Changing the Paradigm:

Vaccination as a Key Prevention Step in Daily Practice

Moderator

Charles Feldman, MB BCh, DSc, PhD

Professor of Pulmonology and Chief Physician Charlotte Maxeke Johannesburg Academic Hospital University of the Witwatersrand Johannesburg, South Africa

Panelists

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

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Discuss the role of the general practitioner in pneumococcal disease prevention

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Identify potential risk factors for pneumococcal disease

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Watch a patient case scenario performed by actors

Patient Case Scenario

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54-year-old woman with type 2 diabetes; treated with metformin

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Hypercholesterolemia; stable angina; BMI 27

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Former smoker with family history of CVD

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Recently had flu vaccine

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Visiting her GP for an annual checkup BMI = body mass index; CVD = cardiovascular disease; GP = general practitioner

Pneumococcal Vaccination Recommendations in the United Kingdom

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All adults ≥ 65 years

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Infants as part of routine childhood immunization program

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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 Chronic respiratory disease CKD COPD, including chronic bronchitis and emphysema; bronchiectasis; cystic fibrosis; interstitial lung fibrosis; pneumoconiosis; bronchopulmonary dysplasia; respiratory disease requiring frequent steroid treatment; children at risk for aspiration (eg, cerebral palsy) 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 Diabetes Immunosuppression Other complications Examples Patients with diabetes controlled by insulin or oral hypoglycemic agents (not diet alone) 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) 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

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Smoking is associated with ≥ 50% increased risk of developing pneumococcal disease.

[a]

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Asthmatics have at least a 2-fold higher risk for pneumococcal disease.

[b]

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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) 300 250 200 150 100 50 0 Healthy Chronic heart disease Diabetes Chronic lung disease 18-34 35-49 50-64 65-79 > 80 Age (years) Healthy vs Immunocompromised Patients Incidence of IPD (cases per 100,000) 800 700 600 500 400 300 200 100 0 Healthy Solid cancer Hematologic cancer 18-34 35-49 50-64 Age (years) 65-79 > 80 IPD = invasive pneumococcal disease

Adapted from Kyaw MH, et al. J Infect Dis. 2005;192(3):377-386.

Respiratory Comorbidities

US Incidence of IPD, 1999-2000 HIV/AIDS Solid cancer Chronic lung disease Chronic heart disease Diabetes Healthy 8,8 62,9 51,4 93,7 300,4 0 100 200 300 400 Incidence Rate (cases per 100,000 persons)

Kyaw MH, et al. J Infect Dis. 2005;192(3):377-386.

422,9 500

Are GPs Aware of Risks for Pneumococcal Disease?

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Many comorbidities could be recognized by a GP or nurse.

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UK NHS has warning system —yellow flag attached to notes of patients with comorbidities

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Nurses and GPs have a duty to recognize the significance of chronic conditions and importance of pneumococcal vaccination.

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Patients also need to be educated so they know they are at risk.

NHS = National Health Service

Patient Case Scenario (cont)

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54-year-old woman with type 2 diabetes; treated with metformin

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Hypercholesterolemia; stable angina; BMI 27

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Former smoker with family history of CVD

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Recently had flu vaccine

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Has started walking regularly for exercise

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Visiting her GP for an annual checkup

Incidence of Pneumococcal Disease in Older Adults

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Very little data on incidence as most people are treated as outpatients with no microbiological diagnosis; bacteriological tests not very sensitive [a]

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United States—annual incidence of IPD or nonbacteremic pneumococcal pneumonia in adults ≥ 50 years: 5.8 per 1000 [b]

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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

S pneumoniae Haemophilus influenzae

Legionella spp.

Staphylococcus spp.

Moraxella catarrhalis

Gram-negative bacilli

Mycoplasma pneumoniae

Chlamydophila spp.

Coxiella burnetii

Viruses No pathogen identified France 37.2

10.3

2.0

11.7

3.3

16.8

0.7

1 0.2

1.7

35.6

Italy 11.9

5.1

4.9

6.5

1.0

24.3

7.0

2.4

0.4

11.6

67.3

Spain 33.7

5.3

12.9

3.2

2.7

7.9

8.4

7.2

6.2

5.9

56.8

Turkey 25.5

44.9

0 1.0

12.2

4.1

0 0 0 0 40.6

UK 42.1

12.3

9.1

2.6

0.8

2.6

5.3

5.9

0.3

18.6

38.4

CAP = community-acquired pneumonia; NR = not reported

Welte T, et al. Thorax. 2012;67(1):71-79.

Germany 40 8 3.1

5 0 7 5.6

1.3

0 9 NR

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

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Pneumococcal infections are prevalent.

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Associated with significant morbidity and mortality, particularly in older patients and those with comorbidities

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Delaying treatment or using an ineffective therapy is associated with higher morbidity and mortality.

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Pneumococcal infections are associated with decreases in quality of life.

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Better to prevent pneumococcal infection than identify and treat it

PPV Immunization Rates in Primary Care

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Immunization rates rising in England: > 70% of people aged > 65 years in 2011

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Rates were much lower in those < 65 years in clinical risk groups.

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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)

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54-year-old woman with type 2 diabetes; treated with metformin

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Hypercholesterolemia; stable angina; BMI 27

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Former smoker with family history of CVD

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Recently had flu vaccine

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Visiting her GP for an annual checkup

Barriers to Pneumococcal Immunization

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Lack of government commitment

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Lack of a national media campaign

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Lack of physician/nurse endorsement

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Lack of vaccine reimbursement

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Level of physician fee

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Fear of adverse reactions

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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)

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Perception that “vaccination is for children”

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Confusion with influenza vaccine

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Not aware of the benefits

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Individual not made aware he/she is in a group at risk

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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?

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Encourage patients to make an appointment

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Invite by letter, telephone, or text message

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Invite when they contact the clinic in person or by phone

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Target specific groups (eg, > 65 years)

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Don’t forget the house bound

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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)

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Opportunistic

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During any nurse or doctor consultation

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While they are waiting at the clinic to see a doctor or nurse

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When they collect a repeat prescription

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When they bring a relative to the clinic

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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

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Pneumococcal disease is associated with considerable mortality and morbidity.

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Pneumococcal disease is best managed by prevention through vaccination rather than treating it once the disease has occurred.

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