March/April 2014

Reducing Pneumococcal
Disease Burden

By Thomas M. File Jr, MD, MSc, MACP, FIDSA, FCCP
Today’s Geriatric Medicine
Vol. 7 No. 2 P. 34

Streptococcus pneumoniae—or simply pneumococcus—is the most common cause of bacterial respiratory infections. The most serious clinical manifestations of pneumococcal disease are pneumonia and invasive pneumococcal disease (IPD), which include meningitis and bacteremia.

Even in 2014, IPD remains a leading cause of death in the United States, especially among older adults. The case fatality rate for pneumococcal bacteremia lies between 15% and 20%, with a higher rate among elderly patients. Despite advances in treatment, the number of IPD cases in individuals over the age of 65 actually has increased over the past decade. This increase can, to an extent, be explained by the increasing age of this population and their associated comorbidities or immunosuppressive conditions.

Comorbidities, such as heart disease, lung disease, diabetes, or rheumatologic diseases, and immunosuppressive conditions, such as cancer or use of immunosuppressive drugs (eg, high-dose steroids), increase the predisposition to and the severity of pneumonia and adversely influence the outcome in older patients. A recent report from multiple sources, including the Centers for Disease Control and Prevention (CDC), projects that between 2004 and 2040, as the US population increases by 38%, pneumococcal pneumonia hospitalizations will increase by 96% since population growth is fastest in older age groups experiencing the highest rates of disease.

The best approach to reducing the burden of pneumococcal disease in older patients is prevention. Vaccination is the mainstay for prevention, but despite the availability of established vaccines, only approximately two-thirds of those aged 65 and older have been vaccinated. While vaccination in the older population and in patients with immunosuppressive conditions affords less robust protection than in younger age groups, it is still recommended because it can reduce the severity of infection and limit complications.

There are now two pneumococcal vaccines approved by the FDA for use in adults: a 23-valent pneumococcal polysaccharide vaccine indicated for all adults and a 13-valent pneumococcal conjugate vaccine (PCV13) indicated for adults aged 50 and older.

Currently, the CDC recommends the PCV13 vaccine for adults with immunosuppressive conditions. It is possible that recommendations for the use of PCV13 for adults may be expanded to other groups of patients aged 65 and older as results of recent studies become available. An outline of pneumococcal vaccine recommendations can be found at the National Foundation for Infectious Diseases Adult Pneumococcal Vaccination Guide for HCPs (www.adultvaccination.org/professional-resources/pneumo-toolkit/adult-pneumo-guide-hcp.pdf).

In recent surveys conducted by the National Foundation for Infectious Diseases, few consumers said they are familiar with pneumococcal disease; however, they largely have a positive attitude toward vaccines. Most will accept vaccination if they know why it is important and if they receive encouragement and even urging to do so.

A strong recommendation from a health care professional is one of the greatest motivators for patients to receive vaccinations. All health care professionals should take advantage of every patient visit to inquire about a patient’s immunization history and provide patients with the recommended vaccines. For example, whenever patients are evaluated for diabetes or heart disease, they should also be assessed for vaccinations.

As I tell my patients after they receive a vaccine in our clinic, “You are leaving healthier than when you arrived.” This is our goal: to promote for healthier patients.

— Thomas M. File Jr, MD, MSc, MACP, FIDSA, FCCP, is president of the National Foundation for Infectious Diseases and chair of the division of infectious disease at Summa Health System in Akron, Ohio. He is a professor of internal medicine and the chair of the infectious disease section at Northeast Ohio Medical University in Rootstown and also is a consultant and/or a member of an advisory board for Astellas, Bayer, Cerexa/Forest, Daiichi Sankyo, Durata, GlaxoSmithKline, Merck, Pfizer, and Tetraphase.