New recommendations for human papillomavirus (HPV) and 13-valent pneumococcal conjugate (PCV13, Prevnar) vaccines emerged from the CDC's Advisory Committee for Immunization Practices (ACIP) meeting in Atlanta on Wednesday.
ACIP members voted unanimously to support "catch-up vaccination for persons through age 26 years who are not adequately vaccinated." The vote brought harmonization to the catch-up ages for both females and males.
The committee also addressed whether catch-up HPV vaccinations be should recommended "for primary prevention of HPV infection and HPV-related disease for all persons aged 27 through 45 years." Currently, CDC recommendations only cover use in individuals up to age 26.
Members had two alternatives before them: an outright recommendation that individuals in the 27-45 age group should be vaccinated, or that patients 27-45 and their physicians should engage in shared decision-making. They voted 10-4 in favor of the latter "for individuals ages 27 through 45 years who are not adequately vaccinated." Notably, HPV vaccines are not licensed for use in people older than 45.
During discussion, committee members who supported shared decision-making for the HPV vaccine pointed out that this type of recommendation would allow for case by case flexibility, healthy disparities might be reduced by health insurance coverage for vaccination, and providers asked by patients about the vaccine may implement clinical decision making anyway.
Committee member Peter Szilagyi, MD, MPH, of the University of California Los Angeles explained his vote in favor of shared decision-making as follows: "I believe the number or the proportion of patients who would benefit is small, but it's there. I also believe that high-risk individuals can be identified and guidance following the vote would be very, very helpful for clinicians...the vast majority or majority of patients in that age group should not get the vaccine."
"We didn't have details on the shared clinical decision-making and to whom would we be suggesting that that vaccine is appropriate for, what size of that population of men and women in that large age group would be suggested to consider this vaccine," said ACIP member Kelly Moore, MD, MPH, of Vanderbilt University in Nashville, who voted no.
"So in the absence of any information on the details of what that meant and in the presence of supply questions, I did not feel comfortable expanding a recommendation to such a huge population," she continued. "I am concerned that, despite the assurances of the company, that supply could potentially be a problem distracting us from the priority recipients who are in early childhood or their teenage years, and I don't want to do anything to compromise that."
Pneumococcal vaccine for older adults
The policy discussion on PCV13 vaccine focused on immunocompetent adults 65 years or older. Current policy adopted in 2015 calls for all adults 65 and older to receive one dose of PCV13 followed by a dose of the 23-valent pneumococcal vaccine, PPSV23 (Pneumovax). There were three proposed policy options:
- PCV13 for all adults 65 years or older who had not received PCV13 before. First, PCV13 should be given, then a dose of [23-valent pneumococcal polysaccharide vaccine] PPSV23.
- No longer recommending "PCV13 for adults ≥ 65 years who do not have an immunocompromising condition. All adults ≥65 years should receive a dose of PPSV23."
- Recommending PCV13 based on shared decision-making for adults 65 years or older who do not have an immunocompromising condition and who have not received PCV13 before.
ACIP members voted down the first two in favor of adopting the third by a vote of 13-1.
ACIP recommendations are not considered final until they are published in the CDC's Morbidity and Mortality Weekly Report.