歐洲疾控中心-侵襲性肺炎球菌疾病-2022年年度流行病學報告Invasive pneumococcal disease Annual Epidemiological Report for 2022

1

SURVEILLANCEREPORT

reportfor2022

SURVEILLANCE

Invasivepneumococcaldisease

AnnualEpidemiologicalReportfor2022

Keyfacts

?In2022,17700confirmedcasesofinvasivepneumococcaldisease(IPD)werereportedintheEuropeanUnion/EuropeanEconomicArea.

?Thecrudenotificationratewas5.1casesper100000population,similarto2018and2019.

?Age-specificrateswerehighestininfantsunderoneyearold(13.4confirmedcasesper100000

population)andinadults65yearsoldandabove(12.6confirmedcasesper100000population),withhigherratesreportedinmalesthanfemalesamongallagegroups.

?Themostcommonserotypeswere3,8,19A,22F,6C,23B,9N,4,23A11A,and15A(inorderofdecreasingfrequency),accountingfor73.9%oftypedisolates.

?Ofcasesunderfiveyearsoldforwhomserotypeinformationwasavailable,approximately46%werecausedbyaserotypeincludedinthe13-valentpneumococcalconjugatevaccine(PCV13).This

proportionhasincreasedoverthelastfiveyears.

?Amongcases65yearsoldandabove,approximately71%ofcaseswithserotypeinformationavailablewerecausedbyserotypesincludedinthe23-valentpolysaccharidevaccine(PPV23).TheproportioncausedbytheserotypesincludedinPCV13was41%.

Introduction

PneumococcaldiseasesaresymptomaticinfectionscausedbythebacteriumStreptococcuspneumoniae

(S.pneumoniae),commonlyreferredtoaspneumococcus.Theterm‘invasivepneumococcaldisease’(IPD)isusedformoresevereandinvasivepneumococcalinfections,suchasbacteraemia,sepsis,meningitisandosteomyelitis.PneumococcalinfectionsandIPDaremajorcausesofcommunicablediseasemorbidityandmortalityinEuropeandglobally,withthehighestburdenofdiseasefoundinyoungchildrenandtheelderly.AlargeproportionofIPDis

vaccinepreventable.

S.pneumoniaeisclassifiedintoserotypesbasedonthepolysaccharidecapsuleantigens.Morethan90

immunologicallydistinctserotypesareknown,andstructurallyrelatedserotypesaregroupedtogetherandlabelledalphabetically(e.g.6A,6B).Someserotypespossessdistinctepidemiologicalpropertiesandsomeserotypesaremorecommonthanothers.Differentserotypesarecoveredbydifferentvaccines,asshowninTable1.Vaccine

recommendationsvaryacrossEuropeanUnion/EuropeanEconomicArea(EU/EEA)countriesintermsofwhichvaccinesare/havebeenusedandwhichagegroupsaretargeted[1].

ECDCSURVEILLANCEAnnualepidemiologicalreportfor2022

2

Methods

Thisreportisbasedondatafor2022retrievedfromTheEuropeanSurveillanceSystem(TESSy)on2February2024.TESSyisasystemforthecollection,analysisanddisseminationofdataoncommunicablediseases.

Foradetaileddescriptionofthemethodsusedtoproducethisreport,refertotheMethodschapterofthe‘ECDCAnnualEpidemiologicalReport[3].Anoverviewofthenationalsurveillancesystemsisavailableonline[4].

AsubsetofthedatausedforthisreportisavailablethroughECDC’sonline‘SurveillanceAtlasofInfectiousDiseases[5].In2022,29EU/EEAcountriesreporteddataonIPD.Twenty-sevencountriesusedthe2018(11countries),2012(6),or2008(10)EUcasedefinition.Foronecountry,thecasedefinitionwasunknown/notspecifiedandforoneotheritwasreportedas‘other’.The2018,2012and2008casedefinitionsdonotdiffer,withtheexceptionofthenoteonantimicrobialresistancethatwasaddedtothe2018casedefinition[6].

NationalIPDsurveillancesystemswereheterogeneous.Ofthe29countriesreportingdata,23conductedsurveillancewithcompulsoryreportingandnationalcoverage.Onecountryconductedsurveillancewithcomprehensivereporting(Iceland,systemcoveragenotspecified),twousedvoluntarycomprehensivesystems(Hungary,Italy)andthreeusedvoluntarysentinelsystems(Belgium,France,theNetherlands).Priorto2022,datafromSpainwerereportedfromaSpanishvoluntarysurveillancesystemfromtheNationalReferenceLaboratorycovering80%ofthepopulation;

however,from2022,100%ofthepopulationhavebeencoveredbyacompulsorysurveillancesystem.The

populationcoverageoftheBelgiansurveillancesystemisunknown,sonotificationrateswerenotcalculated.For

France,notificationratesbetween2000and2012werecalculatedusinganestimatethat82%ofthepopulation

werecoveredbythesurveillancesystem;from2013onwards,notificationrateswerecalculatedusingbetween79–85%ofthetotalpopulation(withtheexactproportionupdatedyearly).In2022,theproportionusedwas85%.

DatafromtheNetherlandswerereportedfromaDutchvoluntarysurveillancesystemfromtheNationalReferenceLaboratory.Thissystemcovered25%oftheDutchpopulationupto2019and28%ofthepopulationfrom2020onwards.Germanyhadavoluntary,laboratory-basedsurveillancesystemanddidnotreportdatatoECDC[7].All

countriesexceptBelgium,BulgariaandCroatiareportedcase-baseddata[4].

Epidemiology

In2022,17700confirmedcasesofIPDwerereportedby29EU/EEAcountries.Thecrudenotificationratewas5.1casesper100000population(Table1).ThehighestnumberofconfirmedcaseswerereportedbyFrance(3387cases),followedbySpain(3132)andPoland(2214).ThehighestnotificationrateswerereportedinSweden

(12.2casesper100000population),theNetherlands(11.4),Slovenia(10.6)andFinland(10.5)(Table1,Figure1).ManycountriesinthesouthernandeasternpartsoftheEUhadlownotificationrates.

3

Table1.Confirmedinvasivepneumococcaldiseasecasesandratesper100000populationbycountryandyear,EU/EEA,2018–2022

Country

2018

2019

2020

2021

2022

Number

Rate

Number

Rate

Number

Rate

Number

Rate

Number

Rate

Austria

611

6.9

615

6.9

355

4.0

398

4.5

558

6.2

Belgium

1553

NRC

890

NRC

940

NRC

845

NRC

1457

NRC

Bulgaria

24

0.3

34

0.5

11

0.2

3

0.0

7

0.1

Croatia

21

0.5

30

0.7

10

0.2

1

0.0

9

0.2

Cyprus

17

2.0

12

1.4

4

0.5

3

0.3

7

0.8

Czechia

535

5.0

481

4.5

247

2.3

264

2.5

472

4.5

Denmark

799

13.8

639

11.0

370

6.4

353

6.0

553

9.4

Estonia

43

3.3

61

4.6

24

1.8

15

1.1

34

2.6

Finland

761

13.8

748

13.6

318

5.8

309

5.6

582

10.5

France

3862

7.0

3907

7.4

2193

4.1

2067

3.7

3387

5.9

Germany

NDR

NRC

NDR

NRC

NDR

NRC

NDR

NRC

NDR

NRC

Greece

42

0.4

47

0.4

17

0.2

18

0.2

28

0.3

Hungary

331

3.4

294

3.0

192

2.0

277

2.8

388

4.0

Iceland

30

8.6

41

11.5

20

5.5

17

4.6

36

9.6

Ireland

514

10.6

419

8.5

246

5.0

177

3.5

375

7.4

Italy

1553

2.6

1671

2.8

499

0.8

472

0.8

1032

1.7

Latvia

76

3.9

83

4.3

67

3.5

70

3.7

125

6.7

Liechtenstein

NDR

NRC

NDR

NRC

NDR

NRC

1

2.6

5

12.7

Lithuania

65

2.3

0

0.0

0

0.0

25

0.9

88

3.1

Luxembourg

1

0.2

1

0.2

32

5.1

41

6.5

63

9.8

Malta

31

6.5

20

4.1

9

1.7

2

0.4

7

1.3

Netherlands

688

16.0

593

13.7

379

7.8

339

6.9

563

11.4

Norway

581

11.0

599

11.2

295

5.5

318

5.9

539

9.9

Poland

1355

3.6

1621

4.3

629

1.7

955

2.5

2214

5.9

Portugal

397

3.9

490

4.8

251

2.4

241

2.3

414

4.0

Romania

74

0.4

72

0.4

25

0.1

10

0.1

39

0.2

Slovakia

98

1.8

124

2.3

55

1.0

35

0.6

92

1.7

Slovenia

276

13.4

280

13.5

175

8.3

187

8.9

224

10.6

Spain

2365

6.3

2465

6.6

1031

2.7

795

2.1

3132

6.6

Sweden

1408

13.9

1345

13.1

648

6.3

731

7.0

1270

12.2

EU/EEA

(30countries)

18111

5.6

17582

5.6

9042

2.8

8969

2.7

17700

5.1

United

Kingdoma

6555

9.9

5622

8.4

NDR

NRC

NA

NA

NA

NA

EU/EEA

(31countries)

24666

6.3

23204

6.1

9042

2.8

NA

NA

NA

NA

Source:Countryreports.

NA:notapplicable;NDR:nodatareported;NRC:noratecalculated.

aNodatafrom2020onwardswerereportedbytheUnitedKingdom,duetoitswithdrawalfromtheEUon31January2020.

4

Figure1.Confirmedinvasivepneumococcaldiseasecasesper100000populationbycountry,EU/EEA,2022

Source:Countryreports

Ageandgender

In2022,IPDwaspredominantlyreportedinolderadultsandinfants,with12.6confirmedcasesper100000

populationinadults65yearsoldandaboveand13.4confirmedcasesper100000populationininfantsunderoneyearold(Figure2).Theratesofdiseasewerelowestinthe15–24yearsagegroup(0.8confirmedcasesper100000population).Thenotificationratewashigherinmalesinallagegroups.Theoverallmale-to-femaleratiowas1.3:1.

Figure2.Confirmedinvasivepneumococcaldiseasecasesper100000population,byageandgender,EU/EEA,2022

Source:CountryreportsfromAustria,Belgium,Bulgaria,Croatia,Cyprus,Czechia,Denmark,Estonia,Finland,France,Greece,

Hungary,Iceland,Ireland,Italy,Latvia,Liechtenstein,Lithuania,Luxembourg,Malta,theNetherlands,Norway,Poland,Portugal,Romania,Slovakia,Slovenia,SpainandSweden.

5

Seasonalityandtrend

TheseasonaldistributionofIPDcasestypicallyfollowsapatternsimilartomanyotherrespiratorydiseases:casenumbersareusuallylowestduringsummerandthenincreaserapidlywiththeonsetofautumn,peakingduringthewintermonths(Figure3).Comparedwith2018and2019,therewasasharpdecreaseinthenumberofreportedcasesduring2020and2021,coincidingwiththeCOVID-19pandemic(Figure3).Thenumberofcasesincreasedoverautumn/winterof2021–2022,andanatypicalincreasealsooccurredinspring2022(Figures3and4).In

autumnandwinter2022,asharpincreaseincaseswasobserved,peakingat3046casesinDecember2022.Theseasonalactivityin2022wasunusualcomparedwiththemean2018–2021activity(Figure4);however,themeanisheavilyinfluencedbythedecreaseinoverallandseasonalactivityduring2020and2021.

Figure3.Confirmedinvasivepneumococcaldiseasecasesbymonth,EU/EEA,2018–2022

Source:CountryreportsfromAustria,Cyprus,Czechia,Denmark,Estonia,Finland,France,Greece,Hungary,Iceland,Ireland,Italy,Latvia,Lithuania,Malta,theNetherlands,Norway,Poland,Portugal,Romania,Slovakia,Slovenia,SpainandSweden.

Figure4.Confirmedinvasivepneumococcaldiseasecasesbymonth,EU/EEA,2022and2018–2021

Source:CountryreportsfromAustria,Cyprus,Czechia,Denmark,Estonia,Finland,France,Greece,Hungary,Iceland,Ireland,Italy,Latvia,Lithuania,Malta,theNetherlands,Norway,Poland,Portugal,Romania,Slovakia,Slovenia,SpainandSweden.

SURVEILLANCEREPORT

Annualepidemiologicalreportfor2022

6

Vaccinationstatus

Thegranularityofdatacollectedinrelationtovaccinationstatusforthestudyperiodislimited.Vaccinationstatuswasreportedfor36.3%(6428/17700cases)oftheIPDcasesreportedin2022.Ofthese,70.3%(4516cases)wereunvaccinated,23.2%(1492)hadreceivedbetweenonetofourdosesofaPCVorPPVvaccine,andanother6.5%(420)werereportedasvaccinatedwithanunknownnumberofdoses.

Serotype

AmongEU/EEAcountriesthatreportedserotypingdatain2022,serotypewasreportedfor52.3%(9256cases)ofcases.The11mostcommonserotypes,inorderofdecreasingfrequency,were:3,8,19A,22F,6C,23B,9N,4,

23A,11Aand15A(Figure5).These11serotypesaccountedfor73.9%ofallcaseswithaknownserotypein2022.

Forcountriesthatreportedserotypingdataconsistentlyforeachyearofthereportingperiod,thedistributionofserotypesbetween2018and2022ispresentedinFigure5.Comparedwith2018,therewasanincreasein

serotypes3,19Aand6Cin2022,by33%,40%and27%,respectively.Duringthesameperiod,adecreasewasobservedinserotypes22Fand9N,by17%and31%,respectively.

Figure5.Distributionofconfirmedserotypedcasesofinvasivepneumococcaldisease,mostcommonserotypes,EU/EEAa,2018–2022

Source:CountryreportsfromAustria,Czechia,Denmark,Estonia,Finland,France,Greece,Hungary,Iceland,Ireland,Italy,Latvia,Lithuania,theNetherlands,Norway,Poland,Portugal,Slovakia,Slovenia,SpainandSweden.

aTheUnitedKingdomareexcludedfrom2018and2019toallowcomparisonacrossallyears.

Thedistributionofserotypesvariedaccordingtotheagegroupsaffected.Thefivemostcommonserotypesineach

agegrouparepresentedinTable2.Forcasesunderoneyearold,serotypes3,19A,8,10Aand24Fwere

predominant.Serotypes19Aand3werethemostcommonintheonetofouryearsagegroup.Serotypes3,8and19Aweremostcommoninindividualsabovefiveyearsold.

Table2.Proportionofconfirmedcasesofinvasivepneumococcaldiseaseforthefivemostfrequentserotypesineachagegroup,EU/EEA,2022

Agegroup(years)

<1

1–4

5–14

15–24

25–44

45–64

65+

Serotype

%

Serotype

%

Serotype

%

Serotype

%

Serotype

%

Serotype

%

Serotype

%

3

11.7

19A

24.8

3

18.6

8

35.6

8

21.3

3

21.1

3

22.4

19A

10.5

3

20.3

19A

17.0

19A

13.0

3

17.9

8

18.3

8

11.3

8

9.9

10A

6.6

8

10.8

3

10.3

19A

15.5

19A

9.7

19A

11.1

10A

7.4

24F

6.6

23B

5.2

4

8.2

4

6.8

22F

5.5

22F

5.8

24F

6.8

23B

4.0

22F

4.6

22F

3.4

22F

4.5

4

5.0

6C

4.9

ECDCSURVEILLANCEAnnualepidemiologicalreportfor2022

7

Source:CountryreportsfromAustria,Czechia,Denmark,Estonia,Finland,Greece,Hungary,Iceland,Ireland,Italy,Latvia,Lithuania,theNetherlands,Norway,Poland,Portugal,Slovakia,Slovenia,SpainandSweden.

In2022,6.6%ofcasesinchildrenunderfiveyearsoldwithserotypeinformationwerecausedbyaPCV10

serotype,39.3%byaPCV13/non-PCV10serotype,3.8%byaPCV15/non-PCV13serotype,17.2%byaPCV20/non-PCV15serotypeand33.1%byaserotypenotincludedinanycurrentPCVvaccine.TheserotypesincludedineachvaccineformulationareshowninAnnex1.

From2018to2022,therewasasubstantial(96%)increaseintheproportionofPCV13/non-PCV10serotypesinchildrenunderfiveyearsold(from17.1%in2018to39.3%in2022;Figure6).Conversely,thereweredecreasesintheproportionsofPCV10,PCV15/non-13andnon-PCVserotypesoverthisfive-yearperiod.TheproportionofPCV20/non-15serotypesremainedunchanged.

Figure6.DistributionofconfirmedserotypedcasesofinvasivepneumococcaldiseaseinchildrenunderfiveyearsoldbyPCVvaccineserotypesabandyear,EU/EEAc,2018–2022

Source:CountryreportsfromAustria,Czechia,Denmark,Estonia,Finland,France,Greece,Hungary,Iceland,Ireland,Italy,Latvia,Lithuania,theNetherlands,Norway,Poland,Portugal,Slovakia,Slovenia,SpainandSweden.

aAlthoughserotype6AisincludedinPCV13andnotinPCV10,forthepurposesofthisanalysisitisconsideredaPCV10serotype

duetodocumentedcross-protectionprovidedbytheserotype6BantigeninPCV10.

bPCV15andPCV20werenotyetauthorisedorusedinchildrenduringthistimeperiod.

cDatafromtheUnitedKingdomareexcludedfrom2018and2019toallowcomparisonacrossallyears.

Forcases5–64yearsoldreportedin2022withknownserotype,8.8%werecausedbyaPCV10serotype,33.0%byaPCV13/non-PCV10serotype,6.4%byaPCV15/non-PCV13serotype,21.5%byaPCV20/non-PCV15serotype,andanother30.3%bynon-PCVserotypes.

In2022,amongcasesinadults65yearsoldandabovewithserotypeinformation,70.8%werecausedbyaserotypeincludedinthePPV23vaccineand29.2%byaserotypenotincludedinthePPV23vaccine.Incomparison,66.1%ofcaseswerecausedbyserotypesincludedinPCV20,whileonly41.0%werecausedbytheserotypesincludedin

PCV13.Therewereincrementaldifferencesbychangingvaccinecomposition/includedserotypes:7.5%werecausedbyaPCV10serotype,33.5%byaPCV13/non-PCV10serotype,6.9%byaPCV15/non-PCV13serotype,18.2%byaPCV20/non-PCV15serotype,and4.8%byaPPV23/non-PCV20serotype(Figure7).

From2018to2022,inadults65yearsoldandabove,therewasa36%increaseintheproportionofPCV13/non-10serotypes,from24.0%in2018to33.5%in2022(Figure7).Therewasalsoasmall(8%)increaseinthe

proportionofnon-PCV/PPVserotypes,from25.9%in2018to29.2%in2022.Theproportionofallremainingserotypesdecreasedfrom2018to2022.

8

Figure7.Distributionofconfirmedserotypedcasesofinvasivepneumococcaldiseaseinadults65yearsoldandabovebyPCV/PPVvaccineserotypesaandyear,EU/EEAb,2018–2022

Source:CountryreportsfromAustria,Czechia,Denmark,Estonia,Finland,France,Greece,Hungary,Iceland,Ireland,Italy,Latvia,Lithuania,theNetherlands,Norway,Poland,Portugal,Slovakia,Slovenia,SpainandSweden.

aAlthoughserotype6AisincludedinPCV13andnotinPCV10,forthepurposesofthisanalysisitisconsideredaPCV10serotypeduetodocumentedcross-protectionprovidedbytheserotype6BantigeninPCV10.

bDatafromtheUnitedKingdomareexcludedfrom2018and2019toallowcomparisonacrossallyears.

Antimicrobialsusceptibility

Antimicrobialsusceptibilitydatawerebasedonthereportingofsusceptibilitytestingcategories

(Susceptible/Intermediate/Resistant)andminimuminhibitoryconcentration(MIC)data.MICdatawereconvertedtoSIRdatabasedonEUCASTbreakpoints.Penicillinsusceptibilitydatawerereportedby12countriesfor54.5%(2816/5168cases)oftheIPDcases.Ofthese,82.3%(2317cases)werereportedassensitive,4.9%(138)as

intermediateand12.8%(361)asresistant.Erythromycinsusceptibilitydatawerereportedby11countriesfor

30.9%(1599/2954cases)oftheirIPDcases.Ofthese,79.4%(1269cases)werereportedassensitive,1.6%

(26)asintermediateand19.0%(304)asresistant.Cephalosporinsusceptibilitydatawerereportedby11countriesfor45.6%(2354/5161cases)oftheirIPDcases.Ofthese,88.5%(2082cases)werereportedassensitive,1.7%(40)asintermediateand9.9%(232)asresistant.

Clinicalpresentation

Clinicalpresentationwasknownfor8882(50.2%)ofallcases.Ofthese,bacteraemicpneumoniawasreportedin3657cases(41.2%),septicaemiain3350cases(37.7%),meningitisin1226cases(13.8%),andmeningitisandsepticaemiain242cases(2.7%).Afurther407cases(4.6%)hadotherclinicalpresentations.

Amonginfantsunderoneyearold,themostcommonclinicalpresentationwasmeningitis(41.8%),followedby

septicaemia(26.4%)andbacteraemicpneumonia(19.6%).Themostcommonclinicalpresentationsinonetofour-year-oldswerebacteraemicpneumonia(38.0%)andsepticaemia(31.6%).Inadults65yearsoldandabove,clinical

presentationswereapproximatelyequallydistributedbetweenbacteraemicpneumonia(44.7%)andsepticaemia(40.7%).

Outcome

Among7000caseswithknownoutcome(39.5%)in2022,895(12.8%)died.Thecasefatalitywashighestamongcases65yearsoldandabove(17.1%)and45–64years(10.9%).Amonginfantsunderoneyearoldandchildrenonetofouryearsold,thecasefatalityrateswere3.9%and3.6%,respectively.

Amongthe895casesthatdied,366(40.9%)presentedwithsepticaemia,257(28.7%)withbacteraemic

pneumonia,53(5.9%)withmeningitis,31(3.5%)withmeningitisandsepticaemia,20(2.2%)withotherclinicalpresentations,and168(18.8%)withclinicalpresentationunknown.

Serotypewasknownfor625(69.8%)deceasedcases.Thefivemostcommonserotypesreportedfordeceasedcases(whereserotypewasknown),inorderofdecreasingfrequency,were3,19A,8,6Cand22F.Thesefiveserotypesaccountedfor54.4%ofdeathswhereserotypewasknown.

9

Discussion

In2022,29EU/EEAcountriesreportedatotalof17700casesofIPD.Thiswassimilarto2018and2019,indicatingthattransmissionand/orreportingpracticeshavereboundedtothesamelevelasbeforetheCOVID-19pandemic.In2020and2021,therewasanapproximately50%reductioninthenumberofreportedIPDcasescomparedwith2018and2019,whichmayhavebeenduetoacombinationofreducedtransmissionfollowingtheimplementationof

non-pharmaceuticalinterventions,reducedlaboratorycapacityfortesting,reducedpublichealthcapacityforsurveillance/reportingofIPDcases,orotherfactors.

In2022,thecrudeIPDnotificationratewas5.1casesper100000population.Olderadults(65yearsoldandabove)andinfants(underoneyearold)werethemostaffectedagegroups,withnotificationratesof12.6and13.4casesper100000population,respectively.Notificationratesvariedbycountry,rangingfrom0.1to12.2casesper100000population.Thevariationmaybeduetodifferencesinhealthcaresystems,vaccination

programmes,caseascertainment(includingbloodculturingpractices)andreporting.

TheimpactofPCVsinreducingtheincidenceofIPDintheEU/EEAhasnowbeenobservedforalmosttwodecades.Aseven-valentPCV(PCV7)wasfirstlicensedin2001foruseininfantsandyoungchildren,andEU/EEAcountriesbeganintroducingthevaccineintoroutinechildhoodimmunisationschedulesin2006.In2009,thehigher-valencyPCV10

andPCV13vaccineswerelicensedandprogressivelyreplacedPCV7onimmunisationschedulesintheEU/EEA.AsaresultoftheintroductionofthePCV7andlaterthePCV10/PCV13vaccines,theincidenceoftheserotypesincludedinthevaccinesdeclined[8-11].Vaccinationofinfantsandyoungchildrenalsoresultedinindirectprotectionofolder

adultsbyreducingnasopharyngealcarriageandtransmissioninchildren,contributingtoadecreaseinmorbidityandmortalityinolderagegroups[12].

However,astheincidenceofvaccineserotypesdeclined,incidenceofnon-vaccineserotypesincreased,indicating

serotypereplacementwasoccurring[9,10].SerotypereplacementhasgraduallyreducedtheimpactofPCVs,astheratesofcarriageanddiseasecausedbynon-vaccineserotypeshaveincreased[10].Toaddresstheissueof

serotypereplacement,vaccinescontinuetobedevelopedtoincludemoreoftheserotypescommonlyresponsibleforcausingIPD.A15-valentPCVwasdeveloped,includingtwoadditionalserotypes(22F&33F)comparedwithPCV13.Thisvaccinewasauthorisedforadults18yearsoldandaboveinOctober2021andforchildrensixmonthstounder18yearsoldinSeptember2022[13].Similarly,a20-valentPCVwasalsodeveloped,forwhichauthorisationfor

adults18yearsoldandabovewasgrantedinFebruary2022.InJanuary2024,thisvaccinewasalsoauthorisedforchildrensixweekstounder18yearsold[14].Thesehigher-valencyvaccines(PCV15/PCV20)havehadlimiteduseintheEU/EEAtodate,astherehavebeenonlyafewcountriesthathaverecommendedtheinclusionofPCV15(for

childrenorolderadults)orPCV20(olderadultsonly)[1].

Overall,fortheEU/EEAin2022,approximately46%ofcasesinchildrenunderfiveyearswerecausedbyPCV13

serotypes,andanincreaseinPCV13/non-10serotypeswasobservedinthisagegroupbetween2018and2022.Thishighlightsthatexistingvaccinescouldpreventalargemajorityofcases.Thefiveserotypesaccountingfor54.4%ofdeaths(whereserotypewasknown)were3,19A,8,6Cand22F.Oftheseserotypes,3and19Aareincludedin

PCV13,PCV15,PCV20andPPV23;serotype22FisinPCV15,PCV20andPPV23;serotype8isinPCV20andPPV23;andserotype6Cisnotincludedinanyvaccine.

Nationalauthoritiesconsidernumerousfactorswhencontemplatingchangestothevaccinationschedules,including:thenational/localepidemiologicalsituationandcirculationofserotypes;realworddataontheperformanceof

differentvaccines(includingeffectiveness,safetyandimpactonspecificgroups);burden/severityofdifferentclinicalpresentationsassociatedwithdifferentserotypes;andcross-protectionagainstdifferentserotypes.Programmatic

considerationofchangestothevaccinationschedulesandotherparametersrelatedtoimplementation(suchascosteffectivenessand/orco-administrationwithothervaccines)arealsotakenintoaccount.

Ofnotein2022,comparedwith2018,therewasadramaticincreaseintheproportionofPCV13/non-10serotypesinchildrenunderfiveyearsold.In2022,amonginfantsandchildrenunderfiveyearsold,approximately39%ofcases(withknownserotype)werecausedbythetwoserotypes(3and19A)coveredbyPCV13butnotPCV10(6Ais

consideredaPCV10serotypeduetocross-protectionfrom6B).In2018,thisproportionwas17%ofcaseswithknownserotype.FurtheranalysisandinvestigationareneededtodeterminethedriversbehindtherelativeincreaseofPCV13/non-10serotypesamongyoungchildrenandtheimpactofsuchchange.

InadditiontothePCVs,PPV23hasbeenavailableinmanycountriessincetheearly2000s,authorisedforusein

childrenundertwoyearsofage,adolescentsandadults.Sinceitsauthorisation,manyEU/EEAcountriesintroducedthisvaccineinnationalprogrammesforolderadultsand/orat-riskindividuals[15].PPV23iseffectiveatpreventinginvasivediseaseamongadults;however,itislesseffectiveagainstnon-invasivediseaseandthedurationof

protectionmaybeshorterthanthatofPCVs[16].Thereissomeevidencethatimmunogenicityanddurationof

protectioncanbeimprovedwithaschedulethatincorporatesadoseofPCVfollowedbyaboosterofPPV23forolderadults[16].SomeEU/EEAcountriesrecommendsuchacombination[1].Ofnoteistheconsiderablevariationin

PCV/PPV23recommendationsacrosstheEU/EEA,notonlywithregardtowhichvaccinesareused,butalsowhichindividualsareconsideredat-riskandfromwhatagetheolderadultagegroupbegins(50,60or65yearsold)[1].

10

In2022,amongadults65yearsoldandabove,approximately71%ofIPDcases(withknownserotype)were

causedbyaserotypeincludedinPPV23and41%werecausedbyoneoftheserotypesincludedinPCV13.Theseproportionshavebeenreasonablystableoverthepastfiveyears.Ofcaseswithaknownoutcomein2022,the

casefatalitywashighestamongadults65yearsoldandabove(17.1%ofalldeaths).DespitePPV23and/orPCVvaccinesbeingrecommendedforolderadultsinmanyEU/EEAcountriesandforalongperiodoftime,thevaccine-preventableserotypescontinuetoberesponsibleforahighproportionofIPDcases.InEU/EEAcountries,

availabilityofcoverageestimatesforat-riskgroupsandolderadultsislimited;however,whereavailable

(predominantlyforolderadults),thecoverageislow,andbelow30%inallcountries[17].Animprovementin

coverageofrecommendedvaccines,irrespectiveofwhichvaccine(oracombinationofvaccines),mayreducetheIPDburdenamongolderadults.However,ongoingmonitoringofIPDserotypetrendsinolderadultsinrelationto

vaccinationrecommendationsinthisagegroup,aswellastheindirectimpactofchildhoodvaccinationrecommendations,isalsorequired.

Publichealthimplications

PneumococcalvaccinescontainarangeofserotypesthatcancauseIPD.Vaccination