Q&A with infectious disease specialist William Schaffner: Preventing pneumococcal illness: Vaccines can prevent pneumococcal disease in all age groups ========================================================================================================================================================== Pneumococcal disease is associated with considerable morbidity and mortality around the globe, as well as sizeable health care costs. Invasive pneumococcal disease causes about 4,800 deaths each year in the United States, yet more than half of such cases, and nearly all deaths, occur among adults for whom vaccination against pneumococcal disease is recommended. The National Foundation for Infectious Diseases and its Pneumococcal Disease Advisory Board, co-chaired by APHA member William Schaffner, MD, is working to raise awareness of the impact of these diseases and the importance of increasing protection through immunization. ## What is pneumococcal disease, and what causes it? Pneumococcal disease is caused by a bacteria, the *streptococcus pneumoniae*, which many adults carry in their throats without symptoms. But from time to time it can get down into the lungs and cause pneumonia. It also has a propensity to get into the bloodstream and cause very serious septic bloodstream infections. And it can cause what we call metastatic infections in different parts of the body. For example, in joints it can cause infectious arthritis. It can produce infection of the covering of the heart, and it can get into the central nervous system and cause meningitis, a very serious infection. ## How many cases of pneumococcal disease occur each year in the United States, and how many people die from it? It is estimated that there are 44,000 cases of this kind of invasive pneumococcal disease that gets beyond the lungs, into the bloodstream and into other parts of the body, and pneumococcus is said to be responsible for approximately 5,000 deaths each year in the United States. ![Figure1](http://www.thenationshealth.org/http://www.thenationshealth.org/content/nathealth/41/1/7/F1.medium.gif) [Figure1](http://www.thenationshealth.org/content/41/1/7/F1) While routine for infants, pneumococcal vaccine is also recommended for older kids with certain health conditions. Photo by Sean Locke, courtesy iStockphoto ## What are the most common pneumococcal diseases and why does seasonal flu put people at increased risk for pneumococcal disease? Pneumonia is far and away the most common. In fact, pneumococcus is the most common bacterial cause of pneumonia, and as we may discuss a little bit further, it often complicates influenza. First you get influenza. That causes inflammation of your respiratory tract mucous membranes and then the pneumococcus, which we may be carrying in our throats, take advantage of that inflammation and cause pneumonia. And so that is the most common kind of infection that the pneumococcus causes. ## Who is at greatest risk for pneumococcal disease? Pneumonia being the big problem, the older we get the more likely it is that we will be at risk of pneumococcal disease, so advancing age is far and away the characteristic that predisposes people to pneumococcal disease. The very young also are susceptible to pneumococcal invasive disease, particularly bloodstream infections and meningitis. Under the age of 65, if you have underlying heart disease of any kind, or lung disease, if you are immunocompromised, if you have diabetes, these are conditions that set you up for pneumococcal disease. We have also discovered that people with asthma have an increased risk of invasive pneumococcal infection, as do cigarette smokers. So we have a whole list of folks who are at increased risk of this serious infection. ## What is the best way to protect against pneumococcal disease? The best way, of course, is vaccination, vaccination, vaccination. Conjugate pneumococcal vaccine is now routinely used for all infants and (young) children in the United States, so that’s very important. And then we have another pneumococcal vaccine, pneumococcal polysaccharide vaccine, which is used in adults and is recommended for everyone in those risk groups that we’ve just mentioned. Vaccinating against the pneumococcal infection per se is important, but influenza can set you up for pneumococcal disease, so vaccination against influenza also offers some protection against pneumococcal disease. ## Infectious disease specialists urge people 65 and older and younger adults with risk factors to get their pneumococcal vaccines, but still the public doesn’t seem to be getting the message. Why? Physicians and the public are doing a better job in vaccinating people ages 65 and older. So, in a stepwise fashion, we are seeing vaccination rates against pneumococcal disease increase in people 65 and older. And pediatricians and family docs are doing a terrific job in vaccinating infants and young children. It’s that group in the middle where we have the biggest problem. Doctors have a hard time identifying patients in their practice with these underlying conditions, and the public has not yet been very well educated about pneumococcal disease and how important it is, so we need to keep working on that. ## Will getting the influenza vaccine help people avoid pneumonia and if so, why do they need both the pneumonia and influenza vaccines? Individuals should get both. It’s now recommended that everyone receive influenza vaccine and those individuals for whom pneumococcal vaccine is indicated should get that vaccine also, definitely. Influenza can affect the respiratory tract and cause inflammation, and that’s a setup for complicating pneumococcal infection. They work hand-in-hand, so we need protection against both. So for those people for whom it’s indicated that they get both, they really should get both vaccines. ![Figure2](http://www.thenationshealth.org/http://www.thenationshealth.org/content/nathealth/41/1/7/F2.medium.gif) [Figure2](http://www.thenationshealth.org/content/41/1/7/F2) Photo courtesy NFID ## Could you touch a bit more on how pneumococcal disease is transmitted? Pneumococci are capable of residing back in our throats for a considerable period of time. Close contact, one person to another, is the way the pneumococcus gets from one person to another, usually within three feet — the breathing zone — and then of course we hug and kiss our relatives and friends and that all provides an opportunity for the pneumococcus to spread. ## How can the public health community raise awareness of the impact of influenza and pneumococcal disease to increase protection through immunization? Clearly the public health community already has a powerful role in working with pediatricians and family physicians to make sure that all infants and children are completely vaccinated against pneumococcal disease. That’s part of the comprehensive childhood immunization program that we have in the United States, and it’s a huge success and we must continue to do that and try to find literally each and every child to get them vaccinated. It’s clear that public health will have a role in adult immunization also. The Centers for Disease Control and Prevention is promoting that and we’re all realizing that there are an awful lot of adults out there who are not appropriately immunized. So local heath departments and others in public health can continue to advocate for good, comprehensive adult immunization programs and to educate the public about vaccine-preventable diseases and the need to get vaccinated and that vaccines are both effective and safe. ## Is it true that pneumococcal disease can be treated very effectively? It can be treated very effectively with antibiotics, but here’s several things to keep in mind. The first is, the most serious kinds of pneumococcal infection — bloodstream infection and meningitis — even in the face of effective antibiotic therapy, and I want to repeat that — even in the face of effective antibiotic therapy — have mortality rates, death rates, somewhere between 15 and 20 percent. So treatment is not the complete answer and furthermore, the pneumococcus has started to get resistant to many first-line antibiotics, making treatment more difficult and that’s all the more important therefore that people get vaccinated to prevent the disease on the front end. In other words, we can’t rely on therapy to bail us out all the time. It comes back to prevention. As we all know, an ounce of prevention is more important than a pound of cure. Prevention on the front end continues to be the highest goal of medicine. I would rather prevent pneumococcal disease than treat it. ## Footnotes * — Interview conducted, edited and condensed by Teddi Dineley Johnson * Copyright The Nation’s Health, American Public Health Association