Questions and Answers
NIP Answers Your Questions
Pneumococcal

• General Questions
• Indications/Risk Factors
• Cochlear Implants
• Safety/Contraindications
• PPV23 Revaccination

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General Questions

• If a child has been diagnosed with pneumococcal disease are they immune?
  
  They are only immune to that serotype of pneumococcus. There are at least 90 serotypes of Streptococcus pneumoniae. The child should still be vaccinated as age-appropriate to protect against the other serotypes in the vaccine. (2/20/03)

• For children over 24 months of age, which pneumococcal vaccine is preferred?
  
  If the child between 24 and 59 months of age is at high risk for pneumococcal disease, then both PCV & PPV are indicated. If the child is not at high risk, then only PCV is indicated. ACIP Pneumococcal (PCV) Recommendations (see pages 21-27) (2/20/03)

• Please clarify the recommended and minimum intervals between doses of PCV vaccine?
  
  The recommended interval between the first 3 doses given under 12 months of age is 8 weeks. The minimum interval is 4 weeks. The minimum age for the 4th dose is 12 months of age and there must be at least 8 weeks between the 3rd and 4th doses. ACIP General Recommendations (see page 3) (2/20/03)

• We have a clinic-based influenza vaccine program and we get a lot of inquiries about the pneumococcal vaccine. The question is do you recommend the pneumococcal vaccine only in a physician-based program? We are concerned that patients don't have their record and aren't sure when or if they have received the vaccine?

  If your state and agency allow you to provide vaccines under a standing order protocol, then both influenza and pneumococcal vaccines can be administered when recommended, www.cdc.gov/mmwr/PDF/rr/rr4901.pdf. The ACIP states in their recommendations for pneumococcal polysaccharide vaccine that elderly persons with unknown vaccination status should be administered one dose of vaccine, ftp://ftp.cdc.gov/pub/Publications/mmwr/rr/rr4608.pdf (See Figure 1 and page 15). (6/26/03)

• Will the pneumococcal polysaccharide vaccine protect against Mycoplasma pneumonia?

  No. Pneumococcal vaccines protect only against certain serotypes of Streptococcus pneumoniae. (6/26/03)

• Is there any situation in which you should give PCV to an adult?

  No, pneumococcal conjugate vaccine is only licensed by FDA for children up to 9 years of age and recommended by ACIP for children up to 5 years of age, http://www.fda.gov/cber/label/pneuled021700LB.pdf and http://www.cdc.gov/mmwr/PDF/rr/rr4909.pdf. (8/21/03)

• When is it appropriate to give both PCV7 and PPV23 vaccines?

  A child who has received pneumococcal conjugate vaccine AND who has a high-risk condition for which PPV23 is recommended, should receive PPV23 vaccine as long as they are at least 2 years of age and it has been at least 2 months since the last dose of PCV7. PPV23 offers protection against additional pneumococcal serotypes, but children less than 2 years of age do not respond well to polysaccharide vaccines, http://www.cdc.gov/mmwr/PDF/rr/rr4909.pdf (see page 27). (8/21/03)

• Why can’t you administer PCV and PPV23 simultaneously?

  We do not have data on what happens when you give them simultaneously, for example severity of local reactions. ACIP recommends the conservative approach, to always separate pneumococcal conjugate and pneumococcal polysaccharide vaccines by two months. (8/21/03)

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Indications/Risk Factors

• Would you give a 3 year old child who attends day care PCV or PPV, and why?
  
  ACIP includes day care attendance as a high-risk factor for pneumococcal conjugate vaccine (PCV). Out-of-home day care increases the risk for invasive pneumococcal disease and
  AOM among children. In a study of risk factors for invasive pneumococcal disease among children in the United States, attendance at a group day care center during the preceding 3 months was associated with an approximately 2.3-fold increase in invasive disease among children aged 12–23 months, and 3.2-fold increased risk among children aged 24–59 months. Moreover, in a recent population-based case-control study, nonelderly adults (i.e., persons aged 18–64 years) who lived in a household that included children who attended day care were at greater risk for acquiring invasive pneumococcal infections than adults who did not (multivariate odds ratio [OR] = 3.0).

  In studies of otitis media resulting from all causes, risk for AOM was higher among children who attended day care outside the home compared with family day care, and risk for middle ear effusions increased with exposure to larger numbers of children in day care settings. Younger age when starting day care also increases risk for experiencing recurrent AOM. Day care attendance is also a risk factor for other acute upper respiratory tract infections among children aged <5 years. ACIP Pneumococcal (PCV) Recommendations (see page 6) (2/20/03)

• The Prevnar package insert seems to suggest the vaccine can be used up to 9 years of age. What does ACIP recommend? Is there any advantage to giving the vaccine to older children with chronic health conditions?
  
  Data are limited regarding efficacy of PCV7 among children 5 and older, and adults. However, limited studies report that a) a 5-valent pneumococcal conjugate vaccine was immunogenic among HIV-infected children aged 2–9 years; b) PCV7 is immunogenic
  among children aged 2–13 years with recurrent respiratory infections ; and c) PCV7 is immunogenic among older children and adults aged 4–30 years with SCD. Administering PCV7 to older children with high-risk conditions is not contraindicated. ACIP Pneumococcal (PCV) Recommendations (see page 26) (2/20/03)

• Should pneumococcal vaccine be given to someone with asthma?
  
  "Asthma has not been associated with an increased risk for pneumococcal disease unless it occurs with chronic bronchitis, emphysema, or long-term use of systemic corticosteroids." This is from page 3 of the ACIP PPV23 recommendations. Asthma alone is also not an indication for PCV. ACIP Pneumococcal (PPV) Recommendations (see page 3) and ACIP Pneumococcal (PCV) Recommendations (see page 22) (2/20/03)

• Is a history of pneumonia a high risk factor for pneumococcal vaccine?
  
  Pneumococcal vaccine is indicated for persons with chronic lung disease (e.g., COPD and emphysema). Pneumonia without a history of chronic lung disease is not an indication for pneumococcal immunization. ACIP Pneumococcal (PPV) Recommendations and ACIP Pneumococcal (PCV) Recommendations (2/20/03)

• What vaccines are indicated for someone with a splenectomy and is there concern that a person with a splenectomy may have a less than optimum response to vaccines?
  
  Persons who do not have a functioning spleen or who have had a splenectomy do not handle encapsulated bacteria well and, therefore, are at increased risk for infection with encapsulated bacteria, especially Neisseria meningitidis and Streptococcus pneumoniae. They should be vaccinated with age-appropriate pneumococcal vaccine and meningococcal vaccine.
  
  Persons two years of age and older should receive two doses of pneumococcal polysaccharide vaccine separated by 3-5 years, depending on the age at time of revaccination. One dose of meningococcal vaccine should be administered. The recommendation for a booster dose is somewhat vague because polysaccharides aren’t the best antigens and don’t boost antibody titers very much with subsequent doses. However, high-risk people, including those without a functioning spleen can receive a one-time revaccination 3-5 years after the first dose. Certainly no more than a total of two doses should be given. Some providers also choose to administer one pediatric dose of Haemophilus influenzae type b vaccine, regardless of age. Ideally the Hib dose should be given a couple of weeks prior to a scheduled splenectomy.
  
  Immunosuppression is not an issue unless the patient has other health issues or treatments that are suppressing the immune system. Their response to vaccination should not be affected by the lack of a functioning spleen, ACIP Adult Recommendations (See “ Splenic Dysfunction or Anatomic Asplenia”) and ACIP Altered Immunocompetence Recommendations (see page 2). (2/13/03)

• Should a person who has received a stapes prothesis be vaccinated with the age-appropriate pneumococcal vaccine?

  There are no ACIP recommendations regarding pneumococcal vaccination of persons with a stapes prothesis. (8/21/03)

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Cochlear Implants

• Should an adult who has had a cochlear implant be vaccinated with meningococcal or pneumococcal vaccine?
  
  The recommendation is to include people who have had a cochlear implant in the high risk group for pneumococcal disease. If the person is under 2 years of age, give pneumococcal conjugate vaccine. If the person is between 2 and 5 years of age, give two doses of pneumococcal conjugate vaccine and one dose of pneumococcal polysaccharide vaccine, separating the doses by a two months each. Persons 5 years of age and older should get a single dose of pneumococcal polysaccharide vaccine.
  
  The cases of meningitis reported to date have been mostly pneumococcal. There have only been one or two cases caused by Neisseria meningitidis and none caused by Haemophilus influenzae. There are no recommendations at this time to vaccinate these individuals with meningococcal vaccine. NIP Cochlear Implant Webpage (2/20/03)

• Should you complete the pneumococcal vaccination series prior to a scheduled cochlear implant if possible?
  
  Yes, if you can. You can accelerate the schedule since the child will become high risk after the implant. You want to get in as many doses as possible, then complete the series after the implant if necessary. The child will probably need a booster after a year anyway. A child less than 2 years of age should receive only pneumococcal conjugate vaccine. A child 2 to 5 years of age should receive both pneumococcal conjugate and pneumococcal polysaccharide vaccines. A person 5 years of age or older should receive the pneumococcal polysaccharide vaccine. NIP Cochlear Implant Webpage (2/20/03)

• If an adult with a cochlear implant receives a dose of PPV, when should they receive the second dose?

  Persons aged 5 to 64 years with a cochlear implant should receive a single dose of pneumococcal polysaccharide vaccine. These persons should receive a second dose of pneumococcal polysaccharide vaccine at age 65 years, if at least 5 years have elapsed since their last dose. People with cochlear implants should be treated like other people with underlying illness like cardiac or renal disease. They are not in the highest risk group like persons with asplenia or other immunocompromising conditions for whom a second dose is recommended 5 years after the first dose, http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5231a5.htm and ftp://ftp.cdc.gov/pub/Publications/mmwr/rr/rr4608.pdf. (8/21/03)

• If a child less than 24 months of age with a cochlear implant receives the recommended doses of PCV, will the child need a dose of PPV23 at 24 months of age?

  Yes, these children should also receive one dose of pneumococcal polysaccharide vaccine, at least 2 months after the last dose of pneumococcal conjugate vaccine, http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5231a5.htm. (8/21/03)

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Safety/Contraindications

• Concerning PPV - In the hospital setting, a number of physicians are questioning the safety of administration of PPV to patients who have pneumonia. What literature can you recommend to demonstrate the safety of administration of PPV to these patients? Also, a number of physicians are questioning the safety of administration of PPV to patients who have pneumonia. What literature can you recommend to demonstrate the safety of administration of PPV to these patients? Can you tell us the specific contraindications to this vaccine?

  These issues are discussed in an article by David Fedson in Infection Control and Hospital Epidemiology:
  "Hospital-based influenza and pneumococcal vaccination: Sutton's Law applied to prevention." Fedson DS, Houck P, Bratzler D. Infect Control Hosp Epidemiol. 2000 Nov;21(11):692-9.
  
  There is no published evidence that vaccination of hospitalized people at discharge is any more or less safe than vaccination in any other circumstance. The vaccine components are inactivated and CANNOT cause disease. Hospitalized patients for whom PPV23 is recommended should be vaccinated at discharge. Failing to do so is missing an important opportunity to protect these patients against pneumococcal disease.

  Vaccination of anyone with an acute disease should be delayed until the acute symptoms abate, however, this does not mean that the illness must be completely resolved.

  Following are the contraindications and precautions:

  • A serious allergic reaction to a dose of pneumococcal vaccine or a vaccine component 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.
    
    You will find further information about PPV23 in the ACIP statement, ftp://ftp.cdc.gov/pub/Publications/mmwr/rr/rr4608.pdf. (6/26/03)

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PPV23 Revaccination

• Why isn’t there a recommendation to give pneumococcal polysaccharide vaccine (PPV23) boosters to high-risk individuals every 5 years? Is it because of severe local reactions?

  No. Ongoing booster doses are not recommended because pneumococcal polysaccharide vaccine does not boost well. Current data do not indicate that administering multiple boosters of PPV23 provides any more protection than one dose followed by a one-time booster 5 years later. (6/26/03)

• Do person who get their first dose of pneumococcal polysaccharide vaccine at 65 years of age need a booster dose later on?

  It depends. Healthy persons who get their first dose just because they hit that magic mark of 65 years old don’t automatically need a booster dose 5 years later. Only those who have or later develop a high-risk condition for which revaccination is recommended, should receive a booster dose after 5 years or more. (6/26/03)

• Please clarify the recommendations for revaccination with PPV23?

  The following fact sheet provides an excellent summary of the ACIP recommendations for PPV23 revaccination, http://www.immunize.org/catg.d/2015pne.pdf. (8/21/03)

This page last modified on April 22, 2004