Pneumococcal disease

What

Pneumococcal disease is caused by the bacterium Streptococcus pneumoniae. It can cause severe invasive disease, including meningitis, pneumonia and bacteraemia, and non-invasive disease, including otitis media.

Who

Pneumococcal vaccine is recommended for:

• infants and children aged <5 years
• non-Indigenous adults aged ≥70 years
• Aboriginal and Torres Strait Islander adults aged ≥50 years
• children, adolescents and adults with risk conditions for pneumococcal disease

How

There are two types of pneumococcal vaccines registered in Australia:

1. Pneumococcal conjugate vaccines: Prevenar 13 - 13vPCV (13-valent pneumococcal conjugate vaccine), Vaxneuvance - 15vPCV (15-valent pneumococcal conjugate vaccine), and Prevenar 20 - 20vPCV (20-valent pneumococcal conjugate vaccine)
2. Pneumococcal polysaccharide vaccines: Pneumovax 23 - 23vPPV (23-valent pneumococcal polysaccharide vaccine)

The recommended number and timing of doses, and type of vaccine depend on:

• the person’s age
• their Aboriginal and Torres Strait Islander status
• the state or territory they live in
• whether they have conditions that increase their risk of pneumococcal disease
• whether they have received a pneumococcal conjugate vaccine or 23vPPV before

Why

Infants and elderly people have the highest pneumococcal disease burden. Pneumococcal disease disproportionately affects Aboriginal and Torres Strait Islander children and adults. Pneumococcal disease is more common in people with certain risk conditions.

See

• Infographic. Pneumococcal vaccination for all Australians
• Infographic. Pneumococcal vaccination for children <5 years old
• Infographic. Pneumococcal vaccination for people with risk conditions for pneumococcal disease
• Infographic. Vaccination for healthy ageing
• Infographic. Pneumococcal vaccination recommendations for people who have previously received a pneumococcal vaccine.

Pneumococcal vaccines available in Australia

The Therapeutic Goods Administration website provides product information for each vaccine.

See also Vaccine information and Variations from product information for more details.

Dose and route

13vPCV

The dose of 13vPCV is 0.5 mL, given by intramuscular injection.

15vPCV

The dose of 15vPCV is 0.5 mL, given by intramuscular injection.

20vPCV

The dose of 20vPCV is 0.5 mL, given by intramuscular injection.

23vPPV

The dose of 23vPPV is 0.5 mL, given by either intramuscular or subcutaneous injection.

The intramuscular route is preferred. A 3-fold greater rate of injection site reactions is found following administration of 23vPPV by the subcutaneous route.¹¹ However, a vaccine dose given subcutaneously does not need to be repeated.

Co-administration with other vaccines

Infants can receive 13vPCV, 15vPCV or 20vPCV at the same time as other vaccines in the infant schedule, including inactivated influenza vaccine. However, there is a possible small increased risk of fever if 13vPCV is given at the same time as influenza vaccine. At present, this possible risk has not been observed for 15vPCV, and there is no data available for 20vPCV. Advise parents/carers of infants or children who are recommended to receive both influenza vaccine and 13vPCV of this risk. See Contraindications and precautions.

Adults can receive pneumococcal vaccines (any pneumococcal conjugate vaccine or 23vPPV) with herpes zoster vaccines, seasonal influenza vaccines, RSV vaccines and COVID-19 vaccines at the same time if required. ^12-18 See also Herpes zoster and Influenza.

Interchangeability of pneumococcal conjugate vaccines

It is preferable to complete a primary course of pneumococcal conjugate vaccine with the same formulation. However, if a person started their vaccination course with one PCV (for example, 13vPCV), it is acceptable to complete the course with the other (for example, 15vPCV). A study of 900 infants found comparable antibody responses (for shared serotypes) and a similar safety profile when 13vPCV and 15vPCV were used interchangeably.¹⁹

Contraindications

The only absolute contraindications to pneumococcal vaccines are:

• anaphylaxis after a previous dose of any pneumococcal vaccine
• anaphylaxis after any component of a pneumococcal vaccine

Precautions

13vPCV and inactivated influenza vaccine

Children can receive 13vPCV and inactivated influenza vaccine at the same visit if both vaccines are due.

One study found a slightly higher risk of fever and febrile convulsions in children aged 6 months to <5 years (especially those aged 12–24 months) when they received 13vPCV and inactivated influenza vaccine at the same time, compared with receiving the vaccines separately.²⁰

The risk was about 18 excess cases per 100,000 doses in children aged 6 months to <5 years. The highest risk was 45 per 100,000 doses in children aged 16 months. This is a relatively small risk increase.

A later study did not show the same association between febrile seizures and co-administering these 2 vaccines.²¹

At present, this possible risk has not been observed for 15vPCV.

However, immunisation providers should: 

• advise parents of the possible risk 
• provide the option of administering these 2 vaccines on separate days, with an interval of at least 3 days

See also Influenza.

Women who are pregnant or breastfeeding

Pneumococcal vaccines are not routinely recommended for pregnant women.

Women of child-bearing age who have a risk condition(s) for pneumococcal disease are normally recommended to receive pneumococcal vaccine either: 

• before a planned pregnancy, or
• as soon as practicable after delivery 

Data on 13vPCV, 15vPCV, 20vPCV and 23vPPV in pregnant or breastfeeding women are limited.²² However, pregnant women who receive these vaccines are unlikely to have serious adverse effects.

Give special consideration to vaccinating women at the highest increased risk of pneumococcal disease who were not vaccinated before pregnancy but need vaccination before delivery. See List. Risk conditions for pneumococcal disease.

Breastfeeding women can receive 13vPCV, 15vPCV, 20vPCV and 23vPPV.

See Table. Vaccines that are not routinely recommended in pregnancy: inactivated bacterial vaccines in Vaccination for women who are planning pregnancy, pregnant or breastfeeding for more details.

13vPCV

Adverse events in children

Pooled safety analysis from 13 clinical trials showed that 13vPCV is safe in children, and the safety profile is similar to that of 7vPCV.^23,24

In young children who received 13vPCV:²⁴

• about 50% had any pain/tenderness and erythema at the injection site
• about 33% had any hardness (induration) or swelling
• about 8% had pain interfering with movement
• about 13% had moderate erythema and induration; this was more common after the dose at 12 months of age than after an infant dose
• about 37% reported fever, and about 5% had fever >39°C;²⁴ fever was more common after the dose at 12 months of age than after the primary doses²⁵
• about 70% had irritability
• about 60% had drowsiness/increased sleep
• about 39% had decreased appetite

Frequencies of each of these adverse events were comparable to those in 7vPCV recipients.²⁴

One post-marketing study in the United States found a higher rate of febrile seizures for children who received inactivated influenza vaccine at the same time as pneumococcal vaccine.²⁰ See Precautions.

Adverse events in adults

Clinical studies of 13vPCV in adults showed it to be safe.^26-30 In two clinical studies of 13vPCV and 23vPPV in people aged 60–64 years:^26,27

• local reactions were more common after 13vPCV (71–82% of participants) than after a first dose of 23vPPV (62–76%)
• pain was the most common local reaction after 13vPCV
• the frequency of fever of any grade was low (<2%) after either 13vPCV or 23vPPV

Local reactions were more common after a dose of 23vPPV given 1 or 3.5–4 years after a dose of 13vPCV than after either: 

• a single dose of either 13vPCV or 23vPPV
• a 2nd dose of 13vPCV (regardless of which vaccine was used as the initial dose)^26,28

Systemic reactions such as chills and myalgia have been reported more frequently in adults when pneumococcal vaccine and inactivated influenza vaccine are given at the same time.³⁰ In the same study, there was no significant difference in the prevalence of fever of any grade. See Precautions.

Adverse events in people with risk conditions for pneumococcal disease

Studies have investigated the safety of 13vPCV in people with risk conditions for pneumococcal disease, such as:

• HIV infection
• chronic kidney disease
• haematopoietic stem cell transplant
• kidney transplant
• people who are receiving immunosuppressive therapy for cancers

In these studies:

• local reactions were the most common type of adverse event, and were somewhat higher after 13vPCV than after the first dose of 23vPPV
• pain was the most common local reaction (around 60% of people who received a vaccine)
• local reactions were more common if the person had received 2 previous doses of 23vPPV than if they had received 1 previous dose
• among people who received a haematopoietic stem cell transplant, both local and systemic reactions were higher after a 4th dose than after doses 1 to 3
• there was no substantial difference between safety in children and adults (in the few studies that have data available)

15vPCV

Adverse events in children

Safety data from clinical trials have found that 15vPCV is safe in children and has a similar safety profile to 13vPCV.^19,31-37

In infants and children who received 15vPCV:

• the majority of adverse events were mild to moderate in severity
• the most common local reactions were pain (9-55%), erythema (11-22%) and swelling (10-14%)
• the most common systemic reactions were irritability (14–55%), somnolence (8-41%) and decreased appetite (5-19%)
• the frequency of fever ≥40°C was low (<4%)

Adverse events in adults

Evidence from clinical trials found that 15vPCV is safe in adults.^10,38,39 In people who receive 15vPCV:

• the majority of adverse events were mild and lasted 1-3 days
• the most common local reactions were pain (54-76%), swelling (13-22%) and erythema (9-15%)
• the most common systemic reactions were fatigue (17-34%), myalgia (15-29%) and headache (12-27%)
• the frequency of fever ≥38°C was low (<2%)
• older adults reported fewer adverse reactions than younger adults

20vPCV

Adverse events in children

Evidence from clinical trials found that 20vPCV is safe in children, and it has a similar safety profile to 13vPCV.^18,40

• the majority of adverse events were mild to moderate
• the most common local adverse event was pain, and all local adverse events were comparable between 20vPCV (25%-60%)  and 13vPCV (27%-57%)
• the most common systemic adverse event was irritability, and all systemic adverse events were comparable between 20vPCV (55%-86%) and 13vPCV (55%-87%)

Adverse events in adults

Evidence from four trials found that 20vPCV is safe in adults.^41-44

• the majority of adverse events were mild to moderate
• the most common local adverse event was pain and all were comparable between 20vPCV (55-79%) and 13vPCV (53-76%)
• the most common systemic adverse event was muscle pain and was slightly higher for those who received 20vPCV (39-77%) and compared to 13vPCV (37-65%)

23vPPV

The proportion of vaccine recipients reporting local and systemic reactions after a primary or a repeat dose of pneumococcal polysaccharide vaccines varies among different study populations, and possibly with age.^45-47

In people who receive 23vPPV:5^45-47

• about 50% or more have some soreness after the 1st dose
• about 20% have swelling and redness
• up to 5% have moderate or severe local adverse events that limit arm movement after the 1st dose
• up to 10% have fever ≥37.5°C, but high fever is uncommon

Transient systemic reactions such as myalgia, fatigue and chills are also common.

Larger and more recent studies indicate that both local and systemic adverse events are more common after a repeat dose of 23vPPV than after the 1st dose in adults. In particular, up to 20% of revaccinated people have more severe local adverse events.^45-47 These findings supersede the inconsistent findings from some smaller studies, which were limited by subject numbers and methodology.^48-52 These local adverse events are mostly non-serious and self-limiting.

In these studies, the repeat doses were given at least 5 years after the previous dose. Another study used hospitalisations as a proxy measure for very severe local adverse events. The study used hospitalisations coded as cellulitis or abscess of the upper limb within 3 days of pneumococcal vaccination. These adverse events were significantly more likely when a repeat dose was given within 5 years of the 1st dose.⁵³

Severe local reactions are also associated with higher antibody levels.^11,46,47,54 This may explain why severe adverse events are associated with shorter intervals between doses. It suggests that such local reactions are associated with more robust immunity.

Streptococcus pneumoniae (pneumococcus) is a gram-positive coccus.

The polysaccharide capsule is the most important virulence factor of pneumococci.^3,55 There are more than 95 capsular antigenic types (serotypes), with each serotype eliciting type-specific immunity.⁵⁶

Pathogenesis

The natural reservoir of pneumococci is the mucosal surface of the human upper respiratory tract.^3,57  Different pneumococcal serotypes vary in their propensity to cause nasopharyngeal colonisation or disease.

Worldwide, a small number of serotypes cause most cases of pneumococcal disease. The predominant serotypes vary by age group and geographic area.³

Antibiotic resistance in pneumococci is an increasing challenge. In 2012, 10% of Australian invasive pneumococcal disease isolates were non-susceptible to penicillin, and 2% were non-susceptible to ceftriaxone/cefotaxime.⁵⁸

Transmission

Streptococcus pneumoniae is transmitted from person to person through contact with respiratory droplets of colonised people.

Almost all pneumococcal disease probably begins with nasopharyngeal colonisation.

Invasive pneumococcal disease (IPD) is defined as detection of Streptococcus pneumoniae in a normally sterile site (such as blood, cerebrospinal fluid or pleural fluid) by culture or nucleic acid testing. IPD includes:^3,55,57,59

• meningitis
• pneumonia with bacteraemia or empyema
• bacteraemia without focus

Pneumococci may spread from the nasopharynx into adjacent sites to cause non-invasive disease such as:^3,55,57,59

• sinusitis
• otitis media
• pneumonia

Pneumococcal disease in children

In children, the most common manifestation is bacteraemia without focus. This accounts for approximately 70% of IPD, followed by pneumonia with bacteraemia.

Meningitis is the least common but most severe category of IPD. Pneumococcal meningitis symptoms include:^55,59,60

• stiff neck
• fever
• headache
• photophobia
• confusion
• irritability
• seizures

Acute otitis media is the most common non-invasive manifestation of pneumococcal disease in children. Streptococcus pneumoniae is detected in 28–55% of middle ear aspirates from children with acute otitis media.^55,59,60

Pneumococcal disease in adults

In adults, pneumonia with bacteraemia is the most common manifestation of IPD.

Pneumococci may account for:^55,61,62

• more than one-third of all community-acquired pneumonia
• up to half of hospitalised pneumonia in adults

However, it is difficult to accurately determine the proportion attributable to pneumococci in cases of non-bacteraemic pneumonia.

Symptoms of pneumonia include:

• fever and chills
• coughing
• difficulty breathing
• chest pain

Groups at risk of IPD

People who are immunocompromised and unable to mount an adequate immune response to pneumococcal capsular antigens have the highest risk of IPD.^3,5,55 This includes people with asplenia.

Greater risk and/or severity of IPD is also associated with:

• household crowding
• exposure to cigarette smoke
• childcare attendance
• excessive alcohol consumption
• certain non-immunocompromising chronic medical conditions^3,55,63,64

Indigenous populations in developed countries, including Aboriginal and Torres Strait Islander people in Australia, have a disproportionately high burden of IPD.^1,3,65

Young children and elderly people have the highest incidence of invasive pneumococcal disease (IPD).^58,59,66 Disease burden is also disproportionately high in Aboriginal and Torres Strait Islander people.^1,3

Disease in children

From January 2005, 7vPCV was funded under the National Immunisation Program for all infants in Australia. At this time, IPD incidence was greatest in the primary target group of children <2 years of age and for IPD caused by the 7 serotypes in the 7vPCV vaccine.

After 7vPCV was introduced, the notification rate of IPD due to 7vPCV serotypes decreased overall in all age groups.^58,66 However, rates of IPD caused by serotypes that were not contained in 7vPCV increased in Australia and several other countries.⁶⁷ This is known as serotype replacement. It was particularly evident among non-Indigenous children aged <5 years, in whom non-vaccine serotypes increased by 168%.⁶⁷

13vPCV was introduced to the National Immunisation Program in 2012. There was a 42% reduction in cases due to 13vPCV-non-7vPCV serotypes (reduced to 1.8 per 100,000) by 2014.⁶⁶ Serotype 19A caused around 80% of 13vPCV-type disease in children and around 40% in adults before 13vPCV was introduced. The introduction of 13vPCV was followed by a reduction in disease caused by serotype 19A by almost 70% overall.⁶⁶

In 2018, the National Immunisation Program schedule changed from one that had 3 primary doses only to one with 2 primary doses and a booster dose (i.e. 3+0 schedule to a 2+1 schedule). This was in response to an increased incidence of breakthrough disease in children from 12 months of age in Australia. A similar increase in breakthrough disease was not seen in countries that included a booster dose in their schedule.⁶⁸

Disease in adults

Vaccination using 23vPPV was introduced in 1999 for all Aboriginal and Torres Strait Islander adults aged ≥50 years, and younger Aboriginal and Torres Strait Islander adults with risk factors. From 2005, 23vPPV was funded under the National Immunisation Program for non-Indigenous adults aged ≥65 years.

In older non-Indigenous adults, the largest disease burden caused by pneumococcus is non-bacteraemic community-acquired pneumonia (CAP). The efficacy of 13vPCV against CAP is higher than that of 23vPPV.^69-72 IPD incidence is almost 2-fold higher in non-Indigenous people aged ≥70 years than in those aged 65–69 years, and only a small proportion of cases are due to 23v-non-13v serotypes in people who do not have underlying risk conditions. In non-Indigenous adults, the prevalence of risk factors among those with IPD increases with age. In contrast, Aboriginal and Torres Strait Islander adults have a high prevalence of IPD risk factors at all ages.^73,74 The higher burden of disease in Aboriginal and Torres Strait Islander adults also includes a higher proportion of disease (around 26% of IPD cases) caused by 23v-non-13v serotypes.⁷⁵

The impact of 23vPPV on rates of IPD in Aboriginal and Torres Strait Islander adults has varied in different geographical areas. At a national level, disparities remain in disease rates between Aboriginal and Torres Strait Islander adults and non-Indigenous adults. As is the case for influenza and pneumonia, rates of IPD are highest in older Aboriginal and Torres Strait Islander adults.¹ See Vaccination for Aboriginal and Torres Strait Islander people.

There are 2 types of pneumococcal vaccines:

• pneumococcal conjugate vaccine (PCV)
• pneumococcal polysaccharide vaccine (PPV)

Conjugate vaccine formulations vary in:

• the number of pneumococcal serotypes included
• the conjugating proteins used

Pneumococcal conjugate vaccines are immunogenic in young infants and adults and can induce an immune memory response.

In contrast, 23vPPV is poorly immunogenic for most serotypes in children aged <2 years and does not induce immune memory. However, 23vPPV contains more serotypes.

13vPCV

Immunogenicity in children

As a result of extensive post-marketing analyses of 7vPCV, and the established correlates of protection against invasive pneumococcal disease (IPD) for PCVs in children, the registration of 13vPCV was based on immunogenicity studies showing:

• immune responses at least equivalent to those of 7vPCV
• sufficient antibody response to provide protection against the additional serotypes^76-81

Vaccine effectiveness in children

A large retrospective cohort study estimated the vaccine effectiveness of 13vPCV in Australia. The vaccine effectiveness of 3 doses of 13vPCV against IPD due to 13vPCV serotypes was estimated at 86% for non-Indigenous children. These data were similar to those from a previous case–control study, which showed vaccine effectiveness of 87% for 3 doses of 13vPCV.⁸²

Immunogenicity in adults

13vPCV is registered for adults based on immunogenicity data showing equivalent or better antibody responses compared with those provided by 23vPPV for the shared vaccine serotypes.

Vaccine efficacy in adults

A large randomised controlled trial (known as the CAPiTA study – Community Acquired Pneumonia Immunisation Trial in Adults) showed that 13vPCV was protective against pneumococcal disease in vaccine-naive adults aged ≥65 years.⁶⁹ Efficacy was:

• 46% against a 1st episode of vaccine-type community-acquired pneumonia (CAP)
• 75% against a 1st episode of vaccine-type IPD

Duration of protection in adults

Exploratory analysis of data from the CAPiTA study suggests that immune responses in immunocompetent adults ≥65 years of age persist for 2 years after vaccination with 13vPCV for all 13 serotypes, regardless of comorbidity.⁸³ In people aged ≥80 years, antibody levels remained well above baseline, but were lower than in younger age groups.

Immunogenicity in people with risk conditions

Post-hoc analysis of the CAPiTA study⁸⁴ assessed the efficacy of 13vPCV in people with certain risk conditions:

• heart disease
• lung disease
• asthma
• diabetes
• liver disease
• smoking
• splenectomy

In these people, the efficacy of 13vPCV against vaccine-type IPD was 77%, and 40% against vaccine-type CAP.⁸⁴ Although these point estimates were lower than for healthy study participants, the confidence intervals overlapped, indicating a statistically similar response to the vaccine. Vaccine efficacy is expected to be the same or better in younger adults with these risk conditions.

For some risk conditions that involve compromised immunity, immunogenicity data indicate that 13vPCV induces a protective response. These conditions include:

• HIV infection
• cancer therapy
• solid organ transplant
• chronic kidney disease
• haematopoietic stem cell transplant

15vPCV

Immunogenicity in children

The registration of 15vPCV in children is based on immunogenicity studies showing equivalent antibody responses compared with those provided by 13vPCV for the shared vaccine serotypes. For the serotypes unique to 15vPCV (15vPCV-non-13vPCV serotypes 22F and 33F) antibody responses appear to be better compared to 13vPCV.^{19,31-35,85,86}

Immunogenicity in adults

15vPCV is registered for adults based on immunogenicity data showing equivalent antibody responses compared with those provided by 13vPCV for the shared vaccine serotypes. For the serotypes unique to 15vPCV (22F and 33F) antibody responses appear to be better compared to 13vPCV.^38,39,87-89

Immunogenicity in people with risk conditions

15vPCV has been assessed in adults living with HIV and in older adults with certain medical factors that increased their risk for pneumococcal disease. These studies found that 15vPCV resulted in similar immunogenicity responses compared to 13vPCV.^10,90

20vPCV

Immunogenicity in children

20vPCV is registered in children based on immunogenicity studies showing antibody responses are comparable when compared with 13vPCV for the shared vaccine serotypes. For the seven additional serotypes unique to 20vPCV (20vPCV-non-13vPCV serotypes 8, 10A, 11A, 12F, 15B, 22F and 33F) antibody responses appear to be better compared to 13vPCV.^18,40 

There are currently no immunogenicity studies on 20vPCV followed by 23vPPV.

Immunogenicity in adults

20vPCV is registered for adults based on immunogenicity data showing antibody responses for shared serotypes are likely equivalent when compared to 13vPCV. For the serotypes unique to 20vPCV (8, 10A, 11A, 12F, 15B, 22F and 33F), antibody responses appear to be better compared to 13vPCV.^41-44 

For six of these seven serotypes that are shared with 23vPPV, antibody responses are equivalent between 20vPCV and 23vPPV; however serotype 8 did not meet the non-inferiority criteria.^41,42 This lower immune response is mitigated by those at risk receiving 23vPPV after 20vPCV.⁹¹

Immunogenicity in people with risk conditions

20vPCV has been assessed in adults with chronic medical conditions or smoking that increase their risk of developing pneumococcal disease. These studies found that 20vPCV resulted in similar immunogenicity responses compared to 13vPCV.⁹²

There are currently no studies on immunogenicity in children with risk conditions.

23vPPV

23vPPV contains polysaccharides derived from the 23 most frequent or most virulent capsular types of Streptococcus pneumoniae isolated from sterile fluids in the United States in the 1970s and early 1980s. Vaccine development also considered worldwide serotype distribution and potential cross-reactive serotypes.⁹³ 12 of these serotypes are also in 13vPCV.

Immunogenicity in children

In children aged <2 years primed with pneumococcal conjugate vaccine, 23vPPV is immunogenic. This boosts the immune response against some of the 12 shared serotypes.^94,95

23vPPV is immunogenic in children, and the level of immune response varies by age and serotype.^96,97 Studies in children with risk conditions for pneumococcal disease (including cardiac transplant, HIV infection, renal disease and sickle cell disease) show that 23vPPV can elicit an immune response in these populations. However, responses are variable and likely depend on the level of immunosuppression at the time of vaccination.⁹⁸

Vaccine efficacy and effectiveness in children

Few studies report the efficacy of 23vPPV in children. A study from the United States before conjugate vaccine was introduced showed efficacy of 83% (95% CI: 15–97%) against bacteraemia in children aged 6–15 years. However, this study did not distinguish between immunocompetent and immunocompromised children.⁹⁹

Immunogenicity in adults

23vPPV induces significant immune responses in immunocompetent adults. Immune responses are similar in older people (aged 70–80 years) and younger people (aged 50–60 years), but poorer in people who are immunocompromised.¹⁰⁰

Vaccine efficacy and effectiveness in adults

Estimates of efficacy and effectiveness for 23vPPV are lower and more variable than for 13vPCV, particularly against CAP outcomes:

• Vaccine effectiveness against vaccine-type IPD is estimated at 61.1% (95% CI: 55.1–66.9%), based on data from an Australian observational study, national notification data and adult health surveys.⁷⁰
• Vaccine effectiveness against CAP outcomes ranges from 27% (95% CI: 3–46%) to 51% (95% CI: 16–71%) from observational studies.^71,72

Vaccine efficacy and effectiveness in people with risk conditions

Studies of 23vPPV indicate that this vaccine can be effective in people with risk conditions. In people with HIV and other immunocompromising conditions, vaccine effectiveness against IPD is estimated to be 35–50%.^101,102 In people with chronic conditions who are not immunocompromised, vaccine effectiveness against IPD is estimated to be 50–60%.^28,101,103

Sequential administration of a dose of PCV and 23vPPV in people with risk conditions is therefore likely to protect these people against 23v-non-PCV serotypes. This is supported by immunogenicity studies that compared sequential administration of 7vPCV, 13vPCV, 15vPCV or 20vPCV and 23vPPV in varying combinations and dose intervals in children and adults.^{10,26,28,41,42,88,90,104-109}

Duration of protection in adults

Data from England and Wales reported 23vPPV vaccine effectiveness of 48% against IPD within 2 years of vaccination for adults aged ≥65 years. But effectiveness waned and became insignificant beyond 5 years. In the subset of adults aged 65–74 years with no risk factors, 23vPPV effectiveness was higher (65% within 2 years) and was maintained for longer.¹¹⁰

Significant and sustained antibody responses after revaccination are seen in adults, including the elderly.^{45,46,111-113} Evidence of lesser antibody responses to 2nd or subsequent doses of 23vPPV in adults is variable,^{45,46,106,111,112} but the clinical relevance of this is unknown.

Transport according to National Vaccine Storage Guidelines: Strive for 5.¹¹⁴ Store at +2°C to +8°C. Do not freeze.

Invasive pneumococcal disease is a notifiable disease in all states and territories in Australia.

State and territory public health authorities can provide advice about the public health management of invasive pneumococcal disease, including case management.

Prevenar 13 (13vPCV)

Dosing schedule

The product information for Prevenar 13 recommends:

• 4 doses of 13vPCV for vaccination starting at 6 weeks of age, with further doses at 4 and 6 months of age, and a booster at 12–15 months of age
• 3 doses for vaccination starting between 7 and 11 months of age
• 2 doses for vaccination starting between 12 and 23 months of age

The Australian Technical Advisory Group on Immunisation (ATAGI) recommends that healthy children who do not have an identified risk conditions for pneumococcal disease should receive 1 dose less than that stated in the product information.

ATAGI recommends that the 1st dose be given at 2 months of age, and that this dose can be given as early as 6 weeks of age. The next scheduled dose should be given at 4 months and a booster at 12 months of age.

Preterm infants

The product information for Prevenar 13 recommends a four-dose schedule in children born prior to 37 weeks gestation.

ATAGI recommends a four-dose schedule for infants born less than 28 weeks gestation. Infants and children born ≥28 weeks are recommended to receive a three-dose schedule.

Pneumovax 23 (23vPPV)

The product information for Pneumovax 23 states that Pneumovax 23 and Zostavax should not be given at the same time.

ATAGI recommends that Pneumovax 23 can be given at the same time as Zostavax if both are due.

Vaxneuvance (15vPCV)

Catch-up vaccination

The product information for Vaxneuvance recommends children aged 7 months through 17 years who completed a dosing regimen with lower valency pneumococcal conjugate vaccine should consider a catch-up schedule with Vaxneuvance.

ATAGI recommends that infants and children who receive lower valency pneumococcal conjugate vaccines do not need a catch-up dose of Vaxneuvance. If a child started their vaccination course with 13vPCV (Prevenar 13), it is acceptable to complete the course with 15vPCV (Vaxneuvance).

Preterm infants

The product information for Vaxneuvance recommends a four-dose schedule in children born prior to 37 weeks gestation. 

ATAGI recommends a four-dose schedule for infants born less than 28 weeks gestation. Infants and children born ≥28 weeks are recommended to receive a three-dose schedule.

Prevenar 20 (20vPCV)

The product information for Prevenar 20 recommends a four-dose schedule in children born prior to 37 weeks gestation.

ATAGI recommends a four-dose schedule for infants born less than 28 weeks gestation. Infants and children born ≥28 weeks are recommended to receive a three-dose schedule.

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3. Klugman KP, Dagan R, Malley R, Whitney CG. Pneumococcal conjugate vaccine and pneumococcal common protein vaccines. In: Plotkin SA, Orenstein WA, Offit PA, Edwards KM, eds. Plotkin's vaccines. 7th ed. Philadelphia, PA: Elsevier; 2018.
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