Incidence trends of parapneumonic pleural effusions/empyema in children 2009 to 2018 from health insurance data: Only temporal reduction after the introduction of PCV13
Introduction
Parapneumonic pleural effusions/empyema (PPE/PE) are observed in 5–10% of all children hospitalized with pneumonia [1], [2]. In children, Streptococcus pneumonia is the leading pathogen accounting for PPE/PE [3], [4], [5]. The most common serotypes of Streptococcus pneumonia in PPE/PE are serotype 1 and serotype 3 [3]. Both are included in the 13-valent pneumococcal conjugate vaccine (PCV13). Since 2009, PCV13 is used for standard vaccination in infants from the age of 2 months in Germany to prevent invasive pneumococcal disease (IPD).
We tried to assess the impact of the introduction of PCV13 on the overall incidence of PPE/PE in children in an analysis using health care insurance data. We had access to the Barmer data warehouse providing ICD diagnoses for hospitalized children.
We hypothesized a decrease in the overall incidences of PPE/PE after 2009, the date of the introduction of PCV13 in Germany.
Section snippets
Data
We used data of Barmer, a statutory health insurer, providing health insurance to about 11% of the German population. Health insurance providers in Germany have some inequalities in the structure of the respectively insured population and thus also differences in the prevalence of some diseases. [9] Slightly more elderly people and less males than females are insured with Barmer than with other statutory health insurance providers. However, although external validity might be limited with
Results
During the observation period the number of children under observation in each year varied by calendar year (table 1). In total, 2 667 504 children contributed 15 208 024 person years of observation. The proportion of boys was 51.2%.
Table 1 shows absolute numbers of observed children in the calendar years 2009 to 2018 in total and by age group (0–1 year of age, 2–5 years of age, >5 years of age). It also shows the number of cases of PPE/PE and the incidence estimate per 100 000 children overall
Discussion
In children aged 0–18 years old, the incidence of PPE/PE changed considerably between 2009 and 2018 with a decrease after 2009 and a subsequent increase above the 2009 incidence in 2018. The nadir was in 2013. This observation of a U-shape incidence curve is in accordance with incidence data published from a German prospective hospital surveillance study on paediatric parapneumonic pleural effusion/empyema (PPE/PE) performed between 2010 and 2017 [3].
The initial decrease following the
Strengths and limitations
The major strength is the sample size of Barmer insured children in 2009–2018, allowing for precise annual incidence estimates. The applied statistical model for identification of changes in incidence over time made no a priori assumption (such as linearity) to the temporal trend. The pneumococcal vaccination rate in children remained stable over time [18] thus the observed changes in incidences are likely to reflect the impact of pneumococcal vaccination in children irrespective of vaccine
Conclusion
Our data suggest that the recently observed trend in the proportion of pneumococcal serotypes in PPE/PE appears to be associated with a decrease in the overall incidence of PPE/PE from 2009 to 2013 and a subsequent increase in the incidence of PPE/PE. The former might be explained by a quasi elimination of serotype 1, the latter by an increase in the proportion of serotype 3 as demonstrated in German surveillance data of paediatric PPE/PE cases generated during the same observation period. [3],
Contribution of the authors
All authors attest they meet the ICMJE criteria for authorship.
A. Sorg, R. von Kries: Conceptualization; Writing - original draft; Interpretation of data; Writing - review & editing.
Obermeier: analysis, responsible for data integrity.
J.G. Liese: Critical Review & editing.
All authors have approved the final article. All authors attest they meet the ICMJE criteria for authorship.
Funding
This study was not funded by any grant.
Declaration of Competing Interest
The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: A. Sorg and V. Obermeier declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
R. von Kries and J. Liese declare the following financial interests/personal relationships, which may be considered as potential competing interests:
R. von Kries was supported by a
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