1. Pneumococcal vaccination for high risk adults
Sponsored by bioCSL (Australia) Pty Ltd. 63 Poplar Rd Parkville 3052.

2. S. pneumoniae and pneumococcal disease
The bacterium Streptococcus pneumoniae causes pneumococcal disease
The pneumococcus is commonly found in human nasopharynx (nose and throat)
without disease
Vulnerable individuals (e.g: asplenic, HIV, malignancy) may develop pneumococcal disease
S pneumoniae spreads from person to person through contaminated respiratory droplets (i.e. droplets containing the bacteria)
Streptococcus pneumoniae
Ref: Dowling JN, et al. J Infect Dis 1971; 124: Hendley JO, et al. J Infect Dis 1975; 132: Musher DM, in Mandell “Principles and Practice of Infectious Diseases” 2005

3. What is pneumococcal disease?
Pneumococcal disease covers a wide spectrum of illnesses ranging from mild to life-threatening
Sinusitis
Otitis media
Bacteraemia (bacterial septicaemia)
Pneumonia
Meningitis
Peritonitis
Septic arthritis
Osteomyelitis
Ref: Musher DM, in Mandell “Principles and Practice of Infectious Diseases” 2005

4. Possible progression pathway of disease
Ref: Musher DM, in Mandell “Principles and Practice of Infectious Diseases” 2005
Adapted from Musher DM, Principles and Practice of Infectious Diseases, 2005

5. Treating pneumococcal disease
Antibiotics
However, emergence of antibiotic-resistant strains and their spread around the world has become a concern
Therefore, prevention of pneumococcal disease, especially in vulnerable individuals, is a priority
Ref: Ward J. Rev Infect Dis 1981; 3: NHMRC. The Australian Immunisation Handbook 10th Edition Schoemakers MCJ, et al Reviews in Med Microbiology 2002

6. What is invasive pneumococcal disease?
Invasive pneumococcal disease (IPD) is defined as the isolation of a pneumococcus from a normally sterile site (generally blood, and also pleural, joint and cerebrospinal fluid)
Major clinical presentations of IPD include:
Pneumococcal pneumonia (commonest in adults)
Bacteraemia without focus (most common in children)
Meningitis
IPD is used as an overall indicator of pneumococcal disease burden
IPD may be life-threatening – resulting in hospitalisations and death
Ref: Musher DM, in Mandell “Principles and Practice of Infectious Diseases” NHMRC. The Australian Immunisation Handbook 10th Edition McIntyre PB, et al. Medical Journal of Australia 2000; 173(Suppl):S Robinson KA, et al. JAMA 2001;285:
WHO Position paper, WER Oct 2008, Vol. 83, 42 (pp. 373–384).

7. Invasive Pneumococcal Disease (IPD) in Australia
Highest incidence is seen at extremes of age: infants and elderly
In 2008:
1,628 cases of IPD were reported to the National Notifiable Diseases Surveillance System (NNDSS)
Notification rate of 7.6 cases per 100,000 population
There were 113 deaths known to be associated with IPD
The case fatality rate was higher in patients aged ≥ 65 years (14.3%) than in children aged < 5 years (1.5%);
The overall rate of IPD in Indigenous Australians was almost 5 times that in non-Indigenous Australians
Ref: NHMRC. The Australian Immunisation Handbook 10th Edition Barry C, et al. Commun Dis Intell 2012; 36(2): E

8. Invasive pneumococcal disease in Australia
Rates of IPD reported in 2008, varied across states
Notification rates of IPD, 2008, by Statistical Division of residence. Source: Barry C, et al 2012.
Ref Barry C, et al. Commun Dis Intell 2012; 36(2): E

9. Who is at risk of IPD? Children < 2 years and adults ≥ 65 years
Aboriginal and Torres Strait Islanders
Category A – Individuals with conditions associated with the highest increased risk:
Functional or anatomical asplenia
Immunocompromising conditions:
Immune deficiency, immunosuppressive therapy, solid organ transplant, HIV infection/AIDS, renal failure
CSF leak
Cochlear implants
Intracranial shunts
Presenter to briefly list the various risk factors for IPD as a lead-in to the category of interest with respect to these discussions– i.e. chronic conditions.
Highlight that the chronic conditions, which increase the risk of developing IPD are the same as those that predispose to influenza complications.
Ref: NHMRC. The Australian Immunisation Handbook 10th Edition

10. Who is at risk of IPD?
Category B – Individuals with conditions associated with an increased risk:
Chronic cardiac disease
Chronic lung disease
Diabetes mellitus
Down Syndrome
Alcoholism
Chronic liver disease
Tobacco smoking
Ref: NHMRC. The Australian Immunisation Handbook 10th Edition

11. Invasive pneumococcal disease risk in people with underlying chronic conditions
Adults with diabetes, chronic heart disease, or chronic lung disease exhibit a 3 to 6-fold increased risk of IPD, compared with healthy adults
Ref: Kyaw MH et al. J Infect Dis 2005; 192:377–86

12. Pneumococcal disease and diabetes
Diabetics have impaired pulmonary host defences which may predispose to lower respiratory tract infections
In people with diabetes, S. pneumoniae infections are associated with increased morbidity and mortality
Diabetes is a risk factor for bacteremia in patients with pneumococcal pneumonia & associated with increased mortality
Diabetes is often associated with cardiovascular or renal disease, which increases the risk for severe pneumococcal illness
S. pneumoniae infection can impair blood glucose control
Ref: Koziel H, et al. Infect Dis Clin North Am 1995, 9(1) Joshi N, et al. NEJM 1999, 341(25) MMWR. Prevention of pneumococcal disease — recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 1997;46(RR-8): Therapeutic Guidelines Endocrinology, version 4, 2009.

13. Pneumococcal disease and diabetes
Vaccination recommendations
The following guidelines recommend vaccination against pneumococcal disease for people with diabetes:
NHMRC The Australian Immunisation Handbook 10th Edition 2013
The Diabetes Management in General Practice 2012/13 Guidelines for Type 2 Diabetes (Diabetes Australia and the RACGP)
Ref: NHMRC. The Australian Immunisation Handbook 10th Edition Diabetes Management in General Practice 2012/13 18th Ed Guidelines for Type 2 Diabetes.

14. Pneumococcal disease and chronic cardiac disease
Chronic heart failure
Patients with chronic heart failure are at increased risk of respiratory infections
Respiratory infections are a major cause of acute cardiac decompensation in heart failure patients, especially in the elderly
Ref: National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand (Chronic Heart Failure Guidelines Expert Writing Panel). Guidelines for the prevention, detection and management of chronic heart failure in Australia. Updated October 2011.

15. Pneumococcal disease and chronic cardiac disease
Vaccination recommendations
The following guidelines recommend vaccination against pneumococcal disease for people with chronic cardiac disease including chronic heart failure:
NHMRC The Australian Immunisation Handbook 10th Edition 2013
Guidelines for the prevention, detection and management of chronic heart failure in Australia Updated 2011
(National Heart Foundation of Australia and
the Cardiac Society of Australia and New Zealand)
Ref: NHMRC. The Australian Immunisation Handbook 10th Edition National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand (Chronic Heart Failure Guidelines Expert Writing Panel). Guidelines for the prevention, detection and management of chronic heart failure in Australia. Updated July 2011.

16. Pneumococcal disease and COPD ie chronic obstructive pulmonary disease
People with COPD are at increased risk of developing pneumococcal disease
In patients hospitalised for acute COPD
exacerbations and concomitant pneumonia
– where infection was the cause of the exacerbation,
S. pneumoniae is one of commonest bacteria identified in sputum
Patients on high-dose inhaled corticosteroids may have impaired airway defense mechanisms making them susceptible
Ref: MMWR. Prevention of pneumococcal disease — recommendations of the Advisory Committee on Immunization Practices (ACIP). Ko FW, et al. Respir Med 2008; 102(8):

17. Pneumococcal disease and chronic pulmonary disease
Asthma
Asthma is an independent risk factor for IPD
People with asthma have at least a two-fold higher risk of developing IPD
Vaccination recommendations
For people with chronic pulmonary disease, vaccination against pneumococcal disease is recommended by the NHMRC
The Australian Immunisation Handbook 10th Edition 2013
Ref: Talbot TR, et al. N Engl J Med 2005; 352: MMWR. Updated recommendations for prevention of invasive pneumococcal disease among adults using the 23-valent pneumococcal polysaccharide vaccine (PPSV23) 3rd September
NHMRC. NHMRC. The Australian Immunisation Handbook 10th Edition

18. Invasive pneumococcal disease and tobacco smoking
Cigarette smoking is the strongest independent risk factor for IPD among immunocompetent, non-elderly adults
Smoking:
Damages the mucosal lining of the airways
Increases number inflammatory molecules
Hinders mucociliary clearance
Increases susceptibility to upper respiratory tract colonisation, infection and otitis media
About half of otherwise healthy adults with IPD are tobacco smokers
Vaccination against pneumococcal disease is recommended by The Australian Immunisation Handbook 10th Edition 2013
Ref: Nuorti JP, et al NEJM 2000; 382: Schoemakers MCJ, et al Reviews in Med Microbiology Dye JA, Adler. KB. Thorax 1994; 49:

19. 23-valent pneumococcal polysaccharide vaccine (23vPPV)
Has capsular polysaccharides from 23 types of S. pneumoniae
In , these 23 serotypes were identified as the cause of 74% of notified IPD cases in Australia
Indicated for immunisation against pneumococcal disease due to pneumococcal types contained in the vaccine
Not recommended for children less than 2 years of age
23-valent pneumococcal polysaccharide vaccine has been available in Australia since 1983
For adults ≥ 65 years:
Funded in Victoria since 1998
Listing on the National Immunisation Program commenced in 2005
Ref: Pneumovax®23 Approved Product Information Barry C, et al. Commun Dis Intell (2): E NHMRC. The Australian Immunisation Handbook 10th Edition

20. 23-valent pneumococcal polysaccharide vaccine (23vPPV)
Administered as a single 0.5mL dose S/C or IM
Most commonly reported adverse events include fever and injection site reactions
Duration of immunity: antibody levels decline after 5-10 years A more rapid decline may occur in some groups (e.g. the elderly)
The minimum recommended interval between any 2 doses of 23vPPV is 5 years
Immune hyporesponsiveness (‘blunting’ of the antibody response) may occur after repeat doses
Not known if this has any significant negative outcome on effectiveness
A higher rate of self-limited injection site reactions following revaccination (compared with first vaccination) has been observed and is described in the Product Information 
Ref: Pneumovax®23 Approved Product Information ATAGI Statement Updated recommendations for revaccination of adults with 23-valent pneumococcal polysaccharide vaccine (23vPPV), Pneumovax®23. December 2011.

21. Recommendations for pneumococcal vaccination using 23vPPV for adults who are not at increased risk
ATAGI has reviewed available evidence on the safety, efficacy and effectiveness of Pneumovax23 and its place within the National Immunisation Program (NIP). Following the review, vaccination recommendations for non-Indigenous adults aged ≥65 years were revised are shown in this slide.
A dose of Pneumovax23 should be given to adults at 65 years of age. Every effort should be made to provide a dose to anyone aged >65 years who has not previously received a dose of Pneumovax23.
A second dose (a single revaccination) of Pneumovax23, to be given ≥5 years after the first dose, is recommended for those who have a condition that predisposes them to an increased risk of invasive pneumococcal disease, this includes patients with diabetes, chronic cardiac, renal or pulmonary disease.
A second dose is no longer recommended for those without any of these predisposing conditions.
Ref: NHMRC. The Australian Immunisation Handbook 10th Edition

22. Recommendations for adults with a condition associated with an increased risk of IPD:
Use of 23vPPV:
All adults with an at risk condition are recommended to receive additional doses of 23vPPV:
A 2nd dose of 23vPPV is recommended for all at-risk adults in Category A and B at approximately 5-10 years (minimum 5 years) after the first dose
A 3rd dose of 23vPPV is recommended at the age of 50 years for Indigenous adults and 65 years for non-indigenous adults, or a minimum of 5 years after the 2nd dose, whichever is later
Adults with a:
Pre-existing condition (See Category A and B) associated with increased risk of IPD:
1st dose of 23vPPV is recommended at approximately 18 years, or a minimum of 5 years after the most recent dose of 23vPPV
2nd dose of 23vPPV is recommended at least 5 years after the 1st dose and
3rd dose of 23vPPV is recommended at least 5 years after the 2nd dose
Ref: NHMRC. The Australian Immunisation Handbook 10th Edition

23. Recommendations for adults with a condition(s) associated with an increased risk of IPD:
Newly diagnosed condition associated with increased risk of IPD, or who have never received pneumococcal vaccination:
Category A (those at the highest risk of IPD):
Single dose of 13-valent pneumococcal conjugate vaccine (13vPCV) followed by
1st dose of 23vPPV a minimum of 2 months later
Category B (those at increased risk of IPD):
1st dose of 23vPPV is recommended at identification of the risk condition if they are at increased risk
In general, no more than three 23vPPV doses are recommended during a persons’ adult life

24. Recommendations for adults with condition associated with an increased risk of IPD:
Use of 13vPCV:
Category A (those at highest increased risk of IPD) are recommended to receive a:
Single dose of 13vPCV (except haematopoietic stem cell transplant recipients)
Newly diagnosed condition:
Single dose of 13vPCV at time of diagnosis followed by
23vPPV doses:
1st dose of 23vPPV should be given a minimum of 2 months after 13vPCV
Pre-existing condition(s):
Adults who have received 1 or more prior doses of 23vPPV, the dose of 13vPCV should be given at least 12 months after the most recent dose of 23vPPV
Although 13vPCV is registered for use in adults aged ≥50 years, there is currently insufficient evidence to recommend its use in preference to 23vPPV at the individual or population level for persons aged ≥18 years who do not have a condition associated with an increased risk or IPD.
Ref: NHMRC. The Australian Immunisation Handbook 10th Edition

25. 23-valent pneumococcal polysaccharide vaccine (23vPPV) NIP and PBS information
National Immunisation Program
23vPPV is listed on the NIP for:
People aged ≥ 65 years
Aboriginal and Torres Strait Islanders
≥ 50 years of age
15–49 years of age who have underlying conditions placing them at risk of IPD.
Children aged 4 years with a condition(s) associated increased risk of IPD
Pharmaceutical Benefits Scheme (PBS)
23vPPV is listed on the PBS (restricted benefit) for:
Persons at high risk of pneumococcal infections
Splenectomised persons over 2 years of age
Persons with Hodgkin’s disease
Ref: NHMRC. The Australian Immunisation Handbook 10th Edition Schedule of Pharmaceutical Benefits (PBS) [Accessed December 2012]

26. Vaccination coverage 65 years and over 54%1 75%1
Pneumococcal pneumonia immunisation coverage
Seasonal influenza immunisation coverage
65 years and over
54%1
75%1
‘At risk’ patients (≥18 to 64 years)
<10% 2-5*
36%1
* Based on CSL estimates, may not reflect actual coverage
Ref: 1. Australia Institute of Health and Welfare Adult Vaccination Survey: Summary results. Cat. no. PHE 13. Canberra: AIHW. 2. Harrison, C, Bayram, C, Charles, J & Britt, H. ‘Pneumococcal vaccination coverage of Australian general practice patients.’ Presented at the Public Health Association of Australia (PHAA) 13th National Immunisation Conference, Darwin, June 20, 2012.
3. IMS Data

27. The practice nurse as an advocate for adult immunisation
Accessible by patients
Trusted and credible
Ability to educate and provide additional information
Identify misconceptions e.g. “can get flu from the flu vaccine”
Address concerns
Ref: Lockwood, A. & Maguire, F. Australian Journal of Primary Health - Interchange (2) Cheek, J., et al. Consumer Perceptions of Nursing and Nurses in General Practice RACGP Putting prevention into practice: guidelines for the implementation of prevention in the general practice setting 2nd Ed 2006

28. Conclusions
Many people are at increased risk of severe influenza, influenza-related complications, or invasive pneumococcal disease
To prevent the disease burden of influenza and pneumococcal disease in at-risk individuals, Australian guidelines recommend:
Yearly influenza vaccination, and
Vaccination with pneumococcal vaccine
Funding for the vaccines in at-risk groups is available through the NIP or PBS
At-risk individuals should be encouraged to speak to their doctor about their influenza and pneumococcal vaccination status
Ref: NHMRC. The Australian Immunisation Handbook 10th Edition TGA. Pneumovax®23 - recommendation about revaccination 18 April Accessed 20 December 2012 from:

29. Please review Product Information before prescribing.
Product Information is available from bioCSL (Australia) Pty Limited ABN , 63 Poplar Road, Parkville, ® Pneumovax 23 is a registered trademark of Merck & Co. Inc. Whitehouse Station, NJ, USA
Pneumovax23 PBS Information: This product is listed on the National Immunisation Program (NIP) Schedule and the PBS. Refer to the NIP and PBS Schedule.