Research and analysis

Pneumococcal polysaccharide vaccine (PPV): coverage report, England, April 2022 to March 2023

Updated 1 May 2024

Applies to England

Main points

Main conclusions of this of this report of coverage during the financial year 2022/23 are that:

• coverage among individuals aged 65 years and over was estimated at 71.8% (men 71.5%, women 72.1%): a 1.4% increase in coverage from financial year 2021/22

• coverage ranged from 67.2% in the London commissioning region to 73.7% in the Northeast and Yorkshire commissioning region

• estimated uptake was highest in the Southeast and Midlands commissioning region (4.6%) and lowest in the London, Northeast and Yorkshire, and Northwest commissioning regions (4.3%)

• coverage increased with increasing age from 33.1% in those aged 65 years to 83.9% in those aged 75 years and over

• uptake was estimated at 4.5% among all individuals aged 65 years and over

• uptake was 0.3% lower among individuals aged 65 years and over in the current reporting period when compared with 2021/22

• vaccine coverage among individuals aged 2 to 64 years in any clinical risk group was 46.2% (women 46.6 %, men 46.0%)

• coverage in individual clinical risk groups ranged from 40.2% (chronic liver disease) to 70.0% (cochlear implants)

• PPV coverage among both the 65 years and above, and 75 years and above, age groups was higher in 2022/23 than in any other year since 2005/06

Introduction

Pneumococcal disease can present as non-invasive or invasive infections caused by the bacterium Streptococcus pneumoniae (also called pneumococcus). Non-invasive disease includes middle ear infections (otitis media), sinusitis and bronchitis, whilst invasive pneumococcal disease (IPD) includes septicaemia, pneumonia and meningitis (1).

Invasive pneumococcal disease (IPD) is a significant cause of morbidity and mortality globally and in the UK with more than 5,000 confirmed cases reported in 2016 to 2017 in England and Wales. Pneumococcal immunisation is currently offered to young children, the elderly (people aged 65 years and over) and individuals with certain medical conditions – because these groups are at the highest risk of IPD (2).

Pneumococcal immunisation has been recommended for clinical risk groups since 1992 (1). The pneumococcal immunisation programme was introduced in the UK in August 2003 and offered a single dose of PPV to people aged 80 years and over in addition to those at high risk under 65 years of age (3, 4). In April 2004, the programme was expanded to include all people aged 75 years and over. Since April 2005, all people aged 65 years and over have been eligible for the vaccine.

PPV (also currently known as PPV23) is an inactivated vaccine that contains purified polysaccharide from 23 capsular pneumococcus types, including the 10 most prevalent serotypes: 14, 9V, 1, 8, 23F, 4, 3, 6B, 19F and 7F. Most healthy adults develop a good antibody response to a single dose of PPV (1). Among people aged 65 years and over, PPV offers moderate short-term protection against IPD caused by the 23 serotypes targeted by the vaccine (5). In contrast, children younger than 2 years of age show poor antibody response to vaccination with PPV and there is no evidence to support effectiveness of the vaccine among this population group (1). Children younger than 2 years of age are therefore offered a pneumococcal conjugate vaccine (PCV13) through the childhood immunisation programme. Further information on PPV vaccine eligibility is available in ‘Immunisation against infectious disease’ (the Green Book) (1).

This report describes vaccine coverage and uptake of the pneumococcal polysaccharide vaccine (PPV) programme in England. The report includes data from adults aged 65 years and over and individuals aged 2 to 64 years in 9 clinical risk groups associated with elevated risk of adverse outcomes of pneumococcal disease. The current report presents vaccine coverage and uptake estimates for the period between 1 April 2022 to 31 March 2023 and compares them to the previous annual report (1 April 2021 to 31 March 2022) (6).

Methods

The current report presents coverage and uptake estimates among GP-registered individuals in England who were eligible for PPV because of either being 65 years of age and over, or aged 2 to 64 years and in a clinical risk group.

GP IT suppliers used a standardised script (developed by UKHSA and PRIMIS) to automatically extract GP-level data from medical records of individuals, who were registered with a GP in England on the last day of the collection period, 31 March 2023.

The number of individuals registered with the GP and the number of individuals vaccinated with PPV were captured by age group, clinical risk group, and gender.

Age, gender and clinical risk groups of the data used for this report

The age, gender and clinical risk groups of the data used for this report are as follows:

Age groups

• 65 years
• 66 years
• 67 years
• 68 years
• 69 years
• 70 to 74 years
• 75 years and over
• total (65 years and over)

Clinical risk groups

• asplenia
• chronic respiratory disease
• chronic heart disease
• chronic kidney disease
• chronic liver disease
• diabetes requiring insulin or oral hypoglycaemic medication
• immunosuppression
• cochlear implants
• cerebrospinal fluid leak

Gender groups

• men
• women
• gender not specified
• gender not known
• total (all genders)

All data was aggregated by GP, by sub-Integrated Care Board (SUB-ICB), Integrated Care Board (ICB), Local Authority (LA) and NHS commissioning region. The data was obtained from secure online platform, ImmForm, where it was accessed by UKHSA for analysis. UKHSA validated the data using analytical and visual inspections and queried any outliers or anomalous results with data providers before producing the results presented in the current report.

Definitions of ‘uptake’ and ‘coverage’

Uptake and coverage estimates were calculated using the following definitions:

Vaccine coverage among individuals aged 65 years and over

This is the percentage of GP-registered individuals who were 65 years and over on 31 March 2023 and who received PPV any time on or before 31 March 2023.

Vaccine uptake among individuals aged 65 years and over

This is the percentage of GP-registered individuals who were 65 years and over on 31 March 2023 and who received PPV between 1 April 2022 and 31 March 2023.

Vaccine coverage among individuals aged 2 to 64 years in individual clinical risk groups

This is the percentage of GP-registered individuals, who were 2 to 64 years on 31 March 2023, who were in clinical risk groups any time on or before 31 March 2023, and who received PPV any time on or before 31 March 2023.

Vaccine coverage among individuals aged 2 to 64 years in one or more clinical risk groups

This is the percentage of GP-registered individuals, who were 2 to 64 years on 31 March 2023, who were in one or more clinical risk groups any time on or before 31 March 2023, and who received PPV any time on or before 31 March 2023.

Vaccine uptake among individuals aged 2 to 64 years in one or more clinical risk group

This is the percentage of GP-registered individuals, who were 2 to 64 years on 31 March 2023, who became at risk in one or more risk groups between 1 April 2022 and 31 March 2023, and who received PPV between 1 April 2022 and 31 March 2023.

Estimates of vaccine coverage and uptake among individuals aged 65 years and over are presented overall and by age group and gender. Estimates of vaccination coverage and uptake among individuals aged 2 to 64 years in one or more clinical risk groups are presented overall and by gender. Vaccination coverage among individuals aged 2 to 64 years is further presented by individual clinical risk groups. It should be noted that individuals in individual risk groups are counted in each individual group and that the sum of individuals across clinical risk groups does not directly compare to the overall and gender separated estimates, for which individuals in more than one risk groups were counted only once.

Supplementary data – presenting coverage estimates broken down by ICB, SUB–ICB, CCG, LA and NHS commissioning region – is published separately in a supplementary tables appendix associated with this report.

Vaccine uptake for individuals aged 2 to 64 in individual clinical risk groups, and the percentage of individuals who declined or refused vaccines, has been excluded from this report due to data quality issues.

Results

Response summary

All three GP IT suppliers provided data for the financial year 2022/23. Data was provided for 6,051 of 6,443 GP practices which accounted for 93.9% reporting.  The analysis was performed using GP level aggregated data and included 10,455,173 individuals aged 65 years and over and 3,919,539 individuals aged 2 to 64 years in 9 clinical risk groups, who were registered with 6,051 GPs in England on 31 March 2023.

Coverage and uptake among individuals aged 65 years and over

PPV coverage by age group

PPV coverage was estimated at 71.8% among those aged 65 years and over (Table 1). Coverage increased across groups of individuals as the age increased, from the youngest individuals aged 65 years (33.1%) to individuals aged 75 years and over (83.9%). Vaccine coverage was higher in the current reporting period than in 2021/22 among individuals aged 65 years and over (0.3 percentage points as well as in most age groups ranging from 0.1 percent points for 65 year-olds to 0.7 percentage point for 70-74 year-olds (Table 1).

In contrast, coverage was 1.6 percent lower in the 66 years age group and 0.4 percent lower among 67 year-olds compared to 2021/22.

Table 1.  Estimated vaccine coverage, uptake and differences in estimated coverage and uptake since 2021/22 among GP-registered individuals aged 65 years and over, as of 31 March 2023, by age group in England

Age group	GP-registered individuals on 31 March 2023	Estimated PPV uptake	Difference in estimated PPV uptake between 2021/22 and 2022/23 (%)	Estimated PPV coverage	Difference in estimated PPV coverage between 2021/22 and 2022/23 (% difference)
65 years	618,327	13.3%	0.1%	33.1%	0.1%
66 years	586,557	11.2%	0.3%	43.6%	1.6%
67 years	558,575	7.8%	0.3%	52.3%	0.4%
68 years	540,630	6.2%	0.5%	58.1%	0.5%
69 years	536,651	5.4%	0.5%	62.3%	0.6%
70 to 74 years	2,538,293	4.6%	0.4%	72.8%	0.7%
75 years and over	5,076,140	1.9%	0.3%	83.9%	0.4%

PPV uptake by age group

Uptake was estimated at 4.5% among all individuals aged 65 years and over. Uptake decreased with each increase in age group from an estimated 13.3 % among people aged 65 years to 1.9 % among people aged 75 years and over (Table 1).

Uptake was 0.3 % lower among individuals aged 65 years and over in the current reporting period when compared with 2021/22 (Table 1). Uptake was lower than in 2021/22 in all age groups ranging from 0.1 percentage points lower for 65-year-olds; 0.5 percentage points lower for 67-year-olds and 68-year-olds; and 0.3 percentage points lower among those aged 75 years and over.

Figure 1. Uptake and coverage of PPV as of 31 March 2023 by age group, England*

*Coverage = uptake plus total PPV delivered.

PPV coverage by gender

Table 2: Coverage and uptake among individuals aged 65 years and over by gender

Gender	GP-registered individuals on 31 March 2023 (n)	Estimated PPV uptake (%)	Estimated PPV coverage (%)
Men	4,830,201	4.6	71.5
Women	5,624,940	4.3	72.1
Total	10,455,141	4.5	71.8

Among individuals aged 65 years and over, uptake estimates were 4.3% among women and 4.6% among men. Uptake in men was 0.4% lower in men and 0.3% lower in women for the 2022/23 financial year compared to 2021/22. PPV coverage in men was 71.5% and 72.1% in women for the reporting year 2022/23. Coverage was 0.4% higher in men and 0.3% higher in women for the 2022/23 financial year compared to 2021/22 (Table 2).

Figure 2. PPV coverage among individuals aged 65 years from 2005/06 to 2022/23 in England

PPV coverage among individuals aged 65 years and above was the highest (71.8%) in 2022/23 compared to any other year since 2005/06. This trend is also observed among the 75 and over age group, with coverage in 2022/23 at 83.9%. For 65-year-olds, coverage was highest (39.7%) in 2006/07, decreasing to its lowest in 2017/18 (30.9%), with marginal increases in subsequent years to 33.1% in 2022/23. Among those aged 66 to 74 years, coverage was highest (70.1%) in 2007/08, decreasing to its lowest 61.0% in 2019/20, increasing again in subsequent years to 63.9% in 2022/23 (Figure 2).

Figure 3. PPV coverage and uptake by age group and NHS Commissioning region*

*Coverage = uptake plus total PPV delivered.

Figure 3 shows coverage and uptake for age 65 years and above by commissioning region. The estimated coverage was highest in in the Northeast and Yorkshire commissioning region (73.7%) and lowest in the London commissioning region (67.2 %). Estimated uptake was highest in the Southeast, and in the Midlands, commissioning regions (4.6%) and lowest in the London, Northeast, and Yorkshire and Northwest commissioning regions (4.3%).

Coverage among individuals aged 2 to 64 years in clinical risk groups

Vaccine coverage among individuals aged 2 to 64 years in one or more clinical risk groups was 46.3%, an 0.1% increase compared to 2021 to 2022. Vaccine coverage estimates among individuals aged 2 to 64 years in specific clinical risk groups ranged from 40.2 % (chronic liver disease) to 70.0 % (cochlear implants) (Table 3). Coverage among individuals with asplenia or dysfunction of spleen was estimated at 51.8% which was 6.0 percent points higher than 2021 to 2022. Coverage estimates for some the remaining clinical risk groups showed various coverage difference from last year’s estimates (range: coronary heart disease was 0.5% lower, while cerebrospinal fluid leaks was 1.0% higher than the previous year) (data not shown).

Estimates of vaccine coverage and uptake were separated by gender in the group of individuals aged 2 to 64 years in one or more clinical risk groups. It should be noted that in contrast to the clinical risk group separated analysis above, in which patients were counted in each clinical risk group they were identified in, the gender-separated analysis counted patients in one or more risk groups only once. Due to small numbers, estimates were suppressed for 67 people, for whom gender was unknown or unspecified.

Table 3. PPV vaccine coverage by individual clinical risk group as of 31 March 2023 in England

Clinical risk group	GP-registered individuals on 31 March 2023	Estimated PPV coverage (%)
Asplenia / dysfunction of the spleen	234,788	51.8
Chronic respiratory disease	500,389	56.4
Chronic heart disease	384,379	43.6
Chronic kidney disease	47,139	54.9
Chronic liver disease	47,469	40.2
Diabetes requiring insulin or oral hypoglycaemic medication	859,574	55.8
Immuno-suppression	1,081,788	41.0
Cochlear implants	9,746	70.0
Cerebrospinal fluid leaks	2,293	42.0

Estimates of vaccine coverage and uptake were separated by gender in the group of individuals aged 2 to 64 years in one or more clinical risk groups. It should be noted that in contrast to the clinical risk-group-separated analysis above, in which patients were counted in each clinical risk group they were identified in, the gender-separated analysis counted patients in one or more risk groups only once. Due to small numbers, estimates were suppressed for those whose gender was unknown or unspecified.

Table 4.  Coverage and uptake among individuals aged 2 to 64 years in one or more clinical risk groups, by gender

Gender	GP-registered individuals on 31 March 2023 (n)	Estimated PPV coverage (%)	Estimated PPV uptake (%)
Men	2,081,814	46.0	4.5
Women	1,837,692	46.6	4.5
Total	3,919,563	46.3	4.5

Among individuals in one or more at-risk groups, coverage was 46.0% for men and 46.6% for women. When compared to 2021/22, coverage was same among men and 0.2% higher in women.

Uptake estimates were 4.5% among men and women respectively which were 0.9 percent points lower among men and 1.0 percent lower among women compared to 2021/22.

Coverage and uptake estimates for women and men in one or more clinical risk groups were not compared to estimates from 2021/22 because of data quality issues.

Discussion

The current analysis used GP-aggregated data from 6,443 practices in England. The response rate among included practices was 93.9% and was considered representative of the English population belonging to the groups of individuals assessed in the current report.

We observed a 0.3 percent point increase in estimated coverage to 71.8% compared to 2021/22, and a 0.3 percent point decrease in estimated uptake to 4.5%. This year had the highest coverage (71.8%) among individuals aged 65 years and above compared to any other year since 2005/06. The highest coverage was also observed this year among the 75 years and over age group.

The trend of increasing coverage and decreasing uptake across patient groups with increasing age was consistent with previous years and is expected.

The number of people who received PPV in the past 12 months as a proportion of the population in the age group (uptake) is expected to decrease with increasing age because older individuals, who have been eligible for longer, are more likely to have had the vaccine prior to the most recent 12 months (contributing to coverage statistics). The increase in vaccine coverage in the older age groups demonstrates that PPV continues to be offered opportunistically in primary care to individuals aged 65 years and over who remain eligible as they age. The increase in vaccine coverage in the older age groups demonstrates that PPV continues to be offered opportunistically in primary care to individuals aged 65 years and over who remain eligible as they age.

Varying coverage and uptake estimates across regions suggest that efforts to promote PPV should be sustained across all geographies.

Vaccine coverage by gender indicated that coverage was marginally higher in females (72.1%) than in males (71.5%) and this is consistent with the previous year’s estimates.

We observed that, among individuals aged 2 to 24 years in one or more clinical risk groups, vaccine coverage among females was 46.6% and 46.0% in men. Coverage varied by clinical risk group from 40.2% (chronic liver disease) to 70.0% (cochlear implants). The differences in coverage among individuals in clinical risk groups could suggest that vaccine offers or awareness of eligibility and importance of PPV among individuals and clinicians vary substantially according to clinical risk.

Due to the ambiguity of certain clinical codes, there will be individuals eligible for vaccination in clinical risk groups who are not included in these estimates.

References

1. UKHSA and DHSC. ‘Immunisation against infectious disease, chapter 25: Pneumoccal’ (the Green Book)

2. Ladhani SN, Collins S, Djennad A, Sheppard CL, Borrow R (2018). Rapid increase in non-vaccine serotypes causing invasive pneumococcal disease in England and Wales, 2000 to 2017: a prospective national observational cohort study. Lancet Infectious Diseases: volume 18 number 4, pages 441 to 451

3. PHE (2014). Pneumococcal Polysaccharide Vaccine (PPV) Uptake.

4. Department of Health and Chief Medical Officer (2003). Adult immunisation update. PLO CMO (2003)6

5. Djennad A, Ramsay ME, Pebody R and others (2018). ‘Effectiveness of 23-valent Polysaccharide Pneumococcal Vaccine and changes in invasive pneumococcal disease incidence from 2000 to 2017 in those aged 65 and over in England and Wales’. EClinincalMedicine volume 6, pages 42 to 50.

6. UKHSA (2023). Pneumococcal Polysaccharide Vaccine (PPV) coverage report, England, April 2021 to March 2022