The following article is based on expert discussions taken from the MSD Pneumococcal Vaccination Policy Roundtable that took place in Cape Town, South Africa on March 18, 2024.
The global population is ageing. This has long been a trend in Western nations. However, many developing countries are now witnessing a similar societal shift. This will profoundly affect our economic well-being (as I wrote about here) and security and cohesion (as I wrote about here) unless countries focus much more on the health of older people. Health systems must adapt to this new reality, or we will all face dire health and economic burdens in the future.
Adult vaccination is a key area where we are simply not keeping up with shifting dynamics. Pneumococcal disease is a prominent example. Pneumococcal disease is a name for any infection caused by bacteria called Streptococcus pneumoniae, or pneumococcus. Pneumococcal infections can range from ear and sinus infections to pneumonia, meningitis and bloodstream infections[1].
We have made great strides when it comes to pneumococcal disease prevention. However, there is a lot of work that needs to be done to improve protection through vaccination, most prominently among the adult population.
Paediatric pneumococcal vaccination had been introduced in 155 WHO Member States by the end of 2022. Though coverage rates vary considerably by region, the global third dose coverage was estimated at 60%[2]. This is contrasted sharply by the situation regarding adult vaccination. Despite WHO recommendations, only 31 countries currently include adults in the pneumococcal vaccination schedule. Coverage rates are often lacking in countries with a programme in place, and the implementation is suboptimal.
It has been estimated that between 2004 and 2040, the economic burden of pneumococcal pneumonia will increase by US $2.5 billion per year[3]. A global burden of disease study on lower respiratory tract infections (LRTIs) indicated that in 2016, a total of 2,377,697 deaths occurred from LRTIs in people of all ages. Of these, close to half, or 1,080,958 deaths, occurred in adults over 70 years of age[4]. Streptococcus pneumoniae was the leading cause of LRTI morbidity and mortality globally, causing more deaths than all other etiologies combined in 2016. As the population ages, the at-risk group is increasing. Despite nearly half of current deaths already being associated with older adults, adult pneumococcal vaccination remains a low priority for policy makers in most countries. This is a major mistake.
Health system recommendations are not the only issue. Perceptions and visibility of the pneumococcal vaccine also limit uptake where they are available. One assessment suggests that the two most cost-effective adult vaccines are flu and pneumococcal[5], but the pneumococcal vaccine uptake is much lower. A survey conducted by the International Longevity Centre (ILC)[6] found that in adults over 50 across a number of European countries, 94% had heard of the flu and COVID-19 vaccines. Still, only 42% had heard about the pneumococcal vaccine. This lack of knowledge translated directly into uptake rates. Flu vaccine uptake was 59%, 85% got the COVID-19 vaccine, while only 18% got the pneumococcal vaccine. “We know that knowledge is a key driver for vaccination…when people aren’t aware a vaccine exists, they won’t get it,” said Arunima Himawan, Senior Health Research Lead, ILC, UK.
Need for policy prioritisation and igniting longer-term thinking amongst decision-makers
Scientists working in the field of pneumococcal disease and immunisation feel that a key challenge is convincing policymakers to implement strategies within their five-year election cycles. This focus on reelection often favours spending on the immediate and the concrete rather than on prevention policies which will pay off over decades.
“Now, how can we make the same argument for adults? I think the argument is beginning to emerge in the concept of healthy ageing and living, and there are dividends in this. Healthier populations result in higher economic productivity and more societal cohesion. I think these are the things we need to be framing to policymakers,” said Dr Sipho Dlamini of the University of Cape Town, South Africa.
Policymakers make the same errors in value calculation over and over again. Officials calculate value in the short term without looking at the associated costs. The narrative must shift from thinking of pneumococcal vaccination as just preventing hospitalisations directly from the illness.
Many of the longer-term effects of pneumococcal infection are delayed and masked. Myocardial infarction risk is significantly elevated following a bout of pneumococcal infection[7]; however, due to the delay or a focus on the immediate issue of the myocardial infarction, the diagnosis of the infection may not occur. Without clear visibility of an issue, and a lack of data, there is no immediate political incentive to address it.
The relationship between viral and bacterial infections is another matter that must be highlighted. In many instances, a viral infection may be an instigator of a secondary infection from a bacterial pathogen.
Antimicrobial resistance (AMR) brings enormous costs — even in 2013, the US Centers for Disease Control and Prevention estimated that antimicrobial resistance added $20 billion to direct healthcare costs in the United States alone and a further $35 billion in loss of productivity annually. Vaccines reduce antibiotic use and this slows AMR, especially in life-threatening illnesses such as pneumonia where clinicians are reluctant to postpone treatment until lab results on bacterial susceptibility are available.
If a policymaker wishes to implement longer-term strategies, they must be reelected. It is vital, therefore, to have evidence-based information available to them. To justify the immediate expense of vaccination campaigns, they also need immediate rewards that alert the electorate or their superiors to their far-sighted decision-making. This might come from social media posts or press events with heads of NGOs and professional societies or through recognition in international comparisons.
Productivity as an incentive for vaccination
Productivity may be a critical narrative focus for adult immunisation. Politicians, in the face of an ageing society, are more interested in getting older people to stay in work.Employers may fund vaccination too to keep an older workforce engaged and productive.
Population demographics across the globe are aligning to effectively make it a necessity for adults to work into older ages. The world’s median age has been projected to increase from 31 to 36 by 2050. Europe is projected to have the oldest median age, at 47 years[8]. A considerable, and ever-increasing proportion of the population will fall into the over-65 category. Keeping these individuals healthy and productive will be essential to the economy.
Businesses must also be persuaded of the merits of adult vaccination, as they both directly benefit from them, and can also be one of the most powerful advocates for changes in government policy. “The reason that Rotary was so successful in their polio campaign was that they had so many business leaders there who could influence governments and had access,” said Michael Moore, former member of the ACT Legislative Assembly of Australia and Former District Governor, Rotary.
Younger workers also benefit, as they will not be taking time off work to care for their older family members.
Delivering the data to policymakers
A very small proportion of health budgets is earmarked for preventative health, and less specifically for immunisation and even less for adult immunisation. According to ILC UK, if preventative health spending increases by just 0.1% of GDP, it could unlock a 9% increase in annual spending by people aged 60 plus and an additional 10 hours of volunteering[9].
Data may not be enough; we need charismatic individuals. Australia is a clear example of the benefits of having a champion to rally around. Professor Ian Fraser, one of the inventors of the HPV vaccine, had a significant impact on the uptake of the vaccine by the government and was named Australian of the Year. Having a well-known, trusted advocate can be invaluable in providing policymakers with support.
Clear messaging, confidence, and convenience
Often unclear messaging permeates where vaccines are available, and this can have an impact on coverage rates. South Africa has provided a case study on how to address this. A group from a number of medical disciplines met with the aim of producing a simple-to-use guide. “The idea is that you produce a one-stop document. So any clinician anywhere, whether it be a GP or other specialist can say, I’ve got a haematology patient, how should I give vaccination? And the document is there.” said Dr Sipho Dlamini. This massively simplified the process and allowed for standardisation, overall improving access. It also meant that cardiologist, rheumatologists, diabetologists and others could be reassured that their own colleagues had endorsed the guidelines.
Confidence and awareness play important roles in the acceptance of vaccination. However, convenience is a factor that is often overlooked. “Older adults may need to rely on their children and their schedules to be able to take them to get the vaccines. That can make a very big difference,” said Lois Privor Dumm, Johns Hopkins Bloomberg School of Public Health.
A documented success story is the availability of vaccines through pharmacies. Pharmacists are a well-trusted source, but they’re also convenient, and many people are used to going to their pharmacy much more regularly than a general practitioner.
If we are to convince both policymakers and the public that adult vaccination for illnesses such as pneumococcal disease is a necessity, the narrative must shift. The health of older adults has an impact on the entire community. Vaccination has a significant positive economic impact on the productivity of older adults, the people who are taking care of older adults and the people who rely on older adults for childcare. Much like childhood vaccination, life course immunisation is an investment opportunity that will pay dividends for years to come and improve the health of the population.
[1]https://www.cdc.gov/pneumococcal/index.html#:~:text=Pneumococcal%20%5Bnoo%2Dmuh%2DKOK,to%20help%20prevent%20pneumococcal%20disease.
[2] WHO Immunization Coverage https://www.who.int/news-room/fact-sheets/detail/immunization-coverage
[3] Wroe PC, Finkelstein JA, Ray GT, et al. Aging population and future burden of pneumococcal pneumonia in the United States. J Infect Dis. 2012;205(10):1589–1592. doi: 10.1093/infdis/jis240
[4] Anderson R, Feldman C. The Global Burden of Community-Acquired Pneumonia in Adults, Encompassing Invasive Pneumococcal Disease and the Prevalence of Its Associated Cardiovascular Events, with a Focus on Pneumolysin and Macrolide Antibiotics in Pathogenesis and Therapy. Int J Mol Sci. 2023 Jul 3;24(13):11038. doi: 10.3390/ijms241311038. PMID: 37446214; PMCID: PMC10341596.
[5] Leidner AJ, Murthy N, Chesson HW, Biggerstaff M, Stoecker C, Harris AM, Acosta A, Dooling K, Bridges CB. Cost-effectiveness of adult vaccinations: A systematic review. Vaccine. 2019 Jan 7;37(2):226–234. doi: 10.1016/j.vaccine.2018.11.056. Epub 2018 Dec 4. PMID: 30527660; PMCID: PMC6545890.
[6] https://ilcuk.org.uk/european-pneumococcal-vaccination-a-progress-report/
[7] Ohland, J., Warren-Gash, C., Blackburn, R., Mølbak, K., Valentiner-Branth, P., Nielsen, J., & Emborg, D. (2020). Acute myocardial infarctions and stroke triggered by laboratory-confirmed respiratory infections in Denmark, 2010 to 2016. Eurosurveillance, 25(17). https://doi.org/10.2807/1560-7917.ES.2020.25.17.1900199
[8] https://www.imf.org/en/Publications/fandd/issues/2020/03/infographic-global-population-trends-picture
[9] https://ilcuk.org.uk/major-conditions-strategy-time-to-act-on-prevention/
