Stellungnahme zur Empfehlung der Pneumokokken-Impfung für Erwachsene

Zusammenfassung

Die Ständige Impfkommission (STIKO) empfiehlt im Gegensatz zum Advisory Committee on Immunization Practices (ACIP) und verschiedenen Fachgesellschaften den Polysaccharidimpfstoff PPSV23 anstelle des Konjugatimpfstoffes PCV13 für die Standardimpfung für Personen über 60 Jahre. PSV23 hat eine nachgewiesene Wirksamkeit gegen die Bakteriämie. Es gibt jedoch Evidenz, die gegen eine PSV23-Wirksamkeit bei der Pneumonie spricht, die in der überwiegenden Mehrzahl nicht-bakteriämisch verläuft. Für PCV13 hingegen konnte die CAPITA-Studie eine klare Effektivität von 45 % gegen (nicht-bakteriämische) Pneumonien durch die 13 Impfserotypen zeigen.

Dieses Positionspaper der Deutschen Gesellschaft für Pneumologie und Beatmungsmedizin und der Deutschen Gesellschaft für Geriatrie wertet die verfügbare Evidenz und schlussfolgert, dass die Empfehlung von PSV23 als Standardimpfung für Erwachsene nicht gerechtfertigt ist, da

i) die (nicht-bakteriämische) Pneumonie die Hauptkrankheitslast der Pneumokokken-Infektionen repräsentiert,

ii) die klinische Evidenz hinsichtlich Schutzwirkung gegen Pneumonie durch Pneumokokken für PCV13 von höherer Qualität ist als für PSV23,

iii) die Schutzwirkung nach Impfung mit PSV23 bereits nach 2 Jahren abzunehmen scheint, während eine solche Abnahme für PCV13 während der CAPITA-Studie über mindestens 4 Jahre nicht beobachtet wurde, und

iv) die nach Empfehlung der 7 valenten Konjugatvakzine für Kleinkinder beobachtete Herdenprotektion für invasive Pneumokokken-Erkrankungen nicht für PCV13 und nicht-bakteriämische Pneumonien extrapoliert werden darf.

Abstract

Currently, the German Advisory Committee on Immunization Practices recommends the pneumococcal polysaccharide vaccine (PSV23) instead oft the pneumococcal conjugate vaccine (PCV13) for standard vaccination of adults > 60 years. Whereas the efficacy of PSV23 against bacteraemia has been proven by numerous studies, there is increasing evidence that there is no efficacy against non-bacteraemic pneumococcal pneumonia. This is in contrast to PCV13, for which the CAPITA study has recently revealed an efficacy of 45 % against non-bacteraemic pneumonia by the 13 vaccine types.

In this position paper we argue that this decision is not justified by the available evidence for the following reasons:

i) the main burden of pneumococcal diseases is non-bacteraemic pneumonia

ii) the clinical evidence for the efficacy against pneumonia is of higher quality for PCV13 than for PSV23

iii) the duration of clinical efficacy PSV23 starts to decrease after 2 years, whereas this has not yet been observed for PCV13 in the CAPITA study for at least four years, and

iv) herd protection effects observed after PCV7 infant vaccination program on invasive pneumococcal disease must not be extrapolated to PCV13 and non-invasive pneumococcal diseases.

• Literatur

• 1 Torres A, Blasi F, Peetermans WE et al. The aetiology and antibiotic management of community-acquired pneumonia in adults in Europe: a literature review. Eur J Clin Microbiol Infect Dis 2014; 33: 1065-1079
• 2 Said MA, Johnson HL, Nonyane BA et al. Estimating the burden of pneumococcal pneumonia among adults: a systematic review and meta-analysis of diagnostic techniques. PLoS One 2013; 8: e60273
• 3 Ruiz-Gonzalez A, Falguera M, Nogues A et al. Is Streptococcus pneumoniae the leading cause of pneumonia of unknown etiology? A microbiologic study of lung aspirates in consecutive patients with community-acquired pneumonia. Am J Med 1999; 106: 385-390
• 4 Bella F, Tort J, Morera MA et al. Value of bacterial antigen detection in the diagnostic yield of transthoracic needle aspiration in severe community acquired pneumonia. Thorax 1993; 48: 1227-1229
• 5 Welte T, Torres A, Nathwani D. Clinical and economic burden of community-acquired pneumonia among adults in Europe. Thorax 2012; 67: 71-79
• 6 Schnoor M, Hedicke J, Dalhoff K et al. Approaches to estimate the population-based incidence of community acquired pneumonia. J Infect 2007; 55: 233-239
• 7 Pletz MW, von Baum H, van der Linden M et al. The burden of pneumococcal pneumonia – experience of the German competence network CAPNETZ. Pneumologie 2012; 66: 470-475
• 8 Ewig S, Klapdor B, Pletz MW et al. Nursing-home-acquired pneumonia in Germany: an 8-year prospective multicentre study. Thorax 2012; 67: 132-138
• 9 Pletz MW, Welte T, Klugman KP. The paradox in pneumococcal serotypes: highly invasive does not mean highly lethal. Eur Respir J 2010; 36: 712-713
• 10 Capelastegui A, Zalacain R, Bilbao A et al. Pneumococcal pneumonia: differences according to blood culture results. BMC Pulm Med 2014; 14: 128
• 11 Bordon J, Peyrani P, Brock GN et al. The presence of pneumococcal bacteremia does not influence clinical outcomes in patients with community-acquired pneumonia: results from the Community-Acquired Pneumonia Organization (CAPO) International Cohort study. Chest 2008; 133: 618-624
• 12 Lin SH, Lai CC, Tan CK et al. Outcomes of hospitalized patients with bacteraemic and non-bacteraemic community-acquired pneumonia caused by Streptococcus pneumoniae. Epidemiol Infect 2011; 139: 1307-1316
• 13 Brandenburg JA, Marrie TJ, Coley CM et al. Clinical presentation, processes and outcomes of care for patients with pneumococcal pneumonia. J Gen Intern Med 2000; 15: 638-646
• 14 Jover F et al. A comparative study of bacteremic and non-bacteremic pneumococcal pneumonia. European journal of internal medicine 2008; 19: 15-21
• 15 Sager MA, Franke T, Inouye SK et al. Functional outcomes of acute medical illness and hospitalization in older persons. Arch Intern Med 1996; 156: 645-652
• 16 Covinsky KE et al. Loss of independence in activities of daily living in older adults hospitalized with medical illnesses: increased vulnerability with age. J Am Geriatr Soc 2003; 51: 451-458
• 17 Davydow DS, Hough CL, Levine DA et al. Functional disability, cognitive impairment, and depression after hospitalization for pneumonia. Am J Med 2013; 126: 615-624
• 18 Martin-Salvador A, Torres-Sánchez I, Sáez-Roca G et al. Age Group Analysis of Psychological, Physical and Functional Deterioration in Patients Hospitalized for Pneumonia. Arch Bronconeumol 2015; 51: 496-501
• 19 Bonten MJ, Huijts SM, Bolkenbaas M et al. Polysaccharide conjugate vaccine against pneumococcal pneumonia in adults. N Engl J Med 2015; 372: 1114-1125
• 20 Andrews NJ, Waight PA, George RC et al. Impact and effectiveness of 23-valent pneumococcal polysaccharide vaccine against invasive pneumococcal disease in the elderly in England and Wales. Vaccine 2012; 30: 6802-6808
• 21 Maruyama T, Taguchi O, Niederman MS et al. Efficacy of 23-valent pneumococcal vaccine in preventing pneumonia and improving survival in nursing home residents: double blind, randomised and placebo controlled trial. BMJ 2010; 340: c1004
• 22 Huss A, Scott P, Stuck AE et al. Efficacy of pneumococcal vaccination in adults: a meta-analysis. CMAJ 2009; 180: 48-58
• 23 Jackson LA, Gurtman A, van Cleeff M et al. Influence of initial vaccination with 13-valent pneumococcal conjugate vaccine or 23-valent pneumococcal polysaccharide vaccine on anti-pneumococcal responses following subsequent pneumococcal vaccination in adults 50 years and older. Vaccine 2013; 31: 3594-3602
• 24 de Roux A, Schmöle-Thoma B, Siber GR et al. Comparison of pneumococcal conjugate polysaccharide and free polysaccharide vaccines in elderly adults: conjugate vaccine elicits improved antibacterial immune responses and immunological memory. Clin Infect Dis 2008; 46: 1015-1023
• 25 Pilishvili T, Lexau C, Farley MM et al. Sustained reductions in invasive pneumococcal disease in the era of conjugate vaccine. J Infect Dis 2010; 201: 32-41
• 26 van der Linden M, Falkenhorst G, Perniciaro S et al. Effects of Infant Pneumococcal Conjugate Vaccination on Serotype Distribution in Invasive Pneumococcal Disease among Children and Adults in Germany. PLoS One 2015; 10: e0131494
• 27 Sherwin RL, Gray S, Alexander R et al. Distribution of 13-valent pneumococcal conjugate vaccine Streptococcus pneumoniae serotypes in US adults aged ≥ 50 years with community-acquired pneumonia. J Infect Dis 2013; 208: 1813-1820
• 28 Rodrigo C, Bewick T, Sheppard C et al. Clinical features of adults with seven-valent-conjugated-vaccine-serotype pneumococcal pneumonia. Vaccine 2014; 32: 1460-1465
• 29 Simonsen L, Taylor RJ, Schuck-Paim C et al. Effect of 13-valent pneumococcal conjugate vaccine on admissions to hospital 2 years after its introduction in the USA: a time series analysis. Lancet Respir Med 2014; 2: 387-394
• 30 Pletz MW, Welte T In: Community-Acquired Pneumonia. Chalmers J, Pletz MW, Aliberti S, eds. European Respiratory Society 2014; 63: 266-285
• 31 Kim DK, Bridges CB, Harriman KH et al. Advisory committee on immunization practices recommended immunization schedule for adults aged 19 years or older--United States, 2015. MMWR Morb Mortal Wkly Rep 2015; 64: 91-92
• 32 Pilkinton MA, Talbot HK. Update on vaccination guidelines for older adults. J Am Geriatr Soc 2015; 63: 584-588