Seasonal respiratory infections rise during winter months. Various viruses or bacteria can cause these respiratory infections. The most common are the influenza virus (flu), the respiratory syncytial virus (RSV), the coronavirus SARS-CoV-2 (COVID-19) and pneumococcal disease. Pharmacists routinely vaccinate those at increased risk from the flu and COVID-19. Many of these patients are also recommended to have pneumococcal vaccination.
Pneumococcal disease is a seasonal respiratory illness which increases in prevalence during the winter months. It is a bacterial infection caused by streptococcus pneumoniae of which there are more than 90 serotypes. The organism is found in the upper respiratory tract of healthy individuals.
Streptococcus pneumoniae has become resistant to many antibiotics making the prevention of disease through vaccination increasingly important.
Pneumococcal infection is responsible for 50 per cent of community acquired pneumonia and bacteraemia in Ireland. It can also cause a wide variety of other infections including sinusitis, osteomyelitis, bronchitis and otitis media. Invasive pneumococcal disease (IPD) is very serious and a major cause of illness and death, particularly amongst the very young, the very old, those who have an absent or non-functioning spleen, or those with weakened immunity.
Health Protection Surveillance Centre data shows that there were 433 confirmed cases of IPD reported in Ireland in 2023. It also noted 19 (4.4 per cent) cases of IPD related deaths, and the incidence rate was 8.4 per 100,000 population.
Transmission is by droplet infection and requires close contact with cases or carriers. Person-to person transmission of the organism is common. The incubation period can be difficult to determine but can be as short as one to three days.
Two vaccine types are currently licensed in Ireland, Pneumococcal conjugate vaccines and pneumococcal polysaccharide vaccines.
PCV 13 – Prevenar 13 – contains polysaccharide from 13 of the most common capsular types (1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F and 23F). PCV13 is recommended for the routine primary, booster and catch-up vaccination of all children. This replaced PCV 7 (Prevenar 7) the pneumococcal conjugate vaccine introduced into the routine Primary Childhood Immunisation Schedule in September 2008.
Community pharmacists do not routinely provide a PCV13 or PCV 7 vaccination service.
This vaccine contains purified polysaccharide from 23 of the most common capsular types of streptococcus pneumoniae, which account for up to 90 per cent of all serious pneumococcal infections. This vaccine is recommended for those aged 65 years and older and ‘at-risk’ adults and children over two years of age. It is only suitable for use in those ≥ two years of age as an adequate antibody response does not develop in those under two years of age.
NIAC recommends one dose of PPV23 pneumococcal vaccination for anyone aged 65 years or older irrespective of immune status. A once-only booster vaccination is recommended five years after the first vaccination for those who received a previous dose at less than 65 years of age.
NIAC recommends vaccination of those at increased risk of pneumococcal infection. This refers to everybody aged 65 years and over, and those aged two years and over with the conditions listed in Table 1.
Table 1: Conditions for which pneumococcal vaccination is recommended
NIAC recommends pneumococcal vaccination for those aged two years and over with the following conditions:
Source: NIAC
Some patients at high-risk of IPD are recommended both the PCV13 vaccine and the PPV23 vaccines. Patients aged two years and older who require both vaccines should receive PPV23 vaccination as part of their routine Primary Childhood Immunisation Schedule.
One booster vaccination is recommended five years after the first vaccination for those whose antibody levels are likely to decline rapidly, for example, those who have asplenia, hyposplenism, immunosuppression including HIV infection, chronic renal disease, nephrotic syndrome or renal transplant. Patients with these conditions who received PPV23 at less than 65 years of age require one further PPV23 booster at or after 65 years of age (five years after the previous dose). If PPV23 was given during chemotherapy or radiotherapy a further dose vaccine is recommended three months after treatment.
NIAC Immunisation Guidelines’ Chapter 16: Pneumococcal Infection provides further guidance on these at-risk patients in Table 16.1: Conditions associated with an increased risk of invasive pneumococcal disease and in Table 16.2: Pneumococcal immunisation for those at increased risk of IPD. NIAC Immunisation Guidelines’ Chapter 3: Immunisation of Immunocompromised Persons, also provides further information.
Many patients presenting to pharmacy for flu and COVID-19 vaccination are also identified by NIAC as being at increased risk of IPD. The consultation which takes place prior to COVID-19 and flu vaccination provides an opportunity to review with these vulnerable patients their vaccination history in relation to pneumococcal disease and recommend vaccination where appropriate.
“Pneumococcal infection is responsible for 50 per cent of community acquired pneumonia and bacteraemia in Ireland. It can also cause a wide variety of other infections including sinusitis, osteomyelitis, bronchitis and otitis media.”
PPV23 vaccination is not recommended for healthy children and adults as they are at low-risk of pneumococcal disease. It is assumed that childhood vaccinations will be carried out as part of the Primary Childhood Immunisation Schedule through established HSE pathways. Pneumoccocal vaccinations are not reimbursed by the HSE PCRS at community pharmacy level.
Table 2: Eligibility for free vaccination
The following cohorts are eligible for free PPV23 vaccination from their GP:
People with one or more of these health conditions can get a free Pneumococcal PPV23 vaccine (aged two years and over):
Children aged between two and five who have a history of pneumococcal disease should get the pneumococcal vaccine.
Community pharmacy may provide a private Pneumococcal Vaccination Service. The Medicinal Products (Prescription and Control of Supply) (Amendment) Regulations of 2015 (S.I. No 449 of 2015) enables community pharmacist to supply and administer PPV23 only. The Irish Institute of Pharmacy (IIOP) has an associated training course, ‘Administration of Pneumococcal Vaccine’, available. This training is valid for two years.
Administration of PPV23 can be recorded on HSE PharmaVax since 2022. However, it is important to check the patient’s medical record with their GP and, where necessary, the local health office in addition to HSE PharmaVax, to have clarity of the previous history of pneumococcal vaccine administrations. Revaccination with PPV23 can produce severe local reactions, especially if given within five years of the previous injection.
The HSE have a wide range of support materials available for healthcare professionals including patient algorithms, patient information leaflets in a variety of languages and a frequently asked questions booklet for those administering PPV23 (available at immunisation.ie > Healthcare Worker Information > Pneumococcal Disease).
Further clinical guidance can be found in the NIAC Immunisation Guidelines’ Chapter 3: Immunisation of Immunocompromised Persons and Chapter 16 Pneumococcal Infection. The PSI also provide Guidance on the Provision of Vaccination Services by Pharmacists in Retail Pharmacy Businesses (available at psi.ie > Practice Supports > Guidance and Guidelines For Pharmacists and Pharmacies). The IPU Pneumococcal Vaccination Hub provides support materials such as an SOP template on Pneumococcal Vaccination Service, and a patient consent form (ipu.ie > Professional > Vaccines and Injectables).
Susan O’Donnell MPSI
Professional Services Pharmacist, IPU
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