NIHR Signal Pneumococcal vaccines for people with COPD reduce their chance of catching pneumonia

Published on 30 May 2017

Pneumococcal vaccines reduce the risk of community-acquired pneumonia in people with moderate to severe chronic obstructive pulmonary disease (COPD).

Pneumococcal vaccination is currently recommended for people with COPD and other respiratory diseases. However, until now there has been a lack of data whether it actually improves outcomes in these groups. 

This updated Cochrane review identified 12 trials including 2171 adults with COPD, comparing those who did and did not receive pneumococcal vaccination. One episode of community-acquired pneumonia was prevented for every 21 people vaccinated. There was also evidence that vaccination reduced the risk of exacerbations of COPD. However, vaccination had no effect on deaths from respiratory causes or likelihood of hospitalisation.

This evidence lends further support to current government recommendations to provide the pneumococcal vaccine to people with COPD.

Pneumococcal vaccines for people with COPD reduce their chance of catching pneumonia

Why was this study needed?

COPD involves irreversible, usually progressive, shortness of breath and frequent chest infections. It affects around three million people in the UK, predominantly adults aged over 40 years who have smoked. In 2005, the Department of Health estimated an annual direct NHS healthcare cost of COPD of over £800 million. COPD led to over 113,000 emergency hospital admissions in 2013-2014.

People with COPD are at greater risk of pneumonia and its complications than healthy adults, and Streptococcus pneumoniae bacteria is a common cause, though not always identified as a cause of exacerbations of COPD. In the UK, a vaccine is recommended to protect at-risk adults, including those with COPD. However, much evidence for the effect of the vaccine comes from observational studies or trials in people without COPD.

This updated Cochrane review aimed to gather the available evidence to see whether vaccination prevents community-acquired pneumonia and improves other outcomes for people with COPD.

What did this study do?

The review identified 12 randomised controlled trials (five additional since the last review) including 2171 adults with moderate or severe COPD. Eligible trials compared people receiving a pneumococcal vaccine with a group receiving a placebo, no treatment or alternative vaccine. Trial participants were an average 66 years old. Vaccines were almost all of the polysaccharide type.

There was potential for bias around the lack of blinding of participants and personnel. There was little variability in the results of the individual trials making it appropriate to pool their findings. The overall quality of evidence for reducing pneumonia across six trials was assessed as moderate.

What did it find?

  • Pneumococcal vaccines reduced the risk of community-acquired pneumonia, though very few of these in the control group were identified as pneumococcal pneumonia. Nine percent of vaccinated participants developed pneumonia in the 36 months after vaccination, compared with 14% of the control group (odds ratio [OR] 0.62, 95% confidence interval [CI] 0.43 to 0.89; six trials, 1372 adults).
  • The researchers calculated that 21 people would need to be vaccinated to avoid one episode of community-acquired pneumonia (95% CI 15 to 74 people).
  • Vaccination also reduced risk of acute  exacerbations of COPD, which occurred in 48% of participants up to 24 months after vaccination, compared with 61% of the control group (OR 0.60, 95% CI 0.39 to 0.93; four trials, 446 adults). An estimated eight people would need to be vaccinated to prevent one acute exacerbation (95% CI 5 to 58).
  • There was no difference between groups in mortality rate or deaths from respiratory disease (up to 48 months after vaccination) or likelihood of hospital admission (up to 12 months after vaccination).

What does current guidance say on this issue?

Public Health for England’s Green Book (2013) recommends the polysaccharide PPV-23 vaccine for all adults aged 65 and over, and other children or adults with risk factors, which includes COPD and other respiratory diseases. Current NICE guidelines on management of COPD (due for update in 2018) also recommend pneumococcal vaccination. 

The Joint Committee on Vaccination and Immunisation stated in 2015 that there was no evidence that the PPV-23 vaccine reduced risk of community-acquired pneumonia or mortality in over-65s and at-risk groups.

What are the implications?

For the first time, we have systematic review evidence specific to COPD to support government recommendations to provide pneumococcal vaccination for this group.

There isn’t yet sufficient evidence to decide which is the best type of vaccine (conjugate or polysaccharide) or to conclude if there are differences in their cost effectiveness.

Health Protection Agency statistics (2009) showed only half of people aged 16-64 years with chronic respiratory disease receive pneumococcal vaccination. This was lower than the 75% uptake for all adults aged 65+ years. So it would be helpful to explore any barriers to vaccine uptake among people with COPD.

Citation and Funding

Walters JA, Tang JN, Poole P, Wood-Baker R. Pneumococcal vaccines for preventing pneumonia in chronic obstructive pulmonary disease. Cochrane Database
Syst Rev. 2017;1:CD001390.

This project was supported by the National Institute for Health Research (NIHR), via Cochrane Infrastructure funding to the Cochrane Airways Review Group.

Bibliography

NHS Choices. COPD. London: Department of Health; 2016.

NHS Choices. Pneumococcal vaccine. London: Department of Health; 2016.

NICE. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. CG101. London: National Institute for Health and Care Excellence; 2010.

NICE. Chronic obstructive pulmonary disease: Costing report: Implementing NICE guidance. CG101. London: National Institute for Health and Care Excellence; 2011.

PHE. Pneumococcal: the green book, chapter 25. London: Public Heath England; 2013.

JCVI. JCVI interim statement on adult pneumococcal vaccination in the UK. London: Joint Committee on Vaccination and Immunisation; 2015.

Why was this study needed?

COPD involves irreversible, usually progressive, shortness of breath and frequent chest infections. It affects around three million people in the UK, predominantly adults aged over 40 years who have smoked. In 2005, the Department of Health estimated an annual direct NHS healthcare cost of COPD of over £800 million. COPD led to over 113,000 emergency hospital admissions in 2013-2014.

People with COPD are at greater risk of pneumonia and its complications than healthy adults, and Streptococcus pneumoniae bacteria is a common cause, though not always identified as a cause of exacerbations of COPD. In the UK, a vaccine is recommended to protect at-risk adults, including those with COPD. However, much evidence for the effect of the vaccine comes from observational studies or trials in people without COPD.

This updated Cochrane review aimed to gather the available evidence to see whether vaccination prevents community-acquired pneumonia and improves other outcomes for people with COPD.

What did this study do?

The review identified 12 randomised controlled trials (five additional since the last review) including 2171 adults with moderate or severe COPD. Eligible trials compared people receiving a pneumococcal vaccine with a group receiving a placebo, no treatment or alternative vaccine. Trial participants were an average 66 years old. Vaccines were almost all of the polysaccharide type.

There was potential for bias around the lack of blinding of participants and personnel. There was little variability in the results of the individual trials making it appropriate to pool their findings. The overall quality of evidence for reducing pneumonia across six trials was assessed as moderate.

What did it find?

  • Pneumococcal vaccines reduced the risk of community-acquired pneumonia, though very few of these in the control group were identified as pneumococcal pneumonia. Nine percent of vaccinated participants developed pneumonia in the 36 months after vaccination, compared with 14% of the control group (odds ratio [OR] 0.62, 95% confidence interval [CI] 0.43 to 0.89; six trials, 1372 adults).
  • The researchers calculated that 21 people would need to be vaccinated to avoid one episode of community-acquired pneumonia (95% CI 15 to 74 people).
  • Vaccination also reduced risk of acute  exacerbations of COPD, which occurred in 48% of participants up to 24 months after vaccination, compared with 61% of the control group (OR 0.60, 95% CI 0.39 to 0.93; four trials, 446 adults). An estimated eight people would need to be vaccinated to prevent one acute exacerbation (95% CI 5 to 58).
  • There was no difference between groups in mortality rate or deaths from respiratory disease (up to 48 months after vaccination) or likelihood of hospital admission (up to 12 months after vaccination).

What does current guidance say on this issue?

Public Health for England’s Green Book (2013) recommends the polysaccharide PPV-23 vaccine for all adults aged 65 and over, and other children or adults with risk factors, which includes COPD and other respiratory diseases. Current NICE guidelines on management of COPD (due for update in 2018) also recommend pneumococcal vaccination. 

The Joint Committee on Vaccination and Immunisation stated in 2015 that there was no evidence that the PPV-23 vaccine reduced risk of community-acquired pneumonia or mortality in over-65s and at-risk groups.

What are the implications?

For the first time, we have systematic review evidence specific to COPD to support government recommendations to provide pneumococcal vaccination for this group.

There isn’t yet sufficient evidence to decide which is the best type of vaccine (conjugate or polysaccharide) or to conclude if there are differences in their cost effectiveness.

Health Protection Agency statistics (2009) showed only half of people aged 16-64 years with chronic respiratory disease receive pneumococcal vaccination. This was lower than the 75% uptake for all adults aged 65+ years. So it would be helpful to explore any barriers to vaccine uptake among people with COPD.

Citation and Funding

Walters JA, Tang JN, Poole P, Wood-Baker R. Pneumococcal vaccines for preventing pneumonia in chronic obstructive pulmonary disease. Cochrane Database
Syst Rev. 2017;1:CD001390.

This project was supported by the National Institute for Health Research (NIHR), via Cochrane Infrastructure funding to the Cochrane Airways Review Group.

Bibliography

NHS Choices. COPD. London: Department of Health; 2016.

NHS Choices. Pneumococcal vaccine. London: Department of Health; 2016.

NICE. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. CG101. London: National Institute for Health and Care Excellence; 2010.

NICE. Chronic obstructive pulmonary disease: Costing report: Implementing NICE guidance. CG101. London: National Institute for Health and Care Excellence; 2011.

PHE. Pneumococcal: the green book, chapter 25. London: Public Heath England; 2013.

JCVI. JCVI interim statement on adult pneumococcal vaccination in the UK. London: Joint Committee on Vaccination and Immunisation; 2015.

Pneumococcal vaccines for preventing pneumonia in chronic obstructive pulmonary disease

Published on 25 January 2017

Walters, J. A.,Tang, J. N.,Poole, P.,Wood-Baker, R.

Cochrane Database Syst Rev Volume 1 , 2017

BACKGROUND: People with chronic obstructive pulmonary disease (COPD) are at increased risk of pneumococcal disease, especially pneumonia, as well as acute exacerbations with associated morbidity and healthcare costs. OBJECTIVES: To determine the efficacy of injectable pneumococcal vaccination for preventing pneumonia in persons with COPD. SEARCH METHODS: We searched the Cochrane Airways COPD Trials Register and the databases CENTRAL, MEDLINE and Embase, using prespecified terms. Searches are current to November 2016. SELECTION CRITERIA: We included randomised controlled trials (RCT) comparing injectable pneumococcal polysaccharide vaccine (PPV) or pneumococcal conjugated vaccine (PCV) versus a control or alternative vaccine type in people with COPD. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methodological procedures. For meta-analyses, we subgrouped studies by vaccine type. MAIN RESULTS: For this update, we added five studies (606 participants), meaning that the review now includes a total of 12 RCTs involving 2171 participants with COPD. Average age of participants was 66 years, male participants accounted for 67% and mean forced expiratory volume in one second (FEV1) was 1.2 L (five studies), 54% predicted (four studies). We assessed risks of selection, attrition and reporting bias as low, and risks of performance and detection bias as moderate.Compared with control, the vaccine group had a lower likelihood of developing community-acquired pneumonia (CAP) (odds ratio (OR) 0.62, 95% confidence interval (CI) 0.43 to 0.89; six studies, n = 1372; GRADE: moderate), but findings did not differ specifically for pneumococcal pneumonia (Peto OR 0.26, 95% CI 0.05 to 1.31; three studies, n = 1158; GRADE: low). The number needed to treat for an additional beneficial outcome (NNTB) (preventing one episode of CAP) was 21 (95% CI 15 to 74). Mortality from cardiorespiratory causes did not differ between vaccine and control groups (OR 1.07, 95% CI 0.69 to 1.66; three studies, n = 888; GRADE: moderate), nor did all-cause mortality differ (OR 1.00, 95% CI 0.72 to 1.40; five studies, n = 1053; GRADE: moderate). The likelihood of hospital admission for any cause, or for cardiorespiratory causes, did not differ between vaccine and control groups. Vaccination significantly reduced the likelihood of a COPD exacerbation (OR 0.60, 95% CI 0.39 to 0.93; four studies, n = 446; GRADE: moderate). The NNTB to prevent a patient from experiencing an acute exacerbation was 8 (95% CI 5 to 58). Only one study (n = 181) compared the efficacy of different vaccine types - 23-valent PPV versus 7-valent PCV - and reported no differences for CAP, all-cause mortality, hospital admission or likelihood of a COPD exacerbation, but investigators described a greater likelihood of some mild adverse effects of vaccination with PPV-23. AUTHORS' CONCLUSIONS: Injectable polyvalent pneumococcal vaccination provides significant protection against community-acquired pneumonia, although no evidence indicates that vaccination reduced the risk of confirmed pneumococcal pneumonia, which was a relatively rare event. Vaccination reduced the likelihood of a COPD exacerbation, and moderate-quality evidence suggests the benefits of pneumococcal vaccination in people with COPD. Evidence was insufficient for comparison of different pneumococcal vaccine types.

The recommended 23-valent pneumococcal polysaccharide vaccine (PPV-23) contains material from 23 different strains of Streptococcus pneumoniae bacteria. This is thought to cover the majority of strains that cause serious pneumococcal infection in adults.

Expert commentary

Pneumococcal immunisation aims to protect patients with COPD as they are more likely than others to get a serious pneumococcal infection. This immunisation protects but not in the way you would expect. Immunisation reduces acute exacerbations of COPD and community acquired pneumonia but has no effect on cardiorespiratory and all-cause mortality, hospital admissions, or even confirmed pneumococcal pneumonia. You have to wonder that if it doesn’t do what you think it’s doing then what is it doing and does this really benefit patients? Would using patient reported outcomes be a better measure of useful effectiveness?

Dr Terrence Kemple, GP, NHS England

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