As One Of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously?
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March, 2019 Table of Contents
02 04 06 About the Authors and Executive National Institute Reviewers Summary on Ageing
10 24 27 Background Di erent Types Who Should and Context of Pneumococcal Get Vaccinated? Vaccines
32 41 44 Vaccination Policies Improving What Are Our and Their Outcomes Vaccination Governments Doing in Canada Rates To Improve Vaccination Rates?
45 50 56 Not Enough Data Evidence- References Exists To Fully Informed Understand Recommendations Pneumococcal Disease In Canada As One of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously?
About the National Institute on Ageing
The National Institute on Ageing federal and global partnerships with (NIA) is a policy and research centre other academic centres, and based at Ryerson University in ageing-related organizations. Toronto. The NIA is dedicated to enhancing successful ageing across The NIA further serves as the the life course. It is unique in its academic home for the National mandate to consider ageing issues Seniors Strategy (NSS), an evolving from a broad range of important evidence-based policy document perspectives, including those of co-authored by a group of leading nancial, physical, psychological, researchers, policy experts and and social wellness. stakeholder organizations from across Canada and rst published in The NIA is also focused on leading October 2015. The NSS outlines four cross-disciplinary research to better pillars that guide the NIA's work to understand the issues that can lead advance knowledge and inform to the development of policies through evidence-based evidence-informed actionable research around ageing in Canada insights that can meaningfully that include Independent, contribute towards shaping the Productive and Engaged Citizens; innovative policies, practices and Healthy and Active Lives; Care Closer products that will be needed to to Home; and Support for Caregivers. address the multiple challenges and opportunities presented by Canada’s coming of age. The NIA is committed to providing national leadership in promoting a collaborative approach that also seeks to continually establish municipal, provincial,
About the National Institute on Ageing 02 National Institute on Ageing Immunization Series
Suggested Citation: National Institute on Ageing. (2019). As One of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously? Toronto, ON: National Institute on Ageing White Paper.
Mailing Address: National Institute on Ageing Ted Rogers School of Management 350 Victoria St. Toronto, Ontario M5B 2K3 Canada As One of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously?
In 2018, the NIA began looking at policy and decision-makers can adult immunizations as a part of its better understand and promote ‘Healthy and Active Lives’ pillar of policies and activities that better work, encouraging education and support wellness, prevention, and support so that Canadians, as well as overall healthy ageing.
NATIONAL SENIORS STRATEGY
INDEPENDENT, HEALTHY CARE CLOSER SUPPORT FOR PRODUCTIVE & AND ACTIVE TO HOME CAREGIVERS ENGAGED CITIZENS LIVES Provides Enables older Supports Canadians person-centered, Acknowledges and Canadians to remain to lead healthy and high quality, support the family independent, active lives for as integrated care as and friends of older productive and long as possible. close to home as Canadians who engaged members possible by providers provide unpaid care of our communities. who have the for their loved ones. knowledge and skills to care for them.
THE FOUR PILLARS SUPPORTING A NATIONAL SENIORS STRATEGY
ACCESS EQUITY CHOICE VALUE QUALITY
THE FIVE FUNDAMENTAL PRINCIPLES UNDERLYING A NATIONAL SENIORS STRATEGY
About the National Institute on Ageing 03 As One of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously?
Authors and Reviewers
The background research for this David N Fisman, MD, MPH, FRCPC report was undertaken by Julie Professor and Chair, Division of Dunning (NIA Policy Analyst) and Dr. Epidemiology Shara Nauth (NIA Junior Research Dalla Lana School of Public Health Fellow). It was written by Dr. Samir University of Toronto Sinha (Director of Geriatrics, Sinai Health System and University Health Dawn Bowdish, PhD Network; Associate Professor of M.G. DeGroote Institute for Infectious Medicine, Family and Community Disease Research Medicine, Health Policy, McMaster Immunology Research Management and Evaluation, Centre, McMaster University University of Toronto; NIA Director of Health Policy Research), Julie Dr. Natasha S. Crowcroft, Dunning (NIA Policy Analyst), Ivy MD(Cantab), MSc, MRCP, FFPH Wong (NIA Policy Director), Michael Chief, Applied Immunization Research Nicin (NIA Executive Director), and and Evaluation, Public Health Ontario Dr. Shara Nauth (NIA Junior Professor, Laboratory Medicine and Research Fellow). This report was Pathobiology and Dalla Lana School of edited by Arianne Persaud (NIA Public Health, University of Toronto Manager of Advocacy, Government Adjunct Scientist, ICES Relations and Stakeholders). Allison McGeer, MD, FRCPC We gratefully acknowledge our Medical Director, Infection Prevention contributors who provided much and Control, Sinai Health System guidance on the content and nal Professor, Laboratory Medicine and recommendations. Any opinions or Pathobiology, Dalla Lana School of errors re ected in this report are of Public Health, University of Toronto the NIA alone:
Authors and Reviewers 04 As One of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously?
Disclaimer: The NIA has developed Funding for this report was this document to provide a summary generously provided by P zer Canada of general information about the in the form of an unrestricted burden of pneumococcal disease and educational grant. All of the research, the bene t of the pneumococcal writing and recommendations herein vaccine, as well as provide have been independently produced evidence-informed recommendations by the NIA on the basis of sound to support uptake of the evidence. pneumococcal vaccine. The NIA’s work is guided by the current evidence. This document can be reproduced without permission for non-commercial purposes, provided that the NIA is acknowledged.
Authors and Reviewers 05 As One of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously?
Executive Summary
For over a decade, the Public Health breathing, coughing, fever, fatigue, Agency of Canada (PHAC) set an 80% nausea and vomiting, chest pain, target vaccination coverage rate changes in heartbeat, confusion or with the pneumococcal vaccine for delirium, and diarrhea.4 those over the age of 651 – however, estimates suggest that as of 2016, Many Canadians only 42% of Canadians had received their pneumococcal vaccination.2 At believe that they the same time the target vaccination are up-to-date coverage rate for children under the age of two was set at 95%1, and on their recommended research shows children are doing vaccinations, the reality is much better with conservative estimates suggesting 80% of quite different. In 2016, Canadian children have been 88% of Canadians vaccinated against pneumococcal disease.3 While many Canadians responding to a PHAC believe that they are up-to-date on survey reported that they their recommended vaccinations, the reality is quite di erent. In 2016, were up-to-date on their 88% of Canadians responding to a PHAC survey reported that they were vaccinations, but only 3% up-to-date on their vaccinations, but were found to be actually only 3% were found to be actually up-to-date according to Canadian up-to-date according to recommended standards.2 Canadian recommended 2 Pneumonia represents only one standards possible manifestation of It can be serious and sometimes fatal – pneumococcal disease or infection. especially for older adults, infants, and Pneumonia is a common lung young children.5 Pneumonia can be infection that can have many caused by bacteria, viruses, and more symptoms including diculty rarely by fungal infections.6
Executive Summary 06 As One of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously?
The most common cause of bacterial Pneumonia is among one pneumonia is a bacteria called Streptococcus pneumoniae.6 S. of the top ten reasons that pneumoniae can lead to a more people went to Emergency serious condition called invasive pneumococcal disease, which is Departments (ED) in when the bacteria enters parts of the Canada, with 135,000 body where it is not typically found.7 This can result in meningitis and pneumonia-related ED bacteremia.7 visits last year.11
The incidence of pneumonia Lack of availability of speci c amongst adults is highest with older diagnostic tests means that the true Canadians.8 There are increased rates burden of pneumonia across the of pneumonia in older adults when country is likely underestimated.12 compared to those under age 65, Better ways to test for and determine with residents of long-term care the cause of disease, will allow for homes having even higher rates. 9 better vaccine development but Pneumonia can be a consequence of there is a lack of good data on how in uenza infection. Together with many people are actually vaccinated. in uenza, pneumonia was the 8th In Canada, the reality is that we do leading cause of death in Canada in not actually know how many people 2016 – however, when looking at have been vaccinated. individuals 85-89 years of age it is the 7th leading cause of death and Vaccination is an e ective way to at 90 years of age it is the 6th protect against pneumococcal leading cause of death.10 disease. Vaccines help the immune system develop antibodies which Pneumonia is among one of the top protect us from getting sick when ten reasons that people went to infected with that particular bacteria Emergency Departments (ED) in or virus.13 There are two main types of Canada, with 135,000 vaccines for S. pneumoniae currently pneumonia-related ED visits last available – polysaccharide and year.11 conjugate vaccines.14,15 Polysaccharide vaccines are
Executive Summary 07 As One of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously?
recommended for healthy adults, as Based on examination of the current well as adults and children at high evidence, there is additional work to risk of invasive pneumococcal be done to improve the prevention of disease15, while conjugate vaccines pneumonia and pneumococcal disease were created to provide a stronger in Canada. immune response for children and other immunocompromised The following recommendations populations.14 provide evidence-informed policy and practice approaches that can be used In Canada, it is recommended that by health authorities and adults over 65, children, and organizations to support vaccination individuals at high-risk of developing and overall prevention across Canada. invasive pneumococcal disease are vaccinated against pneumococcal 1. Promote General Preventive disease.15 Practices in Addition to Vaccination
When children are vaccinated, the 2. Promote a Life-Course Vaccination overall rates of pneumococcal Schedule that includes Older Adults disease decrease.16 This is why it is important that children are 3. Improve Diagnosis and Surveillance vaccinated to protect themselves, of Pneumococcal Disease as well as the older adults in the population.16 4. Improve Monitoring of Pneumococcal Vaccination Rates Providers play a signi cant role in increasing vaccination rates. In order 5. Continue Working Towards to improve vaccination rates there is Developing Better Pneumococcal a need to improve education both Vaccines among the public and health care professionals as there still exists a 6. Provide Clinician Education and general lack of awareness about Support for Primary Care Providers which vaccines Canadians should and Pharmacists to Deliver receive and when. Vaccinations
Executive Summary 08 As One of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously?
7. Harmonize the Funding and Messaging for Pneumococcal Vaccinations for Target Populations Across Canada
8. Recommend the Administration of the Pneumococcal Vaccine in Conjunction with In uenza Vaccination.
9. Promote Following the Current National Advisory Committee on Immunization (NACI) Statement for Pneumococcal Vaccination
10. Consider Mandating Pneumococcal Vaccination for Residents of Long-Term Care Homes
Executive Summary 09 As One of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously?
Background and Context
Figure 1: Pneumococcal Disease12 Pneumococcal Disease
Invasive Noninvasive (mucosal)
Meningitis Bacteraemia Pneumonia Acute otitis Sinusitis media
What is Pneumonia? And Why Should We Care About It? Pneumonia versus Pneumococcal Disease
Pneumonia can be serious and, in only type of pneumococcal disease some cases, fatal. It is one of the or infection. As depicted in the leading causes of death and chart above, adapted from Ludwig hospitalizations in older adults, and et al. (2012), pneumococcal disease for adults living with chronic can cause a variety of disease conditions.17 Pneumonia can also be manifestations, including serious for infants and young pneumonia.12 Pneumococcal children.5 It is a common lung disease can be broadly separated infection that can lead to diculty into invasive and non-invasive breathing, coughing, fever or other types of illnesses.12 As depicted on symptoms.4,5 While pneumonia is the the right-hand side of Figure 1 on most common manifestation of S. page 9, pneumonia is typically pneumoniae infection, it is not the caused by a non-invasive type of pneumococcal disease.
Background and Context 10 The background research for this report was undertaken by Julie Dunning (NIA Policy Analyst) and Dr. Shara Nauth (NIA Junior Research Fellow). It was written by Dr. Samir Sinha (Director of Geriatrics, Sinai Health System and University Health Network; Associate Professor of Medicine, Family and Community Medicine, Health Policy, Management and Evaluation, University of Toronto; NIA Director of Health Policy Research), Julie Dunning (NIA Policy Analyst), Ivy Wong (NIA Policy Director), Michael Nicin (NIA Executive Director), and Dr. Shara Nauth (NIA Junior Research Fellow). This report was edited by Arianne Persaud (NIA Manager of Advocacy, Government Relations and Stakeholders).
We gratefully acknowledge our contributors who provided much guidance on the content and nal recommendations. Any opinions or errors re ected in this report are of the NIA alone:
As One of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously?
Pneumonia can be caused by bacteria, with someone who carries the viruses, and more rarely by fungal bacteria asymptomatically.7 infections.6 The most common cause of bacterial pneumonia is a bacteria When bacteria, virus or fungus called Streptococcus pneumoniae (also enters an individual’s lungs it can known as S. pneumoniae, Strep lead to pneumonia in one of the pneumo, or pneumococcus) that can lungs, or both, causing them to live in the human nose and throat.6 It become infected and in amed.4 can be transmitted through direct When the lungs are infected, it can mouth-to-mouth contact, coughing or become harder to breathe and the sneezing, or through indirect contact lungs may become lled with mucus, making it more dicult for oxygen to reach the lungs.17
What is Community-Acquired
Pneumonia (CAP)? Types of pneumonia are often classi ed based on where the disease was contracted. A community-acquired pneumonia (CAP) refers to a pneumonia that was contracted in the community – during daily activities such as going to school, work, or generally being out in the community.4,20 Healthcare-associated or hospital-acquired pneumonia (HAP) refers to a pneumonia that was contracted while in the care of a hospital or long-term care home setting, and often refers to more serious cases of pneumonia with more severe symptoms because patients are already sick to begin with and may have acquired a more virulent strain of bacterial pneumonia as well21. Walking pneumonia refers to a pneumonia where the symptoms may be quite mild and generally people with this type of pneumonia are able to function regularly and may think that they only have a cold.22
One study found that patients who had CAP had increased rates of hospitalizations and ED visits when compared to patients who never had CAP.23 The rate of mortality for CAP is still found to be highest among those over age 65.23
Background and Context 11 Funding for this report was generously provided by P zer Canada in the form of an unrestricted educational grant. All of the research, writing and recommendations herein have been independently produced by the NIA on the basis of sound evidence.
As One of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously?
Other symptoms may include: that include fever, chills, and lack of - Feeling very tired or weak alertness.18 In adults, IPD typically - Nausea and vomiting presents as something called - Chest pain – this may become ‘bacteremic pneumococcal more painful during coughing or pneumonia’, which can be a common taking a breath in complication of in uenza.7,19 IPD is - Experiencing a faster than normal more common in the very young, heartbeat older adults, and high-risk groups - Confusion or delirium in older during winter/spring months in adults countries with temperate - Diarrhea4 climates.7,15
As can be seen on the left-hand The Burden of Pneumonia in side of Figure 1 on page 9, there Canada are also invasive types of Older Canadians Are At Greatest Risk pneumococcal disease. In these cases, when bacteria enters parts of Pneumonia incidence is highest the body where it is not typically amongst older Canadians and is found, for example the expected to increase as the bloodstream or central nervous population ages.8 In 2010, there system, the patient is diagnosed were 24,761 cases of with invasive pneumococcal community-acquired pneumonia in disease (IPD).7 In children under Canada that required the age of two, IPD typically hospitalization, this number is manifests as bacteremia or expected to double by 2025 with the meningitis.7 Meningitis occurs largest increases being in adults over when the pneumococcal disease age 75.8 There are higher incidence infects the tissue that covers the rates for older adults over 65 living brain and the spinal cord that may in the community when compared to cause symptoms, including, sti those under age 65.9 The highest neck, fever, headache, eye incidence rates, however exist sensitivity to light, and confusion.18 amongst older adults living in Bacteremia is an infection of the long-term care homes.9 blood, which leads to symptoms
Background and Context 12 As One of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously?
Estimates of the annual incidence of re ects a decline in the rate of pneumonia among those over age hospitalization from 1,766 per 65 range from 2.5-4.4%.9 In 100,000 people in 2004-2005, due comparison, estimates suggest that to the growing uptake of the incidence rate for those over 65 childhood pneumonia living in a long-term care home vaccination.24 The associated ranges from 3.3-11.4% annually,9 length of stay in those 70 and over almost double the incidence rate of in 2009-2010 is 12.98 days.24 those living in the community. More speci cally, hospitalization In Canada, rates of hospitalization rates for pneumonia in individuals due to pneumonia in individuals over the age of 75 (1,303 per aged 65 and over was 1,537 per 100,000 for males and 1,003 per 100,000 people in 2009-2010.24 This 100,000 for females), is almost ve times higher than for 65-69
Figure 2: Rates of Hospitalization Due to Pneumonia - Age and Sex Standardized Incidence Rate, by Province, 20158
(cases per 100,000)
300-340
260-299
220-259 180-219 YT/NT/NU <180 335 BC NL 229 AB 273 235 SK QC 271 MB ON PE 254 211 283 NB NS 279 175
Note: Data from Quebec are not available. Sources: The Conference Board of Canada; Canadian Institute for Health Information
Background and Context 13 As One of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously?
year-olds (280 per 100,000 for males Together with influenza, and 226 per 100,000 for females) demonstrating the greater burden of pneumonia was the 8th pneumonia amongst the oldest leading cause of death members of our society.8 There are 10 limitations to this data as it only in Canada in 2016. includes hospitalized cases where This likely underestimates the number pneumonia was listed as the primary of cases because pneumonia may have diagnosis. been listed as secondary to another diagnosis and then those cases would be excluded from the rates.8 Hospitalization rates of Pneumonia - Over 75 Years Old8 One study testing for CAP and IPD in nine hospitals across ve provinces (BC, Females 1,003 per 100,000 ON, QC, NB, and NS) found that mortality was the highest for those over Males 1,303 per 100,000 age 50 in comparison to younger age groups.25 As age increased, so did the hospital length of stay.25 Pneumococcal Hospitalization rates of CAP and IPD, when compared to all-cause CAP, led to more severe 8 Pneumonia - 70-74 Years Old outcomes, including being admitted to an Intensive Care Unit (ICU), needing a Females 331 per 100,000 ventilator, developing additional complications when in the hospital, and Males 450 per 100,000 an increased 30-day mortality rate.25
In Canada, IPD is most common among Hospitalization rates of the very young and those over age 65.7 Pneumonia - 65-69 Years Old8 The incidence rate for IPD cases has remained relatively stable between Females 226 per 100,000 2009-2014, with an average of 9.6 cases per 100,000 persons per year, with
26 Males 280 per 100,000 ranges between 8.9 and 9.8.
Background and Context 14 As One of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously?
The incidence of IPD has been Estimates from CIHI declining for children, but the rates among older adults have generally suggest that there were remained stable between approximately 135,000 2009-2014.26 In 2014 in Canada, the highest incidence rates were in pneumonia-related ED adults over 60 years with rates of visits last year, a 13% 21.5 cases per 100,000 persons.26 This is compared to a rate of 16.9 per increase over the 100,000 for infants under the age of previous year.11 one.26 More than 25% of the ED visits for Together with in uenza, pneumonia pneumonia led to a hospital admission was the 8th leading cause of death for at least one night.11 in Canada in 2016.10 However, in uenza and pneumonia are the 7th Pneumonia is of particular concern leading cause of death for Canadians because it is consistently among the aged 85-89, and the 6th leading leading causes of in-hospital deaths in cause of death for Canadians aged Canada.11 Older adults accounted for 90 and older.10 In 2016, in uenza and approximately 65% of pneumonia caused 6,235 deaths, pneumonia-related admission.11 88% (5,491) of which, were Canadians over the age of 65.10 Incidence Rates of Invasive A new report from the Canadian 26 Institute for Health Information Pneumococcal Disease (CIHI) found that pneumonia was Average IPD cases 9.6 cases per 100,000 one of the top ten reasons that between 2009-2014 (ranging from 8.9-9.8) Canadians reported going to the
11 ED in 2017. Estimates from CIHI Adults over 21.5 cases per 100,000 suggest that there were 60, 2014 approximately 135,000 pneumonia-related ED visits for Infants (under 16.9 per 100,000 2017-2018, a 13% increase over the age 1), 2014 previous year.11
Background and Context 15 As One of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously?
In Ontario, S. pneumoniae remains the Public Health Agency of Canada, among the top ten most burdensome respiratory infections (including infectious diseases across the pneumonia, in uenza and other province, along with in uenza, infections) have a total indirect cost of HIV/AIDS, hepatitis C and B, and $2.8 billion.28 In this case, indirect others.27 Most of the burden costs refer to the cost of lost associated with S. pneumoniae is productivity due to illness, injury, or related to premature mortality and premature death.28 For this particular living for additional years with analysis, it did not include activities reduced functioning.27 such as the cost of unpaid caregiving to support those caring for people The Cost of Pneumonia in Canada with respiratory infections.28 Pneumonia is a costly disease, due to its associated costs of hospitalizations and other treatments.8 According to Figure 3: Pneumonia Average Cost per Case by Province, 2015 8
(C$)
16,500-19,500
13,500-16,499
10,500-13,499
7500-10,499 YT/NT/NU <7,500 7,577
BC NL 8,951 AB MB 11,197 12,671 11,692 QC PE SK ON 8,712 9,686 8,510 NS NB 10,105 9,311 Note: Data from Quebec are not available. Sources: The Conference Board of Canada; Canadian Institute for Health Information
Background and Context 16 As One of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously?
In 2012, a study from the United by 2025 the costs per case of States compared the costs per year pneumonia will range from a low of after a person was admitted to $8,689 in PEI to a high of $18,340 in hospital for pneumonia versus an Manitoba.8 This di erence in costs is admission without pneumonia and likely due to regional di erences in found approximately $15,000 the cost of services, for example, increase in costs over a year for Alberta has a higher average cost those with an index-pneumonia but they also have a higher average admission.29 The predicted hospital length of stay.8 This is in comparison cost per case by province in 2015 to the territories which have a lower was found to range from a low of cost per case, but also report a lower $8,510 in Ontario to $12,671 in length of stay.8 Alberta.8 Projections suggest that
Glossary Non-invasive pneumococcal infections: “these occur outside the major organs or the blood and tend to be less serious” (NHS, 2018) 30
Invasive pneumococcal infections: “these occur inside a major organ or the blood and tend to be more serious” (NHS, 2018) 30
Bacteremic pneumococcal pneumonia: A type of invasive pneumococcal infection more common among older adults and often times is a complication of in uenza7
Serotype: “Name given to a strain of bacteria, or other pathogen, that can be distinguished from other strains of the same species by speci c antibodies.” 31
Polysaccharide vaccine: this vaccine is made by using a capsule that surrounds the pneumococcal bacteria.13
Conjugate vaccine: this vaccine is made by taking a capsule that surrounds the pneumococcal bacteria and linking it to a protein carrier.13
Background and Context 17 As One of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously?
Who is at Higher Risk for Older Adults: Pneumonia? With ageing, the e ectiveness of the Older adults, people with chronic human immune system declines, conditions such as heart, kidney, commonly referred to as lung or liver disease, diabetes, immunosenescence.33 smokers and individuals with Immunosenescence causes older immuno-de ciencies, such as HIV, or adults to be more likely to contract transplants, are at higher risk for pneumonia and other infections and contracting pneumonia.15,32 These less likely to respond to vaccines.33 groups are also at an increased risk There have been attempts to better of complications and death.32 address the lack of vaccine-ecacy in adults over 65, including using Children, particularly those under new vaccines that have been the age of 1, are also at increased developed to address the changes in risk as their immune systems have immune function.33 Please see “The not fully matured.15 History of Pneumococcal Vaccine” box on page 24.
Figure 4: Annual Incidence of IPD cases in Canada, 30 by age groups, for the years 2009-2014
25
2009 2010 2011 2012 2013 2014 20
15 POPULATION 10 INCIDENCE RATE PER 100,000 INCIDENCE RATE 5
0 <1 1-4 5-9 10-14 15-19 20-24 25-29 30-39 40-59 60+ ALL AGES AGE GROUPS
Source: Demczuk, W.H.B., Grith, A., Singh, R., Montes, K., Sawatzky, P., Martin, I., & Mulvey, M. (2015). National Laboratory Surveillance of Invasive Streptococcal Disease in Canada – Annual Summary 2014. Retrieved from: http://www.healthycanadians.gc.ca/ publications/drugs-products-medicaments-produits/2014-streptococcus/alt/surveillance-streptococca-eng.pdf
Background and Context 18 As One of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously?
Due to physical changes in the lungs Understanding the Greater as an individual ages, including Association of Pneumonia in changes to the elasticity of the lungs People Living with Chronic and decreases in the strength of the Conditions: muscles needed to breathe, there may be a further decreased ability to Underlying Heart Conditions deal with any lung infections that may occur.9 The presence of Pneumonia (speci cally functional impairments (i.e. needing community-acquired) has been help bathing or walking), having a associated with an increased risk of low body weight, and recent weight heart failure. Individuals who have loss among older adults is also experienced a pneumonia event, are related to an increased risk of at a 12% increased risk of developing developing CAP, which may be heart failure when compared to related to frailty.34 people who did not have pneumonia.35 Eurich et al.(2017) studied patients admitted to hospital for CAP and followed them after discharge and found that those
According to Canada’s National Advisory Committee on Immunization (NACI) the following conditions put people at increased risk of both becoming infected and experiencing worse outcomes:
1. chronic heart, kidney or lung disease 2. chronic liver disease, including cirrhosis 3. diabetes mellitus 4. conditions that a ect the immune system, such as HIV 5. having your spleen removed or a spleen that does not work properly 6. sickle cell disease 7. organ or stem cell transplant 8. cochlear implants 9. neurologic conditions that may impair clearance of oral secretions15
Background and Context 19 As One of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously?
who had been hospitalized for CAP Underlying Respiratory Conditions versus those not hospitalized for CAP Individuals living with chronic had a 50% increase in ‘incident heart respiratory diseases including failure’, de ned as any heart failure chronic obstructive pulmonary admission to hospital after CAP disorder (COPD), chronic bronchitis, admission. This increased risk should and/or asthma are at increased risk be considered when aiming of CAP and IPD when compared to screening and prevention towards individuals who do not have populations with underlying cardiac respiratory diseases.32 Age matters as issues and looking for other heart well, with one UK study disease risk factors that can be demonstrating that people living modi ed.35 with COPD older than 65 were at In one study, it was found that the increased risk of developing CAP excess risk of developing CAP versus younger people living with amongst older adults was highly COPD.37 Older adults with lung related to having underlying diseases, even those not currently on congestive heart failure, when medication or oxygen, are at twice compared to those with heart the risk of developing CAP, while diseases other than congestive heart those with severe lung disease were failure.34 found to be at an eight-fold risk of developing CAP.34 In addition, being In addition, research has found that previously hospitalized for COPD patients with heart disease who have complications was associated with a in uenza will have an increased risk greater chance of developing CAP.37 of developing pneumonia, being admitted to hospital, and needing a Adults living with asthma have been ventilator.36 Due to its strong found to be more likely to have IPD connection with heart failure, there when compared to adults without is increased need to prevent asthma.38 The severity of the asthma pneumonia, which suggests that is important, with the risk of IPD both pneumococcal and in uenza becoming greater as the asthma vaccines are important, particularly severity increases.38 As such in 2014, for people at higher risk of NACI added asthma as a high-risk developing pneumonia and condition.38 Individuals who require cardiovascular conditions.35 medical attention for asthma should
Background and Context 20 As One of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously?
be given the appropriate vaccine for Other Chronic Conditions their age group.38 Individuals living with diabetes also have an increased risk of developing Cognitive Impairment C A P. 32 Diabetes has the largest One prospective cohort impact on the development of IPD study found that approximately 25% and CAP in people under the age of of patients who were hospitalized 64.32 Additionally, individuals with CAP had moderate-to-severe previously hospitalized with cognitive impairment that lasted for diabetes had an increased risk of at least a year after developing CAP developing di erent types of and approximately 33% had mild pneumonia and meningitis.41 cognitive impairment.39 Cognitive Interestingly, unlike heart failure or impairment was found in both older COPD/asthma, rates of and younger adults, many of whom pneumococcal disease in individuals were completely health y prior to with diabetes were found to be their episode of CAP.39 higher among those under the age of 60 versus those over age 60.41 Other studies have found that hospitalization for pneumonia is Obesity, de ned as having a Body associated with functional decline Mass Index (BMI) over 30, was found and a nearly 2.5 times increase in to be associated with an increased risk of developing risk of being hospitalized for moderate-to-severe cognitive respiratory diseases (including impairment.40 Similar to other pneumonia) during periods of studies, it was also found that these seasonal in uenza.42 associations are present in individuals who were only Finally, it has been found that a hospitalized once and without hospitalization for pneumonia comorbidities.40 These results are not increases the risk of developing limited to older adults who require depressive symptoms by 1.6 times.40 the most critical care.40
Background and Context 21 As One of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously?
Special Populations: infants (less than one year) was 34.6 per 100,000 compared to 19.0 per Canada has an International 100,000 adults.7 The ICS found that Circumpolar Surveillance (ICS) data in the North the results were similar collection system that collects data to Canadian national data, where about IPD in the North.43 This system infants and those over 65 have has shown that IPD remains a higher rates, however the overall signi cant cause of morbidity in rates in the North were much higher Northern Canada.43 In one particular than national rates.43 study, Indigenous populations were found to have rates 2-16 times In individuals under 5 and between higher than those of non-Indigenous the ages of 5-17 with high-risk people.43 In Manitoba, communities conditions, (including prematurity, that are socio-economically asthma, chronic heart disease, and disadvantaged and predominantly chronic lung disease), an increased Indigenous have increased rates of risk of pneumonia has been IPD.44 It has been suggested that demonstrated.47 For children higher rates of respiratory problems between the ages of 5-17 with may be related to housing conditions high-risk conditions, there is a 40 including crowding, needing repairs, fold increased rate of IPD when and compromised air quality, compared to children of the same however, additional factors must also age without these high-risk be considered.45 conditions.47 Speci cally, there were increased rates of IPD, pneumococcal pneumonia, and Children: all-cause pneumonia in
S. pneumoniae is the leading cause of immunocompetent children with invasive bacterial infections in high-risk conditions – most children, which includes meningitis, speci cally heart and lung diseases 47 bacteremia, sepsis, and pneumonia.46 including asthma and diabetes. The average age-speci c incidence rates for IPD from 2000-2011 for
Background and Context 22 As One of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously?
Polysaccharide Coating13 BACTERIUM are created against the speci c serotype or strain.48 Both of the existing pneumococcal vaccines are inactivated, which means that they do not contain a live organism so they cannot cause the disease that they are preventing against.14,48
How Do Pneumococcal Vaccines There are two main types of Protect Us? pneumococcal vaccines available: Vaccines are used to “show” the polysaccharide and conjugate immune system a bacteria or virus vaccines. See the box below for before the body encounters it further explanations of the naturally.13,14 This allows the body to di erences between these vaccines. develop antibodies, which protects and prevents us from getting After the implementation of sick.13,14 There are two ways of immunization programs for children, developing anti-bodies, the rst “serotype replacement” may occur.50 being naturally when an individual This is when there is an increase in gets sick and survives the infection.14 cases caused by serotypes that are Vaccines are the other way to help not covered in the vaccine.50 After create antibodies, which are protein the introduction of the PCV7 molecules that help to kill and get vaccine, PCV7 cases decreased rid of the bacteria.13,14 across all age groups and there were increases in the number of cases S. pneumoniae has a coating called a caused by serotypes not covered by ‘polysaccharide capsule’.48 It is this PCV7.51 There was an increase in a capsule, or covering, that prevents it speci c serotype 19A51, which is from being killed by immune cells.48 included in the PCV13 vaccine now.15 S. pneumoniae has 92 serotypes (or Since PCV13 has been introduced in strains).7 The invasive disease caused children, there have been reductions by 24 of these serotypes can be in these serotypes in people over prevented by vaccinating against age 65.52 these speci c types.7 The vaccines
Background and Context 23 As One of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously?
Different Types of Pneumococcal Vaccines
Pneumococcal Polysaccharide better immune response in infants and 23-Valent Vaccine (PPV23): other immunocompromised Polysaccharide vaccines are made up of populations.14 Thus, it is able to provide long chains of sugar molecules that a ‘booster’ e ect that the polysaccharide make up the surface ‘polysaccharide’ vaccines lack.14 This ‘booster’ e ect capsule of certain bacteria.14 In Canada, occurs when a person is given repeated this vaccine goes by the name of dosages which causes the antibody “Pneumovax23” and protects against 23 levels to go higher and higher.14 serotypes.15 Young children under age 2 Conjugated vaccines are used routinely do not respond very well to in Canada for the infant immunization polysaccharide vaccinations.14 This is programs. Currently Quebec is the only because their immune systems are not province that uses the pneumococcal properly developed to adequately 10-valent conjugate vaccine (PCV10), respond to them.14 also known as “Syn orix”.49 PCV10 protects against 10 serotypes of Pneumococcal Conjugate Vaccine pneumococcal disease.49 (PCV): All other provinces and territories In the 1980s, scientists discovered that if administer the pneumococcal 13-valent the vaccine was conjugated, it could x conjugate vaccines (PCV13), also known the problems with the polysaccharide as “Prevnar-13”, which protects against vaccines that made them less e ective in 13 serotypes of pneumococcal disease.15 children.14 This process requires that the This vaccine is funded for children and polysaccharide be combined with a high-risk adult groups. protein molecule, which allows for a
Different Types of Pneumococcal Vaccines 24 As One of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously?
The History of the Pneumococcal Vaccine
Development of the rst Development of a new vaccine in the pneumococcal vaccine began with 1960s gold miners in South Africa by Sir • In the 1960s, pneumococcal disease Almorth Wright.53 still caused illness and death even with the development and In 1886, gold was discovered in widespread use of antibiotics54 Johannesburg, South Africa, and large numbers of people were being • This led to the development of brought in to work in the mines.53 polysaccharide vaccines54 The rate of pneumonia was as high as 100 cases per 1000 persons per • However, polysaccharide vaccines year, with a fatality rate of 25%.53 were less e ective in children, who were getting pneumococcal Due to these numbers, pneumonia disease at very high rates54 was seen as one of the greatest threats to the South African mining Development of conjugating industry.53 vaccines in the 2000s
Sir Almorth Wright, and three • The realization that polysaccharide colleagues, arrived in 1911 to begin vaccines could be linked, or trying to develop an e ective ‘conjugated’, lead the development 53 pneumococcal vaccine. Sir Almorth of pneumococcal conjugate Wright worked to develop an vaccines (PCVs) that are widely e ective vaccine that could help used now.54 protect against pneumonia.53 Sir
Almorth Wright left South Africa • The first ones became available in before completing his trials and F. 2000 and were found to be more Spencer Lister, a protégé of Wright, e ective for children a ected by 53 took over the work on the vaccine. this disease.54
The Hisotry of the Pneumococcal Vaccine 25 As One of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously?
The Current State of the into the vaccines, there are current Pneumococcal Vaccine: limits on how many serotypes can be included.57 New vaccines with more • PCV7 was one of the first conjugate coverage that are also a ordable and vaccinations funded for children that have longer-lasting immunity under the age of two between (particularly for older adults) are also 2002-2006.7 needed.56
• This vaccine was replaced by the Additionally, a phenomenon called PCV10 in 2009; then these were “serotype replacement” may take replaced by PCV13 in 2010.7 Quebec place in certain populations whereby used PCV13 in 2011, but then after vaccination there are increases switched back to PCV10 in 2018.49 in disease caused by serotypes that are not covered in the vaccine.54 This S.pneumoniae has 92 serotypes (or needs to be further understood. strains).7 The invasive disease caused by 24 of these serotypes can be prevented by vaccinating against these speci c types.7
Although expanding the amounts of serotypes in the vaccines seems logical, there must also be comprehensive measures to improve current vaccination adherence.56 Due to diculties in adding serotypes
The Hisotry of the Pneumococcal Vaccine 26 As One of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously?
Who Should Get Vaccinated?
Current NACI Recommendations for For older adults who wish to seek Pneumococcal Vaccination in Older additional protection, NACI says that Canadians: PCV13 can be considered for those who are 65 and over and who have NACI recommends the routine never received a pneumococcal administration of the PPV23 vaccine.15 Please refer to the diagram vaccination to all adults over age 65 on page 27 for additional and all residents of long-term care information. These homes.15 This includes recommending recommendations are the most the vaccine for all of those adults, current at the time of publication. even if they have no current risk The next version of the NACI factors.15 This recommendation is due statements will be released within to IPD being more common amongst the next few years with any older adults.15 additional changes or updates that have been made.
What is
NACI? The National Advisory Committee on Immunization (NACI) is a national committee consisting of many experts in the elds of pediatrics, infectious diseases, immunology, nursing, pharmacy, and public health among other specialties.58 NACI makes recommendations around the use of vaccines to the Public Health Agency of Canada (PHAC).58 The main populations that they recommend the use of the pneumococcal vaccine is for older adults, children, and individuals de ned as high-risk – including those living with chronic conditions.15
The chart below summarizes the current recommended and funded schedules for Canadians. The next updates to this NACI statement are expected to be published within the upcoming years.
Who Should Get Vaccinated? 27 As One of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously?
Summary of Funded Recommended Schedules for Canadians15
AGE/CONDITION Pneu-P-23 Pneu-C-13 Healthy Children (2 months - 5 years) Children at high risk of IPD (2 months - less than 18 years) Adults 18-64 with chronic health conditions Adults 18-64 in long-term care homes, or who are smokers, living with alcoholism, or homeless persons All adults over age 65- with or without risk factors Adults with a compromised immune system
iI Please note: there may be exceptions to the above table, please refer to https://www.canada.ca/en/public-health/services/immunization/national-advisory-committee-on-immunization- naci.html for all up-to-date recommendations from NACI
Figure 5: Recommended two-step vaccination process for individuals who need or wish to protect themselves against the 13 serotypes in PNEU-C-13
Received PNEU-P-23 previously
YES NO How long ago? PNEU-C-13
Less than 1 year At least 1 year ago >8_ weeks
PNEU-P-23 Wait for 1 year since PNEU-P-23 PNEU-C-13
Source: Public Health Agency of Canada. (2016). An Advisory Committee Statement (ACS) National Advisory Committee on Immunization (NACI) - Update on the use of 13-valent pneumococcal conjugate vaccine (PNEU-C-13) in addition to 23-valent pneumococcal polysaccharide vaccine (Pneu-P-23) in immunocompetent adults 65 years of age and older - Interim Recommendation. Retrieved from: https://www.canada.ca/content/dam/phac-aspc/documents/services/ publications/healthy-living/update-use-of-13-valent-pneumococcal-conjugate-vaccine-pneu-c-13-in-addition-to-23-vale nt-pneumococcal-polysaccharide-vaccine-pneu-p-23-immunocompetent-adults-65-years-and-older-interim-recommend ation/update-pneu-c-13-and-pneu-p-23-mise-a-jour-2016-eng.pdf
Who Should Get Vaccinated? 28 As One of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously?
Current NACI Recommendations for because the most resistant serotypes Pneumococcal Vaccination in Younger were in the PCV7.59 In children under the Canadians: age of 5, the e ectiveness of the conjugate vaccine has been found to be Vaccinating Children Helps Everyone in the range of 86% to 97% against the IPD serotypes which are covered in the The Public Health Agency of Canada vaccine.15 calls for the routine immunization of all infants (2 months to less than 12 Studies have further suggested that months of age) with PCV13, as well as publicly funded immunization programs additional doses and vaccination with for PCV7, PCV10 and PCV13 have been PPV23 for children who are at high-risk associated with decreases in of pneumococcal disease.15 In addition, hospitalizations and the related costs of any child under the age of 18 who is at pneumococcal disease for younger high-risk of pneumococcal disease children in Ontario.55 Bene ts were also should receive PCV13 if they did not extended to older children and older receive it as a child.15 IPD is more adults who did not receive the vaccine.55 common amongst very young children.15 The achievement of signi cant Increasing the number of children decreases in hospitalizations for vaccinated protects individuals over 65 pneumonia after the introduction of indirectly through the principle of herd PCV10 and PCV13, further suggest that immunity (i.e. vaccinating those around the strains covered in these vaccines others who are at greater risk). were likely responsible for a signi cant proportion of the remaining burden of In 2010, a study in Manitoba found that pneumococcal disease after the switching to the PCV13 vaccine for introduction of the PCV7 vaccine.55 infants versus the previous PCV7 Indeed, publicly-funded pneumococcal version, signi cantly decreases the rates vaccinations with increasing serotype of disease among children.44 Studies coverage has led to decreases in have found that the PCV7 vaccine was hospitalizations, and health care costs protective for children 3-59 months along with other costs in Ontario and against disease caused by all of the elsewhere.55 Furthermore, the bene ts seven serotypes covered in the vaccine, of vaccination have likely extended it was also e ective against beyond those vaccinated which has antibiotic-resistant strains and all IPD implications for parents, grandparents, and caregivers.55
Who Should Get Vaccinated? 29 As One of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously?
Between 2010-2011, PCV13 became the the same one to two week period conjugate vaccine used for the routine each year.60 These patterns were the immunization of Canadian infants.7 One same whether there were di erences in study looked at data three years after it weather, and colder temperatures did was universally introduced and found not appear to drive higher rates.60 The approximately 15% of adult spike occurs during the weeks of hospitalizations for community-acquired December 24th to January 7th when pneumonia were caused by PCV13 and families typically gather for the holidays, PPV23 serotypes.25 This suggests that which tends to be a time when older hospitalizations for the PCV13 and adults are exposed to new serotypes PPV23 serotypes decreased in adults, that young children may have.60 even when children were the ones However, this spike in older adults has principally being vaccinated.25 Herd been eliminated in the United States immunity can occur through childhood following the introduction of PCV7.61 vaccination programs, however, there will still be morbidity and mortality for Current NACI Recommendations for adults because there are still di erent People Living with Chronic serotypes that can cause disease and Conditions: illness.16 Vaccinating children will not completely eliminate the risk of For people living with chronic pneumococcal disease for adults, as conditions, it is recommended that they such there remains a strong need to get vaccinated because they are at an vaccinate adults as well.16 overall increased risk of infection or developing more serious complications PCV7 and PCV13 serotypes have been should they get an infection in the rst declining among all age groups from place.62 Vaccines may not elicit as strong 2010 to 2014.26 However, PPV23 of a response in certain populations and serotypes have increased when looking conditions, this is why PHAC has created at all age groups between the speci c recommendations for additional 2010-2014 years.26 doses or higher doses for certain populations or conditions.62 Please see Historically, there have been spikes in Recommendation 9 for the full pneumococcal incidence during recommended schedules for all populations.
Who Should Get Vaccinated? 30 As One of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously?
Highlight on Influenza and Pneumonia in Older Adults
People infected with in uenza pneumococcal vaccinations.65 who subsequently contract pneumonia develop worse In one study, the in uenza outcomes, and experience increased vaccination was associated with a incidence of hospitalization, likely reduction in the risk of due to damage to the lungs and hospitalization with airway caused by in uenza.63,64 community-acquired pneumonia, and it reduced risk of death during Due to the combined e ects of the in uenza season.66 Although it pneumonia and in uenza, it is did not have an e ect on the recommended that individuals over occurrence of outpatient pneumonia age 65 are vaccinated against both or pneumococcal bacteremia.66 of these infections. One study in Sweden found a 29% reduction in The Ministry of Health and all-cause pneumonia and a 35% Long-Term Care (MOHLTC) in Ontario reduction in death for people who currently recommends that all got both vaccines.64 Furthermore, for long-term care residents, people individuals who were hospitalized visiting long-term care homes, and for either pneumonia or in uenza, caregivers of these individuals, be shorter hospital stays were achieved vaccinated against in uenza.67 if they were immunized against Studies have found that in uenza in uenza and pneumonia.64 One vaccination for long-term care study from Japan also showed residents may reduce pneumonia reductions in medical costs for those among residents and death related to over age 75 who were vaccinated both pneumonia and in uenza.68,69 against in uenza in the rst year after receiving their
Highlight on Influenza and Pneumonia in Older Adults 31 As One of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously?
Vaccination Policies and Their Outcomes PPV23. However, despite this in Canada longstanding recommendation, in 2016, only an estimated 42% of Each province and territory controls those over age 65 had received their what is covered for residents. All of pneumococcal vaccination2, while in the provinces and territories cover 2014 only 17% of those 18-64 living the polysaccharide (PPV23) vaccine with a chronic condition had for adults over 65. Similarly, all received theirs.70 provinces and territories have coverage for the conjugate (PCV) Similar to in uenza target rates, vaccines for children, although the PHAC set an 80% target vaccination ages of eligibility for coverage vary. coverage rate for the pneumococcal Similarly, all provinces and territories vaccine for age 65 an over by 201071 have some type of coverage for and has now revised its target to those living with chronic conditions, 2025.1 Although the vaccine is however, the recommendations and available for free to both the conditions covered vary. The populations, those over 65 have table below (page 33) shows that reported receiving the vaccine at a most Canadians receive their greater rate in comparison to the vaccinations through their primary younger population with chronic care provider, however, in some conditions.70 Research also provinces pharmacists are also concludes that Canadians do not licensed to administer know enough about vaccines. In pneumococcal vaccines. Below is a 2016, 88% of Canadians responding table (page 33) that describes the to a PHAC survey reported that they funding and availability of the were up-to-date on their various pneumococcal vaccines vaccinations, but only 3% were across Canada’s provinces and found to be actually up-to-date territories. according to Canadian recommended standards.2 In Ontario, it is currently recommended that all adults age 65 and over receive a free single dose of
Vaccination Policies and Their Outcomes in Canada 32 As One of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously?
At the same time, PHAC has established a 95% vaccination target for children under the age of two for the pneumococcal vaccine.1 In general, Canadian children are doing far better at getting vaccinated, with some data showing that 80% of children under the age of two had been vaccinated against pneumococcal disease in 2015.3 In 2015, 97% of the parents surveyed believe that childhood vaccinations are safe and e ective.3 From 2011 to 2015, the amount of parents that were concerned about side e ects of the pneumococcal vaccine also reportedly decreased from 74% to 66%.3
Vaccination Policies and Their Outcomes in Canada 33 As One of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously?
Pneumococcal Vaccination Policies
by Province (2018-2019) Pneumococcal vaccines are provided at public health clinics, physician’s oces, travel clinics, or pharmacies in certain provinces.
Province/ Where can Funding Funding Territory you get it? for PPV 23 for PCV13
Adults over 65 Children 2-12 months Health care providers Adults in care Children 5-18 months in the community British facilities without a spleen Columbia Pharmacy 72 Funded for high-risk Adults and children 5+ conditions* 73 with HIV or stem cell transplant74
Health care providers Children 2 months + in the community, Adults over 65 public health units, Individuals over age and doctors. Adults in care 2 at high-risk for IPD Alberta facilities As of January 2019 O ered to adults over pharmacists may be Funded for high-risk age 65 (but they 76 able to administer conditions* must pay)77 the vaccine. 75
Public health clinics Adults over 65 Children 2 months-59 months Physicians and nurse Residents of care practitioners 78 Saskatchewan facilities Individuals over age 5 that are Pharmacists in High-Risk high-risk * 81 79 certain situations conditions* 80
Physicians, public health nurses, Adults over 65 Children 2 months- less pharmacists (only for than 5 years Residents of care PPV23), physician Manitoba facilities Individuals 5 years and assistants, nurses and over with HIV or who nurse practitioners High-Risk have had a stem cell or can administer 83 Conditions* organ transplant. 83 vaccines.82
Vaccination Policies and Their Outcomes in Canada 34 As One of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously?
Pneumococcal Vaccination Policies
by Province (2018-2019) Pneumococcal vaccines are provided at public health clinics, physician’s oces, travel clinics, or pharmacies in certain provinces.
Province/ Where can Funding Funding Territory you get it? for PPV 23 for PCV13
Health care professionals or Adults over 65 public health units84 Children 6 weeks Residents of care – 4 years Pharmacists are able facilities to administer the Ontario High-Risk for vaccine, but there High-Risk adults over 50** 86 may be a fee for Conditions *86 administering the vaccine85
Asplenia or weakened immune system88
Since 2011, Prevnar 13 has been the vaccine used for children – Have to contact the however in May 2018 Centre Local de Syn orix (PCV10) Services replaced Prevnar 13 Communautaires (CLSCs – local Quebec is the only community service Adults over 65 province in Canada to Quebec centre) or doctor to use Syn orix in determine more Limited high-risk children. 88 information as the conditions*** procedure to get Prevnar 13 is still vaccinated varies recommended for: depending on the region in Quebec.87 People 5-17 at increased risk of serious pneumococcal infection due to a medical condition; and adults without a spleen and those with a weakened immune system 49
Vaccination Policies and Their Outcomes in Canada 35 As One of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously?
Pneumococcal Vaccination Policies
by Province (2018-2019) Pneumococcal vaccines are provided at public health clinics, physician’s oces, travel clinics, or pharmacies in certain provinces.
Province/ Where can Funding Funding Territory you get it? for PPV 23 for PCV13
Health care providers Adults over 65 Children 2 months and and public health older 89 oces89 Nova Residents of care facilities High-Risk Groups**91 Scotia Pharmacists can administer both High-Risk pneumococcal Conditions*91 vaccinations to at-risk adults 90
Adults over 65 Children under 5 Primary care providers Residents of care Children and adults including family New facilities (including with HIV or doctors, nurse those newly admitted immunosuppressive Brunswick practitioners and to long-term care conditions and Public Health.92 homes) hematopoetic stem cell transplant 93 High-Risk Conditions*93
Physicians and nurse practitioners are able to provide PPV23 in Children 2 months 95 their oces or adults Adults over 65 and up can make Prince appointments at the Residents of care Certain high-risk Edward local Health PEI Public facilities conditions** Island Health nursing oce. High-Risk PCV3 is recommended Residents in long-term Conditions*94 for all adults over age care facilities are 65 but is not funded 94 immunized by the sta for this population. in the home.94
Vaccination Policies and Their Outcomes in Canada 36 As One of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously?
Pneumococcal Vaccination Policies
by Province (2018-2019) Pneumococcal vaccines are provided at public health clinics, physician’s oces, travel clinics, or pharmacies in certain provinces.
Province/ Where can Funding Funding Territory you get it? for PPV 23 for PCV13
Adults over 65 Children 2 months – Available through less than 5 years97 local Health and Residents of care Newfoundland Community Service facilities Funded for those with and Labrador oces in cochlear implants, Newfoundland and Indigenous asplenia, sickle-cell 96 Labrador. Populations disease, and immunosuppression97 High-risk conditions*96
Adults over 65 Community health Children 2 months – 99 Yukon centres o er Residents of care less than 5 years 98 immunizations. facilities High-risk 99 High-risk conditions** conditions*99
Children over 2 years who have not had this vaccine prior (but who Health care providers have received the Nunavut and local health care complete Children 2 months to centres100 pneumococcal less than 5 years.100 conjugate 13 series)
Adults over 50
High-risk conditions*100
Children 2 months to Local health centres Adults 65 and over less than 5 years Northwest or public health High-risk conditions For those over age 5 clinics101 Territories (not speci ed) 101 with certain health conditions (not speci ed). 101
Vaccination Policies and Their Outcomes in Canada 37 As One of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously?
* High-risk conditions include: ** Asplenia, congenital *** Heart disease; lung disease asplenia; sickle-cell disease; immunode ciencies, HIV, (e.g. emphysema, chronic weakened immune system (due to hematopoietic stem cell bronchitis); asthma requiring disease and/or treatment – transplant, immunocompromising regular medical follow-up for including HIV); chronic liver therapy, malignant neoplasms, people aged 50 and older; kidney disease; chronic kidney disease; sickle cell disease, and solid organ disease; diabetes; poor spleen chronic heart disease; chronic or cell transplant. function or no spleen; liver disease lung disease; cell, organ, or stem (e.g. hepatitis, cirrhosis, cell transplant; cochlear implant; alcoholism); immune system diabetes; cystic brosis; malignant de ciency (e.g. cancer, HIV neoplasms; chronic cerebrospinal infection). uid leak; chronic neurological conditions that may impair clearing of oral secretions; hemoglobinopathies(MB); alcoholism/alcohol dependency; homelessness; and users of illicit drugs.
Vaccination Policies and Their Outcomes in Canada 38 As One of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously?
Pneumococcal Vaccination Around the World
The majority of European countries recommend PCV for children, have developed schedules similar to however do not recommend any the existing Canadian schedule.102 routine pneumococcal vaccination Most recommend that the conjugate for adults.102 vaccine be used for children – while the speci cs of funding, the number In the United States, the Centers for of doses, and age at which it should Disease Control and Prevention be administered di ers.102 The (CDC), recommends a PCV13 recommendations for adults, vaccination for those younger than 2 however, are not as uniform. years of age and recommends both Countries such as Finland, Italy, the PCV13 and PPV23 for those over Luxembourg, Austria, Denmark, and age 65.103 However, the Belgium recommend a combination recommendation about the routine of conjugate and polysaccharide use of PCV13 in adults was to be vaccines for adults over age 65.102 reevaluated and revised as Sweden, Spain, Slovenia, Ireland, needed.104 For those with high-risk Germany, and Cyprus recommend conditionsa it is generally PCV for children and PPV23 for recommended that they receive both adults.102 Iceland and Finland vaccines with appropriate timing speci cally recommends PCV10 for between vaccinations.105 children.102 Hungary and Norway speci cally recommend PCV13 for The World Health Organization children and PPV23 for adults.102 The (WHO) recommends that PCVs be Netherlands and France included in childhood immunization programmes globally.106 The WHO
a High-risk conditions: chronic heart disease, chronic lung disease, chronic liver disease, diabetes, cerebrospinal uid leaks, cochlear implants, sickle cell disease or other hemoglobinopathies, asplenia, HIV, chronic kidney failure, immunosuppression, alcoholism, cigarette smoking, cancer, and transplants
Pneumococcal Vaccination Around the World 39 As One of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously?
considers PCVs to be safe for those in target groups, including immunocompromised individuals.106 The WHO considers PCV10 and PCV13 to be comparable in safety and suggest that the choice of which vaccine depends on additional factors including the vaccine serotypes typical in the location, the supply of vaccines in the region, and cost considerations.106 Additionally, in high-or middle-income countries the WHO recommends PPV23 to high-risk populations including those over age 65 and also as a supplement to the PCV13 vaccine for some populations.106
Pneumococcal Vaccination Around the World 40 As One of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously?
Improving Vaccination Rates
Pneumonia is a serious, potentially The public also understands that fatal disease and is in many cases vaccinations are helpful and preventable with vaccination. consider the side e ects less severe Despite this, vaccination rates for than the condition the vaccine is both children and older Canadians in preventing - in this case, pneumonia particular remain below national and related respiratory diseases. targets. Factors that in uence the However, only 21.7% strongly agreed low rate of vaccinations include a or agreed that they knew what lack of awareness about which vaccines they should have received vaccines are needed, when they are according to public health needed, and the role of health care recommendations.107 providers in recommending vaccines. One study found participants had higher coverage rates than the Education Canadian national survey found, Although Canadians are generally however, 20% of individuals receptive to receiving vaccines, surveyed who were eligible to there is still a signi cant lack of receive the vaccination for free said awareness about which vaccines that they had never heard of the they need and how they work. In pneumococcal vaccine.108 In another one study, just under 60% of study, when asked whether they felt respondents agreed or strongly pneumonia could be prevented by a agreed with the statement, ‘it is vaccine only 43% of adults said yes, important for adults to receive all compared with 60% saying yes to recommended vaccinations’.107 in uenza being preventable by a Studies show that the public and vaccine.107 The PneuVUE study found health care providers generally that only 44% of Europeans thought accept the concept of vaccination pneumonia was contagious, and less and understand that prevention is a than 30% were aware of the better option than treatment.107 vaccine.109 Only 13% of people
Improving Vaccination Rates 41 As One of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously?
considered themselves ‘very much at educated consistently emphasizing risk’ of developing pneumonia, while the importance of vaccination approximately 70% of the people as a way to maintain overall had at least one risk factor for good health.108 developing pneumonia.109 Approximately 59% of older adults Provider in uence considered themselves to be only Doctors and other health care slightly at risk, followed by 21% who professionals play a signi cant role thought they were at no risk.109 in increasing vaccination rates. A European study found 75% of people People over 65 tend to achieve who got the vaccine were prompted higher vaccination rates.70 by their doctor to do so.109 Only 55% Individuals surveyed who considered of respondents over 65 years old themselves to be “well” or “very t” were o ered the vaccine by their were less likely to think that they doctor, despite all qualifying for it.109 were at high risk for pneumonia in Providing education for clinicians comparison to individuals who were and reminders for clinicians was considered to be “well, with treated associated with achieving a greater co-morbid disease” or “apparently pneumococcal vaccination rate.108,111 vulnerable”.108 Similar small studies have found that adults with If a health care professional comorbidities were more likely to recommends a pneumonia report receiving a pneumococcal vaccination it signi cantly increases vaccination.110 Future education the probability of immunization. programs should consider those However, one study found that only adults who are apparently healthy, 13.8% of individuals reported that a focusing on their risk of pneumonia health care provider recommended and IPD, and the likelihood of them that they receive a pneumonia having more severe outcomes vaccine, compared with 52.8% who because of their age.108 Generally, said that their provider the older population should be
Improving Vaccination Rates 42 As One of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously?
recommended an in uenza There are some successful vaccination.107 In the same study, interventions that have been used to 59.7% of those respondents improve pneumococcal vaccine rates reported that if a health care among adults in the community. provider recommended it they Some of these include changing the would have received the provider administering the vaccine vaccination.107 Another study with from a physician to a nurse; veterans in the United States improved patient outreach, identi ed barriers for patients including handing out including not having the vaccine information/brochures prior to the o ered to them or being given appointment; and through providing incorrect information that they clinician education and reminders.111 could not receive the pneumococcal Additionally, having vaccines and zoster vaccination at the available free of charge, increases same time.112 uptake and reduces both social and health inequities.113
Improving Vaccination Rates 43 As One of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously?
What Are Our Governments Doing to Improve Vaccination Rates? The current National Immunization The Canadian Immunization Strategy in Canada aims to reduce Research Network (CIRN) further the incidence of vaccine preventable supports research projects on diseases and to increase the number vaccination issues and out of the $10 of Canadians receiving their million of funding allocated for vaccinations.114 One of its objectives 2017-2021, $2 million will be used was to create goals and vaccination for research around vaccination rate targets, including an 80% acceptance.114 CANImmunize is an vaccination coverage rate for app that has been developed that pneumococcal vaccination among allows Canadians to keep track of adults over age 65.1 their vaccination records so that they are easily accessible and it Canada is working to nd better helps ensure that vaccinations can ways to conduct national be received on time.114 vaccination coverage surveys and try to better understand the determinants of vaccination acceptance and uptake, including asking questions about knowledge, attitudes, and behaviours of people.114 The Canadian Institutes of Health Research (CIHR) have funded studies to better understand why people are not vaccinated and where people who are receiving vaccines are getting vaccinated.114
Not Enough Data Exists to Fully Understand Pneumococcal Disease In Canada 44 As One of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously?
Not Enough Data Exists to Fully Understand Pneumococcal Disease in Canada More Data is Needed for do not require speci c diagnostic Diagnosis, Treatment, and tests, unless there is a speci c need Surveillance determined for diagnostic collection.115 For patients who are Pneumonia is typically diagnosed by admitted to the hospital, cultures a health care professional after a and sputum/mucous ( uid that is history is taken and an examination coughed up) should be taken, is performed sometimes in however, treatment should not be combination with an X-ray and/or delayed if the person is ill and blood test.4 Additional or more having trouble obtaining a speci c tests may be ordered in specimen.115 certain cases, such as in older adults or those with chronic conditions. 4 It is also noted that correctly diagnosing CAP can be dicult.12 In Diagnostic testing for patients practice, CAP is generally diagnosed presenting with CAP has been based on clinical symptoms and a debated amongst experts in this physical exam.12 There are some eld including respirologists and diculties with the tests that infectious disease specialists.115 currently exist including low There is a lack of consensus on what sensitivity and a delay in receiving the appropriate use of diagnostic lab results.12 However, where tests should be for pneumonia. microbiological testing is done, it In 2000, a committee made up of can provide useful data that would representatives from the Canadian allow for more appropriate Infectious Disease Society (CIDS) and treatment and better surveillance on 12 the Canadian Thoracic Society (CTS) a larger level. There is a need released recommendations on the to develop new tests that are initial management of CAP.115 They more speci c and better able to 12 suggest that the majority of patients diagnose CAP. who are treated outside of a hospital
Not Enough Data Exists to Fully Understand Pneumococcal Disease In Canada 45 As One of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously?
Urinary tests are sometimes used for allow for proper surveillance data to diagnosis of pneumococcal support vaccination pneumonia because they are easy to recommendations for Canadians. use and non-invasive.116,117 However, Due to some of the challenges with they lack speci city in children and the tests and a lack of consensus on may give false positive results for when and whether they should be children.116,117 P zer has developed a used, the number of cases of CAP, non-commercial serotype-speci c and the complications associated urinary antigen detection (SSUAD) with them, are underrepresented. assay that is more sensitive and was developed to determine vaccine The current patchwork of data which 118 ecacy. This test is not is available also has limitations. In commerically available yet and is Canada, national surveillance data of only able to identify the serotypes IPD is available, but there is little 117,119 covered in the PCV13 vaccine. data available on the actual burden However, if this test was used in of CAP or on the complications and combination with the current urinary e ects that CAP has on individual tests, it would be able to identify the Canadians, for example 117,119 speci c serotype causing CAP. hospitalization rates, complications from CAP, and mortality.25 There are, Non-invasive accurate diagnostic however, several existing and tests would also allow treatment to emerging surveillance systems and be targeted more appropriately and networks that are aiming to address ensure that the treatment used is this gap (see box on page 46). Better necessary.116 Determining the cause surveillance data would be helpful of illness earlier can lead to patients for prevention and treatment of being provided with the right pneumococcal disease. We currently treatment earlier, improve the require a better understanding of e ectiveness of treatments, serotypes that are causing illnesses ultimately reducing the spread of among Canadians in order to create disease and the costs associated better vaccines to reduce the burden with treatment and of illness. hospitalization.116, 117 This would also
Not Enough Data Exists to Fully Understand Pneumococcal Disease In Canada 46 As One of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously?
$ $ A Snapshot of Pneumonia $ Surveillance Systems in Canada
Since 2000, invasive pneumococcal Two specialized pneumonia disease (IPD) has been identi ed as a surveillance programs exist for nationally noti able condition speci c populations, the through the Canadian Noti able Immunization Monitoring Program, Disease Surveillance System ACTive (IMPACT) and International (CNDSS).7 IPD is considered a priority Circumpolar Surveillance (ICS). for monitoring as it can lead to many IMPACT is surveillance for children serious outcomes.120 Once a disease and ICS is surveillance for the three is noti able, the provinces and territories, Labrador and northern territories must submit disease data Quebec.121 Both of these link to estimate disease rates.120 This epidemiologic and laboratory data system collects epidemiological (i.e. demographic information and trends and reports on the rates and serotypes).121 These are good data cases of IPD, it also collects basic collection systems, but because they demographic information including are collecting results speci c to age and sex.121 children and northern populations their results cannot be Additionally, limited data on IPD is generalized.121 collected through the National Microbiology Laboratory (NML) There is a need for a more enhanced Streptococcus Surveillance, which surveillance system that would be began in 2010.7 This laboratory data able to combine epidemiological includes serotype data121, but it is data, such as risk factors and not nationally representative and is immunization status, with more limited by reporting di erences speci c laboratory data to monitor between jurisdictions.7 Other the serotypes that are causing limitations exist, for example disease.121,122 The Enhanced National currently only approximately 50% of Invasive Pneumococcal Disease invasive cases are sent to the NML Surveillance System (eIPDSS) pilot and it is not linked to the was launched in 2011.121 It is being epidemiological data in the piloted in New Brunswick to CNDSS.121
A Snapshot of Pneumonia Suveillance Systems in Canada 47 As One of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously?
$ $ $
determine the feasibility of Our ability to develop more e ective conducting timely data collection pneumococcal vaccines will depend and linking epidemiologic and on whether the serotypes that are laboratory data.121 If this system causing the most signi cant were expanded it would create morbidity, mortality, and burden, are better understanding of IPD trends covered in the vaccines.25 Data is across Canada, speci cally looking at needed to determine which serotype distribution.121 This would serotypes are found in hospitalized allow better estimates of the rates of or ill individuals so that the vaccines IPD across the country and identify can be adapted to ensure they are variations across the country. covering the serotypes that are most a ecting Canadians. In 2009, the Serious Outcomes Surveillance (SOS) Network, a hospital-based surveillance system that collects information about patients admitted to hospital with either in uenza or pneumonia was created.123 SOS provides real-time surveillance data for both in uenza and CAP.123 Currently the network has participating hospitals from British Columbia, Ontario, Quebec, New Brunswick, and Nova Scotia that provide data.123
A Snapshot of Pneumonia Suveillance Systems in Canada 48 As One of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously?
A Lack of Data on Vaccination Across Canada, it is even dicult to Rates Further Compounds the capture those who are receiving Problem pneumococcal vaccinations through physician billing data. For example, Canada lacks good data on its actual in Ontario, there is an Ontario Health rates of pneumococcal vaccination. Insurance Plan (OHIP) billing code to In other words, we do not fully know help capture the administration of who is getting the vaccine and who the pneumococcal conjugate vaccine is not. Without this data we are (typically given to children), but the unable to clearly identify where pneumococcal polysaccharide messaging, such as outreach vaccine (typically given to older campaigns, or where educational adults) does not have a speci c materials should be targeted to best OHIP code to help capture increase vaccination rates overall. its administration.124
To estimate vaccination rates for common vaccines in Canada, the Public Health Agency of Canada (PHAC) collects survey data approximately every two years though the adult National Immunization Coverage Survey (aNICS).70 However, there are signi cant limitations to this data, including both the survey’s low response rate and the fact that the data is all self-reported.70
Improving Vaccination Rates 49 As One of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously?
Evidence-Informed Recommendations
Based on examination of current 1. Promote General evidence, Canadian and Preventive Practices in international policies, and our Addition to Vaccination existing estimated vaccination rates, there is much more work to be done There are other mechanisms of to improve prevention of pneumonia prevention that will be helpful to and other pneumococcal diseases in prevent the spread of pneumonia and Canada. The following other respiratory conditions. We recommendations provide should continue to encourage the evidence-informed policy and routine adoption of these practices in practice approaches that can be addition to vaccination. used by health authorities and organizations to support vaccination and overall prevention across Canada.
Other Means of Prevention For Lung 125 Disease More Generally - Wash your hands - Cover your coughs - Avoid those individuals around you who may be sick - Stop smoking - Avoid second hand or third hand smoke - Keep the air in the home clean (or example, try to reduce mould, pet dander, or air fresheners) - Wear a mask against harmful exposures
Evidence-Informed Recommendations 50 As One of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously?
2. Promote a Life-Course importance of adult immunizations, Vaccination Schedule that there is inconsistent messaging includes Older Adults around which vaccinations should be given or when. Primary care physicians, nurses and in many jurisdictions, pharmacists 3. Improve Monitoring of are able to administer pneumococcal Pneumococcal Disease vaccinations and should be Rates discussing vaccination options with their patients. However, due to the As previously discussed, we lack an connection with speci ed conditions easy way to test and treat for (including heart, lung, and kidney pneumonia. Currently, most disease, diabetes, and cognitive pneumonia cases are diagnosed impairment) specialists should also using X-rays and does not allow the be discussing this option with their doctor to determine which serotype patients. Studies have found that is causing the disease. professionals play a signi cant role in increasing vaccination rates.107,109 The lack of speci c diagnostic tests available means the true burden of Consistent messaging around which pneumonia across the country is vaccinations should be given and likely underestimated.12 In Canada, when they should be given is national surveillance data of IPD is required. Universal vaccination available, but there is little available schedules for children are commonly data on the actual burden of CAP.25 accepted as part of routine care, This means that there is a lack of however, routine vaccinations are good quality national data on the also important for adults. complications and e ects of CAP on Establishing a life-course vaccination individual Canadians, for example schedule that includes both children hospitalization rates, complications and older adults would streamline from CAP, and mortality.25 If we can messaging and practice for providers link the serotype and other and the general public to support laboratory data to the increased vaccination rates. epidemiological data it would result Although public health agencies and in better data and potentially lead to governments communicate the the creation of better vaccines.25
Evidence-Informed Recommendations 51 As One of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously?
4. Improve Reporting and 5. Continue Working Surveillance of towards Developing Pneumococcal Better Pneumococcal Vaccination Vaccines
Currently, Canadians estimate Although it seems logical to expand vaccination rates based on a the serotypes covered in the vaccine, self-reported survey, the aNICS, we must also consider the bene t of which has a low response rate and a comprehensive measure to therefore cannot be largely improve immunization adherence.56 generalized to the population.70 Implementation is dicult as there Better data on who has received a are two di erent vaccines available vaccination is needed in order to that need to be administered using a determine how far Canada actually is speci c schedule.56 from the 80% target vaccination rate for adults and 95% for children. This New vaccines developed will need to will help understand where be a ordable and will need to cover additional e ort is needed to get against more or better strains.56 more people vaccinated and address Additionally, there is a need to focus potential equitable access issues. on longer-lasting immunity e ects for more strains, which will The administration of vaccinations particularly bene t our ageing could also be monitored through population.56 The World Health provincial billing data. The federal Organization (WHO) has similarly government can help by setting a called for a more ecacious national standard which will keep conjugated vaccine or a di erent the data collection consistent across type of vaccine that covers the the country. serotypes causing the most serious disease in children and adults.126
Ideally, universal pneumococcal vaccines would be useful for older populations.127 However, polysaccharide vaccines are always going to be serotype-speci c,
Evidence-Informed Recommendations 52 As One of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously?
therefore future directions may also 7. Harmonize the Funding focus on a vaccine against a surface and Messaging for protein on pneumococci versus each Pneumococcal 127,128 serotype. Vaccinations for Target Populations Across 6. Provide Clinician Canada Education and Support for Primary Care It is also important that we Providers and harmonize the funding and Pharmacists to Better messaging of the vaccines for the Deliver Vaccinations same target populations. Right now, there are di erences across the As can be seen from the table country in the coverage of presented above (pages 33-37), pneumococcal vaccinations. For there are many di erences among example, all provinces and territories the provinces and territories on who provide the polysaccharide vaccine can administer the vaccination, for adults over 65 and most provide which vaccinations are some coverage for adults in care recommended, and which institutions. All provinces and populations are funded to receive territories provide funding for the the vaccine. This can lead to conjugate vaccine for children, but confusion for the general population the ages for which the vaccine are about whether they should be funded di er across the provinces vaccinated, which will be funded for and territories. Also, the funding for them, and where they can get it. high-risk conditions varies across Pharmacists should be able to the provinces. Therefore, there is a administer both pneumococcal need to harmonize the funding and vaccinations to their target coverage policies for those with populations. This will reduce high-risk conditions and children so confusion around messaging about that there is a common message where to receive the vaccine which being given to all Canadians and will reduce barriers to its uptake by a their care providers regarding larger population of appropriately pneumococcal vaccination. eligible Canadians.
Evidence-Informed Recommendations 53 As One of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously?
8. Recommend the 9. Promote Following the Administration of Current NACI Statement Pneumococcal Vaccine in for Pneumococcal Conjunction with the Vaccination In uenza Vaccination The NIA recommends that Canadians In uenza and pneumonia as a cause continue to follow the suggested of death are often recorded vaccination schedule that NACI together. Those who acquire both recommends. Vaccination is in uenza and pneumonia have recommended for adults over 65, worse outcomes, increased individuals with high-risk conditions, hospitalization, and sustain more and infants/children. We believe that damage to their lungs.63 Studies these are strong recommendations have found reductions in death and based on the current data available. lesser hospital stays and costs when The NIA recommends that older adults are vaccinated against individuals discuss with their both diseases.64,65 health-care provider which option is best for them. It is safe to administer both the in uenza and pneumococcal vaccine Please refer to at the same time. As in uenza is https://www.canada.ca/en/public-he provided annually, it provides a alth/services/immunization/national good opportunity for health care -advisory-committee-on-immunizati professionals to inquire about on-naci.html for all current pneumococcal vaccination status recommendations for Canadians. annually and if necessary, provide both vaccines at the same time.
Evidence-Informed Recommendations 54 As One of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously?
10. Consider Mandating Pneumococcal Vaccination for Residents of Long-Term Care Homes
The estimated incidence of previously recommended that pneumonia is higher for people mandatory in uenza vaccination living in long-term care settings.9 It should be considered for those living has been estimated that people over in long-term care homes. Studies 65 in long-term care homes have an have shown that in uenza annual incidence of pneumonia up vaccination can reduce pneumonia to 7% higher than those over 65 in among residents in long-term care the community (3.3-11.4% in long facilities and death due to term care versus 2.5-4.4%).9 pneumonia and in uenza.68,69 The NIA therefore recommends PHAC currently recommends that making pneumococcal residents of long-term care homes vaccination mandatory for all should consider the in uenza, long-term care residents. pneumococcal and herpes zoster (shingles) vaccination.129 The NIA has
Evidence-Informed Recommendations 55 As One of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously?
References
1 Government of Canada. (2017). 6 American Lung Association. (2018). Vaccination Coverage Goals and What Causes Pneumonia? Retrieved Vaccine Preventable Disease from: http://www.lung.org/ Reduction Targets by 2025. Retrieved lung-health-and-diseases/lung-disea from: https://www.canada.ca/en/ se-lookup/pneumonia/what-causes- public-health/services/immunization pneumonia.html -vaccine-priorities/national-immuniz ation-strategy/vaccination-coverage 7 Government of Canada. (2016). -goals-vaccine-preventable-diseases Invasive Pneumococcal Disease. -reduction-targets-2025.html#1.1.2 Retrieved from: https://www.canada. ca/en/public-health/services/immuni 2 Government of Canada. (2018). zation/vaccine-preventable-diseases Vaccine uptake in Canadian adults: /invasive-pneumococcal-disease/hea Highlights from the 2016 adult lth-professionals.html National Immunization Coverage Survey (aNICS). Retrieved from: 8 The Conference Board of Canada. https://www.canada.ca/en/services/ (April 2017). The Economic Burden of health/publications/healthy-living/2 Pneumonia in Canada: A Status Quo 016-vaccine-uptake-canadian-adults Forecast. -survey.html 9 Janssens, J.P., & Krause, K.H. (2004). 3 Government of Canada. (2018). Pneumonia in the very old. Lancet Vaccine uptake in Canadian children: Infectious Diseases, 4(2), 112-24. Doi: Highlights from childhood National 10.1016/S1473-3099(04)00931-4 Immunization Coverage Survey. Retrieved from: 10 Statistics Canada. (2018). Leading https://www.canada.ca/en/public-he causes of death, total population, by alth/services/publications/healthy-li age group. Retrieved from: ving/2015-vaccine-uptake-canadian- https://www150.statcan.gc.ca/t1/tbl children-survey.html 1/en/tv.action?pid=1310039401&pic kMembers%5B0%5D=2.26&pickMem 4 HealthLink BC. (2017). Pneumonia. bers%5B1%5D=3.1 Retrieved from: https://www.health linkbc.ca/health-topics/hw63868 11 Canadian Institute for Health Information. (2018). Pneumonia a 5 Mayo Clinic. (2018). Pneumonia. leading cause of emergency Retrieved from: https://www.mayo department visits in Canada last clinic.org/diseases-conditions/pneu year. Retrieved from: monia/symptoms-causes/syc-203542 https://www.cihi.ca/en/pneumonia-a 04 -leading-cause-of-emergency-depart ment-visits-in-canada-last-year
References 56 As One of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously?
12 Ludwig, E., Bonnani, P., Rohde, G., 17 The Lung Association. (2014). Sayiner, A., & Torres, A. (2012). The Pneumonia. Retrieved from: remaining challenges of https://www.lung.ca/lung-health/ pneumococcal disease in adults. lung-disease/pneumonia European Respiratory Review, 21(123), 57-65. Doi: 18 Centers for Disease Control and 10.1183/09059180.00008911 Prevention [CDC]. (2017). Pneumococcal Disease – Symptoms 13 Centers for Disease Control and and Complications. Retrieved from: Prevention (CDC). (n.d.). https://www.cdc.gov/pneumococcal/ Immunization – You call the Shots: about/symptoms-complications.html Understanding the Basics: General Recommendations on Immunization. 19 Drijkoningen, J.J., & Rohde, G.G. Retrieved from: https://www2a.cdc. (2014). Pneumococcal infection in gov/nip/isd/ycts/mod1/courses/genr adults: burden of disease. Clinical ec/11005.asp?student_id= microbiology and infection: the ocial publication of the European 14 Centers for Disease Control and Society of Clinical Microbiology and Prevention [CDC]. (n.d.). Principles of Infectious Diseases, 20(S5), 45-51. Vaccination. Retrieved from: Doi: 10.1111/1469-0691.12461 https://www.cdc.gov/vaccines/pubs/ pinkbook/downloads/prinvac.pdf 20 National Heart, Lung, and Blood Institute [NHLBI]. (n.d.). Pneumonia. 15 Government of Canada. (2016). https://www.nhlbi.nih.gov/health-to Page 16: Canadian Immunization pics/pneumonia Guide: Part 4 – Active Vaccines – Pneumococcal Vaccine. 21 Healthlink BC. (2017). https://www.canada.ca/en/public-he Healthcare-Associated Pneumonia alth/services/publications/healthy-li (Nosocomial Pneumonia). Retrieved ving/canadian-immunization-guide- from: https://www.healthlinkbc.ca/ part-4-active-vaccines/page-16-pneu health-topics/ug2993#ug2993-sec mococcal-vaccine.html 22 The Lung Association of Ontario. 16 Rudnick, W., Liu, Z., Shigayeva, A., (2018). Pneumonia FAQs. Retrieved Low, D.E., Green, K., Plevneshi, A., …. from: https://lungontario.ca/disease/ Toronto Invasive Bacterial Diseases u-pneumonia/overview-and-facts/p Network. (2013). Pneumococcal neumonia-faqs vaccination programs and the burden of invasive pneumococcal 23 Eurich, D.T., Marrie, T.J., disease in Ontario, Canada, Minhas-Sandhu, J.K., & Majumdar, 1995-2011. Vaccine, 31, 5863-5871. S.R. (2015). Ten-year mortality after http://dx.doi.org/10.1016/j.vaccine.2 community-acquired pneumonia. 013.09.049 American Journal of Respiratory and Critical Care Medicine, 192(5), 597-604.
References 57 As One of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously?
24 McNeil, S.A., Qizilbash, N., Ye, J., 27 Kwong, J.C., Crowcroft, N.S., Gray, S., Zanotti, G., Munson, S., Campitelli, M.A., Ratnasingham, S., Dartois, N., & Laferriere, C. (2016). A Daneman, N., Deeks, S.L., Manuel, Retrospective Study of the Clinical D.G. (2010). Ontario Burden of Burden of Hospitalized All-Cause and Infectious Disease Study Advisory Pneumococcal Pneumonia in Group; Ontario Burden of Infectious Canada. Canadian Respiratory Disease Study Advisory Group, Journal, 2016. Doi: Ontario Burden of Infectious Disease 10.1155/2016/3605834. Study (ONBOIDS): An OAHPP/ICES Report. Toronto: Ontario Agency for 25 LeBlanc, J.J., ElSherif, M., Ye, L., Health Protection and Promotion, MacKinnon-Cameron, D., Li, L., Institute for Clinical and Evaluative Mabrose, A., … on behalf of the Sciences. Retrieved from: Serious Outcomes Surveillance (SOS) https://www.publichealthontario.ca/ Network of the Canadian en/eRepository/ONBoID_ICES_Repor Immunization Research Network t_ma18.pdf (CIRN). (2017). Burden of vaccine-preventable pneumococcal 28 Public Health Agency of Canada. disease in hospitalized adults: A (2014). Economic Burden of Illness in Canadian Immunization Research Canada, 2005-2008. Retrieved from: Network (CIRN) Serious Outcomes http://www.phac-aspc.gc.ca/publicat Surveillance (SOS) network study. /ebic-femc/2005-2008/assets/pdf/ebi Vaccine, 35, 3647-3654. c-femc-2005-2008-eng.pdf http://dx.doi.org/10.1016/j.vaccine.2 017.05.049 29 Thomas, C.P., Ryan, M., Chapman, J.D., Stason, W.B., Tompkins, C.P., 26 Demczuk, W.H.B., Grith, A., Singh, Suaya, J.A., Polsky, D., Mannino, D.M., R., Montes, K., Sawatzky, P., Martin, I., & Shepard, D.S. (2012). Incidence and & Mulvey, M. (2015). National Cost of Pneumonia in Medicare Laboratory Surveillance of Invasive Bene ciaries. Chest, 142(4), 973-981. Streptococcal Disease in Canada – Doi: 10.1378/chest.11-1160 Annual Summary 2014. Retrieved from: http://www.healthycanadians. 30 NHS. (2018). Pneumococcal gc.ca/publications/drugs-products- Infections. Retrieved from: medicaments-produits/2014-strepto https://www.nhsinform.scot/illnesse coccus/alt/surveillance-streptococca s-and-conditions/infections-and-pois -eng.pdf oning/pneumococcal-infections
31 Murphy, K. (2012). Janeway’s Immunobiology 8th edition. New York, NY: Garland Science, Taylor & Francis Group, LLC.
References 58 As One of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously?
32 Torres, A., Blasi, F., Dartois, N., & 37 Mullerova, H., Chigbo, C., Hagan, Akova, M. (2015). Which individuals G.W., Woodhead, M.A., Miravitlles, are at increased risk of M., Davis, K.J., & Wedzicha, J.A. pneumococcal disease and why? (2012). The natural history of Impact of COPD, asthma, smoking, community-acquired pneumonia in diabetes, and/or chronic heart COPD patients: A population disease on community-acquired database analysis. Respiratory pneumonia and invasive Medicine, 106, 1124-1133. Doi: pneumococcal disease. Thorax, 70, 10.1016/j.rmed.2012.04.008 984-989. Doi: 10.1136/thoraxjnl -2015-206780 38 Public Health Agency of Canada. (2014). An Advisory Committee 33 Dorrington, M.G., & Bowdish, Statement (ACS) National Advisory D.M.E. (2013). Immunosenescence Committee on Immunization (NACI): and novel vaccination strategies for Update on the Use of Pneumococcal the elderly. Frontiers in Immunology, Vaccines: Addition of Asthma as a 4(171), 1-10. Doi: 10.3389/ mmu. High-Risk Condition. Retrieved from: 2013.00171 https://www.canada.ca/content/dam /phac-aspc/documents/services/pub 34 Jackson, M.L., Nelson, J.C., & lications/healthy-living/update-use- Jackson, L.A. (2009). Risk factors for pneumococcal-vaccines-addition-ast community-acquired pneumonia in hma-high-risk-condition-eng.pdf immunocompetent seniors. The American Geriatrics Society, 57, 39 Girard, T.D., Self, W.H., Edwards 882-888. Doi: K.M., Grijalva, C.G., Zhu, Y., Williams, 10.1111/j.1532-5415.2009.02223.x D.J., Jain, S., & Jackson, J.C. (2018). Long-Term Cognitive Impairment 35 Eurich, D.T., Marrie, T.J., after Hospitalization for Minhas-Sandhu, J.K., & Majumdar, Community-Acquired Pneumonia: a S.R. (2017). Risk of heart failure after Prospective Cohort Study. Society of community acquired pneumonia: General Internal Medicine, 33(6), prospective controlled study with 10 929-35. Doi: years of follow-up. British Medical 10.1007/s11606-017-4301-x Journal, 356(j413). http://dx.doi.org/10.1136/bmj.j413 40 Davydow, D.S., Hough, C.L., Levine, D.A., Langa, K.M., & Iwashyna, T.J. 36 Mertz, D., Kim, T.H., Johnstone, J., (2013). Functional Disability, Lam, P., Science, M., Kuster, S.P., Cognitive Impairment, and Fadel, S.A., Tran, D., Fernandez, E., Depression Following Bhatnagar, N. & Loeb, M. (2013). Hospitalization for Pneumonia. Populations at risk for severe or American Journal of Medicine, complicated in uenza illness: 126(7), 615-624.e5. doi: systematic review and meta-analysis. 10.1016/j.amjmed.2012.12.006 British Medical Journal, 347, f5061. Doi: 10.1136/bmj.f5061
References 59 As One of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously?
41 Seminog, O.O., & Goldacre, M.J. 45 Carriere, G.M., Garner, R., & (2013). Research of pneumonia and Sanmartin, C. (2017). Housing pneumococcal disease in people conditions and respiratory hospitalized with diabetes mellitus: hospitalizations among First Nations English record-linkage studies. people in Canada. Statistics Canada: Diabetic Medicine, 30, 1412-1419. Health Reports, 28(4), 9-15. Doi: 10.1111/dme.12260 Retrieved from: https://www150. statcan.gc.ca/n1/en/pub/82-003-x/2 42 Kwong, J.C., Campitelli, M.A., & 017004/article/14789-eng.pdf?st=W Rosella, L.C. (2011). Obesity and KISJas5 respiratory hospitalizations during in uenza seasons in Ontario, Canada: 46 Health Canada. (2002). An Advisory a cohort study. Clinical infectious Committee Statement (ACS) National diseases: an ocial publication of Advisory Committee on the Infectious Diseases Society of Immunization – Statement on American, 53(5), 413-21. Doi: Recommended Use of Pneumococcal 10.1093/cid/cir442 Conjugate Vaccine. Canada Communicable Disease Report, 28, 43 Helferty, M., Rotondo, J.L., Martin, 1-32. Retrieved from: I., & Desai, S. (2013). The https://www.cfpc.ca/uploadedFiles/R epidemiology of invasive esources/Resource_Items/Health_Pr pneumococcal disease in the ofessionals/PneumococcalVaccine.pd Canadian North from 1999 to 2010. f International Journal of Circumpolar Health, 72.http://dx.doi.org/ 47 Pelton, S.I., Weycker, D., Farkouh, 10.3402/ijch.v72i0.21606 R.A., Strutton, D.R., Shea, K.M., & Edelsberg, J. (2014). Risk of 44 Mahmud, S.M., Sinnock, H., pneumococcal disease in children Mostaco-Guidolin, L.C., Pabla, G., with chronic medical conditions in Wierzbowski, A.K., & Bozat-Emre, S. the era of pneumococcal conjugate (2017). Long-term trends in invasive vaccine. Clinical Infectious Diseases, pneumococcal disease in Manitoba, 59(5), 615-23. Doi: Canada. Human Vaccines & 10.1093/cid/ciu348 Immunotherapies, 13(8), 1884-1891. https://doi.org/10.1080/21645515.20 48 Centers for Disease Control and 17.1320006 Prevention (CDC). (n.d.). Pneumococcal Disease. Retrieved from: https://www.cdc.gov/ vaccines/pubs/pinkbook/downloads /pneumo.pdf
References 60 As One of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously?
49 Gouvernement du Quebec. (2018). 53 Austrian, R. (1999). A Brief History Pneumococcal Conjugate Vaccine. of Pneumococcal Vaccines. Drugs & Retrieved from: https://www.quebec. Aging, 151, 1-10. Doi: ca/en/health/advice-and-prevention 10.2165/00002512-199915001-00001 /vaccination/pneumococcal-conjuga te-vaccine/ 54 World Health Organization. (2012). Measuring impact of Streptococcus 50 Waye, A., Chuck, A.W., Jacobs, P., pneumoniae and Haemophilus Tyrrell, G., & Kellner, J.D. (2015). in uenzae type b conjugate Prevnar 7 Childhood Immunization vaccination. Expanded Programme Program and Serotype Replacement: on Immunization (EPI) of the Changes in Pneumococcal Incidence Department of Immunization, and Resulting Impact on Health Care Vaccines and Biologicals. Retrieved Costs in Alberta (2003-2008). Drugs from: http://apps.who.int/iris/ Real World Outcomes, 2(2), 153-161. bitstream/handle/10665/75835/WHO https://doi.org/10.1007/s40801-015- _IVB_12.08_eng.pdf;jsessionid=8C95 0024-7 DD7BA757F048FA51F2EE3D2D89A4? sequence=1 51 Bettinger, J.A., Scheifele, D.W., Kellner, J.D., Halperin, S.A., Vaudry, 55 Luca, D.L., Kwong, J.C., Chu, A., W., Law, B., Tyrrell, G., for the Sander, B., O’Reilly, R., McGeer, A.J., & Members of the Canadian Bloom, D.E. (2018). Impact of Immunization Monitoring Program, pneumococcal vaccination on Active (IMPACT). (2010). The e ect of pneumonia hospitalizations and routine vaccination on invasive related costs in Ontario: A pneumococcal infections in population-based ecological study. Canadian children, Immunization Clinical Infectious Diseases, 66(4), Monitoring Program, Active 541-547. Doi: 10.1093/cid/cix850 2000-2007. Vaccine, 28, 2130-2136. Doi: 10.1016/j.vaccine.2009.12.026 56 Berical, A.C., Harris, D., Dela Cruz, C.S., & Possick, J.D. (2016). 52 Public Health Agency of Canada. Pneumococcal Vaccination (2018). An Advisory Committee Strategies. An Update and Statement (ACS) National Advisory Perspective. Annals of the American Committee on Immunization (NACI): Thoracic Society, 13(6), 933-944. Doi: Update on the use of pneumococcal 10.1513/AnnalsATS.201511-778FR vaccines in adults 65 years of age and older – A Public Health 57 Westerink, M.A.J., Schroeder, H.W., Perspective. Retrieved from: & Nahm, M.H. (2012). Immune https://www.canada.ca/content/dam Responses to pneumococcal /phac-aspc/documents/services/pub vaccines in children and adults: lications/healthy-living/update-on-t Rationale for age-speci c he-use-of-pneumococcal-vaccines-in vaccination. Aging and Disease, 3(1), -adult/update-on-the-use-of-pneum 51-67. Retrieved from: ococcal-vaccines-in-adult-eng.pdf https://www.ncbi.nlm.nih.gov/pmc/a rticles/PMC3320805/
References 61 As One of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously?
58 Government of Canada. (2018). 63 Assaad, U., El-Masri, I., National Advisory Committee on Porhomayon, J., & El-Solh, A.A. Immunization. Retrieved from: (2012). Pneumonia immunization in https://www.canada.ca/en/public-he older adults: review of vaccine alth/services/immunization/national e ectiveness and strategies. Clinical -advisory-committee-on-immunizati Interventions in Aging, 7, 453-461. on-naci.html Doi: https://dx.doi.org/10.2147%2FCIA.S2 59 Whitney, C.G., Pilishvili, T., Farley, 9675 M.M., Scha ner, W., Craig, A.S., …. & Schuchat, A. (2006). E ectiveness of 64 Christenson, B., Hedlund, J., seven-valent pneumococcal Lundbergh, P., & Ortqvist, A. (2004). conjugate vaccine against invasive Additive preventive e ect of pneumococcal disease: a matched in uenza and pneumococcal case-control study. Lancet, 368, vaccines in elderly persons. The 1495-502.Doi: European Respiratory Journal, 23(3), 10.1016/S0140-6736(06)69637-2 363-8. Retrieved from: https://www.ncbi.nlm.nih.gov/pubm 60 Dowell, S.F., Whitney, C.G., Wright, ed/15065822 C., Rose, C.E., & Schuchatt, A. (2003). Seasonal Patterns of Invasive 65 Kawakami, K., Ohkusa, U., Kuroki, Pneumococcal Disease. (2003). R., Tanaka, T., Koyama, K., Harada, Y., Emerging Infectious Diseases, 9(5), Iwanaga, K., Yamaryo, T., & Oishi, K. 573-579. Retrieved from: (2010). E ectiveness of https://www.ncbi.nlm.nih.gov/pubm pneumococcal polysaccharide ed/12737741 vaccine against pneumonia and cost analysis for the elderly who receive 61 Klugman, K.P. (2011). Contribution seasonal in uenza vaccine in Japan. of vaccines to our understanding of Vaccine, 28(43), 7063-9. Doi: pneumococcal disease. Philosophical 10.1016/j.vaccine.2010.08.010. Transactions of the Royal Society B: Biological Sciences, 366(1579), 66 Jackson, L.A., Neuzil, K.M., Yu, O., 2790-2798. Doi: Benson, P., Barlow, W.E., Adams, A.L., 10.1098/rstb.2011.0032 Hanson, C.A., Mahoney, L.D., Shay, D.K., Thompson, W.W., for the 62 Government of Canada. (2016). Vaccine Safety Datalink. (2003). Page 7: Canadian Immunization E ectiveness of pneumococcal Guide: Part 3 – Vaccination of polysaccharide vaccine in older Speci c Populations. Retrieved from: adults. The New England Journal of https://www.canada.ca/en/public-he Medicine, 348(18), 1747-55. alth/services/publications/healthy-li Retrieved from: ving/canadian-immunization-guide- https://www.nejm.org/doi/pdf/10.10 part-3-vaccination-speci c-populatio 56/NEJMoa022678 ns/page-7-immunization-persons-wi th-chronic-diseases.html
References 62 As One of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously?
67 Ministry of Health and Long-Term 71 Public Health Agency of Canada. Care and Public Health Division (2008). Supplement: Final Report to Toronto. (2018 March). Outcomes from the National Recommendations for the Control of Consensus Conference for Respiratory Infection Outbreaks in Vaccine-Preventable Diseases in Long-Term Care Homes. Retrieved Canada – June 12-14, 2005 – Quebec from: City, Quebec. Retrieved from: http://www.health.gov.on.ca/en/pro/ http://www.phac-aspc.gc.ca/publicat programs/publichealth/oph_standar /ccdr-rmtc/08pdf/34s2-eng.pdf ds/docs/reference/RESP_Infectn_ctrl _guide_LTC_2018_en.pdf 72 British Columbia Immunization Committee (BCIC). (2012). 68 Monto, A. S., Hornbuckle, K., & Pharmacist Access to Publicly OHmit, S.E. (2001). In uenza Vaccine Funded Vaccine in British Columbia: E ectiveness among Elderly Nursing Implementation Guideline – Home Residents: A Cohort Study. Pharmacist and Immunization American Journal of Epidemiology, Working Group. Retrieved from: 154(2), 155-60. Retrieved from: https://www.interiorhealth.ca/sites/P https://www.ncbi.nlm.nih.gov/pubm artners/ImmunizationResourcesTools ed/11447049 /Documents/Pharmacist%20Provinci al%20Implementation%20Guideline. 69 Chan, T.C., Fan-Ngai Hung, I., pdf Ka-Hay Luk, J., Chu, L.W., & Hon-Wai Chan F. (2014). E ectiveness of 73 HealthLink BC. (2017 March). in uenza vaccination in Pneumococcal Polysaccharide institutionalized older adults: a Vaccine. Retrieved from: systematic review. Journal of the https://www.healthlinkbc.ca/healthli American Medical Directors nkbc- les/pneumococcal-polysaccha Association, 15(3), 226.e1-226.e6. ride-vaccine doi: 10.1016/j.jamda.2013.10.008 74 HealthLink BC. (2017 July). 70 Government of Canada. (2016). Pneumococcal Conjugate (PCV13) Vaccine uptake in Canadian adults: Vaccine. Retrieved from: Results from the 2014 adult National https://www.healthlinkbc.ca/healthli Immunization Coverage Survey. nkbc- les/pcv-13-vaccine Retrieved from: https://www.canada. ca/en/public-health/services/publica 75 MyHealth Alberta. (2017). tions/healthy-living/vaccine-uptake- Pneumococcal Vaccines. Retrieved canadian-adults-results-2014-adult-n from: https://myhealth.alberta.ca ational-immunization-coverage-surv /alberta/Pages/pneumococcal-polys ey.html accharide-immunization-faqs.aspx
References 63 As One of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously?
76 Alberta Health Services. (2014 82 Government of Manitoba. (n.d.). October 17). Pneumococcal Frequently Asked Questions and Polysaccharide Immunization Answers about Vaccines. Retrieved Clinical Guidelines 2014/2015. from: https://www.gov.mb.ca/health Retrieved from: https://www. /publichealth/cdc/div/about.html#c albertahealthservices.ca/assets/healt hinfo/hi- u-clinical-guidelines-pneu 83 Government of Manitoba. (2018 mococcal-polysaccharide.pdf March). Manitoba’s Immunization Program: Vaccines O ered 77 Alberta Health Services. (2017 Free-of-Charge (Eligibility Criteria for January 1). Pneumococcal Conjugate Publicly-Funded Vaccines. Retrieved (Pneu-C13) Vaccine. Retrieved from: from: https://www.gov.mb.ca/ https://www.albertahealthservices.c health/publichealth/cdc/vaccineeligi a/assets/info/hp/cdc/if-hp-cdc-pneu bility.html -conjate-vac-info-sht-07-291-r01.pdf 84 Government of Ontario. (2015). 78 Government of Saskatchewan. Immunization: Pneumococcal (2018). Immunization Services. Polysaccharide Vaccine. Retrieved Retrieved from: https://www. from: http://www.health.gov.on.ca/ saskatchewan.ca/residents/health/ac en/public/publications/immune/ cessing-health-care-services/immuni pnem.aspx zation-services 85 Pharmacy Connection. (2017 79 Saskatchewan College of Pharmacy Winter). Pharmacists Now Authorized Professionals. (2017). Administration to Administer Additional Vaccines. of Drugs by Injection Supplementary Retrieved from: http://www.ocpinfo. Guidelines for Pharmacists. Retrieved com/library/pharmacy-connection/d from: https://scp.in1touch.org/ ownload/OCP_PharmacyConnection document/3616/ _Winter2017_AdditionalVaccines.pdf
80 Government of Saskatchewan. 86 Government of Ontario. (2016 (2016 September). Pneumococcal December). Publicly Funded Polysaccharide 23 Vaccine. Retrieved Immunization Schedules for Ontario from: http://publications.gov.sk.ca/ – December 2016. Retrieved from: documents/13/108111-Pneu-P-23%2 http://www.health.gov.on.ca/en/pro/ 0April%202017.pdf programs/immunization/docs/immu nization_schedule.pdf 81 Government of Saskatchewan. (2017 April). Pneumococcal 87 Gouvernement du Quebec. (2018). Conjugate 13 Vaccine. Retrieved Quebec Immunisation Program. from: http://publications.gov.sk.ca/ Retrieved from: https://www. documents/13/108097-Pneu-C-13%2 quebec.ca/en/health/advice-and- 0April%202017.pdf prevention/vaccination/quebec-imm unisation-program/#c2566
References 64 As One of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously?
88 Sante et Services Sociaux Quebec. 94 Prince Edward Island. (2018 (2017). Vaccine against January). Prince Edward Island Adult pneumococcal infections. Retrieved Immunization Detailed Schedule. from: http://publications.msss.gouv. Department of Health and Wellness qc.ca/msss/ chiers/2017/17-213-01A Chief Public Health Oce: Prince .pdf Edward Island. Retrieved from: https://www.princeedwardisland.ca/sit 89 Nova Scotia. (n.d.). Routine es/default/ les/publications/ai_detail Immunization Schedules for ed_sch_jan2018.pdf Children, Youth & Adults. Retrieved from: https://novascotia.ca/dhw/ 95 Government of Prince Edward CDPC/documents/Routine-Immuniza Island. (2018). Childhood tion-Schedules-for-Children-Youth-A Immunizations. Retrieved from: dults.pdf https://www.princeedwardisland.ca/e n/information/health-and-wellness/chi 90 Capital Health. (2011). Medication ldhood-immunizations Manual – Policy & Procedure. Retrieved from: http://policy. 96 Government of Newfoundland and nshealth.ca/Site_Published/Provincia Labrador. (2018 May). Immunization l/document_render.aspx?documentR Programs for High Risk Groups. ender.IdType=6&documentRender.G Retrieved from: http://www.health. enericField=&documentRender.Id=5 gov.nl.ca/health/publichealth/cdc/im_ 3122 section5.pdf
91 Government of Nova Scotia. 97 Government of Newfoundland and (2013). Adult Pneumococcal Labrador. (2018 May). Routine Vaccination Guide for Health Care Immunization Products. Retrieved Professionals. Retrieved from: from: https://www.health.gov.nl.ca/ https://www.cdha.nshealth.ca/syste health/publichealth/cdc/Section3_Rou m/ les/sites/833/documents/adult-p tine_Immunization_Products_May_20 neumococcal-vaccination-guide.pdf. 18.pdf
92 Horizon Health Network. (2018). 98 Yukon Immunize. (2018). Get Immunization. Retrieved from: Immunized. Retrieved from: http:// http://en.horizonnb.ca/facilities-and- yukonimmunization.ca/get-vaccinated services/services/public-health-prog rams/immunization.aspx 99 Yukon Health and Social Services. (2018 March). Section 8 – Biological 93 Government of New Brunswick. Products. Community Health (2018 July). Standard 3.3 – Eligibility Programs: Immunization Program. Criteria for Publicly Funded Retrieved from: http://www.hss.gov. Vaccines/Biologics. Retrieved from: yk.ca/pdf/im_manual_section8.pdf http://www2.gnb.ca/content/dam/g nb/Departments/h-s/pdf/en/CDC/He althProfessionals/NBIPG-standard3-3 -e.pdf
References 65 As One of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously?
100 Government of Nunavut. (2017 105 Centers for Disease Control and December). 9.0 Active Immunization Prevention [CDC]. (2017b). Protocols. Retrieved from: https:// Pneumococcal Vaccination: Summary www.gov.nu.ca/sites/default/ les/9. of Who and When to Vaccinate. 0_active_immunization_protocols_- Retrieved from: _april_20_2018_with_factsheets.pdf https://www.cdc.gov/vaccines/vpd/pn eumo/hcp/who-when-to-vaccinate.ht 101 Government of Northwest ml Territories. (2018 April). NWT Immunization Schedule. Retrieved 106 World Health Organization. (2012). from: https://www.hss.gov.nt.ca/ Weekly epidemiological record. 87(14), sites/hss/ les/immunization-schedul 129-144. Retrieved from: e-general-public.pdf http://www.who.int/wer/2012/wer871 4.pdf?ua=1 102 European Centre for Disease Prevention and Control (ECDC). 107 MacDougall, D.W., Halperin, B.A., (2018). Vaccine Scheduler – MacKinnon-Cameron, D., Li, L., McNeil, Pneumococcal Disease: S.A., Langley, J.M., & Halperin, S.A. Recommended vaccinations. (2015). The challenge of vaccinating Retrieved from: https://vaccine- adults: attitudes and beliefs of the schedule.ecdc.europa.eu/Scheduler/ Canadian public and healthcare ByDisease?SelectedDiseaseId=25&Se providers. British Medical Journal lectedCountryIdByDisease=-1 Open, 5, e009062. Doi: 10.1136/bmjopen-2015-009062 103 Centers for Disease Control and Prevention [CDC]. (2017a). 108 Schneeberg, A., Bettinger, J.A., Pneumococcal Vaccine McNeil, S., Ward, B.J., Dionne, M., Recommendations. Retrieved from: Cooper, C., Coleman, B., Loeb, M., https://www.cdc.gov/vaccines/vpd/p Rubinsteain, E., McElhaney, J., neumo/hcp/recommendations.html Scheifele, D.W., & Halperin, S.A. (2014). Knowledge, attitudes, beliefs and 104 Tomczyk S., Bennett, N.M., behaviours of older adults about Stoecker, C., Gierke, R., Moore, M.R., pneumococcal immunization, a Public Whitney, C.G., Halder, S., & Pilishvili, Health Agency of Canada/Canadian T. (2014). Use of 13-Valent Institutes of Health Research In uenza Pneumococcal Conjugate Vaccine Research Network (PCIRN) and 23-Valent Pneumococcal investigation. BMC Public Health, Polysaccharide Vaccine Among 14(442), 1-9. http://www. Adults Aged ≥65 Years: biomedcentral.com/1471-2458/14/442 Recommendations of the Advisory Committee on Immunization 109 Ipsos. (2016). PneuVUE – Adult Practices (ACIP). Retrieved from: Pneumonia Vaccine Understanding in https://www.cdc.gov/mmwr/preview Europe: A New View into Pneumonia /mmwrhtml/mm6337a4.htm Among Older Adults.
References 66 As One of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously?
110 Krueger, P., Amant, O.S., & Loeb, 115 Mandell, L.A., Marrie, T.J., Grossman, M. (2010). Predictors of R.F., Chow, A.W., Hyland, R.H., & the pneumococcal vaccination among Canadian Community-Acquired older adults with pneumonia: Pneumonia Working Group. (2000). ndings form the Community Canadian Guidelines for the Initial Acquired Pneumonia Impact Study. Management of Community-Acquired BMC Geriatrics, 10(44). https://doi. Pneumonia: An Evidence-Based Update org/10.1186/1471-2318-10-44 by the Canadian Infectious Diseases Society and the Canadian Thoracic 111 Lau, D., Hu, J., Majumdar, S.R., Society. Clinical Infectious Diseases, 31, Storie, D.A., Rees, S.E., & Johnson, 383-421. Doi: 10.1086/313959 J.A. (2012). Interventions to improve 116 in uenza and pneumococcal Vernet, G., Saha, S., Satzke, C., vaccination rates among Burgess, D.H., Alderson, M., acommunity-dwelling adults: A Maisonneuve, J.F., Beall, B.W., Steinho , systematic review and meta-analysis. M.C., & Klugman, K.P. (2011). Annals of Family Medicine, 10(6), Laboratory-based diagnosis of 538-546. Doi: 10.1370/afm.1405 pneumococcal pneumonia: state of the art and unmet needs. Clinical 112 Jindracek, L, & Stark, J.E (2018). Microbiology and Infection, 17(3), 1-13. Identifying missed opportunities for Doi: 10.1111/j.1469-0691.2011. the pneumococcal conjugate vaccine 03496.x (PCV13). Journal of Pharmacy 117 Young Song, J., Wook Eun, B., & Technology, 34(1), 24-27. Doi: Nahm, M.H. (2013). Diagnosis of 10.1177/8755122517740364 Pneumococcal Pneumonia: Current Pitfalls and the Way Forward. Infection 113 De Wals, P., Boulianne, N., Sevin, & Chemotherapy, 45(4), 351-366. Doi: E., Ouakki, M., Deceuninck, G., & 10.3947/ic.2013.45.4.351 Guay, M. (2009). Uptake of Pneumococcal Conjugate Vaccine: 118 Wunderink, R.G., Self, W.H., Waterer, Methodological Issues in G.W., Anderson, E., Balk, R., Fakhran, S., Measurement and Impact of Publicly Courtner, D., Qi, C., Williams, D., Zhu, Y., Funded Programs. Canadian Journal Hicks, L., Whitney, C.G., Moore, M.R., of Public Health, 100(6), 413-16. Carvalho, M.D.G., Bramley, A., Jain, S., Retrieved from: Edwards, K., & Grijalva, C.G. (2014). https://www.ncbi.nlm.nih.gov/pubm Occult Pneumococcal Community- ed/20209732 Acquired Pneumonia (cap) in the Cdc Etiology of Pneumonia in the 114 Government of Canada. (2017). Community (epic) Study Detected by National Immunization Strategy. Serotype-Speci c Urinary Antigen Retrieved from: https://www. Detection (ssuad). American Journal of canada.ca/en/public-health/services Respiratory and Critical Care Medicine, /immunization-vaccine-priorities/nat 189, 1. Retrieved from: https://www. ional-immunization-strategy.html atsjournals.org/doi/abs/10.1164/ajrccm -conference.2014.189.1_MeetingAbstra cts.A4639 References 67 As One of Canada’s Top Killers, Why Isn’t Pneumonia Taken More Seriously?
119 Pride, M.W., Huijts, S.M., Wu, K., 124 Government of Ontario. (2016 Souza, V., Passador, S., Tinder, C., March). Schedule of Bene ts – Song, E., Elfassy, A., McNeil, L., Physician Services Under the Health Menton, R., French, R., Callahan, J., Insurance Act. Retrieved from: Webber, C., Gruber, W.C., Bonten, http://www.health.gov.on.ca/en/pro/p M.J.M., & Jansen, K.U. (2012). rograms/ohip/sob/physserv/sob_mast Validation of an Immunodiagnostic er20160401.pdf Assay for Detection of 13 Streptococcus pneumoniae 125 The Lung Association. (2017). Serotype-speci c polysaccharides in Prevent Lung Disease. Retrieved from: human urine. Clinical and Vaccine https://www.lung.ca/lung-health/prev Immunology, 19(8), 1131-1141. Doi: ent-lung-disease 10.1128/CVI,00064-12 126 World Health Organization. (2008). 120 Government of Canada. (2018). Weekly epidemiological record. 83(42), Noti able diseases online. Retrieved 373-384. Retrieved from: from: http://diseases.canada. http://www.who.int/wer/2008/wer834 ca/noti able/ 2.pdf?ua=1
121 Pan-Canadian Public Health 127 Weinberger, B. (2018). Vaccines for Network. (2016 April). Antimicrobial the elderly: current use and future Resistance Surveillance Data challenges. Immunity & Ageing, 15(3), Requirements for Priority Organisms: 1-8. Doi: 10.1186/s12979-017-0107-2 The Communicable and Infectious Disease Steering Committee 128 Daniels, C.C., Rogers, D., & Shelton, Antimicrobial Resistance C.M. (2016). A review of pneumococcal Surveillance Task Group. Final Report vaccines: Current polysaccharide to the Public Health Network vaccine recommendations and future Council. Retrieved from: http:// protein antigens. Journal of Pediatric www.phn-rsp.ca/pubs/arsdrpo-dsecr Pharmacology and Therapeutics, 21(1), ao/pdf/arsdrpo-dsecrao-eng.pdf 27-35. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/art 122 Canadian Institute for Health icles/PMC4778694/pdf/i1551-6776-21- Information (CIHI). (2001 1-27.pdf September). Respiratory Disease in Canada. Retrieved from: 129 Government of Canada. (2016). https://secure.cihi.ca/free_products/ Page 6: Canadian Immunization Guide: RespiratoryComplete.pdf Part 3 – Vaccination of Speci c Populations. Retrieved from: 123 Canadian Immunization Research https://www.canada.ca/en/public-heal Network [CIRN]. (2018). Serious th/services/publications/healthy-livin Outcomes Surveillance (SOS) g/canadian-immunization-guide-part- Network. Retrieved from: 3-vaccination-speci c-populations/pa http://cirnetwork.ca/network/serious ge-6-immunization-patients-health-ca -outcomes/ re-institutions.html
References 68 Funding for this report was generously provided by P zer Canada in the form of an unrestricted educational grant. All of the research, writing, and recommendations herein have been independently produced by the NIA on the basis of sound evidence. To learn more about the NIA visit our website at http://www.ryerson.ca/nia and follow us on twitter @RyersonNIA