Vaccine Preventable Diseases

Pneumococcal

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Advisory Committee on Immunization Practices (ACIP) Recommendations

Infants
- All infants without contraindications should receive four doses of pneumococcal conjugate vaccine (abbreviation: PCV13; trade name: Prevnar13), beginning no earlier than 6 weeks of age.
- The primary series of three doses is generally administered at 2, 4 and 6 months of age. A booster dose should be administered between 12-15 months of age.
- The minimum interval between doses is 4 weeks for infants under one year of age, and 8 weeks for infants over one year of age.

Children, Adolescents and Adults
- Children 6-18 years of age who have not previously received PCV13 or who have specific risk factors (such as anatomic asplenia including sickle-cell disease; immunocompromising conditions including HIV infection; cochlear implant; or cerebrospinal fluid leak) should receive a dose of PCV13.
- Adults over 18 years of age with any of the aforementioned risk factors should also receive a dose of PCV13 followed by a dose of pneumococcal polysaccharide vaccine (abbreviation: PPSV23; trade name: Pneumovax 23) at least 8 weeks later if they have not previously received it.
- PPSV23 is also recommended for persons over 2 years of age with any of the following specific risk factors (anatomic or functional asplenia; cochlear implant; cerebrospinal fluid leak; immunocompromising conditions including HIV infection, disease, chemotherapy and steroids; chronic illness including heart, pulmonary and liver disease; alcoholism; or asthma or cigarette smoking in adults over 19 years of age), with a revaccination dose after 5 years, and a third dose after the 65th birthday at least 5 years from the second dose.
- When both the conjugate and plain polysaccharide pneumococcal vaccines are recommended for a given individual, the conjugate vaccine should be given first. If the plain polysaccharide vaccine was given first, the conjugate vaccine should be administered one year after the polysaccharide vaccine [1, 2].

For More Information
ACIP recommendations:https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/pneumo.html
Immunization schedules: http://www.cdc.gov/vaccines/schedules/index.html
 

Disease 

Streptococcus pneumoniae is a facultative anaerobic gram-positive bacterium. 92 serotypes of S. pneumoniae have been documented, classified by their antigenic polysaccharide capsules. Antibodies provide protection specific to serotype. Pneumococci are often asymptomatically carried in the respiratory tracts of healthy persons.
Pneumococcal infections can cause pneumonia, sepsis, meningitis, otitis media, bone and joint infections, sinusitis, orbital cellulitis and skin infections. Pneumonia occurs at all ages and is the most common cause of death from Streptococcus pneumoniae. The incubation period of pneumococcal pneumonia is 1-3 days and is associated with fever, rigors (in adults), pleuritic chest pain, productive cough, dyspnea, tachypnea, hypoxia, tachycardia, malaise and weakness. Pneumococcal pneumonia has a case-fatality rate of 5-7% (may be substantially higher among the elderly). Roughly 25-30% of patients with pneumococcal pneumonia also develop pneumococcal bacteremia, which has a case-fatality rate of about 20% (may be as high as 60% among the elderly). Pneumococcal meningitis has a case-fatality rate of about 8% among children and 22% among adults, with neurologic sequelae often persisting among survivors. Over half of all cases of bacterial meningitis in the United States are caused by pneumococci [1]. WHO estimates that over 1.6 million people, including 0.7-1 million children under 2 years of age, die every year from pneumococcal infections worldwide [3].

Vaccine

The pneumococcal conjugate vaccine licensed for use in the United States is the aluminum phosphate-adjuvanted 13-valent PCV13, which contains the purified capsular polysaccharide from 13 serotypes of S. pneumoniae conjugated to a nontoxic diphtheria toxin known as CRM197.

The pneumococcal polysaccharide vaccine licensed for use in the United States is PPSV23, which contains the purified capsular polysaccharide antigen from 23 serotypes of S. pneumoniae [1].

Vaccine Effectiveness: PPSV23 is 60-70% effective against invasive pneumococcal disease caused by vaccine serotypes, although ineffective in children younger than 2 years of age. PCV13 is highly immunogenic and estimated to be over 90% effective in children against invasive pneumococcal disease caused by vaccine serotypes. In addition, PCV13 has been shown to reduce nasopharyngeal carriage of vaccine serotypes, which is important in reducing the disease burden by further limiting the spread of S. pneumonia from person to person [1].

Vaccine Safety: Local reactions such as pain, redness and swelling occur in 30-50% of PPSV23 recipients and 5-49% of PCV13 recipients. Moderate reactions such as fever and myalgia are uncommon (<1%) and severe adverse reactions are rare in PPSV23 recipients. However, about 8% of PCV13 local reactions are considered severe, for example causing tenderness that interferes with movement of the limb. Local reactions are typically more common after the fourth dose of PCV13 than after the first three. Fever over 100.4F within 7 days after vaccination was reported in 24-35% of PCV13 recipients in clinical trials; high fever was reported in less than 1% [1]. Cellulitis-like reactions after Pneumovax 23 vaccination have also been reported in the literature [4, 5].

Vaccines which may induce fever may also rarely induce febrile seizures. Febrile seizures are a common and typically benign childhood condition, occurring in 2-5% of children at some point during their first five years of life. Febrile seizures have an estimated background incidence of 240480 per 100,000 person-years in children under five years, although this varies considerably by age, genetics, co-morbidities and environmental risk factors. There are no long-term effects of simple febrile seizures, with the possible exception of an increased risk of recurrence [6-9]. Febrile seizures were estimated to occur at a rate of 5.3 per 100,000 doses in children aged 6-59 months receiving PCV13, and 17.5 per 100,000 doses after receiving PCV13 and concomitant trivalent inactivated influenza vaccine. These risk differences varied with age due to the age-dependent background rates of febrile seizures, with the highest estimates at 16 months and the lowest at 59 months [9]. See the Do Vaccines Cause Seizures summary for more details.

Contraindications and Precautions: Severe allergic reaction (e.g. anaphylaxis) to a previous dose or vaccine component is a contraindication to further vaccination with pneumococcal vaccines. Current moderate to severe acute illness is a precaution to any vaccination [1].

Considerations in Pregnancy: Pneumococcal vaccines are not routinely recommended in pregnancy.
The safety of PPSV23 vaccine in pregnancy has not been studied. However, no adverse outcomes have been reported among newborns whose mothers were inadvertently vaccinated with PPSV23 during pregnancy. Women who are at high risk of pneumococcal disease should be vaccinated before pregnancy, if possible [1].

References

1. Epidemiology and Prevention of Vaccine-Preventable Diseases. Washington D.C.: Centers for Disease Control and Prevention; 2015.
2. Kobayashi M, Bennett NM, Gierke R, et al. Intervals Between PCV13 and PPSV23 Vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morbidity and mortality weekly report 2015;64:944-7.
3. Organization WH. Pneumococcal vaccines WHO position paper--2012. Wkly Epidemiol Rec 2012;87:129-44.
4. von Elten KA, Duran LL, Banks TA, Banks TA, Collins LC, Collins LC. Systemic inflammatory reaction after pneumococcal vaccine: a case series. Human vaccines & immunotherapeutics 2014;10:1767-70.
5. Huang DT, Chiu NC, Chi H, Huang FY. Protracted fever with cellulitis-like reaction in pneumococcal polysaccharide-vaccinated children. The Pediatric infectious disease journal 2008;27:937-9.
6. (AAP) AAoP. Neurodiagnostic evaluation of the child with a simple febrile seizure. Pediatrics 2011;127:389-94.
7. (AAP) AAoP. Febrile seizures: clinical practice guideline for the long-term management of the child with simple febrile seizures. Pediatrics 2008;121:1281-6.
8. Bonhoeffer J, Menkes J, Gold MS, et al. Generalized convulsive seizure as an adverse event following immunization: case definition and guidelines for data collection, analysis, and presentation. Vaccine 2004;22:557-62.
9. Tse A, Tseng HF, Greene SK, Vellozzi C, Lee GM. Signal identification and evaluation for risk of febrile seizures in children following trivalent inactivated influenza vaccine in the Vaccine Safety Datalink Project, 2010-2011. Vaccine 2012;30:2024-31.