Key Points for Practice
• Healthy adults 65 years and older receiving a pneumococcal vaccine for the first time should receive PCV13 and then PPSV23 six to 12 months later.
• If a patient has already received the PPSV23 vaccine after 65 years of age, the PCV13 dose should be administered at least one year after the PPSV23 dose.
• Recent, current, or upcoming surgery or anesthesia is not a contraindication or precaution to giving a vaccine.
• For pregnant patients, the Tdap vaccine is now recommended with each pregnancy between 27 and 36 weeks of gestation.
From the AFP Editors
The 2015 adult immunization schedule from the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) has a few changes that are particularly relevant to family physicians. The schedule is available at https://www.aafp.org/patient-care/immunizations/schedules.html.
The most significant change involves the pneumococcal 13-valent conjugate vaccine (PCV13; Prevnar 13). You might recall that ACIP recommends that adults older than 18 years with certain high-risk conditions receive PCV13 and the pneumococcal polyvalent-23 vaccine (PPSV23; Pneumovax 23). In August 2014, ACIP extended that recommendation to older adults. The committee reviewed a large, randomized controlled trial that showed good protection against vaccine-specific pneumococcal pneumonia using PCV13 in older patients (the CAPITA trial; http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6337a4.htm). Based on this study, ACIP now recommends that all adults 65 years and older receive both PCV13 and PPSV23 vaccines.
Logistically, the recommendation is complicated, and vaccine timing depends on the patient's age, medical condition, and if he or she has previously received PPSV23 or PCV13. If the patient is a healthy adult who has just turned 65 and has not received either vaccine, PCV13 should be given first and the PPSV23 six to 12 months later. If the patient has already received the PPSV23 vaccine after age 65, the PCV13 dose should be administered at least one year after the PPSV23 dose.
The Centers for Medicare and Medicaid Services has updated its regulations to allow coverage of both pneumococcal vaccines for adults 65 years and older as long as the two vaccines are spaced a year apart (http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9051.pdf). The key wording states that Medicare will cover a different, second pneumococcal vaccine one year after the first vaccine was administered. Although ACIP recommendations allow a second vaccine as early as six months in some circumstances, Medicare will not reimburse for both unless the two vaccines are given a year apart.
There is no convincing evidence that anesthesia or surgery significantly affects the immunologic response to vaccines. Thus, ACIP concluded that recent, current, or upcoming surgery or anesthesia is not a contraindication or precaution to giving a vaccine. You should routinely offer appropriate vaccinations, such as influenza, PPSV23, and PCV13, unless there is a specific reason not to do so, such as moderate or severe illness.
For pregnant patients, the tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine is now recommended with each pregnancy between 27 and 36 weeks of gestation. Recent safety data on repeated doses of Tdap in subsequent pregnancies have been highly favorable.
For patients hesitant to get vaccinated, the CDC recommends using the SHARE acronym: Share the reasons why the recommended vaccine is right for each patient; Highlight positive personal experiences with immunizations; Address patient questions and concerns in plain, understandable language; Remind patients that vaccine-preventable diseases still exist in the United States; and Explain the potential costs of getting the disease (e.g., health effects, time lost, financial costs).
editor's note: The author serves as liaison to ACIP for the AAFP.