The following policy has been developed by the Thoracic Society of Australia and New Zealand.1
Analysis of the data available does not support a public health strategy to vaccinate all individuals in a particular at-risk group. Clinicians should consider vaccination for individuals in the following groups:
1. All individuals with functional or anatomic asplenia, including sickle cell disease. The vaccine should preferably be administered before splenectomy but not if the patient is within 14 days of beginning chemotherapy.
2. Adult patients with chronic underlying disease including
- chronic lung disease
- cardiac failure
- chronic alcoholism
- chronic liver disease
- nephrotic syndrome.
In particular, patients who have been hospitalised for one of the above in the last 5 years represent the major group in whom vaccination should be considered.
3. Patients with HIV infection which is asymptomatic or associated only with generalised lymphadenopathy.
4. Patients over two years of age with the nephrotic syndrome.
5. Patients with chronic and surgically in correctible cerebrospinal fluid leak.
6. Selected groups of Aboriginal adults in regions with a high attack-rate may also benefit from the vaccine.
The vaccine is safe and can be administered at the same time as the influenza vaccine.
Transient and minor adverse effects occur in up to 50% of primary vaccinations and include local pain, erythema and induration. Systemic adverse effects are rare _ fever (rarely above 390C), myalgia and local reactions that are severe, occur in 1% of cases. Anaphylactoid reactions occur in 5 per million doses. There are no comprehensive data regarding safety in pregnancy. The Australian Drug Evaluation Committee gives the vaccine a B2 category, i.e. studies in animals are inadequate or lacking but available data show no increased incidence of fetal damage. The NHMRC suggests deferral during pregnancy unless the risk of reinfection is increased substantially.
Revaccination at intervals greater than 4 years is not associated with an increased risk of adverse effects. Antibody levels decline variably according to the serotype examined. Antibody persistence is shorter in children, asplenia, nephrotic syndrome or immunosuppression. Therefore, revaccination is recommended in children with nephrotic syndrome, asplenia or sickle cell anaemia after 3-5 years if older than 10 years at the time of revaccination. Otherwise, it is recommended that revaccination occurs every 6 years for those who have received the 23 valent vaccine.