Pneumococcal Vaccination - Myths and Facts by hcj


									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

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

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.

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