pneumococcal polysaccharide vaccine, polyvalent (PneumoVax 23, Pnu-Immune 23, PPSV-23)

Indications

• primary immunization: immunity to pneumococcal lobar pneumonia & bacteremia in individuals >= 2 years of age who are at high risk of morbidity & mortality from pneumococcal infection
  • all persons over 64 years of age
  • persons aged 2-64 with chronic disease, especially:
    • chronic cardiovascular disease, including hypertension
      • congestive heart failure
    • pulmonary disease, including COPD, asthma & smoking
    • renal failure including nephrotic syndrome
    • diabetes mellitus
    • malignancy
    • HIV infection
    • chronic liver disease (including cirrhosis)
    • alcoholism
    • CSF leak
    • cohlear implant
    • immunosuppression or immunodeficiency
  • hyposplenism
    • splenectomy
    • autosplenectomy, i.e. sickle cell disease
  • asbestosis (vaccination at diagnosis & 5 years later)
• revaccination
  • consider if >= 6 years since initial vaccination
    • asplenic patients who have received 14 valent pneumococcal vaccine
  • recommended after 6 years in patients with nephrotic syndrome, renal failure or transplant patients
  • recommended after 3-5 years in children with nephrotic syndrome, asplenia or sickle cell disease
  • 3-4 months after completion of chemotherapy in patients with Hodgkin's disease who were vaccinated during chemotherapy
  • a single revaccination is recommended in adults > 65 years of age >= 6 years since initial vaccination
  • revaccination 5 years after diagnosis & initial vaccination for asbestosis

* antibody levels remain at levels considered protective beyond 5 years in patients with autoimmune rheumatic disease

Contraindications

• active infections
• Hodgkin's disease (within 10 days of chemotherapy or radiation therapy)
• patients < 2 years of age
• pregnancy
• hypersensitivity to pneumococcal vaccine or any component

Caution:

• use with caution in individuals who have had pneumococcal infection within the past 3 years
• may cause relapse in patients with stable idiopathic thrombocytopenic purpura (ITP)
• have epinephrine available
• considered safe if patients on warfarin, if INR is therapeutic
• considered safe in hospitalized patients with mild to moderate illness

pregnancy-category C

safety in lactation ?

Benefit/risk

• number needed to treat to prevent one case of invasive pneumococal pneumonia = 3,333 (range: 1429-12,500)
• NNT to prevent one case of pneumococal pneumonia = 38

Dosage

• adults & children >= 2 years of age: 0.5 mL IM or SC
• adults who have not previously received either vaccine should be given one dose of Prevnar followed by one dose of Pneumovax > 1 year later (CDC)
• CDC's Advisory Committee on Immunization Practices (ACIP) recommends
  • for all adults >= 65 years [19
    • 20-valent (PCV20) pneumococcal conjugate vaccine by itself or
    • 15-valent ( PCV15) vaccine followed by PPSV23 if not already received PPSV23
      • currently PPSV23 + PCV13 as a shared decision process
  • Prevnar-13 prior to this recommended for at risk seniors
    • immunosuppression, CSF leak, or cochlear implant
    • long-term care residemts

Injection:

• 25 ug each of 23 polysaccharide isolates
• 0.5 mL/dose (2.5 mL vials)

Pharmacokinetics

• protective effects seen by the 3rd week after vaccination
• antibody levels remain elevated for at least 5 years after vaccination
• elimination: liver

Adverse effects

• common (> 10%)
  • induration & soreness at the injection site (2-3 days)
• ucommon (< 1%)
  • paresthesias, Guillain-Barre syndrome, low-grade fever, erythema, rash, myalgia, arthralgia, anaphylaxis
• other - headache, photophobia

Drug interactions

• decreased effect with immunosuppressive agents, immune globulin, & other live virus vaccines within 1 month*

* patients with lupus erythematosus or rheumatoid arthritis treated with immunosuppressive agents respond variably to the pneumococcal vaccine

Mechanism of action

• primary immunization with 23 polysaccharide isolates
• reduces macrolide-resistant pneumococcal infections
• reduces mortality of hospitalized elderly
• reduces pneumococcal bacteremia, but not noninvasive pneumococcal pneumonia or bronchitis

Notes

introduced in 1983

More general terms

• pneumococcal vaccine

Additional terms

• pneumococcal congugate vaccine (Prevnar, Prevnar 13, PCV13, Prevnar-20, PCV20, Prevnar-15, PCV15, Vaxneuvance, PHiD-CV10, PCV10, Synflorix)
• Streptococcus pneumoniae (pneumococcus)