The American Academy of Family Physicians (AAFP), the American Medical Association (AMA) and nine other medical societies have issued a joint health alert calling for more extensive use of immunization to combat increasingly resistant strains of bacteria that cause pneumonia. Pneumococcal disease is caused by the Streptococcus pneumoniae bacterium. Recent evidence shows that the rate of immunizations against pneumonia is as low as 45 percent in persons over age 65, according to the alert.

This Quality Care Alert provides a synthesis of the most recent evidence and recommendations for use of the pneumococcal polysaccharide vaccine. According to the alert, the importance of pneumococcal immunization cannot be overstated.

Recommendations

The alert recommends that all persons at increased risk of invasive pneumococcal disease should be immunized, including the following groups:

• Immunocompetent persons 65 years of age and older.

• Immunocompetent persons two to 64 years of age with chronic illnesses, including persons with cardiovascular or pulmonary disease such as congestive heart failure, cardiomyopathies, chronic obstructive pulmonary disease, recurrent bronchitis, and emphysema; and persons with diabetes mellitus, alcoholism, chronic liver disease (including cirrhosis), cerebrospinal fluid leaks, and functional or anatomic asplenia (including sickle cell disease and splenectomy).

• Immunocompetent persons two to 64 years of age in special environments, including persons in nursing homes or other long-term care facilities, and certain Native American populations and the Alaskan American population.

• Immunocompromised persons two years of age and older, including persons with functional or anatomic asplenia (including sickle cell disease and splenectomy), Hodgkin's disease, lymphoma, leukemia, multiple myeloma, chronic renal failure, other conditions, such as organ transplantation, or drug regimens causing immunosuppression, and HIV infection.

• Persons in identified risk groups whose vaccination status is unknown or uncertain.

Revaccination

Revaccination is recommended once for the following high-risk groups:

• Immunocompetent persons 65 years of age and older, if the person received his or her first vaccination before the age of 65 and if more than five years has elapsed since the first dose.

• Immunocompromised persons and persons with asplenia, if the person is over 10 years of age and more than five years has elapsed since the first vaccination; if the patient is 10 years of age and under, consider revaccinating once after three years has elapsed since the first vaccination.

Other Considerations

• To avoid missed opportunities, all persons at increased risk of infection should have their immunization status assessed, when feasible, during any health care encounter.

• Pregnant women at high risk of invasive pneumococcal disease may be vaccinated, preferably during the second or third trimesters.

• The effectiveness of the current polysaccharide vaccine has not been demonstrated against noninvasive (nonbacteremic) pneumococcal disease in elderly persons and other adults at increased risk.

• The currently available vaccine is not recommended for children under two years of age.

• The vaccine is covered by Medicare.

In addition to the AAFP and the AMA, the other nine medical societies joining in issuing this alert are the American Academy of Pediatrics, the American Association of Clinical Endocrinologists, the American College of Chest Physicians, the American College of Obstetricians and Gynecologists, the American College of Physicians/American Society of Internal Medicine, the Infectious Diseases Society of America, the American Geriatrics Society, the American College of Preventive Medicine, and the American College of Emergency Physicians.

For additional information, contact the National Immunization Program at 404-639-8254 or the National Center for Infectious Diseases at 404-639-2215.