Pneumococcal disease is the term used to describe infections caused by the bacterium Streptococcus pneumoniae (also called pneumococcus).

Invasive pneumococcal
disease is a major cause of morbidity and mortality. It particularly affects the very young, the elderly, those with an absent or nonfunctioning spleen and those with other causes of impaired immunity.

History and epidemiology of the disease

Currently, the pneumococcus is one of the most frequently reported causes of bacteraemia and meningitis. During 2005, 6207 laboratory isolates from blood, CSF or other normally sterile sites were reported to the Health Protection Agency Centre for Infection (HPA CfI) from laboratories in England and Wales. (Health Protection Agency, 2006.The pneumococcus is also the commonest cause of community-acquired pneumonia (Bartlett and Mundy, 1995). Pneumococcal pneumonia is estimated to affect one in a thousand adults each year and has a case fatality ratio of 1020% (World Health Organization, 1999).

Pneumoco
Antimicrobial resistance among pneumococci occurs and susceptibility to macrolide antimicrobials, penicillin and cephalosporin can no longer be assumed. In 2000, 15% of invasive isolates in England and Wales reported to the HPA CDSC were resistant to erythromycin and 7% showed full or intermediate resistance to penicillin (George and Melegaro, 2000). An increase

in pneumococcal antibiotic resistance has been reported worldwide (Appelobaum, 1992; Butler et al., 1996; Davies et al., 1999).

The Pneumococcal vaccine: pneumococcal

vaccinationThe pneumococcal vaccination
There are two types of pneumococcal vaccine: pneumococcal polysaccharide vaccine (PPV) contains purified capsular polysaccharide from each of 23 capsular types* of pneumococcus. pneumococcal conjugate vaccine (PCV) contains polysaccharide from seven common capsular types

Pneumococcal polysaccharide vaccine (PPV)

Most healthy adults develop a good antibody response to a single dose of PPV by the third week following immunisation. Antibody response may be reduced in those with immunological impairment and those with an absent or dysfunctional spleen. Children younger than two years of age show poor antibody responses to immunisation with PPV.

It is difficult to reach firm conclusions about the effectiveness of PPV, but overall efficacy in preventing pneumococcal bacteraemia is probably 5070%

Pneumococcal Vaccination Uptake Monitoring on behalf of the Department of Health 2007/08 Collection
The Pneumococcal polysaccharide vaccine uptake survey for 2007/08 started on 1 April 2008:

GPs: From 1 April 2008 to 1 May 2008 PCTs: From 1 April 2008 to 16 May 2008

All 152 PCTs responded to the 2007/08 survey however the GP response rate fell slightly to 84% (7020 out of 8361 practices) compared to last year. The use of automated extraction and upload facilities increased with 69.8% of GP practices (4903 out of 7020) having their data automatically extracted and uploaded. The vaccine uptake results were as follows: 65 66-74 75-79 80+ Total years year year year 65 old olds olds olds year only old and over Vaccinated between 1 April 2007 and 31 March 2008 Vaccinated anytime up until 31 March 2008 18.2% 5.2% 2.7% 2.1% 4.6%

37.9% 70.1% 77.3% 75.8% 69%

The 2007/08 Annual PPV Report can be accessed via the NHS Immunisation website or

here; Begum F, Pebody R. Annual Pnuemococcal Polysaccharide Vaccine Uptake Report in 65 years old and over for England (PDF, 514 KB) published by the Health Protection Agency. Annual Pneumococcal Polysaccharide Vaccine Uptake Report for England 65 years old and over Final v1.0 7th July 2008 10

Conclusions and Recommendations

Actual uptake of pneumococcal polysaccharide vaccine is encouraging. The overall success of the pneumococcal campaign in the elderly is reflected in the mostly high levels of coverage achieved. In terms of vaccine uptake success by age group, the 75 to 79 year old cohort had the most extensive coverage at 77.3% ever vaccinated, whilst the greatest recent uptake rate (excluding the new 65 years cohort) was for the 66 to 74 year olds at 5.2%, vaccinated between 1st April 2007 and 31st March 2008. Since the final phase of the three-step implementation of the policy to vaccinate all those aged 65 years and older took place in 2005/06, it is hoped GP practices concentrate more on targeting those not yet vaccinated but in particular, on the incoming cohort of newly turned 65 year olds. It is evident that the 2007/08 65 year olds cohort was not especially targeted for vaccination recording a relatively lower uptake level of 18.2% compared to last year of 20.3%. The Health Protection Informatics Website continues to be a successful tool for monitoring PPV uptake in primary care, as demonstrated by the high GP practice response rates now being achieved in recent years. With almost 70% of responding practices using automated or semi-automated data extraction processes in season 2007/08, it is a clear indication that these data providers have benefited by having a system that enables data input in the most efficient and timely manner. By publicising the availability of automated options, it is hoped that the numbers of GP practices participating in future surveys will continue to rise. It is in the interest of all those participating in the survey for the options available for automated extraction and submission to be extended. It is recommended that where possible non-automated GP practices and their PCTs inform software suppliers of their desire for more automated and semi-automated extraction methods to be introduced in support of Cabinet Office guidelines, which recommend that data transfers between the Government and the NHS should be web based. The survey demonstrated geographical variation in PPV uptake levels across SHAs and PCTs, with certain areas achieving higher uptake than others. Success in uptake levels may be attributed to the implementation of good local practice such as regular audits and/or removing patients who have moved away, died or who are not responding to GP letters, from GP practice lists. It is difficult however to identify specific reasons accounting for individual performances but it is hoped PCT pneumococcal coordinators and SHA Immunisation Leads will find the data in this report helpful in identifying where further improvements can be

made. In addition, with the experience of the Influenza vaccine uptake survey to consider, it is evident that employing a range of techniques as well as conducting publicity and awareness before hand, immunisation campaigns prove successful.

2006/07 Collection
For the 2007 pneumococcal polysaccharide vaccine uptake survey, data was gathered via the Health Protection Informatics website for the period between 1 April 2006 to 31 March 2007 and anytime on or up until 31 March 2007. Data was also collected on vaccine uptake in the newly turned 65 years olds forming thier own cohort. The age breakdowns were as follows:

65 years old 66 to 74 75 to 79 80 years old and over 65 years old and over

For the first time, data by gender was an optional addition for GPs to complete:

Males aged 65 years and over Females aged 65 years and over

In total, all 152 PCTs in England responded to the survey which saw an increase in the response rate compared to last year to 85.5% (7216 out of 8439 GP practices). The vaccine uptake results were as follows: 65 years 66-74 old only year olds Vaccinated between 1 April 2006 and 31 March 2007 Vaccinated anytime up until 31 March 2007 20.3% 39.7% 9.0% 75-79 year olds 4.5% 80+ Total 65 year year old olds and over 3.1% 6.5%

66.5% 76.0% 74.5% 66.7%

Zhang N, Pebody R. Pnuemococcal Polysaccharide Vaccine Uptake Report for the 2006/07 collection (England) (PDF, 292 KB)
Results: The national GP response rate to the survey increased in 2006/07 to 85.5% compared to the previous year. 66.6% of patients aged 65 years and over were vaccinated anytime on or up until 31st March 2007. 6.5% of these patients were

vaccinated between 1st April 2006 and 31st March 2007. PPV uptake in the twelve months prior to 31st March 2007 was highest for those turning 65 years during the year at 20.3%. PPV uptake for vaccinations carried out anytime on or up until 31st March 2007 was highest in those aged 75 to 79 years at 76.0%. Overall coverage in the elderly male population (71.8%) was found to be higher than in their female counterparts (69.8%). Conclusions: High GP response rates were achieved in 2006/07 by using the HPI website to collect data on PPV uptake in primary care. Data indicate that the overall coverage of the elderly in England is encouraging, especially for the 75 to 79 year olds. However vaccine coverage for the incoming cohort of newly turned 65 year olds was comparitively low indicating that GP practices were either not actively or effectively targeting those reaching 65 years for vaccination in 2006/07 or that this age group was declining pneumococcal vaccination. Vaccine coverage in the older age groups continues to increase each year suggesting that vaccination is being given opportunistically to anyone over 65 years rather than the 65 age group specifically being targetted. If this is the case we would expect vaccine uptake in these younger cohorts to increase over time.

2005/06 Collection
The 2006 pneumococcal polysaccharide vaccine uptake survey collected data on vaccine uptake in all persons aged 65 years and over in England between April 2005 and March 2006, and on vaccine uptake in this age-group at anytime until March 2006. Data was collected using a web-based reporting system, (called the Vaccine Tracking Programme website ). All GP practices in England provided data electronically from May - July 2006. PCTs provided data on behalf of their GP practices from May to August 2006. In total, 7157 of 8503 GP practices (84%) in England responded. All 303 (100%) PCTs provided data.The vaccine uptake results were as follows: Total 65 65-74 75-79 80+ year old and over year olds year olds year olds Vaccinated between 1April 2005 and 31March 2006 Vaccinated anytime up until 31 March 2006 26.2% 64.4% 38.1% 62.4% 20.6% 68.9% 9.5% 68.1%

Older Adults - All adults aged 65 or over are recommended to have the Pneumococcal Polysaccharide Vaccine (PPV) In 2003 the Chief Medical Officer (CMO) outlined a new pneumococcal immunisation programme for older adults to be phased in over 3 years (CMO's letter). In August 2003, the first phase was implemented and the PPV was recommended to those aged 80 and over. In April 2004, phase 2 began. Anyone age 75 or over were offered the PPV. This included those aged 80 or more who did not receive their vaccine in the first phase. In April 2005 the policy was fully implemented and all those aged 65 and over were recommended to have the Pneumococcal polysaccharide vaccine.