Post on 30-Apr-2020
PNEUMONIA :PROMISE FULFILLED?
Regina Berba MD FPSMID
Objectives of Lecture
• Know the quality of current evidence based guidelines on immunization
• Appreciate the performance of pneumonia vaccines in terns of hard clinical outcomes such as preventing deaths and hospitalization
Streptococcus pneumoniae (the pneumococcus)
• Pathogen1,2
– Gram-positive diplococcus: first isolated 1881
– More than 90 known serotypes
– Polysaccharide capsule: key virulence factor
• Reservoir1,3
– Human nasopharynx: children (~20–40%) > adults (~5–10%)
• Transmission1
– Self-inoculation
– Respiratory droplets
• Incubation1
– As short as 1 to 3 days (specific to pneumococcal pneumonia)
1. Centers for Disease Control and Prevention (CDC). In: Atkinson W et al, eds. Epidemiology and Prevention of Vaccine-Preventable Diseases. 12th ed., 2nd printing. Public Health Foundation; 2012:233–248. cdc.gov/vaccines/pubs/pinkbook/downloads/pneumo.pdf. Accessed July 10, 2013. 2. World Health Organization. Wkly Epidemiol Rec. 2008;83:373–384. 3. García-Rodríguez JA et al. J Antimicrob Chemother. 2002;50(Suppl S2):59–73.
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1. World Health Organization. Wkly Epidemiol Rec. 2008;83:373–384.
All-Cause Community-Acquired
Pneumonia (CAP)
Pneumococcal
Pneumonia
Other Noninvasive Forms of
Pneumococcal Disease
(eg, sinusitis, bronchitis)
Other Invasive
Pneumococcal Disease(eg, bacteremia, meningitis)
Diagram for illustrative purposes only – not drawn to scale
Invasive
Pneumococcal
Pneumonia (eg, bacteremic
pneumonia)
Pneumococcal Disease Manifestations1
Pneumococcal Disease Burden in Adults Aged ≥50 Years: Estimated Annual Health Care Burden of Major Disease
Manifestations — United States, 20041,a
Diagram for illustrative purposes only – not drawn to scale. ED=emergency department.aBased on data from the Centers for Disease Control and Prevention (CDC) Active Bacterial Core surveillance, national health care utilization data,
existing literature, and expert panel opinion.1. Huang SS et al. Vaccine. 2011;29:3398–3412.
Outpatient
Pneumonia140,000 cases
51,000 ED visits
Inpatient Pneumonia302,000 cases
223,000 ED visits
1.7 million hospital days
Bacteremia7,000 cases
61,000 hospital days
Meningitis1,700 cases
19,000 hospital
days
Incidence Rate of IPD, United States (1999–2000)
IPD=invasive pneumococcal disease.1. Kyaw MH et al. J Infect Dis. 2005;192:377–386. © Kyaw MH et al. The influence of chronic illnesses on the incidence of invasive pneumococcal disease in adults. J Infect Dis,
2005, Vol 192, Issue 3, 377–386, by permission of Oxford University Press on behalf of the Infectious Diseases Society of America.
The Incidence Rate of Pneumococcal Disease Increases With Age and With Certain Chronic Conditions1
Risk of IPD
Dwindling Vaccine Response with Age
Pneumococcal Vaccines1
Pneumococcal polysaccharide vaccines (PPVs)
Serotype-specific capsular
polysaccharides
1. Grabenstein JD et al. Clin Microbiol Infect. 2012;18(Suppl 5):15–24.
Pneumococcal conjugate
vaccines (PCVs) Serotype-specific capsular
Serotype-specific
polysaccharides linked (“conjugated”)
to a protein carrier
Immune Response to PPVs vs PCVs1
LegendPPV
PCV
Ig=immunoglobulin; PCV=pneumococcal conjugate vaccine; PPV=pneumococcal polysaccharide vaccine.1. Siegrist C-A. Vaccine immunology. In: Plotkin SA, Orenstein WA, Offit PA (eds). Vaccines. 6th ed. Philadelphia, PA: WB Saunders Company; 2013:14–32. Reprinted from Vaccines, 6th edition, Siegrist C-A, Vaccine Immunology, p14–32, Copyright 2013, with permission from Elsevier.
Serotypes Contained in PCV13 and PPV23
PCV13=13-valent pneumococcal polysaccharide-protein conjugate vaccine; PPV23=23-valent pneumococcal polysaccharide vaccine. 1. PREVNAR 13 ® [prescribing information]. New York, NY: Pfizer; 2013. PREVNAR 13 ® (Pneumococcal 13-valent Conjugate Vaccine [Diphtheria CRM197 Protein]) is a registered trademark of Pfizer.
Serotypes contained in both vaccines Serotypes unique to PPV23 Serotype unique to PCV13
PCV13
PPV23
1
33F2
3 4 5
6A
6B 7F
8 9N
9V
10A 11A 12F
14
15B 17F
18C 19A 19F
20 22F
23F
PPV23 contains 23 serotypes, of which 11 are unique
PCV13 contains 13 serotypes, of which 1 is unique1
What are the recommendations?
PPV 23• Adults 65 years of age and older• High risk; chronic cardiovascular and
pulmonary disease (including asthma), cigarette smokers and diabetes
• People without a spleen, undergoing chemotherapy, infected with the AIDS virus
• There may be occasions where a second dose is given (consult provider)
• One dose
SCIM or
PPV 23
For CANCER Patients
• When Cancer chemotherapy or other immunosuppressive therapy is being considered, the interval between vaccination and initiation of immunosuppressive therapy should be AT LEAST 2 WEEKS.
• Vaccination during chemotherapy and radiation therapy should be avoided.
Revaccination with PPV 23
• One time revaccination 5 years after 1st dose for aged 19-64 years with immunocompromised states
• If 1st dose given before age 65- revaccinate once at age 65
• No further doses if given at or after age 65 years.
IMMUNOCOMPROMISED STATES
• Patients are recommended to receive both.
PCV 13
BOTH VACCINES
For those uncertain of vaccination status
• May give PCV 13 and PPV 23 if indicated and no record exists
Contraindications and Precautions
• Both PPV 23 and PCV 13
– Severe allergic reaction after previous dose
– Precaution for those with moderate to severe acute illness with or without fever.
Efficacy Trials: PPV 23
Efficacy of PPV 23 : RCT
Mortality Benefit
Well conducted RCT: Efficacy of PPV 23
Efficacy of PPV 23
PPV 23 : EVAN Study
EVAN Study
But we need to use the vaccines for them to work….
Rates of Vaccination in the US
TAKE HOME MESSAGES
• Pneumococcal diseases are serious and
associated with significant mortality
– 1 in every 20 adults who gets pneumococcal
pneumonia die.
– 2 out of every 10 adults who get bacteremia die.
– 3 out of every 10 adults who get meningitis die.
www.cdc.gov/vaccines
ACIP Products
“WHEN MEDITATING OVER A DISEASE, I NEVER THINK OF FINDING A
REMEDY FOR IT,
BUT, INSTEAD, A MEANS OF PREVENTION.”
LOUIS PASTEUR