Introduction: Pneumococcal conjugate vaccines (PCV) have revolutionized the prevention of invasive pneumococcal disease (IPD) globally.The initial 7-valent (PCV7) vaccine has gradually been replaced by higher valency vaccines such as PCV10 and PCV13, as these cover additionalserotypes causing increased immunization. Objective: The purpose of this study was to determine the overall attitude and practices of the Indian public toward PCV for their infants. Materials and Methods: Data were collected over a period of 18 months from a tertiary perinatal center. Pneumococcal vaccine leaflets with current, unbiased information on PCV10 and PCV13 were circulated to parents, who were then asked to opt for either one or none of the vaccines for their infants at their 6 weeks immunization check-up. Results: A total of 3406 infants came for follow-up. Among them, 84% chose to give the PCV while the remaining 16% opted out. Among the parents that opted for the vaccines, 90% chose PCV13 over PCV10. This may be attributable to its increased immunogenicity and broader serotype coverage as understood by the parents - who seem to want the best for their children. Conclusion: PCV13 was a preferred vaccine of choice for infants by majority of the parents, as compared to PCV10. Such information is of valuable importance in deciding which vaccine to go for if and when India goes for PCV in the future with Global Alliance for Vaccines and Immunization and United Nations Children’s Fund funding

Kumar, R Kishore

Suma, A R

English

Atharva Scientific Publications (E-Jounals)

Vol 1 | Issue 3 | Oct - Dec 2014 Indian J Child Health 119
Kumar and Suma KAP of pneumococcal vaccine in India
Original Article
Knowledge attitude and practices of pneumococcal vaccines in India
R Kishore Kumar1,2, A R Suma3
Consultant Neonatologist & Paediatrician, Cloudnine Hospitals, Bengaluru, Karnataka, India, 2Adjunct Professor in Neonatology & 
Paediatrics, Department of Neonatology, Notre Dame University, Perth, Australia, 3Paediatric Registrar, Cloudnine Hospital, 
Bengaluru, Karnataka, India
Correspondence to: Dr. R Kishore Kumar, Consultant Neonatologist & Paediatrician, Cloudnine Hospital, 1533, 3rd Block Jayanagar, 
9th Main, Bengaluru - 560 011, Karnataka, India. Phone: + 91-8040202222, Fax: +91-8040202233, E-mail: drkishore@cloudninecare.com
Received – 02 August 2014 Initial Review – 06 August 2014 Published Online – 14 December 2014
Abstract
Introduction: Pneumococcal conjugate vaccines (PCV) have revolutionized the prevention of invasive pneumococcal disease (IPD) globally. 
The initial 7-valent (PCV7) vaccine has gradually been replaced by higher valency vaccines such as PCV10 and PCV13, as these cover additional 
serotypes causing increased immunization. Objective: The purpose of this study was to determine the overall attitude and practices of the Indian 
public toward PCV for their infants. Materials and Methods: Data were collected over a period of 18 months from a tertiary perinatal center. 
Pneumococcal vaccine leaflets with current, unbiased information on PCV10 and PCV13 were circulated to parents, who were then asked to 
opt for either one or none of the vaccines for their infants at their 6 weeks immunization check-up. Results: A total of 3406 infants came for 
follow-up. Among them, 84% chose to give the PCV while the remaining 16% opted out. Among the parents that opted for the vaccines, 90% 
chose PCV13 over PCV10. This may be attributable to its increased immunogenicity and broader serotype coverage as understood by the 
parents - who seem to want the best for their children. Conclusion: PCV13 was a preferred vaccine of choice for infants by majority of the 
parents, as compared to PCV10. Such information is of valuable importance in deciding which vaccine to go for if and when India goes for PCV 
in the future with Global Alliance for Vaccines and Immunization and United Nations Children’s Fund funding.
Key words: Attitude, Invasive pneumococcal diseases, Pneumococcal conjugate vaccine, Pneumococcal conjugate vaccine 10, 
Pneumococcal conjugate vaccine 13, Practices
Pneumococcal vaccines are designed to prevent diseases caused by Streptococcus pneumonia (pneumococci); broadly referred to as pneumococcal diseases. Currently, 
two different types of vaccines are available for prevention 
of pneumococcal diseases, namely conjugate vaccines and 
polysaccharide vaccines. Pneumococcal conjugate vaccines 
(PCV) have revolutionized the preventive measures by 
decreasing the invasive pneumococcal disease (IPD) across the 
world since their introduction in 2000 [1,2]; however, it was 
not until 2006 when the PCV7 vaccines became available in 
India. The conjugate vaccines function by inducing an immune 
memory response, and are immunogenic in young infants. In 
contrast, the pneumococcal polysaccharide vaccines are poorly 
immunogenic in children under the age of 2 years and in those 
with impaired immunity. Although they contain more serotypes, 
they are not conjugated to a protein and hence, do not induce a 
memory immune response [3].
Among the PCV, formulations vary by the number of 
pneumococcal serotypes included (valency) and the conjugating 
proteins used. Initially, these vaccines were only made available 
in various developed countries [4]. Subsequently, many national 
programs have made them part of their vaccines’ regime, being 
given free to the children based on disease surveillance and 
various other factors. India is one of the few countries where 
the pneumococcal vaccination is available to the public on 
private prescription and the original PCV7 conjugate vaccine 
has now been superseded. The public has to decide which one 
to choose among the available PCV10 (synflorix) and PCV13 
(prevenar13). PCV10/PCV13 is not yet available on Extended 
Program of Immunization.
The objective of the present study was to assess the awareness 
of PCV among the public through educational leaflets and to 
evaluate which vaccine they chose. A study was conducted to 
determine the attitude and practices of pneumococcal vaccines 
among the general public in India.
MATERIALS AND METHODS
Prospective data over a period of 18 months from November 
2011 to May 2013 were collected from Cloudnine Hospital, 
Bengaluru, Karnataka, India - a tertiary perinatal center with 
over 2000 deliveries per year. Ethics Committee approved 
the study since there were no interventions carried out on any 
babies, and no blood or body fluid samples were collected. 
Vol 1 | Issue 3 | Oct - Dec 2014 Indian J Child Health 120
Kumar and Suma KAP of pneumococcal vaccine in India
Pneumococcal vaccine leaflet for information was prepared 
based on the current available knowledge, and the serotypes 
they cover including the information about the disease. This 
leaflet was shown to both PCV10 and PCV13 company 
personnel for their satisfaction to ensure that it contains 
appropriate scientifically available information, and covered 
the vaccines currently available along with their serotypes as 
depicted in Table 1.
As per the hospital protocol, the leaflets containing 
information on pneumococcal vaccines (both synflorix - PCV10 
and prevenar13 - PCV13) were distributed among all parents 
during their visit for the 10 days check (post delivery). The 
designed leaflets were unbiased and provided information about 
the vaccines available in the current literature at the time of 
printing the leaflets. A copy of the leaflet is enclosed for the 
reader’s perusal along with the manuscript (Web table). They 
contained information on the cost, benefits, availability of the 
vaccines, dosing schedule, and additional details, in order to 
prepare the parents for vaccination at 6 weeks. In addition, all 
parents were asked whether they have read the leaflet, if not it 
was ensured that they read it before the vaccination was decided.
RESULTS
During the study period, 3624 babies were born in the hospital, 
out of which 3406 (94%) came for follow-up and vaccinations. 
Majority of the 6% (218/3624) babies who did not come at 
6 weeks were because they went to their native place to spend 
time with their parents or moved interstate for various other 
reasons.
At the 6 weeks check for vaccinations, most parents 
(84%; 2861/3406) chose to give the pneumococcal vaccine to 
their infants, with only 16% (545/3406) of parents choosing 
otherwise and quoting that it is an optional vaccine and they 
would want to give it later or wanted some government 
recommendations. Among the parents who chose to give the 
pneumococcal vaccine to their infants, 90% (2575/2861) opted 
for the PCV13 vaccine, while 10% (286/2861) chose PCV10 
(Figure 1).
DISCUSSION
This study evaluated the awareness of pneumococcal vaccines 
among the general public in India and determined which 
conjugate vaccine was opted by the majority. The public was 
informed through educational leaflets, specifically designed to 
share unbiased information from current literature on two PCV 
i.e., PCV10 and PCV13.
Majority of the parents chose to give pneumococcal vaccines 
to their infants (84%), while a smaller sum opted out. This 
study projects to the increased awareness and improvement 
in attitude among the general public toward realizing the 
importance of immunization for their infants through education 
and providing best available healthcare medications to them. 
Among the parents who chose to give the vaccines to their 
infants, majority (90%) went ahead with PCV13. While both 
vaccines have revolutionized the treatment of IPD in children 
across the world, they hold a greater value for the Indian 
population.
Prior to the existence of the universal infant PCV programs, 
about 85% of pneumococcal diseases in the Western countries 
in children below the age of 2 years were caused by the 
serotypes present in the 7-valent (PCV7) conjugate vaccine, 
while in India, only 47-50% of IPD in children were thought 
Table 1: Pneumococcal vaccines and their serotypes
Vaccine type Valency 
(brand name)
Conjugating protein Shared 
serotypes
Additional 
serotypes
Conjugate 
vaccines
7-valent 
(Prevenar)
Non-toxic Corynebacterium 
diphtheria CRM197 protein
4, 6B, 9V, 14, 
18C, 19F, 23F
-
10-valent 
(Synflorix)
Protin D from non-typeable 
Haemophilus influenza, tetanus 
toxoid and diphtheria toxoid
4, 6B, 9V, 14, 
18C, 19F, 23F
1, 5, 7F
13-valent 
(Prevenar 13)
Non-toxic Corynebacterium 
diphtheria CRM197 protein
4, 6B, 9V, 14, 
18C, 19F, 23F
1, 5, 7F, 3, 19A, 6A
Polysaccharide 
vaccine
23-valent 
(Pneumovax 23)
None 4, 6B, 9V, 14, 
18C, 19F, 23F
1, 5, 7F, 3, 19A, 2, 8, 9N, 10A, 
11A, 12F, 15B, 17F, 20, 22F, 33F
Figure 1: (a) Percentage that opted for pneumococcal 
conjugate vaccine versus the remaining. (b) Comparison 
between pneumococcal conjugate vaccines 13 and 
pneumococcal conjugate vaccines 10 parent population
ba
Vol 1 | Issue 3 | Oct - Dec 2014 Indian J Child Health 121
Kumar and Suma KAP of pneumococcal vaccine in India
to be covered with those serotypes. Hence, the uptake of the 
vaccines by the Indian pediatricians was patchy at the most. The 
different serotypes vary in their propensity for nasopharyngeal 
colonization and for causing the disease. Now, there are two 
vaccines PCV10 and PCV13 that are available. Among the two 
vaccines, PCV13 is expected to have a substantial impact on the 
overall public health as well as cost-effectiveness in healthcare, 
as it demonstrates greater immunogenicity and broader serotype 
coverage as compared to PCV10. This prevents additional cases 
of pneumococcal diseases among children, hence factoring for 
the cost utility as well. PCV13 also greatly helps in reducing 
cases of preventable diseases in India [5-7].
Any country willing to include a new vaccine in its 
immunization schedule refers to the WHO recommendations 
and current literature around the world, along with their 
own epidemiological data. India is a vast country, but our 
epidemiological data for pneumococcal diseases is lacking in 
several ways. The available epidemiological data is patchy 
and insufficient. Hence, the decision to include a particular 
vaccine in our immunization schedule is highly dependable on 
the research from other developing nations, which is simply 
extrapolated from demographically similar places as our 
country. Although, International bodies such as the Global 
Alliance for Vaccines and Immunization and United Nations 
Children’s Fund have been willing to provide these vaccines 
at a reasonable cost to the developing countries for early 
introduction, India has been relatively slow in requesting for 
their help in introducing pneumococcal vaccines for the Indian 
population. In the future, when we take a decision to seek their 
help, our country will require plenty of local data in the form of 
analyses, and cross-sectional as well as observational studies, 
to convince the deciding bodies in order to justify procuring 
the vaccines.
With studies such as ours that are performed on general 
public, disease surveillance goes a long way in contributing 
toward the efforts to choose the appropriate vaccine for the 
population. It is essential for a country to recognize these 
vaccines and make them available through International bodies 
or other means.
CONCLUSION
In conclusion, our study highlights that there is an increased 
awareness among the general public in India toward opting for 
optional immunization measures to ensure the overall health 
and safety of their infants. It was observed that the majority 
had a positive attitude toward information in the educational 
leaflets. This study also demonstrated that PCV13 is a highly 
favorable vaccine among the Indian population as compared 
to PCV10. This information would be of great importance in 
developing immunization programs and awareness campaigns 
within our country. Further studies with larger population and 
different hospital settings may contribute toward better data 
specific to the Indian public.
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2. Are current recommendations for pneumococcal vaccination 
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Funding: None; Conflict of Interest: None Stated
How to cite this article: Kumar RK, Suma AR. Knowledge 
attitude and practices of pneumococcal vaccines in India. Indian J 
Child Health. 2014;1(3):119-21.


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