Simultaneous immunisation with influenza vaccine and pneumococcal polysaccharide vaccine in patients with chronic respiratory disease

BMJ 1997; 314 doi: (Published 07 June 1997) Cite this as: BMJ 1997;314:1663
  1. T J Fletcher, research fellowa,
  2. W S Tunnicliffe, research fellowa,
  3. K Hammond, research nursea,
  4. K Roberts, research scientista,
  5. J G Ayres, professor of respiratory medicinea
  1. a Chest Research Institute, Birmingham Heartlands Hospital, Birmingham B9 5SS
  1. Correspondence to: Professor Ayres
  • Accepted 6 December 1997


Pneumococcal disease is an important cause of morbidity and mortality in the United Kingdom.1 The increasing numbers of elderly people and the development of drug resistant Streptococcus pneumoniae will exacerbate this problem. The safety, efficacy, and cost effectiveness of immunisation with pneumococcal polysaccharide vaccine is established,2 and immunisation is now recommended for all patients aged over 2 years with chronic lung disease, a target group for influenza vaccination.3 Coadministration of the vaccines is recommended, though the efficacy of pneumococcal polysaccharide vaccine given in this way has been questioned.4 We examined whether an immunoresponsive interaction exists between 23 valent pneumococcal polysaccharide vaccine (Pnu-Imune 23) and influenza vaccine (Fluarix).

Patients, methods, and results

One hundred and fifty two adults with chronic respiratory disease were randomised to receive either pneumococcal vaccination and influenza vaccination on the same day (concurrent group; n=76) or influenza vaccination first, followed by pneumococcal vaccination one month later (interval group; n=76). The pneumococcal vaccine was given into the left deltoid muscle and the influenza vaccine into the right deltoid muscle. At the initial visit and one month after each injection venesection was performed for blinded analysis of pneumococcal antibody titres (serotypes 4, 6B, 14, 18C, 19F, 23F) by enzyme linked immunosorbent assay (ELISA) and influenza antibody titres (strains A (Taiwan), A (Johannesburg), B (Harbin)) by haemagglutination inhibition. Patients recorded local and systemic side effects for four days after each vaccination.

Three patients in the concurrent group and 18 in the interval group failed to complete the study. Geometric mean titres, geometric mean ratios (geometric mean titres after vaccination/geometric mean titres before vaccination), and the proportions of patients in each group with a greater than twofold rise in pneumococcal antibody titres and greater than fourfold rise in influenza antibody titres were compared (table 1).

Table 1

Demography and serological responses to pneumococcal and influenza vaccination by treatment group

View this table:

There were no significant differences in serological responses between the groups. The incidence and severity of both local side effects (pain, redness, swelling) and systemic side effects were also similar in the treatment groups. Mild local reactions occurred in 49 subjects, 28 (38%) in the concurrent group and 21 (36%) in the interval group. Systemic reactions occurred in three and five patients in the respective groups.


Patients with chronic lung disease should be offered pneumococcal and yearly influenza vaccination.3 In the United Kingdom targeting these patients in general practice has resulted in reasonable influenza vaccination rates but uptake of pneumococcal vaccination in this group has been poor.5 Our findings suggest that in adults with chronic respiratory disease concurrent immunisation with 23 valent pneumococcal polysaccharide vaccine and influenza vaccine is as well tolerated and immunologically effective as interval vaccination. Our sixfold greater drop out rate in the interval group as compared with the concurrent group raises the possibility that bias could explain our findings. However, there was no significant difference in clinical characteristics between patients who completed the study and those who did not. The drop out rate in the interval group illustrates the practical difficulty of getting patients to return for repeated injections.

With the skills and infrastructure in place for influenza vaccination greater coverage of the population at risk from pneumococcal disease could readily be achieved. When appropriate the opportunity to offer and administer pneumococcal vaccination to adults with respiratory disease at the time of their influenza vaccination should not be missed.


Funding: Wyeth Lederle Vaccines and Paediatrics.

Conflict of interest: None.


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