23-valent pneumococcal polysaccharide vaccine improves survival in dialysis patients by preventing cardiac events

Associations of infections and vaccines with Alzheimer's disease point to a role of compromised immunity rather than specific pathogen in AD

INTRODUCTION

Diverse pathogens (viral, bacterial, fungal) have been associated with Alzheimer's disease (AD) and related traits in various studies. This suggests that compromised immunity, rather than specific microbes, may play a role in AD by increasing an individual's vulnerability to various infections, which could contribute to neurodegeneration. If true, then vaccines that have heterologous effects on immunity, extending beyond protection against the targeted disease, may hold a potential for AD prevention.

METHODS

We evaluated the associations of common adult infections (herpes simplex, zoster (shingles), pneumonia, and recurrent mycoses), and vaccinations against shingles and pneumonia, with the risks of AD and other dementias in a pseudorandomized sample of the Health and Retirement Study (HRS).

RESULTS

Shingles, pneumonia and mycoses, diagnosed between ages 65 and 75, were all associated with significantly increased risk of AD later in life, by 16 %-42 %. Pneumococcal and shingles vaccines administered between ages 65-75 were both associated with a significantly lower risk of AD, by 15 %-21 %. These effects became less pronounced when AD was combined with other dementias.

DISCUSSION

Our findings suggest that both the pneumococcal polysaccharide vaccine and the live attenuated zoster vaccine can offer significant protection against AD. It remains to be determined if non-live shingles vaccine has a similar beneficial effect on AD. This study also found significant associations of various infections with the risk of AD, but not with the risks of other dementias. This indicates that vulnerability to infections may play a more significant role in AD than in other types of dementia, which warrants further investigation.

Associations of infections and vaccines with Alzheimer's disease point to a major role of compromised immunity rather than specific pathogen in AD

INTRODUCTION

Diverse pathogens (viral, bacterial, fungal) have been linked to Alzheimer's disease (AD) indicating a possibility that the culprit may be compromised immunity rather than particular microbe. If true, then vaccines with broad beneficial effects on immunity might be protective against AD.

METHODS

We estimated associations of common adult infections, including herpes simplex, zoster (shingles), pneumonia, and recurrent mycoses, as well as vaccinations against shingles and pneumonia, with the risk of AD in a pseudorandomized sample of the Health and Retirement Study.

RESULTS

Shingles, pneumonia, and mycoses diagnosed between ages 65-75, were all associated with higher risk of AD later in life, by 16%-42%. Pneumococcal and shingles vaccines received between ages 65-75 both lowered the risk of AD, by 15%-21%.

DISCUSSION

Our results support the idea that the connection between AD and infections involves compromised immunity rather than specific pathogen. We discuss mechanisms by which the declining immune surveillance may promote AD, and the role of biological aging in it. Repurposing of vaccines with broad beneficial effects on immunity could be a reasonable approach to AD prevention. Pneumococcal and zoster vaccines are promising candidates for such repurposing.

Prognoses of patients undergoing hemodialysis administered 23-valent pneumococcal polysaccharide versus 13-valent pneumococcal protein conjugate vaccines

INTRODUCTION

Sequential vaccination with the 13-valent pneumococcal protein conjugate vaccine (PCV13) and 23-valent pneumococcal polysaccharide vaccine (PPSV23) is recommended for patients undergoing hemodialysis; however, evidence for the efficacy of these pneumococcal vaccines for patients undergoing hemodialysis is limited to a single dose. We aimed to evaluate the prognosis of patients undergoing hemodialysis who received vaccination with PPSV23 alone versus sequential vaccination with PCV13 and PPSV23.

METHODS

Patients undergoing hemodialysis who were vaccinated with PPSV23 alone (PPSV23 group) or PCV13 followed by PPSV23 (PCV13+PPSV23 group) between 2014 and 2016 were included; the observation period was three years from the first injection. Patients who underwent hemodialysis between 2011 and 2012 were included as controls. After propensity score matching using age, sex, dialysis vintage, diabetes history, pneumonia history, and serum albumin and creatinine levels, survival analysis was performed.

RESULTS

The study included 89, 71, and 319 patients in the PPSV23, PCV13+PPSV23, and control groups, respectively. After propensity score matching, the PPSV23 and control group 1 (79 patients each) and the PCV13+PPSV23 and control group 2 (61 patients each) were compared. Significant differences were observed in the survival rate between the PPSV23 group and control group 1 (p = 0.005) but not between the PCV13+PPSV23 group and control group 2. Pneumonia-related mortality in the two vaccinated groups did not differ significantly during the observation period.

CONCLUSIONS

Patients who received PPSV23 had a favorable prognosis; however, no positive effect was demonstrated in the PCV13+PPSV23 group.

23-valent pneumococcal polysaccharide vaccine and the risk of renal progression in older patients with chronic kidney disease

BACKGROUND

The 23-valent pneumococcal polysaccharide vaccine (PPSV23) ensures favorable outcomes and reduces the risk of cardiac events in patients on dialysis. However, the effect of PPSV23 vaccination on renal function remains unknown, particularly in patients with chronic kidney disease (CKD). Therefore, we investigated the association between PPSV23 efficacy and renal progression in older patients (age ≥ 75 years) with CKD.

METHODS

This multicenter, longitudinal cohort study was conducted using data (2008-2016) from the Epidemiology and Risk Factors Surveillance of CKD database. This database was associated with Taiwan's National Health Insurance Research Database (for period: 2008-2019). A total of 1195 older patients with CKD were recruited from 14 hospitals and communities across Taiwan. Renal progression was defined as a > 25% reduction in estimated glomerular filtration rate from the baseline value.

RESULTS

A significant reduction in the risk of renal progression was observed in patients who had received PPSV23 (adjusted hazard ratio [HR]: 0.57; 95% confidence interval [CI]: 0.35-0.91). However, when stratified by CKD stage, this significant reduction was observed in patients with early-stage CKD but not in those with late-stage CKD. Furthermore, a significant reduction in the risk of renal progression was noted in male patients and those with hypertension.

CONCLUSION

Our findings support the protective effect of PPSV23 against renal deterioration in older patients with CKD.

Persistence of Detectable Anti-Pneumococcal Antibodies 4 Years After Pneumococcal Polysaccharide Vaccination in a Randomised Controlled Trial: The Australian Study for the Prevention through Immunisation of Cardiovascular Events (AUSPICE)

AIM

Mouse models have indicated that the pneumococcal polysaccharide vaccine (PPV) can reduce atherosclerosis. This is probably through a process of molecular mimicry, where phosphorylcholine in the capsular polysaccharide of the vaccine elicits antibodies that cross-react with oxidised low-density lipoprotein and reduce plaque. We investigated whether a similar mechanism occurs in humans.

METHODS

A large national blinded, randomised, placebo-controlled trial of the PPV (Australian Study for the Prevention through Immunisation of Cardiovascular Events [AUSPICE]) is underway with fatal and nonfatal cardiovascular disease (CVD) events as the primary outcome. Participants at one centre agreed to a substudy measuring a number of biomarkers and surrogates of CVD over 4 years, including anti-pneumococcal antibodies (immunoglobulin G and immunoglobulin M), C-reactive protein, carotid intima-media thickness, pulse wave velocity, insulin, fasting blood glucose, glycated haemoglobin, and hepatorenal index.

RESULTS

Antipneumococcal immunoglobulin G and immunoglobulin M were both present and statistically significantly increased in the treated group compared to control at 4 years. However, there were no differences in any of the surrogate measures of CVD or metabolic markers at 4 years.

CONCLUSIONS

While there were prolonged differences in anti-pneumococcal antibody titres following PPV vaccination, these did not appear to provide any cardioprotective effect, as measured by a range of markers. Final results using the fatal and nonfatal CVD events await the completion of national health record linkage next year.

TRIAL REGISTRATION

ACTRN12615000536561.

Pneumococcal Pure Polysaccharide Vaccination in Pediatric Patients With Chronic Heart Disease

INTRODUCTION

This study aimed to describe pneumococcal polysaccharide vaccine-23 (PPSV23) vaccination use in high-risk pediatric patients with chronic heart disease (CHD).

METHOD

This was a single-center retrospective cohort study. Patients were included if they were aged 2-18 years and were diagnosed with CHD. The primary outcome was PPSV23 vaccination. Secondary outcomes included missed opportunities and the incidence of infections.

RESULTS

Three hundred ninety-two patients were included; the mean age was 8.8 years. Only 40 patients (10.2%) had documentation of PPSV23 vaccination. Patients had a median number of three clinic visits in 2019. There were 114 cases of pneumonia documented in patients before receiving PPSV23 and one case reported after PPSV23 vaccination.

DISCUSSION

PPSV23 vaccination in high-risk pediatric patients with CHD was low, with many documented missed opportunities for vaccination. This may be attributed to the PPSV23 not being a routine vaccination on the pediatric schedule.

Vaccination Against Pneumonia May Provide Genotype-Specific Protection Against Alzheimer's Disease

Vaccine repurposing that considers individual genotype may aid personalized prevention of Alzheimer's disease (AD). In this retrospective cohort study, we used Cardiovascular Health Study data to estimate associations of pneumococcal polysaccharide vaccine and flu shots received between ages 65-75 with AD onset at age 75 or older, taking into account rs6859 polymorphism in NECTIN2 gene (AD risk factor). Pneumococcal vaccine, and total count of vaccinations against pneumonia and flu, were associated with lower odds of AD in carriers of rs6859 A allele, but not in non-carriers. We conclude that pneumococcal polysaccharide vaccine is a promising candidate for genotype-tailored AD prevention.

Effect of Pneumococcal Vaccine on Mortality and Cardiovascular Outcomes: A Systematic Review and Meta-Analysis

Various studies have suggested the possible cardiovascular (CV) protective effects of the pneumococcal vaccine (PV). Therefore, we conducted a meta-analysis to assess the association between recipients of PV with mortality and CV outcomes among patients with and without established cardiovascular disease. We performed a systematic literature search in PubMed, Embase, and Scopus for studies evaluating the effect of PV on mortality and CV outcomes. A total of 15 studies with 347,444 patients were included in the meta-analysis: 111,784 patients received PV (32%) and 235,660 patients were in the unvaccinated group (68%). Recipients of PV were associated with decreased all-cause mortality (HR, 0.76 (95% CI: 0.66 to 0.87), p < 0.001). PV was associated with a decrease in the incidence of myocardial infarction (MI) (HR, 0.73 (95% CI: 0.56−0.96), p = 0.02), without significant reduction in CV mortality (HR, 0.87 (95% CI: 0.72−1.07), p = 0.18) and stroke (HR, 1.01 (95% CI: 0.93−1.10), p = 0.82). Our study found PV was associated with decreased risk of all-cause mortality and MI. Future RCTs will be necessary to confirm benefits associated with receipt of PV.

Risk factors for infection-related hospitalization in end-stage renal disease patients during peri-dialysis period

Infection-related hospitalization during the peri-dialysis period (PDP) in patients with end-stage renal disease (ESRD) has received less attention. Considering the limited data, we explored the risk factors in this population. Retrospective analysis using the data system to examine factors for infection in ESRD during PDP between January 2012 and December 2017. Patients were divided into infected group and non-infected group according to the history of infection. Binary Logistic Regression Model was used to search for risk factors. A total of 478 patients were hospitalized during their PDP. One hundred and ninety patients developed infection (39.75%). Thirty-six patients (18.95%) had two or more infection events, all due to recurrent respiratory infections. The respiratory system was the main site of infection (63.68%), followed by the urinary system and digestive system. Compared with the non-infected group, the infected group had more patients with hypoproteinemia and coronary heart disease. The following factors: C-reactive protein >15 mg/L, procalcitonin >1 ng/L, neutrophil percentage >75%, age >52.5 years, platelet >300 × 10⁹ /L, neutrophil to lymphocyte ratio, and concomitant coronary heart disease were associated with the occurrence of infection in ESRD patients during PDP. Patients with ESRD have a high incidence of infection during the PDP, with respiratory infection most commonly seen. This research identified several factors associated with risk for infection, which should guide the design of infection prevention strategies.

Pneumococcal Vaccination in Immunocompromised Hosts: An Update

Infections with the pathogen, Streptococcus pneumoniae, are a common cause of morbidity and mortality worldwide. It particularly affects those at the extremes of age and immunocompromised individuals. Preventing pneumococcal disease is paramount in at risk individuals, and pneumococcal vaccination should be offered. Here, we discuss the role of pneumococcal vaccination in specific groups of immunocompromised hosts.

Effectiveness and safety of pneumococcal vaccines used alone or combined with influenza vaccination in dialysis patients: A systematic review and meta-analysis

BACKGROUND

A lower conversion vaccination rate and a more rapid decline in antibody titers over time in dialysis patients raise concerns about the effectiveness of pneumococcal vaccination (PV) in this population, which has not been systematically reviewed.

METHODS

We searched PubMed, Cochrane Library, Embase and three Chinese databases from inception until February 29th, 2020 for interventional, cohort and case-control studies evaluating PV alone or combined with influenza vaccination (IV) on outcomes (all-cause mortality, pneumonia, cardiovascular events, antibody response and safety). Independent reviewers completed citation screening, data extraction, risk assessment, meta-analysis, and GRADE rating of the quality of evidence.

RESULTS

Five cohort studies and one quasirandomized control trial enrolling 394,299 dialysis patients with high to moderate quality were included. Compared with unvaccinated individuals, those receiving PV had lower risk of all-cause mortality [Adjusted relative risk (RR) 0.73, 95% CI 0.67-0.79, I² = 31.1%, GRADE low certainty] and cardiovascular events (adjusted RR 0.80, 95% CI 0.69-0.93, I² = 47.2%, GRADE low certainty) without serious adverse effect reported. Compared with no vaccination, lower all-cause mortality was observed in those receiving PV combined with IV (Adjusted RR 0.71, 95%CI 0.67-0.75, I² = 63.3%), PV alone (Adjusted RR 0.86, 95% CI 0.78-0.94,I² = 0%], and IV alone (Adjusted RR 0.76, 95% CI 0.73-0.79, I² = 0%]. There was no difference between pneumococcal vaccinated patients vs non-vaccinated patients with respect to pneumonia. Immune response to pneumococcal conjugate vaccine-13 was weaker in polysaccharide pneumococcal vaccine-23-pre-vaccinated compared with vaccine-naive patients.

CONCLUSIONS

The use of pneumococcal vaccine especially combined with influenza vaccination is associated with lower risks of all-cause mortality but may be affected by residual confounding/healthy vaccinee bias.

Risk for prolonged hospitalization and mortality in aged community acquired pneumonia patients: a retrospective study in Japan

The present study aimed to reveal; i) risk for prolonged hospitalization and mortality in aged community acquired pneumonia patients, and ii) whether swallowing ability was related to re-hospitalization. The present retrospective study included 92 patients older than 75 years hospitalized with community acquired pneumonia in Takagi Hospital between April 2017 and March 2018. The patients were classified into 3 groups; discharged within 17 days (group I): hospitalized more than 18 days (group II): died during the hospitalization (group III). Swallowing ability was evaluated if available. Univariate analysis indicated males and body mass index (BMI) in group I (n = 24) were higher than group II (n = 46). Group III (n = 22) had low serum albumin, low BMI, and severe disease progression compared with group I. Multivariate analysis demonstrated that group II BMI was lower than group I [odds ratio (OR) = 1.18, p = 0.042]. Group III had lower serum albumin level compared with group I (OR = 81.01, p = 0.025). Diabetes mellitus (p = 0.009), but not swallowing disability, was risk for readmission. Malnutrition represented by low albumin enhanced mortality rate in the pneumonia patients, and low BMI and diabetes mellitus might increase the pneumonia risk.

Pneumococcal vaccination reduces in-hospital mortality, length of stay and medical expenditure in hospitalized elderly patients

Pneumococcal vaccination has been shown to reduce occurrence of invasive pneumococcal diseases in elderly patients. In this study, we investigated the real-world efficacy of pneumococcal vaccination implemented in elderly individuals in Japan. We reviewed the in-patient database of Juntendo University Hospital and selected elderly patients (≥65 years-old) who had received in-patient care in the general medicine department during 2014-2018. A total of 1355 patients were retrospectively enrolled and comprised of 1045 unvaccinated and 315 vaccinated elderly individuals. Prior vaccination was found associated with all-cause shorter hospital stays (adjusted RR = 0.66, 95% CI = 0.57 to 0.76) and less medical expenditure (adjusted RR = 0.76, 95% CI = 0.66 to 0.87) compared with no vaccination, as well as protection for all-cause in-hospital mortality (adjusted OR = 0.42, 95% CI = 0.22 to 0.83). The association of shorter hospital stays and less medical expenditure with vaccination was also observed in the context of pneumonia, although no altered risk in mortality was observed. In conclusion, this study is one of the first reporting real-world data after the initiation of pneumococcal vaccination program in 2014 in Japan. The national PPV23 vaccination program contributed to the reduction of all-cause in-patient days, mortality, and medical expenses in the elderly aged ≥65 years. Further data is warranted to evaluate the contribution from influenza vaccination and protein-conjugate based pneumococcal vaccine.