Cases Of Pneumococcal Pneumonia Research Articles

Effectiveness and Serotype Coverage: Key Criteria for Pneumococcal Vaccines for Adults

Pneumococcal polysaccharide vaccines (PPSVs) received their proof-of-principle affirmation over 65 years ago, in the pivotal trial led by Colin MacLeod and Michael Heidelberger at a military technical school in the 1940s [1]. Four cases of vaccine-type pneumococcal pneumonia developed among 8586 vaccine recipients, in contrast to 26 cases among 8449 controls injected with saline as placebo. All 4 cases among vaccinees developed within 2 weeks of vaccination. Cases of non–vaccine-type pneumococcal pneumonia occurred at comparable rates in each group of young, working adults. Interestingly, the pneumococcal carriage rate in vaccine recipients was significantly lower than in the control group, similar to findings from South Africa in the 1970s [2]. Robert Austrian cited the MacLeod-Heidelberger study, among others, in concluding that PPSVs prevent nonbacteremic pneumococcal pneumonia [3]. Subsequent randomized clinical trials and observational studies, overall and in strata of older populations (discussed below), provide further evidence for PPSV efficacy in preventing invasive pneumococcal disease (IPD) and pneumococcal pneumonia [4–6]. The 14-valent PPSV14 was licensed in 1977 for people 50 years and older or those 2 years and older with certain underlying health conditions, targeting 70%– 80% of IPD cases [7–9]. Expansion to 23 serotypes (PPSV23) was based on a broader global survey of invasive pneumococcal isolates coordinated by multiple national governments and the World Health Organization. Thus, PPSV23 was introduced in 1983 with serotypes covering about 87% of bacteremic pneumococcal disease in the United States [9, 10]. Although the technology for conjugate vaccines dates back to the 1920s [11, 12], that technique was applied to useful pneumococcal conjugate vaccines (PCVs) only since 2000. The most recent development has been licensing of PCV13 for adults in industrialized countries since late 2011. Now that 2 forms of pneumococcal vaccine are available for adults, how should clinicians choose between them? Clinical efficacy measures (eg, reduction in disease incidence, safety) are obvious choices, as is the proportion of disease burden a vaccine can target. Except for a 2-dose PCV7 study among adults infected with human immunodeficiency virus (HIV) in Malawi [13], the randomized clinical trial results for preventing pneumococcal disease in adults currently available assess the performance of PPSVs against clinical endpoints [4–6]. As discussed at the February 2012 meeting of the US Advisory Committee on Immunization Practices (ACIP), the recent licensure of PCV13 for adults is based on noninferiority of antibody concentrations (typically at day 30 after vaccination) in relation to PPSV23 serotypes in common. Until now, clinicaloutcome studies with PCVs have been conducted in infants and young children, whose response to vaccination varies substantially from that of adults (who respond robustly to both PPSVs and PCVs). PCV13 is the subject of a randomized clinical trial in Netherlands adults that eventually will compare its clinical performance to a saline placebo; key endpoints are not expected until the latter part of 2013 [14, 15]. Received 28 December 2011; accepted 29 February 2012; electronically published 11 April 2012. Correspondence: John D. Grabenstein, RPh, PhD, Merck Vaccines, 770 Sumneytown Pike, WP97-B364, West Point, PA 19426 ( john_grabenstein@merck.com). Clinical Infectious Diseases 2012;55(2):255–8 © The Author 2012. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com. DOI: 10.1093/cid/cis354

A Retrospective Analysis of 111 Cases of Pneumococcal Pneumonia: Clinical Features and Prognostic Factors

Streptococcus pneumoniae is an important and common pathogen of acute pneumonia. The urinary pneumococcal antigen test has been increasingly used for the diagnosis of pneumococcal pneumonia, but there have been few studies on pneumococcal pneumonia after this test became prevalent. The present study was conducted to characterize the clinical features of pneumococcal pneumonia after the introduction of the urinary antigen test. We retrospectively analyzed 111 cases from 105 patients with pneumococcal pneumonia in our hospital between 2007 and 2010, and collected data regarding background characteristics, laboratory data, isolated bacteria, and clinical courses. The cases analysed included 77 of community-acquired pneumonia (CAP), 21 of healthcare-associated pneumonia (HCAP), and 13 of hospital-acquired pneumonia (HAP). Penicillin-resistant Streptococcus pneumoniae was isolated in 12.5 and 55.6% of non-HAP and HAP cases, respectively. When the cases were divided into 5 groups according to A-DROP scores (0, 1, 2, 3 and 4 points), critical events occurred at 0, 0, 8.7, 15.4, and 75.0% in groups of cases of 0, 1, 2, 3, and 4 points, respectively. Similarly, critical events occurred at 66.7, 4.7, 3.8, and 9.1% in groups of cases according to WBC counts of <4,000, 4,000-9,999, 10,000-19,999, and ≥20,000 cells/µL, respectively. Most of the pneumococcal pneumonia cases occurred as CAP and were treated successfully. HAP cases were frequently penicillin resistant. Elevated A-DROP scores and decreased WBC counts were found to be predictive of critical events.

Burden of pneumonia and meningitis caused by Streptococcus pneumoniae in China among children under 5 years of age: a systematic literature review.

Background and MethodsTo understand the burden and epidemiology of Streptococcus pneumoniae disease among children between 1 and 59 months of age in China, we conducted a review of literature published between 1980 and 2008 applying standardized algorithms. Because of the absence of population-based surveillance for pneumococcal disease (PD), we identified all-cause pneumonia, bacteremia and meningitis burden, syndromes most commonly associated with S. pneumoniae, and applied the proportion of disease attributable to S. pneumoniae from studies that determined the etiology of these three syndromes to calculate PD burden. Because of the microbiologic difficulties in identifying S. pneumoniae–attributable pneumonia which likely underestimates the pneumonia burden, we also used the proportion obtained from vaccine efficacy trials.ResultsBetween 1980 and 2008, there were 12,815 cases/100,000/year of all-cause pneumonia among children between 1 month and 59 months, with 526 deaths/100,000 annually. There were 14 meningitis cases/100,000/year. We estimate that as of 2000, there were 260,768 (113,000 to 582,382) and 902 (114–4,463) cases of pneumococcal pneumonia and meningitis, respectively with 10,703 (4,638–23,904) and 75 (9–370) pneumococcal pneumonia and meningitis deaths, respectively. Pneumococcal pneumonia cases and deaths were more than two-fold higher, 695,382 (173,845–1,216,918) and 28,542 (7,136–49,949), respectively, when parameters from efficacy trials were used. Serotypes 19F, 19A and 14 were the most common serotypes obtained from pneumonia/meningitis patients. Currently available vaccines are expected to cover 79.5% to 88.4% of the prevalent serotypes. With high antibiotic resistance, introducing pneumococcal vaccines to the routine immunization program should be considered in China. Population-based studies are warranted.

Risk of pneumonia in patients taking statins: population-based nested case-control study

Community-acquired pneumonia is one of the most common causes of hospitalisation and death in older people. Recent research suggests that statins might improve the outcome of infectious diseases because of their anti-oxidative and anti-inflammatory properties. To estimate the association between current statin use and the risk of community-acquired pneumonia. Nested case-control study of 443 general practices in the UK within the QResearch® database. Individuals with newly recorded pneumonia, diagnosed between 1996 and 2006 and aged 45 years and older, were matched with up to five controls by age, sex, general practice, and calendaryear Odds ratios for pneumonia associated with statin use were adjusted for smoking status, deprivation, comorbidities, use of acid-lowering drugs, influenza, and pneumococcal vaccines. The analysis found a decreased risk of pneumonia in patients prescribed statins in the year prior to diagnosis (adjusted odds ratio = 0.78, 95% confidence interval [CI] = 0.74 to 0.83), particularly in patients with prescriptions in the last 28 days (adjusted odds ratio = 0.68, 95% CI = 0.63 to 0.73). Atorvastatin and simvastatin had similar associations with pneumonia risk. Analysis repeated on lobar and pneumococcal pneumonia cases showed comparable results. In this large population-based case-control study, current exposure to statins was associated with a reduced risk of pneumonia. The findings were similar to other observational population-based studies, but further randomised controlled trials are necessary before recommending statins to patients at high risk of pneumonia.

The Incidence of Necrotizing Changes in Adults With Pneumococcal Pneumonia

Necrotizing pneumonia is generally considered a rare complication of pneumococcal infection in adults. We systematically studied the incidence of necrotizing changes in adult patients with pneumococcal pneumonia and examined the severity of infection, role of causative serotypes, and association with bacteremia. We used a database of all pneumococcal infections identified at our medical center between 2000 and 2010. Original readings of chest X-rays (CXR) and computerized tomography (CT) were noted. Images were then independently reevaluated by 2 radiologists. The severity of disease at admission was assessed using SMART-COP and Pneumonia Outcomes Research Team (PORT) scoring systems. In 351 cases of pneumococcal pneumonia, necrosis was reported in no (0%) original CXR readings and in 6 of 136 (4.4%) CTs. With rereading, 8 of 351 (2.3%) CXR and 15 of 136 (11.0%) CT had necrotizing changes. Overall, these changes were identified in 23 of 351 (6.6%) patients. The incidence of bacteremia and the admitting SMART-COP and PORT scores were similar in patients with and without necrosis (P = 1.00, P = .32, and P = .54, respectively). Type 3 pneumococcus was more commonly isolated from patients with necrosis than from patients without necrosis (P = .05), but 10 other serotypes were also implicated in 16 cases for which the organism was available for typing. Necrotizing changes in the lungs were seen in 6.6% of a large series of adults with pneumococcal pneumonia but were often overlooked on initial readings. Patients with necrosis were not more likely to have bacteremia or more severe disease. Type 3 pneumococcus was the most commonly identified serotype.

Necrotizing Pneumococcal Pneumonia With Bronchopleural Fistula Among Children in Taiwan

Severe necrotizing pneumococcal pneumonia may progress to the development of bronchopleural fistula (BPF). The purpose of this study was to describe the clinical courses and identify risk factors for the development of bronchopleural fistula in children with pneumococcal pneumonia. Histopathologic features of children receiving surgical resections of the lung because of BPF were analyzed to explore the pathogenesis of destructive lung disease caused by Streptococcus pneumoniae. A total of 112 cases of culture-proven pneumococcal pneumonia were identified between January 2001 and March 2010 at Chang Gung Children's Hospital. The medical charts of all cases of culture-proven pneumococcal pneumonia were reviewed. Pneumococcal pneumonia in 18 children (18/112, 16.1%) was complicated by BPF. As compared with children without BPF, children with BPF had significantly lower white blood cell counts at admission (P = 0.03) and significantly longer durations of fever and hospitalization (P < 0.001). Multivariate analysis revealed that acute respiratory failure (odds ratio = 8.9; 95% confidence interval = 2.6-30.9; P = 0.001) and serotype 19A infection (odds ratio = 5.0; 95% confidence interval = 1.2-22.1; P = 0.03) were risk factors for the development of BPF. Histopathologic analyses were available for 12 children who underwent surgical resections of the lung. Coagulative necrosis with pulmonary infarction was found in 11 of the 12 cases. Serotype 19A was strongly associated with BPF. Vaccines containing this serotype will be important for prevention.

Cost-effectiveness of stockpiling 23-valent pneumococcal polysaccharide vaccine to prevent secondary pneumococcal infections among a high-risk population in the united states during an influenza pandemic

Background: Secondary bacterial infections (especially pneumococcal infections) were a major cause of death during prior influenza pandemics. One strategy to prevent pneumococcal infections in adults during a future pandemic is to stockpile 23-valent pneumococcal polysaccharide vaccine (PPSV23). Stockpiling a pneumococcal vaccine can ensure that it is available when needed most—that is, at the onset of a pandemic. Objective: The purpose of this article was to project the health and economic impact of stockpiling PPSV23 to prevent secondary pneumococcal infections among high-risk adults aged 18 to 64 years during an influenza pandemic within the United States. Methods: A cost-effectiveness model was developed to evaluate the health and economic effects of stockpiling PPSV23 versus not stockpiling this vaccine for preventing secondary pneumococcal infections among 20 million high-risk US adults aged 18 to 64 years during an influenza pandemic. The model was used to project the number of pneumococcal cases, hospitalizations, deaths, and days of work loss averted. Three health outcomes (deaths, hospitalizations, and outpatient care) were estimated from secondary pneumococcal infections. To assess the overall effectiveness of the different strategies, the quality-adjusted life-year (QALY) was used as a measure of these 3 health outcomes. The results are presented for 3 scenarios based on the pandemic severity and anticipated prepandemic influenza vaccine availability: base case, more-severe case, and less-severe case. Results: In the base-case scenario, vaccinating 20 million high-risk adults with PPSV23 avoided 2858 deaths, 878 hospitalizations, 41,881 pneumococcal pneumonia cases, and 232,891 days of work loss during a pandemic. Under the more-severe case scenario, vaccination avoided 21,921 deaths, 10,280 hospitalizations, 70,345 pneumococcal cases, and ∼1.12 million days of work loss. Under the less-severe case scenario, pneumococcal vaccination avoided 715 deaths, 219 hospitalizations, 10,470 pneumococcal cases, and 58,235 days of work loss. The incremental cost-effectiveness ratio for stockpiling PPSV23 versus no stockpiling for the base-case and less-severe case scenarios was $39,946 and $198,653 per QALY, respectively. For the more-severe case scenario, stockpiling PPSV23 was cost saving. Probabilistic sensitivity analyses found that the range of incremental cost-effectiveness ratio values was broad due to the large uncertainty regarding the timing and impact of the next pandemic. In addition, the shelf life of PPSV23 and stockpile management substantially influenced the cost-effectiveness ratio. Conclusions: For severe pandemics or pandemics in which prepandemic influenza vaccine is unavailable, stockpiling of PPSV23 can be a cost-effective strategy for reducing the health and economic burden associated with secondary pneumococcal infections in a high-risk US population. However, for a mildly severe pandemic in which prepandemic influenza vaccine is available, stockpiling of PPSV23 may not be cost-effective.

Clinical and economic burden of pneumococcal disease in older US adults

We developed a model characterizing rates and costs of pneumococcal disease in the US to estimate the expected annual clinical and economic burden of this condition among older adults. Among the 91.5 million US adults aged ≥50 years, 29,500 cases of invasive pneumococcal disease, 502,600 cases of nonbacteremic pneumococcal pneumonia, and 25,400 pneumococcal-related deaths are estimated to occur yearly; annual direct and indirect costs are estimated to total $3.7 billion and $1.8 billion, respectively. Pneumococcal disease remains a substantial burden among older US adults, despite increased coverage with PPV23 and indirect benefits afforded by PCV7 vaccination of young children.

Comparative Study of Pneumonia Caused by Streptococcus pneumonia and Legionella pneumophila

Background: Legionella pneumophila has been recognized as an important cause of pneumonia. However, limited data are available in the literature regarding legionella pneumonia in Korea. The objective of this study was to compare epidemiological data and clinical presentation of legionella pneumonia and pneumococcal pneumonia. Methods: We retrospectively compared clinical, radiological, and laboratory data, antimicrobial treatment, and treatment outcomes between 28 cases of legionella pneumonia and 56 cases of pneumococcal pneumonia. Diagnoses of both legionella and pneumococcal pneumonia were based on commercial urinary antigen tests. Results: Legionella pneumonia patients included 23 men and 5 women, with a mean age of 61.6 years (range 36∼88). Fifteen were smokers and 26 had some underlying diseases. Legionella pneumonia occurred more frequently in healthcare-associated settings than pneumococcal pneumonia (42.9% vs 21.4%, respectively, p=0.040). There were no significant differences in clinical signs and symptoms. Compared to patients with pneumococcal pneumonia, patients with legionella pneumonia presented more frequently with anemia (39.3% vs 8.9%, p=0.001), increased C-reactive protein (57.1% vs 30.4%, p=0.018) and increased alkaline phosphatase (46.4% vs 16.1%, p=0.003). Also, legionella pneumonia patients more often showed pleural effusion on simple chest X-rays (50.0% vs 12.5%, p＜0.001). Conclusion: Legionella pneumonia and pneumococcal pneumonia can not be distinguished by clinical manifestations alone. However, legionella pneumonia occurred as a healthcare-associated pneumonia more frequently and was more often associated with anemia and increased CRP and alkaline phosphatase levels.

Costos médicos directos de enfermedades neumocócicas invasoras y neumonías con diagnóstico radiológico en niños chilenos

To determine the direct medical costs of health care services for cases of invasive pneumococcal disease (IPD) and pneumonia acquired in the community and confirmed by radiology (NAC-Rx) among Chilean children. A prospective follow-up study of the health services delivered to 594 children 0-35 months of age with IPD and 1 489 children 1-35 months with NAC-Rx, diagnosed and treated by organizations within public health network of the Región Metropolitana de Chile. The value of the health services was established according to rates supplied by the Fondo Nacional de Salud (FONASA, the National Health Fund) and prices charged by two private clinics. The national IPD and NAC-Rx rates were estimated to calculate the total national economic burden for the population covered by state health insurance. The mean cost of cases requiring hospitalization was US$ 1 056.20 for IPD and US$ 594.80 for NAC-Rx, while that of cases treated by out-patient services was US$ 77.70 and US$ 65.20, respectively. The cost of the same services for in-patient care at the private clinics was US$ 4 484.10 and US$ 2 962.70 at one clinic and US$ 9 967.50 and US$ 6 578.40 at the other. The estimated national annual cost of services for children under 5 years of age, according to FONASA rates, was US$ 789 045 for IPD and US$ 13 823 289 for NAC-Rx. The high demand for services and financial resources for NAC-Rx in children 0-3 years of age is a tremendously powerful public health reason to support the routine use of pneumococcal vaccination in Chilean children.

The efficacy of high-dose penicillin for community-acquired pneumonia diagnosed by pneumococcal urine antigen test

We analyzed the efficacy of both the Streptococcus pneumoniae urine antigen test as a quick diagnostic tool and the administration of high-dose penicillin in response to a positive S. pneumoniae urine antigen test. We conducted a retrospective analysis of 48 cases of pneumococcal pneumonia, in which the patients were treated with high-dose penicillin. All the cases were diagnosed by a positive urine antigen test. Treatment with high-dose penicillin was effective in 43 of the 48 patients. This treatment was also effective in 12 of 16 culture-confirmed cases with low susceptibility to penicillin. Eleven patients who were positive for the S. pneumoniae urine antigen test but culture-negative showed clinical improvement with high-dose penicillin. Pneumonia caused by S. pneumoniae appeared to be treated safely and effectively with high-dose penicillin based on positive results of the urine antigen test, as penicillin resistance was unlikely to be a problem.

Pneumococcal serotype matters

The development of pneumococcal conjugate vaccines requires knowledge of specific serotypes causing disease. The implementation and universal use of 7-valent conjugate pneumococcal vaccine in children in the United States in 2000 has taught us that we need to continue to monitor the relative importance as well as the population-based incidence of disease caused by specific serotypes of Streptococcus pneumoniae. Both have shifted in surprising ways in less than a decade of conjugate vaccine use in the United States. Specific serotypes and relevant pneumococcal diseases vary by demography and geography. In this issue of The Journal, Hortal et al provide difficult-to-obtain serotype data on 387 culture-proven cases of pneumococcal pneumonia in Uruguayan children. They show that universal implementation of the 7-valent conjugate pneumococcal vaccination in Uruguay, even if 100% effective, would be expected to prevent only 60% of cases of pneumococcal pneumonia requiring hospitalization. The more we learn, the more we realize that disease due to S. pneumoniae—with at least 90 serotypes and a niche in the normal flora of the respiratory tract—will be far more difficult to prevent using protein-conjugate polysaccharide vaccines than was and still is disease due to Haemophilus influenzae type b.

Pneumococcal Necrotizing Pneumonia in Utah: Does Serotype Matter?

Streptococcus pneumoniae is the most common cause of bacterial pneumonia in children. Despite the use of the 7-valent pneumococcal conjugate vaccine, the incidence of pneumococcal necrotizing pneumonia (PNP) has been increasing. Our objectives were to describe temporal trends in PNP and to evaluate pneumococcal serotypes associated with PNP in Utah. We performed a retrospective review of all children <18 years of age who were cared for at a tertiary care children's hospital and who had blood, lung tissue, broncheoalveolar lavage, or pleural fluid cultures that grew S. pneumoniae, as well as radiographic evidence of pneumonia, from January 1997 through March 2006. All S. pneumoniae isolates were typed. A total of 124 children with pneumococcal pneumonia were identified, and 33 (27%) of these children had radiographic evidence of PNP. During the period 1997-2000, 5 (13%) of 39 cases of culture-confirmed pneumococcal pneumonia were associated with PNP. In contrast, during the period 2001-2006, 28 (33%) of 85 pneumococcal pneumonia cases were complicated by PNP (odds ratio, 3.34; 95% confidence interval, 1.11-12.03). Non-7-valent pneumococcal conjugate vaccine serotypes comprised 49% of the isolates during 1997-2000 and 88% of isolates during 2001-2006 (odds ratio, 7.89; 95% confidence interval, 2.91-21.90). Pneumonia due to serotype 3 was most often associated with PNP. Eleven (79%) of 14 cases of serotype 3-associated pneumonia were associated with PNP. When compared with all other serotypes, serotype 3 was strongly associated with necrosis (odds ratio, 14.67; 95% confidence interval, 3.39-86.25). PNP is a serious and increasingly common complication of S. pneumoniae pneumonia in Utah. Infection with serotype 3 is associated with an increased risk of developing PNP. The increase in the incidence of infection due to nonvaccine serotypes reported worldwide and the changing epidemiology of invasive pneumococcal disease should be considered when developing vaccine strategies.

Editorial Commentary:Replacement Pneumococcal Disease in Perspective

Bender et al. [1] describe 33 patients with pneumococcal necrotizing pneumonia who were admitted to Primary Children's Medical Center (Salt Lake City, Utah) from January 2001 through March 2006. One-third of all hospitalized cases of pneumococcal pneumonia in the period after the introduction of 7-valent pneumococcal conjugate vaccine (PCV-7) were complicated by radiographic evidence of necrosis (evidence of necrotic lung, lung abscess, or pneumatocele), compared with 13% of cases before 2001. This group has also reported an increase in pediatric parapneumonic empyema beginning the same year [2]. The number of cases of parapneumonic empyema among children also increased in Spain and France during the period following the introduction of PCV-7. At Primary Children's Medical Center, 88% of cases of necrotizing pneumonia and 86% of cases of parapneumonic empyema identified from January 2001 through March 2006 were due to nonvaccine serotypes. These reports represent the latest part of the changing ecology of pneumococcal disease in association with the universal vaccination of infants with PCV-7. PCV-7 was introduced in 2000 for universal vaccination of infants 85% of cases of invasive pneumococcal disease (IPD) in children in North America. Following the introduction of PCV-7, a rapid decrease in the incidence of IPD occurred as a result of the direct effect of vaccination. A decrease in the incidence of IPD in children <5

Austrian's syndrome: The first described case of pneumococcal meningitis pneumonia and endocarditis in an injecting drug user

We describe the first reported case of Austrian's syndrome in an injecting drug user (IDU). The triad of endocarditis, meningitis and pneumonia caused by invasive pneumococcal disease (IPD) is most commonly associated with excess alcohol. Injecting drug use is a recognised risk factor for IPD, whose prevalence and resistance continue to rise. We propose that injecting drug use is associated with Austrian's syndrome and that it should at least be considered in ‘at risk’ groups presenting with IPD. Furthermore, IDU presenting with IPD, meningitis and pneumonia should be considered for echocardiography.

Combination Vaccine Against Invasive Meningococcal B and Pneumococcal Infections

Streptococcus pneumoniae and Neisseria meningitidis group B are among the main causes of invasive bacterial meningitis infections in infants. Worldwide, these diseases lead to significant mortality, morbidity and costs. The societal impact is especially severe since the majority of cases occur in very young infants. A combination vaccine consisting of 9-valent conjugated pneumococcal and meningococcal B components is currently being developed. The aim of this study was to estimate the potential impact and cost effectiveness from the societal perspective of vaccinating infants in The Netherlands with this combination pneumococcal and meningococcal B vaccine versus no vaccination. A Markov cycle model was developed using epidemiological and healthcare resource use data from 1996 to 2001. This model was used to project the annual costs, benefits and health gains associated with vaccinating all newborns. The base year for the costing was 2003 and all costs and health effects were discounted at 4%. The results of the analysis are expressed in costs per QALY and both probabilistic and univariate sensitivity analyses were used to identify the robustness of the results. Annually, an average of 755 cases of invasive pneumococcal and meningococcal B infection occurred in infants aged 0-10 years in The Netherlands. Introduction of the combination vaccine would prevent 201 cases of meningococcal B meningitis and 165 cases of invasive pneumococcal disease per year. Additionally, 3410 cases of pneumococcal pneumonia and 46,350 cases of otitis media would be prevented. Vaccination would save 35 lives per year and prevent 71 cases of severe sequelae. This translates into 860 life-years gained, or 1128 QALYs gained. Alongside these health gains, vaccination would prevent euro 17,681,370 of direct medical and indirect costs attributable to meningococcal and pneumococcal infections in The Netherlands. Depending on vaccine price, cost effectiveness varied from euro 3160 (vaccine price per dose euro 20) to euro 32,170 (vaccine price euro 60 per dose) per QALY. Base-case cost effectiveness (vaccine price euro 40) was euro 17,700 per QALY. The model was most sensitive to changes in incidence, vaccine price and duration of protective efficacy. Our results suggest that the introduction of a combination meningococcal B and pneumococcal vaccine into the Dutch infant vaccination programme is potentially cost effective compared with no vaccination.

Impact of Influenza Vaccine on Response to Vaccination with Pneumococcal Vaccine in HIV Patients

The clinical effectiveness of 23-valent pneumococcal vaccine in human immunodeficiency virus (HIV)-infected patients is controversial, because of the low immunological response in these subjects. We studied the clinical response of pneumococcal vaccine and the relative impact of influenza vaccine by administering both pneumococcal and influenza vaccine in a group of 150 HIV patients belonging to all CDC categories. In the group of 90 HIV-infected patients vaccinated against both pneumonia and influenza virus, there was a low incidence of mild influenza (13.3%) and no case of pneumococcal pneumonia. On the contrary, among 60 nonvaccinated HIV patients, 61.6% underwent mild to severe influenza and two developed pneumococcal pneumonia. 23-valent pneumococcal vaccine (PV) seems to be clinically effective in preventing pneumonia in HIV-infected patients, and even more if strengthened by influenza vaccine.

Post-viral influenza Streptococcus pneumoniae pneumonia in an intravenous drug abuser

Viral influenza is a seasonal cause of community-acquired pneumonia (CAP). Viral influenza may be caused by influenza A or B and affect any age group. Viral influenza A is usually more severe than influenza B in adults. Viral influenza may present as 3 clinical scenarios: viral influenza alone, viral influenza followed in 1 to 3 days by Staphylococcus aureus pneumonia, or viral influenza followed in 1 to 3 weeks by pneumonia caused by Streptococcus pneumoniae or Haemophilus influenzae. Intravenous drug abusers (IVDAs) are predisposed to a variety of infectious diseases but are not particularly predisposed to viral influenza. We present a case of a young IVDA who presented with influenza A pneumonia who subsequently developed S. pneumoniae CAP. The pneumonococcal suprainfection was severe and prolonged and characterized by a small cavity, empyema, pneumatoceles, and bronchopleural fistulae. S. pneumoniae pleural effusions are uncommon, but pleural empyemas are often demonstrated. Tracheobronchial fistulae and cavitation are rare complications of S. pneumoniae CAP in adults. To the best of our knowledge, this is the first case of post-viral influenza pneumococcal pneumonia in an IVDA.

The Impact of a 9-Valent Pneumococcal Conjugate Vaccine on the Public Health Burden of Pneumonia in HIV-Infected and -Uninfected Children

Pneumococcal conjugate vaccine (PnCV) may be used as a probe to define the burden of pneumococcal disease and better characterize the clinical presentation of pneumococcal pneumonia. This study used a 9-valent PnCV to define different end points of vaccine efficacy and the preventable burden of pneumococcal pneumonia in 39,836 children who were randomized in a double-blind, placebo-controlled trial in South Africa. Whereas the point-estimate of vaccine efficacy was greatest when measured against the outcome of vaccine-serotype specific pneumococcal bacteremic pneumonia (61%; P = .01), the sensitivity of blood culture to measure the burden of pneumococcal pneumonia prevented by vaccination was only 2.6% in human immunodeficiency virus (HIV)-uninfected children and 18.8% in HIV-infected children. Only 37.8% of cases of pneumococcal pneumonia prevented by PnCV were detected by means of chest radiographs showing alveolar consolidation. A clinical diagnosis of pneumonia provided the best estimate of the burden of pneumococcal pneumonia prevented through vaccination in HIV-uninfected children (267 cases prevented per 100,000 child-years) and HIV-infected children (2573 cases prevented per 100,000 child-years). Although outcome measures with high specificity, such as bacteremic pneumococcal pneumonia, provide a better estimate as to vaccine efficacy, the burden of disease prevented by vaccination is best evaluated using outcome measures with high sensitivity, such as a clinical diagnosis of pneumonia.

Economic evaluation of pneumococcal conjugate vaccination in Finland

The aim of this study was to evaluate cost-effectiveness of pneumococcal conjugate vaccine (PCV7) in children <5 y of age. A Markov simulation model was used to compare the cost-effectiveness of 4 doses (assumed 50.5 euros per dose) of PCV7 with no intervention. Only direct effects of the vaccine were taken into account. In Finland, vaccination of a birth cohort of 57,500 healthy infants would potentially prevent annually 60 cases of invasive PD, 1,400 cases of pneumococcal pneumonia, 15,000 episodes of acute otitis media, 3,000 otological surgery procedures and 0.9 deaths in children aged <5 y. Investing 12.0 million euros to vaccinate a birth cohort would save annually 6.3 million euros in medical, and 2.0 million euros in productivity and other, costs. Therefore, investing 1 euros in a vaccination programme would return 0.53 euros in medical costs and 0.70 euros in societal costs. In the base case, vaccination would cost society 139,986 euros per life y gained. To achieve cost savings from a health care provider (societal) perspective, without considering herd effects or replacement phenomenon, the price of PCV7 should be 50% (70%) of the price used in the base case.