Pneumococcal conjugate vaccines probe studies: the solution points to the problem

Use of Chest Radiography Examination as a Probe for Pneumococcal Conjugate Vaccine Impact on Lower Respiratory Tract Infections in Young Children

BACKGROUND

Community-acquired alveolar pneumonia (CAAP) is considered a bacterial disease, mainly pneumococcal. CAAP rates markedly declined following 7- and 13-valent pneumococcal conjugate vaccine (PCV) introductions worldwide. In contrast, non-CAAP lower respiratory tract infections (NA-LRIs) are generally not considered pneumococcal diseases. We assessed CAAP, NA-LRIs, and overall visits with chest radiograph (CXR) examination rates in the pediatric emergency room in southern Israel before and after PCV implementation.

METHODS

This was an ongoing, prospective observational study. Our hospital serves a captive population of approximately 75 000 children aged <5 years, enabling incidence calculation. PCV7 and PCV13 were implemented in Israel in July 2009 and November 2010, respectively. All CXRs were analyzed according to the World Health Organization Standardization of Interpretation. We calculated CAAP, NA-LRI, and CXR examinations annual incidences from 2004 to 2017 and incidence rate ratios comparing the PCV13 (2014-2017) with the pre-PCV (2004-2008) periods.

RESULTS

Overall, 72 746 CXR examinations were recorded: 14% CAAP and 86% NA-LRI. CAAP, NA-LRI, and CXR examination visit rates declined by 49%, 34%, and 37%, respectively. This pattern was seen in Jewish and Bedouin children (the 2 ethnically distinct populations), with steeper declines observed among Jewish children and children aged >12 months.

CONCLUSIONS

PCV7/PCV13 implementation resulted in a marked decline in CAAP and overall visits with CXR examination rates in young children. Overall, approximately 14 750 hospital visits with CXR were prevented annually per 100 000 population aged <5 years. These findings suggest that although NA-LRIs are usually not considered pneumococcal, many can be prevented by PCVs.Pneumococcal conjugate vaccine (PCV7/PCV13) implementation resulted in significant declines in community-acquired alveolar pneumonia (CAAP) and overall chest radiography examination rates in young children. Although non-CAAP lower respiratory tract infections are usually not considered pneumococcal, many can be prevented by PCVs.

Use of vaccines as probes to define disease burden

Vaccine probe studies have emerged in the past 15 years as a useful way to characterise disease. By contrast, traditional studies of vaccines focus on defining the vaccine effectiveness or efficacy. The underlying basis for the vaccine probe approach is that the difference in disease burden between vaccinated and unvaccinated individuals can be ascribed to the vaccine-specific pathogen. Vaccine probe studies can increase understanding of a vaccine's public health value. For instance, even when a vaccine has a seemingly low efficacy, a high baseline disease incidence can lead to a large vaccine-preventable disease burden and thus that population-based vaccine introduction would be justified. So far, vaccines have been used as probes to characterise disease syndromes caused by Haemophilus influenzae type b, pneumococcus, rotavirus, and early infant influenza. However, vaccine probe studies have enormous potential and could be used more widely in epidemiology, for example, to define the vaccine-preventable burden of malaria, typhoid, paediatric influenza, and dengue, and to identify causal interactions between different pathogens.

Effect of 5-azacytidine on in vitro biofilm formation of Streptococcus pneumoniae

Streptococcus pneumoniae is a gram-positive bacterium that causes otitis media, pneumonia, meningitis and sepsis in young children and the elderly. Previous studies reported that pneumococci in different diseases do not behave as planktonic cells, but predominantly show characteristics of a biofilm. In this study we examine the effect of 5-azacytidine on S. pneumoniae, particularly on biofilm formation and investigate the gene expression involved in synthesis of autoinducer-2, competence and DNA repair. The effect of 5-aza on in vitro biofilm formation was studied by the crystal violet microtiter plate method. The S. pneumoniae biofilms were grown with different concentration of 5-azacytidine (15-500 μm), at variable time intervals and the inhibition percentages were calculated. The effects of 5-aza on the morphology of biofilms were analyzed by scanning electron microscope. The relative quantification of 11 genes of biofilms grown with 5-aza involved in autoinducer-2 synthesis, competence and DNA repair was carried out by real-time RT-PCR with respect to biofilms grown without 5-aza. The crystal violet microtiter assay detected a significant inhibitory effect of 5-aza on in vitro biofilm formation, at concentration that did not inhibited planktonic cell growth. The SEM analysis demonstrated thin and disrupted biofilms, without micro-colonies in the samples treated with 5-aza, while these structures were present in the biofilms grown without 5-aza. The relative quantification of gene expression of 5-aza biofilms showed a significant down regulation of genes involved in the methionine and homocysteine recycling pathway which produces quorum sensing molecule autoinducer-2 as by-products. A significant decrease in the expressions of luxS, metK, pfs and cmK was detected. In conclusion, 5-aza inhibits in vitro biofilm formation and decreases the expression of luxS, pfs and metK, which are involved in the synthesis of autoinducer-2 as by-products of the methionine recycling pathway. The inhibitory effect of 5-aza may be either due to down regulation of pfs, luxS and metK or due to accumulation of the toxic substrate of pfs, luxS and metK genes.

LuxS mediates iron-dependent biofilm formation, competence, and fratricide in Streptococcus pneumoniae

During infection, Streptococcus pneumoniae exists mainly in sessile biofilms rather than in planktonic form, except during sepsis. The capacity to form biofilms is believed to be important for nasopharyngeal colonization as well as disease pathogenesis, but relatively little is known about the regulation of this process. Here, we investigated the effect of exogenous iron [Fe(III)] as well as the role of luxS (encoding S-ribosylhomocysteine lyase) on biofilm formation by S. pneumoniae D39. Fe(III) strongly enhanced biofilm formation at concentrations of ≥50 μM, while Fe(III) chelation with deferoxamine was inhibitory. Importantly, Fe(III) also upregulated the expression of luxS in wild-type D39. A luxS-deficient mutant (D39luxS) failed to form a biofilm, even with Fe(III) supplementation, whereas a derivative overexpressing luxS (D39luxS+) exhibited enhanced biofilm formation capacity and could form a biofilm without added Fe(III). D39luxS exhibited reduced expression of the major Fe(III) transporter PiuA, and the cellular [Fe(III)] was significantly lower than that in D39; in contrast, D39luxS+ had a significantly higher cellular [Fe(III)] than the wild type. The release of extracellular DNA, which is an important component of the biofilm matrix, also was directly related to luxS expression. Similarly, genetic competence, as measured by transformation frequency as well as the expression of competence genes comD, comX, comW, cglA, and dltA and the murein hydrolase cbpD, which is associated with fratricide-dependent DNA release, all were directly related to luxS expression levels and were further upregulated by Fe(III). Moreover, mutagenesis of cbpD blocked biofilm formation. We propose that competence, fratricide, and biofilm formation are closely linked in pneumococci, and that luxS is a central regulator of these processes. We also propose that the stimulatory effects of Fe(III) on all of these parameters are due to the upregulation of luxS expression, and that LuxS provides for a positive Fe(III)-dependent amplification loop by increasing iron uptake.

Extracellular matrix formation enhances the ability of Streptococcus pneumoniae to cause invasive disease

During infection, pneumococci exist mainly in sessile biofilms rather than in planktonic form, except during sepsis. However, relatively little is known about how biofilms contribute to pneumococcal pathogenesis. Here, we carried out a biofilm assay on opaque and transparent variants of a clinical serotype 19F strain WCH159. After 4 days incubation, scanning electron microscopy revealed that opaque biofilm bacteria produced an extracellular matrix, whereas the transparent variant did not. The opaque biofilm-derived bacteria translocated from the nasopharynx to the lungs and brain of mice, and showed 100-fold greater in vitro adherence to A549 cells than transparent bacteria. Microarray analysis of planktonic and sessile bacteria from transparent and opaque variants showed differential gene expression in two operons: the lic operon, which is involved in choline uptake, and in the two-component system, ciaRH. Mutants of these genes did not form an extracellular matrix, could not translocate from the nasopharynx to the lungs or the brain, and adhered poorly to A549 cells. We conclude that only the opaque phenotype is able to form extracellular matrix, and that the lic operon and ciaRH contribute to this process. We propose that during infection, extracellular matrix formation enhances the ability of pneumococci to cause invasive disease.

Burden and cost of hospital admissions for vaccine-preventable paediatric pneumococcal disease and non-typable Haemophilus influenzae otitis media in New Zealand

INTRODUCTION

Streptococcus pneumoniae (Sp.) is a leading cause of paediatric bacterial meningitis, pneumonia and acute otitis media, as is non-typable Haemophilus influenzae (NTHi) for acute otitis media. In 2008, a 7-valent conjugated pneumococcal vaccine (PCV7) was included in the New Zealand (NZ) childhood immunization schedule.

OBJECTIVE

To estimate the potentially vaccine-preventable annual hospital admissions and cost to the NZ Government of paediatric admissions for pneumococcal disease and NTHi otitis media prior to the immunization programme.

METHODS

Admissions (2000-7) and deaths (2000-5) in children aged<20 years with pneumococcal meningitis or bacteraemia, pneumonia or otitis media were identified in national datasets and linked by unique patient identifiers. New episodes of illness were defined as admissions occurring >30 days after discharge from a previous admission. Informed by the literature, pneumococcal pneumonia episodes were estimated at 33% of all-cause pneumonia admissions; Sp. and NTHi otitis media episodes were estimated jointly at 72% of otitis media admissions. Each episode was assigned a single diagnosis according to the following hierarchy: meningitis>bacteraemia>pneumonia>otitis media. Incidence rates for episodes were determined for 2000-7 (meningitis, bacteraemia and pneumonia) and 2006-7 (otitis media). Annual DRG-based costs for pneumococcal meningitis, bacteraemia, pneumonia and otitis media were estimated as (episode rate)x(DRG cost weight per episode)x(2007 population)x(national price per cost weight).

RESULTS

Episode rates for pneumococcal meningitis, bacteraemia and pneumonia were stable in 2000-7, highest in the second 6 months of life and declined steeply over the first 5 years of life. Mean rates per 100000 in 2000-7 were 18.4, 27.6 and 464 for pneumococcal meningitis, bacteraemia and pneumonia, respectively, for children aged<2 years; 8.4, 14.9 and 295 for children aged<5 years (including those aged<2 years); and 2.2, 4.4 and 97 for children aged<20 years (including those aged<5 years). Mean rates per 100000 in 2006-7 for Sp. and NTHi otitis media combined were 631 (surgical) and 197 (medical) for children aged<2 years; 691 and 116 for children aged<5 years; and 281 and 35 for children aged<20 years. Pacific Island and indigenous Māori children generally had higher rates than European/other children. Rates increased with socioeconomic disadvantage, across all diagnoses. The annual cost to Government of pneumococcal disease and NTHi otitis media admissions for children aged<20 years was estimated at New Zealand dollars ($NZ)9.95 million (range 7.7-12.2 million) [about $US7.1 million]. Most of this cost was shared between pneumococcal pneumonia (48%) and otitis media (45%), and 78% was incurred in the first 2 years of life. Estimated annual paediatric mortality rates per 100 000 for children aged<5 years were 0.48, 0.30 and 0.54 for pneumococcal meningitis, bacteraemia and pneumonia, respectively. The analysis predicted four or five pneumococcal deaths per year (range 1-8) for children aged<5 years.

CONCLUSIONS

Prior to the introduction of a national Sp. immunization programme, hospital admissions for Sp. disease and NTHi otitis media in NZ cost about $NZ10 million annually, mostly for children aged<2 years and particularly for those living in relative socioeconomic deprivation and for Pacific Island and Māori children. There were about five pneumococcal deaths annually. With adjustment for local serotypes, vaccine serotype coverage and uptake, immunization with any of the three available pneumococcal vaccines would reduce this burden substantially.

Seven-valent pneumococcal conjugate vaccines for developing countries

Protein conjugate bacterial vaccines for invasive pneumococcal diseases have revolutionized the epidemiology of invasive bacterial disease in young children in most of the developed world, but only a small proportion of children at greatest risk of dying from this disease are vaccinated in less developed countries. Pneumococcal disease kills more children than any other illness - more than AIDS, malaria and measles combined. While the noble effort of international agencies to promote the use of pneumococcal vaccines is commendable, studies from several developing countries have failed to recognize invasive pneumococcal disease as a major problem. Thus, even at considerably subsidized vaccine pricing, this failure to recognize the pneumococcal disease burden will deter the introduction of vaccine programs in areas where it is most needed. This lack of awareness creates an impassé for the acceptance of a 'solution'. Whether this absence of evidence is real or simply misleading deserves further urgent evaluation. Such an evaluation could propose the use of the vaccine as a 'probe' for defining the problem. In settings where disease burden is likely to be highest, disease surveillance is nonexistent, childhood immunization programs are fractured or nonexistent, and there is no system to ensure delivery, even if the vaccine is offered free of charge. Ongoing challenges with global polio eradication programs suggest that, critical to the success of any immunization program, is investment in setting up credible disease surveillance systems for vaccine preventable diseases to generate local or regional disease burden data. This will promote local ownership of any immunization programs and reveal myths about a 'hidden agenda' by foreign vaccine manufacturers.