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A summary of presentations from the weekly Summit partner webinars

February 17, 2022 – The latest Summit summary

Pneumococcal Vaccination Implementation Clinical Considerations Update – Miwako Kobayashi (CDC)

Miwako Kobayashi, MD, MPH, Respiratory Diseases Branch, Division of Bacterial Diseases, CDC, gave an update presentation on pneumococcal vaccination implementation clinical considerations.

In October 2021 the ACIP recommended updates regarding pneumococcal vaccines among adults. The recommendations are summarized in the January 28, 2022 MMWR policy note Use of 15-Valent Pneumococcal Conjugate Vaccine and 20-Valent Pneumococcal Conjugate Vaccine Among U.S. Adults: Updated Recommendations of the Advisory Committee on Immunization Practices — United States, 2022.

There were two pneumococcal vaccines licensed for use in U.S. adults before 2021: 23-valent pneumococcal polysaccharide vaccine (PPSV23) and 13-valent pneumococcal conjugate vaccine (PCV13). In 2021, two new pneumococcal conjugate vaccines were licensed for use in U.S. adults: 15-valent pneumococcal conjugate vaccine (PCV15) and 20-valent pneumococcal conjugate vaccine (PCV20).

The new recommendations simplified the previous recommendations for both adults age 65 and older and for adults age 19–64 with certain underlying medical conditions or other risk factors. The new recommendation for adults 65+ and 19-64-year-olds with one or more medical conditions or other risk factors who have not previously received a pneumococcal vaccine is to receive either PCV20 or PCV15 in series with PPSV23.   For those that have already received PCV13, the recommendation is to complete the PPSV23 series. Those that have received only PPSV23, they can receive PCV15 to complete their pneumococcal vaccination.

Streptococcus pneumoniae are classified into serotypes based on the composition of the capsular polysaccharides. Both pneumococcal conjugate vaccines and pneumococcal polysaccharide vaccines use these polysaccharides as antigens, however, the PCV capsular polysaccharides are conjugated to a carrier protein.

PCVs induce a T-cell-dependent response, whereas PPSV does not. There are several other advantages of PCV vaccines, including memory B cell production and the reduction of pneumococcal carriage. Reducing pneumococcal carriage is important because it is a precursor to pneumococcal disease.  Pneumococcus can cause noninvasive and invasive pneumococcal disease (IPD). A person may carry pneumococcal bacteria in the nasal passage and may transmit bacteria to others as a symptomless carrier.

PCV13 use in children has reduced the vaccine-type IPD incidence in children who received the vaccine. This also decreased IPD in adults due to the decline in transmission. Both types of vaccines protect against vaccine-type IPD, but only PCV has been definitively shown to prevent non-vaccine IPD.

In 2014, ACIP reviewed results of a randomized placebo-controlled trial (CAPITA Trial) among community-dwelling, pneumococcal vaccine naïve adults age 65 and older in the Netherlands. This trial showed that PCV13 in older adults had 45% vaccine efficacy against the first episode of vaccine-type nonbacteremic/noninvasive pneumococcal pneumonia. These findings were decisive in the 2014 recommendation on routine PCV13 use for all adults age 65 and older in series with PPSV23.

The routine PCV13 use in adults age 65 and older was changed in 2019 to a recommendation based on shared clinical decision-making. In 2018–2019, two additional serotypes included in PCV15 (PCV15 non-PCV13 serotypes) accounted for 12–15% of IPD in adults and the additional serotypes in PCV20 (PCV20 non-PCV15 serotypes) in the same year accounted for 14–18% of IPD in adults.

New vaccine recommendations and guidance

  1. Adults aged ≥65 years and adults aged 19–64 years with certain underlying medical conditions or other risk factors who have not previously received PCV or whose previous vaccination history is unknown should receive: one dose of PCV20 OR one dose of PCV15 followed by one dose of PPSV23 at ≥1 year. A minimum of 8 weeks can be considered for adults with an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak to minimize the risk for IPD caused by serotypes unique to PPSV23
  2. Adults with previous PPSV23 vaccination only may receive one dose of PCV20 or PCV15 at ≥1 year after their last PPSV23 dose. When PCV15 is used, there is no need for it to be followed by another dose of PPSV23
  3. Adults with previous PCV13, with or without PPSV23:
  • Must complete the previously recommended PPSV23 series
  • For adults who have received PCV13 but have not completed the recommended pneumococcal vaccine series with PPSV23, one dose of PCV20 may be used if PPSV23 is unavailable
  • The incremental public health benefits of providing PCV15 or PCV20 to these adults have not been evaluated
  1. PCV15, PCV20, and PPSV23 can be co-administered with quadrivalent influenza vaccines. However, PPSV23 should not. Be administered at the same time as any PCV vaccine. Evaluation of PCV vaccines and COVID-19 vaccines is ongoing and there’s no data on co-administration with other vaccines.  However, CDC has stated that COVID-19 may be administered with any other vaccine per the CDC immunization best practices guidelines.

 

Currently, only PCV13 and PPSV23 are licensed in and recommended for use in children.   CDC does not have recommendations on repeating the PCV15 and PCV20 doses in adults. There is limited data on the duration of protection from these vaccines, and the potential future indirect effects from PCV15 (pediatric licensure anticipated in 2022) or PCV20 (pediatric licensure anticipated in 2023) use in children is unknown. The ACIP pneumococcal vaccine workgroup is currently reviewing data on PCV15 use in children. And ACIP plans to evaluate the incremental public health impact of recommending PCV15 and PCV20 to adults who have previously received PCV13. The next generation of pneumococcal vaccines is under development, so they may be on the market in the near future.

Two pneumococcal vaccine resources have been updated to reflect new ACIP recommendations:

Questions

Question

If you substitute PCV20 for PPSV23 in a patient who is immunocompromised and has already received PCV13, are you still able to use the 8-week interval that is an option for the conjugate polysaccharide interval in immunocompromised people?

Miwako Kobayashi

Currently, there has not been specific discussion on using PCV20 and PCV15 together because the assumption is if providers are going to buy the new vaccine, they will most likely use PCV15 or PCV20. For people who have previously gotten PCV13, there has been no mention of the interval recommended between PCV13 and PCV20. Currently, data suggests it might be better to use the shorter interval for people with immunocompromised conditions because of concern of having less serotype coverage for those highest at risk for IPD. However, when discussing the interval related to the new guidance, the workgroup did not go into using the 8-week as a baseline or one year. There is also data suggesting if the intervals are too close that the immune response after the second dose might not be as high. The 8-week interval is coming more from the concern that people might have about the necessity of higher serotype coverage for those at high risk.

Question

Looking back at the prior PSV23 recommendation, ACIP stated that public health authorities may recommend PPSV23 for Alaska Natives and American Indians aged 50-64 years who are living in areas where the risk of IPD is increased.  Is this recommendation still in place given the new recommendations?

Miwako Kobayashi

There are recommendations that were not mentioned specifically for certain groups. Alaska is considering having separate recommendations for the Alaska Native group given the historic disease background.

Question

In the new recommendations, if you have had PCV13 and are due for PPSV23, but  PPSV23 is not available, you can substitute PCV20.  Can you provide any more background about this recommendation?  Are there concerns about the vaccine supply for PPSV23 or is there anything that vaccinators need to be aware of?

Miwako Kobayashi

No, there are no supply issues.  We presented an earlier version of clinical guidance at the January 8 ACIP meeting, and at that point, there was no option of using PCV20 if someone is due for PPSV23 and previously had PCV13. There is no change in the recommendation to when a clinic does not have PPSV23 available, and a formal ACIP process needs to be conducted to make a recommendation on the new conjugate vaccine use in adults with previous PCV13 vaccination. We don’t have a definitive answer for this yet.

Question

Is there a precaution about the co-administration of the new conjugate vaccines (PCV15 or PCV20) and Menactra (for example, in an asplenic or immunocompromised patient) due to potential interference in the same way we are recommended not to co-administer PCV13 and Menactra?

Miwako Kobayashi

There is no data on the co-administration of PCV15 and Menactra. It makes sense to assume there might be similar issues given the similarities between the vaccines. With no guidance on this yet, it makes sense to apply similar caution when the two vaccines are co-administered, or a patient is indicated to receive both.

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The 2022 Adult Immunization Schedule and Other CDC Resources – Neil Murthy (CDC)

Neil Murthy, MD, MPH, MSJ, LCDR, United States Public Health Service, Immunization Services Division, NCIRD, CDC, gave a presentation on the 2022 adult immunization schedule and other CDC resources.

Disclaimer: The use of vaccine trade names is for identification purposes only and does not imply endorsement by the CDC. There will be no discussion of all the details of the changes to the 2022 schedule in this presentation. Please refer to the NAIIS presentation on November 18, 2021.

Major updates to the 2022 adult immunization schedule include vaccine-specific changes to pneumococcal vaccines, hepatitis B vaccine, and zoster vaccine. There are also changes to the Appendix.

Changes to the pneumococcal vaccines listed for adults include:

  • Removal of PCV13 from the list and the inclusion of the two new pneumococcal conjugate vaccines: PCV15 and PCV20
  • Table 1: Routine Immunization Schedule
    • Removal of PCV13 and the addition of PCV15 and PCV20
    • PCV15 and PCV20 and PPSV23 have been collapsed into one row to reflect the new ACIP recommendations
  • Table 2: Medical Indications Schedule
    • PCV15 and PCV20 and PPSV23 have been collapsed into one row
    • Guidance on which vaccines are indicated for certain risk groups is displayed by corresponding colors and overlaying text
  • The notes section has been substantially modified to reflect the new ACIP recommendations
    • Providers can refer to the MMWR report to learn more about the guidance for patients who have previously received a dose of PCV13 or PPSV23, including dosing intervals (especially for patients with certain medical conditions)

Changes to the hepatitis B vaccine schedule for adults include:

  • The hepatitis B vaccine is universally recommended for all adults age 19–59 years.
  • Table 1: Routine Immunization Schedule
    • The hepatitis B row is yellow for age 19–59 years and purple from age 60 and older, indicating that the risk-based recommendations remain for the older age group.
  • Table 2: Medical Indications Schedule
    • The hepatitis B row is now entirely yellow, indicating that the vaccine is recommended for all of the risk-based groups presented on the schedule
  • Notes section
    • The routine vaccination section shows that hepatitis B vaccination is recommended for all adults age 19–59
    • A detailed description of the 2,3, and 4 dose hepatitis B series and indications for their use is presented in the routine vaccination section
    • The special situations section describes the risk-based recommendations for hepatitis B vaccination for adults age 60 and older
    • A special note that reflects the new ACIP recommendations at the end of the hepatitis B section states that adults age 60 and older, who do not meet the risk-based recommendations and would like to receive a hepatitis B vaccination may be vaccinated

Changes to the zoster vaccine schedule for adults include:

  • Two doses of the recombinant zoster vaccine are now recommended for all immunodeficient or immunosuppressed adults age 19 and older
  • Table 1: Routine Immunization Schedule
    • To reflect the new ACIP recommendations, the zoster row is now purple for all adults age 19–49
  • Table 2: Medical Indications Schedule
    • To reflect the new ACIP recommendations, the zoster row is now purple for all adults age 19–49
    • Two doses of recombinant zoster vaccine are now recommended for adults age 19 and older who have immunocompromising conditions including HIV infection
  • Notes section
    • To reflect the new ACIP recommendations, the zoster row is now purple for all adults age 19–49
    • Two doses of recombinant zoster vaccine are now recommended for adults age 19 and older who have immunocompromising conditions including HIV infection
    • Additional language was added to reflect the new recommendations for immunocompromising conditions: “RZV is recommended for use in persons aged 19 years or older who are or will be immunodeficient or immunosuppressed because of disease or therapy.”

Changes to the Appendix section

The Appendix shows the contraindications and precautions to all the vaccines listed in the adult schedule.

  • As noted at the beginning of the Appendix, it states that it is adapted from the ACIP General Best Practice Guidelines for Immunization and from the 2021–2022 influenza vaccine recommendations.
  • There is also a link to the Interim Clinical Considerations for Use of COVID-19 Vaccines, which lists the contraindications and precautions to COVID-19 vaccines.
  • The first page of the Appendix lists all of the influenza vaccines approved for adults and the second page lists all of the non-influenza vaccines listed for adults, followed by the contraindications and precautions listed for all non-influenza vaccines

CDC resources for providers and the public to help adults stay up to date on vaccines

Online Version of Schedule – A QR code at the bottom of the right-hand corner of the cover page can be scanned by a smartphone and the user will be taken to the CDC website with the adult immunization schedule. This will show all of the same information as the hard copy.

Schedules App – This app contains both the adult and child schedules. This app can be downloaded onto an apple or android device.

Pneumococcal Vaccination App – This app for providers incorporates the new guidance on the new PCV15 and PCV20 vaccines to help assess their patients for the need of pneumococcal vaccines.

Adult Vaccine Assessment Tool – This tool is a questionnaire for the public used to figure out which vaccines they need. Based on their answers, the patient will receive a list showing all the vaccines they might need. Patients can use the list to discuss the vaccines with their healthcare provider.

Storage and Handling Toolkit – This toolkit is a handy resource for healthcare professionals, immunization managers, and immunization partners to reference the best practices for safely storing and handling vaccines and to maintain the cold chain. You can download a PDF copy of the toolkit as well.

Vaccinations during COVID-19 Pandemic ­– This website offers resources on how to encourage routine vaccinations during the pandemic.

Interim Clinical Considerations for Use of COVID-19 Vaccines – This website presents the latest guidance on COVID-19 vaccine recommendations, indications, intervals, and more as a resource for healthcare providers.

Questions

 Question

Where is dengue considered endemic?

Neil Murthy

Endemic areas for dengue include Puerto Rico, American Samoa, U.S. Virgin Islands, Federated States of Micronesia, Republic of Marshall Islands, and the Republic of Palau. For updated guidance on dengue-endemic areas and pre-vaccination laboratory testing see https://www.cdc.gov/mmwr/volumes/70/rr/rr7006a1.htm and https://www.cdc.gov/dengue/vaccine/hcp/index.html.

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Announcements

1. AIM and the National Association of School Nurses (NASN) have collaborated on a project for “School-Located Vaccination (SLV) Clinics in the Era of COVID-19.” This has been published in a supplemental issue of the NASN School Nurse journal. (https://bit.ly/SLVSupplement) The issue, which is offered with free digital access for the next year, includes a Letter to the Editor, environmental scan, roundtable report, checklists for school nurses, and a tip sheet for immunization programs.

ACOG offers new resources:

  • ACOG’s first-ever video PSA encouraging all people who are pregnant, thinking about becoming pregnant, and lactating to get vaccinated against COVID-19. This PSA is designed to work on multiple platforms including TV, radio, social media, and websites. You can find the PSA here: acog.org/covidvaccine and on ACOG’s Twitter page: @ACOG
  • COVID-19 Patient Education Video which can be shared on clinician websites and via social media. ACOG hopes that this resource helps to support clinicians and partners in counseling their patients to get vaccinated against COVID-19. Get Your Recommended COVID-19 Vaccine During Pregnancy | ACOG

2. The NAIIS Annual meeting will be split into two segments The NAIIS Flu Day will be virtual this year. The tentative day for the virtual flu session is May 19 from 2:00–4:30 p.m. (ET). The adult vaccination component will hopefully be in person, COVID-19 permitting, in September or October 2022.

3. Immunize​.org has introduced a new patient handout to assist providers with influenza vaccination uptake: Not Sure If You Can Get an Influenza Vaccine? This handout, ideally printed as a two-sided, single page, addresses a variety of concerns (e.g., egg allergy, history of Guillain-Barre syndrome, pregnancy, and a weakened immune system). Immunize.org has also recently introduced How to Administer Multiple Intramuscular Vaccines to Adults During One Visit co-administration handout for healthcare workers.

4. We would welcome having even more NAIIS member organizations to add their support to the Call to Action on adult immunization. Access the call to action and click on the top righthand button to add your organization.

5. If you are not getting NAIIS emails, please add info@izsummitpartners.org (sender: NAIIS) to your list of email contacts to keep receiving the NAIIS emails.

6. There is new zoom login information this year. Please check your emails with the call agendas from NAIIS for the new zoom link and password information.

7. Immunize.org hosted two influenza webinars that can be viewed online:

8. Immunize.org is offering free flu buttons and stickers (in Spanish) and free COVID-19 stickers (in English and Spanish). Click the links to order.

 

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