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#217 Pneumonia Vaccine for Adults: Is the efficacy as effective as the effort?


CLINICAL QUESTION
QUESTION CLINIQUE
How effective is the pneumococcal vaccine in preventing pneumonia or other clinically important outcomes in adults?


BOTTOM LINE
RÉSULTAT FINAL
At best, pneumococcal vaccines may prevent pneumonia for an additional 1 in 55 adults and 1 in 20 COPD patients, and COPD exacerbations for 1 in 8, over ~3 yearsPneumococcal 23 polysaccharide vaccine (PPV23) prevents pneumonia for 1 in 13 long-term care residentsPneumococcal 13 conjugate vaccine (PCV13) does not decrease pneumonia. No systematic review of randomized controlled trials (RCTs) or high-quality RCTs found a reduction in mortality.   



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EVIDENCE
DONNÉES PROBANTES
 Any pneumococcal vaccine: 
  • Systematic review of 18 RCTs, 64,901 heterogeneous patients (examples HIV or long-term care) and 13 different vaccine serotypes:1 
      • Pneumonia (at 2-3 years): Vaccine 4.3%, placebo 6.2%, Number Needed to Vaccinate (NNV)=55. 
    • Systematic review of 12 RCTs, 2,171 community-dwelling COPD patients, up to 32 months:2 
      • Pneumonia: Vaccine 9.4%, control 14.3%, NNV=20. 
      • COPD exacerbations: Vaccine 48.2%, control 60.8%, NNV=8. 
      • Hospital admissions: No difference. 
    • Vaccine effectiveness appears to show greater benefit in:3 
      • Miners, soldiers, and patients from developing countries. 
      • Lower quality (example non-blinded) studies. 
  • PPV23 highest quality RCTs at 2-3 years of: 
    • Long-term care: 1,006 Japanese residents.4  
      • Pneumonia: Vaccine 12.6%, placebo 20.6%, NNV=13. 
    • ≥65 years: 778 Japanese patients.5 
      • Pneumonia: Vaccine 17.1%, control 20.9%, not statistically different. 
    • COPD: 596 Spanish patients.6    
      • Pneumonia: Vaccine 12.4%, control 13.1%, not statistically different. 
    • Previous pneumonia: 691 Swedish patients.7 
      • Pneumonia: Vaccine 18.6%, placebo 16.2%, not statistically different. 
        • Study stopped for futility. 
  • PCV13 RCT of 84,492 healthy Dutch patients ≥65 years at four years:8    
    • PneumoniaVaccine 1.8%, placebo 1.9%, not statistically different. 
  • No systematic review of RCTs or high-quality RCTs demonstrated mortality reduction. 
Context:  
  • Guidelines recommend:9,10 
    • PPV23 for: 
      • Adults ≥65 years. 
      • Long-term care residents.  
    • PPV23 booster (after five years) if: 
      • PPV23 given before 65 years. 
      • “High risk for pneumococcal diseaseExample chronic kidney/liver disease or immunocompromised. 
    • PCV13 (in addition to PPV23): 
      • Canada: Only if immunocompromised.9 
      • USFor all 65 years.10 


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Author(s)
Auteur(s)
  • Jamil Ramji BSc BSP ACPR
  • Michael R Kolber BSc MD CCFP MSc

1. Moberly S, Holden J, Tatham DP, et al. Cochrane Database Syst Rev. 2013; 1:CD000422.

2. Walters JAE, Tang JNQ, Poole P, et al. Cochrane Database Syst Rev. 2017; 1:CD001390.

3. Huss A, Scott P, Stuck AE, et al. CMAJ. 2009; 180(1):48-58.

4. Maruyama T, Osamu T, Niederman M, et al. BMJ. 2010; 340:c1004.

5. Kawakami K, Ohkusa Y, Kuroki R, et al. Vaccine. 2010; 28:7063-9.

6. Alfageme I, Vazquez R, Reyes N, et al. Thorax. 2006; 61:189-95.

7. Ortqvist A, Hedlund J, Burman LA, et al. Lancet. 1998; 351:399-403.

8. Bonten MJM, Huijts SM, Bolkenbaas M, et al. NEJM. 2015; 372:1114-25.

9. Public Health Agency of Canada. Available at: https://www.canada.ca/en/public-health/services/publications/healthy-living/canadian-immunization-guide-part-4-active-vaccines/page-16-pneumococcal-vaccine.html. Last Accessed: April 2, 2018.

10. Centers for Disease Control and Prevention. Available at: https://www.cdc.gov/vaccines/vpd/pneumo/hcp/recommendations.html. Last Accessed: April 2, 2018.

Authors do not have any conflicts of interest to declare.

Les auteurs n’ont aucun conflit d’intérêts à déclarer.