Pneumococcal disease Back to top

What causes pneumococcal disease?

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.

How does pneumococcal disease spread?

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.

How long does it take to show signs of pneumococcal disease after being exposed?

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.

What are the types of invasive pneumococcal disease?

There are two major types of invasive pneumococcal disease: sepsis, 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 sepsis 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 sepsis occurs in about 25%-30% of patients with pneumococcal pneumonia. More than 50,000 cases of pneumococcal sepsis occur each year in the United States. Sepsis 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).

How serious is pneumococcal disease in the U.S?

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 5,500 deaths from invasive pneumococcal diseases (bacteremia and meningitis) are estimated to have occurred in the United States in 2002. More than half of these cases occurred in adults who had an indication for pneumococcal polysaccharide vaccine. Young children and the elderly (less than five 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%.

General information about PPV Back to top

For whom is pneumococcal polysaccharide vaccine recommended?

Pneumococcal polysaccharide vaccine is recommended for all adults who are age 65 years and older. It is also recommended 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, diabetes mellitus, alcoholism, cirrhosis, or cerebrospinal fluid leaks) or are a candidate for or recent recipient of a cochlear implant. 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). Persons living in special environments or social settings with an identified increased risk from pneumococcal infection (e.g., certain Alaskan Natives and American Indian populations) should also be vaccinated. The vaccine is not indicated for patients having recurrent acute upper respiratory tract infections, such as otitis media and sinusitis.

My patient doesn't remember if he ever was vaccinated with PPV and we can't locate a record of vaccination. What should we do?

Providers should not withhold vaccination in the absence of an immunization record or complete record. For pneumococcal vaccine, the patient's verbal history can be used to determine vaccination status. Persons with uncertain or unknown vaccination status should be vaccinated.

If a high-risk child is indicated to receive both the pneumococcal conjugate (PCV) and pneumococcal polysaccharide (PPV) vaccines, at what intervals should they be administered?

ACIP recommends that PCV and PPV be separated by at least 8 weeks. Give PCV first and then wait 8 weeks before giving PPV. For more information, click here to see the ACIP statement on PCV (MMWR 1999; 49[RR-9]:26-27).

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?

No, although ACIP does not routinely recommend pneumococcal vaccine for healthy persons of this age.

I've heard pneumococcal vaccine (PPV23) isn't very effective. Should I use it?

Yes. PPV23 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 PPV23 is not as effective as some other vaccines, it can significantly lower the risk of serious pneumococcal disease and its complications in most recipients.

For persons with high-risk conditions Back to top

Should people with asthma receive pneumococcal vaccine?

Asthma is not an indication for routine pneumococcal vaccination unless it occurs with chronic bronchitis, emphysema, or long-term systemic corticosteroid use. However, all persons with chronic obstructive lung disease should be vaccinated regardless of the cause.

Are smokers at increased risk for pneumococcal disease? Should they be vaccinated?

A study of patients with invasive pneumococcal disease during 1995-1996 identified cigarette smoking as a strong independent risk factor for invasive pneumococcal disease among immunocompetent non-elderly adults (Nuorti et al. NEJM 2000; 342[10]:681-9). However, ACIP does not currently recommend routine pneumococcal vaccination for people just because they smoke. People who smoke (sooner or later) develop chronic obstructive lung disease, heart disease, and/or various types of cancer. When end organ damage occurs, the person becomes a candidate for pneumococcal polysaccharide vaccine.

Should persons who are HIV positive receive pneumococcal polysaccharide vaccine?

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.

Is pneumococcal polysaccharide vaccine safe to administer to patients with multiple sclerosis?

Multiple sclerosis is not a contraindication to any vaccine, including pneumococcal vaccine.

How often should diabetic patients receive pneumococcal polysaccharide vaccine?

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.

How often should adult dialysis patients receive pneumococcal polysaccharide vaccine?

Adult dialysis patients need a dose of pneumococcal vaccine followed by a one-time revaccination 5 years later.

When should I vaccinate persons who are planning to have either a cochlear implant or elective splenectomy?

If time permits, give PPV to such patients at least 2 weeks before surgery.

My patient has had laboratory-confirmed pneumococcal pneumonia. Does he/she still need to be vaccinated?

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.

Should all nursing home patients ages 65 years and older be vaccinated against pneumococcal disease?

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.

If influenza is recommended for healthcare workers to protect high-risk patients from getting influenza, why isn't pneumococcal vaccine also recommended?

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.

Recommendations for revaccination Back to top

Could you briefly summarize the recommendations for PPV revaccination?

The revaccination recommendations were modified slightly by ACIP in their 1997 statement (MMWR 1997; 46[RR-8]:1-24). Revaccination with pneumococcal polysaccharide vaccine is not routinely recommended for all healthy persons age 65 years and older. A one-time revaccination should be considered for adults at highest risk for serious pneumococcal infection and persons likely to have a rapid decline in antibody levels, provided at least five years have passed since receipt of the first dose of pneumococcal vaccine. 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. Persons age 65 years and older should be administered a second dose of pneumococcal vaccine if they received the vaccine more than five years previously, and were less than age 65 years at the time of the first dose.

Should a healthy 75-year-old patient who was given PPV at age 65 years be revaccinated?

No, he would only need revaccination if he has developed a high-risk condition after receiving the first dose of PPV. An excellent fact sheet on pneumococcal polysaccharide vaccination and revaccination is available on the IAC website at www.immunize.org/catg.d/2015pne.pdf

Administering PPV Back to top

What route and needle length is recommended for administration of pneumococcal polysaccharide vaccine?

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.

If I give pneumococcal polysaccharide vaccine to my patient now, how long must I wait before giving the influenza, Td, or zoster (shingles) vaccines?

PPV, 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 more information, click here to see General Recommendations on Immunization, 2006 (MMWR 2006; 55[RR-15]:6).

Reviewed on 12/06