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| What causes
pneumococcal disease? |
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| Pneumococcal disease is caused by Streptococcus
pneumoniae, a bacterium that has more than 90 serotypes. Most serotypes
cause disease, but only a few
produce the majority of invasive pneumococcal disease. The 10 most common
types cause 62% of invasive disease worldwide. |
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| How does pneumococcal disease spread? |
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| The disease is spread from person to
person by droplets in the air. The pneumococci bacteria are common
inhabitants of the human respiratory tract. They may
be isolated from the nasopharnyx of 5%-70% of
normal, healthy adults. |
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| How long does it take to show signs
of pneumococcal disease after being exposed? |
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| As noted above, many people carry the
bacteria in their nose and throat without ever developing invasive
disease. The incubation period for specific diseases
caused by an invasive pneumococcal infection is
noted below. |
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| What are the types of invasive pneumococcal
disease? |
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| There are two major clinical syndromes of invasive
pneumococcal disease: bacteremia, and meningitis. They are both caused
by infection with the same bacteria, but have different
manifestations.
Pneumococcal pneumonia is the most common
disease caused by pneumococcal infection. Pneumococcal pneumonia can
occur in combination with bacteremia and/or meningitis, or it can occur
alone. Isolated pneumococcal pneumonia is not considered invasive disease
but it can be severe. It is estimated that 175,000 cases occur each
year in the United States. The incubation period is short (1-3 days).
Symptoms include abrupt onset of fever, shaking chills or rigors, chest
pain, cough, shortness of breath, rapid breathing and heart rate, and
weakness. The fatality rate is 5%-7% and may be much higher in the
elderly.
Pneumococcal bacteremia occurs in about 25%-30%
of patients with pneumococcal pneumonia. More than 50,000 cases of
pneumococcal bacteremia occur each year in the United States.
Bacteremia is
the most common clinical presentation among children less than two
years, accounting for 70% of invasive disease in
this group.
Pneumococci cause 13%-19% of all cases of bacterial
meningitis in the United States. There are 3,000-6,000 cases of pneumococcal
meningitis each year. Symptoms and signs may include headache, tiredness, vomiting,
irritability, fever, seizures, and coma. Children less than one year have the
highest rate of pneumococcal meningitis, approximately 10 cases per 100,000 population.
The mortality rate is high
(30% overall, up to 80% in the elderly). |
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| How serious is pneumococcal disease
in the U.S? |
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| Pneumococcal disease is a serious disease
that causes much sickness and death. In fact, pneumococcal disease
kills more people in the United States each year
than all other vaccine-preventable
diseases combined.
More than 40,000 cases and more than 4,400
deaths from invasive pneumococcal diseases (bacteremia and meningitis)
are estimated to have occurred in the United States in 2005. More than
half of these cases occurred in adults who had an indication for pneumococcal
polysaccharide vaccine. Young children and the elderly (younger than
age five years and older than 65) have the highest incidence of serious disease.
Case-fatality rates are highest for meningitis
and bacteremia, and the highest mortality occurs among the elderly
and patients who have underlying medical conditions. Despite appropriate
antimicrobial therapy and intensive medical care, the overall case-fatality
rate for pneumococcal bacteremia is about 20% among adults. Among elderly
patients, this rate may be as high as
60%. |
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| For whom is pneumococcal polysaccharide
vaccine recommended? |
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Pneumococcal polysaccharide vaccine is
recommended for all adults who are age 65 years and older. It is also
recommended for adults age 19 years and older who smoke cigarettes, and
for persons between the ages of 2 and 64 years who have chronic
illnesses specifically associated with increased risk from pneumococcal
infection (e.g., cardiovascular disease, pulmonary disease [including
asthma in adults age 19 years and older], diabetes mellitus, alcoholism,
cirrhosis, or cerebrospinal fluid leaks), or are a candidate for or
recent recipient of a cochlear implant.
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Persons with asymptomatic or symptomatic
HIV infection should be vaccinated. In addition, immunocompromised
adults with chronic illnesses specifically associated with increased
risk from pneumococcal infection should receive the vaccine (e.g.,
persons with splenic dysfunction or anatomic asplenia, Hodgkin's disease,
lymphoma, multiple myeloma, chronic renal failure, nephrotic syndrome,
or conditions such as organ transplantation associated with immunosuppression).
Residents of nursing homes or long-term
care facilities should also be vaccinated. Public health authorities may
consider recommending PPSV for Alaska Natives and American Indians ages
50 through 64 years who are living in areas in which the risk of
invasive pneumococcal disease is increased. The vaccine is not indicated
for patients having recurrent acute upper respiratory tract infections,
such as otitis media and sinusitis. |
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| We have begun a more aggressive approach to vaccinating our high-risk patients against pneumococcal disease. Do you have any suggestions on how we can improve our system? |
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| Congratulations on your efforts to increase your clinic's vaccination rates against this serious and deadly disease. Health experts have found that influenza predisposes individuals to bacterial community-acquired pneumonia, and studies have shown that this is heightened during influenza pandemics. In June 2009, CDC issued interim guidance for use of 23-valent pneumococcal polysaccharide vaccine (PPSV)
in preparation for the circulation of the pandemic H1N1 virus. Though the
guidance does not change the groups indicated for PPSV vaccination, it
does remind providers that many at-risk people younger than age 65 years
and many people who are age 65 and older have not yet been
vaccinated--and they need to be. For more information on PPSV vaccination, including a listing of the high-risk people recommended to be vaccinated, read IAC's professional education sheet
"Pneumococcal polysaccharide vaccine (PPSV): CDC answers your questions" (see www.immunize.org/catg.d/p2015.pdf). |
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| Can you please explain when and why
the recommendations for vaccination were changed for persons with asthma
and for cigarette smokers? |
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| The 1997 CDC recommendations for the use
of PPSV exclude asthma in the chronic pulmonary disease category because
no data on increased risk of pneumococcal disease among persons with
asthma were available when the recommendation was issued. At its June
2008 meeting, the Advisory Committee on Immunization Practices (ACIP)
reviewed new information that suggests that asthma is an independent
risk factor for pneumococcal disease among adults. At its October 2008
meeting, ACIP reviewed new information that demonstrates an increased
risk of pneumococcal disease among smokers. Consequently, ACIP voted to
include both asthma and cigarette smoking as risk factors for
pneumococcal disease among adults age 19 through 64 years and as
indications for PPSV. |
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| My patient doesn't remember if he
ever was vaccinated with PPSV and we can't locate a record of
vaccination. What should we do? |
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| Providers should not withhold
pneumococcal polysaccharide vaccination in the absence of an
immunization record or complete record. Persons with uncertain or
unknown vaccination status should be vaccinated. |
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| Is there any reason to withhold pneumococcal
vaccine from a healthy 45-year old who requests it to decrease
his/her risk of this disease? |
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| No, although ACIP does not routinely
recommend pneumococcal vaccine for healthy
persons of this age. |
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| I've heard pneumococcal vaccine (PPSV)
isn't very effective. Should I use it? |
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| Yes. PPSV vaccine is 60%-80% effective
against invasive pneumococcal disease when it is given to immunocompetent
persons age 65 years and older or people
with chronic illnesses. The vaccine is
less
effective in immunodeficient people. So, although PPSV is not as effective as
some other vaccines, it can significantly lower the risk of serious pneumococcal
disease and its complications in most recipients. |
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| In its September 2010
publication of updated recommendations for prevention of invasive
pneumococcal disease among adults, ACIP recommends immunizing adult
asthmatics with PPSV. Should I give PPSV to people with mild,
intermittent asthma or exercise-induced asthma? Why isn't PPSV
recommended for asthmatic children? |
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| PPSV is recommended for adults 19 years
and older with all types of asthma. Available data do not indicate that
asthma alone increases the risk of invasive pneumococcal disease among
persons younger than 19 years, so PPSV is not currently recommended for
persons younger than 19 years with asthma. For more information, go to www.cdc.gov/mmwr/preview/mmwrhtml/mm5934a3.htm. |
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| Should persons who are HIV positive
receive pneumococcal polysaccharide vaccine? |
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| Yes. Persons with HIV infection should
receive the vaccine as soon as possible after diagnosis and a one-time
revaccination dose at the appropriate interval.
The risk of pneumococcal infection is up to 100 times greater in HIV-infected
persons than in other adults of similar age. Although severely immunocompromised
persons may not respond well to the vaccine, and there is a chance that the vaccine
may not produce an antibody response, the risk of disease is great enough to
warrant vaccination. |
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| Is pneumococcal polysaccharide vaccine
safe to administer to patients with multiple sclerosis? |
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| Multiple sclerosis is not a contraindication to any vaccine, including
pneumococcal vaccine. |
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| How often should diabetic patients
receive pneumococcal polysaccharide vaccine? |
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| Persons with diabetes who are ages 2-64
years who have not already received a dose of pneumococcal vaccine
should receive one now. At age 65 years they should
receive a one-time revaccination if 5 years
have elapsed since the previous dose. |
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| We have a newly diagnosed diabetic
who was given the first dose of PPSV at age 65 years. Should I give him
a second dose in 5 years because of his chronic disease? |
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| No. People who are vaccinated with
PPSV23 at age 65 years and older should receive only one dose. |
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| How often should adult dialysis patients
receive pneumococcal polysaccharide vaccine? |
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| Adult dialysis patients younger than age
65 years need a dose of pneumococcal vaccine followed by a one-time
revaccination 5 years later. If they were age 65 years or older when
first vaccinated, only one dose of PPSV is recommended. |
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| When should I vaccinate persons who
are planning to have either a cochlear implant or
elective splenectomy? |
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| If time permits, give PPSV to such patients at least 2 weeks before
surgery. |
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| My patient has had laboratory-confirmed
pneumococcal pneumonia. Does he/she still need to
be vaccinated? |
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| There are more than 90 known serotypes
of pneumococcus (23 serotypes are in the current vaccine). Infection
with one serotype does not necessarily produce immunity
to other serotypes. As a result, if the person is a candidate for vaccination,
s/he should receive it even after one or more episodes of invasive pneumococcal
disease. |
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| Should all nursing home patients ages
65 years and older be vaccinated against
pneumococcal disease? |
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| Yes. Standing orders for vaccination
of persons admitted to long term care facilities can help simplify
the procedure. Providers should not withhold vaccination in
the absence of documentation of previous vaccination. The patient's verbal history
should be used to determine prior vaccination status. Persons with uncertain
or unknown vaccination status should be vaccinated. |
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| If influenza is recommended for healthcare
workers to protect high-risk patients from getting influenza, why
isn't pneumococcal vaccine also recommended? |
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| Influenza virus is easily
spread from healthcare workers to their patients, and infection usually
leads to
clinical
illness. Pneumococcus is probably not spread from healthcare workers to their
patients as easily as is influenza, and infection with pneumococcus does not
necessarily lead to clinical illness. Host factors (such as age, underlying illness)
are more important in the development of invasive pneumococcal disease than nasopharyngeal
colonization with the organism. When you're giving influenza vaccine to your
patients in the fall, don't forget to assess their need for pneumococcal vaccine
as well as all other vaccines. |
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| Could you briefly summarize the recommendations
for PPSV revaccination? |
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| A one-time revaccination 5 years after
the first dose is recommended for 1) children and adults younger than
age 65 years at highest risk for serious pneumococcal infection or who
are likely to have a rapid decline in antibody levels (see below) and 2)
adults age 65 years and older who received their first dose for any
indication when they were younger than age 65 years. Adults who receive
PPSV at or after age 65 years should receive only a single dose.
Persons at highest risk include
children age two years and older and adults with functional or
anatomic asplenia, HIV infection, leukemia, lymphoma, Hodgkin's
disease, multiple myeloma, generalized malignancy, chronic renal
failure, nephrotic syndrome, or other conditions associated with
immunosuppression (such as organ or bone marrow transplantation), and
those receiving immunosuppressive chemotherapy, including long-term
corticosteroids. |
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| Some physicians in our area order
PPSV every 5 years for their patients. Is this correct? |
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| No. CDC recommends 1 dose of PPSV for
most people in a lifetime and 2 doses for certain people. PPSV is a
polysaccharide vaccine that does not boost well, and data do not
indicate that more than 2 doses are beneficial. IAC has a handy summary
piece about the use of PPSV vaccine at www.immunize.org/catg.d/p2015.pdf. For detailed information, see the
1997 ACIP recommendations on prevention of pneumococcal disease at ftp://ftp.cdc.gov/pub/Publications/mmwr/RR/RR4608.pdf. Also see the
2008 provisional recommendations at www.cdc.gov/vaccines/recs/provisional. |
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| I continue to see conflicting advice
for giving pneumococcal vaccine to patients who do not have a spleen. Do
they get re-immunized with pneumococcal polysaccharide vaccine (PPSV)
every 5 years, or do they get only 1 additional dose in their lifetime? |
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| Giving pneumococcal vaccine
every 5 years is a widespread myth; ACIP has never recommended an
every-5-year schedule. People with asplenia age 2 years and older should
receive a lifetime total of 2 doses of PPSV separated by a minimum of 5
years. Here is a good resource: www.immunize.org/catg.d/p2015.pdf |
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| Should a healthy 75-year-old patient
who was given PPSV at age 65 years be revaccinated? |
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| No. Adults who were first vaccinated at
age 65 years or older need only one dose. An excellent fact sheet on
pneumococcal polysaccharide vaccination and revaccination is available
on the IAC website at www.immunize.org/catg.d/p2015.pdf |
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| What route and needle length is recommended
for administration of pneumococcal
polysaccharide vaccine? |
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| Pneumococcal polysaccharide vaccine may
be given either by intramuscular (IM)
or subcutaneous
(SC) injection. When administration is IM, a 1-1½" needle is recommended
for adults, depending on muscle
mass. When administration is SC, a 5/8" needle is recommended. |
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| If I give pneumococcal polysaccharide
vaccine to my patient now, how long must I wait before giving the
influenza, Td, or zoster (shingles) vaccines? |
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| PPSV, injectable influenza (TIV), and Td
are all inactivated products while zoster is a live attenuated vaccine.
ACIP states that an inactivated vaccine can be given at the same time or
at any time before or after a different inactivated vaccine or a live
vaccine. For the most current information, see General Recommendations
on Immunization at www.cdc.gov/vaccines/pubs/ACIP-list.htm. |
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| Reviewed on November 16. 2010 |
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