ACIP Expands PCV13 Immunization Recommendations, But Makes No Flu Vaccine Changes

The CDC's Advisory Committee on Immunization Practices (ACIP) voted to expand the age recommendation for administration of the 13-valent pneumococcal conjugate vaccine (PCV13) during its June 20-21 meeting (2-page PDF; About PDFs) in Atlanta.

According to Jamie Loehr, M.D., of Ithaca, N.Y., the AAFP's liaison to the ACIP, the committee voted in favor of a category A recommendation to administer PCV13, which is marketed as Prevnar 13, to adults 19 and older who have certain immunocompromising conditions, such as patients undergoing dialysis or chemotherapy, as well as those with HIV infection.

Currently, PCV13 is recommended (4-page PDF; About PDFs) solely for children ages 6 weeks to 5 years.

ACIP recommendations are considered provisional until they have been approved by the CDC director and HHS and published in Morbidity and Mortality Weekly Report. Only after that step has occurred would the recommendation be formally reviewed by the AAFP Commission on Health of the Public and Science's Subcommittee on Clinical Preventive Services.

The ACIP's action follows the December 2011 vote by the FDA's Vaccines and Related Biologics Advisory Committee to expand the indication for PCV13 to include adults 50 and older. In January, the FDA approved the expanded indication.

As for the details of administering the vaccine, "There are two ways to introduce PCV13 to these adults," Loehr explained. "If they have never received a pneumococcal vaccine, it would be best to first do a PCV13, followed by PPSV23 eight weeks later, followed by another PPSV23 five years later. If they've already received the PPSV23, they can get the PCV13 a year later."

The committee also considered other issues during the June 20 session, including annual influenza immunization in younger patients and hepatitis B protection among health care personnel.

Part of the influenza vaccine discussion focused on safety, and Loehr said that even though there was still a slight increase in febrile seizures reported after concomitant administration of PCV13 and trivalent flu vaccines during the 2011-12 season, no change was made to the existing influenza recommendations. The committee did, however, vote to simplify the decision tree for determining whether children younger than age 9 years will receive one or two doses of influenza vaccine this fall.

"There will be footnotes that explain the more complicated of the two versions," he said. "The simplified version -- what the (American Academy of Pediatrics) already agreed to -- is not the most technically accurate version, so some kids will get two vaccinations who don't really need two vaccinations. The footnotes are there to explain how you can avoid the second vaccination in some of those kids."

Finally, the committee's hepatitis B vaccine discussion was purely informational at this point, according to Loehr. Although most health care personnel, especially those now entering the workforce, were vaccinated against hepatitis B as infants, it is hard to know how well protected they are because their immunity may have waned. Complicating the picture further is the fact that even if an individual's hepatitis B surface antigen level has dropped below 10 IU/mL -- the level that confers protection -- the person's immune memory response may be intact.

"So the debate is how do you handle a situation when someone who got vaccinated as an infant is going to get exposed to hepatitis B?" Loehr asked. "Do you check them all when they start training? Do you just test the people when they get exposed to blood, knowing that half of the people don't report that exposure?

"It is a very detailed conversation with no good answers, especially because the cost-effectiveness data aren't favorable and the actual immunity of the 25- or 30-year-old who was immunized as an infant -- you don't know the percentage of those people who are actually susceptible, and that's the data we still need."