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Pneumococcal Immunization in Older Adults: Implications for the Long-Term–Care Setting

Published online by Cambridge University Press:  02 January 2015

Mark Loeb ,
Kurt B. Stevenson  and
SHEA Long-Term-Care Committee
Mark Loeb
Affiliation:
Department of Clinical Epidemiology and Biostatistics, McMaster University and Hamilton Regional Laboratory Program, Hamilton, Ontario, Canada
Kurt B. Stevenson*
Affiliation:
Qualis Health, Boise, Idaho Division of Clinical Epidemiology, Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah
*
Qualis Health, 720 Park Boulevard, Suite 120, Boise, ID 83712-7756
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Abstract

Objectives:

To compare the efficacy of the polysaccharide pneumococcal vaccine in older adults between clinical trial and observational studies and to discuss the implications for long-term–care facilities (LTCFs).

Data Source:

A Medline search (to April 2003).

Study Selection:

All meta-analyses of randomized and quasi-randomized trials of pneumococcal vaccines with placebo or no treatment were sought. All cohort or case–control studies were sought.

Data Synthesis:

Of the 16 individual randomized clinical trials included in the reviews, 8 compared pneumococcal vaccine in individuals 55 years and older individuals. Only one study specifically addressed LTCF residents. Although no significant protective effect of the vaccine in elderly subpopulations was found, on the basis of wide confidence intervals and small subpopulation sample sizes, beneficial effects, particularly for pneumococcal bacteremia, could not be ruled out. Of the individual observational studies, 11 specifically evaluated vaccine efficacy in older adults. Vaccine efficacy was demonstrated in 9 of the 11 studies with no protective effect was shown in 2 studies.

Conclusion:

Although the pooling of clinical trial data does not demonstrate significant efficacy of the pneumococcal polysaccharide vaccine in subgroups of older adults, these subgroup studies lacked power to show significant differences. Observational studies repeatedly demonstrate efficacy in older adults, and the vaccine has been demonstrated to be cost-effective and safe. It is strongly promoted by U.S. and Canadian advisory committees. On the basis of this available evidence, the pneumococcal polysaccharide vaccine should currently be recommended for older adults, especially those who are residents of LTCFs.

Type
SHEA Position Paper
Information
Infection Control & Hospital Epidemiology , Volume 25 , Issue 11 , November 2004 , pp. 985 - 994
Copyright
Copyright © The Society for Healthcare Epidemiology of America 2004

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Footnotes

*

Members of the SHEA Long-Term–Care Committee include Sky Blue, MD; Suzanne Bradley, MD; Kent Crossley, MD; Nelson Gantz, MD; Mark Loeb, MD; Lindsay Nicolle, MD; Rodolfo Quiros, MD; Andrew Simor, MD; Philip Smith, MD; Lynn Steele, MS, CIC; and Kurt Stevenson, MD

References

1. Bartlett, JG, Mundy, LM. Community-acquired pneumonia. N Engl J Med 1995;333:1618-1624.Google Scholar
2. Marrie, TJ. Community-acquired pneumonia: epidemiology, etiology, treatment. Infect Dis Clin North Am 1998;12:723–740.Google Scholar
3. Centers for Disease Control and Prevention. Prevention of pneumococcal disease: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1997;46:1–24.Google Scholar
4. Butler, JC, Schuchat, A. Epidemiology of pneumococcal infections in adults. Drugs Aging 1999;15:11–19.Google Scholar
5. National Advisory Committee on Immunization. Canadian Immunization Guide. Ottawa, Ontario, Canada: Minister of Public Works and Government Services; 1998.Google Scholar
6. U.S. Department of Health and Human Services. Healthy People 2010. Washington, DC: U.S. Department of Health and Human Services; 2000.Google Scholar
7. Greby, SM, Singleton, JA, Sneller, VP, Strikas, RA, Williams, WW. Pneumococcal and influenza vaccination coverage in nursing homes, U.S. Presented at the 32nd National Immunization Conference; July 2124, 1998; Atlanta, GA.Google Scholar
8. Fedson, DS, Shapiro, ED, LaForce, FM, et al. Pneumococcal vaccine after 15 years of use: another view. Arch Intern Med 1994;154:2531–2535.Google Scholar
9. Hirschmann, JV, Lipsky, BA. The pneumococcal vaccine after 15 years of use. Arch Intern Med 1994;154:373–377.CrossRefGoogle ScholarPubMed
10. Nuorti, JP, Butler, JC, Crutcher, JM, et al. An outbreak of multidrug-resistant pneumococcal pneumonia and bacteremia among unvaccinated nursing home residents. N Engl J Med 1998;338:1861–1868.CrossRefGoogle ScholarPubMed
11. Centers for Disease Control and Prevention. Outbreaks of pneumococcal pneumonia among unvaccinated residents in chronic-care facilities: Massachusetts, October 1995, Oklahoma, February 1996, and Maryland, May-June 1996. MMWR 1997;46:60–62.Google Scholar
12. Outbreak of pneumococcal pneumonia among unvaccinated residents of a nursing home: New Jersey, April 2001. MMWR 2001;50:707–710.Google Scholar
13. Rubins, JB, Puri, AKG, Loch, J, et al. Magnitude, duration, quality, and function of pneumococcal vaccine responses in elderly patients. J Infect Dis 1998;178:431–440.CrossRefGoogle Scholar
14. Anonymous. The place of pneumococcal vaccination. Drug Ther Bull 1998;36:73–76.CrossRefGoogle Scholar
15. Fine, MJ, Smith, MA, CA, Carson et al. Efficacy of pneumococcal vaccination in adults: a meta-analysis of randomized clinical trials. Arch Intern Med 1994;154:2666–2677.CrossRefGoogle Scholar
16. Hutchison, BG, Oxman, AD, Shannon, HS, Lloyd, S, Altmayer, CA, Thomas, K. Clinical effectiveness of pneumococcal vaccine. Can Fam Physician 1999;45:2381–2393.Google Scholar
17. RA, Moore Wiffen, PJ, Lipsky, BA. Are the pneumococcal polysaccharide vaccines effective? Meta-analysis of the prospective trials. Bio Med Central Family Practise 2000;1:1.Google Scholar
18. Cornu, C, Yzebe, D, Leophonte, P, Gaillat, J, Boissel, JP, Cucherat, M. Efficacy of pneumococcal polysaccharide vaccine in immunocompetent adults: a meta-analysis of randomized trials. Vaccine 2001;19:4780–4790.Google Scholar
19. Watson, L, Wilson, BJ, Waugh, N. Pneumococcal polysaccharide vaccine: a systematic review of clinical effectiveness in adults. Vaccine 2002;20:2166–2173.Google Scholar
20. Austrian, R, Douglas, RM, Schiffman, G, et al. Prevention of pneumococcal pneumonia by vaccination. Transactions of the Association of American Physicians 1976;89:184–194.Google Scholar
21. Gaillat, J, Zmirou, D, Mallaret, MR, et al. Essai clinique du vaccin antipheumococcique ches des personnages agees vivant en institution. Rev Epidemiol Sante Publique 1985;33:437–444.Google Scholar
22. Klatersky, J, Mommen, P, Canteraine, F, Safary, A. Placebo controlled pneumococcal immunization in patients with bronchogenic carcinoma. European Journal of Cancer and Clinical Oncology 1986:22:807–813.CrossRefGoogle Scholar
23. Simberkoff, MS, Cross, AP, Al-Ibrahim, M, et al. Efficacy of pneumococcal vaccine in high-risk patients: results of a Veterans Administration Cooperative Study. N Engl J Med 1986;315:1318–1327.CrossRefGoogle ScholarPubMed
24. Davis, AL, Aranda, CP, Schiffman, G, Christianson, LC. Pneumococcal infection and immunologic response to pneumococcal vaccine in chronic obstructive pulmonary disease. Chest 1987;92:202–212.CrossRefGoogle ScholarPubMed
25. Leech, JA, Gervais, A, Ruben, FL. Efficacy of pneumococcal vaccine in severe chronic obstructive pulmonary disease. Canadian Medical Association Journal 1987;136:361–365.Google Scholar
26. Koivula, I, Sten, M, Leinonen, M, Makela, PH. Clinical efficacy of pneumococcal vaccine in the elderly: a randomized, single-blind population-based study. Am J Med 1997;103:281–290.Google Scholar
27. Ortqvist, A, Hedlund, J, Burman, A, et al. Randomised trial of 23-valent pneumococcal capsular polysaccharide vaccine in prevention of pneumonia in middle-aged and elderly people. Lancet 1998;351:399–403.Google Scholar
28. French, N, Nakiyingi, J, Carpenter, M, et al. 23-valent pneumococcal polysaccharide vaccine in HIV-1-infected Ugandan adults: double-blind, randomised and placebo controlled trial. Lancet 2000;355:2106–2111.CrossRefGoogle ScholarPubMed
29. Kaufman, P. Pneumonia in old age: active immunization against pneumonia with pneumococcus polysaccharide, results of a six year study. Arch Intern Med 1947;79:518–531.Google Scholar
30. Austrian, R. Surveillance of Pneumococcal Infection for Field Trials of Polyvalent Pneumococcal Vaccines. Bethesda, MD: National Institutes of Health; 1980. DAB-VDP-12-84, Contract No. IA13257.Google Scholar
31. Smit, P, Oberholzer, D, Hayden-Smith, S, Koornman, HJ, Hillman, JR. Protective efficacy of pneumococcal polysaccharide vaccines. JAMA 1977;238:2613–2616.CrossRefGoogle ScholarPubMed
32. Riley, ID, Tarr, PI, Andrews, M, et al. Immunisation with a polyvalent pneumococcal vaccine: reduction of adult respiratory mortality in a New Guinea Highlands community. Lancet 1977;1:1338–1341.Google Scholar
33. Kaufman, P. Studies in old age pneumonia: II. Prophylactic effect of pneumococcus polysaccharide against pneumonia. Arch Intern Med 1941;67:304–319.CrossRefGoogle Scholar
34. Macleod, CM, Hodges, RG, Heidelberger, M, Bernhard, WG. Prevention of pneumococcal pneumonia by immunization with specific capsular polysaccharides. J Exp Med 1945;82:445–465.Google Scholar
35. Honkanen, PO, Keistinen, T, Miettinen, L, et al. Incremental effectiveness of pneumococcal vaccine on simultaneously administered influenza vaccine in preventing pneumonia and pneumococcal pneumonia among persons aged 65 years or older. Vaccine 1999;17:2493–2500.Google Scholar
36. Chalmers, TC, Smith, H Jr, Blackburn, B, et al. A method for assessing the quality of a randomized controlled trial. Control Clin Trials 1981;2:31–49.CrossRefGoogle Scholar
37. Jadad, AR, Moore, RA, Carroll, D, et al. Assessing the quality of randomized clinical trials: is blinding necessary? Control Clin Trials 1996:17:112.Google Scholar
38. Mangtani, P, Cutts, F, Hall, AJ. Efficacy of polysaccharide pneumococcal vaccine in adults in more developed countries: the state of the evidence. Lancet Infect Dis 2003;3:71–78.Google Scholar
39. Shapiro, ED, Clemens, JD. A controlled evaluation of the protective efficacy of pneumococcal vaccine for patients at high risk of serious pneumococcal infections. Ann Intern Med 1984;101:325–330.Google Scholar
40. Shapiro, ED, Berg, AT, Austrian, R, et al. The protective efficacy of polyvalent pneumococcal polysaccharide vaccine. N Engl J Med 1991;325: 1453–1460.CrossRefGoogle ScholarPubMed
41. Farr, BM, Johnston, L, Cobb, DK, et al. Preventing pneumococcal bacteremia in patients at risk: results of a matched case-control study. Arch Intern Med 1995,155:2336–2340.Google Scholar
42. Forrester, HL, Jahnigen, DW, LaForce, FM. Inefficacy of pneumococcal vaccine in a high-risk population. Am JMed 1987;83:425–430.Google Scholar
43. Sims, RV, Steinmann, WC, McConville, JH, King, LR, Zwick, WC, Schwartz, JS. The clinical effectiveness of pneumococcal vaccine in the elderly. Ann Intern Med 1988;108:653–657.Google Scholar
44. Nichol, KL, Baken, L, Wuorenma, J, Nelson, A. The health and economic benefits associated with pneumococcal vaccination of elderly persons with chronic lung disease. Arch Intern Med 1999;159:2437–2442.CrossRefGoogle ScholarPubMed
45. Jackson, LA, Neuzil, KM, Yu, O, et al. Effectiveness of pneumococcal polysaccharide vaccine in older adults. N Engl J Med 2003;348:1747–1755.CrossRefGoogle ScholarPubMed
46. Mak, DB, Plant, AJ, Rushworth, RL. Where the data are deficient: a field evaluation of the effectiveness of pneumococcal vaccination in remote Australia. The Australian Journal of Rural Health 2001;9:38–46.Google Scholar
47. Christenson, B, Lundbergh, P, Hedlund, J, Ortqvist, A. Effects of a large-scale intervention with influenza and 23-valent pneumococcal vaccines in adults aged 65 years or older: a prospective study. Lancet 2001;357:1008–1011.Google Scholar
48. Broome, CV, Facklam, RR, Fraser, DW. Pneumococcal disease after pneumococcal vaccination: an alternative method to estimate the efficacy of pneumococcal vaccine. N Engl J Med 1980;303:549–552.Google Scholar
49. Bolan, G, Broome, CV, Facklam, RR, Plikayatis, BD, Fraser, DW, Schlech, WE. Pneumococcal vaccine efficacy in selected populations in the United States. Ann Intern Med 1986;104:1–6.Google Scholar
50. Butler, JC, Breiman, RF, Campbell, JF, Lipman, HB, Broome, CV, Facklam, RR. Pneumococcal polysaccharide vaccine efficacy: an evaluation of current recommendations. JAMA 1993;270:1826–1831.Google Scholar
51. Musher, DM, Luchi, MJ, Watson, DA, Hamilton, R, Baughn, RE. Pneumococcal polysaccharide vaccine in young adults and older bron-chitics: determination of IgG responses by ELISA and the effect of adsorption of serum with non-type-specific cell wall polysaccharide. J Infect Dis 1990;161:728–735.Google Scholar
52. Grimfors, G, Soderqvist, M, Holm, G, Lefvert, AK, Bjorkholm, M. A longitudinal study of class and subclass antibody response to pneumococcal vaccination in splenectomized individuals with special reference to patients with Hodgkin's disease. Eur J Haematol 1990:45:101–108.Google Scholar
53. Cancato, J, Shah, N, Horwitz, RI. Randomized, controlled trials, observational studies, and the hierarchy of research designs. N J Engl J Med 2000;342:1887–1892.Google Scholar
54. Sisk, JE, Moskowitz, AJ, Whang, W, et al. Cost-effectiveness of vaccination against pneumococcal bacteremia among elderly people. JAMA 1997;278:1333–1339.Google Scholar
55. Laupacis, A, Feeny, D, Detsky, AS, et al. How attractive does a new technology have to be to warrant adoption and utilization? Tentative guidelines for using clinical and economic evaluation. Canadian Medical Association Journal 1992;146:473–881.Google Scholar
56. Laupacis, A, Feeny, D, Detsky, AS, Tugwell, PX. Tentative guidelines for using clinical and economic evaluations revisited. Canadian Medical Association Journal 1993;148:927–929.Google ScholarPubMed
57. Anient, A, Baltussen, R, Duru, G, et al. Cost-effectiveness of pneumococcal vaccination of older people: a study in 5 western European countries. Clin Infect Dis 2000;31:444–450.Google Scholar
58. Jencks, SF, Cuerdon, T, Burwen, DR, et al. Quality of medical care delivered to Medicare beneficiaries: a profile at state and national levels. JAMA 2000;284:1670–1676.CrossRefGoogle ScholarPubMed
59. Centers for Medicare & Medicaid Services. Medicare and Medicaid programs. Conditions of participation: immunization standards for hospitals, long-term care facilities, and home health agencies. Federal Register 2002;67:61808–61814.Google Scholar
60. Meehan, TP, Fine, MJ, Krumholz, HM, et al. Quality of care, process, and outcomes in elderly patients with pneumonia. JAMA 1997;278:2080–2084.Google Scholar
61. Stevenson, KB, McMahon, JW, Harris, J, Hillman, JR, Helgerson, SD. Increasing pneumococcal vaccination rates among residents of long-term care facilities: provider-based improvement strategies implemented by peer review organizations in four western states. Infect Control Hosp Epidemiol 2000;21:705–710.Google Scholar