Pneumococcal Vaccination - Myths and Facts
Dale W. Bratzler, DO, MPH
Epidemiology of Pneumococcal Disease
Disease due to Streptococcus pneumoniae continues to be a major cause of morbidity and
mortality in the United States. S. pneumoniae causes approximately 500,000 cases of
pneumonia each year and is the leading cause of meningitis in this country.1-4
Pneumococcal infection accounts for more deaths than any other vaccine-preventable
bacterial disease. Despite appropriate antimicrobial therapy and intensive medical care,
the overall case-fatality rate for pneumococcal bacteremia is 15% to 20% among adults
and 30% to 40% in the elderly.5 Recently, antibiotic-resistant strains of S. pneumoniae
have been reported at alarming rates.6-12 Over the past 5 to 7 years there has been a 60-
fold increase in the number of resistant isolates of pneumococcus.12 Although the
incidence varies considerably across the United States, some areas of the country report
rates of penicillin-resistant isolates that approach 30% to 60%.6-8 Resistance to penicillin
is an important marker of resistance to other classes of antibiotics. In 1996, up to 25% of
strains of pneumococcus were resistant to more than one antibiotic.9 Strains of
pneumococcus that are penicillin-resistant are frequently resistant to trimethoprim-
sulfamethoxazole (TMP-SXT) and many are resistance to macrolides, tetracyclines, and
Facts about Pneumococcal Vaccination
The currently available pneumococcal vaccines contain 23 purified capsular
polysaccharide antigens of S. pneumoniae. The 23 capsular antigens in the vaccines
represent at least 85% to 90% of the serotypes that cause invasive pneumococcal disease
in children and adults in this country. Even though these vaccines have been widely
available since 1983, they remain underutilized. Much of this underuse may be attributed
to uncertainties and myths about the benefits of the vaccines.
Myth #1 - Most eligible patients have received the pneumococcal vaccine. Despite
widely disseminated guidelines for use,5 pneumococcal vaccine remains underutilized.
Approximately 50% of elderly and high-risk patients in the United States have not been
immunized.15 Based on surveillance data from 1997, only 33% of diabetic patients had
received the vaccine.16 A recent survey of nearly 7,000 Medicare beneficiaries revealed
that the most common reason for not getting the pneumococcal vaccination was that they
did not know they needed the shot.17 "The doctor did not recommend the pneumonia
shot" was the second most commonly reported reason for not being vaccinated.17
Myth #2 - The pneumococcal vaccine is not effective. Numerous epidemiologic studies
have demonstrated the effectiveness of pneumococcal vaccine at preventing invasive
disease (bacteremia and meningitis) due to Streptococcus pneumoniae.18-23 The overall
efficacy against invasive disease among immunocompetent adults is approximately 75%.
Vaccination of elderly patients has been shown to be cost-effective.24 In a recent
retrospective cohort study25 of patients with chronic lung disease, pneumococcal
vaccination was shown to have substantial health and economic benefits. Pneumococcal
vaccination was associated with a 43% reduction in the number of hospitalizations for
pneumonia and a 29% reduction in the risk of death from all causes. Estimates of health
care cost savings ranged from $113 to $512 per person vaccinated.25
Myth #3 - Revaccination of a previously immunized patient can be dangerous. Localized
reactions at the injection site (redness and tenderness) may occur in 10% to 15% of
patients being re-immunized with the pneumococcal vaccine.26 These reactions are
almost always mild and self-limited and are consistent with a localized Arthus-type
reaction (type 3 hypersensitivity reaction). Reactions are more likely to occur in
immunocompetent healthy patients. The risk of a sizeable (> 10 cm) local reaction
correlates with pre-vaccination streptococcal antibody titers. Serious adverse events
associated with revaccination are rare. Studies of large populations of Medicare patients
have demonstrated rates of hospitalization within 30 days of revaccination that are no
higher than rates of admission for patients being vaccinated the first time.27 In a meta-
analysis of nine randomized controlled trials of pneumococcal vaccine efficacy
(including more than 7,500 patients), there were no reports of severe febrile,
anaphylactic, or neurologic complications.28
Myth # 4 - Hospitalized patients are too sick to be vaccinated. In the 1995 National
Health Interview Survey, 67% of all recently hospitalized persons age 65 years or greater
had not receive the pneumococcal vaccine. Fedson et al29 demonstrated that two-thirds
of persons with serious pneumococcal disease had been hospitalized within the previous
4 years, yet few had received the pneumococcal vaccine. In a study of Medicare patients
hospitalized with pneumonia, opportunities to provide pneumococcal vaccination were
missed in 80% of the cases.30 Although the manufacturers recommend that the
pneumococcal vaccine not be administered to patients with severely compromised
cardiac or pulmonary function, there have been many hospital-based standing orders
programs to immunize patients prior to discharge that have been safely and effectively
implemented.31-39 In addition, successful programs to vaccinate elderly persons
presenting to the emergency department for care have been implemented.40,41 There is
no evidence of significant risk from the vaccination of hospitalized patients demonstrated
in any of these studies.31-41
Recommendations for Pneumococcal Vaccination
The current recommendations5 from the Advisory Committee on Immunization Practices
(ACIP) for vaccination against pneumococcal disease are summarized in the table and
figure. Recent outbreaks of antibiotic-resistant S. pneumoniae have highlighted the
importance of vaccination.42-45 The ACIP has recently endorsed recommendations for
standing orders programs in outpatient and inpatient settings to increase adult
immunization rates. Risk factors for pneumococcal disease in adults include chronic
cardiovascular diseases, chronic pulmonary diseases, chronic liver disease, chronic renal
disease, diabetes mellitus, and alcoholism. In addition, patients who are
immunosuppressed or who have functional asplenia are at increased risk for
pneumococcal disease. Age greater than 65 years is also considered a major risk factor.
Vaccination against pneumococcal disease is recommended for all patients with risk
factors. Any patient who has an unknown immunization status should receive at least one
dose of the vaccine. Patients who receive their first dose of vaccine before the age of 65
or those patients who are immunosuppressed should be revaccinated after 5 years.
Presently, there are no studies that document benefit of the pneumococcal vaccine given
more than twice.5
Though widely available, efficacious, and cost-effective, pneumococcal vaccine is
underutilized. Approximately half of the deaths from invasive pneumococcal disease
could be prevented by use of the vaccine. The emergence of antibiotic-resistant S.
pneumoniae supports the urgent need for an increased rate of vaccination among high-
Centers for Disease Control and Prevention. Premature deaths, monthly mortality and
monthly physician contacts?United States. MMWR Morb Mortal Wkly Rep.
Marston BJ, Plouffe JF, File TM, et al. Incidence of community-acquired pneumonia
requiring hospitalization. Results of a population-based active surveillance study in Ohio.
The Community-Based Pneumonia Incidence Study Group. Arch Intern Med.
Schuchat A, Deaver-Robinson K, Wenger JD, et al. Bacterial meningitis in the United
States in 1995. N Engl J Med. 1997;337:970-976.
Fine MJ, Smith MA, Carson CA, et al. Prognosis and outcomes of patients with
community-acquired pneumonia. A meta-analysis. JAMA. 1996;275:134-141.
Centers for Disease Control and Prevention. Prevention of pneumococcal disease:
recommendations of the Advisory Committee on Immunization Practices (ACIP).
MMWR Morb Mortal Wkly Rep. 1997;46(RR-8):1-24.
Breiman RF, Butler JC, Tenover GC, et al. Emergence of drug-resistant pneumococcal
infections in the United States. JAMA. 1994;271:1831-1835.
Hofmann J, Cetron MS, Farley MM, et al. The prevalence of drug-resistant Streptococcus
pneumoniae in Atlanta. N Engl J Med. 1995;333:481-486.
Appelbaum PC. Emerging resistance to antimicrobial agents in gram positive bacteria:
pneumococci. Drugs. 1996;51(suppl 1): 1-5.
Butler JC, Hofmann J, Cetron MS, et al. The continued emergence of drug-resistant
Streptococcus pneumoniae in the United States: an update from the Centers for Disease
Control and Prevention?s Pneumococcal Sentinel Surveillance System. J Infect Dis.
Thornsberry C, Burton PH, Vanderhoof BH. Activity of penicillin and three third-
generation cephalosporins against US isolates of Streptococcus pneumoniae: a 1995
surveillance study. Diagn Microbiol Infect Dis. 1996;25:89-95.
Thornsberry C, Ogilvie P, Kahn J, Mauriz Y. Surveillance of antimicrobial resistance in
Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis in the
United States in 1996-1997 respiratory season. The Laboratory Investigator Group. Diagn
Microbiol Infect Dis. 1997;29:249-257. 1.
Jacobs MR. Drug-resistant Streptococcus pneumoniae: rational antibiotic choices. Am J
Low DE. Resistance issues and treatment implications: pneumococcus, Staphylococcus
aureus, and gram-negative rods. Infect Dis Clin North Am. 1998;12:613-630.
Barry AL. Antimicrobial resistance among clinical isolates of Streptococcus pneumoniae
in North America. Am J Med. 1999;107(1A):28S-33S.
Centers for Disease Control and Prevention. Influenza and pneumococcal vaccination
levels among adults aged greater than or equal to 65 years - United States. MMWR Morb
Mortal Wkly Rep. 1998;47:797-802.
Centers for Disease Control and Prevention. Influenza and pneumococcal vaccination
rates among persons with diabetes mellitus - United States, 1997. MMWR Morb Mortal
Wkly Rep. 1999;48:961-967.
Centers for Disease Control and Prevention. Reasons reported by Medicare beneficiaries
for not receiving influenza and pneumococcal vaccinations - United States, 1996.
MMWR Morb Mortal Wkly Rep. 1999;48:556-559.
Shapiro ED, Clemens JD. A controlled evaluation of the protective efficacy of
pneumococcal vaccine for patients at high risk of serious pneumococcal infections. Ann
Intern Med. 1984;101:325-330.
Sims RV, Steinmann WC, McConville JH, et al. The clinical effectiveness of
pneumococcal vaccine in the elderly. Ann Intern Med. 1988;108:653-657.
Shapiro ED, Berg AT, Austrian R, et al. The protective efficacy of polyvalent
pneumococcal polysaccharide vaccine. N Engl J Med. 1991;325:1453-1460.
Butler JC, Breiman RF, Campbell JF, et al. Polysaccharide pneumococcal vaccine
efficacy: an evaluation of current recommendations. JAMA. 1993;270:1826-1831.
Farr BM, Johnston BL, Cobb DK, et al. Preventing pneumococcal bacteremia in patients
at risk. Results of a matched case-control study. Arch Intern Med. 1995;155:2336-2340.
Butler JC, Shapiro ED, Carlone GM. Pneumococcal vaccines: history, current status, and
future directions. Am J Med.1999;107(1A):69S-76S.
Sisk JE, Moskowitz AJ, Whang W, et al. Cost-effectiveness of vaccination against
pneumococcal bacteremia among elderly people. JAMA. 1997;278:1333-1339.
Nichol KL, Baken L, Wuorenma J, Nelson A. The health and economic benefits
associated with pneumococcal vaccination of elderly persons with chronic lung disease.
Arch Intern Med. 1999;159:2437-2442.
Jackson LA, Benson P, Sneller VP, et al. Safety of revaccination with pneumococcal
polysaccharide vaccine. JAMA. 1999;281:243-248.
Snow R, Babish JD, McBean AM. Is there any connection between a second pneumonia
shot and hospitalization among Medicare beneficiaries? Pub Health Rep. 1995;110:720-
Fine MJ, Smith MA, Carson CA, et al. Efficacy of pneumococcal vaccination in adults: a
meta-analysis of randomized controlled trials. Arch Intern Med. 1994;154:2666-2677.
Fedson DS, Harward MP, Reid RA, Kaiser DL. Hospital-based pneumococcal
immunization. Epidemiologic rationale from the Shenandoah study. JAMA.
Centers for Disease Control and Prevention. Missed opportunities for pneumococcal and
influenza vaccination of Medicare pneumonia patients - 12 Western States, 1995.
MMWR Morb Mortal Wkly Rep. 1997;46:919-923.
Klein RS, Adachi N. Pneumococcal vaccine in the hospital. Improved use and
implications for high-risk patients. Arch Intern Med. 1983;143:1878-1881.
Magnussen CR, Valenti WM, Mushlin AI. Pneumococcal vaccine strategy. Feasibility of
a vaccination program directed at hospitalized and ambulatory patients. Arch Intern Med.
Klein RS, Adachi N. An effective hospital-based pneumococcal immunization program.
Arch Intern Med. 1986;146:327-329.
Bloom HG, Bloom JS, Krasnoff L, Frank AD. Increased utilization of influenza and
pneumococcal vaccines in an elderly hospitalized population. J Am Geriatr Soc.
Clancy CM, Gelfman D, Poses RM. A strategy to improve the utilization of
pneumococcal vaccine. J Gen Intern Med. 1992;7:14-18.
Crouse BJ, Nichol K, Peterson DC, Grimm MB. Hospital-based strategies for improving
influenza vaccination rates. J Fam Pract. 1994;38:258-261.
Landis S, Scarbrough ML. Using a vaccine manager to enhance in-hospital vaccine
administration. J Fam Pract. 1995;41:364-369.
Nichol KL. Ten-year durability and success of an organized program to increase
influenza and pneumococcal vaccination rates among high-risk adults. Am J Med.
Vondracek TG, Pham TP, Huycke MM. A hospital-based pharmacy intervention program
for pneumococcal vaccination. Arch Intern Med. 1998;158:1543-1547.
Rodriquez RM, Baraff LJ. Emergency department immunization of the elderly with
pneumococcal and influenza vaccines. Ann Emerg Med. 1993;22:1729-1732.
Slobodkin D, Kitlas J, Zielske P. Opportunities not missed - systematic influenza and
pneumococcal immunization in a public inner-city emergency department. Vaccine.
Hoge CW, Reichler MR, Dominguez EA, et al. An epidemic of pneumococcal disease in
an overcrowded, inadequately ventilated jail. N Engl J Med. 1994;331:643-648.
Musher DM, Groover JE, Reichler MR, et al. Emergence of antibody to capsular
polysaccharides of Streptococcus pneumoniae during outbreaks of pneumonia:
association with nasopharyngeal colonization. Clin Infect Dis. 1997;24:441-446. 1.
Nuorti JP, Butler JC, Crutcher JM, et al. An outbreak of multidrug-resistant
pneumococcal pneumonia and bacteremia among unvaccinated nursing home residents.
N Engl J Med. 1998;338:1861-1868.
Quick RE, Hoge CW, Hamilton DJ, et al. Underutilization of pneumococcal vaccine in
nursing homes in Washington State: report of a serotype-specific outbreak and a survey.
Am J Med. 1993;94:149-152.