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Pneumococcal Vaccination - Myths and Facts Dale W. Bratzler, DO, MPH Epidemiology of Pneumococcal Disease Disease due to Streptococcus pneumoniae continues to be a major cause of morbidity and mortality in the United States. S. pneumoniae causes approximately 500,000 cases of pneumonia each year and is the leading cause of meningitis in this country.1-4 Pneumococcal infection accounts for more deaths than any other vaccine-preventable bacterial disease. Despite appropriate antimicrobial therapy and intensive medical care, the overall case-fatality rate for pneumococcal bacteremia is 15% to 20% among adults and 30% to 40% in the elderly.5 Recently, antibiotic-resistant strains of S. pneumoniae have been reported at alarming rates.6-12 Over the past 5 to 7 years there has been a 60- fold increase in the number of resistant isolates of pneumococcus.12 Although the incidence varies considerably across the United States, some areas of the country report rates of penicillin-resistant isolates that approach 30% to 60%.6-8 Resistance to penicillin is an important marker of resistance to other classes of antibiotics. In 1996, up to 25% of strains of pneumococcus were resistant to more than one antibiotic.9 Strains of pneumococcus that are penicillin-resistant are frequently resistant to trimethoprim- sulfamethoxazole (TMP-SXT) and many are resistance to macrolides, tetracyclines, and cephalosporins.13,14 Facts about Pneumococcal Vaccination The currently available pneumococcal vaccines contain 23 purified capsular polysaccharide antigens of S. pneumoniae. The 23 capsular antigens in the vaccines represent at least 85% to 90% of the serotypes that cause invasive pneumococcal disease in children and adults in this country. Even though these vaccines have been widely available since 1983, they remain underutilized. Much of this underuse may be attributed to uncertainties and myths about the benefits of the vaccines. Myth #1 - Most eligible patients have received the pneumococcal vaccine. Despite widely disseminated guidelines for use,5 pneumococcal vaccine remains underutilized. Approximately 50% of elderly and high-risk patients in the United States have not been immunized.15 Based on surveillance data from 1997, only 33% of diabetic patients had received the vaccine.16 A recent survey of nearly 7,000 Medicare beneficiaries revealed that the most common reason for not getting the pneumococcal vaccination was that they did not know they needed the shot.17 "The doctor did not recommend the pneumonia shot" was the second most commonly reported reason for not being vaccinated.17 Myth #2 - The pneumococcal vaccine is not effective. Numerous epidemiologic studies have demonstrated the effectiveness of pneumococcal vaccine at preventing invasive disease (bacteremia and meningitis) due to Streptococcus pneumoniae.18-23 The overall efficacy against invasive disease among immunocompetent adults is approximately 75%. Vaccination of elderly patients has been shown to be cost-effective.24 In a recent retrospective cohort study25 of patients with chronic lung disease, pneumococcal vaccination was shown to have substantial health and economic benefits. Pneumococcal vaccination was associated with a 43% reduction in the number of hospitalizations for pneumonia and a 29% reduction in the risk of death from all causes. Estimates of health care cost savings ranged from $113 to $512 per person vaccinated.25 Myth #3 - Revaccination of a previously immunized patient can be dangerous. Localized reactions at the injection site (redness and tenderness) may occur in 10% to 15% of patients being re-immunized with the pneumococcal vaccine.26 These reactions are almost always mild and self-limited and are consistent with a localized Arthus-type reaction (type 3 hypersensitivity reaction). Reactions are more likely to occur in immunocompetent healthy patients. The risk of a sizeable (> 10 cm) local reaction correlates with pre-vaccination streptococcal antibody titers. Serious adverse events associated with revaccination are rare. Studies of large populations of Medicare patients have demonstrated rates of hospitalization within 30 days of revaccination that are no higher than rates of admission for patients being vaccinated the first time.27 In a meta- analysis of nine randomized controlled trials of pneumococcal vaccine efficacy (including more than 7,500 patients), there were no reports of severe febrile, anaphylactic, or neurologic complications.28 Myth # 4 - Hospitalized patients are too sick to be vaccinated. In the 1995 National Health Interview Survey, 67% of all recently hospitalized persons age 65 years or greater had not receive the pneumococcal vaccine. Fedson et al29 demonstrated that two-thirds of persons with serious pneumococcal disease had been hospitalized within the previous 4 years, yet few had received the pneumococcal vaccine. In a study of Medicare patients hospitalized with pneumonia, opportunities to provide pneumococcal vaccination were missed in 80% of the cases.30 Although the manufacturers recommend that the pneumococcal vaccine not be administered to patients with severely compromised cardiac or pulmonary function, there have been many hospital-based standing orders programs to immunize patients prior to discharge that have been safely and effectively implemented.31-39 In addition, successful programs to vaccinate elderly persons presenting to the emergency department for care have been implemented.40,41 There is no evidence of significant risk from the vaccination of hospitalized patients demonstrated in any of these studies.31-41 Recommendations for Pneumococcal Vaccination The current recommendations5 from the Advisory Committee on Immunization Practices (ACIP) for vaccination against pneumococcal disease are summarized in the table and figure. Recent outbreaks of antibiotic-resistant S. pneumoniae have highlighted the importance of vaccination.42-45 The ACIP has recently endorsed recommendations for standing orders programs in outpatient and inpatient settings to increase adult immunization rates. Risk factors for pneumococcal disease in adults include chronic cardiovascular diseases, chronic pulmonary diseases, chronic liver disease, chronic renal disease, diabetes mellitus, and alcoholism. In addition, patients who are immunosuppressed or who have functional asplenia are at increased risk for pneumococcal disease. Age greater than 65 years is also considered a major risk factor. Vaccination against pneumococcal disease is recommended for all patients with risk factors. Any patient who has an unknown immunization status should receive at least one dose of the vaccine. Patients who receive their first dose of vaccine before the age of 65 or those patients who are immunosuppressed should be revaccinated after 5 years. Presently, there are no studies that document benefit of the pneumococcal vaccine given more than twice.5 Conclusion Though widely available, efficacious, and cost-effective, pneumococcal vaccine is underutilized. Approximately half of the deaths from invasive pneumococcal disease could be prevented by use of the vaccine. The emergence of antibiotic-resistant S. pneumoniae supports the urgent need for an increased rate of vaccination among high- risk patients. References Centers for Disease Control and Prevention. Premature deaths, monthly mortality and monthly physician contacts?United States. MMWR Morb Mortal Wkly Rep. 1997;46:556-561. Marston BJ, Plouffe JF, File TM, et al. Incidence of community-acquired pneumonia requiring hospitalization. Results of a population-based active surveillance study in Ohio. The Community-Based Pneumonia Incidence Study Group. Arch Intern Med. 1997;157:1709-1718. Schuchat A, Deaver-Robinson K, Wenger JD, et al. Bacterial meningitis in the United States in 1995. N Engl J Med. 1997;337:970-976. Fine MJ, Smith MA, Carson CA, et al. Prognosis and outcomes of patients with community-acquired pneumonia. A meta-analysis. JAMA. 1996;275:134-141. Centers for Disease Control and Prevention. Prevention of pneumococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 1997;46(RR-8):1-24. Breiman RF, Butler JC, Tenover GC, et al. Emergence of drug-resistant pneumococcal infections in the United States. JAMA. 1994;271:1831-1835. Hofmann J, Cetron MS, Farley MM, et al. The prevalence of drug-resistant Streptococcus pneumoniae in Atlanta. N Engl J Med. 1995;333:481-486. Appelbaum PC. Emerging resistance to antimicrobial agents in gram positive bacteria: pneumococci. Drugs. 1996;51(suppl 1): 1-5. Butler JC, Hofmann J, Cetron MS, et al. The continued emergence of drug-resistant Streptococcus pneumoniae in the United States: an update from the Centers for Disease Control and Prevention?s Pneumococcal Sentinel Surveillance System. J Infect Dis. 1996;174:986-993. Thornsberry C, Burton PH, Vanderhoof BH. Activity of penicillin and three third- generation cephalosporins against US isolates of Streptococcus pneumoniae: a 1995 surveillance study. Diagn Microbiol Infect Dis. 1996;25:89-95. Thornsberry C, Ogilvie P, Kahn J, Mauriz Y. Surveillance of antimicrobial resistance in Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis in the United States in 1996-1997 respiratory season. The Laboratory Investigator Group. Diagn Microbiol Infect Dis. 1997;29:249-257. 1. Jacobs MR. Drug-resistant Streptococcus pneumoniae: rational antibiotic choices. Am J Med. 1999;106(1A):19S-25S. Low DE. Resistance issues and treatment implications: pneumococcus, Staphylococcus aureus, and gram-negative rods. Infect Dis Clin North Am. 1998;12:613-630. Barry AL. Antimicrobial resistance among clinical isolates of Streptococcus pneumoniae in North America. Am J Med. 1999;107(1A):28S-33S. Centers for Disease Control and Prevention. Influenza and pneumococcal vaccination levels among adults aged greater than or equal to 65 years - United States. MMWR Morb Mortal Wkly Rep. 1998;47:797-802. Centers for Disease Control and Prevention. Influenza and pneumococcal vaccination rates among persons with diabetes mellitus - United States, 1997. MMWR Morb Mortal Wkly Rep. 1999;48:961-967. Centers for Disease Control and Prevention. Reasons reported by Medicare beneficiaries for not receiving influenza and pneumococcal vaccinations - United States, 1996. MMWR Morb Mortal Wkly Rep. 1999;48:556-559. Shapiro ED, Clemens JD. A controlled evaluation of the protective efficacy of pneumococcal vaccine for patients at high risk of serious pneumococcal infections. Ann Intern Med. 1984;101:325-330. Sims RV, Steinmann WC, McConville JH, et al. The clinical effectiveness of pneumococcal vaccine in the elderly. Ann Intern Med. 1988;108:653-657. Shapiro ED, Berg AT, Austrian R, et al. The protective efficacy of polyvalent pneumococcal polysaccharide vaccine. N Engl J Med. 1991;325:1453-1460. Butler JC, Breiman RF, Campbell JF, et al. Polysaccharide pneumococcal vaccine efficacy: an evaluation of current recommendations. JAMA. 1993;270:1826-1831. Farr BM, Johnston BL, Cobb DK, et al. Preventing pneumococcal bacteremia in patients at risk. Results of a matched case-control study. Arch Intern Med. 1995;155:2336-2340. Butler JC, Shapiro ED, Carlone GM. Pneumococcal vaccines: history, current status, and future directions. Am J Med.1999;107(1A):69S-76S. Sisk JE, Moskowitz AJ, Whang W, et al. Cost-effectiveness of vaccination against pneumococcal bacteremia among elderly people. JAMA. 1997;278:1333-1339. Nichol KL, Baken L, Wuorenma J, Nelson A. The health and economic benefits associated with pneumococcal vaccination of elderly persons with chronic lung disease. Arch Intern Med. 1999;159:2437-2442. Jackson LA, Benson P, Sneller VP, et al. Safety of revaccination with pneumococcal polysaccharide vaccine. JAMA. 1999;281:243-248. Snow R, Babish JD, McBean AM. Is there any connection between a second pneumonia shot and hospitalization among Medicare beneficiaries? Pub Health Rep. 1995;110:720- 725. Fine MJ, Smith MA, Carson CA, et al. Efficacy of pneumococcal vaccination in adults: a meta-analysis of randomized controlled trials. Arch Intern Med. 1994;154:2666-2677. Fedson DS, Harward MP, Reid RA, Kaiser DL. Hospital-based pneumococcal immunization. Epidemiologic rationale from the Shenandoah study. JAMA. 1990;264:1117-1122. Centers for Disease Control and Prevention. Missed opportunities for pneumococcal and influenza vaccination of Medicare pneumonia patients - 12 Western States, 1995. 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Using a vaccine manager to enhance in-hospital vaccine administration. J Fam Pract. 1995;41:364-369. Nichol KL. Ten-year durability and success of an organized program to increase influenza and pneumococcal vaccination rates among high-risk adults. Am J Med. 1998;105:385-392. Vondracek TG, Pham TP, Huycke MM. A hospital-based pharmacy intervention program for pneumococcal vaccination. Arch Intern Med. 1998;158:1543-1547. Rodriquez RM, Baraff LJ. Emergency department immunization of the elderly with pneumococcal and influenza vaccines. Ann Emerg Med. 1993;22:1729-1732. Slobodkin D, Kitlas J, Zielske P. Opportunities not missed - systematic influenza and pneumococcal immunization in a public inner-city emergency department. Vaccine. 1998;16:1795-1802. Hoge CW, Reichler MR, Dominguez EA, et al. An epidemic of pneumococcal disease in an overcrowded, inadequately ventilated jail. N Engl J Med. 1994;331:643-648. Musher DM, Groover JE, Reichler MR, et al. Emergence of antibody to capsular polysaccharides of Streptococcus pneumoniae during outbreaks of pneumonia: association with nasopharyngeal colonization. Clin Infect Dis. 1997;24:441-446. 1. Nuorti JP, Butler JC, Crutcher JM, et al. An outbreak of multidrug-resistant pneumococcal pneumonia and bacteremia among unvaccinated nursing home residents. N Engl J Med. 1998;338:1861-1868. Quick RE, Hoge CW, Hamilton DJ, et al. Underutilization of pneumococcal vaccine in nursing homes in Washington State: report of a serotype-specific outbreak and a survey. Am J Med. 1993;94:149-152.
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