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Q:

1/14/2015
Current guidelines recommend vaccinating all asthma patients, ages 18-65 years, with PCV 23. Regarding PCV13...I have seen some recommendations to vaccinate all adult asthmatics, to vaccinate just those that are on long term systemic steroids (CDC), or to not vaccinate at all. Since all asthma patients, even those with mild asthma, may be at risk for invasive pneumococcal disease, looks like immunizing with PCV13 would be a good idea. Any recommendations on this?

A:


I find the pneumococcal recommendations somewhat confusing as well. I think this may be due to the evolution of recommendations with the availability of the conjugated vaccine for adults. There is a recent question in the archives of Ask The Expert which I think summarize the issue. There is no additional information of which I am aware that would modify my opinion.

In summary, the recommendation is that all asthmatic receive the unconjugated pneumococcal vaccine and the conjugated vaccine be given to subjects who do not respond or are judged to be at risk not to respond to the unconjugated vaccine.

Conjugated pneumococcal vaccine CDC recommendations for asthmatics
Q: 12/19/2014
Why is Prevnar 13 not approved by the CDC for asthmatics? Without this recommendation, insurance will not cover the cost of the Prevnar vaccine but they will cover cost of the Pneumovax 23.

A: I cannot speak for the Centers for Disease Control and Prevention (CDC) but their recommendations are generally conservative and whenever possible evidence based. Since the conjugated pneumococcal vaccine was only approved in 2011 for adults > 50 years of age, there has not been sufficient accumulated data to advise that the conjugated vaccine (PCV13) is preferable to the nonconjugated (PPSV23) unless there is immunologic impairment, CSF leak or cochlear implant. There is some loss of breadth of coverage by using the 13 strains in the PCV13 compared to the 23 strains in the PPSV23 vaccine (one strain is present in the PCV13 that is not in the PPSV23 (serotype 6A). Therefore, in immunocompetent subjects with asthma, there may be an advantage of the breadth of coverage offered by the PPSV23 vaccine. Until there are data to establish the preference, the conservative approach is to continue with current recommendations, PPSV23 pneumococcal vaccine in younger subjects with chronic lung disease and both vaccines with immune impairment or age greater than 50 years. Cost effectiveness of using the PCV13 in adults is based primarily on the benefits in subjects with HIV infection and receiving dialysis.

I have attached a response from the archives of Ask The Expert that discusses the recommendations for PPSV23 in asthma.

In summary, my approach is to use PPSV23 for subjects with asthma who are otherwise normal and PCV13 when the person with asthma reaches the age of 50 years. I also prefer to reserve PCV13 in case specific antibody responses need to be assessed, as the conjugated vaccine does not allow ideal assessment of specific antibody response (Orange J et al. Use and interpretation of diagnostic vaccination in primary immunodeficiency: A working group report of the Basic and Clinical Immunology Interest Section of the American Academy of Allergy Asthma and Immunology. J Allergy Clin Immunol 2012;130:S1-24). Subsequent boosting after 5 years is with either the PPSV23 or PCV13.

Indications for pneumococcal vaccine (Pneumovax 23) in asthma
Q: 11/14/2013
Could you clarify recommendations for administration of pneumovax to asthmatics? Is it recommended for all ages, only those over 18, is there a consensus? Having a hard time getting clarification on CDC website.

A: The CDC considers asthmatics at increased risk of pneumococcal disease and therefore have suggested that all asthmatics ages 19 to 64 receive pneumococcal vaccine (Pneumovax 23). Below you will see quotes from three different sources that allow you to follow the rationale of the updated recommendations by the CDC.

The first is directly from the Pneumovax 23 package insert which states that anyone who is at “increased risk” receive the vaccine. The next is a quote taken directly from a news release (a link to that release is copied below) that describes the rationale of the CDC. This was based upon a study that showed that asthmatics are at increased risk. Finally, there is a quote taken directly from the CDC website which states that asthmatics ages 19 to 64 receive the vaccine. A link to the CDC website is also copied below.

Thank you again for your inquiry and we hope this response is helpful to you.

“1 INDICATIONS AND USAGE

1.1 Indications and Use
PNEUMOVAX® 23 is a vaccine indicated for active immunization for the prevention of pneumococcal disease caused by the 23 serotypes contained in the vaccine (1, 2, 3, 4, 5, 6B, 7F, 8, 9N, 9V, 10A, 11A, 12F, 14, 15B, 17F, 18C, 19F, 19A, 20, 22F, 23F, and 33F). PNEUMOVAX 23 is approved for use in persons 50 years of age or older and persons aged =2 years who are at increased risk for pneumococcal disease.”

"The U.S. Centers for Disease Control and Prevention's (CDC) Advisory Committee on Immunization Practices (ACIP) voted unanimously yesterday to recommend that adults ages 19 to 64 with asthma receive pneumococcal polysaccharide vaccine (PPSV23.................

The ACIP based this recommendation on study data that showed an increased risk of pneumococcal disease among people with asthma. Pneumococcal diseases are caused by common bacteria and can lead to potentially serious bacterial infections of the lungs (pneumonia), lining of the brain (meningitis) and blood (bacteremia)."

“Pneumovax® is 23-valent polysaccharide vaccine (PPVSV23) that is currently recommended for use in all adults who are older than 65 years of age and for persons who are 2 years and older and at high risk for disease (e.g., sickle cell disease, HIV infection, or other immunocompromising conditions). It is also recommended for use in adults 19 through 64 years of age who smoke cigarettes or who have asthma.”

Sincerely,
Phil Lieberman, M.D.

I hope this information is of help to you and your patient.

All my best.
Dennis K. Ledford, MD, FAAAA

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