Pneumococcal disease prevention
Author Dr Penny Abbott
Expert reviewer Professor Anne Chang
The pneumococcus Streptococcus pneumoniae, is a Gram positive bacterium with more than 90 serotypes determined by the polysaccharide composition of its capsule. It is carried by 50% of the population. It can cause noninvasive disease such as otitis media and bronchitis and can cause serious illness through invasive pneumococcal disease (IPD): diseases such as pneumonia, meningitis and septicaemia. Among infectious illnesses, IPD is a leading cause of morbidity and mortality in children and adults.1,2 Pneumococcal pneumonia is the most common clinical presentation of IPD in adults, while bacteraemia accounts for more than two-thirds of cases in children.2 Pneumonia commonly occurs in people with pre-existing illnesses, such as chronic obstructive pulmonary disease (COPD), chronic renal failure, alcoholism and diabetes, and deaths from pneumonia are most common in people with chronic respiratory disease or in the elderly.3 IPD in children is more common in those with immune deficiency and chronic disease.1
Aboriginal and Torres Strait Islander children and adults have a significantly higher incidence of all pneumococcal disease than non-Indigenous Australians, but detailed data are available only for IPD, which has been notifiable Australia wide since 2001.4 The risk of IPD in Aboriginal and Torres Strait Islander children under the age of 5 years is doubled and in young adults is raised 11-fold compared to non-Indigenous people. Pneumonia is the most common communicable disease contributor to premature death in Aboriginal adults.4 Hospitalisation for pneumonia is four times more common in Aboriginal and Torres Strait Islander people than in non-Indigenous Australians and up to eight times higher in younger Aboriginal and Torres Strait Islander adults.3,4
Pneumococcal immunisation is indicated for those most at risk of initially contracting or developing serious complications from infection. Immunisation with the 23-valent pneumococcal polysaccharide vaccine (23vPPV) is funded for all Aboriginal and Torres Strait Islander people aged ≥50 years and for those aged 15–49 years who have high risk underlying conditions. These high risk conditions include being a current smoker, suffering alcohol related disease or having a chronic disease such as COPD, chronic renal failure or diabetes.3,5 A single revaccination is recommended after 5 years, and a second revaccination is recommended at either 5 years after the first revaccination or at 50 years of age (whichever is later) for those with high risk conditions.2 Although the Therapeutic Goods Administration issued precautionary advice early in 2011 not to administer a second dose of Pneumovax 23 due to concern regarding increased local reactions, the most recent statement at the time of writing now recommends to revaccinate as per previous advice.6
Despite these indications, the overall health benefits of pneumococcal vaccination in otherwise healthy adults remain uncertain. Vaccination appears to be most beneficial for people with chronic disease, particularly COPD and bronchiectasis.7–9 Pneumococcal immunisation is known to be effective in preventing invasive bacteraemic pneumococcal pneumonia, but may be less effective in immunosuppressed patients.2,7,10,11 Population level health benefits have been seen since pneumococcal immunisation of Aboriginal and Torres Strait Islander adults and children became funded nationally in 1999 and 2001 respectively. In 2004, the rate of IPD in children younger than 2 years had decreased in Indigenous children (91.5 per 100 000) to become similar to their non-Indigenous peers (93.6 per 100 000).2 The effects of pneumococcal vaccination on adults are not as substantial and clear as in children, and may be in part due to the indirect effects of improved herd immunity from childhood vaccination.4,12,13 There are ongoing studies into which vaccines are likely to be most effective in preventing pneumococcal disease in adults,14,15 and into the changing prevalence of different pneumococcal serotypes as a result of vaccination.13,16 Although this improvement in outcomes is encouraging, Aboriginal and Torres Strait Islander people of all ages continue to suffer higher rates of pneumococcal disease compared with non-Indigenous people, despite the immunisation programs in place.4,17
Immunisation programs targeting Aboriginal and Torres Strait Islander people demonstrate substantially lower coverage than recommended, particularly for adults where the indications are based on presence of risk factors rather than age.4 In many Aboriginal and Torres Strait Islander communities, overall immunisation coverage is higher than that in non-Indigenous settings but the timeliness of recommended immunisations lags behind, leaving children underimmunised for their age.18 Thus, lack of apparent effect of the 23vPPV in the prevention of IPD and pneumonia in at risk Aboriginal and Torres Strait Islander people may be related to poor uptake rather than vaccine failure.13,19 Surveillance studies in Queensland provide ‘circumstantial evidence’ for both indirect and direct positive effect of pneumococcal immunisation in Aboriginal and Torres Strait Islander adults, though there has been an accompanying rise in different serotypes of pneumococcal disease in adults.13
There is a strong evidence base for the effectiveness of recall and reminder systems in promoting immunisation in primary care.20 Primary care, community based strategies to improve the uptake of adult pneumococcal vaccination are therefore recommended (see Chapter 2: Child health, for childhood vaccination recommendations).
Recommendations: Pneumococcal disease prevention
|Preventive intervention type||Who is at risk?||What should be done?||How often?||Level/strength of evidence|
||Healthy adults aged ≥50 years
See also Chapter 2: Child health, for childhood vaccination recommendations
|Pneumococcal vaccine (23vPPV) is recommended for the prevention of invasive pneumococcal disease
A second vaccination is recommended 5 years later
|People aged 15–49 years who are smokers or have an underlying high risk conditions (eg. chronic cardiac, renal or lung disease, diabetes, alcohol related problems, immunosuppression)
||Pneumococcal vaccine (23vPPV) is recommended for the prevention of invasive pneumococcal disease
A second vaccination is required 5 years later
A third vaccination is recommended 5 years later or at 50 years of age (whichever is later)
||Promote primary care, community based strategies to improve pneumococcal vaccination uptake and timeliness, particularly the implementation of reminder/recall systems
||Promote community awareness of benefits and timeliness of vaccines and enhancing access to vaccination services
- Randle E, Ninis N, Inwald D. Invasive pneumococcal disease. Archives of disease in childhood. Education and practice edition 2011;96(5):183–90.
- National Health and Medical Research Council. The Australian immunisation handbook, 9th edn. Canberra: Commonwealth of Australia, 2008. Cited October 2011. Available at www.health.gov.au/ internet/immunise/publishing.nsf/ content/handbook-home.
- Australian Institute of Health and Welfare. Asthma, chronic obstructive pulmonary disease and other respiratory diseases in Australia. Canberra: AIHW, 2010.
- Menzies R, Turnour C, Chiu C, McIntyre P, Department of Health and Ageing. Vaccine preventable diseases and vaccination coverage in Aboriginal and Torres Strait Islander people, Australia 2003–2006. Communicable Diseases Intelligence, National Centre for Immunisation Research and Surveillance of Vaccine preventable diseases, 2008.
- Pesek R, Lockey R. Vaccination of adults with asthma and COPD. Allergy 2011;66(1):25–31.
- Australian Technical Advisory Group on Immunisation. Updated recommendations for revaccination of adults with 23-valent pneumococcal polysaccharide vaccine (23vPPV), Pneumovax 23®, 2011. Cited January 2012. Available at http://immunise.health.gov.au/ internet/immunise/publishing.nsf/Content/pneumo23 -atagi-statement-cnt.htm.
- Moberley SA, Holden J, Tatham DP, Andrews RM. Vaccines for preventing pneumococcal infection in adults. Cochrane Database Syst Rev 2008;Jan 23;(1):CD000422.
- Walters JA, Smith S, Poole P, Granger RH, Wood-Baker R. Injectable vaccines for preventing pneumococcal infection in patients with chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2010;Nov 10;(11):CD001390.
- Chang CC, Singleton RJ, Morris PS, Chang AB. Pneumococcal vaccines for children and adults with bronchiectasis. Cochrane Database Syst Rev 2009;Apr 15;(2):CD006316.
- Simberkoff MS, Cross AP, Al-Ibrahim M, et al. Efficacy of pneumococcal vaccine in high-risk patients. Results of a Veterans Administration Cooperative Study. N Engl J Med 1986;315(21):1318–27.
- McKenzie DK, Abramson M, Crockett AJ, et al. The COPD-X Plan: Australian and New Zealand guidelines for the management of chronic obstructive pulmonary disease 2011. COPDX, 2011. Cited October 2011. Available at www.copdx.org.au.
- Hanna JN, Humphreys JL, Murphy DM. Invasive pneumococcal disease in Indigenous people in north Queensland: an update,2005–2007. Med J Aust 2008;189(1):43–6.
- Hanna JN, Humphreys JL, Murphy DM, Smith HV. Invasive pneumococcal disease in non-Indigenous people in north Queensland, 2001–2009. Med J Aust 2010;193(7):392–6.
- Andrews RM, Counahan ML, Hogg GG, McIntyre PB. Effectiveness of a publicly funded pneumococcal vaccination program against invasive pneumococcal disease among the elderly in Victoria, Australia. Vaccine 2004;23(2):132–8.
- Vila-Corcoles A. Advances in pneumococcal vaccines: what are the advantages for the elderly? Drugs Aging 2007;24(10):791–800.
- Ansaldi F, De Florentiis D, Canepa P, Durando P, Bassetti M, Icardi G. Serotype replacement in Streptococcus pneumoniae after conjugate vaccine introduction: impact, doubts and perspective for new vaccines. Rev Med Microbiol 2010;21(3):56–64.
- Hanna JN, Humphreys JL, DM M. Hanna JN, Humphreys JL, Murphy DM. Invasive pneumococcal disease in Indigenous people in north Queensland,1999–2004. Med J Aust 2006;184:118–21.
- O’Grady KA, Krause V, Andrews R. Immunisation coverage in Australian Indigenous children: Time to move the goal posts. Vaccine 2009 Jan 7;27(2):307–12.
- Moberley S, Krause V, Cook H, et al. Failure to vaccinate or failure of vaccine? Effectiveness of the 23-valent pneumococcal polysaccharide vaccine program in Indigenous adults in the Northern Territory of Australia. Vaccine 2010;28(11):2296–301.
- Jacobson V, Szilagyi P. Patient reminder and patient recall systems to improve immunization rates. Cochrane Database Syst Rev 2005;Jul 20;(3):CD003941.
- Centers for Disease Control and Prevention. Updated recommendations for prevention of invasive pneumococcal disease among adults using the 23-valent pneumococcal polysaccharide vaccine (PPSV23). MMWR Morb Mortal Wkly Rep (serial on the internet), 2010;59(34). Cited October 2011. Available at www.cdc.gov/ mmwr/preview/mmwrhtml/mm5934a3.htm.
- Management of COPD Working Group. VA/DoD clinical practice guideline for the management of outpatient chronic obstructive pulmonary disease. Washington: Department of Veterans Affairs, Department of Defense, 2007.
- Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Bethesda: Global Initiative for Chronic Obstructive Lung Disease, 2009. Cited October 2011. Available at www.guideline.gov/content.aspx?id=25648.
- Granger R, Walters J, Poole PJ, et al. Injectable vaccines for preventing pneumococcal infection in patients with chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2006;Oct 18;(4):CD001390.
- Guide to Community Preventive Services. Universally recommended vaccinations: community-based interventions implemented in combination (abbreviated). The Community Guide, 2010. Cited October 2011. Available at www.thecommunityguide.org/ vaccines/universally/communityinterv entions.html.