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An Evaluation of Current Recommendations

Jay C. Butler, MD; Robert F. Breiman, MD; John F. Campbell, MD; Harvey B. Lipman, PhD; Claire V. Broome, MD; Richard R. Facklam, PhD

JAMA. 1993;270(15):1826-1831.

Abstract
Objective.
—To determine pneumococcal polysaccharide vaccine efficacy in selected populations at risk for serious pneumococcal infection for whom vaccination is currently recommended and to assess duration of protection after vaccination.

Design.
—Vaccine efficacy was estimated using indirect cohort analysis to compare the proportion of pneumococcal infections caused by serotypes included in the vaccines of vaccinated and unvaccinated persons who were identified during 14 years of national surveillance.

Setting.
—Hospital laboratories in the United States that submitted pneumococcal isolates to the Centers for Disease Control and Prevention between May 1978 and April 1992.

Participants.
—A total of 2837 persons older than 5 years who had pneumococcus isolated from blood or cerebrospinal fluid.

Results.
—Overall efficacy for preventing infection caused by serotypes included in the vaccine was 57% (95% confidence interval [Cl], 45% to 66%). Efficacy among persons with diabetes mellitus was 84% (95% Cl, 50% to 95%); with coronary vascular disease, 73% (95% Cl, 23% to 90%); with congestive heart failure, 69% (95% Cl, 17% to 88%); with chronic pulmonary diseases, 65% (95% Cl, 26% to 83%); and with anatomic asplenia, 77% (95% CI, 14% to 95%). Efficacy was not documented for patients with alcoholism or cirrhosis, sickle cell disease, chronic renal failure, lymphoma, leukemia, or multiple myeloma, although sample sizes were small for these groups. Efficacy for immunocompetent persons older than 65 years was 75% (95% Cl, 57% to 85%). Efficacy did not decline with increasing interval after vaccination: 5 to 8 years after vaccination it was 71% (95% Cl, 24% to 89%), and 9 years or more after vaccination it was 80% (95% Cl, 16% to 95%).

Conclusions.
—Intensified efforts to improve pneumococcal vaccine coverage among certain populations for whom vaccination is currently recommended is indicated, but universal revaccination is not warranted at this time.

(JAMA. 1993;270:1826-1831)

Author Affiliations
From the Respiratory Diseases Branch (Drs Butler, Breiman, Campbell, and Facklam), the Biostatistics and Information Management Branch (Dr Lipman), Division of Bacterial and Mycotic Diseases, National Center for Infectious Diseases, and the Office of the Director (Dr Broome), Centers for Disease Control and Prevention, Atlanta, Ga. Dr Campbell is now with the Department of Internal Medicine, Moses Cone Memorial Hospital, Greensboro, NC.

Footnotes
Presented in part at the 32nd Interscience Conference on Antimicrobial Agents and Chemotherapy, Anaheim, Calif, October 14, 1992.

Reprint requests to the Respiratory Diseases Branch, Division of Bacterial and Mycotic Diseases, Centers for Disease Control and Prevention, MS C-09, 1600 Clifton Rd, Atlanta, GA 30333 (Dr Butler).

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