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Treatment of almost all medical conditions has been affected by the COVID-19 pandemic. NICE has issued rapid update guidelines in relation to many of these. This guidance is changing frequently. Please visit https://www.nice.org.uk/covid-19 to see if there is temporary guidance issued by NICE in relation to the management of this condition, which may vary from the information given below.
Serious or life-threatening infection is seen more commonly in children, the elderly, and 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 the majority 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, the elderly and people infected with HIV[1, 2].
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 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 re-vaccination 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 12 weeks and 12 months if born after 1st January 2020.
- Children under 1 year who were born before 1st January 2020 receive three doses of PCV, at 8 weeks, 16 weeks and 12 months.
- Unimmunised or partially immunised children who present late for vaccination before the age of 1 year should receive a single priming dose of PCV, followed by a PCV booster at 1 year of age. If the first dose is given within four weeks of the first birthday, the second dose should be delayed to ensure a gap of at least four weeks between doses.
- Chilren who are unimmunised or partially vaccinated and aged between 1 and 2 years should receive a single dose of the PCV vaccine.
- Routine immunisation with PCV should not be offered after the second birthday.
- 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 eight weeks after the last dose of conjugate vaccine.
- At-risk children aged over 2 years and under the age of 10 years who have asplenia or splenic dysfunction, or who are immunocompromised, require one dose of PCV13 followed by the pneumococcal polysaccharide vaccine (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.
- Children with asplenia, splenic dysfunction, complement disorder or severe immunocompromise require the following:
- Under 1 year - two PCV doses at least eight weeks apart (commencing no earlier than 6 weeks of age).
- From 1-2 years of age - PCV booster at 1 year (on or after the first birthday) and additional PCV dose at least eight weeks later.
- At 2 years if severely immunocompromised only - one PCV dose (even if unimmunised or partially immunised).
- At 2 years (but under 10 years) - PPV at 2 years, at least eight weeks after last PCV dose.
- At over 10 years and adult if severely immunocompromised only - one PCV dose. However, PCV or additional PPV not needed if individual received PPV in the previous two years because of a theoretical risk of pneumococcal serotype-specific hyporesponsiveness with re-vaccination.
- Aged over 10 and adult - one PPV dose, at least eight weeks after last PCV dose. However, PCV or additional PPV not needed if individual received PPV in the previous two years because of a theoretical risk of pneumococcal serotype-specific hyporesponsiveness with re-vaccination.
Indications for pneumoccocal vaccination
PPV23 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:
- All adults over the age of 65 years.
- 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 8 weeks with increased risk (base decision to immunise on clinical judgment).
|Pneumococcal clinical risk groups - those aged 8 weeks 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 coronary 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 should 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 breastfeeding.
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 and references
Immunizations - pneumococcal; NICE CKS, August 2016 (UK access only)
Falkenhorst G, Remschmidt C, Harder T, et al; Effectiveness of the 23-Valent Pneumococcal Polysaccharide Vaccine (PPV23) against Pneumococcal Disease in the Elderly: Systematic Review and Meta-Analysis. PLoS One. 2017 Jan 612(1):e0169368. doi: 10.1371/journal.pone.0169368. eCollection 2017.
Moreira M, Castro O, Palmieri M, et al; A reflection on invasive pneumococcal disease and pneumococcal conjugate vaccination coverage in children in Southern Europe (2009-2016). Hum Vaccin Immunother. 2016 Dec 20:0.
Shaughnessy EE, Stalets EL, Shah SS; Community-acquired pneumonia in the post 13-valent pneumococcal conjugate vaccine era. Curr Opin Pediatr. 2016 Dec28(6):786-793.
Immunisation against infectious disease - the Green Book (latest edition); Public Health England