Cent Eur J Public Health 2012; 20 (2): 121–125
OPPORTUNITY FOR HEALTHY AGEING: LESSENING 
THE BURDEN OF ADULT PNEUMOCOCCAL DISEASE 
IN CENTRAL AND EASTERN EUROPE, AND ISRAEL
REVIEW AND ANALYSIS OF THE PROBLEM
Endre Ludwig1, Serhat Ünal2, Miron Bogdan3, Roman Chlibek4, Yavor Ivanov5, Roman Kozlov6, Mark van der 
Linden7, Hartmut Lode8, Zsófia Mészner9, Roman Prymula10, Galia Rahav11, Anna Skoczynska12, Ivan Solovic13, 
Esra Uzaslan14
1Division of Infectious Diseases, Department of Internal Medicine No. II, Semmelweis Medical University, Budapest, Hungary
2Department of Internal Medicine, Hacettepe University Faculty of Medicine, Section of Infectious Diseases, Ankara, Turkey
3Carol Davila University of Medicine, Bucharest and Marius Nasta Institute of Pneumophthisiology, Bucharest, Romania
4Department of Epidemiology, Faculty of Military Health Sciences, University of Defence, Hradec Králové, Czech Republic
5Pulmonology and Phthisiatry Clinic, University Hospital, Pleven, Bulgaria
6Institute of Antimicrobial Chemotherapy, Smolensk State Medical Academy, Smolensk, Russia
7German National Reference Center for Streptococci, Department of Medical Microbiology, University Hospital RWTH Aachen, Aachen, Germany
8Research Center of Medical Studies (RCMS), Institut für Klinische Pharmakologie, Charite Universitätsmedizin Berlin, Germany
9National Institute of Child Health, Szent Laszlo Hospital for Infectious Diseases, Budapest, Hungary
10University Hospital, Hradec Králové, Czech Republic
11Infectious Disease Unit, Sheba Medical Centre, Tel Hashomer, Ramat-Gan, Israel
12National Reference Centre for Bacterial Meningitis, Department of Epidemiology and Clinical Microbiology, National Medicines Institute, 
Warsaw, Poland 
13Pulmonology Department in National Institute for TB, Lung Diseases and Thoracic Surgery, Vyšné Hágy, Catholic University in Ružomberok, 
Slovakia 
14 Department of Pulmonology, Uludag University Faculty of Medicine, Bursa, Turkey
SUMMARY
The population of the Region (Central Europe, Eastern Europe, and Israel) is ageing, necessitating preventative programmes to maintain a 
healthy and active lifestyle in older age groups. Invasive pneumococcal disease (including bacteremic pneumonia, bacteremia without a focus, 
and meningitis) has higher incidence, morbidity and mortality in older adults and is a substantial public health burden in the ageing population.
Surveillance in the Region establishes a significant burden in older adults of invasive pneumococcal disease (IPD), which still appears to be 
under-estimated as compared with other countries, and this warrants an improvement in surveillance systems. The largest proportion of IPD in adults 
is bacteremic pneumonia. Community-acquired pneumonia (CAP), largely attributable to S. pneumoniae, can be bacteremic or non-bacteremic; 
the non-bacteremic forms of CAP also represent a significant burden in the Region.
The burden of pneumococcal disease can be reduced with programmes of effective vaccination. Recommendations on pneumococcal vaccina-
tion in adults vary widely across the Region. The main barrier to implementation of vaccination programmes is low awareness among healthcare 
professionals on serious heatlh consequences of adult pneumococcal disease and of vaccination options.  
The Expert Panel calls on healthcare providers in the Region to improve pneumococcal surveillance, optimize and disseminate recommenda-
tions for adult vaccination, and support awareness and education programmes about adult pneumococcal disease. 
Key words: invasive pneumococcal disease (IPD), community-acquired pneumonia (CAP), Central and Eastern Europe (CEE), Israel, pneumo-
coccal vaccines, vaccination, elderly adults
Address for correspondence: E. Ludwig, Division of Infectious Diseases, Department of Internal Medicine No. II, Semmelweis Medical University, 
1097 Gyáli ut 5-7. Budapest, Hungary. E-mail: eludwig@laszlokorhaz.hu
in the past six decades (Fig. 1) and is forecasted to double again 
Healthy Ageing: a Growing Public Health Issue by 2040 (1). As a consequence, the Region will increasingly face 
The proportion of adults in the Region (Central Europe, Eastern the issue of “healthy ageing” (i.e. maintaining the general level of 
Europe, and Israel) over the age of 50 years has nearly doubled health, quality of life and active lifestyle in an ageing population). 
121
tion, may reduce the risk of myocardial infarction and stroke 
in the elderly (5). 
However, the preventative value of vaccination in adults is 
under-recognised. Healthcare providers traditionally associate 
vaccination programmes with paediatric practice. “Vaccination 
for kids” is the current paradigm that needs to be transformed 
to address the substantial but not fully appreciated public health 
needs of the ageing population. Preventive potential of adult pneu-
mococcal vaccination is particularly neglected in the Region, due 
to low awareness of the burden of pneumococcal disease in adults 
and under-recognition of the potential of preventive measures (6). 
Fig. 1. Proportion of population over 50 years of age is grow-
ing in the countries of the Region. National census data from Pneumococcal Disease: a Major Preventable Health 
1950 to 2000 (Hungary (43, 44), Turkey (45)) or 2010 (Russia Burden
(46), Slovakia (47)). Country forecast through 2040 by US S. pneumoniae causes invasive and non-invasive pneumococ-
Census Bureau (44). cal diseases. IPD includes bacteremic pneumonia, bacteremia 
without a focus, and meningitis. The majority of IPD cases in 
adults presents as bacteremic pneumonia (7−11). The incidence, 
morbidity and mortality of IPD are especially elevated in older 
Public health should target preventable diseases associated with adults and present a significant burden to individuals and to 
older age and related co-morbidities (2) by programmes ranging society (Fig. 2). Among the other risk factors for pneumococ-
from already established initiatives for reduction of cardiovascular cal disease such as co-morbidities, residence in a long-term 
risks to currently less utilized options for adult vaccination. care facility or smoking, age is an independent risk factor. The 
most prevalent form of pneumococcal disease in older adults 
is community-acquired pneumonia (CAP), which presents 
Adult Vaccination – the Neglected Solution? a substantial clinical and economic burden (12−15). Moreover, 
The public health value of prevention through vaccination S. pneumoniae is a major contributor to exacerbations of COPD 
(i.e. lowering disease incidence in the target population) is well (16), the disease burden in the Region is at least comparable to, 
documented in paediatric populations and likewise in adults. The and may even exceed, that of CAP (13, 17). Therefore, the burden 
value can expand beyond direct effects like an impact on the of pneumococcal disease in adults is immense.  
incidence of invasive pneumococcal disease (IPD) cases in the 
target population. For instance, successful pneumococcal vac-
cination in paediatric programmes has associated individual and The Burden of IPD – How Much Remains Hidden?
economic benefits, such as an impact on the patterns of antibiotic Diagnosis of IPD (via positive blood or cerebrospinal fluid 
therapy, thus reducing the number of treatment failures linked culture) requires laboratory analysis that cannot be established 
to antibiotic resistance (3). In adults, pneumococcal vaccina- without adequate infrastructure and resources. Therefore, reliable 
tion, in addition to its protective effect against pneumococcal epidemiological data on IPD depend on the quality of surveillance 
disease, may prevent pneumonia-associated cardiovascular systems and in particular on collaboration between laboratory and 
events (4) and, when co-administered with influenza vaccina- clinical facilities. Diverse surveillance systems in many countries 
Fig. 2. Older adults have a high incidence of IPD and represent a growing share of national IPD burden. Left panel: IPD in-
cidence (per 100,000) by age group, Czech Republic, 2009 (10). Right panel: Share of adults over 50 (%) in IPD case load, 
Poland, 2007–2009 (11).
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of the Region merit improvement (18); in particular, systems of Bacteremia in pneumococcal CAP is more frequent in older 
active surveillance are under-represented. In many cases, blood adults and may be a risk factor for greater likelihood of severity 
culture is not performed at all, or performed at later stage, or the and mortality (27, 28). Referral decisions can be ameliorated by 
results are not reported correctly. Furthermore, national com- the application of validated risk scales, such as CRB65 (Severity 
pulsory surveillance for IPD does not exist in several countries. score for CAP based on: Confusion, Respiratory rate, Blood pres-
A specific issue in the Region is the lack of continuity in the fund- sure, and 65 years of age and older) (25). Furthermore, the burden 
ing of such systems. Surveillance systems in some countries, such of CAP remains profound even after recovery and discharge from 
as Poland and the Czech Republic, have recently been improved, the hospital (24−32). Symptoms can take weeks to resolve (29), 
and in 2009 the reported figures for the burden of IPD in adults in and a substantial proportion of patients hospitalized with CAP 
these countries were greater than in previous years, possibly due require re-hospitalization within 30 days (30). Of even more 
to these improvements (10, 11) (Fig. 2). The largest age-specific concern is long-term mortality, which remains significantly higher 
IPD mortality rate values were 44% (55–64 years) and 59% (65+ than in the general population for several years after the initial 
years) in Poland (10, 11). In the Czech Republic, the 65+ years episode, especially in CAP caused by S. pneumoniae (31, 32). 
age group had the greatest age-related IPD incidence of 8.8 per 
100,000 population per year (and it was 3.3 per 100,000 for age 
group 40–64 years) (10). By contrast, these reported IPD incidence Pneumococcal Vaccinations in Adults: Recommenda-
rates are substantially lower than the 51.9 and 18.1 per 100,000 in tions vs. Implementation
the same age groups in Israel for pneumococcal bacteremia (9). Recommendations for pneumococcal vaccination in adults 
Comparisons with current data from other European countries exist in most countries of the Region and predominantly call for 
also suggest that IPD may still be dramatically under-reported in a single dose of plain polysaccharide vaccine in adults older than 
the Region, especially in adults in the 50+ years age group (19). 65 years of age (33) or in younger adults with well-established 
Publications from the Region also report a significant burden of risk factors. At the same time, the actual uptake of pneumococcal 
adult IPD in terms of healthcare costs and resource utilization vaccination in adults has been negligible (34). Consequently, the 
(15, 20, 21). content of national recommendations from different bodies needs 
to be accurate, uniform, simple and practical. More importantly, 
their implementation needs to be addressed to improve the impact 
The Burden of CAP – Are Antibiotics an Easy Cure? of adult pneumococcal vaccination.
A significant proportion of CAP is attributable to S. pneumo-
niae. In multiple European studies investigating the aetiology of 
CAP, S. pneumoniae was the most frequently identified pathogen Considerations for Vaccination Recommendations
(12, 22) regardless of age group, clinical severity or country. S. IPD and CAP represent a significant preventable burden in 
pneumoniae is also the most frequently identified cause of bacter- adults from the age of 50 years. With increasing life expectancy, 
emia in CAP (23). Aetiological verification of CAP and detection vaccination recommendations should address the extended period 
of bacteremia in clinical practice may be challenging because of of risk. A primary dose of vaccine, followed by the ability to main-
initiation of antibiotic therapy before obtaining cultures, and cul- tain a protective immune response through regular re-vaccination 
tures are often not performed due to limited practice of collecting as needed, may provide continued protection even in the face of 
bacteriological material in hospital settings and/or limited labora- the immunosenescence associated with aging. Polysaccharide 
tory capacity. Given the current reliance on clinical examination vaccines have shown a certain level of effectiveness against in-
and X-ray diagnosis in CAP, there may be insufficient recognition vasive pneumococcal disease but evidence of their effectiveness 
that this disease is predominantly caused by the pneumococcus. in all-cause pneumonia is inconsistent. Furthermore, polysac-
This may be especially true in primary care, where a vast majority charide vaccines have a number of limitations with regard to the 
of CAP patients receive empiric antibacterial therapy. immune responses in older age groups (35): protection provided 
Improvement of diagnostic and treatment pathways alone, by a dose of plain polysaccharide vaccine wanes over time, and 
without a clear preventative strategy, may not be sufficient to re-vaccination is currently not recommended as the benefit is 
adequately control the burden of CAP. Rates of CAP hospitaliza- doubtful (36−38). Protection is also less likely to be demonstrated 
tion and CAP mortality remain especially high in older patients in more elderly age groups or in immuno-compromised individu-
in spite of apparent advances in therapy. According to a German als (39, 40). Consequently, pneumococcal vaccines are needed 
nationwide hospital audit, hospital mortality in CAP significantly that are capable of establishing immune memory initially and 
increases from the age of 40 years and hospitalization rates signifi- that retain the potential for an individual to be re-vaccinated as 
cantly increase from the age of 50 years (24). Early recognition necessary throughout the aging adult risk period. 
and adequate antibiotic therapy in the first hours after admission 
improve the outcomes of hospitalization in both bacteremic and 
non-bacteremic CAP (25, 26), although antibiotic resistance of S. Overcoming Barriers to Successful Implementation
pneumoniae may lead to some treatment failures (12). Moreover, A number of barriers hinder the successful implementation 
hospital mortality is especially high in the first 4 days after admis- of vaccination recommendations in adults (41). Patient barriers 
sion, which may be explained by the fact that pneumonia is a severe include general low health awareness and poor knowledge of 
inflammatory illness, with the gravity of  disease compounded by the safety and benefits of vaccination in adults. A major barrier 
delayed referral of (potentially severe) cases by primary care physi- for potential vaccine recipients is missing opportunities to have 
cians (PCPs) and/or delayed initiation of antibacterial treatment. vaccination recommended and administered during their encoun-
123
ters with healthcare professionals (42), who in-turn may have an • Educational programmes with clear messages and usable tools 
incomplete understanding of the seriousness of pneumococcal should be addressed in a top-down approach to multiple audi-
disease (6). Additional barriers specific to the Region are: incon- ences including PCPs and allied healthcare professionals.
sistent reimbursement policies in several countries and associated 
low public compliance to carry out-of-pocket expenses; variability Acknowledgements 
in the age and risk groups for which vaccination is recommended; Editorial assistance for the manuscript was provided by Dr. Dmitry 
a negative attitude of the media towards vaccination in general. Nonikov, Edelman, London, and funded by Pfizer Inc.
For pneumococcal disease in adults, PCPs may play a key 
part in prevention, diagnosis and referral, especially in those Conflicts of interest
healthcare systems where they play a gatekeeper role. Continual Endre Ludwig: Financial support for participating and working as con-
changes in healthcare systems overwhelm PCPs with multiple sultant in advisory boards by Astellas, MSD; Honoraria as speakers in 
complex procedures and guidelines, which are often poorly scientific meetings by Bayer
implemented. A key success factor is therefore the implementa- Roman Chlibek: Principal investigator in clinical studies supported by 
tion of clear and easy-to-follow recommendations and tools to GlaxoSmithKline and Novartis; Scientific consultant to Baxter, Glaxo-
motivate PCPs to vaccinate adults. Other stakeholders such as SmithKline, Novartis, Aventis Pasteur and Pfizer; Sponsorship from 
policy makers, payers, media and the public have low aware- GlaxoSmithKline and Aventis Pasteur to attend scientific meetings.
ness of, and commitment to vaccination in adults. There are Mark van der Linden: Member of advisory boards for Pfizer, GlaxoSmith-
even examples of anti-vaccination attitudes among the public Kline and Sanofi, invited speaker for Pfizer and GSK 
and the media. However, the attitude of non-medical audiences Zsofia Meszner: Financial support for participating and working as 
is unlikely to change before healthcare professionals manifest consultant in advisory boards by Pfizer, GSK and Sanofi
improved awareness of, and commitment to pneumococcal vac- Roman Prymula: Received honoraria and research grants form GSK, 
cination of adults. Pfizer, and Sanofi-Pasteur
Anna Skoczynska: Assistance to attend scientific meetings; honoraria for 
lecturing funded from Pfizer/Wyeth and from GlaxoSmithKline 
Conclusions: Call to Action
The Expert Panel calls on healthcare providers and policy mak- Sponsorship
ers in the Region to lessen the burden of pneumococcal disease in Financial support for the Regional Advisory Board on Pneumococcal 
adults and to make a concerted effort to address the unmet needs. Diseases in Adults was provided by Pfizer, Inc. 
Optimised Surveillance Systems and Epidemiology 
Studies
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