Pneumococcal Conjugated Vaccine Reduces the High Mortality for Community-Acquired Pneumonia in the Elderly: an Italian Regional Experience

Abstract

BackgroundCommunity-acquired pneumonia (CAP) is an important cause of illness and death worldwide, particularly among the elderly. Previous studies on the factors associated with mortality in patients hospitalized for CAP revealed a direct association between the type of microorganism involved, the characteristics of the patient and mortality. Vaccination status against pneumococcal disease was not considered. We conducted a retrospective analysis on the mortality rates after a first hospitalization for CAP in north-east Italy with a view to examining especially the role of anti-pneumococcal vaccination as a factor associated with pneumonia-related mortality at one year.MethodBetween 2012–2013, patients aged 65+ hospitalized with a primary diagnosis of CAP, identified based on International Classification of Diseases, Ninth Revision, Clinical Modification codes 481–486, were enrolled in the study only once. Patients were divided into three groups by pneumococcal vaccination status: 1) 13-valent pneumococcal conjugate vaccine (PCV13) prior to their hospitalization; 2) 23-valent pneumococcal polysaccharide vaccine (PPV23) within 5 years before hospitalization and 3) unvaccinated or PPV23 more than 5 years prior to admission. Gender, age, length of hospital stay and influenza vaccination were considered. Comorbidities were ascertained by means of a properly coded diagnosis. Every patient was followed up for 1 year and the outcome investigated was mortality for any cause and for pneumonia.ResultsA total of 4,030 patient were included in the study; mean age at the time of admission to hospital was 84.3±7.7; 50.9% were female. 74.2% of subjects had at least one comorbidity; 73.7% has been vaccinated against influenza. Regard to pneumococcal vaccine, 80.4% of patients were not vaccinated, 14.5% vaccinated with PPV23 and 5.1% with PCV13. The 1-year survival rates after hospitalization for pneumonia were 83.6%, 85.9% and 89.3% in the unvaccinated, PPV23 and PCV13 groups, respectively. Regression analysis indicated that the risk of death due to pneumonia increased significantly with age (adjusted OR: 1.073; 1.061–1.085), shorter hospital stay (adjusted OR: 0.981; 0.971–0.990), and male gender (adjusted OR: 1.372; 1.165–1.616). The model also confirmed the pneumococcal 13-valent conjugated vaccine as an independent protective factor for mortality-related pneumonia (adjusted OR: 0.599; 0.390–0.921).ConclusionThe main finding of our observational cohort study is a high mortality rate among elderly patients admitted to hospital for pneumonia. The present study suggests a protective role for PCV13 vaccination.

Why Infants Rarely Die of COVID-19 and Morbidity and Mortality Rates Vary by Location: Pneumococcal and Hib Vaccinations as Possible Means to Mitigate Future Pandemics

“…Because the more broadly vaccinations are implemented, the stronger both individual immunity and herd immunity becomes, the greater the benefits for everyone. Indeed, every study that has been done of the economic impact of pneumococcal and Hib vaccination programs has shown that for every billion dollars invested in vaccination, several billions are saved in critical care costs for elderly and atrisk patients (Wateska, et al, 2020;Richter, et al, 2019;Zhang, et al, 2018;Ciruela, et al, 2018;Baldo, et al, 2016;Arencibia Jiménez, et al, 2014;Isaacman, et al, 2008 ). Actual savings may be significantly greater since these economic studies have not included the benefits that may accrue from protection against the global economic devastation that a coronavirus or influenza pandemic can cause by shutting down businesses and harming trade.…”

“…Thus, childhood vaccination rates against pneumococcal infections correlate poorly with COVID-19 deaths per capita in individual regions of Italy. Baldo, et al (2016) documented the probable reason for this lack of correlation: Italy has, until very recently, relied on the PCV-7 pneumococcal vaccine, which protects against only seven pneumococcal serotypes, rather than PCV-13, resulting in selection for pneumococcal serotypes in Italy to non-vaccinated types and a documented loss of herd immunity for the elderly. Similarly, many regions in Spain not only have very low rates of adult and childhood vaccination but have relied on PCV7 or PCV10 for both groups, again limiting herd immunity against many serotypes (Arencibia Jiménez, et al, 2014;Ciruela, 2018).…”

“…* Gervaix, et al, 2014;^ Mereckiene, 2017;+ WHO, 2020;> Blank, et al, 2018; # estimated from accumulated yearly vaccinations. Austria (Richter, et al, 2019); France (Contou, et al, 2020); Germany (Theidel, et al, 2013;Pletz, et al, 2016); Greece (Maraki, et al, 2018);US (FluVaxView;Wateska, et al, 2020;Zhang, et al, 2018;Sings, 2017;Williams, et al, 2016); UK (Tolman, et al, 2016); Australia (Hull, et al, 2019;Yang, et al, 2019;Dyda, et al, 2016); Japan (Naito, et al, 2020;Takeda, et al, 2019;Shibata, et al, 2019;Kajikawa, et al, 2019;Kumar, et al, 2014); S. Korea (Song, et al, 2013;Yang, et al, 2015;Park, et al, 2019;Yang, et al, 2020); Italy (Giammanco, et al, 2018;Baldo, et al, 2016;Tozzi, et al, 2014;Fedson, 2011); Spain (Ciruela, et al, 2018;Arencibia Jiménez, et al, 2014;Fedson, 2011); Canada (Kaplan, et al, 2019;Farmanara, et al, 2018); Portugal (Kislaya, et al, 2019); Netherlands (Vestjens, et al, 2019); Switzerland ** NB no current data available (Büla, et al, 1996). (TABLE 1).…”

Incidence, trends, and outcomes of infection sites among hospitalizations of sepsis: A nationwide study

“…Another aspect that could be influenced by studying current trends of infectious sites and their outcome could be researching specific preventative measures tailored towards the most common or highest risk infectious site. Current interventions to prevent certain anatomic site infections are in place such are vaccination against pneumococcal pneumonia or ventilator and line associated bundles [13,14]. Thus, a study directed towards investigating these issues is important for intensive care resource allocation, public health prevention, and helping prioritize future research.…”

Why is vaccination frequency low in elderly patients?

“…In an observational study from Italy (mean age = 84), 73% of patients had influenza vaccination, and 20% had pneumococcal vaccination. Especially, the protective effect of the new conjugated pneumococcal vaccine on mortality has been emphasized in this study [19]. In the CAPITA trial, pneumococcal vaccine has been shown to be effective in reducing community-acquired pneumonia and invasive pneumococcal disease in individuals aged 65 years and older [20].…”