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Pneumococcal meningitis

Meningitis is an inflammation of the lining around the brain and spinal cord. Most severe cases are caused by bacteria. Pneumococcal bacteria (Streptococcus pneumoniae) are the second biggest cause of bacterial meningitis in the UK and Ireland.

Many people, including approximately half of pre-school children¹, carry pneumococcal bacteria in the back of their nose and throat, and constantly pass them around by coughing and sneezing and close contact. This is completely harmless most of the time. However, in a susceptible person, these bacteria can cause a wide range of disease, from fairly minor bronchitis and ear and sinus infections to life-threatening pneumonia, septicaemia (blood poisoning), and less frequently, meningitis. Sometimes pneumococcal meningitis can develop from minor forms of the infection, such as earache.

Although the bacteria are easy to pass on, it is extremely rare for a healthy person to catch severe pneumococcal disease from someone in their household who has the illness.

What are the symptoms?

The symptoms of meningitis differ in adults and infants and are outlined in the box below. Symptoms can occur in any order and may not all be present.

Meningitis symptoms in adults children and infants
Early General Symptoms	Fever Vomiting
Classic and late symptoms in adults and children	Headache Stiff Neck Dislike of bright light Very sleepy/vacant/difficult to wake
Other symptoms in infants	Refusing to feed High pitched moaning cry Stiff body/Jerky Movements/floppy lifeless body Irritable Tense or bulging soft spot on the head

Pneumococcal infection can also cause septicaemia. The early signs of septicaemia are difficult to tell apart from less serious illnesses and include fever and vomiting, aches and pains, and feeling generally unwell. As the disease develops, the person becomes more severely ill with further signs including:

Cold hands and feet,
Pale, mottled or bluish skin,
Rapid breathing,
Very sleepy/vacant/difficult to wake
Confused/delirious.

Not everyone gets all the symptoms, and no two cases are exactly the same. People with pneumococcal disease do not often get the rash that is typical of the most common kind of meningitis and septicaemia, meningococcal disease.

How severe is pneumococcal meningitis?

Of the people who catch pneumococcal meningitis, about four out of five recover. Even so, it is among the most life-threatening major forms of meningitis². Approximately half of survivors are left with after effects that may be mild or temporary and improve with time. However, after effects may be as severe as deafness, severe learning difficulties, speech and language problems³, paralysis, cerebral palsy, epilepsy and blindness. Especially when the patient is a baby not long out of hospital, it can be difficult to tell whether any problems detected will be long lasting. The picture becomes clearer as the baby grows and develops, but parents are often distressed by not knowing the extent of the after effects in the first weeks and months after taking their child home from hospital.

Who is at risk of getting pneumococcal meningitis?

People most likely to get pneumococcal disease are:

young children, particularly under age two;
older people – in adults, the risk begins to increase from around the age of 50 and continues to rise with increasing age;
people with health conditions that increase their risk from pneumococcal infection.

Certain social and environmental factors such as ethnic background⁴, poverty⁵, or in children exposure to cigarette smoke^6, family size⁶; nursery attendance and not being breast-fed⁷ also play a role and may increase the chances of carrying the bacteria or becoming ill.

Can pneumococcal meningitis be prevented?

Yes, some types of pneumococcal meningitis are preventable.

There are two different vaccines available to protect against serious pneumococcal disease. However the recommendations for their use are different in the UK to those in the Republic of Ireland.

Information about pneumococcal meningitis vaccines in the Republic of Ireland

Currently two different vaccines are used in the UK, one in the routine childhood immunisation schedule for all babies and the other for everyone over 65. These vaccines are also available to people with particular health conditions that increase their risk from pneumococcal infection. The single most important thing you can do to prevent pneumococcal meningitis is to make sure your children are up to date with their routine immunisations, and to have the immunisations you are eligible for.

Pneumococcal ‘conjugate’ vaccine (PCV)

The current vaccine in the childhood immunisation schedule, Prevenar13® (PCV13) can protect against severe infection caused by thirteen of the most common strains of pneumococcal bacteria. Conjugate vaccines are explained in more detail in the box opposite.

This vaccine:

is routinely offered to all babies at 2, 4 and 13 months of age, within the routine childhood immunisation programme,
is similar to the successful Hib and MenC vaccines, which are also conjugate vaccines,
provides direct protection to those who are vaccinated. However, because the vaccine also reduces the number of people who are carrying and potentially transmitting the bacteria, people who are not vaccinated also benefit from indirect protection. This is called ‘herd’ immunity.

PCV13 was introduced in spring 2010 and directly replaced PCV7, which only provided protection against seven strains of pneumococcal bacteria. The change was made to provide broader coverage for children by protecting against six additional strains of bacteria.

Is this vaccine safe for my child?

Yes. The widespread use of PCV7 in over 100 countries, with over 300 million doses distributed worldwide, established a solid safety record. Clinical trial data from studies involving more than 7000 children show that PCV13 has a similar safety profile to PCV7.

What if my child has already received one or two doses of PCV7?

Children who have already received one or two doses of PCV7 can complete their vaccination course with PCV13 with no change to the routine vaccination schedule.

Did PCV7 vaccine reduce cases of pneumococcal meningitis after it was introduced in 2006?

PCV7 has been very successful at preventing the seven strains of pneumococcal infection it covers. In the first two and a half years after the introduction of PCV7, it has been estimated that 959 cases of serious illness and 53 deaths due to invasive pneumococcal disease were prevented⁹.

Meanwhile, as disease caused by the seven most common strains decreased, cases caused by other strains of pneumococcal bacteria had been increasing¹⁰ (see graph). Therefore, the vaccine was upgraded to provide broader protection.

There are over 90 strains of pneumococcal bacteria, but most strains rarely cause disease. PCV13 covers the strains that account for approximately 74% of all severe pneumococcal disease in young children in England and Wales⁸.

Severe pneumococcal disease in children aged under 5 caused by strains in Prevenar and Prevenar13

Graph reproduced with kind permission of HPA Centre for Infections

Pneumococcal ‘polysaccharide’ vaccine (PPV)¹¹

This vaccine provides a level of short-term protection against serious pneumococcal disease caused by the top 23 disease-causing types of pneumococcal bacteria (see box opposite). This vaccine is offered to adults over the age of 65 and children over the age of 2 who have health conditions which put them at increased risk from pneumococcal infection.

What health conditions increase the risk from pneumococcal infection?

Health conditions which increase the risk of infection include¹¹:

having no spleen, due to injury or disease, or a spleen that does not work properly as in sickle cell disorder, and coeliac disease;
other immunodeficiency, whether inherited or acquired (e.g. HIV);
immunosuppression as with cancer therapy or organ transplant;
chronic disease of the heart, kidney or liver;
chronic respiratory diseases, including, for example, asthma requiring repeated use of systemic steroids, chronic obstructive pulmonary disease;
diabetes requiring insulin;
people with or about to have cochlear implantation or other conditions where leakage of cerebrospinal fluid can occur (but vaccination must not delay cochlear implantation).

What protection is offered to people with 'at risk' health conditions?

People with at risk health conditions should be offered vaccination with PCV, PPV or both depending on their age and the condition they have.

In general the following applies to people with “at risk” health conditions*:

Babies should be immunised according to the routine schedule followed by one dose of PPV after their second birthday,
Children under 5 years of age, who haven’t previously been vaccinated should be offered PCV and then PPV after their second birthday,
Children over 5 years of age and adults should be offered PPV if they haven’t already received this.

*People with an absent or damaged spleen, who are HIV positive, receive bone marrow transplants or have chronic renal disease should seek specialist advice as recommendations in these cases can differ.

Children under 2 years of age with at risk conditions and who have already had the full course of PCV7 are eligible for a PCV13 vaccination.

Children who get severe pneumococcal disease

Any child under age 5 years who gets pneumococcal meningitis or other severe pneumococcal disease will be followed up by their GP or paediatrician, to check whether they have an ‘at-risk’ health condition¹². These children should be offered PCV even if they have already had it. They may also be offered PPV.ALL children who are under the age of 2 and have missed immunisations are entitled to receive PCV and are entitled to receive other routine immunisations up to age 10.

IMPORTANT: Vaccines cannot protect against all forms of meningitis

It is important to remember that although vaccines can provide excellent protection, there are still some types of meningitis and septicaemia for which there are no vaccines. It is important to be aware of the symptoms of these diseases and to seek medical help immediately if you suspect that someone has meningitis or septicaemia.

References

Hussain M, Melegaro A, Pebody RG, George R, Edmunds WJ, Talukdar R et al. A longitudinal household study of Streptococcus pneumoniae nasopharyngeal carriage in a UK setting. Epidemiol Infect 2005; 133:891-8.

Baraff LJ, Lee SI, Schriger DL. Outcomes of bacterial meningitis in children: a meta-analysis. Pediatr Infect Dis J. May 1993; 12(5):389-94. (accessed 29 Feb 2008)

Bedford H, de Louvois J, Halket S, Peckham C, Hurley R, Harvey D. Meningitis in infancy in England and Wales: follow up at age 5 years. BMJ. Sept 2001; 323(7312):533-6. (accessed 17 March 2008)

Urwin G, Yuan MF, Hall LMC, Brown K, Efstratiou A, Feldman RA. Pneumococcal meningitis in the North East Thames region UK: epidemiology and molecular analysis of isolates. Epidemiol Infect 1996; 117:95-102.

Grant CC, Harnden AR, Jewell G, Knox K, Peto TE, and Crook DW. Invasive pneumococcal disease in Oxford, 1985–2001: a retrospective case series Arch Dis Child 2003; 88: 712-4.

Leino T, Auranen K, Jokinen J, Leinonen M, Tervonen P, Takala AK. Pneumococcal carriage in children during their first two years: important role of family exposure. Pediatr Infect Dis J 2001; 20:1022-7.

Levine OS, Farley M, Harrison LH, Lefkowitz L, McGeer A, Schwartz B. Risk factors for invasive pneumococcal disease in children: a population-based case-control study in North America. Pediatrics 1999; 103. (accessed 10 March 2008).

Kaye P, Malkani E, Martin S, Slack M, Trotter C, Jit M, George R & Miller E. Invasive pneumococcal disease (IPD) in England & Wales after 7-valent conjugate vaccine (PCV7); potential impact of 10 and 13-valent vaccines.

Report of the Director of Immunisation: April 2009.(Accessed 17 Feb 2010).

Pichon B, Beasley L, Slack M, Efstratiou A, Miller E. and George R. Effect of the introduction of the pneumococcal conjugate vaccine in the UK childhood immunisation scheme on the genetic structure of paediatric invasive pneumococci. (Accessed 17 Feb 2010)

Department of Health. Immunisation against infectious diseases. Chapter 25: Pneumococcal. August 2006. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4137924.pdf (accessed 25 Feb 2010).

Health Protection Agency. Clinical Management Protocol version 3: January 2007 (accessed 17 March 2008).

Janine Dunbar

Pneumococcal meningitis