Pneumococcal disease: For health professionals
On this page
- Key information
- Epidemiology
- Clinical manifestations
- Risk factors
- Diagnosis and laboratory testing
- Treatment
- Prevention
- Surveillance and monitoring
Key information
Pneumococcal disease is caused by the bacterium Streptococcus pneumoniae (S. pneumoniae). More than 100 serotypes are recognized worldwide. When the bacterium invades a normally sterile site, it is known as invasive pneumococcal disease (IPD). Pneumonia with bacteremia, bacteremia, and meningitis are the most common forms of IPD.
The National Advisory Committee on Immunization (NACI) recommends immunization against pneumococcal disease for specific ages and underlying medical conditions.
Learn more:
- Pneumococcal vaccines: Canadian Immunization Guide
- NACI statements and publications: Pneumococcal vaccines
Epidemiology
S. pneumoniae is a gram-positive, facultative anaerobic bacterium, which belongs to the Streptococcus genus in the Streptococcaceae family.
Reservoir
Humans are the only reservoir. S. pneumoniae is a common bacteria that can colonize the human respiratory tract.
Incubation period
The incubation period varies by type of infection but may be as short as 1 to 3 days.
Transmission
S. pneumoniae can be transmitted through:
- inhalation of infectious respiratory particles
- direct contact of mucosal surfaces (for example, ocular, nasal, or oral) with infectious respiratory particles or secretions
- contaminated fomites (rare)
Transmission depends on multiple factors, including having bacteria present in secretions from the nose and mouth. Following initiation of appropriate antibiotics, a person likely stops being infectious within 24 hours.
Clinical manifestations
Transient pneumococcal colonization of the upper respiratory tract is common among healthy people. Colonization occurs in many healthy children and adults. Most typically, colonized individuals are asymptomatic carriers and show no symptoms.
Pneumococci can cause many infections including those that are:
- non-invasive, such as:
- otitis media
- sinusitis
- pneumonia
- invasive, such as:
- pneumonia with bacteremia
- bacteremia
- meningitis
Invasive diseases
Pneumococcal infection can cause severe disease and can lead to significant morbidity and mortality.
When the bacteria invade a normally sterile site, it becomes known as IPD. Pneumonia with bacteremia, bacteremia, and meningitis are the most common forms of IPD.
In Canada, IPD is more common in the winter and spring.
Pneumococcal pneumonia with bacteremia is the most common invasive presentation among adults and is a common complication following influenza, respiratory syncytial virus or other respiratory viruses. The case fatality rate is 5% to 7% and is higher among older adults and those with multiple co-morbidities.
Bacteremia is the most common presentation of IPD in unvaccinated children under 2 years of age.
Pneumococcal meningitis has a case-fatality rate of 8% among children and 22% among adults. Deafness and permanent neurologic injury are common among survivors.
Risk factors
IPD is most common in children under 5 and adults over 65 years of age, and individuals with risk factors. It is often preceded by a viral respiratory tract infection.
Risk factors include medical conditions related to:
- congenital immunodeficiencies
- immunocompromising conditions or immunosuppressive therapy within the last 2 years, including:
- use of long-term corticosteroids
- chemotherapy
- radiation therapy
- immunosuppressive biologics
- HIV infection
- hematopoietic stem cell transplant recipients
- chronic kidney disease, particularly:
- in individuals with stage 4 or 5 chronic kidney disease
- for those on dialysis
- for those with renal transplants
- for those with nephrotic syndrome
- active malignant neoplasms, including leukemia and lymphoma
- candidates and recipients of solid organ or islet transplants
- chronic liver disease, including hepatic cirrhosis, biliary atresia and chronic hepatitis
- functional or anatomic asplenia (congenital or acquired) or splenic dysfunction, including sickle cell disease and other hemoglobinopathies
- chronic cerebrospinal fluid leak
- candidates and recipients of cochlear implants
- chronic neurologic conditions that may impair clearance of oral secretions
- chronic heart disease requiring regular medication and follow-up for:
- ischemic heart disease
- congenital heart disease
- chronic heart failure
- hypertension with cardiac complications
- diabetes mellitus, particularly in those over 50 years of age
- chronic lung disease (particularly chronic obstructive pulmonary disease, emphysema, bronchiectasis, interstitial lung fibrosis, and cystic fibrosis), including asthma requiring medical care in the preceding 12 months
Risk is also increased with certain social, behavioural and environmental factors, such as:
- for individuals who are unhoused
- for individuals living in communities or settings experiencing sustained high IPD rates, including those who are in residential care (e.g., living in long-term care homes and residential care homes)
- smoking cigarettes, particularly in those over 50 years of age
- substance use disorders (i.e., alcohol misuse, cocaine use and injection drug use)
- occupational risk with long-term continuous exposure to metal fumes (i.e., welders)
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Diagnosis and laboratory testing
Diagnosis of S. pneumoniae infection typically involves isolating the organism from clinical specimens.
There are also polymerase chain reaction (PCR) tests that are useful in specific circumstances.
Health care providers are required to report confirmed cases of IPD to their local public health unit or office, as it is a nationally notifiable disease.
National case definition: Invasive pneumococcal disease
Learn more:
- Notifiable Diseases Online
- Pathogen: Streptococcus pneumoniae
- Laboratory: Streptococcus and STI Section
- Serotype determination of Streptococcus pneumoniae
- Antimicrobial susceptibility testing on Streptococcus pneumoniae
- Molecular detection and serotyping by PCR of Streptococcus pneumoniae
Treatment
Antibiotics are used to treat pneumococcal disease, and may vary depending on the type of infection. As antimicrobial resistance can occur, treatment is tailored to sensitivities from laboratory testing.
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Prevention
Routine vaccination
The most effective way to prevent pneumococcal disease is through immunization. Pneumococcal vaccines are recommended as part of routine immunizations in children and older adults, and for individuals at high risk of IPD.
The following pneumococcal vaccines are authorized for use in Canada. None are live vaccines:
- pneumococcal 10-valent conjugate vaccine (Pneu-C-10)
- pneumococcal 13-valent conjugate vaccine (Pneu-C-13)
- pneumococcal 15-valent conjugate vaccine Pneu-C-15)
- pneumococcal 20-valent conjugate vaccine (Pneu-C-20)
- pneumococcal 21-valent conjugate vaccine (Pneu-C-21)
- pneumococcal polysaccharide 23-valent vaccine (Pneu-P-23)
Pneu-C vaccine schedules vary by age, pneumococcal vaccine history and risk for IPD. The Pneu-P vaccine is only recommended in specific cases or for specific individuals.
Learn more:
- NACI: Pneumococcal vaccines
- Canadian Immunization Guide: Vaccine safety
- World Health Organization: Pneumococcal disease
- Pneumococcal vaccines: Canadian Immunization Guide
- Immunization of travellers: Canadian Immunization Guide
- World Health Organization: Position papers on pneumococcus
- Highlights from the 2021 childhood National Immunization Coverage Survey
- Vaccination coverage goals and vaccine preventable disease reduction targets by 2025
- Provincial and territorial routine vaccination programs for healthy, previously immunized adults
- Provincial and territorial routine and catch-up vaccination schedule for infants and children in Canada
Adverse events and contraindications
To ensure the ongoing safety of vaccines in Canada, it's critical that vaccine providers and clinicians report adverse events following immunization (AEFI). In most jurisdictions, reporting may also be mandatory under the public health legislation. Vaccine providers are to report AEFIs through their local public health unit or office.
Reporting of serious adverse events following immunization is important to inform vaccine safety surveillance. The Public Health Agency of Canada (PHAC):
- compiles and analyzes reports (without personal identifiers) received from across the country
- follows international data, current literature and expert opinions
There are circumstances in which pneumococcal vaccines may be contraindicated, such as in persons with a history of anaphylaxis post-vaccination.
Learn more:
- Vaccine safety: Canadian Immunization Guide
- Adverse events following immunization (AEFI) reporting form
- Safety and adverse events: Pneumococcal vaccines (Canadian Immunization Guide)
Surveillance and monitoring
Surveillance systems to monitor invasive pneumococcal disease in Canada
IPD has been nationally notifiable in Canada since 2000.
Cases that meet the national case definition are reported to PHAC for national monitoring purposes. Health care providers and laboratories report cases to their local public health unit or office. These reports are forwarded to provincial and territorial public health officials, then to PHAC through the Canadian Notifiable Disease Surveillance System.
The Surveillance of Invasive Streptococcal Disease, or eSTREP, carries out national laboratory surveillance of:
- IPD serotypes
- patterns of antimicrobial resistance in Canada
eSTREP is a voluntary, passive system where isolates are submitted to the National Microbiology Laboratory for serotyping.
In addition, the International Circumpolar Surveillance of invasive bacterial diseases collects epidemiologic and laboratory data without personal identifiers from northern regions of Canada and countries with Arctic regions. Since 2000, the system has been collecting data from the territories and northern regions of Quebec and Labrador.
Learn more:
- Notifiable Diseases Online
- Invasive pneumococcal disease in Canada, 2020
- National case definition: Invasive pneumococcal disease
- Surveillance of invasive streptococcal disease (eSTREP)
- Invasive bacterial diseases in northern Canada, 1999 to 2018
- Invasive pneumococcal disease surveillance in Canada, 2021–2022
- International Circumpolar Surveillance program of invasive bacterial diseases
- Vaccine Preventable Diseases: Surveillance Report to December 31, 2019 (invasive pneumococcal disease)
Invasive pneumococcal disease epidemiology and immunization in Canada
After implementing Pneu-C vaccination programs in Canada beginning in 2002, there was a significant reduction in overall incidence in children under 5 years of age from the pre-vaccine period. Pneu-C-7 vaccine had the largest impact on incidence in the under-5 age group. In 2010, after a change in product to Pneu-C-13, further decreases in this age group were observed. The average annual incidence rate (IR) in children under 5 years of age was approximately:
- 31.6 cases per 100,000 population from 2000-2001
- 24.9 cases per 100,000 population from 2002-2010
- 13.0 cases per 100,000 population from 2011-2019
During the COVID-19 pandemic, IPD incidence decreased across all age groups. After reaching its lowest levels in 2020, IPD incidence began to increase across most age groups in 2022 and 2023. In children under 5 years of age, the reported IR reached lows of 6.1 cases per 100,000 population in 2020 and 9.7 cases per 100,000 population in 2021, respectively. The reported IR in children under 5 years of age increased to 16.2 cases per 100,000 population in 2022, and 17.1 cases per 100,000 in 2023, respectively.
Figure 1: Text description
| Year | Less than 5 | 5 to 19 | 20 to 39 | 40 to 59 | 60 and over |
|---|---|---|---|---|---|
| 2000 | 35.6 | 1.9 | 3.1 | 5.1 | 13.8 |
| 2001 | 27.5 | 2.0 | 3.1 | 4.1 | 10.8 |
| 2002 | 36.6 | 1.9 | 3.9 | 4.7 | 15.6 |
| 2003 | 39.3 | 2.1 | 5.1 | 6.5 | 18.3 |
| 2004 | 33.4 | 2.1 | 5.2 | 7.6 | 20.7 |
| 2005 | 22.3 | 2.7 | 5.7 | 8.1 | 20.4 |
| 2006 | 15.1 | 2.6 | 7.0 | 9.0 | 19.1 |
| 2007 | 18.8 | 2.4 | 8.1 | 10.2 | 20.5 |
| 2008 | 19.4 | 2.3 | 6.2 | 9.6 | 21.6 |
| 2009 | 20.6 | 2.9 | 6.3 | 8.9 | 22.3 |
| 2010 | 18.3 | 2.5 | 5.9 | 9.0 | 23.4 |
| 2011 | 16.5 | 3.0 | 5.9 | 9.2 | 21.8 |
| 2012 | 14.5 | 2.7 | 6.6 | 9.2 | 22.9 |
| 2013 | 12.7 | 2.1 | 5.4 | 8.4 | 21.9 |
| 2014 | 12.2 | 1.9 | 5.3 | 8.6 | 21.2 |
| 2015 | 10.7 | 2.2 | 5.5 | 8.9 | 20.6 |
| 2016 | 12.8 | 2.2 | 5.9 | 9.0 | 20.0 |
| 2017 | 12.9 | 2.1 | 6.1 | 9.0 | 21.4 |
| 2018 | 12.5 | 2.0 | 6.8 | 11.5 | 23.4 |
| 2019 | 11.7 | 2.1 | 7.1 | 10.3 | 21.3 |
| 2020 | 6.1 | 1.0 | 5.0 | 7.2 | 11.0 |
| 2021 | 9.7 | 0.8 | 3.3 | 6.6 | 9.3 |
| 2022 | 16.2 | 3.1 | 5.6 | 11.3 | 15.6 |
| 2023 | 17.1 | 3.0 | 7.0 | 13.9 | 24.4 |
Note: IPD became nationally notifiable in 2000. Therefore, national incidence rate estimates are not available for years prior to 2000. The 2000 data from Ontario are not available, and the population of this province has been removed for rate calculation. Additionally, the 2023 data from Manitoba were not available at time of data preparation. The population of this province has been removed for rate calculation.
| Year | Less than 1 | 1 to 4 | 5 to 9 | 10 to 14 | 15 to 19 | 20 to 24 | 25 to 29 | 30 to 39 | 40 to 59 | 60 and over |
|---|---|---|---|---|---|---|---|---|---|---|
2001 |
37.8 | 25.2 | 3.6 | 1.1 | 1.5 | 1.6 | 1.8 | 2.5 | 4.1 | 10.8 |
2002 |
50.0 | 33.5 | 3.2 | 1.6 | 1.2 | 1.6 | 2.1 | 3.5 | 4.7 | 15.6 |
2003 |
54.5 | 35.6 | 4.4 | 1.2 | 1.0 | 1.4 | 3.0 | 4.7 | 6.5 | 18.3 |
2004 |
42.9 | 31.0 | 4.3 | 1.2 | 1.3 | 1.6 | 2.8 | 4.9 | 7.6 | 20.7 |
2005 |
25.9 | 21.4 | 5.3 | 1.8 | 1.3 | 2.6 | 3.2 | 5.0 | 8.1 | 20.4 |
2006 |
20.3 | 13.7 | 4.6 | 1.8 | 1.8 | 2.0 | 3.8 | 6.8 | 9.0 | 19.1 |
2007 |
30.3 | 15.8 | 3.4 | 1.9 | 2.1 | 3.4 | 4.5 | 7.1 | 10.2 | 20.5 |
2008 |
29.8 | 16.7 | 4.6 | 1.4 | 1.4 | 2.7 | 3.5 | 5.2 | 9.6 | 21.6 |
2009 |
27.8 | 18.7 | 5.8 | 1.6 | 1.8 | 2.4 | 3.5 | 5.5 | 8.9 | 22.3 |
2010 |
25.1 | 16.5 | 4.8 | 1.8 | 1.3 | 1.9 | 3.1 | 5.2 | 9.0 | 23.4 |
2011 |
20.7 | 15.5 | 5.3 | 2.5 | 1.7 | 1.4 | 3.1 | 5.4 | 9.2 | 21.8 |
2012 |
18.3 | 13.6 | 4.3 | 2.5 | 1.6 | 2.5 | 4.0 | 5.1 | 9.2 | 22.9 |
2013 |
18.7 | 11.2 | 3.8 | 1.5 | 1.3 | 1.5 | 2.8 | 4.6 | 8.4 | 21.9 |
2014 |
17.6 | 10.9 | 3.7 | 1.1 | 1.0 | 1.7 | 2.6 | 4.4 | 8.6 | 21.2 |
2015 |
14.4 | 9.8 | 3.9 | 1.2 | 1.5 | 1.9 | 2.8 | 4.5 | 8.9 | 20.6 |
2016 |
15.7 | 12.1 | 3.6 | 1.3 | 1.7 | 2.3 | 2.6 | 4.8 | 9.0 | 20.0 |
2017 |
15.6 | 12.3 | 3.5 | 1.2 | 1.4 | 1.5 | 2.8 | 5.3 | 9.0 | 21.4 |
2018 |
12.0 | 12.6 | 3.7 | 1.2 | 1.2 | 1.6 | 3.6 | 5.7 | 11.5 | 23.4 |
2019 |
13.4 | 11.3 | 3.8 | 1.2 | 1.3 | 2.1 | 2.8 | 6.0 | 10.3 | 21.3 |
2020 |
6.0 | 6.1 | 1.7 | 0.5 | 0.8 | 1.5 | 2.5 | 3.9 | 7.2 | 11.0 |
2021 |
10.3 | 9.5 | 1.5 | 0.4 | 0.6 | 2.0 | 2.5 | 4.2 | 6.6 | 9.3 |
2022 |
15.1 | 16.5 | 5.2 | 2.1 | 2.0 | 2.9 | 4.7 | 7.3 | 11.3 | 17.7 |
2023 |
12.8 | 17.1 | 5.7 | 1.6 | 1.5 | 2.9 | 5.8 | 8.9 | 13.4 | 23.6 |
Case and incidence data from 2000 to 2023 were obtained from the Canadian Notifiable Disease Surveillance System.
As described in Figure 2, PCV20/21 serotypes caused the largest burden of disease in all age groups (29.5%), followed by PCV21/non-PCV20 serotypes (25.3%). PCV20/21 serotypes accounted for a majority of cases in the:
- under 2 age group (30.3%)
- 2 to 4 age group (39.4%)
- 5 to 14 age group (41.7%)
- 50 to 64 age group (28.2%)
- over 65 age group (31.7%)
Across all age groups, non-vaccine serotypes accounted for around 8% of IPD cases.
Figure 2: Text description
| Age category | PCV20/non-PCV21 | PCV20/21 | PCV20/21/non-PCV15 | PCV21/non-PCV20 | Non-vaccine type |
|---|---|---|---|---|---|
| Under 2 years | 7.6% | 30.3% | 24.6% | 24.5% | 13.0% |
| 2 to 4 years | 6.2% | 39.4% | 22.6% | 23.2% | 8.6% |
| 5 to 14 years | 12.9% | 41.7% | 16.3% | 22.1% | 7.0% |
| 15 to 49 years | 31.1% | 25.4% | 21.3% | 17.9% | 4.4% |
| 50 to 64 years | 20.3% | 28.2% | 19.1% | 25.3% | 7.1% |
| Older than 65 years | 11.2% | 31.7% | 14.6% | 31.6% | 10.9% |
| All ages | 18.8% | 29.5% | 18.3% | 25.3% | 7.98% |
Note: Data as captured by National Microbiology Laboratory (NML) Surveillance of Invasive Streptococcal Disease (eSTREP) through reference testing for passively received specimens.
- PCV20/non-PCV21 serotypes: 1, 4, 5, 6B, 9V, 14, 18C, 19F and 23F
- PCV20/21 serotypes: 3, 6A, 7F, 19A, 22F and 33F
- PCV20/21/non-PCV15 serotypes: 8, 10A, 11A, 12F and 15BC
- PCV21/non-PCV20 serotypes: 9N, 15A, 16F, 17F, 20A, 23A, 23B, 24F, 31 and 35B
- All serotypes included in PCV15 are included in the 20-valent formulation, and are designated as "PCV20" for clarity
Serotyping data was missing for 39 of 16,467 cases sent to the NML and are excluded from this figure. Age was not available for 217 of 16,467 cases where specimens were sent to NML for serotyping. These were excluded from the proportion by age group and vaccine associated serotype, but included in the all-ages data.
Learn more:
- Invasive pneumococcal disease surveillance in Canada, 2023
- Vaccination coverage goals and vaccine preventable disease reduction targets by 2025