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In the [[United States]], the [[Centers for Disease Control and Prevention]]<ref name="pmid9132580">{{cite journal |author= |title=Prevention of pneumococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP) |journal=MMWR Recomm Rep |volume=46 |issue=RR-8 |pages=1–24 |year=1997 |month=April |pmid=9132580 |doi= |url=http://www.cdc.gov/mmwr/preview/mmwrhtml/00047135.htm |issn=}}</ref><ref>Centers for Disease Control and Prevention. [http://www.cdc.gov/mmwr/pdf/wk/mm5641-Immunization.pdf Recommended Adult Immunization Schedule—United States, October 2007–September 2008]. MMWR 2007;56:Q1–Q4.:</ref> and the  Joint Commission on Accreditation of Healthcare Organizations<ref name="urlSpecification Manual | Joint Commission">{{cite web |url=http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm |title=Specifications Manual for National Hospital Inpatient Quality Measures |author=Anonymous |authorlink= |coauthors= |date=September 19, 2008 |format=pdf |work= |publisher=Joint Commission |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref> have created recommendations for vaccination.
In the [[United States]], the [[Centers for Disease Control and Prevention]]<ref name="pmid9132580">{{cite journal |author= |title=Prevention of pneumococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP) |journal=MMWR Recomm Rep |volume=46 |issue=RR-8 |pages=1–24 |year=1997 |month=April |pmid=9132580 |doi= |url=http://www.cdc.gov/mmwr/preview/mmwrhtml/00047135.htm |issn=}}</ref><ref>Centers for Disease Control and Prevention. [http://www.cdc.gov/mmwr/pdf/wk/mm5641-Immunization.pdf Recommended Adult Immunization Schedule—United States, October 2007–September 2008]. MMWR 2007;56:Q1–Q4.:</ref> and the  Joint Commission on Accreditation of Healthcare Organizations<ref name="urlSpecification Manual | Joint Commission">{{cite web |url=http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm |title=Specifications Manual for National Hospital Inpatient Quality Measures |author=Anonymous |authorlink= |coauthors= |date=September 19, 2008 |format=pdf |work= |publisher=Joint Commission |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref> have created recommendations for vaccination.


The most recent guidelines by on CAP by IDSA/ATS state that pneumococcal polysaccharide vaccine is recommended for persons over 65 years of age and for those with selected high-risk concurrent diseases, according to current ACIP guidelines.
ACIP Guidelines
#'''Adults <u>></u>65 years of age'''
#'''Persons <u>></u>2 years with'''
* '''chronic illness'''
* '''anatomic or functional asplenia'''
* '''immunocompromised (disease, chemotherapy, steroids)'''
* '''HIV infection'''
* '''environments or settings with increased risk'''
===Efficacy===
Ideally, an effective pneumococcal vaccine would provide protection against incidence against pneumonia, invasive pneumococcal disease (bacteremia and meningitis), hospitalizations and mortality.
A patient having received the pneumonia vaccine prior to hospitalization for community acquired pneumonia had improved all cause mortality, respiratory failure and reduced length of stay after adjustment for comorbid illnesses, age, etc. after examining 62,000+ consecutive individuals hospitalized with community-acquired pneumonia. <ref name="pmid16575726">{{cite journal |author=Fisman DN, Abrutyn E, Spaude KA, Kim A, Kirchner C, Daley J |title=Prior pneumococcal vaccination is associated with reduced death, complications, and length of stay among hospitalized adults with community-acquired pneumonia |journal=Clin. Infect. Dis. |volume=42 |issue=8 |pages=1093–101 |year=2006 |month=April |pmid=16575726 |doi=10.1086/501354 |url=http://www.journals.uchicago.edu/doi/abs/10.1086/501354?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dncbi.nlm.nih.gov |issn=}}</ref>
A Cochrane review regarding pneumococcal disease prevention found effectiveness at reducing the risk of invasive pneumococcal disease among adults and the immunocompetent elderly (55 years and above) with an OR 0.47 corresponding to an efficacy of 53%.  Efficacy of 50% in developed countries with an incidence of 0.01% then results in a number-needed-to-treat (NNT) of 20,000 vaccinations per infection avoided, and perhaps 50,000 per death avoided. <ref name="pmid14583920">{{cite journal |author=Dear K, Holden J, Andrews R, Tatham D |title=Vaccines for preventing pneumococcal infection in adults |journal=Cochrane Database Syst Rev |volume= |issue=4 |pages=CD000422 |year=2003 |pmid=14583920 |doi=10.1002/14651858.CD000422 |url=http://dx.doi.org/10.1002/14651858.CD000422 |issn=}}</ref>
An updated Cochrane review of 2008 found:
*          RCTs provided strong evidence of PPV efficacy against IPD with no statistical heterogeneity (OR 0.26).  Non-RCTs provided evidence for protection against IPD in populations for whom the vaccine is currently utilized (OR 0.48).
*          Efficacy against all cause pneumonia was inconclusive with substantial statistical heterogeneity
*          PPV was not associated with substantial reductions in all-cause mortality.
*          Vaccine efficacy against primary outcomes appeared poorer in adults with chronic illness but the difference was not statistically significant.
The authors concluded that evidence supports the recommendation for PPV to prevent IPD in adults, but does not provide compelling evidence to support the routine use of PPV to prevent all-cause pneumonia or mortality. <ref name="pmid18253977">{{cite journal |author=Moberley SA, Holden J, Tatham DP, Andrews RM |title=Vaccines for preventing pneumococcal infection in adults |journal=Cochrane Database Syst Rev |volume= |issue=1 |pages=CD000422 |year=2008 |pmid=18253977 |doi=10.1002/14651858.CD000422.pub2 |url=http://dx.doi.org/10.1002/14651858.CD000422.pub2 |issn=}}</ref>
There has also been some concern due to the immune response to the traditional PPV.  The conjugated pneumonia vaccine (PCV) is known to have better immunogenicity in children due to this age groups lack of immune response to polysaccharides.  A recent RCT compared the immunogenicity in elderly patients with recent pneumococcal pneumonia after recovery and found that PCV stimulates a more prolonged response than PPV.  <ref name="pmid18710324">{{cite journal |author=Musher DM, Rueda AM, Nahm MH, Graviss EA, Rodriguez-Barradas MC |title=Initial and subsequent response to pneumococcal polysaccharide and protein-conjugate vaccines administered sequentially to adults who have recovered from pneumococcal pneumonia |journal=J. Infect. Dis. |volume=198 |issue=7 |pages=1019–27 |year=2008 |month=October |pmid=18710324 |doi=10.1086/591629 |url=http://www.journals.uchicago.edu/doi/abs/10.1086/591629?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dncbi.nlm.nih.gov |issn=}}</ref>  Musher et. al. concluded that protein vaccines may be needed in the high risk elderly. 
In regards to which people are at risk of invasive pneumococcal disease (IPD), a recent  Finnish study found that this diagnosis carried a 12% 1 month mortality for patients 65 and over.  46% of those patients that died within 1 month of having IPD did not have an indication for receipt of the vaccination prior to hospitalization, with the age group of 50-64 having proportionally higher mortality.  The authors concluded that policy makers should consider lowering the age criteria to 50.  <ref name="pmid18647385">{{cite journal |author=Klemets P, Lyytikäinen O, Ruutu P, Ollgren J, Pekka Nuorti J |title=Invasive pneumococcal infections among persons with and without underlying medical conditions: implications for prevention strategies |journal=BMC Infect. Dis. |volume=8 |issue= |pages=96 |year=2008 |pmid=18647385 |pmc=2507715 |doi=10.1186/1471-2334-8-96 |url=http://www.biomedcentral.com/1471-2334/8/96 |issn=}}</ref>
PPV has been shown to be cost effective for general populations of adults 50–64 years of age <ref name="pmid12809452">{{cite journal |author=Sisk JE, Whang W, Butler JC, Sneller VP, Whitney CG |title=Cost-effectiveness of vaccination against invasive pneumococcal disease among people 50 through 64 years of age: role of comorbid conditions and race |journal=Ann. Intern. Med. |volume=138 |issue=12 |pages=960–8 |year=2003 |month=June |pmid=12809452 |doi= |url=http://www.annals.org/cgi/pmidlookup?view=long&pmid=12809452 |issn=}}</ref> and 65 years of age and older<ref name="pmid9343464">{{cite journal |author=Sisk JE, Moskowitz AJ, Whang W, ''et al'' |title=Cost-effectiveness of vaccination against pneumococcal bacteremia among elderly people |journal=JAMA |volume=278 |issue=16 |pages=1333–9 |year=1997 |pmid=9343464 |doi= |url= |issn=}}</ref>.
===Vaccination of hospitalized patients===
===Vaccination of hospitalized patients===
Although vaccination is viewed as purview of [[primary care physician]]s, vaccinating inpatients during hospitalizations may improve vaccination rates<ref name="pmid12418949">{{cite journal |author=Bratzler DW, Houck PM, Jiang H, ''et al'' |title=Failure to vaccinate Medicare inpatients: a missed opportunity |journal=Arch. Intern. Med. |volume=162 |issue=20 |pages=2349–56 |year=2002 |month=November |pmid=12418949 |doi= |url=http://archinte.ama-assn.org/cgi/pmidlookup?view=long&pmid=12418949 |issn=}}</ref>; however, inpatient vaccination may be difficult to implement<ref name="pmid16533904">{{cite journal |author=Winston CA, Lindley MC, Wortley PM |title=Lessons learned from inpatient vaccination in Michigan |journal=Am J Med Qual |volume=21 |issue=2 |pages=125–33 |year=2006 |pmid=16533904 |doi=10.1177/1062860605284361 |url=http://ajm.sagepub.com/cgi/pmidlookup?view=long&pmid=16533904 |issn=}}</ref>. Paradoxically, inpatient strategies may be less successful in hospitals that have a high volume of pneumonia cases.<ref name="pmid16490912">{{cite journal |author=Lindenauer PK, Behal R, Murray CK, Nsa W, Houck PM, Bratzler DW |title=Volume, quality of care, and outcome in pneumonia |journal=Ann. Intern. Med. |volume=144 |issue=4 |pages=262–9 |year=2006 |month=February |pmid=16490912 |doi= |url=http://www.annals.org/cgi/content/full/144/4/262 |issn=}}</ref>
Although vaccination is viewed as purview of [[primary care physician]]s, vaccinating inpatients during hospitalizations may improve vaccination rates<ref name="pmid12418949">{{cite journal |author=Bratzler DW, Houck PM, Jiang H, ''et al'' |title=Failure to vaccinate Medicare inpatients: a missed opportunity |journal=Arch. Intern. Med. |volume=162 |issue=20 |pages=2349–56 |year=2002 |month=November |pmid=12418949 |doi= |url=http://archinte.ama-assn.org/cgi/pmidlookup?view=long&pmid=12418949 |issn=}}</ref>; however, inpatient vaccination may be difficult to implement<ref name="pmid16533904">{{cite journal |author=Winston CA, Lindley MC, Wortley PM |title=Lessons learned from inpatient vaccination in Michigan |journal=Am J Med Qual |volume=21 |issue=2 |pages=125–33 |year=2006 |pmid=16533904 |doi=10.1177/1062860605284361 |url=http://ajm.sagepub.com/cgi/pmidlookup?view=long&pmid=16533904 |issn=}}</ref>. Paradoxically, inpatient strategies may be less successful in hospitals that have a high volume of pneumonia cases.<ref name="pmid16490912">{{cite journal |author=Lindenauer PK, Behal R, Murray CK, Nsa W, Houck PM, Bratzler DW |title=Volume, quality of care, and outcome in pneumonia |journal=Ann. Intern. Med. |volume=144 |issue=4 |pages=262–9 |year=2006 |month=February |pmid=16490912 |doi= |url=http://www.annals.org/cgi/content/full/144/4/262 |issn=}}</ref>

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Pneumococcal vaccine
MedlinePlus 007332
MeSH D022242

In medicine, pneumococcal vaccines are "vaccines or candidate vaccines used to prevent infections with streptococcus pneumoniae."[1] These infections include pneumonia, meningitis, otitis media, and sepsis.

Indications

In the United States, the Centers for Disease Control and Prevention[2][3] and the Joint Commission on Accreditation of Healthcare Organizations[4] have created recommendations for vaccination.

The most recent guidelines by on CAP by IDSA/ATS state that pneumococcal polysaccharide vaccine is recommended for persons over 65 years of age and for those with selected high-risk concurrent diseases, according to current ACIP guidelines.


ACIP Guidelines

  1. Adults >65 years of age
  2. Persons >2 years with
  • chronic illness
  • anatomic or functional asplenia
  • immunocompromised (disease, chemotherapy, steroids)
  • HIV infection
  • environments or settings with increased risk

Efficacy

Ideally, an effective pneumococcal vaccine would provide protection against incidence against pneumonia, invasive pneumococcal disease (bacteremia and meningitis), hospitalizations and mortality.

A patient having received the pneumonia vaccine prior to hospitalization for community acquired pneumonia had improved all cause mortality, respiratory failure and reduced length of stay after adjustment for comorbid illnesses, age, etc. after examining 62,000+ consecutive individuals hospitalized with community-acquired pneumonia. [5]

A Cochrane review regarding pneumococcal disease prevention found effectiveness at reducing the risk of invasive pneumococcal disease among adults and the immunocompetent elderly (55 years and above) with an OR 0.47 corresponding to an efficacy of 53%. Efficacy of 50% in developed countries with an incidence of 0.01% then results in a number-needed-to-treat (NNT) of 20,000 vaccinations per infection avoided, and perhaps 50,000 per death avoided. [6]

An updated Cochrane review of 2008 found:

  • RCTs provided strong evidence of PPV efficacy against IPD with no statistical heterogeneity (OR 0.26). Non-RCTs provided evidence for protection against IPD in populations for whom the vaccine is currently utilized (OR 0.48).
  • Efficacy against all cause pneumonia was inconclusive with substantial statistical heterogeneity
  • PPV was not associated with substantial reductions in all-cause mortality.
  • Vaccine efficacy against primary outcomes appeared poorer in adults with chronic illness but the difference was not statistically significant.

The authors concluded that evidence supports the recommendation for PPV to prevent IPD in adults, but does not provide compelling evidence to support the routine use of PPV to prevent all-cause pneumonia or mortality. [7]

There has also been some concern due to the immune response to the traditional PPV. The conjugated pneumonia vaccine (PCV) is known to have better immunogenicity in children due to this age groups lack of immune response to polysaccharides. A recent RCT compared the immunogenicity in elderly patients with recent pneumococcal pneumonia after recovery and found that PCV stimulates a more prolonged response than PPV. [8] Musher et. al. concluded that protein vaccines may be needed in the high risk elderly.

In regards to which people are at risk of invasive pneumococcal disease (IPD), a recent Finnish study found that this diagnosis carried a 12% 1 month mortality for patients 65 and over. 46% of those patients that died within 1 month of having IPD did not have an indication for receipt of the vaccination prior to hospitalization, with the age group of 50-64 having proportionally higher mortality. The authors concluded that policy makers should consider lowering the age criteria to 50. [9]

PPV has been shown to be cost effective for general populations of adults 50–64 years of age [10] and 65 years of age and older[11].

Vaccination of hospitalized patients

Although vaccination is viewed as purview of primary care physicians, vaccinating inpatients during hospitalizations may improve vaccination rates[12]; however, inpatient vaccination may be difficult to implement[13]. Paradoxically, inpatient strategies may be less successful in hospitals that have a high volume of pneumonia cases.[14]

References

  1. ↑ Anonymous (2024), Pneumococcal vaccine (English). Medical Subject Headings. U.S. National Library of Medicine.
  2. ↑ (April 1997) "Prevention of pneumococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP)". MMWR Recomm Rep 46 (RR-8): 1–24. PMID 9132580. [e]
  3. ↑ Centers for Disease Control and Prevention. Recommended Adult Immunization Schedule—United States, October 2007–September 2008. MMWR 2007;56:Q1–Q4.:
  4. ↑ Anonymous (September 19, 2008). Specifications Manual for National Hospital Inpatient Quality Measures (pdf). Joint Commission.
  5. ↑ Fisman DN, Abrutyn E, Spaude KA, Kim A, Kirchner C, Daley J (April 2006). "Prior pneumococcal vaccination is associated with reduced death, complications, and length of stay among hospitalized adults with community-acquired pneumonia". Clin. Infect. Dis. 42 (8): 1093–101. DOI:10.1086/501354. PMID 16575726. Research Blogging.
  6. ↑ Dear K, Holden J, Andrews R, Tatham D (2003). "Vaccines for preventing pneumococcal infection in adults". Cochrane Database Syst Rev (4): CD000422. DOI:10.1002/14651858.CD000422. PMID 14583920. Research Blogging.
  7. ↑ Moberley SA, Holden J, Tatham DP, Andrews RM (2008). "Vaccines for preventing pneumococcal infection in adults". Cochrane Database Syst Rev (1): CD000422. DOI:10.1002/14651858.CD000422.pub2. PMID 18253977. Research Blogging.
  8. ↑ Musher DM, Rueda AM, Nahm MH, Graviss EA, Rodriguez-Barradas MC (October 2008). "Initial and subsequent response to pneumococcal polysaccharide and protein-conjugate vaccines administered sequentially to adults who have recovered from pneumococcal pneumonia". J. Infect. Dis. 198 (7): 1019–27. DOI:10.1086/591629. PMID 18710324. Research Blogging.
  9. ↑ Klemets P, Lyytikäinen O, Ruutu P, Ollgren J, Pekka Nuorti J (2008). "Invasive pneumococcal infections among persons with and without underlying medical conditions: implications for prevention strategies". BMC Infect. Dis. 8: 96. DOI:10.1186/1471-2334-8-96. PMID 18647385. PMC 2507715. Research Blogging.
  10. ↑ Sisk JE, Whang W, Butler JC, Sneller VP, Whitney CG (June 2003). "Cost-effectiveness of vaccination against invasive pneumococcal disease among people 50 through 64 years of age: role of comorbid conditions and race". Ann. Intern. Med. 138 (12): 960–8. PMID 12809452. [e]
  11. ↑ Sisk JE, Moskowitz AJ, Whang W, et al (1997). "Cost-effectiveness of vaccination against pneumococcal bacteremia among elderly people". JAMA 278 (16): 1333–9. PMID 9343464. [e]
  12. ↑ Bratzler DW, Houck PM, Jiang H, et al (November 2002). "Failure to vaccinate Medicare inpatients: a missed opportunity". Arch. Intern. Med. 162 (20): 2349–56. PMID 12418949. [e]
  13. ↑ Winston CA, Lindley MC, Wortley PM (2006). "Lessons learned from inpatient vaccination in Michigan". Am J Med Qual 21 (2): 125–33. DOI:10.1177/1062860605284361. PMID 16533904. Research Blogging.
  14. ↑ Lindenauer PK, Behal R, Murray CK, Nsa W, Houck PM, Bratzler DW (February 2006). "Volume, quality of care, and outcome in pneumonia". Ann. Intern. Med. 144 (4): 262–9. PMID 16490912. [e]
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