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Serious or life-threatening infection is seen more commonly in children, the elderly, patients who have had their spleen removed and in immunocompromised patients.
The vaccine most commonly used in the UK is a polyvalent vaccine containing purified capsular polysaccharide from each of the 23 types of pneumococcus which are responsible for about 96% of serious pneumococcal infections seen in this country.
Despite this vaccine, pneumococcal infections still disproportionately affect people with certain high-risk conditions. The conjugated pneumococcal vaccines have been shown to be highly effective in preventing vaccine-type disease in infants and people infected with HIV.
Children under the age of 2 years, who are unlikely to develop an immune response to the polysaccharide form of vaccination, and those who are considered to be at risk of serious pneumococcal infection should receive a conjugate vaccine (Prevenar®) containing 13 types of pneumococcus.
These vaccines are both inactivated and contain no live organisms.
Pneumococcal vaccination schedule
A single dose of 23 polyvalent vaccine, with no repeat vaccination, is normally all that is required for individuals over the age of 2 years, with the following exceptions:
- Patients with no spleen
- Patients with splenic dysfunction
- Patients with chronic kidney disease
Antibody levels are more likely to decline rapidly in these individuals and they should receive further vaccinations every five years. Routine checks of antibody levels prior to revaccination in these individuals are not required.
Childhood immunisation schedule
The current schedule is as follows:
- Children under 1 year of age receive the pneumococcal conjugate vaccine (PCV) - Prevenar® at 2 months, 4 months and 12 months (or at least two months after the last dose of this vaccine).
- Chilren who are unimmunised or partially vaccinated and aged between 1 and 2 years should receive a single dose of the PCV vaccine.
- Children at special risk of infection, who have received the conjugate vaccine, should also have the 23 polyvalent vaccine following their second birthday to protect them from other forms of the organism. This should be given at least two months after the last dose of conjugate vaccine.
- At-risk children aged over 2 and under 5 years who have asplenia or splenic dysfunction, or who are immunocompromised, require one dose of PCV13 followed by PPV23 at least two months after. Those who are unimmunised or partially vaccinated need to have two doses of PCV13 (separated by at least two months) followed by the PPV23 as before.
Indications for pneumoccocal vaccination
Pneumococcal vaccination (PPV23) is recommended for all those in whom pneumococcal infection is likely to be more common or more dangerous. It is currently recommended in the following circumstances:
- All adults over the age of 65
- Adults and children over 2 years of age in an at-risk group.
In addition, severely immunocompromised children aged at least 5 years and adults (including bone marrow transplant patients, patients with acute and chronic leukaemia, multiple myeloma or genetic disorders affecting the immune system) should be offered a single dose of PCV13 followed by PPV23 at least two months later. This is irrespective of their routine childhood vaccinations.
Consider all patients over the age of 2 months with increased risk (base decision to immunise on clinical judgment).
|Pneumococcal clinical risk groups - those aged 2 months and over|
|Clinical risk group||Examples (base decision on clinical judgement)|
|Asplenia or dysfunction of the spleen||For example, homozygous sickle cell disease and coeliac disease.|
|Chronic respiratory disease||For example, chronic obstructive pulmonary disease (COPD), including chronic bronchitis and emphysema; bronchiectasis, cystic fibrosis, interstitial lung fibrosis, pneumoconiosis and bronchopulmonary dysplasia (BPD). Patients with respiratory conditions caused by aspiration, or a neuromuscular disease (eg, cerebral palsy) with a risk of aspiration.
Asthma is not an indication, unless continuous or frequently repeated use of systemic steroids (as defined in 'Immunosuppression', below) is needed.
|Chronic heart disease||Patients requiring regular medication and/or follow-up for ischaemic heart disease, congenital heart disease, hypertension with cardiac complications, and chronic heart failure.|
|Chronic kidney disease||Includes nephrotic syndrome, chronic kidney disease at stages 4 and 5, those on kidney dialysis and those with renal transplantation.|
|Chronic liver disease||Includes cirrhosis, biliary atresia, chronic hepatitis.|
|Diabetes (requiring insulin or oral hypoglycaemic drugs)||Diabetes mellitus requiring insulin or oral hypoglycaemic drugs.
It does not include diabetes that is diet-controlled.
|Immunosuppression||Due to disease or treatment, including patients undergoing chemotherapy leading to immunosuppression, bone marrow transplant, asplenia or splenic dysfunction, HIV infection at all stages, multiple myeloma or genetic disorders affecting the immune system.
Individuals treated with or likely to be treated with systemic steroids for more than a month at a dose equivalent to prednisolone 20 mg or more per day (any age), or for children under 20 kg, a dose of ≥1 mg/kg/day.
Some immunocompromised patients may have a suboptimal immunological response to the vaccine.
|Individuals with cochlear implants||It is important that immunisation does not delay the cochlear implantation. Where possible, pneumococcal vaccination should be completed at least two weeks prior to surgery, to allow a protective immune response to develop. In some cases it will not be possible to complete the course prior to surgery. In this instance, the course should be started at any time prior to or following surgery and completed according to the immunisation schedule.|
cerebrospinal fluid leaks
|This includes leakage of cerebrospinal fluid such as following trauma or major skull surgery.|
|Individuals at occupational risk||There is a strong association between welding and the development of pneumococcal disease, particularly lobar pneumonia. Therefore, those at risk of frequent or continuous occupational exposure to metal fumes (eg, welders) who have not received PPV23 previously, should be offered a single dose of 0.5 ml of PPV23 vaccine.|
Contra-indications to pneumococcal vaccine
There are very few contra-indications to the giving of pneumococcal vaccine. The vaccine should not be given to individuals who have had:
- A confirmed anaphylactic reaction to a previous dose of the vaccine.
- A confirmed anaphylactic reaction to any component of the vaccine.
There is no evidence of risk from vaccinating pregnant women with these vaccines or those who are breast-feeding.
The only adverse reactions likely to be encountered with either vaccine are:
- Mild soreness and induration at the injection site, which can last up to three days.
- A low-grade fever, which may less commonly occur.
Further reading & references
- Immunizations - pneumococcal; NICE CKS, October 2012
- Vila-Corcoles A, Ochoa-Gondar O; Preventing pneumococcal disease in the elderly: recent advances in vaccines and implications for clinical practice. Drugs Aging. 2013 May;30(5):263-76. doi: 10.1007/s40266-013-0060-5.
- Rozenbaum MH, van Hoek AJ, Fleming D, et al; Vaccination of risk groups in England using the 13 valent pneumococcal conjugate vaccine: economic analysis. BMJ. 2012 Oct 26;345:e6879. doi: 10.1136/bmj.e6879.
- Plosker GL; 13-valent pneumococcal conjugate vaccine: a review of its use in infants, children, and adolescents. Paediatr Drugs. 2013 Oct;15(5):403-23. doi: 10.1007/s40272-013-0047-z.
- Immunisation against infectious disease - the Green Book (latest edition); Public Health England
Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.
Dr Hayley Willacy
Dr Louise Newson
Dr Helen Huins