National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people


Chapter 9: Respiratory health
Pneumococcal disease prevention
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☰ Table of contents


Recommendations: Pneumococcal disease prevention

Preventive intervention type

Who is at risk?

What should be done?

How often?

Level/ strength of evidence

References

Immunisation

All children Recommend 13-valent pneumococcal conjugate vaccine (13vPCV) at two, four and six months of age As part of the routine childhood vaccination schedule




 
IA 1
Aboriginal and Torres Strait Islander children aged 12–18 months in Queensland, Northern Territory, Western Australia and South Australia Recommend an additional 13vPCV dose IA 1
Medically at-risk children aged <5 years regardless of geographical location
(Box 1)
 
Recommend an additional 13vPCV at age 12–18 months* IA 1
Recommend 23-valent pneumococcal polysaccharide vaccine (23vPPV) at age four years IA 1
Medically at-risk children aged 5–18 years Recommend second dose of 23vPPV

Time period varies according to risk – Category A (five years after the first dose) and Category B (10 years after the first dose) (Box 1); consult The Australian immunisation handbook for details
IA 1
Aboriginal and Torres Strait Islander children aged 15 years in Northern Territory Recommend 23vPPV (this should be considered the first adult dose) IA 1
Those aged >18 years with the highest increased risk of invasive pneumococcal disease (Box 1, Category A conditions) Recommend 13vPCV Schedule is complex – refer to The Australian immunisation handbook IA 1
Those aged >18 years with increased risk of invasive pneumococcal disease (Box 1, Category B conditions) Recommend 23vPPV Give and repeat vaccination five years later. A third dose may be needed at age 50 years (refer to The Australian immunisation handbook) IA 1
Aboriginal and Torres Strait Islander people aged ≥50 years Recommend 23vPPV Give as part of annual health assessment and repeat vaccination five years later

Provide no more than three adult doses in lifetime
  1

Environmental

Communities Reduce environmental risk factors for pneumococcal disease, such as exposure to tobacco smoke, overcrowding, poor nutrition, lack of breastfeeding, poor respiratory hygiene, contact with chidren/pets, sudden changes in temperature   IIIB 15, 16, 17
Promote primary care, community-based strategies to improve pneumococcal vaccination uptake and timeliness, particularly using reminder/ recall systems, provider prompts, provider audit and feedback   IB 12, 14
Activities should also focus on increasing community awareness of benefits and timeliness of vaccines and enhancing access to vaccination services (home visits, clinics in public settings, reduced costs)   GPP 12, 13, 14
*For any child, only one booster dose of 13vPCV is required in the second year of life

 

Box 1. Conditions associated with an increased risk of invasive pneumococcal disease (IPD) in children and adults, by severity of risk*1

Category A: Conditions associated with the highest increased risk of IPD

  • Functional or anatomical asplenia
  • Immunocompromising conditions, including:
    • congenital or acquired immune deficiency
    • immunosuppressive therapy (including corticosteroid therapy ≥2 mg/kg per day of prednisolone or equivalent for more than one week)
    • radiation therapy, where there is sufficient immune reconstitution for vaccine response to be expected
  • Haematological and other malignancies
  • Solid organ transplant
  • Human immunodeficiency virus (HIV) infection (including acquired immune deficiency syndrome [AIDS])
  • Chronic renal failure, or relapsing or persistent nephrotic syndrome
  • Proven or presumptive cerebrospinal fluid leak
  • Cochlear implants
  • Intracranial shunts

Category B: Conditions associated with an increased risk of IPD

  • Chronic cardiac disease, particularly cyanotic heart disease or cardiac failure in children
  • Chronic lung disease, including:
    • cystic fibrosis
    • severe asthma in adults (requiring frequent hospital visits and use of multiple medications)
  • Diabetes mellitus
  • Down syndrome
  • Alcoholism
  • Chronic liver disease
  • Tobacco smoking

*Please refer to the full and most up-to-date table (Table 4.13.1) in The Australian immunisation handbook1 for details.



Background


The pneumococcus, Streptococcus pneumoniae, is a Gram-positive bacterium with more than 90 serotypes determined by the polysaccharide composition of its capsule, each eliciting type-specific immunity in the host. The mucosal surface of the upper respiratory tract is colonised in humans (mostly asymptomatically) in 50% of the population and spread person to person by respiratory droplets.1 After colonisation of the nasopharynx, local spread may occur to cause otitis media (most common manifestation in children) or sinusitis; by inhalation to cause bronchitis/pneumonia (estimated to account for one-third of communityacquired pneumonia); or via the bloodstream to other sites including bones, joints and soft tissues, resulting in invasive pneumococcal disease (IPD).1 The most common presentations of IPD are septicaemia (approximately 70% of presentations in children), meningitis (most severe category with a case fatality rate of 30%) or bacteremic pneumonia (thought to be up to half of hospitalised pneumonia in adults).1 IPD is a leading cause of morbidity and mortality in children and adults.2–4

The highest risk of IPD is in those who are immunocompromised or have functional/anatomical asplenia, the presence of a cerebrospinal fluid leak or cochlear implants. Increased risk or severity of IPD is associated with other chronic medical conditions (eg chronic respiratory diseases, chronic heart disease, chronic liver disease, diabetes mellitus), household crowding, active or passive exposure to tobacco smoke, excessive alcohol consumption, prematurity and childcare attendance. The highest incidence of IPD is seen in children aged <5 years and the elderly.4 Like other respiratory illnesses there is a distinct seasonal trend, with peak incidence in the winter months.5

Aboriginal and Torres Strait Islander people in all age groups have a significantly higher incidence of all pneumococcal disease than non-Indigenous Australians. Detailed data are available only for IPD, which has been notifiable Australia-wide since 2001.6 Rates of notification for IPD declined in non-Indigenous people from 2005 and onwards when universal childhood pneumococcal conjugate vaccination and adult polysaccharide vaccine were introduced.5 However, during the period 2005–14, the notification rate of IPD in Aboriginal and Torres Strait Islander people remained 4–8 times higher than for other Australians.5

Hospitalisations coded as pneumococcal pneumonia are a potential indicator of the burden of non-invasive pneumococcal infections, and changes in the rates of these hospitalisations may reflect the effect of pneumococcal vaccines on non-invasive disease.6 There have been substantial overall reductions in IPD and some impact on pneumonia hospitalisations in Aboriginal and Torres Strait Islander children since the introduction of vaccination. Impacts in Aboriginal and Torres Strait Islander adults have been less obvious and may be due in part to the indirect effects of improved herd immunity from childhood vaccination.5,7 Also, while there has been a reduction in the number of hospital procedures for otitis media in non-Indigenous children, no such reductions have been observed for Aboriginal and Torres Strait Islander children.6


Interventions


Currently there are two types of pneumococcal vaccine: conjugate and polysaccharide. Conjugate vaccines are immunogenic in young infants and induce an immune memory response; the vaccine used in the National Immunisation Program Schedule (NIPS) for children since 2011 contains 13 serotypes (13-valent pneumococcal conjugate vaccine [13vPCV]). The polysaccharide vaccine is poorly immunogenic for most serotypes in children aged <2 years and does not induce immune memory; however, it contains 23 serotypes (23-valent pneumococcal polysaccharide vaccine [23vPPV]).1 In older people who are not immunocompromised, 23vPPV induces a significant immune response.

13vPCV is recommended and funded under the National Immunisation Program (NIP) at two, four and six months of age. The two-month dose may be given at six weeks of age. Because of the increased burden of disease in Aboriginal and Torres Strait Islander children living in Queensland, Northern Territory, Western Australia and South Australia, a booster is recommended and funded at 12–18 months of age. For any medically at-risk children, a fourth dose of 13vPCV is given at 12 months of age with a booster dose of 23vPPV at four years of age.1

For those aged 5–18 years who have received a primary vaccination course, further pneumococcal immunisation is only indicated for those at increased risk of contracting or developing serious complications from infection. In the Northern Territory, a dose of 23vPPV is provided to all young people at around age 15 years based on the very high incidence of IPD in this sub-population; this dose should be considered an adult dose. Please refer to the current The Australian immunisation handbook for the specific increased risk conditions for other children in this age group.1 These are categorised as Category A if considered at the highest risk and Category B if considered at higher risk, and revaccination guidelines depend on the categorisation for these medically at-risk children (Box 1).

Adults (≥18 years) with medical conditions only in Category A (highest risk) are recommended to have a single dose of 13vPCV. For those with a new diagnosis of a severe Category A condition in this age group, a 13vPCV should be given upon diagnosis, with a follow-up dose of 23vPPV two months later. For those with pre-existing Category A conditions who may have received one or more prior doses of 23vPPV, the 13vPCV should be given at least 12 months after the most recent dose of 23vPPV. Currently, adults in Category B are not recommended to receive a dose of conjugate vaccine.1
Immunisation with 23vPPV is funded for all Aboriginal and Torres Strait Islander people aged ≥50 years. This is based on the increased risk of IPD in Aboriginal and Torres Strait Islander adults compared with nonIndigenous adults, and the high prevalence of conditions associated with an increased risk of IPD (including tobacco smoking) in Aboriginal and Torres Strait Islander adults >50 years of age, compared with younger ages. A second dose of 23vPPV is recommended five years after the first dose. No more than three lifetime adult doses of 23vPPV are recommended based on limited data on adverse events and effectiveness, as well as uncertainty regarding the clinical significance of blunting of antibody response (immune hyporesponsiveness) following revaccination with 23vPPV, especially with multiple revaccinations.1,8 Please also refer to The Australian immunisation handbook1 for recommendations for pneumococcal vaccination for Aboriginal and Torres Strait Islander people aged ≥50 years with higher (Category B) or highest risk (Category A) conditions.

The CAPITA study in The Netherlands showed that vaccinating older adults with 13vPCV was effective in preventing vaccine-type pneumococcal, bacteremic, and nonbacteremic community-acquired pneumonia and vaccine-type invasive pneumococcal disease but not in preventing community-acquired pneumonia from any cause.9 As a result of this study, the Advisory Committee on Immunisation Practices in the US then recommended that 13vPCV should be administered in series with 23vPPV to elderly adults.10 As yet, a recommendation for older Australians to have pneumococcal conjugate vaccines has not yet been made in Australia, and this may be a reflection of the varying and prevalent serotypes and the benefits provided to adults from herd immunity from the childhood pneumococcal vaccine schedule.

Aboriginal and Torres Strait Islander people of all ages have higher rates of pneumococcal disease compared with non-Indigenous people, despite the immunisation programs in place.4–6 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.6,11 In many Aboriginal and Torres Strait Islander communities, overall immunisation coverage is higher than that in nonIndigenous settings but the timeliness of recommended immunisations lags behind, leaving children underimmunised for their age.11 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.6 There is a strong evidence base for the effectiveness of recall and reminder systems in promoting immunisation in primary care,12 and good evidence for provider prompts, provider audit and feedback.13,14 Activities should also focus on increasing community awareness of benefits and timeliness of vaccinations and enhancing access to vaccination services (home visits, clinics in public settings, reduced costs).13,14


 

National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people

 





 
 
  1. Australian Technical Advisory Group on Immunisation. 4.13 Pneumococcal disease. In: The Australian immunisation handbook. 10th edn. Canberra: Department of Health, 2017. [Accessed 28 November 2017].
  2. Moberley S, Holden J, Tatham DP, Andrews RM. Vaccines for preventing pneumococcal infection in adults. Cochrane Database Syst Rev 2008;(1):CD000422.
  3. Randle E, Ninis N, Inwald D. Invasive pneumococcal disease. Archives of disease in childhood education and practice edition 2011;96(5):183–90.
  4. Toms C, de Kluyver R, Enhanced Invasive Pneumoococcal Disease Surveillance Working Group for the Communicable Diseases Network Australia. Invasive pneumococcal disease in Australia, 2011 and 2012. Commun Dis Intell Q Rep 2016;40(2):E267–84.
  5. NNDSS Annual Report Working Group. Australia’s notifiable disease status, 2014: Annual report of the National Notifiable Diseases Surveillance System. Commun Dis Intell 2016;40(1):148–54.
  6. National Centre for Immunisation Research and Surveillance of Vaccine Preventable Diseases. Vaccine preventable diseases and vaccination coverage in Aboriginal and Torres Strait Islander people, Australia 2006–2010. Canberra: Department of Health, 2013.
  7. Davis S, Deloria-Knoll M, Kassa H, O’Brien K. Impact of pneumococcal conjugate vaccine on nasopharyngeal carriage and invasive disease among unvaccinated peope: Review of evidence on indirect effects. Vaccine 2014;32:133–45.
  8. Australian Technical Advisory Group on Immunisation. Updated recommendations for revaccination of adults with 23-valent pneumococcal polysaccharide vaccine (23vPPV), Pneumovax 23® 2011. [Accessed May 2017].
  9. Bonten M, Huijts S, Bolkenbaas M, Webber C, Patterson S, Gault Sea. Polysaccharide conjugate vaccine against pneumococcal pneumonia in adults. N Engl J Med 2015;372(12):1114–125.
  10. Tomczyk S, Bennett NM, Stoecker C, Gierke R, Moore MR, Whitney CG, et al. Use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine among adults aged≥ 65 years: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep 2014;63(37):822–25.
  11. Hull BP, Hendry AJ, Dey A, Beard FH, Brotherton JM, McIntyre PB. Annual immunisation coverage report: 2014. Canberra: National Centre for Immunisation Research and Surveillance of Vaccine Preventable Diseases, 2014. [Accessed May 2017].
  12. Jacobson V, Szilagyi P. Patient reminder and patient recall systems to improve immunization rates. Cochrane Database Syst Rev 2005;(3):CD003941.
  13. Ward K, Chow MYK, King C, Leask J. Strategies to improve vaccination uptake in Australia, a systematic review of types and effectiveness. Aust N Z J Public Health 2012;36(4):369–77.
  14. Guide to Community Preventive Services. Universally recommended vaccinations: Community-based interventions implemented in combination (abbreviated) 2010. [Accessed 28 November 2017].
  15. Almirall J, Bolibar I, Serra-Prat M, Roig J, Carandell E, Agustí M, et al. New evidence of risk factors for community-acquired pneumonia: A population-based study. Eur Respir J 2008;31(6):1274–84.
  16. Levine OS, Farley M, Harrison LH, Lefkowitz L, McGeer A, Schwartz B. Risk factors for invasive pneumococcal disease in children: A population-based case–control study in North America. Pediatrics 1999;103(3):e28.
  17. Nuorti JP, Butler JC, Farley MM, Harrison LH, McGeer A, Kolczak MS, et al. Cigarette smoking and invasive pneumococcal disease. New Engl J Med 2000;342(10):681–89.