Dear Editor
As a follow up to this article, the most recent CMO letter
[1] sent out in August 2002, updates the recommendations issued by the Dept. of
Health (DoH) in January 2002[2] 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 paper[3] 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 2 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.
Adam Finn
Robert Booy
Mike Sharland
Paul Heath
References
(1) CMO letter. August 2002. http://www.doh.gov.uk/cmo/letters/cmo0204.htm#iii
(accessed 18th Sept 2002)
(2) CMO letter. January 2002. http://www.doh.gov.uk/cmo/cmo0201.htm(accessed 18th Sept 2002)
(3) Finn A, Booy R, Moxon R, Sharland M, Heath P. Should the
new pneumococcal vaccine be used in high-risk children? Arch Dis Child 2002;87:18-21
(4) RCPCH best practice statement. Immunisation of the
immunocompromised child. http://www.rcpch.ac.uk/publications/recent_publications/Immunocomp.pdf
(accessed 18th Sept 2002)
Dear Editor
As a follow up to this article, the most recent CMO letter [1] sent out in August 2002, updates the recommendations issued by the Dept. of Health (DoH) in January 2002[2] 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 paper[3] 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 2 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.
Adam Finn
Robert Booy
Mike Sharland
Paul Heath
References
(1) CMO letter. August 2002. http://www.doh.gov.uk/cmo/letters/cmo0204.htm#iii (accessed 18th Sept 2002)
(2) CMO letter. January 2002. http://www.doh.gov.uk/cmo/cmo0201.htm(accessed 18th Sept 2002)
(3) Finn A, Booy R, Moxon R, Sharland M, Heath P. Should the new pneumococcal vaccine be used in high-risk children? Arch Dis Child 2002;87:18-21
(4) RCPCH best practice statement. Immunisation of the immunocompromised child. http://www.rcpch.ac.uk/publications/recent_publications/Immunocomp.pdf (accessed 18th Sept 2002)