Adult Vaccinations by Unknown

Author:Unknown
Language: eng
Format: epub
ISBN: 9783030051594
Publisher: Springer International Publishing

11.7 Vaccination Strategy Against Pneumococcal Disease: The Example of Germany

Since 1998, Germany’s Standing Committee on Vaccination (Ständige Impfkommission, STIKO) has recommended vaccination with the 23-valent pneumococcal polysaccharide vaccine (PPSV23) for all people aged ≥60 years. Universal vaccination of infants with a pneumococcal conjugate vaccine (initially PCV7, replaced by PCV13 in 2010) has been recommended by STIKO since 2006. Since then, a decline in IPD cases due to pneumococcal serotypes contained in PCV7/PCV13 has been observed not only in children but, through herd protection, also in older adults. Triggered by the approval of PCV13 for use in adults, STIKO investigated whether PCV13 or PPSV23 (or the combination of both) should be preferred for the vaccination of older adults and at what age the vaccine should be given.

Based on the meta-analysis of PPSV23 efficacy/effectiveness by Falkenhorst et al. [10] and the results of the PCV13 trial in the Netherlands [19], STIKO concluded that PPV23 continues to be the vaccine of choice for people aged 60 years or older. An important reason for this is the decrease of PCV13 serotypes among adults resulting from herd protection through routine infant immunization with PCV13. Due to the waning immunity, PPSV23 vaccination should be repeated every 6 years. Sequential vaccination with PCV13 followed by PPSV23 is only recommended for high-risk patients, i.e. people with immunocompromising conditions and those with a specific risk for pneumococcal meningitis. The evidence substantiating the updated recommendations for pneumococcal vaccination for older adults in Germany is presented in a background paper [25].

In Germany, IPD is not a mandatory notifiable disease, but there is a voluntary laboratory-based surveillance system in place (www.​rki.​de/​pneumoweb). Data from this system indicates that serotypes included in PCV13 have decreased in all age groups over time, while serotypes not included in any vaccine are on the rise. Serotype 3 (included in PCV13) is unique in that it did not decline and now represents more than half of the remaining PCV13 serotypes. It has been postulated that this is due to the fact that serotype 3 strains are heavily encapsulated, inhibiting opsonisation. Once opsonized by antibodies, serotype 3 strains can even eject the polysaccharide together with the antibody and, as a result, escape phagocytosis [26–29]. It is legitimate to wonder whether it is even possible to achieve effective protection against serotype 3 with a vaccine based on its polysaccharide antigens.

Another question that arises is whether the usual distinction between IPD and pneumonia without bacteraemia is justified and useful. In the elderly, most cases of bacteraemia occur as a complication of pneumococcal pneumonia, while usually about 10–15% of pneumococcal pneumonia patients are diagnosed as having also bacteraemia. This percentage depends heavily on the frequency with which blood cultures are used. For example, in a patient with pneumococcal pneumonia, the disease will always be classified as non-bacteraemic, if no blood culture is taken. In patients with negative blood culture, it could be positive some hours later, or it could be negative, because the patient has already been put on antibiotic treatment.

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