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How effective is Pneumococcal vaccine?


PPSV23 Vaccine Effectiveness

pneumococcal
Image source: CDC PHIL

The initial pre-licensing clinical trials of a pneumococcal capsular polysaccharide involved a comparison study of the effectiveness of a 6-valent polysaccharide vaccine against a 12-valent polysaccharide vaccine. The study involved South African gold miners between the ages of 16 and 58, a population noted to be at a higher risk for pneumococcal pneumonia. The 6-valent vaccine was reported to be 76 percent effective while the 12-valent vaccine was found to be 92 percent effective against the particular pneumococcal strains found in the vaccine.1 2

The long-term effectiveness of the vaccine was not measured as the study was limited to only one year. An additional polysaccharide vaccine effectiveness study involving both a 6-valent and 13-valent polysaccharide vaccine found a 79 percent reduction in pneumococcal pneumonia and an 82 percent reduction in pneumococcal bacteremia caused by the strains found in the vaccine.3

In the United States, two post-licensing trials on the effectiveness of the original 14-valent pneumococcal polysaccharide vaccine in the elderly or persons with chronic medical conditions found the vaccine to be ineffective against bronchitis and pneumonia in this particular population.4 5 6

Additional research on the effectiveness of the pneumococcal polysaccharide vaccine based on the CDC’s pneumococcal surveillance system found the vaccine to be 57 percent effective against the serotypes found within PNEUMOVAX23 (PPSV23) in persons 6 and older, between 65 and 84 percent effective in persons with chronic illness (ie diabetes, congestive heart failure, COPD, etc), and 75 percent effective in healthy persons 65 and older. Vaccine effectiveness, however, could not be determined in certain populations of individuals with immunosuppressive conditions.7

When PNEUMOVAX23 (PPSV23) was administered in combination with ZOSTAVAX, Merck’s live attenuated shingles vaccine, shingles antibody levels were found to be significantly lower when compared to administering the shingles vaccine four weeks after PNEUMOVAX23 administration.8

A 2008 study found that while PPSV23 reduced the risk of invasive pneumococcal disease in the elderly by 38 percent, it had no impact on pneumonia rates.9 In 2010, researchers found the vaccine to be completely ineffective at reducing the rates of hospitalization or death in persons previously treated for community acquired pneumonia.10 The vaccine was also found to be ineffective in both transplant patients,11 and persons with HIV who had low CD4+ cell counts12 and did not reduce the rates of pneumonia in persons with rheumatoid arthritis.13

PCV 13 Vaccine Effectiveness

Information on pneumococcal conjugate vaccine efficacy found in the Prevnar 13(PCV13) product insert reports information pertaining to the original PCV vaccine, Prevnar (PCV7). PCV7 was reported to be 100 percent effective at preventing invasive disease caused by S. pneumoniae during the pre-licensing clinical trial which took place over a 34 month period. An eight month extended follow-up of vaccine recipients reported the vaccine’s efficacy to be between 93 and 97.4 percent effective.14

In clinical studies pertaining to the PCV vaccine for the prevention of acute otitis media, studies found PCV7 to be only 7 percent effective at preventing acute otitis media and children who received PCV7 were noted to be at a higher risk for developing acute otitis media from strains not covered by the vaccine. Studies also found that PCV7 reduced the need for tympanostomy tubes (ear tubes) by only about 20 percent.15

One large scale study involving nearly 85,000 adults 65 and older found PCV13 to be 45.6 percent effective against vaccine-type pneumococcal pneumonia, 45 percent effective against vaccine-type non-bacteremic pneumococcal pneumonia and 75 percent effective against all vaccine-type invasive pneumococcal disease.16

The Prevnar 13(PCV13) product insert also states that effectiveness of the vaccine cannot be established in the following population:17

  • Infants born prematurely
  • Persons with HIV-infection
  • Children with sickle cell disease
  • Persons who had received an allogeneic hematopoietic stem cell transplant

Following FDA approval of the first pneumococcal conjugate vaccine, Prevnar (PCV7), researchers discovered that while the vaccine was effective in reducing the risk of infection caused by the 7 strains found within the vaccine, strains not found within the vaccine began to increase. Most notably, strain 19A, a highly virulent strain resistant to all antibiotics FDA approved for use in children for the treatment of acute otitis media, emerged.18 19

In addition to pneumococcal strain replacement, the introduction of PCV7 resulted in a significant increase in pneumococcal empyema, a complication of pneumococcal pneumonia resulting in an accumulation of pus between the lungs and the inner aspect of the chest wall.20 21 The most common strains causing empyema were found to be pneumococcal strains 1, 3 and 19A, three strains not covered in the PCV7 vaccine.22 23

While invasive disease from vaccine-type strains decreased significantly within the first four years following the introduction of PCV7, antibiotic resistant non-vaccine type strains began to take their place.24 In one particular population of Alaska Native children, the introduction of the PCV7 vaccine caused a 140 percent increase of invasive pneumococcal disease from strains not found in the vaccine.25

Rates of pneumococcal meningitis by antibiotic resistant strains not found in the PCV7 vaccine continued to increase, which prompted researchers to emphasize the need for better pneumococcal vaccines.26

The 2010 introduction of PCV13 vaccine, adding six additional strains to the original PCV7, resulted in a further decline of invasive pneumococcal disease. However, PCV 13 vaccine has not been completely effective in eliminating vaccine-strain invasive pneumococcal disease and serious infections have persisted despite the licensing of a broader targeting vaccine.27 28 29 30

In addition to the vaccine’s ineffectiveness in eliminating pneumococcal disease from all strains contained within the vaccine, non-vaccine type strains have also emerged in the United States, most notably strains 33F, 22F, 12, 15B, 15C, and 23 A.31 Other countries have experienced a similar situation, including Taiwan, which noted a decrease in vaccine-type strain invasive disease and confirmed pneumococcal disease but an increase in non-vaccine type strain invasive disease, most notably caused by strains 23A, 15A and 15B.32

Korea has also reported high rates of antibiotic-resistant strains not found in PCV13 since the introduction of the vaccine.33 Non-vaccine type strains continue to appear in many Western European countries, prompting researchers stress the need for new vaccines to cover the antibiotic-resistant strains of S. pneumoniae not found within the current vaccines.34 35 36

Researchers in the United States have noted that while invasive pneumococcal disease has decreased since the introduction of pneumococcal conjugate vaccines, S. pneumoniae strains have continued to adapt and this has resulted in the ongoing emergence of antibiotic resistant non-vaccine serotypes.37 38

The use of pneumococcal conjugate vaccines has also caused an increase in other serious pathogens such as Haemophilus influenzae and Moraxella catarrhalis. Since the introduction of PCV vaccines, H. influenzae and M. catarrhalis otitis media have increased to replace S.pneumoniae otitis media.39

While the CDC and other global health organizations have attributed the decrease in invasive pneumococcal disease to vaccination, the introduction of pneumococcal conjugate vaccines has brought changes to clinical practice. Emergency room collection of blood cultures, once a routine practice in the assessment and treatment of children presenting with fever in the emergency room, have decreased since PCV vaccine introduction. 40 This change in clinical treatment protocol may be artificially inflating the rate of decrease of pneumococcal disease in children and reducing the detection of non-vaccine type replacement strains.41

A study of Aboriginals living in Western Australia found that while PCV7 vaccination decreased the number of vaccine-type invasive pneumococcal infections in the elderly and young children, it significantly increased the amount of non-vaccine type pneumococcal diseases in adults.42

Another study involving a similar population in Australia found that vaccine strains of pneumococcal were not replaced by non-vaccine strain infections in children but non-vaccine strain infections rose significantly in adults. This offset any potential benefit that vaccination might have had on the adult population.43

At the CDC’s October 2018 ACIP meeting, public health officials that vaccinating all persons 65 and older with PCV13 has had no impact on reducing the rates of both invasive and non-invasive pneumococcal disease.44 In June 2019, ACIP voted to pull back from its 2014 recommendation and stated that healthy seniors 65 and older could consider this vaccination after discussions with their physician. PCV13 is still recommended for seniors 65 years and older who have chronic health conditions and a single dose of PPSV23 is still recommended for all persons 65 and older.45

The continued emergence of non-vaccine type pneumococcal strains has resulted in the development of new pneumococcal vaccines. Merck is currently in stage 3 clinical trials of a 15-valent pneumococcal conjugate vaccine, which will add strain 22F and 33F to the 13 strains currently found in PCV13.46 

Pfizer was recently awarded Breakthrough Therapy Designation by the FDA for a new 20-valent pneumococcal vaccine.47  Breakthrough Therapy Designation allows drug companies the opportunity “to expedite the development and review of drugs that are intended to treat a serious condition and preliminary clinical evidence indicates that the drug may demonstrate substantial improvement over available therapy on a clinically significant endpoint(s).”48

IMPORTANT NOTE: NVIC encourages you to become fully informed about Pneumococcal and the Pneumococcal vaccine by reading all sections in the Table of Contents , which contain many links and resources such as the manufacturer product information inserts, and to speak with one or more trusted health care professionals before making a vaccination decision for yourself or your child. This information is for educational purposes only and is not intended as medical advice.

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References

1 FDA Pneumovax 23 - Pneumococcal Vaccine, Polyvalent Package Insert Dec 30, 2014

2 Smit P, Oberholzer D, Hayden-Smith S, et al. Protective efficacy of pneumococcal polysaccharide vaccines. JAMA. 1977 Dec 12; 238(24):2613-6.

3 FDA Pneumovax 23 - Pneumococcal Vaccine, Polyvalent. Package Insert Dec 30, 2014

4 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 Nov 20; 315(21):1318-27.

5 FDA Pneumovax 23 - Pneumococcal Vaccine, Polyvalent. Package Insert Dec 30, 2014

6 CDC Recommendations of the Immunization Practices Advisory Committee (ACIP) Update: Pneumococcal Polysaccharide Vaccine Usage – United States. MMWR May 25, 1984;33(20) 273-281

7 FDA Pneumovax 23 - Pneumococcal Vaccine, Polyvalent. Package Insert Dec 30, 2014

8 Ibid

9 Jackson LA, Janoff EN. Pneumococcal vaccination of elderly adults: new paradigms for protection. Clin Infect Dis. 2008 Nov 15; 47(10):1328-38.

10 Johnstone J, Eurich DT, Minhas JK et al. Impact of the pneumococcal vaccine on long-term morbidity and mortality of adults at high risk for pneumonia. Clin Infect Dis. 2010 Jul 1; 51(1):15-22.

11 Kumar D, Chen MH, Welsh B et al. A randomized, double-blind trial of pneumococcal vaccination in adult allogeneic stem cell transplant donors and recipients. Clin Infect Dis. 2007 Dec 15;45(12):1576-82

12 Hung CC, Chang SY, Su CT et al A 5-year longitudinal follow-up study of serological responses to 23-valent pneumococcal polysaccharide vaccination among patients with HIV infection who received highly active antiretroviral therapy. HIV Med. 2010 Jan;11(1):54-63.

13 Yasumori I Manabu A, Yukihiro A et al The 23-valent pneumococcal polysaccharide vaccine in patients with rheumatoid arthritis: a double-blinded, randomized, placebo-controlled trial Arthritis Res Ther. 2017; 19: 15.

14 FDA Prevnar 13 Package Insert Aug 22, 2017

15 Ibid

16 Ibid

17 Ibid

18 Pichichero ME, Casey JR, Emergence of a multiresistant serotype 19A pneumococcal strain not included in the 7-valent conjugate vaccine as an otopathogen in children. JAMA. 2007 Oct 17; 298(15):1772-8.

19 Moore MR, Gertz RE Jr, Woodbury RL et al. Population snapshot of emergent Streptococcus pneumoniae serotype 19A in the United States, 2005. J Infect Dis. 2008 Apr 1;197(7):1016-27

20 Burgos J1, Lujan M, Falcó V, et al. The spectrum of pneumococcal empyema in adults in the early 21st century. Clin Infect Dis. 2011 Aug 1;53(3):254-61

21 Fletcher, MA, Schmitt HJ, Syrochkina M et al. Pneumococcal empyema and complicated pneumonias: global trends in incidence, prevalence, and serotype epidemiology. Eur J Clin Microbiol Infect Dis. 2014; 33(6): 879–910.

22 Shen CF, Wang SM, Lee KH et al. Childhood invasive pneumococcal disease caused by non-7-valent pneumococcal vaccine (PCV7) serotypes under partial immunization in Taiwan. J Formos Med Assoc. 2013 Sep;112(9):561-8

23 Byington CL, Korgenski K, Daly J et al. Impact of the pneumococcal conjugate vaccine on pneumococcal parapneumonic empyema. Pediatr Infect Dis J. 2006 Mar; 25(3):250-4.

24 CDC Farrell DJ, Klugman KP, Pichichero M. Increased antimicrobial resistance among nonvaccine serotypes of Streptococcus pneumoniae in the pediatric population after the introduction of 7-valent pneumococcal vaccine in the United States. Pediatr Infect Dis J. 2007 Feb; 26(2):123-8.

25 Singleton RJ, Hennessy TW, Bulkow LR et al. Invasive pneumococcal disease caused by nonvaccine serotypes among alaska native children with high levels of 7-valent pneumococcal conjugate vaccine coverage. JAMA. 2007 Apr 25; 297(16):1784-92.

26 Hsu HE, Shutt KA, Moore MR, et al. Effect of Pneumococcal Conjugate Vaccine on Pneumococcal Meningitis. N Engl J Med. 2009 Jan 15; 360(3): 244–256.

27 Diawara I, Zerouali K, Elmdaghri N et al. A case report of parapneumonic pleural effusion caused by Streptococcus pneumoniae serotype 19A in a child immunized with 13-valent conjugate pneumococcal vaccine. BMC Pediatr. 2017; 17: 114.

28 Antachopoulos C, Tsolia MN, Tzanakaki G, et al Parapneumonic pleural effusions caused by Streptococcus pneumoniae serotype 3 in children immunized with 13-valent conjugated pneumococcal vaccine. Pediatr Infect Dis J. 2014 Jan;33(1):81-3

29 Syrogiannopoulos GA, Michoula AN, Tsimitselis G et al. Pneumonia with empyema among children in the first five years of high coverage with 13-valent pneumococcal conjugate vaccine. Infect Dis (Lond). 2016 Oct;48(10):749-53.

30 Silva-Costa C, Brito MJ, Pinho MD, et al. Pediatric Complicated Pneumonia Caused by Streptococcus pneumoniae Serotype 3 in 13-Valent Pneumococcal Conjugate Vaccinees, Portugal, 2010-2015. Emerg Infect Dis. 2018 Jul;24(7):1307-1314

31 Lee LH, Gu XX, Nahm MH Towards New Broader Spectrum Pneumococcal Vaccines: The Future of Pneumococcal Disease Prevention Vaccines (Basel). 2014 Mar; 2(1): 112–128.

32 Su LH,  Kuo AJ, Chia JH et al. Evolving pneumococcal serotypes and sequence types in relation to high antibiotic stress and conditional pneumococcal immunization Sci Rep. 2015; 5: 15843.

33 Choe YJ, Lee HJ, Lee H et al. Emergence of antibiotic-resistant non-vaccine serotype pneumococci in nasopharyngeal carriage in children after the use of extended-valency pneumococcal conjugate vaccines in Korea. Vaccine. 2016 Sep 14; 34(40):4771-6.

34 Tin Tin Htar M, Christopoulou D, Schmitt HJ Pneumococcal serotype evolution in Western Europe. BMC Infect Dis. 2015; 15: 419.

35 Büyükcam A, Güdücüoğlu H, Karaman K et al. Invasive pneumococcal infection due to serotype 15A after the pneumococcal conjugate vaccine implementation in Turkey. Hum Vaccin Immunother. 2017 Aug 3; 13(8):1892-1894.

36 Steens A, Bergsaker MA, Aaberge IS et al. Prompt effect of replacing the 7-valent pneumococcal conjugate vaccine with the 13-valent vaccine on the epidemiology of invasive pneumococcal disease in Norway. Vaccine. 2013 Dec 16; 31(52):6232-8.

37 Lee GM, Kleinman K, Pelton S et al. Immunization, Antibiotic Use, and Pneumococcal Colonization Over a 15-Year Period. Pediatrics. 2017 Nov; 140(5).

38 Bender, K Pneumococcal Colonization Adapts to Vaccination, Antibiotics. MD Magazine. Dec. 1, 2017

39 Murphy TF. Vaccines for Nontypeable Haemophilus influenzae: the Future Is Now Clin Vaccine Immunol. 2015 May; 22(5): 459–466.

40 Weinberger DM, Malley R, Lipsitch M Serotype replacement in disease following pneumococcal vaccination: A discussion of the evidence. Lancet. 2011 Dec 3; 378(9807): 1962–1973.

41 Ibid

42 Lehmann D, Willis J, Moore HC et al The changing epidemiology of invasive pneumococcal disease in aboriginal and non-aboriginal western Australians from 1997 through 2007 and emergence of nonvaccine serotypes. Clin Infect Dis. 2010 Jun 1;50(11):1477-86

43 Hanna JN, Humphreys JL, Murphy DM. Invasive pneumococcal disease in Indigenous people in north Queensland: an update, 2005-2007. Med J Aust. 2008 Jul 7; 189(1):43-6.

44 CDC ACIP Meeting Presentation. Incidence of non-Invasive Pneumococcal Pneumonia before and after PCV13 recommendation for adults ≥65yo. Mr. Ryan Gierke. CDC/NCIRD. Oct. 24, 2018

45 Crawford, C ACIP Approves New Guidance on HPV, Pneumococcal Vaccines AAFP Jul. 3, 2019

46 Greenberg D, Hoover PA, Vesikari T et al. Safety and immunogenicity of 15-valent pneumococcal conjugate vaccine (PCV15) in healthy infants. Vaccine. 2018 Oct 29;36(45):6883-6891

47 Sagonowsky, E Racing with Merck, Pfizer wins FDA 'breakthrough' tag for 20-valent pneumococcal vaccine. Fierce Pharma. Sep. 20, 2018

48 FDA Breakthrough Therapy. Jan 4, 2018


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