Streptococcus pneumoniae polysaccharide vaccine: age and dose responses, safety, persistence of antibody, revaccination, and simultaneous administration of pneumococcal and influenza vaccines

Pneumococcal Disease: Global Disease Prevention Strategies with a Focus on the Challenges in Iraq

Pneumococcal disease is a global public health concern that significantly contributes to clinical disease burden and economic burden. Patients frequently afflicted are young children and older adults, as well as the immunocompromised population. Immunization is the most effective public health strategy to combat pneumococcal disease and several vaccine formulations have been developed in this regard. Although vaccines have had a significant global impact in reducing pneumococcal disease, there are several barriers to its success in Iraq. The war and conflict situation, increasing economic crises and poverty, poor vaccine accessibility in the public sector, and high vaccine costs are a few of the major obstacles that impede a successful immunization program. The last reported third dose pneumococcal conjugate vaccine coverage for Iraq was 37% in 2019, which is expected to reduce even further owing to the COVID-19 pandemic. Thus, strategies and policies to improve pneumococcal vaccine availability and coverage need to be strengthened to achieve maximum benefits of immunization. In the current review, we provide an overview of the existing knowledge on pneumococcal disease-prevention strategies across the globe. The main aim of this manuscript is to discuss the current status and challenges of pneumococcal vaccination in Iraq as well as the strategies to prevent pneumococcal infections.

Immune system correlates of extensive limb swelling in response to conjugated pneumococcal vaccination

Pneumococcal conjugate vaccine (PCV) is recommended for adults with chronic disease. Extensive limb swelling (ELS) is an acute vigorous local inflammatory reaction following vaccination. Predisposing immune system correlates and the influence of ELS on vaccine responses are not known. Here, we report a case of a 67-year-old woman with a history of multiple pneumonias who had a detailed immunological work-up pre-vaccination because of suspected immunodeficiency. Four days following a first vaccination with PCV13 she developed ELS—mimicking erysipelas. Treatment with 20 mg cortisone completely alleviated symptoms within 2 days. Skin biopsy showed a dense dermal and subdermal infiltration dominated by CD4⁺ T cells and macrophages. In a multiplexed serotype-specific measurement of the anti-pneumococcal IgG response, the patient showed very broad and strong vaccine responses. Pre-vaccination titers were low for the vaccine serotypes. We did not find in vivo nor in vitro evidence of an excessive T cell response to the diphtheria-derived PCV carrier protein. However, we could demonstrate a high antibody titer to a non-vaccine serotype, indicating in vivo pre-exposure to pneumococcus bacteria. Thus, traces of pneumococcal proteins included in PCV13 may have boosted pre-existing pneumococcus-specific T helper cells, which subsequently orchestrated ELS. Our case raises awareness for the risk of vaccine-induced ELS, especially in patients with a history of recurrent pneumococcal disease and thus partial immunity.

Immunohistochemical Analysis of Mononuclear Inflammatory Cells in Nasal and Sinus Epithelium in Children with Sinusitis

The etiology and pathophysiology of both recurrent acute and chronic sinusitis in children are not well understood. To investigate this problem, the nature and magnitude of the local cellular inflammatory response was evaluated in the sinus mucosa of 34 children (25 with chronic sinusitis and 9 with recurrent acute sinusitis), of which 27 are atopic and 7 are nonatopic. In addition, sinus mucosa from three patients who underwent sinus surgery for noninfectious sinus disease (two with antral choanal polyp and one with facial pain syndrome) was studied for comparison and “controls. “ Immunohistochemical methods were used to identify phenotypically distinct mononuclear cells subpopulations (B cells, T cells, macrophages, and MHC class II antigen presenting cells) in the epithelium, stroma, and periglandular compartments of the uncinate and ethmoid mucosal tissue layers. Eosinophils were assessed in the same sinus mucosal tissue compartments and in nasal secretions. For all patients, most of the inflammatory cells were found in the stroma. MHC class II positive cells and T cells were found in the epithelium of greater than 50%, and in the stroma of almost 100% of either the uncinate or ethmoid mucosa. Of interest, the local accumulation of tissue eosinophils and/or their presence in nasal smears was not closely linked to the presence of atopy. In three patients with noninfectious sinusitis, the majority of inflammatory cells had also accumulated in the stroma; the mononuclear cell subset composition in those controls was indistinguishable from the sinusitis population. No difference in the number and distribution of any inflammatory cell subset was noted with respect to clinical classification, atopy or immunocompetency profile in our patient population. These observations indicate that the mucosal surfaces studied were likely to have been immunocompetent. Taken together, the uniformly modest local inflammation and the similarity of cell subpopulations in patients with different clinical profiles suggest that local inflammatory mechanisms may not account for clinical differences in the pathophysiology of sinusitis.

Drug Interactions Involving Immunologic Agents Part I. Vaccine–Vaccine, Vaccine–Immunoglobulin, and Vaccine–Drug Interactions

Information about immunologic drug interactions is needed by pharmacists to make rational drug-use decisions. Previously, reports of interactions involving vaccines, immune globulins, and immunodiagnostic reagents were widely dispersed. In this two-part review article, over 50 individual and categorical interactions are described, as are dozens of vaccine–vaccine and vaccine–immunoglobulin combinations for which interactions have been demonstrated not to occur. Vaccine–vaccine, vaccine–immunoglobulin, and vaccine–drug interactions are reviewed in this first part. Vigilance by all pharmacists is needed to detect previously unreported immunologic drug interactions and to further assess known interactions.

Pneumococcal vaccines for preventing pneumonia in chronic obstructive pulmonary disease

BACKGROUND

People with chronic obstructive pulmonary disease (COPD) are at increased risk of pneumococcal disease, especially pneumonia, as well as acute exacerbations with associated morbidity and healthcare costs.

OBJECTIVES

To determine the efficacy of injectable pneumococcal vaccination for preventing pneumonia in persons with COPD.

SEARCH METHODS

We searched the Cochrane Airways COPD Trials Register and the databases CENTRAL, MEDLINE and Embase, using prespecified terms. Searches are current to November 2016.

SELECTION CRITERIA

We included randomised controlled trials (RCT) comparing injectable pneumococcal polysaccharide vaccine (PPV) or pneumococcal conjugated vaccine (PCV) versus a control or alternative vaccine type in people with COPD.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures. For meta-analyses, we subgrouped studies by vaccine type.

MAIN RESULTS

For this update, we added five studies (606 participants), meaning that the review now includes a total of 12 RCTs involving 2171 participants with COPD. Average age of participants was 66 years, male participants accounted for 67% and mean forced expiratory volume in one second (FEV1) was 1.2 L (five studies), 54% predicted (four studies). We assessed risks of selection, attrition and reporting bias as low, and risks of performance and detection bias as moderate.Compared with control, the vaccine group had a lower likelihood of developing community-acquired pneumonia (CAP) (odds ratio (OR) 0.62, 95% confidence interval (CI) 0.43 to 0.89; six studies, n = 1372; GRADE: moderate), but findings did not differ specifically for pneumococcal pneumonia (Peto OR 0.26, 95% CI 0.05 to 1.31; three studies, n = 1158; GRADE: low). The number needed to treat for an additional beneficial outcome (NNTB) (preventing one episode of CAP) was 21 (95% CI 15 to 74). Mortality from cardiorespiratory causes did not differ between vaccine and control groups (OR 1.07, 95% CI 0.69 to 1.66; three studies, n = 888; GRADE: moderate), nor did all-cause mortality differ (OR 1.00, 95% CI 0.72 to 1.40; five studies, n = 1053; GRADE: moderate). The likelihood of hospital admission for any cause, or for cardiorespiratory causes, did not differ between vaccine and control groups. Vaccination significantly reduced the likelihood of a COPD exacerbation (OR 0.60, 95% CI 0.39 to 0.93; four studies, n = 446; GRADE: moderate). The NNTB to prevent a patient from experiencing an acute exacerbation was 8 (95% CI 5 to 58). Only one study (n = 181) compared the efficacy of different vaccine types - 23-valent PPV versus 7-valent PCV - and reported no differences for CAP, all-cause mortality, hospital admission or likelihood of a COPD exacerbation, but investigators described a greater likelihood of some mild adverse effects of vaccination with PPV-23.

AUTHORS' CONCLUSIONS

Injectable polyvalent pneumococcal vaccination provides significant protection against community-acquired pneumonia, although no evidence indicates that vaccination reduced the risk of confirmed pneumococcal pneumonia, which was a relatively rare event. Vaccination reduced the likelihood of a COPD exacerbation, and moderate-quality evidence suggests the benefits of pneumococcal vaccination in people with COPD. Evidence was insufficient for comparison of different pneumococcal vaccine types.

Evaluation of antibody levels over 3 years after 23-valent pneumococcal polysaccharide vaccination in patients with pulmonary diseases receiving steroids and immunosuppressive agents

OBJECTIVES

Pneumococcal capsular polysaccharide vaccine is a mainstay for prevention of Streptococcus pneumoniae infection in adults. There is the possibility that this vaccine is less effective in patients undergoing immunosuppressive therapy. In the present study, we aimed to evaluate the immune response following 23-valent pneumococcal polysaccharide vaccination in pulmonary disease patients receiving steroids and immunosuppressive agents (immunosuppressive group).

DESIGN AND METHODS

Antibody levels were measured over 3 years in the immunosuppressive group (median age: 68.5 years) and in aged-match pulmonary disease patients not being treated with immunosuppressive therapy (control group) using enzyme-linked immunosorbent assays.

RESULTS

The geometric mean antibody levels were significantly increased after vaccination in both groups (p < 0.05) and remained above baseline for 3 years. The fold increases 1 month after vaccination were 9.4 (95% confidence interval [CI]: 5.7-15.6) and 8.8 (95% CI: 5.8-13.2) in the immunosuppressive and control groups, respectively (p = 0.813). There was no significant difference in the proportion of subjects with a ≥ two-fold increase of antibody level between the immunosuppressive and control groups at any point.

CONCLUSIONS

These results suggest that immunization with the 23-valent pneumococcal polysaccharide vaccine was effective, even in patients undergoing immunosuppressive therapy and should be recommended for such patients.

Pneumococcal serotype diversity among adults in various countries, influenced by pediatric pneumococcal vaccination uptake

Streptococcus pneumoniae serotypes differ in clinical manifestations among adults. Indirect effects of pediatric use of pneumococcal conjugate vaccines (PCVs) affect rates of adult serotype-specific invasive pneumococcal disease (IPD). To characterize PCV effect on adult serotype patterns, we reviewed the literature for differences in proportions and incidence matching the 23-valent pneumococcal polysaccharide vaccine (PPSV23) and 13-valent PCV within specified geographic and time conditions. For adult IPD serotype distribution before widespread pediatric PCV7 use, the median differential between the 23 and 13 serotypes was 16.3% in the core analysis. After pediatric PCV7 adoption, the median differential was 24.4% (P < .003).The median differential in IPD incidence among adults was 5.6 cases per 100 000 population before pediatric PCV7 use and 6.4 afterward (P = .52). The differential for the serotypes in alternate vaccines helps explain recent national recommendations for one or both vaccines in various populations. These differences may widen further, with more extensive pediatric uptake of higher-valence PCVs.

A century of pneumococcal vaccination research in humans

Sir Almroth Wright coordinated the first trial of a whole-cell pneumococcal vaccine in South Africa from 1911 to 1912. Wright started a chain of events that delivered pneumococcal vaccines of increasing clinical and public-health value, as medicine advanced from a vague understanding of the germ theory of disease to today's rational vaccine design. Early whole-cell pneumococcal vaccines mimicked early typhoid vaccines, as early pneumococcal antisera mimicked the first diphtheria antitoxins. Pneumococcal typing systems developed by Franz Neufeld and others led to serotype-specific whole-cell vaccines. Pivotally, Alphonse Dochez and Oswald Avery isolated pneumococcal capsular polysaccharides in 1916-17. Serial refinements permitted Colin MacLeod and Michael Heidelberger to conduct a 1944-45 clinical trial of quadrivalent pneumococcal polysaccharide vaccine (PPV), demonstrating a high degree of efficacy in soldiers against pneumococcal pneumonia. Two hexavalent PPVs were licensed in 1947, but were little used as clinicians preferred therapy with new antibiotics, rather than pneumococcal disease prevention. Robert Austrian's recognition of high pneumococcal case-fatality rates, even with antibiotic therapy, led to additional trials in South Africa, the USA and Papua New Guinea, with 14-valent and 23-valent PPVs licensed in 1977 and 1983 for adults and older children. Conjugation of polysaccharides to proteins led to several pneumococcal conjugate vaccines licensed since 2000, enabling immunization of infants and young children and resultant herd protection for all ages. Today, emergence of disease caused by pneumococcal serotypes not included in various vaccine formulations fuels research into conserved proteins or other means to maximize protection against more than 90 known pneumococcal serotypes.

The immunogenicity of pneumococcal polysaccharides in infants and children: a meta-regression

The immunogenicity of plain (not conjugated) pneumococcal polysaccharides in children and infants was reviewed using a systematic literature search. Immunogenicity was defined as the fold-increase in serotype specific antibody concentration after a single dose of plain polysaccharide vaccine in unprimed subjects. Meta-regression was used to calculate the influence of study treatments including subject age, sampling time, dosage, immunization route, vaccine composition and study location. Immunogenicity increased with age for all serotypes, and the increase was more rapid in the first 11 months of life. Study location was the next most significant study variable, with higher responses in countries with lower GDP. A flat dose-response curve was observed over a range from 5 to 50 μg polysaccharide. Serotypes 6A, 6B, 14, 19F and 23F were significantly less immunogenic than serotypes 2, 3, 4, 7F, 8, 9N, 9V and 18C in 11 month old children, but continued to increase in immunogenicity with age until reaching similar levels at 6 years. Some proposed T-independent immune mechanisms could explain the differences in serotype immunogenicity.

Injectable vaccines for preventing pneumococcal infection in patients with chronic obstructive pulmonary disease

BACKGROUND

As chronic obstructive pulmonary disease (COPD) progresses, exacerbations can occur with increasing frequency. One goal of therapy is to prevent these exacerbations, thereby reducing morbidity and associated healthcare costs. Pneumococcal vaccinations are one strategy for reducing the risk of infective exacerbations.

OBJECTIVES

To determine the safety and efficacy of pneumococcal vaccination in COPD. The primary outcomes assessed were episodes of pneumonia and acute exacerbations. Secondary outcomes of interest included hospital admissions, adverse events related to treatment, disability, change in lung function, mortality, and cost effectiveness.

SEARCH STRATEGY

We searched the Cochrane Airways Group COPD trials register and the databases CENTRAL, MEDLINE and EMBASE using pre-specified terms. The latest searches were performed in March 2010.

SELECTION CRITERIA

Randomised controlled trials assessing the effects of injectable pneumococcal vaccine in people with COPD were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and three review authors independently assessed trial quality.

MAIN RESULTS

Seven studies were identified that met the inclusion criteria for this review and were included in the 2010 review update. Two older trials used a 14-valent vaccine and five more recent trials used a 23-valent injectable vaccine.In six studies involving 1372 people, the reduction in likelihood of developing pneumonia with pneumococcal vaccination compared to control did not achieve statistical significance, the odds ratio (OR) was 0.72 (95% confidence interval (CI) 0.51 to 1.01), with moderate heterogeneity present between studies. The reduction in likelihood of acute exacerbations of COPD from two studies involving 216 people was not statistically significant (Peto OR 0.58; 95% CI 0.30 to 1.13).Of the secondary outcomes for which data were available there was no statistically significant effect for reduction in hospital admissions (two studies) or emergency department visits (one study). There was no significant reduction in pooled results from three studies involving 888 people for odds of all-cause mortality for periods up to 48 months post-vaccination (OR 0.94; 95% CI 0.67 to 1.33), or for death from cardiorespiratory causes (OR 1.07; 95% CI 0.69 to 1.66).

AUTHORS' CONCLUSIONS

The limited evidence from randomised controlled trials (RCTs) included in this review suggests that, while it is possible that injectable polyvalent pneumococcal vaccines may provide some protection against morbidity in persons with COPD, no significant effect on any of the outcomes was shown. Further large RCTs in this population would be needed to confirm effectiveness of the vaccine suggested by results from longitudinal studies.

Expression profiling of inflammatory mediators in pediatric sinus mucosa

OBJECTIVE

To evaluate gene expression by microarray analyses of inflammatory mediators in the sinus mucosa of children with and without chronic rhinosinusitis (CRS).

DESIGN

Prospective molecular genetics analysis.

SETTING

Children's National Medical Center, Washington, DC.

SUBJECTS

Eleven patients with CRS who underwent endoscopic sinus surgery and 10 control children who underwent craniofacial resection or neurosurgical procedures.

MAIN OUTCOME MEASURES

Gene expression levels of sinus tissue from 6 patients with CRS and 6 controls and messenger RNA expression levels of upregulated inflammatory/immune response genes, as well as cytokines of interest, determined by quantitative reverse transcription-polymerase chain reaction.

RESULTS

Gene expression using the Plier algorithm yielded the most consistent grouping of samples: 96 genes were significantly upregulated more than 2-fold, and 123 genes were downregulated by at least 50% in the CRS sinus tissues compared with controls (P < .05). GeneSpring analysis demonstrated significant changes in several ontology categories in the CRS samples, including inflammatory/immune response genes. The chemokines CXCL13 and CXCL5, serum amyloid A, serpin B4, and defensin beta1 were highly upregulated (> or =5-fold). Increased expression of these genes was validated by quantitative reverse transcription-polymerase chain reaction in an independent set of tissues. Expression levels of interleukins 5, 6, and 8 were similar in both cohorts; these results were validated by reverse transcription-polymerase chain reaction.

CONCLUSIONS

Microarray analyses of sinus mucosa in children with CRS showed an increased expression of inflammatory genes involved in innate and adaptive immune systems. This technology can be successfully used to identify genes implicated in the pathogenesis of pediatric CRS.

Adverse reactions to simultaneous influenza and pneumococcal conjugate vaccinations in children: randomized double-blind controlled trial

In a randomized double-blind controlled trial, the safety was assessed of simultaneous administration of influenza and pneumococcal conjugate vaccines in children with previous physician-diagnosed respiratory tract infections. In total, 579 children aged 18-72 months were assigned to receive simultaneous intramuscular influenza and pneumococcal heptavalent conjugate vaccinations (IV + PV), influenza and placebo vaccinations (IV + plac) or control hepatitis B and placebo vaccinations (HepB + plac) in separate extremities. Local and systemic adverse events were recorded in parental diaries for 7 days after vaccination. No immediate adverse reactions were recorded. In most children local adverse reactions disappeared 2 days after vaccination. Local and systemic reactions were more prevalent (30% and 10% more) in the IV + PV group compared with the IV + plac and HepB + plac group. These results are important for designing future vaccination schedules.

Localization and expression of MUC5B and MUC7 mucins in pediatric sinus mucosa

OBJECTIVES

The purpose of this study was to analyze the secretory cell population and distribution of MUC5B and MUC7 mucins in the sinus mucosa of pediatric patients with and without chronic rhinosinusitis (CRS).

METHODS

Sinus mucosal specimens were collected at surgery in a pediatric tertiary care facility. Histologic, immunohistochemical, and morphometric analyses were performed on sinus mucosa of 20 children with CRS and 7 children without CRS.

RESULTS

A significant increase in the area of submucosal glands was evident in the sinus mucosa of children with CRS as compared to controls. MUC5B and MUC7 mucins were expressed in the submucosal glands, as well as in goblet cells, in the sinus mucosa of both populations. No differences in MUC5B or MUC7 expression were observed when mucin expression was normalized to glandular area.

CONCLUSIONS

Children with CRS have an increased number of submucosal glands, indicating that glandular mucins contribute to mucus overproduction in CRS. MUC5B and MUC7 mucins, which have previously been considered only glandular mucins, are also expressed in goblet cells in the sinus mucosa.

Injectable vaccines for preventing pneumococcal infection in patients with chronic obstructive pulmonary disease

BACKGROUND

As chronic obstructive pulmonary disease (COPD) progresses, exacerbations can occur with increasing frequency. One goal of therapy in COPD is to try and prevent these exacerbations, thereby reducing disease morbidity and associated healthcare costs. Pneumococcal vaccinations are considered to be one strategy for reducing the risk of infective exacerbations.

OBJECTIVES

To determine the safety and efficacy of pneumococcal vaccination in COPD. The primary outcome assessed was acute exacerbations. Secondary outcomes of interest included episodes of pneumonia, hospital admissions, adverse events related to treatment, disability, change in lung function, mortality, and cost effectiveness.

SEARCH STRATEGY

We searched the Cochrane Airways Group COPD trials register using pre-specified terms. We also conducted additional handsearches of conference abstracts. The last round of searches were performed in April 2006.

SELECTION CRITERIA

Only randomised controlled trials assessing the effects of injectable pneumococcal vaccine in people with COPD were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and three review authors independently assessed trial quality.

MAIN RESULTS

Although 10 studies cited in 11 publications were identified that met the inclusion criteria for this review, only four of these provided data on participants with COPD. The studies which did provide data for this review consisted of two trials using a 14-valent vaccine, and two using a 23-valent injectable vaccine. Data for the primary outcome, acute exacerbation of COPD, was available from only one of the four studies. The odds ratio of 1.43 (95% confidence interval (CI) 0.31 to 6.69) between interventions was not statistically significant. Of the secondary outcomes for which data were available and could be extracted, none reached statistical significance. Three studies provided dichotomous data for persons who developed pneumonia (OR 0.89, 95% CI 0.58 to 1.37, n = 748). Rates of hospital admissions and emergency department visits came from a single study. There was no significant reduction in the odds of all-cause mortality 1 to 48 months post-vaccination (Peto odds ratio 0.94, 95% CI 0.67 to 1.33, n = 888), or for death from cardiorespiratory causes (OR 1.07, 95% CI 0.69 to 1.66).

AUTHORS' CONCLUSIONS

There is no evidence from randomised controlled trials that injectable pneumococcal vaccination in persons with COPD has a significant impact on morbidity or mortality. Further large randomised controlled trials would be needed to ascertain if the small benefits suggested by individual studies are real.

Immunization of aged mice with a pneumococcal conjugate vaccine combined with an unmethylated CpG-containing oligodeoxynucleotide restores defective immunoglobulin G antipolysaccharide responses and specific CD4+-T-cell priming to young adult levels

Polysaccharide (PS)-protein conjugate vaccines, in contrast to purified PS vaccines, recruit CD4+-T-cell help and restore defective PS-specific humoral immunity in the immature host. Surprisingly, in the immunocompromised, aged host, anti-PS responses to conjugate vaccines are typically no better than those elicited by purified PS vaccines. Although aging leads to defects in multiple immune cell types, diminished CD4+-T-cell helper function has recently been shown to play a dominant role. We show that in response to immunization with purified pneumococcal capsular PS serotype 14 (PPS14) in saline, the T-cell-independent immunoglobulin G (IgG) anti-PPS14 response in aged mice was comparable to that in young mice. In contrast, the T-cell-dependent IgG anti-PPS14 response to a soluble conjugate of PPS14 and pneumococcal surface protein A (PspA) (PPS14-PspA) in saline was markedly defective. This was associated with defective priming of PspA-specific CD4+ T cells. In contrast, immunization of aged mice with PPS14-PspA combined with an unmethylated CpG-containing oligodeoxynucleotide (CpG-ODN) restored IgG anti-PPS14 responses to young adult levels, which were substantially higher than those observed using purified PPS14. This was associated with enhanced PspA-specific CD4+-T-cell priming. Similarly, intact Streptococcus pneumoniae capsular type 14, which contains Toll-like receptor (TLR) ligands, also induced substantial, though modestly reduced, T-cell-dependent (TD) IgG ant-PPS14 responses in aged mice. Spleen and peritoneal cells from aged and young adult mice made comparable levels of proinflammatory cytokines in response to CpG-ODN, although cells from aged mice secreted higher levels of interleukin-10. Collectively, these data suggest that inclusion of a TLR ligand, as an adjuvant, with a conjugate vaccine can correct defective TD IgG anti-PS responses in elderly patients by augmenting CD4+-T-cell help.

Reactions after 3 or More Doses of Pneumococcal Polysaccharide Vaccine in Adults in Alaska

BACKGROUND

Following vaccination with 23-valent pneumococcal polysaccharide vaccine (PPV), pneumococcal antibody levels decline to prevaccination levels within 6-10 years. The Advisory Committee on Immunization Practices does not recommend routine revaccination because data on the safety and effectiveness of additional doses are insufficient.

METHODS

To determine whether medically attended adverse events occur more frequently after the third dose of PPV than after the first or second dose, we performed a retrospective review of medical records from a computer database for health care facilities that serve more than one-half of the Alaska Native population. All persons who had received > or = 3 PPV doses (n = 179) were included in the review, as were a randomly selected comparison group of 181 persons who had received 1 or 2 doses.

RESULTS

Only 1 (0.55%) of 179 persons who had received > or = 3 PPV doses and 4 (2.76%) of 181 persons in the comparison group had a medically attended adverse event, and no severe adverse events were recorded.

CONCLUSION

We found no difference in the risk of medically attended adverse events following > or = 3 doses of PPV, compared with 1 or 2 doses.

Reactions after pneumococcal vaccine alone or in combination with influenza vaccine

We studied adverse reactions to immunisation in 541 individuals receiving simultaneous pneumococcal and influenza vaccination, and in 320 recipients of pneumococcal vaccine alone. Five days after immunisation, the participants completed a questionnaire covering systemic and local reactions to vaccination. Adverse effects were rated as mild if they did not interfere with the participant's daily activities, and moderate or serious if they moderately or markedly restricted these activities. There were no differences between the groups regarding general malaise, headache, myalgias and elevated body temperature. Redness at the injection site, but not soreness or swelling, occurred more frequently in individuals immunised simultaneously with both vaccines. Except for fever and local swelling, adverse reactions were significantly more frequent in women than in men in study groups. The rate of adverse reactions was higher in individuals less then 65 years of age than in older participants. Local reactions were reported by 358 (41.6%) participants, but they were mild and soon subsided. No serious reactions were reported. pneumococcal and influenza vaccine can be safely administered simultaneously.

Vaccines administered simultaneously: directions for new combination vaccines based on an historical review of the literature

OBJECTIVES

The recognized benefits of administering vaccines simultaneously has encouraged vaccine producers to develop combination vaccines. If contemporary research and development can realize vaccines that achieve the current standards for safety, immunogenicity, and efficacy, other specific vaccine associations may also merit reconsideration as combination vaccines.

METHODS

An historical review of the vaccine association literature reveals two important themes: first, the programs of mass vaccination, in particular, the eradication of smallpox, sessions where multiple vaccines (other than the smallpox vaccine) were given concurrently, and the Expanded Programme on Immunization (EPI); and, second, the domain of travel vaccines, including travellers to a disease-endemic country (such as migrants, tourists, military personnel, or expatriates) and WHO requirements for international travellers.

RESULTS/CONCLUSIONS

Based on this historical review, combination vaccines worth reconsideration could fill epidemiologic niches in the EPI with, for instance, a measles--yellow fever, a measles--Japanese encephalitis or a pertussis-based paediatric combination rabies vaccine. Furthermore, other combinations could broaden protection against the pathogens responsible for meningitis, pneumonia, or enteric diseases. Nevertheless, complex issues such as necessity, feasibility, or affordability will ultimately determine if any one of these becomes a combination vaccine.

Preventive health care in the elderly population: a guide for practicing physicians

Preventive medicine provides important benefits to all persons, including older adults; however, these benefits may be seen more clearly in younger adults than in older persons. Smoking cessation, proper nutrition, exercise, and immunizations are important regardless of age. The prevalence of illness increases as we age; at the same time, life expectancy decreases. All physicians and patients should consider the potential benefits of screening and treatment vs conservative management. We discuss lifestyle recommendations such as smoking cessation, exercise, and good nutrition, as well as the role of screening for cardiovascular disease, cancer, and sensory and other disorders. These recommendations are derived from evidence-based guidelines when available; issues not associated with established guidelines are discussed on the basis of best current thinking.

Safety profile of recombinant canarypox HIV vaccines

Attenuated poxviruses have been developed for use as candidate vaccine vectors. ALVAC, a strain of the Avipoxvirus canarypox, has been extensively evaluated as a vector for vaccines against the human immunodeficiency virus type 1 (HIV-1). This report presents the safety and reactogenicity data derived from 11 multicenter, randomized controlled trials of ALVAC-HIV vaccines conducted by the HIV Vaccine Trials Network (HVTN) and its predecessor, the AIDS Vaccine Evaluation Group (AVEG). Five different ALVAC vaccine constructs were tested among 1497 volunteers. Reactogenicity was similar for different ALVAC constructs. Local reactions of any grade to ALVAC vaccines were common. However, fewer than 2% of vaccinees had severe local responses, and less than 1% experienced severe local pain or tenderness. Systemic responses were mild and transient. As combination vaccine regimens are in common use, we also evaluated side effects of ALVAC vectors given in combination with a recombinant subunit protein. No significant differences were noted in the reactogenicity of ALVAC given with or without a recombinant envelope subunit vaccine. Black, non-Hispanic and male recipients of ALVAC-HIV reported less pain following vaccination than White, non-Hispanics and females, respectively. ALVAC-HIV vaccines are well tolerated at tested doses. The reactogenicity profiles are comparable to those reported for existing vaccines licensed for use among adults. Reactogenicity does not appear to be related to the number or type of inserted genes, and did not vary between different ALVAC constructs.

Pneumococcal vaccination and revaccination of older adults

As individuals advance in age, the risk of infection, bacteremia, and mortality caused by Streptococcus pneumoniae rises. Retrospective data demonstrate that the licensed penumococcal polysaccharide vaccine (PPV) is effective in older persons in reducing serotype-specific invasive disease. PPV demonstrates good immunogenicity in older adults, generally comparable to that in younger subjects, although certain cohorts respond less well. The response to PPV is T cell independent, however, and does not elicit immunologic memory. The duration of the anti-capsular polysaccharide antibody response appears to wane as early as 3 years after vaccination. In older persons, revaccination induces an antibody response, although it may not be as strong as that from the initial vaccine. While revaccination of older adults has been recommended, clinical efficacy has not yet been proven. Measures of antibody function may be at least as important in determining protection as are quantitative antibody levels. Additional studies of immunogenicity, particularly regarding revaccination, will facilitate the design of an optimal pneumococcal vaccination policy. Research into conjugate- and protein-based pneumococcal vaccines, which elicit T-cell-dependent responses and induce immunologic memory, is needed in older persons. In the meantime, administering to PPV to recommended groups should be a public health priority.

Rare systemic dermatologic reaction after pneumococcal vaccine administration

This case report describes a rare dermatologic reaction in a patient after administration of pneumococcal vaccine. A 65-year-old man developed an extensive dermatitis with pruritus, urticaria, and petechiae 1 week after receiving an intramuscular injection o the vaccine. The reaction resolved with application of topical steroids and oral diphenhydramine hydrochloride. This case report and others in the literature suggest the importance of recognizing the possibility of cutaneous adverse reactions with vaccines, such as the pneumococcal vaccine, which in general have a good safety profile.

Assessing pneumococcal revaccination safety among New York State Medicare beneficiaries

OBJECTIVE

There have not been adequate studies of the safety of pneumococcal revaccination, especially for revaccination at intervals of less than five years. The objective of this study was to assess revaccination safety by determining whether pneumococcal revaccination is associated with greater utilization of postvaccination health care, compared with initial vaccination.

METHODS

The authors conducted a retrospective cohort study of 119,990 New York State Medicare beneficiaries 65 years of age and older who received pneumococcal vaccinations from February 1, 1999, through December 17, 1999. The study used a multivariate regression model with three primary outcome measures-emergency room visits, hospitalizations, and office visits during the two weeks postvaccination. Secondary outcome measures were specific International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes potentially related to adverse vaccine reactions.

RESULTS

Of 119,990 patients, 23,663 had previous claims for pneumococcal vaccination, including 13,466 for whom the revaccination interval was less than five years. After adjustment for demographic and comorbidity factors, revaccination at less than five years was associated with higher rates of emergency room visits (odds ratio [OR] = 1.17; 95% confidence interval [CI] 1.02, 1.34) and office visits (OR = 1.13; 95% CI 1.09, 1.18) during the two-weeks postvaccination, compared with initial vaccination. In addition, several ICD-9-CM codes that might indicate vaccine reactions were recorded more frequently for the revaccination group than for the comparison group.

CONCLUSIONS

Because of potential policy implications, further investigation is needed of the causes and consequences of short-interval revaccination.

Cost-effectiveness of the pneumococcal vaccine in healthy younger adults

OBJECTIVES

Routine vaccination for Streptococcus pneumoniae has been recommended as a cost-effective measure for elderly and immunocompromised patients, yet no analysis has been performed for healthy younger adults in America. The authors evaluated the cost-effectiveness of the pneumococcal vaccine and determined the net health benefits conferred for the healthy young adult population.

METHODS

The authors developed a decision model to compare the health and economic outcomes of vaccinate versus do not vaccinate for S. pneumoniae.

RESULTS

Vaccinating patients for S. pneumoniae generates benefits that are dependent on incidence rates and the efficacy of the vaccine. In the 22-year-old patient with a pneumonia incidence of 0.3/1000, the vaccine would need to be > 71 percent effective for the vaccination strategy to cost less than $50,000/QALY gained. At an incidence of 0.4/1000, the threshold efficacy is 53 percent, whereas at 0.5/1000 it is 43 percent. In the 35-year-old patient where the incidence of pneumococcal pneumonia is higher (0.85/1000), the vaccine would be cost-effective with an efficacy as low as 30 percent.

CONCLUSIONS

Use of the S. pneumoniae vaccine in young adults would provide modest reductions in pneumonia-associated morbidity and mortality. Vaccination of young adults is moderately expensive unless vaccine efficacy is above 50% to 60%. In 35-year-old adults, use of the vaccine is cost-effective even with moderate efficacy.

Safety and acceptability of pneumococcal vaccinations administered in nontraditional settings

BACKGROUND

Concerns about the safety and acceptability of vaccine administration in nontraditional settings might leave patients and their providers reluctant to take advantage of nontraditional settings for immunizations.

METHODS

Elderly persons who received pneumococcal vaccinations in these settings were surveyed with a structured questionnaire. They were asked about local and systemic symptoms during the postvaccination week versus a comparison time period.

RESULTS

Of the 1136 people included in the convenience sample, 636 responded (56%). Systemic symptoms were generally at similar or lower rates for the postvaccination week versus the comparison week, although fever was more common during the postvaccination week (3% vs 0.3%; P <.01). After vaccination 23.1% had any local symptom (soreness, redness, or swelling). Subjects who had been previously vaccinated were more likely to report local redness or swelling than were first-time vaccine recipients or people who were unsure of their vaccination status (13.1% vs 4.4% vs 1.4%, respectively; P =.001). In multivariate analyses, local symptoms were strongly associated with fever after vaccination (adjusted odds ratio, 13.15; P <.001), and revaccination was strongly associated with local symptoms (adjusted odds ratio, 3.77; P <.001). One hundred percent of respondents were very or somewhat satisfied with their experience, and >99% would recommend a nontraditional setting to a friend or family member.

CONCLUSION

Nontraditional settings offer a safe and highly satisfactory option for the administration of pneumococcal vaccinations to the elderly.

Introducing a pneumococcal vaccine to an existing influenza immunization program: vaccination rates and predictors of noncompliance

PURPOSE

Influenza vaccination has been recommended for all elderly people in The Netherlands since 1996, with greater than 80% compliance. It is unknown, however, if the addition of another vaccine to this immunization program will affect compliance.

SUBJECTS AND METHODS

General practitioners offered a pneumococcal vaccine together with the yearly influenza vaccination to 3365 patients aged 65 years and older. A questionnaire was then mailed to a stratified sample (n = 972) of these patients. Factors associated with noncompliance with vaccination were assessed using polytomous logistic regression.

RESULTS

A total of 2529 patients (75%) received the pneumococcal vaccine and 2812 (84%) received the influenza vaccine. Predictors of noncompliance with the pneumococcal vaccine were perceived lack of recommendation by the general practitioner (odds ratio [OR] = 4.6; 95% confidence interval [CI], 2.6 to 8.3) and fear of local side effects (OR = 2.8; 95% CI, 1.6 to 4.6). Predictors of noncompliance with both vaccinations also included unwillingness to comply with the doctor's advice (OR = 6.1; 95% CI, 2.4 to 15.4), the belief that vaccinations weaken one's natural defenses (OR = 2.7; 95% CI, 1.4 to 5.3) or that influenza is not dangerous (OR = 2.9; 95% CI, 1.5 to 5.4), and the fear of becoming sick from pneumococcal vaccination (OR = 2.9; 95% CI, 1.1 to 7.9). People who felt healthy, found it difficult to visit the doctor's office, had private medical insurance, or were younger than 75 years of age also had a greater risk of not being vaccinated.

CONCLUSION

Introducing a pneumococcal vaccine to an existing influenza immunization program resulted in high pneumococcal and influenza vaccination rates. A wider diversity of patient characteristics and attitudes was present when neither vaccination was received.

Rethinking recommendations for use of pneumococcal vaccines in adults

Streptococcus pneumoniae remains a major cause of disease worldwide; the emergence of antibiotic-resistant strains emphasizes the importance of disease prevention by use of vaccines. Recent studies have provided information that is useful for the evaluation of current vaccine recommendations. Recommendations target most people who are at high risk for invasive pneumococcal disease. However, higher risk has also been identified for African Americans and smokers, but these groups are not specifically targeted by current recommendations. The vaccine is effective against invasive disease in immunocompetent people, although studies in immunocompromised subjects have found few subgroups in which the vaccine appears to be effective. Questions with regard to optimal timing and indications for revaccination remain a challenge, because the duration of protection and effectiveness of revaccination remain unknown. New pneumococcal vaccines appear promising but will need to be tested against the performance of the polysaccharide vaccine. Improving delivery of the currently available pneumococcal polysaccharide vaccine to adults who will benefit should be a high priority.

Pneumococcal disease among human immunodeficiency virus-infected persons: incidence, risk factors, and impact of vaccination

To determine the factors associated with pneumococcal disease (pneumococcal pneumonia or invasive disease) and the impact of pneumococcal vaccine in HIV-infected persons, we analyzed patient data collected by the Adult and Adolescent Spectrum of HIV Disease Project for person-time between January 1990 and December 1998. Among 39,086 persons with 71,116 person-years (py) of observation, 585 episodes of pneumococcal disease were diagnosed (incidence, 8.2 episodes per 1000 py). Factors associated with an increased risk for pneumococcal disease (P < .05) included injection drug use (adjusted relative risk [RR], 1.5) and blood transfusion (RR, 2.0) as the mode of HIV transmission (referent, male-male sex); black race/ethnicity (RR, 1.5; referent, white race); history of acquired immunodeficiency syndrome (AIDS)-defining opportunistic illness (RR, 2.1); a CD4(+) cell count of 200-499 cells/microL (RR, 2.5) or < 200 cells/microL (RR, 3.7; referent, CD4(+) cell count of > or = 500 cells/microL); and alcoholism (RR, 2.0). Factors associated with a decreased risk included prescription of antiretroviral therapy (RR for monotherapy, 0.6; for dual therapy, 0.7; for triple therapy, 0.5) and pneumococcal vaccination (RR for persons vaccinated at a CD4(+) cell count of > or = 500 cells/microL, 0.5). We recommend that pneumococcal vaccine be given to HIV-infected persons before profound immunosuppression has occurred.

A cost-effectiveness analysis of pneumococcal vaccination in street-involved, HIV-infected patients

BACKGROUND

Delivery of the pneumococcal vaccine (PCV) to street-involved, HIV patients in British Columbia is low due to poor compliance. Since the use of PCV is expected to reduce morbidity and mortality, it may be more cost-effective to provide the vaccine directly to clinics.

METHODS

Three strategies were compared for a cohort of 5000 patients: 1) administering PCV at the clinics; 2) giving a prescription for PCV and expecting patients to fill it at a pharmacy and return for administration; and 3) no administration of vaccine. Decision analysis was utilized to map the costs and outcomes of the patients over 5 years and conduct an incremental cost-effectiveness analysis from the perspective of the Ministry of Health.

RESULTS

The average cost per patient was the lowest in Strategy 1 ($549) compared to Strategy 2 ($702) and Strategy 3 ($714). For the cohort, Strategy 1 prevented 269 and 299 additional cases of pneumococcal disease and resulted in a cost savings of $535,000 and $595,000 in direct medical costs when compared to Strategies 2 and 3, respectively. The model was robust to extensive sensitivity analyses.

CONCLUSIONS

The Ministry of Health should supply PCV to clinics involved in the care of street-involved HIV patients as this is the most cost-effective strategy.

Cost-effectiveness of the pneumococcal vaccine in the United States Navy and Marine Corps

Vaccination for Streptococcus pneumoniae has been recommended for its efficacy and cost-effectiveness in elderly and immunocompromised populations. However, its use in active-duty military personnel has not been analyzed. We developed a Markov model to evaluate health and economic outcomes of vaccinating or not vaccinating all members of the active-duty cohort, measuring quality-adjusted life years (QALYs) gained, costs, and marginal cost-effectiveness. Pneumococcal pneumonia vaccination increased each person's life expectancy by 0. 03 days and decreased costs by $9.88 per person. The magnitude of the benefit of immunization is moderately sensitive to the rate of serious side effects caused by the vaccine, the incidence of pneumonia, the length of protection, and the efficacy of the vaccine. Vaccinating all 575,000 active-duty US Navy and Marine Corps members could save $5.7 million during the time the members are alive and on active duty and could provide a total gain of 54 QALYs. On the basis of these results, the military should consider expanding current guidelines to include pneumococcal vaccine immunization for all active-duty members of the military.

Determination of antibody responses of elderly adults to all 23 capsular polysaccharides after pneumococcal vaccination

The 23-valent pneumococcal polysaccharide vaccine was formulated to prevent invasive infection in the elderly and other high-risk populations from the most prevalent Streptococcus pneumoniae serotypes. However, the immunogenicity of all 23 vaccine polysaccharides has not been fully characterized in elderly adults. We previously reported that whereas the majority of elderly subjects had vigorous immune responses to selected pneumococcal vaccine polysaccharides, a subset of elderly individuals responded to fewer than two of seven vaccine serotypes after immunization. To determine whether these elderly low responders have a general inability to respond to pneumococcal vaccine and to determine whether elderly low responders might be identified by their responses to a few polysaccharides, we measured antibody responses of elderly adults to all 23 vaccine polysaccharides after pneumococcal immunization. As a group, elderly subjects showed a significant rise after immunization in geometric mean antibody levels to all 23 vaccine serotypes. However, when individual rather than group immune responses were assessed, the 23-valent vaccine did not appear to be uniformly immunogenic in these elderly subjects. Eleven elderly subjects (20%) had twofold increases in specific antibody after vaccination to only 5 or fewer of the 23 vaccine polysaccharides, and they did not respond to the most prevalent serotypes causing invasive disease. Antibody responses to serotype 9N were found to reliably distinguish low vaccine responders from other elderly subjects. However, no particular group of vaccine polysaccharides could be used as a marker for adequate immune responses if only postvaccination sera were analyzed.

Personal historical chronicle of six decades of basic and applied research in virology, immunology, and vaccinology

The sciences of vaccinology and of immunology were created just two centuries ago by Jenner's studies of prevention of smallpox by inoculation with cowpox virus. This rudimentary beginning was expanded greatly by the giants of late 19th and early 20th centuries biomedical sciences. The period from 1930 to 1950 was a transitional era with the introduction of chick embryos and minced tissues for propagating viruses and rickettsiae in vitro for vaccines. Modern era vaccinology began about 1950 as a continuum of notable advances made during the 1940s and World War II. Present vaccinology is based largely on breakthroughs in cell culture, bacterial polysaccharide chemistry, molecular biology, and immunology. By invitation, the author, who is a microbe hunter in fact, was asked to chronicle his six decades of pioneering achievements in basic and applied virology, bacteriology, immunology, molecular biology, epidemiology, and cancer, with special reference to the pioneering creation of most of the present day vaccines. Knowledge of the past may guide the present and future. This chronicle will have achieved its legacy if it helps others to understand the why and how of the past that may help to create the substance of the future.

The additive benefits of influenza and pneumococcal vaccinations during influenza seasons among elderly persons with chronic lung disease

Uncertainty regarding the benefits of pneumococcal vaccination may contribute to the under use of this vaccine. The present study was conducted to clarify the benefits of influenza and pneumococcal vaccinations during 3 influenza seasons among elderly persons with chronic lung disease. All elderly members of a large managed care organization with a prior diagnosis of chronic lung disease were included in a cohort that was followed over three influenza seasons (1993-1994, 1994-1995, and 1995-1996). Data obtained from the administrative data bases of the health care organization included baseline demographic and health characteristics, influenza vaccination status for each season, date of pneumococcal vaccination, and outcomes for each season including hospitalization for pneumonia and death. Cox proportional hazards regression and Poisson regression with repeated measures were used to compare the risk of outcomes among vaccinated and unvaccinated persons while controlling for covariates and confounders. During the three influenza seasons, influenza vaccination alone was associated with a 52% reduction (95% CI 18-72) in hospitalizations for pneumonia and a 70% reduction (95% CI 57-89) in death. Pneumococcal vaccination alone during the three influenza seasons was associated with a 27% reduction (95% CI 13-52) in hospitalizations for pneumonia and a 34% reduction (95% CI 6-54) in death. Both vaccinations together demonstrated additive benefits. When both vaccinations had been received, there was a 63% reduction (95% CI 29-80) in hospitalizations for pneumonia and an 81% reduction (95% CI 68-88) in death versus when neither had been received. These findings suggest pneumococcal vaccination is associated with substantial benefits for elderly persons with chronic lung disease.

Pneumococcal vaccines: history, current status, and future directions

Streptococcus pneumoniae is the leading cause of community-acquired pneumonia and bacterial meningitis. Although effective antimicrobial drugs have reduced case fatality, the pneumococcus remains a leading global cause of morbidity and mortality. Therefore, prevention of infection by vaccination with the pneumococcal polysaccharide vaccine is recommended for persons at high risk for serious pneumococcal disease, such as the elderly and individuals with certain underlying medical conditions. Pneumococcal polysaccharide vaccines are safe and effective for the prevention of invasive infection among immunocompetent children and adults but are not immunogenic in infants. Conjugation of pneumococcal polysaccharides to a carrier protein improves immune responses among infants, and conjugate vaccines are currently being evaluated in large efficacy trials. The role of pneumococcal conjugate vaccines in adults has not been determined. Pneumococcal vaccines directed against pneumococcal proteins and DNA vaccines that induce anti-pneumococcal antibodies have been evaluated in animal models and may someday provide complementary or alternative methods for preventing pneumococcal infection. Improved utilization of the pneumococcal polysaccharide vaccine and continued development of improved vaccines are essential, and the emergence of drug-resistant strains of S. pneumoniae highlights the importance of preventing pneumococcal infections by vaccination.

Immediate hypersensitivity in adults with IgG deficiency and recurrent respiratory infections

BACKGROUND

Little is known about the prevalence of atopy in adults with recurrent respiratory infections and IgG deficiency.

OBJECTIVE AND METHODS

To elucidate this aspect, we skin-tested 95 consecutive adults with respiratory infections, subnormal levels of IgG subclasses or common variable immunodeficiency and usually poor response to vaccination. In 50 subjects we also measured total IgE.

RESULTS

We found 67 subjects with IgG subclass deficiency, 21 subjects with mild (partial) and 5 with usual common variable immunodeficiency, and 2 subjects with functional IgG deficiency. Atopy was encountered in 42/95 subjects, 33/44 (75%) with asthma, 7/19 (38%) with isolated rhinosinusitis, 1/27 (4%) with chronic obstructive lung disease, and 1/5 (20%) with both the latter disease and asthma, respectively. Atopy was preferentially clustered in subjects with asthma (P < .05) who were less than 40 years of age (P < .05) and nonsmoking. Atopy was not affected by the type of IgG deficiency, unless it was usual common variable immunodeficiency, in which case the skin tests tended to be negative (4/5). Total IgE was within normal range but less elevated than usually seen in asthma or chronic obstructive lung disease. Total IgE was independent of the type of IgG deficiency, except for usual common variable immunodeficiency in which it remained < 10 IU/mL.

CONCLUSIONS

In adults with symptomatic IgG deficiency, the prevalence of immediate hypersensitivity and its modulation by age and smoking are similar to the referred, non-IgG deficient population; however, total IgE may be lower in the former than in the latter. In common variable immunodeficiency, consistent with the literature data, both the prevalence of atopy and serum total IgE are decreased.

Associations of prevaccination antibody levels with adverse reactions to pneumococcal and influenza vaccines administered simultaneously in the elderly

The association of prevaccination antibodies with the adverse reactions seen after vaccination was studied in 85 elderly subjects (65-90 years) vaccinated simultaneously with pneumococcal and influenza vaccines. The subjects with a temperature rise (9% of vaccinees) had significantly higher prevaccination antibody levels to pneumococcal capsular polysaccharides (PPSs) than those without a temperature rise; no difference was seen in their haemagglutination inhibiting (HI) influenza virus antibody levels. Pain in the left arm (the pneumococcal vaccine injection site) occurred in 45% of the subjects and was likewise associated with elevated PPS antibody levels. Pain at the site of influenza vaccine injection (the right arm) seen in 33% of the vaccinees was significantly more common among those who had previously received influenza vaccine, but was not associated with elevated HI antibody levels. In conclusion, prevaccination pneumococcal but not influenza antibodies were associated with both systemic and local reactions following vaccination.

Side effects associated with pneumococcal vaccination

BACKGROUND

Pneumococcal disease is a major cause of morbidity and death, especially among elders and other people at high risk. In spite of long-standing national recommendations for its use, pneumococcal vaccine is underused, with 70% or more of targeted persons as yet unimmunized. Concern about side effects is a barrier to successful vaccine delivery.

METHODS

Persons attending a walk-in pneumococcal vaccination clinic were surveyed by use of structured telephone interviews. They were asked about health characteristics and local and systemic symptoms experienced during the week after their vaccination (postvaccination period). These responses were compared with the symptoms they reported for the 7 days immediately preceding their interview (the comparison period).

RESULTS

A total of 1006 persons were interviewed a mean of 65.4 days after their vaccination. They had an average age of 69.9 years, and approximately 95% were in a high-risk group targeted for pneumococcal vaccination. For all systemic symptoms including fever, rash, myalgias, fatigue, malaise, and headache, subjects reported similar or lower rates during the postvaccination week than during the comparison week. Local reactions occurred in 28.2% of subjects. These local symptoms were mild to moderate for more than 90% of subjects and rarely resulted in the need to decrease the use of their arm.

CONCLUSION

Pneumococcal vaccination was not associated with an increase in systemic symptoms but was associated with mild to moderate local symptoms in about one fourth of vaccine recipients. These findings should help health care providers and their patients address an important barrier to pneumococcal immunization.

Comparison of pneumococcal polysaccharide and CRM197-conjugated pneumococcal oligosaccharide vaccines in young and elderly adults

Conjugation of carbohydrate antigens to protein carriers significantly improves the immune response to many carbohydrates. In order to evaluate the potential for this approach to improve the performance of pneumococcal vaccine in the elderly, we evaluated pneumococcal polysaccharide-derived oligosaccharides conjugated to cross-reacting material 197 (CRM197) (CRM-OS) in 49 older adults over 60 years of age (median age, 66 years) and compared the results to those from 50 younger adults under age 45 (median age, 27 years). Subjects were randomly assigned to receive licensed 23-valent polysaccharide vaccine (PS) which contain 25 micrograms of polysaccharide per serotype, or 5-valent CRM-OS, which contains 10 micrograms of oligosaccharide per serotype, in double-blind fashion. Both vaccines were associated with moderate local pain on administration. Antibody responses to type 14 were seen in the majority of both younger and older subjects following administration of both CRM-OS and PS, and there was no significant improvement of responses with CRM-OS in either age group. Antibody responses in young adults to the less immunogenic type 6B were seen in only 36% of subjects receiving PS and in 56% of subjects receiving CRM-OS (P = 0.15), and the geometric mean 6B titer 1 month after vaccination was higher in CRM-OS recipients (10.9 versus 3.7 micrograms/ml; P = 0.04). However, 6B responses were poor following the administration of either vaccine to elderly adults and there was no difference between results with CRM-OS and those with PS in this age group. Relatively few subjects developed measurable mucosal immunoglobulin A responses in nasal secretions following administration of either vaccine. Revaccination of CRM-OS recipients with PS at 2 months did not result in significant additional responses to 6B or 14. Though CRM-OS is possibly more immunogenic in young adults, the formulation of the pneumococcal glycoconjugate vaccine used in this study does not appear to offer an advantage to the elderly for types 6B or 14.

Human anti-pneumococcal polysaccharide antibodies are secreted by the CD5- B cell lineage

To determine whether human antibody responses to T cell-independent pneumococcal polysaccharide antigens are derived from CD5+ or CD5- B cells, we utilized an ELISPOT assay to detect individual anti-polysaccharide antibody-secreting cells. Human anti-type IV pneumococcal polysaccharide antibody-secreting cells were found in the CD5- B cell subpopulation. An EBV transformed anti-pneumococcal antibody-secreting B cell line was also CD5-. The ontogeny of CD5 expressing B cells correlated with the age at which polysaccharide responsiveness is acquired (generally around age 2 years in humans). The CD5- B cell subset represents only 25-30% of the B cells in young children, but this fraction increases throughout childhood to a plateau of 70-80% of the B cells in adults. These results support the hypothesis that the developmental change in responsiveness to T cell-independent polysaccharide antigens in humans is associated with maturation of the CD5- B cell subset.