Impact of the introduction of pneumococcal conjugate vaccination on pneumonia in The Gambia: population-based surveillance and case-control studies

Grant A. Mackenzie, Philip C. Hill, Shah M. Sahito, David J. Jeffries, Ilias Hossain, Christian Bottomley, Uchendu Uchendu, David Ameh, Malick Ndiaye, Chidebereh D. Osuorah, Oyedeji Adeyemi, Jayani Pathirana, Yekini Olatunji, Bade Abatan, Ebirim Ahameefula, Bilquees S. Muhammad, Augustin E. Fombah, Debasish Saha, Roslyn Mackenzie, Ian PlumbAliu Akano, Bernard Ebruke, Readon C. Ideh, Bankole Kuti, Peter Githua, Emmanuel Olutunde, Ogochukwu Ofordile, Edward Green, Effua Usuf, Henry Badji, Usman N.A. Ikumapayi, Ahmad Manjang, Rasheed Salaudeen, E. David Nsekpong, Sheikh Jarju, Martin Antonio, Sana Sambou, Lamin Ceesay, Yamundow Lowe-Jallow, Dawda Sowe, Momodou Jasseh, Kim Mulholland, Maria Deloria Knoll, Orin S. Levine, Stephen R. Howie, Richard A. Adegbola, Brian M. Greenwood, Tumani Corrah

Research output: Contribution to journalArticle

Abstract

Background Pneumococcal conjugate vaccines (PCVs) are used in many low-income countries but their impact on the incidence of pneumonia is unclear. The Gambia introduced PCV7 in August, 2009, and PCV13 in May, 2011. We aimed to measure the impact of the introduction of these vaccines on pneumonia incidence. Methods We did population-based surveillance and case-control studies. The primary endpoint was WHO-defined radiological pneumonia with pulmonary consolidation. Population-based surveillance was for suspected pneumonia in children aged 2–59 months (minimum age 3 months in the case-control study) between May 12, 2008, and Dec 31, 2015. Surveillance for the impact study was limited to the Basse Health and Demographic Surveillance System (BHDSS), whereas surveillance for the case-control study included both the BHDSS and Fuladu West Health and Demographic Surveillance System. Nurses screened all outpatients and inpatients at all health facilities in the surveillance area using standardised criteria for referral to clinicians in Basse and Bansang. These clinicians recorded clinical findings and applied standardised criteria to identify patients with suspected pneumonia. We compared the incidence of pneumonia during the baseline period (May 12, 2008, to May 11, 2010) and the PCV13 period (Jan 1, 2014, to Dec 31, 2015). We also investigated the effectiveness of PCV13 using case-control methods between Sept 12, 2011, and Sept 31, 2014. Controls were aged 90 days or older, and were eligible to have received at least one dose of PCV13; cases had the same eligibility criteria with the addition of having WHO-defined radiological pneumonia. Findings We investigated 18 833 children with clinical pneumonia and identified 2156 cases of radiological pneumonia. Among children aged 2–11 months, the incidence of radiological pneumonia fell from 21·0 cases per 1000 person-years in the baseline period to 16·2 cases per 1000 person-years (23% decline, 95% CI 7–36) in 2014–15. In the 12–23 month age group, radiological pneumonia decreased from 15·3 to 10·9 cases per 1000 person-years (29% decline, 12–42). In children aged 2–4 years, incidence fell from 5·2 to 4·1 cases per 1000 person-years (22% decline, 1–39). Incidence of all clinical pneumonia increased by 4% (–1 to 8), but hospitalised cases declined by 8% (3–13). Pneumococcal pneumonia declined from 2·9 to 1·2 cases per 1000 person-years (58% decline, 22–77) in children aged 2–11 months and from 2·6 to 0·7 cases per 1000 person-years (75% decline, 47–88) in children aged 12–23 months. Hypoxic pneumonia fell from 13·1 to 5·7 cases per 1000 person-years (57% decline, 42–67) in children aged 2–11 months and from 6·8 to 1·9 cases per 1000 person-years (72% decline, 58–82) in children aged 12–23 months. In the case-control study, the best estimate of the effectiveness of three doses of PCV13 against radiological pneumonia was an adjusted odds ratio of 0·57 (0·30–1·08) in children aged 3–11 months and vaccine effectiveness increased with greater numbers of doses (p=0·026). The analysis in children aged 12 months and older was underpowered because there were few unvaccinated cases and controls. Interpretation The introduction of PCV in The Gambia was associated with a moderate impact on the incidence of radiological pneumonia, a small reduction in cases of hospitalised pneumonia, and substantial reductions of pneumococcal and hypoxic pneumonia in young children. Low-income countries that introduce PCV13 with reasonable coverage can expect modest reductions in hospitalised cases of pneumonia and a marked impact on the incidence of severe childhood pneumonia. Funding GAVI's Pneumococcal vaccines Accelerated Development and Introduction Plan, Bill & Melinda Gates Foundation, and UK Medical Research Council.

Original languageEnglish (US)
Pages (from-to)965-973
Number of pages9
JournalThe Lancet Infectious Diseases
Volume17
Issue number9
DOIs
StatePublished - Sep 1 2017

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Population Surveillance
Gambia
Case-Control Studies
Pneumonia
Vaccination
Incidence
Pneumococcal Vaccines
Pneumococcal Pneumonia
Conjugate Vaccines
Demography
Health
Vaccines

ASJC Scopus subject areas

  • Infectious Diseases

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Impact of the introduction of pneumococcal conjugate vaccination on pneumonia in The Gambia : population-based surveillance and case-control studies. / Mackenzie, Grant A.; Hill, Philip C.; Sahito, Shah M.; Jeffries, David J.; Hossain, Ilias; Bottomley, Christian; Uchendu, Uchendu; Ameh, David; Ndiaye, Malick; Osuorah, Chidebereh D.; Adeyemi, Oyedeji; Pathirana, Jayani; Olatunji, Yekini; Abatan, Bade; Ahameefula, Ebirim; Muhammad, Bilquees S.; Fombah, Augustin E.; Saha, Debasish; Mackenzie, Roslyn; Plumb, Ian; Akano, Aliu; Ebruke, Bernard; Ideh, Readon C.; Kuti, Bankole; Githua, Peter; Olutunde, Emmanuel; Ofordile, Ogochukwu; Green, Edward; Usuf, Effua; Badji, Henry; Ikumapayi, Usman N.A.; Manjang, Ahmad; Salaudeen, Rasheed; Nsekpong, E. David; Jarju, Sheikh; Antonio, Martin; Sambou, Sana; Ceesay, Lamin; Lowe-Jallow, Yamundow; Sowe, Dawda; Jasseh, Momodou; Mulholland, Kim; Knoll, Maria Deloria; Levine, Orin S.; Howie, Stephen R.; Adegbola, Richard A.; Greenwood, Brian M.; Corrah, Tumani.

In: The Lancet Infectious Diseases, Vol. 17, No. 9, 01.09.2017, p. 965-973.

Research output: Contribution to journalArticle

Mackenzie, GA, Hill, PC, Sahito, SM, Jeffries, DJ, Hossain, I, Bottomley, C, Uchendu, U, Ameh, D, Ndiaye, M, Osuorah, CD, Adeyemi, O, Pathirana, J, Olatunji, Y, Abatan, B, Ahameefula, E, Muhammad, BS, Fombah, AE, Saha, D, Mackenzie, R, Plumb, I, Akano, A, Ebruke, B, Ideh, RC, Kuti, B, Githua, P, Olutunde, E, Ofordile, O, Green, E, Usuf, E, Badji, H, Ikumapayi, UNA, Manjang, A, Salaudeen, R, Nsekpong, ED, Jarju, S, Antonio, M, Sambou, S, Ceesay, L, Lowe-Jallow, Y, Sowe, D, Jasseh, M, Mulholland, K, Knoll, MD, Levine, OS, Howie, SR, Adegbola, RA, Greenwood, BM & Corrah, T 2017, 'Impact of the introduction of pneumococcal conjugate vaccination on pneumonia in The Gambia: population-based surveillance and case-control studies', The Lancet Infectious Diseases, vol. 17, no. 9, pp. 965-973. https://doi.org/10.1016/S1473-3099(17)30321-3
Mackenzie, Grant A. ; Hill, Philip C. ; Sahito, Shah M. ; Jeffries, David J. ; Hossain, Ilias ; Bottomley, Christian ; Uchendu, Uchendu ; Ameh, David ; Ndiaye, Malick ; Osuorah, Chidebereh D. ; Adeyemi, Oyedeji ; Pathirana, Jayani ; Olatunji, Yekini ; Abatan, Bade ; Ahameefula, Ebirim ; Muhammad, Bilquees S. ; Fombah, Augustin E. ; Saha, Debasish ; Mackenzie, Roslyn ; Plumb, Ian ; Akano, Aliu ; Ebruke, Bernard ; Ideh, Readon C. ; Kuti, Bankole ; Githua, Peter ; Olutunde, Emmanuel ; Ofordile, Ogochukwu ; Green, Edward ; Usuf, Effua ; Badji, Henry ; Ikumapayi, Usman N.A. ; Manjang, Ahmad ; Salaudeen, Rasheed ; Nsekpong, E. David ; Jarju, Sheikh ; Antonio, Martin ; Sambou, Sana ; Ceesay, Lamin ; Lowe-Jallow, Yamundow ; Sowe, Dawda ; Jasseh, Momodou ; Mulholland, Kim ; Knoll, Maria Deloria ; Levine, Orin S. ; Howie, Stephen R. ; Adegbola, Richard A. ; Greenwood, Brian M. ; Corrah, Tumani. / Impact of the introduction of pneumococcal conjugate vaccination on pneumonia in The Gambia : population-based surveillance and case-control studies. In: The Lancet Infectious Diseases. 2017 ; Vol. 17, No. 9. pp. 965-973.
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abstract = "Background Pneumococcal conjugate vaccines (PCVs) are used in many low-income countries but their impact on the incidence of pneumonia is unclear. The Gambia introduced PCV7 in August, 2009, and PCV13 in May, 2011. We aimed to measure the impact of the introduction of these vaccines on pneumonia incidence. Methods We did population-based surveillance and case-control studies. The primary endpoint was WHO-defined radiological pneumonia with pulmonary consolidation. Population-based surveillance was for suspected pneumonia in children aged 2–59 months (minimum age 3 months in the case-control study) between May 12, 2008, and Dec 31, 2015. Surveillance for the impact study was limited to the Basse Health and Demographic Surveillance System (BHDSS), whereas surveillance for the case-control study included both the BHDSS and Fuladu West Health and Demographic Surveillance System. Nurses screened all outpatients and inpatients at all health facilities in the surveillance area using standardised criteria for referral to clinicians in Basse and Bansang. These clinicians recorded clinical findings and applied standardised criteria to identify patients with suspected pneumonia. We compared the incidence of pneumonia during the baseline period (May 12, 2008, to May 11, 2010) and the PCV13 period (Jan 1, 2014, to Dec 31, 2015). We also investigated the effectiveness of PCV13 using case-control methods between Sept 12, 2011, and Sept 31, 2014. Controls were aged 90 days or older, and were eligible to have received at least one dose of PCV13; cases had the same eligibility criteria with the addition of having WHO-defined radiological pneumonia. Findings We investigated 18 833 children with clinical pneumonia and identified 2156 cases of radiological pneumonia. Among children aged 2–11 months, the incidence of radiological pneumonia fell from 21·0 cases per 1000 person-years in the baseline period to 16·2 cases per 1000 person-years (23{\%} decline, 95{\%} CI 7–36) in 2014–15. In the 12–23 month age group, radiological pneumonia decreased from 15·3 to 10·9 cases per 1000 person-years (29{\%} decline, 12–42). In children aged 2–4 years, incidence fell from 5·2 to 4·1 cases per 1000 person-years (22{\%} decline, 1–39). Incidence of all clinical pneumonia increased by 4{\%} (–1 to 8), but hospitalised cases declined by 8{\%} (3–13). Pneumococcal pneumonia declined from 2·9 to 1·2 cases per 1000 person-years (58{\%} decline, 22–77) in children aged 2–11 months and from 2·6 to 0·7 cases per 1000 person-years (75{\%} decline, 47–88) in children aged 12–23 months. Hypoxic pneumonia fell from 13·1 to 5·7 cases per 1000 person-years (57{\%} decline, 42–67) in children aged 2–11 months and from 6·8 to 1·9 cases per 1000 person-years (72{\%} decline, 58–82) in children aged 12–23 months. In the case-control study, the best estimate of the effectiveness of three doses of PCV13 against radiological pneumonia was an adjusted odds ratio of 0·57 (0·30–1·08) in children aged 3–11 months and vaccine effectiveness increased with greater numbers of doses (p=0·026). The analysis in children aged 12 months and older was underpowered because there were few unvaccinated cases and controls. Interpretation The introduction of PCV in The Gambia was associated with a moderate impact on the incidence of radiological pneumonia, a small reduction in cases of hospitalised pneumonia, and substantial reductions of pneumococcal and hypoxic pneumonia in young children. Low-income countries that introduce PCV13 with reasonable coverage can expect modest reductions in hospitalised cases of pneumonia and a marked impact on the incidence of severe childhood pneumonia. Funding GAVI's Pneumococcal vaccines Accelerated Development and Introduction Plan, Bill & Melinda Gates Foundation, and UK Medical Research Council.",
author = "Mackenzie, {Grant A.} and Hill, {Philip C.} and Sahito, {Shah M.} and Jeffries, {David J.} and Ilias Hossain and Christian Bottomley and Uchendu Uchendu and David Ameh and Malick Ndiaye and Osuorah, {Chidebereh D.} and Oyedeji Adeyemi and Jayani Pathirana and Yekini Olatunji and Bade Abatan and Ebirim Ahameefula and Muhammad, {Bilquees S.} and Fombah, {Augustin E.} and Debasish Saha and Roslyn Mackenzie and Ian Plumb and Aliu Akano and Bernard Ebruke and Ideh, {Readon C.} and Bankole Kuti and Peter Githua and Emmanuel Olutunde and Ogochukwu Ofordile and Edward Green and Effua Usuf and Henry Badji and Ikumapayi, {Usman N.A.} and Ahmad Manjang and Rasheed Salaudeen and Nsekpong, {E. David} and Sheikh Jarju and Martin Antonio and Sana Sambou and Lamin Ceesay and Yamundow Lowe-Jallow and Dawda Sowe and Momodou Jasseh and Kim Mulholland and Knoll, {Maria Deloria} and Levine, {Orin S.} and Howie, {Stephen R.} and Adegbola, {Richard A.} and Greenwood, {Brian M.} and Tumani Corrah",
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TY - JOUR

T1 - Impact of the introduction of pneumococcal conjugate vaccination on pneumonia in The Gambia

T2 - population-based surveillance and case-control studies

AU - Mackenzie, Grant A.

AU - Hill, Philip C.

AU - Sahito, Shah M.

AU - Jeffries, David J.

AU - Hossain, Ilias

AU - Bottomley, Christian

AU - Uchendu, Uchendu

AU - Ameh, David

AU - Ndiaye, Malick

AU - Osuorah, Chidebereh D.

AU - Adeyemi, Oyedeji

AU - Pathirana, Jayani

AU - Olatunji, Yekini

AU - Abatan, Bade

AU - Ahameefula, Ebirim

AU - Muhammad, Bilquees S.

AU - Fombah, Augustin E.

AU - Saha, Debasish

AU - Mackenzie, Roslyn

AU - Plumb, Ian

AU - Akano, Aliu

AU - Ebruke, Bernard

AU - Ideh, Readon C.

AU - Kuti, Bankole

AU - Githua, Peter

AU - Olutunde, Emmanuel

AU - Ofordile, Ogochukwu

AU - Green, Edward

AU - Usuf, Effua

AU - Badji, Henry

AU - Ikumapayi, Usman N.A.

AU - Manjang, Ahmad

AU - Salaudeen, Rasheed

AU - Nsekpong, E. David

AU - Jarju, Sheikh

AU - Antonio, Martin

AU - Sambou, Sana

AU - Ceesay, Lamin

AU - Lowe-Jallow, Yamundow

AU - Sowe, Dawda

AU - Jasseh, Momodou

AU - Mulholland, Kim

AU - Knoll, Maria Deloria

AU - Levine, Orin S.

AU - Howie, Stephen R.

AU - Adegbola, Richard A.

AU - Greenwood, Brian M.

AU - Corrah, Tumani

PY - 2017/9/1

Y1 - 2017/9/1

N2 - Background Pneumococcal conjugate vaccines (PCVs) are used in many low-income countries but their impact on the incidence of pneumonia is unclear. The Gambia introduced PCV7 in August, 2009, and PCV13 in May, 2011. We aimed to measure the impact of the introduction of these vaccines on pneumonia incidence. Methods We did population-based surveillance and case-control studies. The primary endpoint was WHO-defined radiological pneumonia with pulmonary consolidation. Population-based surveillance was for suspected pneumonia in children aged 2–59 months (minimum age 3 months in the case-control study) between May 12, 2008, and Dec 31, 2015. Surveillance for the impact study was limited to the Basse Health and Demographic Surveillance System (BHDSS), whereas surveillance for the case-control study included both the BHDSS and Fuladu West Health and Demographic Surveillance System. Nurses screened all outpatients and inpatients at all health facilities in the surveillance area using standardised criteria for referral to clinicians in Basse and Bansang. These clinicians recorded clinical findings and applied standardised criteria to identify patients with suspected pneumonia. We compared the incidence of pneumonia during the baseline period (May 12, 2008, to May 11, 2010) and the PCV13 period (Jan 1, 2014, to Dec 31, 2015). We also investigated the effectiveness of PCV13 using case-control methods between Sept 12, 2011, and Sept 31, 2014. Controls were aged 90 days or older, and were eligible to have received at least one dose of PCV13; cases had the same eligibility criteria with the addition of having WHO-defined radiological pneumonia. Findings We investigated 18 833 children with clinical pneumonia and identified 2156 cases of radiological pneumonia. Among children aged 2–11 months, the incidence of radiological pneumonia fell from 21·0 cases per 1000 person-years in the baseline period to 16·2 cases per 1000 person-years (23% decline, 95% CI 7–36) in 2014–15. In the 12–23 month age group, radiological pneumonia decreased from 15·3 to 10·9 cases per 1000 person-years (29% decline, 12–42). In children aged 2–4 years, incidence fell from 5·2 to 4·1 cases per 1000 person-years (22% decline, 1–39). Incidence of all clinical pneumonia increased by 4% (–1 to 8), but hospitalised cases declined by 8% (3–13). Pneumococcal pneumonia declined from 2·9 to 1·2 cases per 1000 person-years (58% decline, 22–77) in children aged 2–11 months and from 2·6 to 0·7 cases per 1000 person-years (75% decline, 47–88) in children aged 12–23 months. Hypoxic pneumonia fell from 13·1 to 5·7 cases per 1000 person-years (57% decline, 42–67) in children aged 2–11 months and from 6·8 to 1·9 cases per 1000 person-years (72% decline, 58–82) in children aged 12–23 months. In the case-control study, the best estimate of the effectiveness of three doses of PCV13 against radiological pneumonia was an adjusted odds ratio of 0·57 (0·30–1·08) in children aged 3–11 months and vaccine effectiveness increased with greater numbers of doses (p=0·026). The analysis in children aged 12 months and older was underpowered because there were few unvaccinated cases and controls. Interpretation The introduction of PCV in The Gambia was associated with a moderate impact on the incidence of radiological pneumonia, a small reduction in cases of hospitalised pneumonia, and substantial reductions of pneumococcal and hypoxic pneumonia in young children. Low-income countries that introduce PCV13 with reasonable coverage can expect modest reductions in hospitalised cases of pneumonia and a marked impact on the incidence of severe childhood pneumonia. Funding GAVI's Pneumococcal vaccines Accelerated Development and Introduction Plan, Bill & Melinda Gates Foundation, and UK Medical Research Council.

AB - Background Pneumococcal conjugate vaccines (PCVs) are used in many low-income countries but their impact on the incidence of pneumonia is unclear. The Gambia introduced PCV7 in August, 2009, and PCV13 in May, 2011. We aimed to measure the impact of the introduction of these vaccines on pneumonia incidence. Methods We did population-based surveillance and case-control studies. The primary endpoint was WHO-defined radiological pneumonia with pulmonary consolidation. Population-based surveillance was for suspected pneumonia in children aged 2–59 months (minimum age 3 months in the case-control study) between May 12, 2008, and Dec 31, 2015. Surveillance for the impact study was limited to the Basse Health and Demographic Surveillance System (BHDSS), whereas surveillance for the case-control study included both the BHDSS and Fuladu West Health and Demographic Surveillance System. Nurses screened all outpatients and inpatients at all health facilities in the surveillance area using standardised criteria for referral to clinicians in Basse and Bansang. These clinicians recorded clinical findings and applied standardised criteria to identify patients with suspected pneumonia. We compared the incidence of pneumonia during the baseline period (May 12, 2008, to May 11, 2010) and the PCV13 period (Jan 1, 2014, to Dec 31, 2015). We also investigated the effectiveness of PCV13 using case-control methods between Sept 12, 2011, and Sept 31, 2014. Controls were aged 90 days or older, and were eligible to have received at least one dose of PCV13; cases had the same eligibility criteria with the addition of having WHO-defined radiological pneumonia. Findings We investigated 18 833 children with clinical pneumonia and identified 2156 cases of radiological pneumonia. Among children aged 2–11 months, the incidence of radiological pneumonia fell from 21·0 cases per 1000 person-years in the baseline period to 16·2 cases per 1000 person-years (23% decline, 95% CI 7–36) in 2014–15. In the 12–23 month age group, radiological pneumonia decreased from 15·3 to 10·9 cases per 1000 person-years (29% decline, 12–42). In children aged 2–4 years, incidence fell from 5·2 to 4·1 cases per 1000 person-years (22% decline, 1–39). Incidence of all clinical pneumonia increased by 4% (–1 to 8), but hospitalised cases declined by 8% (3–13). Pneumococcal pneumonia declined from 2·9 to 1·2 cases per 1000 person-years (58% decline, 22–77) in children aged 2–11 months and from 2·6 to 0·7 cases per 1000 person-years (75% decline, 47–88) in children aged 12–23 months. Hypoxic pneumonia fell from 13·1 to 5·7 cases per 1000 person-years (57% decline, 42–67) in children aged 2–11 months and from 6·8 to 1·9 cases per 1000 person-years (72% decline, 58–82) in children aged 12–23 months. In the case-control study, the best estimate of the effectiveness of three doses of PCV13 against radiological pneumonia was an adjusted odds ratio of 0·57 (0·30–1·08) in children aged 3–11 months and vaccine effectiveness increased with greater numbers of doses (p=0·026). The analysis in children aged 12 months and older was underpowered because there were few unvaccinated cases and controls. Interpretation The introduction of PCV in The Gambia was associated with a moderate impact on the incidence of radiological pneumonia, a small reduction in cases of hospitalised pneumonia, and substantial reductions of pneumococcal and hypoxic pneumonia in young children. Low-income countries that introduce PCV13 with reasonable coverage can expect modest reductions in hospitalised cases of pneumonia and a marked impact on the incidence of severe childhood pneumonia. Funding GAVI's Pneumococcal vaccines Accelerated Development and Introduction Plan, Bill & Melinda Gates Foundation, and UK Medical Research Council.

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