Seasonal drivers of pneumococcal disease incidence: impact of bacterial carriage and viral activity

Abstract

Background: Winter-seasonal epidemics of pneumococcal disease provide an opportunity to understand the drivers of incidence. We sought to determine whether seasonality of invasive pneumococcal disease is caused by increased nasopharyngeal transmission of the bacteria or increased susceptibility to invasive infections driven by cocirculating winter respiratory viruses.

Methods: We analyzed pneumococcal carriage and invasive disease data collected from children <7 years old in the Navajo/White Mountain Apache populations between 1996 and 2012. Regression models were used to quantify seasonal variations in carriage prevalence, carriage density, and disease incidence. We also fit a multivariate model to determine the contribution of carriage prevalence and RSV activity to pneumococcal disease incidence while controlling for shared seasonal factors.

Results: The seasonal patterns of invasive pneumococcal disease epidemics varied significantly by clinical presentation: bacteremic pneumococcal pneumonia incidence peaked in late winter, whereas invasive nonpneumonia pneumococcal incidence peaked in autumn. Pneumococcal carriage prevalence and density also varied seasonally, with peak prevalence occurring in late autumn. In a multivariate model, RSV activity was associated with significant increases in bacteremic pneumonia cases (attributable percentage, 15.5%; 95% confidence interval [CI], 1.8%-26.1%) but was not associated with invasive nonpneumonia infections (8.0%; 95% CI, -4.8% to 19.3%). In contrast, seasonal variations in carriage prevalence were associated with significant increases in invasive nonpneumonia infections (31.4%; 95% CI, 8.8%-51.4%) but not with bacteremic pneumonia.

Conclusions: The seasonality of invasive pneumococcal pneumonia could be due to increased susceptibility to invasive infection triggered by viral pathogens, whereas seasonality of other invasive pneumococcal infections might be primarily driven by increased nasopharyngeal transmission of the bacteria.

Keywords: RSV; co-infections; pneumococcal; pneumonia; seasonality.

Figure 1.

A, Estimated average cases of invasive pneumococcal disease incidence in each month among children <7 years old. Markers indicate the estimated monthly cases of disease calculated from a Poisson regression model controlling for vaccination period (±95% confidence intervals). B, Estimated cases of bacteremic pneumonia (light gray) and nonpneumonia invasive disease cases (dark gray) each month among children <7 years old.

Figure 2.

A, Estimated pneumococcal carriage prevalence in each month among <7 year olds. B, Estimated prevalence of high- and low-density pneumococcal carriers among all individuals with swab samples in study 1. The markers indicate the average monthly prevalence, controlling for age and vaccination period. Estimates were calculated using generalized estimating equations (controlling for repeated sampling of individuals; A) and generalized logit regression (±95% confidence intervals; B).

Figure 3.

Comparison of the relative monthly variations in carriage prevalence (dotted line), bacteremic pneumonia (light gray solid line), and nonpneumonia invasive disease (dark gray solid line) among children <7 years old. Disease curves represent incidence rate ratios relative to July, and carriage curves represent risk ratios for carriage relative to July. Numbers represent changes at the peaks (ratios) relative to July.

Figure 4.

Proposed model for seasonal effect of carriage and viral infection on pneumococcal disease incidence in children.