Adult Pneumococcal Recommendations in Practice

by Kerry Nolan, Oregon Immunization Program Pharmacy Intern

This is part one of our two part pneumococcal vaccination series. 

Update: This post was edited on 2/5/2015 for clarification.

Situation: A 65 year-old patient has come to our clinic today for a pneumococcal vaccination following her first dose of Pneumovax at age 62.

What vaccination should she receive today? If and when will she need another one? Will it be covered? Since the Advisory Committee on Immunization Practices (ACIP) introduced their latest pneumococcal recommendations for patients 65 and older, both providers and patients have been asking the right questions.

What are the new recommendations?

Adults aged 65 and older should now receive one dose each of Prevnar 13 and Pneumovax 23. Previously, a single dose of Pneumovax 23 alone was recommended for this age group. Although Prevnar 13 has been FDA approved for adults 50 years and over since 2011, it just earned the ACIP recommendation for adults age 65 and up last September. ACIP recommends that adults 19–64 years receive PCV13 if they have an identified health risk.  Healthy individuals age 50–64 may have a dose of Prevnar 13 per FDA approval, however, this dose may not be covered by insurance.  Sounds simple enough, but determining when and who should receive which vaccine gets a bit more complicated. The recommended pneumococcal vaccination schedule separates patients ≥65 years into those who have:
1. Never received any pneumococcal vaccine, and should receive Prevnar 13 first then Pneumovax 23 between 6 to 12 months later
2. Received one (or more) doses of Pneumovax 23, and should receive Prevnar 13 at least one year after their last Pneumovax 23 vaccination
3. Received Pneumovax 23 before turning 65, and should still wait at least one year since their last Pneumovax 23 vaccination to receive Prevnar 13, but must also wait at least 5 years between Pneumovax 23 doses to receive one final dose at ≥65.

In this diagram provided by the ACIP, the latest adult pneumococcal vaccination schedules are summarized:
Pneumococcal vaccine
Image: Sequential administration and recommended intervals for PCV13 and PPSV23 for adults aged ≥65 years — Advisory Committee on Immunization Practices, MMWR 2014

So- which should our patient receive and when? She received a dose of Pneumovax 23 prior to turning 65, which places her in the third category. It has been 3 years since Pneumovax was given, so she should receive Prevnar 13 today. However, when considering the best time for her to return for the final Pneumovax dose, we find that even in 12 months, only a total of four years (not the recommended five) will have passed since her last dose. What should we do? In this situation, the patient should wait the full five years since her Pneumovax dose before receiving the final one. In other words, she will receive Prevnar 13 today and a final Pneumovax 23 dose in about two years.

Will the new vaccine be covered?
On December 31st the Center for Medicaid and Medicare Services (CMS) released a statement announcing that an update to pneumococcal vaccine coverage requirements would be in effect as of September 19, 2014 to align with ACIP recommendations. Effective February 2nd, two pneumococcal vaccines and their administration will be covered under Medicare part B: the first for patients who have never received any pneumococcal vaccine and a second (different) vaccine one year after the first was administered. This coverage is not perfectly aligned with ACIP’s recommendations, but captures where vaccination schedules overlap at the one-year mark. Additionally, Medicare will adjust previously denied claims for qualifying pneumococcal vaccinations administered September 19th or later if the claim is resubmitted. Our patient is more likely to have her second vaccination covered if she is insured privately. As part of the Affordable Care Act, health plans are now required to cover ACIP-recommended vaccines without co-pays or cost-sharing.

As we become comfortable with the nuances of these recommendations, we are better able to provide vaccine protection and education. Tricky timing, different vaccines and varying coverage are each good reasons for giving pneumococcal vaccines in older adults your careful consideration.

References:

1. CDC. Use of 13-Valent Pneumococcal Conjugate Vaccine and 23-Valent Pneumococcal Polysaccharide Vaccine among Adults Aged ≥65 Years: Recommendations of the Advisory Committee on Immunization Practices (ACIP) MMWR 2014; 63 (37); 822-825. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6337a4.htm. Accessed 26 Jul 2015.
2. Centers for Medicare & Medicaid Services (CMS). Modifications to Medicare Part B Coverage of Pneumococcal Vaccinations. MLN Matters 2014; p1-3. Available at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9051.pdf. Accessed 26 Jan 2015.

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