Volume 93, Issue 6
  • ISSN: 0002-9637
  • E-ISSN: 1476-1645



The incidence of pneumococcal pneumonia among adults is a key driver for the cost-effectiveness of pneumococcal conjugate vaccine used among children. We sought to obtain more accurate incidence estimates among adults by including results of pneumococcal urine antigen testing (UAT) from population-based pneumonia surveillance in two Thai provinces. Active surveillance from 2006 to 2011 identified acute lower respiratory infection (ALRI)–related hospital admissions. Adult cases of pneumococcal pneumonia were defined as hospitalized ALRI patients aged ≥ 18 years with isolation of from blood or with positive UAT. Among 39,525 adult ALRI patients, we identified 481 pneumococcal pneumonia cases (105 by blood culture, 376 by UAT only). Estimated incidence of pneumococcal pneumonia hospitalizations was 30.5 cases per 100,000 persons per year (2.2 and 28.3 cases per 100,000 persons per year by blood culture and UAT, respectively). Incidence varied between 22.7 in 2007 and 43.5 in 2010, and increased with age to over 150 per 100,000 persons per year among persons aged ≥ 70 years. Viral coinfections including influenza A/B, respiratory syncytial virus (RSV), and adenovirus occurred in 11% (44/409) of pneumococcal pneumonia cases tested. Use of UAT to identify cases of pneumococcal pneumonia among adults in rural Thailand substantially increases estimates of pneumococcal pneumonia burden, thereby informing cost-effectiveness analyses and vaccine policy decisions.

[open-access] This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


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  1. WHO, 2013. Pneumonia. Available at: http://www.who.int/mediacentre/factsheets/fs331/en/. Accessed December 2014.
  2. Walker CLF, Rudan I, Liu L, Nair H, Theodoratou E, Bhutta ZA, O'Brien KL, Campbell H, Black RE, , 2013. Global burden of childhood pneumonia and diarrhoea. Lancet 381: 14051416.[Crossref]
  3. Zar HJ, Madhi SA, Aston SJ, Gordon SB, , 2013. Pneumonia in low and middle income countries: progress and challenges. Thorax 68: 10521056.[Crossref]
  4. Whitney CG, , 2013. More evidence for use of pneumococcal conjugate vaccines. Lancet 381: 182183.[Crossref]
  5. Black SB, Shinefield HR, Ling S, Hansen J, Fireman B, Spring D, Noyes J, Lewis E, Ray P, Lee J, Hackell J, , 2002. Effectiveness of heptavalent pneumococcal conjugate vaccine in children younger than five years of age for prevention of pneumonia. Pediatr Infect Dis J 21: 810815.[Crossref]
  6. Cutts FT, Zaman SM, Enwere G, Jaffar S, Levine OS, Okoko JB, Oluwalana C, Vaughan A, Obaro SK, Leach A, McAdam KP, Biney E, Saaka M, Onwuchekwa U, Yallop F, Pierce NF, Greenwood BM, Adegbola RA, , 2005. Efficacy of nine-valent pneumococcal conjugate vaccine against pneumonia and invasive pneumococcal disease in The Gambia: randomised, double-blind, placebo-controlled trial. Lancet 365: 11391146.[Crossref]
  7. Madhi SA, Kuwanda L, Cutland C, Klugman KP, , 2005. The impact of a 9-valent pneumococcal conjugate vaccine on the public health burden of pneumonia in HIV-infected and -uninfected children. Clin Infect Dis 40: 15111518.[Crossref]
  8. Griffin MR, Zhu Y, Moore MR, Whitney CG, Grijalva CG, , 2013. U.S. hospitalizations for pneumonia after a decade of pneumococcal vaccination. N Engl J Med 369: 155163.[Crossref]
  9. Grijalva CG, Nuorti JP, Arbogast PG, Martin SW, Edwards KM, Griffin MR, , 2007. Decline in pneumonia admissions after routine childhood immunisation with pneumococcal conjugate vaccine in the USA: a time-series analysis. Lancet 369: 11791186.[Crossref]
  10. O'Brien K, Wolfson L, Watt J, Henkle E, Deloria-Knoll M, McCall N, Lee E, Mulholland K, Levine O, Cherian T, , 2009. Burden of disease caused by Streptococcus pneumoniae in children younger than 5 years: global estimates. Lancet 374: 893902.[Crossref]
  11. Feikin D, Schuchat A, Kolczak M, Barrett N, Harrison L, Lefkowitz L, McGeer A, Farley M, Vugia D, Lexau C, Stefonek K, Patterson J, Jorgensen J, , 2000. Mortality from invasive pneumococcal pneumonia in the era of antibiotic resistance, 1995–1997. Am J Public Health 90: 223229.[Crossref]
  12. Pilishvili T, Lexau C, Farley MM, Hadler J, Harrison LH, Bennett NM, Reingold A, Thomas A, Schaffner W, Craig AS, Smith PJ, Beall BW, Whitney CG, Moore MR, Active Bacterial Core Surveillance/Emerging Infections Program Network; , 2010. Sustained reductions in invasive pneumococcal disease in the era of conjugate vaccine. J Infect Dis 201: 3241.[Crossref]
  13. Miller E, Andrews NJ, Waight PA, Slack MP, George RC, , 2011. Herd immunity and serotype replacement 4 years after seven-valent pneumococcal conjugate vaccination in England and Wales: an observational cohort study. Lancet Infect Dis 11: 760768.[Crossref]
  14. Jackson ML, Neuzil KM, Thompson WW, Shay DK, Yu O, Hanson CA, Jackson LA, , 2004. The burden of community-acquired pneumonia in seniors: results of a population-based study. Clin Infect Dis 39: 16421650.[Crossref]
  15. Feikin DR, Kagucia EW, Loo JD, Link-Gelles R, Puhan MA, Cherian T, Levine OS, Whitney CG, O'Brien KL, Moore MR, Serotype Replacement Study Group; , 2013. Serotype-specific changes in invasive pneumococcal disease after pneumococcal conjugate vaccine introduction: a pooled analysis of multiple surveillance sites. PLoS Med 10: e1001517.[Crossref]
  16. Bravo LC, Asian Strategic Alliance for Pneumococcal Disease Prevention Working Group; , 2009. Overview of the disease burden of invasive pneumococcal disease in Asia. Vaccine 27: 72827291.[Crossref]
  17. Gutierrez F, Masia M, Rodriguez J, Ayelo A, Soldan B, Cebrian L, Mirete C, Royo G, Hidalgo A, , 2003. Evaluation of the immunochromatographic Binax NOW assay for detection of Streptococcus pneumoniae urinary antigen in a prospective study of community-acquired pneumonia in Spain. Clin Infect Dis 36: 286292.[Crossref]
  18. Marcos MA, Jimenez de Anta MT, de la Bellacasa JP, Gonzalez J, Martinez E, Garcia E, Mensa J, de Roux A, Torres A, , 2003. Rapid urinary antigen test for diagnosis of pneumococcal community-acquired pneumonia in adults. Eur Respir J 21: 209214.[Crossref]
  19. Murdoch D, Laing R, Cook J, , 2003. The NOW S. pneumoniae urinary antigen test positivity rate 6 weeks after pneumonia onset and among patients with COPD. Clin Infect Dis 37: 153154.[Crossref]
  20. Klugman KP, Madhi SA, Albrich WC, , 2008. Novel approaches to the identification of Streptococcus pneumoniae as the cause of community-acquired pneumonia. Clin Infect Dis 47 (Suppl 3): S202S206.[Crossref]
  21. Smith MD, Derrington P, Evans R, Creek M, Morris R, Dance DAB, Cartwright K, , 2003. Rapid diagnosis of bacteremic pneumococcal infections in adults by using the Binax NOW Streptococcus pneumoniae urinary antigen test: a prospective, controlled clinical evaluation. J Clin Microbiol 41: 28102813.[Crossref]
  22. Werno AM, Murdoch DR, , 2008. Medical microbiology: laboratory diagnosis of invasive pneumococcal disease. Clin Infect Dis 46: 926932.[Crossref]
  23. Butler J, Cosshardt S, Phelan M, Moroney S, Tondella M, Farley M, Schuchat A, Fields B, , 2003. Classical and latent class analysis evaluation of sputum polymerase chain reaction and urine antigen testing for diagnosis of pneumococcal pneumonia in adults. J Infect Dis 187: 14161423.[Crossref]
  24. Olsen SJ, Laosiritaworn Y, Siasiriwattana S, Chunsuttiwat S, Dowell SF, , 2006. The incidence of pneumonia in rural Thailand. Int J Infect Dis 10: 439445.[Crossref]
  25. TNEASD, 2013. Population Projection of Thailand 2010–2040. Bangkok, Thailand: Office of the National Economic and Social Development Board.
  26. National Economic and Social Development Board of Thailand, 2007. Population Projections of Thailand 2000–2030. Available at: http://social.nesdb.go.th/social/Portals/0/Documents/pop_34.zip. Accessed December 2014.
  27. Bruns AH, Oosterheert JJ, Prokop M, Lammers JW, Hak E, Hoepelman AI, , 2007. Patterns of resolution of chest radiograph abnormalities in adults hospitalized with severe community-acquired pneumonia. Clin Infect Dis 45: 983991.[Crossref]
  28. Javadi M, Subhannachart P, Levine S, Vijitsanguan C, Tungsagunwattana S, Dowell SF, Olsen SJ, , 2006. Diagnosing pneumonia in rural Thailand: digital cameras versus film digitizers for chest radiograph teleradiology. Int J Infect Dis 10: 129135.[Crossref]
  29. WHO, 2009. CDC Protocol of Realtime RTPCR for Swine Influenza A (H1N1). Atlanta, GA: WHO Collaborating Centre for Influenza.
  30. Baggett HC, Peruski LF, Olsen SJ, Thamthitiwat S, Rhodes J, Dejsirilert S, Wongjindanon W, Dowell SF, Fischer JE, Areerat P, Sornkij D, Jorakate P, Kaewpan A, Prapasiri P, Naorat S, Sangsuk L, Eampokalap B, Moore MR, Carvalho G, Beall B, Ungchusak K, Maloney SA, , 2009. Incidence of pneumococcal bacteremia requiring hospitalization in rural Thailand. Clin Infect Dis 48 (Suppl 2): S65S74.[Crossref]
  31. Rhodes J, Hyder JA, Peruski LF, Fisher C, Jorakate P, Kaewpan A, Dejsirilert S, Thamthitiwat S, Olsen SJ, Dowell SF, Chantra S, Tanwisaid K, Maloney SA, Baggett HC, , 2010. Antibiotic use in Thailand: quantifying impact on blood culture yield and estimates of pneumococcal bacteremia incidence. Am J Trop Med Hyg 83: 301306.[Crossref]
  32. Rhodes J, Dejsirilert S, Maloney S, Jorakate P, Kaewpan A, Salika P, Akarachotpong T, Prapasiri P, Naorat S, Areerat P, Ruayajin A, Sawanpanyalert P, Akarasewi P, Peruski L, Baggett H, , 2013. Pneumococcal bacteremia requiring hospitalization in rural Thailand: an update on incidence, clinical characteristics, serotype distribution, and antimicrobial susceptibility, 2005–2010. PLoS One 8: e66038.[Crossref]
  33. Ferdinands JM, Gargiullo P, Haber M, Moore M, Belongia EA, Shay DK, , 2013. Inactivated influenza vaccines for prevention of community-acquired pneumonia: the limits of using nonspecific outcomes in vaccine effectiveness studies. Epidemiology 24: 530537.[Crossref]
  34. Roson B, Fernandez-Sabe N, Carratala J, Verdaguer R, Dorca J, Manresa F, Gudiol F, , 2004. Contribution of a urinary antigen assay (Binax NOW) to the early diagnosis of pneumococcal pneumonia. Clin Infect Dis 38: 222226.[Crossref]
  35. Said M, Johnson H, Nonyane B, Deloria-Knoll M, O'Brien K, , 2013. Estimating the burden of pneumococcal pneumonia among adults: a systematic review and meta-analysis of diagnostic techniques. PLoS One 8: e60273.[Crossref]
  36. Chiang C-S, Chen Y-Y, Jiang S-F, Liu D-P, Kao P-H, Teng H-J, Kuo T-L, Yao S-M, Tseng L-R, Wang Y-L, Wu H-S, Chang F-Y, Lin T-Y, , 2014. National surveillance of invasive pneumococcal diseases in Taiwan, 2008–2012: differential temporal emergence of serotype 19A. Vaccine 32: 33453349.[Crossref]
  37. Scientific Committee on Vaccine Preventable Diseases, 2007. Recommendations on the Use of Pneumococcal Vaccines. Wanchai, Hong Kong: Centre for Health Protection.
  38. Low S, Chan FL, Cutter J, Ma S, Goh KT, Chew SK, , 2007. A national study of the epidemiology of pneumococcal disease among hospitalised patients in Singapore: 1995 to 2004. Singapore Med J 48: 824829.
  39. Walter ND, Taylor TH, Shay DK, Thompson WW, Brammer L, Dowell SF, Moore MR, , 2010. Influenza circulation and the burden of invasive pneumococcal pneumonia during a non-pandemic period in the United States. Clin Infect Dis 50: 175183.[Crossref]
  40. Talbot TR, Poehling KA, Hartert TV, Arbogast PG, Halasa NB, Edwards KM, Schaffner W, Craig AS, Griffin MR, , 2005. Seasonality of invasive pneumococcal disease: temporal relation to documented influenza and respiratory syncytial viral circulation. Am J Med 118: 285291.[Crossref]
  41. Kulpeng W, Leelahavarong P, Rattanavipapong W, Sornsrivichai V, Baggett HC, Meeyai A, Punpanich W, Teerawattananon Y, , 2013. Cost-utility analysis of 10- and 13-valent pneumococcal conjugate vaccines: protection at what price in the Thai context? Vaccine 31: 28392847.[Crossref]
  42. Bonten MJ, Huijts SM, Bolkenbaas M, Webber C, Patterson S, Gault S, van Werkhoven CH, van Deursen AM, Sanders EA, Verheij TJ, Patton M, McDonough A, Moradoghli-Haftvani A, Smith H, Mellelieu T, Pride MW, Crowther G, Schmoele-Thoma B, Scott DA, Jansen KU, Lobatto R, Oosterman B, Visser N, Caspers E, Smorenburg A, Emini EA, Gruber WC, Grobbee DE, , 2015. Polysaccharide conjugate vaccine against pneumococcal pneumonia in adults. N Engl J Med 372: 11141125.[Crossref]

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  • Received : 10 Jun 2015
  • Accepted : 20 Aug 2015

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