There are two types of pneumococcal vaccine (1,2):

• pneumococcal polysaccharide vaccine (PPV) contains purified capsular polysaccharide from each of 23 capsular types of pneumococcus
• pneumococcal conjugate vaccine (PCV) contains polysaccharide from seven common capsular types.These are conjugated to protein (CRM197) using similar manufacturing technology to that for Haemophilus influenzae type b (Hib) and meningococcal C conjugate vaccines

The polysaccharide vaccine is not recommended for children under 2 years as their naturally low level of IgG2 prevents response to polysaccharide antigens. However the conjugate pneumococcal vaccine overcomes the shortcomings of the polysaccharide vaccine.

Immunisation is recommended in (1):

• over 65year olds (6) - should receive the polysaccharide vaccine
• all at-risk individuals above the age of five years should receive the polysaccharide vaccine:
  • adults 65 years and over
    • a single dose of PPV should be offered
  • children aged two to five years of age who are in an at-risk group
    • immunisation guidance depends on previous immunisation history (2)
      • single dose of PPV should be offered, at least two months after the final dose of PCV
      • at-risk children under five years of age who have either not been vaccinated with PCV or not completed a primary course should have a single dose of PCV. For those children in this age group who have asplenia or splenic dysfunction, or who are immunocompromised and may have a sub-optimal immunological response to the first dose of PCV, a second dose should be given two months after the first dose. At-risk children under five years who have already received 23-valent PPV should receive a dose of PCV at least two months after the PPV
      • children between two and five years who have been fully immunised with PCV as part of the routine programme and who then develop splenic dysfunction or immunosuppression should be given an additional dose of PCV
  • children aged over five years and and at risk adults
    • conjugate vaccine is not recommended
    • should be offered a single dose of PPV. If had PCV previously then should have at least two months after final dose of PCV
• PCV is part of the childhood immunisation schedule
  • primary immunisation
    • infants under one year of age
      • primary course of PCV vaccination consists of two doses with an interval of two months between each dose (i.e. at two and four months of age)
  • reinforcing immunisation
    • a reinforcing (booster) dose of PCV is recommended at 13 months of age for children who have received a complete primary course of two PCV vaccines. It should be given one month after the Hib/MenC vaccine

At-risk individuals include:

• post-splenectomy patients, though it is preferable to administer the vaccine some weeks before elective splenectomy; also decreased splenic function (hypoplasia e.g. due to coeliac disease, homozygous sickle cell disease (4))
• diabetics
• immunocompromised and HIV-infected patients
• chronic liver disease or alcoholism
• congestive heart failure
• chronic renal disease which includes Nephrotic syndrome, chronic kidney disease at stage 4 and 5 and those on kidney dialysis or with kidney transplant
• chronic lung disease e.g. obstructive pulmonary disease
• children under five years old who have suffered a bout of invasive pneumococcal disease (1)
• patients with cerebrospinal fluid shunts (1)
• patients with cochlear implants (5)

Reference:

1. GP magazine (August 16th 2004):1.
2. Immunisation Against Infectious Disease - "The Green Book".Chapter 25 Pneumococcal (October 2012)
3. Drug and Therapeutics Bulletin (1998), 36 (10), 73-6.
4. Extending meningitis C vaccine to 20-24 year olds; pneumococcal vaccine for at-risk under 2 year olds (4/1/02). PL/CMO/2002, PL/CNO/2002/1, PL/CPHO/2002/1.
5. Adult immunisation update (6/8/03).PL/CMO/2003/6, PL/CNO/2003/7, PL/CPHO/2003/4
6. Letter from the Chief Medical Officer, 31st March 2005.PL/CMO/2005/1.