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Sinusitis and Pneumonia Hospitalization After Introduction of Pneumococcal Conjugate Vaccine

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Sinusitis and Pneumonia Hospitalization After Introduction of Pneumococcal Conjugate Vaccine Sinusitis and Pneumonia Hospitalization After Introduction of Pneumococcal Conjugate Vaccine WHAT’S KNOWN ON THIS SUBJECT: Pneumococcal conjugated AUTHORS: Ann Lindstrand, MD, MPH,a,b Rutger Bennet, MD, vaccines (PCVs) are known to decrease invasive pneumococcal PhD,c Ilias Galanis, MSc,a Margareta Blennow, MD, PhD,d,e disease in children, but their effect on pneumonia necessitating Lina Schollin Ask, MD,d Sofia Hultman Dennison, MD,f hospitalization is more variable across study sites, and effects on Malin Ryd Rinder, MD, PhD,d Margareta Eriksson, MD, c a,g,h hospitalization for sinusitis have not been shown previously. PhD, Birgitta Henriques-Normark, MD, PhD, Åke Örtqvist, MD, PhD,i, j and Tobias Alfvén, MD, PhDb,d WHAT THIS STUDY ADDS: There was a significant decrease in aPublic Health Agency of Sweden, Solna, Sweden; Departments of b , Public Health Sciences, Division of Global Health, eClinical hospitalizations for sinusitis in children 2 years of age, and Sciences and Education, and gMicrobiology, Tumor and Cell hospitalization for pneumonia decreased in children aged ,5 Biology, Karolinska Institutet, Stockholm, Sweden; cAstrid years after sequential introduction of PCV7 and PCV13. Lindgren Children’s Hospital, and hDepartment of Laboratory Medicine, Division of Clinical Microbiology, Karolinska University Hospital, Solna, Sweden; dSachs’ Children and Youth Hospital, South General Hospital, Stockholm, Sweden; fDepartment of Otorhinolaryngology, Karolinska University Hospital, Stockholm, Sweden; iDepartment of Communicable Disease Control and abstract Prevention, Stockholm County Council, Sweden; and jDepartment of Medicine, Unit of Infectious Diseases, Karolinska Institutet, BACKGROUND AND OBJECTIVE: Streptococcus pneumoniae is a major Karolinska, Solna, Sweden cause of pneumonia and sinusitis. Pneumonia kills .1 million chil- KEY WORDS dren annually, and sinusitis is a potentially serious pediatric disease Streptococcus pneumoniae, sinusitis, pneumonia, pneumococcal that increases the risk of orbital and intracranial complications. conjugated vaccine Although pneumococcal conjugate vaccine (PCV) is effective against ABBREVIATIONS CI—confidence interval invasive pneumococcal disease, its effectiveness against pneumonia ICD-10—International Classification of Diseases, 10th Revision is less consistent, and its effect on sinusitis is not known. We com- PCV—pneumococcal conjugate vaccine pared hospitalization rates due to sinusitis, pneumonia, and empyema RR—rate ratio before and after sequential introduction of PCV7 and PCV13. RSV—respiratory syncytial virus , Drs Örtqvist and Alfvén made equal contributions to this article. METHOD: All children 0 to 18 years old hospitalized for sinusitis, Dr Lindstrand conceptualized and designed the study, carried pneumonia, or empyema in Stockholm County, Sweden, from 2003 to out data collection and analyzed the data, and drafted and 2012 were included in a population-based study of hospital registry revised the manuscript; Dr Bennet conceptualized and designed the study, carried out data collection, and reviewed and revised data on hospitalizations due to sinusitis, pneumonia, or empyema. the manuscript; Mr Galanis performed statistical analysis and Trend analysis, incidence rates, and rate ratios (RRs) were calculated reviewed and revised the manuscript; Drs Blennow, Rinder, comparing July 2003 to June 2007 with July 2008 to June 2012, ex- Eriksson, Henriques-Normark, Örtqvist, and Alfvén cluding the year of PCV7 introduction. conceptualized and designed the study and reviewed and revised the manuscript; Drs Ask and Dennison revised medical RESULTS: Hospitalizations for sinusitis decreased significantly in chil- records of the sinusitis patients and reviewed and revised the dren aged 0 to ,2 years, from 70 to 24 cases per 100 000 population manuscript; and all authors approved the final manuscript as submitted. (RR = 0.34, P , .001). Hospitalizations for pneumonia decreased sig- nificantly in children aged 0 to ,2 years, from 450 to 366 per 100 000 www.pediatrics.org/cgi/doi/10.1542/peds.2013-4177 population (RR = 0.81, P , .001) and in those aged 2 to ,5 years from doi:10.1542/peds.2013-4177 250 to 212 per 100 000 population (RR = 0.85, P = .002). Hospitalization Accepted for publication Sep 2, 2014 for empyema increased nonsignificantly. Trend analyses showed in- Address correspondence to Ann Lindstrand, MD, MPH, Public , Health Agency of Sweden, Nobels väg 18, 171 82 Stockholm, creasing hospitalization for pneumonia in children 0 to 2yearsbefore Sweden. E-mail: [email protected] intervention and confirmed a decrease in hospitalizations for sinusitis and pneumonia in children aged 0 to ,5 years after intervention. (Continued on last page) CONCLUSIONS: PCV7 and PCV13 vaccination led to a 66% lower risk of hospitalization for sinusitis and 19% lower risk of hospitalization for pneu- moniainchildrenaged0to,2 years, in a comparison of 4 years before and 4 years after vaccine introduction. Pediatrics 2014;134:e1528–e1536 e1528 LINDSTRAND et al Downloaded from www.aappublications.org/news by guest on September 28, 2021 ARTICLE Streptococcus pneumoniae is a com- less consistent, with a decrease rang- ,18 years (458 000) and 7% (144 000) mon cause of invasive infections in ing from 13% to 65% in all-cause were ,5 years old.17 Data on hospi- children, such as bacteremic pneumo- pneumonia hospitalizations in chil- talizations were collected from the 3 nia, septicemia, and meningitis, but dren.8,9 However, some studies show children’s hospitals in the county. For also of noninvasive infections such as decreased risk only in infants and in- the diagnosis of sinusitis, data were nonbacteremic pneumonia, sinusitis, creasing risk in older children.10–12 also included from the only otorhinophar- and otitis. Pneumococcal disease is To our knowledge PCV effectiveness yngeal clinic where children are treated the vaccine-preventable disease that against hospitalizations due to sinus- as inpatients in Stockholm. Children currently causes most child deaths itis in children has not been clarified 0to,18 years with the diagnoses be- worldwide. Every year 826 000 deaths previously.13–15 ing studied were hospitalized exclu- in children 1 to 59 months old are caused In Stockholm County, Sweden, PCV7 was sively in these 4 places. All children with by S. pneumoniae, corresponding to offered on a 2+1 schedule at 3, 5, and 12 ICD-10 discharge diagnosis codes J13– 7% of all deaths in this age group.1 months of age to all children born since J18 (pneumonia coded as bacterial Pneumonia makes up 90% of these July1,2007. PCV7was changedtoPCV13 pneumonia, or pneumonia unspecified), deaths.2–4 in January 2010, even for children who J86 (empyema), and J01 (sinusitis) Sinusitis in preschool children is a po- had received 1 or 2 doses of PCV7. No were included. In Sweden children with tentially serious disease because of catch-up program was implemented. sinusitis are treated as inpatients only anatomic closeness to the orbita and High coverage with the vaccine was when they have complications, either the brain. Complications include peri- reached early on, and by 2 years of age with orbital or periorbital cellulitis, or orbital and orbital cellulitis, abscesses, 96% of children born in 2008 and 98% of are in need of drainage or other surgical and meningitis. The most commonly those born in 2010 had received 3 doses procedures. isolated pathogens in pediatric sinusi- of PCV.16 We used pyelonephritis as a control tis are S. pneumoniae (30%), Haemo- The aim of this study was to evaluate the for the effect of PCV on number of philus influenzae (30%), and Moraxella impact of PCV7 and PCV13 on the in- admissions (N10.9). To control for catarrhalis (10%).5 The disease is cidence of hospitalization due to pedi- possible changes in diagnosis rou- more severe in patients infected with atric sinusitis, pneumonia coded as tines we also recorded the number of pneumococci than in those infected bacterial pneumonia, and empyema. children admitted with asthma and with H. influenzae.6 We compared hospital discharge di- obstructive bronchitis (J45.1, J20.9), Pneumococci may be divided into .90 agnoses during the 4-year periods be- respiratory syncytial virus (RSV) (J21, serotypes, depending on the structure fore and after introduction of PCV7. J20.5, J12.1), and viral pneumonia – of their polysaccharide capsules. Ef- (J09 12, except for J12.1 respiratory fl fective pneumococcal conjugate vac- METHODS syncytial pneumonia, J10.1 in uenza, cines (PCVs) targeting an increasing A retrospective population-based study and J09 H1N1) during the same time number of serotypes (PCV7, PCV10, and was performed using International period. PCV13) have been developed for chil- Classification of Diseases, 10th Revision Data on age, gender, and date of ad- dren ,2 years of age. Meta-analyses of (ICD-10) coded hospital registries to mission were recorded for all children. randomized placebo-controlled clinical identify all children hospitalized with Patients readmitted with the same di- trials in children ,2 years show that sinusitis, pneumonia, and empyema in agnoses within 30 days of discharge PCVs have a vaccine efficacy against Stockholm County between July 2003 and were excluded. The children were di- vaccine-type invasive pneumococcal June 2012. The year of introduction of vided into the age groups 0 to ,2, 2 to disease (80% [58%–90%]), radiologi- PCV7, from July 1, 2007 to June 30, 2008, ,5, and 5 to ,18 years for analysis. cally verified
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