Home
|
About IAC
|
Contact
|
A-Z Index
|
Donate
|
Shop
|
SUBSCRIBE
Immunization Action Coalition

Ask the Experts

Pneumococcal polysaccharide vaccine (PPSV)

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 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).
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 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%.
General information about PPSV 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 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.
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.
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?
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).
Can you please explain when and why the recommendations for vaccination were changed for persons with asthma and for cigarette smokers?
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.
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?
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.
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 (PPSV) isn't very effective. Should I use it?
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.
For persons with high-risk conditions Back to top
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?
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.
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.
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?
No. People who are vaccinated with PPSV23 at age 65 years and older should receive only one dose.
How often should adult dialysis patients receive pneumococcal polysaccharide vaccine?
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.
When should I vaccinate persons who are planning to have either a cochlear implant or elective splenectomy?
If time permits, give PPSV 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 PPSV revaccination?
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.
Some physicians in our area order PPSV every 5 years for their patients. Is this correct?
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.
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?
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
Should a healthy 75-year-old patient who was given PPSV at age 65 years be revaccinated?
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
Administering PPSV 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?
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.
Reviewed on November 16. 2010
Immunization Action Coalition  •  1573 Selby Ave  •  St. Paul, MN 55104
tel 651-647-9009  •  fax 651-647-9131
 
This website is supported in part by a cooperative agreement from the National Center for Immunization and Respiratory Diseases (Grant No. 5U38IP000290) at the Centers for Disease Control and Prevention (CDC) in Atlanta, GA. The website content is the sole responsibility of IAC and does not necessarily represent the official views of CDC.