Research Pneumococcal vaccination coverages by age, sex and specific underlying risk conditions among middle-aged and older adults in Catalonia, Spain, 2017 Angel Vila-Córcoles1,2, Olga Ochoa-Gondar1,2, Cinta de Diego1, Eva Satué1,2, Angel Vila-Rovira³, Maria Aragón⁴ 1. Primary Health Care Service Camp de Tarragona, Tarragona, Spain 2. Unitat de Suport a la Recerca of Tarragona, Institut Universitari d’Investigacio en Atencio Primaria Jordi Gol (IDIAP Jordi Gol), Tarragona, Spain 3. Primary Care Research Institute Jordi Gol. Barcelona, Spain 4. Information System for the Improvement of Research in Primary Care (SIDIAP), Primary Care Research Institute Jordi Gol, Universitat Autonoma de Barcelona, Barcelona, Spain Correspondence: Olga Ochoa-Gondar (oochoa.tgn.ics@gencat.cat) Citation style for this article: Vila-Córcoles Angel, Ochoa-Gondar Olga, de Diego Cinta, Satué Eva, Vila-Rovira Angel, Aragón Maria. Pneumococcal vaccination coverages by age, sex and specific underlying risk conditions among middle-aged and older adults in Catalonia, Spain, 2017. Euro Surveill. 2019;24(29):pii=1800446. https://doi.org/10.2807/1560- 7917.ES.2019.24.29.1800446 Article submitted on 10 Aug 2018 / accepted on 25 Apr 2019 / published on 18 Jul 2019 Background: Recent published data on pneumococ- chronic renal disease (5,633/158,726; 3.5%) and cal vaccination coverages among adults are scarce. chronic bronchitis/emphysema (2,859/132,306; 2.2%). Aim: To update on pneumococcal vaccination uptakes Conclusion: Pneumococcal vaccination coverages among middle-aged and older adults in Catalonia. in Catalonian adults are suboptimal, especially for Methods: We conducted a population-based retro- PCV13. spective observational study including 2,057,656 individuals ≥ 50 years old assigned to primary care cen- Introduction tres managed by the Catalonian Health Institute on 1 Infections caused by Streptococcus pneumoniae are January 2017 (date of data collection). An institutional an important cause of morbidity and mortality around clinical research database (SIDIAP) was used to clas- the world [1]. At present, two pneumococcal vaccines, sify persons by vaccination status for both 23-valent the classical 23-valent pneumococcal polysaccharide pneumococcal polysaccharide (PPsV23) and 13-valent vaccine (PPsV23) and the new 13-valent pneumococcal pneumococcal conjugate (PCV13) vaccines, as well as conjugate vaccine (PCV13), are available for using in at- to identify underlying risk conditions. Results: Overall, risk individuals and older adults [2,3]. 796,879 individuals (38.7%) had received PPsV23 and 13,607 (0.7%) PCV13. PPsV23 coverage increased with In the United States (US), a leading setting on pneumo- age: 9.2% (95,409/1,039,872) in 50–64 year olds, coccal vaccination in adults, the Healthy People 2020 63.1% (434,408/688,786) in 65–79 year olds and 81.2% goals include to increase pneumococcal vaccination (267,062/328,998) in ≥ 80 year olds (p < 0.001). PCV13 coverages to 60% in high-risk adults aged 18–64 years coverage also increased with age, although percent- and to 90% in all people aged ≥ 65 years [4]. However, ages were smaller in all age strata (4,250/1,039,872: few recent coverage data (i.e. after PCV13 approval for 0.4%; 6,005/688,786: 0.9% and 3,352/328,998: 1.0%, adults in 2012) are available [5-7]. Updated data on both respectively; p < 0.001). By sex, no substantial cover- PPsV23 and PCV13 vaccination coverages in adults are age differences were observed. Considering publi- therefore needed, especially now that pneumococcal cally funded target groups for PPsV23 vaccination vaccination programmes for adults and children are in Catalonia (i.e. < 65 year olds with at least one risk routinely implemented in many settings. Moreover, factor, plus all adults aged ≥ 65 years), PPsV23 cover- these data are also relevant to evaluate direct and age reached 52.8% (771,722/1,462,261) in our study indirect protective effects (e.g. herd protection) on the population. Regarding PCV13 publicly funded targets population [8]. (i.e. all-age immunocompromised persons), PCV13 cov- erage was 3.3% (6,617/202,348). By risk conditions, In Catalonia, similar to the rest of Spain, PPsV23 is the highest PPsV23 coverage appeared in congestive publicly funded since the 2000s for all individuals aged heart failure (51,909/63,596; 81.6%), chronic renal dis- ≥ 65 years (with or without risk conditions) and for indi- ease (122,791/158,726; 77.4%) and chronic bronchitis/ viduals 18–64 years old with certain at-risk conditions emphysema (96,453/132,306; 72.9%). Maximum PCV13 (i.e. immunocompromising conditions, chronic pul- coverage appeared in cirrhosis (294/7,957; 3.7%), monary/respiratory diseases, heart diseases, chronic www.eurosurveillance.org 1 renal disease, diabetes mellitus, cirrhosis, alcohol- Drug Administration (FDA) and the European Medicines ism and/or smoking). PPsV23 revaccination is recom- Agency (EMA) approved PCV13 use in adults  ≥ 50 years mended and publicly funded for those persons who old [16,17]. Subsequently, information on pneumococ- received a prime dose before 65 years of age [9]. Since cal vaccination with this vaccine for this age group was 2012 the PCV13 is publicly funded only for some indi- recorded in the SIDIAP research database. Vaccination viduals at high risk (mainly immunocompromised per- with PPsv23 is recorded since 1999. sons). The PCV13 is also prescribed by some clinicians for patients with certain at-risk conditions (i.e. chronic The SIDIAP research database was used to classify bronchitis, asthma, cardiac diseases, etc.) although it study persons by their pneumococcal vaccination sta- is not publicly funded for these patients [9,10]. tus as well as to identify comorbidities and underlying risk conditions in each individual. The following risk This study reports current pneumococcal vaccination conditions were defined on the basis of ICD-10 codes uptakes for both PPsV23 and PCV13 vaccines among registered in the electronic PCCs medical records con- the general adult population ≥ 50 years old in Catalonia tained in the SIDIAP research database: asthma (J45– in January 2017, assessing vaccine coverages by age, J46), chronic bronchitis/emphysema (J41–J44), chronic sex and presence of major underlying risk conditions. renal disease (N18–N19), congestive heart failure (I50), coronary artery disease (I20–I22, I25), diabetes mel- Methods litus (E10–E14), liver cirrhosis (K74), solid organ or haematological neoplasia (C00–C97), as well as alco- Study type holism (F10, G31.2, G62.1, G72.1, I42.6, K29.2, K70) and This is a population-based retrospective observational current smoking (F17). We considered healthy (immu- study involving 2,057,656 individuals aged ≥ 50 years, nocompetent persons without risk conditions), at-risk who constituted all persons registered in the primary (immunocompetent persons with any risk condition) care centres (PCCs) managed by the Catalonian Health and high-risk (immunocompromised persons) groups. Institute (ICS, Institut Català de la Salut) in Catalonia Immunocompromisation was considered as a compos- on 1 January 2017 (date of the study). ite variable defined by the presence of any of the fol- lowing: HIV infection, immunodeficiency, severe renal Ethical statement disease, solid organ or haematological neoplasia and/ The study was approved by the ethical committee of or immunosuppressive treatment. the institution (file P14/134) and was conducted in accordance with the general principles for observa- Review of vaccination status tional studies [11]. Pneumococcal vaccination status for PPsV23 and PCV13 was determined by reviewing the electronic PCCs clini- Setting and study population cal records of the SIDIAP database, which contain spe- In Catalonia, similar to the rest of Spain, a compulsory cially designated fields for both PCV13 and PPsV23 health insurance system by the National Health Service pneumococcal vaccinations (virtually all of them are covers all inhabitants’ medical needs and all inhabit- administered at the PCCs in the Spanish healthcare ants are assigned to a PCC. In Catalonia there are 358 system). We assumed that information in electronic PCCs, including 274 (76.5%) managed by the ICS and clinical records was complete, so a person was con- 84 by other providers. The study population assigned sidered as unvaccinated when a vaccination was not to the 274 PCCs managed by the ICS (n = 2,057,656 per- recorded. Persons were considered vaccinated against sons aged ≥ 50 years) represents a 76.3% of the total pneumococcus if they had received at least one dose of 2,693,570 Catalonian inhabitants in this age strata [12]. PPsV23 or PCV13. In all PCCs, doctors and nurses systematically use elec- Data analysis tronic medical records to record diagnoses, prescrip- Vaccination coverage for both PPsV23 and PCV13 was tions, vaccinations and patient management activities estimated by age strata, sex and presence of at-risk coded according to the International Classification of conditions. The chi-squared test was used to compare Diseases, 10th Revision (ICD-10) [13]. proportions of PPSV23/PCV13 vaccinated vs non-vac- cinated in the initial univariate analyses. Unadjusted Data sources odds ratios (ORs) were calculated to estimate the The Catalonian Health Institute Information System for probability of vaccination according to each one of the Development of Research in Primary Care (SIDIAP the studied covariables (age strata, sex and presence research database), which compiles coded clinical of distinct risk conditions). We did logistic regression information from the electronic medical records of the analyses (with the ‘enter’ method including all covaria- 274 PCCs managed by the ICS, was used as main data bles with a significance level p < 0.10 in previous univar- source for this report [14]. The SIDIAP sample is rep- iate analyses) to calculate multivariable-adjusted ORs resentative of the general Catalan population in terms for vaccination (PPSV23 and/or PCV13) [18]. Statistical of geographical, age and sex distributions according to significance was set at p < 0.05 (two-tailed). Data were census data [12], and its utility for clinical research has analysed by using IBM SPSS Statistics for Windows, been previously reported [15]. In 2012, the US Food and version 24 (IBM Corp., Armonk, New York, US). 2 www.eurosurveillance.org Table 1 Pneumococal vaccination coverages with PPsV23 and PCV13 by sex and age strata, Catalonia, Spain, 2017 (n = 2,057,656) PPsV23 PCV13 Characteristic n % n % Aged 50–64 years Men (n = 512,108) 51,120 10 2,409 0.5 Women (n = 527,764) 44,289 8.4 1,841 0.3 All (n = 1,039,872) 95,409 9.2 4,250 0.4 Aged 65–79 years Men (n = 316,831) 203,020 64.1 3,430 1.1 Women (n = 371,955) 231,388 62.2 2,575 0.7 All (n = 688,786) 434,408 63.1 6,005 0.9 Aged ≥ 80 years Men (n = 121,103) 101,199 83.6 1,637 1.4 Women (n = 207,895) 165,863 79.8 1,715 0.8 All (n = 328,998) 267,062 81.2 3,352 1.0 All-age groups Men (n = 950,042) 355,339 37.4 7,476 0.8 Women (n = 1,107,614) 441,540 39.9 6,131 0.6 Overall (n = 2,057,656) 796,879 38.7 13,607 0.7 PPsV23: 23-valent pneumococcal polysaccharide vaccine; PCV13: 13-valent pneumococcal conjugate vaccine. Results and 60 received three doses. Table 1 shows both The studied population included 2,057,656 persons, PPSV23 and PCV13 pneumococcal vaccination cover- of whom 950,042 (46.2%) were men and 1,107,614 ages by sex and age strata. PPsV23 coverage largely (53.8%) were women. By age strata, 1,039,872 (50.5%) increased with increasing age (9.2% in 50–64 years vs were aged 50–64 years, 688,786 (33.5%) were aged 63.1% in 65–79 years vs 81.2% in ≥ 80 years; p < 0.001) 65–79 years and 328,998 (16.0%) were aged ≥ 80 years. and was slightly lower in men than in women (37.4% vs 39.9%; p < 0.001). PCV13 coverage also increased Considering chronic respiratory diseases, 132,306 with age, although it was very low in all age groups study persons (6.4%) had chronic bronchitis/emphy- (0.4% in 50–64 years vs 0.9% in 65–79 years vs 1.0% sema and 95,600 (4.6%) had asthma. Considering in ≥ 80 years; p < 0.001) and was slightly greater in men other at-risk conditions, 350,511 study persons (17.0%) than in women (0.8% vs 0.6%; p < 0.001). had diabetes mellitus, 344,471 (16.7%) were current smokers, 236,623 (11.5%) had cancer, 158,726 (7.7%) Table 2 shows pneumococcal vaccination coverages by chronic renal disease, 117,575 (5.7%) coronary artery underlying risk conditions. The highest PPsV23 cov- disease, 63,596 (3.1%) congestive heart failure, 64,829 erage was observed among persons with congestive (3.2%) abused alcohol and 7,957 (0.4%) had cirrhosis. heart failure (81.6%) followed by chronic renal dis- ease (77.4%), chronic bronchitis/emphysema (72.9%) Overall, 796,879 persons (38.7%) had received PPsV23 and coronary artery disease (69.3%). Maximum PCV13 at any time (186,242 vaccinated within the last 5 years) coverage was observed among patients with cirrho- and 13,607 (0.7%) had received PCV13 (all of them sis (3.7%) followed by chronic renal disease (3.5%), within the previous 5 years). Of the 796,879 PPsV23 chronic bronchitis/emphysema (2.2%) and congestive vaccinated persons, 121,595 had received two doses heart failure (2.1%). The lowest PPsV23 coverage was and 2,347 received three or more doses. Of the 13,607 observed among patients who abused alcohol (35.5%) PCV13 vaccinated persons, 148 had received two doses and smoked (20.0%). Similarly, the lowest PCV13 www.eurosurveillance.org 3 Table 2 Pneumococcal vaccination coverages with PPsV23 and PCV13 by underlying risk conditions, Catalonia, Spain, 2017 (n = 2,057,656) PPsV23 PCV13 Risk condition/factor n % n % Chronic respiratory diseases Chronic bronchitis/emphysema (n = 132,306) 96,453 72.9 2,859 2.2 Asthma (n = 95,600) 52,817 55.2 1,218 1.3 Chronic heart diseases Congestive heart failure (n = 63,596) 51,909 81.6 1,327 2.1 Coronary artery disease (n = 117,575) 81,491 69.3 715 0.6 Diabetes mellitus (n = 350,511) 242,214 69.1 4,179 1.2 Chronic renal disease (n = 158,726) 122,791 77.4 5633 3.5 Cirrhosis (n = 7,957) 4,576 57.5 294 3.7 Cancer (n = 236,623) 139,911 59.1 3,758 1.6 Alcoholism (n = 64,829) 22,992 35.5 492 0.7 Smoking (n = 344,471) 68,966 20.0 1,646 0.5 Splenectomy (n = 362) 190 52.5 92 25.4 PPsV23: 23-valent pneumococcal polysaccharide vaccine; PCV13: 13-valent pneumococcal conjugate vaccine. coverage was also observed in people who smoke 95% CI: 7.19–7.79), followed by cirrhosis (OR: 4.21; (0.5%) or abuse alcohol (0.7%). 95% CI: 3.72–4.76) and chronic bronchitis/emphysema (OR: 2.54; 95% CI: 2.43–2.66). Table 3 shows distinct pneumococcal vaccine cover- ages (PPsV23, PCV13, dual vaccination, any vaccine) Discussion according to age subgroups (50–64 years, ≥ 65 years) Pneumococcal vaccination (including both PPsV23 and and risk strata (healthy, at-risk and high-risk/immu- PCV13) is commonly recommended for individuals at nocompromised) in the study population. Considering risk or at high risk and older adults [2,3]. However, exclusively persons who had any type of risk condition, there is scarce available data about pneumococcal vac- the proportion vaccinated with any vaccine was 16.1% cination coverages among adults in recent years (after (71,495/444,477) among those aged < 65 years and PCV13 licensure) and information on pneumococcal 76.4% (426,429/558,070) among those aged ≥ 65 years. vaccination uptake is not routinely available. Considering target groups where PPsV23 is recom- mended and publicly funded in Catalonia (i.e. all adults The present large population-based study, involv- who are either < 65 years old with at least one risk fac- ing more than 2 million persons ≥ 50 years old in tor plus all adults ≥ 65 years), PPsV23 coverage reached Catalonia, shows an overall vaccination uptake of 52.8% (771,722/1,462,261). Considering exclusively approximately 39% for the classical PPsV23 and 1% persons for whom PCV13 is publicly funded in our set- for the new PCV13 in January 2017. As compared with ting (i.e. all-age immunocompromised/high-risk per- a prior study that evaluated vaccination coverages in sons), PCV13 coverage was 3.3% (6,617/202,348). Catalonia in January 2015 [7], current PPsV23 uptake is essentially similar (38.8% (789,098/2,033,465) in Tables 4 and 5 show unadjusted and multivariable- 2015 vs 38.7% (796,879/2,057,657) in 2017, p = 0.105) adjusted analysis estimating ORs for PPsV23 and whereas PCV13 uptake, while very low, has slightly PCV13 vaccinations considering the distinct study increased (from 0.2% (5,031/2,033,465) in 2015 to covariables. In the multivariable analysis, age was the 0.7% (13,607/2,057,657) in 2017, p < 0.001). strongest predictor for PPsV23 vaccination. If we con- sider PCV13, the strongest predictor for vaccination Our global pneumococcal vaccination coverage seems was the presence of chronic renal disease (OR: 7.49; to be so far from the Healthy People 2020 goals (60% 4 www.eurosurveillance.org Table 3 Pneumococcal vaccination coverages with PPsV23, PCV13, dual vaccination, or any vaccine, by age subgroups and risk strata among adults aged over 50 years, Catalonia, Spain, 2017 (n = 2,057,656) PPsV23 PCV13 PCV13 + PPsV23 PCV13 or PPsV23 Age groups n % n % n % n % Aged 50–64 years Healthy (n = 595,395) 25,157 4.2 705 0.1 300 0.1 25,562 4.3 At-riska (n = 385,743) 58,318 15.1 1,097 0.3 615 0.2 58,800 15.2 High-risk b (n = 58,734) 11,934 20.3 2,448 4.2 1,687 2.9 12,695 21.6 All (n = 1,039,872) 95,409 9.2 4,250 0.4 2,602 0.3 97,057 9.3 Aged ≥ 65 years Healthy (n = 459,714) 275,700 60.0 1,607 0.3 1,371 0.3 275,936 60.0 At-riska (n = 414,456) 315,897 76.2 3,581 0.9 3,298 0.8 316,180 76.3 High-risk b (n = 143,614) 109,873 76.5 4,169 2.9 3,793 2.6 110,249 76.8 All (n = 1,017,784) 701,470 68.9 9,357 0.9 8,462 0.8 702,365 69.0 Overall (≥ 50 years) Healthy (n = 1,055,109) 300,857 28.5 2,312 0.2 1,671 0.2 301,498 28.6 At-riska (n = 800,199) 374,215 46.8 4,678 0.6 3,913 0.5 374,980 46.9 High-risk b (n = 202,348) 121,807 60.2 6,617 3.3 5,480 2.7 122,944 60.8 All (n = 2,057,656) 796,879 38.7 13,607 0.7 11,064 0.5 799,422 38.9 PPsV23: 23-valent pneumococcal polysaccharide vaccine; PCV13: 13-valent pneumococcal conjugate vaccine. a Individuals considered at risk include immunocompetent persons with any of the following conditions: immunocompromising conditions, chronic pulmonary/respiratory diseases, heart diseases, chronic renal disease, diabetes mellitus, cirrhosis, alcoholism and/or smoking. b Individuals considered at high risk are immunocompromised persons. for at-risk adults aged < 65 years and 90% for elderly only for immunocompromised persons), together with people) [4], but it must be noted that this global vac- its greater price and lower serotype-coverage than the cination coverage is estimated considering the total classical PPsV23, could explain, in part, the very low population aged ≥ 50 years. Coverage rates are consid- PCV13 uptakes observed in our population. erably greater when younger persons in this population (i.e. aged < 65 years) without underlying risk condi- Since pneumococcus is a major cause of morbidity tions are excluded in the analyses. Indeed, some spe- and mortality in high-risk adults and elderly people, cific population subgroups in this study have PPsV23 routine vaccination against pneumococcal diseases uptakes near to the Healthy People 2020 goal. If we is recommended for these persons in many countries consider exclusively elderly people, (i.e. ≥ 65 years), (although national guidelines differ, recommending the observed PPsV23 coverage was 63.1% among either the PPsV23, the PCV13 or both). The classi- persons 65–79 years and reached 81.2% among per- cal PPsV23 offers 40–60% efficacy against invasive sons ≥ 80 years old. Similarly, high PPsV23 coverage pneumococcal disease but its clinical effectiveness emerged among persons with cardiac diseases (81.6% against pneumonia is uncertain [2]. The new PCV13 in congestive heart failure and 69.3% in coronary artery has better immunogenicity than the polysaccharide disease), chronic renal disease (77.4%) and chronic vaccine and has a demonstrated 45% effectiveness bronchitis/emphysema (72.9%). against vaccine-type pneumococcal pneumonia, but it has lower serotype-coverage than the PPsV23 [3,19]. If we consider PCV13, the global vaccine uptake The lowest vaccination coverages for both PPsV23 and remains very low in our setting at the beginning of 2017, PCV13 in this study were observed among people who despite being approved for use in adults since 2012 smoked and people who abused alcohol. Both are at- [3]. The lack of public funding in our setting (funded increased risk to suffer pneumococcal infections and, www.eurosurveillance.org 5 Table 4 Unadjusted and multivariable-adjusted odds ratios for PPsV23 vaccination in adults, according to distinct study covariables, Catalonia, Spain, 2017 (n = 2,057,656)) Unadjusted Multivariable-adjusted Characteristic OR 95% CI p OR 95% CI p Age 50–64 years (reference) 1.00 Reference 1.00 Reference 65–79 years 16.91 16.77–17.05 < 0.001 14.21 14.09–14.34 < 0.001 ≥ 80 years 42.68 42.22–43.16 30.63 30.27–31.00 Sex Male (reference) 1.00 Reference 1.00 Reference < 0.001 < 0.001 Female 1.11 1.10–1.12 1.05 1.04–1.05 Chronic bronchitis/emphysema 4.71 4.66–4.76 < 0.001 3.64 3.58–3.71 < 0.001 Asthma 2.02 1.99–2.05 < 0.001 2.21 2.17–2.25 < 0.001 Congestive heart failure 7.45 7.30–7.60 < 0.001 1.51 1.48–1.55 < 0.001 Coronary artery disease 3.87 3.82–3.92 < 0.001 1.61 1.59–1.64 < 0.001 Diabetes mellitus 4.64 4.61–4.68 < 0.001 3.74 3.70–3.78 < 0.001 Cirrhosis 6.21 6.13–6.29 < 0.001 1.81 1.70–1.92 < 0.001 Chronic renal disease 2.15 2.05–2.25 < 0.001 1.61 1.58–1.63 < 0.001 Cancer 2.56 2.54–2.59 < 0.001 1.32 1.31–1.34 < 0.001 Alcoholism 0.87 0.85–0.88 < 0.001 1.15 1.12–1.18 < 0.001 Smoking 0.34 0.33–0.34 < 0.001 0.68 0.67–0.69 < 0.001 CI: confidence interval; OR: odds ratio; PPsV23: 23-valent pneumococcal polysaccharide vaccine. consequently, vaccination uptakes should be largely vaccine recommendations in Catalonia, where PPSV23 improved in these groups. We underline the impor- is recommended (and publicly funded) for all persons tance to continue public funding, especially among aged ≥ 65 years (with or without underlying conditions) such target groups, to achieve reasonable vaccination whereas PCV13 is only publicly funded for persons with uptakes. Barriers which limit vaccination uptake in high-risk conditions [9]. these at-risk persons also require further investiga- tion. In general, major factors related with vaccination In Europe, there is very scarce population-based data acceptance in adults are self-perceived health and atti- reporting pneumococcal vaccination coverages among tudes (which could be an important barrier in people adults [7,21-26], and vaccine uptakes are generally who abuse alcohol and/or smoke) as well as percep- inferred from vaccine doses distributed [22]. According tions about mortality risk of the infectious disease and to available data, estimates of PPsV23 uptakes among vaccine effectiveness [20]. We underline the key role of older adults in Western European countries vary largely general practice doctors in recommending vaccination (between 8% and 69%), with greater uptakes in those in these persons [21]. countries with age-based recommendations and public funding/reimbursement [21-26]. In our multivariable analyses, age was the strong- est predictor for PPsV23 vaccination, whereas the Considering that PCV13 use for at-risk and older adults presence of some underlying conditions (particularly was approved a few years ago (2012), there is very chronic renal disease, cirrhosis and chronic bronchi- scarce published data about PCV13 uptakes in adult tis/emphysema) was more predictive for PCV13 vac- populations [6,7]. Our data showing a global PCV13 cination. These data fit with current pneumococcal uptake less than one per cent (with maximum coverage 6 www.eurosurveillance.org Table 5 Unadjusted and multivariable-adjusted odds ratios for PCV13 vaccination in adults, according to distinct study covariables, Catalonia, Spain, 2017 (n = 2,057,656) Unadjusted Multivariable-adjusted Characteristic OR 95% CI p OR 95% CI p Age 50–64 years 1.00 Reference 1.00 Reference 65–79 years 2.14 2.06–2.23 < 0.001 1.11 1.06–1.16 < 0.001 ≥ 80 years 2.51 2.40–2.63 0.68 0.64–0.72 Sex Male 1.00 Reference 1.00 Reference < 0.001 < 0.001 Female 0.70 0.68–0.73 0.81 0.78–0.84 Chronic bronchitis/emphysema 3.93 3.77–4.10 < 0.001 2.54 2.43–2.66 < 0.001 Asthma 2.03 1.91–2.16 < 0.001 1.83 1.72–1.94 < 0.001 Congestive heart failure 3.44 3.25–3.64 < 0.001 1.19 1.12–1.27 < 0.001 Coronary artery disease 2.40 2.28–2.53 < 0.001 1.14 1.08–1.21 < 0.001 Diabetes mellitus 2.17 2.10–2.25 < 0.001 1.30 1.25–1.35 < 0.001 Cirrhosis 8.73 8.43–9.03 < 0.001 4.21 3.72–4.76 < 0.001 Chronic renal disease 5.87 5.21–6.60 < 0.001 7.49 7.19–7.79 < 0.001 Cancer 2.97 2.86–3.08 < 0.001 2.13 2.04–2.21 < 0.001 Alcoholism 1.15 1.06–1.26 0.002 0.91 0.83–1.01 0.059 Smoking 0.68 0.65–0.72 < 0.001 0.80 0.76–0.85 < 0.001 CI: confidence interval; OR: odds ratio; PCV13: 13-valent pneumococcal conjugate vaccine. of 3.7% in liver cirrhosis) 5 years after its licensure, vaccine uptakes and limits the comparability of cover- suggests that, apart from public funding/reimburse- age rates [9,10,27-30]. ment, risk-based vaccination strategies likely result in less vaccine uptake than age-based vaccination strat- Considering PPsV23, we also note the difficulty to egies [22]. In the US, where PCV13 is recommended improve vaccination uptakes when the vaccine cover- for all persons aged ≥ 65 years (with or without risk age is already relatively high. In fact, the reported conditions) [27], a coverage of 31% has been recently PPsV23 uptakes among elderly individuals and specific reported [6]. comorbidity subgroups in Catalonia years ago were similar to PPsV23 uptakes observed currently [31]. Considering the possibility of a sequential use of PCV13 plus PPsV23 (as recommended by the US Centers for Our study has several strengths. Design was popula- Disease Control and Prevention for immunocompro- tion-based and study population (which included more mised/high-risk persons and elderly people) [3,27], than 75% of the total Catalonian inhabitants ≥ 50 years) only 2.7% of high-risk individuals (5,480/202,348) had was representative and large enough to estimate received dual PCV13/PPsV23 vaccination in our setting. accurately vaccination uptakes for both PPSV23 and To date, recommendations for PPsV23 and PCV13 vac- PCV13 according to distinct age subgroups and specific cination in adults are not uniform (varying between underlying risk conditions. Quality criteria and utility countries, scientific societies and clinical guidelines), of the SIDIAP research database (used to identify vac- with diversity in funding for PPsV23/PCV13 in distinct cinations, comorbidities and underlying risk conditions settings, which makes it difficult to achieve optimal in the study population) have been previously reported www.eurosurveillance.org 7 [15], and this database has been used as a reliable tool be needed. These should be age-based, risk-based for epidemiological studies in our setting [7]. or consensus-based and derived from updated data on efficacy, clinical effectiveness, epidemiological With regard to limitations of the study, we did not impact and cost-effectiveness for both PPsV23/PCV13 include people < 50 years old in our analyses. Moreover, in adults. for people aged ≥ 50 years, we assumed that informa- tion in PCCs medical records was complete, but infor- mation bias may have occurred if some comorbidities Acknowledgments and/or vaccinations were not recorded. Concerning Funding: This work is funded by a grant from the Pla vaccination, while the utility of the SIDIAP database Estratègic De Recerca I Innovació En Salut (PERIS) of the for clinical research has been previously described Departament de Salut de la Generalitat de Catalunya; code [15], there has not been any validation sub-study spe- file SLT002/16/00063. cifically focused on vaccination registries in the data- base records. However possible bias/misclassification would likely be very small since almost all of adult vac- Conflict of interest cinations are administered in the PCCs in the Spanish None declared. Health System. Similarly, although it is possible that some comorbidities/chronic diseases (particularly in persons with mild symptoms or less frequency of Authors’ contributions attendance) were missed because a diagnosis code A. Vila-Corcoles, O. Ochoa-Gondar, C. de Diego and E. Satue was not recorded, the possible misclassification would designed the study, assessed outcomes, wrote and edited likely also be small considering that the observed the paper; M. Aragon obtained the data; O. Ochoa-Gondar and A. Vila-Rovira did statistical analyses; A. Vila-Corcoles prevalences fit with commonly reported prevalences coordinated the study. for major comorbidities/risk conditions [32]. Patients attitudes, ethnicity and socio-economical information were not available in the present study, which may also References be considered as a limitation given that disparities 1. Örtqvist A, Hedlund J, Kalin M. 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