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Pneumococcal

PneumococcalStreptococcus pneumoniae bacteria, or pneumococcus, are common inhabitants of the respiratory tract and can cause many types of illnesses. The major clinical syndromes of pneumococcal disease are pneumonia (infection in the lungs), bacteremia (blood stream infection) and meningitis (infection of the covering around the brain and spinal cord). Pneumococcus can cause other types of infections too, such as ear infections and sinus infections. Some of these infections are considered “invasive.” Invasive disease means that germs invade parts of the body that are normally free from germs. When this happens, disease is usually very severe, requiring treatment in a hospital and even causing death in some cases.

Pneumococcal pneumonia is the most common form of pneumococcal disease among adults, but can cause mild to severe illness in people of all ages. Symptoms usually include an abrupt onset of fever, chills, productive cough, shortness of breath, rapid breathing and heart rate, low oxygen level, malaise and weakness. Complications of pneumococcal pneumonia include infection of the space between membranes that surround the lungs (empyema), inflammation of the sac surrounding the heart (pericarditis), and blockage of the airway that allows air into the lungs (endobronchial obstruction), with lung collapse (atelectasis) and collection of pus (abscess) in the lungs. About 5-7 out of 100 people will die from it, but that rate may be much higher among elderly patients.

Bacteremia is a type of invasive pneumococcal disease that infects the blood. Bacteremia without a known site of infection is the most common form of pneumococcal infection among children 2 years of age and younger, accounting for 70% of invasive disease in this age group. In adults, more than 12,000 cases occur without pneumonia per year. The case fatality rate in this group is about 20% and may be as high as 60%.

Meningitis is the most severe type of invasive pneumococcal disease. Pneumococci cause over 50% of all cases of bacterial meningitis in the United States. Symptoms may include headache, lethargy, vomiting, irritability, fever, nuchal rigidity, seizures and coma. Of children younger than 5 years old who get pneumococcal meningitis, about 1 out of 15 dies of the infection and others may have long-term problems, such as hearing loss or developmental delay. The case fatality rate in adults is about 22%. Among survivors, long-term neurologic problems are common.

Pneumococcus is a common cause of acute otitis media (middle ear) infections. Middle ear infections in children account for 20 million office visits annually. Complications of pneumococcal otitis media include mastoiditis (infection of the bone behind the ear) and meningitis.

The CDC identifies many conditions that increase a person’s risk for invasive pneumococcal disease.

Children at increased risk for pneumococcal disease include those:

  • Younger than 2 years old
  • Who have certain illnesses (sickle cell disease, HIV infection, diabetes, immune compromising conditions, nephrotic syndrome, or chronic heart, lung, kidney, or liver disease)
  • With cochlear implants or cerebrospinal fluid (CSF) leaks (escape of the fluid that surrounds the brain and spinal cord)

Adults at risk for pneumococcal disease include:

  • Adults 65 years or older
  • Adults 19 through 64 years old:
    • With chronic illnesses (chronic heart, liver, kidney, or lung disease; diabetes; or alcoholism)
    • With conditions that weaken the immune system (HIV/AIDS, cancer, or damaged/absent spleen)
    • With cochlear implants or cerebrospinal fluid (CSF) leaks (escape of the fluid that surrounds the brain and spinal cord)
    • Who smoke cigarettes

The best way to prevent pneumococcal disease is by getting vaccinated.  There are now four pneumococcal vaccines currently available in the United States: pneumococcal 13-valent conjugate vaccine (PCV13 or Prevnar 13®), pneumococcal 20-valent conjugate vaccine (PCV20 or Prevnar 20TM), pneumococcal 15-valent conjugate vaccine (PCV15 or VAXNEUVANCETM) and pneumococcal polysaccharide vaccine (PPSV23 or PNEUMOVAX® 23). All of these of these vaccines are good at preventing severe pneumococcal disease, which often requires treatment in the hospital and can be deadly. However, these vaccines will not prevent all infections.

Because of the new availability of PCV20 and PCV15, the CDC updated their recommendations for adult pneumococcal vaccinations in January 2022 and published the changes in the Adult Immunization Schedule in February 2022. The CDC recommends PCV20 or PCV15 followed by PPSV23 for all adults over age 65 as well as adults aged 19-64 years with certain underlying medical conditions or other risk factors.

Therefore, Military Treatment Facilities (MTFs) and clinics should immediately begin the transition from PCV13 and PPSV23 toward PCV20 or PCV15 followed by PPSV23 as outlined in these recommendations. That is, MTFs should begin to add either PCV15 or PCV20 to their adult immunization formulary. The recommendations for routine pneumococcal vaccine in children have not changed and PCV13 is still recommended for this age group. In addition PPSV23 is still recommended in children with certain underlying medical conditions. Therefore PCV13 and PPSV23 will still need to remain on the MTF formulary in addition to either PCV15 or PCV20.

CDC recommends PCV13 for:

  • All children younger than 2 years old
  • People 2-18 years with certain medical conditions

CDC recommends PPSV23 for:

  • People 2-18 years old with certain medical conditions

CDC recommends 1 dose of PCV20 or 1 dose of PCV15 followed by 1 dose of PPSV23 1 year later for:

  • All adults age 65 years or older
  • Adults age 19-64 years with certain underlying medical conditions or risk factors

A minimum interval of 8 weeks between PCV15 and PPSV23 can be considered for adults with an immunocompromising condition, cochlear implant or cerebrospinal fluid leak to minimize the risk of invasive pneumococcal disease caused by serotypes unique to PPSV23 in these vulnerable groups.

CDC recommends the following for those that have received PPSV23 or PCV13 in the past:

  • Adults who have only received PPSV23 may receive a PCV (either PCV20 or PCV15) ≥1 year after their last PPSV23 dose. When PCV15 is used in those with history of PPSV23 receipt, it need not be followed by another dose of PPSV23.
  • The incremental public health benefits of providing PCV15 or PCV20 to adults who have received PCV13 only or both PCV13 and PPSV23 have not been evaluated. These adults should complete the previously recommended PPSV23 series.

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This information paper describes pneumococcal disease and the vaccines to prevent it.

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Last Updated: April 18, 2022

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