Disease caused by Streptococcus pneumoniae results in wide-spread
illness and death throughout the United States each year. The bacterium,
also called pneumococcus, was first identified by Pasteur in
1881 from the saliva of a patient with rabies. The association
between the pneumococcus bacterium and lobar pneumonia was
first described by Friedlander and Talamon in 1883, but pneumococcal
pneumonia was confused with other types of pneumonia
until the discovery of the Gram stain in 1884. From 1915 to
1945, the chemical structure and antigenicity of the pneumococcal
capsular polysaccharide, its association with virulence, and the role
of bacterial polysaccharides in human disease were explained.
More than 80 serotypes of pneumococci had been described by
1940.
Efforts to develop effective pneumococcal vaccines began as early
as 1911. However, with the advent of penicillin in the 1940s,
interest in the vaccine declined, until it was observed that many
patients still died despite antibiotic treatment. By the late 1960s,
efforts were again being made to develop a polyvalent pneumococcal
vaccine. The first pneumococcal vaccine was licensed in the
United States in 1977. The first conjugate pneumococcal vaccine
was licensed in 2000.

STREPTOCOCCUS PNEUMONIAE
Streptococcus pneumoniae are lancet-shaped, gram-positive, facultative
anaerobic organisms. They are typically observed in pairs
(diplococci) but may also occur singularly or in short chains.
Some pneumococci are encapsulated, their surfaces composed of
complex polysaccharides. Encapsulated organisms are pathogenic
for humans and experimental animals, whereas organisms without
capsular polysaccharides are not. Capsular polysaccharides are the
primary basis for the pathogenicity of the organism. They are antigenic
and form the basis for classifying pneumococci by serotypes.
Ninety serotypes have been identified, based on their reaction with
type-specific antisera. Type-specific antibody to capsular polysaccharide
is protective. These antibodies and complement interact to
opsonize pneumococci, which facilitates phagocytosis and clearance
of the organism. Antibodies to some pneumococcal capsular
polysaccharides may cross-react with related types as well as with
other bacteria, providing protection to additional serotypes.
Most S. pneumoniae serotypes have been shown to cause serious
disease, but only a few serotypes produce the majority of pneumococcal
infections. The 10 most common serotypes are estimated to
account for about 62% of invasive disease worldwide. The ranking
and serotype prevalence differs by age group and geographic area.
In the United States the seven most common serotypes isolated
from the blood or cerebrospinal fluid (CSF) of children <6 years
of age account for 80% of infections. These 7 serotypes account
for only about 50% of isolates from older children and adults.
Pneumococci are common inhabitants of the respiratory tract, and
may be isolated from the nasopharynx of 5% to 70% of normal
adults. Rates of asymptomatic carriage vary with age, environment,
and the presence of upper respiratory infections. Only 5%-
10% of adults without children are carriers. In schools and
orphanages, 27% to 58% of students and residents may be carriers.
On military installations, as many as 50% to 60% of service
personnel may be carriers. The duration of carriage varies and is
generally longer in children than adults. In addition, the relationship
of carriage to the development of natural immunity is poorly
understood.

CLINICAL FEATURES
The major clinical syndromes of pneumococcal disease include
pneumonia, bacteremia, and meningitis. The immunologic
mechanism that allows disease to occur in a carrier is not clearly
understood. However, disease most often occurs when a predisposing
condition exists, particularly pulmonary disease.
Pneumococcal pneumonia is the most common clinical presentation
of pneumococcal disease among adults. The incubation
period of pneumococcal pneumonia is short, about 1 to 3 days.
Symptoms generally include an abrupt onset of fever and chills or
rigors. Typically there is a single rigor, and repeated shaking chills
are uncommon. Other common symptoms include pleuritic chest
pain, cough productive of mucopurulent, rusty sputum, dyspnea
(shortness of breath), tachypnea (rapid breathing), hypoxia (poor
oxygenation), tachycardia (rapid heart rate), malaise, and weakness.
Nausea, vomiting, and headaches occur less frequently.
Up to an estimated 175,000 hospitalized cases of pneumococcal
pneumonia occur annually in the United States. Pneumococci
account for up to 36% of adult community-acquired pneumonia
and 50% of hospital-acquired pneumonia. It is a common bacterial
complication of influenza and measles. The case-fatality rate is
5%-7%, and may be much higher in elderly persons.
Complications of pneumococcal pneumonia include empyema
(i.e., infection of the pleural space), pericarditis (inflammation of
the sac surrounding the heart), and endobronchial obstruction,
with atelectasis and lung abscess formation.
More than 50,000 cases of pneumococcal bacteremia occur
each year. Bacteremia occurs in about 25%-30% of patients with
pneumococcal pneumonia. The overall mortality rate for bacteremia
is about 20%, but may be as high as 60% in elderly
patients. Patients with asplenia who develop bacteremia may experience
a fulminant clinical course.
Pneumococci cause 13%-19% of all cases of bacterial meningitis
in the United States. An estimated 3,000 to 6,000 cases of pneumococcal
meningitis occur each year. One-quarter of patients
with pneumococcal meningitis also have pneumonia. The clinical
symptoms, CSF profile and neurologic complications are similar to
other forms of purulent bacterial meningitis. Symptoms may
include headache, lethargy, vomiting, irritability, fever, nuchal
rigidity, cranial nerve signs, seizures and coma. The mortality rate
of pneumococcal meningitis is about 30%, but may be as high as
80% in elderly persons. Neurologic sequelae are common among
survivors.

PNEUMOCOCCAL DISEASE IN CHILDREN
Bacteremia without a known site of infection is the most common
invasive clinical presentation among children <2 years of age,
accounting for approximately 70% of invasive disease in this age
group. Bacteremic pneumonia accounts for 12%-16% of invasive
pneumococcal disease among children <2 years of age. With the
decline of invasive Hib disease, S. pneumoniae has become the leading
cause of bacterial meningitis among children <5 years of age in
the United States. Before routine use of pneumococcal conjugate
vaccine, children <1 year had the highest rates of pneumococcal
meningitis, approximately 10 cases per 100,000 population.
Pneumococci are a common cause of acute otitis media, and are
detected in 28%-55% of middle ear aspirates. By age 12 months,
62% of children have had at least one episode of acute otitis
media. Middle ear infections are the most frequent reasons for
pediatric office visits in the United States, resulting in more than
20 million visits annually. Complications of pneumococcal otitis
media may include mastoiditis and meningitis.
Before routine use of pneumococcal conjugate vaccine, the burden
of pneumococcal disease among children <5 years of age was significant.
An estimated 17,000 cases of invasive disease occured
each year, of which 13,000 were bacteremia without a known site
of infection and about 700 were of meningitis. An estimated 200
children died every year as a result of invasive pneumococcal disease.
Although not considered invasive disease, an estimated 5
million cases of acute otitis media occur each year among children
<5 years of age.

LABORATORY DIAGNOSIS
A definitive diagnosis of infection with Streptococcus pneumoniae
generally relies on isolation of the organism from blood or other
normally sterile body sites. Tests are also available to detect capsular
polysaccharide antigen in body fluids.
The appearance of lancet-shaped diplococci on Gram stain is
suggestive of pneumococcal infection, but interpretation of stained
sputum specimens may be difficult because of the presence of normal
nasopharyngeal bacteria. The suggested criteria for obtaining
a diagnosis of pneumococcal pneumonia using Gram stained sputnum
includes >25 white blood cells and <10 epithelial cells per
100-power field, and a predominance of gram-positive diplococci.
The quellung reaction (capsular swelling; capsular precipitation
reaction) is a test that provides rapid identification of pneumococci
in clinical specimens including spinal fluid, sputum, and exudates.
The procedure involves mixing loopfuls of bacteria in suspension,
pneumococcal antiserum, and methylene blue on the surface of a
glass slide and examination under oil immersion. If the reaction is
positive, the organism will be surrounded by a large capsule.
Several rapid tests for the detection of pneumococcal polysaccharide
antigen in CSF and other body fluids are available. These tests
generally lack sufficient sensitivity or specificity to assist in the
diagnosis of invasive pneumococcal disease.

MEDICAL MANAGEMENT
Resistance to penicillin and other antibiotics is common. In some
areas of the U.S. up to 40% of invasive pneumococcal isolates are
resistant to penicillin.Treatment will usually include a broad spectrum
cephalosporin, and often vancomycin, until results of antibiotic
sensitivity testing are available.

EPIDEMIOLOGY
OCCURRENCE
Pneumococcal disease occurs throughout the world.

RESERVOIR
Streptococcus pneumoniae is a human pathogen. The reservoir for
pneumococci is presumably the nasopharynx of asymptomatic
human carriers. There is no animal or insect vector.

TRANSMISSION
Transmission of Streptococcus pneumoniae occurs as the result of
direct person-to-person contact via respiratory droplets, and by
autoinoculation in persons carrying the bacteria in their upper respiratory
tract. The pneumococcal serotypes most often responsible
for causing infection are those most frequently found in carriers.
The spread of the organism within a family or household is
influenced by such factors as crowding, season, and the presence of
upper respiratory infections or pneumococcal disease such as
pneumonia or otitis media. The spread of pneumococcal disease is
usually associated with increased carriage rates. However, high carriage
rates do not appear to increase the risk of disease transmission
in households.

TEMPORAL PATTERN
Pneumococcal infections are more common during the winter and
in early spring when respiratory diseases are more prevalent.

COMMUNICABILITY
The period of communicability for pneumococcal disease is
unknown, but presumably transmission can occur as long as the
organism appears in respiratory secretions.

SECULAR TRENDS IN THE UNITED STATES
Estimates of the incidence of pneumococcal disease have been
made from a variety of population-based studies. More than
40,000 cases and more than 5,500 deaths from invasive pneumococcal
disease (bacteremia and meningitis) are estimated to have
occurred in the United States in 2002. More than half of these
cases occur in adults who have an indication for pneumococcal
polysaccharide vaccine. In addition, there are thousands of cases
of non-bacteremic pneumonia, and millions of cases of otitis media
which are considered noninvasive infections.
The overall incidence of invasive pneumococcal disease (bacteremia,
meningitis, or other infection of a normally sterile site) in
the United States in 1998-1999 was estimated to be approximately
24 cases per 100,000 population. However, incidence rates vary
greatly by age group. The highest rates of invasive pneumococcal
disease occur in young children, especially those <2
years of age. In 1998, the rate of invasive disease in this age
group was estimated to be 188 per 100,000 population; this age
group accounted for 20% of all cases of invasive pneumococcal
disease. Incidence was lowest in persons 5-17 years of age, and
increased to 61 per 100,000 population in persons 65 years of age
and older.
Data from the Active Bacterial Core Surveillance (ABCs) system
suggests that the use of pneumococcal conjugate vaccine is having
an impact on the incidence of invasive disease among young children.
Preliminary data from 2002 indicate that rates of invasive
pneumococcal disease have declined 70%-80% among children <2
years of age, compared to 1998-1999 (prior to licensure of the vaccine).
Rates of invasive disease have also declined among older age
groups, although the decline is less than among young children.
The decline among older age groups may indicate a reduction in
transmission from vaccinated children to their household and other
close contacts.
Children with functional or anatomic asplenia, particularly
those with sickle cell disease, and children with HIV infection
are at very high risk of invasive disease, with rates in
some studies more than 50 times higher than children of the same
age without these conditions (i.e., incidence rates of 5,000-9,000
per 100,000 population). Children of certain racial and ethnic
groups have increased rates, in particularly children of Alaskan
Native, certain American Indian groups, and of African American
origin. The reason for this increased risk by race and ethnicity is
not known with certainty, but was also noted for invasive
Haemophilus influenzae infection (also an encapsulated bacteria).
Attendance at a daycare center has also been shown to increase the
risk of invasive pneumococcal disease and acute otitis media from
2-3-fold among children <59 months of age.
Community-acquired pneumococcal pneumonia is usually a sporadic
disease in carriers who have a breakdown in their pulmonary
defense mechanisms. Outbreaks of pneumococcal pneumonia are
not common. When outbreaks occur, they are usually in crowded
environments, such as jails and nursing homes. During outbreaks,
persons with invasive disease often have underlying illness and may
have a high fatality rate.

PNEUMOCOCCAL VACCINES
CHARACTERISTICS
PNEUMOCOCCAL POLYSACCHARIDE VACCINE
Pneumococcal polysaccharide vaccine is composed of purified
preparations of pneumococcal capsular polysaccharide. The first
polysaccharide pneumococcal vaccine was licensed in the United
States in 1977. It contained purified capsular polysaccharide antigen
from 14 different types of pneumococcal bacteria. In 1983, a
23-valent polysaccharide vaccine (PPV23) was licensed and
replaced the 14- valent vaccine, which is no longer produced.
PPV23 contains polysaccharide antigen from 23 types of pneumococcal
bacteria which cause 88% of bacteremic pneumococcal disease.
In addition, cross-reactivity occurs for several capsular types
which account for an additional 8% of bacteremic disease.
The polysaccharide vaccine currently available in the United States
(Pneumovax 23, Merck) contains 25 mcg of each antigen per dose
and contains 0.25% phenol as a preservative. The vaccine is available
in a single dose vial or syringe, and in a 5 dose vial.
Pneumococcal vaccine is given by injection, and may be administered
either intramuscularly or subcutaneously.
PNEUMOCOCCAL CONJUGATE VACCINE
The first pneumococcal conjugate vaccine (PCV7) was licensed in
the United States in 2000. It includes purified capsular polysaccharide
of 7 serotypes of S. pneumoniae (4, 9V, 14, 19F, 23F, 18C,
and 6B) conjugated to a nontoxic variant of diphtheria toxin
known as CRM197. The serotypes included in PCV7 accounted
for 86% of bacteremia, 83% of meningitis, and 65% of acute otitis
media among children <6 years of age in the United States during
1978-1994. Additional pneumococcal polysaccharide conjugate
vaccines containing 9 and 11 serotypes of S. pneumoniae are being
developed. The vaccine is administered intramuscularly. It does
not contain thimerosal as a preservative, and is available only in
single dose vials.

IMMUNOGENICITY AND VACCINE EFFICACY
PNEUMOCOCCAL POLYSACCHARIDE VACCINE
More than 80% of healthy adults who receive PPV23 develop
antibodies against the serotypes contained in the vaccine, usually
within 2 to 3 weeks after vaccination. Older adults, and persons
with some chronic illnesses or immunodeficiency may not respond
as well, if at all. In children less than 2 years of age, antibody
response to most serotypes is generally poor. Elevated antibody
levels persist for at least 5 years in healthy adults, but fall more
quickly in persons with certain underlying illnesses.
PPV23 vaccine efficacy studies have resulted in various estimates
of clinical effectiveness. Overall, the vaccine is 60%-70% effective
in preventing invasive disease. The vaccine appears to be less effective
in preventing nonbacteremic pneumococcal pneumonia. The
vaccine may be less effective in preventing pneumococcal infection
in some groups, particularly those with significant underlying illness.
Although the vaccine may not be as effective in some persons,
especially those who do not have normal resistance to infections, it
is still recommended for such persons because they are at high risk
of developing severe disease.
Studies comparing patterns of pneumococcal carriage before and
after PPV23 vaccination have not shown clinically significant
decreases in carrier rates among vaccinees. In addition, no change
in the distribution of vaccine-type and nonvaccine-type organisms
have been observed as the result of vaccination.
PNEUMOCOCCAL CONJUGATE VACCINE
After 4 doses of PCV7 vaccine, >90% of healthy infants develop
antibody to all 7 serotypes contained in the vaccine. PCV7 has
been shown to be immunogenic in infants and children, including
those with sickle cell disease and HIV infection. In a large clinical
trial, PCV7 was shown to reduce invasive disease caused by vaccine
serotypes by 97%, and reduce invasive disease caused by all
serotypes, including serotypes not in the vaccine, by 89%. Efficacy
against pneumonia varied depending on the specificity of the diagnosis.
The vaccine reduced clinically diagnosed pneumonia by
11%, but reduced pneumonia confirmed with X-ray with consolidation
of >2.5 centimeters by 73%. Children who received PCV7
had 7% fewer episodes of acute otitis media and underwent 20%
fewer tympanostomy tube placements than unvaccinated children.
The duration of protection following PCV7 is currently unknown.
The effect of PCV7 on nasopharyngeal carriage of pneumococci is
not clear at this time.

VACCINATION SCHEDULE AND USE
PNEUMOCOCCAL POLYSACCHARIDE VACCINE
Pneumococcal polysaccharide vaccine should be administered rou-
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tinely to all adults 65 years of age and older. The vaccine is
also indicated for persons aged >2 years with a normal
immune system who have a chronic illness, including cardiovascular
disease, pulmonary disease, diabetes, alcoholism, cirrhosis,
or cerebrospinal fluid leak.
Immunocompromised persons aged >2 years who are at
increased risk of pneumococcal disease or its complications should
also be vaccinated. This group includes persons with splenic dysfunction
or absence (either from disease or surgical removal),
Hodgkin’s disease, lymphoma, multiple myeloma, chronic renal
failure, nephrotic syndrome (a type of kidney disease), or conditions
such as organ transplantation associated with immunosuppression.
Persons immunosuppressed from chemotherapy or high
dose corticosteroid therapy (>14 days) should be vaccinated.
Persons aged >2 years with with asymptomatic or symptomatic
HIV infection should be vaccinated. Pneumococcal vaccine should
be considered for persons living in special environments or social
settings with an identified increased risk of pneumococcal disease
or its complications, such as certain Native American populations.
If elective splenectomy is being considered, the vaccine should be
given at least 2 weeks before the operation. If vaccination prior to
splenectomy is not feasible, the vaccine should be given as soon as
possible after surgery. Similarly, there should also be a two week
interval between vaccination and initiation of cancer chemotherapy
or other immunosuppressive therapy, if possible.
Providers should not withhold vaccination in the absence of an
immunization record or complete record. The patient’s verbal history
may be used to determine vaccination status. Persons with
uncertain or unknown vaccination status should be vaccinated.
The target groups for pneumococcal polysaccharide vaccine and
influenza vaccine overlap. These vaccines should be given at the
same time at different sites if indicated.

PNEUMOCOCCAL CONJUGATE VACCINE
All children <24 months of age and children age 24-59 months
with a high risk medical condition should be routinely vaccinated
with PCV7. The primary series beginning in infancy consists of
three doses routinely given at 2, 4, and 6 months of age. A fourth
(booster) dose is recommended at 12-15 months of age. PCV7
should be administered at the same time as other routine childhood
immunizations, using a separate syringe and injection site.
For children vaccinated at <12 months of age, the minimum interval
between doses is 4 weeks. Doses given at >12 months of age
should be separated by at least 8 weeks.
Unvaccinated children 7 months of age and older do not require a
full series of 4 doses. The number of doses a child needs to complete
the series depends on the child’s current age. Unvaccinated
children aged 7-11 months should receive two doses of vaccine, at
least 4 weeks apart, followed by a booster dose at age 12-15
months. Unvaccinated children aged 12-23 months should receive
two doses of vaccine, at least 8 weeks apart. Previously unvaccinated
healthy children aged 24-59 months should receive a single dose
of PCV7. Unvaccinated children aged 24-59 months with sickle
cell disease, asplenia, HIV infection, chronic illness, or immunocompromising
conditions should receive 2 doses of PCV7 separated
by at least 8 weeks.
ACIP recommends that healthcare providers consider PCV7 for all
children aged 24-59 months, with priority given to children aged
24-35 months, children of Alaskan Native, American Indian or
African American descent, and children who attend group daycare
(defined as any setting outside the home where a child regularly
spends >4 hours per week with >2 unrelated children under adult
supervision).
PCV7 is not routinely recommended for persons >59 months of
age.
Few data are available on the use of PCV7 among children previously
vaccinated with PPV23. Children 24-59 months of age who
have already received PPV23 and who are at high-risk of invasive
pneumococcal disease (sickle cell disease, asplenia, HIV infection
or other immunocompromising conditions or chronic diseases)
could benefit from the immunologic priming induced by PPV23.
ACIP recommends these children receive 2 doses of PCV7 separated
by at least 8 weeks. The first dose of PCV7 should be given
no sooner than 2 months after PPV23. Similarly, children 24-59
months of age who have already received one or more doses of
PCV7 and who are at high risk of invasive pneumococcal disease
will benefit from the additional serotypes included in PPV23.
Vaccination with PPV23 should be considered for these high risk
children. PPV23 should be given no sooner than 2 months after
the last dose of PCV7. Routine administration of PPV23 to
healthy children 24-59 months of age is not recommended.

REVACCINATION
PNEUMOCOCCAL POLYSACCHARIDE VACCINE
Following vaccination with PPV23, antibody levels decline after 5-
10 years and decrease more rapidly in some groups than others.
However, the relationship between antibody titer and protection
from invasive disease is not certain (i.e., higher antibody level does
not necessarily mean better protection), so the ability to define the
need for revaccination based only on serology is limited. In addition,
currently available pneumococcal polysaccharide vaccines
elicit a T-independent response, and do not produce a sustained
increase (“boost”) in antibody titers. Available data do not indicate
a substantial increase in protection in the majority of revaccinated
persons.
Because of the lack of evidence of improved protection with multiple
doses of pneumococcal vaccine, routine revaccination of
immunocompetent persons previously vaccinated with 23-
valent polysaccharide vaccine is not recommended. However,
revaccination is recommended for persons 2 years of age and older
who are at highest risk for serious pneumococcal infection and for
those who are likely to have a rapid decline in pneumococcal antibody
levels. Only one PPV23 revaccination dose is recommended
for high risk persons. The second dose should be
administered five or more years after the first dose. Revaccination
3 years after the previous dose may be considered for children at
highest risk for severe pneumococcal infection who would be aged
10 years or less at the time of revaccination, including children
who received PCV7.
Persons at highest risk include all people >2 years of age with functional
or anatomic asplenia (e.g., sickle cell disease or splenectomy),
HIV infection, leukemia, lymphoma, Hodgkins disease, multiple
myeloma, generalized malignancy, chronic renal failure,
nephrotic syndrome, or other conditions associated with immunosuppression
(e.g., organ or bone marrow transplantation) and those
receiving immunosuppressive chemotherapy, including long term
corticosteroids. Persons aged 65 years and older should be administered
a second dose of pneumococcal vaccine if they received the
vaccine more than 5 years previously, and were less than 65 years
of age at the time of the first dose.

PNEUMOCOCCAL CONJUGATE VACCINE
Revaccination after an age-appropriate primary series with PCV7 is
not currently recommended.

ADVERSE REACTIONS FOLLOWING VACCINATION
PNEUMOCOCCAL POLYSACCHARIDE VACCINE
The most common adverse reactions following either pneumococcal
polysaccharide or conjugate vaccine are local reactions. For
PPV23, from 30% to 50% of vaccinees report pain, swelling, or
erythema at the site of injection. These reactions usually persist for
less than 48 hours.
Local reations are reported more frequently following a second
dose of PPV23 vaccine than following the first dose. Moderate
systemic reactions (such as fever and myalgias) are not common
(<1% of vaccinees), and more severe systemic adverse reactions are
rare.
A transient increase in HIV replication has been reported following
PPV23 vaccine. No clinical or immunologic deterioration has
been reported in these persons.

PNEUMOCOCCAL CONJUGATE VACCINE
Local reactions following PCV7 occur in 10%-20% of recipients.
Fewer than 3% of local reactions are considered to be severe (e.g.,
tenderness that interferes with limb movement). Local reactions
are more common with the fourth dose than with the first 3 doses.
In clinical trials of pneumococcal conjugate vaccine, fever >38 degrees C
within 48 hours of any dose of the primary series was reported in
15%-24% of children. However, in these studies, whole-cell pertussis
vaccine was administer simultaneously with each dose, and
some or most of the reported febrile episodes may be attributable
to the DTP. In one study acellular pertussis vaccine (DTaP) was
given at the same visit as the booster dose of PCV7. In this study,
11% of recipients had a temperature >39 degrees C. No severe adverse
events attributable to PCV7 have been reported.

CONTRAINDICATIONS AND PRECAUTIONS TO
VACCINATION
For both pneumococcal polysaccharide and conjugate vaccines, a
serious allergic reaction to a vaccine component or following a
prior dose is a contraindication to further doses of vaccine. Such
allergic reactions are rare. Persons with moderate or severe
acute illness should not be vaccinated until their condition
improves. However, minor illnesses, such as upper respiratory
infections, are not a contraindication to vaccination.
The safety of PPV23 vaccine for pregnant women has not been
studied, although no adverse consequences have been reported
among newborns whose mothers were inadvertently vaccinated
during pregnancy. Women who are at high risk of pneumococcal
disease and who are candidates for pneumococcal vaccine should
be vaccinated before pregnancy, if possible.

VACCINE STORAGE AND HANDLING
Pneumococcal polysaccharide vaccine should be shipped in an insulated
container with coolant packs. Although pneumococcal polysaccharide
vaccine can tolerate room temperature for a few days,
CDC recommends that the vaccine be stored at refrigerator temperature
(2-8 degrees C [35-46 degrees F])
Pneumococcal conjugate vaccine should be stored at refrigerator
temperature. Pneumococcal vaccines must not be frozen.
Opened multidose vials may be used until the expiration date printed
on the package if not visibly contaminated.

GOALS AND COVERAGE LEVELS
The Healthy People 2010 goal is to achieve at least 90% coverage
for pneumococcal polysaccharide vaccine among persons >65 years
of age. Data from the 2002 Behavioral Risk Factor Surveillance
System (BRFSS, a population-based, random-digit-dialed telephone
survey of the noninstitutionalized U.S. population 18 years of age
and older) estimates that 54% of persons 65 years of age or older
had ever received pneumococcal polysaccharide, an increase of 18%
since the 1995 survey. Vaccination levels increased in all but one
state and were significantly lower among black and Hispanic
persons than among white persons.
Opportunities to vaccinate high-risk persons are missed both at the
time of hospital discharge and during visits to clinicians’ offices.
Effective programs for vaccine delivery are needed, including offering
the vaccine in hospitals at discharge, clinicians’ offices, nursing
homes, and other chronic care facilities.
More than two-thirds of the persons who have been hospitalized
with serious pneumococcal disease had been admitted to a hospital
in the preceding 3 to 5 years. In addition, persons who frequently
visit physicians and who have chronic conditions are more likely to
be at high risk of pneumococcal infection than those who require
infrequent visits. Screening and subsequent immunization of hospitalized
persons found to be at high-risk could have a significant
impact in reducing complications and death associated with pneumococcal
disease.

SELECTED REFERENCES
American Academy of Pediatrics. Pneumococcal infections. In:
Pickering L, ed. Red Book: 2003 Report of the Committee on Infectious
Diseases. 26th ed. Elk Grove Village, IL: American Academy of
Pediatrics; 2003:490-500.
Black S, Shinefield HR, Fireman B, et al. Efficacy, safety and
immunogenicity of heptavalent pneumococcal conjugate vaccine in
children. Pediatr Infect Dis J 2000;19:187-95.
Butler JC, Breiman RF, Campbell JF, et al. Pneumococcal polysaccharide
vaccine efficacy: an evaluation of current recommendations.
J Am Med Assoc 1993;270:1826-31.
CDC. Active Bacterial Core Surveillance. Available at
http://www.cdc.gov/ncidod/dbmd/abcs/. Accessed January 7, 2004.
CDC. Prevention of pneumococcal disease among infants and
young children using a pneumococcal conjugate vaccine.
Recommendations of the Advisory Committee on Immunization
Practices (ACIP). MMWR 2000;49(RR-9):1-35.
CDC. Prevention of pneumococcal disease. Recommendations of
the Advisory Committee on Immunization Practices (ACIP).
MMWR 1997;46(RR-8):1-24.
CDC. Public health and aging: influenza vaccination coverage
among adults aged >50 years and pneumococcal vaccination coverage
among adults aged >65 years - United States, 2002. MMWR
2003;(52);987-92.
Jackson LA, Benson P, Sneller VP, et al. Safety of revaccination with
pneumococcal polysaccharide vaccine. J Am Med Assoc
1999;281:243-8.
Robinson KA, Baughman W, Rothrock G. Epidemiology of invasive
Streptococcus pneumoniae infections in the United States, 1995-
1998. Opportunities for prevention in the conjugate vaccine era. J
Am Med Assoc 2001;285:1729-35.
Whitney CG. The potential of pneumococcal conjugate vaccines for
children. Pediatr Infect Dis J 2002;21:961-70.
Whitney CG, Farley MM, Hadler J, et al. Decline in invasive pneumococcal
disease after introduction of protein-polysaccharide conjugate
vaccine. N Eng J Med 2003;348:1737-46.
Whitney CG, Shaffner W, Butler JC. Rethinking recommendations
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