Could Disparities in Childhood PCV Adherence Become Disparities in Pneumococcal Disease Rates Under a Reduced Schedule?
ACIP recommends that PCV13 be given to children as a 3-dose (d) primary series at 2, 4, and 6 months (m) with a booster dose at 12-15m. This 4d (3+1) schedule is associated with remarkable declines in vaccine-type childhood pneumococcal disease. Recently, however, ACIP discussed reducing this 4d schedule to a 3d schedule—forgoing either the 6m or 12-15m dose. While this 3d schedule has been a success in other developed countries that have national immunization programs with high levels of adherence, childhood PCV adherence rates in the US are lower. Moreover, US PCV adherence appears to have plateaued, and significant racial and socioeconomic disparity still exists.
Data from the 2002-2012 National Immunization Survey (NIS) and 2013 IMS Health database were evaluated to assess adherence to the ACIP-recommended US childhood PCV immunization schedule.
NIS data showed that adherence decreased at each subsequent primary series milestone (Figure). At 19-35m, the overall proportion of US children receiving 4 doses of PCV increased from 54% in 2005 to 82% (only 75% at age 19m) in 2012. Rates varied by state and city with Indiana and New York City reporting the lowest 19-35m, 4d PCV adherence (73%) in 2012. According to IMS data, US 4d 2013 PCV adherence rates remained <80% at 24m, with lower rates for children aged 12-15m (12m: 45%; 15m: 66%; 18m: 74%; 24m: 77%). In 2012, compared to whites, 19-35m, 4d PCV adherence for African American children was worse (84% vs 77%). Similarly, compared to those at or above poverty, those below poverty had worse adherence (85% vs 77%).
A recent cost-effectiveness study concluded that a US switch to a 3d PCV schedule would have considerable cost savings, but would likely result in more childhood disease. The study also stressed that any dose reduction must be coupled with a significant increase in PCV adherence. This suggestion appears unrealistic given that US adherence rates have leveled-off since 2008. Finally, more assurance is needed that, under a reduced schedule, racial, socioeconomic, and geographic disparities in PCV coverage will not correspond with disadvantaging poor or minority children in terms of disease burden. This consideration remains a dilemma for both the policymaker and clinician.
J. M. Mclaughlin,
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