Pneumococcal Disease Guide

About pneumococcal disease

Pneumococcal disease is caused by the bacterium, Streptococcus pneumoniae (pneumococcus). Infection usually starts with a colonising event in the nose and throat, which is asymptomatic, and most infections do not amount to anything beyond colonisation. Some, however, spread locally or invasively to cause disease. 

Certain pneumococcal diseases are non-invasive, such as middle-ear infections (otitis media), sinusitis or bronchitis.^[4] Others are invasive, involve the blood or a major organ and are potentially life-threatening. Examples of invasive pneumococcal diseases (IPDs) include septicaemia (sepsis), meningitis or bacteraemic pneumonia. 

Pneumococci usually possess a polysaccharide capsule, which occurs as more than 90 serotypes ^[12], and immunity to the organism is capsule type- specific. Although many serotypes cause disease, only a few cause most infections. The predominant serotypes vary with age, time and geography.^[5][6] 

A PDF of the 2020 Pneumococcal disease guide for HCPs is available here.

Antibiotic Resistance

Pneumococcal disease is mainly treated using β-lactam antibiotics, though pneumococci bacteria are increasingly developing antibiotic resistance. Strains have variably become resistant to penicillin, cephalosporins, macrolides, tetracycline, clindamycin and the quinolones.^[7]

Transmission

Transmission occurs through respiratory droplets from people with pneumococcal disease or healthy carriers. If the infected person coughs or sneezes in close proximity of others, infection may spread. 

Following acquisition, the bacterium becomes established in the nasopharynx of the host with asymptomatic colonisation. It may then spread to other parts of the body where it causes disease. The bacteria’s polysaccharide capsule helps it to resist phagocytosis. If no anti-capsular antibody pre-exists, alveolar macrophages cannot kill the pneumococci.^[1][2][3][5]

Clinical Features

The major clinical syndromes of IPD are pneumonia, septicaemia and meningitis.^[2][8] Symptoms of pneumonia include fever, chills, coughing, rapid or difficult breathing, chest pain, rigors, tachycardia, rusty-coloured sputum, cough productive of mucopurulent, dyspnea, tachypnea, hypoxia, or, in older patients, confusion or low alertness. 

Meningitis, although least common, is the most severe category of IPD and is often fatal.^[2][3] Symptoms include a stiff neck, fever, lethargy, nuchal rigidity, cranial nerve signs, seizures, coma, headache, pain when looking into bright lights, confusion, or, in babies, poor eating and drinking, low alertness or vomiting. 

Septicaemia is the most common IPD among young children. Symptoms include fever, chills and low alertness. By 12 months, most children have also experienced otitis media. Pneumococcus is detected in 28 to 55% of middle ear aspirates from children with otitis media. Symptoms include ear pain, a red, swollen eardrum, fever, and sleepiness. Complications of otitis media may include mastoiditis and meningitis.^[2][5][9] 

Who is most at risk

Anyone can contract IPD though some groups are at heightened risk.

These include:

• people younger than two years of age or older than 70
• children in group childcare
• children in developing countries
• nursing homes residents
• smokers
• people suffering from chronic conditions such as lung, heart, liver or kidney disease, asthma, diabetes or alcoholism
• people with cochlear ear implants, cerebrospinal fluid (CSF) leaks or impaired immunity for any reason, including those arising from conditions such as HIV/AIDS, cancer or a damaged or absent spleen
• Aboriginal and Torres Strait Islander peoples^[3][10][11]

Vaccination is strongly recommended for groups at risk.

Young children

IPD still causes serious illness and occasional deaths.

By 2011 this had become much less common than it was before the widespread introduction of infant pneumococcal vaccine in 2005.  However, several harmful strains of the pneumococcal germ continue to circulate and cause illness.

The introduction of Prevenar 13® in 2011 is expected to provide protection against the most important of these remaining strains. Routine vaccination of children under the age of three is recommended.

People aged over 70 years

Pneumococcal disease is an important cause of pneumonia in adults aged 70 years or older. The elderly are especially at risk of serious illness and death from this disease.

People with underlying medical risk conditions

Adults and children with the following serious medical conditions are at a greater risk of life threatening infection and hospitalisation from pneumococcal disease:

• people with chronic illnesses such as diabetes, heart, lung or kidney disease
• people without a spleen or whose spleen does not work properly
• people with serious problems with their immune system
• Aboriginal and Torres Strait Islander people

All Aboriginal and Torres Strait Islander people over the age of 50 should be offered pneumococcal vaccine.

Who should receive pneumococcal disease vaccination

Pneumococcal disease vaccination is recommended for all children < 5 years of age and is funded by the National Immunisation Program.

Children > 5 years and adults with medical conditions associated with an increased risk of invasive pneumococcal disease should receive pneumococcal disease vaccinations.

Non-indigenous adults ≥ 70 years and Indigenous adults ≥ 50 years should routinely be offered pneumococcal disease vaccination.

The type and number of doses of pneumococcal disease vaccination vary in different age groups and risk groups. See the Australian Immunisation Handbook for further details.

Dosage and administration

The dose of pneumococcal conjugate vaccine (13vPCV) is 0.5 mL, to be given by IM injection, in the opposite limb to other injectable vaccines, if possible.

The dose of pneumococcal polysaccharide vaccine (23vPPV) is 0.5 mL, to be given by either IM or SC injection, in the opposite limb to other injectable vaccines, if possible. The IM route is preferred, as a 3-fold greater rate of injection site reactions is found following administration of 23vPPV by the SC route.^[13] A vaccine dose administered subcutaneously does not need to be repeated.

– 13vPCV (Prevenar 13) is registered for use in infants and children aged ≥6 weeks and in adults.

– 23vPPV (Pneumovax 23) is registered for use in children aged  ≥2 years and in adults.

Adult Vaccination Recommendations

Both 13vPCV and 23vPPV are recommended for individuals with certain medical conditions (refer to the Australian Immunisation Handbook), however not all are funded by the NIP.

Unless previously received, one dose of 13vPCV and two doses of 23vPPV are recommended and funded by the NIP for individuals with certain medical conditions (see table below), and for all Aboriginal and Torres Strait Islander adults ≥50 years of age. Across a lifetime there is a maximum of two doses of 23vPPV. The minimum interval between 23vPPV doses is five years.

One dose of 13vPCV is recommended and funded by the NIP for all healthy non-Indigenous adults ≥70 years of age who have not previously received a dose of 13vPCV. 

There are no pneumococcal vaccines subsidised on the PBS. 

When administering 13vPCV for people who have previously received 23vPPV, the interval should be a minimum of 12 months.

Pregnancy and breastfeeding

23vPPV is not routinely recommended for pregnant or breastfeeding women – deferral of vaccination with 23vPPV until after delivery is recommended unless there is an increased risk of IPD. 23vPPV may be given to breastfeeding women.

Data on use the use of 13vPCV during pregnancy or lactation are limited.

Co-administration with other vaccines

The Pneumococcal vaccine (either 13vPCV or 23vPPV) can be concurrently administered with Zostavax using separate syringes and injection sites (Refer also to the Australian Immunisation Handbook).

Reference list

1. Kadioglu A, Weiser JN, Paton JC, Andrew PW. The role of Streptococcus pneumoniae virulence factors in host respiratory colonization and disease. Nature Reviews Microbiology 2008;6:288-301. 

2. Centers for Disease Control and Prevention (CDC). Pneumococcal disease. In: Atkinson W, Wolfe C, Hamborsky J, eds. Epidemiology and prevention of vaccine-preventable diseases. 12th ed. Washington, D.C.: Public Health Foundation, 2011. 

3. Black S, Eskola J, Whitney C, Shinefield H. Pneumococcal conjugate vaccine and pneumococcal common protein vaccines. In: Plotkin SA, Orenstein WA, Offit PA, eds. Vaccines. 5th ed. Philadelphia, PA: Saunders Elsevier, 2008.
4. Weinberger DM, Harboe ZB, Sanders EA, et al. Association of serotype with risk of death due to pneumococcal pneumonia: a meta-analysis. Clinical Infectious Diseases 2010;51:692-9.
5. World Health Organization (WHO). 23-valent pneumococcal polysaccharide vaccine: WHO position paper. Weekly Epidemiological Record 2008;83:373- 84.
6. Hausdorff WP, Feikin DR, Klugman KP. Epidemiological differences among pneumococcal serotypes. The Lancet Infectious Diseases 2005;5:83-93.
7. Roche PW, Krause V, Cook H, et al. Invasive pneumococcal disease in Australia, 2006. Communicable Diseases Intelligence 2008;32:18-30. 

8. File TM, Jr., Marrie TJ. Burden of community- acquired pneumonia in North American adults. Postgraduate Medicine 2010;122:130-41.
9. Eskola J, Kilpi T, Palmu A, et al. Efficacy of a pneumococcal conjugate vaccine against acute.
otitis media. New England Journal of Medicine 2001;344:403-9.
10. Menzies R, Turnour C, Chiu C, McIntyre P. Vaccine preventable diseases and vaccination coverage.
in Aboriginal and Torres Strait Islander people, Australia, 2003 to 2006. Communicable Diseases Intelligence 2008;32 Suppl:S2-67.
11. van der Poll T, Opal SM. Pathogenesis, treatment, and prevention of pneumococcal pneumonia. The Lancet 2009;374:1543-56. 

12. Geno KA, Gilbert GL, Song JY, et al. Pneumococcal capsules and their types: past, present, and future. Clinical Microbi0logy Reviews 2015;28:871-99

13. Cook IF, Pond D, Hartel G. Comparative reatogenicixy and immunogenicity of 23 talent pneumococcal vaccine administered by intramuscular or subcutaneous injection in elderly adults. Vaccine 2007;25:4767-74.