Pneumococcal Infection — Low Awareness as a Potential Barrier to Vaccination: Results of a European Survey



Elderly people and adults with chronic disease or compromised immune status are at increased risk of pneumococcal infection, with pneumonia being the most common serious presentation and a significant cause of morbidity and mortality. Most European countries have recommendations for pneumococcal vaccination but vaccination rates have remained low. In the present article, the authors present the results of a European survey that investigated the current level of awareness of pneumococcal infection among primary care physicians and specialists, and attitudes to vaccination in these physicians and members of the general public aged >50 years.


Primary care physicians (n = 1,300) and specialists (n = 926) from 13 Western European countries participated in online/face-to-face interviews, and a further 6,534 individuals aged >50 years from a population sample reflecting local socio-demographic structure participated in telephone/face-to-face interviews.


Pneumonia was the most well-known of the pneumococcal infections amongst primary care physicians and specialists. However, there was a relatively low awareness of the term invasive pneumococcal disease (IPD), with only 50% of primary care physicians and 71% of specialists reporting knowledge of the term IPD. Key factors influencing a physician’s decision to prescribe pneumococcal vaccination were the patient’s health condition, recommendations from health authorities, and the tolerability of the vaccine. Perceptions regarding vaccination were good amongst the members of the general public; individuals did not fear vaccines or their side effects. The main drivers for vaccination were recommendations from a healthcare professional and, to a lesser extent, that vaccination provides reassurance against contracting a disease.


These findings highlight the low awareness of the term IPD in comparison with individual pneumococcal conditions. Given the importance of physician recommendations in encouraging patients to be vaccinated, primary care physicians need to be vigilant of patients at risk of pneumococcal infections in order to increase vaccination rates.


  1. 1.

    Htwe TH, Mushtaq A, Robinson SB, Rosher RB, Khardori N. Infection in the elderly. Infect Dis Clin North Am. 2007;21:711–743, ix.

    PubMed  Article  Google Scholar 

  2. 2.

    Liang SY, Mackowiak PA. Infections in the elderly. Clin Geriatr Med. 2007;23:441–456, viii.

    PubMed  Article  Google Scholar 

  3. 3.

    Gusmano MK, Michel JP. Life course vaccination and healthy aging. Aging Clin Exp Res. 2009;21:258–263.

    PubMed  Google Scholar 

  4. 4.

    Gavazzi G, Krause KH. Ageing and infection. Lancet Infect Dis. 2002;2:659–666.

    PubMed  Article  Google Scholar 

  5. 5.

    Welte T, Torres A, Nathwani D. Clinical and economic burden of community-acquired pneumonia among adults in Europe. Thorax. 2012;67:71–79.

    PubMed  Article  CAS  Google Scholar 

  6. 6.

    Weiskopf D, Weinberger B, Grubeck-Loebenstein B. The aging of the immune system. Transpl Int. 2009;22:1041–1050.

    PubMed  Article  CAS  Google Scholar 

  7. 7.

    Blasi F, Mantero M, Santus P, Tarsia P. Understanding the burden of pneumococcal disease in adults. Clin Microbiol Infect. 2012;18:7–14.

    PubMed  Article  Google Scholar 

  8. 8.

    Sjostrom K, Spindler C, Ortqvist A, et al. Clonal and capsular types decide whether pneumococci will act as a primary or opportunistic pathogen. Clin Infect Dis. 2006;42:451–459.

    PubMed  Article  CAS  Google Scholar 

  9. 9.

    Reinert RR, Haupts S, van der Linden M, et al. Invasive pneumococcal disease in adults in North-Rhine Westphalia, Germany, 2001–2003. Clin Microbiol Infect. 2005;11:985–991.

    PubMed  Article  CAS  Google Scholar 

  10. 10.

    Robinson KA, Baughman W, Rothrock G, et al. Epidemiology of invasive Streptococcus pneumoniae infections in the United States, 1995–1998: opportunities for prevention in the conjugate vaccine era. JAMA. 2001;285:1729–1735.

    PubMed  Article  CAS  Google Scholar 

  11. 11.

    Fung HB, Monteagudo-Chu MO. Communityacquired pneumonia in the elderly. Am J Geriatr Pharmacother. 2010;8:47–62.

    PubMed  Article  CAS  Google Scholar 

  12. 12.

    Moberley SA, Holden J, Tatham DP, Andrews RM. Vaccines for preventing pneumococcal infection in adults. Cochrane Database Syst Rev. 2008;CD000422.

    Google Scholar 

  13. 13.

    Siemieniuk RA, Gregson DB, Gill MJ. The persisting burden of invasive pneumococcal disease in HIV patients: an observational cohort study. BMC Infect Dis. 2011;11:314.

    PubMed  Article  Google Scholar 

  14. 14.

    Yin Z, Rice BD, Waight P, et al. Invasive pneumococcal disease among HIV-positive individuals, 2000–2009. AIDS. 2012;26:87–94.

    PubMed  Article  Google Scholar 

  15. 15.

    Grau I, Ardanuy C, Linares J, Podzamczer D, Schulze MH, Pallares R. Trends in mortality and antibiotic resistance among HIV-infected patients with invasive pneumococcal disease. HIV Med. 2009;10:488–495.

    PubMed  Article  CAS  Google Scholar 

  16. 16.

    Elston JW, Santaniello-Newton A, Meigh JA, et al. Increasing incidence of invasive pneumococcal disease and pneumonia despite improved vaccination uptake: surveillance in Hull and East Yorkshire, UK, 2002–2009. Epidemiol Infect. 2012;140:1252–1266.

    PubMed  Article  CAS  Google Scholar 

  17. 17.

    Kyaw MH, Christie P, Clarke SC, et al. Invasive pneumococcal disease in Scotland, 1999–2001: use of record linkage to explore associations between patients and disease in relation to future vaccination policy. Clin Infect Dis. 2003;37:1283–1291.

    PubMed  Article  Google Scholar 

  18. 18.

    Trotter CL, Waight P, Andrews NJ, et al. Epidemiology of invasive pneumococcal disease in the pre-conjugate vaccine era: England and Wales, 1996–2006. J Infect. 2010;60:200–208.

    PubMed  Article  Google Scholar 

  19. 19.

    Jansen AG, Rodenburg GD, de Greeff SC, et al. Invasive pneumococcal disease in the Netherlands: syndromes, outcome and potential vaccine benefits. Vaccine. 2009;27:2394–2401.

    PubMed  Article  Google Scholar 

  20. 20.

    Ardanuy C, Tubau F, Pallares R, et al. Epidemiology of invasive pneumococcal disease among adult patients in Barcelona before and after pediatric 7-valent pneumococcal conjugate vaccine introduction, 1997–2007. Clin Infect Dis. 2009;48:57–64.

    PubMed  Article  Google Scholar 

  21. 21.

    Giner AM, Kuster SP, Zbinden R, Ruef C, Ledergerber B, Weber R. Initial management of and outcome in patients with pneumococcal bacteraemia: a retrospective study at a Swiss university hospital, 2003–2009. Infection. 2011;39:519–526.

    PubMed  Article  Google Scholar 

  22. 22.

    Fedson DS, Nicolas-Spony L, Klemets P, et al. Pneumococcal polysaccharide vaccination for adults: new perspectives for Europe. Expert Rev Vaccines. 2011;10:1143–1167.

    PubMed  Article  CAS  Google Scholar 

  23. 23.

    Department of Health. Pneumococcal polysaccharide vaccine (PPV) uptake summary report. Available at: Accessed Apr 9 2013.

  24. 24.

    World ESOMAR Research, ICC. ICC/ISOMAR International Code on market and social research. ESOMAR 2007. Available at: Accessed Mar 27 2013.

  25. 25.

    CNIL. Decree No 2005-1309 of 20 October 2005 enacted for the application of Act No 78-17 of 6 January 1978 on Data Processing, Files and Individual Liberties (Amended by Decree 2007-451 of 25 March 2007) Consolidated on the 25th of March 2007. CNIL 2007. Available at: Accessed Mar 27 2013.

    Google Scholar 

  26. 26.

    Musher DM. Pneumococcal infections. In: Kasper DL, Fauci AS, eds. Harrison’s Infectious Diseases. McGraw Hill Medical; 2010:374–385.

    Google Scholar 

  27. 27.

    Bordon J, Peyrani P, Brock GN, et al. The presence of pneumococcal bacteraemia does not influence clinical outcomes in patients with community-acquired pneumonia: results from the Community-Acquired Pneumonia Organization (CAPO) International Cohort study. Chest. 2008;133:618–624.

    PubMed  Article  Google Scholar 

  28. 28.

    Gil-Prieto R, Garcia-Garcia L, Alvaro-Meca A, Mendez C, Garcia A, de Miguel AG. The burden of hospitalisations for community-acquired pneumonia (CAP) and pneumococcal pneumonia in adults in Spain (2003–2007). Vaccine. 2011;29:412–416.

    PubMed  Article  Google Scholar 

  29. 29.

    Bewick T, Sheppard C, Greenwood S, et al. Serotype prevalence in adults hospitalised with pneumococcal non-invasive community-acquired pneumonia. Thorax. 2012;67:540–545.

    PubMed  Article  Google Scholar 

  30. 30.

    van Mens SP, Meijvis SC, Endeman H, et al. Longitudinal analysis of pneumococcal antibodies during community-acquired pneumonia reveals a much higher involvement of Streptococcus pneumoniae than estimated by conventional methods alone. Clin Vaccine Immunol. 2011;18:796–801.

    PubMed  Article  Google Scholar 

  31. 31.

    Gavazzi G, Wazieres B, Lejeune B, Rothan-Tondeur M. Influenza and pneumococcal vaccine coverages in geriatric health care settings in France. Gerontology. 2007;53:382–387.

    PubMed  Article  Google Scholar 

  32. 32.

    Martinelli D, Tafuri S, Caputi G, et al. Eight years of active proposal of pneumococcal 23-valent polysaccharide vaccine: survey on coverage rate among elderly and chronic patients. Am J Infect Control. 2010;38:e8–e15.

    PubMed  Article  Google Scholar 

  33. 33.

    Mohseni-Zadeh M, Rey D, Batard ML, et al. Inadequate vaccination coverage in a French cohort of HIV positive patients [In French]. Med Mal Infect. 2010;40:683–690.

    PubMed  Article  CAS  Google Scholar 

  34. 34.

    Teich N, Klugmann T, Tiedemann A, et al. Vaccination coverage in immunosuppressed patients: results of a regional health services research study. Dtsch Arztebl Int. 2011;108:105–111.

    PubMed  Google Scholar 

  35. 35.

    Zimmerman RK, Nowalk MP, Tabbarah M, Hart JA, Fox DE, Raymund M. Understanding adult vaccination in urban, lower-socioeconomic settings: influence of physician and prevention systems. Ann Fam Med. 2009;7:534–541.

    PubMed  Article  Google Scholar 

  36. 36.

    Krueger P, St Amant O, Loeb M. Predictors of pneumococcal vaccination among older adults with pneumonia: findings from the Community Acquired Pneumonia Impact Study. BMC Geriatr. 2010;10:44.

    PubMed  Article  Google Scholar 

  37. 37.

    Michel JP. Updated vaccine guidelines for aging and aged citizens of Europe. Expert Rev Vaccines. 2010;9:7–10.

    PubMed  Article  Google Scholar 

  38. 38.

    Lau D, Hu J, Majumdar SR, Storie DA, Rees SE, Johnson JA. Interventions to improve influenza and pneumococcal vaccination rates among community-dwelling adults: a systematic review and meta-analysis. Ann Fam Med. 2012;10:538–546.

    PubMed  Article  Google Scholar 

  39. 39.

    Badertscher N, Morell S, Rosemann T, Tandjung R. General practitioners’ experiences, attitudes, and opinions regarding the pneumococcal vaccination for adults: a qualitative study. Int J Gen Med. 2012;5:967–974.

    PubMed  Google Scholar 

  40. 40.

    Huss A, Scott P, Stuck AE, Trotter C, Egger M. Efficacy of pneumococcal vaccination in adults: a meta-analysis. CMAJ. 2009;180:48–58.

    PubMed  Google Scholar 

  41. 41.

    Foster D, Walker AS, Paul J, et al. Reduction in invasive pneumococcal disease following implementation of the conjugate vaccine in the Oxfordshire region, England. J Med Microbiol. 2011;60:91–97.

    PubMed  Article  Google Scholar 

  42. 42.

    Pilishvili T, Lexau C, Farley MM, et al. Sustained reductions in invasive pneumococcal disease in the era of conjugate vaccine. J Infect Dis. 2010;201:32–41.

    PubMed  Article  Google Scholar 

  43. 43.

    Simonsen L, Taylor RJ, Young-Xu Y, Haber M, May L, Klugman KP. Impact of pneumococcal conjugate vaccination of infants on pneumonia and influenza hospitalization and mortality in all age groups in the United States. MBio. 2011;2:e00309–e00310.

    PubMed  Article  Google Scholar 

  44. 44.

    Reinert RR, Paradiso P, Fritzell B. Advances in pneumococcal vaccines: the 13-valent pneumococcal conjugate vaccine received market authorization in Europe. Expert Rev Vaccines. 2010;9:229–236.

    PubMed  Article  Google Scholar 

  45. 45.

    Zhou F, Shefer A, Kong Y, Nuorti JP. Trends in acute otitis media-related health care utilization by privately insured young children in the United States, 1997–2004. Pediatrics. 2008;121:253–260.

    PubMed  Article  Google Scholar 

  46. 46.

    Cohen R, Levy C, de La Rocque F, et al. Impact of pneumococcal conjugate vaccine and of reduction of antibiotic use on nasopharyngeal carriage of nonsusceptible pneumococci in children with acute otitis media. Pediatr Infect Dis J. 2006;25:1001–1007.

    PubMed  Article  Google Scholar 

  47. 47.

    Whitney CG, Farley MM, Hadler J, et al. Decline in invasive pneumococcal disease after the introduction of protein-polysaccharide conjugate vaccine. N Engl J Med. 2003;348:1737–1746.

    PubMed  Article  Google Scholar 

  48. 48.

    Lexau CA, Lynfield R, Danila R, et al. Changing epidemiology of invasive pneumococcal disease among older adults in the era of pediatric pneumococcal conjugate vaccine. JAMA. 2005;294:2043–2051.

    PubMed  Article  CAS  Google Scholar 

  49. 49.

    Miller E, Andrews NJ, Waight PA, Slack MP, George RC. Herd immunity and serotype replacement 4 years after seven-valent pneumococcal conjugate vaccination in England and Wales: an observational cohort study. Lancet Infect Dis. 2011;11:760–768.

    PubMed  Article  CAS  Google Scholar 

  50. 50.

    Myint TT, Madhava H, Balmer P, et al. The impact of 7-valent pneumococcal conjugate vaccine on invasive pneumococcal disease: a literature review. Adv Ther. 2013;30:127–151.

    PubMed  Article  CAS  Google Scholar 

  51. 51.

    Pfizer Limited. Prevenar 13 suspension for injection summary of product characteristics. eMC. Available at: Accessed Feb 4 2013.

  52. 52.

    European Medicines Agency. Prevenar 13. European Medicines Agency 2013. Available at: Accessed Mar 4 2013.

  53. 53.

    GlaxoSmithKline Biologicals s.a. Synoflorix. Summary of product characteristics. European Medicines Agency 2013. Available at: Accessed Mar 4 2013.

  54. 54.

    Jackson LA, Gurtman A, van Cleeff M. Immunogenicity and safety of a 13-valent pneumococcal conjugate caccine in pneumococcal vaccine naive adults, 50–64 years of age [abstract O426]. Clin Microbiol Infect. 2011;17:S85.

    Google Scholar 

  55. 55.

    Jackson LA, Gurtman A, van Cleeff M. 13-valent pneumococcal conjugate vaccine (PCV13) enhances the response to subsequent PCV13 and 23-valent pneumococcal polysaccharide (PPSV23) vaccinations in adults 50 years and older [abstract LB-3]. Presented at the 49th Annual Meeting of the Infectious Diseases Society of America; October 20–23, 2011; Boston, MA.

Download references

Author information



Corresponding author

Correspondence to George Kassianos.

Additional information

To view enhanced content go to

This article is published with open access at

Electronic supplementary material

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 2.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Reprints and Permissions

About this article

Cite this article

Lode, H., Ludwig, E. & Kassianos, G. Pneumococcal Infection — Low Awareness as a Potential Barrier to Vaccination: Results of a European Survey. Adv Therapy 30, 387–405 (2013).

Download citation


  • Europe
  • Immunology
  • Infectious diseases
  • Invasive pneumococcal disease
  • Pneumococcal infection
  • Survey
  • Vaccination