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

Adv Ther 2013;30:387–405.

Lode H, Ludwig E, Kassianos G.



Introduction: 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. Methods: 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. Results: 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. Conclusion: 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.




Pneumococcal disease is a broad term for infections caused by the Streptococcus pneumoniae bacterium. Pneumococcal diseases vary in severity from mild diseases, such as middle-ear infection (acute otitis media), to more serious diseases, such as pneumonia and meningitis. In the more serious cases the bacterium is found in the blood or the membranes surrounding the brain and spinal cord (meninges) and these pneumococcal infections are classified as ‘invasive pneumococcal disease’.

Elderly adults and adults with chronic diseases or immunodeficiency are most likely to be affected by pneumococcal disease. Two types of vaccine are available in Europe to protect adults against contracting the disease (23-valent purified capsular polysaccharide vaccine [PPV-23] and 13-valent pneumococcal conjugate vaccine [PCV-13]); however the rate of vaccination varies considerably from country to country.

We hypothesized that the variability in the rate of uptake of pneumococcal vaccination could be due to a lack of awareness of pneumococcal disease amongst physicians and patients. Therefore we conducted a survey of primary care physicians and specialists (mostly respiratory or infectious disease specialists) across Europe, to assess their knowledge of pneumococcal disease and their attitudes towards vaccination. We also surveyed members of the general public (aged >50 years) to ask about their attitudes towards vaccination.

Survey results

When asked to name types of pneumococcal infections, the most common answer was ‘pneumonia’, provided by 78% of physicians and specialists. ‘Meningitis’ and ‘sepsis/septicaemia’ were named by 54% and 25% of physicians and 60% and 36% of specialists. Out of a list of terms for pneumococcal infections, 93% and 96% of primary care physicians and specialists, respectively, knew about ‘non-invasive pneumococcal pneumonia’, but only 50% and 71% knew about ‘invasive pneumococcal disease’. In fact, in some countries just 30% of primary care physicians were aware of ‘invasive pneumococcal disease’.

When asked about attitudes towards pneumococcal vaccination, primary care physicians and specialists stated that patient’s health condition, recommendations from health authorities, patient’s age and tolerability of the vaccine were the most important factors to consider when recommending a pneumococcal vaccine (Figure 1). In contrast, factors that would cause a physician not to recommend vaccination included that pneumococcal vaccination only concerns specific subgroups of adults, vaccination not being at the forefront of the physician’s mind and a lack of time.

Perceptions of vaccination amongst the general public were positive. Vaccines were generally thought to be lifesaving and concerns regarding side effects were minimal. The main factors given by patients supporting receiving a vaccination were protection against illness and recommendation to receive a vaccine from their physician. Similarly, the vaccine not being recommended by their physician, lack of awareness of the availability of a vaccine and a lack of concern for catching pneumonia/pneumococcal infections were provided as reasons for not wanting to receive a vaccination. Among those surveyed, 10% claimed to have received a pneumococcal vaccination in adulthood, compared with 70% and 49% who had received vaccines for tetanus/diphtheria or influenza, respectively.


Our survey demonstrates a lack of knowledge of the term ‘invasive pneumococcal disease’ amongst some primary care physicians and specialists. It would appear that uptake of vaccination is greatly influenced by patients receiving a physician recommendation. Therefore we believe that rates of uptake of pneumococcal vaccination could be increased by raising awareness of pneumococcal disease amongst healthcare professionals and patients and by encouraging patients to receive a pneumococcal vaccination.


Joanne Vaughan-1

Figure 1. Factors influencing physicians’ decision when recommending or prescribing pneumococcal vaccinationa

a Physicians (primary care physicians: n = 1,277; specialists: n = 891) were asked to indicate how important the above factors (using a 7-point scale) were when recommending or prescribing pneumococcal vaccination for adult patients. Figure shows percentage of physicians rating each factor 6 or 7

Reproduced from Lode et al. Adv Ther 2013;30:387–405.

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