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Streptococcus pneumoniae (Pneumococcus) and Disease Prevention by Immunization 2001

Streptococcus pneumoniae (Pneumococcus) and Disease Prevention by Immunization 2001. Richard D. Clover, M.D. Dept. of Family and Community Medicine University of Louisville. PNEUMOCOCCAL CARRIER STATE. Disease occurs in persons who are already asymptomatic carriers Carrier rates

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Streptococcus pneumoniae (Pneumococcus) and Disease Prevention by Immunization 2001

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  1. Streptococcus pneumoniae(Pneumococcus) and Disease Prevention by Immunization2001 Richard D. Clover, M.D. Dept. of Family and Community Medicine University of Louisville

  2. PNEUMOCOCCAL CARRIER STATE • Disease occurs in persons who are already asymptomatic carriers • Carrier rates 38%-60% in preschool children 29%-35% in grammar school children 9%-25% in junior high school students 18%-29% in adults with children at home 6% in adults with no children at home Virtually all children <2 of age become carriers

  3. LOWER RESPIRATORY TRACT INFECTIONS • S. pneumoniae is the most common cause of community-acquired bacterial pneumonia • >500,000 cases annually 25%-35% require hospitalization 10%-25% have concomitant bacteremia

  4. No. cases per 100,000 Total no. cases Overall 15-30 39,000-79,500 >65 yrs 50-83 25,000-26,560 Children <2 yrs 163 3260 Black Adults 49-58 Certain Native 156 Americans Children <2 yrs 2396 DISSEMINATED INVASIVE INFECTIONS: INCIDENCE OF BACTEREMIA

  5. S. pneumoniae MORTALITY • ~40,000 deaths annually due to pneumococcal infection • More deaths than any other vaccine-preventable disease; half preventable with vaccination • Case-fatality rates for bacteremia: 30%-40% elderly; 15%-20% adults • Highest mortality in the elderly and in patients with underlying medical conditions • S.pneumoniae and influenza together are the 6th leading cause of death; more deaths than BC and AIDS combined

  6. DRUG-RESISTANT S.pneumoniae • Mortality associated with S. pneumoniae dropped with advent of penicillin in the 1940’s • During the 1960’s, isolates of S.pneumoniae moderately resistant to penicillin appeared • Isolates with high-level resistance emerged in the 1970’s • 60-fold increase in 1992 vs 1987 • Prevalence of drug-resistant strains continues to increase -- up to 35% in some communities

  7. 1996 NURSING HOME OUTBREAK OF MULTIDRUG-RESISTANT S. pneumoniae DISEASE • First such outbreak documented in adult population • 11 cases of pneumonia among 84 residents • 3 deaths • Multidrug-resistant S. pneumoniae, serotype 23F, isolated from blood, sputum, and nasopharyngeal specimens of 74 residents and employees • Only 3 residents had received pneumococcal vaccine • No further cases after residents received vaccine and prophylactic antibiotics

  8. PNEUMOCOCCAL POLYSACCHARIDE VACCINE • 14-valent pneumococcal vaccine licensed in 1977 • 23-valent preparation licensed in 1983 • 23-valent vaccines cover 85%-90% of serotypes that cause invasive pneumococcal infections • 23-valent vaccines contain serotypes 1, 2, 3, 4, 5, 6B, 7F, 8, 9N, 9V, 10A, 11A, 12F, 14, 15B, 17F, 18C, 19A, 19F, 20, 22F, 23F, and 33F • 6 serotypes most frequently associated with drug-resistant infection: 6B, 9V, 14, 19A, and 23F

  9. Study, yr Type of infection %Efficacy (95% CI) Shapiro 1984 Invasive infection 67 (13-87) Sims 1988 Invasive infection 70 (37-86) Shapiro 1991 Invasive infection All pts 56 (42-67) Immunocompromised pts 21 (<0-60) Immunocompetent pts 61 (47-72) Persons aged 65-74 yrs 80 (51-92) Farr 1995 Bacteremia 81 (34-94) Forrester 1987* Bacteremia <0 (<0-55) *Only case-controlled study that failed to demonstrate effectiveness against bacteremic disease. Methodologic concerns have been raised regarding this trial. EFFECTIVENESS IN CASE-CONTROLLED STUDIES

  10. ADVERSE REACTIONS TO PNEUMOCOCCAL VACCINE Low incidence of adverse reactions • ~50% of patients experience mild, local reactions, usually lasting <48 hours • More severe local reactions, moderate systemic reactions, and severe systemic reactions are rare • ~33% of 7531 vaccine recipients had local reactions and none had severe febrile or anaphylactic reactions CDC. MMWR.February 1989;38:64-68, 73-76 CDC. MMWR. April 1997;46(RR-8):1-24 Fine et al. Arch Intern Med. 1994;154:2666-2677

  11. CONTRAINDICATIONS TO VACCINATION • Allergy to any vaccine component, including thimerosal • Acute febrile illness

  12. COST-EFFECTIVENESS OF PNEUMOCOCCAL VACCINE IN PREVENTING BACTEREMIA IN THE ELDERLY • Vaccination is cost saving in preventing bacteremia alone • With prevention of pneumonia, meningitis, and other complications added, vaccination is even more cost effective • Cost saving of more than $8 per person vaccinated • Vaccination of 23 million >65 years in 1993 would have saved $194 million Sisk etr al. JAMA. 1997;278:1333-1339.

  13. COST-EFFECTIVENESS OF PNEUMOCOCCAL VACCINE IN ELDERLY AND HIGH-RISK PATIENTS • Pneumococcal pneumonia - 78% of the annual cost of CAP • Vaccinating seniors, high-risk groups <65 years, and HIV patients is cost effective • Net saving/person >50 years of age (in U.S.) is $225 LMS Alert Vaccines. 1998; No. 5

  14. CDC RECOMMENDATIONS • All adults >65 years • Immunocompetent persons >2 years with: Chronic cardiovascular disease Chronic pulmonary disease Diabetes mellitus Alcoholism Chronic liver disease CSF leaks

  15. CDC RECOMMENDATIONS • Immunocompromised persons >2 years with: Functional or anatomic asplenia HIV, AIDS Leukemia, lymphoma, Hodgkin’s disease, multiple myeloma Generalized malignancy Chronic renal failure, nephrotic syndrome Receiving immunosuppressive chemotherapy, radiation Organ and bone marrow transplant patients

  16. CDC RECOMMENDATIONS • Persons >2 years living in special environments or social settings, such as: Nursing homes Chronic-care facilities Alaskan Natives Certain Native American populations

  17. CDC RECOMMENDATIONS Uncertain vaccination status • All persons who have unknown vaccination status should receive one dose of pneumococcal vaccine • When in doubt, vaccinate

  18. DURATION OF PROTECTION • Full antibody response occurs in 2-3 week • Antibody levels remain elevated for at least 5 years • May decrease to preimmunization levels within 10 years • May decline within 3-5 years in children, within 5-10 years in elderly, splenectomy and renal dialysis patients, transplant recipients • Duration of protection suggests revaccination for some patients • CDC.MMWR.February 1989;38:64-68, 73-76

  19. REVACCINATION GUIDELINES Revaccinate persons who: • Are >65 years of age, if vaccinated >5 years earlier and aged <65 years when first vaccinated • Are 2-64 years and at high risk for serious pneumococcal infection • Are at high risk and have shown a rapid decline in antibody levels, if first vaccinated >5 years earlier Revaccination is not routinely recommended for most patients

  20. ADVERSE REACTIONS FOLLOWING REVACCINATION • Revaccination after intervals of >5 years is associated with an increased incidence of adverse side effects: 3% after first dose 11% after second dose • This increased risk is not a contraindication to revaccination Jackson et al.JAMA.1999;281:243-248

  21. REVACCINATION OF THE ELDERLY • Protection by pneumococcal polysaccharide vaccine may not be lifelong • One-time revaccination after >5 years is recommended for persons >65 years vaccinated at <65 years Jackson et al. JAMA. 1999;281:243-248

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