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Introduction: Vaccinations are an essential aspect of preventive medicine. In October 2021, the pneumococcal conjugate vaccine-20 (PCV-20) and PCV-15 were authorized for use in adults by the U.S. FDA. In 2022, the Advisory Committee on Immunization Practices (ACIP) subsequently published updated pneumococcal vaccination recommendations that incorporate both PCV-20 and PCV-15. Pneumococcal vaccination is effective in reducing pneumococcal disease, particularly in high-risk patient groups such as those with chronic lung disease; however, the updated dosing schedule for pneumococcal vaccinations can be quite confusing, especially if patients have previously received "older" vaccinations, such as pneumococcal polysaccharide vaccine-23 or PCV-13. The purpose of this quality improvement project was to increase providers' knowledge of current ACIP pneumococcal vaccination recommendations, including indications and dosing schedule, and to improve pneumococcal vaccination rates among eligible adults and children., Materials and Methods: Focused education sessions were presented to primary care and subspecialty residents, fellows, and staff at Brooke Army Medical Center and Wilford Hall Ambulatory Surgical Center regarding current ACIP pneumococcal vaccination recommendations. Sessions included information about PCV-15 and PCV-20 vaccines, indications for vaccination, and dosing schedules. Subjective knowledge of updated ACIP pneumococcal vaccination recommendations was assessed among primary care and subspecialty residents, fellows, and staff via an anonymous survey both pre- and post-intervention. Number of PCV-20 vaccinations given and estimated vaccination rates of patients aged 19 to 64 years with asthma were assessed pre- and post-intervention over a 6 month time span., Results: Of surveyed providers, only 9% discussed vaccinations at every visit and 11% did not discuss vaccinations at all. There was a statistically significant increase in providers' knowledge of pneumococcal vaccination guidelines for children post-intervention (P = .01) but no statistically significant increase in knowledge for guidelines for adults, for patients that have received prior pneumococcal vaccines, or in overall confidence in recommending pneumococcal vaccines. There was a 17% increase in the number of PCV-20 vaccinations given post-intervention (198 pre-intervention, 232 post-intervention). The estimated PCV-20 vaccination rate for adults aged 19 to 64 years with asthma increased from 14.9% pre-intervention to 19.5% post-intervention (P = .33)., Conclusions: There is a significant knowledge gap regarding ACIP pneumococcal vaccination recommendations among military providers and a low pneumococcal vaccination rate for adults aged 19 to 64 years with asthma at Joint Base-San Antonio MTFs. Focused education sessions were effective in increasing providers' knowledge of updated pneumococcal vaccination recommendations, confidence in recommending vaccines, total number of pneumococcal vaccinations given, and estimated pneumococcal vaccination rate for adults with asthma. The validity of conclusions drawn from our data were limited because of discordant numbers of survey respondents as well as potentially inaccurate estimates of pneumococcal vaccination rates pre- and post-intervention. Despite this, the results warrant continued education of pneumococcal vaccines, indications, and dosing schedules., (© The Association of Military Surgeons of the United States 2024. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: The PCV13 immunization demonstration program began in October 2017 in Indonesia. The aim of this study is to assess the dynamic changes of pneumococcal serotype before and after PCV13 administration, with two primary and one booster doses., Methods: The prospective cohort study was conducted as a follow up study measuring the impact of PCV13 demonstration program by the Indonesian Ministry of Health in Lombok Island, West Nusa Tenggara, Indonesia, from March 2018 to June 2019. The subjects were two-month-old healthy infants who were brought to the primary care facility for routine vaccination and followed until 18 months of age. We use convenience sampling method. There were 115 infants in the control group and 118 infants in the vaccine group, and the PCV immunization was given on a 2+1 schedule. Nasopharyngeal (NP) swabs were collected four times during the vaccination periods by trained medical staff. Specimens were analyzed by culture methods to detect S. pneumonia colonization and multiplex polymerase chain reaction (mPCR) to determine serotype. The most frequently detected serotypes will be named as dominant serotypes. Descriptive analysis of demographic characteristics, the prevalence of overall and serotype colonization, and the distribution of serotypes were performed. The prevalence of both cohort groups were compared using chi-square test. Statistical significance was set at p < 0.05., Results: Two hundred and thirty three infants age two months old were recruited, with 48.9% of the subjects were male and 51.1% of the subjects were female. Sociodemographic data in both cohort groups were relatively equal. Nasopharyngeal pneumococcal colonization before PCV13 administration occurred in 19.1% of the control and 22.9% of the vaccine group. The prevalence increased with increasing age in both groups. The prevalence of VT serotypes in control groups aged 2 months, 4 months, 12 months, and 18 months was 40.9%, 44.2%, 53.8%, and 54.3%, respectively, and in the vaccine group, 25.9%, 40.4%, 38.0%, and 22.6%, respectively. The most common VT serotypes in both groups were 6A/6B, 19F, 23F, and 14. The prevalence of VT serotypes decreased significantly compared to non-vaccine type serotypes after three doses of the PCV13 vaccine (p < 0.001). Another notable change was the decline in prevalence of serotype 6A/6B after PCV13 administration using the 2+1 schedule., Conclusions: This study shows lower prevalence of VT and 6A/6B serotypes in the nasopharynx among children who were PCV13 vaccinated compared with those who were unvaccinated. The result from this study will be the beginning of future vaccine evaluation in larger population and longer period of study., Competing Interests: The authors have declared that no competing interests exist.

Pneumonia is a major cause of morbidity and mortality in the United States. Therefore, prevention of pneumococcal pneumonia by administering effective and well-tolerated vaccines is an important goal, especially in the immunocompromised patients who are at an increased risk of infections. At a large Midwestern Veterans Affairs Rheumatology Clinic, an internal audit revealed a baseline immunization rate of 3%. Through the Lean Six Sigma approach, the investigators sought to increase the rate to 70%. An interprofessional approach incorporating provider education, reinforcement at the point of care, and workflow simplification was sequentially implemented. Lean Six Sigma tools, including process mapping, voice of the customer, and statistical process control charts were utilized. These interventions increased the percentage of eligible patients receiving vaccinations from 3% (n = 19/687) to 23% (n = 11/48) and decreased the vaccine administration time from 15 to 7 minutes. No adverse reactions were reported. This was balanced by an increase in appointment time by 4 minutes in those who received vaccines. The Lean Six Sigma approach was critical to reducing waste and improving value for patients and providers by increasing pneumococcal vaccination rates among the immunocompromised veteran population in a Midwestern Veterans Affairs Rheumatology Clinic.

Background: Of over 90 serotypes of Streptococcus pneumoniae, only seven were included in the first pneumococcal conjugate vaccine (PCV). While PCV reduced the disease incidence, in part because of a herd immunity effect, a replacement effect was observed whereby disease was increasingly caused by serotypes not included in the vaccine. Dynamic transmission models can account for these effects to describe post-vaccination scenarios, whereas economic evaluations can enable decision-makers to compare vaccines of increasing valency for implementation., Aim: The aim of this review was to examine epidemiological and economic models and their assumptions for their potential contributions to future research and immunisation policy., Sources: Pubmed, Scopus, Ovid, ISI Web of Knowledge, Centre of Reviews and Dissemination (CRD) databases were searched., Content: Twenty-three dynamic transmission models and 21 economic models were retrieved and reviewed. Published models employed various templates, revealing several key uncertainties regarding the biology and epidemiology of pneumococcal infection. While models suggested that PCVs will reduce the burden of disease, the extent to which they are predicted to do so depended on various assumptions regarding features of pneumococcal infection and epidemiology that governed PCV cost-effectiveness as well. Such features include the duration of protection and competitive interactions between serotypes, which are unclear at present, but which directly relate to herd immunity and serotype replacement., Implications: Economic evaluations are not typically based on transmission dynamic models and hence omit indirect herd immunity effects. The two tools could be used in conjunction to inform decision-makers on vaccine implementation, but so far there have been few attempts to build economic evaluations on transmission dynamic models, and none in this field. Future directions for research could include studies to evaluate key parameters for the models involving herd immunity, serotype competition and the natural history of infection., (Copyright © 2019 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved.)

ACIP no longer recommends routine use of PCV13 in immunocompetent adults ≥ 65 years. Three simple statements summarize guidance on intervals to follow when administering both PCV13 and PPSV23.

Each year millions of pilgrims perform the annual Hajj from more than 180 countries around the world. This is one of the largest mass gathering events and may result in the occurrence and spread of infectious diseases. As such, there are mandatory vaccinations for the pilgrims such as meningococcal vaccines. The 2019 annual Hajj will take place during August 8-13, 2019. Thus, we review the recommended and mandated vaccinations for the 2019 Hajj and Umrah. The mandatory vaccines required to secure the visa include the quadrivalent meningococcal vaccine for all pilgrims, while yellow fever, and poliomyelitis vaccines are required for pilgrims coming from countries endemic or with disease activity. The recommended vaccines are influenza, pneumococcal, in addition to full compliance with basic vaccines for all pilgrims against diphtheria, tetanus, pertussis, polio, measles, and mumps. It is imperative to continue surveillance for the spread of antimicrobial resistance and occurrence of all infectious diseases causing outbreaks across the globe in the last year, like Zika virus, MDR-Typhoid, Nipah, Ebola, cholera, chikungunya and Middle East Respiratory Syndrome Coronavirus., Competing Interests: The authors declare they have no conflicts of interest., (© 2019 Atlantis Press International B.V.)

Background: Pneumococcal conjugate vaccines (PCVs) have had a well-documented impact on the incidence of invasive pneumococcal disease (IPD). However, declines in IPD due to vaccine-targeted serotypes have been partially offset by increases in IPD due to nonvaccine serotypes (NVTs). The goal of this study was to quantify serotype-specific changes in the incidence of IPD that occurred in different age groups, with or without certain comorbidities, following the introduction of 7-valent pneumococcal conjugate vaccine (PCV7) and 13-valent pneumococcal conjugate vaccine (PCV13) in the childhood vaccination program in Denmark., Methods: We used nationwide surveillance data for IPD and a hierarchical Bayesian regression framework to estimate changes in the incidence of IPD associated with the introduction of PCV7 (2007) and PCV13 (2010) while controlling for serotype-specific epidemic cycles and unrelated secular trends., Results: Following the introduction of PCV7 and PCV13 in children, the net impact of serotype replacement varied considerably by age group and comorbidities. Differences in the magnitude of serotype replacement were due to variations in the incidence of NVTs in the different risk groups before the introduction of PCVs. The relative increases in the incidence of IPD caused by specific NVTs did not differ appreciably between risk groups in the postvaccination period. Serotype replacement offset a greater proportion of the benefit of PCVs in strata in which the NVTs comprised a larger proportion of cases prior to the introduction of the vaccines., Conclusions: These findings could help to predict the impact of next-generation PCVs in specific risk groups., (© The Author(s) 2018. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.)

Background : No head-to-head studies are currently available comparing pneumococcal non-typeable Haemophilus influenzae protein D conjugate vaccine (PHiD-CV) with 13-valent pneumococcal conjugate vaccine (PCV-13). This study explored the feasibility of using network meta-analysis (NMA) to conduct an indirect comparison of the relative efficacy or effectiveness of the two vaccines. Methods : A systematic literature search was conducted for published randomized controlled trials (RCTs) and non-RCT studies reporting data on vaccine efficacy or effectiveness against invasive pneumococcal disease in children aged <5 years receiving 7-valent pneumococcal conjugate vaccine (PCV-7), PHiD-CV or PCV-13. Study quality was evaluated using published scales. NMA feasibility was assessed by considering whether a connected network could be constructed by examining published studies for differences in study or patient characteristics that could act as potential treatment effect modifiers or confounding variables. Results : A total of 26 publications were included; 2 RCTs (4 publications), 7 indirect cohort studies, and 14 case-control studies (15 publications). Study quality was generally good. The RCTs could not be connected in a network as there was no common comparator. The studies differed considerably in design, dose number, administration schedules, and subgroups analyzed. Reporting of exposure status and subject characteristics was inconsistent. Conclusion : NMA to compare the relative efficacy or effectiveness of PHiD-CV and PCV-13 is not feasible on the current evidence base, due to the absence of a connected network across the two RCTs and major heterogeneity between studies. NMA may be possible in future if sufficient RCTs become available to construct a connected network.

Objective: Guidelines for vaccination of cochlear implant (CI) recipients have been promulgated and updated by the Center for Disease Control and Prevention (CDC) to mitigate bacterial meningitis risk. The objective of this study was to survey current CI specialists on: 1) knowledge of current CDC CI recipient immunization recommendations, and 2) impediments to implementation of those guidelines., Methods: A survey to assess knowledge of the CI recipient vaccination guidelines was administered to the American Academy of Otolaryngology-Head and Neck surgery (AAO-HNS), the American Cochlear Implant Alliance (ACIA), and the American Neurotology Society (ANS). The members of the AAO-HNS and ACIA were invited to participate in the survey via an e-mail. The members of the ANS were polled during a session of their fall meeting., Results: A total of 256 individuals participated: 64 from AAO, 59 from ACIA, and 133 from ANS. Participants reported knowledge of the vaccination guidelines as high among all groups and statistically similar. The survey indicated that the participants noted difficulty in obtaining age-group-specific immunizations. Vaccination status was not consistently reported., Conclusion: Cochlear implant providers have high awareness of vaccination guidelines but less detailed knowledge of age-specific recommendations. Obtaining age-specific vaccines is a challenge, as is consistent documentation of vaccination. Future efforts should be focused on improving knowledge of age-specific recommendations, easing access of age-specific vaccines, and improving documentation., Level of Evidence: NA. Laryngoscope, 128:2145-2152, 2018., (© 2018 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives: Current strategies to prevent adult pneumococcal disease have been recently reviewed in Italy. We did a postlicensure study to estimate the direct vaccine effectiveness (VE) of the 13-valent pneumococcal conjugate vaccine (PCV13) against adult pneumococcal community-acquired pneumonia (pCAP)., Study Design: Between 2013 and 2015, a 2-year prospective cohort study of adults with CAP was conducted in the Apulia region of Italy where the average vaccine uptake of PCV13 was 32% among adults ≥65 years. The test-negative design was used to estimate VE against all episodes of confirmed pCAP and vaccine-type (VT)-CAP. VE in a subgroup of patients managed in the community was also estimated using a matched case-control design. VE was calculated as one minus the OR times 100%., Results: The overall VE of PCV13 was 33.2% (95% CI -106.6% to 82%) against pCAP irrespective of serotype and 38.1% (95% CI -131.9% to 89%) against VT-CAP in the cohort of adults ≥65 years. The VE was 42.3% (95% CI -244.1% to 94.7%) against VT-CAP in the age group at higher vaccine uptake. For the subgroup of cases managed in the community, the overall VE against disease due to any pneumococcal strain was 88.1% (95% CI 4.2% to 98.5%) and 91.7% (95% CI 13.1% to 99.2%) when we controlled for underlying conditions., Conclusions: Although our results are non-significant, PCV13 promises to be effective against all confirmed pCAP already with modest levels of uptake in the population of adults ≥65 years of age. Larger studies are needed to confirm the direct vaccine benefits., Competing Interests: Competing interests: RP reports grants from Pfizer, during the conduct of the study; grants, personal fees and non-financial support from Pfizer, personal fees and non-financial support from SanofiPasteurMSD, personal fees and non-financial support from GSK, outside the submitted work. DM reports grants and non-financial support from GSK, non-financial support from SanofiPasteurMSD, non-financial support from Pfizer, outside the submitted work., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Objective: Molecular characterization of Streptococcus pneumoniae isolates recovered in the Czech Republic from previously vaccinated patients diagnosed with invasive pneumococcal disease caused by vaccine serotypes in 2012-2014. The target group were children under five years of age., Material and Methods: S. pneumoniae strains are referred to the National Reference Laboratory for Streptococcal Infections (NRL) from all over the Czech Republic. Pneumococcal vaccine failure was identified based on the international definition. The NRL routinely performs identification and typing of isolates using both conventional and molecular methods. To characterize in more detail eight isolates from cases of pneumococcal vaccine failure, multilocus sequence typing (MLST) was used., Results: In 2012-2014, eight S. pneumoniae strains were recovered from children under five years of age diagnosed with vaccine failure. The strains were assigned to serotypes 1 (n = 4), 14 (n = 2), and 3 (n = 2). Serotype 1 isolates were of one sequence type, ST306, which is typical for serotype 1. Similarly, serotype 14 was exclusively of ST124, which is often linked to serotype 14 in the Czech Republic, although in other geographical areas, other STs are often found. Serotype 3 is highly heterogeneous, which is also reflected in multiple STs found in it. We identified a clonal complex comprising ST505 and ST124. ST124 is for the first time reported in S. pneumoniae of serotype 3 in the world., Conclusion: Results are presented of a pilot project conducted in the Czech Republic and focused on molecular characterization of S. pneumoniae strains recovered from cases of pneumococcal vaccine failure in children under five years of age. The data obtained are helpful in improving the surveillance of IPD in the Czech Republic.

Streptococcus pneumoniae is an important cause of community-acquired pneumonia and pneumococcal conjugate vaccines (PCVs) may reduce this burden. This study's goal was to analyse trends in lower respiratory tract infections (LRTI) hospitalisations before and during a routine vaccination programme targeting all newborns with PCV was started in the province of Quebec, Canada in December 2004. The study population included hospital admissions with a main diagnosis of LRTI among 6-59 month-old Quebec residents from April 2000 to December 2014. Trends in proportions and rates were analysed using Cochran-Armitage tests and Poisson regression models. We observed a general downward trend in all LTRI hospitalisations rate: from 11·55/1000 person-years in 2000-2001 to 9·59/1000 in 2013-2014, a 17·0% reduction, which started before the introduction of PCV vaccination. Downward trends in hospitalisation rates were more pronounced for all-cause of pneumonia (minus 17·8%) than for bronchiolitis (minus 15·4%). There was also a decrease in the mean duration of hospital stay. There was little evidence that all-cause pneumonia decreased over the study period due mainly to the introduction of PCVs. Trends may be related to changes in clinical practice. This study casts doubt on the interpretation of ecological analyses of the implementation of PCV vaccination programmes.

A new pneumococcal conjugate vaccine is currently undergoing advanced clinical evaluation prior to its planned introduction in Cuba. The implementation of the pneumococcal vaccination strategy has been designed with consideration of the need to maximize both its direct and indirect effects. A novel approach is suggested, which addresses preschool children as the first-line target group to generate herd immunity in infants and to have an impact on transmission at the community level. The clinical evaluation pipeline is described herein, including evaluations of effectiveness, cost-effectiveness, and impact. The scientific contribution of the Cuban strategy could support a paradigm shift from individual protection to a population effect based on a rigorous body of scientific evidence., (Copyright © 2017 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: Clinical vaccine failure is the occurence of the specific vaccine-preventable disease in an appropriately and fully vaccinated person after enough time has elapsed for protection against the antigens of the vaccine to develop. Fully immunized cases with pneumoccal vaccine may sometimes develop a complicated pneumonia with empyema caused by a vaccine serotype., Case Report: A 2 year-old male patient was admitted with the complaints of fever. On the basis of findings and laboratory results, the patient was diagnosed as having empyema. He was successfully treated with parenteral antibiotics and chest tube drainage. The pleural fluid culture and hemoculture of the patient yielded penicillin-susceptible pneumococci and the isolate was identified as serotype 9V. The patient had been vaccinated with a 13-valent pneumococcal conjugate vaccine according to the Turkish national immunization schedule at 2, 4, 6 and 12 months of age. His medical history and basic immunological profile were inconsistent with a primary immunodeficiency., Conclusion: The failure of the PCV13 vaccine may results in a complicated pneumonia with empyema. It is important to investigate serotypes of pneumococci in these cases to determine other possible vaccine failures due to PCV13 and to study the underlying mechanisms., Competing Interests: Conflict of Interest: No conflict of interest was declared by the authors.

Immunizations protect individual persons and contribute to public health by reducing morbidity and mortality associated with common infectious diseases. In this Practice Pearl, we review guidelines for adult immunizations and recent and potential changes in vaccines.

Controversy exists regarding the optimal use of the 23-valent pneumococcal conjugate vaccine for the protection of high-risk individuals, such as children and adults with immunocompromising conditions and the elderly. The effectiveness and immunogenicity of 23-valent pneumococcal polysaccharide vaccine (PPV23) are limited in such high-risk populations compared to the healthy, with meta-analyses failing to provide robust evidence on vaccine efficacy against invasive pneumococcal disease (IPD) or pneumonia. Moreover, several studies have demonstrated a PPV23-induced state of immune tolerance or hyporesponsiveness to subsequent vaccination, where the response to revaccination does not reach the levels achieved with primary vaccination. The clinical significance of hyporesponsiveness is not yet clarified, but attenuated humoral and cellular response could lead to reduced levels of protection and increased susceptibility to pneumococcal disease. As disease epidemiology among high-risk groups shows that we are still in need of maximum serotype coverage, the optimal use of PPV23 in the context of combined conjugate/polysaccharide vaccine schedules is an important priority. In this minireview, we discuss PPV23-induced hyporesponsiveness and its implications in designing highly effective vaccination schedules for the optimal protection for high-risk individuals., (Copyright © 2016, American Society for Microbiology. All Rights Reserved.)

Medical guidelines tend to convey a sense of unanimity of opinion that may not reflect the deliberations of the experts who wrote them. Using, as an example, an analysis of the recently published recommendations on administering pneumococcal conjugate vaccine to adults, the present article raises the question of whether official recommendations and guidelines should include dissenting opinions, analogous to decisions issued by the US Supreme Court. The argument that such a policy would lead to confusion in our profession is addressed in 2 ways: (1) the current system, in which different professional societies publish conflicting recommendations, as in the case of breast or prostate cancer screening, can be far more confusing, and (2) in the long run, greater transparency will lead to more thoughtful and higher-quality medical care. Perhaps the most important point of this paper is the suggestion that it is far better to bring dissent into the recommendation process than to act as if it is not there., (Copyright © 2016 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

The Advisory Committee on Immunization Practices recently updated its guidelines on pneumococcal pneumonia vaccines for older adults. The new guidelines recommend that patients age 65 years and older receive the PCV13 vaccine in a series along with the PPSV23 vaccine. This article summarizes these changes along with a review of when to vaccinate other key adult populations.

The 9-valent formulation of HPV vaccine is now on the schedule, but don't delay starting or continuing the vaccine series just because HPV9 is not on hand. Give the 2 pneumococcal vaccines a year apart.

Objectives: We described the following among U.S. primary care physicians: (1) perceived importance of vaccines recommended by the Advisory Committee on Immunization Practices relative to U.S. Preventive Services Task Force (USPSTF) preventive services, (2) attitudes toward the U.S. adult immunization schedule, and (3) awareness and use of Medicare preventive service visits., Methods: We conducted an Internet and mail survey from March to June 2012 among national networks of general internists and family physicians., Results: We received responses from 352 of 445 (79%) general internists and 255 of 409 (62%) family physicians. For a 67-year-old hypothetical patient, 540/606 (89%, 95% confidence interval [CI] 87, 92) of physicians ranked seasonal influenza vaccine and 487/607 (80%, 95% CI 77, 83) ranked pneumococcal vaccine as very important, whereas 381/604 (63%, 95% CI 59, 67) ranked Tdap/Td vaccine and 288/607 (47%, 95% CI 43, 51) ranked herpes zoster vaccine as very important (p<0.001). All Grade A USPSTF recommendations were considered more important than Tdap/Td and herpes zoster vaccines. For the hypothetical patient aged 30 years, the number and percentage of physicians who reported that the Tdap/Td vaccine (377/604; 62%, 95% CI 59, 66) is very important was greater than the number and percentage who reported that the seasonal influenza vaccine (263/605; 43%, 95% CI 40, 47) is very important (p<0.001), and all Grade A and Grade B USPSTF recommendations were more often reported as very important than was any vaccine. A total of 172 of 587 physicians (29%) found aspects of the adult immunization schedule confusing. Among physicians aware of "Welcome to Medicare" and annual wellness visits, 492/514 (96%, 95% CI 94, 97) and 329/496 (66%, 95% CI 62, 70), respectively, reported having conducted fewer than 10 such visits in the previous month., Conclusions: Despite lack of prioritization of vaccines by ACIP, physicians are prioritizing some vaccines over others and ranking some vaccines below other preventive services. These attitudes and confusion about the immunization schedule may result in missed opportunities for vaccination. Medicare preventive visits are not being used widely despite offering a venue for delivery of preventive services, including vaccinations.

Background: The Kenyan Ministry of Public Health and Sanitation was the first in Africa to introduce the new 10-valent Pneumococcal Conjugate Vaccine, PCV-10, in 2011. For successful implementation and to avoid adverse events following immunisation, specific training on handling and storage of the PCV-10 vaccine was required. Therefore, a training DVD was recorded in English and partly in Kiswahili to be used in combination with in-classroom training. Since the Kenyan Immunisation Programme was the first to use a DVD for training healthcare workers, an evaluation was done to obtain feedback on content, format and use, and propose suggestions to improve quality and uptake of the DVD., Methods: Feedback was obtained from nurses and vaccinology course participants through the completion of a questionnaire. Nurses also participated in focus group discussions and trainers in key informant interviews., Results: Twelve trainers, 72 nurses and 26 international vaccinology course participants provided feedback, with some notable differences between the three study groups. The survey results confirmed the acceptability of the content and format, and the feasibility of using the DVD in combination with in-classroom teaching. To improve the quality and adoption of the DVD, key suggestions were: Inclusion of all EPI vaccines and other important health issues; broad geographic distribution of the DVD; and bilingual English/Kiswahili use of languages or subtitles., Discussion: The Kenyan DVD is appreciated by a heterogeneous and international audience rendering the DVD suitable for other Anglophone African countries. Differences between feedback from nurses and vaccinology course participants can be explained by the practical approach of the DVD and the higher education and service level of the latter. A drawback is the use of DVD players and televisions due to lack of electricity, but it is a matter of time before all rural health facilities in Africa will have access to electricity and modern technology.

Background: Pediatric respiratory infections caused by antibiotic-nonsusceptible Streptococcus pneumoniae (ANSP) continue to present an important challenge, even after introduction of 7-valent pneumococcal conjugate vaccine (PCV7). This randomized double-blind trial assessed the potential additional impact of PCV13 over PCV7 on reducing ANSP carriage., Methods: Healthy infants were randomly assigned to receive PCV13 (n = 932) or PCV7 (n = 934) at ages 2, 4, 6, or 12 months. Eight nasopharyngeal specimens were collected by swabbing between ages 2 and 24 months. S. pneumoniae isolates were serotyped and tested for antimicrobial susceptibility by the disk-diffusion method and the Etest. Nasopharyngeal acquisition and prevalence of ANSP during ages 7-24 months were compared between the 2 vaccine groups., Results: In general, new acquisition of pneumococci nonsusceptible to penicillin, erythromycin, clindamycin, penicillin plus erythromycin, and multiple drugs (≥3 antibiotics) was significantly lower in the PCV13 group compared with the PCV7 group; the main serotypes contributing to this significant decrease were serotype 19F, present in PCV13 and PCV7, and serotypes 6A and 19A, present in PCV13 only., Conclusions: PCV13 has a significant added benefit over PCV7 in reducing carriage of ANSP. Because carriage determines transmission, these results suggest that PCV13 will provide protection against ANSP disease that exceeds protection provided by PCV7., Clinical Trials Registration: NCT00508742., (© The Author 2014. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.)

Purified polysaccharide and conjugate vaccines are widely used for preventing infections in adults and in children against the Gram-positive bacterium Streptococcus pneumoniae, a pathogen responsible for high morbidity and mortality rates, especially in developing countries. However, these polysaccharide-based vaccines have some important limitations, such as being serotype-dependent, being subjected to losing efficacy because of serotype replacement and high manufacturing complexity and cost. It is expected that protein-based vaccines will overcome these issues by conferring a broad coverage independent of serotype and lowering production costs. In this study, we have applied the "shaving" proteomic approach, consisting of the LC/MS/MS analysis of peptides generated by protease treatment of live cells, to a collection of 16 pneumococcal clinical isolates from adults, representing the most prevalent strains circulating in Spain during the last years. The set of unique proteins identified in all the isolates, called "pan-surfome", consisted of 254 proteins, which included most of the protective protein antigens reported so far. In search of new candidates with vaccine potential, we identified 32 that were present in at least 50% of the clinical isolates analyzed. We selected four of them (Spr0012, Spr0328, Spr0561 and SP670&#95;2141), whose protection capacity has not yet been tested, for assaying immunogenicity in human sera. All of them induced the production of IgM antibodies in infected patients, thus indicating that they could enter the pipeline for vaccine studies. The pan-surfomic approach shows its utility in the discovery of new proteins that can elicit protection against infectious microorganisms.

Evaluating vaccine efficacy for protection against colonization with bacterial pathogens is an area of growing interest. Colonization of the nasopharynx is an asymptomatic carrier state responsible for person-to-person transmission. It differs from most clinical outcomes in that it is common, recurrent, and observed only in its prevalent state. To estimate rates of acquisition and clearance of colonization requires repeated active sampling of the same individuals over time, an expensive and invasive undertaking. Motivated by feasibility constraints in efficacy trials with colonization endpoints, investigators have been estimating vaccine efficacy from cross-sectional studies without principled methods. We present two examples of vaccine studies estimating vaccine efficacy from cross-sectional data on nasopharyngeal colonization by Streptococcus pneumoniae (pneumococcus). This study presents a framework for defining and estimating strain-specific and overall vaccine efficacy for susceptibility to acquisition of colonization (VE(acq)) when there is a large number of strains with mutual interactions and recurrent dynamics of colonization. We develop estimators based on one observation of the current status per study subject, evaluate their robustness, and re-analyze the two vaccine trials. Methodologically, the proposed estimators are closely related to case-control studies with prevalent cases, with appropriate consideration of the at-risk time in choosing the controls., (Copyright © 2013, The International Biometric Society.)

Introduction: Cochlear implant recipients are known to be at an increased risk of meningitis. It is routine practice to check that pneumococcal vaccinations have been received prior to surgery. Recent changes in United Kingdom national guidelines mean that children who were previously thought to be fully immunized may in fact not be optimally protected. We present a simple, robust audit tool that can be used in both primary care and tertiary centres to identify those children at risk., Methods: The pneumococcal immunization status of 63 paediatric cochlear implant recipients was assessed using a unique and comprehensive flowchart-style audit tool. The data collected included age at implantation, details of previous immunizations, and whether or not further vaccinations were required., Results: Fifty-four per cent of children were not optimally immunized prior to implantation. Seventy per cent of children required further vaccinations following surgery. The commonest reason for an incomplete immunization history was failure to administer the 23-valent vaccine after the second birthday., Conclusion: The pneumococcal immunization schedule for high-risk children is complicated and nationally available guidance can be difficult to interpret. There are multiple types of vaccines and their use is not standardized across the UK. Cochlear implant programmes may find that a large proportion of their patients are in fact not optimally vaccinated, particularly in light of recent changes in the national guidelines. Our audit tool allows health professionals, in both primary care and implant centres, to accurately assess the status and immunization requirements for both new and old patients.

Community-acquired pneumonia (CAP) is an important cause of morbidity and mortality worldwide. This review summarises current trends and knowledge gaps in CAP management and prevention. Although Streptococcus pneumoniae is the most frequent cause of CAP, identification of the microbial cause of infection remains unsuccessful in most episodes, and little is known about the aetiology of CAP in immunocompromised patients. Urinary antigen testing has become standard care for diagnosing Legionella infection, and pneumococcal urinary antigen testing is now recommended in the Dutch guidelines to streamline antibiotic therapy in patients hospitalised with CAP. In primary care C-reactive protein determination is recommended to improve antibiotic prescription for lower respiratory tract infections. In patients hospitalised with CAP, three strategies are considered equally effective for choosing empirical antibiotic treatment. Yet, more (and better designed) studies are needed to determine the best strategy, as well as to determine optimal (which usually means the minimum) duration of antibiotic therapy and the role of adjuvant treatment with corticosteroids. The effectiveness of the 23-valent pneumococcal polysaccharide vaccine in preventing invasive pneumococcal disease and pneumococcal CAP remains debated, and whether the newer conjugate vaccines are more effective remains to be determined. Many of these questions are currently being addressed in large-scaled trials in the Netherlands, and their results may allow evidence-based decisions in CAP management and prevention.

Enhanced surveillance for invasive pneumococcal disease (IPD) was conducted in all Australian states and territories in 2007 and 2008 with comprehensive comparative data available since 2002. There were 1,477 cases of IPD notified to the National Notifiable Diseases Surveillance System in Australia in 2007; a notification rate of 7.0 cases per 100,000 population. In 2008 there were 1,628 cases; a notification rate of 7.6 cases per 100,000 population. The overall rate of IPD in Indigenous Australians was almost 6 times the rate in non-Indigenous Australians in 2007 and almost 5 times in 2008. By 2008, the 4th year of a funded universal infant 7-valent pneumococcal conjugate vaccine (7vPCV) program in Australia with a 3+0 schedule, vaccine serotype IPD notification rates in those identified as non-Indigenous decreased in all age groups compared with 2002 levels, most significantly by 96% in children aged less than 5 years. However, rates of disease in non-vaccine serotypes increased by 168% in children aged less than 5 years, including a four-fold increase in the number of cases due to serotype 19A. For the Aboriginal and Torres Strait Islander population, national pre-vaccination data are not available, as the vaccine program was funded for this group from 2001. From 2002 to 2008, the proportion of disease due to 7vPCV serotypes in children aged less than 5 years decreased by 77%, while disease due to non-7vPCV serotypes increased by 76%. In Indigenous adults (≥50 years), rates of 23vPPV serotypes increased by 92%. There were 120 deaths attributed to IPD in 2007 and 113 in 2008, although it should be noted that deaths may be under-reported. The number of invasive pneumococcal isolates with reduced penicillin susceptibility remains low and reduced susceptibility to third-generation cephalosporins is rare., (This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be reproduced by any process without prior written permission from the Commonwealth. Requests and inquiries concerning reproduction and rights should be addressed to the Commonwealth Copyright Administration, Attorney General's Department, Robert Garran Offices, National Circuit, Barton ACT 2600 or posted at http://www.ag.gov.au/cca.)

13-valent pneumococcal conjugate vaccine (PCV13) includes polysaccharide conjugates from six pneumococcal serotypes in addition to those in the licensed 7-valent vaccine, thereby offering expanded protection against pneumococcal disease. The phase 3 trial reported here was conducted per a regulatory requirement to evaluate the immunogenicity, safety, and tolerability of two lots of the final PCV13 formulation that differed with respect to production scale but not the manufacturing process. The anti-pneumococcal polysaccharide immunogenicity and safety/tolerability were found to be similar between the two PCV13 vaccine lots., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

To evaluate the effectiveness of the 7-valent pneumococcal conjugate vaccine (PCV7) program, we conducted a cross-sectional observational study on nasopharyngeal carriage of Streptococcus pneumoniae 3 years after implementation of the program in the Netherlands. We compared pneumococcal serotypes in 329 prebooster 11-month-old children, 330 fully vaccinated 24-month-old children, and 324 parents with age-matched pre-PCV7 (unvaccinated) controls (ages 12 and 24 months, n = 319 and n = 321, respectively) and 296 of their parents. PCV7 serotype prevalences before and after PCV7 implementation, respectively, were 38% and 8% among 11-month-old children, 36% and 4% among 24-month-old children, and 8% and 1% among parents. Non-PCV7 serotype prevalences were 29% and 39% among 11-month-old children, 30% and 45% among 24-month-old children, and 8% and 15% among parents, respectively; serotypes 11A and 19A were most frequently isolated. PCV7 serotypes were largely replaced by non-PCV7 serotypes. Disappearance of PCV7 serotypes in parents suggests strong transmission reduction through vaccination.

Sequential multiplex PCR was evaluated for detection of multiple Streptococcus pneumoniae serotypes directly from nasopharyngeal secretions. A total of 279 nasopharyngeal swab samples were tested blindly. When limited to the 29 serotypes identifiable by the molecular method, the mean number of serotypes identified by the conventional latex/Quellung method was 0.85, which was significantly lower than that by the molecular method (P <0.0001). The multiplex PCR method identified significantly more serotypes than the latex/Quellung method if limited to the 29 serotypes (P=0.001 and P=0.014, respectively).

Aim: The aim of the study was to reduce the number of hospitalizations in a population of children enrolled in the Einstein Program of the Paraisópolis Community, in São Paulo, Brazil, particularly hospitalizations caused by respiratory diseases., Methods: All hospitalizations of this paediatric population enrolled in the Einstein Program of the Paraisópolis Community Outpatient Clinic were followed up between 2002 and 2004. The following four strategies to reduce or control respiratory diseases with an impact on hospitalizations were established: specific protocol, educational activities, vaccination against pneumococci and vaccination against influenza., Results: In 2002, 1025 hospitalizations due to all causes were recorded. This number significantly decreased to 862 hospitalizations in 2004 after implementation of the program, corresponding to a reduction of 15.9% (p < 0.0001). Hospitalizations due to respiratory diseases decreased by 23.37% (p < 0.02), and those due to cases of wheezing bronchitis fell by 51.61% (p < 0.001)., Conclusion: The strategies chosen and implemented in the Einstein Program of the Paraisópolis Community Outpatient Clinic over the first 6 months of 2003 were effective in reducing the number of children's hospital admissions due to respiratory disease.

Objectives: The goals were (1) to compare pediatricians' heptavalent pneumococcal conjugate vaccine shortage experience and adherence to shortage recommendations during 2 heptavalent pneumococcal conjugate vaccine shortages, (2) to assess factors associated with nonadherence to second shortage recommendations, and (3) to assess opinions about national immunization policy during vaccine shortages., Methods: We mailed surveys to all pediatrician immunization providers in the greater Cincinnati, Ohio, metropolitan area. We assessed heptavalent pneumococcal conjugate vaccine supply and immunization practices during the shortages and provider attitudes regarding immunization shortage policy., Results: The response rate was 61% (171 of 282 providers). Most pediatricians experienced heptavalent pneumococcal conjugate vaccine shortages (first shortage: 86%; second shortage: 84%). The rate of adherence to recommendations to defer the fourth heptavalent pneumococcal conjugate vaccine dose for healthy children was significantly higher during the second shortage, compared with the first shortage (first shortage: 62%; second shortage: 89%). Adherence to recommendations to administer the fourth dose to high-risk children remained unchanged (first shortage: 43%; second shortage: 45%). Controlling for other factors, pediatricians who reported a severe second shortage had greater odds of not fully vaccinating high-risk children, compared with those who reported no shortage. Contrary to recommendations, many pediatricians did not maintain tracking systems during the heptavalent pneumococcal conjugate vaccine shortages (first shortage: 37%; second shortage: 46%). Most pediatricians (91%) thought that national vaccine shortage recommendations were needed to protect them from liability., Conclusions: The rate of adherence to recommendations to defer heptavalent pneumococcal conjugate vaccine doses for healthy children increased significantly from the first shortage to the second shortage. The nonadherent practice of deferring the fourth dose for high-risk children was associated with more severe shortages and, potentially, an inability to vaccinate.

The Merck pneumococcal (Pn) enzyme-linked immunosorbent assays (ELISAs) for measuring antibodies to 12 serotypes (serotypes 1, 3, 4, 6B, 7F, 8, 9V, 12F, 14, 18C, 19F, and 23F) were validated in 1999. Merck Laboratories developed the Pn assays using 10 microg/ml C polysaccharide, 100 microg/ml Pn polysaccharide (PnPs) 25, and 100 microg/ml PnPs 72 for preadsorption of samples, standards, and controls in order to improve the specificity to the Pn serotypes in the vaccine. The Pn assays utilize postimmunization sera obtained from subjects immunized with PNEUMOVAX 23 as standards for measuring immunoglobulin G concentrations in sera obtained from vaccine clinical trials with adults and infants. This material was calibrated to the Pn reference standard serum, 89SF, subjected to the Merck Pn ELISA adsorbants. Comparisons were made between the Merck Pn assay and the international Pn assay, showing moderate agreement between the two assay formats. This work describes the test procedures and operating characteristics of the Merck Pn assays and the results of experiments performed to compare the Merck Pn ELISAs to the international Pn ELISAs.

Objectives: To evaluate the impact of heptavalent pneumococcal conjugate vaccine in invasive pneumococcal diseases in the United States, and to analyze the potential impact of this vaccine in Brazil., Sources of Data: MEDLINE, LILACS, Cochrane Database Reviews, as well as the websites of the Centers for Disease Control and Prevention (CDC), Brazilian Ministry of Health and Centro de Vigilância Epidemiológica do Estado de São Paulo from January 2000 to January 2006. Articles retrieved with the keywords Streptococcus pneumoniae, pneumococcal diseases, conjugate vaccine, antimicrobial resistance and meningitis were reviewed., Summary of the Findings: The introduction of heptavalent pneumococcal conjugate vaccine caused a dramatic reduction in the incidence of invasive pneumococcal diseases in American children, reduced antibiotic use and the number of medical visits due to otitis media and pneumonia by children. The incidence of invasive pneumococcal diseases caused by resistant strains declined in immunized children, adults and elderly individuals. In Brazil, the mortality rate of pneumococcal meningitis is very high and the resistance to antibiotics has increased over the last 5 years., Conclusions: Heptavalent pneumococcal conjugate vaccine can benefit not only children, but the entire community and should be included in the Brazilian routine immunization schedule.

Background: Based on two clinical trials in healthy infants the American Academy of Pediatrics (AAP) advices immunization with a 7-valent pneumococcal conjugate vaccine in children with recurrent acute otitis media (AOM)., Objective: To study the efficacy of a 7-valent pneumococcal conjugate vaccine on acute otitis media recurrences, its immunogenicity and impact on nasopharyngeal Streptococcus pneumoniae carriage in children with a history of frequent acute otitis media., Methods: In this double-blind, randomized study, 74 Belgian children, aged 1-7 years, with at least 2 clinically diagnosed episodes of acute otitis media in the previous year were enrolled. Children were immunized with either a 7-valent pneumococcal conjugate vaccine followed by a 23-valent pneumococcal polysaccharide booster or a control hepatitis A vaccine. Total follow-up was 26 months., Results: Despite adequate serum IgG responses to all conjugate vaccine pneumococcal serotypes, no reduction of acute otitis media episodes was observed in the pneumococcal vaccine group as compared to the control group (rate ratio: 1.16; 95% CI: 0.69-1.96). Overall nasopharyngeal pneumococcal carriage remained stable. However, a transient shift from conjugate vaccine related S. pneumoniae serogroups to non-vaccine related serogroups was noted following conjugate vaccination., Conclusion: Clinically no protective effect of pneumococcal conjugate vaccination on acute otitis media recurrences was found in children with a history of frequent AOM.

The goal of this final rule is to increase immunization rates in Medicare and Medicaid participating long term care (LTC) facilities by requiring LTC facilities to offer each resident immunization against influenza annually, as well as lifetime immunization against pneumococcal disease. LTC facilities will be required to ensure that before offering the immunization, each resident or the resident's legal representative receives education regarding the benefits and potential side effects of immunization. The facilities will be required to offer immunization against influenza annually and immunization against pneumococcal disease once, unless medically contraindicated or the resident or the resident's legal representative refuses immunization. Increasing the use of Medicare-funded preventive services is a goal of both CMS and the Centers for Disease Control and Prevention (CDC). This final rule is intended to increase the number of elderly receiving influenza and pneumococcal immunization and decrease the morbidity and mortality rate from influenza and pneumococcal diseases.

Vaccination is an effective possibility to prevent many bacterial or viral infections, but for several important pathogens still no vaccines are available. The sequences of complete genomes are now decoded for an increasing number of bacterial pathogens and offer the possibility for comprehensive screenings to identify targets for vaccine development. In this article current genomic approaches to identify antigenic proteins of Neisseria meningitidis, Streptococcus pneumoniae, Staphylococcus aureus, and Chlamydia pneumoniae are summarized.

Background: Little is known about whether pneumococcal conjugate vaccine (PCV) has altered pediatricians' practices regarding well-child and acute care., Objectives: To (1) describe whether PCV caused pediatricians to move other routine infant vaccines and/or add routine visits; (2) characterize adherence to national immunization recommendations; and (3) determine whether PCV altered pediatricians' planned clinical approach to well-appearing febrile infants., Design and Methods: One year after PCV was added to the pediatric immunization schedule, we mailed a 23-item survey to 691 randomly selected pediatricians in Massachusetts. The adjusted response rate was 77%., Results: After PCV introduction, 39% of pediatricians moved other routine infant vaccines to different visits and 15% added routine visits to the infant schedule. The self-reported immunization schedules of 36% were nonadherent to national immunization guidelines for at least 1 vaccine. Nonadherence rates were significantly higher among pediatricians who had been in practice longer, moved another vaccine because of PCV introduction, and/or offered to give shots later when multiple injections were due. For a hypothetical febrile 8-month-old girl who had received 3 doses of PCV, pediatricians reported they were significantly less likely to (1) perform both blood and urine testing and (2) prescribe antibiotics than in the pre-PCV era., Conclusions: The introduction of PCV may have had unintended effects on pediatric primary care, including decreased adherence to national recommendations for the timing of immunizations and decreased urine testing for well-appearing febrile infants. Special efforts may be warranted to ensure that pediatricians remain current with changing recommendations.

First vaccines are traditionally licensed after showing favourable results from phase III efficacy trials. Subsequent competing vaccines, however, have been licensed primarily on the basis of immunogenicity data rather than clinical efficacy. Focusing on pneumococcal vaccines where optical densities are measured and serum antibody concentrations are 'estimated' (from a statistical model) using an immunoglobulin (IgG) enzyme-linked immunosorbent assay (ELISA), the focus of this paper will centre on two highly related issues: the determination of an upper limit for quality control used in the assay methodology (let us call it the maximum tolerated limit or MTL) and the identification of vaccine responders. The goal is to show that these two issues are inter-related, so that investigators could reduce misclassification which would interfere with the eventual comparison of immunogenicity results., (Copyright 2003 John Wiley & Sons, Ltd.)