g logo nhs blue

Overview

This section is part 3 of the PHE pneumococcal guideline summary.

Contents included in this summary

 

The objective of the immunisation programme is to protect all of those for whom pneumococcal infection is likely to be more common and/or serious, i.e.:

  • infants as part of the routine childhood immunisation programme
  • those aged 65 years or over
  • children and adults in the clinical risk groups shown in Table 1

Primary care staff should identify patients for whom vaccine is recommended and use all opportunities to ensure that they are appropriately immunised, for example:

  • when immunising against influenza
  • at other routine consultations, especially on discharge after hospital admission.

Primary immunisation

PCV13

PCV13 is recommended for infants from two months of age as part of the routine childhood immunisation schedule.

The primary course of PCV13 vaccination consists of two doses with an interval of two months between each dose. The recommended schedule for vaccination is two and four months of age. If the primary course is interrupted then give a dose of PCV13 as soon as possible followed by the booster dose on or after the first birthday, allowing an interval of two months between the doses.

PPV23

Adults 65 years or over

A single dose of PPV23 should be administered.

Table 1 Clinical risk groups who should receive the pneumococcal immunisation
Clinical risk groupExamples (decision based on clinical judgement)

Asplenia or dysfunction of the spleen

This also includes conditions such as homozygous sickle cell disease and coeliac syndrome that may lead to splenic dysfunction.

Chronic respiratory disease (chronic respiratory disease refers to chronic lower respiratory tract disease)

This includes chronic obstructive pulmonary disease (COPD), including chronic bronchitis and emphysema; and such conditions as bronchiectasis, cystic fibrosis, interstitial lung fibrosis, pneumoconiosis and bronchopulmonary dysplasia (BPD). Children with respiratory conditions caused by aspiration, or a neurological disease (e.g. cerebral palsy) with a risk of aspiration. Asthma is not an indication, unless so severe as to require continuous or frequently repeated use of systemic steroids (as defined in Immunosuppression below).

Chronic heart disease

This includes those requiring regular medication and/or follow-up for ischaemic heart disease, congenital heart disease, hypertension with cardiac complications, and chronic heart failure.

Chronic kidney disease

Nephrotic syndrome, chronic kidney disease at stages 4 and 5 and those on kidney dialysis or with kidney transplantation.

Chronic liver disease

This includes cirrhosis, biliary atresia and chronic hepatitis.

Diabetes

Diabetes mellitus requiring insulin or oral hypoglycaemic drugs. This does not include diabetes that is diet controlled.

Immunosuppression

Due to disease or treatment, including patients undergoing chemotherapy leading to immunosuppression, bone marrow transplant, asplenia or splenic dysfunction, HIV infection at all stages, multiple myeloma or genetic disorders affecting the immune system (e.g. IRAK-4, NEMO, complement deficiency)

Individuals on or likely to be on systemic steroids for more than a month at a dose equivalent to prednisolone at 20 mg or more per day (any age), or for children under 20 kg, a dose of 1 mg or more per kg per day.

Individuals with cochlear implants

It is important that immunisation does not delay the cochlear implantation.

Individuals with cerebrospinal fluid leaks

This includes leakage of cerebrospinal fluid such as following trauma or major skull surgery. Conditions related to CSF leaks include all CSF shunts.

Occupational risk

Please see Individuals at occupational risk

Reinforcing immunisation

PCV13

A reinforcing (booster) dose of PCV13 is recommended on or after the first birthday. This vaccine is given at the same time as the Hib/MenC, 4CMenB and MMR vaccines (see Chapter 11).

PPV23

Antibody levels are likely to decline rapidly in individuals with no spleen, splenic dysfunction or chronic renal disease and therefore re-immunisation with PPV23 is recommended every five years in these groups. Revaccination is well tolerated. Testing of antibody levels prior to vaccination is not required. Although there is evidence of a decline in protection with time, there are no studies showing additional protection from boosting individuals with other indications, including age, and therefore routine revaccination is not currently recommended.

Individuals with unknown or incomplete vaccination histories

Unless there is a reliable history of previous immunisation, individuals should be assumed to be unimmunised. The full UK recommendations should be followed. Unimmunised or partially immunised children who present late for vaccination and before the age of one year should receive two doses of PCV13 two months apart1, and a further dose on their first birthday, at least two months after the last PCV13 dose1. An unimmunised or partially immunised child aged between one and under two years of age should have a single dose of PCV13. Routine immunisation with PCV is not offered after the second birthday unless the individual is at increased risk of pneumococcal disease.

Risk groups

Children and adults in at-risk groups as outlined in Table 1 may require additional protection against pneumococcal disease. The vaccine(s) and schedule used will depend on the age at presentation, their routine vaccination status and the nature of the underlying condition:

Infants diagnosed with at-risk conditions from birth to two years of age

All at-risk infants younger than one year (see Table 1), including those severely immunocompromised2, should be given PCV13 according to the schedule for the routine immunisation programme, at 8 weeks, 16 weeks and on their first birthday. At-risk infants who present late for vaccination should be immunised according to ‘Individuals with unknown or incomplete vaccination histories’ above. A single dose of PPV23 should be then given when they reach the age of two years, at least two months after the last dose of PCV.

Children in this age group who are severely immunocompromised2 and those with asplenia, splenic dysfunction or complement disorders are recommended to have an additional PCV13 dose. A second dose of PCV13 should be given at least two months after the routine dose due on their first birthday1. A single dose of PPV23 should be then given when they reach the age of two years, at least two months after the last dose of PCV.

Children diagnosed with at-risk conditions from two years to under ten years of age

Children diagnosed (or first presenting as) at-risk aged from two to under ten years of age who completed the recommended routine PCV immunisation schedule at 8 weeks, 16 weeks and on their first birthday should also receive PPV23. A single dose of PPV23 should be given, at least two months after the last dose of PCV. Children in this age group who are previously unvaccinated or partially vaccinated for PCV should receive one dose of PCV13, followed by a single dose of PPV23 at least two months later.

Severely immunocompromised2 children in this age group may have a sub-optimal immunological responses to the vaccine and should be given an additional dose of PCV13 even if they are fully vaccinated. A single dose of PPV23 should then be given, at least two months after the last dose of PCV. If PPV23 has already been administered, then wait at least six months after the PPV23 dose to give PCV13 in order to reduce the theoretical risk of pneumococcal serotype-specific hypo-responsiveness.

Children aged 10 years onwards and adults diagnosed with at-risk conditions

Individuals diagnosed (or first presenting as) from ten years of age should receive a single dose of PPV23, regardless of prior PCV vaccination. No additional PPV23 is recommended when they reach 65 years of age.

Older children and adults who are severely immunocompromised2 should be offered a single dose of PCV13 followed by PPV23 at least two months later (irrespective of their previous pneumococcal vaccinations). If PPV23 has already been administered, then wait at least six months after the PPV23 dose to give PCV13 in order to reduce the theoretical risk of pneumococcal serotype-specific hypo-responsiveness.

Timing of vaccination for individuals with splenic dysfunction or those requiring splenectomy or commencing immunosuppressive treatment

Because of the high risk of overwhelming infection, particularly for pneumococcal disease, vaccination against pneumococcal infection is recommended for all individuals who have splenic dysfunction. Because of this high risk, individuals with conditions which may lead splenic dysfunction in the future, including haemoglobinopathies such as sickle cell disease and coeliac syndrome, should also be vaccinated. See Chapter 7 for an example schedule including the other vaccines indicated in these groups.

Children and adults requiring splenectomy or commencing immunosuppressive treatment should be vaccinated according to the age-specific advice outlined above for risk groups. Ideally, pneumococcal vaccine should be given four to six weeks before elective splenectomy or initiation of treatment such as chemotherapy or radiotherapy. Where this is not possible, it can be given up to two weeks before treatment. If it is not possible to vaccinate beforehand, splenectomy, chemotherapy or radiotherapy should never be delayed.

If it is not practicable to vaccinate two weeks before splenectomy, immunisation should be delayed until at least two weeks after the operation. This is because there is evidence that functional antibody responses may be better from this time. If it is not practicable to vaccinate two weeks before the initiation of chemotherapy and/or radiotherapy, immunisation can be delayed until at least three months after completion of therapy in order to maximise the response to the vaccine. Immunisation of these patients should not be delayed if this is likely to result in a failure to vaccinate.

For leukaemia patients, PCV13 should be given from six months after completion of chemotherapy, and for bone marrow transplant patients, PCV13 should be offered 9–12 months following transplantation.

Individuals at occupational risk

There is an association between exposure to metal fume and pneumonia and infectious pneumonia, particularly lobar pneumonia and between welding and invasive pneumococcal disease. PPV23 (single 0.5 ml dose in those who have not received PPV previously) should be considered for those at risk of frequent or continuous occupational exposure to metal fume (e.g. welders) taking into account the exposure control measures in place. Vaccination may reduce the risk of invasive pneumococcal disease but should not replace the need for measures to prevent or reduce exposure.

1 the intervals may be reduced to one month if necessary to ensure that the immunisation schedule is completed

2 including bone marrow transplant patients, patients with acute and chronic leukaemia, multiple myeloma or genetic disorders affecting the immune system (e.g. IRAK-4, NEMO, complement deficiency)

Did you find this guideline summary useful?
Yes
No

full guideline are available from…

www.gov.uk/government/publications/pneumococcal-the-green-book-chapter-25

Public Health England. Pneumococcal: the green book, chapter 25. January 2018.

Contains public sector information licensed under the Open Government Licence v3.0.

First included: May 2019.

 

PHE pneumococcal guideline (Green Book chapter 25)