Pneumococcal Disease (Children)

Pneumococcal disease refers to illness caused by the bacteria Streptococcus pneumoniae. This is a common cause of bacterial infections in children such as pneumonia (lung infection), otitis media (middle ear infection), meningitis (infection of the lining of the brain), and bacteraemia (bloodstream infection). 

Symptoms will vary depending on the site of infection. For example, pneumonia causes fever, fast breathing and cough; otitis media causes fever, vomiting and ear pain (in older children who can communicate this); meningitis causes fever, vomiting, headache, abnormal behaviour or fits (uncontrollable movements).  

Pneumococcal disease can develop spontaneously or after a recent viral infection. It can range from mild to invasive or severe infections, the latter of which can be life-threatening. A thorough history and examination by a physician is important to determine diagnosis and institute appropriate treatment in a timely fashion.

Streptococcus pneumoniae is a bacteria (gram-positive coccus), which is typically spread via droplets (coughing or sneezing) especially in close contact.  

There are many different subtypes of Streptococcus pneumoniae, which can vary in their ability to cause infection and severity of illness. In most healthy people, the bacteria exist in the nasopharynx (mouth and throat) without causing harm (known as carriage).  

Pneumococcal bacteria can infect persons of any age group. However, pneumococcal disease is most prevalent among the young (especially younger than 2 years old) and elderly, those with weakened immune systems (e.g., those with HIV, cancer or who are on immunosuppressants), those with chronic heart and lung conditions (including diabetes) and those with an absent or removed spleen. 

Pneumococcal disease affects children in much the same way as it does adults, by causing infections in the lungs (pneumonia), ears (otitis media), blood (bacteraemia) and membranes covering the brain (meningitis). 
  
Children who attend preschool are more exposed to this bacteria and more likely to develop carriage. As such, it also follows that pneumococcal infections occur at higher rates in children who attend daycare than those who do not.  
 
Whilst most pneumococcal infections are mild and can be treated in the outpatient setting with oral antibiotics, some can be severe and cause complications, even possibly death. For example, 20% of those who contract pneumococcal meningitis do not survive; 50% experience long-term health complications such as deafness or neurological disability.  

Bloodstream infections can also lead to blood pressure instability and involvement of internal organs, which can be life-threatening. Such cases may require more intensive and prolonged treatment.

​Diagnosis

Diagnosis by bacterial culture remains the gold standard; samples (blood, phlegm or swab testing) from the relevant site can be collected and sent to the lab for culture. This usually takes at least 48 to 72 hours for initial results to return. 

There are also rapid methods of identifying pneumococcal bacteria via antigen detection, but such methods are not always readily available and may not be useful in all settings.  Samples of sputum (phlegm from deep coughing or suctioning), nasal aspirate, or urine, may be analysed by certain test kits, but these tests are of varying accuracy. Many of these tests are unable to differentiate between carriage (the normal presence of the pneumococcal bacteria which is common in children) and an actual infection causing illness. Hence, detection of these bacteria on such rapid antigen test kits do not always mean there is a true infection. These tests should be ordered in the right clinical context and interpreted properly by the physician for any results to be useful.  

 

Treatment

Treatment of pneumococcal disease is through use of appropriate antibiotics. In mild diseases, oral antibiotics will usually suffice but in severe or complicated disease, the patient may require intravenous antibiotics. Choice and duration of antibiotics will also differ based on the site and severity of the infection and should be decided by a physician experienced in the treatment of such conditions. 

Personal hygiene and proper handwashing help prevent the transmission of pneumococcal bacteria, while vaccination remains the most effective way to prevent the development of pneumococcal disease. 

There are currently a few pneumococcal vaccinations on the market, namely the conjugate vaccine (the most commonly used in the national childhood immunisation schedule is PCV13, but also PCV 15 and PCV 20) and the polysaccharide vaccine (PPSV23). These vaccines are classified based on the mechanism through which they induce immune protection. The numbers indicate the number of subtypes each vaccine covers, although more is not always better. Individuals should seek the advice of their healthcare provider about which type of vaccine would be most appropriate for them. 

When administered in infancy, pneumococcal conjugate vaccines can reduce carriage of and confer immune protection against Streptococcus pneumoniae. Vaccination is hence extremely important to protect children younger than 2 years of age who are at highest risk of pneumoccocal disease. 

The dosing schedule can differ based on the age at which the child initiates the vaccination course. In the national childhood immunisation schedule, it is recommended to receive 3 doses at 4, 6 and 12 months of age. If administered in a child older than 2 years old, only one dose is needed. However, it is important to note that the later the child begins the vaccination course, the later the protection takes effect. Since the highest risk of pneumococcal disease is in those younger than 2 years of age, it is extremely important that children receive these vaccinations as soon as they are eligible. 

An added benefit of vaccinating children is also to increase herd immunity and reduce circulation of these bacteria in the community. This would in turn lower the exposure of and disease in other vulnerable individuals such as young infants and newborns who are not yet eligible for the vaccine, the elderly or immunosuppressed. 

Outside of the national childhood immunisation schedule, vulnerable individuals who are at increased risk of pneumococcal disease may be advised to receive the pneumococcal polysaccharide vaccine (PPSV23) in addition to the conjugate vaccines. This may include patients with chronic lung disease, absent or removed spleen, or with underlying immune problems. 

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