Changing the Paradigm:
Vaccination as a Key Prevention
Step in Daily Practice
Moderator
Panelists
Charles Feldman, MB BCh, DSc, PhD
Professor of Pulmonology and
Chief Physician
Charlotte Maxeke
Johannesburg Academic Hospital
University of the Witwatersrand
Johannesburg, South Africa
George Kassianos, MD
General Practitioner
The Ringmead Medical Practice
Bracknell, United Kingdom
President, British Global and Travel
Health Association
Abdullah Sayiner, MD
Professor, Department of Chest Diseases
Ege University Faculty of Medicine
Izmir, Turkey
Program Overview
• Discuss the role of the general practitioner in
pneumococcal disease prevention
• Identify potential risk factors for
pneumococcal disease
• Watch a patient case scenario performed by
actors
Patient Case Scenario
• 54-year-old woman with type 2 diabetes;
treated with metformin
• Hypercholesterolemia; stable angina; BMI 27
• Former smoker with family history of CVD
• Recently had flu vaccine
• Visiting her GP for an annual checkup
BMI = body mass index; CVD = cardiovascular disease; GP = general practitioner
Pneumococcal Vaccination Recommendations
in the United Kingdom
• All adults ≥ 65 years
• Infants as part of routine childhood
immunization program
• Those < 65 years and ≥ 2 months in “at-risk”
clinical groups
Salisbury D, et al. Immunisation against infectious disease. UK Department of Health; 2006.
http://media.dh.gov.uk/network/211/files/2012/07/Green-Book-Chapter-25-v4_0.pdf.pdf
Clinical Risk Groups for Vaccination
Clinical Risk Group
Examples
Chronic heart disease
Congenital heart disease; ischemic heart disease; chronic
heart failure; hypertension with cardiac complications
COPD, including chronic bronchitis and emphysema;
bronchiectasis; cystic fibrosis; interstitial lung fibrosis;
Chronic respiratory disease pneumoconiosis; bronchopulmonary dysplasia;
respiratory disease requiring frequent steroid treatment;
children at risk for aspiration (eg, cerebral palsy)
CKD
Nephrotic syndrome; CKD stages 4 or 5; patients on
dialysis or with kidney transplant
Chronic liver disease
Cirrhosis; biliary atresia; chronic hepatitis
CKD = chronic kidney disease; COPD = chronic obstructive pulmonary disease
Salisbury D, et al. Immunisation against infectious disease. UK Department of Health, 2006.
http://media.dh.gov.uk/network/211/files/2012/07/Green-Book-Chapter-25-v4_0.pdf.pdf
Clinical Risk Groups for Vaccination (cont)
Clinical Risk Group
Examples
Diabetes
Patients with diabetes controlled by insulin or oral
hypoglycemic agents (not diet alone)
Immunosuppression
Due to disease or treatment, including asplenia, splenic
dysfunction, homozygous sickle cell disease, and celiac
syndrome; all stages of HIV infection; chemotherapy;
systemic steroid treatment for > 1 month (eg, those on ≥ 20
mg/day prednisolone, children < 20 kg on ≥ 1 mg/kg/day)
Other complications
Cochlear implants; cerebrospinal fluid leaks (eg, after
trauma or major skull surgery); inhaling metal fumes (eg,
welders)
Base your decision on clinical judgment.
Give the vaccine if you feel the patient needs it.
Salisbury D, et al. Immunisation against infectious disease. UK Department of Health; 2006.
http://media.dh.gov.uk/network/211/files/2012/07/Green-Book-Chapter-25-v4_0.pdf.pdf
Respiratory Comorbidities
• Smoking is associated with ≥ 50% increased
risk of developing pneumococcal disease.[a]
• Asthmatics have at least a 2-fold higher risk for
pneumococcal disease.[b]
• Streptococcus pneumoniae is 1 of 3 core
pathogens exacerbating COPD and chronic
bronchitis.[c]
a. Baik I, et al. Arch Intern Med. 2000;160(20):3082-3088.
b. Juhn YJ, et al. J Allergy Clin Immunol. 2008;122(4):719-723.
c. Sethi S, et al. N Engl J Med. 2008;359(22):2355-2365.
Risk for IPD Increases With Age and Comorbidities
Patients With and Without
Comorbidities
Incidence of IPD (cases per 100,000)
300
250
200
Healthy
Chronic heart disease
Diabetes
Chronic lung disease
150
100
50
0
18-34
35-49
50-64
65-79
> 80
Healthy vs
Immunocompromised Patients
Incidence of IPD (cases per 100,000)
800
700
600
500
400
300
200
100
0
Age (years)
IPD = invasive pneumococcal disease
Adapted from Kyaw MH, et al. J Infect Dis. 2005;192(3):377-386.
Healthy
Solid cancer
Hematologic cancer
18-34
35-49
50-64
Age (years)
65-79
> 80
Respiratory Comorbidities
US Incidence of IPD, 1999-2000
HIV/AIDS
422.9
Solid cancer
300.4
Chronic lung disease
62.9
Chronic heart disease
93.7
Diabetes
51.4
Healthy
8.8
0
100
200
300
400
Incidence Rate (cases per 100,000 persons)
Kyaw MH, et al. J Infect Dis. 2005;192(3):377-386.
500
Are GPs Aware of Risks for Pneumococcal
Disease?
• Many comorbidities could be recognized by a GP or nurse.
• UK NHS has warning system —yellow flag attached to notes
of patients with comorbidities
• Nurses and GPs have a duty to recognize the significance of
chronic conditions and importance of pneumococcal
vaccination.
• Patients also need to be educated so they know they are at
risk.
NHS = National Health Service
Patient Case Scenario (cont)
• 54-year-old woman with type 2 diabetes;
treated with metformin
• Hypercholesterolemia; stable angina; BMI 27
• Former smoker with family history of CVD
• Recently had flu vaccine
• Has started walking regularly for exercise
• Visiting her GP for an annual checkup
Incidence of Pneumococcal Disease in Older
Adults
• Very little data on incidence as most people are
treated as outpatients with no microbiological
diagnosis; bacteriological tests not very sensitive[a]
• United States—annual incidence of IPD or
nonbacteremic pneumococcal pneumonia in adults ≥
50 years: 5.8 per 1000[b]
• Spain—annual hospitalization rate for pneumococcal
pneumonia in adults > 50 years: 1.09 per 1000[c]
a. Werno AM, et al. Clin Infect Dis. 2008;46(6):926-932.
b. Weycker D, et al. Vaccine. 2010;28(31):4955-4960.
c. Gil-Prieto R, at al. Vaccine. 2011;29(3):412-416.
Clinical and Economic Burden of CAP Among
Adults in Selected Countries in Europe
Frequency of Isolation of Causative Organisms of CAP in Europe by Country
Percentage Means of Frequency of Isolation in Each Country
France
Italy
Spain
Turkey
UK
Germany
S pneumoniae
37.2
11.9
33.7
25.5
42.1
40
Haemophilus influenzae
10.3
5.1
5.3
44.9
12.3
8
Legionella spp.
2.0
4.9
12.9
0
9.1
3.1
Staphylococcus spp.
11.7
6.5
3.2
1.0
2.6
5
Moraxella catarrhalis
3.3
1.0
2.7
12.2
0.8
0
Gram-negative bacilli
16.8
24.3
7.9
4.1
2.6
7
Mycoplasma pneumoniae
0.7
7.0
8.4
0
5.3
5.6
1
2.4
7.2
0
5.9
1.3
Coxiella burnetii
0.2
0.4
6.2
0
0.3
0
Viruses
1.7
11.6
5.9
0
18.6
9
No pathogen identified
35.6
67.3
56.8
40.6
38.4
NR
Chlamydophila spp.
CAP = community-acquired pneumonia; NR = not reported
Welte T, et al. Thorax. 2012;67(1):71-79.
Proportion of Penicillin-Resistant (R+I) S pneumoniae
Isolates in 2011
Percentage resistance
< 1%
1 to < 5%
5 to < 10%
10 to < 25%
25 to < 50%
≥ 50%
No data reported or less than 10 isolates
Not included
Liechtenstein
Luxembourg
Malta
R+I = resistance and intermediate
Source: European Antimicrobial Resistance Surveillance System
http://ecdc.europa.eu/EN/ACTIVITIES/SURVEILLANCE/EARS-NET/DATABASE/Pages/maps_report.aspx
Pneumococcal Disease: Key Points
• Pneumococcal infections are prevalent.
• Associated with significant morbidity and mortality,
particularly in older patients and those with
comorbidities
• Delaying treatment or using an ineffective therapy is
associated with higher morbidity and mortality.
• Pneumococcal infections are associated with
decreases in quality of life.
• Better to prevent pneumococcal infection than
identify and treat it
PPV Immunization Rates in Primary Care
• Immunization rates rising in England: > 70% of
people aged > 65 years in 2011
• Rates were much lower in those < 65 years in
clinical risk groups.
• Need to promote vaccination to at-risk patients
PPV = pneumococcal polysaccharide vaccine
UK Department of Health. Pneumococcal Polysaccharide Vaccine (PPV) Uptake Report; 2012.
Patient Case Scenario (cont)
• 54-year-old woman with type 2 diabetes;
treated with metformin
• Hypercholesterolemia; stable angina; BMI 27
• Former smoker with family history of CVD
• Recently had flu vaccine
• Visiting her GP for an annual checkup
Barriers to Pneumococcal Immunization
• Lack of government commitment
• Lack of a national media campaign
• Lack of physician/nurse endorsement
• Lack of vaccine reimbursement
• Level of physician fee
• Fear of adverse reactions
• Fear of injections
Burns IT, et al. J Fam Pract. 2005;54(Suppl 1):S58-S62.
Rehm SJ, et al. Postgrad Med. 2010;124(3):71-79.
Barriers to Pneumococcal Immunization
(cont)
• Perception that “vaccination is for children”
• Confusion with influenza vaccine
• Not aware of the benefits
• Individual not made aware he/she is in a group
at risk
• Professional apathy to vaccination
Burns IT, et al. J Fam Pract. 2005;54(Suppl 1):S58-S62.
Rehm SJ, et al. Postgrad Med. 2010;124(3):71-79.
How Can We Increase Pneumococcal
Immunization Rates in Primary Care?
• Encourage patients to make an appointment
– Invite by letter, telephone, or text message
– Invite when they contact the clinic in person or by
phone
– Target specific groups (eg, > 65 years)
– Don’t forget the house bound
– Vaccinate during the annual influenza campaign
Willis BC, et al. MMWR Recomm Rep. 2005;54(RR-5):1-11.
How Can We Increase Pneumococcal
Immunization Rates in Primary Care? (cont)
• Opportunistic
– During any nurse or doctor consultation
– While they are waiting at the clinic to see a
doctor or nurse
– When they collect a repeat prescription
– When they bring a relative to the clinic
– While at the clinic for cervical cytology, family
planning, diabetes, COPD clinic, etc.
Willis BC, et al. MMWR Recomm Rep. 2005;54(RR-5):1-11.
Conclusions
• Pneumococcal disease is associated with
considerable mortality and morbidity.
• Pneumococcal disease is best managed by
prevention through vaccination rather than
treating it once the disease has occurred.
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