Pneumococcal vaccination coverages by age, sex and specific underlying risk conditions among middle-aged and older adults in Catalonia, Spain, 2017

Background: Recent published data on pneumococcal vaccination coverages among adults are scarce. Aim: To update on pneumococcal vaccination uptakes among middle-aged and older adults in Catalonia. Methods: We conducted a population-based retrospective observational study including 2,057,656 individuals ≥ 50 years old assigned to primary care centres managed by the Catalonian Health Institute on 1 January 2017 (date of data collection). An institutional clinical research database (SIDIAP) was used to classify persons by vaccination status for both 23-valent pneumococcal polysaccharide (PPsV23) and 13-valent pneumococcal conjugate (PCV13) vaccines, as well as to identify underlying risk conditions. Results: Overall, 796,879 individuals (38.7%) had received PPsV23 and 13,607 (0.7%) PCV13. PPsV23 coverage increased with age: 9.2% (95,409/1,039,872) in 50-64 year olds, 63.1% (434,408/688,786) in 65-79 year olds and 81.2% (267,062/328,998) in ≥ 80 year olds (p < 0.001). PCV13 coverage also increased with age, although percentages were smaller in all age strata (4,250/1,039,872: 0.4%; 6,005/688,786: 0.9% and 3,352/328,998: 1.0%, respectively; p < 0.001). By sex, no substantial coverage differences were observed. Considering publi-cally funded target groups for PPsV23 vaccination in Catalonia (i.e. < 65 year olds with at least one risk factor, plus all adults aged ≥ 65 years), PPsV23 coverage reached 52.8% (771,722/1,462,261) in our study population. Regarding PCV13 publicly funded targets (i.e. all-age immunocompromised persons), PCV13 coverage was 3.3% (6,617/202,348). By risk conditions, the highest PPsV23 coverage appeared in congestive heart failure (51,909/63,596; 81.6%), chronic renal disease (122,791/158,726; 77.4%) and chronic bronchitis/ emphysema (96,453/132,306; 72.9%). Maximum PCV13 coverage appeared in cirrhosis (294/7,957; 3.7%), chronic renal disease (5,633/158,726; 3.5%) and chronic bronchitis/emphysema (2,859/132,306; 2.2%). Conclusion: Pneumococcal vaccination coverages in Catalonian adults are suboptimal, especially for PCV13

The burden of community-acquired pneumonia in the elderly: the Spanish EVAN-65 Study

BACKGROUND: Community-acquired pneumonia (CAP) is generally considered a major cause of morbidity and mortality in the elderly. However, population-based data are very limited and its overall burden is unclear. This study assessed incidence and mortality from CAP among Spanish community-dwelling elderly. METHODS: Prospective cohort study that included 11,240 individuals aged 65 years or older, who were followed from January 2002 until April 2005. Primary endpoints were all-cause CAP (hospitalised and outpatient) and 30-day mortality after the diagnosis. All cases were radiographically proved and validated by checking clinical records. RESULTS: Incidence rate of overall CAP was 14 cases per 1,000 person-year (95% confidence interval: 12.7 to 15.3). Incidence increased dramatically by age (9.9 in people 65–74 years vs 29.4 in people 85 years or older), and it was almost double in men than in women (19.3 vs 10.1). Hospitalisation rate was 75.1%, with a mean length-stay of 10.4 days. Overall 30-days case-fatality rate was 13% (15% in hospitalised and 2% in outpatient cases). CONCLUSION: CAP remains as a major health problem in older adults. Incidence rates in this study are comparable with rates described in Northern Europe and America, but they largely doubled prior rates reported in other Southern European regions

Evolution of vaccination rates after the implementation of a free systematic pneumococcal vaccination in Catalonian older adults: 4-years follow-up

BACKGROUND: The systematic vaccination with 23-valent polysaccharide pneumococcal vaccine (PPV) was introduced as a strategic objective of health for all the people over 65 in Catalonia in 1999. We analysed the evolution of the pneumococcal vaccination rates from 2000 to 2003. METHODS: We conducted a retrospective population-based study including all the individuals 65 years or older assigned to 8 Primary Care Centres (PCCs) in Tarragona (Catalonia, Spain), who figured in the administrative population databases on 31 December 2003 (n = 10,410 persons). We assessed whether every person had received PPV during the last four years (2000 to 2003) or whether they had received it before January 2000. Data sources were the computerised clinical records of the 8 participating PCCs, which included adult vaccination registries and diagnoses coded of International Classification of Diseases 9(th )Review RESULTS: The overall vaccination uptake increased to 38.6% at the end of 2000. Global accumulated coverages increased more slowly the following years: 44.4% in 2001, 50.9% in 2002, and 53.1% at the end of 2003. Vaccine uptake varied significantly according to age (46.7% in people 65–74 years-old, 60.9% in people 75 years or more; p < 0.001) and number of diseases or risk factors (DRFs) for pneumonia (47.1% vaccinated in people without DRFs, 56.8% in patients with one DRF, and 62.2% in patients with two or more DRFs; p < 0.001). The highest coverages were observed among those patients with: diabetes (65.9%), active neoplasia (64.8%), history of stroke (63.7%), and chronic lung disease (63.5%). The lowest uptake was observed among smokers (48.7%). DISCUSSION: The pneumococcal vaccination coverage increased quickly after the introduction of the recommendation for free vaccination in all the elderly people (with and without risk factors), but two years after the improvement the coverage became stable and increased slowly

Efectividad de la vacunación antineumocícica en la población mayor de 65 años

FUNDAMENTOS: La actual vacuna antineumocócica polisacárida de 23 serotipos (VAN-23s) está disponible desde 1983 y es corrientemente recomendada para personas mayores y grupos de alto riesgo. Sin embargo, pese a la realización de numerosos estudios, su efectividad sigue siendo controvertida. OBJETIVO: La presente tesis tuvo como objetivo evaluar la efectividad de la VAN-23s para la prevención de enfermedad invasiva, neumonía y muerte entre las personas mayores de 65 años. METODOLOGÍA: Estudio de cohortes prospectivo con 40 meses de seguimiento, que incluyó todos los individuos >65 años asignados a 8 Áreas Básicas de Salud en Tarragona (n=11.241) Los eventos principales considerados fueron enfermedad neumocócica invasiva, neumonía adquirida en la comunidad (hospitalizada o ambulatoria) y muerte por neumonía. La asociación entre vacunación antineumocócica y el riesgo para cada evento fue evaluado mediante un análisis multivariante por Regresión de Cox para variables que varían con el tiempo, con cálculo de hazards ratios (HR) multiajustados por edad, género, vacunación antigripal previa, co-morbilidad y situación de inmunocompromiso. La situación vacunal frente al neumococo fue considerada como tiempo-variable, mientras que el resto de co-variables fueron consideradas al inicio del estudio.RESULTADOS: En el conjunto de la población estudiada, la VAN-23s tuvo una efectividad del 69% (-20% a 82 %) para prevenir enfermedad neumocócica invasiva por serotipos vacunales, del 59% (1% a 83 %) para prevenir enfermedad invasiva por todos los serotipos, del 64 % (1 % a 87 %) para prevenir neumonía neumocócica bacteriémica, y del 52 % (10 % a 74 %) para prevenir neumonía neumocócica no bacteriémica) Aunque no alcanzó significación estadística debido al bajo número de eventos, la VAN-23s también mostró una reducción del 57 % (-76 % a 90 %) en riesgo de muerte por infección neumocócica entre los sujetos vacunados. La vacuna no ha evidenciado un efecto significativo para prevenir hospitalizaciones por neumonía ni neumonías totales en los sujetos vacunados puesto que, aunque se observó una reducción del 18% (-4% a 36 %) en el riesgo de hospitalización por NAC y del 17 % (-3 a 33 %) en el riesgo de NAC total, estos efectos no alcanzaron significación. Finalmente, la VAN-23s mostró una efectividad del 60 % (29 % a 78 %) para prevenir la muerte causada por neumonía entre los vacunados.CONCLUSIONES: Los resultados observados avalan la efectividad de la VAN-23s para prevenir no sólo la enfermedad invasiva o bacteriemia neumocócica (como hasta ahora había sido documentado en otros estudios) sino que también evidencian, por primera vez tras más de 20 años de utilización de la vacuna, que la VAN-23s es también efectiva a nivel poblacional para prevenir otros eventos específicamente relacionados con la infección neumocócica (tales como la neumonía neumocócica no bacteriémica y la mortalidad total causada por neumonía. Estos datos no habían podido ser evidenciados hasta ahora, y suponen que la vacunación sería más eficiente para prevenir una neumonía neumocócica o una muerte por neumonía que para evitar un caso de enfermedad invasiva en el ámbito poblacional y, por tanto, dan soporte a la recomendación para la vacunación sistemática con la VAN-23S en este grupo de edad.PALABRAS CLAVE: efectividad, vacuna antineumocócica, ancianos, neumonía, enfermedad neumocócica invasiva, neumonía neumocócica.BACKGROUND: Infecctions caused by Streptococcus Pneumoniae are an important cause of morbidity and mortality in the elderly, especially in those with chronic diseases. The 23-valent polysaccharide pneumococcal vaccine (PPV) has been available since 1983 and is currently recommended for use in the elderly and high-risk groups. People over 65-years soffer the greatest burden of infection and death by pneumonia and they are the greatest target group for pneumococcal vaccination. However, despite numerous studies, the effectiveness of 23-valent PPV in the prevention of pneumococcal infections and other clinically relevant medical outcomes remains unclear in general elderly population and high-risk elderly subjects.OBJECTIVE: The present study assessed the effectiveness of the 23-valent pneumococcal polysaccharide vaccine to prevent pneumococcal disease, pneumonia and death in older adults. METHODS: A prospective cohort study was conducted between January 2002 and April 2005, including all individuals >65 yrs of age assigned to 8 Primary Care Centres in Tarragona, Spain (n=11,241). The primary outcomes were invasive pneumococcal disease, pneumococcal pneumonia, overall pneumonia (hospitalised or outpatient) and death from pneumonia. All pneumonias were validated by checking clinical records. The association between the pneumococcal vaccination and the risk of each outcome was evaluated by means of multivariate Cox proportional-hazard models, adjusted by age, sex, comorbidity, inmunological situation, and influenza vaccination situation, Pneumococcal vaccine status was a time-varying covariate, ant other covariate were defined at study entry.RESULTS: Pneumococcal vaccination was effective to prevent invasive pneumococcal disease (hazard ratio (HR): 0.41; 95% confidence interval (CI): 0.13-0.99), bacteraemic pneumococcal pneumonia (HR: 0.36; 95% CI: 0.13-0.99) and non-bacteraemic pneumococcal pneumonia (HR: 0.48 ; 95% CI: 0.26-0.90), but the vaccine did not alter significantly the risk of hospitalisation from pneumonia (HR: 0.82; 95% CI: 0.64-1.04) or overall pneumonia (HR: 0.83; 95% CI: 0.67-1.03). The pneumococcal vaccine was associated with considerable reductions of death risk from pneumonia (HR: 0.40; 95% CI: 0.22-0.71) and death risk from pneumococcal infection (HR: 0.43; CI 95%: 0.10-1.76). CONCLUSSIONS: These results suggest that the pneumococcal polysaccharide vaccine may not be effective in reducing the incidence of overall pneumonia, but may be able to diminish the incidence and severity of the pneumococal infections. These findings confirm the effectiveness of 23-valent PPV to prevent IPD, but its also show a protective effect against non-bacteraemic pneumococcal pneumonia and mortality caused by pneumonia in older adults, providing a new arguments to recommend systematic vaccination in elderly subjects..KEYWORDS: effectivenees, elderly, pneumococcal vaccine, community-acquired pneumonia, pneumococcal pneumonia, invasive pneumococcal disease, death

Enfermedad neumocócica en el adulto: niveles de riesgo y recomendaciones de vacunación

Actualmente 2 vacunas antineumocócicas están disponibles para uso en adultos: la «clásica» vacuna neumocócica polisacárida tricosavalente (VNP23) y la «nueva» vacuna neumocócica conjugada tridecavalente (VNC13). La principal ventaja de la VNC13 sería su potencial mejor inmunogenicidad, siendo sus principales inconvenientes el elevado coste y la baja cobertura de serotipos en comparación con la VNP23. Las evidencias actualmente disponibles apoyan las siguientes recomendaciones básicas: a) en los adultos con más alto riesgo (básicamente inmunocompromiso y/o asplenia) se recomienda la vacunación dual con ambas vacunas; b) en los sujetos con riesgo elevado (básicamente personas > 65 años y pacientes de 15-64 años con enfermedad pulmonar o cardiaca crónica, diabetes y/o alcoholismo) se recomienda la vacunación simple con VNP23 (dosis única en primovacunados ≥ 65 años; revacunación a los 5-10 años en el caso de primovacunados antes de los 65 años), y c) en el resto de adultos (riesgo normal/bajo) no se recomienda la vacunación