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The pneumococcal vaccination: an update

Sara Richards
RGN BSc(Hons)
Vice-Chair
RCN Practice Nurse Association
E:sararichards@aol.com

Invasive pneumococcal disease (IPD) is a major cause of morbidity and mortality in the UK. The serious infections include meningitis and septicaemia and affect all age groups, although they are most common in the very young and very old. Of all cases of IPD, about a quarter have pneumococcal meningitis, which often leaves sequelae and has a higher incidence of neurological and hearing deficit than Haemophilus influenzae type b (Hib) and meningococcal disease combined. With the advent of effective vaccines against Hib and meningitis C, the pneumococci are one of the few remaining causes of bacterial meningitis and septicaemia in the UK.(1)
There are currently two pneumococcal vaccines available. The polysaccharide vaccine contains 25mg of purified capsular polysaccharide from each of 23 capsular types of pneumococcus, and is supplied by Aventis Pasteur MSD.(2) There are 90 serotypes of pneumococci, but together these 23 capsular types account for about 96% of the pneumococcal isolates causing serious infection in Britain.(2) A single dose of this vaccine is recommended for "at-risk" children over the age of 5. The second vaccine, supplied by Wyeth, is a conjugate vaccine containing seven of the common capsular serotypes and is recommended for children aged between 2 months and 5 years in the at-risk groups as defined by the Chief Medical Officer.(2)
The schedule for giving these vaccines is detailed in the Department of Health (DH) Green Book and is dependent on age. The DH pneumococcal vaccine programme, which uses the 23-valent vaccine, targets the older person. From April 2004 everyone over 75, and from April 2005 everyone over 65, will be included. The 2004 Chief Medical Officer's letter also describes certain at-risk groups who should be given the vaccines (see Box 1). These groups have been extended from last year to include those who have asthma and require continuous or repeated use of inhaled or systemic steroids, individuals with CSF shunts, and children under 5 who have previously had IPD.(3)

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As there are nearly 9.5 million people in the over-65 age group,(4) it is essential that general practices develop strategies to identify and vaccinate these large numbers to avoid being overwhelmed.

Recommendations - sharing good practice
Inevitably, the burden of implementing the pneumococcal vaccination programme falls on the practice nurse, but with administration staff willing to help and GPs being aware of offering the vaccine opportunistically, the workload can be distributed.
The pneumococcal vaccination programme is a Directed Enhanced Service (DES), and some of the key service requirements of the programme are:

  • To develop and maintain a register of all at-risk patients using national Read codes.
  • To offer immunisations during the period from 1 August to 31 March.
  • To concentrate the immunisation programme ­during the period from 1 September to 31 January.

This means that the pneumococcal vaccine can be administered at any time of the year and does not have to be given with the influenza vaccine. However, for some practices, administering the two vaccines simultaneously may be an appropriate strategy, being the only time they are able to "target" the well elderly.
Some practices ask administration staff to tag the notes of at-risk patients or put a flag on the computer so that all practice staff are made aware of the need for vaccination at opportune times. However, if this procedure is adopted, all staff should be trained to identify whether a patient has already received the vaccine. It is not currently recommended to give more than one vaccine, except in individuals with no spleen, with splenic dysfunction or with chronic renal diseases, and in this case further vaccinations should be administered every five years.(2)
Those practices that run designated clinics for diabetes, heart disease, asthma or over-75 checks could ask patients if they want the vaccine as part of the consultation. Patients attending the surgery can also be reminded and educated about the vaccine via posters on surgery walls and leaflets.
It is essential to order adequate supplies of the vaccines at points in the year. The shelf-life of the polysaccharide vaccine is two years, so you should ensure that there is enough fridge space. Unlike the influenza vaccine, the serotypes that make up the pneumococcal vaccines do not change every year, so it can be ordered and administered throughout the year.

Reimbursement - understanding the process
The pneumococcal immunisation programme for older people is a DES that primary care organisations (PCOs) must commission. Practices need to register with their PCO to agree they will provide this service. The fee that has been set in England, Wales and Scotland is £7.28 for each vaccine given.(5)
In England and Wales, the vaccines can be purchased in bulk directly from the manufacturer or other supplier with a negotiated discount. In addition to the £7.28, a prescription should be generated for each one given and endorsed as personally administered (PA). Payment is recovered from the Prescription Pricing Authority (PPA) and is made up of the basic price of the drug together with an on-cost allowance, a container allowance, a dispensing fee and a VAT allowance. A small deduction takes into account that a discount will have been negotiated with the supplier.
The vaccine given to other at-risk patients will be reimbursed as a PA drug by the PPA as above. The £7.28 fee does not apply as it does not come within the scope of the nationally specified DES. No patient pays a prescription charge.
There have been many recent changes to the DH pneumococcal vaccination programme, and it is critical for practice nurses to keep abreast of new policies and DH guidance. Your local PCO will be able to provide you with the latest information. Posters and leaflets are available from the DH (see Resources).

References

  1. Lajeunesse M. Pneumococcal vaccines: the issues for primary care. Airways J 2004;2:152-5.
  2. Department of Health. Immunisation against infectious disease. In: The Green Book. London: DH; 2004. ch. 25, p. 1-15.
  3. Department of Health. Update on the influenza and pneumococcal ­immunisation programmes. CMO Letter PL/CMO/2004/4. London: DH; 2004.
  4. Office for National Statistics. National statistics online. London: ONS; 2004. Available from URL: http://www.statistics.gov.uk/cci/nugget.asp?id=949
  5. British Medical Association. Focus on … payments to influenza and ­pneumococcal vaccinations 2004/05. General Practitioners Committee. London:?BMA; 2004.

Resources
Posters and leaflets are ­available from the Department of Health by email
E:dh@prolog.uk.com
NHS Immunisation Information
W:www.immunisation.nhs.uk
For further general ­information about immunisations