertain vaccine histories as ‘unvaccinated,’ consistent with the ACIP General Recommendations for Immunizations. Specifically, CDC has been recommending PCV13 to patients with ACIP indications for PCV13 and for whom pneumococcal vaccination history is unknown,” wrote Matthew Moore, MD, MPH; Tamara Pilishvili, MPH; and Cyndy Whitney, MD, MPH, of CDC.

“The ACIP voted to recommend PCV13 for immunocompromised individuals, in part, because a randomized controlled trial of 7-valent conjugate vaccine (PCV7) among adults with HIV in Malawi demonstrated 74 percent efficacy against invasive pneumococcal disease caused by serotypes included in PCV7,” CDC staff continued. CDC surveillance also shows that rates of vaccine-type invasive disease remain high in the U.S. among those with immunocompromising conditions, “and because of these high rates, PCV13 use in this population is a cost-effective measure,” the CDC responders noted.

The advisory committee recommended a combined regimen of PCV13 and 23-valent pneumococcal polysaccharide vaccine “because broader serotype coverage could be achieved through the use of both vaccines,” CDC staff wrote. “Immunogenicity studies have shown that an improved antibody response is achieved when conjugate vaccine is given before polysaccharide vaccine compared to the other way around. The ACIP decided to defer recommendations for PCV13 use in adults without immunocompromising conditions until results of a large clinical trial are available.”

With no additional studies of PCV efficacy in immunocompromised adults expected, “the ACIP felt that the currently available evidence supports the use of PCV in these immunocompromised populations,” the CDC responders wrote.

E-mail the Emerging Infections Network.

The Emerging Infections Network (EIN) is a provider-based sentinel network designed to help the public health community detect trends in emerging infectious diseases.

A joint project of IDSA and the Pediatric Infectious Diseases Society (PIDS) with funding from the Centers for Disease Control and Prevention (CDC), EIN tracks emerging infectious diseases and keeps the public health community up to date with new disease trends, difficult cases, and other issues affecting members’ clinical practices. The Network provides a great opportunity for members to share knowledge quickly across large geographical distances. Both IDSA and PIDS members are eligible to join. Click here for more information or to join EIN.
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