Aashrey Child Clinic

• OVERVIEW OF THE DISEASE (What is Pneumonia?; Pneumonia Indian Context; Pneumonia in Gujarati; Pneumonia in Hindi)
• TYPES OF PNEUMOCOCCAL VACCINE (Conjugate: PCV 13 (Prevenar 13); PCV 10 (Synflorix & Pneumosil); Polysaccharide: PPSV 23 (Pneumovax); About vaccines; Pneumonia vaccine price)
• PNEUMONIA VACCINATION SCHEDULE (Primary Pneumonia schedule; Catch-up or missed dose of Pneumonia; Interesting FAQ)
• PNEUMONIA VACCINE SIDE-EFFECTS  (Minor Side effects; Severe reactions; vaccine side effects in general; people who had a life-threatening allergic reaction)
• WHO NEEDS THE VACCINE?
• WHO SHOULDN’T GET THE VACCINE?
• HOW WELL DO THESE VACCINES WORK? (Data comparing PCV13 & PCV7)
• ADULT PNEUMONIA VACCINATION (PCV 13 & PPSV 23 difference, Dose & schedule of vaccine according to medical conditions)
• CONCLUSION

PNEUMONIA – INDIAN CONTEXT

Pneumonia is a leading cause of death in children under 5 years of age (16-25%) in India.

4,10,000 children under 5 years of age die of pneumonia every year. If applied in Indian context, it can be said that 1,23,000 to 1,64,000 under 5 year children die due to pneumococcal pneumonia.

Pneumonia is easily treatable as well as preventable cause of death in children below 5 years of age, yet a child dies from infection every 20 seconds in the world.

POLYSACCHARIDE VACCINE IS:

PNEUMOVAX23 (by MSD)

WHAT TO PREFER CONJUGATE VACCINES OR POLYSACCHARIDE VACCINES?

Conjugate vaccines are preferred over Polysaccharide vaccines because:

1. antibody response is generated within 2-4 weeks of immunization after polysaccharide vaccine but it generates predominantly Ig M response with low titers of low affinity Ig G. Thus the half-life of plasma cells is short and antibody titers decline rapidly.
2. polysaccharide vaccine are unable to evoke an immune response in those aged less than 2 years due to immaturity of the marginal zones
3. as polysaccharide vaccine do not induce germinal centers bonafide, memory B cells are not elicited. Thus repeat exposure of same polysaccharide antigen results in a primary response that follows the same kinetics in previously vaccinated as in naïve individuals.

So it is better to vaccinate your child with conjugate vaccines as they give  a life-long immunity to the individual.

Routine Primary Vaccine schedule for children is a 4 dose schedule. First 3 doses are given one month apart each of them with the first dose at 6 weeks. ie. First dose at 6 weeks (1.5 month); Second dose at 10 weeks (2.5 month) and Third dose at 14weeks (3.5 month). Booster dose is given at 15 months of age.

Other schedule that is followed by Government of India is 3 dose schedule. First dose at 6 weeks (1.5 month), Second dose at 14 weeks (3.5 month) and Booster at 9 months of age. There are several studies done for 4 dose regimen but not many for 3 dose regimen. So 4 dose schedule should be preferred at any cost over 3 dose regimen as followed in many countries as well as backed by several studies & clinical trials. Government of India is following 3 dose regimen in certain 7 states due to cost effectiveness.

FOLLOW UP VACCINATION OR MISSED DOSES

For children  who were given no doses of pneumonia vaccine during the first year of life can also be vaccinated with pneumonia vaccine.

Catch-up Schedule:

For completed 12 months of age: 2 doses of Synflorix or Prevenar 13 at interval of 8 weeks ( 2 months) apart.

For 2 to 5 years of age: single dose of Prevenar 13 or 2 doses of Synflorix

For 5 to adult of any age: single dose of Prevenar 13.

Q: INTERCHANGABILITY OF PNEUMONIA VACCINES?

A: Can pneumonia vaccine be interchanged between brands? The answer to that is definitely, No. As each brand of conjugate pneumonia vaccine is made for different serotypes and also contain different proteins & adjuvants, so they cannot be used interchangeably. So, always choose the first vaccine very carefully ie considering future costs, availability and total cost with all the vaccines to be given.

Q: WHY MULTIPLE DOSES OF SAME PNEUMONIA VACCINE?

A: Although some of the available vaccines can give you immunity after a single dose no matter when you receive it, others have to be given several times at certain ages and intervals to provide full protection. With some diseases your immunity will eventually wear off, and so you will need booster immunizations at intervals to stay fully protected. Because of this, it’s important to keep your child’s (and your own) immunization schedule up to date.

Q: WHY ARE PNEUMONIA VACCINES GIVEN AT SUCH AN EARLY AGE?

A: Vaccines are given at an early age because the diseases they prevent can strike at an early age. Some diseases are far more serious or common among infants or young children. For example, up to 60% of severe disease caused by pneumonia occurs in children under 12 months of age.

After 2 years, option of single dose of pneumonia vaccine is not preferred as pneumonia is lethal for young children. Commonest cause of  death and hospitalization in young children is pneumonia so if you are going for pneumonia vaccine then go for 4 dose regimen as primary schedule not as a single dose catch up schedule.

Q: ANY SIDE EFFECTS OF GIVING 3 VACCINES AT THE SAME TIME?

A: No, major side effects have been noted by given pentavalent/ hexavalent, rotavirus vaccine with pneumonia vaccine. Routine side effects that are discussed  below are observed with this 3 different vaccines given at the same time.

Q: DOES PNEUMONIA VACCINE PROTECT FROM PNEUMONIA ONLY?

A: Due to marketing, anti-pneumococcal vaccine is branded as pneumonia vaccine. It is efficacious not only against pneumonia but also against meningitis (brain infection), sinusitis, ear infection and bacteremia (blood infection) caused by pneumococcal disease ie Streptococcus pneumoniae.

Q: ARE PNEUMOCOCCAL CONJUGATE VACCINE PROTECTIVE AGAINST ALL PNEUMONIA?

A: No. Pneumonia conjugate vaccine is protective against only Pneumococcal disease with serotypes 13 or 10 depending on the vaccine selected. Pneumonia is caused by several other bacteria’s, viruses, fungi, chemical and several other reasons so the vaccine is not effective against all the types of pneumonia.

Q: PNEUMONIA VACCINATION IN CORONA PANDEMIC?

A: Pneumonia conjugate vaccine is not directly beneficial for corona affected patients. It does not prevent Corona infection as the vaccine is for an bacterial infection and Coronavirus is an virus. But in Coronavirus infection (SARS CoV-2; Covid-19) majority of patients die due to pneumonia and this pneumonia is commonly due to Streptococcus Pnemoniae so vaccination against Pneumococcal conjugate vaccine can benefit against Corona infection indirectly.

Several viruses like Influenza type A & B, Parainfluenza viruses, Rhinoviruses, Respiratory Syncytial viruses including Coronaviruses are responsible for secondary bacterial infection with Pneumococcal Pneumonia, so it is better to vaccinate with pneumonia vaccination.

Child vaccination in Corona pandemic schedule should be followed according to the primary schedule. Adult if not vaccinated can get vaccinated with pneumonia vaccine for the above indirect benefit.

Also data are available suggesting that PCV 13 vaccinated adults required 35% lower risk of Covid19 diagnosis; 32% lower incidence of Covid 19 hospitalisation and 32% lower incidence of Covid 19 death then adults who didn’t receive the vaccine.

Q: PNEUMONIA VACCINE WITH CORONA VACCINE?

A: Yes pneumonia vaccine can be taken before the Corona vaccine and at an interval of 28 days of Covid vaccine. Corona vaccine available in India (Covishield & Covaxin) are inactivated vaccine. But as enough research and clinical trials are not available for these vaccines so difference of 28 days minimum should be kept between pneumonia and corona vaccine (atleast 15 days minimum). Countries with the lowest rates of COVID-19 – Japan, Korea, Denmark, Australia and New Zealand – have the highest rates of pneumococcal vaccination among both infants and adults, according to studies.

Problems that Could Happen After Getting Any Injected Vaccine

• People sometimes faint after a medical procedure, including vaccination. Sitting or lying down for about 15 minutes can help prevent fainting and injuries caused by a fall. Tell your doctor if you or your child:
  • Feel dizzy
  • Have vision changes
  • Have ringing in the ears
• Some people get severe pain in the shoulder and have difficulty moving the arm where the doctor gave the shot. This happens very rarely.
• Any medicine can cause a severe allergic reaction. Such reactions from a vaccine are very rare, estimated at about 1 in a million shots. These types of reactions would happen within a few minutes to a few hours after the vaccination.
• As with any medicine, there is a very remote chance of a vaccine causing a serious injury or death.

WHAT OTHER VACCINE PROTECT AGAINST PNEUMONIA?

We know now that pneumonia is caused by multiple organisms and reasons, so Pneumococcal vaccine is not the only vaccine that can help prevent against pneumonia. Other vaccines that can be beneficial for the baby and can help against prevention of pneumonia are:

Bacterial vaccine: HiB (H. Influenza type b) & Pertussis (whooping cough)

Viral vaccine: Measles, Chicken pox (Varicella) & Influenza (swine flu)

Above are the diseases which can cause pneumonia and are vaccine preventable.

HOW WELL DO THESE VACCINES WORK?

Summary

Vaccines that help protect against pneumococcal disease work well, but cannot prevent all cases.

Studies^* show that getting at least 1 shot of PCV13 protects:

• At least 8 in 10 babies from serious infections called invasive pneumococcal disease
• 3 in 4 adults 65 years or older against invasive pneumococcal disease
• 9 in 20 adults 65 years or older against pneumococcal pneumonia

Studies^* show that getting 1 shot of PPSV23 protects:

• Between 10 to 17 in 20 healthy adults against invasive pneumococcal disease

* Studies looked at protection against pneumococcal infections caused by the serotypes covered by the specific vaccine used

After introduction of the pneumococcal conjugate vaccine in 2000, several studies described a decrease in invasive pneumococcal disease in the United States. One year after its introduction, a group of investigators found a 69% drop in the rate of invasive disease in those of less than two years of age. By 2004, all-cause pneumonia admission rates had declined by 39% (95% CI 22–52) and rates of hospitalizations for pneumococcal meningitis decreased by 66% (95% CI 56.3-73.5) in children younger than 2.

Rates of invasive pneumococcal disease among adults have also declined since the introduction of the vaccine.

In Depth

The Food and Drug Administration (FDA) licensed the first pneumococcal conjugate vaccine (PCV7 or Prevnar^®) in 2000. That same year, the United States began using PCV7 routinely in children. It provided protection against infections caused by 7 types (serotypes) of pneumococcal bacteria. Studies showed PCV7 was highly effective in preventing invasive pneumococcal disease caused by serotypes included in the vaccine (vaccine serotypes) in young children.

In 2010, FDA licensed PCV13, which provides protection against infections caused by 6 more serotypes than PCV7. Studies show PCV13 causes the body’s immune system to create antibodies, which help fight the pneumococcal bacteria, similar to PCV7.

In a California study, PCV7 protected more than 9 in 10 babies from invasive disease caused by vaccine serotypes. The children who got the vaccine also had fewer ear infections and fewer ear tubes placed. The study also showed the vaccine prevented pneumonia in children.

A CDC study found PCV7 protected nearly all (96%) healthy children against pneumococcal disease caused by vaccine serotypes. Receiving at least one shot also protected 4 in 5 (81%) children with sickle cell disease, who are at increased risk of pneumococcal disease. The vaccine also prevented antibiotic-resistant pneumococcal infections caused by vaccine serotypes.

Another study showed that receiving at least one shot of PCV13 protects 4 in 5 babies from invasive disease caused by vaccine serotypes. This protection was similar among children with and without medical conditions that put them at increased risk of pneumococcal disease. The vaccine is also effective at preventing antibiotic-resistant pneumococcal infections caused by vaccine serotypes.

Rates of invasive pneumococcal disease caused by the serotypes in PCV7 declined by 99% in the United States since 2000. Unvaccinated people of all ages, including babies too young to get the vaccine, have seen decreases in disease. Since it helps protect unvaccinated people, this shows the vaccine decreased the bacteria’s spread in the community. Rates of invasive pneumococcal disease caused by some serotypes not in PCV7 increased between 2000 and 2010. However, these increases were small compared to the decreases in serotypes in the vaccine. Also, PCV13 covers the main serotypes that caused the increases. Thus, rates of disease caused by these serotypes declined once PCV13 replaced PCV7 in 2010. Experts estimate PCV13 prevented more than 30,000 cases of invasive pneumococcal disease and 3,000 deaths in its first 3 years of use.

In 2011, FDA licensed PCV13 for use in adults 50 years or older. A study in the Netherlands included approximately 85,000 adults 65 years or older. In this study, PCV13 protected 3 in 4 of those vaccinated against invasive pneumococcal disease caused by vaccine serotypes. PCV13 also protected 9 in 20 vaccinated against pneumococcal pneumonia caused by vaccine serotypes.

Studies show PPSV23 protects between 10 to 17 in 20 adults with healthy immune systems against invasive disease caused by vaccine serotypes.

ADULT PNEUMONIA VACCINATION

Just like in young infants, pneumonia is common cause of death in elderly. In this Corona pandemic, we have seen several adults dying due to pneumonia.

Streptococcus Pneumoniae is the commonest cause of Pneumonia in elderly after viral infections like Influenza type A & B, Parainfluenza viruses, Rhinoviruses, Respiratory Syncytial viruses including Coronaviruses. After this viral infection in adults, Streptococcal Pneumonia is the commonest secondary infection leading to death so it is better to vaccinate with Pneumococcal Pneumonia vaccine to protect elderly.

Also data are available suggesting that PCV 13 vaccinated adults required 35% lower risk of Covid19 diagnosis; 32% lower incidence of Covid 19 hospitalisation and 32% lower incidence of Covid 19 death then adults who didn’t receive the vaccine.

Countries with the lowest rates of COVID-19 – Japan, Korea, Denmark, Australia and New Zealand – have the highest rates of pneumococcal vaccination among both infants and adults, according to studies.

According to the latest government of India guidelines (JUNE 2021), PCV 13 ie PREVENAR 13 of Pfizer has been approved for vaccination of all age groups. Earlier it was approved for child immunisation and for elderly 65+ years of age. Now it is approved for age 19 to 65 years, so a single dose of PCV 13 can protect all adults from pneumococcal disease.

Pneumococcal Vaccine Timing for Adults

Make sure your patients are up to date with pneumococcal vaccination.

Two pneumococcal vaccines are recommended for adults:

• 13-valent pneumococcal conjugate vaccine (PCV13, Prevnar13®)
• 23-valent pneumococcal polysaccharide vaccine (PPSV23, Pneumovax®23)

PCV13 and PPSV23

should not be administered during the same office visit.

When both are indicated, PCV13 should be given before PPSV23 whenever possible.

If either vaccine is inadvertently given earlier than the recommended window, do not repeat the dose.

One dose of PCV13 is recommended for adults:

• 19 years or older with certain medical conditions and who have not previously received See Table 1  for specific guidance.
• Adults 65 years or older can discuss and decide, with their clinician, to receive PCV13 if they have not previously received a dose (shared clinical decision-making).

One dose of PPSV23 is recommended for adults:

• 65 years or older, regardless of previous history of vaccination with pneumococcal vaccines.
  • Once a dose of PPSV23 is given at age 65 years or older, no additional doses of PPSV23 should be
• 19 through 64 years with certain medical
  • A second dose may be indicated depending on the medical See Table 1 for specific guidance.

WHAT’S THE DIFFERENCE BETWEEN PCV13 & PPSV23?

Adults 65 years or older without an immunocompromising condition, CSF* leak, or cochlear implant

Pneumococcal vaccine timing for adults with certain medical conditions

If the patient and provider decide (through shared clinical decision-making) PCV13 is to be given at age 65 years or older:

• Administer 1 dose of PPSV23 at 19 through 64
• Administer 1 dose of PCV13 at 65 years or older. This dose should be given at least 1 year after
• Administer 1 final dose of PPSV23 at 65 years or older. This dose should be given at least 1 year after PCV13 and at least 5 years after the most recent dose of

Includes adults with: ‚ chronic heart, lung, or liver disease ‚ diabetes mellitus ‚ alcoholism ‚ Also includes adults who smoke cigarettes

Indicated to receive 1 dose of PCV13 at ≥ 19 years and 1 or 2 doses of PPSV23 at 19 through 64 years

Includes adults with:

• cerebrospinal fluid (CSF) leaks*
• cochlear implants*
• sickle cell disease or other hemoglobinopathies
• congenital or acquired asplenia
• congenital or acquired immunodeficiencies
• HIV infection
• chronic renal failure

• nephrotic syndrome
• leukemia
• lymphoma
• Hodgkin disease
• generalized malignancy
• iatrogenic immunosuppression
• solid organ transplant
• multiple myeloma

For those who have not received any pneumococcal vaccines, or those with unknown vaccination history:

• Administer 1 dose of
• Administer 1 dose of PPSV23 at least 8 weeks
• Administer a second dose of PPSV23 at least 5 years after the previous dose (*note: a second dose is not indicated for those with CSF leaks or cochlear implants).
• Administer 1 final dose of PPSV23 at 65 years or older. This dose should be given at least 5 years after the most recent dose of PPSV23.

Additional Scenarios

Adults recommended to receive PCV13 at ≥ 19 years who already received 1 dose of PPSV23 at < 65 years

Adults recommended to receive PCV13 at ≥ 19 years who already received 2 doses of PPSV23 at < 65 years and 1 dose of PPSV23 at ≥ 65 years

Adults recommended to receive PCV13 at ≥ 19 years who already received 2 doses of PPSV23 and 1 dose of PCV13 at < 65 years

Adults recommended to receive PCV13 at ≥ 19 years who already received 2 doses of PPSV23 at < 65 years and 1 dose of PCV13 at ≥ 65 years

• For those who have already received 1 or more doses of PPSV23, or those with unclear documentation of the type of pneumococcal vaccine received:
  • Administer 1 dose of PCV13 at least 1 year after the most recent pneumococcal vaccine
  • Administer a second dose of PPSV23 at least 8 weeks after PCV13 and at least 5 years after the previous dose of PPSV23 (note: a second dose is not indicated for those with CSF leaks or cochlear implants).
  • Administer 1 final dose of PPSV23 at 65 years or older. This dose should be given at least 5 years after the most recent dose of PPSV23.
• For those who have already received 1 dose of PCV13, do not administer an additional dose at 65 years or older.

CONCLUSION