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

  1. Brendan Flannery, PhD;
  2. Richard T. Heffernan, MPH;
  3. Lee H. Harrison, MD;
  4. Susan M. Ray, MD;
  5. Arthur L. Reingold, MD;
  6. James Hadler, MD, MPH;
  7. William Schaffner, MD;
  8. Ruth Lynfield, MD;
  9. Ann R. Thomas, MD, MPH;
  10. Jianmin Li, DPE;
  11. Michael Campsmith, DDS, MPH;
  12. Cynthia G. Whitney, MD, MPH; and
  13. Anne Schuchat, MD
  1. 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.

    Abstract

    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.

    Article and Author Information

    • 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.

    Responses to this article

    • Increased Prevalence of Pediatric Pneumococcal
      • Lawrence A. Cone and
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      Ann Intern Med published online October 26, 2009
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