Pneumococcal pneumonia and influenza: A deadly combination
Introduction
Pneumonia is the leading cause of death in children worldwide [1]. Bacterial pneumonia is clinically diagnosed based on the results of a number of diagnostic tests. In increasing order of specificity, and decreasing order of sensitivity, these tests include a clinical diagnosis based on signs and symptoms, non-specific changes on chest X-ray, raised indirect markers such as C-reactive protein and procalcitonin, lobar consolidation on chest X-ray, and, finally, culture-confirmed pneumonia. The tools used to define bacterial culture-confirmed pneumonia lack sensitivity. Blood culture is often of limited utility; cultures are infrequently positive and interpretation is strongly influenced by disease severity, prior antibiotic use, and false-positive tests [2], [3]. Lung puncture, bronchoalveolar lavage (BAL), and protected specimen brush techniques are rarely done and are overly invasive. Serological tests have been confounded by lack of specificity, although new enzyme-linked immunosorbent assay (ELISA) protocols and Luminex-type platforms offer some promise [4]. The urine–Binax assay to detect pneumococcal C polysaccharide antigen in the urine is promising in adults but is confounded by nasopharyngeal (NP) carriage in children [5]. Polymerase chain reaction (PCR) does not have sensitivity greater than that of culture, although it is hoped that real-time PCR (rtPCR) may offer a quantitative differential of carriage versus pneumonia [4]. In addition, resistance to commonly prescribed antibiotics is of concern, given the extent of empiric treatment necessitated by the lack of ability to detect bacterial pathogens. With widespread global use of the pneumococcal conjugate vaccine (PCV), it is hoped that the incidence of pneumonia in children will decrease, similar to the marked reduction (39%) in clinical pneumonia among children observed following the introduction of seven-valent PCV (PCV7) in the United States [6].
Section snippets
PCV as a probe to determine the vaccine-preventable fraction of pneumonia attributable to Streptococcus pneumoniae
PCV7 was approved for use in the United States in 2000, and has since been introduced in several countries around the world. Black et al. measured the efficacy of PCV7 in preventing clinical and radiograph-confirmed pneumonia in children. Results showed that the incidence of a first pneumonia episode in the control group was 55.9/1000 person-years versus 53.4/1000 person-years in the vaccine group, a reduction of 4.3%, which failed to reach statistical significance. Episodes in which a
Endemic and pandemic influenza
Endemic seasonal influenza exerts a considerable annual toll of morbidity and mortality, including very young children [16]. In a paper on “fatal discontinuities,” Smil [17] states that despite continuing natural disasters such as tsunamis and earthquakes, the highest probability for massive global mortality in the next 50 years is an influenza pandemic that would rival or surpass the greatest such event on record, the influenza pandemic of 1918. There have been three influenza pandemics in the
Conclusions
Significant morbidity due to pneumococcal co-infection is associated with viral respiratory infections. PCVs have reduced hospitalisations associated with influenza in children. The majority of the mortality associated with the influenza pandemic of 1918 was attributable to bacterial infections, especially the pneumococcus. Vaccination with the pneumococcal conjugate for children and pneumococcal polysaccharide vaccine for adults should be considered an essential part of pandemic influenza
Acknowledgments
The authors thank Excerpta Medica (Bridgewater, NJ) for professional writing assistance, which was funded by Wyeth Pharmaceuticals, Collegeville, PA.
Conflicts of interest: Dr Klugman has received research support and consultant fees from Wyeth and consultant fees from Merck. Dr Chien declares that he has no conflict of interest related to the content of this manuscript. Dr Madhi has received speaker's honorarium and research support from Wyeth and GlaxoSmithKline.
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