Ontario’s Pneumococcal Vaccination Program Allison McGeer

Adult pneumococcal vaccination - expert opinion Public health experts uniformly recommend vaccine (NACI, ACIP) Clinician experts tend not to (eg. CTFPHE) Ontario mounts population-based pneumococcal vaccination program

Prevention of pneumococcal disease in adults NACI recommends vaccine for: all those >65 years of age all persons with asplenia, splenic dysfunction or sickle cell disease all persons with: chronic cardiorespiratory disease (except asthma), cirrhosis, alcoholism, chronic renal disease, nephrotic syndrome diabetes mellitus, chronic CSF leak, HIV infection and other conditions associated with immunosuppression

Provincial pneumococcal vaccine program - primary strategies Deliver pneumococcal vaccine with influenza vaccine Target 70% of NACI eligible persons Supply vaccine over three years; withhold enough stock for mid-year use

Implementation Focus groups Mailing to all physicians describing program Q&A on program, vaccine articles (rationale, repeat vaccination, combined vaccine) Press Conference for launch Notification with influenza vaccine order that 30% as many doses of pneumococcal vaccine would be supplied

Hypothesis: The Ontario pneumococcal vaccination program will reduce the rate of invasive pneumococcal disease in the vaccine-eligible population

Anticipated impact of Ontario vaccination program

Outcome evaluation Telephone surveys of vaccine eligible population to determine vaccination rates Assessment of disease incidence: comparison of disease incidence by age, and in vaccine eligible and non-eligible groups comparison of disease incidence with Quebec indirect cohort analysis of vaccine efficacy time series analysis

LSPQ surveillance Jan 1, 1996 - Lab-based reporting of number of sterile site pneumococcal isolates from all labs in of Quebec Sentinel laboratories (N=20-25) send isolates for serotyping, susceptibility testing

Vaccine Coverage (pre-program) Community Surveys: Duclos (1994) 1.8% >65 yrs (Canada) Hockin (1996) 7.4% eligibles (Ottawa) MD survey: 8% of GPs recommended vaccine to eligible patients 1994: 40% LTCF residents vaccinated

Vaccine Distributed and Estimated Coverage - Ontario

Pneumococcal vaccination rates, by risk group

Rate of invasive pneumococcal disease, by age group, metropolitan Toronto/Peel region

Cases of invasive disease by vaccine eligibility, Metro/Peel, 1995-8

Rate of invasive pneumococcal disease: Metro/Peel vs. Quebec

Total rates of invasive pneumococcal disease in Metropolitan Toronto and Quebec population (per 100,000 populations), 1995-9

Indirect cohort analysis

Rates of invasive pneumococcal disease in vaccine eligible population (per 100,000 population) Metropolitan Toronto/Peel Region, 1995-9

Rate of invasive pneumococcal disease in vaccine ineligible populations (per 100,000 populations) Metropolitan Toronto/Peel Region, 1995-9

Anticipated/observed impact of Ontario Vaccination Program

Conclusions Ontario program increased pneumococcal vaccination rates, largely in the >65 yr group New program will be needed for further increases The increase was associated with a significant reduction in the incidence of invasive disease

Next Questions Vaccine efficacy in subgroups Defining additional risk groups (smokers, cancer) Duration of immunity Impact on pneumonia

Microbiology technologists, infection control TIBDN Wigdan Al-Sukhni (U of T) Patricia Avarino (Ryerson) Lynda Eunson Ellie Goldenberg Karen Green Lisa Landry Margaret McArthur Sharon Miller Andrew Morris (U of T) Agron Plevneshi Sylvia Pong-Porter Nilofar Siddiqi Liljana Trpeski Barbara Willey Microbiology technologists, infection control practitioners, public health inspectors from metropolitan Toronto/Peel region

TIBDN 2003/2004 NEW: sterile site Salmonella spp. S. pneumoniae - sterile sites and respiratory Clinical isolates of MRSA Group B streptococci Group A streptococci NEW: sterile site Salmonella spp.