A. Pneumococcal Infection
1. What is pneumococcal infection?
Pneumococcal infection represents a wide range of diseases caused by the bacterium Streptococcus pneumoniae (or more commonly referred as pneumococcus). While pneumococcus is a common cause of mild illnesses such as sinus or middle ear infections, it may also cause severe or even life-threatening invasive pneumococcal diseases (IPD) such as bacteremic pneumonia, sepsis, and meningitis. The outcomes for IPD are usually more severe among young children and elderly persons.
2. What is Streptococcus pneumoniae / pneumococcus?
Streptococcus pneumoniae (pneumococcus) is the causative agent of pneumococcal infections. It is a Gram-positive bacterium encapsulated with polysaccharides. The difference in the composition of capsular polysaccharides constitutes to at least 100 different serotypes of pneumococci identified thus far.
3. How does individual acquire pneumococcal infections? What is the route of transmission for pneumococci?
Pneumococci are carried on human bodies. They are present in the upper respiratory tracts even in some healthy carriers. The bacteria can be transmitted via spread of droplet, direct oral contact or indirect contact with articles soiled with respiratory discharges.
4. What is the incidence rate of invasive pneumococcal diseases (IPD) in Hong Kong?
In Hong Kong, the annual incidence of IPD ranged from 0.34 to 2.54 per 100,000 from 2018 to 2022. IPD was more commonly found among children aged 2 to 4 years and elderly aged 65 years or above, while serotype 3 was the predominant serotype causing IPD accounting for about half of all cases recorded during 2015 to 2019.
5. How can pneumococcal infections be treated?
The treatment of pneumococcal infections usually involves the use of antibiotic(s). But there is a problem of increasing resistance of the bacterium to antibiotics, which makes prevention of pneumococcal infections important
6. Is a person previously contracted with pneumococcal disease immune from future invasive pneumococcal diseases?
As there are over 100 serotypes of pneumococcus, previous infection of a serotype of pneumococcus may not confer immunity to other serotypes of pneumococcus.
7. How can invasive pneumococcal diseases be prevented?
Pneumococcal vaccination is one of the most effective means of preventing pneumococcal diseases. The public should also maintain good personal and environmental hygiene practices, balanced diet, regular exercise, adequate rest, and no smoking.
8. What is the relationship between influenza and pneumococcal infection?
Influenza predisposes individuals to community-acquired bacterial pneumonia. Secondary bacterial pneumonia has been an important cause of morbidity and mortality for those infected with influenza.
B. Pneumococcal Vaccine
1. Are there different types of pneumococcal vaccines?
There are different types of pneumococcal vaccines available in the market, such as 13-valent pneumococcal conjugate vaccine (PCV13), 15-valent pneumococcal conjugate vaccine (PCV15), 20-valent pneumococcal conjugate vaccine (PCV20) and 23-valent pneumococcal polysaccharide vaccine (23vPPV). Pneumococcal conjugate vaccines (i.e. PCV13, PCV15 and PCV20) contain pneumococcal capsular polysaccharides conjugated to carrier proteins, while 23vPPV contains pneumococcal capsular polysaccharides for 23 pneumococci serotypes.
2. What are the differences between 13-valent pneumococcal conjugate vaccine (PCV13), 15-valent pneumococcal conjugate vaccine (PCV15), 20-valent pneumococcal conjugate vaccine (PCV20) and 23-valent pneumococcal polysaccharide vaccine (23vPPV)?
PCV13, PCV15 and PCV20 contain different number of capsular polysaccharide for various kinds of pneumococcal serotypes. PCV13 includes 13 capsular antigens (1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F and 23F), whereas PCV15 and PCV20 contain additional 2 (22F, 33F) and 7 (8, 10A, 11A, 12F, 15B, 22F and 33F) capsular antigens respectively.
PCV13 is effective against both invasive pneumococcal disease and non-invasive pneumococcal pneumonia. Available scientific data showed that both PCV15 and PCV20 should confer an overall non-inferior protection against invasive pneumococcal disease (IPD) caused by serotypes covered by PCV13. Compared to PCV13 and PCV20, PCV15 induced higher immunogenicity against serotype 3 which may potentially be more effective in preventing IPD caused by serotype 3, although further evidence on clinical effectiveness and impact is still pending.
23vPPV consists of pneumococcal capsular polysaccharides for 23 pneumococci serotypes. While clinical studies indicated that 23vPPV is generally effective in preventing IPD, its efficacy against non-invasive pneumococcal pneumonia is suboptimal. Nevertheless, it is worth noting that 23vPPV contains more serotypes and theoretically offers extra protection.
3. Who should get pneumococcal vaccines?
The Scientific Committee on Vaccine Preventable Diseases (SCVPD) recommends children to receive 13-valent pneumococcal conjugate vaccines (PCV13), with 2 primary doses given at 2 and 4 months followed by a booster dose at 12 months, under the Hong Kong Childhood Immunisation Programme (HKCIP).
For elders 65 years of age or older, the SCVPD recommends either a single dose of 13-valent pneumococcal conjugate vaccine (PCV13) or a single dose of 23-valent pneumococcal polysaccharide vaccine (23vPPV). For high-risk* individuals aged 2 years or above, the SCVPD recommends a single dose of PCV13, followed by a single dose of 23vPPV 1 year later. For those who have already received 23vPPV, a single dose of PCV13 should be administered 1 year after previous 23vPPV vaccination. For those who have already received PCV13, a single dose of 23vPPV should be administered 1 year after previous PCV13.
Taking into consideration of available scientific evidence and local situation, the SCVPD recommends PCV15 to replace PCV13 when it is available for use under the the Hong Kong Childhood Immunisation Programme and the Government pneumococcal vaccination programme. Related immunization schedules in children and high-risk individuals would remain unchanged.
For individuals not eligible for government vaccination programme, they may choose to receive any locally registered pneumococcal vaccine to protect themselves against invasive pneumococcal disease following the manufacturer’s recommendations and upon discussion with healthcare professionals.
*High-risk conditions include:
(a) History of invasive pneumococcal disease
(b) Immunocompromised states:
- Asplenia, HIV /AIDS , primary immunodeficiency
- Immunodeficiencies related to malignancies and transplantation
- Immunodeficiencies related to use of immunosuppressive drugs / systemic steroid
(c) Chronic disease
- Chronic cardiac, pulmonary, liver or renal disease
- Diabetes mellitus or Cerebrospinal fluid leakage
(d) With cochlear implants
(Essential hypertension per se is not considered as a high-risk condition)
Different factors such as age and clinical condition may affect the risk of pneumococcal disease. Patients with high-risk conditions should discuss with their attending doctors on the most appropriate vaccination regimen.
Remarks: Under the Government Vaccination Programme and Vaccination Subsidy Scheme, aside from the above list of high-risk conditions, elders 65 years or above with chronic metabolic diseases, obesity (BMI 30 or above), chronic neurological conditions or those with financial difficulties are eligible for free/subsidised pneumococcal vaccination. Please see annex for the list of high-risk conditions eligible for free / subsidized PCV 13 under Government Vaccination Programme and Vaccination Subsidy Scheme.
4. Why is it necessary for elders to receive both influenza vaccine and pneumococcal vaccines?
Secondary bacterial pneumonia is an important cause of morbidity and mortality for those infected with influenza. Data from a local study shows that dual vaccination with influenza vaccine and pneumococcal vaccines can lower the risk of hospitalisation and mortality among elderly people.
5. Can pneumococcal vaccines be received together with seasonal influenza vaccine?
Yes. Both 23-valent pneumococcal polysaccharide vaccine (23vPPV) and pneumococcal conjugate vaccines (PCV) can be given together with other vaccines, including influenza vaccine, but they should be administered with a different syringe and at a different injection site.
6. Can pneumococcal vaccine be given together with COVID-19 vaccine?
COVID-19 vaccines can be co-administered with, or at any time before or after, pneumococcal vaccines under informed consent.
7. Can pneumococcal vaccines be given prior to / after certain medical procedures?
For individuals who will undergo elective splenectomy, pneumococcal vaccines should be given at least 2 weeks before the procedures if possible. Pneumococcal vaccines should ideally be given before or after completion of chemotherapy/radiotherapy but they may still be given as clinically indicated during long term use of chemotherapeutic agents.
8. What are the possible adverse reactions following 23-valent pneumococcal polysaccharide vaccine administration (23vPPV)?
Common adverse reactions include slight swelling and tenderness at the injection site shortly following injection but most resolve within two days. Fever, muscle aches or more severe local reactions are uncommon.
Receiving vaccination is safe. If you experience persistent fever, severe allergic reactions (e.g. difficulty in breathing, swelling of the lips or tongue, or hives, etc.) or other adverse events after vaccination, please consult a doctor immediately.
9. What are the possible adverse reactions following pneumococcal conjugate vaccine (PCV) administration?
Common adverse reactions after PCV13 administration include slight swelling and tenderness at the injection site shortly following injection but most resolve within two days. Some may experience mild fever, fatigue, headache, chills, or muscle pain. Severe pain or difficulty in moving the arm where the shot was given was very rare.
For PCV15, the most common adverse reactions observed in children less than 2 years old are fever, irritability, somnolence and injection-site pain while injection-site pain, fatigue, myalgia and headache are the commonest in adults.
Receiving vaccination is safe. If you experience persistent fever, severe allergic reactions (e.g. difficulty in breathing, swelling of the lips or tongue, or hives, etc.) or other adverse events after vaccination, please consult a doctor immediately.
10. Who are not suitable to receive pneumococcal vaccines?
Severe allergic reaction following a prior dose of pneumococcal vaccine or to the vaccine component or any diphtheria toxoid-containing vaccine is a contraindication to further doses of vaccine.
11. Can individual receive pneumococcal vaccines if they are not feeling well on the day of vaccination?
Minor illnesses such as upper respiratory tract infections are not contraindications to vaccination. Vaccination may also be deferred until symptoms subside in case of any worry.
12. Can 13-valent pneumococcal conjugate vaccine (PCV13) administered other than intramuscularly?
PCV13 should be administered intramuscularly. This vaccine should not be given to individuals with thrombocytopenia or any coagulation disorders that would contraindicate intramuscular injection unless the potential benefit clearly outweighs the risk of administration.
Do not administer PCV 13 intravascularly or into the gluteal area. Do not administer PCV13 intravenously, subcutaneously or intradermally, since the safety and immunogenicity of these routes have not been evaluated.
Please refer to the drug insert for detailed information.
C. Schedule for Pneumococcal Vaccination to Elders
1. What is the interval between 23-valent pneumococcal polysaccharide vaccine (23vPPV) and 13-valent pneumococcal conjugate vaccine (PCV13) or 15-valent pneumococcal conjugate vaccine (PCV15)?
According to the recommendation of SCVPD, the recommended interval between 23vPPV and PCV13 or PCV15 should be 1 year.
2. Should high-risk elderly receive 2 doses of 23-valent pneumococcal polysaccharide vaccine (23vPPV) instead of 1 dose of 13-valent pneumococcal conjugate vaccine (PCV13) or 15-valent pneumococcal conjugate vaccine (PCV 15) and 1 dose of 23vPPV?
No. High-risk individuals aged 65 years and above should receive one dose of PCV13 or PCV15 and one dose of 23vPPV.
3. Should high-risk elderly receive 2 doses of 13-valent pneumococcal conjugate vaccine (PCV13) or 15-valent pneumococcal conjugate vaccine (PCV15) instead of 1 dose of PCV13 or PCV15 and 1 dose of 23-valent pneumococcal polysaccharide vaccine (23vPPV)?
No. High-risk individuals aged 65 years and above should receive one dose of PCV13 or PCV15 and one dose of 23vPPV.
4. Should high-risk elderly receive 13-valent pneumococcal conjugate vaccine (PCV13) or 15-valent pneumococcal conjugate vaccine (PCV15) if they have already received 2 doses of 23-valent pneumococcal polysaccharide vaccine (23vPPV)?
Yes, they should receive a single dose of PCV13 or PCV15 one year after the last dose of 23vPPV vaccination.
5. How can elders confirm their previous pneumococcal vaccination history?
Elders should try to find out all their previous vaccination records/cards and bring them to their attending doctor. Vaccination records are important reference to doctors before they can provide appropriate vaccination. Else, elders should return to the clinics where they received previous vaccinations to trace their records. If they still cannot trace the records, they should tell their doctors their vaccination history as far as they can recall so that their doctor can make assessment and provide them with the necessary vaccination.
6. If elders with high-risk conditions are not sure if they have previously received pneumococcal vaccine (type and time), should they still go for vaccination?
Yes. If elderly with high-risk conditions do not have a documented vaccination history (vaccination card and electronic record) for pneumococcal vaccine, they should trace record from clinics receiving previous dose of pneumococcal vaccine. If the elderly still cannot trace the record and cannot recall the type and time of vaccination, they should still receive the recommended doses, i.e. a single dose of PCV13 or PCV15 followed by a dose of 23vPPV one year later.
7. Can elders with high-risk conditions choose to have 23-valent pneumococcal polysaccharide vaccine (23vPPV) vaccination first?
SCVPD recommends individuals with high-risk conditions who have not received any pneumococcal vaccines to receive one dose of PCV13 or PCV15 followed by 23vPPV one year later. For advice on individual cases, elderly should consult their family doctor.
8. If elders have received 23-valent pneumococcal polysaccharide vaccine (23vPPV) before, do they need revaccination of pneumococcal vaccine?
For elderly who have previously received 23vPPV before, if they do not have risk factors for IPD, no further pneumococcal vaccination is needed. If they have risk factors for IPD, they should receive one dose of PCV13 or PCV15 one year after the previous 23vPPV.
9. If elderly have received 13-valent pneumococcal conjugate vaccine (PCV13) or 15-valent pneumococcal conjugate vaccine (PCV15) before, do they need revaccination of pneumococcal vaccine?
For elderly aged 65 years or above, who have previously received one dose of PCV13 or PCV15 before, if they do not have risk factors for IPD, no further pneumococcal vaccination is needed. If they have risk factors for IPD, they should receive one dose of 23vPPV one year after the previous PCV13 or PCV15 administration.
10. Under the "Vaccination Subsidy Scheme", what is the subsidy amount for pneumococcal vaccination? What is the vaccination schedule for eligible elderly?
Eligible elderly aged 65 or above can receive Government subsidy for pneumococcal vaccination (available throughout the year). The subsidy level of 23-valent pneumococcal polysaccharide vaccine (23vPPV) is HK$400 per dose, and the subsidy level of 13-valent pneumococcal conjugate vaccine (PCV13) and 15-valent pneumococcal conjugate vaccine (PCV15) is HK$800 per dose.
| Elderly aged 65 years or above | Have not received any pneumococcal vaccination |
Have received 23vPPV |
Have received PCV13/PCV15 |
Have Have received both PCV13/PCV15 and 23vPPV |
| Without high-risk conditions* | Subsidise one dose of 23vPPV | No vaccination needed | No vaccination needed | No vaccination needed |
| With high-risk conditions* | Subsidise one dose of PCV13/PCV15 followed by one dose of 23vPPV one year after | Subsidise one mop-up dose of PCV13/PCV15 one year after the previous 23vPPV | Subsidise one dose of 23vPPV one year after the previous PCV13/PCV15 | No vaccination needed |
Annex: List of high-risk conditions eligible for receiving free / subsidized 13-valent pneumococcal conjugate vaccine (PCV13) under Government Vaccination Programme and Vaccination Subsidy Scheme 2023/24
Source: Centre for Health Protection
last update：15 Mar 2024
https://www.chp.gov.hk/en/features/100770.html
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