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Original Investigation
February 4, 2019

Long-term Association of 13-Valent Pneumococcal Conjugate Vaccine Implementation With Rates of Community-Acquired Pneumonia in Children

Author Affiliations
  • 1Association Clinique et Thérapeutique Infantile du Val-de-Marne, St Maur-des-Fossés, France
  • 2Groupe de Pathologie Infectieuse Pédiatrique, Paris, France
  • 3Unité d’Épidémiologie Clinique, Assistance Publique–Hôpitaux de Paris, Hôpital Robert Debré, Unité Mixte de Recherche 1123–Epidémiologie Clinique et Évaluation Économique Appliquées aux Populations Vulnérables, Institut National de la Santé et de la Recherche Médicale, Paris, France
  • 4Urgences Pédiatriques, Hôpital Necker Enfants Malades, Université Paris Descartes, Paris, France
  • 5Université Paris Est, L’Institut Mondor de Recherche Biomédicale Groupement de Recherche Clinique Groupe d'Etude de Maladies Infectieuses Néonatales et Infantiles, Créteil, France
  • 6Clinical Research Center, Centre Hospitalier Intercommunal de Créteil, Créteil, France
  • 7Department of Pediatric Emergency, Centre Hospitalier Universitaire Nord, Marseille, France
  • 8Department of General Pediatrics, Assistance Publique–Hôpitaux de Paris, Hôpital Robert Debré, Université Paris Diderot, Sorbonne Paris Cité, Paris, France
  • 9Department of Pediatric Emergency, Hôpital Intercommunal, Créteil, France
  • 10Pediatric Emergency Unit and Infectious Diseases, Université de Lille, Centre Hospitalier Universitaire Lille, Lille, France
  • 11Department of General Pediatrics, Centre Hospitalier de Versailles, Le Chesnay, France
  • 12Pediatric Nephrology, Rheumatology, Dermatology Unit, Femme Mère Enfant Hospital, Hospices Civils de Lyon, University Lyon 1 Lyon, Lyon, France
  • 13Department of Pediatrics, Centre Hospitalier Universitaire Nantes, Nantes, France
  • 14Department of General Pediatrics, Hôpital Intercommunal, Créteil, France
  • 15Department of Pediatric Emergency, L'Hôpital Femme Mère Enfant Lyon, Lyon, France
  • 16Department of Pediatric Emergency, Assistance Publique–Hôpitaux de Paris, Hôpital Le Kremlin-Bicêtre, Université Paris, Paris, France
  • 17Department of General Pediatrics, Assistance Publique–Hôpitaux de Paris, Hôpital Armand Trousseau, Université Sorbonne Paris Cité, Paris, France
  • 18National Reference Center for Pneumococci, Laboratoire de Microbiologie, Assistance Publique–Hôpitaux de Paris, Hôpital Européen Georges-Pompidou, Paris, France
  • 19Unité Court Séjour, Petits Nourrissons, Service de Néonatologie, Centre Hospitalier Intercommunal de Créteil, Créteil, France
JAMA Pediatr. Published online February 4, 2019. doi:10.1001/jamapediatrics.2018.5273
Key Points

Question  In a context of the emergence of nonvaccine serotypes, has the long-term protective outcome of 13-valent pneumococcal conjugate vaccine (PCV13) on community-acquired pneumonia in children eroded?

Findings  This time-series analysis of an 8-year prospective multicenter study finds a significant decrease in the frequency of community-acquired pneumonia over 4 years after PCV13 implementation, followed by a slight increase thereafter. The frequency of the most severe cases decreased more markedly, without any rebound.

Meaning  Seven years after PVC13 implementation, the protection against pneumonia seems unthreatened by the increase in nonvaccine serotypes recently reported in several countries.

Abstract

Importance  In several countries, 5 years after 13-valent pneumococcal conjugate vaccine (PCV13) implementation, serotype replacement has been reported for invasive pneumococcal disease, which raises concerns about the long-term outcome of PCV13 implementation. The long-term effect of vaccination on community-acquired pneumonia (CAP) remains unknown.

Objective  To assess the long-term outcome of PCV13 implementation on CAP in children.

Design, Setting, and Participants  This quasi-experimental, population-based, interrupted time-series analysis was based on a prospective multicenter study conducted from June 2009 to May 2017 in 8 French pediatric emergency departments. All patients 15 years and younger with chest radiography–confirmed CAP were included.

Exposures  Community-acquired pneumonia.

Main Outcomes and Measures  The number of CAP cases per 1000 pediatric emergency department visits over time, analyzed using a segmented regression model, adjusted for influenza-like illness syndromes.

Results  We enrolled 12 587 children with CAP, including 673 cases of CAP with pleural effusion (5.3%), 4273 cases of CAP requiring hospitalization (33.9%), 2379 cases of CAP with high inflammatory biomarkers (18.9%), and 221 cases of proven pneumococcal CAP (1.8%). The implementation of PCV13 in 2010 was followed by a sharp decrease in the frequency of CAP (−0.8% per month [95% CI, −1.0% to −0.5% per month]), from 6.3 to 3.5 cases of CAP per 1000 pediatric emergency department visits until May 2014, then a slight increase since June 2014 (0.9% per month [95% CI, 0.4%-1.4% per month]), until 3.8 cases of CAP per 1000 pediatric emergency department visits in May 2017. There were marked immediate decreases in cases of CAP with pleural effusion (−48% [95% CI, −84% to −12%]), CAP requiring hospitalization (−30% [95% CI, −56% to −5%]), and CAP with high inflammatory biomarkers (−30% [95% CI, −54% to −6%]), without any rebound thereafter.

Conclusions and Relevance  The changes associated with PCV13 use 7 years after implementation remain substantial, especially for CAP with pleural effusion, CAP requiring hospitalization, and CAP with high inflammatory biomarkers. Emerging non-PCV13 serotypes may be less likely involved in severe CAP than invasive pneumococcal disease.

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