Clinical presentation varied with age (Table 2); LRTI was the most common presentation (34.7%, 378/1089) followed by meningitis (30.5%, 332/1089) and septicemia (29.2%, 318/1089). Meningitis was most prevalent among 3- to 11-month olds (45.8%, 209/456) compared with 12- to 23-month olds (22.1%, 77/348; RRR compared with LRTI, 0.35, 95% CI: 0.23–0.52) and 24- to 59-month olds (16.1%, 46/285; RRR 0.22; 95% CI: 0.14–0.35). The reverse was true for LRTI: 115/456 (25.2%), 130/348 (37.4%) and 133/285 (46.7%), respectively.
IPD due to PCV13 serotypes declined with time since PCV13 introduction, while IPD due to the additional PPV23 and NVTs increased. The contribution of PCV13 serotypes to total IPD cases within the different childhood age-groups, however, remained relatively consistent (Table 2). More than half the PCV13-type IPD cases presented with LRTI (51.4%, 110/214) compared with 26.5% (115/434) for PPV23 and 29.4% (85/289) for NVT IPD cases.
Of the cases with complete serotype and clinical presentation data, the most common serotypes among children with LRTI cases were 3 (12.6%, 40/317), 19A (11.7%, 37/317), 12F (8.2%, 26/317), 33F (6.6%, 21/317) and 22F (6.3%, 20/317).
The most common serotypes responsible for meningitis included 22F (10.3% 30/292), 33F (10.3%, 30/292), 15B/C (9.9%, 29/292), 10A (9.9%, 29/292) and 12F (6.5%, 19/292). The most common serotypes causing septicemia cases were 15B/C (11.4%, 31/271), 12F (10.7%, 29/271), 23B (9.6%, 26/271), 22F (8.5%, 23/271) and 33F (8.1%, 22/271).
Children with PCV13-type IPD were least likely to present with septicemia (16.4%, 35/214) compared with PPV23 (32.5%, 141/434) and NVT IPD cases (33.9%, 95/280) (Table, Supplemental Digital Content 1, http://links.lww.com/INF/C880). This relationship persisted in the multinomial model (RRR 0.27, 95% CI: 0.17–0.45 compared with NVT IPD cases). Children with PCV13-type IPD were also least likely to present with meningitis (RRR 0.43, 95% CI: 0.27–0.70). Table 2 summarizes the clinical presentations by serotype group.
Overall, 259 children (20.6%) had 292 comorbidities, particularly immunosuppression (31.6%, 92/292), chronic heart disease (23.3%, 68/292) and chronic respiratory disease (17.8%, 52/292) (Table 2). Comorbidity prevalence varied between 12.0% and 29.6% per year and increased with age, being 14.2% (72/508) in 3- to 11-month olds, 16.5% (69/419) in 12- to 23-month olds and 36.0% (118/328) in 24- to 59-month olds. Congenital heart disease was more prevalent in 3- to 11-month olds (33.8%, 27/80), and 12- to 23-month olds (29.9%, 23/77), while immunosuppression was responsible for almost half the comorbidities reported among cases 24–59 months of age (46.7%, 63/135).
Children with comorbidity were more likely to present with septicemia compared with previously healthy children (95/217 [43.8%] vs. 223/872 [25.6%]; RRR 1.90, 95% CI: 1.26–2.87); no such associations were identified for other clinical presentations.
Children with comorbidities were less likely to develop PCV13-type IPD (14.7%, 35/238) compared with those with the additional 11 PPV23 (19.4%, 96/496; RRR 1.36, 95% CI: 0.87–2.13), or NVT (31.1%, 101/325; RRR 2.39, 95% CI: 1.52–3.76).
Overall, 170 children (14.1% 169/1198) had been born prematurely; this group was also more likely to have additional comorbidities (31.8%, 54/170) compared with those born at term (196/1028, 19.1%, P < 0.001). The main serotypes causing IPD in children with comorbidity over the 6 surveillance years included 23B (11.2%, 26/232), 24F (8.2%, 19/232) 15B/C (7.8%, 18/232) 22F (7.8%, 18/232) and 12F (6.9%, 16/232) (Fig. 2).
Sixty-four children died over the 6-year period (64/1255; CFR, 5.1%; 95% CI: 3.9%–6.5%); CFR after PCV13-type IPD was 6.7%, 5.2% with the extra PPV23 serotypes and 4.6% with NVT (Table 3). Meningitis cases had the highest CFR (9.6%), followed by septicemia (5.3%) and LRTI (3.7%). CFR was also higher for children with comorbidities (8.1%), compared with 4.3% for previously healthy children; this difference was most apparent among <2-year olds (Table 3).
Of those with comorbidities, although the number of cases were small, a higher CFR was observed for children with sickle cell disease (25.0%, 4/16), splenic dysfunction (20.0%, 2/10) and diabetes mellitus (20.0%, 1/5) compared with those with chronic respiratory (7.7%, 4/52), chronic heart (13.2%, 9/68), chronic renal (4.3%, 1/23) or chronic liver (11.1%, 1/9) diseases. Immunosuppression had the lowest CFR with one case (1/92, 1.1%) proving fatal. In children with comorbidities, CFR was higher in 3–11 months (12.5%, 9/72) and 12–23 months (13.0%, 9/69), but lower in 24–59 months (4.2%, 5/118).
In the univariate analysis, a fatal outcome was associated with male gender, underlying comorbidity and meningitis presentation (Table, Supplemental Digital Content 2, http://links.lww.com/INF/C881), but not with age at IPD onset or serotype group. In a multivariable logistic regression model, only comorbidity (aOR 2.41; 95% CI: 1.25–4.64) and meningitis (aOR 3.53; 95% CI: 1.62–7.7) were independently associated with death.
Repeat IPD Episodes
Twenty-one children had repeat IPD episodes (21/1255, 1.7%), including 17 (1.4%, 17/1255) with 2 episodes and 4 with 3 episodes (0.3% 5/1255). Of the 17 children with 2 repeat IPD episodes, 7 had the same serotype for both episodes (38, 17F, 23F, 24F, 22F, 23B and 10A). Of the 4 children with 3 episodes, the responsible serotypes were 15A/15A/38, 22F/22F/6D, 23B/unserotyped/23B and 17F/16F/15A. Nineteen children had an underlying comorbidity, including immunosuppression (n = 9, 47.4%), cochlear implant (n = 4, 21.1%), chronic heart (n = 2, 10.5%), chronic real (n = 2, 10.5%) and chronic liver (n = 1, 5.3%) disease, while one had multiple comorbidities (splenic dysfunction, liver and renal). Two cases were 3-dose PCV13 failures. None of the children with repeat IPD episodes died.
Cases in 2015/2016
In 2015/2016, when all children <5 years of age were eligible for PCV13, 38.0% (103/271) cases were 3–11 months, 25.1% (68/271) were 12–23 months and 36.9% (100/271) were 24–59 months. Comorbidity prevalence was 19.2% (52/271) (Table, Supplemental Digital Content 3, http://links.lww.com/INF/C882) and CFR was 4.1% (11/271); of the 255 cases with information about clinical presentation, 91 (35.7%) had LRTI, 74 (29.0%) had meningitis and 73 (28.6%) had septicemia. Figure 3 summarizes the clinical presentation for the 10 most common serotypes.
PCV13 serotypes were responsible for 10.8% (25/232) of cases with serotyped isolates, the additional 11 PPV23 serotypes for 60.8% (141/232) and NVT for 28.4% (66/232) cases. The most prevalent non-PCV13 serotypes were 12F (16.4%, 38/232), 10A (10.8%, 25/232), 23B (8.6%, 20/232), 33F (8.6%, 20/232), and 15B/C (7.3%, 17/232) and 8 (7.3%, 17/232).
Of the 25 children with PCV13-type IPD, 17 had received a full course of PCV13 (median age at IPD, 33 [interquartile range, 22–50] months); 3 received 2 doses (two 3–11 months, one 24–59 months of age) and 2 received one dose (3–11 months) of age; the remaining 3 (one 3–11 months, two 24–59 months) were unimmunized. The most prevalent serotypes associated with PCV13 failure were 19A (11/25, 44%) and 3 (8/25, 32%); vaccine failure due to other PCV13 serotypes was rare. Five children (20.0%) had comorbidity and 2 healthy children died of serotype 19A IPD.
We have previously reported large and significant declines in childhood IPD incidence following PCV7 introduction into the UK immunization program and described the characteristics of IPD in the PCV7-eligible children. In particular, we found that comorbidities were more prevalent in children with IPD due to non-PCV13 serotypes and were associated with higher case fatality.1–3 Following the introduction of PCV13 in April 2010, IPD cases in <5-year olds declined until 2012/2013, before increasing in subsequent years. The rapid decline in IPD due to the additional PCV13 serotypes has been offset by replacement disease with non-PCV13 serotypes, suggesting that the maximum benefit of the childhood PCV program may already have been achieved. By 2015/2016, 6 years after PCV13 replaced PCV7, the PCV13 serotypes were responsible for only 11% of IPD cases in our cohort. Most cases are now due to non-PCV13 serotypes and associated with higher comorbidity prevalence. The clinical presentation has also changed such that children are equally likely to present with septicemia, meningitis or LRTI. Reassuringly, vaccine failures, recurrent IPD and CFRs remain low, the latter being independently associated with underlying comorbidities and presentation with meningitis.
When comparing the 6 post-PCV13 years with the pre-PCV13 period, comorbidity prevalence among IPD cases increased from 14.9% to 20.6%.3 This had been predicted in our previous study because of serotype replacement disease; both the extra 11 PPV23 and NVTs were more likely to cause IPD in children with underlying comorbidities. In 2015/2016, 13.7% of children with IPD had also been born prematurely; this vulnerable group is known to be at increased risk for IPD.5 Notably, though, despite the dynamic shift in serotypes causing IPD, childhood CFR has remained low throughout the surveillance period. The CFR in children with comorbidity who developed IPD during the PCV13 period (8.1%) is similar to the 8.5% reported during the PCV7 period (Table 1).3
We also observed a shift in clinical presentations of IPD. The rise and fall of IPD due to PCV13 serotypes following PCV7 introduction and its subsequent replacement with PCV13, respectively, was associated with an increase followed by a decrease in LRTI presentations. This is in keeping with other studies that found non-PCV13 serotypes were more likely to cause septicemia in patients with underlying diseases. In a recent Swedish study using clinical data from 2096 adults and 192 children with IPD alongside 165 invasive and 550 carriage isolates from children, for example, the authors found a lower invasive potential for non-PCV13 compared with PCV13-type strains. Moreover, those infected with non-PCV13 strains were more likely to have underlying diseases, less likely to develop LRTI and, in adults, tended to have a higher CFR.6 In 2015/2016, although, overall, the children were equally likely to present with LRTI, septicemia or meningitis, we did observe an age effect, with infants more likely to present with meningitis and older children with LRTI. Other studies, albeit with fewer cases over a shorter post-PCV13 surveillance period have also observed a higher comorbidity prevalence among childhood IPD cases but changes in clinical presentations of IPD have been variable. In Spain, hospitalizations for pneumococcal pneumonia and meningitis among <5-year olds were significantly reduced during the first 3 years after PCV13 replaced PCV7,7 while an observational study from Massachusetts did not identify any significant changes in clinical presentation.8 In Calgary, Canada, the proportion of cases presenting with pneumonia increased after PCV7 introduction and then nearly halved after replacement with PCV13.9 The proportion of cases with empyema and meningitis presentations, however, increased over the same period, as did hospitalization rates for IPD, raising concerns about more severe disease due to the replacing serotypes. Interestingly, recent studies from Israel found that PCV impact may vary for the different IPD presentations.10–12 In the most recent study, for example, meningitis rates declined by 24% only compared with 57% for bacteremic pneumonia and 70% for other presentations. Notably, too, bacteremic pneumonia rates did not decline after PCV7 introduction and fell only after replacement with PCV13. The authors also found differential increases in clinical presentations following IPD due to non-PCV13 serotypes after PCV13 introduction.12
We have consistently observed higher case fatality associated with meningitis presentations across the age groups.3 Other recent studies have been unable to identify any differences in the clinical characteristics of children with pneumococcal meningitis even though cases due to PCV13 serotypes declined rapidly after PCV13 introduction and those due to non-PCV13 serotypes increased.13 It is likely that, once meningitis occurs, the course, severity and outcomes are more dependent on host factors rather than the infecting pneumococcal serotype.
The comorbidities associated with an increased risk of IPD are well described.14 The serotypes causing IPD in children with comorbidity were different from those identified in healthy children; these serotypes usually have low invasive potential, but are often associated with higher CFR because of the child’s vulnerable state. In our cohort, children with splenic dysfunction, particularly those with sickle cell disease, were more likely to die of IPD. This group continues to have a significantly higher risk of IPD despite current preventative measures such as early detection through universal screening, early penicillin prophylaxis and high immunization uptake.15 On the other hand, although immunosuppression (including malignancy) was the most prevalent comorbidity in children with IPD, especially among 24- to 59-month olds, only one child died. Consequently, CFR in children 24–59 months of age with and without comorbidity was remarkably similar (Table 3). This reassuring finding is likely to be a result of rapid access to medical care for immunosuppressed children presenting with fever and strict protocol adherence with low threshold for initiating antimicrobial therapy by clinicians.16
The strength of this study lies in the consistently high case ascertainment and extensive national follow-up of all confirmed cases during the past decade, alongside a national reference laboratory to serotype nearly all invasive isolates across England and Wales. This has allowed us to monitor not only serotype-specific trends over time, but also changes in disease characteristics and outcomes in young children, who are most at risk for IPD. Like all large-scale surveillance programs, this study has some limitations. Not all laboratories, for example, routinely submit clinical isolates for serotyping to the national reference laboratory and some information in the questionnaires remained incomplete despite multiple follow-up attempts; these limitations, however, were generally overcome by the large number of cases included in our analysis. Another limitation of this study is the lack of long-term complications among survivors of pneumococcal meningitis, especially because this pathogen has the worst prognosis among encapsulated bacteria causing meningitis in children.17
In England and Wales, most cases are now due to non-PCV13 serotypes, which are more likely to cause septicemia, especially in children with comorbidities. The lack of any serotype predominance in replacement disease highlights the need for a universal vaccine against the pneumococcus. Additional interventions are also required to protect children with specific comorbidities and those presenting with meningitis from fatal outcomes.
We thank (1) Sarah Collins for maintaining the pneumococcal surveillance database in the Immunisation Department at PHE; (2) Melissa Kephalas and Rashmi Malkani for the follow-up of confirmed cases; (3) Pauline Waight who managed the pneumococcal surveillance before 2016; (4) Catrin Moore for reporting IPD cases in southern England serotyped by the John Radcliffe Hospital Oxford (Oxford, United Kingdom) laboratory; (5) the staff at hospital laboratories across England and Wales who referred isolates for serotyping and provided additional information on request and (6) general practitioners of patients with IPD for completing the surveillance questionnaires.
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PCV13; serotype; comorbidity; meningitis; outcome
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