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SURVEILLANCEREPORT
reportfor2022
SURVEILLANCE
Invasivepneumococcaldisease
AnnualEpidemiologicalReportfor2022
Keyfacts
•In2022,17700confirmedcasesofinvasivepneumococcaldisease(IPD)werereportedintheEuropeanUnion/EuropeanEconomicArea.
•Thecrudenotificationratewas5.1casesper100000population,similarto2018and2019.
•Age-specificrateswerehighestininfantsunderoneyearold(13.4confirmedcasesper100000
population)andinadults65yearsoldandabove(12.6confirmedcasesper100000population),withhigherratesreportedinmalesthanfemalesamongallagegroups.
•Themostcommonserotypeswere3,8,19A,22F,6C,23B,9N,4,23A11A,and15A(inorderofdecreasingfrequency),accountingfor73.9%oftypedisolates.
•Ofcasesunderfiveyearsoldforwhomserotypeinformationwasavailable,approximately46%werecausedbyaserotypeincludedinthe13-valentpneumococcalconjugatevaccine(PCV13).This
proportionhasincreasedoverthelastfiveyears.
•Amongcases65yearsoldandabove,approximately71%ofcaseswithserotypeinformationavailablewerecausedbyserotypesincludedinthe23-valentpolysaccharidevaccine(PPV23).TheproportioncausedbytheserotypesincludedinPCV13was41%.
Introduction
PneumococcaldiseasesaresymptomaticinfectionscausedbythebacteriumStreptococcuspneumoniae
(S.pneumoniae),commonlyreferredtoaspneumococcus.Theterm‘invasivepneumococcaldisease’(IPD)isusedformoresevereandinvasivepneumococcalinfections,suchasbacteraemia,sepsis,meningitisandosteomyelitis.PneumococcalinfectionsandIPDaremajorcausesofcommunicablediseasemorbidityandmortalityinEuropeandglobally,withthehighestburdenofdiseasefoundinyoungchildrenandtheelderly.AlargeproportionofIPDis
vaccinepreventable.
S.pneumoniaeisclassifiedintoserotypesbasedonthepolysaccharidecapsuleantigens.Morethan90
immunologicallydistinctserotypesareknown,andstructurallyrelatedserotypesaregroupedtogetherandlabelledalphabetically(e.g.6A,6B).Someserotypespossessdistinctepidemiologicalpropertiesandsomeserotypesaremorecommonthanothers.Differentserotypesarecoveredbydifferentvaccines,asshowninTable1.Vaccine
recommendationsvaryacrossEuropeanUnion/EuropeanEconomicArea(EU/EEA)countriesintermsofwhichvaccinesare/havebeenusedandwhichagegroupsaretargeted[1].
ECDCSURVEILLANCEAnnualepidemiologicalreportfor2022
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Methods
Thisreportisbasedondatafor2022retrievedfromTheEuropeanSurveillanceSystem(TESSy)on2February2024.TESSyisasystemforthecollection,analysisanddisseminationofdataoncommunicablediseases.
Foradetaileddescriptionofthemethodsusedtoproducethisreport,refertotheMethodschapterofthe‘ECDCAnnualEpidemiologicalReport[3].Anoverviewofthenationalsurveillancesystemsisavailableonline[4].
AsubsetofthedatausedforthisreportisavailablethroughECDC’sonline‘SurveillanceAtlasofInfectiousDiseases[5].In2022,29EU/EEAcountriesreporteddataonIPD.Twenty-sevencountriesusedthe2018(11countries),2012(6),or2008(10)EUcasedefinition.Foronecountry,thecasedefinitionwasunknown/notspecifiedandforoneotheritwasreportedas‘other’.The2018,2012and2008casedefinitionsdonotdiffer,withtheexceptionofthenoteonantimicrobialresistancethatwasaddedtothe2018casedefinition[6].
NationalIPDsurveillancesystemswereheterogeneous.Ofthe29countriesreportingdata,23conductedsurveillancewithcompulsoryreportingandnationalcoverage.Onecountryconductedsurveillancewithcomprehensivereporting(Iceland,systemcoveragenotspecified),twousedvoluntarycomprehensivesystems(Hungary,Italy)andthreeusedvoluntarysentinelsystems(Belgium,France,theNetherlands).Priorto2022,datafromSpainwerereportedfromaSpanishvoluntarysurveillancesystemfromtheNationalReferenceLaboratorycovering80%ofthepopulation;
however,from2022,100%ofthepopulationhavebeencoveredbyacompulsorysurveillancesystem.The
populationcoverageoftheBelgiansurveillancesystemisunknown,sonotificationrateswerenotcalculated.For
France,notificationratesbetween2000and2012werecalculatedusinganestimatethat82%ofthepopulation
werecoveredbythesurveillancesystem;from2013onwards,notificationrateswerecalculatedusingbetween79–85%ofthetotalpopulation(withtheexactproportionupdatedyearly).In2022,theproportionusedwas85%.
DatafromtheNetherlandswerereportedfromaDutchvoluntarysurveillancesystemfromtheNationalReferenceLaboratory.Thissystemcovered25%oftheDutchpopulationupto2019and28%ofthepopulationfrom2020onwards.Germanyhadavoluntary,laboratory-basedsurveillancesystemanddidnotreportdatatoECDC[7].All
countriesexceptBelgium,BulgariaandCroatiareportedcase-baseddata[4].
Epidemiology
In2022,17700confirmedcasesofIPDwerereportedby29EU/EEAcountries.Thecrudenotificationratewas5.1casesper100000population(Table1).ThehighestnumberofconfirmedcaseswerereportedbyFrance(3387cases),followedbySpain(3132)andPoland(2214).ThehighestnotificationrateswerereportedinSweden
(12.2casesper100000population),theNetherlands(11.4),Slovenia(10.6)andFinland(10.5)(Table1,Figure1).ManycountriesinthesouthernandeasternpartsoftheEUhadlownotificationrates.
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Table1.Confirmedinvasivepneumococcaldiseasecasesandratesper100000populationbycountryandyear,EU/EEA,2018–2022
Country
2018
2019
2020
2021
2022
Number
Rate
Number
Rate
Number
Rate
Number
Rate
Number
Rate
Austria
611
6.9
615
6.9
355
4.0
398
4.5
558
6.2
Belgium
1553
NRC
890
NRC
940
NRC
845
NRC
1457
NRC
Bulgaria
24
0.3
34
0.5
11
0.2
3
0.0
7
0.1
Croatia
21
0.5
30
0.7
10
0.2
1
0.0
9
0.2
Cyprus
17
2.0
12
1.4
4
0.5
3
0.3
7
0.8
Czechia
535
5.0
481
4.5
247
2.3
264
2.5
472
4.5
Denmark
799
13.8
639
11.0
370
6.4
353
6.0
553
9.4
Estonia
43
3.3
61
4.6
24
1.8
15
1.1
34
2.6
Finland
761
13.8
748
13.6
318
5.8
309
5.6
582
10.5
France
3862
7.0
3907
7.4
2193
4.1
2067
3.7
3387
5.9
Germany
NDR
NRC
NDR
NRC
NDR
NRC
NDR
NRC
NDR
NRC
Greece
42
0.4
47
0.4
17
0.2
18
0.2
28
0.3
Hungary
331
3.4
294
3.0
192
2.0
277
2.8
388
4.0
Iceland
30
8.6
41
11.5
20
5.5
17
4.6
36
9.6
Ireland
514
10.6
419
8.5
246
5.0
177
3.5
375
7.4
Italy
1553
2.6
1671
2.8
499
0.8
472
0.8
1032
1.7
Latvia
76
3.9
83
4.3
67
3.5
70
3.7
125
6.7
Liechtenstein
NDR
NRC
NDR
NRC
NDR
NRC
1
2.6
5
12.7
Lithuania
65
2.3
0
0.0
0
0.0
25
0.9
88
3.1
Luxembourg
1
0.2
1
0.2
32
5.1
41
6.5
63
9.8
Malta
31
6.5
20
4.1
9
1.7
2
0.4
7
1.3
Netherlands
688
16.0
593
13.7
379
7.8
339
6.9
563
11.4
Norway
581
11.0
599
11.2
295
5.5
318
5.9
539
9.9
Poland
1355
3.6
1621
4.3
629
1.7
955
2.5
2214
5.9
Portugal
397
3.9
490
4.8
251
2.4
241
2.3
414
4.0
Romania
74
0.4
72
0.4
25
0.1
10
0.1
39
0.2
Slovakia
98
1.8
124
2.3
55
1.0
35
0.6
92
1.7
Slovenia
276
13.4
280
13.5
175
8.3
187
8.9
224
10.6
Spain
2365
6.3
2465
6.6
1031
2.7
795
2.1
3132
6.6
Sweden
1408
13.9
1345
13.1
648
6.3
731
7.0
1270
12.2
EU/EEA
(30countries)
18111
5.6
17582
5.6
9042
2.8
8969
2.7
17700
5.1
United
Kingdoma
6555
9.9
5622
8.4
NDR
NRC
NA
NA
NA
NA
EU/EEA
(31countries)
24666
6.3
23204
6.1
9042
2.8
NA
NA
NA
NA
Source:Countryreports.
NA:notapplicable;NDR:nodatareported;NRC:noratecalculated.
aNodatafrom2020onwardswerereportedbytheUnitedKingdom,duetoitswithdrawalfromtheEUon31January2020.
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Figure1.Confirmedinvasivepneumococcaldiseasecasesper100000populationbycountry,EU/EEA,2022
Source:Countryreports
Ageandgender
In2022,IPDwaspredominantlyreportedinolderadultsandinfants,with12.6confirmedcasesper100000
populationinadults65yearsoldandaboveand13.4confirmedcasesper100000populationininfantsunderoneyearold(Figure2).Theratesofdiseasewerelowestinthe15–24yearsagegroup(0.8confirmedcasesper100000population).Thenotificationratewashigherinmalesinallagegroups.Theoverallmale-to-femaleratiowas1.3:1.
Figure2.Confirmedinvasivepneumococcaldiseasecasesper100000population,byageandgender,EU/EEA,2022
Source:CountryreportsfromAustria,Belgium,Bulgaria,Croatia,Cyprus,Czechia,Denmark,Estonia,Finland,France,Greece,
Hungary,Iceland,Ireland,Italy,Latvia,Liechtenstein,Lithuania,Luxembourg,Malta,theNetherlands,Norway,Poland,Portugal,Romania,Slovakia,Slovenia,SpainandSweden.
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Seasonalityandtrend
TheseasonaldistributionofIPDcasestypicallyfollowsapatternsimilartomanyotherrespiratorydiseases:casenumbersareusuallylowestduringsummerandthenincreaserapidlywiththeonsetofautumn,peakingduringthewintermonths(Figure3).Comparedwith2018and2019,therewasasharpdecreaseinthenumberofreportedcasesduring2020and2021,coincidingwiththeCOVID-19pandemic(Figure3).Thenumberofcasesincreasedoverautumn/winterof2021–2022,andanatypicalincreasealsooccurredinspring2022(Figures3and4).In
autumnandwinter2022,asharpincreaseincaseswasobserved,peakingat3046casesinDecember2022.Theseasonalactivityin2022wasunusualcomparedwiththemean2018–2021activity(Figure4);however,themeanisheavilyinfluencedbythedecreaseinoverallandseasonalactivityduring2020and2021.
Figure3.Confirmedinvasivepneumococcaldiseasecasesbymonth,EU/EEA,2018–2022
Source:CountryreportsfromAustria,Cyprus,Czechia,Denmark,Estonia,Finland,France,Greece,Hungary,Iceland,Ireland,Italy,Latvia,Lithuania,Malta,theNetherlands,Norway,Poland,Portugal,Romania,Slovakia,Slovenia,SpainandSweden.
Figure4.Confirmedinvasivepneumococcaldiseasecasesbymonth,EU/EEA,2022and2018–2021
Source:CountryreportsfromAustria,Cyprus,Czechia,Denmark,Estonia,Finland,France,Greece,Hungary,Iceland,Ireland,Italy,Latvia,Lithuania,Malta,theNetherlands,Norway,Poland,Portugal,Romania,Slovakia,Slovenia,SpainandSweden.
SURVEILLANCEREPORT
Annualepidemiologicalreportfor2022
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Vaccinationstatus
Thegranularityofdatacollectedinrelationtovaccinationstatusforthestudyperiodislimited.Vaccinationstatuswasreportedfor36.3%(6428/17700cases)oftheIPDcasesreportedin2022.Ofthese,70.3%(4516cases)wereunvaccinated,23.2%(1492)hadreceivedbetweenonetofourdosesofaPCVorPPVvaccine,andanother6.5%(420)werereportedasvaccinatedwithanunknownnumberofdoses.
Serotype
AmongEU/EEAcountriesthatreportedserotypingdatain2022,serotypewasreportedfor52.3%(9256cases)ofcases.The11mostcommonserotypes,inorderofdecreasingfrequency,were:3,8,19A,22F,6C,23B,9N,4,
23A,11Aand15A(Figure5).These11serotypesaccountedfor73.9%ofallcaseswithaknownserotypein2022.
Forcountriesthatreportedserotypingdataconsistentlyforeachyearofthereportingperiod,thedistributionofserotypesbetween2018and2022ispresentedinFigure5.Comparedwith2018,therewasanincreasein
serotypes3,19Aand6Cin2022,by33%,40%and27%,respectively.Duringthesameperiod,adecreasewasobservedinserotypes22Fand9N,by17%and31%,respectively.
Figure5.Distributionofconfirmedserotypedcasesofinvasivepneumococcaldisease,mostcommonserotypes,EU/EEAa,2018–2022
Source:CountryreportsfromAustria,Czechia,Denmark,Estonia,Finland,France,Greece,Hungary,Iceland,Ireland,Italy,Latvia,Lithuania,theNetherlands,Norway,Poland,Portugal,Slovakia,Slovenia,SpainandSweden.
aTheUnitedKingdomareexcludedfrom2018and2019toallowcomparisonacrossallyears.
Thedistributionofserotypesvariedaccordingtotheagegroupsaffected.Thefivemostcommonserotypesineach
agegrouparepresentedinTable2.Forcasesunderoneyearold,serotypes3,19A,8,10Aand24Fwere
predominant.Serotypes19Aand3werethemostcommonintheonetofouryearsagegroup.Serotypes3,8and19Aweremostcommoninindividualsabovefiveyearsold.
Table2.Proportionofconfirmedcasesofinvasivepneumococcaldiseaseforthefivemostfrequentserotypesineachagegroup,EU/EEA,2022
Agegroup(years)
<1
1–4
5–14
15–24
25–44
45–64
65+
Serotype
%
Serotype
%
Serotype
%
Serotype
%
Serotype
%
Serotype
%
Serotype
%
3
11.7
19A
24.8
3
18.6
8
35.6
8
21.3
3
21.1
3
22.4
19A
10.5
3
20.3
19A
17.0
19A
13.0
3
17.9
8
18.3
8
11.3
8
9.9
10A
6.6
8
10.8
3
10.3
19A
15.5
19A
9.7
19A
11.1
10A
7.4
24F
6.6
23B
5.2
4
8.2
4
6.8
22F
5.5
22F
5.8
24F
6.8
23B
4.0
22F
4.6
22F
3.4
22F
4.5
4
5.0
6C
4.9
ECDCSURVEILLANCEAnnualepidemiologicalreportfor2022
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Source:CountryreportsfromAustria,Czechia,Denmark,Estonia,Finland,Greece,Hungary,Iceland,Ireland,Italy,Latvia,Lithuania,theNetherlands,Norway,Poland,Portugal,Slovakia,Slovenia,SpainandSweden.
In2022,6.6%ofcasesinchildrenunderfiveyearsoldwithserotypeinformationwerecausedbyaPCV10
serotype,39.3%byaPCV13/non-PCV10serotype,3.8%byaPCV15/non-PCV13serotype,17.2%byaPCV20/non-PCV15serotypeand33.1%byaserotypenotincludedinanycurrentPCVvaccine.TheserotypesincludedineachvaccineformulationareshowninAnnex1.
From2018to2022,therewasasubstantial(96%)increaseintheproportionofPCV13/non-PCV10serotypesinchildrenunderfiveyearsold(from17.1%in2018to39.3%in2022;Figure6).Conversely,thereweredecreasesintheproportionsofPCV10,PCV15/non-13andnon-PCVserotypesoverthisfive-yearperiod.TheproportionofPCV20/non-15serotypesremainedunchanged.
Figure6.DistributionofconfirmedserotypedcasesofinvasivepneumococcaldiseaseinchildrenunderfiveyearsoldbyPCVvaccineserotypesabandyear,EU/EEAc,2018–2022
Source:CountryreportsfromAustria,Czechia,Denmark,Estonia,Finland,France,Greece,Hungary,Iceland,Ireland,Italy,Latvia,Lithuania,theNetherlands,Norway,Poland,Portugal,Slovakia,Slovenia,SpainandSweden.
aAlthoughserotype6AisincludedinPCV13andnotinPCV10,forthepurposesofthisanalysisitisconsideredaPCV10serotype
duetodocumentedcross-protectionprovidedbytheserotype6BantigeninPCV10.
bPCV15andPCV20werenotyetauthorisedorusedinchildrenduringthistimeperiod.
cDatafromtheUnitedKingdomareexcludedfrom2018and2019toallowcomparisonacrossallyears.
Forcases5–64yearsoldreportedin2022withknownserotype,8.8%werecausedbyaPCV10serotype,33.0%byaPCV13/non-PCV10serotype,6.4%byaPCV15/non-PCV13serotype,21.5%byaPCV20/non-PCV15serotype,andanother30.3%bynon-PCVserotypes.
In2022,amongcasesinadults65yearsoldandabovewithserotypeinformation,70.8%werecausedbyaserotypeincludedinthePPV23vaccineand29.2%byaserotypenotincludedinthePPV23vaccine.Incomparison,66.1%ofcaseswerecausedbyserotypesincludedinPCV20,whileonly41.0%werecausedbytheserotypesincludedin
PCV13.Therewereincrementaldifferencesbychangingvaccinecomposition/includedserotypes:7.5%werecausedbyaPCV10serotype,33.5%byaPCV13/non-PCV10serotype,6.9%byaPCV15/non-PCV13serotype,18.2%byaPCV20/non-PCV15serotype,and4.8%byaPPV23/non-PCV20serotype(Figure7).
From2018to2022,inadults65yearsoldandabove,therewasa36%increaseintheproportionofPCV13/non-10serotypes,from24.0%in2018to33.5%in2022(Figure7).Therewasalsoasmall(8%)increaseinthe
proportionofnon-PCV/PPVserotypes,from25.9%in2018to29.2%in2022.Theproportionofallremainingserotypesdecreasedfrom2018to2022.
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Figure7.Distributionofconfirmedserotypedcasesofinvasivepneumococcaldiseaseinadults65yearsoldandabovebyPCV/PPVvaccineserotypesaandyear,EU/EEAb,2018–2022
Source:CountryreportsfromAustria,Czechia,Denmark,Estonia,Finland,France,Greece,Hungary,Iceland,Ireland,Italy,Latvia,Lithuania,theNetherlands,Norway,Poland,Portugal,Slovakia,Slovenia,SpainandSweden.
aAlthoughserotype6AisincludedinPCV13andnotinPCV10,forthepurposesofthisanalysisitisconsideredaPCV10serotypeduetodocumentedcross-protectionprovidedbytheserotype6BantigeninPCV10.
bDatafromtheUnitedKingdomareexcludedfrom2018and2019toallowcomparisonacrossallyears.
Antimicrobialsusceptibility
Antimicrobialsusceptibilitydatawerebasedonthereportingofsusceptibilitytestingcategories
(Susceptible/Intermediate/Resistant)andminimuminhibitoryconcentration(MIC)data.MICdatawereconvertedtoSIRdatabasedonEUCASTbreakpoints.Penicillinsusceptibilitydatawerereportedby12countriesfor54.5%(2816/5168cases)oftheIPDcases.Ofthese,82.3%(2317cases)werereportedassensitive,4.9%(138)as
intermediateand12.8%(361)asresistant.Erythromycinsusceptibilitydatawerereportedby11countriesfor
30.9%(1599/2954cases)oftheirIPDcases.Ofthese,79.4%(1269cases)werereportedassensitive,1.6%
(26)asintermediateand19.0%(304)asresistant.Cephalosporinsusceptibilitydatawerereportedby11countriesfor45.6%(2354/5161cases)oftheirIPDcases.Ofthese,88.5%(2082cases)werereportedassensitive,1.7%(40)asintermediateand9.9%(232)asresistant.
Clinicalpresentation
Clinicalpresentationwasknownfor8882(50.2%)ofallcases.Ofthese,bacteraemicpneumoniawasreportedin3657cases(41.2%),septicaemiain3350cases(37.7%),meningitisin1226cases(13.8%),andmeningitisandsepticaemiain242cases(2.7%).Afurther407cases(4.6%)hadotherclinicalpresentations.
Amonginfantsunderoneyearold,themostcommonclinicalpresentationwasmeningitis(41.8%),followedby
septicaemia(26.4%)andbacteraemicpneumonia(19.6%).Themostcommonclinicalpresentationsinonetofour-year-oldswerebacteraemicpneumonia(38.0%)andsepticaemia(31.6%).Inadults65yearsoldandabove,clinical
presentationswereapproximatelyequallydistributedbetweenbacteraemicpneumonia(44.7%)andsepticaemia(40.7%).
Outcome
Among7000caseswithknownoutcome(39.5%)in2022,895(12.8%)died.Thecasefatalitywashighestamongcases65yearsoldandabove(17.1%)and45–64years(10.9%).Amonginfantsunderoneyearoldandchildrenonetofouryearsold,thecasefatalityrateswere3.9%and3.6%,respectively.
Amongthe895casesthatdied,366(40.9%)presentedwithsepticaemia,257(28.7%)withbacteraemic
pneumonia,53(5.9%)withmeningitis,31(3.5%)withmeningitisandsepticaemia,20(2.2%)withotherclinicalpresentations,and168(18.8%)withclinicalpresentationunknown.
Serotypewasknownfor625(69.8%)deceasedcases.Thefivemostcommonserotypesreportedfordeceasedcases(whereserotypewasknown),inorderofdecreasingfrequency,were3,19A,8,6Cand22F.Thesefiveserotypesaccountedfor54.4%ofdeathswhereserotypewasknown.
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Discussion
In2022,29EU/EEAcountriesreportedatotalof17700casesofIPD.Thiswassimilarto2018and2019,indicatingthattransmissionand/orreportingpracticeshavereboundedtothesamelevelasbeforetheCOVID-19pandemic.In2020and2021,therewasanapproximately50%reductioninthenumberofreportedIPDcasescomparedwith2018and2019,whichmayhavebeenduetoacombinationofreducedtransmissionfollowingtheimplementationof
non-pharmaceuticalinterventions,reducedlaboratorycapacityfortesting,reducedpublichealthcapacityforsurveillance/reportingofIPDcases,orotherfactors.
In2022,thecrudeIPDnotificationratewas5.1casesper100000population.Olderadults(65yearsoldandabove)andinfants(underoneyearold)werethemostaffectedagegroups,withnotificationratesof12.6and13.4casesper100000population,respectively.Notificationratesvariedbycountry,rangingfrom0.1to12.2casesper100000population.Thevariationmaybeduetodifferencesinhealthcaresystems,vaccination
programmes,caseascertainment(includingbloodculturingpractices)andreporting.
TheimpactofPCVsinreducingtheincidenceofIPDintheEU/EEAhasnowbeenobservedforalmosttwodecades.Aseven-valentPCV(PCV7)wasfirstlicensedin2001foruseininfantsandyoungchildren,andEU/EEAcountriesbeganintroducingthevaccineintoroutinechildhoodimmunisationschedulesin2006.In2009,thehigher-valencyPCV10
andPCV13vaccineswerelicensedandprogressivelyreplacedPCV7onimmunisationschedulesintheEU/EEA.AsaresultoftheintroductionofthePCV7andlaterthePCV10/PCV13vaccines,theincidenceoftheserotypesincludedinthevaccinesdeclined[8-11].Vaccinationofinfantsandyoungchildrenalsoresultedinindirectprotectionofolder
adultsbyreducingnasopharyngealcarriageandtransmissioninchildren,contributingtoadecreaseinmorbidityandmortalityinolderagegroups[12].
However,astheincidenceofvaccineserotypesdeclined,incidenceofnon-vaccineserotypesincreased,indicating
serotypereplacementwasoccurring[9,10].SerotypereplacementhasgraduallyreducedtheimpactofPCVs,astheratesofcarriageanddiseasecausedbynon-vaccineserotypeshaveincreased[10].Toaddresstheissueof
serotypereplacement,vaccinescontinuetobedevelopedtoincludemoreoftheserotypescommonlyresponsibleforcausingIPD.A15-valentPCVwasdeveloped,includingtwoadditionalserotypes(22F&33F)comparedwithPCV13.Thisvaccinewasauthorisedforadults18yearsoldandaboveinOctober2021andforchildrensixmonthstounder18yearsoldinSeptember2022[13].Similarly,a20-valentPCVwasalsodeveloped,forwhichauthorisationfor
adults18yearsoldandabovewasgrantedinFebruary2022.InJanuary2024,thisvaccinewasalsoauthorisedforchildrensixweekstounder18yearsold[14].Thesehigher-valencyvaccines(PCV15/PCV20)havehadlimiteduseintheEU/EEAtodate,astherehavebeenonlyafewcountriesthathaverecommendedtheinclusionofPCV15(for
childrenorolderadults)orPCV20(olderadultsonly)[1].
Overall,fortheEU/EEAin2022,approximately46%ofcasesinchildrenunderfiveyearswerecausedbyPCV13
serotypes,andanincreaseinPCV13/non-10serotypeswasobservedinthisagegroupbetween2018and2022.Thishighlightsthatexistingvaccinescouldpreventalargemajorityofcases.Thefiveserotypesaccountingfor54.4%ofdeaths(whereserotypewasknown)were3,19A,8,6Cand22F.Oftheseserotypes,3and19Aareincludedin
PCV13,PCV15,PCV20andPPV23;serotype22FisinPCV15,PCV20andPPV23;serotype8isinPCV20andPPV23;andserotype6Cisnotincludedinanyvaccine.
Nationalauthoritiesconsidernumerousfactorswhencontemplatingchangestothevaccinationschedules,including:thenational/localepidemiologicalsituationandcirculationofserotypes;realworddataontheperformanceof
differentvaccines(includingeffectiveness,safetyandimpactonspecificgroups);burden/severityofdifferentclinicalpresentationsassociatedwithdifferentserotypes;andcross-protectionagainstdifferentserotypes.Programmatic
considerationofchangestothevaccinationschedulesandotherparametersrelatedtoimplementation(suchascosteffectivenessand/orco-administrationwithothervaccines)arealsotakenintoaccount.
Ofnotein2022,comparedwith2018,therewasadramaticincreaseintheproportionofPCV13/non-10serotypesinchildrenunderfiveyearsold.In2022,amonginfantsandchildrenunderfiveyearsold,approximately39%ofcases(withknownserotype)werecausedbythetwoserotypes(3and19A)coveredbyPCV13butnotPCV10(6Ais
consideredaPCV10serotypeduetocross-protectionfrom6B).In2018,thisproportionwas17%ofcaseswithknownserotype.FurtheranalysisandinvestigationareneededtodeterminethedriversbehindtherelativeincreaseofPCV13/non-10serotypesamongyoungchildrenandtheimpactofsuchchange.
InadditiontothePCVs,PPV23hasbeenavailableinmanycountriessincetheearly2000s,authorisedforusein
childrenundertwoyearsofage,adolescentsandadults.Sinceitsauthorisation,manyEU/EEAcountriesintroducedthisvaccineinnationalprogrammesforolderadultsand/orat-riskindividuals[15].PPV23iseffectiveatpreventinginvasivediseaseamongadults;however,itislesseffectiveagainstnon-invasivediseaseandthedurationof
protectionmaybeshorterthanthatofPCVs[16].Thereissomeevidencethatimmunogenicityanddurationof
protectioncanbeimprovedwithaschedulethatincorporatesadoseofPCVfollowedbyaboosterofPPV23forolderadults[16].SomeEU/EEAcountriesrecommendsuchacombination[1].Ofnoteistheconsiderablevariationin
PCV/PPV23recommendationsacrosstheEU/EEA,notonlywithregardtowhichvaccinesareused,butalsowhichindividualsareconsideredat-riskandfromwhatagetheolderadultagegroupbegins(50,60or65yearsold)[1].
10
In2022,amongadults65yearsoldandabove,approximately71%ofIPDcases(withknownserotype)were
causedbyaserotypeincludedinPPV23and41%werecausedbyoneoftheserotypesincludedinPCV13.Theseproportionshavebeenreasonablystableoverthepastfiveyears.Ofcaseswithaknownoutcomein2022,the
casefatalitywashighestamongadults65yearsoldandabove(17.1%ofalldeaths).DespitePPV23and/orPCVvaccinesbeingrecommendedforolderadultsinmanyEU/EEAcountriesandforalongperiodoftime,thevaccine-preventableserotypescontinuetoberesponsibleforahighproportionofIPDcases.InEU/EEAcountries,
availabilityofcoverageestimatesforat-riskgroupsandolderadultsislimited;however,whereavailable
(predominantlyforolderadults),thecoverageislow,andbelow30%inallcountries[17].Animprovementin
coverageofrecommendedvaccines,irrespectiveofwhichvaccine(oracombinationofvaccines),mayreducetheIPDburdenamongolderadults.However,ongoingmonitoringofIPDserotypetrendsinolderadultsinrelationto
vaccinationrecommendationsinthisagegroup,aswellastheindirectimpactofchildhoodvaccinationrecommendations,isalsorequired.
Publichealthimplications
PneumococcalvaccinescontainarangeofserotypesthatcancauseIPD.Vaccination
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