Commentary: Pneumococcal disease: is prevention possible?
Comentario: Enfermedad neumocócica: ¿es posible la prevención?
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"tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:1 [ "paginaInicial" => "283" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "MJ Álvarez Pasquín, JJ Gómez Marco" "autores" => array:2 [ 0 => array:3 [ "Iniciales" => "MJ" "apellidos" => "Álvarez Pasquín" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 1 => array:3 [ "Iniciales" => "JJ" "apellidos" => "Gómez Marco" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:3 [ "entidad" => "Members of the Infectious Disease Group of the PAPPS-semFYC, Madrid, Spain." "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Comentario: Enfermedad neumocócica: ¿es posible la prevención?" ] ] "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. Effective prevention of <span class="elsevierStyleItalic">Streptococcus pneumoniae</span> infection has become a priority in the current era, when the emergence of antibiotic-resistant strains can compromise efforts to reduce mortality from invasive pneumococcal infection.</p><p class="elsevierStylePara">Despite the seriousness of pneumococcal disease, we do not yet have a vaccine that has been shown to be effective in all target groups. Polysaccharide vaccines are effective in preventing invasive disease in immunocompetent persons. However, studies in different groups of the immunodepressed population have shown their efficacy in these groups to be questionable. The is still little evidence of their usefulness in persons with asthma, patients with HIV infection, and­as discussed in this editorial­in persons older than 65 years. Moreover, recommendations for vaccination have thus far not included other subgroups at high risk for the disease, such as smokers and African Americans.<span class="elsevierStyleSup">1</span></p><p class="elsevierStylePara">As regards the immunogenicity of the vaccine, the immune response induced is not the same in all patients or for all serotypes. Moreover, immunogenicity does not guarantee that opsonizing antibodies will be produced. 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.<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. The analysis by Moore et al. confused circumstances with populations, and as noted in an earlier commentary, the effectiveness of the vaccine was compared in the general population, immunocompromised patients and older persons.<span class="elsevierStyleSup">3</span> The authors of the meta-analysis published in this issue of Atención 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. However, 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.</p><p class="elsevierStylePara">The authors found no proof that pneumococcal polysaccharide vaccination was effective in older persons. As the authors note in their article, the meta-analysis by Hutchinson et al. yielded findings that contradicted those of Puig et al. because the former combined results for different age groups. When this fact was taken into account, the statistical significance of the estimates disappeared. The review by Cornu et al. likewise failed to find any preventive effect, a result the authors attributed to weak statistical power.<span class="elsevierStyleSup">4</span></p><p class="elsevierStylePara">However, questions have been raised with regard to the indication for vaccination. Is it ineffective but nonetheless cost-effective? Does a combined strategy of vaccination during the flu vaccination campaign improve performance by extending coverage? Some clinical studies suggested an additive effect of double vaccination in preventing community-acquired pneumonia, particularly in older persons at greater risk for this disease and for hospitalization.<span class="elsevierStyleSup">5</span> Is pneumococcal vaccination advisable for older institutionalized patients to prevent outbreaks of the disease? Are there any subgroups among older persons for which the indication for vaccination has been clearly established, such as persons with chronic obstructive lung disease? Some indications seem to reserve a role for this controversial vaccination.</p><p class="elsevierStylePara">The recent appearance of conjugate pneumococcal vaccines, which are currently useful in pediatrics, appears to disrupt the transmission of antibiotic-resistant pneumococci, and thereby reduce the rate of resistance in the immunized population and persons who come in contact with immunized individuals, as a result of the «herd effect». 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, particularly in cases caused by resistant germs. The effectiveness of conjugate vaccines for adults, especially for groups at greatest risk, also remains to be investigated.</p><p class="elsevierStylePara">A fundamental consideration is immunological memory. Experience to date is limited to <span class="elsevierStyleItalic">Haemophilus influenza</span> type B vaccination, whose epidemiological impact was evident when a conjugate vaccine was used but not with a vaccine prepared from a panel of polysaccharides. Even with the limited information available, the theoretical superiority of conjugate pneumococcal vaccines does not guarantee clinical efficacy.<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, the serogroups that cause invasive and noninvasive disease, and the serogroups linked to higher rates of resistance. In addition, information is still needed on the existence of carriers and the possible shift of the ecological niche toward other, previously less pathogenic serogroups. The geographic variability of invasive pneumococcal disease supports the need for such studies, and should favor the development of vaccines with shared antigens such as <span class="elsevierStyleItalic"> Pneumococcus</span> surface protein A (PspA) or <span class="elsevierStyleItalic">Pneumococcus</span> surface adhesin (Psa A).<span class="elsevierStyleSup">3</span></p><p class="elsevierStylePara">As important factor in health care management is cost-effectiveness. In Spain, studies of the type suggested above should be done to determine whether or not vaccination is indicated for older persons, and scientific evidence should be used to try to avoid inequities in the health care system.</p><p class="elsevierStylePara">In conclusion, these are the main issues awaiting resolution:</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">­ 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 (conjugate and DNA, currently in the experimental phase).</p><p class="elsevierStylePara">­ Efforts are needed to determine whether treatment of a correctable nutritional deficit would improve the immune response to the polysaccharide vaccine in this group.</p><p class="elsevierStylePara">­ Whether the adult population responds more uniformly to new (ie, conjugate and DNA) pneumococcal vaccines should be determined.</p><p class="elsevierStylePara">­ Whether smoking cessation decreases the incidence of invasive pneumococcal disease in older persons should be investigated.<span class="elsevierStyleSup">7</span></p>" "pdfFichero" => "27v30n05a13037692pdf001.pdf" "tienePdf" => true "multimedia" => array:2 [ 0 => array:6 [ "identificador" => "tbl1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "27v30n05-13037692tab01.gif" "imagenAlto" => 260 "imagenAncho" => 334 "imagenTamanyo" => 9847 ] ] ] ] ] ] 1 => array:5 [ "identificador" => "tbl2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" ] ] "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Rethinking recommendations for use of pneumococcal vaccines in adults. 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| 2024 September | 13 | 6 | 19 |
| 2024 August | 21 | 2 | 23 |
| 2024 July | 16 | 4 | 20 |
| 2024 June | 18 | 1 | 19 |
| 2024 May | 21 | 4 | 25 |
| 2024 April | 11 | 8 | 19 |
| 2024 March | 19 | 5 | 24 |
| 2024 February | 19 | 12 | 31 |
| 2024 January | 21 | 7 | 28 |
| 2023 December | 13 | 5 | 18 |
| 2023 November | 22 | 5 | 27 |
| 2023 October | 30 | 10 | 40 |
| 2023 September | 9 | 1 | 10 |
| 2023 August | 11 | 3 | 14 |
| 2023 July | 13 | 8 | 21 |
| 2023 June | 17 | 6 | 23 |
| 2023 May | 13 | 5 | 18 |
| 2023 April | 9 | 4 | 13 |
| 2023 March | 6 | 1 | 7 |
| 2023 February | 9 | 4 | 13 |
| 2023 January | 8 | 11 | 19 |
| 2022 December | 18 | 9 | 27 |
| 2022 November | 26 | 13 | 39 |
| 2022 October | 25 | 17 | 42 |
| 2022 September | 26 | 6 | 32 |
| 2022 August | 30 | 8 | 38 |
| 2022 July | 19 | 8 | 27 |
| 2022 June | 13 | 9 | 22 |
| 2022 May | 16 | 19 | 35 |
| 2022 April | 27 | 14 | 41 |
| 2022 March | 24 | 11 | 35 |
| 2022 February | 14 | 8 | 22 |
| 2022 January | 13 | 11 | 24 |
| 2021 December | 18 | 9 | 27 |
| 2021 November | 13 | 8 | 21 |
| 2021 October | 19 | 10 | 29 |
| 2021 September | 15 | 13 | 28 |
| 2021 August | 9 | 7 | 16 |
| 2021 July | 15 | 6 | 21 |
| 2021 June | 21 | 14 | 35 |
| 2021 May | 25 | 9 | 34 |
| 2021 April | 38 | 5 | 43 |
| 2021 March | 22 | 10 | 32 |
| 2021 February | 11 | 9 | 20 |
| 2021 January | 12 | 6 | 18 |
| 2020 December | 15 | 5 | 20 |
| 2020 November | 8 | 4 | 12 |
| 2020 October | 8 | 3 | 11 |
| 2020 September | 4 | 7 | 11 |
| 2020 August | 11 | 7 | 18 |
| 2020 July | 14 | 6 | 20 |
| 2020 June | 13 | 9 | 22 |
| 2020 May | 12 | 6 | 18 |
| 2020 April | 11 | 6 | 17 |
| 2020 March | 16 | 5 | 21 |
| 2020 February | 18 | 6 | 24 |
| 2020 January | 24 | 4 | 28 |
| 2019 December | 33 | 4 | 37 |
| 2019 November | 10 | 10 | 20 |
| 2019 October | 9 | 4 | 13 |
| 2019 September | 4 | 7 | 11 |
| 2019 August | 8 | 3 | 11 |
| 2019 July | 6 | 5 | 11 |
| 2019 June | 32 | 10 | 42 |
| 2019 May | 96 | 6 | 102 |
| 2019 April | 32 | 6 | 38 |
| 2019 March | 7 | 4 | 11 |
| 2019 February | 9 | 33 | 42 |
| 2019 January | 11 | 14 | 25 |
| 2018 December | 11 | 14 | 25 |
| 2018 November | 9 | 21 | 30 |
| 2018 October | 12 | 13 | 25 |
| 2018 September | 7 | 5 | 12 |
| 2018 August | 6 | 0 | 6 |
| 2018 July | 5 | 1 | 6 |
| 2018 June | 8 | 1 | 9 |
| 2018 May | 6 | 0 | 6 |
| 2018 April | 1 | 1 | 2 |
| 2018 March | 4 | 0 | 4 |
| 2018 February | 2 | 3 | 5 |
| 2018 January | 8 | 0 | 8 |
| 2017 December | 2 | 0 | 2 |
| 2017 November | 9 | 1 | 10 |
| 2017 October | 6 | 1 | 7 |
| 2017 September | 12 | 4 | 16 |
| 2017 August | 9 | 1 | 10 |
| 2017 July | 2 | 0 | 2 |
| 2017 June | 8 | 0 | 8 |
| 2017 May | 3 | 4 | 7 |
| 2017 April | 10 | 6 | 16 |
| 2017 March | 11 | 23 | 34 |
| 2017 February | 9 | 2 | 11 |
| 2017 January | 8 | 0 | 8 |
| 2016 December | 22 | 3 | 25 |
| 2016 November | 12 | 2 | 14 |
| 2016 October | 19 | 4 | 23 |
| 2016 September | 19 | 2 | 21 |
| 2016 August | 16 | 1 | 17 |
| 2016 July | 10 | 1 | 11 |
| 2016 June | 22 | 14 | 36 |
| 2016 May | 16 | 3 | 19 |
| 2016 April | 8 | 3 | 11 |
| 2016 March | 13 | 4 | 17 |
| 2016 February | 12 | 4 | 16 |
| 2016 January | 17 | 4 | 21 |
| 2015 December | 19 | 1 | 20 |
| 2015 November | 18 | 3 | 21 |
| 2015 October | 15 | 4 | 19 |
| 2015 September | 12 | 0 | 12 |
| 2015 August | 12 | 3 | 15 |
| 2015 July | 6 | 2 | 8 |
| 2015 June | 5 | 1 | 6 |
| 2015 May | 2 | 1 | 3 |
| 2015 April | 5 | 4 | 9 |
| 2015 March | 4 | 3 | 7 |
| 2015 February | 3 | 0 | 3 |
| 2015 January | 17 | 2 | 19 |
| 2014 December | 27 | 7 | 34 |
| 2014 November | 11 | 0 | 11 |
| 2014 October | 24 | 3 | 27 |
| 2014 September | 25 | 1 | 26 |
| 2014 August | 13 | 0 | 13 |
| 2014 July | 15 | 0 | 15 |
| 2014 June | 33 | 1 | 34 |
| 2014 May | 22 | 2 | 24 |
| 2014 April | 16 | 0 | 16 |
| 2014 March | 9 | 1 | 10 |
| 2014 February | 21 | 1 | 22 |
| 2014 January | 11 | 0 | 11 |
| 2013 December | 14 | 2 | 16 |
| 2013 November | 16 | 0 | 16 |
| 2013 October | 26 | 1 | 27 |
| 2013 September | 8 | 3 | 11 |
| 2013 August | 14 | 2 | 16 |
| 2013 July | 16 | 1 | 17 |
| 2002 September | 361 | 0 | 361 |
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