Review
Efficacy of polysaccharide pneumococcal vaccine in adults in more developed countries: the state of the evidence

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Summary

We review studies on the efficacy against disease caused by Streptococcus pneumoniae of the 23-valent polysaccharide pneumococcal vaccine in adult populations in the more developed countries. Meta-analyses of primary vaccine trials have attempted to reduce uncertainty from lack of power. Vaccine efficacy calculated from studies in South African gold-miners and in Papua New Guinea, with high attack rates and differing serotype patterns, cannot automatically be applied to more developed countries. Meta-analyses will overestimate a protective effect if this clinical heterogeneity is ignored. Meta-analyses limited to trials in the more developed setting show no protective effect against pneumococcal pneumonia and a non-significant protective effect against bacteraemia. Lack of a specific diagnosis limits the ability to detect a protective effect against pneumococcal pneumonia. Most, but not all, observational studies confirm a protective effect against bacteraemia. An effect on mortality in more developed countries has yet to be documented.

Section snippets

Vaccine efficacy against pneumococcal pneumonia in populations with high attack rates

Previously reported estimates of the effect of vaccines have been converted here to vaccine efficacy (1 minus the relative risk of events in vaccinated compared with unvaccinated individuals). Protection against pneumococcal pneumonia of 60–80% was noted in randomised controlled trials of a 6–12-valent polysaccharide vaccine in young healthy South African gold-miners and in Papua New Guinea highlanders in the 1970s.6, 9, 10 In Papua New Guinea, efficacy against all radiological pneumonia was

Efficacy of the current polysaccharide pneumococcal vaccine against pneumococcal pneumonia in more developed countries

The two main outcome measures in the vaccine trials discussed here are pneumococcal pneumonia and pneumococcal bacteraemia. However, there is no standard definition of pneumococcal pneumonia. Because the sensitivity of culture is very low, the trial sample size required would be prohibitively large if culture of S pneumoniae from a normally sterile site was required for diagnosis of pneumococcal pneumonia; other, imperfect, correlates have therefore been used. The most commonly used definition

Primary trials and meta-analyses

There is consistent, though not significant, evidence that the incidence of bacteraemia is reduced with the polysaccharide vaccine in populations in more developed countries, but the primary trials were not designed to be powered for this outcome.34 In the trial of 600 patients discharged with pneumonia,27 five cases of bacteraemic disease occurred in the placebo group and one in the vaccine group. There was no difference in mortality. The study was included in a small meta-analysis by Moore

Efficacy of the polysaccharide vaccine against mortality

Although there is some evidence from trials, supported by most observational studies, that the vaccine may reduce the incidence of pneumococcal bacteraemia, there is no evidence as yet that death is prevented in more developed countries.

Two meta-analyses tried to summarise the effect of the vaccine against death from pneumonia (table 3).23, 24 None of the deaths in the trials included were in patients diagnosed as having pneumococcal bacteraemia. The point estimate of the vaccine efficacy

Summary of the evidence

The 23-valent polysaccharide pneumococcal vaccine has been recommended for elderly people in more developed countries because they are at higher risk of pneumococcal disease than the general population and the vaccine is considered a cost-effective intervention against bacteraemia.

In the USA, pneumococcal vaccination of people aged 65 years and older was estimated to be cost-saving,4 with the assumption that hospital-admission costs associated with bacteraemia were saved, and that vaccine

Further issues

Other outstanding issues with the current pneumococcal polysaccharide vaccine are the basis for recommending booster doses and rates of adverse events.

Search strategy and selection criteria

Publications from searches over all available years in Medline and PubMed databases were used as source material for this update. Relevant papers were considered for inclusion irrespective of primary language if an English translation of the title and abstract was provided. Search terms were “pneumococcal vaccines”, “pneumococcal infections—prevention and control”, and “pneumococcal infections—epidemiology”. Several other sources were obtained from hand searches of references in reviews in

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