Home | About us | Editorial Board | Search | Ahead of print | Current Issue | Archives | Instructions | Online submissionContact Us   |  Subscribe   |  Advertise   |  Login  Page layout
Wide layoutNarrow layoutFull screen layout
Lung India Official publication of Indian Chest Society  
  Users Online: 279   Home Print this page  Email this page Small font size Default font size Increase font size

  Table of Contents    
GUIDELINES
Year : 2020  |  Volume : 37  |  Issue : 7  |  Page : 19-29  

Clinical practice guidelines 2019: Indian consensus-based recommendations on pneumococcal vaccination for adults


1 Department of Pulmonology, Fortis Hospital, Kolkata, West Bengal, India
2 Department of Pulmonary Medicine, National Allergy Asthma Bronchitis Institute, Kolkata, West Bengal, India
3 Department of Pulmonary Medicine and Sleep Disorders, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
4 Department of Pulmonology and Critical Care Medicine, Fortis Hospital, Kolkata, West Bengal, India
5 Department of Respiratory, Critical Care and Sleep Medicine, Getwell Hospital and Research Institute, Nagpur, Maharashtra, India
6 Department of TB and Chest Diseases, Centre for Research and Treatment of Allergy, Asthma and Bronchitis, Varanasi, Uttar Pradesh, India
7 Department of Pulmonology, Kulwanti Hospitals and Research Center, Kanpur, Uttar Pradesh, India
8 Department of Respiratory Medicine and Tuberculosis, School of Medical Sciences and Research, Greater Noida, Uttar Pradesh, India
9 Department of Pulmonary Medicine, Christian Medical College, Vellore, Tamil Nadu, India
10 Department of Pulmonary Medicine, Asthma Bhawan, Shastri Nagar, Jaipur, Rajasthan, India
11 Department of Nephrology, Madras Medical Mission, Chennai, Tamil Nadu, India
12 Department of Pulmonology, Zenith Superspeciality Hospital, Kolkata, West Bengal, India
13 Department of Pulmonology, National Allergy Asthma Bronchitis Institute, Kolkata, West Bengal, India
14 Department of Medicine, SCB Medical College, Cuttack, Odisha, India
15 Division of Infectious Diseases, Gleneagles Global Health City, Chennai, Tamil Nadu, India
16 Department of Chest Medicine, Bombay Hospital, Mumbai, Maharashtra, India
17 Department of Chest Medicine, Apollo Hospital, Bengaluru, Karnataka, India
18 Department of Pulmonary Medicine, Lung Clinica, Andheri West Mumbai, Maharashtra, India
19 Department of Pulmonary Medicine, MKCG Medical College, Berhampur, Odisha, India
20 Department of Chest Medicine, Apollo Hospital, Kolkata, West Bengal, India
21 Department of Pulmonary Medicine, College Of Medicine & JNM Hospital, Kalyani, Nadia, Uttar Pradesh, India
22 Chest Care Center, Kanpur, Uttar Pradesh, India
23 Department of Respiratory Medicine, Mahatma Gandhi Medical College and Hospital, Jaipur, Rajasthan, India
24 Dr Rakesh Chawla's Chest, Asthma Allergy and Sleep Clinic, Delhi, India
25 Department of Internal and Pulmonary Medicine, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India

Date of Submission21-Apr-2020
Date of Acceptance29-Apr-2020
Date of Web Publication22-Aug-2020

Correspondence Address:
Raja Dhar
Department of Pulmonology, Fortis Hospital, Kolkata, West Bengal
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/lungindia.lungindia_272_20

Rights and Permissions
   Abstract 


Similar to the global scenario, pneumococcal diseases are a significant health concern in India. Pneumococcal diseases occur frequently among adults and are largely preventable through vaccines. Globally, several guidelines and recommendations are available for pneumococcal vaccination in adults. However, owing to wide variations in the disease burden, regulatory landscape, and health-care system in India, such global guidelines cannot be unconditionally implemented throughout the country. To address these gaps, the Indian Chest Society and National College of Chest Physicians of India jointly conducted an expert meeting in January 2019. The aim of the discussion was to lay down specific evidence-based recommendations on adult pneumococcal vaccination for the country, with a view to further ameliorate the disease burden in the country. This article presents an overview of the closed-door discussion by the expert members on clinical practice guidelines to be followed for adult pneumococcal vaccination in India.

Keywords: Adult vaccination, consensus-based recommendations, elderly, guidelines, India, PCV13, pneumonia, PPSV23


How to cite this article:
Dhar R, Ghoshal AG, Guleria R, Sharma S, Kulkarni T, Swarnakar R, Samaria J K, Chaudhary S, Gaur S N, Christopher D J, Singh V, Abraham G, Sarkar A, Mukhopadhyay A, Panda J, Swaminathan S, Nene A, Krishnan S, Shahi PK, Sarangdhar N, Mishra N, Chowdury SR, Halder I, Katiyar S K, Jain V K, Chawla R, Koul PA. Clinical practice guidelines 2019: Indian consensus-based recommendations on pneumococcal vaccination for adults. Lung India 2020;37, Suppl S1:19-29

How to cite this URL:
Dhar R, Ghoshal AG, Guleria R, Sharma S, Kulkarni T, Swarnakar R, Samaria J K, Chaudhary S, Gaur S N, Christopher D J, Singh V, Abraham G, Sarkar A, Mukhopadhyay A, Panda J, Swaminathan S, Nene A, Krishnan S, Shahi PK, Sarangdhar N, Mishra N, Chowdury SR, Halder I, Katiyar S K, Jain V K, Chawla R, Koul PA. Clinical practice guidelines 2019: Indian consensus-based recommendations on pneumococcal vaccination for adults. Lung India [serial online] 2020 [cited 2021 Apr 13];37, Suppl S1:19-29. Available from: https://www.lungindia.com/text.asp?2020/37/7/19/292989




   Executive Summary Top


Pneumococcal diseases are a preventable set of diseases caused mainly by Streptococcus pneumoniae (Pneumococcus). The disease can be broadly classified into invasive and noninvasive forms. The incidence rates of pneumococcal disease in India in 2018 were found to be 31.3%, 22.7%, and 13.9% among adults aged ≥60 years, 44–60 years, and 18–44 years, respectively. Apart from the increased burden of disease in the country, antibiotic resistance to strains of S. pneumoniae is also increasing at an alarming rate, which is an obstacle in the effective treatment of the disease. Hence, pneumococcal vaccination has potential as a preventive strategy in the country.


   Pneumococcal Vaccination Top


1. Is the use of pneumococcal vaccines for preventing pneumococcal disease in India justifiable?

  • The use of pneumococcal vaccine is worthwhile in India, as it not only reduces the burden of pneumococcal disease but also leads to a positive impact on health-care economics by reducing overall health-care expenditure (3A).


2. What is the dose and route of administration for pneumococcal vaccines?

  • Two inactivated pneumococcal vaccines are available and approved for use in the country for preventing pneumococcal disease, viz., conjugated 13-valent pneumococcal conjugate vaccine (PCV13) and 23-valent pneumococcal polysaccharide vaccine (PPSV23)
  • Pneumococcal vaccines are administered as mentioned in [Table 1].
Table 1: Dose and route of administration for pneumococcal vaccines

Click here to view


3. What are the contraindications and precautions for pneumococcal vaccines?

  • PCV13 and PPSV23 are contraindicated if the individual has hypersensitivity to any component of the vaccine
  • Both PPSV23 and PCV13 should not be given during acute respiratory illness
  • Caution should be exercised in individuals with altered immunocompetence (congenital or acquired splenic dysfunction, HIV [human immunodeficiency virus] infection, malignancy, hematopoietic stem cell transplant, and nephrotic syndrome), including those at higher risk for invasive pneumococcal disease, as such individuals may have reduced antibody responses to immunization with the pneumococcal vaccine
  • Appropriate agents should be made available immediately if allergic reactions occur due to the vaccine
  • In the case of pregnancy, although not contraindicated, there is no recommendation regarding the use of PCV13. Even the use of PPSV23 during pregnancy is not specifically recommended, due to the lack of adequate safety data[1]
  • The use of pneumococcal vaccine in solid-organ transplant recipients is not contraindicated. However, adequate data are lacking for a proper recommendation[2]
  • Pneumonia vaccine is not contraindicated in rheumatoid arthritis patients[3]


4. What is the coadministration schedule of pneumococcal vaccines with respect to other recommended vaccines?

  • In adults, PCV13 can be concomitantly administered with:


    • Trivalent/quadrivalent inactivated influenza vaccine
    • Tetanus–diphtheria vaccine
    • Diphtheria–tetanus–acellular pertussis hepatitis B-inactivated polio-Haemophilus influenzaeType B.


  • PCV13 and PPSV23 can be administered concomitantly with all other recommended vaccines:
  • At the same clinical visit, using separate syringes and at different anatomical sites
  • At any later time with no waiting period following the vaccination (except for the quadrivalent meningococcal conjugate vaccine [MCV4]-D).


5. Which among PCV13 and PPSV23 should be administered first and what is the immunization schedule of pneumococcal vaccines for the adult population at risk for pneumococcal disease in India?

Adults Aged 19–64 Years

  • Pneumococcal vaccination is usually not recommended for healthy adults under the age of 65 years (UPP)
  • In immunocompetent patients with chronic conditions such as chronic heart disease, chronic liver disease, poorly controlled diabetes mellitus, chronic lung disease, and in current smokers and those with alcohol abuse, a single dose of PCV13 followed by PPSV23 ≥8 weeks later is recommended (UPP) [Box 1]
  • In adults with a history of invasive pneumococcal disease, those with cochlear implants, cerebrospinal fluid (CSF) leak, or impaired splenic function (anatomic asplenia or hyposplenism, sickle cell disease or other hemoglobinopathy or functional asplenia or hyposplenism), a single dose of PCV13 followed by PPSV23 ≥8 weeks later is recommended (2A) [Box 1]
  • In all immunocompromised individuals, such as those with HIV infection, iatrogenic immunosuppression, chronic kidney disease, hematologic malignancy, other solid tumor malignancies with or without metastasis, hematopoietic stem cell transplantation and solid-organ transplantation, administration of a single dose of PCV13 followed by PPSV23 ≥ 8 weeks later is recommended (2A) [Box 1].



Adults aged 65 years or older

  • Vaccination with PPSV23 in all adults above 65 years of age is recommended because of the overall higher incidence of invasive pneumococcal disease in this age group (2A)
  • Vaccination with PCV13 first, followed by PPSV23, is usually recommended for individuals who have immunocompromising conditions, functional or anatomic asplenia, cochlear implant, CSF leak or history of invasive pneumococcal disease (2A). However, in this group of patients, the decision regarding giving PCV13 before PPSV23 can be discussed on a case-to-case basis between the physician and the patient
  • For adults with chronic conditions such as chronic heart disease, chronic liver disease, poorly controlled diabetes mellitus, chronic lung disease, and in current smokers and those with alcohol abuse, the decision to administer a dose of PCV13 preceding PPSV23 should be taken jointly by the physician and the patient, on a case-to-case basis (UPP)
  • Repeat vaccination with PPSV23 causes hyporesponsiveness, and hence revaccination of an individual with PPSV23 must be solely based on clinical judgment.


6. What are the recommendations for pneumococcal vaccination for travelers, Hajj pilgrims, and individuals attending mass gatherings?

  • The working group for the prevention of pneumococcal disease in Hajj pilgrims has recommended administration of PCV13 4 weeks before travel to Hajj, while PPSV23 can be administered after return from the Hajj pilgrimage[4]
  • The data regarding other mass gatherings such as Kumbh Mela are lacking; however, we recommend extrapolating the data from Hajj pilgrims to vaccinate individuals attending large mass gatherings, as mentioned in the above statement.


7. Why should PCV13 be administered before PPSV23?

  • PCV13 is recommended first, as it amplifies the antipneumococcal response to subsequent administration of PPSV23 for many common vaccine serotypes. In line with the evidence, there is unanimous agreement on the benefits of PCV13 over a polysaccharide vaccine, as the former has a T-cell-dependent response and causes induction of immunological memory and long-lasting immunity (2A)


8. What is the pneumococcal vaccination recommendation if an individual has received PPSV23 first?

  • For individuals who have already received PPSV23 initially, and where PCV13 is indicated, a single dose of PCV13 should be administered ≥1 year following the receipt of PPSV23 (UPP)
  • Further revaccination with PPSV23 should be done as per the usual regime, maintaining a gap of 5–7 years between the two doses of PPSV23
  • Repeat vaccination with PPSV23 causes hyporesponsiveness and hence revaccination of an individual with PPSV23 must be solely based on clinical judgment


9. What is the recommendation on coadministration of the two pneumococcal vaccines?

  • The experts recommended that a gap of at least 8 weeks be maintained between the two vaccines and that they should not be given simultaneously (UPP)



   Introduction Top


Pneumonia and influenza are key clinical conditions encountered by clinicians and pulmonologists in the country. Several evidence-based global guidelines and recommendations from numerous bodies are available for pneumococcal and influenza vaccination for the diverse adult population. However, due to differences in the disease burden, regulatory landscape, health-care infrastructure, and functioning in India, these global guidelines cannot be implemented unconditionally in the region. Hence, in the absence of country-specific structured clinical recommendations on adult respiratory vaccination, this document is a first-of-its-kind multidisciplinary effort to lay down specific evidence-based recommendations on adult pneumococcal and influenza vaccination for the country. It further aims (1) to guide practicing clinicians and health-care professionals in the country from various specialties to make informed decisions about adult respiratory vaccination and (2) to facilitate consistent adult respiratory vaccinations in the region and further help reduce the disease burden in the country.


   Methodology Top


The pioneering attempt to develop easily implementable clinical recommendations for the prevention of pneumonia and influenza with vaccination in India was undertaken as a joint exercise by the Indian Chest Society and National College of Chest Physicians of India by a panel of experts at a closed-door meeting held in Kolkata on 13 January 2019.

There were 24 expert members with four moderators and four rapporteurs. The expert panel members included an oncologist, pulmonologists, a nephrologist, a diabetologist, and an infectious disease specialist. These experts were from various parts of India. The experts critically analyzed existing literature, including randomized clinical trials, systematic reviews, and meta-analyses, as well as key global and Indian guidelines and recommendations on pneumococcal and influenza vaccine. Evidence to frame specific questions was obtained through a literature search of MEDLINE (via PubMed) and Cochrane-indexed databases on pneumococcal and influenza vaccination published between January 1995 and December 2018. The keywords for the literature search were as follows: definitions, epidemiology, India, pneumonia, prevention, mortality, vaccine, impact, elderly, serotype, safety, immunogenicity, comorbid conditions, community-acquired pneumonia, mass gatherings, antibiotics, guidelines, and recommendations. These questions were formulated following discussions on several factors unique to the Indian context.

Literature review and discussions for each disease were coordinated by group chairs and were well documented by rapporteurs. Discussions regarding grading of evidence and recommendations were held independently in four parallel-group sessions and, thereafter, in a joint session including all the experts. A consensus-based approach was used to arrive at the final decision on clinical recommendations in the joint session. The modified Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system was utilized for categorizing the level of evidence as 1, 2, 3, or usual practice point (UPP) [Figure 1].[5]
Figure 1: Classification of level of evidence and grading of clinical recommendations

Click here to view


The strength of recommendation was graded as A or B, based on the level of evidence. Grade A should be interpreted as “recommended,” while Grade B as “suggested.” All aspects related to practicality, implementation, costs, and clinical feasibility in the region at various health-care levels were duly considered while formulating the clinical recommendations.[6]


   Epidemiology Top


01. What is the burden of pneumococcal disease in India?

Pneumococcal diseases are a group of preventable diseases caused by the pathogen Streptococcus pneumoniae (Pneumococcus) and are preventable.[7],[8],[9] They are broadly categorized into invasive and noninvasive forms. The invasive form leads to bacteremia, sepsis, and meningitis. The noninvasive form, or the less severe variant, causes sinusitis, acute otitis media, and community-acquired pneumonia (CAP). The noninvasive form of pneumonia can change into the severe invasive variant when accompanied by bacteremia.[7],[10],[11] According to the 2016 Global Burden of Disease estimates, pneumonia along with bronchiolitis (low respiratory tract infection) was the leading cause of mortality and morbidity globally.[12] Furthermore, according to the 2008 World Health Organization (WHO) data, Asia had the highest burden of pneumonia, with the Indian subcontinent contributing to a major share of the disease burden.[13]

Various studies evaluating the bacteriological profiles of invasive pneumococcal bacteria from across various parts of India revealed the predominance of S. pneumoniae in the country. Meningitis and pneumonia were the most common clinical conditions found in the adult population and were associated with a high fatality rate despite treatment in hospital settings.[14],[15],[16],[17],[18],[19]

A recent laboratory-based surveillance study on invasive pneumococcal disease (IPD) in the Indian adult population revealed that S. pneumoniae-positive cultures were characterized by serotype prevalence and antimicrobial resistance patterns. The study is consistent with findings from previous studies in the country, which showed pneumonia and meningitis to be the most common clinical conditions, accounting for 39% and 24.3%, respectively, of the total of IPD cases.[20]

Prevention of pneumonia through vaccination

02. What are the various vaccines available for preventing pneumococcal disease in India?

At present, two inactive vaccines are recommended and clinically used in India: PPSV23 and PCV13. The characteristics of both vaccines are summarized in [Table 2].[4],[21],[22],[23],[24]
Table 2: Detailed characteristics and serotype coverage of pneumococcal vaccines used in India

Click here to view


03. What is the dose and route of administration for PPSV23 and PCV13?

Pneumococcal vaccines have a pivotal role in preventing pneumococcal disease; the dosing and administration of these vaccines are discussed in [Table 3].[25],[26],[27],[28]
Table 3: Administration and dosage details for pneumococcal vaccines

Click here to view


Recommendation

  • The experts recommended the dose and route of administration of the two pneumococcal vaccines in keeping with the approved prescribing information [Table 3].[25],[26],[27],[28]


04. Is the use of pneumococcal vaccines for preventing pneumococcal disease in India justifiable?

Pneumococcal vaccination offers several benefits, ranging from reduction of disease burden and mortality to a positive economic impact. A population-based study conducted over a 2-year period revealed CAP patients previously vaccinated with PPSV23 to have a 40% lower rate of mortality or intensive care unit admission compared with nonvaccinated patients.[29] Pneumococcal vaccination exerts a potentially beneficial economic impact, as it leads to reduced usage of antibiotics and decreased overall health-care expenditure.[30] In a retrospective study conducted among an elderly population with chronic obstructive pulmonary disease (COPD), elderly vaccinated patients were found to have reduced hospitalization, mortality, and direct medical care costs compared to unvaccinated patients. Pneumococcal vaccines led to a 43% reduction in hospitalization due to pneumonia.[31]

Furthermore, PCV13 also has the potential to slow the rate of antibiotic resistance. The vaccine exerts this effect by preventing the disease in the first place, slowing the spread of resistant pneumococcal serotypes (19A) and thereby eliminating the need for antibiotics.[22]

A reduction in the rate of antibiotic-resistant infection among older adults was also observed in a laboratory-based study. The incidence rate of pneumococcal diseases caused by penicillin-resistant strains reduced to 8.4 from 16.4 cases per 100,000. Furthermore, the rates of resistant pneumococcal disease caused by vaccine serotypes reduced by 87%.[32]

PCV13 immunization was also found to be relatively more cost-effective for immunocompromised individuals versus previously recommended vaccinations.[33] This benefit is especially noteworthy for developing nations such as India.

Recommendation

  • The use of pneumococcal vaccine is worthwhile in India, as it not only reduces the burden of pneumococcal disease but also leads to a positive impact on health-care economics by reducing overall health-care expenditure.


05. What are the contraindications and precautions for pneumococcal vaccines?

Although pneumococcal vaccines are indispensable elements in the preventive strategy for pneumococcal diseases, certain contraindications and precautions govern their administration [Table 4].[24],[25],[27],[34],[35],[36],[37],[38],[39]
Table 4: Contraindications and precautions for pneumococcal vaccines

Click here to view


Recommendations

  • PCV13 and PPSV23 are contraindicated if an individual has hypersensitivity to any component of the vaccine
  • Both PPSV23 and PCV13 should not be given during acute respiratory illness. Caution should be exercised in individuals with altered immunocompetence, CSF leakage, severely compromised cardiovascular and/or pulmonary function receiving the pneumococcal vaccine, since in such cases, the pneumococcal vaccines may not be effective in preventing pneumococcal infection
  • Appropriate agents should be made available immediately if allergic reactions occur due to the vaccines.


06. What is the coadministration schedule of pneumococcal vaccines with respect to other recommended vaccines?

Evidence indicates that coadministration or concomitant administration of PCV13 with other vaccines (trivalent inactivated influenza vaccine [MF59-aTIV], tetanus–diphtheria vaccine [Td], diphtheria–tetanus–acellular pertussis hepatitis B-inactivated polio-Haemophilus influenzae type B [DTaP-HBV-IPV/Hib] vaccine) in the adult as well as pediatric populations is associated with functional opsonophagocytic activity (OPA) responses for all serotypes, induces sufficient immunity without significant interference, and has a good safety profile.[40],[41],[42],[43],[44],[45],[46],[47] All other recommended vaccines can be coadministered with PPSV23 and PCV13 at the same visit using different syringes or at any later date with no waiting period following the vaccination, except the quadrivalent meningococcal conjugate vaccine (MCV4)-D.

For the pediatric population (aged ≥2 years) at high risk for invasive meningococcal disease with functional or anatomic asplenia, two doses of MCV4-D are administered 2 months apart and ≥4 weeks after completion of the PCV13 vaccine series.[48],[49],[50] Furthermore, PPSV23 and PCV13 are inactivated vaccines.

Recommendations

  • Experts recommended that in adults, PCV13 can be concomitantly administered with:


    • Trivalent/quadrivalent inactivated influenza vaccine
    • Tetanus–diphtheria vaccine
    • Diphtheria–tetanus–acellular pertussis hepatitis B-inactivated polio-Haemophilus influenzae type B.


  • PCV13 and PPSV23 can be administered concomitantly with all other recommended vaccines:


  • At the same clinical visit, using separate syringes and at different anatomical sites
  • At any later time with no waiting period following the vaccination (except for the quadrivalent meningococcal conjugate vaccine [MCV4]-D).
  • PPSV23 and PCV13 should not be administered simultaneously at the same visit, and a time gap of at least 8 weeks should be maintained between the administration of the two vaccines.


07. What is the immunogenicity and safety profile of PCV13 and PPSV23?

PPSV23 has been available for clinical use for more than three decades now and has an established, protective effect against all-cause pneumonia in healthy adults. Evidence generated over the years has shown that PPSV23's effectiveness ranges from 50% to 80% against invasive pneumococcal forms among adults with comorbid conditions. However, the vaccine has not shown benefit in reducing the risk of CAP associated with seasonal influenza in the adult population.[51] The major limitations associated with the vaccine are hyporesponsiveness on repeated administration; uncertain effectiveness for prevention against nonbacteremic pneumococcal pneumonia; low immunological response in adults who are immunocompromised and/or with underlying comorbid conditions; and a decrease in clinical protection with age in the adult population.[52],[53],[54],[55],[56]

As PPSV23 has a T-cell-independent immune response, it does not provide long-lasting immunity to adult patients and, further, has no anamnestic effect upon revaccination. Immune response to the vaccine is also found to be low in immunocompromised adults and adults with various underlying comorbid conditions.[53] A meta-analysis by Huss et al. found little evidence in favor of the effectiveness of PPSV23 against pneumonia in elderly patients or adults with chronic illness.[54] In view of such studies, in general, PCV13 is usually preferred over PPSV23 in the older adult population. The immunogenicity and safety profiles of PPSV23 and PCV13 are summarized in [Table 5].[55],[56],[57],[58],[59],[60],[61],[62]
Table 5: Immunogenicity and safety evidence summarization for pneumococcal vaccines

Click here to view


08. Which among PCV13 and PPSV23 should be administered first and what is the immunization schedule of pneumococcal vaccines for the adult population at risk for pneumococcal disease in India?

A single dose of PCV13 should be given first, followed by a single dose of PPSV23. In older adults (>65 years), a single dose of PCV13 is administered first, followed by a single dose of PPSV23 a year later. According to established global guidelines, adults aged ≥65 years with immunocompromising conditions, functional or anatomic asplenia, CSF leaks, or cochlear implants are recommended a single dose of PCV13 first, followed by a single dose of PPSV23 at ≥8 weeks.[63],[64],[65],[66] As enumerated in the immunogenicity profile of the pneumococcal vaccine [Table 5],[55],[56],[57],[58],[59],[60],[61],[62] evidence shows that the initial single dose of PCV13 amplifies the antipneumococcal response to subsequent administration of PPSV23 for many common vaccine serotypes.

Contrary to this, the administration of PPSV23 before PCV13 results in a diminished response to subsequent administration of PCV13 for all serotypes. These findings have helped in providing a reasonable rationale for the recommendation for administering PCV13 first followed by PPSV23.[67],[68]

Recommendations

Adults aged 19–64 years

  • Pneumococcal vaccination is usually not recommended for healthy adults under the age of 65 years
  • In immunocompetent patients with chronic conditions such as chronic heart disease, chronic liver disease, poorly controlled diabetes mellitus, chronic lung disease, and in current smokers and those with alcohol abuse, a single dose of PCV13 followed by PPSV23 ≥8 weeks later is recommended
  • In adults with a history of invasive pneumococcal disease, those with cochlear implants, CSF leak, or impaired splenic function (anatomic asplenia or hyposplenism, sickle cell disease or other hemoglobinopathy or functional asplenia or hyposplenism), a single dose of PCV13 followed by PPSV23 ≥8 weeks later is recommended
  • In all immunocompromised individuals, such as those with HIV infection, iatrogenic immunosuppression, chronic kidney disease, hematologic malignancy, other solid tumor malignancies with or without metastasis, hematopoietic stem cell transplantation, and solid-organ transplantation, administering a single dose of PCV13 followed by PPSV23 ≥8 weeks later is recommended [Box 1].


Adults aged 65 years or older

  • Vaccination with PPSV23 in all adults above 65 years of age is recommended because of the overall higher incidence of invasive pneumococcal disease in this age group
  • Vaccination with PCV13 first, followed by PPSV23, is usually recommended for individuals who have immunocompromising conditions, functional or anatomic asplenia, cochlear implant, CSF leak, or history of invasive pneumococcal disease. In this group of patients, the decision regarding giving PCV13 before PPSV23 can be discussed on a case-to-case basis between the physician and the patient
  • For adults with chronic conditions such as chronic heart disease, chronic liver disease, poorly controlled diabetes mellitus, chronic lung disease, and in current smokers and those with alcohol abuse, the decision to administer a dose of PCV13 preceding PPSV23 should be taken jointly by the physician and the patient, on a case-to-case basis
  • The experts acknowledged that repeated vaccination with PPSV23 causes hyporesponsiveness and hence revaccination with PPSV23 must be based only on clinical judgment.


09. What are the recommendations for pneumococcal vaccination for travelers, Hajj pilgrims, and individuals attending mass gatherings?

The working group for the prevention of pneumococcal disease in Hajj pilgrims has recommended administration of PCV13 4 weeks before travel to Hajj, while PPSV23 can be administered after return from the Hajj pilgrimage.[4]

The data regarding other mass gatherings such as Kumbh Mela are lacking; however, we recommend extrapolating the data from Hajj pilgrims to vaccinate individuals attending large mass gatherings, as mentioned in the above statement.

10. Why should PCV13 be administered before PPSV23?

PCV13 should always be administered first.[69],[70],[71],[72],[73] Administration of PPSV23 8 weeks after PCV13 provides protection against an additional 11 pneumococcal serotypes covered by PPSV23 that are not covered by PCV13.[69] However, evidence reveals that repeated administration of PPSV23 causes hyporesponsiveness: The response to revaccination will not reach the levels achieved with primary vaccination.[71],[72],[73]

Although both vaccines elicit a B-cell-mediated immune response, only PCV13 has a T-cell-dependent immune response, which is essential for the maturation of the B-cell response and development of immunological memory.[70],[71],[72],[73],[74]

Recommendations

  • The initial single dose of PCV13 is recommended first, as it amplifies the antipneumococcal response to subsequent administration of PPSV23 for many common vaccine serotypes
  • Furthermore, in line with the evidence, unanimous agreement was obtained on the benefits of PCV13 over a polysaccharide vaccine, as the former is associated with a T-cell-dependent response and causes induction of immunological memory and long-lasting immunity.


11. What is the pneumococcal vaccination recommendation if an individual has received PPSV23 first?

PCV13 should still be administered to individuals who have already received PPSV23.[67] The Advisory Committee on Immunization Practices (ACIP) recommends that all adults aged ≥ 65 years who have already received PPSV23 receive a dose of PCV13 ≥ 1 year after receiving PPSV23, wherever indicated.[67] Furthermore, only PCV13 produces a T-cell-dependent response, which is essential for the development of immunological memory and therefore, primes the immune system for natural exposure.[69],[75],[76]

Recommendation

  • If individuals (aged ≥65 years) have already received PPSV23 initially, and wherever it is indicated to give PCV13, a single dose of PCV13 should be administered ≥1 year after the receipt of PPSV23.


Acknowledgment

We would like to thank BioQuest Solutions for their contribution in research, and data analysis, and for providing writing assistance.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Centers for Disease Control and Prevention. Guidelines for Vaccinating Pregnant Women. Available from: https://www.cdc.gov/vaccines/pregnancy/hcp-toolkit/guidelines.html. [Last accessed on 2019 Dec 11].  Back to cited text no. 1
    
2.
Dendle C, Stuart RL, Mulley WR, Holdsworth SR. Pneumococcal vaccination in adult solid organ transplant recipients: A review of current evidence. Vaccine 2018;36:6253-61.  Back to cited text no. 2
    
3.
Meroni PL, Zavaglia D, Girmenia C. Vaccinations in adults with rheumatoid arthritis in an era of new disease-modifying anti-rheumatic drugs. Clin Exp Rheumatol 2018;36:317-28.  Back to cited text no. 3
    
4.
Mathai D, Shamsuzzaman AK, Feroz AA, Virani AR, Hasan A, Ravi Kumar KL, et al. Consensus recommendation for India and Bangladesh for the use of pneumococcal vaccine in mass gatherings with special reference to Hajj Pilgrims. J Glob Infect Dis 2016;8:129-38.  Back to cited text no. 4
    
5.
Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, et al. GRADE: An emerging consensus on rating quality of evidence and strength of recommendations. BMJ 2008;336:924-6.  Back to cited text no. 5
    
6.
Guyatt GH, Rennie D, Meade MO, Cook DJ. Users' Guide to the Medical Literature: A Manual for Evidence-Based Clinical Practice. 2nd ed. New York: McGraw Hill; 2008.  Back to cited text no. 6
    
7.
Ludwig E, Bonanni P, Rohde G, Sayiner A, Torres A. The remaining challenges of pneumococcal disease in adults. Eur Respir Rev 2012;21:57-65.  Back to cited text no. 7
    
8.
Pneumococcal disease Immunization, Vaccines, and Biologicals. WHO. Available from: https://www.who.int/immunization/diseases/pneumococcal/en/. [Last accessed on 2019 Dec 09].  Back to cited text no. 8
    
9.
Randle E, Ninis N, Inwald D. Invasive pneumococcal disease. Arch Dis Child Educ Pract Ed 2011;96:183-90.  Back to cited text no. 9
    
10.
Drijkoningen JJ, Rohde GG. Pneumococcal infection in adults: Burden of disease. Clin Microbiol Infect 2014;20 Suppl 5:45-51.  Back to cited text no. 10
    
11.
Dockrell DH, Whyte MKB, Mitchell TJ. Pneumococcal pneumonia: Mechanisms of infection and resolution. Chest 2012;142:482-91.  Back to cited text no. 11
    
12.
Global Burden of Disease (GBD) Group. GBD 2016 Causes of Death Collaborators Global, regional, and national age-sex specific mortality for 264 causes of death, 1980–2016: A systematic analysis for the Global Burden of Disease Study 2016. Lancet 2017;390:1151-10.  Back to cited text no. 12
    
13.
Ghoshal AG. Burden of pneumonia in the community. JAPI 2016;64:8-11.  Back to cited text no. 13
    
14.
Muley VA, Ghadage DP, Yadav GE, Bhore AV. Study of invasive pneumococcal infection in adults with reference to penicillin resistance. J Lab Physicians 2017;9:31-5.  Back to cited text no. 14
[PUBMED]  [Full text]  
15.
Thomas K, Mukkai Kesavan L, Veeraraghavan B, Jasmine S, Jude J, Shubankar M, et al. Invasive pneumococcal disease associated with high case fatality in India. J Clin Epidemiol 2013;66:36-43.  Back to cited text no. 15
    
16.
Shah BA, Singh G, Naik MA, Dhobi GN. Bacteriological and clinical profile of Community acquired pneumonia in hospitalized patients. Lung India 2010;27:54-7.  Back to cited text no. 16
[PUBMED]  [Full text]  
17.
Oberoi A, Aggarwal A. Bacteriological profile, serology and antibiotic sensitivity pattern of micro-organisms from community acquired pneumonia. JK Sci 2006;8:79–82.  Back to cited text no. 17
    
18.
Bansal S, Kashyap S, Pal LS, Goel A. Clinical and bacteriological profile of community acquired pneumonia in Shimla, Himachal Pradesh. Indian J Chest Dis Allied Sci 2004;46:17-22.  Back to cited text no. 18
    
19.
Para RA, Fomda BA, Jan RA, Shah S, Koul PA. Microbial etiology in hospitalized North Indian adults with community-acquired pneumonia. Lung India 2018;35:108-15.  Back to cited text no. 19
[PUBMED]  [Full text]  
20.
Jayaraman R, Varghese R, Kumar JL, Neeravi A, Shanmugasundaram D, Ralph R, et al. Invasive pneumococcal disease in Indian adults: 11 years' experience. J Microbiol Immunol Infect 2019;52:736-42.  Back to cited text no. 20
    
21.
Hayward S, Thompson LA, McEachern A. Is 13-valent pneumococcal conjugate vaccine (PCV13) Combined With 23-valent pneumococcal polysaccharide vaccine (PPSV23) superior to PPSV23 alone for reducing incidence or severity of pneumonia in older adults? A Clin-IQ. J Patient Cent Res Rev 2016;3:111-5.  Back to cited text no. 21
    
22.
Cafiero-Fonseca ET, Stawasz A, Johnson ST, Sato R, Bloom DE. The full benefits of adult pneumococcal vaccination: A systematic review. PLoS One 2017;12:e0186903.  Back to cited text no. 22
    
23.
World Health Organization Pneumococcal Vaccines. Available from: http://www.who.int/vaccine_safety/initiative/tools/Pneumococcal_Vaccine_rates_information_sheet.pdf. [Last accessed on 2019 Dec 09].  Back to cited text no. 23
    
24.
Song JY, Nahm MH, Moseley MA. Clinical implications of pneumococcal serotypes: Invasive disease potential, clinical presentations, and antibiotic resistance. J Korean Med Sci 2013;28:4-15.  Back to cited text no. 24
    
25.
Prevenar 13® Prescribing Information; 2017. Available from: https://www.fda.gov/media/107657/download. [Last accessed on 2019 Dec 09].  Back to cited text no. 25
    
26.
Prevenar 13® European Summary of Product Characteristics; 2014. Available from: https://www.ema.europa.eu/en/documents/product-information/prevenar-13-epar-product-information_en.pdf. [Last accessed on 2019 Dec 09].  Back to cited text no. 26
    
27.
Swaminathan S, Mathai D. Protocols for pneumococcal vaccination understanding the term. JAPI 2016;64:52–62.  Back to cited text no. 27
    
28.
Pneumovax23. Prescribing Information; 2015. Available from: https://www.merck.com/product/usa/pi_circulars/p/pneumovax_23/pneum ovax_pi.pdf. [Last accessed on 2019 Dec 09].  Back to cited text no. 28
    
29.
Johnstone J, Marrie TJ, Eurich DT, Majumdar SR. Effect of pneumococcal vaccination in hospitalized adults with community-acquired pneumonia. Arch Intern Med 2007;167:1938-43.  Back to cited text no. 29
    
30.
Bärnighausen T, Bloom DE, Cafiero-Fonseca ET, O'Brien JC. Valuing vaccination. Proc Natl Acad Sci U S A 2014;111:12313-9.  Back to cited text no. 30
    
31.
Nichol KL, Baken L, Wuorenma J, Nelson A. The health and economic benefits associated with pneumococcal vaccination of elderly persons with chronic lung disease. Arch Intern Med 1999;159:2437-42.  Back to cited text no. 31
    
32.
Kyaw MH, Lynfield R, Schaffner W, Craig AS, Hadler J, Reingold A, et al. Effect of introduction of the pneumococcal conjugate vaccine on drug-resistant Streptococcus pneumonia. N Engl J Med 2006;354:1455-63.  Back to cited text no. 32
    
33.
Smith KJ, Nowalk MP, Raymund M, Zimmerman RK. Cost-effectiveness of pneumococcal conjugate vaccination in immunocompromised adults. Vaccine 2013;31:3950-6.  Back to cited text no. 33
    
34.
Centers for Disease Control and Prevention. Pink Book; 2014. Available from: https://www.cdc.gov/vaccines/pubs/pinkbook/downloads/pneumo.pdf. [Last accessed on 2019 Dec 09].  Back to cited text no. 34
    
35.
Immunization Action Coalition. Standing Orders for Administering Pneumococcal Vaccines (PCV13 and PPSV23) to Adults; 2018. Available from: https://www.immunize.org/catg.d/p3075.pdf. [Last accessed on 2019 Dec 09].  Back to cited text no. 35
    
36.
Centers for Disease Control and Prevention. Advisory Committee on Immunization Practices. Contraindications and Precautions. Available from: https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/contraindications.html#ref-49. [Last accessed on 2019 Dec 09].  Back to cited text no. 36
    
37.
Centers for Disease Control and Prevention PCV 13 VIS. Available from: https://www.cdc.gov/vaccines/hcp/vis/vis-statements/pcv13.html. [Last accessed on 2019 Dec 09].  Back to cited text no. 37
    
38.
Nilsson L, Brockow K, Alm J, Cardona V, Caubet JC, Gomes E, et al. Vaccination and allergy: EAACI position paper, practical aspects. Pediatr Allergy Immunol. 2017;28:628-40.   Back to cited text no. 38
    
39.
McNeil MM, Weintraub ES, Duffy J, Sukumaran L, Jacobsen SJ, Klein NP, et al. Risk of anaphylaxis after vaccination in children and adults. J Allergy Clin Immunol 2016;137:868-78.  Back to cited text no. 39
    
40.
Song JY, Cheong HJ, Noh JY, Choi MJ, Yoon JG, Lee SN, et al. Immunogenicity and safety of a tetanus diphtheria vaccine and a 13-valent pneumococcal conjugate vaccine after concomitant vaccination in≥50-year-old adults. BMC Infect Dis 2018;18:628.  Back to cited text no. 40
    
41.
Song JY, Cheong HJ, Hyun HJ, Seo YB, Lee J, Wie SH, et al. Immunogenicity and safety of a 13-valent pneumococcal conjugate vaccine and an MF59-adjuvanted influenza vaccine after concomitant vaccination in P60-year-old adults. Vaccine 2017;35:313-20.  Back to cited text no. 41
    
42.
Esposito S, Tansey S, Thompson A, Razmpour A, Liang J, Jones TR, et al. Safety and immunogenicity of a 13-valent pneumococcal conjugate vaccine compared to those of a 7-valent pneumococcal conjugate vaccine given as a three-dose series with routine vaccines in healthy infants and toddlers. Clin Vaccine Immunol 2010;17:1017-26.  Back to cited text no. 42
    
43.
Frenck RW Jr., Gurtman A, Rubino J, Smith W, van Cleeff M, Jayawardene D, et al. Randomized, controlled trial of a 13-valent pneumococcal conjugate vaccine administered concomitantly with an influenza vaccine in healthy adults. Clin Vaccine Immunol 2012;19:1296-303.  Back to cited text no. 43
    
44.
Schwarz TF, Flamaing J, Rümke HC, Penzes J, Juergens C, Wenz A, et al. A randomized, double-blind trial to evaluate immunogenicity and safety of 13-valent pneumococcal conjugate vaccine given concomitantly with trivalent influenza vaccine in adults aged≥65 years. Vaccine 2011;29:5195-2.  Back to cited text no. 44
    
45.
DeStefano F, Goodman RA, Noble GR, McClary GD, Smith SJ, Broome CV, et al. Simultaneous administration of influenza and pneumococcal vaccines. JAMA 1982;247:2551-4.  Back to cited text no. 45
    
46.
Tse A, Tseng HF, Greene SK, Vellozzi C, Lee GM; VSD Rapid Cycle Analysis Influenza Working Group. Signal identification and evaluation for risk of febrile seizures in children following trivalent inactivated influenza vaccine in the Vaccine Safety Datalink Project, 2010-2011. Vaccine 2012;30:2024-31.  Back to cited text no. 46
    
47.
Leroy Z, Broder K, Menschik D, Shimabukuro T, Martin D. Febrile seizures after 2010-2011 influenza vaccine in young children, United States: A vaccine safety signal from the vaccine adverse event reporting system. Vaccine 2012;30:2020-3.  Back to cited text no. 47
    
48.
Centers for Disease Control and Prevention. Timing and Spacing of Immunobiologics; 2018. Available from: https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/timing.html. [Last accessed on 2019 Dec 09].  Back to cited text no. 48
    
49.
Centers for Disease Control and Prevention (CDC). Recommendation of the Advisory Committee on Immunization Practices (ACIP) for use of quadrivalent meningococcal conjugate vaccine (MenACWY-D) among children aged 9 through 23 months at increased risk for invasive meningococcal disease. MMWR Morb Mortal Wkly Rep 2011;60:1391-2.  Back to cited text no. 49
    
50.
MenACWY-CRM (Menveo®) & MenACWY-D (Menactra™). Meningococcal Conjugate Vaccines Factsheet; 2014. Available from: http://publichealth.lacounty.gov/acd/docs/MeningococcalVaccines.pdf. [Last accessed on 2019 Dec 09].  Back to cited text no. 50
    
51.
23-valent pneumococcal polysaccharide vaccine. WHO position paper. Wkly Epidemiol Rec 2008;83:373-84.  Back to cited text no. 51
    
52.
Sings HL. Pneumococcal conjugate vaccine use in adults-Addressing an unmet medical need for non-bacteremic pneumococcal pneumonia. Vaccine 2017;35:5406-17.  Back to cited text no. 52
    
53.
Swaminathan S, Balajee G. Pneumococcal vaccines – A real world perspective cost-effectiveness of pneumococcal vaccination. JAPI 2015;63:25-8.  Back to cited text no. 53
    
54.
Huss A, Scott P, Stuck AE, Trotter C, Egger M. Efficacy of pneumococcal vaccination in adults: A meta-analysis. CMAJ 2009;180:48-58.  Back to cited text no. 54
    
55.
McLaughlin JM, Jiang Q, Isturiz RE, Sings HL, Swerdlow DL, Gessner BD, et al. Effectiveness of 13-valent pneumococcal conjugate vaccine against hospitalization for community-acquired pneumonia in older US adults: A test-negative design. Clin Infect Dis 2018;67:1498-506.  Back to cited text no. 55
    
56.
Prato R, Fortunato F, Cappelli MG, Chironna M, Martinelli D. Effectiveness of the 13-valent pneumococcal conjugate vaccine against adult pneumonia in Italy: A case-control study in a 2-year prospective cohort. BMJ Open 2018;8:e019034.  Back to cited text no. 56
    
57.
Solanki BB, Juergens C, Chopada MB, Supe P, Sundaraiyer V, Le Dren-Narayanin N, et al. Safety and immunogenicity of a 13-valent pneumococcal conjugate vaccine in adults 50 to 65 years of age in India: An open-label trial. Hum Vaccin Immunother 2017;13:2065-71.  Back to cited text no. 57
    
58.
Bonten MJ, Huijts SM, Bolkenbaas M, Webber C, Patterson S, Gault S, et al. Polysaccharide conjugate vaccine against pneumococcal pneumonia in adults. N Engl J Med 2015;372:1114-25.  Back to cited text no. 58
    
59.
Greenberg RN, Gurtman A, Frenck RW, Strout C, Jansen KU, Trammel J, et al. Sequential administration of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine in pneumococcal vaccine-naïve adults 60-64 years of age. Vaccine 2014;32:2364-74.  Back to cited text no. 59
    
60.
Jackson LA, Gurtman A, Rice K, Pauksens K, Greenberg RN, Jones TR, et al. Immunogenicity and safety of a 13-valent pneumococcal conjugate vaccine in adults 70 years of age and older previously vaccinated with 23-valent pneumococcal polysaccharide vaccine. Vaccine 2013;31:3585-93.  Back to cited text no. 60
    
61.
Jackson LA, Gurtman A, van Cleeff M, Jansen KU, Jayawardene D, Devlin C, et al. Immunogenicity and safety of a 13-valent pneumococcal conjugate vaccine compared to a 23-valent pneumococcal polysaccharide vaccine in pneumococcal vaccine-naive adults. Vaccine 2013;31:3577-84.  Back to cited text no. 61
    
62.
Jackson LA, Gurtman A, van Cleeff M, Frenck RW, Treanor J, Jansen KU, et al. Influence of initial vaccination with 13-valent pneumococcal conjugate vaccine or 23-valent pneumococcal polysaccharide vaccine on anti-pneumococcal responses following subsequent pneumococcal vaccination in adults 50 years and older. Vaccine 2013;31:3594-602.  Back to cited text no. 62
    
63.
Kobayashi M, Bennett NM, Gierke R, Almendares O, Moore MR, Whitney CG, et al. Intervals Between PCV13 and PPSV23 Vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep 2015;64:944-7.  Back to cited text no. 63
    
64.
Centers for Disease Control and Prevention. Adults: Protect Yourself with Pneumococcal Vaccines; 2018. Available from: https://www.cdc.gov/features/adult-pneumococcal/index.html. [Last accessed on 2019 Dec 09].  Back to cited text no. 64
    
65.
Immunization Action Coalition. Ask the Experts: Pneumococcal Vaccines (PCV13 and PPSV23); 2018. Available from: https://www.immunize.org/askexperts/experts_pneumococcal_vaccines.asp. [Last accessed on 2019 Dec 09].  Back to cited text no. 65
    
66.
Chilson E, Atkinson B, Hall-Murray C, Snow V, Schmoele-Thoma B, Isturiz RE, Scott DA. Sequential administration of PCV13 followed by PPSV23 results in a more robust immune response in PPSV23-naïve adults aged 60–64 years. OFID 2017;4 Suppl 1:S470.  Back to cited text no. 66
    
67.
The Immunization Advisory Centre; 2017. Available from: https://www.immune.org.nz/sites/default/files/resources/Written%20Resources/VaccinePneumococcal20170807V01Final.pdf. [Last accessed on 2019 Dec 09].  Back to cited text no. 67
    
68.
Pallotta A, Rehm SJ. Navigating pneumococcal vaccination in adults. Cleve Clin J Med 2016;83:427-33.  Back to cited text no. 68
    
69.
Papadatou I, Spoulou V. Pneumococcal vaccination in high-risk individuals: Are we doing it right? Clin Vaccine Immunol 2016;23:388-95.  Back to cited text no. 69
    
70.
Papadatou I, Piperi C, Alexandraki K, Kattamis A, Theodoridou M, Spoulou V. Antigen-specific B-cell response to 13-valent pneumococcal conjugate vaccine in asplenic individuals with β-thalassemia previously immunized with 23-valent pneumococcal polysaccharide vaccine. Clin Infect Dis 2014;59:862-5.  Back to cited text no. 70
    
71.
Orthopoulos GV, Theodoridou MC, Ladis VA, Tsousis DK, Spoulou VI. The effect of 23-valent pneumococcal polysaccharide vaccine on immunological priming induced by 7-valent conjugate vaccine in asplenic subjects with beta-thalassemia. Vaccine 2009;27:350-4.  Back to cited text no. 71
    
72.
Bajaj S. RSSDI clinical practice recommendations for the management of type 2 diabetes mellitus 2017. Int J Diabetes Dev Ctries 2018;38:1-15.  Back to cited text no. 72
    
73.
Clutterbuck EA, Lazarus R, Yu LM, Bowman J, Bateman EA, Diggle L, et al. Pneumococcal conjugate and plain polysaccharide vaccines have divergent effects on antigen-specific B cells. J Infect Dis 2012;205:1408-16.  Back to cited text no. 73
    
74.
Mackay IR, Rosen FS. Vaccines and vaccination. N Engl J Med 2001;345:1042-53.  Back to cited text no. 74
    
75.
Dhar R. Review of guidelines for the use of vaccines to prevent community-acquired pneumonia in Indian adults. JAPI 2016;64:45-51.  Back to cited text no. 75
    
76.
Indian Society of Nephrology Vaccination Work Group. Guidelines for vaccination in chronic kidney disease. Indian J Nephrol 2016;26(Suppl 1):S15-S18.  Back to cited text no. 76
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

Top
  
 
  Search
 
  
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
    Abstract
   Executive Summary
    Pneumococcal Vac...
   Introduction
   Methodology
   Epidemiology
    References
    Article Figures
    Article Tables

 Article Access Statistics
    Viewed4504    
    Printed29    
    Emailed0    
    PDF Downloaded801    
    Comments [Add]    

Recommend this journal