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Universal pneumococcal vaccination of <2‐year‐olds decreased pneumococcal bacteremia and antibiotic resistance in <5‐year‐olds

Sir, As published recently (1), the annual number of pneumococcemia (occult pneumococcal bacteremia) cases varied between 3 and 10 with no increasing or decreasing trend, and the annual number of bacteremic pneumococcal pneumonia cases varied between 1 and 7 with an increasing trend, in Tampere University Hospital District. All but one of pneumococcemia cases were in <5-year-old children, with the highest incidence in 1–2-year-olds. Universal vaccinations with 10-valent PCV (PCV-10) were started in September 2010 in Finland, and from January 2011 onwards, the coverage of vaccinations in 3, 5 and 12 months old infants has been more than 95% (National Institute for Health and Welfare, Finland). The programme did not include any catch-up vaccinations. In 2011, there were 12 children aged <5 years without a severe underlying illness who had a positive pneumococcal blood culture; 3 had bacteremic pneumonia and 9 pneumococcemia. One of them had received PCV-10 vaccination: a 7-month-old child with pneumococcemia (the serotype not known). In 2012, there was only one <5-year-old child without severe underlying illness with a positive pneumococcal blood culture: a 3.5year-old child with pneumococcemia (blood leucocytes 34.0 9 10E9/L and serum C-reactive protein 122.7 mg/L on admission). The child had not been vaccinated with PCV vaccine. The serotype was 6B which is included in PCV-10. The patient was treated successfully with intravenous penicillin G. Thus, the effect of universal pneumococcal vaccination programme was dramatic in our hospital district with 33 500 children aged <5 years. Positive pneumococcal findings in blood cultures nearly disappeared, although at the beginning of 2012, only one age cohort and at the end of 2012, only two age cohorts had been vaccinated with PCV-10 at the ages of 3, 4 and 12 months. In many countries, invasive pneumococcal infections in young children decreased dramatically following the introduction of PCV-7, and preliminary evidence suggests that the change from PCV-7 to PCV-10 or to PCV-13 has further increased the beneficial effects of pneumococcal vaccinations (2). In a recent nationwide vaccination study from Finland, PCV-10 had 100% effectiveness in the prevention of serotype-specific bacteremia with 3+1 dosage and 92% effectiveness with 2+1 dosage, respectively (3). Simultaneously with the disappearance of pneumococcal bacteremia, pneumococcal antibiotic resistance in the strains cultured from middle ear and respiratory samples of <5 yearold children decreased dramatically in the hospital district (Table 1). Pneumococcal penicillin resistance has been rare in Finland (4% in 2006, nonsusceptibility 16%) but macrolide resistance has been very high (28% in 2008, 46% at age <24 months) (4). Both the decreased susceptibility to penicillin (20% in 2010) and resistance to macrolides (32% in 2010) have been on a continuous increase (FinRes database at www.thl.fi). In many countries, the use of 7-valent PCV has decreased pneumococcal antibiotic resistance, but on the other hand, the carriage of serotypes prone to develop resistance has been increased (5). Thus, the use of PCV-10 or PCV13 will probably lead to further reduction in pneumococcal resistance or nonsusceptibility (2,3) although not thus far documented at the population level. In our area, pneumococcal antibiotic resistance in middle ear and respiratory samples obtained from <5-year-old children decreased dramatically, although only <2-year-old children had been vaccinated. This means that the vaccination programme must have influenced on pneumococcal carriage, especially on the carriage of pneumococcal serotypes commonly associated with antibiotic resistance in children (6).