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Pneumococcal Disease Guide

Over 100 pneumococcal strains exist, but just a few cause most disease – learn how updated vaccination programs protect patients in 2026

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About Pneumococcal Disease

Pneumococcal disease is caused by the Gram-negative bacterium, Streptococcus pneumoniae (pneumococcus). Infection usually starts with a colonising event in the nose and throat, which is asymptomatic, and most infections do not progress beyond colonisation. However, some infections spread locally or invasively to cause disease.


Certain pneumococcal diseases are non-invasive, such as middle ear infections (otitis media), sinusitis, or bronchitis.[1] Others are invasive, involving the blood or a major organ, and are potentially life-threatening. Examples of invasive pneumococcal diseases (IPDs) include septicaemia (sepsis), meningitis, or bacteraemic pneumonia.


Pneumococci usually possess a polysaccharide capsule, which appears as more than 100 serotypes,[2]and immunity to the organism is capsule-type specific. Although many serotypes cause disease, only a few cause most infections. The predominant serotypes vary with age, time, and geography.[3][4]

Transmission

Transmission occurs through respiratory droplets from people with pneumococcal disease or healthy carriers. If an infected person coughs or sneezes in close proximity to others, the infection may spread.

Following acquisition, the bacterium becomes established in the nasopharynx of the host, leading to asymptomatic colonisation. It may then spread to other parts of the body, causing disease. The bacteria’s polysaccharide capsule helps it resist phagocytosis. If no anti-capsular antibody pre-exists, alveolar macrophages cannot kill the pneumococci.[6][7][8][9]

Clinical Features

The major clinical syndromes of IPD are pneumonia, septicaemia, and meningitis.[10][11] Symptoms of pneumonia include fever, chills, coughing, rapid or difficult breathing, chest pain, rigors, tachycardia, rusty-coloured sputum, cough productive of mucopurulent material, dyspnoea, tachypnoea, hypoxia, or, in older patients, confusion or low alertness.

Meningitis, although the least common, is the most severe category of IPD and is often fatal.[12][13] Symptoms include a stiff neck, fever, lethargy, nuchal rigidity, cranial nerve signs, seizures, coma, headache, pain when looking into bright lights, confusion, or, in babies, poor feeding, low alertness, or vomiting.

Septicaemia is the most common IPD among young children. Symptoms include fever, chills, and low alertness. By 12 months, most children have also experienced otitis media. Pneumococcus is detected in 28 to 55% of middle ear aspirates from children with otitis media. Symptoms include ear pain, a red, swollen eardrum, fever, and sleepiness. Complications of otitis media may include mastoiditis and meningitis.[14][15][16]

Antibiotic Resistance

Pneumococcal disease is mainly treated using β-lactam antibiotics, though pneumococci are increasingly developing antibiotic resistance. Strains have variably become resistant to penicillin, cephalosporins, macrolides, tetracycline, clindamycin, and quinolones.[5]

The following recommendations have been taken from both the NIP Schedule and Australian Immunisation Handbook.

Who Should Receive Pneumococcal Disease Vaccination

Infants and children

Infants and children are recommended to receive a pneumococcal conjugate vaccine.

Adults

Adults aged ≥65 years are recommended to receive pneumococcal vaccine

Aboriginal and/or Torres Strait Islander people

Aboriginal and Torres Strait Islander children are recommended to receive pneumococcal vaccine

Aboriginal and Torres Strait Islander adults aged ≥25 years are recommended to receive pneumococcal vaccine

People with medical risk factors

Infants aged <12 months with a risk condition are recommended to receive pneumococcal vaccine

Children and adolescents aged ≥12 months to <18 years with a risk condition are recommended to receive pneumococcal vaccine

Adults aged ≥18 years with a risk condition are recommended to receive pneumococcal vaccine

Vaccine Type and Dosage

The type and number of doses of pneumococcal disease vaccination vary across age groups and risk categories. This can be quite complicated to follow, but it is summarised in the NIP Schedule and Australian Immunisation Handbook (AIH).

The Immunisation Coalition has developed the PneumoSmart Vaccination Tool (PTV), a digital tool  which identifies the vaccine type and dosage based on patient criteria. The PVT is based on the AIH and is intended for use by practitioners and nurse immunisers.  It is currently being updated to reflect the changes in vaccine recommendations. Join our free weekly newsletter and be notified once it’s completed, as well as other key infectious diseases information.

Diagnosis

Diagnosis of pneumococcal disease should be based on the following:

  • Clinical evaluation: Based on symptoms and physical examination.
  • Laboratory tests: Blood tests, sputum cultures, and urine tests to identify S. pneumoniae.
  • Imaging: Chest X-rays for pneumonia and CT scans for sinusitis or suspected meningitis.

Dosage And Administration

The dose of 20-valent pneumococcal conjugate vaccine (20vPCV) is 0.5 mL, to be given by IM injection in the opposite limb to other injectable vaccines, if possible. 20vPCV (Prevenar 20) is registered for use in people aged ≥6 weeks.[18]

The dose of 21-valent pneumococcal conjugate vaccine (21vPCV) is 0.5mL, given by intramuscular injection. 21vPCV (Capvaxive) is registered for use in people aged ≥18 years.[19]

Childhood Vaccination Recommendations

Routine schedule for all children[20]

All children are recommended to receive 20vPCV in a 3-dose schedule at 2, 4 and 12 months of age. The first dose may be given from 6 weeks of age, with subsequent doses still administered according to the routine schedule.

Children who commenced vaccination with 13vPCV or 15vPCV (now both discontinued and replaced by 20vPCV) should complete their schedule with 20vPCV. Children who have already completed their schedule with 13vPCV or 15vPCV do not require a supplementary dose of 20vPCV.

For catch-up vaccination recommendations for non-Indigenous children without risk conditions, see Table. Catch-up schedule for 20vPCV for children aged <5 years who are either non-Indigenous without a risk condition for pneumococcal disease, or Aboriginal and Torres Strait Islander children living in ACT, NSW, Tas or Vic born before 1 March 2025. 

Aboriginal and Torres Strait Islander children and children with eligible risk conditions require an additional dose at 6 months of age (see below sections).

20vPCV (Prevenar 20®) is funded under the National Immunisation Program (NIP) for all children aged <5 years.

Aboriginal and/or Torres Strait Islander children[21]

Aboriginal and Torres Strait Islander children are recommended to receive 4 doses of 20vPCV at 2, 4, 6 and 12 months of age, with the additional 6-month dose recommended because of the higher burden of pneumococcal disease in this population.

Children who commenced vaccination with 13vPCV or 15vPCV should complete their schedule with 20vPCV. Once they have received at least one dose of 20vPCV, no further pneumococcal doses are required at 4 years of age.

Catch-up recommendations vary by jurisdiction:

  • NT, QLD, WA and SA: Children who completed their schedule with 13vPCV or 15vPCV only should receive one dose of 20vPCV at 4 years of age or at least 12 months after their last PCV dose (whichever is later). If they have already received one dose of 23vPPV, they should instead receive one dose of 20vPCV at least 5 years after the 23vPPV dose. Children who have already received two doses of 23vPPV do not require a supplementary 20vPCV dose.
  • ACT, NSW, Victoria and Tasmania: Aboriginal and Torres Strait Islander children without a risk condition who completed their schedule with 13vPCV or 15vPCV do not require a supplementary dose of 20vPCV.

For catch-up vaccination recommendations for Aboriginal and Torres Strait Islander children see:

20vPCV is funded through the NIP for Aboriginal and Torres Strait Islander children aged <18 years.

Children with risk conditions[22]

Infants aged <12 months with a risk condition are recommended to receive 20vPCV in a 4-dose schedule at 2, 4, 6 and 12 months of age. The additional dose at 6 months is recommended because of the higher risk of pneumococcal disease and reduced immune responses in this population.

Children who commenced vaccination with 13vPCV or 15vPCV should complete their schedule with 20vPCV. Once they have received at least one dose of 20vPCV, no additional pneumococcal dose is required at 4 years of age.

Children aged 6–11 months who are newly diagnosed with a risk condition and did not receive the 6-month dose should receive one dose of 20vPCV at diagnosis. (Exception: children who have received a haematopoietic stem cell transplant should receive 3 doses of 20vPCV after transplantation, regardless of previous pneumococcal vaccination history.) See Table. Recommendations for vaccination after haematopoietic stem cell transplant in children and adults.

Children and adolescents aged 12 months to <18 years with a risk condition who have completed their routine childhood pneumococcal schedule are recommended to receive one additional dose of 20vPCV. Aboriginal and Torres Strait Islander children with a risk condition already receive this dose as part of their routine schedule and do not require an extra dose.

Catch-up recommendations:

  • Children with a risk condition who completed their schedule with 13vPCV or 15vPCV only should receive one dose of 20vPCV at 4 years of age or at least 12 months after their last PCV dose (whichever is later).
  • If they have already received one dose of 23vPPV, they should instead receive one dose of 20vPCV at least 5 years after the 23vPPV dose.
  • Children who have already received two doses of 23vPPV do not require a supplementary dose of 20vPCV.
  • Any 20vPCV dose should be administered at least 8 weeks after a previous PCV dose and at least 12 months after a previous 23vPPV dose.

20vPCV is funded under the National Immunisation Program (NIP) for eligible children with specified risk conditions.

Adult Vaccination Recommendations[23]

A single dose of 21vPCV is recommended for:

  • All adults aged ≥65 years
  • All Aboriginal and Torres Strait Islander adults aged ≥25 years
  • People aged ≥18 years with eligible risk conditions

People who have previously received 23vPPV*, 13vPCV*, 15vPCV* or 20vPCV should receive 21vPCV at least 12 months after their most recent pneumococcal vaccine. See Infographic. Pneumococcal vaccination for people who have previously received a pneumococcal vaccine.

* As of 1 July 2026, has been replaced by 21vPCV

Additional recommendations:

  • Adults aged 18–64 years who receive 21vPCV because of a risk condition do not require another dose at 65 years.
  • Aboriginal and Torres Strait Islander adults aged 18–24 years who receive 21vPCV because of a risk condition do not require another dose at 25 years.
  • Children with a risk condition who received 20vPCV before 18 years of age should receive one dose of 21vPCV at 18 years of age.
  • Adults aged ≥65 years and Aboriginal and Torres Strait Islander adults aged ≥25 years who later develop a risk condition do not require an additional dose of 21vPCV if they have already received it as part of the routine adult program.
  • People who have received a haematopoietic stem cell transplant should receive 3 doses of 21vPCV after transplantation, regardless of previous pneumococcal vaccination history.

21vPCV is funded under the National Immunisation Program (NIP) for all adults aged ≥65 years, Aboriginal and Torres Strait Islander adults aged ≥25 years, and eligible adults aged ≥18 years with specified risk conditions.

Pregnancy And Breastfeeding[24]

Pneumococcal vaccines are not routinely recommended during pregnancy. Women with risk conditions for pneumococcal disease should ideally be vaccinated before a planned pregnancy or as soon as practicable after delivery.

Although data on the use of 15vPCV, 20vPCV and 21vPCV during pregnancy and breastfeeding are limited, there is no evidence to suggest a significant risk of serious adverse effects. Vaccination during pregnancy may be considered for women at highest risk of pneumococcal disease when the benefits outweigh the potential risks.

15vPCV, 20vPCV and 21vPCV can be safely administered during breastfeeding.

Co-Administration With Other Vaccines[25]

Pneumococcal conjugate vaccines (PCVs) can be administered at the same time as, or separately from, other recommended vaccines.

  • Infants and children: PCVs may be co-administered with all routine childhood vaccines, including influenza vaccine and RSV-specific monoclonal antibody.
  • Adults: PCVs may be co-administered with herpes zoster, influenza, RSV and COVID-19 vaccines. Co-administration offers practical advantages by improving vaccine uptake and helping ensure vaccinations are received on schedule.

Studies have shown that co-administration of 21vPCV with influenza vaccine may result in lower antibody responses to some pneumococcal serotypes and influenza strains compared with separate administration. However, the clinical significance of this finding is currently unknown.

References

  1. Weinberger DM, Harboe ZB, Sanders EA, et al. Association of serotype with risk of death due to pneumococcal pneumonia: a meta-analysis. Clinical Infectious Diseases 2010;51:692-9.
  2. Bertran M et al. Invasive pneumococcal disease 3 years after introduction of a reduced 1 + 1 infant 13-valent pneumococcal conjugate vaccine immunisation schedule in England: a prospective national observational surveillance study  The Lancet Infectious Diseases May 2024 https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(23)00706-5/fulltext
  3. World Health Organization (WHO). 23-valent pneumococcal polysaccharide vaccine: WHO position paper. Weekly Epidemiological Record 2008;83:373- 84.
  4. Klugman KP, Dagan R, Malley R, Whitney CG. Pneumococcal conjugate vaccine and pneumococcal common protein vaccines. In: Plotkin SA, Orenstein WA, Offit PA, Edwards KM, eds. Plotkin’s vaccines. 7th ed. Philadelphia, PA: Elsevier; 2018.
  5. Roche PW, Krause V, Cook H, et al. Invasive pneumococcal disease in Australia, 2006. Communicable Diseases Intelligence 2008;32:18-30
  6. Kadioglu A, Weiser JN, Paton JC, Andrew PW. The role of Streptococcus pneumoniae virulence factors in host respiratory colonization and disease. Nature Reviews Microbiology 2008;6:288-301.
  7. Centers for Disease Control and Prevention (CDC). Pneumococcal disease. In: Atkinson W, Wolfe C, Hamborsky J, eds. Epidemiology and prevention of vaccine-preventable diseases. 12th ed. Washington, D.C.: Public Health Foundation, 2011.
  8. Black S, Eskola J, Whitney C, Shinefield H. Pneumococcal conjugate vaccine and pneumococcal common protein vaccines. In: Plotkin SA, Orenstein WA, Offit PA, eds. Vaccines. 5th ed. Philadelphia, PA: Saunders Elsevier, 2008.
  9. World Health Organization (WHO). 23-valent pneumococcal polysaccharide vaccine: WHO position paper. Weekly Epidemiological Record 2008;83:373- 84.
  10. Centers for Disease Control and Prevention (CDC). Pneumococcal disease. In: Atkinson W, Wolfe C, Hamborsky J, eds. Epidemiology and prevention of vaccine-preventable diseases. 12th ed. Washington, D.C.: Public Health Foundation, 2011.
  11. File TM, Jr., Marrie TJ. Burden of community- acquired pneumonia in North American adults. Postgraduate Medicine 2010;122:130-41.
  12. CDC. Pneumococcal disease. In: Atkinson W, Wolfe C, Hamborsky J, eds. Public Health Foundation, 2011.
  13. Black S, Eskola J, Whitney C, Shinefield H. Pneumococcal conjugate vaccine and pneumococcal common protein vaccines. In: Plotkin SA, Orenstein WA, Offit PA, eds. Vaccines. 5th ed. Philadelphia, PA: Saunders Elsevier, 2008.
  14. CDC. Pneumococcal disease. In: Atkinson W, Wolfe C, Hamborsky J, eds. Public Health Foundation, 2011.
  15. World Health Organization (WHO). 23-valent pneumococcal polysaccharide vaccine: WHO position paper. Weekly Epidemiological Record 2008;83:373- 84.
  16. Eskola J, Kilpi T, Palmu A, et al. Efficacy of a pneumococcal conjugate vaccine against acute. otitis media. New England Journal of Medicine 2001;344:403-9.
  17. VAXNEUVANCE® (Pneumococcal 15-valent Conjugate Vaccine [CRM197 Protein], adsorbed) [Internet]. ebs.tga.gov.au. [cited 2024 Aug 26]. Available from https://www.ebs.tga.gov.au/ebs/picmi/picmirepository.nsf/pdf?OpenAgent&id=CP-2022-PI-01039-1
  18. PREVENAR 20® (pneumococcal polysaccharide conjugate, 20-valent adsorbed) VACCINE [Internet]. ebs.tga.gov.au. [cited 2024 Aug 26]. Available from https://www.ebs.tga.gov.au/ebs/picmi/picmirepository.nsf/pdf?OpenAgent&id=CP-2022-PI-02385-1
  19. CAPVAXIVE® (Pneumococcal 21-valent Conjugate Vaccine) [Internet]. ebs.tga.gov.au. [cited 2026 Jul 8]. Available from: https://www.ebs.tga.gov.au/ebs/picmi/picmirepository.nsf/pdf?OpenAgent&id=CP-2025-PI-01205-1&d=20260708172310101
  20. Australian Technical Advisory Group on Immunisation (ATAGI). Pneumococcal disease: Infants and children – Recommendations [Internet]. Canberra: Australian Immunisation Handbook, Department of Health, Disability and Ageing; 2026 [cited 2026 Jul 8]. Available from: https://immunisationhandbook.health.gov.au/pneumococcal-disease#infants-and-children 
  21. Australian Technical Advisory Group on Immunisation (ATAGI). Pneumococcal disease: Aboriginal and Torres Strait Islander people – Recommendations [Internet]. Canberra: Australian Immunisation Handbook, Department of Health, Disability and Ageing; 2026 [cited 2026 Jul 8]. Available from: https://immunisationhandbook.health.gov.au/pneumococcal-disease#aboriginal-and-torres-strait-islander-people
  22. Australian Technical Advisory Group on Immunisation (ATAGI). Pneumococcal disease: People with medical risk factors – Recommendations [Internet]. Canberra: Australian Immunisation Handbook, Department of Health, Disability and Ageing; 2026 [cited 2026 Jul 8]. Available from: https://immunisationhandbook.health.gov.au/pneumococcal-disease#people-with-medical-risk-factors 
  23. Australian Technical Advisory Group on Immunisation (ATAGI). Pneumococcal disease: Adults – Recommendations [Internet]. Canberra: Australian Immunisation Handbook, Department of Health, Disability and Ageing; 2026 [cited 2026 Jul 8]. Available from: https://immunisationhandbook.health.gov.au/pneumococcal-disease#adults 
  24. Australian Technical Advisory Group on Immunisation (ATAGI). Pneumococcal disease: Women who are pregnant or breastfeeding [Internet]. Canberra: Australian Immunisation Handbook, Department of Health, Disability and Ageing; 2026 [cited 2026 Jul 8]. Available from: https://immunisationhandbook.health.gov.au/pneumococcal-disease#women-who-are-pregnant-or-breastfeeding 
  25. Australian Technical Advisory Group on Immunisation (ATAGI). Pneumococcal disease: Co-administration with other vaccines [Internet]. Canberra: Australian Immunisation Handbook, Department of Health, Disability and Ageing; 2026 [cited 2026 Jul 8]. Available from: https://immunisationhandbook.health.gov.au/pneumococcal-disease#coadministration-with-other-vaccines 

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