Pneumococcal and influenza vaccination coverage among at-risk adults: A 5-year French national observational study

National recommendations for adult pneumococcal vaccination in countries of the WHO regions of Americas, Africa, Eastern Mediterranean, South East Asia, and Western Pacific

BACKGROUND

Adults who are elderly or who have underlying health conditions are at particular risk of Streptococcus pneumoniae infections, and pneumococcal vaccines are available. Nonetheless, only national recommendations from countries of North America and Europe have been previously reviewed in the literature.

METHODS

Consequently, we aimed to collate national guidelines for adult pneumococcal immunization across the 161 countries within the World Health Organization (WHO) regions-the Americas (except Canada and the United States of America), Africa, Eastern Mediterranean, South East Asia, and Western Pacific-from country-level official websites and documents, from the WHO portal, and from direct contact with public health officials, pertinent governmental sources, or local vaccination experts.

RESULTS

For 40.4 % (65/161) of these countries, adult pneumococcal vaccination information was available. Among these 65 with available information, 63.1 % (41/65) include adult pneumococcal vaccination in the national vaccination schedule: 58.5 % (24/41) recommend vaccination both for older adults and for risk groups, while 9.8 % (4/41) recommend it only for older adults, and 31.7 % (13/41) only for risk groups. Of note, among the 13 national risk based-only recommendations, 30.8 % (4/13) are age-dependent and strictly reserved for older adults. The regions where age-based adult pneumococcal vaccination recommendations seem to predominate are South East Asia, Western Pacific, and the Americas. The threshold for age-based pneumococcal vaccination recommendations varies between 50 and 70 years of age. The Americas has the highest proportion of countries with risk-based recommendations. Three-quarters of these countries include PCV and PPV23 in the recommendations, most often given in sequence.

CONCLUSIONS

Less than half of countries of the five WHO regions analyzed have accessible information on adult pneumococcal vaccination, and only 25.5 % (41/161) of all countries reviewed recommend adult pneumococcal immunization within the national vaccination schedule. Policymakers should consider extending pneumococcal vaccination guidelines-adapted to national priorities for adult healthcare-as based on local age demographics and risk factor predominance.

The latest news in France before distribution of third-generation pneumococcal conjugate vaccines

INTRODUCTION

In 2023 in France, 15 valent- pneumococcal conjugate vaccines (PCV15) have been recommended as alternatives to PCV13 for children < 2 years. PCV20 has been recommended for at-risk adults but not yet for infants, while PCV21 targets older adults. We endeavored to estimate the potential benefit of new pneumococcal vaccines in preventing invasive pneumococcal infections by comparing serotype extension to PCV13.

PATIENTS AND METHODS

The National Reference Centre for Pneumococci distributed S. pneumoniae IPD serotypes from children and adults.

RESULTS

In 2022, for children under 24 months, PCV15 and PCV20 ensured 10 % and 36 % more coverage against IPD than PCV13. For adults, PCV15, PCV20, and PCV21 covered up to 3 %, 26 %, and 50 % more IPD cases than PCV13.

CONCLUSION

The new generation of pneumococcal vaccines could reduce the burden of invasive pneumococcal infections through serotype extension. Additional studies are needed in parallel to optimize their utilization and improve vaccine coverage in France.

Hospital Burden of All-Cause Pneumonia and Nonbacteremic Pneumococcal Pneumonia in Adults in France Between 2013 and 2019

Background

Community-acquired pneumonia (CAP) is associated with significant morbidity and mortality. The study objective was to describe the hospital burden of pneumonia in the adult population in France.

Methods

This retrospective study was conducted from the National Health Insurance Database. All hospitalizations for pneumonia (all-cause) between 2013 and 2019 were included. Different risk categories for patients were established based on pneumococcal vaccine recommendations by French health authorities.

Results

A total of 2 199 240 episodes of CAP were registered over the study period (annual mean, 314 177 [standard deviation, 17 818.6]); 75% occurred in patients aged ≥65 years, among whom 47% were not classified in the moderate- or high-risk categories recommended for French pneumococcal vaccination. The incidence of CAP increased with age (117.9, 395.3, and 1916.7 per 100 000 for the age groups 18-49, 50-64, and ≥65 years, respectively, in 2019). Furthermore, being at risk of pneumococcal disease resulted in more severe outcomes, including longer episode duration (mean, 14 days in low-risk vs 17 days in high-risk patients) and higher risk of referral to critical care units (from 20% to 27%), of rehospitalization up to 180 days (from 39% to 67%), of in-hospital death (from 12% to 19%), and of 1-year mortality (from 26% to 49%).

Conclusions

This study establishes the incidence of CAP in adults in France, describes the significant burden of disease, and highlights the need for better prevention policies.

Influenza and pneumococcal vaccination in patients with COPD from 3 French cohorts: Insufficient coverage and associated factors

BACKGROUND

Low vaccination rates against influenza and Streptococcus (S.) pneumoniae infections in COPD could impair outcomes. Understanding underlying factors could help improving implementation.

OBJECTIVES

To describe vaccination rates at inclusion in COPD cohorts and analyze associated factors.

METHODS

Between 2012 and 2018, 5927 patients with sufficient data available were recruited in 3 French COPD cohorts (2566 in COLIBRI-COPD, 2653 in PALOMB and 708 in Initiatives BPCO). Data at inclusion were pooled to describe vaccination rates and analyze associated factors.

RESULTS

Mean age was 66 years, 34 % were women, 35 % were current smokers, mean FEV1 was 58 % predicted, 22 % reported ≥2 exacerbations in the year prior to inclusion, mMRC dyspnea grade was ≥2 in 59 %, 52 % had cardiovascular comorbidities and 9 % a history of asthma. Vaccinations rates in the year prior to study entry were 34.4 % for influenza + S. pneumoniae, 17.5 % for influenza alone and 8.9 % for S. pneumoniae alone. In multivariate analyses, influenza vaccination rate was greater in older age, smoking status, low FEV1, exacerbation history, mMRC dyspnea>2, asthma history, hypertension, diabetes mellitus, and the year of inclusion. SP vaccination was associated with type of practice of the respiratory physician, age, smoking status, FEV1, exacerbation history, dyspnea grade, asthma history and the year of inclusion.

CONCLUSION

Rates of vaccination against influenza and S. pneumoniae infection at inclusion in COPD cohorts remain insufficient and vaccination appears restricted to patients with specific features especially regarding severity and comorbidities, which is not consistent with current recommendations.

Prevalence and disparities in influenza vaccination among patients with COPD: A French nationwide population study

INTRODUCTION

Despite concordant international recommendations, many surveys found disappointing rates of influenza vaccination in at-risk populations, ranging from 23% in overall COPD population to more than 70% in more severe COPD subjects. Therefore, we assessed the proportion of French COPD patients non-vaccinated for influenza and their clinical and socio-demographic factors.

MATERIEL AND METHODS

This was a national retrospective study based on the French health insurance database. We identified "diagnosed COPD", defined as subjects hospitalized at least once in 2017 with a principal or associated diagnosis of COPD, and "suspected COPD" as those who were prescribed at least thrice long-acting bronchodilators (LAB), after exclusion of patients with a principal diagnosis or secondary associated diagnosis of asthma or cystic fibrosis, patients deceased before the influenza season and patients hospitalized in long-term or in palliative care unit. Multivariate logistic regression was used to assess the association between patients' characteristics and the lack of influenza vaccination.

RESULTS

From the national database, 1 474 396 subjects were identified as "suspected COPD" of whom 528 114 were excluded because of previous diagnosis of asthma or cystic fibrosis, and 350 566 as "diagnosed COPD". Among the 1 296 848 patients included, 646 687 patients (53.3%) were vaccinated against influenza. Non-vaccinated subjects were significantly younger (62.1 vs 71.6 years old), more often women (47.9% vs 43.1%) and had fewer comorbidities assessed by Charlson's index (3.0 ± 2.2 vs 4.3 ± 2.1). Lack of vaccination was also associated with a lower LAB usage. Also, non-vaccinated subjects neither had severe exacerbation during the study period. Besides there was a significant heterogeneity in vaccination rate by geographic region, from 47% to 57%. In multivariate analysis, variables independently associated with the lack of influenza vaccination were female gender, younger age, fewer comorbidities and lower socio-economic level.

CONCLUSIONS

This study using the French exhaustive health insurance database shows that influenza vaccination among COPD patients remains dramatically low and must become a high-priority public-health strategy.

Uptake of pneumococcal vaccines in older Australian adults before and after universal public funding of PCV13

BACKGROUND

In 2020 Australia changed the funded universal older adult pneumococcal vaccination program from use of the 23-valent pneumococcal polysaccharide vaccine (PPV23) at age 65 to the 13-valent pneumococcal conjugate vaccine (PCV13) at age 70 years. We investigated uptake of both PCV13 and PPV23 in older adults before and after the program change.

METHODS

We analysed a national dataset of records of patients attending general practices (GPs). We included regular attendees aged 65 or above in 2020. Cumulative uptake of PCV13 and monthly uptake of PPV23 was compared for the two periods before (January 2019 to June 2020) and after (July 2020 to May 2021) the program change on 1 July 2020, by age groups and presence of comorbid conditions.

RESULTS

Our study included data from 192,508 patients (mean age in 2020: 75.1 years, 54.2 % female, 46.1 % with at least one comorbidity). Before July 2020, for all adults regardless of underlying comorbidities, the cumulative uptake of PCV13 was < 1 % but by May 2021, eleven months after the program changes, cumulative uptake of PCV13 had increased among those aged 70-79 years (without comorbidity: 16.3 %; with comorbidity: 21.1 %) and 80 + years (without comorbidity: 13.5 %; with comorbidity: 17.7 %), but not among those aged 65-69 years (without comorbidity: 1.3 %; with comorbidity: 3 %). Monthly uptake of PPV23 dropped following the program change across all age groups.

CONCLUSIONS

Changes in uptake of PCV13 and PPV23 among those aged 70 + years were consistent with program changes. However, PCV13 uptake was still substantially lower in individuals aged 65-69 years overall and in those with comorbidities.

Epidemiology of community-acquired pneumonia caused by S treptococcus pneumoniae in older adults: a narrative review

PURPOSE OF REVIEW

This review covers updated perspectives on different aspects of pneumococcal community-acquired pneumonia (pCAP), including the epidemiology, clinical presentation, risk factors, antibiotic treatment, and existing preventive strategies in older adults.

RECENT FINDINGS

pCAP remains the most prevalent condition among lower respiratory tract infections in the older adults according to Global Burden of Diseases 2019. Older adults can display atypical symptoms such as confusion, general clinical deterioration, new onset of and exacerbation of underlying illness that might trigger clinical suspicion of pCAP. Older adults with pCAP often experience increased disease severity and a higher risk of pulmonary complications compared with younger individuals, owing to age-related changes in immunity and a higher prevalence of comorbidities. Vaccination stands fundamental for prevention, emphasizing the need for effective immunization strategies, specifically tailored for older adults. There is a pressing need to reinforce efforts aimed at boosting pneumococcal vaccination rates.

SUMMARY

Despite a high morbidity and mortality, the burden of pCAP, in particular hospital admission and occurrence of invasive infections, among the elderly population is not sufficiently documented. This review findings emphasize the substantial burden of pCAP in this vulnerable population, driven by factors such as advancing age and underlying comorbidities. The emergence of antibiotic-resistant pneumococcal strains further complicates treatment decisions and highlights the importance of tailored approaches for managing pCAP in older adults.

Infection prevention for immunocompromised patients: A cross-translational multicentric survey of current organization in France

OBJECTIVES

To evaluate current organization of infection prevention for immunocompromised patients (ICP) at a countrywide level.

METHODS

Nationwide cross-sectional multicenter study based on an online survey disseminated in 2022 to physicians invested with preventive healthcare missions.

RESULTS

A total of 341 physicians (96% graduates, 32% infectious disease specialists), participated in the survey, with a median age of 40 [35-51] years. On-site access to infection prevention consultations for ICP was reported by 30%, dedicated pre-travel consultations for ICPs by 29%, consultations for infection prevention in solid organ transplant candidates by 16% and return-to-work consultations for ICPs by 6%. Most participants (73%) were aware of nationwide vaccination guidelines for ICP, while 50% felt comfortable using them. Tools for infection prevention advice and ICP vaccination had been developed by 10%, while 89% would have appreciated access to tools developed by others.

CONCLUSIONS

Infection prevention for ICPs remains neglected. Guidelines covering all fields of prevention for ICPs would be more than welcome.

Recent changes to adult national immunization programs for pneumococcal vaccination in Europe and how they impact coverage: A systematic review of published and grey literature

Despite widespread use of pneumococcal vaccines throughout Europe, the burden of pneumococcal disease (PD) in adults is considerable. To mitigate this burden, National Immunization Technical Advisory Groups (NITAGs) and Health Technology Assessment (HTA) agencies assess the value of different vaccine schedules for protecting against PD. The aim of this review was to assess the evidence and rationales used by NITAGs/HTA agencies, when considering recent changes to National Immunization Programs (NIPs) for adults, and how identified changes affected vaccine coverage rates (VCRs). A systematic review was conducted of published literature from PubMed® and Embase®, and gray literature from HTA/NITAG websites from the last 5 y, covering 31 European countries. Evidence related to NIP recommendations, epidemiology (invasive PD, pneumonia), health economic assessments and VCRs were collected and synthesized. Eighty-four records providing data for 26 countries were identified. Of these, eight described explicit changes to NIPs for adults in seven countries. Despite data gaps, some trends were observed; first, there appears to be a convergence of NIP recommendations in many countries toward sequential vaccination, with a pneumococcal conjugate vaccine (PCV), followed by pneumococcal polysaccharide vaccine 23. Second, reducing economic or healthcare burden were common rationales for implementing changes. Third, most health economic analyses assessing higher-valency PCVs for adults found its inclusion in NIPs cost-effective. Finally, higher coverage rates were seen in most cases where countries had expanded their NIPs to cover at-risk populations. The findings can encourage agencies to improve surveillance systems and work to reach the NIP's target populations more effectively.

A Nationwide Digital Multidisciplinary Intervention Aimed at Promoting Pneumococcal Vaccination in Immunocompromised Patients

Immunocompromised patients (IPs) are at high risk for infections, some of which are vaccine-preventable. The Israeli Ministry of Health recommends pneumococcal conjugate vaccine 13 (PCV13) and pneumococcal polysaccharide vaccine 23 (PPSV23) for IP, but vaccine coverage is suboptimal. We assessed the project's effectiveness in improving the pneumococcal vaccination rate among IP. An automated population-based registry of IP was developed and validated at Maccabi Healthcare Services, an Israeli health maintenance organization serving over 2.6 million members. Included were transplant recipients, patients with asplenia, HIV or advanced kidney disease; or those receiving immunosuppressive therapy. A personalized electronic medical record alert was activated reminding clinicians to consider vaccination during IP encounters. Later, IP were invited to get vaccinated via their electronic patient health record. Pre- and post-intervention vaccination rates were compared. Between October 2019 and October 2021, overall PCV13 vaccination rates among 32,637 IP went up from 11.9% (n = 3882) to 52% (n = 16,955) (p < 0.0001). The PPSV23 vaccination rate went up from 39.4% (12,857) to 57.1% (18,652) (p < 0.0001). In conclusion, implementation of targeted automated patient- and clinician-facing alerts, a remarkable increase in pneumococcal vaccine uptake was observed among IP. The outlined approach may be applied to increase vaccination uptake in large health organizations.

General Practitioners' Awareness and Perception of Current Pneumococcal Vaccination for Adult Patients with Known Risk Factors in Switzerland: Evidence from a Survey

In Switzerland, the National Immunization Advisory Group (NITAG) has formulated recommendations for pneumococcal vaccination among adult risk patients. Little is known about general practitioners' (GPs') perception, knowledge, and implementation of these recommendations. Therefore, we investigated GPs' awareness and drivers of and barriers to pneumococcal vaccination using a cross-sectional web-based survey of GPs. Of the 300 study participants, 81.3% were aware of the recommendations for vaccinating at-risk adult patients, but only 42.7% were aware of all risk groups. The recommendations were perceived by 79.7% as slightly to very complex. Most GPs (66.7%) had good arguments to convince patients to get vaccinated, but only 41.7% reported recognizing patients at risk for pneumococcal disease, and only 46.7% checked their patients' vaccination status and proposed vaccination if needed. The main reasons for not vaccinating were patients' refusal (80.1%), lack of reimbursement by the health insurance (34.5%), patients' fear of side effects (25.1%), and lack of regulatory approval despite the NITAG recommendations (23.7%). Most (77.3%) agreed that the treating chronic disease specialist should recommend the vaccination and 94.7% believed that adult-risk patients would not be aware of their need for pneumococcal vaccinations. Optimal implementation of the recommendations will require addressing knowledge gaps and reported barriers.

Pneumococcal vaccination coverage at the initiation of chronic dialysis, and its association with mortality during the first year

OBJECTIVES

Pneumococcal immunization is recommended in dialysis patients. We aimed to estimate pneumococcal vaccination coverage among patients who initiate dialysis in France, and its association with mortality.

METHODS

Data were extracted from two prospective national databases, merged using a deterministic linkage method: renal epidemiology and information network (REIN) registry, which includes all patients on dialysis and kidney transplants recipients in France, and the national health insurance information system (SNIIRAM) which collects individual data on health expenditure reimbursement, including vaccines. We enrolled all patients who initiated chronic dialysis in 2015. Data on health status at dialysis initiation, dialysis modalities, and pneumococcal vaccine prescribed from 2 years before to 1 year after dialysis start were collected. Univariate and multivariate Cox proportional hazard models were used to assess one-year all-cause mortality.

RESULTS

Among the 8,294 incident patients included, 1,849 (22.3 %) received at least one pneumococcal vaccine before (n = 542, 6.5 %), or after (n = 1,307, 15.8 %) dialysis start, as follows: 13-valent pneumococcal conjugated vaccine (PCV13) followed by 23-valent pneumococcal polysaccharide vaccine (PPSV23), n = 938 (50.7 %); only PPSV23, n = 650 (35.1 %); or only PCV13, n = 261 (14.1 %). Vaccinated patients were younger (mean, 66.5 ± 14.8 years vs. 69.0 ± 14.9 years, P ≤ 0.001), more likely to suffer from glomerulonephritis (17.0 % vs. 11.0 %, P ≤ 0.001), and less likely to start dialysis in emergency (27.2 % vs. 31.1 %, P = 0.001). On multivariate analysis, patients who received PCV13 and PPSV23, or only PCV13 were less likely to die (respectively, HR = 0.37; 95 %CI 0.28-0.51, and HR = 0.35; 95 %CI 0.19-0.65).

CONCLUSIONS

Pneumococcal immunization with PCV13 followed by PPSV23, or with PCV13 alone, but not with PPSV23 alone, is independently associated with decreased one year-mortality in patients who start dialysis.