Updated recommendations for use of pneumococcal vaccines in children

The National Advisory Committee on Immunization (NACI) has issued updated guidance on the use of pneumococcal vaccines for preventing invasive pneumococcal disease in children.1,2 An update was needed due to Health Canada’s approval of two new pneumococcal conjugate vaccines for use in infants, children and adolescents (six weeks through 17 years of age). Pneumococcal 15-valent conjugate vaccine (Vaxneuvance) is authorized for prevention of invasive pneumococcal disease caused by 15 serotypes of Streptococcus pneumoniae,3 while pneumococcal 20-valent conjugate vaccine (Prevnar 20) is authorized for prevention of invasive pneumococcal disease caused by 20 serotypes of S. pneumoniae.4Pneumococcal 13-valent conjugate vaccine (Prevnar 13) has been used in routine childhood immunization programs in Canada for several years (three- or four-dose schedules). Infants at increased risk of invasive pneumococcal disease due to an underlying medical condition have been recommended to receive a four-dose schedule of pneumococcal 13-valent conjugate vaccine plus one dose of pneumococcal 23-valent polysaccharide vaccine (Pneumovax 23) at 24 months of age, at least eight weeks after pneumococcal 13-valent conjugate vaccine.1 In March 2023, NACI provided interim guidance on the use of pneumococcal 15-valent conjugate vaccine in children, with the recommendation that it can be used interchangeably with pneumococcal 13-valent conjugate vaccine in children six weeks to 17 years of age.5 The 2024 NACI update was stimulated by the more recent approval of pneumococcal 20-valent conjugate vaccine for use in children.The current NACI update reviews evidence on the immunogenicity, safety and cost-effectiveness of using pneumococcal 15-valent or 20-valent conjugate vaccines in pediatric pneumococcal immunization programs to reduce the burden of pneumococcal disease in Canada. It provides recommendations for the use of pneumococcal 15-valent and 20-valent conjugate vaccines in routine pediatric programs in Canada and for children at increased risk of invasive pneumococcal disease.1,2NACI RecommendationsNACI continues to recommend that a conjugate pneumococcal vaccine should be included in all routine infant immunization programs in Canada.1,2 Routine immunization programs in children < 5 years of age who are not at increased risk of invasive pneumococcal disease1. Either pneumococcal 15-valent or 20-valent conjugate vaccine should be the current product of choice for routine immunization programs. (Strong NACI recommendation)Pneumococcal 15-valent or 20-valent conjugate vaccines should be provided to children using previously recommended routine schedules for pneumococcal 13-valent conjugate vaccine.Pneumococcal 20-valent conjugate vaccine is preferred for children at increased risk of invasive pneumococcal disease (see Recommendation #2).1,2Children with medical conditions or environmental or living conditions that place them at increased risk of invasive pneumococcal disease2. Pneumococcal 20-valent conjugate vaccine should be used for infants and children at increased risk of invasive pneumococcal disease who are starting their pneumococcal vaccine series, and for series completion for those who have started their vaccine series with pneumococcal 13-valent or 15-valent conjugate vaccine. (Strong NACI Recommendation)Infants at increased risk of invasive pneumococcal disease should be immunized with pneumococcal 20-valent conjugate vaccine using a 4-dose (3+1) schedule at 2 months, 4 months, 6 months and 12–15 months of age.Infants and children who have not started their immunization schedule by seven months of age should be immunized according to the schedule provided in Table 7 of the guidance document (see page 41 of reference #1 below).Children ≥ 2 years of age who are at increased risk of invasive pneumococcal disease and have never received any pneumococcal vaccination, should receive one dose of pneumococcal 20-valent conjugate vaccine.A vaccine series started with pneumococcal 13-valent or 15-valent conjugate vaccine should be completed with pneumococcal 20-valent conjugate vaccine (see recommended schedule in Table 7 of the guidance document).Children at increased risk of invasive pneumococcal disease who have completed a vaccine series appropriate for their age that includes at least one dose of pneumococcal 20-valent conjugate vaccine do not require further doses.1,2Catch-up doses for children with medical conditions or environmental or living conditions that place them at increased risk of invasive pneumococcal disease 3a. Children < 18 years of age who have medical risk factors and who have completed their recommended immunization schedule with pneumococcal 13-valent or 15-valent conjugate vaccine should receive one catch-up (additional) dose of pneumococcal 20-valent conjugate vaccine. (Strong NACI recommendation)Those with medical risk factors who have previously received pneumococcal 23-valent polysaccharide vaccine should be given one dose of pneumococcal 20-valent conjugate vaccine one year following the last dose of pneumococcal 23-valent polysaccharide vaccine.1,23b. Children < 18 years of age who have environmental or living conditions that result in increased risk for invasive pneumococcal disease, and who have completed therecommended immunization schedule with pneumococcal 13-valent or 15-valent conjugate vaccine, should receive one catch-up (additional) dose of pneumococcal 20-valent conjugate vaccine. (Strong NACI recommendation).1,2Hematopoietic stem cell transplant recipients 4. Pneumococcal 20-valent conjugate vaccine should be offered to children < 18 years of age who have received a hematopoietic stem cell transplant, after consultation with their transplant specialist. (Strong NACI recommendation)A primary series of three doses of pneumococcal 20-valent conjugate vaccine, starting three to nine months after transplant, should be administered at least four weeks apart, followed by an additional dose 12–18 months post-transplant (6–12 months after the last dose of pneumococcal 20-valent conjugate vaccine).The recommended timing of pneumococcal 20-valent conjugate vaccine for hematopoietic stem cell transplant recipients should be determined in consultation with the recipient’s transplant specialist.1,2Additional informationConsult the guidance document for details on the following:Risk conditions resulting in increased risk of invasive pneumococcal disease Table comparing vaccines authorized for use in children < 18 years of age in Canada.Evidence on safety of pneumococcal 15-valent and 20-valent conjugate vaccines in pediatric populations.A model-based economic evaluation on the use of pneumococcal 15-valent and 20-valent conjugate vaccines in the pediatric population.1,2References1. National Advisory Committee on Immunization (NACI). An Advisory Committee Statement (ACS). Recommendations for public health programs on the use of pneumococcal vaccines in children, including the use of 15-valent and 20-valent conjugate vaccines. (accessed March 19, 2024).2. National Advisory Committee on Immunization. Summary of NACI statement of March 11, 2024: Recommendations for public health programs on the use of pneumococcal vaccines in children, including the use of 15-valent and 20-valent conjugate vaccines. (accessed March 19, 2024).3. Merck Canada Inc. Vaxneuvance (pneumococcal 15-valent conjugate vaccine [CRM197 protein], adsorbed) product monograph. Kirkland QC; July 7, 2023. (accessed March 19, 2024).4. Pfizer Canada. Prevnar 20 (pneumococcal 20-valent conjugate vaccine (diphtheria CRM197 protein) product monograph. Kirkland, QC; November 16, 2023. (accessed March 19, 2024). 5. National Advisory Committee on Immunization (NACI). An Advisory Committee Statement (ACS). Interim guidance on the use of pneumococcal 15-valent conjugate vaccine (PNEU-C-15) in pediatric populations. (accessed March 19, 2024).

Updated recommendations for use of pneumococcal vaccines in children

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