PNEUMOCOCCAL IMMUNIZATION

Unconjugated 23-valent polysaccharide vaccine ("Pneumovax 23"; "Pnu-Imune 23"):

• In a Finnish cohort of 62 elderly pts who had been given pneumococcal immunization at age 72y on average, all had good antibody levels at 1y but at 3y had fallen almost to baseline levels.
• 691 Swedish immunocompetent men & women aged 50-85yo who had been hosp'd previously for community-acquired pneumonia randomized to pneumococcal vaccine (23-valent) vs. placebo; no sig. diff. in incidence of pneumonia, pneumococcal pneumonia, or death. Summary doesn't mention duration of f/u (Lancet 351:399, 1998--JW)
• Systemic reactions may be more likely in repeat compared with first-time recipients of pneumococcal immunization (JAMA 281:243, 1999--JW)
• In a meta-analysis of 22 randomized studies involving over 100,000 subjects, pneumococcal vaccination in adults was associated with sig. lower incidence of pneumonia (RR 0.73) though when only high-quality trials were analyzed the effect was not significant.  On subgroup analyses of only older subjects or subjects with chronic illness, using data from all trials, there was no sig. benefit. (CMAJ 180:48, 2009-JW)

In children, a 7-valent conjugate vaccine (pneumococcal conjugate vaccine, aka "PCV"; brand name "Prevnar"):

• Covers the 7 serotypes responsible for 80% of pediatric pneumococcal bacteemia in the US
• Unlike the unconjugated vaccine, it's effective in kids < 2yo
• In a randomized double-blind trial in 37,868 infants, RR of invasive pneumococcal disease was 16 in placebo group c/w vaccine group. Only slight decrease in incidence of Otitis Media, though sig. decrease in likelihood of getting ear tubes. Adverse f/x in excess of placebo rate included local reaction (10-20%) and fever higher than 38'C in 15-20% (Ped. Inf. Dis. J. 19:187, 2000--Med. Lett.)
• Recc'd schedule is 2,4,6, and 12-15mos of age. For kids 7-11mos old, 3 doses is OK; 12-23mos old, 2 doses is OK; > 2yo, 1 dose is OK.

PCV is recc'd for:

1. All children < 2yo

• If first dose given < 7mo then Q2mo x 3 and 4th dose at 12-15mos (must be > 8wks after 3d dose). Start at 2mos if possible.
• If first dose given > 7mo and < 12mo, then Q2mo x 2 and 3rd dose at 12-15mos (must be >8wks after 2nd dose).
• If first dose given > 12mo, then Q2mo x 2
• If at high risk for pneumococcal infection (see below), give 1 dose of Pneumovax at 2yo (should be 2mos or more after last dose of Prevnar)
• Minimum interval between doses is 4wks for kids < 1yo

2. Children 24-59mos at high risk for pnuemococcal infection, i.e.:

• Sickle cell disease, Hb SC, HbS-beta thal [282.4; 282.6-282.7]
• Asplenia (functional or anatomic) [No ICD-9-CM code; CPT 38100, 38101, 38102]
• HIV [Per column F of spreadsheet; see below]
• Chronic cardiac disease [Column B EXCEPT 440-440.9; 443-444.9]
• Chronic pulmonary disease EXCEPT ASTHMA [Column A except 493-493.9; ALSO include 277-277.01]
• DM [250-250.9; 357.2; 362.0-.02]
• CSF leak [No ICD-9 code I can find]
• Immunocompromise [per column F of spreadsheet]
• Malignancy ass'd with immunosuppressive therapy or radiation therapy [140-208.9]
• Chronic renal failure or nephrotic syndrome [per column D of spreadsheet; also 581-581.9]
• On immunosuppressive meds including long-term systemic steroids [no way to capture]
• Transplant status [as above for immunosuppression; also 996.8-996.89]

Schedule = 2 doses 2mos apart then 1 dose of 23-valent (Pneumovax) 2 or more mos after 2nd dose (if have received Pneumovax in the past, then just 2 doses 2mos apart of Prevnar)

3. "Consider" vaccination of all kids 24-59mos with priority given to the following (1 dose)

• 24-35mo
• American Indian, Alaska Native, or African-American descent (1 dose)
• Daycare attendance > 4h/wk

(Source: Preventing Pneumococcal Disease Among Infants and Young Children: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR October 06, 2000 / 49(RR09);1-38, at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr4909a1.htm)