1 Pneumococcal disease
what is pneumococcal disease?
The term pneumococcal disease describes infections caused by the bacterium Streptococcus pneumoniae. Pneumococcal infection causes a broad range of diseases in older people (see Table 1). It is the most common cause of serious pneumonia. As well as infecting the lungs, pneumococcal bacteria can infect the blood stream. This type of infection is called invasive pneumococcal disease (IPD). It is responsible for causing the more serious consequences of pneumococcal infection, such as septicaemia (blood poisoning), meningitis or invasive pneumococcal pneumonia, which are more likely to lead to death than non-invasive infections.
Table 1. diseases caused by pneumococcal infection in older people
Disease caused by pneumococcal infection
Cough, breathing difficulties,chest pains, fever, headache, confusion
Can cause death
Can lead to septicaemia (bacteria in the blood stream) where the infection can spread to the lining of the heart (pericarditis) or brain (meningitis)
Pleural effusion (fluid around the lungs)
Septicaemia (blood poisoning)
Fever, confusion, low bloodpressure (shock)
Can cause death
Pericarditis (inflammation around the heart)
Fever, breathing difficulties, chest pains
Can cause death
Meningitis (inflammation around the brain)
Confusion, fever, headache
Can cause death
Peritonitis (inflammation of the abdomen)
Abdominal pain, fever
Can cause death
Coughing, mucus secretion
what is the cause?
Streptococcus pneumoniae (the pneumococcus) is a Gram positive organism carried in the nasopharynx of up to 30% of healthy adults and 60% of children, usually with no ill-effects1. If, however, it enters the lungs or bloodstream of elderly or infant patients especially those who are already ill, have no spleen, or have a weakened immune system through illness or treatment, it can cause serious problems.
Ninety different types of Streptococcus pneumoniae have been identified; of these, 8-10 cause two-thirds of the serious infections in adults and about 80% in children2, 3. Most pneumococcal disease in the world is caused by 20-30 of the most common types4, 5.
Streptococcus pneumoniae poses a significant public health problem. It accounts for more cases of community acquired pneumonia than any other cause. Pneumococcal pneumonia affects around 1/1000 adults yearly with a mortality rate of 10-20%. The pneumococcus is also one of the most frequently reported causes of bacteraemia and meningitis2.
It is estimated that 2 in every 1,000 adults over the age of 65 in England are admitted to hospital because of pneumococcal pneumonia each year rising to over 4 in every 1,000 adults aged 80 years or over6. This means that there may be more than 18,000 hospitalised cases of pneumococcal pneumonia each year in the UK in people aged 65 years and over.
In Scotland, the Scottish Meningococcal and Pneumococcal Reference Laboratory (SMPRL) and the Scottish Centre for Infection and Environmental Health (SCIEH) have supported an enhanced pneumococcal surveillance system since 1999. Approximately 600 cases of invasive pneumococcal disease are being identified per year: 48.5% of these occur in people over 65 years, with just over 11% in the 0-4 age group.
Data from SCIEH/SMPRL show that the rate of invasive pneumococcal disease (IPD) in Scotland was 11.3 per 100,000 in 2002. As Figure 1 shows, IPD has a reported rate of more than 35 per 100,000 in the over 65s [Source: SCIEH/SMPRL]; the actual rate will be higher, as not all IPD is investigated or reported3.
how common is pneumococcal disease?
Figure 1: Incidence of disease and case-fatality rate (CFR) of invasive pneumococcal disease by age groups 1999-2001 in Scotland
As shown in Figure 1 above, case fatality generally increases with advancing age in adults: data for Scotland show the case fatality in those aged 65 and over for 1999-2001 was 10.6% compared with 1%-5% in other age groups (Source: SCIEH/SMPRL)3.
who is most at risk?
Older people and very young children are most at risk from pneumococcal disease, particularly if they are already ill, have no spleen, or have a weakened immune system, eg if they are having treatment for cancer. The risk in adults increases sharply in those aged 65 and over (see Figure 1 above).2 Vaccination policy background
23-valent pneumococcal polysaccharide vaccine was introduced in 1983 and has been used for over 10 years in the UK for people who are at particular risk from pneumococcal disease. The previous policy in the UK was to vaccinate only people in high-risk groups.
The Scottish Executive Health Department asked the Joint Committee on Vaccination and Immunisation (JCVI) (which includes representation from all UK Health Departments) to consider the case for extending pneumococcal vaccination policy to include all people aged 65 years and over.
A JCVI panel reviewed the policy, taking account of the effectiveness and cost effectiveness of the pneumococcal polysaccharide vaccine (PPV) for older people. The literature on this topic is varied, complicated by a number of poorly designed studies, leading to considerable uncertainty surrounding estimates of vaccine effectiveness.
The JCVI also acknowledged the high burden of disease due to pneumococcal infection and that current data considerably under estimate it. While noting the limitations of the evidence, JCVI agreed that given the burden of disease, particularly in the over 65s, and the safety of the vaccine, there was sufficient evidence to support a change in policy and extend the vaccination programme to include all those aged 65 and over7.
This advice is in line with current pneumococcal vaccination policy in other countries including the USA, Canada, Australia, New Zealand, many European countries and elsewhere in the UK*.
In line with JCVI advice, the Scottish Executive Health Department is introducing the policy of offering pneumococcal polysaccharide vaccination for people aged 65 and over from October 2003 (see CMO letters SEHD/CMO (2003) 4 and 9). The established policy of offering pneumococcal vaccination to at-risk groups under 65 years remains unchanged and is discussed briefly below, in Section 7.
The Implementation Group, set up to manage and co-ordinate the implementation of the Scottish programme of pneumococcal polysaccharide vaccination for people aged 65 and over, advised that the programme should launch with a one-off 'catch up' beginning in October 2003, linked to the annual influenza vaccination programme. This will avoid the need for patients to make second visits to their general practice and will help aid uptake. In future years, those who become 65 years of age within any year, and have not previously been protected against pneumococcal disease, will be offered vaccination.
* In England PPV will be offered to all people aged 80 and over in 2003-04, aged 75 and over in 2004-05 and all aged 65 and over in 2005-06.
It will be offered routinely to all people aged 65 and over by 2006-07.3 Pneumococcal vaccination of people aged 65 years and over
who should receive pneumococcal vaccine?
People who are aged 65 years and over by 31 March 2004, and who have not previously been vaccinated against pneumococcal infection, should be offered the vaccine during the winter of
2003-2004, linked with the offer of vaccination against influenza.
Where offers are not taken up, pneumococcal vaccination can be offered opportunistically at patients' future visits to their general practice. In future years, the aim will be to offer vaccination to individuals who reach the age of 65 in any particular year4 Pneumococcal vaccine
what is pneumococcal vaccine?
There are two types of pneumococcal vaccine:
The 23-valent pneumococcal polysaccharide vaccine (PPV) can be used for adults and children over the age of two years. This vaccine contains part of the polysaccharide (sugar) coat that surrounds the pneumococcal bacterium. It stimulates the body to produce antibodies that help to protect against 23 types of pneumococcal bacteria. These 23 types of bacteria cause about 96% of all pneumococcal disease cases in the UK4.
The polysaccharide vaccine should be used for adults. The 7-valent pneumococcal conjugate vaccine (PCV), is currently only licensed for children under the age of two years. Its effectiveness in preventing disease in adults is not currently known.
how effective is the vaccine?
A number of studies have shown that pneumococcal polysaccharide vaccine gives substantial, but not complete, protection against the serious forms of pneumococcal infection where the bacteria have entered the blood stream (invasive pneumococcal disease - IPD). The effectiveness of the vaccine in preventing IPD (such as septicaemia, meningitis and invasive pneumococcal pneumonia) is likely to be around 50%-70% in older age groups8, 9, 10, 11. Studies suggest that it is not effective in preventing pneumococcal pneumonia that occurs without septicaemia12.
Recent extensive reviews of the evidence base for the effectiveness of PPV have been undertaken by the Scottish Intercollegiate Guidelines Network (SIGN)13 and by the JCVI, as outlined in Section 2 above.5 Surveillance of pneumococcal disease
A pneumococcal disease surveillance system is already in place in Scotland. The system will be enhanced to assess the effectiveness of this new pneumococcal vaccination programme.
To improve the accuracy and success of disease surveillance it is essential that robust pneumococcal vaccination data are captured. The Standard Immunisation and Recall System (SIRS) is being
modified to facilitate this.
Patient information may be used by NHS Scotland to help develop better health care for patients and for administration and payment purposes within NHSScotland.6 Frequently asked questions
do people who have had pneumococcal disease need the vaccine?
People who have had pneumococcal disease in the past should still be vaccinated as there is more than one type of pneumococcal bacterium and they can still become infected with another type. The vaccine protects against all the common types of pneumococcal bacteria.
why vaccinate when Streptococcus pneumoniae can be treated with antibiotics?
While treatment with antibiotics can be effective against pneumococcal infections, Streptococcus pneumoniae is becoming increasingly resistant to antibiotics in the UK14 and world-wide15. Susceptibility to penicillin, cephalosporins and macrolide antimicrobials is not assured2.
In Scotland during 1999-2001:
As pneumococcal disease becomes harder to treat because of its resistance, its prevention by vaccination becomes more important.
when should pneumococcal vaccine be given?
Unlike influenza vaccine which is different each year and is given before the start of the influenza season (from October), pneumococcal vaccine can be given at any time of the year. However for convenience pneumococcal vaccination can be offered at the same time as offering vaccination against influenza. This avoids the need for a second visit by the patient to their general practice. Where offers are not taken up, these could, in the case of pneumococcal vaccination, be offered opportunistically at patients' future visits to the practice, or the following year.
is it safe to give pneumococcal vaccine at the same time as influenza vaccine?
Studies have shown that there are no problems in giving the two vaccines at the same time and that there is no interaction between them16. Although pneumococcal vaccine can be given all year round, for convenience it can be given at the same time as the influenza vaccine. However, the injections should be given at a different site or in separate limbs.
Further details of administration can be found in:
Immunisation Against Infectious Disease ("The Green Book")2.
how often should it be given?
It is currently recommended that most adults will only need one dose of pneumococcal polysaccharide vaccine in their lifetime.
Re-vaccination with pneumococcal polysaccharide vaccine is not normally advised except, every 5 years, in people whose antibody levels are likely to have declined more rapidly eg those with no spleen, with splenic dysfunction or with nephrotic syndrome2. A few centres are able to measure antibody levels in cases where there is doubt about the need for re-vaccination.
Re-vaccination is contraindicated within three years of a previous dose.
See the Green Book for other guidance and contraindications.
what are the adverse reactions?
Local reactions such as mild soreness, redness and induration at the injection site can occur lasting no longer than 1-3 days; less commonly, low-grade fever or muscle pain can develop. See the Green Book for more details on adverse reactions2.
There is no risk of pneumococcal vaccine causing pneumococcal infection or disease as it does not contain live bacteria, only their polysaccharide (sugar) coat.
More serious adverse reactions are rare. However if a doctor, nurse or pharmacist suspects that a serious reaction to pneumococcal vaccine has occurred they should report it to the Committee on Safety of Medicines using the Yellow Card Spontaneous Reporting Scheme17.7 Pneumococcal vaccination - other groups
The prime focus of this leaflet is the introduction of pneumococcal vaccination of people aged 65 and over from October 2003.
The established policy of offering pneumococcal vaccination to at-risk groups under 65 years
People under the age of 65 who are at higher risk from pneumococcal disease are already recommended to receive the vaccine. These are listed below and further details are given in the new Pneumococcal Chapter of the Health Departments' publication: Immunisation Against Infectious Disease ("The Green Book")2.
Asplenia or severe dysfunction of the spleen including homozygous sickle cell disease and coeliac syndrome
Chronic renal disease or nephrotic syndrome
Chronic heart disease
Chronic lung disease
Chronic liver disease including cirrhosis
Immunodeficiency or immunosuppression due to disease or treatment
HIV infection at all stages
People with cochlear implants
The polysaccharide vaccine (PPV) used in older people is not suitable for use in children under the age of 2 years, as they are not able to make a long-lasting protective immune response to polysaccharide vaccines. As indicated in Section 4 above, a separate pneumococcal conjugate vaccine (PCV) is licensed and available for use in children in this age group who fall into high-risk categories.
JCVI have recommended that the small number of children under 2 years in the at-risk groups should have pneumococcal conjugate vaccine. (This was adopted as policy by the Scottish Executive Health Department and CMO letters (SEHD/CMO(2002)1) 4 January 2002 and (SEHD/CMO(2002)6) 27 August 2002 refer).8 References
1. Ghaffar F, Friedland IR, McCracken GH Jr. Dynamics of nasopharyngeal colonization by Streptococcus pneumoniae.
Pediatr Infect Dis J. 1999 Jul;18(7):638-46
2. Department of Health, Welsh Office, Scottish Office Department of Health, DHSS (Northern Ireland) (1996) 1996 Immunisation Against Infectious Disease London: HMSO. [see new 2003 Pneumococcal chapter at: www.doh.gov.uk/greenbook ].
3. Kyaw MH, Christie P, Clarke SC, Mooney JD, Ahmed S, Jones IG, Campbell H. Invasive pneumococcal disease in Scotland in
1999-2001: Use of record linkage to explore associations between patients and disease in relation to future vaccination policy. In press: Clin Inf Dis [accepted 2nd July 2003].
4. George AC and Melegaro A. Invasive pneumococcal infection in England and Wales 1999. CDR Weekly 2001 11: 4-17.
5. Sleeman K et al. Invasive pneumococcal disease in England and Wales: vaccination implications. JID 2001 183: 239-46.
6. Hospital Episodes Statistics: Admissions reporting pneumococcal pneumonia and lobar pneumonia codes (ICD-10 code: J13 and J181) in the first diagnostic field (HES 1999-2000). [ www.doh.gov.uk/hes ]
7. Joint Committee on Vaccination and Immunisation Meeting of 3rd May 2002: Open Minutes. [ www.doh.gov.uk/jcvi/mins03may03.htm ]
8. Mantani P et al. Efficacy of polysaccharide pneumococcal vaccine in adults in more developed countries: the state of the evidence. Lancet Infect Dis 2003 3: 71-8.
9. Fedson DS. The clinical effectiveness of pneumococcal vaccination: a brief review.
Vaccine 1999 17: S85-S90.
10 Fine MJ et al. Efficacy of pneumococcal vaccination in adults: a meta-analysis of randomised controlled trials.
Arch Int Med 1994; 154: 2666-77
11 Butler JC et al. Pneumococcal polysaccharide vaccine efficacy: an evaluation of current recommendations JAMA 1993; 270: 1826-31.
12. Jackson LA et al. Effectiveness of pneumococcal polysaccharide vaccine in older adults. N Engl J Med 2003 348: 1747-55.
13. Scottish Intercollegiate Guidelines Network (2002) Community Management of Lower Respiratory Tract Infection in Adults (SIGN Guideline 59). Edinburgh: SIGN. [ www.sign.ac.uk ]
14. Invasive pneumococcal infection, England and Wales: 2000. CDR Weekly 2003 3-9.
15. Davies et al. Molecular epidemilogical
survey of penicillin-resistant Streptococcus pneumoniae from Asia, Europe, and North America. Diagn Microbiol Infect Dis 1999
16. Christenson B et al. Effects of a large-scale intervention with influenza and 23-valent pneumococcal vaccines in adults aged 65 years or older: a prospective study.
Lancet 2001 357: 1008-11.
17. Yellow Card Spontaneous Reporting Scheme see: [ www.mca.gov.uk/ourwork/monitorsafequalmed/yellowcard/how.htm ]
Please Note: Further copies of this document and additional information are available on the Scottish Executive website: www.scotland.gov.uk/health/flu_pneumococcal