Effects of a large-scale intervention with influenza and 23-valent pneumococcal vaccines in elderly people: a 1-year follow-up

doi:10.1016/S0264-410X(03)00296-2

Vaccine

Volume 21, Issues 25–26, 8 September 2003, Pages 3906-3911

https://doi.org/10.1016/S0264-410X(03)00296-2 Get rights and content

Abstract

To assess the effectiveness of influenza and pneumococcal vaccination in reducing hospitalisation and deaths in elderly people, the population aged ≥65 years in Stockholm County, Sweden ( $n=259 627$ ) were invited to take part in a vaccination campaign with influenza and 23-valent pneumococcal vaccine (PV). A no. of persons (100 242) (vaccinated cohort) were vaccinated with one or both vaccines during the campaign. The incidence of hospital admissions during 1 year after the vaccination campaign, adjusted for sex and age, was significantly lower in the vaccinated than in the unvaccinated cohort for influenza (relative risk [RR] 0.68), pneumonia (RR 0.78), and invasive pneumococcal disease (RR 0.46). In the vaccinated cohort, the in-hospital mortality was lower for pneumonia (RR 0.55), COPD (RR 0.53) and cardiac failure (RR 0.72).

Introduction

Influenza and pneumococcal diseases continue to cause mortality and serious morbidity in elderly persons, especially in those with underlying chronic medical conditions [1], [2], [3]. However, the use of influenza and pneumococcal vaccines (PV) has been limited in many countries. Persistent uncertainties about the benefits of vaccination may contribute to the under-use of these vaccines [1]. A prospective randomised trial [4] has shown that influenza vaccination lowers the risk of clinically diagnosed and laboratory-confirmed influenza in elderly individuals, but the ability of the vaccine to reduce the risk for more severe disease requiring hospital admission has been shown only in case-control and retrospective cohort studies [3], [5], [6], [7], [8].

There is strong evidence that pneumococcal vaccine is effective in prevention of invasive pneumococcal disease. A 50–70% effectiveness of PV in prevention of invasive pneumococcal disease in elderly people has been shown in case-control studies [9], [10], [11] and in an indirect cohort study [12]. In contrast, previous prospective studies have provided inconclusive evidence for the benefits of pneumococcal vaccination in reducing hospitalisations for pneumonia and death in adults including the elderly [13], [14], [15]. However, a recently published retrospective cohort study [16] showed that pneumococcal vaccination of elderly people with chronic lung diseases was associated with fewer hospital admissions for pneumonia and fewer deaths. This protective effect was additional to that of influenza vaccination.

In Sweden, the costs of influenza and pneumococcal vaccines have not been reimbursed, and the vaccination rate has been low. Influenza vaccination is recommended, and pneumococcal vaccination should be considered for people aged 65 years or older according to the Swedish National Board of Health and Welfare.

To assess the effectiveness of influenza and pneumococcal vaccination in reducing hospitalisation and deaths, we performed a prospective intervention study of the elderly population in Stockholm County. All individuals in Stockholm County aged 65 years or older were invited to take part in a vaccination campaign against influenza and pneumococcal infection during 3 consecutive years, 1998–2000. An early interim analysis indicated that the incidence of hospital admission was lower in the vaccinated than in the unvaccinated cohort for influenza, pneumonia, and invasive pneumococcal disease [17]. Also the total mortality was lower in vaccinated than in unvaccinated individuals.

In this paper, we have analysed the incidence of hospital admissions and deaths due to influenza, pneumonia, invasive pneumococcal disease, cardiac failure and chronic obstructive pulmonary disease during the first 12 months observation period after vaccination, 1 December 1998, through 30 November 1999, and compared the incidences of hospital admissions and deaths between the vaccinated individuals and unvaccinated individuals that served as controls. We also studied the total mortality in the two cohorts. In addition, the analysis includes a comparison between the first 6 months of the observation period, when influenza virus was circulating in the community and the last 6 months, without influenza virus in the community, making it possible to estimate the efficacy of the pneumococcal vaccine separately. The aim of the study was to investigate prospectively the health effects of a large-scale programme of vaccination of individuals aged 65 years or older.

Section snippets

Study population

This cohort study was conducted in Stockholm County, which had a population of 1 783 440 inhabitants on 1 January 1998. All 259 627 people aged 65 years or older (born in 1933 or earlier) were invited by a personal letter to receive, at reduced cost, influenza and pneumococcal vaccines during 8 weeks between 22 September and 13 November 1998. Additionally, the campaign was advertised in the daily papers and on posters at general practitioners’ offices and pharmacies. General practitioners did most

Demographic data

A no. of individuals (100 242) (39% of the target population) were vaccinated during the 8 weeks vaccination campaign. Of these, 76 177 had both vaccines, 23 224 had only the influenza vaccine, and 841 had only the pneumococcal vaccine. Table 1 shows the distribution of the study population by age group and vaccination status. The proportion of individuals that were vaccinated was lowest among persons less than 70 years of age, and persons above 84 years of age. By multiplying the median age with

Discussion

This is, to our knowledge, the largest prospective cohort study performed of the effectiveness of influenza and pneumococcal vaccination in reducing hospitalisation and deaths among elderly individuals. Our findings strongly suggest that influenza and pneumococcal vaccination of the elderly reduces hospital admissions for influenza, pneumonia, invasive pneumococcal disease, and also reduces mortality related to these diseases, their complications, and death from all causes. Our results agree

Acknowledgements

Financial supported for this study was received from The Stockholm City Council, The Swedish Heart-Lung Foundation, The Swedish Society of Medicine, and Karolinska Institutet.

References (24)

K.L. Nichol
The additive benefit of influenza and pneumococcal vaccinations during influenza seasons among elderly persons with chronic lung disease
Vaccine
(1999)
Å. Örtqvist et al.
Randomised trial of 23-valent pneumococcal capsular polysaccharide vaccine in prevention of pneumonia in middle-aged and elderly people
Lancet
(1998)
I. Koivula et al.
Clinical efficacy of pneumococcal vaccine in the elderly: a randomized, single-blind population-based trial
Am. J. Med.
(1997)
B. Christenson et al.
Effects of a large-scale intervention with influenza and 23-valent pneumococcal vaccines in adults aged 65 years or older: a prospective study
Lancet
(2001)
CDC. Influenza and pneumococcal vaccination levels among adults aged ≥65 years United States, 1997. MMWR...
D.S. Fedson et al.
Clinical effectiveness of influenza vaccination in Manitoba
JAMA
(1993)
M.E. Govaert et al.
The efficacy of influenza vaccination in elderly individuals
JAMA
(1994)
J.P. Mullooly et al.
Influenza vaccination programs for elderly persons: cost-effectiveness in a health maintenance organization
Ann. Int. Med.
(1994)
K.L. Nichol et al.
The efficacy and cost effectiveness of vaccination against influenza among elderly persons living in the community
New Engl. J. Med.
(1994)
A.H. Ahmed et al.
Effectiveness of influenza vaccine in reducing hospital admissions during the 1989–90 epidemic
Epidemiol. Infect.
(1997)

D.A. Foster et al.

Influenza vaccine effectiveness in preventing hospitalization for pneumonia in the elderly

Am. J. Epidemiol.

(1992)

E.D. Shapiro et al.

The protective efficacy of polyvalent pneumococcal polysaccharide vaccine

New Engl. J. Med.

(1991)

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Effects of a large-scale intervention with influenza and 23-valent pneumococcal vaccines in elderly people: a 1-year follow-up

Abstract

Introduction

Section snippets

Study population

Demographic data

Discussion

Acknowledgements

Vaccine

Lancet

Am. J. Med.

Lancet

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JAMA

The efficacy of influenza vaccination in elderly individuals

JAMA

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Ann. Int. Med.

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New Engl. J. Med.

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Epidemiol. Infect.

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Am. J. Epidemiol.

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New Engl. J. Med.