Incremental effectiveness of pneumococcal vaccine on simultaneously administered influenza vaccine in preventing pneumonia and pneumococcal pneumonia among persons aged 65 years or older

doi:10.1016/S0264-410X(99)00069-9

Vaccine

Volume 17, Issues 20–21, 4 June 1999, Pages 2493-2500

https://doi.org/10.1016/S0264-410X(99)00069-9 Get rights and content

Abstract

The effectiveness of simultaneously administered influenza and pneumococcal vaccines vs. influenza vaccine alone in preventing pneumonia, pneumococcal pneumonia and pneumococcal bacteraemia among the elderly was studied. The vaccines were offered to all persons aged 65 years or older (N=43500) living in 35 administrative districts in Northern Finland. A total of 26925 persons (62%) decided to participate. Allocation to the vaccination groups took place by year of birth (odd/even). The total follow-up of those vaccinated consisted of 38037 person years. The incremental effectiveness of the pneumococcal vaccine was −20 (95% CI −50–+10%) for pneumonia, −20 (95% CI −90–+20%) for pneumococcal pneumonia and +60% (95% CI −40–+90%) for pneumococcal bacteraemia. Thus the pneumococcal polysaccharide vaccine did not offer any additional protection from pneumonia among elderly people in Finland although it reduced the incidence of bacteraemia.

Introduction

A large group of people, including those with various chronic conditions and those aged 65 years or older, have an increased risk of contracting influenza and its complications, including pneumococcal infection [1], [2], [3]. Despite the risk, the use of pneumococcal vaccine has been minimal in European countries [4]. Pneumococcal vaccine has not generally been recommended for the elderly, nor has it been included in national immunisation programmes [4], [5].

The limiting factor for giving recommendations is obviously the paucity of published data on the effectiveness of vaccine against pneumococcal pneumonia among elderly people. The 50–100% efficacy observed in cohort studies among young persons living in circumstances associated with a high attack rate of pneumococcal pneumonia [6], [7] cannot be directly applied to a nonepidemic situation among elderly people. There is, furthermore, little data on the incremental effectiveness of pneumococcal vaccine over influenza vaccine alone. Our own experience confirms the findings of previous studies that simultaneous administration of these two vaccines does not significantly affect the immunogenicity of either, nor does it increase the number of adverse reactions or their seriousness [8], [9], [10].

We present here our findings on the incremental effectiveness of pneumococcal vaccine in preventing pneumococcal pneumonia among 26925 persons aged 65 years or older who received either influenza and pneumococcal vaccine or only influenza vaccine.

Section snippets

Subjects and methods

All persons aged 65 years or older living in 23 administrative districts in northern Finland (cohort I, N=20640) were offered either influenza and pneumococcal vaccines or influenza vaccine alone in autumn 1992, and this was extended to a further 12 districts (cohort II, N=22860) in 1993. The vaccines were administered at the local health centres by the regular staff. Contraindications were, as usual, hypersensitivity to any component of the vaccines or an acute illness with fever. Terminally

Ethical aspects

Participation was voluntary for all health centres and vaccinees. The decision to participate was made at each health centre by its administration after discussion with other staff. The protocol was approved by the Ethics Committee of the Faculty of Medicine of the University of Oulu and by Oulu Municipal Health Centre. Permission to use data in the national registers was given by the Ministry of Social Affairs and Health, the National Research and Development Centre for Welfare and Health and

The vaccination groups

The total number of persons enrolled was 26,925 (Table 1). In autumn 1992 (cohort I) 4973 persons received influenza vaccine and 4902 both influenza and pneumococcal vaccine (47.8% of those aged 65 years or older living in the districts concerned). The corresponding figures for cohort II in autumn 1993 were 7972 and 9078 (74.6% of those aged 65 years or older living in those districts). Within each cohort the two vaccination groups were similar in their distribution by sex and age and in their

Discussion

No evidence of any incremental effectiveness of the 23-valent pneumococcal polysaccharide vaccine given together with influenza vaccine in preventing pneumonia was observed over the protection afforded by the influenza vaccine alone. The result is concordant with those of several previous studies with pneumococcal vaccine in this age group [18], [19], [20], whereas a protective effect was found among nursing home residents in France [21] and in a subgroup of patients with an increased risk of

Conclusion

This study did not point to any incremental protective effectiveness against pneumonia attributable to pneumococcal vaccine over influenza vaccine alone. The size of the population, 38,000 person years of follow-up, was nevertheless insufficient to exclude the possibility of a protective effectiveness of 20% or less. Efficacy rate is a critical point, when calculating the cost effectiveness of pneumococcal vaccine, in that a decrease in efficacy from 100 to 40%, for example, would increase the

Acknowledgments

This study was supported by grant 8474 from the Academy of Finland. The vaccines, together with a grant which made the serological diagnoses possible, were donated by Pasteur–Mérieux, Serums and Vaccins, Lyon, France. We wish to thank Reijo Pyhälä (KTL, Helsinki) for the data on influenza seasons, Juhani Eskola (KTL, Helsinki) and Camilla Jokinen (Kuopio University Hospital) for their critical reading of the manuscript and Riitta Lehtola, Aili Hökkä and Sirpa Raiskio (KTL, Oulu) for their

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Incremental effectiveness of pneumococcal vaccine on simultaneously administered influenza vaccine in preventing pneumonia and pneumococcal pneumonia among persons aged 65 years or older

Abstract

Introduction

Section snippets

Subjects and methods

Ethical aspects

The vaccination groups

Discussion

Conclusion

Acknowledgments

Am J Med

Serodiagn Immunother Infect Dis

J Infect

Lancet

Am J Med

Lancet

Lancet

Survey of underlying conditions of persons hospitalized with acute respiratory disease during influenza epidemics in Houston, 1978–1981

Am Rev Respir Dis

An outbreak of multidrug-resistant pneumococcal pneumonia and bacteremia among unvaccinated nursing home residents

N Engl J Med

Pneumococcal vaccination in the US and 20 other developed countries, 1981–1996

Clin Infect Dis

Suositus pneumokokkirokotteen käytöstä

Suom Lääkäril

Prevention of pneumococcal pneumonia by immunization with specific capsule polysaccharides

J Exp Med

Prevention of pneumococcal pneumonia by vaccination

Trans Assoc Am Physicians

Pneumococcal vaccine: dose, revaccination, and coadministration with influenza vaccine

Proc Soc Exp Biol Med

Simultaneous administration of influenza and pneumococcal vaccines

JAMA

Reactions following administration of influenza vaccine alone or with pneumococcal vaccine to the elderly

Arch Int Med

Antibody response to pneumococcal polysaccharide vaccine in the elderly

J Infect Dis

Epidemiology of invasive Streptococcus pneumoniae infections in adults in Finland

Epidemiol Infect

Calculating confidence intervals for relative risks, odds ratios and standardised ratios and rates