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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 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). |
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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 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%. |
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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 upcoming influenza season. Though the interim 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. You can find the interim guidance statement at www.cdc.gov/h1n1flu/guidance/ppsv_h1n1.htm.
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. The new recommendations will be included in the
2009 Recommended Adult Immunization Schedule, due to be published in
January 2009. |
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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 provisional
pneumococcal recommendations 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. |
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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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| How often should adult dialysis patients
receive pneumococcal polysaccharide vaccine? |
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| Adult dialysis patients need a dose of
pneumococcal vaccine followed by a one-time
revaccination 5
years later. |
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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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| I had my spleen removed as a
teenager. I have been getting PPSV vaccine every 5 years because my
doctor recommends it, but this doesn't agree with what the IAC website
says. Which is right? |
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| No more than 2 lifetime doses of PPSV
vaccine are recommended for anyone. Unfortunately, many healthcare
providers seem to believe that more is better when it comes to PPSV. For
the facts, read Pneumococcal Polysaccharide Vaccine (PPSV): CDC Answers
Your Questions at
www.immunize.org/catg.d/p2015.pdf |
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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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| 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. |
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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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| Should a healthy 75-year-old patient
who was given PPSV at age 65 years be revaccinated? |
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| No, he would only need revaccination
if he has developed a high-risk condition after receiving the first
dose of PPSV. 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 more information, click here to
see General Recommendations
on Immunization, 2006 (MMWR 2006; 55[RR-15]:6). |
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| Reviewed on 10/09 |
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