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Vaccines for Pneumonia

Steven Black, MD

Professor of Pediatrics

Center for Global Health

University of Cincinnati Children’s Hospital

Cincinnati, Ohio USA


QUESTION

Which of the following is NOT a significant

causes of pneumonia in children

a. Pertussis

b. Measles

c. Pneumococcus

d. Hib

e. Influenza

f. Diphtheria


Why Pneumonia

In 2008:

18% of child deaths

globally are due to

pneumonia, more than

any other single cause

24% in children 1-59

months

10% in children


Why Pneumonia

MDG 4:

Reduce by two thirds,

between 1990 and

2015, the under-five

mortality rate

WHO CHERG estimates, R Black et al Lancet 2010


Vaccine Preventable Causes of

Pneumonia

• Streptococcus pneumoniae

• Haemophilus influenza type b

• Pertussis

• Influenza

• Measles


Streptococcus pneumoniae

(pneumococcus)

• Gram-positive encapsulated diplococcus

(found in pairs)

There are >91 serotypes

– 46 Serogroups: 1, 2, 3, 4, 5, 6, 7…

– Some have sub-types: 6, 9, …

• Serotypes 6A, 6B, 6C

• Serotypes 9A, 9F,9L, 9N, 9V

• Normal inhabitant of nasopharynx

• Some episodes of colonization lead to

disease

Polysaccharide capsule

Serotype 19F; Photograph by Rob Smith


Pneumococcal Invasive Disease

Cellulitis

Meningitis

Epidural Abscess

Brain Abscess

Soft Tissue Infection

PNEUMONIA

Purulent Pericarditis

Endocarditis

Osteomyelitis

Peritonitis

Septic Arthritis


Distribution of SP Deaths by Syndrome

Children < 5 years


Deaths per 100,000 persons

Invasive Pneumococcal Disease:

US Deaths

http://www.cdc.gov/ncidod/db

md/abcs. Accessed January

2000.

12

10

8

6

4

2

0

65

Age (years)


Higher Risk of Invasive Pneumococcal Disease

in Developing Countries

Children < 5 years old

The Gambia (IP)

Kenya

US/AUS

Pre-vaccine era

0 100 200 300 400 500 600

Rate per 100,000


Pneumococcal Mortality Rate, year 2000*

(children under age 5)

Deaths per 100,000 children

under age 5

Source: O’Brien, Lancet 2009;374: 893-902


Diagnosis of Pneumococcal Disease

Poor Sensitivity

Gold standard: Culture of organism from a body fluid

Challenges:

• Organism factors

– fastidious growth requirements

– sensitive to environment

• Clinical

– Specimen collection challenges (lumbar puncture, lung taps)

– 10% of pneumonias are bacteremic

• Laboratory

– specimen handling, transport, special media

• Access to health care

– antibiotic use before presentation

– death at home


Specimen collection & handling challenges:

Issues of tests requiring viable organisms

Specimen

transport

Specimen volume

Culture time

Specimen

contamination

13


Top 20 Global Serotypes*

in Children


Pneumococcal Vaccine Development:

1911-1930’s

Whole Cell Pneumococcal

South African goldminers

Sir Almroth Wright, Lister, others

Efficacy not clearly established

1927-1985

Polysaccharide Vaccines

1930’s: sulfonamides

1938: penicillin in use

1960’s: pen resistance in pneumo

1927: PS immunogenic mice

1930: bivalent trial, 29,000

1945: 4-valent, US military

1940’s: 6-valent, kids/adults

1975: 8-valent, sicklers

1976: 14-valent, SA goldminers

1977: 14-valent, adults

1983: 23-valent, adults

1931- 1980

Conjugate vaccine

Strategy developed

1987-2002

Conjugate vaccines

1931: type 3 Spn-horse serum

1987: Hib conjugate

2000: PCV

2002: MCV


Pneumococcal Conjugate Vaccines:

= 7-13 different vaccines combined

4

6B

9V

19F

14

18C

23F


Currently Licensed

Pneumococcal Vaccines

Vaccine

Year

Licensed

23-valent Polysaccharide 1983

7-valent conjugate 2000

10-valent conjugate 2009

13-valent conjugate 2010

Children


Limitations of Polysaccharide vaccines can

be overcome by conjugation technology

Property

Polysaccharide Conjugate

T-cell-dependent immune response No Yes

Immune memory No Yes

Lack of hyporesponsiveness No Yes

Booster effect No Yes

Long-term protection No Yes

Reduction of carriage No Yes

Herd immunity No Yes

Immunogenic in young infancy No Yes

Granoff DM, et al. In: Plotkin SA, ed. Vaccines. 4 th ed. Philadelphia: W.B. Saunders Co; 2004


Serotypes in conjugate vaccines

Formulation 1 3 4 5 6A 6B 7F 9V 14 18C 19A 19F 23F

PCV-7

PCV-10

PCV-13

Serotype included

in the vaccine

Serotype eliciting

cross-protection


% of IPD in children < 5 yo

Proportion of regional IPD represented

by serotypes in vaccine formulations

100%

90%

80%

70%

60%

50%

40%

PCV7

PCV10

PCV13

30%

20%

10%

0%

Africa Asia Europe Latin

America and

Caribbean

North

America

Oceania

Global


Cases per 100,000

Rates of invasive pneumococcal disease

among children


PCV Efficacy Meta-analysis

Endpoints

Vaccine Efficacy (95% CI)

Vaccine-type IPD 80% (58%, 90%)

All IPD 58% (29%, 75%)

Chest x-ray confirmed pneumonia 27% (15%, 36%)

Clinical pneumonia 6% (2%,9%)

Lucero, Cochrane Database of Systematic Reviews, 2009.


Reduction in invasive pneumococcal

disease, vaccine serotypes

U.S. , < 5 yo

UK,


Estimated IPD Cases Prevented Among All Ages,

United States 2001-2009

280,000 cases & 19,000 deaths prevented

Pilishvili JID 2010 & CDC unpublished


PCV Effect on Pneumococcal Carriage Among

Healthy Children (Randomized Trials)

Author

Conjugate

valence

Site

Age (mo) at

vacc.

VT

NVT

Dagan OMPC-7 Israel 12 – 18

Dagan D-4, T-4 Israel 2, 4, 6

No Change

No Change

Obaro CRM-5 Gambia 2, 3, 4

Kristinsson D-8, T-8 Iceland 3, 4, 6

Mbelle CRM-9 S. Africa 1.5, 2.5, 3.5

Edwards CRM-9 U.S. 2, 4, 6, 12

Dagan D/T-11 Israel 2, 4, 6, 12

Dagan CRM-9 Israel 12 – 35 (DCC)

No Change

O’Brien CRM-7 Am. Ind. 2, 4, 6, 12

Kilpi CRM-7 Finland 2, 4, 6, 12


Pneumonia


Gambia 9v-PCV Trial

•> 17,000 children

•Efficacy against:

• Pneumonia

• Invasive disease

• Mortality

Reduced All-Cause

Mortality by 16%

27


Poland, < 2 yo

Reduction all cause pneumonia

hospitalization

Uruguay, < 15 yo

U.S., < 2 yo

U.S., < 2 yo

Australia, < 2yo

U.S., < 2 yo

U.S.,


PCV7 Reduces Pneumonia

Admissions (2004)

65% 73%

39%

30%

17%

26%

41,000 pneumonia admissions

averted among < 2 yo

Grijalva Lancet 2007;369:1179-86.


Efficacy of PCV9 in Reducing

Virus-Associated Pneumonia Hospitalizations

Clinical Diagnosis

Vaccine

(n=18,245)

Placebo

(n=18,268)

Any identified virusassociated

pneumonia

160 231

Influenza A 31 56

RSV 90 115

PIV types 1-3 24 43

Efficacy

(95% CI) p-value

31%

(15, 43)

45%

(14, 64)

22%

(-3, 41)

44%

(8, 66)

0.0004

0.01

0.08

0.02

31% of pneumonia admissions associated with respiratory viruses

in children were prevented

Madhi SA. Nat Med. 2004;10:811-813

Klugman KP. NEJM. 2003; 349:1341-1348

*per protocol analysis in all children (HIV-uninfected, HIV-infected, and HIV status unknown)


What about replacement


Cases per 100,000

Rates of invasive pneumococcal disease

among children


Secular trends in Spain

Spain: temporal trends of

serotypes that were (a) included

and (b) the most prevalent

serotypes not included in PCV7

among invasive isolates, 1979

to 2007

Some “replacement” strains

were increasing in prevalence

years prior to PCV introduction

in 2001

Fenoll et al. J Clin Micro 2009; 47: 1012-1020


% of all IPD in children < 5 yrs

Single Clonal Expansion of S. pneumoniae Serotype 19A in

Korean Children Before PCV7 Introduction

25

20

23

• All 19A isolates were MDR

• All isolates from 2001 exhibited

Sequence Type (ST) 320

15

10

5

0

8

0

1991-1994 1995-1999 2000-2006

Year

A dramatic increase in rates of IPD

caused by antibiotic-resistant

serotype 19A

can occur without vaccination

Choi et al, 45 th IDSA abstract #202, 2007


Despite rise in non-vaccine-type

disease, overall rates of

pneumococcal disease remain

significantly lower after vaccine

introduction


PCV Introduction 2011









Multiple studies in developed countries


Pneumococcal Summary

• Pneumococcal conjugate vaccine impact

– IPD

• elimination of vaccine serotypes among all

ages

• Small increase in non-vaccine types, especially

19A

• Reduction in overall pneumococcal IPD

– Pneumonia

• Impact more difficult to measure

• Likely reduced in pediatric and some adult age

groups

• Future issues

– Common protein vaccines

– Reduced dose schedules


Vaccine Preventable Causes of

Pneumonia

• Streptococcus pneumoniae

• Haemophilus influenza type b

• Pertussis

• Influenza

• Measles


Haemophilus influenza type b

• Difficulty in culture identification has led to

underestimation of disease burden.

• Most common clinical presentation is

meningitis, but can cause epiglottitis, sepsis

and pneumonia.

• Children less than five years of age at the

highest risk.


Haemophilus influenza type b

The Gambia Efficacy Trial


Randomised trial of Haemophilus influenzae type-b tetanus protein conjugate for prevention of pneumonia and meningitis in

Gambian infants. Kim Mulholland et al Lancet 349, 1997.


Haemophilus influenza type b

The Gambia Efficacy Trial


Randomised trial of Haemophilus influenzae type-b tetanus protein conjugate for prevention of pneumonia and meningitis in

Gambian infants. Kim Mulholland et al Lancet 349, 1997.


Haemophilus influenza type b

The Gambia Efficacy Trial


Efficacy against lobar pneumonia = 25.2%

Randomised trial of Haemophilus influenzae type-b tetanus protein conjugate for prevention of pneumonia and meningitis in

Gambian infants. Kim Mulholland et al Lancet 349, 1997.


Pertussis


Pertussis

• Highly contagious respiratory infection caused by

Bordetella pertussis

– Fastidious gram-negative bacteria

– Antigenic and biologically active components:

• pertussis toxin (PT)

• filamentous hemagglutinin (FHA)

• agglutinogens

• adenylate cyclase

• pertactin

• tracheal cytotoxin

• Outbreaks first described in 16th century

• Bordetella pertussis isolated in 1906

• Estimated 294,000 deaths worldwide

in 2002


Pertussis Becomes Communicable

Before the Onset of Paroxysmal Cough 1

The clinical stages of pertussis

Reference: 1. Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine-Preventable Disease.

2007;81-100.


QUESTION

In the US, the major source of pertussis

infection in young infants is in descending

order of frequency is

a. Mothers, siblings, fathers

b. Fathers, mothers, grandparents

c. Siblings, parents, grandparents

d. Babysitters, mothers, fathers

46


Nearly 50% of Infant Pertussis

Sources Are Parents or Older Sibs 1

• In a CDC study of 774 reported cases

of infant pertussis, interviews were

conducted in 616 of the families to

determine the source of the disease

— A source was defined as a person with an acute

cough illness who had contact with the caseinfant

7 to 20 days before the infant’s onset of

cough

The source was identified for 43%

(264) of the infants with pertussis.

Within this subgroup of infants, the

known or suspected source of

pertussis was*:

*

The mother in 32% of these infant

cases

— A parent in 47% of these infant cases

— A family member in 75% of these infant

cases

Reference: 1. Bisgard KM, et al. Pediatr Infect Dis J. 2004;23:985-989.


Deaths

Pertussis Deaths by Decade USA

and Age: 1980-1989 vs 1990-1999 vs 2000-2006 1

160

140

120

100

80

60

40

20

0

0-3

mos

≥4

mos

0-3

mos

≥4

mos

0-4

mos

≥5

mos

1980-1989 1990-1999

2000-2006*

*Deaths reported by CDC were for ≤4 months of age for 2001, 2002, 2003, and 2005 and ≤3 months of age in 2000 and 2004. Data for 2006 are provisional.

1. Vitek CR, et al. Pediatr Infect Dis J. 2003;22:628-634.

2. Centers for Disease Control and Prevention (CDC). Data on file. MKT13012.


Cases

Pertussis—United States, 1980-2005

30000

25000

20000

15000

10000

5000

0

1980 1985 1990 1995 2000 2005

Year


Cases

Reported Pertussis by Age

Group, 1990-2005

18

30000

25000

20000

15000

10000

5000

0

1990 1993 1996 1999 2002 2005

Year


Pertussis Among Adolescents and Adults

• Disease often milder than in infants and children

• Infection may be asymptomatic, or may present as classic

pertussis

• Insidious onset, similar to minor

upper respiratory infection with nonspecific cough

especially in adults

• Fever usually minimal throughout course of illness

• Chronic cough is common presentation. (In China known

as “ 100 day cough”)

• Persons with mild disease may transmit the infection and

adolescents and adults often source of infection for

children

• Incubation period 5-10 days (range 4-21 days)


Disease in Adults and Adolescents

• May account for 20 - 25% of cough illness

lasting > 7 days

• Adult may be the first case in a household

• Adult disease is the prime reservoir for

transmission of B. pertussis to infants and

children


Reasons for Increase in Pertussis in the US

• Waning immunity in adolescents and adults

of parenting age

• Lack of awareness of disease in adults

resulting in unsuspected spread

• High level of contagion.

• Until recently, lack of appropriate vaccine

for use in adolescents and adults.

• Increased availability of diagnostic testing


Break the Cycle of Pertussis Susceptibility

With Tdap Booster for Adults and

Adolescents 1

•Potentially reduce

morbidity in all age

groups

•Reduce reservoir of

pertussis disease

•Potentially prevent

transmission of

pertussis disease

between adults

and adolescents,

and from adults and

adolescents

to infants

Reference: 1. Wirsing von König CH, et al. Lancet Infect Dis. 2002;2:744-750.


Adolescent and Adult

Pertussis Vaccination

• Primary objective

– protect the vaccinated adolescent or adult

• Secondary objective

– reduce reservoir of B. pertussis

– reduce incidence of pertussis in other

age groups especially infants.


ACIP Recommendations Regarding Use of

Tdap Among Pregnant Women*

• Td is generally preferred during pregnancy

• Women who have not received Tdap should receive a dose

in the immediate post-partum period

• Any woman who might become pregnant is encouraged to

receive a single dose of Tdap

• Clinician may choose to administer Tdap to a pregnant

woman in certain circumstances (such as during a

community pertussis outbreak)

• Pregnancy is not a contraindication for Tdap

*Provisional recommendations approved by ACIP June 28, 2006


Influenza

Disease Epidemiology

Prevention Strategies


Influenza Type A

The Influenza Virus

Matrix protein

Segmented

RNA genome

Neuraminidase

(NA)

Hemagglutinin

(HA)

M2 ion channel

protein

(Influenza type B

virus has a different

ion channel protein)

Infection varies with weather zone (temperate vs tropical)

and hemisphere (northern vs southern).


World Health Organization Nomenclature

for Influenza Virus 1

A/Brisbane/59/2007/(H1N1)

• A = The type of isolate: A or B

• Brisbane = Geographic location where it was isolated

• 59 = A laboratory identification number

• 2007 = The year of isolation

• H1N1 = For influenza A viruses, the subtype of HA and NA

References: 1. World Health Organization. http://www.who.int/csr/disease/influenza/recommended_

compositionFeb08FullReport.pdf. Accessed September 25, 2008. 2. Bridges CB, et al. In: Plotkin SA,

Orenstein WA, eds. Vaccines. Fifth edition. Philadelphia, Pa.: Saunders, 2008:261.


Transmission of Influenza

Viruses

• Incubation period 1

– 1-4 days

• Infectious period 1

– Adults infectious from 1 day before to 3-5 days after

symptom onset

– Young children infectious from several days before to ≥10 days

after symptom onset

– Hospitalized patients infectious for 7+ days after symptom onset 2

– Severely immunocompromised patients infectious for weeks or months after

symptom onset 1

• Transmission pathways 1,3

– Coughing and sneezing → respiratory droplets

– Direct contact with respiratory secretions from infected persons (eg, on hands

or environmental surfaces)

References: 1. CDC. MMWR. 2008;57(RR-7):4-5. 2. Leekha S, et al. Infect Control Hosp Epidemiol.

2007;28(9):1071-1076. 3. American Academy of Pediatrics. Red Book. 2006:401-411.

Image courtesy of CDC.


Antigenic Shift & Drift

Shift

• Major change, new

subtype

• Exchange of gene

segments

• Occurs in A subtypes

only

• May cause pandemic

• Example: H3N2

replaced H2N2 in 1968

Occurs infrequently

Cox NJ, Subbarao K. Lancet. 1999;354:1277–

1282.

Drift

• Minor change, within

subtype

• Point mutations

• Occurs in A and B

subtypes

• May cause epidemic

• Example: drifted

A/H3N2/Fujian circulated

vs A/H3N2/Panama

(vaccine strain) in 2003-

2004

Occurs continuously


Antigenic Shift = Pandemic

Potential

• Profound variation in hemagglutinin or neuraminidase

– reassortment of genomic material

• Influenza type A only

• New virus with novel antigenic profile

• Influenza virus transmitted

from aquatic birds (center)

directly (solid lines)

to fowl and pigs, who

transmit to humans

Diagram courtesy of Robert G. Webster, PhD.

Cox NJ, Subbarao K. Lancet. 1999;354:1277-1282.


Why Do New Influenza Strains

Tend to Originate in Asia

• Agricultural practices

•Large populations

•High Proportion of population in agriculture

• Living situations

•People live in close proximity to animals


Epidemic Influenza

Occurs Each Year


Antigenic Drift: a Modest Change

in the Influenza Virus


Influenza Has a High Annual Toll

of Disease in the United States

Hospitalizations

114,000–142,000 2

Deaths

51,203 1

Physician visits

25 million 3

Infections and illnesses

30–60 million 4

Direct medical costs

$3–$5 billion 5

1. Thompson WW, et al. JAMA. 2003;289:179-186.

2. CDC. MMWR Recomm Rep. 2003;52(RR-8):1-36.

3. Couch RB. Ann Intern Med. 2000;133:992-998.

4. Nichol KL, et al. NEJM. 1995;14:889-893

5. Patriarca PA. JAMA. 1999;282:75-77.


Persons at Highest Risk for

Influenza Disease Complications

• Aged 65 and older

• Residents of chronic care facilities

• People with

– chronic pulmonary, metabolic, or cardiovascular disorders

– renal dysfunction

– hemoglobinopathies

– immunosuppression, including HIV infection

• Children aged 6 mo–23 months

• Women who are pregnant

CDC. MMWR Morb Mortal Wkly Rep. 2001;50(RR-4):1-46.


US Burden of Influenza in Children

• Annual attack rates

– 10%-40% in the pediatric population 1

• Hospitalization


Severity of Disease in Children

• Respiratory tract complications 1,2

– Acute otitis media

– Bronchiolitis, bronchitis, sinusitis

– Severe pneumococcal pneumonia

• Nonrespiratory complications 1,2

– Myositis, myocarditis

– Staphylococcal infection or sepsis, 3 including MRSA a

– Central nervous system, including encephalitis, febrile seizures, and

Reye syndrome

• Hospitalization rates in infants and young children are comparable to

rates in elderly 3

References: 1. Bhat N, et al. N Engl J Med. 2005;353(24):2559-2567. 2. Principi N, et al. Lancet

Infect Dis. 2004;4(2):75-83. 3. CDC. MMWR. 2008;57(RR-7):6,7.


Annual average excess no. of

hospitalizations per 100,000 children

1200

1000

Hospitalization Rates in

Children


Influenza-related Deaths in Children

• 1990s: Average 92 deaths per year in children


Influenza in Pregnancy

Impact on Maternal Morbidity

Kathy Neuzel Am J of Epidemiology 148:1094-1102, 1998.

• Study included women of child bearing age (15-44 year

old) in the Tennessee Medicaid program

• Study outcomes included hospitalization for pneumonia,

influenza, other acute respiratory conditions, heart failure,

myocarditis.

• Women in their third trimester had an hospitalization rate

of 21.7 per 10,000 person-months of which 10.7 events per

10,000 person-months was directly attributable to

influenza. There were no influenza related deaths.

• Similar rates in non-pregnant women and post-partum

women were 1.16 and 1.91 respectively.

• This is a more than 9 fold increase in risk over baseline for

pregnant women with influenza.


Influenza in Pregnancy

Influenza Vaccine Safety

Flor Munoz, Paul Glezen et al. Am J Obstet and Gyn 192: 1098-1106, April 2005

• Influenza vaccine evaluated for safety in pregnancy

• Of 252 pregnancies:

– Mean gestational age at vaccination 26.1 weeks with

a range of 14-39 weeks

– No serious adverse events within 42 days of

vaccination

– No difference in pregnancy outcomes (prematurity

rate, C-section rate)

– No difference in infants outcomes to six months of

age.


Influenza Vaccination in Pregnancy

Zaman et al

N Engl J Med 2008;359:1555-64


Influenza Vaccine

CDC. MMWR Morb Mortal Wkly Rep. 2001;50(RR-4):1-46.


Timetable for Influenza Vaccine

Production in the Northern Hemisphere

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Eggs

Production of Concentrates

Need to Know

One or more

strains in

formula *

All strains precise

in formula formulation

Formulation-Testing

FDA Release

Filling-Testing

Packaging

ACIP

recommendations

for use

Distribution

Administration

*The characteristics of the strains circulating the previous season provide the basis for selecting virus strains for

the next year’s vaccine. Courtesy of the Centers for Disease Control and Prevention.

Piedra PA, presented at SHEA symposium, Philadelphia, 2004; Malhotra A et al. Pediatr Clin North Am.

2000;47:353-372; ACIP. MMWR 2003;52(RR-8):1-36; Cox NJ et al. 1999;354:1277-1282.


2008-11: Expanded US Pediatric

Influenza Recommendations

• Annual influenza vaccination now recommended for all

children 6 months-18 years of age 1

– Previous recommendation: 6-59 months of age (2006)

• Expanded immunization (children 5-18 years of age)

should begin in 2008-09 influenza season if feasible, but

no later than 2009-10 1

• Meanwhile, children 6-59 months of age, and older

children with chronic medical conditions (eg, asthma,

diabetes) should remain the focus of immunization

efforts 1

– >9.5 million children in the US


Target Groups for Influenza Vaccination 1

• All persons who want to reduce their risk of becoming ill with

influenza or of transmitting disease to others

• All children 6 months through 18 years of age

• Individuals at high risk for influenza and its complications:

– ≥50 years of age

– Residents of nursing homes and chronic-care facilities

– Persons with chronic pulmonary, cardiovascular, renal, hepatic,

hematologic, or metabolic disorders

– Immunocompromised persons

– People with conditions that compromise respiration or increase risk for

aspiration

– Women who will be pregnant during influenza season

Reference: 1. CDC. MMWR. 2008;57(RR-7):1-4, 25-28.


Target Groups for Influenza Immunization:

Caregivers and Contacts

• Persons who live with or care for persons at high risk

for influenza-related complications 1

• Health-care personnel (HCP), including trainees 1,2

• Healthy household contacts and caregivers of: 1

– children


Per 100,000 population

Influenza-related Hospitalizations and

Deaths Among the Elderly 1

Influenza-related mortality

Influenza-related hospitalizations

1400

1200

1195

1000

800

686

600

400

321

431

357.9

200

0

190

129.1

18.5 33

65.3

65-69 70-74 75-79 ≥85

Age group, years

Mortality rates are for 1976–2000; hospitalization rates are for 1979-2001.

Reference: 1. Thompson WW, et al. J Infect Dis. 2006;194(suppl 2):S82-S91.


Deaths/100,000

Influenza in the Elderly:

Comorbidities Increase Mortality 1

Death rates from influenza and pneumonia among persons

≥65 years of age: epidemics in 1968-69, 1972-73

350

300

306

250

217

200

150

100

50

0

9

None 1 ≥2

Number of high-risk conditions

Reference: 1. Barker WH, Mullooly JP. Arch Intern Med. 1982;142(1):85-89.


Measles

• • Giant cell pneumonia

do to measles has a

high mortality

• Measles can also

predispose to

secondary infection

with bacteria or other

viruses.


Conclusion

• Pneumonia is a major cause of morbidity

and mortality

• Effective vaccines exist for the

pneumococcus, Hib, pertussis, influenza

and measles.

• Significant public health gain can be

achieved by appropriate use of these

vaccines.

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