Medicine by the Numbers

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Pneumococcal Vaccines in Chronic Obstructive Pulmonary Disease

 

Am Fam Physician. 2018 Apr 1;97(7):463-464.

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PNEUMOCOCCAL VACCINES IN PATIENTS WITH COPD

BenefitsHarms

1 in 21 avoided an episode of community-acquired pneumonia

No harms were reported

1 in 8 avoided an acute COPD exacerbation

No deaths were prevented

No hospital admissions were prevented

No cases of pneumococcal pneumonia were prevented

No reduction in all-cause mortality


COPD = chronic obstructive pulmonary disease.

PNEUMOCOCCAL VACCINES IN PATIENTS WITH COPD

BenefitsHarms

1 in 21 avoided an episode of community-acquired pneumonia

No harms were reported

1 in 8 avoided an acute COPD exacerbation

No deaths were prevented

No hospital admissions were prevented

No cases of pneumococcal pneumonia were prevented

No reduction in all-cause mortality


COPD = chronic obstructive pulmonary disease.

Details for This Review

Study Population: Adults with moderate to severe chronic obstructive pulmonary disease (COPD) without previous pneumococcal vaccination

Efficacy End Points: Incidence of community-acquired pneumonia (CAP), morta lity from cardiorespirator y causes, all-cause mortality, hospital admission, and COPD exacerbation

Harm End Points: Adverse effects of vaccination

Narrative: Worldwide, COPD was the fourth leading cause of death in 2015 with exacerbations of the disease contributing to significant health care costs and decline in patient quality of life.14 Infection with Streptococcus pneumoniae is strongly associated with the development of CAP in persons with COPD. However, until recently, the benefit of vaccination against S. pneumoniae for preventing pneumonia was only studied in populations without a diagnosis of COPD.57 In this 2017 Cochrane review of 12 randomized controlled trials with 2,171 participants, the effect of pneumococcal vaccination was compared with that of a control or alternative vaccine type.

Pneumococcal vaccines had a significant effect on reducing CAP when compared with control (number needed to treat [NNT] = 21; six randomized controlled trials [RCTs], N = 1,372; odds ratio [OR] = 0.62; 95% confidence interval [CI], 0.43 to 0.89; moderate certainty evidence), but they had no effect on reducing episodes of pneumococcal pneumonia (three RCTs, N = 1,158; OR = 0.26; 95% CI, 0.5 to 1.31; low certainty evidence). A paucity of confirmed cases of pneumococcal pneumonia may contribute to the lack of evidence for pneumococcal vaccines preventing this disease.8

Pneumococcal vaccines had no significant effect on mortality from cardiorespiratory disease when compared with control (three RCTs, N = 888; OR = 1.07; 95% CI, 0.69 to 1.66; moderate certainty evidence) and had no significant effect on all-cause mortality (five RCTs, N = 1,053; OR = 1.00; 95% CI, 0.72 to 1.40; moderate certainty evidence).8

Pneumococcal vaccines reduced the number of COPD exacerbations (NNT = 8; four RCTs, N = 446; OR = 0.60; 95% CI, 0.39 to 0.93; moderate certainty evidence), but did not significantly reduce the number of hospital admissions (three RCTs, N = 391; OR = 0.74; 95% CI, 0.32 to 1.74; moderate certainty evidence).8

Caveats: Three studies did not blind their participants or use a placebo for comparison, leading to a high risk of bias. Most studies were only at moderate risk of bias because of missing information regarding methods of allocation and concealment. No data were reported comparing adverse outcomes with pneumococcal vaccines vs. standard of care. Although there was no improvement in all-cause mortality, the benefit in vaccination lies in the potential cost and manpower savings. Based on 2008 data, there were nearly 17 million outpatient and emergency department visits related to managing COPD at an estimated cost of $42.6 billion.9 Preventing even a modest number of these visits would translate to considerable reduction in the annual health care burden. The Centers for Disease Control and Prevention recommends that anyone with chronic pulmonary disease between 19 and 64 years of age should routinely receive the 23-valent pneumococcal polysaccharide vaccine (PPSV23; Pneumovax 23). At age 65 years, these patients should next receive the 13-valent pneumococcal conjugate vaccine (PCV13; Prevnar 13) if they have not previously received it, and another dose of the PPSV23 at least one year after receiving PCV13 and at least 5 years after receiving PPSV23.10 [corrected]

Author disclosure: No relevant financial affiliations.


Copyright 2018 The NNT Group (theNNT.com). Used with permission.

This series is coordinated by Dean A. Seehusen, MD, MPH, AFP Contributing Editor, and Daniel Runde, MD, from the NNT Group.

A collection of Medicine by the Numbers published in AFP is available at http://www.aafp.org/afp/mbtn.

References

show all references

1. World Health Organization. The top 10 causes of death. http://www.who.int/mediacentre/factsheets/fs310/en/. Accessed May 19, 2017....

2. Groenewegen K, Schols A, Wouters EF. Prognosis after hospitalization for acute exacerbations of COPD. European Respiratory Journal. 2001;8(suppl 33):209s.

3. Seemungul TA, Donaldson GC, Paul EA, Bestall JC, Jeffires DJ, Wedzicha JA. Effect of exacerbation on quality of life in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 1998;157 (5 pt 1):1418–1422.

4. Wedzicha JA, Donaldson GC. Exacerbation of chronic obstructive pulmonary disease. Respir Care. 2003;48(12):1204–1215.

5. File TM Jr, Monte SV, Schentag JJ, et al. A disease model descriptive of progression between chronic obstructive pulmonary disease exacerbations and community-acquired pneumonia: roles for underlying lung disease and the pharmacokinetics/pharmacodynamics of the antibiotic. Int J Antimicrob Agents. 2009;33(1):58–64.

6. Butler JC, Breiman RF, Campbell JF, Lipman HB, Broome CV, Facklam RR. Pneumococcal polysaccharide vaccine efficacy. An evaluation of current recommendations. JAMA. 1993;270(15):1826–1831.

7. Fine MJ, Smith MA, Carson CA, et al. Efficacy of pneumococcal vaccination in adults. A meta-analysis of randomized controlled trials. Arch Intern Med. 1994;154(23):2666–2677.

8. Walters JA, Tang JN, Poole P, Wood-Baker R. Pneumococcal vaccines for preventing pneumonia in chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2017;(1):CD001390.

9. Dalal AA, Shah M, D'Souza AO, Rane P. Costs of COPD exacerbations in the emergency department and inpatient setting. Respir Med. 2011; 105(3):454–460.

10. Centers for Disease Control and Prevention. Pneumococcal vaccination: summary of who and when to vaccinate. Atlanta, Ga.: December 6, 2017. https://www.cdc.gov/vaccines/vpd/pneumo/hcp/who-when-to-vaccinate.html. Accessed April 10, 2018.

 

 

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