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• W2072217825 abstract "Authors' reply Sir—David Fedson and Michael Watson suggest the failure of the pneumococcal polysaccharide vaccine (PPV) in HIV-1-infected East Africans was not unexpected. Findings from retrospective, case-control studies or both, in North America have shown HIV-1-infected black adults to be at increased risk of invasive pneumococcal disease and to derive little protection from PPV. Reasons for vaccine failure may or may not be linked to factors generating increased susceptibility. We are unaware, however, of any immuno-genicity data of a difference in response to PPV by ethnic origin or skin colour. In addition, the reasons for failure of PPV in East Africa could be different from those in North America. To date, the universal recommendation for the use of PPV in HIV-1-infected adults in the USA is not qualified by ethnic origin. Whether the study of Breiman and colleagues will alter these recommendations remains to be seen. We stress, however, that we did not do our study to influence vaccine policy in North America, but to address an entirely different public-health issue in Uganda. It is difficult to base policy on the results of a single study, but our data give little encouragement for the widespread use of PPV in HIV-1-infected adults in sub-Saharan Africa. In a randomised and (just as critical) blinded study, finding a difference in disease surveillance episodes and investigation requests between vaccine and placebo recipients will not discriminate between a by-chance difference in health-seeking behaviour and a biological effect of the vaccine. Nevertheless disease surveillance between vaccine and placebo recipients did not differ significantly. Although the results of the study were unexpected, we had allowed for them. We based sample-size statistics on two-tailed tests and, as such, the validity of the hazard ratio or p value is no more questionable than if vaccine had been effective. In addition, as we pointed out in the discussion, our results might not be as isolated and unexpected as we first assumed. We cannot comment on lack of trend in the hazard ratios. CI are wide and overlap. Our statements about the limited public-health value of PPV in sub-Saharan Africa refer to its use in HIV-1-infected adults. We would welcome further support and research into pneumococcal vaccination of other at-risk groups in Africa, if done in a way relevant to each region's health-care needs. PPV might offer benefits to non-HIV-1-infected African adults. However, the possible increased risk of invasive pneumococcal disease we saw with HIV-1-infection may mean that individuals offered PPV might also need HIV-1 counselling and testing. The cost-effectiveness of any such widespread intervention will, therefore, be severely compromised. Pneumococcal vaccine and HIV-1 infectionN French and colleagues have documented the high degree of susceptibility of HIV-1-infected patients to invasive pneumococcal disease and their suboptimum response to 23-valent pneumococcal poly-saccharide vaccine (PPV). More recently (June 17, p 2106)1 they have reported that pneumococcal vaccine was not effective and possibly harmful in these patients. Full-Text PDF" @default.
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• W2072217825 title "Pneumococcal vaccine and HIV-1 infection" @default.
• W2072217825 doi "https://doi.org/10.1016/s0140-6736(05)73874-5" @default.
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