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Pneumococcal vaccination in special population

BY:  faiqah   nabilah   binti   noorhaidi

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WHO 2011-2020: Global vaccine action plan (GVAP)

Promotes immunization benefit to be equitably extended to all people including high risk special groups.  Includes preterm infants, pregnant women, those with chronic and immune compromised medical conditions or at immunocompromised due to disease or aging, animal handlers and elderly  Their plan is creating strategies for reaching individuals throughout their life course and developing plans for the systems that will monitor and track their vaccination progress.

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Pneumococcal disease is an invasive disease from  streptococcus pneumoniae Streptococcus pneumoniae  usually found in human nasopharynx, asymptomatically and transmitted to other individual by respiratory droplets. S. pneumoniae  has been the most common cause of acute otitis media and invasive bacterial disease in children, including bacteremia, meningitis and pneumonia  Infants and young children are thought to be the main reservoir in cultivating this variant  In the United States 50% of all cases of pneumococcal disease in adults are pneumonia.  Pneumococcus is classified by the composition of its outer capsule that are identified by their number of serotypes. There are about 93 known serotype of pneumococcus that the prevalence varies depends on the geographic region.

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Approximately half of deaths from pneumococcal disease can be prevented by vaccinations  Pneumococcal diseases cause death in approximately 31000 cases and 3590 deaths from the invasive pneumococcal disease that occurred in United States in 2017   This vaccination implementation can reduced the risk mortality and morbidity in patient suffering from pneumococcal diseases.  Generally, pneumococcal disease can be treated with common antibiotics for example amoxicillin but due to  resistancy  problem of the choice of antibiotic become limited.

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However in  many countries, strain of pneumococcus are becoming resistant to these common antibiotics. These circumstances require treatment of choice with high end antibiotics that are usually reserve in more complicated infection plus it is much more expensive. The risk of pneumococcal disease remain high especially within 24 months of life that can results in high mortality. Vaccination towards this strain of pneumococcal organism can prevent substantial mortality and morbidity especially in low income countries. Everybody is at risk in developing pneumococcal disease but greater in immunocompromised individual, thus instance action need to be taken to addressed this issues.

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Sinusi
Nasopha
is
Otitis
Media
cteremia
umonia
Meningitis
Pneumonia
Osteomyelitis,
Septic Arthritis

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In general the risk factor for pneumococcal diseases: Newborn  Geriatrics  Long- term health problems Weakened immune system  Weakened respiratory system

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Year  Vaccine  1977 14-valent polysaccharide vaccine licensed 1983 23-valent polysaccharide vaccine licensed (PPSV23) 2000 7- valent polysaccharide conjugate vaccine licensed (PCV7)  2010 13–valent PCV licensed

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PCV13 4
4
2
6B 9V 14 18C 19F 23F 1 5
8 9N IOA IIA 12F 15B 17F 20 22F 33

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PCV 13 contain 13 serotype which is one is unique serotypes 6A. PPSV23 contain 12 serotype which is common with PCV13 and additional 11 serotypes that are unique. These unique serotype of PPSV23 that are not in PCV 13 are serotypes 2, 8, 9N, 10A, 11A, 12F, 15B, 17F, 20, 22F and 33F. The additional 11 serotypes account for 32%–37% of IPD among adults aged ≥65 years.

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Vaccine Trade name Pneumococcal polysaccharides vaccine (PPSV23)  Pneumovax ® Pneumococcal conjugate vaccine (PCV7) Prevnar 7 ® Pneumococcal conjugate vaccine (PCV13) Prevnar 13 ®

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ACIP risk groups for pneumococcal infection

(ACIP) recommended vaccination of: All adults ages 65 years old and over  Adults aged 19-64 years with the following underlying medical condition

2. Functional or anatomic  asplenic   Sickle cell disease  Splenectomy Congenital acquired  aplenia

3. Immunocompromised persons Congenital or acquired (HIV) immunodeficiency  Leukaemia  & lymphomas   Generalised  malignancy  Diseases treated with immunocompromised   Solid organ transplantation

Immunocompetent persons Chronic heart diseases  Diabetes mellitus  Cerebrospinal fluid leaks  Cochlear implant   Chronic liver diseases Cigarette smoking

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20,000
15,000
10,000
5,000
1990
Deaths from pneumonia, by age, Malaysia, 1990 to 2017
2000
1995
2005
2010
Source: IHME, Global Burden of Disease Study (GBD)
Our World
in Data
70+ year-olds
50-69 year-olds
15-49 years-olds
5-14 year-olds
Under-5s
2015 2017
OurVVorldlnData.org/pneumonia • CC BY
Note: Deaths from 'clinical pneumonia', which refers to a diagnosis based on disease symptoms such as coughing and difficulty breathing and may include other
lower respiratory diseases.

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Medical conditions or other indication for administration of PCV13 and PPSV23 for adults

Medical indication
persons
Persons with
Under-tying medical
None of the below
AE0holi•n
Chronic heart disease'
Chronic liver Oseæe
Chronic lung disease'
Cigarette smoking
mellitus
Cochlear implants
CSF leaks
Congenital or acquired
aspienia
PCV13for2 19 years
PPSV23• for through 64 years
functional or anatornic
Sickle cell disease/other
asplenia
he-noglobinopathies
Chronic renal failure
Congenital or acquired
immunodeficiencies'
Generalized malignancy
HIV infection
Hodgkin disease
persons
g weeks
after PCV13
g weeks
after PCV13
2 g weeks
after PCV13
Revaccination
2 5 years after
first dose PPSVZ
5 years after
first dose PPSV23
PCVf3 at 65 years
Recomrnended
Based on
shared clinical
decisiorv-making
Based on
shared clinical
decision—making
If no previous
PCV13 vaccination
If no previous
PCVI 3 vaccination
If no previous
PCV13 vaccination
PPSV23 at 65 years
Recommended
If PCV13 has been
given, then give PPSV23
21 year PCV13
tf PCV13 has ben
givgn. then give PPSV23
21 year after PCV13
5 years after any
PPSV23 at < 65 years
2 g weeks after PCVI 3
> 5 years after any
PPSV23 at < 65 years
8 weeks after PCVI 3
> 5 years after any
PPSV23 at < 65 years
> 8 weeks after PCVI 3
> 5 years after any
PPSV23 at 65 years
irnm.unosuppression*
Lymphoma
Multip'e myeloma
Nea-trotic syn&ome
Solid orgul
PPSV23 cce•rnn to outts 19 64 ot aduts 6S years ct
c*d« srcua receive ore dose or PPS'.•23 S cc arec any of PPsv23. reg•-die— or
nlstory or wtth pneumcx:occa vaccne. No of PPSÆ3 •ouE be
atynrestered tooowlng t:r'.e dose aarnlnbtered at 65
'lnc:s.arg ccr.æstree neart raw-xe ana caratcrn»-cpatnæs
NCIAOlg410 | 0025/20
'Includng ct-rcrec purr-vale-y disease. s-nprrs%erna. arc —thrna
"ncuoes B- nrncrao cr T-ryrnpno:yte Cl. C2. C3. arc
CZ dencer--ci-æ). ard gnaæcytZ dlsorCers Pxcüdlng c:nronE disease)
requnng treatment wtn mrruncsuppressl'.e brv-t«rn
ccrt'coste•ron raaÄtEn trerapy•
Pneumococcal Vaccine Timing Adults I Page 3
Centers for Disease Control and Prevention

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Child deaths from diseases caused by invasive pneumococcus, Malaysia, 2000 to
2015
Our World
in Data
Number of under-5 year old deaths by disease caused by pneumococcus. Pneumococcus is the leading cause of pneumonia in children.
200
150
100
50
2000
Source: Wahl (2018)
2002
2004
2006
2008
2010
2012
2014
Invasive
non-pneumonia,
non-meningitis
Meningitis
Pneumonia
2015
CC BY

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Underlying medical condition that are indications for pneumococcal vaccination among children, by risk group

Advisory Committee on Immunization Practices, 2010. MMWR 2010; 59:258-61

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In infant under 12 months of age, WHO recommended 3 primary doses (3p+0 schedule) starting as early as 6 weeks of age. Alternatively 2 primary doses by the age of six months plus a booster dose at 9-15 months of age ( the 2p+1 schedule)  WHO recommended  in choosing between these schedules, health practitioner of every countries need to consider a few factors such as the age distribution for pneumococcal disease, likely vaccine coverage and also the timeliness of the vaccine doses.  If 3p+0 is used, it can be initiated as early as 6 weeks of age with interval between doses of 4-8 weeks, for example at 6,10 and 14 weeks or at 2.,4 and 6 months  If 2p+ 1 scheduled is selected, the 2 primary doses should be completed by 6 month of age  It can be started as early as 6 weeks of age with intervals of 8 weeks or more between the doses. In infants  aged  more and equal 7 months of ages, minimum of 4 weeks interval between the next dose is acceptable  One booster dose should be started between 9 – 15 months of age For unvaccinated older children aged 12 -24 months and children aged 2-5 years old who are at high risk pf pneumococcal disease  Two catch up doses at an interval of at  least 8 weeks may be given

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Recommended schedule for use of 13-valent pneumococcal conjugate vaccine (PCV 13) among previous unvaccinated infants by age of time of first vaccination

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Recommended schedule for administering doses of 13-valent pneumococcal conjugate vaccine(PCV-13)  to children aged < 24 months by vaccination history and aged.

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Risk Group Condition  Children 2 through 5 Years Old with Certain Medical Conditions Immunocompetent children Chronic heart disease* 2 doses of PCV13 if they are unvaccinated or received an incomplete PCV13 series with <3 doses.  Give the second dose at least 8 week interval from the first dose. Give 1 dose of PCV13 if they received 3 doses of PCV13 but none were given after 12 months of age. Give 1 dose of PPSV23 at least 8 weeks after the PCV13 series is complete. Chronic lung disease † Diabetes mellitus Cerebrospinal fluid leaks Cochlear implant Children with immunocompromising conditions HIV Infection Give 2 doses of PCV13 if they are unvaccinated or received an incomplete PCV13 series with <3 doses. Give the second dose at least 8 weeks after the first. Give 1 dose of PCV13 if they received 3 doses of PCV13 but none were given after 12 months of age. Give 2 doses of PPSV23 after the PCV13 series is complete. Give the first dose at least 8 weeks after any prior PCV13 dose, then give the second dose of PPSV23 at least 5 years after the first PPSV23 dose. Diseases associated with immunosuppressive drugs or radiation therapy, including malignant neoplasms, leukemias, lymphomas and Hodgkin disease; or solid transplantation Chronic renal failure and nephrotic syndrome  Congenital immunodeficiency Sickle cell disease and other hemoglobinopathies, congenital or acquired asplenia or splenic dysfunction

*particularly cyanotic congenital heart disease and cardiac failure †  Including asthma if treated with high-dose oral corticosteroid therapy.

https://www.cdc.gov/vaccines/vpd/pneumo/hcp/who-when-to-vaccinate.html

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Risk Group Condition  Children 6 through 18 Years Old with Certain Medical Conditions Immunocompetent children Chronic heart disease* Give 1 dose of PPSV23 (if not already given earlier in childhood). Chronic lung disease † Diabetes mellitus Cerebrospinal fluid leaks Give 1 dose of PCV13 if they have not received any doses of PCV13. Administer PCV13 before giving any recommended doses of PPSV23. Give 1 dose of PPSV23 (if not already given earlier in childhood) at least 8 weeks after PCV13. Cochlear implant Children with immunocompromising conditions HIV Infection Give 1 dose of PCV13 if they have not received any doses of PCV13.  Administer PCV13 before giving any recommended doses of PPSV23. Ensure the child receives 2 doses of PPSV23. The first dose of PPSV23 should be given at least 8 weeks after any prior PCV13 dose,. The second dose of PPSV23 should be given at least 5 years after the first dose of PPSV23. Diseases associated with immunosuppressive drugs or radiation therapy, including malignant neoplasms, leukemias, lymphomas and Hodgkin disease; or solid transplantation Chronic renal failure and nephrotic syndrome  Congenital immunodeficiency Sickle cell disease and other hemoglobinopathies, congenital or acquired asplenia or splenic dysfunction

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NATIONAL IMMUNISATION SCHEDULE
Vaksin
Vaccine
Bacille Calmette-Guerin, BCG
( Tuberculosis)
Omur (Bulon)/Age (Months)
6
Tohun/ Year
18
21
7
13
15
ooo
Tetanus. Pertussis/Botuk
Hepatitis B & Haemophilus B)
Campak (Sabah Sahaia)
Measles (Sabah Only)
Campak/ Measles,
Beguk/Mumps & Rubella. MMR
Human Papillomavirus, HPV
(Perempuan Sahaia/GirIs Only)
Japanese Encephalitis, JE
(Sarawak Sahaia/ Sarawak Only)

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Polysaccharides vaccine  Conjugate vaccine  Contain polysaccharides  antigen  Contain polysaccharides antigens covalently bind to a carrier protein  Polysaccharides: a type of vaccine composed of long chain of sugar molecules that resembles the surface of certain types of bacteria in order to help the immune system mount a response Conjugate vaccine   a type of vaccine that joins a protein to an antigen in order to improve the protection that the vaccine provides  T- cell independent  immunoresponse   T- cell dependent  immunoresponnsive Stimulate B cells to produce antibodies  Stimulate T cells to help B cells produce antibodies and generate immune memory  Provide improved immunological response Prevent nasopharyngeal carriage  PPV23 , Pneumo  23, IM, SC  PCV13, Prevnar, IM  Proven efficacy against invasive pneumococcal diseases (50% to 80%0 No  hyporensposive   effect Polysaccharides vaccine can be only be used for children aged 2 years or older and adults  Can be used in all ages, including infants and children under 2 years of age.

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Growing resistant of  S. pneumonia   towards  commonly used antibiotic such as penicillin, cephalosporin, macrolides and fluoroquinolones is the new normal in hospital setting. This scenario underlines the urge to used vaccine as prevention of pneumococcal disease in order to curb its . Based on CDC recommendations the choice of vaccine to be given depends on a few criteria which are the patients ages > 65 years or younger, patient clinical conditions and history of vaccination. ACIP recommended all adults over age of 65 receive both PCV13  and PPSV23  The ACIP recommendation for routine vaccination with PCV13 and the vaccination schedules for infants and toddlers through age 59 months who have not received any previous PCV7 or PCV13 doses. PCV13 is recommended as a 4-dose series at ages 2, 4, 6, and 12--15 months with no history of previous vaccination.

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World Health Organization.  Introduction of pneumococcal vaccine PCV10, two dose presentation: a handbook for district and health facility staff . No. WHO/IVB/13.09. World Health Organization, 2013. Prevention of pneumococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR  Recomm  Rep. 1997 Apr 4;46(RR-8):1-24. PMID: 9132580. Pneumococcal Vaccine Recommendations  page last reviewed: August 7, 2020 source availab l e at:  https://www.cdc.gov/vaccines/vpd/pneumo/hcp/who-when-to-vaccinate.html   Nuorti , J.  Pekka , and Cynthia G. Whitney. "Prevention of pneumococcal disease among infants and children: use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine: recommendations of the Advisory Committee on Immunization Practices (ACIP)." (2010). Matanock ,  Almea , et al. "Use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine among adults aged≥ 65 years: updated recommendations of the Advisory Committee on Immunization Practices."  Morbidity and Mortality Weekly Report  68.46 (2019): 1069.  Pneumococcal conjugate vaccine in children below 5 years old source available at:  https://www.moh.gov.my/moh/resources/auto%20download%20images/587f11568fcaa.pdf   Pneumococcal Vaccination: Summary of Who and When to Vaccinate source available at:  https://www.cdc.gov/vaccines/vpd/pneumo/hcp/who-when-to-vaccinate.html