Pneumococcal Vaccination in Adults: Awareness, Recommendations and Coverage Dr. Salil Bendre, Dr. Varsha Narayanan

Abstract

Pneumococcus is the main cause of community acquired bacterial pneumonia and invasive pneumococcal disease, and often the cause of secondary infection and complications of viral community acquired pneumonia (CAP) that lead to a rise in health morbidity and economic burden. While pneumococcal vaccination in children below 5 years, especially infants is part of the universal immunization schedule, the awareness and coverage are very low in adults, the risk groups being those over 60 years, and all adults with underlying medical conditions like diabetes, COPD, kidney and heart disease, or immunodeficiency. Adult pneumococcal vaccination has shown to reduce risk of severe pneumococcal pneumonia, invasive pneumococcal disease, hospitalization rates, and mortality. Primary care physicians like general practitioners and family physicians can help greatly enhance awareness, implementation and the overall health benefits derived from adult pneumococcal vaccination.

Keywords: community acquired pneumonia (CAP), pneumococcal vaccination, invasive pneumococcal disease (IPD), chronic obstructive pulmonary disease (COPD), diabetes

Introduction and Epidemiology

November is a month where a number of health days are observed to enhance awareness: World Pneumonia Day (12^th), World Diabetes Day (14^th), World COPD Day (20^th), and in some countries, World Immunization Day (10^th). So, this is an apt time to review pneumonia burden, risk factors like diabetes and COPD, and pneumococcal immunization guidelines.

The annual global pneumonia burden of 400-450 million has adults constituting almost 55-60%, with pneumonia being a major cause (4^th leading cause) of death among all age groups, resulting in 3-4 million annual deaths.^1,2 India contributes about 23% of global pneumonia burden.³ The incidence of CAP (community acquired pneumonia) is 1-10/1000 person-years, and in the elderly and high risk groups, hospitalization rates of 65-75%, with a case fatality rate of up to 20-30% in hospitalized, severe or intensive care patients are seen.^4,5,6

Streptococcus pneumoniae, (Pneumococcus), the common causative organisms of pneumonia, spreads by the saliva or mucus from an infected person to people in close contact, by coughing or sneezing.⁷ Pneumococcus is the most common organism present in 10-40% of CAP and 70-80% of CABP, and is the leading cause of LRTI (lower respiratory tract infection) related morbidity and mortality. The incidence rates of adult pneumococcal disease in India in 2018 were found to be 31.3%, 22.7%, and 13.9% among adults with CAP aged ≥60 years, 44–60 years, and 18–44 years.⁸ Invasive pneumococcal disease (IPD) most commonly manifests as meningitis or sepsis.

Pneumococcal disease carries high mortality in certain population groups (like elderly people especially those living in institutions, and patients with comorbidities and immunodeficiencies). Antibiotic resistance is a major hurdle in management of pneumococcal disease, and multidrug resistance is seen in one third of the S. pneumoniae isolates.⁹

Clinical Aspects and Risk Factors

The populations identified at high risk of pneumococcal disease include persons ≥ 65 years of age (responsible for 50% of hospitalizations), and young children (kills > 300,000 children under 5 years old worldwide every year with most of these deaths occur in developing countries). In adults, lifestyle issues like cigarette smoking, high alcohol intake, crowded living conditions and comorbidities like diabetes, lung diseases especially chronic obstructive pulmonary disease (COPD), as well as kidney, heart, and liver disease, or chronic organ failure, are the recognized risk factors. People with asplenia, and cochlear implants or organ transplants, and conditions or therapies causing immunodeficiency, are also at higher risk.^7,10

Diabetic patients are 3 times likely to contract pneumonia while incidence of hospitalization and IPD is also 3-4 times higher.^11-13 A study reported CAP mortality rates of 17%, 23%, and 34% in non-diabetics, prediabetics and diabetics respectively.¹⁴ The risk of contracting pneumococcal pneumonia, and hospitalization due to it is 7-8 times higher for COPD.^15,16 The risk of pneumonia is higher for COPD-diabetic patients with or without complications compared with COPD without diabetes.¹⁷ The risk of developing respiratory failure, kidney failure, and stroke is higher in COPD patients with diabetes as compared to COPD without diabetes.  Chronic kidney disease (CKD) is an independent risk factor for pneumonia with twice higher risk overall, and 16 times higher mortality rates in dialysis patients due to respiratory infections compared to the general population.^18,19 Community-acquired pneumonia in both dialysis patients and kidney transplant recipients is mainly caused by pneumococcus.

In the COVID pandemic, secondary pneumococcal infection was seen in 45%, and almost half of the COVID-19 mortality cases showed co-infection, with pneumonia-related COVID-19 mortality in patients >65 years being 23%. COVID-19 is now considered a primary risk factor for pneumococcal pneumonia and invasive pneumococcal disease.²⁰

Pneumococcal Vaccination Recommendations for India

As a general Indian consensus, it is recommended to administer at least one dose of Pneumococcal Polysaccharide Vaccine (PPSV23) to all adults aged 65 years or older who have no previous vaccination history or whose vaccination history is unknown.²¹ For adults aged 18 to 65 years with immunocompromised conditions or co-existing medical conditions, administering the Pneumococcal Conjugate Vaccine (PCV13) followed by PPSV23 is recommended. Regardless of whether PCV13 or PPSV23 is administered first, a minimum one-year time gap is advised between the two vaccinations to maximize their effectiveness. In the case of all immunocompromised adults, it is crucial to initiate the vaccination series with PCV13 and follow with PPSV23 after a minimum interval of 8 weeks. It is important to note that repeating the vaccination with PPSV23 can lead to hypo-responsiveness. Therefore, the decision to revaccinate an individual with PPSV23 should be solely based on clinical judgment to balance potential benefits and risks, and not before 5 years from the last dose.

Recently updated guidelines by the Nation Against Pneumonia Expert Panel Opinion (NAP-EXPO) recommends the following: ²²

1. All healthy individuals above the age of 60 should receive the pneumococcal
2. All COPD patients, regardless of severity, should be vaccinated with the pneumococcal
3. High-risk asthma patients (those requiring hospitalization, emergency department visits, long-term oral corticosteroids, or multiple β-agonist prescriptions within a year) should be
4. High-risk post-COVID patients (those with post-COVID lung fibrosis, hypoxia or respiratory failure currently or in past during COVID, or significant lung damage) should receive the pneumococcal vaccine.
5. All current smokers and passive smokers should be educated and offered the pneumococcal vaccine, regardless of their age or health condition.
6. All diabetic individuals should receive the pneumococcal vaccine, irrespective of their diabetes control.
7. Strategies to improve vaccine awareness and uptake should involve General Practitioners (GPs) and Primary Health Physicians (PHPs) and should include special and targeted campaigns on various media platforms

Enhancing Awareness and Coverage

While pneumococcal vaccination is now an integral part of childhood immunization, adult pneumococcal vaccination in the elderly and mentioned high risk groups continues to be low. A study in India found the coverage of each of the studied vaccinations (flu, pneumococcal, typhoid and hepatitis B) >45 years was less than 2%, with pneumococcal vaccination standing at 0.6%.²³ In a survey, 2.5% people interviewed had received the pneumococcal vaccine, but after 60% of them completed an awareness questionnaire and interview, 80% of them went ahead and received the pneumococcal vaccine. As a result, the rates of pneumococcal vaccination increased from 2.5% before the study to 73.5% after the awareness and knowledge was imparted, emphasizing the importance of awareness and counseling in the community for improving adult immunization rates.²⁴

A large study across 255, 330 adults, found that pneumococcal vaccination remains low and most adults diagnosed with underlying medical conditions are unvaccinated.²⁵ It takes around 2.4 years for adults to receive vaccination after initial diagnosis. Adults being diagnosed by other health providers were less likely to be vaccinated than those diagnosed by primary care providers, the latter again emphasizing the importance of raising awareness with general and family physicians to aid counselling the elderly and those diagnosed with medical conditions to receive pneumococcal vaccination.

Conclusion

Adult pneumococcal vaccination is recommended in all healthy elderly adults and those with underlying medical conditions or immunodeficiency. Pneumococcal vaccination can help reduce risk of severe CAP, IPD, hospitalization, morbidity, and mortality. Low community awareness and lack of practical implementation of adult vaccination programs are important issues that need to be managed. Awareness programs at the level of the community and involvement of primary care physicians, general practitioners and family physicians, can help furthering adult pneumococcal vaccination implementation, coverage, and its clinical benefits.

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¹Professor and Head, Pulmonary Medicine, Nanavati Max Super Speciality Hospital, Mumbai.

²Chief Editor, The Indian Practitioner, and Medical Director, Dr Varsha’s Health Solutions, Mumbai. (Corresponding Author– info@drvarsha.com)