This site is intended for health professionals only

Pneumococcal vaccine: recent changes in practice

Jacqueline Burns
RGNDip
Independent Primary Care Adviser

Invasive pneumococcal disease is a major cause of morbidity and mortality. It is caused by the bacterium Streptococcus pneumoniae, which can cause pneumonia or systemic infections, including bacteraemic pneumonia, meningitis and bacteraemia.(1)
Recent research indicated nearly 70% of adults had never heard of pneumococcal disease, though over 90% were aware of pneumonia, meningitis and blood poisoning, but unaware of their causes.(2) In England and Wales there are around 530 cases of invasive pneumococcal disease in children under 2 annually. Estimates vary, but around 50 children under two will die from invasive pneumococcal disease each year.(3)
The final phase of the Chief Medical Officer's (CMO) recommendations for age-related pneumococcal vaccination has now been in place for a year. The three-year programme has extended cover to include everyone over 65 as well as those at clinical risk, bringing recommendations for England and Wales in line with Scotland and Northern Ireland. A 23-valent plain polysaccharide pneumococcal vaccine (Pneumovax II) is licensed for individuals 2 years and over.(1) The vaccination programme is now to be further extended to include infants.

Overview of recommendations
Recommendations for pneumococcal vaccination are currently:(1)

  • Adults aged 65 and over.
  • Clinical risk groups including:

    - Chronic respiratory disease (asthma only indicated when severe as to require continuous or frequently Repeated systemic steroids).
    - Chronic heart disease.
    - Chronic liver disease.
    - Asplenia or splenic dysfunction.
    - Diabetes.
    - Immunosuppression.
    - Individuals with cochlear implants.
    - Individuals with the potential for cerebrospinal fluid leaks.
    - Children under 5 who have previously had invasive pneumococcal disease.
From Summer 2006 the Department of Health plans to introduce a new pneumococcal vaccine and a catch-up programme into the childhood immunisation schedule.(4) A pneumococcal conjugate vaccine (Prevenar) will be introduced into the routine immunisation programme. The vaccine protects against seven common strains of pneumococcal bacteria and is licensed for use in children from 2 months of age.(4) Prevenar has been used in the USA since 2000. Since its introduction, the incidence of invasive pneumococcal disease (IPD) caused by the seven serotypes in the vaccine has fallen by 94% in children under 5 years of age, and by 62% in individuals aged 5 and over.(4)
The proposed new vaccination schedule will be:(5)
2 months         DTaP/IPV/Hib + pneumococcal vaccine
3 months         DTaP/IPV/Hib + Men C vaccine
4 months         DTaP/IPV/Hib + Men C + pneumococcal vaccination
12 months      HIB/Men C
13 months      MMR + pneumococcal vaccine
The DH letter states that primary care organisations should start to plan how current immunisation services can be modified to accommodate an additional vaccination visit at 12 months in the routine programme, and be preparing to implement a pneumococcal vaccination catch-up programme for children up to 2 years of age later this year.
We all know the implications a catch-up programme will have on the already busy practice nurses workload, so careful planning is imperative. Peripatetic teams, organised by PCOs, visiting practices for specific vaccination clinics, would alleviate the time pressures.

Implications for practice nurses
With the introduction of all infant vaccines, there is always understandably parental concern. The most recent concern of parents has been that the additional vaccines will overload the infant's system, but the DH states there is no scientific or medical evidence to suggest multiple immunisation overloads the immune system of infants.(4)
The whole primary care team should be aware of the changes, but particularly practice nurses and health visitors should be prepared to answer parents' questions in a way that is appropriate for the individual concerned. Posters on display in the practice and leaflets with a brief outline of the vaccine, how it works, a schedule of vaccination, and side-effects and contraindications are useful. It is the nurse's responsibility to obtain informed consent for all vaccines they administer at the time of administration, and the parents should be given information about the process, benefits and risks of immunisation.
On occasion it may be that the child may be brought for vaccination by a grandparent or nanny. In this case it should be established that this person has the necessary authority. The addition of a new vaccine should be included within the patient group directive (PGD) of the primary care organisation, and the PGD should be approved and signed by the practice nurse, GP, and the pharmaceutical and clinical governance leads for the appropriate PCO.

Identifying eligible patients
As pneumococcal vaccination for adults can be given all year round, it is beneficial to have an ongoing programme of identifying and targeting patients who have not yet been vaccinated. Not only will this spread the workload over the year, but it is likely to increase vaccination rates in your practice as patients turn 65 or become eligible due to diagnosis of a chronic disease on an ongoing basis.
A targeted approach involving the whole primary care team, making sure everyone is aware of the criteria for vaccination and aware of how to refer eligible patients to the appropriate clinic for vaccination, is important. District nurses and GPs who visit care and nursing homes can ensure that at-risk patients and those over the age of 65 are included in the programme, as well as patients who are unable to attend the surgery and may therefore slip through the net. Health visitors are able to introduce the vaccination programme to new mothers and direct them to the clinic. Receptionists are often the first line of enquiry for patients and should be aware of the criteria and be able to refer patients to the leaflets, or to the practice nurse for vaccination.
The pneumococcal vaccine may be given opportunistically at diabetic or respiratory clinics, or at routine attendance at the surgery. Computer age-related and clinical risk lists are invaluable. An identification of "needs vaccine" on the computer should be flagged up. Repeat prescriptions can be used to search for medication prescribed to those in at-risk categories. A practice protocol is also useful (see Box 1).

[[NIP28_box1_68]]

When the amount of vaccine needed has been assessed, the PCO and the manufacturers will assist in setting up a rolling programme of supply. Ensure that the cold chain has not been broken during delivery, the fridge is not overloaded and the vaccines are stored according to the manufacturer's instructions. A method of checking maximum/minimum temperature of the fridge daily, as well as a control of the numbers of vaccines stored, should be in place.
Remember that individuals who qualify for the pneumococcal vaccine who are at risk or over 65 will probably meet the criteria for influenza vaccines during the October/November programme, and that pneumococcal and influenza vaccine may be given at the same time, administered at separate sites, and with careful recording of sites. However, it is advisable to also target these patients throughout the year for pneumococcal vaccination to reduce the workload during the busy influenza vaccination season.

Conclusion
The new policies for vaccinating children and the recent age-related programme will have a huge impact on the effects of pneumococcal disease. Implementing and modifying a successful vaccination programme requires careful consideration and planning. Making patients aware of the availability, eligibility and need for vaccination is essential to ensure a good uptake in the target groups, and a good uptake will reduce the number of patients to be targeted in the future, therefore reducing future workload. Ensure the whole of the primary healthcare team is involved to assist in identifying, monitoring and vaccinating all elderly patients. Spreading the vaccination programme for the over-65s across the year, as opposed to giving it in conjunction with influenza vaccine, helps reduce the workload. The under-2s are a particular risk group, and the introduction of pneumococcal vaccination will prevent serious illness and save lives.

References

  1. DH. Immunisation against infectious disease: the green book. London: HMSO; 2004.
  2. Know About Pneumo. Market research findings. Available from URL: http://www.aboutpneumo.com
  3. Ispahani P, et al. Arch Dis Child 2004;89:757-62.
  4. DH. Planned changes to the childhood immunisation programme. London: DH; 2006.
  5. DH. Pneumococcal disease added to the childhood immunisation programme. Press release. Available from URL: http://www.dh.gov.uk/PublicationsAndStatistics/PressReleases/Press ReleasesNotices/fs/en?CONTENT_ID=4128036&chk=PI8e57

Resources
NHS Immunisation Information
W:www.immunisation.nhs.uk/

Department of Health
W:www.dh.gov.uk

DH Advisory Bodies
W:www.advisory bodies.doh.gov.uk