Pneumococcal Vaccine

Infection with Streptococcus pneumoniae (pneumococcus) is common, and may produce a range of illnesses some more serious than others e.g. otitis media, meningitis, septicaemia and pneumonia. Serious or life threatening infection is seen more commonly in children, the elderly, patients who have had their spleen removed and in immunocompromised patients.¹

Pneumococcal infection is the most common serious infection seen in the USA and pneumococcal pneumonia is the commonest community acquired pneumonia, a condition which has a mortality of 10-20%. Pneumococci are spread by person to person contact, commonly by sneezing, coughing or close personal contact. Although antibiotics may be used to treat pneumococcal infections, resistance is becoming increasingly common, and it is likely that vaccination against pneumococcus will have an increasingly large role to play in the fight against the infection in the future.

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 the vast majority of serious pneumococcal infections seen in this country. Children under the age of 2 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 containing 7 types of pneumococcus.² The vaccines are both inactivated and do not contain live organisms.

A single dose of 23 polyvalent vaccine, with no repeat vaccination, is normally all that is required for individuals over the age of 5 with the following exceptions:

• Patients with no spleen
• Patients with splenic dysfunction
• Patients with renal disease including nephrotic syndrome

Antibody levels are more likely to decline rapidly in these individuals and they should receive further vaccinations at 5 yearly intervals. Routine checks of antibody levels prior to re-vaccination in these individuals is not required.³

From September 2006:

• Children aged 2 months will receive the conjugate vaccine (PCV) - Prevenar®.
• This will be at 2 months, 4 months and 13 months.
• All children aged over 2 months and under 2 years of age will be offered PCV as part of the catch-up campaign.
• Children at special risk of infection, who have received the conjugate vaccine should also have the 23 polyvalent vaccine following their 2nd 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.³
• At-risk children who present late for immunisation should be offered 2 doses of PCV1 before the age of 12 months, and a further dose at 13 months of age.
• At-risk children aged over 12 months and under 5 years of age should be offered a single dose of PCV. Please note that children in this age group who have asplenia or splenic dysfunction, or who are immunocompromised, require a second dose of PCV because this group may have a sub-optimal immunological response to the first dose of vaccine.

Pneumococcal vaccination 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^3,3:

• All adults over the age of 65 years old⁴

Consider all patients over the age of 2 months with increased risk (base decision to immunise on clinical judgment):

• Asplenia or severe dysfunction of the spleen (e.g. homozygous Sickle Cell disease or Coeliac disease). Immunise 2 weeks prior to splenectomy or delay until 2 weeks after if possible.
• Chronic renal disease, e.g. nephrotic or chronic renal failure or renal transplantation.
• Patients with immunodeficiency or immunosuppression (6 weeks prior to treatment with chemotherapy/radiotherapy or 3 months after completion of treatment).
• Chronic lung disease e.g. COPD, cystic fibrosis, lung fibrosis etc. Asthma is NOT an indication, unless requires continuous or frequently repeated use of systemic steroids. Children with respiratory conditions caused by aspiration, or a neuromuscular disease (e.g. cerebral palsy) with a risk of aspiration should be immunised.
• Chronic heart disease needing regular medication ±follow-up: (IHD, congenital HD, hypertension with cardiac complications).
• Chronic liver disease - including cirrhosis.
• Diabetes mellitus (oral or insulin therapy).
• Patients with cochlear implants, or about to receive cochlear implants.
• Patients with CSF shunts.
• Children under the age of 5 who have previously had invasive pneumococcal disease.

There are very few contraindications 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.
• Although the safety of the vaccine has not been formally assessed during pregnancy, the vaccine may be given if clinically indicated.³

The only adverse reactions likely to be encountered with either vaccine are:

• Mild soreness and induration at the injection site
• ± a low grade fever