Revolutionizing COPD Care: The Role Of Pneumococcal Vaccines in Enhancing Patient Outcomes

Exacerbations are recognized to be crucial acute events that are associated with increased hospitalization rates and worsening clinical outcomes. Both bacterial and viral infections are a major exacerbation triggers that can lead to accelerated decline in pulmonary function.(1) Hence, prevention of future exacerbations is a key strategy in Chronic Pulmonary Obstructive Disorder (COPD) management. While both international and national guidelines advocate the use of pneumococcal vaccination in adults, however, there is limited implementation in the real world.(2)

Dr Rajesh V, Senior Consultant and Head of Department of Pulmonary Medicine at Rajagiri Hospital, Kerala, discusses the burden of pneumococcal disease in patients with COPD, the role of pneumococcal vaccination in mitigating this impact, and the tangible benefits observed in clinical practice in an in-depth interaction with Medical Dialogues.

What is the burden of pneumococcal disease in respiratory clinical practice based on your vast experience?

Pneumococcal disease significantly impacts patients with chronic respiratory diseases, particularly COPD. It is a leading cause of acute bacterial exacerbations in COPD patients and a common cause of community-acquired pneumonia.(3) Persistent pneumococcal colonization can lead to an accelerated decline in lung function and worsened quality of life. Among the bacterial pathogens, Pneumococcus is one of major causative pathogens of pneumococcal disease, with studies showing that 36.1% of first-time COPD exacerbation hospitalizations are linked to pneumonia.(4)This makes pneumococcal disease a serious public health issue in the context of chronic respiratory conditions.

Based on my experience, COPD patients are particularly vulnerable to pneumococcal disease. Pneumococcus is also a critical concern in asthma and interstitial lung diseases, as well as in patients with bronchiectasis, post-chemotherapy lung disease, and post-tubercular lungs.

What respiratory conditions warrant vaccination, and which vaccines would you recommend in those cases?

Vaccinations are essential even in the absence of respiratory diseases, particularly based on age. However, when it comes to respiratory disease, COPD is the prototype condition for which vaccinations, such as influenza and pneumococcal, are highly recommended. I also advocate these vaccinations in asthma, bronchiectasis, post-tubercular lung, and patients undergoing lung cancer treatment. Current smokers and those with chronic respiratory diseases should also receive pneumococcal and influenza vaccines.

Can early vaccination help in controlling disease progression or reducing infective exacerbations in COPD patients?

Yes. The natural history of COPD shows that patients often begin with mild symptoms and infrequent exacerbations, but eventually, over time, infections with organisms like Pneumococcus and Haemophilus influenzae become more recurrent. This leads to frequent exacerbations and worsening resistance to antibiotics. Early vaccination can be expected to delay or prevent the onset of these infections, potentially decelerating the disease’s progression, improving quality of life, and reducing clinical exacerbations and the need for hospitalization.

You have been a part of the landmark HOPE-COPD study in India. What are your insights on the benefit of pneumococcal vaccination on clinical outcomes in patients with COPD?

In the HOPE-COPD study, we divided COPD patients who were hospitalised with exacerbations into two groups - those previously vaccinated and second, who had not received vaccination. Our findings revealed significantly better hospitalization outcomes in the vaccinated group, including shorter hospital stays (Vaccinated group: 4.50±1.64 days vs. unvaccinated group: 5.47±2.03 days, p=0.005), reduced ICU admissions (30% vaccinated vs. 58.3% unvaccinated, p=0.002), and less need for assisted ventilation (assisted ventilation: 43.3% vaccinated vs. 60% unvaccinated, p=0.04). Moreover, prior immunization with the pneumococcal 13-valent conjugate vaccine (PCV13) demonstrated decreased severity of exacerbations in patients with COPD. The un-vaccinated group had increased multilobar consolidation (60% vs. 6.7%; P = 0.0001), incidence of fever (63.3% vs 21.7%; p<0.0001), leukocytosis (80% vs 46.6%; p=0.0002), and elevated C‑reactive proteins than the PCV13 vaccinated group, thereby highlighting the vaccine’s protective effect during hospitalizations for acute exacerbations. (5) Follow-up data, which is yet to be published, indicates that the incidence of exacerbations and community-acquired pneumonia decreased over one year after vaccination.

Why is sequencing PCV13 followed by PPSV23 important?

PPSV23 induces a T cell-independent response which leads to a diminished immune response while PCV13, engenders a T cell dependent immune response which elicits immunological memory and long-lasting immune response. Sequencing these vaccines is crucial as administering PCV13 first amplifies the antipneumococcal response to subsequent administration of PPSV23 for many common vaccine serotypes. However, administering PPSV23 before PCV13 can reduce the effectiveness of the conjugate vaccine. Hence, PCV13 should be given first followed by PPSV23 one year later, unless there is an urgent need, in which case it can be administered post 8 weeks of the conjugate vaccine.(6)

What are the challenges and ideal timing of pneumococcal vaccination in outpatient and inpatient settings to ensure vaccine adherence?

During hospitalization, the consultant has more time to assess the patient’s vaccination needs, explain the benefits, and address concerns. Patients are also more receptive to vaccination when they are already receiving treatment in inpatient settings and are less likely to have injection phobia. Hence with decreased vaccine hesitancy, inpatient settings offer the best opportunity to vaccinate patients either during discharge or at first follow-up.

For outpatient settings, it is ideal to vaccinate patients in the first OPD visit. However, both time constraints for consultants and vaccine hesitancy amongst the patients limit the vaccine uptake. Educating and priming the patients during outpatient visits, keeping educational materials visible to remind the patient of the importance of vaccinations etc can help improve adherence.

What message would you give to doctors regarding effectively implementing vaccinations in outpatient settings, when indicated?

Health care providers (HCPs) need to be well-informed about the available vaccines, their benefits, costs, and schedules. Like pediatric vaccinations, education should be incorporated into the academic curriculum of medical students to ensure that adult vaccination is given the emphasis it deserves.

Keeping visual reminders in consultation rooms can sensitize HCPs in primary and secondary care settings to check if patients have indications for vaccination. This also encourages patients to inquire about these vaccines, making it easier for HCPs to recommend them.

Mass education campaigns are essential to combat adult vaccination inertia. Even among well-educated patients, misinformation, often fueled by online sources, can cause fear of side effects. However, the benefits of vaccines far outweigh the risks, and vaccines like pneumococcal and influenza have been clinically developed with robust scientific sanctity and regulatory compliance with a long track record of safety and efficacy.

References:

1. Sorge, Randy, and Peter DeBlieux. “Acute Exacerbations of Chronic Obstructive Pulmonary Disease: A Primer for Emergency Physicians.” The Journal of emergency medicine vol. 59,5 (2020): 643-659. doi:10.1016/j.jemermed.2020.07.001

2. Koul, Parvaiz A et al. “Expert panel opinion on adult pneumococcal vaccination in the post-COVID era (NAP- EXPO Recommendations-2024).” Lung India : official organ of Indian Chest Society vol. 41,4 (2024): 307-317. doi:10.4103/lungindia.lungindia_8_24

3. Li, Xue-Jun et al. “Bacteriological differences between COPD exacerbation and community-acquired pneumonia.” Respiratory care vol. 56,11 (2011): 1818-24. doi:10.4187/respcare.00915

4. Søgaard, Mette et al. “Incidence and outcomes of patients hospitalized with COPD exacerbation with and without pneumonia.” International journal of chronic obstructive pulmonary disease vol. 11 455-65. 2 Mar. 2016, doi:10.2147/COPD.S96179

5. Venkitakrishnan R, Vijay A, Augustine J, Ramachandran D, Cleetus M, Nirmal AS, John S. Hospitalisation outcomes in pneumococcal-vaccinated versus -unvaccinated patients with exacerbation of COPD: results from the HOPE COPD Study. ERJ Open Res. 2023 May 2;9(3):00476-2022

6. Association of Physicians of India. The New Indian Consensus Guideline on Adult Immunization. 2024 Retrieved on 16 August 2024 from https://apiindia.org/reader/immunization