Changes in Invasive Pneumococcal Disease among HIV-Infected Adults Living in the Era of Childhood Pneumococcal Immunization

3 January 2006 | Volume 144 Issue 1 | Pages 1-9

Background: Adults infected with HIV have high rates of invasive pneumococcal disease. Introduction of pneumococcal conjugate vaccine for children could affect disease among HIV-infected adults.

Objective: To compare invasive pneumococcal disease among HIV-infected adults before and after the introduction of a pediatric conjugate vaccine.

Design: Active laboratory-based surveillance in an adult population of 10.8 million, including 38 314 living with AIDS.

Setting: 7 Active Bacterial Core surveillance areas in the United States.

Patients: All surveillance-area residents 18 to 64 years of age with Streptococcus pneumoniae isolated from a sterile site between 1998 and 2003.

Measurements: Ratio of the number of cases of invasive pneumococcal disease among HIV-infected adults to the estimated number of adults 18 to 64 years of age living with AIDS; serotype-specific subset analyses; and comparison of periods before and after introduction of conjugate vaccine by using exact tests.

Results: Of 8582 cases of invasive pneumococcal disease in adults, 2013 (24%) occurred among persons infected with HIV. Between baseline (1998 to 1999) and 2003, the ratio of invasive pneumococcal disease in HIV-infected adults to the number of adults living with AIDS in the surveillance areas decreased from 1127 to 919 cases per 100 000 AIDS population, a reduction of 19% (P = 0.002). Among HIV-infected adults, the ratio for disease caused by pneumococcal serotypes included in the conjugate vaccine decreased 62% (P < 0.001), although the ratio for disease caused by nonvaccine serotypes increased 44% (P < 0.001).

Limitations: Ratios are proxy measures of incidence rates. The denominator of surveillance-area residents living with HIV infection was not available.

Conclusions: Introduction of the pediatric conjugate vaccine was associated with an overall decrease in invasive pneumococcal disease among HIV-infected adults, despite increased disease caused by nonvaccine serotypes.

Editors' Notes Context Routine pneumococcal conjugate vaccination for infants began in 2000. Its use markedly decreased invasive pneumococcal disease among children, but did it influence rates of disease among HIV-infected adults? Contribution Between 1998 and 2003, invasive pneumococcal disease among adults infected with HIV living in 7 surveillance areas in the United States decreased from 1127 to 919 cases per 100 000 adults with AIDS. Disease caused by serotypes in the vaccine decreased 62%, whereas disease caused by nonvaccine serotypes increased 44%. Implications Indirect evidence suggests that pediatric vaccine use is associated with a decreased incidence of pneumococcal disease among HIV-infected adults. —The Editors

 

Author and Article Information

From National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia; Connecticut Emerging Infections Program, Hartford, Connecticut; Maryland Emerging Infections Program and Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Emory University School of Medicine and the Veterans Affairs Medical Center, Atlanta, Georgia; School of Public Health, University of California, Berkeley, California; Vanderbilt Medical Center, Nashville, Tennessee; Minnesota Emerging Infections Program, Minnesota Department of Health, Minneapolis, Minnesota; Oregon Emerging Infections Program, Department of Human Services, Portland, Oregon; and HIV Incidence and Case Surveillance Branch, Division of HIV/AIDS Prevention, National Center for HIV, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia.

Note: This paper was presented in part at the 4th International Symposium on Pneumococci and Pneumococcal Diseases, Helsinki, Finland, 9 to 13 May 2004 (abstract EPI-05), and at the 42nd Annual Meeting of the Infectious Diseases Society of America, Boston, Massachusetts, 30 September to 3 October 2004 (abstract 746).

Acknowledgments: The authors thank the study personnel from the following institutions: Centers for Disease Control and Prevention; the Active Bacterial Core surveillance sites; Minnesota Department of Health; and the University of Texas Health Science Center. They also thank the AIDS surveillance officers.

Grant Support: By the Emerging Infections Program of the Centers for Disease Control and Prevention.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Brendan Flannery, PhD, Respiratory Diseases Branch, Division of Bacterial and Mycotic Diseases, Centers for Disease Control and Prevention, 1600 Clifton Road NE, MS C-23, Atlanta, GA 30333; e-mail, bflannery{at}cdc.gov.

Current Author Addresses: Drs. Flannery, Campsmith, Li, Whitney, and Schuchat: Centers for Disease Control and Prevention, 1600 Clifton Road NE, Atlanta, GA 30333.

Mr. Heffernan: Connecticut Emerging Infections Program, 410 Capital Avenue, Hartford, CT 06134.

Dr. Harrison: Johns Hopkins University, 615 North Wolfe Street, Baltimore, MD 21205.

Dr. Ray: Emory University School of Medicine, 69 Jesse Hill Jr. Drive SE, Atlanta, GA 30303.

Dr. Reingold: University of California, Berkeley, 140 Warren, Berkeley, CA 94720-7360.

Dr. Hadler: Connecticut Department of Public Health, 410 Capital Avenue, MS 11 FDS, Hartford, CT 06134-0308.

Dr. Schaffner: Vanderbilt University Medical School, A-1124 MCN, Nashville, TN 37232.

Dr. Lynfield: Minnesota Department of Health, 717 Delaware Street SE, Minneapolis, MN 55414.

Dr. Thomas: Oregon Department of Human Services, 800 NE Oregon Street, Portland, OR 97212.

Author Contributions: Conception and design: B. Flannery, L.H. Harrison, A.L. Reingold, J. Hadler, A.R. Thomas, A. Schuchat.

Analysis and interpretation of the data: B. Flannery, R.T. Heffernan, A.L. Reingold, A.R. Thomas, J. Li, C.G. Whitney, A. Schuchat.

Drafting of the article: B. Flannery, A.L. Reingold, M. Campsmith.

Critical revision of the article for important intellectual content: L.H. Harrison, S.M. Ray, A.L. Reingold, J. Hadler, W. Schaffner, R. Lynfield, A.R. Thomas, J. Li, M. Campsmith, C.G. Whitney, A. Schuchat.

Final approval of the article: B. Flannery, L.H. Harrison, S.M. Ray, A.L. Reingold, J. Hadler, W. Schaffner, R. Lynfield, A.R. Thomas, J. Li, M. Campsmith, C.G. Whitney, A. Schuchat.

Provision of study materials or patients: J. Hadler, W. Schaffner, R. Lynfield.

Statistical expertise: J. Li.

Obtaining of funding: C.G. Whitney, A. Schuchat.

Administrative, technical, or logistic support: A.L. Reingold, W. Schaffner, R. Lynfield, C.G. Whitney.

Collection and assembly of data: R.T. Heffernan, S.M. Ray, J. Hadler, W. Schaffner, A.R. Thomas.

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