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Encourage pneumococcal vaccine, as appropriate, in patients for
whom H1N1 vaccine is indicated
Study published in MMWR shows that 29% of 77 fatal H1N1
virus cases had evidence of concurrent bacterial infection.
A recent
article in MMWR highlights the importance of patients
scheduled to receive the 2009 H1N1 vaccine also receiving pneumococcal
immunization if they are at increased risk for pneumococcal
pneumonia.
Postmortem lung specimens from patients dying from 2009 H1N1
influenza were examined by CDC for bacterial causes of pneumonia. The
specimens, which were submitted to CDC by medical examiners and local
and state health departments, were from 77 fatal cases of confirmed 2009
H1N1 virus occurring in the United States between May 1 and August 20,
2009.
Of the 77 patient specimens, 22 (29%) showed evidence of concurrent
bacterial infection, including 10 caused by Streptococcus
pneumoniae (pneumococcus). According to CDC, these results show
that bacterial lung infections are occurring among patients with fatal
cases of 2009 H1N1, therefore highlighting the importance of
pneumococcal vaccination for patients at increased risk for pneumococcal
pneumonia and the need for early recognition of bacterial pneumonia in
influenza patients.
The 22 patients with concurrent H1N1 and bacterial infection had a
median age of 31 years (range 2 months to 56 years), and 11 (50%) were
male. The duration of illness (available for 17 of these 22 patients)
was 6 days (range 1–25). The cases occurred in California, Hawaii,
Illinois, New Jersey, New York, Texas, Utah, and Virginia. A total of 14
of 18 patients with information available sought medical care while ill,
8 of whom were hospitalized. For nine patients with information
available on antimicrobial therapy, seven were treated with antibiotics.
Of the 21 patients for whom previous medical history was known, 16 had
underlying medical conditions that were known to increase the risk for
influenza-associated complications.
Of note, although the findings in the MMWR article confirm
the presence of bacterial lung coinfection, the results cannot be used
to assess the prevalence of bacterial pneumonia among patients who have
died from pandemic H1N1. The cases in the report do not come from a
systematic sample and might not be representative of all pandemic H1N1
deaths or all pandemic H1N1 deaths associated with bacterial pneumonia.
Systematic research is needed to determine the incidence and outcome of
bacterial lung coinfections among patients with pandemic H1N1 virus
infection and to quantify the role of these infections in fatal
cases.
Patients at greatest risk for invasive pneumococcal disease include
young children, older adults, and individuals of any age with certain
conditions, including chronic lung or cardiovascular disease and
immunosuppressive conditions. All children younger than 5 years should
receive pneumococcal conjugate vaccine according to current Advisory
Committee on Immunization Practices (ACIP) recommendations. In
addition, PPSV23 (23-valent pneumococcal polysaccharide vaccine) is
recommended for all patients aged 2 to 64 years with certain health
conditions and all patients 65 years or older. Available vaccination
coverage data indicate that only a small proportion of patients aged 2
to 64 years in the United States who are recommended by ACIP to receive
pneumococcal vaccine have received the vaccine.
Web links
Joe Sheffer (jsheffer@aphanet.org)
Posted October 5, 2009
Revised November 2, 2009
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