Changing the Paradigm: Vaccination as a Key Prevention Step in Daily Practice

1. Changing the Paradigm: Vaccination as a Key Prevention Step in Daily Practice Moderator Charles Feldman, MB BCh, DSc, PhD Professor of Pulmonology and Chief Physician Charlotte Maxeke Johannesburg Academic Hospital University of the Witwatersrand Johannesburg, South Africa Panelists George Kassianos, MD General Practitioner The Ringmead Medical Practice Bracknell, United Kingdom President, British Global and Travel Health Association Abdullah Sayiner, MD Professor, Department of Chest Diseases Ege University Faculty of Medicine Izmir, Turkey

2. Discuss the role of the general practitioner in pneumococcal disease prevention Identify potential risk factors for pneumococcal disease Watch a patient case scenario performed by actors Program Overview

3. 54-year-old woman with type 2 diabetes; treated with metformin Hypercholesterolemia; stable angina; BMI 27 Former smoker with family history of CVD Recently had flu vaccine Visiting her GP for an annual checkup Patient Case Scenario BMI = body mass index; CVD = cardiovascular disease; GP = general practitioner

4. All adults ≥ 65 years Infants as part of routine childhood immunization program Those < 65 years and ≥ 2 months in “at-risk” clinical groups Pneumococcal Vaccination Recommendations in the United Kingdom Salisbury D, et al. Immunisation against infectious disease. UK Department of Health; 2006. http://media.dh.gov.uk/network/211/files/2012/07/Green-Book-Chapter-25-v4_0.pdf.pdf

5. Clinical Risk Groups for Vaccination CKD = chronic kidney disease; COPD = chronic obstructive pulmonary disease Salisbury D, et al. Immunisation against infectious disease. UK Department of Health, 2006. http://media.dh.gov.uk/network/211/files/2012/07/Green-Book-Chapter-25-v4_0.pdf.pdf

6. Clinical Risk Groups for Vaccination (cont) Base your decision on clinical judgment. Give the vaccine if you feel the patient needs it. Salisbury D, et al. Immunisation against infectious disease. UK Department of Health; 2006. http://media.dh.gov.uk/network/211/files/2012/07/Green-Book-Chapter-25-v4_0.pdf.pdf

7. Smoking is associated with ≥ 50% increased risk of developing pneumococcal disease.[a] Asthmatics have at least a 2-fold higher risk for pneumococcal disease.[b] Streptococcus pneumoniae is1 of 3 core pathogens exacerbating COPD and chronic bronchitis.[c] Respiratory Comorbidities a. Baik I, et al. Arch Intern Med. 2000;160(20):3082-3088. b. Juhn YJ, et al. J Allergy Clin Immunol. 2008;122(4):719-723. c. Sethi S, et al. N Engl J Med. 2008;359(22):2355-2365.

8. Risk forIPD Increases With Age and Comorbidities Healthy vs Immunocompromised Patients Patients With and Without Comorbidities Incidence of IPD (cases per 100,000) Incidence of IPD (cases per 100,000) 300 800 700 250 600 200 500 150 400 300 100 200 50 100 0 0 18-34 35-49 50-64 65-79 > 80 18-34 35-49 50-64 65-79 > 80 Healthy Healthy Chronic heart disease Solid cancer Diabetes Hematologic cancer Age (years) Age (years) Chronic lung disease IPD = invasive pneumococcal disease Adapted from Kyaw MH, et al. J Infect Dis. 2005;192(3):377-386.

9. Respiratory Comorbidities Kyaw MH, et al. J Infect Dis. 2005;192(3):377-386.

10. Many comorbidities could be recognized by a GP or nurse. UK NHS has warning system —yellow flag attached to notes of patients with comorbidities Nurses and GPs have a duty to recognize the significance of chronic conditions and importance of pneumococcal vaccination. Patients also need to be educated so they know they are at risk. Are GPs Aware of Risks for Pneumococcal Disease? NHS = National Health Service

11. 54-year-old woman with type 2 diabetes; treated with metformin Hypercholesterolemia; stable angina; BMI 27 Former smoker with family history of CVD Recently had flu vaccine Has started walking regularly for exercise Visiting her GP for an annual checkup Patient Case Scenario (cont)

12. Very little data on incidence as most people are treated as outpatients with no microbiological diagnosis; bacteriological tests not very sensitive[a] United States—annual incidence of IPD or nonbacteremic pneumococcal pneumonia in adults ≥50 years:5.8 per 1000[b] Spain—annual hospitalization rate for pneumococcal pneumonia in adults > 50 years: 1.09 per 1000[c] Incidence of Pneumococcal Disease in Older Adults a. Werno AM, et al. Clin Infect Dis. 2008;46(6):926-932. b. Weycker D, et al. Vaccine. 2010;28(31):4955-4960. c. Gil-Prieto R, at al. Vaccine. 2011;29(3):412-416.

13. Clinical and Economic Burden of CAP Among Adults in Selected Countries in Europe Frequency of Isolation of Causative Organisms of CAP in Europe by Country CAP = community-acquired pneumonia; NR = not reported Welte T, et al. Thorax. 2012;67(1):71-79.

14. Proportion of Penicillin-Resistant (R+I) S pneumoniae Isolates in 2011 Percentage resistance < 1% 1 to < 5% 5 to < 10% 10 to < 25% 25 to < 50% ≥ 50% No data reported or less than 10 isolates Not included Liechtenstein Luxembourg Malta R+I = resistance and intermediate Source: European Antimicrobial Resistance Surveillance Systemhttp://ecdc.europa.eu/EN/ACTIVITIES/SURVEILLANCE/EARS-NET/DATABASE/Pages/maps_report.aspx

15. Pneumococcal infections are prevalent. Associated with significant morbidity and mortality, particularly in older patients and those with comorbidities Delaying treatment or using an ineffective therapy is associated with higher morbidity and mortality. Pneumococcal infections are associated with decreases in quality of life. Better to prevent pneumococcal infection than identify and treat it Pneumococcal Disease: Key Points

16. PPV Immunization Rates in Primary Care • Immunization rates rising in England: > 70% of people aged > 65 years in 2011 • Rates were much lower in those < 65 years in clinical risk groups. • Need to promote vaccination to at-risk patients PPV = pneumococcal polysaccharide vaccine UK Department of Health. Pneumococcal Polysaccharide Vaccine (PPV) Uptake Report; 2012.

17. 54-year-old woman with type 2 diabetes; treated with metformin Hypercholesterolemia; stable angina; BMI 27 Former smoker with family history of CVD Recently had flu vaccine Visiting her GP for an annual checkup Patient Case Scenario (cont)

18. Barriers to Pneumococcal Immunization • Lack of government commitment • Lack of a national media campaign • Lack of physician/nurse endorsement • Lack of vaccine reimbursement • Level of physician fee • Fear of adverse reactions • Fear of injections Burns IT, et al. J Fam Pract. 2005;54(Suppl 1):S58-S62. Rehm SJ, et al. Postgrad Med. 2010;124(3):71-79.

19. Barriers to Pneumococcal Immunization (cont) • Perception that “vaccination is for children” • Confusion with influenza vaccine • Not aware of the benefits • Individual not made aware he/she is in a group at risk • Professional apathy to vaccination Burns IT, et al. J Fam Pract. 2005;54(Suppl 1):S58-S62. Rehm SJ, et al. Postgrad Med. 2010;124(3):71-79.

20. How Can We Increase Pneumococcal Immunization Rates in Primary Care? • Encourage patients to make an appointment • Invite by letter, telephone, or text message • Invite when they contact the clinic in person or by phone • Target specific groups (eg, > 65 years) • Don’t forget the house bound • Vaccinate during the annual influenza campaign Willis BC, et al. MMWR Recomm Rep. 2005;54(RR-5):1-11.

21. How Can We Increase Pneumococcal Immunization Rates in Primary Care? (cont) • Opportunistic • During any nurse or doctor consultation • While they are waiting at the clinic to see a doctor or nurse • When they collect a repeat prescription • When they bring a relative to the clinic • While at the clinic for cervical cytology, family planning, diabetes, COPD clinic, etc. Willis BC, et al. MMWR Recomm Rep. 2005;54(RR-5):1-11.

22. Conclusions • Pneumococcal disease is associated with considerable mortality and morbidity. • Pneumococcal disease is best managed by prevention through vaccination rather than treating it once the disease has occurred.

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