Impact of infant pneumococcal conjugate vaccination on community acquired pneumonia hospitalization in all ages in the Netherlands

Trends in Pneumococcal and Bacterial Meningitis in Brazil from 2007 to 2019

The pneumococcal conjugate vaccination (PCV) was introduced into the Brazilian Childhood National Immunization Program in 2010; however, universal pneumococcal vaccination for older adults has not been implemented yet. Our aim is to evaluate the trends in pneumococcal meningitis incidence and case fatality rate (CFR) across all age groups from 2007 to 2019 using data from the National Surveillance System. The pre-PCV (2007-2009) and post-PCV (2011-2019) periods were compared; changes in incidence and CFR were assessed by joinpoint regression. Additional analyses of bacterial meningitis were performed to compare the patterns and trends. Over the 13-year period, 81,203 and 13,837 cases were classified as bacterial and pneumococcal meningitis, respectively. S. pneumoniae was the main etiological agent of bacterial meningitis in adults aged ≥50 years and the most lethal in all age groups. In the post-PCV period, a 56.5% reduction in the average incidence was seen in pneumococcal meningitis in the pediatric population. In contrast, there was an increasing trend among adults. The CFR for pneumococcal and bacterial meningitis remained stable in most age groups during the study period. These findings highlight the value of expanding pneumococcal vaccination policies, including vaccines that provide better indirect protection from children to adults and broadening vaccination to older adults.

Systematic review on the impact of the pneumococcal conjugate vaccine ten valent (PCV10) or thirteen valent (PCV13) on all-cause, radiologically confirmed and severe pneumonia hospitalisation rates and pneumonia mortality in children 0-9 years old

Background

There is an ongoing need to assess the impact of pneumococcal conjugate vaccines (PCVs) to guide the use of these potentially valuable but under-utilized vaccines against pneumonia, which is one of the most common causes of post-neonatal mortality.

Methods

We conducted a systematic review of the literature on PCV10 and PCV13 impact on all-cause, radiologically confirmed and severe pneumonia hospitalisation rates as well as all-cause and pneumonia-specific mortality rates. We included studies that were published from 2003 onwards, had a post-licensure observational study design, and reported on any of our defined outcomes in children aged between 0-9 years. We derived incidence rates (IRs), incidence rate ratios (IRRs) or percent differences (%). We assessed all studies for risk of bias using the Effective Public Health Practice Project (EPHPP) quality assessment tool.

Results

We identified a total of 1885 studies and included 43 comparing one or more of the following hospitalised outcomes of interest: all-cause pneumonia (n = 27), severe pneumonia (n = 6), all-cause empyema (n = 8), radiologically confirmed pneumonia (n = 8), pneumococcal pneumonia (n = 7), and pneumonia mortality (n = 10). No studies evaluated all-cause mortality. Studies were conducted in all WHO regions except South East Asia Region (SEAR) and low- or middle-income countries (LMICs) in the Western Pacific Region (WPR). Among children <5 years old, PCV impact ranged from 7% to 60% for all-cause pneumonia hospitalisation, 8% to 90% for severe pneumonia hospitalisation, 12% to 79% for radiologically confirmed pneumonia, and 45% to 85% for pneumococcal confirmed pneumonia. For pneumonia-related mortality, impact was found in three studies and ranged from 10% to 78%. No obvious differences were found in vaccine impact between PCV10 and PCV13. One study found a 17% reduction in all-cause pneumonia among children aged 5-9 years, while another found a reduction of 81% among those aged 5-17 years. A third study found a 57% reduction in all-cause empyema among children 5-14 years of age.

Conclusion

We found clear evidence of declines in hospitalisation rates due to all-cause, severe, radiologically confirmed, and bacteraemic pneumococcal pneumonia in children aged <5 years, supporting ongoing use of PCV10 and PCV13. However, there were few studies from countries with the highest <5-year mortality and no studies from SEAR and LMICs in the WPR. Standardising methods of future PCV impact studies is recommended.

Impact of 7-valent versus 10-valent pneumococcal conjugate vaccines on primary care consultations across various age groups in the Netherlands, 5 years after the switch: A time-series analysis

BACKGROUND

In 2011, 10-valent pneumococcal conjugate vaccine (PCV10) replaced PCV7 in The Netherlands. We aimed to assess the impact of this switch on non-invasive pneumococcal disease in primary care across various age-groups, including pneumonia-bronchitis, otitis media (OM) and sinusitis with and without considering pre-PCV10 secular trends.

METHODS

Electronic records of 397,441 individuals included in a regional primary care database from July 2006 to June 2016 were extracted (2,408,762 person-years). We fitted interrupted time-series on annual incidence rates (IR) of primary care diagnosed pneumonia-bronchitis, OM and sinusitis episodes per age-group. We performed these two types of analyses, comparing; 1) the post-PCV10 observed versus expected trend if PCV10 had not been implemented and pre-PCV10 secular trends had continued 2), the pre- versus post-PCV10 observed, model fitted trend. The latter assumes no secular trend. Incidence rate ratios (IRR) were calculated using both methods.

RESULTS

We found significant reductions following PCV10 introduction with both analysis methods for pneumonia-bronchitis in the pediatric and adult age-groups, for sinusitis in the age-group 20-50 years and for OM, the effect across various age-groups are uncertain given contradictory results. For other outcomes and age-groups, the effect estimates were not consistent across the two-method used and heavily depended on the strength of the underlying trend. No consistent effects were observed in the elderly population, considering the two methods used.

CONCLUSION

Our study supports some direct and indirect-effect of PCV10 introduction on non-IPD, mainly on pneumonia-bronchitis, but estimates heavily depend on the method of analysis used. Estimates from the two different approaches may differ substantially if underlying trends are strong.

The impact of 10-valent pneumococcal conjugate vaccine upon hospitalization rate of children with pneumonia in different Brazilian administrative regions

BACKGROUND

Streptococcus pneumoniae is the most frequent bacterial causative agent of pneumonia. Due to its significant contribution to the morbidity and mortality profile and the country's economy, the 10-valent pneumococcal vaccine (PCV10) was introduced in Brazil in 2010. Brazil is divided into five administrative regions which differ in social-economic indices among each other. Estimates of PCV10 impact on hospitalization rates due to pneumonia stratified by distinct Brazilian regions are limited. We assessed this issue.

METHODS

This is a population-based ecological investigation. Data about hospitalizations due to pneumonia, asthma or urinary tract infection (UTI) among patients aged under 20 years in the pre-exposure (2003-2009) and in the post-exposure (2011-2017) periods were retrieved from the National Health System - Hospital Information System (SIH-SUS) database. The total resident population by age group in each year was retrieved from the Brazilian Institute for Geography and Statistics database. Hospitalization rates were estimated for each Brazilian region and the rates obtained in the pre-exposure and in the post-exposure periods were compared by Prais-Winsten regression. The Human Development Index (HDI) evolved differently in the distinct regions during the study period.

RESULTS

Overall, hospitalization rates due to pneumonia declined by 34.5%. Similar trends were observed for hospitalization rates due to asthma and UTI. The same pattern was observed in each Brazilian region. However, the North region was the only one that presented an exponential incidence decline pattern, which could be explained by PCV10 implementation (declined by 10.8% in the quadratic regression, p < 0.01). Only in the North region, significant decline was observed among patients aged 0-4 years (-12.5%; p = 0.01), 5-9 years (-38.5%; p < 0.01) or 10-14 years (-10.7%; p = 0.03).

CONCLUSION

Significant variation in the downward trend of hospitalization rate was only found in the North region, which evolved from very low HDI in 2003; medium HDI in 2010 to high HDI in 2017.

Consensus Document on Community-Acquired Pneumonia in Children. SENP-SEPAR-SEIP

Community-acquired pneumonia (CAP) is a prevalent disease among children and is frequently associated with both diagnostic and therapeutic uncertainties. Consensus has been reached between SEPAR, SENP and SEIP, and their conclusions are as follows.

Declines in Pneumonia and Meningitis Hospitalizations in Children Under 5 Years of Age After Introduction of 10-Valent Pneumococcal Conjugate Vaccine in Zambia, 2010-2016

Background

Pneumococcus is a leading cause of pneumonia and meningitis. Zambia introduced a 10-valent pneumococcal conjugate vaccine (PCV10) in July 2013 using a 3-dose primary series at ages 6, 10, and 14 weeks with no booster. We evaluated the impact of PCV10 on meningitis and pneumonia hospitalizations.

Methods

Using hospitalization data from first-level care hospitals, available at the Ministry of Health, and from the largest pediatric referral hospital in Lusaka, we identified children aged <5 years who were hospitalized with pneumonia or meningitis from January 2010–December 2016. We used time-series analyses to measure the effect of PCV10 on monthly case counts by outcome and age group (<1 year, 1–4 years), accounting for seasonality. We defined the pre- and post-PCV10 periods as January 2010–June 2013 and July 2014–December 2016, respectively.

Results

At first-level care hospitals, pneumonia and meningitis hospitalizations among children aged <5 years accounted for 108 884 and 1742 admissions in the 42 months pre-PCV10, respectively, and 44 715 and 646 admissions in the 30 months post-PCV10, respectively. Pneumonia hospitalizations declined by 37.8% (95% confidence interval [CI] 21.4–50.3%) and 28.8% (95% CI 17.7–38.7%) among children aged <1 year and 1–4 years, respectively, while meningitis hospitalizations declined by 72.1% (95% CI 63.2–79.0%) and 61.6% (95% CI 50.4–70.8%), respectively, in these age groups. In contrast, at the referral hospital, pneumonia hospitalizations remained stable and a smaller but significant decline in meningitis was observed among children aged 1–4 years (39.3%, 95% CI 16.2–57.5%).

Conclusions

PCV10 introduction was associated with declines in meningitis and pneumonia hospitalizations in Zambia, especially in first-level care hospitals.

Influence of pneumococcal vaccination on the hospitalization of healthy pediatric patients due to typical Community-Acquired Pneumonia

INTRODUCTION

Community-Acquired Pneumonia (CAP) is one of the most frequent causes of hospital admission in children. Our objective is to measure the impact of the introduction of pneumococcal conjugate vaccines on the hospitalization of previously healthy children due to CAP.

METHOD

From 2011 to 2016, a partially retrospective, prospective, and descriptive study was carried out on healthy pediatric patients (3 months-14 years old) with CAP, who required hospital admission. Clinical, epidemiological, and demographic characteristics were collected, and vaccination status was obtained from medical records.

RESULTS

A total of 292 cases were included, with a mean age of 33.4 months, 54% males. There was a progressive and significant 42% decrease in the number of admissions each year, without significant changes in the annual percentage of parapneumonic pleural effusion (PPE). Fifty-six percent of patients were immunized with a pneumococcal conjugate vaccine (PCV). The percentage of children who were not vaccinated decreased by 14%, and the coverage with PCV-13 increased by 46%. This revealed a significant increase of PPE in vaccinated patients with PCV-7 (63%) compared with unvaccinated (45%) and with PCV-13 (57%), without association with the presence of severe PPE. Moreover, no significant differences in severity or hospital stay were observed in unvaccinated patients, compared to those who were vaccinated. In >2-year-olds, we observed a significant increase in PPE (59%) compared to 45% in younger children.

CONCLUSIONS

The increase in vaccination coverage with PCV-13 resulted in a decrease in hospitalizations due to CAP and PPE. Vaccination with PCV-7 is associated in our sample with an increase in PPE but not with severe PPE nor an increase in the hospital stay. There was an epidemiological shift of severe forms of pneumonia and empyema at later ages (>2 years).

Estimating the Impact of Switching from a Lower to Higher Valent Pneumococcal Conjugate Vaccine in Colombia, Finland, and The Netherlands: A Cost-Effectiveness Analysis

INTRODUCTION

Widespread use of ten-valent (Synflorix™, GSK) or 13-valent (Prevenar 13™; Pfizer) conjugate vaccination programs has effectively reduced invasive pneumococcal disease (IPD) globally. However, IPD caused by serotypes not contained within the respective vaccines continues to increase, notably serotypes 3, 6A, and 19A in countries using lower-valent vaccines. Our objective was to estimate the clinical and economic benefit of replacing PCV10 with PCV13 in Colombia, Finland, and The Netherlands.

METHODS

Country-specific databases, supplemented with published and unpublished data, informed the historical incidence of pneumococcal disease as well as direct and indirect medical costs. A decision-analytic forecasting model was applied, and both costs and outcomes were discounted. The observed invasive pneumococcal disease (IPD) trends from each country were used to forecast the future number of IPD cases given a PCV13 or PCV10 program.

RESULTS

Over a 5-year time horizon, a switch to a PCV13 program was estimated to reduce overall IPD among 0-2 year olds by an incremental - 37.6% in Colombia, - 32.9% in Finland, and - 26% in The Netherlands, respectively, over PCV10. Adults > 65 years experienced a comparable incremental decrease in overall IPD in Colombia (- 32.2%), Finland (- 15%), and The Netherlands (- 3.7%). Serotypes 3, 6A, and 19A drove the incremental decrease in disease for PCV13 over PCV10 in both age groups. A PCV13 program was dominant in Colombia and Finland and cost-effective in The Netherlands at 1 × GDP per capita (€34,054/QALY).

CONCLUSION

In Colombia, Finland, and The Netherlands, countries with diverse epidemiologic and population distributions, switching from a PCV10 to PCV13 program would significantly reduce the burden of IPD in all three countries in as few as 5 years.

Influence of Older Age and Other Risk Factors on Pneumonia Hospitalization in Switzerland in the Pneumococcal Vaccine Era

Background: Pneumococcal pneumonia is a disease of the extremes of age. However, as other traditional risk factors for pneumococcal pneumonia also increase with older age, it is unclear if older age itself should be an indication for pneumococcal vaccination. Therefore, we assessed the effect of age on risk for hospitalization for pneumonia and for pneumococcal pneumonia. Methods: Using a national hospitalization dataset, all patients ≥16 years hospitalized in a Swiss hospital with a diagnosis of pneumonia or pneumococcal pneumonia between 2002 and 2015 were included. Multivariable logistic regression analysis was used to test the association between age (≥50 or ≥65 years) and hospitalization for pneumonia or pneumococcal pneumonia after adjusting for pneumococcal vaccine indications. Similar analyses were performed for effect of age on length of stay (LOS) and mortality. Results: Among a total of 17,619,016 hospitalizations a diagnosis of pneumonia was present in 421,760 (2.4%) and a diagnosis of pneumococcal pneumonia in 21,610 (0.12%). Age ≥50 years (OR: 3.52 and 2.12, respectively; p for both <0.001) and age ≥65 years (OR: 2.98 and 1.80, respectively; p for both <0.001) as well as most Swiss pneumococcal vaccine indications were independent predictors of hospitalization with a pneumonia and pneumococcal pneumonia diagnosis, respectively. Older age with both age cut-offs were associated with increased LOS (≥50 years: aRR: 1.19 and 1.24, respectively; age ≥65 years: aRR: 1.60 and 1.20, respectively; p < 0.001 for all) and mortality (≥50 years: aOR: 4.73 and 2.84, respectively; age ≥65 years: aOR: 2.38 and 2.69, respectively, p < 0.001 for all) in patients with a pneumonia and pneumococcal pneumonia diagnosis, respectively. The effects of pneumococcal vaccine indications decreased with older age. The incidences of hospitalizations with a pneumonia diagnosis and a pneumococcal pneumonia diagnosis increased significantly from the pre-vaccine era to the PCV7 era and the PCV13 era (p for trend for both analyses <0.001). Conclusion: This study confirms the Swiss indications for pneumococcal vaccination as independent risk factors for pneumonia hospitalizations. Older age itself should be considered as an additional vaccine indication. Pneumonia and pneumococcal pneumonia in adults have increased despite pneumococcal vaccination in children.

Population-based estimates of the burden of pneumonia hospitalizations in Hong Kong, 2011-2015

Up-to-date data on the burden of disease are important to identify patients with unmet needs and to optimize healthcare resources. We aimed to characterize the burden of pneumonia hospitalizations in Hong Kong and inform targeted healthcare policies for pneumonia control in the era of global aging. This was a population-based study using a territory-wide administrative electronic health record system that covers all public hospitals of Hong Kong. Patients admitted to public hospitals, from 2011 to 2015, with a diagnosis of pneumonia at discharge were identified based on the International Classification of Diseases-Ninth Revision-Clinical Modification Codes (480-486 and 487.0). Incidence, inpatient case-fatality, all-cause fatality, 28-day readmission, hospital length of stay, and healthcare costs were assessed for seven age strata. We identified 323,992 patients (median age 80 years, 44.4% female) with hospitalized pneumonia (organism unspecified 84.2%; bacterial pneumonia 12.3%; viral pneumonia 2.5%; others 1.0%). Annual incidence was 955.1 per 100,000 population, with a 10.6% decrease from 2011 to 2015. Case-fatality, all-cause fatality, and 28-days readmission risks were 13.8, 21.6, and 19.5%, respectively. The average hospital length of stay was 14.1 days with corresponding direct costs of $9348 USD per episode in the monetary value of 2015. Individuals aged ≥ 65 years accounted for over 75% of pneumonia-related hospitalizations, 90% of deaths, and the majority of healthcare costs. Hospitalized pneumonia represents a considerable health and economic burden in Hong Kong, especially in older adults. The study provides a population-level baseline estimate for further cost-effective evaluation of targeted strategies for pneumonia control.

Outpatient antibiotic use in Dutch infants after 10-valent pneumococcal vaccine introduction: a time-series analysis

OBJECTIVE

This population-based cohort study assesses the impact of switching from a 7-valent pneumococcal conjugate vaccine (PCV) to a 10-valent PCV on outpatient antibiotic use in Dutch infants, and whether geographical vaccination coverage modifies this association.

SETTING AND PARTICIPANTS

We extracted 2006-2013 anonymised antibiotic purchase data of 255 154 Dutch infants aged below 2 years from Achmea Health, a health insurance fund covering 28% of the national population.

DESIGN AND MAIN OUTCOME MEASURE

Changes in monthly antibiotic use from 2006-2011 (PCV7) to 2011-2013 (PCV10) were estimated using time-series analysis accounting for seasonality and autocorrelation. Interaction terms for vaccination coverage (categorised into seven groups) and period were added to the model to test whether this association was vaccination coverage-dependent.

RESULTS

275 337 antibiotic courses were used by 119 078 infants (461 352 person-years). PCV10 introduction was associated with a modest 1.6% overall reduction in antibiotic use (purchase rate ratio: 0.98, 95% CI: 0.98 to 0.99). Our model showed a significant difference in time trend in antibiotic use after PCV10 introduction (p=0.0084) with an increase in prescriptions in the PCV7 period (slope: 0.0023/month, 95% CI: -0.0001 to 0.0047) versus a decline in the PCV10 period (slope: -0.0089/month, 95% CI: -0.0150 to -0.0029). There was no evidence that PCV vaccination coverage affected this association, but since the largest rate ratios were observed in municipalities with the lowest vaccine coverage and had very wide accompanying CIs, our study might have insufficient power to detect such an association.

CONCLUSIONS

Switching from PCV7 to PCV10 was associated with a modest decline in outpatient antibiotic use in Dutch infants.

Complicated pneumonia: current concepts and state of the art

PURPOSE OF REVIEW

This review aims to provide clinicians engaged in the care of infants and children an update on the current understanding of the epidemiology, etiology, diagnostic evaluation, and clinical management of complicated pneumonia. The review provides timely information surrounding areas of consensus and ongoing research.

RECENT FINDINGS

The epidemiology and etiologies of complicated pneumonia continue to evolve over the past several decades in context of the introduction of new vaccines. We review uncommon and emerging pathogens. Immunocompromised patients are particularly at risk for complications. The 2011 clinical practice guidelines for pediatric community-acquired pneumonia from The Pediatric Infectious Diseases Society/Infectious Diseases Society of America and the British Thoracic Society are changing approaches to evaluation and management. The efficacy of new diagnostic laboratory studies, and imaging techniques, continues to be studied. Antibiotics are the mainstay of treatment, with several new options to consider. Techniques for the drainage of parapneumonic effusions continue to optimize.

SUMMARY

Although much is known about complicated pneumonia, it remains a significant burden. New diagnostic and therapeutic interventions hold much promise. This review seeks to provide clinicians with evidence that motivates a reasoned approach to the evaluation and management of complicated pneumonia.