RAPORT / REPORT

Szczepienia przeciw pneumokokom w populacji osób dorosłych w Polsce – bieżąca analiza

Andrzej M. Fal1, Dorota M. Fal2, Dorota Kiedik1, Barbara Gad-Karpierz3

1 Zakład Ekonomiki i Jakości w Ochronie Zdrowia, Katedra Zdrowia Publicznego, Wydział Nauk o Zdrowiu,  Uniwersytet Medyczny im. Piastów Śląskich we Wrocławiu, Wrocław, Polska

2 Polskie Towarzystwo Zdrowia Publicznego, Warszawa, Polska 

3 Grupa LUX Med, Warszawa, Polska 

Wiad Lek 2018, 71, 5, -1121

 

INTRODUCTION

Chronic respiratory tract diseases and chronic cardiovascular diseases are, apart from the cancer, the main causes of morbidity and mortality in developed countries. These diseases affect primarily people over 40 years of age, and their incidence increases further with age. The main diseases in these groups: chronic obstructive pulmonary disease (COPD), ischemic heart disease and heart failure (HF) belong to the group of chronic diseases of civilization with at least partially defined risk factors. Several elements are important in limiting their impact on the population health as well as on their social and economic effects:

Above all, prevention – the most effective and the most cost-effective way to fight the disease;

Chronic treatment – i.e. the treatment of a disease in a stable period from the moment of its diagnosis;

Prevention and treatment of exacerbations, which have the greatest impact on disease progression, and on the other hand there are periods of the disease with the largest use of healthcare resources;

Rehabilitation – i.e. the attempt to minimize the permanent impact of the disease on the body.

Chronic obstructive pulmonary disease is one of the most serious health problems in the world. It is the fourth most common cause of deaths, and in the US – the third one (GOLD 2018). Exacerbations of COPD present as sudden deterioration of the patient’s health, most often manifested by symptoms intensification (including dyspnea and cough). Symptoms maintain at least 24 hours and force patients to change their treatment and/or visit the doctor. Exacerbations are most often caused by bacterial (pneumococcal) and viral respiratory tract infections (GOLD 2018) [1]i. At the same time, COPD poses a very important economic problem related to both direct costs of chronic therapy and therapy of exacerbations as well as indirect costs (absenteism, giftism, disability). According to the EY report published in 2017, the direct cost of COPD treatment is PLN 441 million (2015), and indirect costs can reach up to PLN 6.5 billion [2]ii.

It is estimated that around 384 million people suffer from COPD in the world (2010). This is approximately 11.7% (95% CI 8.4% – 15.0%) of the whole population. Three million people die every year from COPD, and with the current trend in 2030 it could be as high as 4.5 million people a year (WHO) (Fig. 1.) [3].

In Poland, HF is a common cause of premature mortality and has a significant impact on the standard expected years of life lost. Of all diseases in Poland, HF was in third place in terms of contributing to the life loss in women after vascular diseases of the brain and ischemic heart disease, and before the cancer. In men, HF was in the 6th place before all types of cancers except for lung cancer. The prognosis clearly shows that the incidence of HF in coming years will increase significantly with population aging. For HF diagnostics and treatment the National Health Fund (NHF) spends 3.2% of funds.

The number of hospitalizations due to HF in Poland is the highest among all OECD countries (2013 – 547 hospitalizations due to HF per 100,000 inhabitants (OECD – 257)). In total, NHF spends PLN 900.9 million per year for treatment (2016), and the total cost for the economy is estimated at almost PLN 4 billion [5].

Multimorbidity means the coexistence of several important chronic disease in the same patient. For obvious reasons, its frequency increases with the age of patients. The exacerbation of one of diseases by decompensation usually causes an exacerbation of the remaining, and reaching a stable state, i.e. bringing the patient out of the exacerbation, requires much more time, longer hospitalization, and more intensive pharmacotherapy. It has a negative impact on the health-related quality of life (HRQoL) and it is significantly more cost-intensive than the treatment of patients with a single disease. Infections, including pneumococcal ones, are a frequent factor decomposing and initiating exacerbations in patients with chronic diseases, and in particular in patients with multimorbidity.

In all European countries there is a significant and progressive process of population aging. Together with the increasing percentage of people aged 65+ in the society, the incidences of chronic respiratory tract diseases, chronic cardiovascular diseases as well as the risk of Streptococcus pneumoniae infection are increasing. Diseases caused by pneumococcal infection are classified in two groups: invasive and non-invasive diseases. With age, the risk of the development of the invasive pneumococcal disease increases. In European Union countries, patients over 65 years of age constitute approximately 50% of the total number of registered cases. Exacerbations due to infection in chronic diseases (including COPD and HF) are classified in the group of non-invasive diseases, while their frequency also increases significantly with age.

Recommendations of the American Advisory Committee on Immunization Practices (ACIP) suggest the validity of preventive vaccinations against Streptococcus pneumoniae in risk groups and in the elderly. They recommend routine vaccination with a 13-valent pneumococcal (PCV13) conjugate vaccine for people over 65 years of age [6]. The European Union of Geriatric Medicine Society (EUGMS) and the International Association of Geriatricians and Gerontologists – European Region (IAGG-ER) recommend the vaccination of people over 60 years of age and re-vaccination every 5 years, in particular in adults leaving in nursing homes and undergoing repeated hospitalizations. The European League Against Rheumatism (EULAR) recommends vaccination against influenza and Streptococcus pneumoniae in people over 65 years of age (tabele 1) [7].

In addition, most European countries implement immunization programs against pneumococcal bacteria based on age and risk factors. However, there are quite large differences in the choice of the vaccine (PPSV vs. PCV). Immunizations with polysaccharide vaccines are currently recommended in 17 European countries – however, they differ in the choice of risk groups. Eight countries recommend PPSV23 for all people over 65 years of age, five countries recommend vaccinations over 60 years of age and four countries recommend vaccination only in selected risk groups [9].

In each case, COPD and HF (or more generalized: chronic respiratory tract and cardiovascular diseases) are risk groups for which vaccination is particularly recommended. Despite these recommendations, pneumococcal vaccination is not a widely recognized method of prophylaxis in either COPD or HF. There is definitely no prospective long-term research and no research conducted according to the outcomes research protocol.

ASSUMPTIONS

This preliminary report assessed the frequency of pneumococcal vaccinations in the adult population in Poland and the impact of these vaccinations on the course of chronic respiratory tract and cardiovascular diseases. The following variables were used as parameters of the effect assessment: the number and the total length of sick leaves associated with primary diagnosis one year before and one and two years after the vaccination, and the number of medical visits (AOS – outpatient specialist care) related to baseline diagnosis in the same period.

DATA

The study was conducted in the patient population of medical centers associated with the LUX MED group. At the time of the study the population counted 1.9 million patients, of whom the number of patients covered by permanent pre-paid medical care, i.e. a subscription or a health insurance, was 1.1 million patients. This is important because the group of these patients had better access to specialist doctors than patients who only used healthcare in the public system. All patient data were anonymized according to the rules for dealing with sensitive data.

Population selection might not have been fully representative for the whole country population for several reasons. Firstly, the LUX MED Group centers are located only in cities, which eliminates from the assessment a large part of the rural population, secondly the services analyzed are financed in a different mode than from public funds and thirdly, the analysis is carried out post hoc based on existing data and not in the form of a prospective study.

Despite these limitations, the current analysis is the largest Polish analysis in this respect and should be the starting point for further research.

ANALYSIS

Patient databases were segregated into groups of patients with medical diagnosis of chronic lung diseases (ICD-10 codes: J40-J47) and chronic heart failure (ICD-10 code: I50). There were 61,719 patients with the basic diagnosis of chronic lower respiratory tract diseases (group A). In this group there were excluded neoplasms and specific inflammations, but there were included patients diagnosed with J44 code, i.e. other chronic obstructive pulmonary diseases (2,100). The group B (I50 code, HF) comprised of 1362 patients.

In the whole analyzed population of patients vaccinated against pneumococcal bacteria there were 1385 adult patients, i.e. over 18 years, with the following age distribution:

between 19 and 40 years of age – 223

between 41 and 64 years of age – 341

over 64 years of age – 821

There were two peaks of vaccination. The first one was in the age range of 30 – 47 years, i.e. among people with high professional activity, most often having families. The most likely stimulating factors were: infections with a pathogen carried by children from a kindergarten/school and vaccination funded by the employer (in Poland about 5% of entities declare financing vaccination against pneumococcal bacteria as part of the health package for employees). In the second group (the age range of 59 – 87 years) the probable stimulating factors were: the diagnosis of chronic diseases and/or intensification of their symptoms as well as prevention programs financed by local government units (Fig. 2A).

Depending on the diagnosis in the examined population of adults with lung diseases (ICD 10 codes: J00-J99) there were 250 vaccinated patients, including 126 patients diagnosed with chronic lower respiratory tract diseases (J40-J-47), and 50 patients with the diagnosis of J44 (Fig. 2B). Whereas there were 377 adults diagnosed with heart diseases (ICD 10: I00-I99) and vaccinated against pneumococcal bacteria, including 14 people diagnosed with chronic HF (I-50).

Subgroups vaccinated with different vaccines were not compared. All patients over 18 years of age were vaccinated at most once. The age distribution is shown in Figure 3. Table 2 presents also multiple vaccinations in the group of people below 18 years of age (for comparison only, data are not analyzed in this report).

The widely accepted indicator of economic effectiveness is the sum of days of sick leave in a year. In the studied group of people vaccinated against pneumococcal bacteria, the rate of people taking the sick leave was only 23%. This is due to a significant percentage (59%) of people in the retirement age. However, in the group of people in the working age (18-65 years), this percentage was 58%, which is also a fairly low indicator probably resulting from high involvement in work of employees (a significant part of the population has health care provided by the employer). This allows to conclude that sick leaves were issued only in case of a serious illness. The associations were studied in the whole vaccinated population as well as in the group A and the group B in the 12 months preceding vaccination and in the first and second year after vaccination (Figure 4 and Table 2 applies to all vaccinated people in the study population).

The analysis shows that sickness absence significantly decreased after pneumococcal vaccination (by 18% in the first year and by 21.4% in the second year). Among patients with lower respiratory tract diseases, sickness absence decreased by 23% and 60.3%, respectively. In people diagnosed with cardiovascular diseases, the decrease was 25% in the first year and 38% in the second year after vaccination.

The decrease was associated not only with the total number of days of sick leave in the year, but also with the number of patients taking the sick leave. In all studied groups, the numbers were particularly reduced in the second year after vaccination: by 26% in the whole vaccinated population, by 32% in people with lung diseases and by 17% in people diagnosed with cardiovascular diseases (Table 2).

Taking into account the indirect cost of one day absence in work (according to the calculation of production cost factors – approximately PLN 300), the average reduction of indirect costs per one professionally active vaccinated person in the first year after vaccination was PLN 173, in the second year – PLN 204, and for a patient with lower respiratory tract diseases: PLN 886 and PLN 2307, respectively.

The widely accepted indicator of medical effectiveness of vaccination is the number of medical consultations related to the primary diagnosis in the 12 months preceding vaccination and in the first and second year after vaccination (Figure 5 and Table 2 apply to all vaccinated in the studied population).

The analysis showed that the number of consultations also decreased significantly after vaccination against pneumococcal bacteria (in the first year by 7%, in the second year – by 21%) regardless of the analyzed subgroups (cardiovascular and respiratory tract diseases). In the group of people diagnosed with J44 (COPD), a greater decrease was observed, respectively by 12% and 23%, and in people with asthma – by 9% and 27% (Fig. 5, Tabele 4).

Also, in the case of medical consultations, similarly as in sick leaves, a decrease in the number of patients after vaccination was observed. In the second year after vaccination these drops were: by 13% in the total vaccinated population, by 15% in people with lung diseases, and by 8% in people with cardiovascular disease.

CONCLUSIONS

1. Vaccination against pneumococcal bacteria in the adult population is economically justified. In the context of reducing indirect costs in working people savings can reach up to 60% of the original costs of absenteeism in patients with lower respiratory tract diseases.

2. In the studied population, pneumococcal vaccination seemed to alleviate the course of chronic diseases – especially chronic respiratory tract diseases, which reflected in the decrease in the number of medical visits and the number of patients paying them.

3. Studies on representative populations are recommended in order to precisely determine the economic effect of vaccinations against pneumococcal bacteria depending on the age and patient’s diagnoses.

This Report was created as a part of an educational grant founded by Pfizer Poland Ltd.

References

1. http://goldcopd.org/gold-reports/.

2. http://www.ey.com/pl/pl/industries/life-sciences/koszty-pochp-w-polsce.

3. http://www.who.int/mediacentre/factsheets/fs310/en/.

4. http://stats.oecd.org/OECDStat_Metadata/ShowMetadata.ashx?Dataset=HEALTH_STAT&Coords=%5BVAR%5D.%5BCICDALLC%
5D&ShowOnWeb=true&Lang=en
; Dostęp 22.11.2017.

5. http://ingos.pl/public/userfiles/pdf/Ocena_kosztow_niewydolnosci_serca_w_Polsce_z_perspektywy_gospodarki_panstwa.pdf.

6. Centers for Disease Control and Prevention (CDC). Advisory Committee on Immunization Practices (ACIP) recommended immunization schedules for persons aged 0 through 18 years and adults aged 19 years and older—United States, 2013. MMWR Surveill Summ. 2013;62(Suppl 1):1.

7. Michel JP, Gusmano M, Blank PR, Philp I. Vaccination and healthy ageing, how to make life-course vaccination a successful public health strategy. Eur Geriatr Med. 2010;1(3):155–165.

8. https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf; Dostęp 22.11.2017.

9. Bulira-Pawełczyk J, Partyka O, Fal AM. Epidemiologia i profilaktyka inwazyjnych zakażeń pneumokokowych w grupie osób dorosłych. Public Health Forum 2017;3(11):153-161.

CORRESPONDING AUTHOR

Andrzej M. Fal

Klinika Chorób Wewnętrznych i Alergologii CSK MSW

ul. Wołoska 137, 02-507 Warszawa

e-mail: amfal@wp.pl

Received: 15.12.2017

Accepted: 20.03.2018

Opublikowano za: Public Health Forum 1/2018

 

all diseases

cancer,

cardiovascular diseases

respiratory tract diseases

Fig. 1. Mortality in selected countries in 2014. Own work based on OECD data [4].

Table 1. CDC recommendations for vaccinations in adults (February 2017) [8].

Fig. 2A. Age distribution of the studied population aged 19-100 years (176 480 patients from a sample of 200,000 patients randomly selected from all patients of the LUX MED group)

 

Fig. 2B. The population of patients with J44 (and related) and I50 (and related) diagnoses.

Fig. 3. Age distribution in the population of adult patients vaccinated against pneumococcal bacteria.

Table 2. The number of pneumococcal vaccination shots depending on the patient’s age.

Over 18 years of age

The number
of vaccination shots

The number
of patients

6

2

5

35

4

4413

3

4588

2

3596

1

9960

Below 18 years of age

The number
of vaccination shots

The number
of patients

6

0

5

0

4

0

3

0

2

0

1

1385

Fig. 4. The sum of sick leave days in the year; sick leaves in respiratory tract diseases.

Table 2. Sick leave statistics.

Sick leave statistics

The whole vaccinated population

Respiratory tract diseases

Cardiovascular diseases

Comparison with values from the last 12 months before vaccination

1 year after vaccination

2 years after vaccination

1 year after vaccination

2 years after vaccination

1 year after vaccination

2 years after vaccination

Difference in the number of days of sick leave

18%

21%

23%

60%

25%

38%

The difference in the number of people who were on sick leave in a given year

-1%*

26%

-4%

32%

-11%

17%

*sign “-” means the increase in a given year

the sum of sick leave days in the year

sick leaves in respiratory tract diseases

Fig. 5. The sum of visits number in the year – respiratory tract diseases; the sum of visits number in the year.

Table 3. Analise of the sum of medical visits

Medical consultations statistics

Whole vaccinated population

Respiratory tract diseases

Cardiovascular diseases

J45 code

Comparison with values from the last 12 months before vaccination

1 year after

2 years after

1 year after

2 years after

1 year after

2 years after

1 year after

2 years after

Difference in the number of visits

7%

21%

8%

21%

6%

17%

12%

23%

Difference in the number of people with visits in a given year

0

13%

0

15%

-2%

8%

1%

19%

*sign “-“ means the increase in a given year