II. Indications

  1. Pediatric Vaccine
    1. Primary Immunization series for young children
      1. Four Dose Protocol: ages 2, 4, 6 and 12-15 months
      2. Catchup for healthy children with incomplete series: 1 dose at age 24 to 59 months
    2. Also give Pneumovax 23 to high risk children >2 years old
      1. Administer Prevnar 13 at least 8 weeks before Pneumovax 23
      2. See Pneumovax 23 for indications in children
  2. Adult Vaccine under age 65 years
    1. Immunocompromised patients (e.g. HIV, Chemotherapy, Asplenia) or comorbidities (e.g. Tobacco, diabetes)
      1. Covered by Medicare Part B as of 2012 (CPT 90670)
      2. GIve Prevnar 20 alone (or Vaxneuvance AND Pneumovax 23)
        1. Prevnar 20 is sufficient alone, and does not require Pneumovax
      3. Should also be given two Pneumovax 23Vaccines five years apart
      4. Prevnar 20 recommended for Immunocompromised patients as of 2022
        1. Offers better Immunity in high risk patients
    2. Timing with Pneumovax 23 (not required if Prevnar 20 used)
      1. No prior Pneumovax
        1. Give Prevnar 13 or Vaxneuvance at least 8 weeks before Pneumovax 23
      2. Prior Pneumovax
        1. Give Prevnar 13 or Vaxneuvance at least one year after Pneumovax 23
    3. References
  3. Older adults after age 65 years
    1. Prevnar 20 alone is sufficient coverage without need for Pneumovax
      1. Prevnar 13 or Vaxneuvance should be used with Pneumovax 23
      2. CDC modified Prevnar 20 recommendations for healthy seniors in 2019 and again in 2022
      3. NNT 2600 Prevnar 13 vaccinated healthy seniors to prevent one case of Pneumonia
        1. Prevnar 13 Vaccine in children as Primary Series has protected seniors via Herd Immunity
    2. No prior Pneumovax 23
      1. Prevnar 13 or Vaxneuvance after age 65 year birthday AND
      2. Pneumovax 23 at 6-12 months after Prevnar dose
    3. Prior Pneumovax 23 after age 65 year birthday
      1. Prevnar 13 or Vaxneuvance after age 65 year birthday
      2. No further Pneumovax 23 needed
    4. Prior Pneumovax 23 before age 65 year birthday
      1. Prevnar 13 or Vaxneuvance after age 65 year birthday AND
      2. Pneumovax 23 at 6-12 months after Prevnar dose AND 5 years after prior Pneumovax 23
  4. References
    1. (2012) Presc Lett 19(12): 69
    2. (2014) Presc Lett 21(11): 63-64
    3. (2019) Presc Lett 26(9): 49
    4. (2022) Presc Lett 29(3): 13

III. Pharmacology

  1. Prevnar 20
    1. Expands on Prevnar 13 to contain 7 additional serotypes for a total of 20
    2. Preferred Vaccine, and may be used alone without Pneumovax
    3. Available for use in adults, and expected approval for children in 2023
  2. Vaxneuvance
    1. Contains 15 serotypes (misses 15% of invasive pneumococcal disease covered by Prevnar 20)
    2. Available for use in adults and expected approval for children in 2022
    3. If used in place of Prevnar 20, then also give Pneumovax 23 (at appropriate interval)
  3. Prevnar 13
    1. Contains 13 serotypes
      1. Replaces the Prevnar-7 and includes the prior serotypes and 6 new ones
    2. Prior seven valent Vaccine covered serotypes most affecting children
      1. Serotypes: 4, 6B, 9V, 14, 18C, 19F, 23F
      2. These serotypes are responsible for >80% of Meningitis and bacteremia in age <6 years
  4. Components
    1. Pneumococcal Polysaccharide conjugated to non-toxic Diphtheria toxin
    2. Conjugated Vaccines generate longer lasting, better Immunity than PolysaccharideVaccines
      1. Increased memory cell production
  5. Differs from the adult Vaccine (Pnu-Imune 23)
    1. Prevnar is more immunogenic
    2. Prevnar does not contain Thimerosal

IV. Efficacy: Importance of Vaccine

  1. Infections caused by Streptococcus Pneumoniae (age <6)
    1. Community Acquired Pneumonia (leading cause)
    2. Otitis Media (leading cause)
    3. Bacterial Meningitis (leading cause)
    4. Streptococcus bacteremia
  2. Antibiotic Resistance is growing
    1. Penicillin Resistant Pneumococcus now 24% of isolates

V. Efficacy: Highly effective

  1. Prevents 94-97% invasive disease by immunized serotypes
  2. Decreases Acute Otitis Media episodes in infants
  3. Significant reduction in pneumococcal Meningitis since Vaccine introduction (esp. <2 years old)
    1. Hsu (2009) N Engl J Med 360(3): 244-56 [PubMed]

VI. Adverse Effects

  1. No serious adverse effects
  2. Fever to 38 F
  3. Febrile Seizure (esp. when combined with Influenza Vaccine)
  4. Local inflammation at injection site

VII. Dosing: Regular Schedule started in infancy

  1. Four doses: 2, 4, 6 and 12 to 15 months

VIII. Dosing: Catch up dosing based on age at first dose

  1. Age 2 to 6 months
    1. Primary Series: 3 doses, two months apart
    2. Booster: 12 to 15 months
  2. Age 7 to 11 months
    1. Primary Series: 2 doses, two months apart
    2. Booster: 12 to 15 months
  3. Age 12 to 23 months
    1. Primary Series: 2 doses, two months apart
  4. Age 24 to 59 months in healthy child
    1. Primary Series incomplete: one dose
  5. Age 24 to 59 months in child with chronic illness
    1. Indicated conditions
      1. Sickle Cell Anemia
      2. Asplenic patient
      3. HIV Infection
      4. Other chronic illness
      5. Immunocompromising condition
    2. Primary Series incomplete: two doses, two months apart
  6. Age 5 years and older
    1. Catch-Up Vaccination not recommended

IX. Dosing: Comorbid Conditions

  1. Schedules vary by underlying conditions (see CDC guidelines)
    1. https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html#note-pneumo

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