Answer: Pneumococcal disease is a leading cause of vaccine-preventable illness and death in the United States. Current recommendations from the US Centers for Disease Control and Prevention call for vaccination of all adults aged ≥65 years of age against pneumococcal disease caused by Streptococcus pneumoniae bacteria.^[5] Vaccination is also recommended for the following individuals aged 2 to 64 years who are most susceptible to complications of pneumococcal pneumonia:

• Those with chronic health problems such as heart disease, lung disease, sickle cell disease, diabetes, alcoholism, cirrhosis, leaks of cerebrospinal fluid, or cochlear implants.
• Those with a disease or condition that lowers resistance to infection, such as Hodgkin’s disease, lymphoma or leukemia, kidney failure, multiple myeloma, nephrotic syndrome, HIV/ AIDS, damaged spleen, or no spleen, and organ transplant recipients.
• Those taking a drug or treatment that lowers the body’s resistance to infection, such as long-term steroid use, certain cancer drugs, and radiation therapy.
• Cigarette smokers
• Individuals with asthma
• Residents of nursing homes or long-term care facilities

According to the CDC recommendations, healthy adults need only one lifetime vaccination against pneumococcal disease at age 65. A one-time revaccination is indicated for adults ≥65 years who were previously vaccinated prior to age 65 years, if 5 years or longer have elapsed since the first dose. In addition, patients under the age of 65 should only be revaccinated prior to age 64 if they are at the highest risk of fatal pneumococcal infection or rapid antibody loss.

These recommendations are intended to protect the adult patient populations at highest risk for complications of pneumococcal infection. Despite these recommendations, only 18% of high-risk adults and only 60% of older adults are currently vaccinated against pneumococcal disease.^[4] Barriers to adult immunization include lack of awareness among patients and healthcare providers, and lack of organizational processes that support adult immunization. For example, the National Foundation for Infectious Diseases conducted a survey among consumers to assess their awareness and knowledge of vaccine-preventable disease among adults. While adults’ familiarity with many vaccine-preventable diseases is trending upward, awareness of pneumococcal disease was low.^[6] Only 20% of those surveyed were very familiar with pneumococcal disease, and most of these respondents were licensed medical professionals. Consumers were more concerned about vaccine safety (35%) than their cost or efficacy; only 14% said they were too busy to get a vaccine. However, 87% of respondents indicated they would be likely to get a vaccine if their physician or healthcare provider recommended it.

Healthcare providers can help ensure that patients understand the need for vaccination by discussing it with them during routine office visits, creating standing orders for vaccines, and maintaining electronic records of vaccinations for adult patients. For example, any patient who is receiving an influenza vaccination can be evaluated for pneumococcal vaccination as well. If the patient meets the criteria, the vaccines can be administered simultaneously. Simultaneous administration of most commonly used vaccines does not decrease the response to the vaccines or increase the risk for adverse reactions, and increases compliance with immunization schedules.

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Answer: There are currently 2 types of pneumococcal vaccines: pneumococcal polysaccharide vaccine and pneumococcal conjugate vaccine. Currently, only the polysaccharide vaccine is approved for use in adults in the United States. However, in November 2011, an FDA advisory committee voted in favor of expanding the indication for the conjugate vaccine to include use in adults aged ≥50 years.^[7] This recommendation was based on 5 multicenter phase 3 studies involving more than 5,000 patients in the U.S. and Europe.

A number of studies have demonstrated the effectiveness of pneumococcal polysaccharide vaccine in reducing morbidity and mortality due to invasive pneumococcal disease in adults. A Cochrane Collaboration systematic review of 10 randomized, controlled trials, found the pneumococcal polysaccharide vaccine against invasive pneumococcal disease to be 74% effective (with a 95% confidence interval [CI], ranging from 56% to 85%) among adults.^[3,8] For the subgroup of otherwise healthy adults in developed countries, vaccine efficacy was 80%. When these randomized controlled trials of pneumococcal polysaccharide vaccination were compared with placebo, the overall odds ratio supported vaccination to prevent invasive pneumococcal disease.

Clinical trials evaluating the pneumococcal conjugate vaccine in a variety of adult populations are currently underway, including a phase 3, head-to-head study comparing the safety, tolerability, and immune response of the conjugate vaccine with the polysaccharide vaccine in adults. Another trial is evaluating the efficacy of the conjugate vaccine in preventing pneumococcal community-acquired pneumonia as well as invasive pneumococcal disease in adults.

Vaccines, like any medicine, can cause serious adverse reactions. However, the risk of a vaccine causing serious harm, or death, is extremely small. About 50% of people experience mild side effects with the polysaccharide vaccine, such as redness or pain at the injection site. Less than 1% develop fever, muscle aches, or more severe local reactions.^[5]

Certain individuals should not receive the polysaccharide pneumococcal vaccine. Individuals who have had a life-threatening allergic reaction to the polysaccharide vaccine should not be revaccinated. Individuals who are moderately or severely ill should wait until they have recovered to receive the vaccination, although those with mild illnesses can be vaccinated. While there is no evidence that the pneumococcal polysaccharide vaccine is harmful to pregnant women or the developing fetus, as a precaution, women with conditions that put them at risk for pneumococcal disease should be vaccinated before becoming pregnant, if possible. For many adults, the clinical benefits of vaccination against invasive pneumococcal disease outweigh the risks.

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