Skip to content

Pneumococcal vaccination service clinical update

Course Information

  • Estimated Time: 60 minutes.
  • Difficulty: Intermediate.
  • Categories: Pneumococcal.
  • Quiz: Pass the quiz to pass this course.

Please read our CPD disclaimer before enrolling.

Learning objectives

  • We will help you understand where to seek up-to-date information on pneumococcal disease and vaccination including how guidance currently varies across the UK.
  • We will learn about the cause, characteristics and epidemiology of pneumococcal disease.
  • We will learn about pneumococcal pneumonia.
  • We will find out about the epidemiology of pneumonia and how pneumonia fits in the overall picture of pneumococcal disease.
  • We will help you understand how to assess who is suitable for the pneumococcal vaccination.
  • We will help you understand how to address vaccine hesitancy and also learn about when it can be helpful to suggest the pneumococcal vaccination to your patients.
  • We will find out and become familiar with the pneumococcal vaccines available.
  • We will learn about how to store, prepare and administer the vaccines available.
  • We will describe the information you should give to patients after the vaccination.
  • We will pre-empt some of the questions that patients may ask.

Course contents


Record your CPD

Before starting this course we recommend you reflect on what you know already. The revalidation form below is a useful tool to help you reflect on what you know before commencing the course. We will give you the chance to fill it in at the end so that you can record your learning.

Creating a record of achievement is a very important aspect of continuing professional development so we will give you a chance to complete an assessment at the end too.

If you successfully complete the quiz at the end of the course we will send you a CPD certificate of achievement for this course.

References

  1. Immunisation procedures, The Green Book chapter 4 available here Green-Book-Chapter-4.pdf (publishing.service.gov.uk) [accessed 25.6.2021]
Write your CPD topic in here. The information will be emailed to you.
Selected Value: 0
The range is 0-10. A score of 10 means you feel like you know everything you need to know about this topic.
We will use your email to send you the details of your revalidation CPD entry. As you will see above we have asked specifically for permission for additional uses of your email. You can then copy/paste the detail directly into your GPhC record. Read our privacy policy on the homepage.

Let’s get started.

Pneumococcal disease is a term that describes a group of illnesses caused by Streptococcus pneumoniae of which pneumonia is one. (3)

This bacterium is also known as pneumococcus. Streptococcus pneumoniae is an encapsulated gram-positive coccus and the capsule, of which there are over 90 serotypes, is the most important virulence factor. There are a number of these serotypes that can reside in the nasopharynx without causing any symptoms. A small proportion of these people may suffer from the disease. (3)

The bacteria can spread to the following areas and sometimes cause otitis media or sinusitis: (3)

  • Sinuses.
  • Middle ear cavity.

Invasive infections may also occur occasionally. These can be broadly categorised as the following:

  • Pneumococcal pneumonia.
  • Invasive pneumococcal disease (IPD).

These are caused by other serotypes and can cause severe disease which presents as the following: (3)

  • Pneumonia.
  • Systemic infections
    • Bacteraemic pneumonia.
    • Bacteraemia.
    • Meningitis.

Rare cases of septic arthritis, peritonitis, endocarditis and infections at other sites have been reported.

The term pneumococcal disease describes infections caused by the bacterium Streptococcus pneumoniae. (3)

Transmission of pneumococcal disease happens in the following ways: (3)

  • Aerosol.
  • Droplets.
  • Direct contact with respiratory secretions of a carrier.

Frequent or prolonged close contact is required for transmission to occur. (3)

It should be noted that there is a seasonal element to pneumococcal disease. Levels are higher in the winter months.


[tqb_quiz id=’56633′]


What is pneumonia?

In simple terms, pneumonia is inflammation of the tissue in the lungs. It can occur in one or both lungs. (2)

Pneumonia is caused by bacterial and viral infections. Covid-19 can cause pneumonia. (2)

Common symptoms of pneumonia include the following: (2)

  • Fast heartbeat.
  • Elevated temperature.
  • People may feel generally unwell.
  • Shivering or sweating.
  • Appetite loss.
  • Cough. The nature of the cough can be dry. Phlegm produced as a result of this type of cough may be thick yellow, green, brown and can be blood-stained.
  • Difficulty with breathing. People may experience rapid breathing. Breathing may be shallow and people may feel breathless. Breathlessness can be a feature even at rest.

Less common symptoms include the following: (2)

  • Haemoptysis.
  • Headaches.
  • Fatigue.
  • Nausea and/vomiting.
  • Wheeze
  • Joint pain.
  • Muscle pain.
  • Confusion.
  • Disorientation. Disorientation is more common in the elderly.

These symptoms can come on gradually over a number of days but it should be noted the symptoms of pneumonia can come on more quickly over the course of a 24 to 48 hour period. (2)

A full respiratory examination is usually required to diagnose pneumonia. This is largely because pneumonia shares many of the symptoms of other common respiratory diseases. (2)


[tqb_quiz id=’56613′]


The epidemiology of pneumococcal disease

Pneumococcal disease causes significant mortality and morbidity. (4) The main cause of community-acquired pneumonia in adults is non-invasive pneumococcal disease. (5)

Below is a summary of key epidemiological facts about pnemococcal disease:

  • Community-acquired pneumonia annual incidence is 5-11per 1000 adult. (4)
  • In 2016 Streptococcus pneumoniae contributed to 1.1 million deaths globally.
  • The overall incidence of invasive pneumococcal disease (IPD) has increased in recent years.
    • 2013/14 overall annual incidence was 7.12 per 100,000.
    • 2016/17 overall annual incidence was 9.87 per 100,000.

It is likely that the vaccines available and the evolution of new vaccines over the years have positively impacted these incidence rates. (4) It is important to discuss the benefits of vaccination to patients as and when appropriate.

The incidence of IPD is high in people over the age of 65 years at 28.9 cases per 100,000. (6)

In addition to age as a risk the following are risk factors: (6)

  • Solid-organ (eg lung, heart, liver and kidney) dysfunction.
  • Immunosuppression, including splenic dysfunction and malignancy.

Yes, there is a pattern of disease of IPD that relates to age. IPD rates are higher in children and in the elderly. (6)

  • 75% of cases of IPD happen in children under 2 years old. (6)
  • 83% of cases of pneumococcal meningitis happen in children under 2 years old. (6)

[tqb_quiz id=’56649′]


Pneumoccocal vaccination in the UK – The current picture

In this section, we will take you through the important details of the pneumococcal vaccines currently available in the UK. At this point, it is really important to note that whilst we make general statements to improve your background knowledge we recommend that you consult up-to-date reference sources before making a supply. The responsibility for supply by whatever legal framework you choose (prescribing, PGD or PSD) sits with you the pharmacist. For this section, we have summarised some of the key points from the Green Book and the respective summary of product characteristics.

There are currently two types of pneumonia vaccines available privately. These are:

  • Polysaccharide vaccines.
  • Conjugate vaccines.

You will recall that we discussed serotypes earlier. Each vaccine protects the patient against various serotypes. The summary below describes the coverage of the respective vaccines: (3)

Vaccine typeLicensed vaccineSerotypes covered
Pneumococcal polysaccharide vaccine (PPV23)Pneumococcal Polysaccharide Vaccine®1, 2, 3, 4, 5, 6B, 7F, 8, 9N, 9V, 10A, 11A, 12F, 14, 15B, 17F, 18C, 19F, 19A, 20, 22F, 23F, 33F
Pneumococcal conjugate vaccine (PCV13)Prevenar13®1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, 23F
Pneumococcal conjugate vaccine (PCV10)Synflorix®1, 4, 5, 6B, 7F, 9V, 14, 18C, 19F, 23F

Table adapted from the Green Book and shared under Open Government Licence.

As you would expect the vaccines for the pneumococcal disease are evolving constantly. For example, there used to be a vaccine known as Prevenar7® which covered 7 serotypes. The use of vaccines in this area has been shown to reduce the incidence of disease the consequences of which, as we already covered, can be serious. (6)

The use of Prevenar7® (launched 2006) and its replacement Prevenar13® (launched 2010) has led to a sustained decline in the incidence of invasive pneumococcal disease. (6)

For complete information please consult the Green book or the individual summary of product characteristics.

From here on in this course will focus on PCV23 (Pneumovax 23) and PCV13 (Prevenar 13) vaccinations.


What types of pneumococcal vaccines are available?

Pneumococcal polysaccharide vaccine (PPV23)

PPV23 contains purified capsular polysaccharides from each of 23 common capsular types of pneumococcus. Below we summarise some key aspects of the PPV23 vaccine:

  • The majority of healthy adults develop a good antibody response to a single dose.
  • Antibody response usually happens three weeks post-immunisation.
  • Poor antibody responses to PPV23 immunisation in children under the age of two years. No evidence of efficacy in this age group. (7)
  • The short-term effectiveness of PPV23 against IPD is moderate in adults over 65 years in the first two years post-immunisation (41%). (3) Vaccine effectiveness is higher in healthy people. (8)
  • Duration of protection of PPV23 in adults over the age of 65 years and in at-risk groups varies. This is serotype dependent.

The levels of antibody in the body after immunisation begin to reduce after approximately five years. (9)

It should be noted that antibody levels may decline more rapidly in the following patient groups: (9)

  • Children with nephrotic syndrome.
  • Asplenic patients.

Pneumococcal conjugate vaccines (PCV)

PCVs have been developed containing polysaccharides from the most common capsular types. (3)

  • PCVs are highly immunogenic in children from two months old.
  • PCV13 vaccine replaced PCV7 in 2010.
  • By 2013/14, over 70% of all IPD cases were due to serotypes not covered by PCV13. (10)
  • Since 2013/14 there has been an increase in the overall incidence of IPD.

Pneumococcal polysaccharide conjugate vaccine (13-valent)

Prevenar13® contains the 7 pneumococcal capsular polysaccharides that are in Prevenar (4, 6B, 9V, 14, 18C, 19F, 23F) plus 6 additional polysaccharides (1, 3, 5, 6A, 7F, 19A) all conjugated to CRM197 carrier protein.


Therapeutic indications

  • Active immunisation for the prevention of invasive disease, pneumonia and acute otitis media caused by Streptococcus pneumoniae in infants, children and adolescents from 6 weeks to 17 years of age. (11)
  • Active immunisation for the prevention of invasive disease and pneumonia caused by Streptococcus pneumoniae in adults ≥18 years of age and the elderly. (11)

The manufacturer makes the following recommendation when making a decision as to whether to immunise someone with Prevenar 13: (11)

  • Take into account official recommendations.
  • Consider the risk of invasive disease.
  • Consider the risk of pneumonia in different age groups.
  • Consdier underlying comorbidities.
  • Finally take into consideration serotype epidemiology in particular geographical areas.

Dosage

We recommend you consult the summary of product characteristics and/or the BNF to check comprehensive dosing advice. For the purpose of this course, we will look at adult dosing only.

For adults aged 18 years and over including the elderly, a single dose is recommended. (11)

It has not been established that revaccination with a subsequent dose of Prevenar 13 is required hence the single-dose recommendation by the manufacturer.

Prevenar 13 should be given first if the use of 23-valent PPV vaccine is deemed appropriate Prevenar 13 should be given first. This is regardless of prior pneumococcal vaccination status. (11)

Certain patient populations have conditions that make them more predisposed to IVD including, (11)

  • Sickle cell disease.
  • HIV infection.

Contra-indications

Allergy and/or hypersensitivity to the ingredient in Prevenar13® is considered a contra-indication. Hypersensitivity to the diphtheria toxoid should also be considered a contra-indication. (11)

Prevenar13® administration should be postponed in the following circumstances:

  • People suffering from ‘acute, severe’ febrile illness.

If the person you are about to vaccinate has a minor infection, this could include the common cold, for example, then the vaccination should not be deferred. (11)


Cautions and special considerations

Whilst we recommend you consult the summary of product characteristics there are a number of special considerations that we feel we should draw your attention to. These are aspects of the use Prevenar 13 that you should keep to the forefront of your mind when delivering your service.

The manufacturer specifically states that Prevenar13® must NOT be administered intravascularly. (11)

Like other vaccines, during and after the vaccination procedure, there should be appropriately trained personal and equipment on hand to deal with an unlikely anaphylactic event.

What about people with thrombocytopenia or coagulation disorders?

The manufacturer states that Prevenar 13 should not be given to this group of individuals via the intramuscular route. However, Prevenar 13 may be given via the subcutaneous route but only if the benefit clearly outweighs the risks. (11)

Before administering the vaccination pharmacists should have a conversation with the individual to explain that, as with all vaccines, Prevenar 13 may not protect ALL people from pneumococcal disease. Vaccines are very effective but we cannot tell patients that they are 100% effective all of the time. (11)

People who have ‘impaired immune responsiveness’ might have a reduced antibody response to active immunisation. (11)

Prevenar 13 can be described as ‘sodium-free’ due to the very low concentration of sodium contained in the vaccine preparation. (11)


Interactions, pregnancy and breastfeeding

This course is aimed at adult pneumococcal vaccination services so we have not covered concomitant vaccine administration in children aged 6 weeks to 5 years old. Should you require this information you should check the summary of product characteristics.

It is worth noting that there is currently no data on the concomitant administration of other vaccines with Prevenar13® in the following age groups:

  • Children agred 6 years to 17 years old.
  • Adults aged 18 years to 49 years old.

Adults and children 50 years of age or older.

If you are giving either the trivalent or the quadrivalent flu vaccine at the same time as administering Prevenar13® the manufacturer recommends using different injection sites. For example in adults, you could administer the flu vaccine in the left deltoid but administer the right deltoid. (11)

Pregnancy, breastfeeding and fertility.

The manufacturer has indicated that there is no evidence of harm (direct and indirect) to fertility associated with the use of Prevenar13®. There is currently no research information on the use of Prevenar13® in pregnancy. Therefore, the manufacturer has pragmatically advised against the use of Prevenar13® in people who are pregnant. the final issue in this section is breastfeeding. Again information is limited and it is therefore unknown whether or not Prevenar13® appears in the breastmilk. (11)


Adverse reactions and overdose

The risk of overdose with Prevenar13® is mitigated by the fact that it is delivered in a pre-filled syringe.

We recommend that you review the summary of product characteristics to understand the full side effect profile of Prevenar13®. It is important you are a ware of the common side effects at least so that you are in a position to advise, reassure or triage your patients as appropriate.

Reporting adverse effects

If a patient tells you about any side-effects please remember to submit a report via the Yellow Card Scheme. You can report a side effect here or search for MHRA Yellow Card in the Google Play or Apple App Store.


Storage, handling and disposal

It is very important to follow the manufacturer’s recommendation and store Prevenar13® in a refrigerator. The refrigerator temperature should be strictly monitored and should maintain a temperature of between 2°C–8°C. (11)

In the event of your fridge ceasing to work, you can store Prevenar13® at temperatures of up to 25°C for up to four days. It is very important never to allow the vaccine to freeze. (11)

During storage, a white deposit and clear supernatant can be observed. This does not constitute a sign of deterioration.

Before use

The vaccine should be shaken well to obtain a ‘homogeneous white suspension’ prior to expelling air from the syringe and should be inspected visually for any particulate matter and/or variation of physical aspect prior to administration. Do not use if the content appears otherwise. (11)


Pneumococcal polysaccharide vaccine (23 pneumococcal polysaccharide serotypes)

Pneumovax® 23 is a pneumococcal polysaccharide vaccine. The vaccine is a clear colourless solution and comes in a pre-filled syringe. Pneumovax® 23 protects people vaccinated against 23 pneumococcal polysaccharide serotypes. (12)


Therapeutic indications

Pneumovax® 23 is indicated for active immunisation against pneumococcal. The license extends to children from two years of age, adolescents and adults. (12)


Dosage

We recommend you consult the summary of product characteristics and/or the BNF to check comprehensive dosing advice. For the purpose of this course, we will look at adult dosing only.

Primary vaccination with Pneumovax® 23 for children aged 2 years and older and adults is with a single dose of 0.5 millilitres. (12)

The injection should be either by the intramuscular or subcutaneous route. (12)

There are a number of situations that require additional dosing considerations: (12)

  • Administer at least two weeks before elective splenectomy.
  • Administer at least two weeks before the initiation of chemotherapy.
  • Administer at least two weeks before immunosuppressive treatment.
  • This vaccine should be administered as soon as possible after their diagnosis of HIV is confirmed.
  • There must be a delay in vaccinating people who have completed chemotherapy and/or radiation therapy for neoplastic disease. Longer delays may be required in certain other specific circumstances. You should check the summary of product charachteristics for more detail on this situation.

When should revaccination take place?

Revaccination should not occur more frequently than every three years. It is thought that adverse reactions may become more likely if revaccination with Pneumovax® 23 occurs at a frequency of less than three years. (12)

Vaccinating children with Pneumovax® 23 is outwith the scope of this course but it is worth noting that revaccination is not recommended in healthy children. (12)


Contra-indications

The only contra-indication for the use of Pneumovax® 23 is known hypersensitivity to the vaccine and/or the ingredients. (12)


Cautions and special considerations

There are a number of special considerations and cautions that should be observed before you vaccinate using Pneumovax® 23. We have summarised the important considerations below recommended by the manufacturer. As ever, we recommend you familiarise yourself with the summary of product characteristics for more comprehensive details. This list is not exhaustive: (12)

  • Consider the risk/benefit of going ahead with vaccination with Pneumovax® 23. If the person you are about to vaccinate is systemically unwell with a temperature you should delay vaccination.
  • You should take care never to inject intravascularly or intradermally.
  • You should be aware that if you are immunising people who are immunosupressed may not have as effective an immune response as people who are not immunsuppressed. These people should therefore be treated with caution.
  • Vaccination with Pneumovax® 23 may not result in 100% protection of the population. This is typical of most vaccines and if necessary should be communicated in a way that does not undermine confidence in the vaccine.
  • If the person you are vaccinating is already taking preventative antiobiotic therapy for pneumococcal disease they should be advised to keep taking the antibiotic even after vaccination with Pneumovax® 23.

Adrenaline should be available on-site and pharmacists or other health professionals administering the Pneumovax® 23 vaccine would be trained on their use.


Interactions

There are very few documented interactions of Pneumovax® 23 with other medicines.

Probably the most important consideration in this area is the fact that Pneumovax® 23 can be given at the same time as the influenza vaccines. The manufacturer does however sensibly make it clear that these vaccines should be administered at different injection sites. (12)

It is worth noting that when Pneumovax® 23 was given with Zostavax (a vaccine used to immunise against herpes zoster) reduced immunogenicity was observed. The important caveat with this information is that the clinical trial was very small and another larger observation study indicated that there was no increased risk of developing herpes zoster after the two vaccines were given together. (12)

Pregnancy, breastfeeding and lactation

There have been no trials looking into Pneumovax® 23 use and fertility. In terms of pregnancy, the manufacturer current advises that the vaccine should only be given in pregnancy in circumstances where the benefit outweighs the risks. Finally, it is not known whether or not Pneumovax® 23 will appear in breast milk. It is, therefore, prudent to proceed with caution in breastfeeding mothers. (12)

For all these issues it is essential to consult the summary of product characteristics.


Adverse reactions

The most common systemic adverse events associated with Pneumovax® 23 are known to be as follows: (12)

  • Asthenia/fatigue.
  • Myalgia.
  • Headache.

With symptomatic treatment, the majority of these common adverse events resolved on their own.

If you feel you need to brush up on the complete list of known adverse effects please access the summary of product characteristics below.

Reporting adverse effects

If a patient tells you about any side-effects please remember to submit a report via the Yellow Card Scheme. You can report a side effect here or search for MHRA Yellow Card in the Google Play or Apple App Store.


Storage, handling and disposal

Excipients

Pneumovax® 23 contains phenol, sodium chloride and water for injection. Each injection dose contains 23mg of sodium or less so in practical terms can be considered salt free.

Shelf-life and storage

The shelf life of Pneumovax® 23 is 28 months and should be stored at a temperature of between 2-8°C. It is very important that the vaccine is never frozen.

You should visually inpect the vaccine. Pneumovax® 23 is a clear colourless solution.


Suggested reading

One of the most important factors before entering practice in any clinical area is the importance of understanding what reference sources are relevant and important. This course summarises the area that we feel are most important but we don’t cover every aspect of running a pneumococcal vaccination service in community pharmacy. The following reference sources are important and we strongly recommend you familiarise yourself with them before proceeding.


Record your CPD

The revalidation CPD form below is a useful tool to help you reflect on what you have learned during the course.

Creating a record of achievement is a very important aspect of continuing professional development so we will give you a chance to complete an assessment at the end too.

Selected Value: 0
The range is 0-10. A score of 10 means you feel like you know everything you need to know about this topic.
We will use your email to send you the details of your revalidation CPD entry. As you will see above we have asked specifically for permission for additional uses of your email. You can then copy/paste the detail directly into your GPhC record. Read our privacy policy on the homepage.

[tqb_quiz id=’56830′]


References

Below is a complete list of references used in the preparation of this course. We recommend you familiarise yourself with as many as possible and also save for future reference.

  1. Immunisation procedures, The Green Book chapter 4 available here Green-Book-Chapter-4.pdf (publishing.service.gov.uk) [accessed 25.6.2021]
  2. Pneumonia – NHS (www.nhs.uk) [accessed 26.6.2021]
  3. The Green book of immunisation: chapter 25 – pneumococcal (publishing.service.gov.uk) [accessed 26.6.2021]
  4. References | Immunizations – pneumococcal | CKS | NICE [accessed 26.6.2021]
  5. Drijkoningen, J. and Rohde, G. (2014) Pneumococcal infection in adults: burden of disease. Clinical Microbiology and Infection 20 (Suppl 5), 45-51.
  6. Guidelines for the public health management of clusters of severe pneumococcal disease in closed settings (publishing.service.gov.uk) [accessed 26.6.2021]
  7. Grabenstein JD and Musher DM (2018) Pneumococcal Polysaccharide Vaccines. In: Plotkin SA, Orenstein WA, Offit PA and Edwards KM (eds) Vaccine, 7th edition. Philadelphia, PA : Elsevier, [2018]
  8. Djennad A, Ramsay ME, Pebody R et al. (2019) Effectiveness of 23-Valent Polysaccharide Pneumococcal Vaccine and Changes in Invasive Pneumococcal Disease Incidence from 2000 to 2017 in Those Aged 65 and over in England and Wales. EClinicalMedicine. 2019 Jan 2;6:42-50.
  9. Butler JC, Breiman RF, Campbell JF et al. (1993) Pneumococcal polysaccharide vaccine efficacy: an evaluation of current recommendations. JAMA 270: 1826–31.
  10. Waight PA, Andrews NJ, Ladhani SN et al. Effect of the 13-valent pneumococcal conjugate vaccine on invasive pneumococcal disease in England and Wales 4 years after its introduction: an observational cohort study. Lancet Infect Dis 2015 15(5):535-43
  11. Prevenar 13 suspension for injection – Summary of Product Characteristics (SmPC) – (emc) (medicines.org.uk) [accessed 28.6.2021]
  12. Pneumovax 23 solution for injection in pre-filled syringe – Summary of Product Characteristics (SmPC) – (emc) (medicines.org.uk) [accessed 23.7.2021]