ͪy Pneumococcal Diseases

Seminar on "Invasive Pneumococcal Disease and Pneumococcal Conjugate Vaccine"

Co-organized by:
The Hong Kong Medical Association,
The Hospital Authority Infectious Disease Centre
and Centre for Health Protection, Department of Health

Date : Sunday, 8 December 2013
Speakers : 2:30 - 3:00 p.m. Conjugate Pneumococcal Vaccine - A Success Story But Not Complete
Prof. LAU Yu Lung
Doris Zimmern Professor in Community Child Health,
Chair Professor of Paediatrics, Dept. of Paediatrics & Adolescent Medicine, LKS Faculty of Medicine, HKU
Chairman, Working Group on Pneumococcal Vaccination, CHP
3:00 - 3:30 p.m. Resistant Pneumococcal Infections - Still Treatable But Difficult
Prof. HO Pak Leung
President, Centre of Infection, HKU
Member, Working Group on Pneumococcal Vaccination, CHP
3:30 - 4:30 p.m. Discussion and Q&A Session
Venue : Lecture Theatre, 7/F, Block H, Princess Margaret Hospital
2 - 10 Princess Margaret Hospital Road, New Territories
Moderator : Dr. TSE Hung Hing
HKMA President
Discussant : Dr. Alvin Y.S. CHAN
HKMA Vice-President
Chairman, HKMA Task Force on Vaccination PPI
    Dr. LEUNG Ting Hung, JP
Controller, CHP, DH
    Dr. LEUNG Chi Wai
Consultant Paediatrician and Head of Paediatric Infectious Disease, HAIDC, PMH
Member, SCVPD
President, Hong Kong Society for Paediatric Immunology and Infectious Diseases


The Hong Kong Medical Association
Forum on "What's New about Pneumococcal Pneumonia in Children?"

Date : Sunday, 1 December 2013
1:00 - 1:30 p.m. Registration & Lunch
1:30 - 1:45 p.m. Update on Pneumococcal Conjugate Vaccine
Dr. CHOW Chun Bong, BBS, JP
Chairman, Scientific Committee on Vaccine Preventable Diseases, CHP
1:45 - 2:25 p.m. What's New about Pneumococcal Pneumonia in Children?
Dr. HO Pak Leung
President, Centre of Infection, HKU
Member, Working Group on Pneumococcal Vaccination, CHP
2:25 - 2:50 p.m. Discussion and Q&A Session
Venue : The Hong Kong Medical Association Central Premises,
Dr. Li Shu Pui Professional Education Centre,
2/F., Chinese Club Building, 21-22 Connaught Road Central
Moderator : Dr. TSE Hung Hing
HKMA President
Discussant : Dr. Alvin Y.S. CHAN
HKMA Vice-President
Chairman, HKMA Task Force on Vaccination PPI



Introduction

Update on Pneumococcal Conjugate Vaccine (by Dr. CHOW Chun Bong, BBS, JP)

Q&A session after Dr. CHOW Chun Bong's presentation
What's New about Pneumococcal Pneumonia in Children? (by Dr. HO Pak Leung)
Discussion and Q&A session 1
Discussion and Q&A session 2



Advice from the HKMA Advisory Committee on Communicable Diseases on Invasive Pneumococcal Diseases and Community-acquired Pneumonia:

29 November, 2013

1. Two fatal cases of invasive pneumococcal disease (IPD) occurred among young children (3 and 5 years old) recently in Hong Kong. Both of them were caused by serotype 3 Streptococcus pneumoniae. The causative pathogen was resistant to macrolides in both cases, and both died with rapid progression of disease despite antibiotic treatment. One of them previously received 7-valent (PCV-7) and 10-valent (PCV-10) but not 13-valent Pneumococcal Conjugate Vaccine (PCV-13), and the other had not received any.

2. A joint meeting of the Scientific Committee on Vaccine Preventable Diseases and its Working Group on Pneumococcal Vaccination of the Centre for Health Protection, the Department of Health was convened on 25 Nov 2013 and examined the global and local IPD situation, particularly caused by serotype 3 pneumococcus. Based on the information currently available, the meeting considered requiring all children under 5 years old who had received PCV7 or PCV10 to receive a booster dose of PCV13 is not indicated at this point in time.

3. However, taking into account the concerns across the community, the Government has decided to subsidise one booster dose each for children aged 2 to under 5 years old who have never received PCV-13 before through the CHP's Vaccination Subsidy Scheme. Children aged six months and above should also follow the current recommendation for seasonal influenza vaccination unless there is contraindication.

4. The Advisory Committee on Communicable Diseases of the Hong Kong Medical Association reckoned that the previously used conjugated pneumococcal vaccines, PCV-7 and PCV-10, did not include serotype 3, one of the over 90 known serotypes. Even with the PCV-13 (containing polysaccharides of the capsular antigens of serotypes 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, and 23F, individually conjugated to a nontoxic diphtheria cross-reactive material carrier protein ) currently in use, immune response to serotype 3 is less strong than to other included serotypes.

5. The public has therefore to be reminded that protection by the pneumococcal vaccines is INCOMPLETE. Even after vaccination, there is continuing risk of IPD caused by Streptococcus pneumoniae, especially for serotype 3 and serotypes not covered by PCV-13. Professional medical advice should be sought promptly in case of any symptom(s) suggestive of serious respiratory infection.

6. IPD often runs a rapidly progressive course, which calls for early detection and prompt initiation of effective treatment. Besides clinical vigilance, chest radiograph is often useful for detecting lung and pleural involvement in severe or deteriorating respiratory infections. While suitable specimens should be collected for bacteriological investigations, empirical antibiotic treatment generally has to be initiated before identification of the causative organism in community-acquired pneumonia or other severe respiratory infections. Hospital admission should also be considered for careful monitoring, especially in presence of any significant clinical risk factor.

7. As shown by data from the Public Health Laboratory Service Branch, 60-89% of Streptococcus pneumoniae isolates in out-patient setting are currently resistant to erythromycin, representing the macrolide class (http://www.chp.gov.hk/en/epidemiology/29/97/119/321.html). High levels of macrolide resistance have also been reported among other respiratory pathogens, e.g. Streptococcus pyogenes, Staphylococcus aureus, and Mycoplasma pneumoniae. These observations raise serious doubt on the choice of macrolide as first-line antibiotic in monotherapy against community-acquired pneumonia or other serious respiratory infections likely of bacterial origin in both children and adults.

8. Intermediate level penicillin resistance (not beta-lactamase-producing) is increasingly observed among laboratory isolates of Streptococcus pneumoniae. Penicillin or amoxicillin would have to be used in high dose (iv or oral) to over such intermediate level resistance. The addition of a beta-lactamase inhibitor (e.g. clavulanate in a suitable preparation of Augmentin with or without additional amoxicillin) in usual dose will help to cover other respiratory pathogens (e.g. beta-lactamase-producing Haemophilus influenzae.) Ceftriaxone may also be considered as an alternative.

9. Although addition of a macrolide may help to extend initial coverage to macrolide-sensitive Mycoplasma pneumoniae and Legionella pneumophilia in cases showing suggestive clinical features, there are increasing concerns over the high prevalence of macrolide resistance in Mycoplasma pneumoniae (which may require alternative antibiotic such as doxycycline or fluoroquinolones) in recent scientific publications by local investigators.

10. A newer generation fluoroquinolone (e.g. levofloxacin or moxifloxacin) may be considered for Strepotococcus pneumoniae showing high level penicillin resistance (fortunately uncommon locally) and macrolide-resistant Mycoplasma pneumoniae. For life-threatening infections, the benefit likely outweighs the risk of cartilage damage, masking tuberculosis and / or acquisition of fluoroquinolone resistance in children or adults.

11. Careful monitoring of disease progress is essential, and the choice of antibiotic(s) has to be reassessed upon availability of bacteriology results, clinical deterioration or suboptimal response.