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Educational Learning Objectives. Indicate the current burden of pneumococcal disease among adults and identify profiles of specific patients at greatest risk for these preventable diseasesIdentify the challenges facing adequate treatment of pneumococcal disease in adults, such as the emergence of n
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1. Adult Pneumococcal Disease Education: Integrated Regional Learning Series
2. Educational Learning Objectives Indicate the current burden of pneumococcal disease among adults and identify profiles of specific patients at greatest risk for these preventable diseases
Identify the challenges facing adequate treatment of pneumococcal disease in adults, such as the emergence of non-vaccine serotype disease and trends in antibiotic resistance, and define how these elements impact clinical decision making
Describe specific barriers that prevent the proper immunization of adults against pneumococcal disease, and define future strategies for overcoming these barriers
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4. Pneumococcal Disease Burden
5. Streptococcus pneumoniae Gram-positive bacteria
91 distinct capsular types identified
Polysaccharide capsule important pathogenic factor for invasive disease; prevents phagocytosis
Protection is serotype specific; some cross protection within serogroups
6. Pneumococcal Disease Second most common cause of vaccine-preventable death in the US (after influenza)
Major clinical syndromes include
Pneumonia
Bacteremia
Meningitis
Invasive pneumococcal disease (IPD): isolation of S. pneumoniae from a normally sterile site (blood, CSF, pleural, pericardial, peritoneal, bone or joint fluid)
7. S. pneumoniae Infection Nasopharyngeal carriage of S. pneumoniae necessary for transmission of bacteria and invasive disease
Person-to-person contact; respiratory droplets
Autoinoculation
Seasonal patterns
8. Pneumococcal Pneumonia 100,000 to 135,000 cases requiring hospitalization per year in USA
Responsible for at least 1/2 of community-acquired pneumonias and less commonly can cause hospital-acquired pneumonias
Common bacterial complication of influenza and measles
Case-fatality rate 5%–7%, higher in elderly
9. Pneumococcal Bacteremia More than 50,000 cases per year in the United States
Rates higher among elderly and very young infants
Case-fatality rate ~20%; up to 60% among the elderly
10. Pneumococcal Meningitis Estimated 3,000–6,000 cases per year in the United States
Case-fatality rate ~30%, up to 80% in the elderly
Neurologic sequelae common among survivors
Increased risk in persons with cochlear implant
11. Pneumococcal Disease in Children Bacteremia without known site of infection most common clinical presentation
S. pneumoniae leading cause of bacterial meningitis among children younger than 5 years of age
Highest rate of meningitis among children younger than 1 year of age
Common cause of acute otitis media
12. Global Pneumococcal Deaths in Children
13. S. pneumoniae ABCs Provisional Data-2008
14. S. Pneumoniae ABCs Provisional Data-2008All Age Groups
15. Risk Factors for Invasive Pneumococcal Disease Extremes of age
< 2 years; = 65 years
Exposure to cigarette smoke, multiple children in household
Comorbidities
Alcohol abuse
Congestive heart failure
Chronic lung disease
Cigarette smoking
Asthma
Recent influenza infection
Diabetes mellitus
Neurological disorders Certain ethnic groups
American Indians, Alaska Natives, African Americans in the US
Immune deficiencies
B cell defects
Deficiencies of early components of classical pathway of complement
Asplenia
Sickle cell disease
Hematological or solid malignancies
Organ transplant recipients
HIV infection
Immunosuppressive drugs
16. Risk Factors for Invasive Disease – Adults Ages 18 to 64 Years
17. Risk Factors for Death Due to Community-acquired Invasive Pneumococcal Pneumonia
18. Pneumococcal Vaccines
19. Pneumococcal Vaccines
20. Changes in Overall Invasive Pneumococcal Disease, 1998–2007
24. Rates of Invasive Pneumococcal DiseaseMetropolitan Atlanta, Georgia
25. PCV Efficacious in Reducing Radiologically Confirmed Pneumonia in Children
26. Efficacy of PCV in Children < 2 Years 11 publications of 6 randomized controlled trials
N = 57,015 children received PCV; N = 56,029 received placebo or another vaccine
Vaccine-serotype IPD; RR = 0.20 (0.10-0.42); P < 0.0001
All serotypes IPD; RR = 0.42 (0.25-0.71); P = 0.001
WHO X-ray defined pneumonia; RR = 0.73 (0.64-0.85); P < 0.0001
Clinical pneumonia; RR = 0.94 (0.91-0.98); P = 0.0006
All-cause mortality; RR = 0.91 (0.81-1.01); P = 0.07
27. Estimated Changes in Rates of Pneumonia Hospitalizations Post PCV7
28. PCV7 and Community Acquired PneumoniaRetrospective Cohort of Children and Adults - Washington State HMO
29. Invasive Pneumococcal Disease in Children < 2 years
30. Invasive Pneumococcal Disease Penicillin Non-susceptible (> 2 years)
31. Invasive Pneumococcal Disease in Children and Older Adults
32. Change in Serotype-specific Incidence of Invasive Pneumococcal Infections
33. Invasive Pneumococcal Disease Serotype 19A
34. IPD and S. pneumoniae Serotypes
35. ABC Incidence of Pneumococcal Meningitis by PCV7 ST Group Over Time
36. Most clinically significant resistance:
6A, 6B, 9V, 14, 19A, 19F, 23 F
Antibiotic Resistance in S. pneumoniae
37. Revised Penicillin Breakpoints for Treatment of S. pneumoniae Infection 90-95% of all S. pneumoniae strains will have MIC results in the susceptible range
38. Pneumococcal Polysaccharide Vaccine Coverage – Elderly Adults, 1989–2007 (US)
39. Pneumococcal Polysaccharide Vaccine in Older Adults, US Retrospective cohort study; N = 47,365; = 65 years; 1998-2001
Pneumococcal bacteremia
Reduced risk: HR = 0.56 (0.33-0.93); P = 0.03
Hospitalization for pneumonia
Slightly increased risk: HR:1.14 (1.02-1.28); P = 0.02
Outpatient pneumonia
HR: 1.04 (0.96-1.13); P = 0.31
Community-acquired pneumonia
HR: 1.07 (0.99-1.14)
40. Prospective cohort study, N = 11,241; = 65 years; 2002–2005
Overall pneumonia: HR = 0.79 (0.64-0.98); P = 0.032
Pneumococcal pneumonia: HR: 0.55 (0.34-0.88); P = 0.013
Outpatient pneumonia: HR: 0.90 (0.59-1.37); P = 0.619
Risk of hospitalization for pneumonia: HR = 0.74 (0.59-0.92); P = 0.007
Risk of death due to pneumonia: HR: 0.41 (0.23-0.72); P = 0.002
Invasive pneumococcal disease: HR: 0.60 (0.22-1.65) [incidence was low]; P = 0.324
Pneumococcal Polysaccharide Vaccine in Older Adults, Spain
41. Efficacy of PPV Against Invasive Disease
42. Effectiveness of PPV23 in Adults2008 Meta-analysis 22 studies; 15 Randomized controlled trials (RCTs), N = 48,656 patients; 7 non-RCTs, N = 62,294 patients
Results from RCTs
Invasive pneumococcal disease (IPD)
Strong evidence of protection (74%); OR 0.26 (95% CI 0.15–0.46); P < 0.00001
No statistical heterogeneity
All-cause pneumonia
Inconclusive efficacy (29%); OR 0.71 (95% CI 0.52–0.97); P = 0.029
Substantial statistical heterogeneity
All-cause mortality
No evidence of protection; OR 0.87 (95% CI 0.69–1.10); P = 0.25
Adults with chronic illness
Evidence is less clear
Results from non-RCTs
IPD
Evidence of protection (52%); OR 0.48 (95% CI 0.37–0.61); P < 0.00001
43. Efficacy of Pneumococcal Vaccination in Adults
44. PPV23 and PCV7 Adverse Reactions
45. Safety and Acceptability of PPV23 in Nontraditional Settings
46. Safety and Acceptability of PPV23 in Nontraditional Settings Local redness or swelling higher w/ re-vaccination (P = 0.001)
Re-vacc: 13.1%
First time: 4.4%
Unsure: 1.4%
In multivariate analyses:
Local symptoms ? fever (OR 13.15, P < 0.001)
Re-vaccination ? local symptoms (adjusted OR 3.77, P < 0.001)
Patient satisfaction:
Very convenient 96.2%
Very satisfied 97.0%
Would recommend to family/friend 99.4%
47. Safety of 3rd Dose of PPV23 Retrospective analysis of 316,995 elderly members of 3 HMOs participating in Vaccine Safety Datalink project
Medical encounters associated with potential injection site reaction
0.3% of 1st dose recipients
0.7% of 2nd dose recipients
0.5% of 3rd dose recipients
Conclusion: no suggestion of increased risk of medically attended injection site reactions for a 3rd dose compared with 1st or 2nd doses of PPV
48. PPV Prevention of Pneumonia in Elderly Patients Cohort studies suggest protection against IPD
Some cohort studies suggest protection against pneumonia, while others do not
No randomized trials have demonstrated efficacy against pneumonia in the elderly
49. Investigation of Pneumococcal Conjugate Vaccine for Adults
50. Influenza and Pneumococcal Pneumonia
52. 1918 Influenza and Pneumococcal Pneumonia Sequential Infection
53. 1918 Pneumonia Deaths – All of 58 Autopsies Reviewed in 2008 Showed Evidence of Bacterial Infection
55. Improving Immunization Rates
56. Adult Immunization Schedule: US 2010
57. Pneumococcal Polysaccharide Vaccine (PPV23)
58. Gaps Persist Between Vaccination Rates and Healthy People 2010 Goals
59. IPD – Missed Opportunities for Vaccination 1878 cases of IPD in adults from ABCs program
1177 had an indication for vaccination
617 were unvaccinated
92% had 1 or more missed opportunities
54% hospitalized (median # of visits = 1)
58% had ED visits (median # of visits = 1)
76% had PC visits (median # of visits = 6)
Conclusion: 1 or more missed opportunities were documented in almost all unvaccinated IPD adults with a vaccine indication
Implementation of systems strategies in outpatient settings would increase vaccine uptake
60. Patient Issues for Vaccination Awareness
Disease
Vaccine
Personal risk
Provider recommendation
Misconceptions/fears
About vaccine
About health care system
Access and ability to pay
61. Medicare Coverage for Influenza and Pneumococcal Polysaccharide Vaccines
62. Strategies to Improve Immunization Rates Standing orders
Computerized record reminders
Chart reminders
Performance feedback
Home visits
Mailed/Telephoned reminders
Expanding access in health care settings
Patient education
Personal health records
63. Improving Vaccination Rates:Provider Issues Know the facts
Recommend vaccinations to your patients
Get organized and use systems approaches
Ensure offering and administration of vaccine
Automatic processes that empower nurses are effective
Address convenience, efficiency, durability
Evaluate and provide feedback
Consider new paradigms
New venues
Extend vaccination season
Practice what we preach (get vaccinated!)
64. Standing Orders Are Among the Most Effective Strategies Nonphysicians offer and administer vaccinations
No direct MD involvement at the time of the visit
Established with physician-approved policies and protocols
Locations:
Clinics and hospitals
65. Success of Standing Orders as Part of a Multifaceted Program
66. Provider Recommendation Can Overcome Negative Attitudes Among Patients
67. Interventions That Improve Vaccination Rates for Adults
68. Inpatient Computer-Based Standing Orders vs MD Reminders
69. Summary Conjugate Vaccine
Changing epidemiology of IPD
Effectiveness in children
Herd immunity
Antibiotic resistance
Serotype replacement
PPV23 in Adults
Effectiveness against IPD
On the Horizon
Expanded serotype coverage: PCV13
1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, 23F
Conjugate vaccines for older adults?
Protein vaccines that include universal protein antigens (not serotype specific)
Strategies to Improve Vaccination Coverage
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