Prevenar - protection against pneumococcus, or how to help a child get less otitis media and pneumonia

Who is pneumococcus?

There are several vaccines on the modern market, among which there is Prevenar, it is allowed from 2 months of age and contains 13 serotypes. Below is information about the pathogen.

Pneumococcus Streptococcus pneumoiae is a spherical immobile bacterium discovered by E. Klebs and described in 1881 by Louis Pasteur. At the moment, 91 serotypes have been isolated on the basis of capsular antigens, but 23 serotypes have high virulence (this is the ability of the pathogen to lead to disease), of which 10 are widespread.

Streptococcus pneumoniae, which constantly lives in our body, is considered a conditionally pathogenic microorganism, it coexists peacefully with our body, but under certain conditions it causes disease. It would seem that it sounds relatively harmless, but, according to WHO statistics, diseases caused by Str. pneumoniae, along with viral diarrhea, lead in the number of infant mortality from 0 to 5 years in developing countries (pneumococcal infection is the cause of approximately 1.6 million deaths per year in the world, of which 50% occurs in children from birth to 5 years).

What is pneumococcal infection (PI)?

PI is a group of diseases caused by pneumococcus, which has an "adherence" to the lung tissue, but can affect any organ or system.

By localization, it is conventionally accepted to distinguish invasive and non-invasive PI:

Non-invasive infections are a local process, organ damage without streptococcus entering the bloodstream. The prognosis is usually relatively favorable: otitis media (inflammation of the middle ear), sinusitis (inflammation of the frontal, maxillary, sphenoid sinuses of the nose or ethmoid cells), conjunctivitis (inflammation of the outer membrane of the eye), bronchitis, community-acquired pneumonia, tracheitis, nasopharyngitis.
Invasive infections. With them, the pathogen is introduced into the bloodstream and can enter any organ. The prognosis in this case is serious, even fatal: meningitis (inflammation of the meninges), sepsis, pneumonia with bacteremia, endocarditis and pericarditis (inflammation of the inner and outer “leaves” of the heart), peritonitis (inflammation of the peritoneum), arthritis.

Who is most at risk of getting sick?

The frequency of carriage in children is 60 - 70%, in adults living together with small children - 30 - 40%, living without children - about 10%. The percentage of carriage in children decreases as they grow older, which reflects natural immunization, but in old age it increases sharply again, which indicates a decrease in the tension of immunity.

Since this bacterium is conditionally pathogenic, the development of the disease requires either a decrease in immune reactivity, or infection with a pneumococcal strain with high virulence, or both of these circumstances together.

The following are factors that make a person more likely to get this infection:

Children under 2 years old and adults of retirement age.
Postponed or tolerated severe forms of influenza or SARS.
Being in a crowded collective (boarding schools, kindergarten, schools, nursing homes, barracks).
Long-term use of corticosteroid hormones and cytostatics.
Radiation therapy.
Chronic diseases, especially of the cardiovascular and pulmonary systems, liver.
Diabetes.
Having bad habits.
Immune disorders: HIV infection, oncohematological diseases, condition after organ transplantation, asplenia (condition after removal of the spleen), as well as frequently ill children.
Adults and children after cochlear implantation (hearing aids).
Patients with liquorrhea (leakage of cerebrospinal fluid).
The presence of cystic fibrosis.
Tuberculosis disease.

Infection occurs from a carrier or from a sick person by airborne droplets, less often by household contact. Pneumococci persist in dried sputum up to 1 - 2 months, on infected diapers up to 1 - 2 weeks. Microbes are highly sensitive to disinfectant solutions.

The clinical picture of pneumococcal infections

Pneumonia is an inflammation of the lung tissue, the involvement of an entire lobe of the lung and / or the area of the pleura adjacent to the focus of inflammation. The disease begins acutely, high fever, painful cough, at first dry, then it becomes more moist, and as the amount of sputum increases, the painful cough subsides. When the process is localized in the lower parts of the lung, especially in a small child, there may be abdominal pain, frequent liquefied stools, repeated vomiting. In this case, it is necessary to diagnose with diseases of the abdominal organs (intestinal infection, appendicitis, peritonitis). When localized in the tops of the lungs, the baby develops meningeal symptoms. Therefore, it is necessary to exclude or confirm the presence of inflammation of the meninges. Symptoms of pneumonia usually increase up to 5 - 7 - 10 days, then, with a favorable course, recovery begins. The temperature is normalized, the sputum goes away easier, the coughing attacks become shorter, the pain in the chest disappears, the results of laboratory tests and radiographs gradually normalize. Pneumonia is most commonly caused by strains 1, 3, and especially 4.
Pneumococcal meningitis is the most severe purulent meningitis in children along the course and in consequences. In terms of frequency of occurrence in children and the elderly, it is in third place after meningococcal and hemophilic. It develops in children over 6 months old, in younger children it practically does not happen. Most often, the disease develops against the background of an existing disease. The pathogen enters the bloodstream and affects the meninges, often against the background of sinusitis or otitis media. The child's temperature rises to 38 - 40 ˚С, meningeal symptoms develop. They are characterized by the typical position of the patient - a thrown back head with tucked limbs with stiff neck muscles, Kernig's and Brudzinsky's symptoms, severe headache, convulsions, hallucinations, repeated vomiting, photophobia. In children under one year old, there are practically no typical symptoms; one should be guided by the bulging of the fontanelle. Vomiting and crying can occur at the slightest stimulus, be it light or harsh sound. Mortality at the moment is 10 - 20%, a high frequency of profound disability in a child. It is more often caused by serotypes 1 - 7, 14,18,23.
Otitis. 30 - 40% of acute otitis media are caused by pneumococcus, a high frequency of perforation of the tympanic membrane and complications. Most often caused by serotype 3.
Arthritis, osteomyelitis, sepsis, pericarditis, endocarditis, peritonitis. Also caused by pneumococcus. The picture of the disease looks the same as with other bacteria. It happens more often in infants and in early childhood, but it is especially dangerous in premature babies and in crumbs of the 1st month of life.

Diagnosis and treatment of pneumococcal infections

The diagnosis is made based on the detection of the pathogen in the lesion. Therefore, sputum, cerebrospinal fluid, purulent discharge from the middle ear, blood, synovial fluid are taken for examination.

Therapy should be comprehensive. In most cases of non-invasive forms and in all cases of invasive, the doctor will prescribe antibacterial drugs.

In recent years, antibiotic-resistant strains have been increasingly identified. According to various sources, this is from 20 to 40%, which is a very high figure.

Treating resistant bacteria is becoming a real challenge, as it requires either higher doses of antibiotics, or the use of multiple drugs at once (which can be toxic to the patient, or very expensive), or the synthesis of new antibacterial drugs (which is also a difficult and expensive task).

It follows from this that a person who has become ill with an invasive form of antibiotic-resistant pneumococcal infection has practically no protection. So, it's time to reconsider your view of treatment and shift the focus to prevention, that is, to vaccination.

Prevention

The development of a vaccine against PI began in 1911 in the United States, and by 1945 the 4-valent polysaccharide pneumococcal vaccine PPV (polysaccharide is the part of the capsule to which the immune response is generated) was patented. But at this moment, antibiotic therapy began to be actively introduced, the idea arose that all infectious diseases were easily defeated, and interest in the vaccine diminished.

But when antibiotic resistance began to appear, it became clear that resistance would always form faster than pharmacologists could synthesize new drugs, so they began working on a vaccine again. And in 1977 a 14-valent PPV was registered in the USA, and then, in 1983, a 23-valent PPV.

But, according to research results, this polysaccharide does not form an adequate immune response in children under 2 years old, since the T-dependent pathway is not involved. To do this, scientists have combined (conjugated) pneumococcal polysaccharide with a protein of diphtheria or tetanus toxoid. This type of vaccine is called PCV pneumococcal conjugate vaccine. Such vaccines are effective for children from 6 weeks to 2 years old, who are precisely at risk for developing pneumococcal infection.

PCV use both the T-dependent and B-dependent pathways of the immune response. At the moment there are 2 PKV:

Synflorix. 7-valent vaccine, manufactured by GlaxoSmithKline, Belgium;
Prevenar 13. 13-valent vaccine, manufactured by Pfizer, USA, which will be discussed below.

Prevenar vaccine composition

At first Prevenar was released in a 7-valent version, then it was possible to expand its composition to 13 serotypes, thus covering 85% of the virulent serotypes "dominant" in Europe, Russia, and the United States.

Prevenar 13 vaccine composition:

pneumococcal polysaccharides of serotypes 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, 23F;
diphtheria toxoid protein (polysaccharide carrier);
aluminum phosphate;
sodium chloride;
water for injections;
succinic acid;
polysorbate.

The vaccine is presented as suspensions of a uniform white color in an ampoule or in a syringe for injection. In a syringe or ampoule there is 1 dose equal to 0.5 ml.

Indications for vaccination

Prevenar vaccine is indicated:

children on the national vaccination calendar;
high-risk groups of people with the following diseases and conditions:
- immunodeficiency states, including HIV infection, cancer, people receiving immunosuppressive therapy;
- people with a missing spleen or in preparation for its removal;
- after a cochlear implant is installed or in preparation for this operation;
- people with leakage of cerebrospinal fluid (liquorrhea);
- people with chronic diseases, especially of the cardiovascular and pulmonary systems;
- people with diabetes mellitus;
- premature babies;
- children and adults in organized groups (orphanages, nursing homes, boarding schools, army teams);
- recovered from acute otitis media, meningitis, pneumonia;
- frequently ill children;
- tobacco smokers;
- persons with a history of tuberculosis.

Contraindications to vaccination

strong reaction to previous introduction of Prevenar 13;
hypersensitivity to the components of the vaccine (especially if it is diphtheria toxoid);
acute infectious diseases;
chronic diseases in a state of exacerbation

Scheme and timing of vaccine administration

Depends on the patient's age:

from 2 to 6 months - 2 doses with a break of at least 8 weeks between injections, then revaccination once at 11-15 months. (this is a “2 + 1” mass immunization scheme);
from 6 weeks to 6 months Children from risk groups - 3 doses with a break of at least 4 weeks between injections, revaccination once at 12-15 months. (this scheme is called "3 + 1");
from 7 to 11 months - 2 doses are administered with a break of at least 4 weeks, then revaccination in the second year of life, with a break of at least 2 months after 2 doses;
from 12 to 23 months - 2 doses with a break of at least 8 weeks. There is no revaccination;
from 2 to 5 years - 1 dose. There is no revaccination;
50 years and older - 1 dose. There is no revaccination.

Vaccine Administration Notes

if any of the above intervals increased, additional vaccine doses are not required;
for children under 2 years of age, the drug is injected into the upper half of the outer surface of the thigh, after 2 years - into the deltoid muscle of the shoulder. It is strictly prohibited to inject the vaccine intravenously or intramuscularly into the buttock;
at any age, the dose of the injected vaccine is 0.5 ml;
after vaccination, it is necessary to be under the supervision of a medical worker for 30 minutes;
when deciding on the vaccination of children born prematurely, especially with regard to deeply premature babies (the pregnancy lasted less than 28 weeks), one should remember about the immaturity of the lung tissue, which increases the likelihood of an invasive form of this infection. Therefore, Prevenar vaccination in these babies is especially important. Parents need to understand that refusal or postponement of vaccination is fraught with serious consequences and that it is necessary to introduce the vaccine as soon as possible after the stabilization of the child's condition within the prescribed time frame. However, it is necessary to remember about the potential risk of apnea (this reaction is possible with the introduction of any vaccines to premature babies), therefore, the introduction of the first dose of the vaccine should be carried out in a hospital, followed by a stay there for 2 to 3 days;
Prevenar 13 can be administered both separately and together with other vaccines from the National Vaccination Schedule, with the exception of BCG. In the case of joint administration, the vaccine is injected into different limbs, each in its own syringe;
children with febrile seizures and other seizure disorders should be prescribed paracetamol or ibuprofen medications for antipyretic purposes. Especially if the child receives DTP whole-cell pertussis vaccine at the same time as Prevenar 13. The drug can be given in any form (suppositories, syrup, crushed or whole tablet, depending on the patient's age);
the injection site cannot be lubricated with oil solutions, compresses or plasters must be applied. You can wash with warm water. The main thing is not to rub the injection site, so as not to cause irritation, to which a secondary infection can subsequently join.

Can I walk after the vaccination? Doctor Komarovsky claims that it is possible. But it should be remembered that it is necessary to minimize contact with other people. The same should be done 5 to 7 days before vaccination. The less the baby is in contact with people on the street, the less likely it is to contract ARVI.

Injection reactions and side effects

Within one day after the administration of the vaccine, fever, redness, induration / swelling and soreness at the injection site, drowsiness, decreased appetite may occur. There may be a short-term (1 - 2 days) limitation of movement of the limb where the injection was made (the child can spare the leg or the handle). These phenomena occur in 10 and more percent of cases.

If the temperature after Prevenar vaccination lasts more than 5 days, then, most likely, this indicates the development of an acute respiratory infection, which is not related to the vaccine. The severity of the temperature reaction has nothing to do with the quality of the formed immunity. This is an individual reaction of the body to the introduction of a foreign substance. Most often, these reactions or side effects appear on the first administration of the vaccine.

Side effects in childhood:

general reactions: severe temperature reaction, induration or edema at the injection site more than 7 cm in diameter, fainting (less than 0.1%), urticaria, dermatitis, itching at the injection site, flushing of the face;
hematopoietic system - regional lymphadenopathy;
immune system: bronchospasm, Quincke's edema, anaphylactic reaction up to shock (less than 0.1% in total);
nervous system: irritability, sleep disturbance, febrile seizures (0.1% to 1%), crying.
gastrointestinal tract: vomiting, diarrhea;
in patients with remission of thrombocytopenic purpura 2-14 days after vaccination, relapses up to 2 weeks are described (in 0.1% of cases).

In children who received Prevenar 13 in conjunction with DTP, a temperature reaction was observed more often than in those who received DTP alone (temperature more than 38.0 ˚C in 41.2% of those who received 2 vaccines against 27.9% who received DTP).

Children who received Prevenar 13 in conjunction with the 6-component vaccine (DPT + polio inactivated vaccine + hepatitis B vaccine + hemophilus influenza vaccine) also had a temperature reaction more often than children who received only the 6-component vaccine (temperature above 38.0 ˚C 28.3% versus 15.6%).

Evidence-Based Medicine and Prevenar Vaccination

Evaluation of the effectiveness of PCV was carried out for the Prevenar 7 vaccine on a 3 + 1 scheme in California. 19 thousand children participated from 2000 to 2008.

In the USA, mass vaccination within 5 years reduced the incidence of invasive forms of PI in children 0 - 5 years old by 45 times (for 7 strains included in the Prevenar 7 vaccine).
The number of bacteremias decreased by 4 times (from 98.7 to 23.4 per 100,000).
The incidence of pneumococcal meningitis decreased by 73.3%, but the incidence of meningitis caused by non-vaccine strains increased.
Hospitalization of children 0-2 years old due to pneumonia decreased from 12.5 cases to 8.1 cases per 1000 people.
The decrease in the incidence of acute otitis media decreased by 57%, the frequency of the operation to open the tympanic cavity decreased from 39 to 24%
Carriage of vaccine strains in vaccinated children decreased from 42 to 25%, in the control group it increased from 39 to 46%. The proportion of carriers of non-vaccine strains is increasing, but the total number of carriers in the population has decreased.

Conclusion

The composition of Prevenar 13 and the introduction of the vaccine into the National Immunization Schedule with the "2 + 1" immunization schedule significantly reduces the incidence of pneumococcal infections in Russia, and the introduction of Prevenar 13 together with other vaccines maximizes adherence to vaccination due to the simplicity of the combined immunization schedule.

And most importantly, remember that there will come a time when no antibiotic will help. And it will only save the fact that the child already has protective factors acquired through vaccination.