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What is the role of herpes virus serology in sexually transmitted disease screening?
Screening for herpes simplex virus type 2 (HSV-2) infection with antibody testing is not indicated for asymptomatic adults (strength of recommendation [SOR]: B, prevalence studies and predictive value of testing). Screening with serology testing is not indicated for asymptomatic pregnant women (SOR: B, 1 cohort study).
You may consider offering testing to asymptomatic patients with an HSV-positive partner, patients with HIV infection, and those with current or recent sexually transmitted infection or high-risk behavior (SOR: C, expert opinion and 1 case control study with extrapolation of result).
Counsel patients that the diagnostic gold standard remains viral culture or PCR testing of active lesions
John Mercer, MD, FAAFP
Baylor Family Medicine Residency, Garland, Tex
Early in my practice, a couple came to my office demanding serology testing for HSV after resolution of a new genital lesion. The results of the non-type-specific HSV serology led to more questions than answers due to cross-reactivity between virus types. Even with the newer type-specific glycoprotein enzyme immunoassays for HSV 1 and 2, I reserve serologic testing for specific situations, as outlined in this review, and when recurrent genital signs or symptoms of unclear cause present with negative viral culture results. I counsel patients that the diagnostic gold standard remains viral culture or PCR testing of active lesions. The best course of action for most asymptomatic patients remains sexually transmitted disease counseling and returning to the clinic for viral culture if a suspicious lesion returns.
Evidence summary
An effective screening test for HSV would need to identify those with HSV infection before substantial morbidity resulted, and effective interventions would need to be available for use in the asymptomatic stage. Screening for HSV-2 must also consider the psychosocial impact of serologic diagnosis in those without symptoms, as a qualitative study showed both negative and positive emotional responses in those with positive serology, with short-term emotional responses described as surprise, denial, confusion, distress, disappointment, and sense of relief.1 Patients also expressed fear of partner notification, concern for transmission to newborns, and concern for social stigma.
Pre- and post-test counseling must accompany testing as negative emotional or psychological responses are amenable to this intervention. A consideration for screening decisions is the positive predictive value (PPV) of testing for the specific patient, which ranges from 58% (in a British population with 4% prevalence) to 90% (in a population with 22% prevalence taken from sexually transmitted disease clinics in the Netherlands).2 (A PPV of 58% means that only 58% of women with a positive test actually had the disease, and 42% were false-positive).
The primary goal for screening pregnant women is prevention of neonatal transmission of HSV. A prospective observational study3 of 7046 women found that acquisition of HSV-2 during pregnancy was asymptomatic in 74% of 94 cases. No increase in neonatal or pregnancy-related morbidity was seen for those patients who had seroconverted by the time of labor. The main benefit of serology testing during pregnancy has been to identify patients with asymptomatic infection and counsel them on reporting new symptoms for evaluation and treatment.
Another prospective cohort study4 identified seropositive pregnant women with no history of genital herpes. Forty-three of 264 (16%) of these women were able to identify and report clinical HSV to their physician during the pregnancy.
Testing of asymptomatic patients with HSV-2 serology and counseling has been recommended by some experts5 for motivated patients with current or recent sexually transmitted infection or HIV infection and for partners of HSV-positive patients.6 Screening could give those identified the opportunity to learn to recognize symptoms, decrease transmission, and understand risks of acquiring HIV or other sexually transmitted infections. Patients screening negative might have heightened awareness to susceptibility and reinforce lifestyle changes.6 Success of HSV prevention strategies is reviewed elsewhere.7
Recommendations from others
The Centers for Disease Control and Prevention, the United States Preventive Services Task Force, and the American Academy of Family Physicians do not recommend screening asymptomatic adults for HSV infection.7,8 The American College of Obstetricians and Gynecologists does not recommend routine screening of pregnant women for HSV.9
1. Melville J, Sniffen S, Salazar L, et al. Psychosocial impact of serological diagnosis of herpes simplex virus type 2: a qualitative assessment. Sex Trans Infect 2003;79:280-285.
2. Krantz I, Lowhagen G, Ahlberg B, Nilstun T. Ethics of screening for asymptomatic herpes virus type 2 infection. BMJ 2004;329:618-621.
3. Brown Z, Selke S, Zeh J, et al. The acquisition of herpes simplex virus during pregnancy. N Engl J Med 1997;337:509-516.
4. Frenkel L, Garratty E, Ping S, et al. Clinical reactivation of herpes simplex virus type 2 infection in seropositive pregnant women with no history of genital herpes. Ann Int Med 1993;118:414-418.
5. Centers for Disease Control and Prevention. Incorporating HIV prevention into medical care of persons living with HIV: recommendations of CDC, the Health Resources and Services Administration, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. MMWR Recomm Rep 2003;52(RR-12).-
6. Centers for Disease Control and Prevention. Diseases Characterized by Genital Ulcers. Sexually Transmitted Diseases Guidelines. MMWR Recomm Rep 2002;51(RR-6):11-25.
7. Screening for genital herpes simplex. Rockville, Md: US Preventive Task Force updated March 2005. Available at: www.ahrq.gov/clinic/uspstf05/herpes/herpesup.htm. Accessed on April 18, 2006.
8. American Academy of Family Physicians. Summary of policy recommendations for periodic health examinations. Leawood, Kan: American Academy of Family Physicians; 2004. 15pp.
9. American College of Obstetricians and Gynecologists. Guidelines for Perinatal Care. 5th ed. Elk Grove, Ill: AAP; Washington, DC: ACOG; 2002.
Screening for herpes simplex virus type 2 (HSV-2) infection with antibody testing is not indicated for asymptomatic adults (strength of recommendation [SOR]: B, prevalence studies and predictive value of testing). Screening with serology testing is not indicated for asymptomatic pregnant women (SOR: B, 1 cohort study).
You may consider offering testing to asymptomatic patients with an HSV-positive partner, patients with HIV infection, and those with current or recent sexually transmitted infection or high-risk behavior (SOR: C, expert opinion and 1 case control study with extrapolation of result).
Counsel patients that the diagnostic gold standard remains viral culture or PCR testing of active lesions
John Mercer, MD, FAAFP
Baylor Family Medicine Residency, Garland, Tex
Early in my practice, a couple came to my office demanding serology testing for HSV after resolution of a new genital lesion. The results of the non-type-specific HSV serology led to more questions than answers due to cross-reactivity between virus types. Even with the newer type-specific glycoprotein enzyme immunoassays for HSV 1 and 2, I reserve serologic testing for specific situations, as outlined in this review, and when recurrent genital signs or symptoms of unclear cause present with negative viral culture results. I counsel patients that the diagnostic gold standard remains viral culture or PCR testing of active lesions. The best course of action for most asymptomatic patients remains sexually transmitted disease counseling and returning to the clinic for viral culture if a suspicious lesion returns.
Evidence summary
An effective screening test for HSV would need to identify those with HSV infection before substantial morbidity resulted, and effective interventions would need to be available for use in the asymptomatic stage. Screening for HSV-2 must also consider the psychosocial impact of serologic diagnosis in those without symptoms, as a qualitative study showed both negative and positive emotional responses in those with positive serology, with short-term emotional responses described as surprise, denial, confusion, distress, disappointment, and sense of relief.1 Patients also expressed fear of partner notification, concern for transmission to newborns, and concern for social stigma.
Pre- and post-test counseling must accompany testing as negative emotional or psychological responses are amenable to this intervention. A consideration for screening decisions is the positive predictive value (PPV) of testing for the specific patient, which ranges from 58% (in a British population with 4% prevalence) to 90% (in a population with 22% prevalence taken from sexually transmitted disease clinics in the Netherlands).2 (A PPV of 58% means that only 58% of women with a positive test actually had the disease, and 42% were false-positive).
The primary goal for screening pregnant women is prevention of neonatal transmission of HSV. A prospective observational study3 of 7046 women found that acquisition of HSV-2 during pregnancy was asymptomatic in 74% of 94 cases. No increase in neonatal or pregnancy-related morbidity was seen for those patients who had seroconverted by the time of labor. The main benefit of serology testing during pregnancy has been to identify patients with asymptomatic infection and counsel them on reporting new symptoms for evaluation and treatment.
Another prospective cohort study4 identified seropositive pregnant women with no history of genital herpes. Forty-three of 264 (16%) of these women were able to identify and report clinical HSV to their physician during the pregnancy.
Testing of asymptomatic patients with HSV-2 serology and counseling has been recommended by some experts5 for motivated patients with current or recent sexually transmitted infection or HIV infection and for partners of HSV-positive patients.6 Screening could give those identified the opportunity to learn to recognize symptoms, decrease transmission, and understand risks of acquiring HIV or other sexually transmitted infections. Patients screening negative might have heightened awareness to susceptibility and reinforce lifestyle changes.6 Success of HSV prevention strategies is reviewed elsewhere.7
Recommendations from others
The Centers for Disease Control and Prevention, the United States Preventive Services Task Force, and the American Academy of Family Physicians do not recommend screening asymptomatic adults for HSV infection.7,8 The American College of Obstetricians and Gynecologists does not recommend routine screening of pregnant women for HSV.9
Screening for herpes simplex virus type 2 (HSV-2) infection with antibody testing is not indicated for asymptomatic adults (strength of recommendation [SOR]: B, prevalence studies and predictive value of testing). Screening with serology testing is not indicated for asymptomatic pregnant women (SOR: B, 1 cohort study).
You may consider offering testing to asymptomatic patients with an HSV-positive partner, patients with HIV infection, and those with current or recent sexually transmitted infection or high-risk behavior (SOR: C, expert opinion and 1 case control study with extrapolation of result).
Counsel patients that the diagnostic gold standard remains viral culture or PCR testing of active lesions
John Mercer, MD, FAAFP
Baylor Family Medicine Residency, Garland, Tex
Early in my practice, a couple came to my office demanding serology testing for HSV after resolution of a new genital lesion. The results of the non-type-specific HSV serology led to more questions than answers due to cross-reactivity between virus types. Even with the newer type-specific glycoprotein enzyme immunoassays for HSV 1 and 2, I reserve serologic testing for specific situations, as outlined in this review, and when recurrent genital signs or symptoms of unclear cause present with negative viral culture results. I counsel patients that the diagnostic gold standard remains viral culture or PCR testing of active lesions. The best course of action for most asymptomatic patients remains sexually transmitted disease counseling and returning to the clinic for viral culture if a suspicious lesion returns.
Evidence summary
An effective screening test for HSV would need to identify those with HSV infection before substantial morbidity resulted, and effective interventions would need to be available for use in the asymptomatic stage. Screening for HSV-2 must also consider the psychosocial impact of serologic diagnosis in those without symptoms, as a qualitative study showed both negative and positive emotional responses in those with positive serology, with short-term emotional responses described as surprise, denial, confusion, distress, disappointment, and sense of relief.1 Patients also expressed fear of partner notification, concern for transmission to newborns, and concern for social stigma.
Pre- and post-test counseling must accompany testing as negative emotional or psychological responses are amenable to this intervention. A consideration for screening decisions is the positive predictive value (PPV) of testing for the specific patient, which ranges from 58% (in a British population with 4% prevalence) to 90% (in a population with 22% prevalence taken from sexually transmitted disease clinics in the Netherlands).2 (A PPV of 58% means that only 58% of women with a positive test actually had the disease, and 42% were false-positive).
The primary goal for screening pregnant women is prevention of neonatal transmission of HSV. A prospective observational study3 of 7046 women found that acquisition of HSV-2 during pregnancy was asymptomatic in 74% of 94 cases. No increase in neonatal or pregnancy-related morbidity was seen for those patients who had seroconverted by the time of labor. The main benefit of serology testing during pregnancy has been to identify patients with asymptomatic infection and counsel them on reporting new symptoms for evaluation and treatment.
Another prospective cohort study4 identified seropositive pregnant women with no history of genital herpes. Forty-three of 264 (16%) of these women were able to identify and report clinical HSV to their physician during the pregnancy.
Testing of asymptomatic patients with HSV-2 serology and counseling has been recommended by some experts5 for motivated patients with current or recent sexually transmitted infection or HIV infection and for partners of HSV-positive patients.6 Screening could give those identified the opportunity to learn to recognize symptoms, decrease transmission, and understand risks of acquiring HIV or other sexually transmitted infections. Patients screening negative might have heightened awareness to susceptibility and reinforce lifestyle changes.6 Success of HSV prevention strategies is reviewed elsewhere.7
Recommendations from others
The Centers for Disease Control and Prevention, the United States Preventive Services Task Force, and the American Academy of Family Physicians do not recommend screening asymptomatic adults for HSV infection.7,8 The American College of Obstetricians and Gynecologists does not recommend routine screening of pregnant women for HSV.9
1. Melville J, Sniffen S, Salazar L, et al. Psychosocial impact of serological diagnosis of herpes simplex virus type 2: a qualitative assessment. Sex Trans Infect 2003;79:280-285.
2. Krantz I, Lowhagen G, Ahlberg B, Nilstun T. Ethics of screening for asymptomatic herpes virus type 2 infection. BMJ 2004;329:618-621.
3. Brown Z, Selke S, Zeh J, et al. The acquisition of herpes simplex virus during pregnancy. N Engl J Med 1997;337:509-516.
4. Frenkel L, Garratty E, Ping S, et al. Clinical reactivation of herpes simplex virus type 2 infection in seropositive pregnant women with no history of genital herpes. Ann Int Med 1993;118:414-418.
5. Centers for Disease Control and Prevention. Incorporating HIV prevention into medical care of persons living with HIV: recommendations of CDC, the Health Resources and Services Administration, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. MMWR Recomm Rep 2003;52(RR-12).-
6. Centers for Disease Control and Prevention. Diseases Characterized by Genital Ulcers. Sexually Transmitted Diseases Guidelines. MMWR Recomm Rep 2002;51(RR-6):11-25.
7. Screening for genital herpes simplex. Rockville, Md: US Preventive Task Force updated March 2005. Available at: www.ahrq.gov/clinic/uspstf05/herpes/herpesup.htm. Accessed on April 18, 2006.
8. American Academy of Family Physicians. Summary of policy recommendations for periodic health examinations. Leawood, Kan: American Academy of Family Physicians; 2004. 15pp.
9. American College of Obstetricians and Gynecologists. Guidelines for Perinatal Care. 5th ed. Elk Grove, Ill: AAP; Washington, DC: ACOG; 2002.
1. Melville J, Sniffen S, Salazar L, et al. Psychosocial impact of serological diagnosis of herpes simplex virus type 2: a qualitative assessment. Sex Trans Infect 2003;79:280-285.
2. Krantz I, Lowhagen G, Ahlberg B, Nilstun T. Ethics of screening for asymptomatic herpes virus type 2 infection. BMJ 2004;329:618-621.
3. Brown Z, Selke S, Zeh J, et al. The acquisition of herpes simplex virus during pregnancy. N Engl J Med 1997;337:509-516.
4. Frenkel L, Garratty E, Ping S, et al. Clinical reactivation of herpes simplex virus type 2 infection in seropositive pregnant women with no history of genital herpes. Ann Int Med 1993;118:414-418.
5. Centers for Disease Control and Prevention. Incorporating HIV prevention into medical care of persons living with HIV: recommendations of CDC, the Health Resources and Services Administration, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. MMWR Recomm Rep 2003;52(RR-12).-
6. Centers for Disease Control and Prevention. Diseases Characterized by Genital Ulcers. Sexually Transmitted Diseases Guidelines. MMWR Recomm Rep 2002;51(RR-6):11-25.
7. Screening for genital herpes simplex. Rockville, Md: US Preventive Task Force updated March 2005. Available at: www.ahrq.gov/clinic/uspstf05/herpes/herpesup.htm. Accessed on April 18, 2006.
8. American Academy of Family Physicians. Summary of policy recommendations for periodic health examinations. Leawood, Kan: American Academy of Family Physicians; 2004. 15pp.
9. American College of Obstetricians and Gynecologists. Guidelines for Perinatal Care. 5th ed. Elk Grove, Ill: AAP; Washington, DC: ACOG; 2002.
Evidence-based answers from the Family Physicians Inquiries Network
Is pneumococcal vaccine effective in nursing home patients?
Evidence from clinical trials supports the use of pneumococcal polysaccharide vaccine for prevention of pneumonia in nursing home patients (strength of recommendation: B, based on randomized, nonblinded clinical trials).
Case-control studies have consistently shown the efficacy of pneumococcal vaccine in preventing invasive pneumococcal disease and bacteremia for patients with chronic medical illnesses and the elderly, patients typically found in nursing home populations (SOR: B, based on consistent case-control studies).
Evidence summary
Two clinical trials directly addressed the prevention of pneumonia in nursing home patients. A prospective, risk-stratified, randomized study of the 14-valent pneumococcal vaccine in 1686 patients living in hospices and nursing homes in France showed an absolute risk reduction (ARR) of 2.9% in the incidence of all-cause pneumonia, corresponding to a number needed to treat (NNT) of 35.1 This study has 2 major limitations: the authors did not comment on whether the study was blinded, and 31% of patients were lost to follow-up.
A 6-year randomized clinical trial that studied the trivalent pneumococcal vaccine in preventing pneumonia in New York City Home (a nursing home) subjects showed an ARR=2.7% and NNT=37.2 While this report also did not specify whether there was blinding, any bias introduced by absence of blinding is unlikely to account for the large effect size (relative risk reduction=0.56).
Nursing home residents may be especially vulnerable to acquiring pneumococcal infection due to advanced age, chronic illnesses, and their communal setting. The Centers for Disease Control and Prevention (CDC) has reported outbreaks of invasive pneumococcal disease in nursing homes where vaccination rates are low.3 Pneumococcal bacteremia is seen in only 10%–20% of patients with pneumococcal pneumonia but confers a significant risk of death. Therefore, pneumococcal vaccination is indicated for patients ≥ 65 years or those with chronic medical conditions.
Case-control studies have consistently shown efficacy in preventing invasive pneumococcal disease. Farr and colleagues found efficacy of 70% (95% confidence interval [CI], 37%–86%) among 2 groups of patients: those ≥ 2 years of age with chronic disease or those ≥ 65 years.4 A case-control study by Sims and colleagues also found the vaccine to have efficacy of 70% (95% CI, 37%– 86%) in preventing invasive pneumococcal disease in immunocompetent patients aged ≥ 55 years.5
Recommendations from others
The CDC Advisory Committee on Immunization Practices (ACIP) recommends pneumococcal vaccination of persons aged ≥65 years and those aged 2 to 64 who have chronic cardiovascular disease, chronic pulmonary disease, or diabetes mellitus (SOR: A).6
The ACIP also recommends the pneumococcal vaccine for persons aged 2 to 64 years who have alcoholism, chronic liver disease, or cerebrospinal fluid leaks (SOR: B).
The Canadian Task Force on Preventive Health Care endorses vaccination for immunocompetent patients 55 years residing in institutions (SOR: A).7
Paul Tatum, MD, MSPH
Department of Family Medicine, University of Colorado, Boulder.
The importance of pneumococcal vaccine for the elderly is well established. However, the vaccine is underused in long-term care settings, despite being indicated for most residents.
Patient confusion about the need for both influenza and pneumococcal vaccines, poor documentation of adult immunization status, poor availability of records from previous care facilities, and frequent changes in physician all contribute to low vaccination rates.
An optimal strategy to ensure high vaccination rates is to administer the pneumococcal vaccine to patients on admission to long-term care facilities. Patients who are uncertain about their vaccination status may safely receive the vaccine, as revaccination is relatively well tolerated.8
ACKNOWLEDGMENTS
The authors wish to thank Yves LeBlanc, MD, and Khalil Nasrallah, MD, for assistance with translation.
1. Gaillet J, Zmirou D, Mallaret MR, et al. Essai clinique du vaccin antipneumococcoique chez des personnees agees vivant en institution [Clinical trial of an antipneumococcal vaccine in elderly subjects living in institutions]. Rev Epidemiol Sante Publique 1985;33:437-44.
2. Kaufman P. Pneumonia in old age. Arch Intern Med 1947;79:518-31.
3. Centers for Disease Control and Prevention. Outbreaks of pneumococcal pneumonia among unvaccinated residents of a nursing home—New Jersey, April 2001. MMWR Morb Mortal Wkly Rep 2001;50:707-10.
4. Farr BM, Johnston BL, Cobb DK, et al. Preventing pneumococcal bacteremia in patients at risk. Arch Intern Med 1995;155:2336-40.
5. Sims RV, Steinmann WC, McConville JH, King LR, Zwick WC, Schwartz JS. The clinical effectiveness of pneumococcal vaccine in the elderly. Ann Intern Med 1988;108:653-7.
6. Centers for Disease Control and Prevention. Prevention of pneumococcal disease: recommendations of the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep 1997;46:1-24.
7. Wang EEL. Administration of pneumococcal vaccine. Canadian Task Force on Preventive Health Care 1994;385-6.
8. Jackson LA, Benson P, Sneller VP, et al. Safety of revaccination with pneumococcal polysaccharide vaccine. JAMA 1999;281:243-8.
Evidence from clinical trials supports the use of pneumococcal polysaccharide vaccine for prevention of pneumonia in nursing home patients (strength of recommendation: B, based on randomized, nonblinded clinical trials).
Case-control studies have consistently shown the efficacy of pneumococcal vaccine in preventing invasive pneumococcal disease and bacteremia for patients with chronic medical illnesses and the elderly, patients typically found in nursing home populations (SOR: B, based on consistent case-control studies).
Evidence summary
Two clinical trials directly addressed the prevention of pneumonia in nursing home patients. A prospective, risk-stratified, randomized study of the 14-valent pneumococcal vaccine in 1686 patients living in hospices and nursing homes in France showed an absolute risk reduction (ARR) of 2.9% in the incidence of all-cause pneumonia, corresponding to a number needed to treat (NNT) of 35.1 This study has 2 major limitations: the authors did not comment on whether the study was blinded, and 31% of patients were lost to follow-up.
A 6-year randomized clinical trial that studied the trivalent pneumococcal vaccine in preventing pneumonia in New York City Home (a nursing home) subjects showed an ARR=2.7% and NNT=37.2 While this report also did not specify whether there was blinding, any bias introduced by absence of blinding is unlikely to account for the large effect size (relative risk reduction=0.56).
Nursing home residents may be especially vulnerable to acquiring pneumococcal infection due to advanced age, chronic illnesses, and their communal setting. The Centers for Disease Control and Prevention (CDC) has reported outbreaks of invasive pneumococcal disease in nursing homes where vaccination rates are low.3 Pneumococcal bacteremia is seen in only 10%–20% of patients with pneumococcal pneumonia but confers a significant risk of death. Therefore, pneumococcal vaccination is indicated for patients ≥ 65 years or those with chronic medical conditions.
Case-control studies have consistently shown efficacy in preventing invasive pneumococcal disease. Farr and colleagues found efficacy of 70% (95% confidence interval [CI], 37%–86%) among 2 groups of patients: those ≥ 2 years of age with chronic disease or those ≥ 65 years.4 A case-control study by Sims and colleagues also found the vaccine to have efficacy of 70% (95% CI, 37%– 86%) in preventing invasive pneumococcal disease in immunocompetent patients aged ≥ 55 years.5
Recommendations from others
The CDC Advisory Committee on Immunization Practices (ACIP) recommends pneumococcal vaccination of persons aged ≥65 years and those aged 2 to 64 who have chronic cardiovascular disease, chronic pulmonary disease, or diabetes mellitus (SOR: A).6
The ACIP also recommends the pneumococcal vaccine for persons aged 2 to 64 years who have alcoholism, chronic liver disease, or cerebrospinal fluid leaks (SOR: B).
The Canadian Task Force on Preventive Health Care endorses vaccination for immunocompetent patients 55 years residing in institutions (SOR: A).7
Paul Tatum, MD, MSPH
Department of Family Medicine, University of Colorado, Boulder.
The importance of pneumococcal vaccine for the elderly is well established. However, the vaccine is underused in long-term care settings, despite being indicated for most residents.
Patient confusion about the need for both influenza and pneumococcal vaccines, poor documentation of adult immunization status, poor availability of records from previous care facilities, and frequent changes in physician all contribute to low vaccination rates.
An optimal strategy to ensure high vaccination rates is to administer the pneumococcal vaccine to patients on admission to long-term care facilities. Patients who are uncertain about their vaccination status may safely receive the vaccine, as revaccination is relatively well tolerated.8
ACKNOWLEDGMENTS
The authors wish to thank Yves LeBlanc, MD, and Khalil Nasrallah, MD, for assistance with translation.
Evidence from clinical trials supports the use of pneumococcal polysaccharide vaccine for prevention of pneumonia in nursing home patients (strength of recommendation: B, based on randomized, nonblinded clinical trials).
Case-control studies have consistently shown the efficacy of pneumococcal vaccine in preventing invasive pneumococcal disease and bacteremia for patients with chronic medical illnesses and the elderly, patients typically found in nursing home populations (SOR: B, based on consistent case-control studies).
Evidence summary
Two clinical trials directly addressed the prevention of pneumonia in nursing home patients. A prospective, risk-stratified, randomized study of the 14-valent pneumococcal vaccine in 1686 patients living in hospices and nursing homes in France showed an absolute risk reduction (ARR) of 2.9% in the incidence of all-cause pneumonia, corresponding to a number needed to treat (NNT) of 35.1 This study has 2 major limitations: the authors did not comment on whether the study was blinded, and 31% of patients were lost to follow-up.
A 6-year randomized clinical trial that studied the trivalent pneumococcal vaccine in preventing pneumonia in New York City Home (a nursing home) subjects showed an ARR=2.7% and NNT=37.2 While this report also did not specify whether there was blinding, any bias introduced by absence of blinding is unlikely to account for the large effect size (relative risk reduction=0.56).
Nursing home residents may be especially vulnerable to acquiring pneumococcal infection due to advanced age, chronic illnesses, and their communal setting. The Centers for Disease Control and Prevention (CDC) has reported outbreaks of invasive pneumococcal disease in nursing homes where vaccination rates are low.3 Pneumococcal bacteremia is seen in only 10%–20% of patients with pneumococcal pneumonia but confers a significant risk of death. Therefore, pneumococcal vaccination is indicated for patients ≥ 65 years or those with chronic medical conditions.
Case-control studies have consistently shown efficacy in preventing invasive pneumococcal disease. Farr and colleagues found efficacy of 70% (95% confidence interval [CI], 37%–86%) among 2 groups of patients: those ≥ 2 years of age with chronic disease or those ≥ 65 years.4 A case-control study by Sims and colleagues also found the vaccine to have efficacy of 70% (95% CI, 37%– 86%) in preventing invasive pneumococcal disease in immunocompetent patients aged ≥ 55 years.5
Recommendations from others
The CDC Advisory Committee on Immunization Practices (ACIP) recommends pneumococcal vaccination of persons aged ≥65 years and those aged 2 to 64 who have chronic cardiovascular disease, chronic pulmonary disease, or diabetes mellitus (SOR: A).6
The ACIP also recommends the pneumococcal vaccine for persons aged 2 to 64 years who have alcoholism, chronic liver disease, or cerebrospinal fluid leaks (SOR: B).
The Canadian Task Force on Preventive Health Care endorses vaccination for immunocompetent patients 55 years residing in institutions (SOR: A).7
Paul Tatum, MD, MSPH
Department of Family Medicine, University of Colorado, Boulder.
The importance of pneumococcal vaccine for the elderly is well established. However, the vaccine is underused in long-term care settings, despite being indicated for most residents.
Patient confusion about the need for both influenza and pneumococcal vaccines, poor documentation of adult immunization status, poor availability of records from previous care facilities, and frequent changes in physician all contribute to low vaccination rates.
An optimal strategy to ensure high vaccination rates is to administer the pneumococcal vaccine to patients on admission to long-term care facilities. Patients who are uncertain about their vaccination status may safely receive the vaccine, as revaccination is relatively well tolerated.8
ACKNOWLEDGMENTS
The authors wish to thank Yves LeBlanc, MD, and Khalil Nasrallah, MD, for assistance with translation.
1. Gaillet J, Zmirou D, Mallaret MR, et al. Essai clinique du vaccin antipneumococcoique chez des personnees agees vivant en institution [Clinical trial of an antipneumococcal vaccine in elderly subjects living in institutions]. Rev Epidemiol Sante Publique 1985;33:437-44.
2. Kaufman P. Pneumonia in old age. Arch Intern Med 1947;79:518-31.
3. Centers for Disease Control and Prevention. Outbreaks of pneumococcal pneumonia among unvaccinated residents of a nursing home—New Jersey, April 2001. MMWR Morb Mortal Wkly Rep 2001;50:707-10.
4. Farr BM, Johnston BL, Cobb DK, et al. Preventing pneumococcal bacteremia in patients at risk. Arch Intern Med 1995;155:2336-40.
5. Sims RV, Steinmann WC, McConville JH, King LR, Zwick WC, Schwartz JS. The clinical effectiveness of pneumococcal vaccine in the elderly. Ann Intern Med 1988;108:653-7.
6. Centers for Disease Control and Prevention. Prevention of pneumococcal disease: recommendations of the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep 1997;46:1-24.
7. Wang EEL. Administration of pneumococcal vaccine. Canadian Task Force on Preventive Health Care 1994;385-6.
8. Jackson LA, Benson P, Sneller VP, et al. Safety of revaccination with pneumococcal polysaccharide vaccine. JAMA 1999;281:243-8.
1. Gaillet J, Zmirou D, Mallaret MR, et al. Essai clinique du vaccin antipneumococcoique chez des personnees agees vivant en institution [Clinical trial of an antipneumococcal vaccine in elderly subjects living in institutions]. Rev Epidemiol Sante Publique 1985;33:437-44.
2. Kaufman P. Pneumonia in old age. Arch Intern Med 1947;79:518-31.
3. Centers for Disease Control and Prevention. Outbreaks of pneumococcal pneumonia among unvaccinated residents of a nursing home—New Jersey, April 2001. MMWR Morb Mortal Wkly Rep 2001;50:707-10.
4. Farr BM, Johnston BL, Cobb DK, et al. Preventing pneumococcal bacteremia in patients at risk. Arch Intern Med 1995;155:2336-40.
5. Sims RV, Steinmann WC, McConville JH, King LR, Zwick WC, Schwartz JS. The clinical effectiveness of pneumococcal vaccine in the elderly. Ann Intern Med 1988;108:653-7.
6. Centers for Disease Control and Prevention. Prevention of pneumococcal disease: recommendations of the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep 1997;46:1-24.
7. Wang EEL. Administration of pneumococcal vaccine. Canadian Task Force on Preventive Health Care 1994;385-6.
8. Jackson LA, Benson P, Sneller VP, et al. Safety of revaccination with pneumococcal polysaccharide vaccine. JAMA 1999;281:243-8.
Evidence-based answers from the Family Physicians Inquiries Network