# Presentation: 033681

## Pneumococcal Disease and Pneumococcal  Vaccines

**Epidemiology and Prevention of Vaccine-Preventable Diseases**
**National Center for Immunization and Respiratory Diseases**
**Centers for Disease Control and Prevention**

**Revised March 2008**

## Note to presenters:

**Images of vaccine-preventable diseases are available from the Immunization Action Coalition website at ****http://www.vaccineinformation.org/photos/index.asp**

## Pneumococcal Disease

***S. pneumoniae***** first isolated by Pasteur in 1881**
**Confused with other causes of pneumonia until discovery of Gram stain in 1884**
**More than 80 serotypes described by 1940**
**First U.S. vaccine in 1977**

## Streptococcus pneumoniae

**Gram-positive bacteria**
**90 known serotypes**
**Polysaccharide capsule important virulence factor**
**Type-specific antibody is protective**

## Pneumococcal Disease

**Second most common cause of vaccine-preventable death in the U.S. (after influenza)**
**Major clinical syndromes include pneumonia, bacteremia, and meningitis**

## Pneumococcal PneumoniaClinical Features

**Abrupt onset**
**Fever**
**Shaking chills**
**Pleuritic chest pain **
**Productive cough**
**Dyspnea, tachypnea, hypoxia**

## Pneumococcal Pneumonia

**100,000 to 135,000 cases requiring hospitalization per year**
**Responsible for up to 1/3 of community-acquired pneumonias and up to 1/2 of hospital-acquired pneumonias**
**Common bacterial complication of influenza and measles**
**Case-fatality rate 5%-7%, higher in elderly**

## Pneumococcal Bacteremia

**More than 50,000 cases per year in the United States**
**Rates higher among elderly and very young infants**
**Case-fatality rate ~20%; up to 60% among the elderly**

## Pneumococcal Meningitis

**Estimated 3,000 - 6,000 cases per year in the United States**
**Case-fatality rate ~30%, up to 80% in the elderly**
**Neurologic sequelae common among survivors**
**Increased risk in persons with cochlear implant**

## Pneumococcal Disease in Children

**Bacteremia without known site of infection most common clinical presentation**
**S. pneumoniae leading cause of bacterial meningitis among children younger than 5 years of age**
**Highest rate of meningitis among children younger than 1 year of age**
**Common cause of acute otitis media**

## Bacteremia					     		   13,000
Meningitis							       		 700
Death	 								       			 200
Otitis media				    	   5,000,000

**Meningitis****	****	****	****	****	****	****	****       ****	****	**** 700**
**Death****	**** ****	****	****	****	****	****	****	****	****       ****	****	****	**** 200**
**Otitis media****	****	****	****	****    ****	****   5,000,000**

_**Syndrome**_**	****	****	****	****	****	****	****     **_**Cases**_

**Burden of Pneumococcal Disease in Children***

***Prior to routine use of pneumococcal conjugate vaccine**

## Pneumococcal Disease Epidemiology

**Reservoir****	****	****  Human carriers**** **
**Transmission****	****  Respiratory ****	****	****	****	****	****	****	****  Autoinoculation**
**Temporal pattern  Winter and early spring**** **
**Communicability****	****  Unknown             ****	****	****	****	****	****	****  Probably as long as ****	****	****	****	****  organism in respiratory ****	****	****	****	****  secretions****	**

## Invasive Pneumococcal Disease
Incidence by Age Group, 1998 and 2002

**Incidence by Age Group, 1998 and 2002**

*** Rate per 100,000 population**
**Source:  Active Bacterial Core Surveillance/EIP Network**

**Notes:**
79 percent decrease in the incidence rate of invasive disease in children younger than 2 years.  

## Invasive Pneumococcal Disease (IPD) in the United States

**Rate/100,000 children**
**younger than 5 years**

**Before vaccine**
**100**
**80**

**2005**
**24**
**1.5**

**All IPD**
**Vaccine**
**serotypes**

**Source:  Active Bacterial Core Surveillance/EIP Network**

## Children at Increased Risk of Invasive Pneumococcal Disease

**Functional or anatomic asplenia, especially sickle cell disease**
**HIV infection**
**Recipient of cochlear implant**
**Out-of-home group child care**
**African American children**
**Alaska Native and American Indian children who live in Alaska, Arizona, or New Mexico**
**Navaho children who live in Colorado and Utah **

## Pneumococcal Disease Outbreaks

**Outbreaks not common**
**Generally occur in crowded environments (jails, nursing homes)**
**Persons with invasive disease often have underlying illness**
**May have high fatality rate**

## Pneumococcal Vaccines

**1977****	****   14-valent polysaccharide****	****	****    vaccine licensed**** **
**1983****	****   23-valent polysaccharide****	****	****    vaccine licensed (PPV23)**
**2000****	****   7-valent polysaccharide****	****	****   conjugate vaccine licensed ****	****	****   (PCV7)**

## Pneumococcal Polysaccharide Vaccine

**Purified capsular polysaccharide antigen from 23 types of pneumococcus**
**Account for 88% of bacteremic  pneumococcal disease**
**Cross-react with types causing additional 8% of disease**

## Pneumococcal Conjugate Vaccine

**Pneumococcal polysaccharide conjugated to nontoxic diphtheria toxin (7 serotypes)**
**Vaccine serotypes account for 86% of bacteremia and 83% of meningitis among children younger than 6 years of age **

## Pneumococcal Polysaccharide Vaccine

**Not effective in children younger than 2 years**
**60%-70% against invasive disease**
**Less effective in preventing pneumococcal pneumonia ****	****	****	****	****	**

## Pneumococcal Conjugate Vaccine

**Highly immunogenic in infants and young children, including those with high-risk medical conditions**
**97% effective against invasive disease caused by vaccine serotypes**
**73% effective against pneumonia**
**7% reduction in all episodes of acute otitis media**

## Pneumococcal Polysaccharide Vaccine Recommendations

**Adults 65 years and older**
**Persons 2 years and older with**
**chronic illness**
**anatomic or functional asplenia**
**immunocompromised (disease, chemotherapy, steroids)**
**HIV infection**
**environments or settings with increased risk**

***MMWR***** 1997;46(RR-8):1-24**

## Pneumococcal Conjugate Vaccine Recommendations

**All children 24 months of age **
**Unvaccinated children 24-59 months with a high-risk medical condition**

***MMWR***** 2000;49(RR-9):1-35**

## Pneumococcal Conjugate Vaccine Recommendations

**Doses at 2, 4, 6, months of age, booster dose at 12-15 months of age**
**First dose as early as 6 weeks**
**Minimum interval of 4 weeks between first 3 doses**
**At least 8 weeks between dose 3 and dose 4 **
**Unvaccinated children 7 months of age or older require fewer doses**

***MMWR***** 2000;49(RR-9):1-35**

## Pneumococcal Conjugate Vaccine
Schedule for Unvaccinated Older Children

**Schedule for Unvaccinated Older Children**

***separated by at least 8 weeks**
***MMWR***** 2000;49(RR-9):1-35**

## Pneumococcal Conjugate Vaccine
for Children 24-59 Months of Age with a Lapsed Immunization Schedule

**for Children 24-59 Months of Age with a Lapsed Immunization Schedule**

_**Group**_
**Healthy**
**Increase risk***

**Previous **_**Vaccination**_
**Any incomplete**
** ****schedule**
**3 doses**
**Fewer than 3 doses**

**No. of Doses**
_**Recommended**_
**1**
**1**
**2****

** *****due to underlying medical condition**
****separated by at least 8 weeks**
***MMWR***** 2007;57(No. 13):343-4**

## Pneumococcal Conjugate Vaccine

**Children aged 24-59 months at high risk and previously vaccinated with PPV23 should receive 2 doses of PCV7***
**Children at high risk who previously received PCV7 should receive PPV23 at 2 years of age or older**

***separated by at least 8 weeks**
***MMWR***** 2000;49(RR-9):1-35**

## Pneumococcal Polysaccharide Vaccine Revaccination

**Routine revaccination of immuno-competent persons is not recommended**
**Revaccination recommended for persons 2 years of age or older who are at highest risk of serious pneumococcal infection**
**Single revaccination dose at least 5 years after the first dose**

***MMWR***** 1997;46(RR-8):1-24**

## Pneumococcal Polysaccharide VaccineCandidates for Revaccination

**Persons **_**>**_**2 years of age with:**
**functional or anatomic asplenia**
**immunosuppression**
**transplant**
**chronic renal failure**
**nephrotic syndrome**
**Persons vaccinated at <65 years of age**

***MMWR***** 1997;46(RR-8):1-24**

## Pneumococcal Vaccines Adverse Reactions

**Local reactions**
**polysaccharide****	****	****	****   30%-50%**
**conjugate****	****	****	****	****   10%-20%**
**Fever, myalgia**
**polysaccharide****	****	****	****   <1%**
**conjugate****	****	****	****	****   15%-24%**
**Severe adverse ****	****	****	****   ****rare****reactions**

## Pneumococcal VaccinesContraindications and Precautions

**Severe allergic reaction to vaccine component or following prior dose of vaccine**
**Moderate or severe acute illness**

## Pneumococcal Polysaccharide Vaccine Coverage

**Healthy People 2010 goal: 90% coverage for persons **_**>**_**65 years**
**2003 BRFSS: 64% of persons **_**>**_**65 years of age ever vaccinated**
**Vaccination coverage levels were lower among persons 18-64 years of age with a chronic illness**

## Pneumococcal Polysaccharide VaccineMissed Opportunities

**>65% of patients with severe pneumococcal disease had been hospitalized within preceding 3-5 years yet few had received vaccine **
**May be administered simultaneously with influenza vaccine**

## CDC Vaccines and ImmunizationContact Information  

**Telephone     800.CDC.INFO**** **
**Email****	****	****    nipinfo@cdc.gov**** **
**Website****	****    www.cdc.gov/vaccines**