Pneumococcal Disease and Pneumococcal Vaccines

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• Pneumococcal Disease and Pneumococcal Vaccines

Epidemiology and Prevention of Vaccine-Preventable
Diseases National Center for Immunization and
Respiratory Diseases Centers for Disease Control
and Prevention
Revised May 2009
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Note to presenters Images of vaccine-preventable
diseases are available from the Immunization
Action Coalition website at http//www.vaccineinfo
rmation.org/photos/index.asp
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Pneumococcal Disease

• S. pneumoniae first isolated by Pasteur in 1881
• Confused with other causes of pneumonia until
  discovery of Gram stain in 1884
• More than 80 serotypes described by 1940
• First U.S. vaccine in 1977

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Streptococcus pneumoniae

• Gram-positive bacteria
• 90 known serotypes
• Polysaccharide capsule important virulence factor
• Type-specific antibody is protective

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Pneumococcal Disease

• Second most common cause of vaccine-preventable
  death in the U.S. (after influenza)
• Major clinical syndromes include pneumonia,
  bacteremia, and meningitis

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Pneumococcal PneumoniaClinical Features

• Abrupt onset
• Fever
• Shaking chills
• Pleuritic chest pain
• Productive cough
• Dyspnea, tachypnea, hypoxia

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Pneumococcal Pneumonia

• 100,000 to 135,000 cases requiring
  hospitalization per year
• Responsible for up to 1/3 of community-acquired
  pneumonias and up to 1/2 of hospital-acquired
  pneumonias
• Common bacterial complication of influenza and
  measles
• Case-fatality rate 5-7, higher in elderly

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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

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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

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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

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Burden of Pneumococcal Disease in Children
Syndrome Cases

• Bacteremia 13,000
• Meningitis 700
• Death 200
• Otitis media 5,000,000

Prior to routine use of pneumococcal conjugate
vaccine
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Pneumococcal Disease Epidemiology

• Reservoir Human carriers
• Transmission Respiratory
  Autoinoculation
• Temporal pattern Winter and early spring
• Communicability Unknown
  Probably as long as organism in
  respiratory secretions

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• Invasive Pneumococcal Disease
• Incidence by Age Group, 1998 and 2002

Rate per 100,000 population Source Active
Bacterial Core Surveillance/EIP Network
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Direct Benefit of Vaccination Invasive
Pneumococcal Disease (IPD) Among Children Younger
Than 5 Years of Age
Rate/100,000 children younger than 5 years
Before vaccine 100 80
2006 24 0.5
All IPD Vaccine serotypes
Source Active Bacterial Core Surveillance/EIP
Network
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Direct Effect of Vaccination Invasive
Pneumococcal Disease Among Children lt5 Years of
Age, 1998/99-2006
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Rates of PCV7-type Invasive Pneumococcal Disease
among Adults, U.S., 1998/99-2006
2006 vs. baseline gt80 -90 (-93,-86) 65-79
-88 (-91,-83) 50-64 -84 (-87,-79) 18-49
-88 (-91,-86)
gt80 yrs
65-79 yrs
50-64 yrs
18-49 yrs
CDC, unpublished data 2008
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Conditions That Increase Risk for Invasive
Pneumococcal Disease

• Decreased immune function
• Asplenia (functional or anatomic)
• Chronic heart, pulmonary, liver or renal disease
• Cigarette smoking
• Cerebrospinal fluid (CSF) leak

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Children at Increased Risk of Invasive
Pneumococcal Disease

• Functional or anatomic asplenia, especially
  sickle cell disease
• HIV infection
• Recipient of cochlear implant
• Out-of-home group child care
• African American children
• Alaska Native and American Indian children who
  live in Alaska, Arizona, or New Mexico
• Navaho children who live in Colorado and Utah

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Pneumococcal Disease Outbreaks

• Outbreaks not common
• Generally occur in crowded environments (jails,
  nursing homes)
• Persons with invasive disease often have
  underlying illness
• May have high fatality rate

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Pneumococcal Vaccines

• 1977 14-valent polysaccharide vaccine
  licensed
• 1983 23-valent polysaccharide vaccine
  licensed (PPV23)
• 2000 7-valent polysaccharide conjugate
  vaccine licensed (PCV7)

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Pneumococcal Polysaccharide Vaccine

• Purified capsular polysaccharide antigen from 23
  types of pneumococcus
• Account for 88 of bacteremic pneumococcal
  disease
• Cross-react with types causing additional 8 of
  disease

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Pneumococcal Conjugate Vaccine

• Pneumococcal polysaccharide conjugated to
  nontoxic diphtheria toxin (7 serotypes)
• Vaccine serotypes account for 86 of bacteremia
  and 83 of meningitis among children younger than
  6 years of age

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Pneumococcal Polysaccharide Vaccine

• Not effective in children younger than 2 years
• 60-70 against invasive disease
• Less effective in preventing pneumococcal
  pneumonia

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Pneumococcal Conjugate Vaccine

• Highly immunogenic in infants and young children,
  including those with high-risk medical conditions
• 97 effective against invasive disease caused by
  vaccine serotypes
• 73 effective against pneumonia
• 7 reduction in all episodes of acute otitis media

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Pneumococcal Polysaccharide Vaccine
Recommendations

• Adults 65 years and older
• Persons 2 years and older with
• chronic illness
• anatomic or functional asplenia
• immunocompromised (disease, chemotherapy,
  steroids)
• HIV infection
• environments or settings with increased risk

MMWR 199746(RR-8)1-24
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Pneumococcal Conjugate Vaccine Recommendations

• All children 24 months of age
• Unvaccinated children 24-59 months with a
  high-risk medical condition

MMWR 200049(RR-9)1-35
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Pneumococcal Conjugate Vaccine Recommendations

• Doses at 2, 4, 6, months of age, booster dose at
  12-15 months of age
• First dose as early as 6 weeks
• Minimum interval of 4 weeks between first 3 doses
• At least 8 weeks between dose 3 and dose 4
• Unvaccinated children 7 months of age or older
  require fewer doses

MMWR 200049(RR-9)1-35
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• Pneumococcal Conjugate Vaccine
• Schedule for Unvaccinated Older Children

separated by at least 8 weeks MMWR
200049(RR-9)1-35
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• Pneumococcal Conjugate Vaccine
• for Children 24-59 Months of Age with a Lapsed
  Immunization Schedule

Previous Vaccination Any incomplete schedule 3
doses Fewer than 3 doses
No. of Doses Recommended 1 1 2
Group Healthy Increase risk
due to underlying medical condition separated
by at least 8 weeks MMWR 200757(No. 13)343-4
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Pneumococcal Conjugate Vaccine

• Children aged 24-59 months at high risk and
  previously vaccinated with PPV23 should receive 2
  doses of PCV7
• Children at high risk who previously received
  PCV7 should receive PPV23 at 2 years of age or
  older

separated by at least 8 weeks MMWR
200049(RR-9)1-35
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Pneumococcal Polysaccharide Vaccine Revaccination

• Routine revaccination of immuno-competent persons
  is not recommended
• Revaccination recommended for persons 2 years of
  age or older who are at highest risk of serious
  pneumococcal infection
• Single revaccination dose at least 5 years after
  the first dose

MMWR 199746(RR-8)1-24
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Pneumococcal Polysaccharide VaccineCandidates
for Revaccination

• Persons 2 years of age or older with
• functional or anatomic asplenia
• immunosuppression
• transplant
• chronic renal failure
• nephrotic syndrome
• Persons vaccinated at younger than 65 years of
  age (at least 5 years since first dose)

MMWR 199746(RR-8)1-24
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Pneumococcal Vaccines Adverse Reactions

• Local reactions
• polysaccharide 30-50
• conjugate 10-20
• Fever, myalgia
• polysaccharide lt1
• conjugate 15-24
• Severe adverse rarereactions

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Pneumococcal VaccinesContraindications and
Precautions

• Severe allergic reaction to vaccine component or
  following prior dose of vaccine
• Moderate or severe acute illness

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Pneumococcal Polysaccharide Vaccine Coverage

• Healthy People 2010 goal 90 coverage for
  persons gt65 years
• 2003 BRFSS 64 of persons gt65 years of age ever
  vaccinated
• Vaccination coverage levels were lower among
  persons 18-64 years of age with a chronic illness

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Pneumococcal Polysaccharide VaccineMissed
Opportunities

• gt65 of patients with severe pneumococcal disease
  had been hospitalized within preceding 3-5 years
  yet few had received vaccine
• May be administered simultaneously with influenza
  vaccine

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CDC Vaccines and ImmunizationContact Information

• Telephone 800.CDC.INFO
• Email nipinfo_at_cdc.gov
• Website www.cdc.gov/vaccines