Pneumococcal Disease Prevention Among Adults: Strategies for the Use of Pneumococcal Vaccines

Vaccine effectiveness of the pneumococcal polysaccharide and conjugated vaccines in elderly and high-risk populations in preventing invasive pneumococcal disease: a systematic search and meta-analysis

BACKGROUND

Invasive pneumococcal disease (IPD) is a major cause of morbidity and mortality globally. However, the literature on the vaccine effectiveness (VE) of 23-valent polysaccharide vaccine (PPV23) and 13-valent conjugated vaccine (PCV13) against IPD in adults is sparse. The aim was to summarize the available evidence on the VE of the PPV23 and the PCV13 in elderly individuals against IPD and to investigate how age and comorbidities influence VE against IPD.

METHODS

A systematic search was conducted in Medline and Embase in February 2021. We used combinations of terms related to PPV23, PCV13, elderly, high-risk populations, and IPD. Eligible articles published since 2010 were included. Two authors reviewed and extracted data.

RESULTS

Eight studies met the inclusion criteria for PPV23. The meta-analysis showed a reduced OR for all-type IPD with the use of PPV23 vaccine compared with unvaccinated controls (OR 0.69; 95%CI 0.54, 0.88) and a reduced OR for vaccine-type IPD compared with non-vaccine type IPD (0.69; 95%CI 0.63, 0.76). VE against vaccine-type IPD ranged from 28% to 54.1% for individuals aged 65-79 and from 7.5% to 34% for those aged ≥80-85 years. Most studies found a lower VE of PPV23 in populations with comorbidities and in immunocompromised populations compared with the VE for individuals without comorbidities.One study met the inclusion criteria for PCV13. The vaccine efficacy of PCV13 against IPD in individuals aged ≥65 was 75.0% (95% CI, 41.4 to 90.8).

CONCLUSION

The results from this review show a reduction of IPD in elderly and high-risk populations vaccinated with PPV23 and PCV13. The protective effect may be lower in elderly individuals aged >80 and in individuals with comorbidities. However, the literature is sparse; large-scale prospective studies are required to evaluate the VE of PPV23 and PCV13 vaccination in adults against IPD.

Pneumococcal vaccination for adults: History and updates

ABSTRACT

Although pneumococcal vaccination programs have significantly reduced the incidence of pneumococcal infections in the US, pneumococcal pneumonia continues to be a burdensome cause of morbidity and mortality. Pneumococcal vaccination recommendation updates were recently published and introduce two new pneumococcal conjugate vaccines for use in adults ages 19 and older.

Immunogenicity of conjugated and polysaccharide pneumococcal vaccines administered during pregnancy or postpartum to women with HIV

BACKGROUND

Pneumococcal vaccination is recommended in people with HIV prioritizing PCV. We compared the immunogenicity of PCV-10 and PPV-23 administered antepartum or postpartum.

METHODS

This double-blind study randomized 346 pregnant women with HIV on antiretrovirals to PCV-10, PPV-23, or placebo at 14-34 weeks gestational age. Women who received placebo antepartum were randomized at 24 weeks postpartum to PCV-10 or PPV-23. Antibodies against seven serotypes common to both vaccines and one serotype only in PPV-23 were measured by ELISA/chemiluminescence; B- and T-cell responses to serotype-1 by FLUOROSPOT; and plasma cytokines/chemokines by chemiluminescence.

RESULTS

Antibody responses were higher after postpartum versus antepartum vaccination. PCV-10 generated lower antibody levels than PPV-23 against four and higher against one of seven common serotypes. Additional factors associated with high post-vaccination antibody concentrations were high pre-vaccination antibody concentrations and CD4+ cells; low CD8+ cells and plasma HIV RNA; and several plasma cytokines/chemokines. Serotype-1 B- and T-cell memory did not increase after vaccination.

CONCLUSIONS

Antepartum immunization generated suboptimal antibody responses, suggesting that postpartum booster doses may be beneficial and warrant further studies. Considering that PCV-10 and PPV-23 had similar immunogenicity, but PPV-23 covered more serotypes, the use of PPV-23 may be prioritized in women with HIV on ART.

Invasive pneumococcal disease burden in hospitalized adults in Bogota, Colombia

Background

The incidence of invasive pneumococcal disease (IPD) varies depending on a number of factors, including vaccine uptake, in both children and adults, the geographic location, and local serotype prevalence. There are limited data about the burden of Streptococcus pneumoniae (Spn), serotype distribution, and clinical characteristics of adults hospitalized due to IPD in Colombia. The objectives of this study included assessment of Spn serotype distribution, clinical characteristics, mortality, ICU admission, and the need for mechanical ventilation.

Methods

This was an observational, retrospective, a citywide study conducted between 2012 and 2019 in Bogotá, Colombia. We analyzed reported positive cases of IPD from 55 hospitals in a governmental pneumococcal surveillance program. Pneumococcal strains were isolated in each hospital and typified in a centralized laboratory. This is a descriptive study stratified by age and subtypes of IPD obtained through the analysis of medical records.

Results

A total of 310 patients with IPD were included, of whom 45.5% were female. The leading cause of IPD was pneumonia (60%, 186/310), followed by meningitis. The most frequent serotypes isolated were 19A (13.87%, 43/310) and 3 (11.94%, 37/310). The overall hospital mortality rate was 30.3% (94/310). Moreover, 52.6% (163/310 patients) were admitted to the ICU, 45.5% (141/310) required invasive mechanical ventilation and 5.1% (16/310) non-invasive mechanical ventilation.

Conclusion

Pneumococcal pneumonia is the most prevalent cause of IPD, with serotypes 19A and 3 being the leading cause of IPD in Colombian adults. Mortality due to IPD in adults continues to be very high.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-06769-2.

A review of current data to support decision making for introduction of next generation higher valency pneumococcal conjugate vaccination of immunocompetent older adults in the UK

INTRODUCTION

The burden of pneumococcal disease in older UK adults remains substantial. Higher valency pneumococcal conjugate vaccines (PCVs) are currently in development with adult formulations for two of these anticipated to become available in 2022. This article collates and reviews relevant candidate data now available that may be used to support cost effectiveness assessments of vaccinating immunocompetent UK adults aged ≥65-years with PCVs.

AREAS COVERED

This article uses published data from surveillance systems, randomized controlled trials and observational studies. It focuses on local data from the UK but where these are either limited or not available relevant global data are considered.

EXPERT OPINION

The body of relevant data now available suggests the UK is well placed to assess the cost effectiveness of vaccinating immunocompetent ≥65-year olds with new generation higher valency PCVs. Recent contemporary data provide important new and robust insights into the epidemiology of pneumococcal disease in older UK adults and help to address much of the uncertainty and data gaps associated with previous analyses. Using these data to make informed decisions about use of new higher valency PCVs for routine use in older adults will be important for public health in the UK.

Barriers to Vaccination Among People with Parkinson's Disease and Implications for COVID-19

BACKGROUND

Patients with Parkinson's disease (PD) are at higher risk of vaccine-preventable respiratory infections. However, advanced, homebound individuals may have less access to vaccinations. In light of COVID-19, understanding barriers to vaccination in PD may inform strategies to increase vaccine uptake.

OBJECTIVE

To identify influenza and pneumococcal vaccination rates, including barriers and facilitators to vaccination, among homebound and ambulatory individuals with PD and related disorders.

METHODS

Cross-sectional US-based study among individuals with PD, aged > 65 years, stratified as homebound or ambulatory. Participants completed semi-structured interviews on vaccination rates and barriers, and healthcare utilization.

RESULTS

Among 143 participants, 9.8% had missed all influenza vaccinations in the past 5 years, and 32.2% lacked any pneumococcal vaccination, with no between-group differences. Homebound participants (n = 41) reported difficulty traveling to clinic (p < 0.01) as a vaccination barrier, and despite similar outpatient visit frequencies, had more frequent emergency department visits (31.7% vs. 9.8%, p < 0.01) and hospitalizations (14.6% vs. 2.9%, p = 0.03). Vaccine hesitancy was reported in 35% of participants, vaccine refusal in 19%, and 13.3% reported unvaccinated household members, with no between-group differences. Nearly 13% thought providers recommended against vaccines for PD patients, and 31.5% were unsure of vaccine recommendations in PD.

CONCLUSION

Among a sample of homebound and ambulatory people with PD, many lack age-appropriate immunizations despite ample healthcare utilization. Many participants were unsure whether healthcare providers recommend vaccinations for people with PD. In light of COVID-19, neurologist reinforcement that vaccinations are indicated, safe, and recommended may be beneficial.

Safety, immunogenicity, and transplacental antibody transport of conjugated and polysaccharide pneumococcal vaccines administered to pregnant women with HIV: a multicentre randomised controlled trial

BACKGROUND

Pneumococcus remains an important cause of morbidity in pregnant women with HIV and their infants. We compared the safety and immunogenicity of PCV-10 and PPV-23 with placebo administered in pregnancy.

METHODS

This double-blind, multicentre, randomised controlled trial was done at eight outpatient clinics in Brazil. Eligible participants were adult women with HIV who were pregnant at a gestational age between 14 weeks and less than 34 weeks and who were taking antiretroviral therapy at study entry. Participants were randomly assigned (1:1:1) to receive either PCV-10, PPV-23, or placebo. Participants and study teams were unaware of treatment allocation. Antibodies against seven vaccine serotypes in PCV-10 and PPV-23 were measured by ELISA. The primary outcomes were maternal and infant safety assessed by the frequency of adverse events of grade 3 or higher; maternal seroresponse (defined as ≥2-fold increase in antibodies from baseline to 28 days after immunisation) against five or more serotypes; and infant seroprotection (defined as anti-pneumococcus antibody concentration of ≥0·35 μg/mL) against five or more serotypes at 8 weeks of life. The study was powered to detect differences of 20% or higher in the primary immunological outcomes between treatment groups. This trial is registered with ClinicalTrials.gov, NCT02717494.

FINDINGS

Between April 1, 2016, and Nov 30, 2017, we enrolled 347 pregnant women with HIV, of whom 116 were randomly assigned to the PCV-10 group, 115 to the PPV-23 group, and 116 to the placebo group. One participant in the PCV-10 group did not receive the vaccine and was excluded from subsequent analyses. The frequency of adverse events of grade 3 or higher during the first 4 weeks was similar in the vaccine and placebo groups (3% [90% CI 1-7] for the PCV-10 group, 2% [0-5] for the PPV-23 group, and 3% [1-8] for the placebo group). However, injection site and systemic grade 2 adverse reactions were reported more frequently during the first 4 weeks in the vaccine groups than in the placebo group (14% [9-20] for the PCV-10 group, 7% [4-12] for the PPV-23 group, and 3% [1-7] for the placebo group). The frequency of grade 3 or higher adverse effects was similar across maternal treatment groups (20% [14-27] for the PCV-10 group, 21% [14-28] for the PPV-23 group, and 20% [14-27] for the placebo group). Seroresponses against five or more serotypes were present in 74 (65%) of 114 women in the PCV-10 group, 72 (65%) of 110 women in the PPV-23 group, and none of the 113 women in the placebo group at 4 weeks post vaccination (p<0·0001 for PPV-23 group vs placebo and PCV-10 group vs placebo). Seroresponse differences of 20% or higher in vaccine compared with placebo recipients persisted up to 24 weeks post partum. At birth, 76 (67%) of 113 infants in the PCV-10 group, 62 (57%) of 109 infants in the PPV-23 group, and 19 (17%) of 115 infants in the placebo group had seroprotection against five or more serotypes (p<0·0001 for PPV-23 vs placebo and PCV-10 vs placebo). At 8 weeks, the outcome was met by 20 (19%) of 108 infants in the PCV-10 group, 24 (23%) of 104 infants in the PPV-23 group, and one (1%) of 109 infants in the placebo group (p<0·0001). Although a difference of 20% or higher compared with placebo was observed only in the infants who received PPV-23 at 8 weeks of life, the difference between the two vaccine groups was not appreciable.

INTERPRETATION

PCV-10 and PPV-23 were equally safe and immunogenic in pregnant women with HIV and conferred similar levels of seroprotection to their infants. In areas in which childhood PCV administration decreased the circulation of PCV serotypes, PPV-23 administration to pregnant women with HIV might be more advantageous than PCV by virtue of including a broader range of serotypes.

FUNDING

Eunice Kennedy Shriver National Institute of Child Health and Human Development.

TRANSLATION

For the Portuguese translation of the abstract see Supplementary Materials section.

Immunogenicity of PCV24, an expanded pneumococcal conjugate vaccine, in adult monkeys and protection in mice

Invasive pneumococcal disease (IPD) is responsible for serious illnesses such as bacteremia, sepsis, meningitis, and pneumonia in young children, older adults, and persons with immunocompromising conditions and often leads to death. Although the most recent pneumococcal conjugate vaccines (PCVs) have been designed to target serotypes identified as the primary causative agents of IPD, the epidemiological landscape continues to change stressing the need to develop new PCVs. We have developed an investigational 24-valent PCV (PCV24) including serotypes 1, 2, 3, 4, 5, 6A, 6B, 7F, 8, 9N, 9V, 10A, 11A, 12F, 14, 15B, 17F, 18C, 19A, 19F, 20, 22F, 23F, and 33F all conjugated to CRM197 and evaluated this vaccine in adult monkeys. PCV24 was shown to be immunogenic and induced functional antibody for all vaccine serotypes. Of the serotypes common to PCV13 and V114 (PCV15), PCV24 had a similar immunogenic response with the exceptions of 23F which had higher IgG GMCs for PCV13 and V114, and 7F which had higher GMCs for PCV13. Functional antibody responses were similar for the serotypes in common between PCV24, PCV13 and V114 vaccines, with the exception of serotype 7F which was greater for PCV13. Overall, this study shows that PCV24 provided similar immunogenicity as the lower valent vaccines in adult monkeys with no apparent serotype interference. In addition, PCV24 also provided protection against pneumococcal infection in a mouse challenge model.

Physician survey regarding updated PCV13 vaccine recommendations for adults ≥65 years

BACKGROUND

In June 2019, the Advisory Committee on Immunization Practices recommended discontinuing the routine use of the pneumococcal conjugate vaccine (PCV13) among adults aged ≥65 years and instead recommended PCV13 be used based on shared clinical decision making (SCDM).

OBJECTIVES

We wanted to assess among primary care physicians (1) knowledge and attitudes regarding the new SCDM PCV13 recommendation and (2) how the new recommendation will affect their likelihood of recommending PCV13 to adults aged ≥65 years.

DESIGN

This was done by mail and internet-based survey, which was conducted October 2019 through January 2020. The study was carried out on a nationally representative sample of general internists (GIMs) and family physicians (FPs).

RESULTS

The response rate was 64% (617/968, GIM 57%, FP 71%). Only 41% of respondents were aware of the SCDM PCV13 recommendation in adults aged ≥65 years; 76% agreed (37% "Strongly," 39% "Somewhat") that their patients aged ≥65 years will get confused by having a SCDM recommendation for PCV13 and a routine recommendation for the pneumococcal polysaccharide vaccine (PPSV23); 60% agreed (18% "Strongly," 42% "Somewhat") that they were unsure of what points to emphasize when having a SCDM conversation with an adult aged ≥65 years about receiving PCV13. Just over 50% reported they would be less likely to recommend PCV13 for adults aged ≥65 years as a result of the new recommendation, but 42% reported that their recommendation for PCV13 would not change.

CONCLUSIONS

Word of the new ACIP recommendation for PCV13 for adults aged ≥65 years needs to be further disseminated. Investigation into why some physicians do not plan to change their recommendations is warranted.

Recent advances in the epidemiology and prevention of Streptococcus pneumoniae infections

The introduction of pneumococcal conjugate vaccines (PCVs) 7 and 13 into national childhood immunization programs in the US in 2000 and 2010, respectively, proved to be remarkably successful in reducing infant mortality due to invasive pneumococcal disease (IPD), resulting in widespread uptake of these vaccines. Secondary herd protection of non-vaccinated adults against IPD has proven to be an additional public health benefit of childhood immunization with PCVs, particularly in the case of the vulnerable elderly who are at increased risk due to immunosenescence and underlying comorbidity. Despite these advances in pneumococcal immunization, the global burden of pneumococcal disease, albeit of unequal geographic distribution, remains high. Reasons for this include restricted access of children living in many developing countries to PCVs, the emergence of infection due to non-vaccine serotypes of the pneumococcus, and non-encapsulated strains of the pathogen. Emerging concerns affecting the elderly include the realization that herd protection conferred by the current generation of PCVs (PCV7, PCV10, and PCV13) has reached a ceiling in many countries at a time of global population aging, compounded by uncertainty surrounding those immunization strategies that induce optimum immunogenicity and protection against IPD in the elderly. All of the aforementioned issues, together with a consideration of pipeline and pending strategies to improve access to, and serotype coverage of, PCVs, are the focus areas of this review.

Recommendations for influenza and Streptococcus pneumoniae vaccination in elderly people in China

Influenza and pneumonia can be prevented by vaccination, but they remain major causes of morbidity and mortality in age-related diseases. In most areas of China, the rates of influenza and pneumococcal vaccination are relatively low and public awareness of vaccination remains insufficient. Thus, it is essential to recommend influenza and Streptococcus pneumoniae vaccination to elderly people in clinical practice. Based on recently published studies and related documents issued by several vaccination authorities, such as the World Health Organization, the National Health and Wellness Committee, the Chinese Center for Disease Control and Prevention, the US Centers for Disease Control and Prevention, and the US Advisory Committee on Immunization Practices, we propose official recommendations for influenza and S pneumoniae vaccination in elderly people in China.

Evaluating the cost-effectiveness of a sequential pneumococcal vaccination compared to single-dose vaccination strategy for adults in Hong Kong

Two vaccines, 23-valent pneumococcal polysaccharide vaccine (PPSV23) and 13-valent pneumococcal conjugate vaccine (PCV13), are widely available for the prevention of pneumococcal disease in adults. However, it is unclear how cost-effective these pneumococcal vaccine choices are in the Hong Kong healthcare environment. We aimed to assess the cost-effectiveness of a sequential administration of PCV13 followed by PPSV23 compared to a single dose of PPSV23 vaccination for pneumococcal disease control in Hong Kong adults aged ≥65 years and individuals aged 20-64 years with immunocompromising and chronic conditions. A previously developed deterministic cohort sequential model was applied to compare the outcomes of two vaccination strategies from a societal perspective. Population-specific model input, including incidence, mortality, case-fatality, risk group distribution, vaccination costs, disease management, and productivity loss, was estimated from a Hong Kong-wide electronic medical database. Costs were valued in US$ in 2017. Vaccination strategies with an incremental cost-effectiveness ratio (ICER, defined as incremental cost per QALY saved) less than one local GDP per capita ($46,193 in 2017) were defined as highly cost-effective. Deterministic sensitivity analyses (SA) were conducted. Compared with single-dose PPSV23, sequential vaccination of PCV13 followed by PPSV23 was cost-saving for adults aged ≥20 years. In the deterministic SA, the base-case results were robust for tested parameter uncertainties. Future vaccination policies should consider the cost-effectiveness of a sequential vaccination strategy as a measure to reduce the vaccine-preventable pneumococcal disease burden in Hong Kong.

Prevalence of Hypogammaglobulinemia in Adult Invasive Pneumococcal Disease

Background

Patients with humoral immune deficiency are susceptible to invasive pneumococcal disease (IPD). This study estimates the prevalence of underlying hypogammaglobulinemia in admitted IPD cases and examines whether IPD cases had received preventative treatment.

Methods

All adult IPD cases (Streptococcus pneumoniae in blood or cerebrospinal fluid) admitted to The Ottawa Hospital (TOH) from January 2013 to December 2015 were identified through the Eastern Ontario Regional Laboratory. Documented clinical demographics, S. pneumoniae serotype, serum immunoglobulins measured previously or in convalescence, and vaccination status of the cases were collected retrospectively for descriptive analyses.

Results

There were 134 IPD in 133 patients (47.4% male; mean age 63, standard deviation [SD] = 15.6 years) during a 3-year observation period. All-cause mortality rate was 22.6% over a mean follow-up time of 362, SD = 345 days. Fifty-seven patients (42.9%) had serum immunoglobulin levels measured. Eighteen were either found to have hypogammaglobulinemia in convalescence (8/18) or previously known to have hypogammaglobulinemia (10/18). None of the known hypogammaglobulinemic patients had received antibiotic prophylaxis and/or immunoglobulin replacement therapy within 4 months prior to IPD. The high and low estimates of prevalence of hypogammaglobulinemia were 31.6% (of all measured) and 13.5% (of all cases). Among 18 patients with hematological malignancies in our cohort, 13 had hypogammaglobulinemia. Many isolates were vaccine serotypes; however, only 8 had documented previous pneumococcal vaccination.

Conclusions

IPD has high mortality, and hypogammaglobulinemia was present in at least 13.5% of IPD cases. Secondary hypogammaglobulinemia is especially common in cases with hematological malignancy and IPD.

The US Military Commitment to Vaccine Development: A Century of Successes and Challenges

The US military has been a leading proponent of vaccine development since its founding. General George Washington ordered the entire American army to be variolated against smallpox after recognizing the serious threat that it posed to military operations. He did this on the recommendation from Dr. John Morgan, the physician-in-chief of the American army, who wrote a treatise on variolation in 1776. Although cases of smallpox still occurred, they were far fewer than expected, and it is believed that the vaccination program contributed to victory in the War of Independence. Effective military force requires personnel who are healthy and combat ready for worldwide deployment. Given the geography of US military operations, military personnel should also be protected against diseases that are endemic in potential areas of conflict. For this reason, and unknown to many, the US military has strongly supported vaccine research and development. Four categories of communicable infectious diseases threaten military personnel: (1) diseases that spread easily in densely populated areas (respiratory and dysenteric diseases); (2) vector-borne diseases (disease carried by mosquitoes and other insects); (3) sexually transmitted diseases (hepatitis, HIV, and gonorrhea); and (4) diseases associated with biological warfare. For each category, the US military has supported research that has provided the basis for many of the vaccines available today. Although preventive measures and the development of drugs have provided some relief from the burden of malaria, dengue, and HIV, the US military continues to fund research and development of prophylactic vaccines that will contribute to force health protection and global health. In the past few years, newly recognized infections with Zika, severe acute respiratory syndrome, Middle East respiratory syndrome viruses have pushed the US military to fund research and fast track clinical trials to quickly and effectively develop vaccines for emerging diseases. With US military personnel present in every region of the globe, one of the most cost-effective ways to maintain military effectiveness is to develop vaccines against prioritized threats to military members' health.

Validation of discharge diagnosis codes to identify serious infections among middle age and older adults

OBJECTIVES

Hospitalisations for serious infections are common among middle age and older adults and frequently used as study outcomes. Yet, few studies have evaluated the performance of diagnosis codes to identify serious infections in this population. We sought to determine the positive predictive value (PPV) of diagnosis codes for identifying hospitalisations due to serious infections among middle age and older adults.

SETTING AND PARTICIPANTS

We identified hospitalisations for possible infection among adults >=50 years enrolled in the Tennessee Medicaid healthcare programme (2008-2012) using International Classifications of Diseases, Ninth Revision diagnosis codes for pneumonia, meningitis/encephalitis, bacteraemia/sepsis, cellulitis/soft-tissue infections, endocarditis, pyelonephritis and septic arthritis/osteomyelitis.

DESIGN

Medical records were systematically obtained from hospitals randomly selected from a stratified sampling framework based on geographical region and hospital discharge volume.

MEASURES

Two trained clinical reviewers used a standardised extraction form to abstract information from medical records. Predefined algorithms served as reference to adjudicate confirmed infection-specific hospitalisations. We calculated the PPV of diagnosis codes using confirmed hospitalisations as reference. Sensitivity analyses determined the robustness of the PPV to definitions that required radiological or microbiological confirmation. We also determined inter-rater reliability between reviewers.

RESULTS

The PPV of diagnosis codes for hospitalisations for infection (n=716) was 90.2% (95% CI 87.8% to 92.2%). The PPV was highest for pneumonia (96.5% (95% CI 93.9% to 98.0%)) and cellulitis (91.1% (95% CI 84.7% to 94.9%)), and lowest for meningitis/encephalitis (50.0% (95% CI 23.7% to 76.3%)). The adjudication reliability was excellent (92.7% agreement; first agreement coefficient: 0.91). The overall PPV was lower when requiring microbiological confirmation (45%) and when requiring radiological confirmation for pneumonia (79%).

CONCLUSIONS

Discharge diagnosis codes have a high PPV for identifying hospitalisations for common, serious infections among middle age and older adults. PPV estimates for rare infections were imprecise.

Deaths From Pneumonia-New York City, 1999-2015

Background

"Pneumonia and influenza" are the third leading cause of death in New York City. Since 2012, pneumonia and influenza have been the only infectious diseases listed among the 10 leading causes of death in NYC. Most pneumonia and influenza deaths in NYC list pneumonia as the underlying cause of death, not influenza. We therefore analyzed death certificate data for pneumonia in NYC during 1999-2015.

Methods

We calculated annualized pneumonia death rates (overall and by sociodemographic subgroup) and examined the etiologic agent listed.

Results

There were 41 400 pneumonia deaths during the study period, corresponding to an annualized age-adjusted death rate of 29.7 per 100 000 population. Approximately 17.5% of pneumonia deaths specified an etiologic agent. Age-adjusted pneumonia death rate declined over the study period and across each borough. Males had an annualized age-adjusted pneumonia death rate 1.5 (95% confidence interval [CI], 1.5-1.5) times that of females. Non-Hispanic blacks had an annualized age-adjusted pneumonia death rate 1.2 (95% CI, 1.2-1.2) times that of non-Hispanic whites. The annualized pneumonia death rate increased with age group above 5-24 years and neighborhood-level poverty. Staten Island had an annualized age-adjusted pneumonia death rate 1.3 (95% CI, 1.2-1.3) times that of Manhattan. In the multivariable analysis, pneumonia deaths were more likely to occur among males, non-Hispanic blacks, persons aged ≥65 years, residents of neighborhoods with higher poverty levels, and in Staten Island.

Conclusions

While the accuracy of death certificates is unknown, investigation is needed to understand why certain populations are disproportionately recorded as dying from pneumonia in NYC.

Otitis Media in Fully Vaccinated Preschool Children in the Pneumococcal Conjugate Vaccine Era

Objectives. To evaluate the effect of pneumococcal conjugate vaccine (PCV13) on the burden of acute otitis media (AOM) and to evaluate the characteristics of AOM versus otitis media with effusion (OME) in the 2 PCV periods. Methods. A cohort of fully vaccinated children aged 18 to 60 months diagnosed with AOM from 2006 to 2015 was identified. Patients with otorrhea/bulging tympanic membrane were considered as true AOM, while those without bulging/otorrhea were considered to have OME. Burden of true AOM in the PCV7 and PCV13 periods and clinical features of true AOM versus OME were compared. Results. Of 393 episodes in our cohort, 50.8% occurred in PCV7 period. Burden of true AOM in the 2 PCV groups was similar: 26% in PCV7 versus 26.4% in PCV13 (odds ratio [OR] = 1.02, 95% confidence interval [CI] = 0.65-1.60). Factors significantly associated with OME were cold season (OR = 1.54, 95% CI = 1.04-2.4), fever (OR = 2.05, 95% CI = 1.29-3.3), and recurrence (OR = 2.24, 95% CI = 1.22-4.09). No complications of AOM were identified. Majority episodes were treated with antibiotics. Conclusion. Unlike the role of PCV13 in reducing invasive pneumococcal disease, its effect on reducing the burden of AOM is minimal as compared with PCV7. With regard to characteristics of AOM versus OME, findings of tympanic membrane should be used to suggest a diagnosis of AOM, instead of occurrence of fever or recurrence of AOM episodes. Using this approach would help in guiding the use of antibiotics appropriately.

Screening, prophylaxis and counselling before the start of biological therapies: A practical approach focused on IBD patients

The standard of care in the management of immune-mediated inflammatory conditions relies on immunomodulators, glucocorticoids, and biologicals (including anti-tumour necrosis factor -α and other monoclonal antibodies). These agents have an overall favourable benefit/risk ratio; however, they modulate the immune response as part of their mechanisms of action, and therefore they may increase the risk of developing infections, particularly in older patients or in patients with concomitant corticosteroids. Some of these infections may be preventable by immunization, chemoprophylaxis or counselling.

AIM

screening for and monitoring infections throughout these therapies is so mandatory to ensure patients' safety. Still, standardized guidelines focused on these procedures have yet to be established. This review aims to fill such a gap. The authors searched for articles published in English from 2009 until 2017 using PUBMED, with the terms "immunomodulators", "biological drugs", "anti-TNF α", "inflammatory bowel diseases", "immunomediated inflammatory diseases", "risk of infection", "infection prevention", "screening", "immunization", "tuberculosis", "latent tuberculosis", "listeriosis", "endemic mycosis", "Pneumocystis jiroveci pneumonia", "granulomatous infection", "varicella", "herpes virus", "hepatitis B", "hepatitis A", "hepatitis C" and identified the journal articles. Based on the literature and in their own experience the authors established recommendations and a practical guide for infections' screening, monitoring and prevention before and during immunomodulatory and biological therapies.

Pneumococcal conjugate vaccine use in adults - Addressing an unmet medical need for non-bacteremic pneumococcal pneumonia

Streptococcus pneumoniae is a frequent cause of community acquired pneumonia (CAP), with the largest burden of disease attributed to non-bacteremic pneumonia. Due to the high persistent burden of disease, pneumococcal pneumonia, particularly non-bacteremic pneumococcal pneumonia, continues to be a major public health concern. There are currently two pneumococcal vaccines approved for use in adults in the United States (US) and other countries worldwide: a 23-valent pneumococcal simple polysaccharide vaccine (PPV23), and a 13-valent pneumococcal conjugate vaccine (PCV13). The capsular polysaccharides included in PPV23 induce antibodies primarily by a T-cell independent mechanism, thus the immune response is short lived and lacks the ability to elicit an anamnestic response. PCV13, on the other hand, has the bacterial polysaccharides covalently conjugated to an immunogenic carrier protein resulting in the formation of memory B lymphocytes, thus proving long-acting immunologic memory and an anamnestic response. Despite 30years of use, the question of PPV23 vaccine efficacy, particularly with respect to efficacy for non-bacteremic pneumonia, has been extensively debated and investigated; whereas PCV13 efficacy against vaccine-type pneumococcal CAP, both bacteremic and non-bacteremic, was confirmed in a large randomized controlled trial in older adults. PCV13 was approved under the US Food and Drug Administration's accelerated pathway, which allows for earlier approval of products that provide meaningful benefit over existing treatments - in this case, protection of adults from non-bacteremic pneumococcal pneumonia. Its use is now increasingly recommended globally. This article summarizes the history and use of PPV23 and PCV13 in adults and how vaccination of adults with PCV13 addresses an unmet medical need.

Predictors of Mortality Among U.S. Veterans With Streptococcus Pneumoniae Infections

INTRODUCTION

Serious Streptococcus pneumoniae infections, encompassing pneumonia, bacteremia, and meningitis, are a major cause of mortality. However, literature regarding mortality is often limited to invasive pneumococcal disease, excluding pneumonia. This study sought to identify predictors of mortality among adults with serious pneumococcal disease, including pneumonia and invasive pneumococcal disease.

METHODS

This was a nested case-control study of unvaccinated older Veterans with positive S. pneumoniae cultures (blood, cerebrospinal fluid, respiratory) admitted to Veterans Affairs medical centers nationally between 2002 and 2011. Patients vaccinated against pneumococcal disease were excluded. Using multivariable logistic regression, predictors of 30-day mortality were identified, including patient demographics, comorbidities during admission, and medical history within the previous year.

RESULTS

Among 9,468 patients, there were 9,730 serious pneumococcal infections; 1,764 (18.6%) resulted in death within 30 days (cases), whereas 7,966 did not (controls). Pneumonia accounted for half (49.4%, n=871) of all deaths. Mortality predictors consistent with vaccine recommendations included dialysis (during hospitalization, OR=3.35, 95% CI=2.37, 4.72), moderate to severe liver disease (during hospitalization, OR=2.47, 95% CI=1.53, 3.99; within 1 year, OR=1.49, 95% CI=1.01, 2.20), and neutropenia (during hospitalization, OR=2.67, 95% CI=1.32, 5.42). Predictors not included in current recommendations included dementia (during hospitalization, OR=1.8, 95% CI=1.23, 2.61) and neurologic disorders (during hospitalization, OR=1.86, 95% CI=1.42, 2.45; within 1 year, OR=1.28, 95% CI=1.02, 1.59).

CONCLUSIONS

Several mortality predictors among unvaccinated Veterans with serious pneumococcal disease were consistent with pneumococcal vaccine recommendations, including organ or immune system dysfunction-related conditions. Other predictors, including neurologic disorders or dementia, may warrant expanded vaccination recommendations.

The herd effects of infant PCV7/PCV13 sequential implementation on adult invasive pneumococcal disease, six years post implementation; a nationwide study in Israel

BACKGROUND

Introduction of pneumococcal conjugate vaccine (PCV) has nearly eliminated vaccine-type (VT) invasive pneumococcal disease (IPD) in children, yet the reported resulting reduction of adult IPD is variable. We present the indirect impact of sequential PCV7/PCV13 implementation in Israel on adult IPD.

METHODS

An ongoing nationwide active surveillance was initiated on July 2009 when PCV7 was implemented (with Catch-up). PCV7 was gradually replaced by PCV13 since November 2010. Comorbidity and outcome data were collected from medical files. Incidence rates were calculated for overall and vaccine-type IPD.

RESULTS

A total of 2579 IPD cases were diagnosed among a population of 5.0-5.5 million adults >18y (2009-2015). Incidence rates were 9.15/100,000 and 10.16/100,000 in the first and second study years, respectively. However, after PCV13 implementation, the rates decreased to 7.19 within four years, and remained stable in the two following years. Within 6years, PCV7-VT-IPD incidence decreased from 2.52 to 0.52 (79%) and PCV13-VT-IPD from 6.15 to 1.81 (71%). Concurrently, non-VT13 incidence increased from 2.99 to 5.25. Approximately 50% of all patients were adults ≥65y, in whom the decrease in PCV13-VT-IPD incidence was smaller and slower (65% vs. >80% decrease in adults <50y).

CONCLUSIONS

Despite continued reduction in PCV13-VT-IPD, overall IPD was stable during the last two years due to serotype replacement. Yet, the significant decrease in adult IPD, six years post-PCV7/13 implementation emphasizes the importance of indirect protection in achieving overall population impact and should be considered when discussing the potential additional benefits of direct adult PCV vaccination.

Changing trends in serotypes of S. pneumoniae isolates causing invasive and non-invasive diseases in unvaccinated population in Mexico (2000-2014)

OBJECTIVE

Introduction of pneumococcal conjugate vaccines (PCV) targeted against a limited number of serotypes substantially decreased invasive (IPD) and non-invasive pneumococcal diseases (NIPD) but it was accompanied by non-vaccine type replacement disease. After 9 years of introduction of PCV in Mexico, we analyze the evidence of the indirect effects on IPD and NIPD serotype distribution among groups not targeted to receive the vaccine.

METHODS

From January 2000 to December 2014, pneumococcal strains isolated from IPD and NIPD cases from patients ≥5 years of age from participant hospitals of the SIREVA II (Sistema Regional de Vacunas) network were serotyped. A regression analysis was performed considering year and proportion of serotypes included in the different vaccine formulations (PCV7, PCV10 and PCV13). The slope was obtained for each regression line and their correspondent p-value. The proportion of each serotype in the pre-PCV7 and post-PCV7 periods was evaluated by χ2 test.

RESULTS

From a total of 1147 pneumococcal strains recovered, 570 corresponded to the pre-PCV7 and 577 to the post-PCV7 periods. The proportion of vaccine serotypes included in the three PCV formulations decreased by 2.4, 2.6 and 1.3%, respectively per year during the study period. A significant increase of serotype 19A was observed in the post-vaccine period in all age groups.

CONCLUSIONS

A percentage of annual decline of serotypes causing IPD and NIPD included in PCV was detected among groups not targeted to receive the vaccine, probably due to herd effect. Considering pneumococcal serotype distribution is a dynamic process, we highlight the importance of surveillance programs.

Prevention of Community-Acquired Pneumonia with Available Pneumococcal Vaccines

Community-acquired pneumonia (CAP) places a considerable burden on society. A substantial number of pediatric and adult CAP cases are due to Streptococcus pneumoniae, but fortunately there are effective vaccines available that have a significant impact on CAP-related medical, social, and economic problems. The main aim of this paper is to evaluate the published evidence concerning the impact of pneumococcal vaccines on the prevention of CAP in children and adults. Available data indicate that pneumococcal conjugate vaccines (PCVs) are effective in children, reducing all-cause CAP cases and bacteremic and nonbacteremic CAP cases. Moreover, at least for PCV7 and PCV13, vaccination of children is effective in reducing the incidence of CAP among adults. Recently use of PCV13 in adults alone or in combination with the pneumococcal polysaccharide vaccine has been suggested and further studies can better define its effectiveness in this group of subjects. The only relevant problem for PCV13 is the risk of a second replacement phenomenon, which might significantly reduce its real efficacy in clinical practice. Protein-based pneumococcal vaccines might be a possible solution to this problem.

"You need to be an advocate for yourself": Factors associated with decision-making regarding influenza and pneumococcal vaccine use among US older adults from within a large metropolitan health system

In the United States, influenza and pneumonia account significantly to emergency room use and hospitalization of adults >65 y. The Centers for Disease Control and Prevention recommends use of the annual influenza vaccine and 2 pneumococcal vaccines for older adults to decrease risks of morbidity and mortality. However, actual vaccine up-take is estimated at 61.3% for pneumococcal vaccines and 65% for influenza vaccine in the 2013-2014 season. Vaccine up-take is affected by multiple socio-cultural and economic factors including general healthcare access and utilization, social networks and norms, communication with health providers and health information sources, as well as perceptions related to vaccines and targeted diseases. In this study, 8 focus group discussions (total N = 48) were conducted with adults 65+ years living in urban and suburban communities in the Detroit Metropolitan Area. The research objective was to increase understanding of barriers and facilitators to vaccine up-take in this age cohort within the context of general healthcare availability and accessibility, social networks, information sources, and personal perceptions of diseases and vaccines. The data suggest the need to integrate broader health care service experiences, concepts of knowledge of one's own well-being and vulnerabilities, and self-advocacy as factors associated with older adults' vaccine-use decisions. These data also support recognition of multiple levels of vaccine acceptance which can be disease specific. Implications include potential for increasing vaccine up-take through general improvement in health care delivery and services, as well as specific vaccine-focused patient and provider education programs.

Anatomical site-specific contributions of pneumococcal virulence determinants

Streptococcus pneumoniae is an opportunistic pathogen globally associated with significant morbidity and mortality. It is capable of causing a wide range of diseases including sinusitis, conjunctivitis, otitis media, pneumonia, bacteraemia, sepsis, and meningitis. While its capsular polysaccharide is indispensible for invasive disease, and opsonising antibodies against the capsule are the basis for the current vaccines, a long history of biomedical research indicates that other components of this Gram-positive bacterium are also critical for virulence. Herein we review the contribution of pneumococcal virulence determinants to survival and persistence in the context of distinct anatomical sites. We discuss how these determinants allow the pneumococcus to evade mucociliary clearance during colonisation, establish lower respiratory tract infection, resist complement deposition and opsonophagocytosis in the bloodstream, and invade secondary tissues such as the central nervous system leading to meningitis. We do so in a manner that highlights both the critical role of the capsular polysaccharide and the accompanying and necessary protein determinants. Understanding the complex interplay between host and pathogen is necessary to find new ways to prevent pneumococcal infection. This review is an attempt to do so with consideration for the latest research findings.