Pneumococcal Vaccines: US CDC Panel Supports Universal Use In Adults Down To Age 50

A US Centers for Disease Control and Prevention advisory committee voted to lower the age-based immunization recommendation for all pneumococcal conjugate vaccines (PCV) from 65 years to 50 years at a 23 October meeting.

By a 14-1 vote, the Advisory Committee on Immunization Practices adopted a working group recommendation to shift from a risk-based to an age-based recommendation for PCV-naïve adults between the ages of 50 and 64 years old.

If adopted by the CDC director, ACIP’s recommendation would put Merck’s recently approved Capvaxive (pneumococcal 21-valent conjugate vaccine, PCV21) and Pfizer’s market-leading Prevnar 20 (PCV20) on equal footing from a policy perspective when it comes to the population recommended to receive PCV. Representatives from both companies spoke in favor of the age-based change.

Separately, ACIP unanimously voted to recommend a second dose of the 2024-2025 COVID-19 vaccine for individuals who are ≥65 years and younger people who are moderately or severely immunocompromised.

PCV: Shifting From Risk-Based To Age-Based

Adults currently recommended to receive a dose of PCV are:

• Individuals ≥65 years who have not received a PCV
• Individuals ages 19-64 with certain underlying conditions or risk factors who have not received a PCV
• Certain adults who have received PCV13 (Prevnar 13) but have not received PCV20.

In June, just days after Capvaxive’s approval, ACIP postponed a vote on recommending Merck’s vaccine for all adults ages 50-64. Instead, the committee recommended PCV21 for adults age 19 and older who currently are recommended to receive a pneumococcal vaccine. This meant that in people younger than age 65, it could only be used for those at increased risk of pneumococcal disease.

The committee requested data on whether an age-based recommendation for pneumococcal vaccines should be lowered to age 50 for all PCVs, not just the Merck product.

Ultimately, the majority of working group members supported a recommendation to lower the age-based recommendation for all PCVs to age ≥50 years, even though a future booster dose may be needed after approximately 15 years to avoid increased pneumococcal disease burden in older adults.

ACIP member and working group chair Jamie Loehr, owner of Cayuga Family Medicine in Ithaca, NY, said several factors were key to the group’s recommendation. These included:

• Health equity: Black/African American adults have higher pneumococcal disease rates, peaking at a younger age.
• Risk prevalence: 33%-54% of adults ages 50-64 years already have an indication for risk-based vaccination.
• Vaccine coverage: An age-based recommendation is likely to improve uptake relative to a risk-based recommendation.
• Simplicity: A uniform recommendation across all PCVs is easier to implement.
• Economic considerations: PCV21 vaccination at 50 and 65 years had lower cost per quality-adjusted life year gained than PCV20, with both improving health outcomes.
• Serotype coverage: The compositions of PCV20 and PCV21 are quite different.

The working group did not make a recommendation for a booster dose because long-term data on the waning of effect are not yet available.

Booster Dose Required?

Some ACIP members questioned whether lowering the vaccination age to 50 would shift the disease burden to older individuals, assuming there is waning but with no recommendation at this time for a second dose at age 65.

The CDC’s Miwako Kobayashi agreed this is a potential risk if there is no future vaccination coverage. However, it is very unlikely that adults will only have the opportunity to get vaccinated at age 50, she said.

“Probably what will happen is that if the age-based recommendation is lowered, people will have an opportunity to get vaccine starting from age 50 unless they were previously vaccinated under risk, so it’s possible some adults will continue to get vaccinated at age 65.” In addition, the recommendations could change as new higher-valent vaccines reach market, she said.

Even though Loehr chaired the working group, he disagreed with its recommendation and was the lone dissenter on the vote. He supported lowering the age limit to 50 years only for Merck’s PCV21, not for all the vaccines.

A major reason why the working group favored lowering of the age for all PCVs was for implementation purposes, Loehr said.

“They were very, very strongly in favor of simplicity. Make it easy. Make it understandable for working physicians to know what’s going on,” Loehr said.

“Personally, I just think that was a mistake because I think that the cost differential is significant. PCV20 is much more expensive when you go down to age 50 compared to PCV21,” he said. “I think that providers are smart enough to know that they are two different vaccines. I think that PCV21 is a better vaccine. … It covers many, many more serotypes for adults.”

“If we vaccinate at 50 and we have to revaccinate at 65, I take that as a total win,” said ACIP chair Helen Keipp Talbot, professor of medicine at Vanderbilt University. “That means our adults have had a healthy life and they have not passed away before their grandkids.”

Second Dose Of COVID Vaccines Endorsed

In June, ACIP unanimously recommended that everyone age 6 months and older receive an updated 2024-2025 COVID-19 vaccine.

The advisory committee now is recommending a second dose for individuals who are ≥65 years or moderately to severely immunocompromised.

Unlike in previous meetings, the panel did not debate whether an additional dose “should” be recommended for these subgroups, versus whether it “may” be recommended under clinical decision-making. The proposed policy options were framed as a “should” recommendation.

However, the panel unanimously supported a more permissive third recommendation allowing immunocompromised individuals to get three or more doses under shared clinical decision-making.

As of 12 October, only 3.7% of children and 11.7% of adults had received the updated COVID vaccine, according to CDC data. For the 2023-2024 season, only 8.9% of adults ≥65 years and 5.4% of immunocompromised individuals had received at least two doses.

The panel also unanimously voted to include in the Vaccines for Children program use of high-dose and adjuvanted influenza vaccine for solid organ transplant recipients ages 18-64. ACIP had supported this use at its June meeting but needed a formal VFC vote because 18 year-olds are covered under the program.