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Commentary: Pneumococcal disease: is prevention possible?
Comentario: Enfermedad neumocócica: ¿es posible la prevención?
MJ. Álvarez Pasquína, JJ. Gómez Marcoa
a Members of the Infectious Disease Group of the PAPPS-semFYC, Madrid, Spain.
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    "textoCompleto" => "<hr></hr><p class="elsevierStylePara"><img src="27v30n05-13037692tab01.gif"></img></p><p class="elsevierStylePara">The two strategies for dealing with pneumococcal infections are the rational use of antibiotics and vaccination&#46; Effective prevention of <span class="elsevierStyleItalic">Streptococcus pneumoniae</span> infection has become a priority in the current era&#44; when the emergence of antibiotic-resistant strains can compromise efforts to reduce mortality from invasive pneumococcal infection&#46;</p><p class="elsevierStylePara">Despite the seriousness of pneumococcal disease&#44; we do not yet have a vaccine that has been shown to be effective in all target groups&#46; Polysaccharide vaccines are effective in preventing invasive disease in immunocompetent persons&#46; However&#44; studies in different groups of the immunodepressed population have shown their efficacy in these groups to be questionable&#46; The is still little evidence of their usefulness in persons with asthma&#44; patients with HIV infection&#44; and&#173;as discussed in this editorial&#173;in persons older than 65 years&#46; Moreover&#44; recommendations for vaccination have thus far not included other subgroups at high risk for the disease&#44; such as smokers and African Americans&#46;<span class="elsevierStyleSup">1</span></p><p class="elsevierStylePara">As regards the immunogenicity of the vaccine&#44; the immune response induced is not the same in all patients or for all serotypes&#46; Moreover&#44; immunogenicity does not guarantee that opsonizing antibodies will be produced&#46; One study showed a pneumococcal polysaccharide vaccine to be ineffective in older persons because of the lower production of opsonizing antibodies regardless of the titer of antibodies achieved&#46;<span class="elsevierStyleSup">2</span></p><p class="elsevierStylePara">Several meta-analyses have brought to light the controversy regarding the efficacy of pneumococcal polysaccharide vaccines&#46; The analysis by Moore et al&#46; confused circumstances with populations&#44; and as noted in an earlier commentary&#44; the effectiveness of the vaccine was compared in the general population&#44; immunocompromised patients and older persons&#46;<span class="elsevierStyleSup">3</span> The authors of the meta-analysis published in this issue of Atenci&#243;n Primaria are to be commended for responding to the challenge of undertaking a study of high quality in the setting of their primary care activities&#46; However&#44; the study is also remarkable for its rigor in the exhaustive search methods used and in its effort to examine a particular subpopulation characterized by immunodepression&#46;</p><p class="elsevierStylePara">The authors found no proof that pneumococcal polysaccharide vaccination was effective in older persons&#46; As the authors note in their article&#44; the meta-analysis by Hutchinson et al&#46; yielded findings that contradicted those of Puig et al&#46; because the former combined results for different age groups&#46; When this fact was taken into account&#44; the statistical significance of the estimates disappeared&#46; The review by Cornu et al&#46; likewise failed to find any preventive effect&#44; a result the authors attributed to weak statistical power&#46;<span class="elsevierStyleSup">4</span></p><p class="elsevierStylePara">However&#44; questions have been raised with regard to the indication for vaccination&#46; Is it ineffective but nonetheless cost-effective&#63; Does a combined strategy of vaccination during the flu vaccination campaign improve performance by extending coverage&#63; Some clinical studies suggested an additive effect of double vaccination in preventing community-acquired pneumonia&#44; particularly in older persons at greater risk for this disease and for hospitalization&#46;<span class="elsevierStyleSup">5</span> Is pneumococcal vaccination advisable for older institutionalized patients to prevent outbreaks of the disease&#63; Are there any subgroups among older persons for which the indication for vaccination has been clearly established&#44; such as persons with chronic obstructive lung disease&#63; Some indications seem to reserve a role for this controversial vaccination&#46;</p><p class="elsevierStylePara">The recent appearance of conjugate pneumococcal vaccines&#44; which are currently useful in pediatrics&#44; appears to disrupt the transmission of antibiotic-resistant pneumococci&#44; and thereby reduce the rate of resistance in the immunized population and persons who come in contact with immunized individuals&#44; as a result of the &#171;herd effect&#187;&#46; One question worth examining is whether a joint strategy of child vaccination with the conjugate vaccine and the simultaneous administration of flu and pneumococcal polysaccharide vaccination in older persons would lead to a significant decrease in the disease&#44; particularly in cases caused by resistant germs&#46; The effectiveness of conjugate vaccines for adults&#44; especially for groups at greatest risk&#44; also remains to be investigated&#46;</p><p class="elsevierStylePara">A fundamental consideration is immunological memory&#46; Experience to date is limited to <span class="elsevierStyleItalic">Haemophilus influenza</span> type B vaccination&#44; whose epidemiological impact was evident when a conjugate vaccine was used but not with a vaccine prepared from a panel of polysaccharides&#46; Even with the limited information available&#44; the theoretical superiority of conjugate pneumococcal vaccines does not guarantee clinical efficacy&#46;<span class="elsevierStyleSup">6</span> The availability of these vaccines makes additional in-depth epidemiologic studies even more necessary to determine the mortality and morbidity associated with the disease&#44; the serogroups that cause invasive and noninvasive disease&#44; and the serogroups linked to higher rates of resistance&#46; In addition&#44; information is still needed on the existence of carriers and the possible shift of the ecological niche toward other&#44; previously less pathogenic serogroups&#46; The geographic variability of invasive pneumococcal disease supports the need for such studies&#44; and should favor the development of vaccines with shared antigens such as <span class="elsevierStyleItalic"> Pneumococcus</span> surface protein A &#40;PspA&#41; or <span class="elsevierStyleItalic">Pneumococcus</span> surface adhesin &#40;Psa A&#41;&#46;<span class="elsevierStyleSup">3</span></p><p class="elsevierStylePara">As important factor in health care management is cost-effectiveness&#46; In Spain&#44; studies of the type suggested above should be done to determine whether or not vaccination is indicated for older persons&#44; and scientific evidence should be used to try to avoid inequities in the health care system&#46;</p><p class="elsevierStylePara">In conclusion&#44; these are the main issues awaiting resolution&#58;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">&#173; The population of older persons who respond poorly to 23-valent pneumococcal capsular polysaccharide vaccination can be identified as a target population for improved vaccines &#40;conjugate and DNA&#44; currently in the experimental phase&#41;&#46;</p><p class="elsevierStylePara">&#173; Efforts are needed to determine whether treatment of a correctable nutritional deficit would improve the immune response to the polysaccharide vaccine in this group&#46;</p><p class="elsevierStylePara">&#173; Whether the adult population responds more uniformly to new &#40;ie&#44; conjugate and DNA&#41; pneumococcal vaccines should be determined&#46;</p><p class="elsevierStylePara">&#173; Whether smoking cessation decreases the incidence of invasive pneumococcal disease in older persons should be investigated&#46;<span class="elsevierStyleSup">7</span></p>"
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos