Information sheet on the pneumococcal vaccination

The pneumococcal vaccination is the only vaccination in the childhood programme that is at the same time an adult vaccination – and the one where the conversation before it runs completely differently depending on age and history. This page sums up what you are told and which questions actually decide the matter.

What it is about

Pneumococci are bacteria that colonise the nose and throat of many healthy people. In rare cases they penetrate normally sterile areas and cause pneumonia, blood poisoning or meningitis. Commoner but less dangerous are infections of the middle ear and the sinuses.

The organism, its serotypes and the illnesses are described in detail on the page pneumococcal disease, and the two customary childhood vaccines on the pages Prevenar 13 and Synflorix.

An inactivated vaccine is used. It contains no organisms capable of multiplying but purified capsular sugars – with conjugate vaccines coupled to a carrier protein – and an aluminium salt as an adjuvant. The vaccine cannot cause pneumococcal disease; fever afterwards is a reaction of the immune system and not an illness.

Two conversations, two questions

Unlike with most vaccinations, the conversation here follows the starting position, and it is about different things.

With a healthy infant the vaccination is part of the general programme. The question is: does the benefit of vaccinating against a rare but serious illness outweigh the reactions to be expected? The answer is a clear yes, and the conversation mostly turns on tolerability and appointments.

With a person at increased risk – of whatever age – the question is different and more pressing. Here it is not about general prevention but about the fact that a particular illness would run a particularly severe course in this person. The conversation turns on the choice of vaccine, the order and the intervals for repeating.

This distinction is the reason why a general information page achieves less here than with other vaccinations. What applies to you depends on your history – and that is why the conversation in this case is irreplaceable not only legally but professionally.

The questions that actually decide

Before a pneumococcal vaccination in adulthood a series of circumstances is asked about. Knowing them helps in preparing for the appointment.

• Is the spleen present and functioning? It filters encapsulated bacteria; without it the risk is considerably increased.
• Is there a chronic illness? Asthma, COPD, heart disease, diabetes, kidney or liver disease.
• Is there an immune deficiency or is immunosuppressive treatment under way?
• Do you smoke? Smoking markedly increases the risk of invasive disease.
• Is there a cochlear implant or a state following certain operations on the skull?
• Which pneumococcal vaccinations have already been given – and of what kind?

The last question is the one that most often sticks in practice. Whether a conjugate or a polysaccharide vaccine was given in the past determines what happens next – and cannot be answered without the vaccination record. The recollection “I think I once had a pneumonia jab” is not enough for this, because both kinds can hide behind that phrase.

Why the order counts

When both kinds of vaccine are used, their sequence is not arbitrary. First the conjugate vaccine, then – after at least a year – the polysaccharide vaccine.

The reason is a phenomenon with the cumbersome name hyporesponsiveness: if the polysaccharide vaccine is given first, the response to a conjugate vaccine given later is weaker. The order cannot be corrected retrospectively.

That is why the question about earlier vaccinations belongs at the beginning of the conversation and not at the end. Anyone who has already received a polysaccharide vaccine can receive a conjugate vaccine later – with an interval of at least a year and in the knowledge that the response will be somewhat smaller.

With the newer conjugate vaccines covering twenty serotypes this becomes considerably simpler: where they are available, a single dose is enough in many recommendations. That is one of the reasons why these recommendations currently change more often than others.

The side effects

Very common in infants – more than one child in ten: redness, swelling and tenderness on the thigh; fever; restlessness, reduced appetite, sleepiness or increased crying. These reactions appear in the first one to two days and subside by themselves.

If the six-in-one vaccination is given at the same time, fever is somewhat commoner than with separate appointments. This is known and accepted, because separate appointments mean more strain overall.

In adults local reactions in the upper arm predominate, together with muscle pain, headache and fatigue for one to two days. The polysaccharide vaccine causes more pronounced local reactions than the conjugate vaccine, particularly on repeated administration – one reason why it is not repeated at will.

Rare to very rare: allergic reactions; in children seizures in connection with fever, without lasting consequences. After every vaccination people wait a quarter of an hour, because immediate reactions occur during this time.

What belongs with a doctor in children: fever above 39.5 degrees, fever lasting more than 48 hours, a seizure, persistent shrill crying or swelling of the whole leg. In infants under three months any temperature above 38 degrees is a reason for assessment.

What the benefit concretely is

Complete information includes not only what can happen but also what the vaccination achieves. This side of the calculation is regularly dealt with more briefly in consent sheets than the side effects.

In children the documented benefit is greatest with invasive disease: effectiveness against blood poisoning and meningitis due to the covered serotypes is more than ninety per cent. Since the introduction of conjugate vaccination these illnesses have fallen sharply in small children in Europe.

In adults over 65 a Dutch study with around 85,000 participants showed a fall in invasive disease due to the covered types of about 75 per cent and in pneumonia due to these types of about 45 per cent.

For the public at large there is an additional effect that was not expected on this scale at its introduction. Conjugate vaccines prevent not only the illness but also colonisation of the throat. Because small children are the main source of spread, the frequency of illness fell in adults as well, who were not vaccinated at all – arithmetically, in some analyses the larger part of the illness prevented falls to people who never received the vaccine.

For a family this means: vaccinating an infant measurably protects its grandparents too. It is one of the few cases in which this connection can be backed with figures.

What the vaccination does not do

This information belongs in the conversation, because false expectations otherwise form.

It protects against the serotypes it contains, not against all ninety-odd. Invasive disease despite complete vaccination is possible and is not a sign that the vaccination has failed.

It reduces the number of middle ear infections only moderately, because numerous other organisms cause the same illness. Anyone expecting the vaccination to produce a child without earache will be disappointed.

And it protects against nothing but pneumococci. Pneumonia or meningitis can be caused by numerous other organisms – see meningitis.

When it is postponed or not given

It is postponed with an acute febrile illness. A cold without fever, a course of antibiotics under way or a chronic illness in a stable state are not reasons.

It is not given where there has been a documented severe allergic reaction to one of its components or to an earlier dose. With conjugate vaccines that includes a severe reaction to vaccines containing diphtheria toxoid, because the carrier protein is a detoxified diphtheria toxin.

With a planned removal of the spleen or before the start of immunosuppressive treatment the opposite applies: here it is not postponed but brought forward. The response to the vaccination is considerably better beforehand than afterwards – ideally at least two weeks before the operation or the start of treatment.

Why the recommendations change often

Anyone following this vaccination over the years will notice that the recommendations change more often than with others. There are two reasons for this, and both belong in the conversation because they save confusion.

First, serotype replacement. A vaccine that eliminates some of the ninety-odd serotypes creates a gap that others fill. That has happened and repeats itself with every extension. The answer to it consists in taking in further serotypes: from seven to ten and thirteen, and now to fifteen and twenty.

Second, the new vaccines themselves. With every extension it changes whether a combination of conjugate and polysaccharide vaccine is needed or whether a single dose is enough. Recommendations that applied three years ago can be outdated today.

For you this means only one thing: do not rely on information you were given years ago, and not on a website either – not even this one. The composition of the vaccine currently used and the schedule in force are set out in the current Austrian immunisation schedule and are settled at the appointment.

That an earlier recommendation was changed does not mean it was wrong. It corresponded to what was available at the time. Anyone vaccinated then according to the schedule of the day has missed nothing.

In pregnancy

There is no general recommendation in Austria. Both kinds of vaccine are inactivated vaccines; no harm is known, but systematic studies in pregnant women are lacking.

Where one of the conditions named above exists, the decision is taken case by case. Anyone planning a pregnancy is best dealing with the vaccination beforehand – that is not an argument about safety but saves the weighing-up.

What is recommended in pregnancy, by contrast, are two other vaccinations: dTpa against whooping cough between weeks 27 and 36 and the influenza vaccination in every trimester. The influenza vaccination is indirectly also a means of preventing pneumococcal disease, because a considerable proportion of severe pneumonia arises as a secondary bacterial infection after influenza.

What the conversation has to contain

The requirements in Austria have been shaped by case law and are the same for every vaccination. Five points belong in it: the illnesses and their consequences, the benefit of the vaccination, the procedure with the number of doses and the intervals, the possible side effects with an indication of frequency and the consequences of refusing.

In addition there must be an opportunity to ask questions, and enough time should remain between being informed and the vaccination for it to be thought over. With plannable vaccinations such as this one a second appointment is no problem – nobody has to decide in the consulting room.

A widespread misunderstanding concerns the signed form. It is not the information but its documentation. Legally it is the conversation that counts: a form without a conversation does not replace it; a conversation without a form is valid – only harder to prove.

For children those with custody consent; for a routine vaccination the consent of one parent is enough. From the age of fourteen a person in Austria counts as capable of deciding in medical matters, provided they understand what is at stake, and can consent or refuse themselves. More on this is on the page information sheet on the six-in-one vaccination.

How to prepare for the conversation

Bring the vaccination record – with this vaccination more than with any other, because the kind of earlier vaccine determines what happens next.

List diagnoses and medicines. From them it follows whether there is an indication at all and which schedule applies. A letter from a hospital clinic is more helpful for this than a recollection.

Write your questions down. The commonest are: do I need this at all? How long does it last? Do I have to repeat it? All three can be answered, but only with knowledge of the history.

Bundle appointments. Pneumococcal and influenza vaccinations can be given on the same day, into different arms. Where several vaccinations are due this saves journeys, and effectiveness is not impaired by it.

If you decide against the vaccination

Vaccinations are voluntary in Austria. A refusal is documented and changes nothing about further care.

Being properly informed nevertheless includes what it means – and the answer differs greatly depending on the starting position. In a healthy adult without risk factors the annual risk of invasive pneumococcal disease is very low; the decision has no great consequences. In a person without a spleen it does not: there pneumococcal sepsis can become life-threatening within hours, and the vaccination is one of the few effective preventive measures.

With an infant the case lies in between. The risk is small but not negligible, and the illness strikes precisely the age group with the most severe courses and the highest rate of lasting damage.

A decision can moreover be changed later. A series that has been started is continued and not begun again, and a later start is better than none – bearing in mind with children that the most vulnerable period lies in the first and second year of life.

What happens next

The child's vaccinations are given by the paediatrician, and that is also where this conversation takes place. In this practice the subject is relevant if you yourself have an indication – especially before a planned pregnancy. Arranging an appointment.

If you are coming for preconception advice or for your yearly check anyway: bring the vaccination record with you. It is the appointment at which all open questions about vaccination can be settled in one go – rubella and measles, which absolutely belong before a pregnancy, the HPV vaccination while it is still within the free programme, the tetanus booster, and indeed pneumococci if there is an indication. What else is provided for at your age is shown by the screening planner.