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Concerning use of conjugate pneumococcal vaccine, the most recent CMO letter1 sent out in August 2002, updates the recommendations issued by the Department of Health (DoH) in January 20022 by making the recommendations for “at risk” under 2 year old children coincide with the manufacturer’s recommendations for immunisation of normal healthy children in their Summary of Product Characteristics for their European product licence.
These schedules differ a little bit from those set out in our paper3 which was subsequently cited in the recent RCPCH guidelines for immunisation of immunocompromised children.4 In particular, the DoH advice does not draw any distinction between different risk groups, whereas our advice is to give extra doses to children with hyposplenism and various forms of immunocompromise. The DoH does not, at present, advocate use of the conjugate vaccine in any children over the age of two, whereas we do, conscious that many experts feel that there are good theoretical reasons to use the conjugate vaccine in this way (just as conjugate meningococcal C vaccine has replaced polysaccharide vaccine use in older children). Finally, the DoH suggests all recipients in the second year of life should receive two doses of conjugate pneumococcal vaccine, whereas we suggest only one for “at risk” children outwith the very high risk groups mentioned above.
The differences between the two sets of advice have led to some enquiries from colleagues as to how best to proceed and why the two documents differ.
We think it is important to emphasise that both sets of recommendations have been drawn up in the absence of much data as to how best to protect these groups of children. What evidence there is, is summarised in our paper. Further immunogenicity studies in children with HIV and other groups are in progress. In addition, it was reassuring to hear the preliminary results of a large efficacy study in children in South Africa at the International Symposium on Pneumococci and Pneumococcal Diseases in May 2002 which suggested that conjugate pneumococcal vaccine is protective in children with HIV infection, albeit less so than in uninfected children. However, most pre-licensure studies were done in normal healthy infants, since that was the target group for the license. In the absence of more data, it is not surprising that different expert groups have come up with slightly differing advice. In addition, presumably, as a government agency, the DoH must be constrained to some extent against issuing recommendations which go beyond or which differ from those contained within an official product license—even if that license relates to healthy rather than “at risk” individuals.
Consistently following either set of recommendations seems reasonable under the circumstances—no doubt further modifications to this advice will follow in due course as further evidence emerges.