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Efficacy of 23-valent pneumococcal vaccine in preventing pneumonia and improving survival in nursing home residents: double blind, randomised and placebo controlled trial

BMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c1004 (Published 08 March 2010) Cite this as: BMJ 2010;340:c1004

Rapid Response:

Invasive Pneumococcal Disease in Adults Previously Vaccinated with 23-valent Pneumococcal Polysaccharide Vaccine

Marayuma et al have recently reported findings of their study
demonstrating efficacy of the 23-valent pneumococcal polysaccharide
vaccine (PPV) in preventing pneumococcal pneumonia in nursing home
residents in Japan.(1)

We wish to report results of a retrospective audit of patients with
invasive pneumococcal disease admitted to a District General Hospital in
England that, contrary to Marayuma’s work, suggest vaccine failure of the
23-valent PPV in preventing invasive pneumococcal disease (IPD).
Streptococcus pneumoniae is a significant pathogen and to date 90
different serotypes have been identified. It is the commonest cause of
community-acquired pneumonia and is associated with considerable morbidity
and mortality.(2) Department of Health (DOH) guidance recommends
vaccination of specific high risk category groups and all patients >65
years of age with 23-valent PPV.(3)

The aim of the audit was to investigate clinical cases of IPD,
documenting prior vaccination status and the pneumococcal serotype causing
disease for each patient (Serotyping was performed by the Respiratory and
Systemic Infection Laboratory, Health Protection Agency, Colindale,
London).

Over an 18-month period (September 2006 - February 2008) 37 adult
patients (age range: 41-91 years) were diagnosed with IPD (Streptococcus
pneumoniae isolated from normally sterile sites including blood, joint
fluid and CSF). Pneumonia was the predominant clinical focus (n=34), two
patients had pneumococcal septic arthritis and one case had meningitis.

31 study patients satisfied DOH criteria for prior PPV immunisation
(25 over the age of 65 years). Vaccination status was available for 28 of
these patients, of whom 17 had received the 23-valent PPV and 11 patients
had never been immunised. Within the sub-group of 17 vaccinated cases, 15
patients had invasive infection due to a recognised serotype contained
within the 23-valent PPV, implying failure of the vaccine in preventing
invasive pneumococcal disease in these patients. Of the 11 unvaccinated
patients nine had clinical isolates of known serogroups contained within
PPV. Thus in total 24 out of 28 patients had invasive disease due to
current PPV serotypes.

Prior to conducting this audit we perceived that the majority of
patients admitted with proven pneumococcal disease would not have been
vaccinated. Results surprisingly demonstrated that, despite being
vaccinated, many patients were not sufficiently protected against
serotypes contained within the 23-valent vaccine and subsequently had
proven pneumococcal infection. In contrast to the work of Marayuma et al,
our study concludes that the efficacy of 23-valent PPV was suboptimal.

Unlike conjugate vaccines, it is well recognised that polysaccharide
vaccines do not promote immunological memory or provide long-lasting
protection.(4) Pneumococcal disease has considerable impact on hospital
activity, especially during winter months. Our study suggests that further
work is required to establish a superior vaccination strategy, in adults,
against this significant pathogen.

References

1. Takaya Marayuma, Osamu Taguchi, Michael S Niederman et al.
Efficacy of 23-valent pneumococcal vaccine in preventing pneumonia and
improving survival in nursing home residents: double blind, randomised and
placebo controlled trial. BMJ 2010;340:c1004

2. http://www.hpa.org.uk/web

3. Salisbury, Ramsay, Noakes. DOH 2006. Immunisation Against
Infectious Disease (The Green Book)

4. Musher DM, Rueda AM, Nahm MH et al. Initial and subsequent
response to pneumococcal polysaccharide and protein-conjugate vaccines
administered sequentially to adults who have recovered from pneumococcal
pneumonia. J Infect Dis 2008 Oct 1;198(7):1019-27

Competing interests:
None declared

Competing interests: No competing interests

25 March 2010
Karen M Fay
ST2 Medicine (previously F2 Medical Microbiology)
Cecilia M Jukka, Judith A Bowley and David R Bramhall.
Southport and Ormskirk NHS Trust, Southport, PR8 6PN.