ACIP Pneumococcal, Zoster, and Flu – October 20, 2021

ACIP met today to discuss pneumococcal, zoster, and influenza vaccines. No influenza votes. The committee voted unanimously on the zoster and pneumococcal vaccines:

• The ACIP committee voted 15-0 to recommend the Zoster vaccine for immunocompromised adults 19 and older: “Two doses of recombinant zoster vaccine are recommended for the prevention of herpes zoster and its complications in adults aged 19 years and older who are or will be immunodeficient or immunosuppressed due to disease therapy.
• The ACIP committee voted 15-0 to recommend pneumococcal vaccine PCV20 alone or PCV15 and PPSV23 in series for adults 65 and older: “Adults 65 years of age and older who have not previously received a pneumococcal conjugate vaccine or whose previous vaccination history is unknown should receive a pneumococcal conjugate vaccine (either PCV20 or PCV15). If PCV15 is used, this should be followed by a dose of PPSV23”
• The ACIP committee voted 15-0 to recommend pneumococcal vaccine PCV20 alone or PCV15 and PPSV23 in series for adults 19-64 with certain underlying medical conditions or risk factors: “Adults aged 19-64 years of age with certain underlying medical conditions or other risk factors who have no previously received a pneumococcal conjugate vaccine or whose previous vaccination history is unknown should receive a pneumococcal conjugate vaccine (either PCV20 or PCV15). If PCV15 is used, this should be followed by a dose of PPSV23.” There was controversy from liaisons, voting members, and public comment speakers on recommending the pneumococcal vaccine for 65+ vs. 50+. See more below for more detail. 

Pneumococcal: The committee was presented a simplification of the policy questions presented during the September 2021 ACIP meeting regarding the pneumococcal vaccines. Previous policy questions included a potential age based recommendation for 50+, 65+, 19-49 with underlying conditions, as well as risk based recommendations. The ACIP committee felt that this language needed to be simplified for implementation purposes and expansion of coverage. The updated policy questions read as follows:

• AGE BASED: Should PCV20 alone OR PCV15 in series with PPSV23 be routinely recommended for US adults aged ≥65 years?
• RISK BASED: Should PCV20 alone OR PCV15 in series with PPSV23 be recommended for U.S. adults aged 19–64 years with certain underlying medical conditions or other risk factors*?

Some committee members felt that underlying conditions included in the risk based considerations (19-64 underlying conditions) were not all encompassing. Furthermore, many liaison and committee members felt that a simple age based recommendation for 50+ would increase access, reduce barriers and protect a larger population. However, voting members noted that since immunity declines between 50-65, it may be more valuable to recommend the pneumococcal vaccines for 65+ to achieve highest immunity in older age (highest risk group). An amendment was proposed to change the age based recommendation to 50+, but the amendment did not pass.

Zoster: Overall, the workgroup felt that the  desirable consequences clearly outweigh undesirable consequences in most settings for a Zoster vaccine for immunocompromised individuals 19 and older. The EtR framework was presented during the meeting. Overall, benefits outweigh the risks, there are no safety concerns, and many physicians are already recommending the Zoster vaccine for adults 19 years and older with immunocompromised individuals. There is an ongoing study of co-administration of the zoster and influenza vaccine.

Influenza: No influenza votes. The committee reviewed the safety and immunogenicity study of the co-administration of Fluzone® HighDose Quadrivalent Influenza Vaccine and a third dose of Moderna vaccine. There were no SAEs or deaths in the Phase II study. Overall, data supports that Fluzone and the Moderna mRNA vaccine can safely be administered together without evidence of immunogenicity interference, supporting existing co-administration recommendations of COVID-19 and influenza vaccines. The committee also received an update regarding change in age indication for Flucelvax Quadrivalent, a cell culture-based inactivated flu vaccine, which is now FDA approved for 6 months and older as of October 14th, 2021.

ACIP will meet tomorrow (agenda here) to vote on recommendations for the Johnson & Johnson and Moderna booster doses, and discuss mixing COVID vaccines for booster doses.