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Recent papers on vaccines that could change the way you practise

Dr George Kassianos looks at recent papers that have caught his eye

Dr George Kassianos looks at recent papers that have caught his eye

Will giving children a 7-valent vaccine against pneumococcal disease protect older adults too?

Paper: Lexau C et al. Changing epidemiology of invasive pneumococcal disease among older adults in the era of paediatric pneumococcal conjugate vaccine. JAMA 2005;294:2043-51

Method: Population-based (18.8 million) surveillance study in eight US geographical areas between1998 and 2003.

Results: The incidence of invasive pneumococcal disease, such as meningitis, pneumonia and bacteraemia of unknown focus reduced by 28 per cent in this adult population. This meant the US government target of 42 cases per 100,000 for the over-65s was reached. The trade-off for protecting healthy adults was an increased incidence in persons with certain comorbidities, such as HIV, recent immunosuppressive therapy, COPD and diabetes.

Most of the overall decline among elderly people was accounted for by the serotypes in the 7-valent children's conjugate vaccine.

Study conclusion: Immunising children with the 7-valent paediatric conjugate vaccine protects healthy adults aged 50 and over, unless they suffer from immunosuppressive or chronic conditions.

What I am going to do: I welcome last week's announcement that the conjugate 7-valent pneumococcal vaccine is to be introduced into the childhood immunisation schedule in the UK. I will double my efforts to immunise my adult patients with immunosuppressive or chronic disease with the adult 23-valent pneumococcal polysaccharide vaccine (which includes the same 7 serotypes plus 16 others).

Does acellular pertussis vaccine prevent whooping cough in adults?

Paper: Ward J et al. Efficacy of an adult pertussis vaccine among adolescents and adults. N Eng J Med 2005;353:1555-63

Method: Randomised, controlled, double-blind study funded by the US National Institute of Allergy and Infectious Diseases. It compared the efficacy of an adult formulation of acellular pertussis vaccine with that of the hepatitis A vaccine (as the control) in over 2,700 adolescents and adults.

Results: The investigators found 10 cases of laboratory-confirmed pertussis during the two-year follow-up period. Nine cases were in the control subjects, and one case was in a pertussis vaccine recipient, resulting in an adjusted efficacy of 92 per cent. The acellular pertussis vaccine was found to be safe and immunogenic. The incidence of pertussis in the controls was estimated at 370 to 450 cases per 100,000 person-years. This translates to more than a million cases of pertussis infection prevented per year in the US, in persons 15 years and older.

Study conclusion: The acellular pertussis vaccine is protective among adolescents and adults.

What I am going to do: I shall campaign for the introduction of a pertussis vaccine booster for our children in their second decade of life. The aim is to reduce pertussis infection among them but also among adults. This achieved, we could see a reduction in the overall disease burden and transmission to young children, especially the unimmunised neonates.

Are hepatitis B boosters necessary for those vaccinated in infancy and adolescence?

Paper: Zanetti A et al. Long-term immunogenicity of hepatitis B vaccination and policy for booster: an Italian multicentre study. Lancet 2005; 366:1379-84

Method: In line with WHO recommendations, universal anti-hepatitis B vaccination of infants and adolescents was implemented in Italy in 1991. This study included 1,212 children previously vaccinated and 446 Air Force recruits. It involved measuring the concentration of antibodies to hepatitis-B surface antigen (anti-HBsAg), over 10 years after vaccination. Individuals with anti-HBsAg concentrations at 10iu/l were regarded as protected; those with antibody less than that were given a booster dose and retested two weeks later. Those showing post-booster antibody <10iu/l were offered two additional vaccine doses and retested a month after the third dose ­ all showed antibody increase to >10iu/l.

Results: Lasting immunity was retained 10 years after vaccination of infants and adolescents. Additional booster doses did not seem necessary to ensure long-term protection.

Study conclusion: Persistence of immunity with long-term protection after hepatitis B vaccination depends on immunological memory, which empowers a protective anamnestic response against hepatitis B virus infection. The need for a booster was explored in those with inadequate response (anti-HBsAg < 10iu/l) by administering booster doses of the vaccine (imitating what will normally happen if the individual came in contact with the real virus). All subjects showed an anamnestic response to the vaccine (virus) antigen.

What I am going to do: I shall support the opinion of the Department of Health in the new Green Book (draft) that booster doses of hepatitis B vaccine are unnecessary other than for those who remain at continuing risk of infection ­ they should receive a single booster, once only, around five years after primary immunisation. But this paper relates only to those vaccinated in infancy and adolescence.

George Kassianos is a GP in Bracknell Forest, Berkshire ­ he is RCGP spokesperson on immunisation and honorary secretary of the British Travel Health AssociationCompeting interests Dr Kassianos has received lecture payments from CHIRON, GSK, Sanofi Pasteur and MSD

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