Pneumococcal disease Pneumococcal Infections Streptococcus pneumoniae (pneumococci) are gram-positive, alpha-hemolytic, aerobic, encapsulated diplococci. In the US, pneumococcal infection is a major cause of otitis media, pneumonia... read more (eg, otitis media Otitis Media (Acute) Acute otitis media is a bacterial or viral infection of the middle ear, usually accompanying an upper respiratory infection. Symptoms include otalgia, often with systemic symptoms (eg, fever... read more , pneumonia Overview of Pneumonia Pneumonia is acute inflammation of the lungs caused by infection. Initial diagnosis is usually based on chest x-ray and clinical findings. Causes, symptoms, treatment, preventive measures, and... read more , sepsis Sepsis and Septic Shock Sepsis is a clinical syndrome of life-threatening organ dysfunction caused by a dysregulated response to infection. In septic shock, there is critical reduction in tissue perfusion; acute failure... read more , meningitis Acute Bacterial Meningitis Acute bacterial meningitis is rapidly progressive bacterial infection of the meninges and subarachnoid space. Findings typically include headache, fever, and nuchal rigidity. Diagnosis is by... read more ) is caused by some of the > 90 serotypes of Streptococcus pneumoniae (pneumococci). Vaccines are directed against many of the serotypes that cause disease. Certain medical conditions (eg, chronic disorders, immunocompromising conditions, cerebrospinal fluid leaks, cochlear implants) increase the risk of pneumococcal disease.
For more information, see Pneumococcal Advisory Committee on Immunization Practices Vaccine Recommendations and Centers for Disease Control and Prevention (CDC): Pneumococcal Vaccination. A summary of changes to the 2021 adult immunization schedule is available here.
(See also Overview of Immunization Overview of Immunization Immunity can be achieved Actively by using antigens (eg, vaccines, toxoids) Passively by using antibodies (eg, immune globulins, antitoxins) A toxoid is a bacterial toxin that has been modified... read more .)
Preparations of Pneumococcal Vaccine
There are 2 types of pneumococcal vaccines.
The 13-valent pneumococcal conjugate vaccine (PCV13, Prevnar®) contains 13 purified capsular polysaccharides of S. pneumoniae (1, 3, 4, 5, 6A, 6 B, 7F, 9V, 14, 18C, 19A, 19F, 23F); each is coupled to a nontoxic variant of diphtheria toxin. This vaccine has replaced the 7-valent vaccine (PCV7); PCV13 contains the 7 serotypes in PCV7 plus 6 additional serotypes.
The 23-valent pneumococcal polysaccharide vaccine (PPSV23, Pneumovax®23) contains antigens from the 23 most virulent of the 83 subtypes of S. pneumoniae (1, 2, 3, 4, 5, 6B, 7F, 8, 9N, 9V, 10A, 11A, 12F, 14, 15B, 17F, 18C, 19F, 19A, 20, 22F, 23F, 33F).
Unlike the older PPSV23, PCV13 can stimulate antibody responses in infants. It also seems to confer greater protection against invasive pneumococcal disorders than PPSV23. PPSV23 reduces bacteremia by 56 to 81% in adults overall but is less effective in debilitated older people. It reduces pneumonia incidence.
Indications for Pneumococcal Vaccine
PCV13 is recommended for
All children (routine childhood vaccine— see Table: Recommended Immunization Schedule for Ages 0–6 Years Recommended Immunization Schedule for Ages 0–6 Years )
Adults ≥ 65 years who have an immunocompromising condition, cerebrospinal fluid leak, or cochlear implant and who have not previously received PCV13
All adults ≥ 65 years based on shared decision-making between clinician and patient regarding risks and benefits
PCV13 is also recommended for people aged 6 to 64 years with any of the following high-risk conditions:
A cochlear implant
Cerebrospinal fluid leak
Immunocompromising conditions Overview of Immunodeficiency Disorders Immunodeficiency disorders are associated with or predispose patients to various complications, including infections, autoimmune disorders, and lymphomas and other cancers. Primary immunodeficiencies... read more (eg, congenital immunodeficiency, chronic renal failure, nephrotic syndrome, HIV infection, leukemia, lymphomas, generalized cancer, use of immunosuppressants, solid organ transplant)
PPSV23 is recommended for
All adults ≥ 65 years
PPSV23 is also recommended for people aged 2 to 64 years with the high-risk conditions listed above. Additional criteria for people aged 2 to 64 years include the following:
A chronic lung disorder (including asthma)
Chronic cardiovascular disorders (excluding hypertension)
A chronic liver disorder
An alcohol use disorder
PPSV23 is no longer recommended for routine use in American Indians and Alaska natives < 65 years unless they have a medical condition or other indication for PPSV23. However, American Indians and Alaskan natives aged 50 to 64 years may be given PPSV23 if they live in areas where risk of invasive pneumococcal disease is increased.
Contraindications and Precautions of Pneumococcal Vaccine
The main contraindication for PCV13 is
A severe allergic reaction (eg, anaphylaxis Anaphylaxis Anaphylaxis is an acute, potentially life-threatening, IgE-mediated allergic reaction that occurs in previously sensitized people when they are reexposed to the sensitizing antigen. Symptoms... read more ) after a previous dose of PCV7 or PCV13, to a vaccine component, or to any vaccine containing diphtheria toxoid
The main contraindication for PPSV23 is
A severe allergic reaction after a previous dose of the vaccine or to a vaccine component
Precautions with either vaccine include
Moderate or severe acute illness with or without fever (vaccination is postponed until illness resolves)
For children with functional or anatomic asplenia, meningococcal conjugate vaccine ( MenACWY Meningococcal Vaccine The meningococcal serogroups that most often cause meningococcal disease in the US are serogroups B, C, and Y. Serogroups A and W cause disease outside the US. Current vaccines are directed... read more ) and PCV13 should not be given during the same visit but should be separated by ≥ 4 weeks.
Administration of Pneumococcal Vaccine
The usual dose is 0.5 mL IM for PCV13 and 0.5 mL IM or subcutaneous for PCSV23.
PCV13 is recommended as a 4-dose IM series for infants at age 2, 4, 6, and 12 to 15 months. Children aged 7 to 59 months who have not been vaccinated with PCV7 or PCV13 previously should be given 1 to 3 doses of PCV13, depending on their age at the initiation of the vaccination series and the presence of medical conditions. Children aged 24 to 71 months with chronic medical conditions that increase their risk of pneumococcal disease and who have received 3 doses of PCV13 should be given 1 dose of PCV13 at least 8 weeks after the most recent dose; if they received less than 3 doses of PCV13, they should be given 2 doses of PCV13 at least 8 weeks apart. Interruption of the vaccination schedule does not require starting the entire series over or giving extra doses.
Children at high risk of pneumococcal disease (eg, children with sickle cell disease, asplenia, or a chronic disorder) should be given a dose of PPSV23 at age 24 months at least 8 weeks after the most recent dose of PCV13.
Children aged 14 to 59 months who have received a complete age-appropriate series of PCV7 should be given a single supplemental dose of PCV13.
If children aged 6 to 18 years with an immunocompromising condition, a cochlear implant, or a cerebrospinal fluid leak have not been vaccinated with PCV13 or PPSV23, they should be given 1 dose of PCV13, followed by 1 dose of PPSV23 ≥ 8 weeks later. If they have been vaccinated with PPSV23 but not PCV13, they are given 1 dose of PCV13 ≥ 8 weeks after the last dose of PPSV23. Children with an immunocompromising condition should be revaccinated once with PPSV23 5 years after the first dose. They should not be given > 2 doses of PPSV23.
Adults aged ≥ 19 years with immunocompromising conditions (eg, functional or anatomic asplenia, HIV infection), cerebrospinal fluid leaks, or cochlear implants should be vaccinated with PCV13 and PSV23. If they have not previously been given PCV13 or PPSV23, they should be vaccinated with a dose of PCV13, followed by a dose of PPSV23 ≥ 8 weeks later. If they have been given PPSV23 but not PCV13, they are given a dose of PCV13 ≥ 1 year after the last dose of PPSV23.
Adults ≥ 65 years with no medical conditions listed above should be given PCV13 first, followed by PPSV23 at least 1 year later. If people have already been vaccinated with PPSV23, PCV13 should be given at least 1 year after the most recent dose of PPSV23.
People with asymptomatic or symptomatic HIV infection should be vaccinated as soon as possible after their diagnosis.
Adults aged 19 to 64 years at highest risk of pneumococcal disease (eg, with functional or anatomic asplenia, chronic kidney disease, or another immunocompromising condition, including cancer and use of corticosteroids) should be given a 2nd dose of PPSV23 5 years after the first PPSV23 dose.
All people should be vaccinated with PPSV23 at age 65. If people were given 1 or 2 doses of PPSV23 before age 65 for any indication and ≥ 5 years have elapsed since their previous PPSV23 dose, they should be given another dose of the vaccine at age 65 or later. The 2nd dose is given 5 years after the first (eg, at age 69 if the previous dose was given at age 64). Those who are given PPSV23 at or after age 65 should be given only 1 dose.
If elective splenectomy is planned, PCV13 should be given ≥ 12 weeks before surgery, followed by a dose of PPSV23 ≥ 8 weeks after PCV13 is given. PPSV23 should be given at least 2 weeks before elective splenectomy. If splenectomy must be done immediately, PCV13 should be given, followed by PPSV23 ≥ 8 weeks later. If patients have already received PCV13, PPSV23 should not be given until ≥ 2 weeks after splenectomy.
When cancer chemotherapy or other immunosuppressive therapy is being considered, the interval between vaccination and initiation of immunosuppressive therapy should be ≥ 2 weeks. People should be not be vaccinated during chemotherapy or radiation therapy.
Adverse Effects of Pneumococcal Vaccine
Adverse effects are usually mild and include fever, irritability, drowsiness, anorexia, vomiting, and local pain and erythema.
The following is an English-language resource that may be useful. Please note that THE MANUAL is not responsible for the content of this resource.
Advisory Committee on Immunization Practices (ACIP): Pneumococcal ACIP Vaccine Recommendations
Centers for Disease Control and Prevention (CDC): Pneumococcal Vaccination: Information for Healthcare Professionals