Pneumococcal Vaccine

Class: Vaccines
ATC Class: J07A1
VA Class: IM100
Brands: Pneumovax 23, Prevnar 13

Introduction

Inactivated (polysaccharide) vaccine.^{105 129 134 181} Commercially available in US as pneumococcal 13-valent conjugate vaccine (diphtheria CRM₁₉₇ protein) (PCV13; Prevnar 13)¹⁸¹ and pneumococcal vaccine, polyvalent (pneumococcal 23-valent vaccine; PPSV23; Pneumovax 23).¹²⁹ Both vaccines contain capsular antigens extracted from Streptococcus pneumoniae and are used to stimulate active immunity to pneumococcal infection.^{105 129 134 181} Various other pneumococcal vaccines are being investigated or may be available in other countries.¹⁸⁸

Uses for Pneumococcal Vaccine

Prevention of Pneumococcal Disease

PCV13 (Prevnar 13): Prevention of invasive disease (e.g., pneumonia, meningitis, bacteremia) caused by Streptococcus pneumoniae in infants 6 weeks through 23 months of age, healthy children 2 through 5 years of age, children and adolescents 6 through 18 years of age at increased risk for pneumococcal disease, adults ≥19 years of age at increased risk for pneumococcal disease†, and adults ≥65 years of age.^{100 181 184 199 200 202 203 204 205 206} Provides protection only against the 13 S. pneumoniae serotypes represented in the vaccine (i.e., 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, 23F).¹⁸¹

PPSV23 (Pneumovax 23): Prevention of invasive disease (e.g., pneumonia, meningitis, bacteremia) caused by S. pneumoniae in children 2 through 18 years of age at increased risk for pneumococcal disease, adults ≥19 years of age at increased risk for pneumococcal disease, and adults ≥65 years of age.^{100 129 169 184 202 203 204 205 206} Provides protection only against the 23 S. pneumoniae serotypes represented in the vaccine (i.e., 1, 2, 3, 4, 5, 6B, 7F, 8, 9N, 9V, 10A, 11A, 12F, 14, 15B, 17F, 18C, 19F, 19A, 20, 22F, 23F, 33F).¹²⁹

S. pneumoniae is a major cause of serious or invasive illness and death worldwide.^{100 105 166 169 184} In the US, pneumococcal pneumonia results in an estimated 175,000 hospitalizations each year (case fatality rate 5–7%); there are >50,000 cases of pneumococcal bacteremia (case fatality rate about 20%) and 3000–6000 cases of pneumococcal meningitis (case fatality rate about 30%) reported annually.¹⁶⁶ Case fatality rates are higher in the elderly (60–80% for pneumococcal bacteremia or meningitis in this age group).¹⁶⁶ In children <5 years of age, S. pneumoniae has been a leading cause of bacterial meningitis.¹⁶⁶

Epidemiology of pneumococcal disease in the US changed substantially after routine infant and childhood vaccination against the disease was initiated in 2000.^{100 184} Overall incidence of invasive pneumococcal disease in children <5 years of age decreased from approximately 99 cases/100,000 population in 1998–1999 to 21 cases/100,000 population in 2008.¹⁸⁴ Routine infant and childhood vaccination against pneumococcal disease also reduced incidence of invasive pneumococcal disease among unvaccinated individuals of all ages.¹⁸⁴ Data from 1998–1999 and 2008 indicate that overall rates of invasive pneumococcal disease in individuals 18–49, 50–64, and ≥65 years of age decreased 34, 14, and 37%, respectively.¹⁸⁴

PCV13 (Prevnar 13) is the pneumococcal vaccine recommended by the USPHS Advisory Committee on Immunization Practices (ACIP), AAP, and others for routine primary and catch-up vaccination in all infants 2 through 23 months of age and healthy children 2 through 5 years of age.^{100 184 199} Vaccine antigens in PCV13 (Prevnar 13) are conjugated to a T-cell dependent carrier protein (diphtheria CRM₁₉₇ protein) and are more immunogenic in infants and young children than the unconjugated antigens contained in PPSV23 (Pneumovax 23).^{100 184}

PPSV23 (Pneumovax 23) contains 11 additional antigens not contained in PCV13 (Prevnar 13) and PCV13 contains one antigen not found in PPSV23; use of both vaccines provides benefits in terms of immunity against a broader range of serotypes.^{202 203 205} Therefore, ACIP, AAP, and others recommend vaccination with PCV13 (Prevnar 13) and PPSV23 (Pneumovax 23) in children ≥2 years of age, adolescents, and adults ≥19 years of age with certain medical conditions that put them at increased risk for pneumococcal disease.^{100 155 156 184 199 200 202 203 205 206} Vaccination with PCV13 (Prevnar 13) and PPSV23 (Pneumovax 23) also is recommended in all adults ≥65 years of age or older.^{200 204} (See Vaccination Against Pneumococcal Disease in Groups At Risk under Uses.)

When both PCV13 (Prevnar 13) and PPSV23 (Pneumovax 23) are indicated, give the vaccines sequentially; do not give concurrently.^{100 184 199 200 202 203 204 205} If possible, give all required doses of PCV13 (Prevnar 13) before PPSV23 (Pneumovax 23).^{100 184 199 200 202 203 204 205} (See Dosage and Administration.)

Pneumococcal 7-valent conjugate vaccine (PCV7; Prevnar) was available in the US from 2000 until 2010^{148 184 185} when it was replaced by PCV13 (Prevnar 13).^{100 184 185} Since PCV13 (Prevnar 13) contains 6 additional antigens not contained in PCV7 (Prevnar), individuals who previously received age-appropriate vaccination or incomplete vaccination with PCV7 (Prevnar) should receive PCV13 (Prevnar 13).^{100 184 199 203 205}

Vaccination Against Pneumococcal Disease in Groups at Risk

Vaccination against pneumococcal disease is recommended in infants, children, adolescents, and adults at risk of exposure to S. pneumoniae or at risk of developing invasive pneumococcal disease if they become infected with S. pneumoniae.^{100 105 169 184 199 200 202 203 204 205}

Infants 2 through 23 months of age are at increased risk for invasive pneumococcal disease and should be vaccinated against the disease with the appropriate number of doses of PCV13 (Prevnar 13).^{100 105 184} PPSV23 (Pneumovax 23) is not recommended in these infants.¹²⁹

ACIP, AAP, and others recommend routine primary and catch-up vaccination against pneumococcal infection in all previously unvaccinated or incompletely vaccinated infants 2 through 23 months of age using the age-appropriate number of doses of PCV13 (Prevnar 13).^{100 184 199}

Infants 14 through 23 months of age who received age-appropriate vaccination with the previously available 7-valent vaccine (PCV7; Prevnar) should receive a single supplemental dose of PCV13 (Prevnar 13) since this may provide additional protection.^{100 184 199}

Healthy children 2 through 5 years of age who have not been vaccinated or are incompletely vaccinated against pneumococcal disease should receive catch-up vaccination with a single dose of PCV13 (Prevnar 13).^{100 184 199} PPSV23 (Pneumovax 23) is not recommended in healthy children 2 through 5 years of age who do not have medical conditions that put them at increased risk for pneumococcal disease.^{100 184 199}

Children 2 through 5 years of age who received age-appropriate vaccination with the previously available 7-valent vaccine (PCV7; Prevnar) should receive a single supplemental dose of PCV13 (Prevnar 13) since this may provide additional protection.^{100 184 199}

Children 2 through 5 years of age at increased risk for pneumococcal disease because of certain medical conditions should be vaccinated against the disease with a sequential regimen of both PCV13 (Prevnar 13) and PPSV23 (Pneumovax 23).^{100 184 199}

Children 2 through 5 years of age with functional or anatomic asplenia (including sickle cell disease or other hemoglobinopathies, congenital or acquired asplenia), immunocompromising medical conditions (congenital or acquired immunodeficiency, HIV infection, chronic renal failure, nephrotic syndrome, malignant neoplasms, leukemia, lymphoma, Hodgkin's disease, solid organ transplantation), or certain other medical conditions (chronic heart disease [especially cyanotic congenital heart disease and cardiac failure], chronic lung disease [including asthma if treated with high-dose oral corticosteroid therapy], diabetes mellitus, CSF leaks, cochlear implants) are considered at increased risk for pneumococcal disease.^{100 184 199}

ACIP, AAP, and others recommend that unvaccinated or incompletely vaccinated children 2 through 5 years of age with these medical conditions should receive catch-up vaccination using an age-appropriate regimen of PCV13 (Prevnar 13) followed by a dose of PPSV23 (Pneumovax 23).^{100 184 199}

Children and adolescents 6 through 18 years of age at increased risk for pneumococcal disease because of certain medical conditions should be vaccinated against the disease.^{100 184 199 203 205}

ACIP, AAP, and others recommend sequential vaccination with both PCV13 (Prevnar 13) and PPSV23 (Pneumovax 23) in children and adolescents 6 through 18 years of age with functional or anatomic asplenia (including sickle cell disease or other hemoglobinopathies, congenital or acquired asplenia), immunocompromising medical conditions (congenital or acquired immunodeficiency, HIV infection, chronic renal failure, nephrotic syndrome, malignant neoplasms, leukemia, lymphoma, Hodgkin's disease, generalized malignancy, solid organ transplantation, multiple myeloma), or certain other medical conditions (CSF leaks, cochlear implants).^{184 199 203 205}

These experts usually recommend vaccination with PPSV23 (Pneumovax 23) alone in children and adolescents 6 through 18 years of age with chronic heart disease (especially cyanotic congenital heart disease and cardiac failure), chronic lung disease (including asthma if treated with prolonged high-dose oral corticosteroids), diabetes mellitus, alcoholism, or chronic liver disease and in those who smoke cigarettes.^{184 199 203} However, AAP states that sequential vaccination with both PCV13 (Prevnar 13) and PPSV23 (Pneumovax 23) can be considered in those with chronic heart disease (especially cyanotic congenital heart disease and cardiac failure), chronic lung disease (including asthma if treated with prolonged high-dose oral corticosteroids), and diabetes mellitus.²⁰⁵

ACIP, AAP, and other experts do not recommend routine use of PCV13 (Prevnar 13) and/or PPSV23 (Pneumovax 23) in healthy children and adolescents 6 through 18 years of age who do not have medical conditions that put them at increased risk for pneumococcal disease.^{100 184 199}

Children and adolescents 6 through 18 years of age at increased risk for pneumococcal disease because of medical conditions who received age-appropriate vaccination with the previously available 7-valent vaccine (PCV7; Prevnar) should receive a single supplemental dose of PCV13 (Prevnar 13) since this may provide additional protection.²⁰³

When PPSV23 (Pneumovax 23) is indicated in children and adolescents 6 through 18 years of age at increased risk for pneumococcal disease because of medical conditions, a dose of the vaccine should be given to those who have not previously received a dose.^{184 199 203 205} In addition, ACIP, AAP, and others recommend that children and adolescents with functional or anatomic asplenia and those with immunocompromising conditions receive revaccination with a second dose of PPSV23 (Pneumovax 23) 5 years after the first dose.^{199 203 205} A second dose of PPSV23 (Pneumovax 23) is not considered necessary in immunocompetent individuals who have chronic heart disease, chronic lung disease, diabetes mellitus, CSF leaks, cochlear implants, alcoholism, or chronic liver disease or smoke cigarettes.^{199 203 205}

Adults ≥19 years of age at increased risk for pneumococcal disease because of certain medical conditions should be vaccinated against the disease.^{200 202}

ACIP and others recommend sequential vaccination with both PCV13 (Prevnar 13) and PPSV23 (Pneumovax 23) in adults ≥19 years of age with functional or anatomic asplenia (including sickle cell disease or other hemoglobinopathies, congenital or acquired asplenia, splenic dysfunction, splenectomy), immunocompromising medical conditions (congenital or acquired immunodeficiency, HIV infection, chronic renal failure, nephrotic syndrome, leukemia, lymphoma, Hodgkin's disease, generalized malignancy, solid organ transplantation, multiple myeloma), iatrogenic immunosuppression (including long-term systemic corticosteroid therapy or radiation therapy), or certain other medical conditions (CSF leaks, cochlear implants).^{200 202 206}

These experts usually recommend vaccination with PPSV23 (Pneumovax 23) alone in adults ≥19 years of age with chronic heart disease (including congestive heart failure and cardiomyopathies [excluding hypertension]), chronic lung disease (COPD, emphysema, asthma), diabetes mellitus, alcoholism, chronic liver disease, or cirrhosis and in those who smoke cigarettes.^{169 200 202}

When PCV13 (Prevnar 13) is indicated in adults ≥19 years of age at increased risk for pneumococcal disease because of medical conditions, a single dose of the vaccine should be given.²⁰³

When PPSV23 (Pneumovax 23) is indicated in adults ≥19 years of age at increased risk for pneumococcal disease because of medical conditions, a dose of the vaccine should be given to those who have not previously received a dose.^{169 200 202} In addition, ACIP and others recommend that those with functional or anatomic asplenia and those with immunocompromising conditions receive revaccination with a second dose of PPSV23 (Pneumovax 23) 5 years after the first dose.^{169 200 202} A second dose of PPSV23 (Pneumovax 23) is not considered necessary in immunocompetent individuals who have chronic heart disease, chronic lung disease, diabetes mellitus, CSF leaks, cochlear implants, alcoholism, or chronic liver disease or smoke cigarettes.^{169 200 202}

Healthy adults 50 through 64 years of age. Although PCV13 (Prevnar 13) and PPSV23 (Pneumovax 23) are labeled by FDA for prevention of pneumonia and invasive pneumococcal disease in adults as young as 50 years of age,¹⁸¹ ACIP and others do not recommend routine pneumococcal vaccination in healthy adults 50 through 64 years of age who do not have medical conditions that increase the risk for pneumococcal disease.^{200 201 204}

Adults ≥65 years of age, including immunocompetent adults, are at increased risk for pneumococcal infection and should be vaccinated against the disease with a sequential regimen of PCV13 (Prevnar 13) and PPSV23 (Pneumovax 23).^{200 204}

ACIP and other experts recommend that all adults ≥65 years of age who are unvaccinated or have unknown vaccination status should receive a dose of PCV13 (Prevnar 13) followed by a dose of PPSV23 (Pneumovax 23) 6–12 months later.^{200 204}

Adults ≥65 years of age who have not received PCV13 (Prevnar 13) but previously received PPSV23 (Pneumovax 23) at <65 years of age should receive a dose of PCV13 (Prevnar 13) at least 1 year after the most recent dose of PPSV23 (Pneumovax 23).^{200 204} These individuals should then be revaccinated with a dose of PPSV23 (Pneumovax 23) 6–12 months after the PCV13 (Prevnar 13) dose and at least 5 years after the previous PPSV23 (Pneumovax 23) dose.^{200 204}

Adults ≥65 years of age who have not received PCV13 (Prevnar 13) but previously received PPSV23 (Pneumovax 23) at ≥65 years of age should receive a dose of PCV13 (Prevnar 13) at least 1 year after the most recent PPSV23 (Pneumovax 23) dose.^{200 204} No additional doses of PPSV23 (Pneumovax 23) recommended.^{200 204}

Adults ≥65 years of age who previously received PCV13 (Prevnar 13) at <65 years of age but have not received PPSV23 (Pneumovax 23) should receive a dose of PPSV23 (Pneumovax 23) 6–12 months after the PCV13 (Prevnar 13) dose.²⁰⁰

Adults ≥65 years of age who previously received PCV13 (Prevnar 13) and PPSV23 (Pneumovax 23) at <65 years of age should be revaccinated with a dose of PPSV23 (Pneumovax 23) 6–12 months after the PCV13 (Prevnar 13) dose and at least 5 years after the previous PPSV23 (Pneumovax 23) dose.²⁰⁰

HIV-infected individuals are at increased risk for pneumococcal disease and should be vaccinated against the disease.^{100 155 156 166 169 184 199 200 202 203 205}

ACIP, AAP, CDC, National Institutes of Health (NIH), IDSA, Pediatric Infectious Diseases Society, and others recommend vaccination using an age-appropriate regimen of PCV13 (Prevnar 13) in all HIV-infected infants 2 through 23 months of age and an age-appropriate sequential regimen of PCV13 (Prevnar 13) and PPSV23 (Pneumovax 23) in all HIV-infected adults, adolescents, and children ≥2 years of age as soon as possible after diagnosis.^{100 155 156 184 199 200 203 205}

PCV13 (Prevnar 13) can be used in HIV-infected adults and adolescents regardless of CD4⁺ T-cell count.^{155 200 202} Although ACIP and other experts state that PPSV23 (Pneumovax 23) also can be used in HIV-infected adults regardless of CD4⁺ T-cell count,²⁰⁰ some experts state that it may be preferable to defer administration of PPSV23 (Pneumovax 23) in HIV-infected adults and adolescents until CD4⁺ T-cell counts increase to >200 cells/mm³ in response to antiretroviral therapy.¹⁵⁵

Revaccination with PPSV23 (Pneumovax 23) at least 5 years after the initial dose is recommended in HIV-infected individuals.^{105 155 156 169 184 202 203 205} Some experts recommend a third dose of PPSV23 (Pneumovax 23) in HIV-infected individuals at ≥65 years of age, as long as 5 years have elapsed since the previous dose.¹⁵⁵ No more than 3 lifetime doses of PPSV23 (Pneumovax 23) are recommended.¹⁵⁵

Cochlear implant recipients are at substantially increased risk for pneumococcal meningitis and should be vaccinated against the disease.^{100 184 199 200 202 203 205} Incidence of bacterial meningitis, particularly pneumococcal meningitis, is higher among children with cochlear implants than children in the general population,^{154 161 189} and S. pneumoniae is the most common pathogen causing bacterial meningitis in cochlear implant recipients of all ages with meningitis of known etiology.¹⁸⁹

AAP, ACIP, CDC, and others recommend vaccination with an age-appropriate sequential regimen of PCV13 (Prevnar 13) and PPSV23 (Pneumovax 23) in all individuals ≥2 years of age who have or are scheduled to receive a cochlear implant.^{100 110 184 189} Vaccination should be completed at least 2 weeks prior to placement of cochlear implant.^{184 189}

Cigarette smokers are at substantially increased risk for invasive pneumococcal disease.¹⁶⁹ ACIP and others recommend that unvaccinated individuals who smoke cigarettes should receive a dose of PPSV23 (Pneumovax 23) and smoking cessation counseling.^{169 200 202 203}

Internationally adopted infants and children whose immune status is uncertain should be vaccinated against pneumococcal disease according to the US recommended childhood and adolescent immunization schedules.¹³⁴ These children should receive pneumococcal vaccine as age-appropriate and as indicated by the presence of underlying medical conditions that increase the risk for pneumococcal disease.¹³⁴ Although pneumococcal vaccine is recommended in many countries, consider that the vaccine may not be routinely administered.¹³⁴

Travelers at highest risk for pneumococcal disease include young children, the elderly, and individuals of any age with chronic medical conditions or immunosuppression.¹⁷¹ Although pneumococcal disease occurs worldwide, CDC makes no specific recommendations regarding pneumococcal vaccination in travelers.¹⁷¹

Prevention of Pneumococcal Acute Otitis Media (AOM)

PCV13 (Prevnar 13) is labeled by FDA for prevention of AOM caused by S. pneumoniae serotypes 4, 6B, 9V, 14, 18C, 19F, and 23F in infants and children 6 weeks through 5 years of age.¹⁸¹ This indication is based on efficacy studies that evaluated use of the previously available 7-valent vaccine (PCV7; Prevnar);¹⁸¹ efficacy data not available regarding use of PCV13 (Prevnar 13) for prevention of AOM caused by the other S. pneumoniae serotypes represented in the vaccine (i.e., 1, 3, 5, 6A, 7F, 19A).¹⁸¹

Pneumococcal Vaccine Dosage and Administration

Administration

PCV13 (Prevnar 13): Administer only by IM injection.¹⁸¹

PPSV23 (Pneumovax 23): Administer only by IM or sub-Q injection.¹²⁹

Do not dilute;^{129 181} do not mix with any other vaccine or solution.^{129 181}

Do not administer PCV13 (Prevnar 13) concomitantly with PPSV23 (Pneumovax 23).^{100 184} When both vaccines indicated, administer PPSV23 (Pneumovax 23) sequentially after the recommended age-appropriate regimen of PCV13 (Prevnar 13), if possible.^{100 184 199 200 202 203 204 205}

PCV13 (Prevnar 13) or PPSV23 (Pneumovax 23) may be given simultaneously with other age-appropriate vaccines during the same health-care visit .^{105 134 184} (See Interactions.) When multiple parenteral vaccines are administered during a single health-care visit, each vaccine should be given with a different syringe and at different injection sites;^{105 134} separate injection sites by at least 1 inch (if anatomically feasible) to allow appropriate attribution of any local adverse effects that may occur.¹³⁴

Syncope (vasovagal or vasodepressor reaction; fainting) may occur following vaccination;¹³⁴ such reactions occur most frequently in adolescents and young adults.¹³⁴ Syncope and secondary injuries may be averted if vaccinees sit or lie down during and for 15 minutes after vaccination.¹³⁴ If syncope occurs, observe patient until symptoms resolve.¹³⁴

IM Administration

Depending on patient age, administer IM into deltoid muscle or anterolateral thigh.¹³⁴ In infants and children 6 weeks to 2 years of age, anterolateral thigh is preferred; ¹³⁴ alternatively, deltoid muscle can be used in those 1 through 2 years of age if muscle mass is adequate.¹³⁴ In adults, adolescents, and children ≥3 years of age, deltoid muscle is preferred.¹³⁴

To ensure delivery into muscle, make IM injections at a 90° angle to the skin using a needle length appropriate for individual’s age and body mass, thickness of adipose tissue and muscle at injection site, and injection technique.¹³⁴

Avoid injection into gluteal area or into or near blood vessels or nerves.¹³⁴ Generally do not administer vaccines into gluteal area or any area where there may be a major nerve trunk.¹³⁴ If the gluteal muscle is chosen for infants <12 months of age because of special circumstances (e.g., physical obstruction of other sites), it is essential that clinician identify anatomic landmarks prior to injection.¹³⁴

PCV13 (Prevnar 13)

Administer only by IM injection.¹⁸¹ Contains an aluminum adjuvant;^{134 181} do not administer sub-Q or intradermally.¹³⁴

Available in single-dose prefilled syringes.¹⁸¹ After attaching sterile needle to prefilled syringe, administer entire contents IM.¹⁸¹

Shake vigorously immediately prior to administration to provide a uniform, white suspension.¹⁸¹ Discard vaccine if it contains particulates, appears discolored, or cannot be resuspended with thorough agitation. ¹⁸¹

PPSV23 (Pneumovax 23)

Administer by IM injection; alternatively, administer by sub-Q injection.¹²⁹ (See Sub-Q Administration under Dosage and Administration.) Do not administer IV or intradermally.¹²⁹

Available in single-dose prefilled syringes and in single- or multiple-dose vials.¹²⁹ If single-dose prefilled syringe used, attach sterile needle according to manufacturer's instructions and administer entire contents IM.¹²⁹ If single- or multiple-dose vial used, withdraw 0.5 mL of vaccine from vial using sterile needle and syringe free of preservatives, antiseptics, and detergents and administer IM.¹²⁹

Should be a clear colorless solution;¹²⁹ discard vaccine if it contains particulates or appears discolored.¹²⁹

Sub-Q Administration

Make sub-Q injections into upper-outer triceps area or anterolateral thigh.^{129 134} In adults, adolescents, and children ≥2 years of age, upper-outer triceps area preferred.¹³⁴

To ensure appropriate delivery, administer sub-Q injections at a 45° angle using a 5/8 inch, 23- to 25-gauge needle.¹³⁴

PPSV23 (Pneumovax 23)

Administer by sub-Q injection; alternatively, administer by IM injection.¹²⁹ (See IM Administration under Dosage and Administration.) Do not administer IV or intradermally.¹²⁹

Available in single-dose prefilled syringes and in single- or multiple-dose vials.¹²⁹ If single-dose prefilled syringe used, attach sterile needle according to manufacturer's instructions and administer entire contents sub-Q.¹²⁹ If single- or multiple-dose vial used, withdraw 0.5 mL of vaccine from vial using sterile needle and syringe free of preservatives, antiseptics, and detergents and administer sub-Q.¹²⁹

Should be a clear colorless solution;¹²⁹ discard vaccine if it contains particulates or appears discolored.¹²⁹

Dosage

Dosage schedule (i.e., number of doses) and specific pneumococcal vaccine administered (PCV13 [Prevnar 13] and/or PPSV23 [Pneumovax 23]) depend on individual’s age, immunization status, and risk factors for pneumococcal disease.^{100 105 129 181 184} Follow age-appropriate recommendations for the specific preparation used.^{129 181}

Medically stable preterm infants (i.e., gestational age <37 weeks), regardless of birthweight, should be vaccinated at usual chronologic age using usual dosage and dosage schedules.¹³⁴

Interruptions resulting in an interval between doses longer than recommended should not interfere with final immunity achieved; there is no need to administer additional doses or start the vaccination series over.¹³⁴

Pediatric Patients

Infants 2 through 23 Months of Age (PCV13 [Prevnar 13])

PCV13 (Prevnar 13)

IM

Each dose is 0.5 mL.¹⁸¹

Routine immunization in early infancy (i.e., initiated before 6 months of age): Give series of 4 doses of PCV13 (Prevnar 13).^{100 181 184 199} ACIP, AAP, and others recommend that doses be given at 2, 4, 6, and 12 through 15 months of age.^{100 181 184 199} Initial dose may be given as early as 6 weeks of age.^{100 181 184 199} Minimum interval between first 3 doses is 4 weeks;^{100 181 184 199} minimum interval between third and fourth dose is 8 weeks.^{100 181 184 199}

Catch-up vaccination in previously unvaccinated infants 7 through 11 months of age: Give 2 doses of PCV13 (Prevnar 13) at least 4 weeks apart followed by a third dose after 12 months of age and at least 8 weeks (2 months) after second dose.^{181 199} A fourth dose is unnecessary in healthy infants unless all previous doses were given at <12 months of age.¹⁹⁹

Catch-up vaccination in previously unvaccinated infants 12 through 23 months of age: Give 2 doses of PCV13 (Prevnar 13) at least 8 weeks (2 months) apart.^{181 199} A third dose is unnecessary if second dose was given at ≥24 months of age.¹⁹⁹

Infants 14 through 23 months of age who previously received age-appropriate vaccination with the previously available 7-valent vaccine (PCV7; Prevnar) but have not received any PCV13 (Prevnar 13) dose: Give a single supplemental dose of PCV13 (Prevnar 13).¹⁹⁹

Healthy Children 2 through 5 Years of Age (PCV13; Prevnar 13)

PCV13 (Prevnar 13)

IM

Single 0.5-mL dose.¹⁸¹

Catch-up vaccination in otherwise healthy children 2 through 5 years of age who are unvaccinated and have not received any doses of PCV13 (Prevnar 13): Give a single dose of PCV13 (Prevnar 13).^{100 181 184 199} Additional doses unnecessary in healthy children if PCV13 (Prevnar 13) dose given at ≥2 years of age.¹⁹⁹

Catch-up vaccination in otherwise healthy children 2 through 5 years of age who are incompletely vaccinated for their age and have not received the total age-appropriate number of doses of PCV13 (Prevnar 13 ) and/or PCV7 (Prevnar): Give a single dose of PCV13 (Prevnar 13) at least 8 weeks after most recent dose of PCV13 (Prevnar 13) or PCV7 (Prevnar).^{181 184 199}

Children 2 through 5 years of age who received age-appropriate vaccination with the previously available 7-valent vaccine (PCV7; Prevnar) but have not received any doses of PCV13 (Prevnar 13 ): Give a single supplemental dose of PCV13 (Prevnar 13).¹⁹⁹

Children 2 through 5 Years of Age at Increased Risk (PCV13; Prevnar 13 and PPSV23; Pneumovax 23)

PCV13 (Prevnar 13)

IM

Each dose is 0.5 mL.¹⁸¹

Previously received <3 doses of PCV13 (Prevnar 13) or <3 doses of previously available 7-valent vaccine (PCV7; Prevnar): Give 2 doses of PCV13 (Prevnar 13) at least 8 weeks apart.^{100 129 184 199}

Previously received a total of 3 doses of PCV given as PCV13 (Prevnar 13) and/or PCV7 (Prevnar) or received 4 doses or other age-appropriate vaccination series of PCV7 (Prevnar): Give a single dose of PCV13 (Prevnar 13).^{100 184 199}

PPSV23 (Pneumovax 23)

IM or Sub-Q

Single 0.5-mL dose.¹²⁹

Has not previously received PPSV23 (Pneumovax 23): Give a single dose of PPSV23 (Pneumovax 23).^{100 129 184 199}

Sequential Administration

IM or Sub-Q

Has not previously received PCV13 (Prevnar 13) or PPSV23 (Pneumovax 23): Give PCV13 (Prevnar 13) first and give PPSV23 (Pneumovax 23) at least 8 weeks after most recent PCV13 (Prevnar 13) dose.¹⁹⁹

Has not previously received PCV13 (Prevnar 13) but previously received PPSV23 (Pneumovax 23): Give PCV13 (Prevnar 13) at least 8 weeks after most recent PPSV23 (Pneumovax 23) dose.¹⁹⁹

Do not give PCV13 (Prevnar 13) and PPSV23 (Pneumovax 23) concurrently.¹⁹⁹

Children and Adolescents 6 through 18 Years of Age at Increased Risk (PCV13; Prevnar 13 and PPSV23; Pneumovax 23)

PCV13 (Prevnar 13)

IM

Single 0.5-mL dose.¹⁸¹

Has not previously received PCV13 (Prevnar 13): Give a single dose of PCV13 (Prevnar 13).^{199 203 205}

PPSV23 (Pneumovax 23)

IM or Sub-Q

Each dose is 0.5 mL.¹²⁹

Has not previously received PPSV23 (Pneumovax 23): Give a single dose of PPSV23 (Pneumovax 23).^{199 203 205}

Functional or anatomic asplenia or immunocompromising conditions: Revaccinate with a second dose of PPSV23 (Pneumovax 23) 5 years after first PPSV23 (Pneumovax 23) dose and at least 8 weeks after most recent PCV13 (Prevnar 13) dose.^{199 203 205}

HIV-infected: Revaccinate with a second dose of PPSV23 (Pneumovax 23) 5 years after first PPSV23 (Pneumovax 23) dose and at least 8 weeks after PCV13 (Prevnar 13).^{156 199}

Sequential Administration

IM or Sub-Q

Has not previously received PCV13 (Prevnar 13) or PPSV23 (Pneumovax 23): Give PCV13 (Prevnar 13) first and give PPSV23 (Pneumovax 23) at least 8 weeks after most recent PCV13 (Prevnar 13) dose.^{199 203 205}

Has not previously received PCV13 (Prevnar 13) but previously received PPSV23 (Pneumovax 23): Give PCV13 (Prevnar 13) at least 8 weeks after most recent PPSV23 (Pneumovax 23) dose.^{199 203 205}

If second dose of PPSV23 (Pneumovax 23) indicated, give at least 8 weeks after PCV13 (Prevnar 13) and at least 5 years after previous PPSV23 (Pneumovax 23) dose.^{156 199 203 205}

Do not give PCV13 (Prevnar 13) and PPSV23 (Pneumovax 23) concurrently.¹⁹⁹

Adults

Adults ≥19 Years of Age at Increased Risk (PCV13; Prevnar 13 and PPSV23; Pneumovax 23)

PCV13 (Prevnar 13)

IM

Single 0.5-mL dose.¹⁸¹

Has not previously received PCV13 (Prevnar 13): Give a single dose of PCV13 (Prevnar 13).^{200 202}

PPSV23 (Pneumovax 23)

IM or Sub-Q

Each dose is 0.5 mL.¹²⁹

Has not previously received PPSV23 (Pneumovax 23): Give a single dose of PPSV23 (Pneumovax 23).^{200 202}

Functional or anatomic asplenia or immunocompromising conditions: Revaccinate with a second dose of PPSV23 (Pneumovax 23) 5 years after first PPSV23 (Pneumovax 23) dose and at least 8 weeks after PCV13 (Prevnar 13).^{200 202}

HIV-infected adults: Revaccinate with a second dose of PPSV23 (Pneumovax 23) 5 years after first PPSV23 (Pneumovax 23) dose and at least 8 weeks after PCV13 (Prevnar 13).^{155 200 202} Some experts recommend a third dose of PPSV 23 (Pneumovax 23) at ≥65 years of age, provided it has been at least 5 years since previous PPSV23 (Pneumovax 23) dose.¹⁵⁵ No more than 3 lifetime doses of PPSV23 (Pneumovax 23) recommended.¹⁵⁵

Sequential Administration

IM or Sub-Q

Has not previously received PCV13 (Prevnar 13) or PPSV23 (Pneumovax 23): Give PCV13 (Prevnar 13) first and give PPSV23 (Pneumovax 23) at least 8 weeks after most recent PCV13 (Prevnar 13) dose.^{200 202 206}

Has not previously received PCV13 (Prevnar 13) but previously received PPSV23 (Pneumovax 23): Give PCV13 (Prevnar 13) at least 1 year after most recent PPSV23 (Pneumovax 23) dose.^{200 202 206}

Has previously received PCV13 (Prevnar 13) but has not previously received PPSV23 (Pneumovax 23): Give PPSV23 (Pneumovax 23) at least 8 weeks after PCV13 (Prevnar 13).^{200 202 206}

If additional dose of PPSV23 (Pneumovax 23) indicated, give at least 8 weeks after PCV13 (Prevnar 13) and at least 5 years after previous PPSV23 (Pneumovax 23) dose.^{155 200 202}

Do not give PCV13 (Prevnar 13) and PPSV23 (Pneumovax 23) concurrently.^{200 202 206}

Healthy Adults 50 through 64 Years of Age (PCV13; Prevnar 13 and PPSV23; Pneumovax 23)

PCV13 (Prevnar 13)

IM

Single 0.5-mL dose.¹⁸¹

ACIP and other experts do not recommend routine pneumococcal vaccination in healthy adults 50 through 64 years of age who do not have medical conditions that increase risk for pneumococcal disease.^{200 201 204}

PPSV23 (Pneumovax 23)

IM or Sub-Q

Single 0.5-mL dose.¹²⁹

ACIP and other experts do not recommend routine pneumococcal vaccination in healthy adults 50 through 64 years of age who do not have medical conditions that increase risk for pneumococcal disease.^{200 201 204}

Adults ≥65 Years of Age (PCV13; Prevnar 13 and PPSV23; Pneumovax 23)

PCV13 (Prevnar 13)

IM

Single 0.5-mL dose.¹⁸¹

Unvaccinated or unknown vaccination status: Give a single dose of PCV13 (Prevnar 13).^{200 204}

PPSV23 (Pneumovax 23)

IM or Sub-Q

Each dose is 0.5 mL.¹²⁹

Unvaccinated or unknown vaccination status: Give a single dose of PPSV23 (Pneumovax 23).^{169 200 204}

Received a dose of PPSV23 (Pneumovax 23) at <65 years of age for any indication: Revaccinate with another dose of PPSV23 (Pneumovax 23) at 65 years of age, provided it has been at least 5 years since previous dose.^{169 200 204}

Sequential Administration

IM or Sub-Q

Has not previously received PCV13 (Prevnar 13) or PPSV23 (Pneumovax 23) or has unknown vaccination status: Give PCV13 (Prevnar 13) first and give PPSV23 (Pneumovax 23) at least 1 year after PCV13 (Prevnar 13) dose.²⁰⁶

Has not previously received PCV13 (Prevnar 13) but previously received PPSV23 (Pneumovax 23) at <65 years of age: Give PCV13 (Prevnar 13) dose at least 1 year after most recent PPSV23 (Pneumovax 23) dose.^{200 204 206} Then, revaccinate with another dose of PPSV23 (Pneumovax 23) at least 1 year after PCV13 (Prevnar 13) dose and at least 5 years after most recent PPSV23 (Pneumovax 23) dose.²⁰⁶

Has not previously received PCV13 (Prevnar 13) but previously received PPSV23 (Pneumovax 23) at ≥65 years of age: Give PCV13 (Prevnar 13) dose at least 1 year after most recent PPSV23 (Pneumovax 23) dose.^{200 204 206}

Previously received PCV13 (Prevnar 13) at <65 years of age but has not previously received PPSV23 (Pneumovax 23): Give PPSV23 (Pneumovax 23) dose at least 1 year after PCV13 (Prevnar 13) dose.²⁰⁶

Previously received PCV13 (Prevnar 13) and PPSV23 (Pneumovax 23) at <65 years of age: Give another dose of PPSV23 (Pneumovax 23) at least 1 year after PCV13 (Prevnar 13) dose and at least 5 years after most recent PPSV23 (Pneumovax 23) dose.²⁰⁶

Do not give PCV13 (Prevnar 13) and PPSV23 (Pneumovax 23) concurrently.^{200 204 206}

To facilitate completion of pneumococcal vaccination in immunocompetent adults ≥65 years of age, ACIP recommends an interval of at least 1 year between PCV13 (Prevnar 13) and PPSV23 (Pneumovax 23), regardless of which order the vaccines are given.²⁰⁶ If PPSV23 (Pneumovax 23) dose inadvertently given earlier than 1 year after PCV13 (Prevnar 13), the dose does not need to repeated.²⁰⁶ The minimum interval between PCV13 (Prevnar 13) and PPSV23 (Pneumovax 23) is 8 weeks.^{200 204 206}

Special Populations

Hepatic Impairment

No specific dosage recommendations.

Renal Impairment

No specific dosage recommendations.

Geriatric Patients

No specific dosage recommendations.

Cautions for Pneumococcal Vaccine

Contraindications

• PCV13 (Prevnar 13): Severe allergic reaction (e.g., anaphylaxis) to any ingredient in the formulation or any vaccine containing diphtheria toxoid.¹⁸¹

• PPSV23 (Pneumovax 23): Anaphylactic/anaphylactoid or severe allergic reaction to any ingredient in the formulation.¹²⁹

Warnings/Precautions

Sensitivity Reactions

Hypersensitivity Reactions

Allergic reactions, including anaphylactic/anaphylactoid reactions,^{129 181} rash,^{129 181} urticaria,^{129 181} bronchospasm,¹⁸¹ serum sickness,¹²⁹ facial edema,¹⁸¹ erythema multiforme,^{129 181} and angioedema,^{129 181} reported with pneumococcal vaccines.

Take all known precautions to prevent adverse reactions, including review of the patient’s history with respect to health status and possible sensitivity to the vaccine or similar vaccines.¹⁸⁴

Epinephrine and other appropriate agents should be readily available in case anaphylaxis or other serious allergic reaction occurs.¹⁸¹

General Precautions

Individuals with Altered Immunocompetence

May be administered to individuals immunosuppressed as the result of disease or immunosuppressive therapy.^{129 134 181} Consider possibility that immune response to vaccines may be diminished or suboptimal in these individuals.^{129 134 181}

If possible, administer pneumococcal vaccine at least 2 weeks prior to initiation of immunosuppressive therapy or defer until at least 3 months after immunosuppressive therapy is discontinued.¹³⁴ (See Specific Drugs under Interactions.)

Since antibody response may be impaired after splenectomy, ACIP and AAP recommend that vaccination with PCV13 (Prevnar 13) and/or PPSV23 (Pneumovax 23) be completed at least 2 weeks prior to elective splenectomy, if possible.^{105 134 184}

Concomitant Illness

A decision to administer or delay administration of vaccination in an individual with a current or recent acute illness depends on the severity of symptoms and etiology of the illness.^{129 134}

ACIP, AAP, and others state that minor acute illness, such as mild diarrhea or mild upper respiratory infection (with or without fever), usually does not preclude vaccination.^{105 134} However, vaccination of individuals with moderate or severe acute illness (with or without fever) generally should be deferred until they have recovered from the acute phase of the illness.^{105 134}

Manufacturer of PPSV23 (Pneumovax 23) states defer vaccination in individuals with moderate or severe illness.¹²⁹

Manufacturer of PPSV23 (Pneumovax 23) states administer with caution in individuals with severely compromised cardiovascular and/or pulmonary function in whom a systemic reaction could pose a substantial risk.¹²⁹

Limitations of Vaccine Effectiveness

May not protect all vaccine recipients against pneumococcal disease.^{129 181}

Will not prevent pneumococcal infection caused by S. pneumoniae serotypes not represented in the vaccines.^{129 181}

Primary immunization with the usually recommended age-appropriate vaccination regimen before an expected exposure to pneumococcal infection ensures the highest level of protection.^{100 105 184}

May not prevent infection in individuals who do not achieve protective antibody titers;^{129 181} minimum titer of serum anticapsular antibody needed to confer immunity against S. pneumoniae serotypes not established.^{129 181}

Manufacturer of PCV13 (Prevnar 13) states effectiveness of the vaccine administered <5 years after PPSV23 (Pneumovax 23) not known.¹⁸¹

Vaccination with PCV13 (Prevnar 13) and/or PPSV23 (Pneumovax 23) does not replace prophylaxis with penicillin (or other appropriate anti-infectives) for prevention of pneumococcal disease in patients with functional or anatomic asplenia (e.g., sickle cell disease).^{105 129} If such prophylaxis indicated, continue regardless of vaccination status.^{105 129}

Although ACIP and AAP recommend use of PPSV23 (Pneumovax 23) in individuals with CSF leaks,^{202 203} the manufacturer states the vaccine may not be effective in preventing pneumococcal meningitis in patients with chronic CSF leakage resulting from congenital lesions, skull fractures, or neurosurgical procedures.¹²⁹

Antigens in PCV13 (Prevnar 13) are conjugated to a carrier protein;¹⁸¹ conjugated antigens are more immunogenic in infants and young children than the unconjugated antigens in PPSV23 (Pneumovax 23).^{100 134 184} (See Actions.)

Duration of Immunity

Duration of protection after age-appropriate vaccination with PCV13 (Prevnar 13) not known.¹⁸¹ Because the capsular antigens contained in PCV13 (Prevnar 13) are conjugated to a T-cell dependent carrier protein (diphtheria CRM₁₉₇ protein), this may result in improved primary response to the antigens.^{134 166} Revaccination with PCV13 (Prevnar 13) after age-appropriate vaccination not currently recommended.^{166 199 200}

Duration of protection after administration of PPSV23 (Pneumovax 23) not fully determined.^{155 169} Because capsular antigens in PPSV23 (Pneumovax 23) are unconjugated, the vaccine antigens do not induce long-lasting immunity or an anamnestic response after subsequent exposure to the same antigens.^{134 166} Although routine revaccination of immunocompetent individuals who previously received a dose of PPSV23 (Pneumovax 23) not recommended,^{129 166 169} revaccination indicated in individuals with certain medical conditions that put them at increased risk for pneumococcal disease, provided at least 5 years have elapsed since the last dose.^{100 129 155 156 166 169 184 199 200 202 203 205} Revaccination with PPSV23 (Pneumovax 23) also recommended in adults ≥65 years of age who received a dose of the vaccine at a younger age, provided at least 5 years have elapsed since the previous dose.^{169 200 204} (See Dosage under Dosage and Administration.)

Improper Storage and Handling

Improper storage or handling of vaccines may reduce vaccine potency resulting in reduced or inadequate immune responses in vaccinees.¹³⁴

Inspect all vaccines upon delivery and monitor during storage to ensure that the appropriate temperature is maintained.¹³⁴ (See Storage under Stability.)

Do not administer vaccine that has been mishandled or has not been stored at the recommended temperature.¹³⁴ If there are concerns about mishandling, contact the manufacturer or state or local immunization or health departments for guidance on whether the vaccine is usable.¹³⁴

Specific Populations

Pregnancy

PCV13 (Prevnar 13): Category B.¹⁸¹ No evidence of fetal harm or impaired fertility in animal studies using the vaccine at doses 20 times the human dose;¹⁸¹ no adequate and well-controlled studies in pregnant women.¹⁸¹ Use during pregnancy only when clearly needed.¹⁸¹

PPSV23 (Pneumovax 23): Category C.¹²⁹ No animal reproduction studies; not known whether the vaccine can cause fetal harm or affect reproductive capacity.¹²⁹ Use during pregnancy only when clearly needed.¹²⁹

ACIP, AAP, and others state PPSV23 (Pneumovax 23) may be used when indicated in pregnant women at increased risk for pneumococcal disease.^{105 200}

AAP states that pneumococcal vaccination generally should be deferred during pregnancy, but risk of severe pneumococcal disease in a pregnant woman who has not received PPSV23 (Pneumovax 23) within the previous 5 years and has underlying medical conditions that increase risk of invasive pneumococcal disease should prompt immunization with PPSV23 (Pneumovax) 23.¹⁰⁵

Lactation

Not known whether antigens contained in PCV13 (Prevnar 13) or PPSV23 (Pneumovax 23) are distributed into milk.^{129 181}

Use with caution in nursing women.^{129 181}

Because inactivated vaccines do not multiply within the body, ACIP states they should not pose any unusual problems for lactating women or their infants.¹³⁴

Pediatric Use

PCV13 (Prevnar 13): Safety and efficacy not established in infants <6 weeks of age.¹⁸¹ Manufacturer states immune response to the vaccine in preterm infants not adequately studied to date.¹⁸¹ Because apnea reported following IM vaccination in some infants born prematurely, base decisions regarding use of IM vaccines in such infants on consideration of the individual infant’s medical status and potential benefits and possible risks of vaccination.¹⁸¹

PPSV23 (Pneumovax 23): Safety and efficacy not established in children <2 years of age.¹²⁹ Children <2 years of age may not have a satisfactory antibody response to PPSV23 (Pneumovax 23).¹²⁹

Geriatric Use

PCV13 (Prevnar 13): Antibody responses in adults ≥65 years of age are lower compared with those in adults 50 through 59 years of age;¹⁸¹ no overall differences in safety between adults ≥65 years of age compared to adults 50 through 59 years of age.¹⁸¹

PPSV23 (Pneumovax 23): Rate of vaccine-related systemic adverse effects was higher following revaccination than primary vaccination in those ≥65 years of age.¹²⁹ Possibility that some older adults may exhibit increased frequency and/or greater severity of adverse reactions cannot be ruled out.¹²⁹

Common Adverse Effects

PCV13 (Prevnar 13): Local reactions at injection site (e.g., pain/tenderness, swelling, erythema, limitation of arm movement), fever, headache, fatigue, muscle or joint pain, chills, rash, decreased appetite, irritability, increased sleep, decreased sleep.¹⁸¹

PPSV23 (Pneumovax 23): Local reactions at injection site (e.g., pain/soreness/tenderness, swelling/induration, erythema), headache, asthenia/fatigue, myalgia.¹²⁹

Interactions for Pneumococcal Vaccine

Other Vaccines

Although specific studies may not be available evaluating concurrent administration with each antigen, simultaneous administration with other age-appropriate vaccines, including live virus vaccines, toxoids, or inactivated or recombinant vaccines, during the same health-care visit generally is not expected to affect immunologic responses or adverse reactions to any of the preparations.^{105 134} Immunization with pneumococcal vaccines can be integrated with immunization against diphtheria, tetanus, pertussis, Haemophilus influenzae type b (Hib), hepatitis A, hepatitis B, human papillomavirus (HPV), influenza, measles, mumps, rubella, meningococcal disease, poliomyelitis, rotavirus, and varicella.^{105 134} However, each parenteral vaccine should be administered using a different syringe and different injection site.^{105 134}

Specific Drugs

Drug	Interaction	Comments
Acetaminophen	Infants receiving PCV13 (Prevnar 13): Prophylactic acetaminophen (first dose given at time of each vaccine dose and additional doses given at 6- to 8-hour intervals) reduced antibody response to some pneumococcal vaccine serotypes after third vaccine dose compared with antibody responses among infants who received antipyretics only as needed for treatment;181 reduced antibody responses not observed after fourth dose of PCV13 in those receiving prophylactic acetaminophen181	ACIP states evidence does not support use of antipyretics before or at time of vaccination, but antipyretics can be used for treatment of fever and local discomfort occurring following vaccination134
Diphtheria and tetanus toxoids and pertussis vaccine adsorbed (DTaP)	PCV13 (Prevnar 13): Has been administered concurrently with fixed-combination vaccine containing DTaP (DTaP-HepB-IPV; Pediarix) in infants at 2, 4, and 6 months of age181	PCV13 (Prevnar 13) or PPSV23 (Pneumovax 23): May be administered concurrently with DTaP (using different syringes and different injection sites)105 134
Haemophilus b (Hib) vaccine	PCV13 (Prevnar 13): Has been administered concurrently with Hib vaccine in infants at 2, 4, and 6 months of age181	PCV13 (Prevnar 13) or PPSV23 (Pneumovax 23): May be administered concurrently with Hib vaccine (using different syringes and different injection sites)105 134 Fixed-combination vaccine containing Hib vaccine and meningococcal polysaccharide groups C and Y vaccine (Hib-MenCY; MenHibrix): May be administered concurrently with PCV13 (Prevnar 13) in infants 2 through 18 months of age (using different syringes and different injection sites)177
Hepatitis A (HepA) vaccine	PCV13 (Prevnar 13): Has been administered concurrently with HepA vaccine in infants 12–15 months of age181 Concomitant administration of previously available 7-valent vaccine (PCV7; Prevnar) and HepA vaccine (Havrix) in infants 15 months of age did not result in decreased immune response to any pneumococcal serotypes contained in PCV7172	PCV13 (Prevnar 13) or PPSV23 (Pneumovax 23): May be administered concurrently with HepA vaccine (using different syringes and different injection sites)105 134
Hepatitis B (HepB) vaccine	PCV13 (Prevnar 13): Has been administered concurrently with fixed-combination vaccine containing HepB (DTaP-HepB-IPV; Pediarix) in infants at 2, 4, and 6 months of age181	PCV13 (Prevnar 13) or PPSV23 (Pneumovax 23): May be administered concurrently with HepB vaccine (using different syringes and different injection sites)105 134
Immune globulin (immune globulin IM [IGIM], immune globulin IV [IGIV]) or specific immune globulin (hepatitis B immune globulin [HBIG], rabies immune globulin [RIG], tetanus immune globulin [TIG], varicella zoster immune globulin [VZIG])	No evidence that immune globulin preparations interfere with immune response to pneumococcal vaccine134	Pneumococcal vaccine may be administered simultaneously with or at any interval before or after immune globulin or specific hyperimmune globulin134
Immunosuppressive agents (e.g., alkylating agents, antimetabolites, corticosteroids, radiation)	Potential for suboptimal antibody response to vaccines105 129 134 181	Pneumococcal vaccine may be administered at least 2 weeks before initiation of immunosuppressive therapy or deferred until ≥3 months after therapy discontinued129 134 If administered during chemotherapy, revaccinate after immune competence is regained134
Influenza vaccine	Parenteral inactivated influenza vaccine: Concomitant administration with PCV13 (Prevnar 13) in adults ≥50 years of age did not increase frequency of local adverse effects, but increases in some solicited systemic reactions were reported compared with administration of either vaccine alone;181 concomitant administration with PPSV23 (Pneumovax 23) has resulted in increased incidence of adverse local and systemic effects compared with administration of influenza vaccine alone;145 146 ACIP states concomitant administration of these vaccines results in satisfactory antibody responses without increasing incidence or severity of adverse reactions134 Intranasal live influenza vaccine: Concomitant administration with pneumococcal vaccines not studied179	Parenteral inactivated influenza vaccine: May be administered concomitantly (using different syringes and different injection sites) with PCV13 (Prevnar 13) or PPSV23 (Pneumovax 23)105 134 Intranasal live influenza vaccine: May be administered simultaneously with or at any time before or after PCV13 (Prevnar 13) or PPSV23 (Pneumovax 23) 134 178
Measles, mumps, and rubella vaccine (MMR)	PCV13 (Prevnar 13): Has been administered concurrently with MMR or fixed-combination vaccine containing MMR and varicella vaccine (MMRV; ProQuad) in infants 12–15 months of age181	PCV13 (Prevnar 13) or PPSV23 (Pneumovax 23): May be administered concurrently with MMR or MMRV (using different syringes and different injection sites)105 134
Meningococcal vaccine	PCV13 (Prevnar 13): Manufacturer states data insufficient to assess concurrent administration with meningococcal (groups A, C, Y and W-135) polysaccharide diphtheria toxoid conjugate vaccine (MCV4-D, MenACWY-D; Menactra) or meningococcal (groups A, C, Y and W-135) oligosaccharide diphtheria CRM197 conjugate vaccine (MCV4-CRM, MenACWY-CRM; Menveo) in children and adolescents181 MCV4-D (Menactra): Concurrent administration with PCV7 (Prevnar) in infants 12 months of age resulted in decreased immune response to some of the pneumococcal vaccine serotypes compared with administration of PCV7 without MCV4-D108 177 MCV4-CRM (Menveo): Concurrent administration with PCV7 (Prevnar) in infants at 2, 4, 6, and 12 months of age resulted in possible interference with antibody response to 2 of the pneumococcal vaccine serotypes at 1 month after third dose, but no evidence of immune interference to any pneumococcal vaccine serotypes after fourth dose176	PCV13 (Prevnar 13): Do not administer MCV4-D (Menactra) concurrently or within 4 weeks after PCV13;105 177 to avoid possible interference with immune response in infants and children with anatomic or functional asplenia, complete PCV13 (Prevnar 13) vaccination series first and then administer MCV4-D (Menactra) at least 4 weeks later177 PPSV23 (Pneumovax 23): May be administered concurrently with MCV4-D (Menactra) or meningococcal polysaccharide vaccine (MPSV4; Menomune) using different syringes and different injection sites105 Fixed-combination vaccine containing Hib vaccine and meningococcal polysaccharide groups C and Y vaccine (Hib-MenCY; MenHibrix): May be administered concurrently with PCV13 (Prevnar 13) in infants 2 through 18 months of age (using different syringes and different injection sites)177
Poliovirus vaccine inactivated (IPV)	PCV13 (Prevnar 13): Has been administered concurrently with fixed-combination vaccine containing IPV (DTaP-HepB-IPV; Pediarix) in infants at 2, 4, and 6 months of age181	PCV13 (Prevnar 13) or PPSV23 (Pneumovax 23): May be administered concurrently with IPV (using different syringes and different injection sites)105 134
Rotavirus vaccine	Concomitant administration of rotavirus vaccine live (Rotarix, RotaTeq) with previously available 7-valent vaccine (PCV7; Prevnar) did not result in reduced immune responses to either vaccine170 174 175	PCV13 (Prevnar 13): May be administered concurrently with rotavirus vaccine105 134
Varicella vaccine	PCV13 (Prevnar 13): Has been administered concurrently with varicella vaccine (Varivax) or fixed-combination vaccine containing MMR and varicella vaccine (MMRV; ProQuad) in infants 12–15 months of age181	PCV13 (Prevnar 13) or PPSV23 (Pneumovax 23): May be administered concurrently with varicella vaccine or MMRV (using different syringes and different injection sites)105 134
Zoster vaccine	PPSV23 (Pneumovax 23): Concurrent administration with zoster vaccine in adults ≥60 years of age resulted in substantially reduced antibody responses to zoster vaccine compared with that reported when the vaccines were administered 4 weeks apart129 180 186	Manufacturer of zoster vaccine and PPSV23 (Pneumovax 23) states consider giving the 2 vaccines at least 4 weeks apart129 186

Stability

Storage

Parenteral

Injection, for IM Use (PCV13; Prevnar 13)

2–8°C;¹⁸¹ after shipping, may arrive at temperatures ranging from 2–25°C.¹⁸¹

Do not freeze.^{134 181} Since it contains an aluminum adjuvant,^{134 181} exposure to freezing temperatures causes irreversible loss of vaccine potency.¹³⁴

Does not contain thimerosal or any other preservatives.^{100 184}

Injection, for Sub-Q or IM Use (PPSV23; Pneumovax 23)

2–8°C.¹²⁹

Does not contain thimerosal, but does contain phenol 0.25% as a preservative.^{105 129}

Actions

• PCV13 (Prevnar 13): Sterile suspension containing purified capsular polysaccharide antigens extracted from 13 serotypes of S. pneumoniae (i.e., 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, 23F) and individually conjugated to diphtheria CRM₁₉₇ protein.^{181 184}

• PPSV23 (Pneumovax 23): Sterile solution containing purified capsular polysaccharide antigens extracted from 23 serotypes of S. pneumoniae (i.e., 1, 2, 3, 4, 5, 6B, 7F, 8, 9N, 9V, 10A, 11A, 12F, 14, 15B, 17F, 18C, 19F, 19A, 20, 22F, 23F, 33F).¹²⁹

• Principal mode of transmission of pneumococcal infection is the respiratory route, most commonly through close personal contact with an individual with invasive pneumococcal disease or direct exposure to nasopharyngeal secretions from an infected individual or by autoinoculation in persons carrying the bacteria in their upper respiratory tract.^{105 166} S. pneumoniae is a common cause of AOM, sinusitis, and pneumonia and can cause invasive disease, including bacteremia and meningitis.¹⁰⁵ Infection with S. pneumoniae has been a leading cause of bacterial meningitis in the US among children <5 years of age.¹⁶⁶

• Surveillance data from 2008 indicated that the 13 serotypes contained in PCV13 (Prevnar 13) accounted for approximately 61% of US cases of invasive pneumococcal disease occurring in children <5 years of age; serotype 19A accounted for 43% of cases.¹⁸⁴ Surveillance data from 2007–2009 indicated that 49% of cases of invasive pneumococcal disease in immunocompromised children and adolescents 6 through 18 years of age were caused by serotypes contained in PCV13 (Prevnar 13); an additional 23% of cases were caused by serotypes contained in PPSV23 (Pneumovax 23).²⁰³ For adults, surveillance data from 2008 indicated that the 13 serotypes contained in PCV13 (Prevnar 13) accounted for 44–53% of invasive pneumococcal disease and the 23 serotypes contained in PPSV23 (Pneumovax 23) accounted for 66–78% of cases.¹⁶⁹ Data from 2010 indicated that 50% of cases of invasive pneumococcal disease in immunocompromised adults were caused by serotypes contained in PCV13 (Prevnar 13); an additional 21% of cases were caused by serotypes contained in PPSV23 (Pneumovax 23).²⁰²

• Pneumococcal vaccines stimulate active immunity to pneumococcal infection by inducing production of antibodies specific for each pneumococcal capsular type represented in the vaccines.^{129 181} Minimum titers of anticapsular antibodies needed to confer protection against S. pneumoniae serotypes contained in the vaccines not established.^{129 181}

• Conjugated antigens contained in PCV13 (Prevnar 13) are more immunogenic in infants and young children than the unconjugated antigens contained in PPSV23 (Pneumovax 23).^{100 184} Conjugated antigens elicit a T-cell dependent immune response;¹⁸¹ antibodies produced in response to pneumococcal conjugate vaccines enhance opsonization, phagocytosis, and killing of S. pneumoniae by leukocytes and other phagocytic cells.¹⁸¹ Unconjugated antigens contained in PPSV23 (Pneumovax 23) do not induce long-lasting immunity or an anamnestic response after subsequent exposure to the same antigens.^{134 166}

• Following primary vaccination with PCV13 (Prevnar 13) in healthy infants (doses given at 2, 4, 6, and 12–15 months of age), 87–98% had anticapsular IgG antibody concentrations ≥0.35 mcg/mL against 12 of the 13 pneumococcal serotypes in the vaccine 1 month after the third dose;^{181 184} 64% achieved an antibody concentration ≥0.35 mcg/mL against serotype 3.^{181 184} Antibody concentrations 1 month after the fourth dose were higher for all 13 serotypes compared with concentrations 1 month after the third dose.^{181 184}

• Following a single dose of PPSV23 (Pneumovax 23) in healthy adults, >80% develop antibodies specific for the pneumococcal capsular types in the vaccine, usually within 2–3 weeks.¹⁶⁶ There is some evidence that the overall protective effectiveness of PPSV23 (Pneumovax 23) against invasive pneumococcal infection caused by serotypes included in the vaccine is 57% in individuals ≥6 years of age, 65–84% among specific patient groups (e.g., those with diabetes mellitus, coronary vascular disease, congestive heart failure, COPD, anatomic asplenia), and 75% in immunocompetent adults ≥65 years of age.¹²⁹ Antibody response to the unconjugated antigens in PPSV23 (Pneumovax 23) generally is poor or inconsistent in infants <2 years of age.^{129 166}

Advice to Patients

• Prior to administration of each vaccine dose, provide a copy of the appropriate CDC Vaccine Information Statement (VIS) to the patient or patient’s legal representative (VISs are available at ).^{129 167 168 181}

• Advise patient and/or patient’s parent or guardian of the risks and benefits of vaccination with pneumococcal vaccine.^{129 181}

• Advise patient and/or patient’s parent or guardian of the importance of completing the primary immunization series or catch-up vaccination with the age-appropriate number of doses of PCV13 (Prevnar 13) in infants 2 through 23 months of age and healthy children 2 through 5 years of age.^{100 167 181 184 199}

• Advise patient and/or patient's parent or guardian of the importance of completing age-appropriate vaccination with PCV13 (Prevnar 13) and PPSV23 (Pneumovax 23) in children ≥2 years of age, adolescents, and adults ≥19 years of age who are at increased risk for pneumococcal disease because of certain medical conditions.^{100 181 184 199 200 202 203 205}

• Advise patient and/or patient's guardian of the importance of routine vaccination with PCV13 (Prevnar 13) and PPSV23 (Pneumovax 23) in adults ≥65 years of age.^{169 200 204}

• Advise patient and/or patient’s parent or guardian that pneumococcal vaccines may not provide protection in all vaccinees.^{129 181}

• Importance of informing clinicians of any history of allergic reactions to pneumococcal vaccines (i.e., PCV7, PCV13, PPSV23) or any vaccine containing diphtheria toxoid.^{129 181}

• Importance of informing clinicians if any severe or unusual adverse reactions (including allergic reactions) occur with pneumococcal vaccine.^{129 167} Clinicians or individuals can report any adverse reactions that occur following vaccination to the Vaccine Adverse Event Reporting System (VAERS) at 800-822-7967 or .^{129 181}

• Importance of informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs, and any concomitant illnesses.^{129 181}

• Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.^{129 181}

• Importance of informing patients of other important precautionary information.^{129 181} (See Cautions.)

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.

Pneumococcal 13-valent Conjugate Vaccine (Diphtheria CRM197 Protein) (PCV13)

Routes	Dosage Forms	Strengths	Brand Names	Manufacturer
Parenteral	Injection		Prevnar 13	Wyeth

Pneumococcal Vaccine, Polyvalent (PPSV23)

Routes	Dosage Forms	Strengths	Brand Names	Manufacturer
Parenteral	Injection		Pneumovax 23	Merck