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ACIP Recommendations Shift Pneumococcal Vaccination Patterns

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New research from Avalere finds that the provision of pneumococcal conjugate vaccines increased immediately after ACIP’s 2014 recommendation to add the vaccine to the routine immunization schedule for older adults.

In 2014, the Advisory Committee on Immunization Practices (ACIP) updated its recommendation to add the pneumococcal conjugate vaccine (PCV13) in series with the pneumococcal polysaccharide vaccine (PPSV23) for all immunocompetent patients aged 65 and older, to increase the breadth of protection against pneumococcal disease. Specifically, the ACIP recommends that patients who have not yet received a pneumococcal vaccine, first receive a dose of PCV13 followed by a dose of PPSV23 after at least one year has passed. For patients who already received PPSV23, the recommendation calls for completion of the series by receiving PCV13 after at least a year has passed.

Prior to 2014, only PPSV23 was routinely recommended for all immunocompetent patients aged 65 and older, though PCV13 was recommended alongside PPSV23 for certain at-risk populations.

Avalere experts observed beneficiaries receiving pneumococcal vaccinations prior to and after 2014 to understand changes in immunization patterns following the ACIP’s decision to revise the pneumococcal vaccination schedule.


Avalere’s analysis showed a substantial increase in the use of PCV13 among Medicare beneficiaries receiving pneumococcal vaccines following the 2014 ACIP recommendation. Avalere observed a nearly 6,000% increase in the total number of Medicare beneficiaries who received the PCV13 vaccine following the 2014 pneumococcal ACIP recommendation, increasing from 115,000 beneficiaries in CY2009–2013 to nearly 7 million in CY2014–2017 (Table 1).

Table 1: Pneumococcal Vaccinations for Medicare Beneficiaries

The share of Medicare beneficiaries receiving pneumococcal vaccinations that were administered a PCV13 vaccine increased from 2% in CY2009–2013 to 87% in CY2014–2017 (Figure 1). Additionally, 42% of beneficiaries who received PPSV23 in CY2009–2013 received a dose of PCV13 in CY2014–2017 to complete the series, as recommended by the ACIP.

Figure 1: Pneumococcal Vaccine Treatment Patterns

The number of beneficiaries that had received both vaccines in the series increased from 23,000 in 2013 to 3.1 million in 2017 (Table 2). An additional 3.8 million likely started the ACIP-recommended series, since they received PCV13.


In 2018, the Centers for Disease Control and Prevention (CDC) published a study demonstrating a year-over-year increase in pneumococcal vaccine coverage for Medicare beneficiaries, with the proportion of Medicare beneficiaries receiving at least 1 pneumococcal vaccination increasing from 40% in enrollment period 2009–2010 to 60% in enrollment period 2016–2017.1 Similar to Avalere’s analysis, much of this increase was seen in patients receiving the newly-recommended PCV13 vaccine.

Both studies demonstrate that vaccination patterns appeared to shift following the 2014 ACIP recommendation. Moreover, both studies demonstrated that the shift occurred rapidly, within a few years of the revised recommendation, indicating active efforts to achieve recommendation compliance among those who received vaccines during that time period. However, despite increases in PCV13 vaccination following the recommendation, barriers to series completion and timely receipt of vaccines remain, with a plurality of vaccinated patients in Avalere’s cohort receiving only 1 pneumococcal vaccine following the 2014 pneumococcal recommendation. Further analysis is needed to determine whether series completion and timely receipt of vaccines is a widespread problem. While vaccination patterns will continue to shift to meet new recommendations, any upcoming changes to the existing ACIP pneumococcal vaccination recommendation could disrupt patterns, emphasizing the need to consider the impact to current pneumococcal vaccination schedules for Medicare beneficiaries.

Furthermore, while vaccinating providers largely adhere to ACIP recommendations, patient barriers to pneumococcal vaccine access remain. Studies suggest that, while there is variance in the immunogenicity and serotypes between products, both vaccines demonstrate efficacy in eliciting an immunologic response in patients compared to no product.2,3 The ACIP has considered the importance of vaccine uptake when discerning the value of a vaccine. For example, at the February 2018 ACIP meeting, the committee evaluated the live attenuated influenza vaccine (LAIV4), and ultimately decided to reinstate it as a recommended seasonal flu vaccine, with some members noting it could increase patient uptake. With several barriers for effective series completion, such as operative means of providers identifying patient immunization history, stakeholders must consider ways to improve vaccine access and drive uptake. The ACIP is reconsidering its adult pneumococcal recommendation and is expected to continue this discussion at its upcoming February 27–28, 2019 meeting.

Methodology and Limitations

Avalere analyzed Medicare Part B claims data for 2009–2017 under a CMS research data use agreement. Avalere analyzed eligible beneficiaries who received either the PCV13 or PPSV23 vaccine during the time periods 2009–2013 or 2014–2017 (the number of patients observed in either time period did not exceed more than 20% of all beneficiaries who were enrolled in Part B during that time period). The analysis captured only pneumococcal vaccines administered during these timeframes and therefore do not reflect overall vaccination rates in the Medicare population. The analysis defined eligible beneficiaries as all patients 65+ covered by Medicare fee-for-service for the entirety of the time window. Beneficiaries who died during the time period were included, so long as they fulfilled the eligibility requirements when alive. Beneficiaries who received both vaccines in the 2009–2013 time period were not considered eligible for the 2014–2017 time period.

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  1. Pneumococcal vaccination among U.S. Medicare beneficiaries aged ≥65 years, 2009–2017. The Centers for Disease Control and Prevention.
  2. Greenberg RN, Gurtman A, Frenck RW, et al. Sequential administration of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine in pneumococcal vaccine-naïve adults 60–64 years of age. Vaccine 2014;32:2364–74.
  3. Musher DM, Rueda AM, Nahm MH, Graviss EA, Rodriguez-Barradas MC. Initial and subsequent response to pneumococcal polysaccharide and protein-conjugate vaccines administered sequentially to adults who have recovered from pneumococcal pneumonia. J Infect Dis 2008;198:1019–27.
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