Pneumococcal vaccination

What is the pneumococcal vaccine?

Pneumococcal vaccines provide immunisation against infection with specific serotypes of Streptococcus pneumoniae. S. pneumoniae causes a range of infections, from mild and often-self limiting conditions such as sinusitis and otitis media, to potentially life-threatening ones such as pneumonia, meningitis, and septicaemia. Pneumococcal vaccination programmes appear to have significantly reduced the incidence of invasive pneumococcal infections, both by preventing infection in vaccine recipients, and indirectly protecting unvaccinated individuals by way of reducing S. pneumoniae carriage and circulation.¹

The vaccine most commonly used in the UK for adults 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 with HIV.²³

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 13®) containing 13 types of pneumococcus, or one containing 15 types (Vaxneuvance®).⁴

These vaccines are inactivated and contain no live organisms.

Pneumococcal infection

Infection with Streptococcus pneumoniae (pneumococcus) is common and may produce a range of illnesses - some more serious than others - eg, otitis media, meningitis, septicaemia and pneumonia.

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.

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.⁴

Childhood immunisation schedule

The current schedule is as follows:⁴

• One dose of PCV13 (Prenevar 13®) or PCV15 (Vaxneuvance®) at 12 weeks of age.

• One dose of PCV13 (Prenevar 13®) or PCV15 (Vaxneuvance®) at one year of age.

Special situations are as follows:

• Unimmunised or partially immunised children who present late for vaccination before the age of 1 year should receive a single priming dose of PCV13 or PCV15, followed by a PCV13 or PCV15 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.

• Children who are unimmunised or partially vaccinated and aged between 1 and 2 years should receive a single dose of PCV13 or PCV15.

• 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 or PCV15 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 or PCV15 (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 PCV13 or PCV15 doses at least eight weeks apart (commencing no earlier than 6 weeks of age).

  • From 1-2 years of age - PCV13 or PCV15 booster at 1 year (on or after the first birthday) and additional PCV13 or PCV15 dose at least eight weeks later.

  • At 2 years if severely immunocompromised only - one PCV 13 or PCV 15 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 PCV13 or PCV15 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 pneumococcal 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:⁴

• 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 over⁴

Contra-indications to pneumococcal vaccine⁴

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.

Adverse reactions

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.