“Pneumonia is still a major health problem and a significant cause of mortality and morbidity worldwide,” said Prof. Antoni Torres (University Hospital Clinic Barcelona, Catalonia, Spain) [1]. Streptococcus pneumoniae was the main cause of morbidity and mortality in the Global Burden of Disease Study [2]. It contributed to more deaths than all other aetiologies combined in 2016 (1,189,937 deaths) [2].
Currently, two approved types of pneumococcal vaccines are available for adults: the pneumococcal polysaccharide vaccine (PPV)23 that contains a polysaccharide antigen and conjugate vaccines that contain polysaccharide antigens covariantly linked to a carrier protein. Pneumococcal conjugate vaccine (PCV)13, 10, and 7 belong to this group. The conjugate vaccines provide improved immunological responses.
People with chronic obstructive pulmonary disease (COPD) are at an increased risk of pneumococcal disease, especially pneumonia, as well as acute exacerbations. In a Cochrane review of COPD patients, the efficacy of injectable PPV or PCV versus a control or alternative vaccine type were compared. There were no differences between the vaccines, but 1 in 21 vaccinated patients avoided an episode of community-acquired pneumonia (CAP) [13]. In addition, 1 in 8 avoided an acute COPD exacerbation due to the vaccination. However, according to this review, no hospital admissions were prevented, and there was no influence of the vaccination on all-cause mortality [13]. On the other hand, no harm was reported. “Taken together, vaccines against Streptococcus pneumoniae offer the possibility of striking reductions in invasive disease,” said Prof. Torres.
In the Dutch CAPiTA study, the efficacy and clinical benefit were assessed of the 13-valent PCV13 in preventing first episodes of vaccine-type strains of pneumococcal CAP, non-bacteraemic and non-invasive pneumococcal CAP, and invasive pneumococcal disease [14]. The trial included 84,496 vaccine-naïve subjects aged >65 years. The vaccine was able to prevent vaccine-type pneumococcal CAP (both invasive and non-invasive forms). In the per-protocol analysis of first episodes of infections due to vaccine-type strains, CAP occurred in 49 persons in the PCV13 group compared with 90 persons in the placebo group, which translates into a vaccine efficacy of 45.6%. Nonbacteraemic and non-invasive CAP occurred in 33 persons in the PCV13 group and 60 persons in the placebo group. The most striking difference was seen in invasive pneumococcal disease, which occurred in 7 persons in the PCV13 group and 28 persons in the placebo group (vaccine efficacy 75.0%). The efficacy of the vaccination persisted throughout the trial with a mean follow-up of 3.97 years.
Overall, the vaccine was well tolerated, and the adverse event profile was consistent with those of prior studies in adults. “Since only 63% of hospitalised CAP episodes were captured in the CAPiTA trial, the vaccine-preventable disease incidence is probably underestimated,” said Prof. Torres.
PCV also effective in real-life setting
It is important to assess not only the clinical efficacy and safety but also the real-world effectiveness of vaccination following routine introduction into a broader population. Patients seen in daily practice differ considerably from participants included in a randomised clinical trial. Therefore, the effectiveness of PCV13 against hospitalised vaccine-type CAP was measured in a US population, the Louisville pneumonia cohort [5]. In this case-control study, a subset of CAP patients was assessed who were aged ≥65 years and consented to have their pneumococcal vaccination history confirmed by health insurance records. All cases were defined as hospitalised CAP patients with PCV13 serotype identified via culture or serotype-specific urinary antigen detection assay. The remaining CAP patients served as test-negative controls. Hospitalised patients were less likely to have received the vaccine compared with controls (4.4% vs 14.5%). This translated into unadjusted vaccine effectiveness of 72.8% [5]. According to Prof. Torres, this trial shows that the PCV13 vaccine is equally effective under real-life conditions.
In another trial, the indirect effect of the childhood PCV10/13 vaccination programme on the incidence of invasive pulmonary disease in older adults across 13 sites in 10 European countries was assessed [6]. Five-year data showed that there was indeed a large decline in invasive pulmonary disease due to vaccine serotypes, which was partly countered by increases in non-PCV13 serotypes, resulting in a limited net effect on overall invasive pulmonary disease. Thus, the potential benefit of a PCV13 programme in older adults may progressively reduce over time due to the gradual rise in non-PCV13 serotypes. Vaccines targeting older adults should include other, or at least more, serotypes to provide a wider mechanism of protection against pneumococcal disease.
Both smokers and COPD patients are high-risk groups that benefit most from vaccination. The ERS president Prof. Tobias Welte (Hannover Medical School, Germany), who chaired the symposium, commented that less than 10% of at-risk populations in Germany are vaccinated against pneumococcal infections because they have to pay for the vaccine and many of them do not realise the importance of the vaccine.
- Torres A. Oral abstract 5110, ERS 2019, 29 Sept-2 Oct, Madrid, Spain.
- GBD 2016 Lower Respiratory Infections Collaborators. The Lancet Infectious Diseases 2018;18(11):1191-1210.
- Walters JA, et al. Cochrane Database Syst Rev 2017;1:CD001390. Doi: 10.1002/14651858.CD001390.pub4.
- Bonten MJ, et al. NEJM. 2015;372(12):1114-25.
- McLaughlin JM, et al. Clin Infect Dis. 2018;67(10):1498-1506.
- Hanquet G, et al. Thorax. 2019;74(5):473-82.
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Table of Contents: ERS 2019
Featured articles
Letter from the Editor
Interview with ERS president Prof. Tobias Welte
Holistic View on Asthma
Holistic view on asthma
COPD Management
COPD patients derive clinical benefit from β-blockers
COPD patients harbouring Pseudomonas Aeruginosa face high risk of hospitalisation
One blood eosinophil count is sufficient to guide ICS therapy
Female COPD patients frequently suffer from anxiety and depression
Dual bronchodilation improves ventilation dynamics in COPD patients
Vaping
Vaping impairs innate immune response of the airway
Alternative nicotine delivery products: no help in smoking cessation
Air Pollution
Pregnant women and their offspring: a high-risk group for air pollution
Taxi drivers exposed to highest levels of black carbon pollution
Infectious Respiratory Disease: the Role of Vaccines
Vaccines show multiple positive effects with respect to respiratory health
Pneumococcal vaccines: an effective way to reduce COPD hospitalisations
Interstitial Lung Disease
Antifibrotic therapy slows disease progression in ILD
Reduction of FVC decline in systemic sclerosis-associated ILD
Registry confirms nintedanib efficacy under real-life conditions
Best of the Posters
Fever during immunotherapy for NSCLC associated with shorter PFS
Smart shirt as a device to measure tidal volumes in real-life setting
Exercise with virtual reality beneficial for COPD patients
NSCLC: A new way to evaluate hilar and mediastinal lymph nodes
COPD patients do not benefit from azithromycin therapy longer than a year
Novel Developments in Infectious Disease
Long-term azithromycin decreases exacerbations in primary ciliary dyskinesia
Predicting community-acquired pneumonia outcomes by microRNA testing
Pulmonary Vascular Disease
Balloon pulmonary angioplasty for inoperable chronic thromboembolic pulmonary hypertension
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