Correspondence

Potential Consequences of the Pneumococcal Conjugate Vaccine

N Engl J Med 2006; 355:95-96July 6, 2006

Article

To the Editor:

Aristotle proclaimed more than 2300 years ago that “nature abhors a vacuum.” This dictum seems to be confirmed by the study by Kyaw et al. (April 6 issue)1 showing that the rate of antibiotic-resistant invasive pneumococcal infections decreased in young children and older persons after the introduction of the pneumococcal conjugate vaccine, at the expense of an increase in infections caused by serotypes not included in the vaccine (so-called replacement types). In addition, other studies have shown a negative association of the nasopharyngeal carriage of vaccine-type Streptococcus pneumoniae with the nasal carriage of Staphylococcus aureus in unvaccinated children2,3 and an increased rate of S. aureus culture–positive otitis media in vaccinated children as compared with controls.4

The prevalence of the carriage of S. aureus in the noninstitutionalized U.S. population is approximately 30 percent, according to data from the National Health and Nutrition Examination Survey. Even though it would be premature to suggest an association between the increasing use of pneumococcal vaccines and the emerging threat of community-associated methicillin-resistant Staphylococcus aureus, 5 we believe that monitoring of S. aureus–related disease is important in studies of S. pneumoniae vaccination.

Petros Kopterides, M.D.
Attikon University Hospital, 12410 Athens, Greece
petkop@ath.forthnet.gr

Matthew E. Falagas, M.D.
Alfa Institute of Biomedical Sciences, 15123 Athens, Greece

5 References

1. 1

   Kyaw MH, Lynfield R, Schaffner W, et al. Effect of introduction of the pneumococcal conjugate vaccine on drug-resistant Streptococcus pneumoniae. N Engl J Med 2006;354:1455-1463
   Full Text | Web of Science | Medline

2. 2

   Regev-Yochay G, Dagan R, Raz M, et al. Association between carriage of Streptococcus pneumoniae and Staphylococcus aureus in children. JAMA 2004;292:716-720
   CrossRef | Web of Science | Medline

3. 3

   Bogaert D, van Belkum A, Sluijter M, et al. Colonisation by Streptococcus pneumoniae and Staphylococcus aureus in healthy children. Lancet 2004;363:1871-1872
   CrossRef | Web of Science | Medline

4. 4

   Veenhoven R, Bogaert D, Uiterwaal C, et al. Effect of pneumococcal vaccine followed by polysaccharide pneumococcal vaccine on recurrent acute otitis media: a randomised study. Lancet 2003;361:2189-2195
   CrossRef | Web of Science | Medline

5. 5

   Moellering RC Jr. The growing menace of community-acquired methicillin-resistant Staphylococcus aureus. Ann Intern Med 2006;144:368-370
   Web of Science | Medline

Author/Editor Response

Kopterides and Falagas suggest that the use of pneumococcal conjugate vaccine has created a void by removing vaccine-type pneumococci from circulation and that other organisms may fill this now opened niche. Although we observed a significant increase in disease caused by nonvaccine serotypes after the introduction of conjugate vaccine, the absolute magnitude of “replacement disease” was quite small as compared with the major reductions in disease that the vaccine provided. These findings suggest that during the time frame studied, most nonvaccine serotypes are not as capable of causing invasive disease among the general U.S. population as are the vaccine serotypes. Persons with immune disorders may be more susceptible to invasive disease caused by nonvaccine serotypes; in a study of adults who were 18 to 64 years of age, the increase in disease caused by nonvaccine types was sizeable among those with human immunodeficiency virus (HIV) infection or AIDS, but no increase was seen among those without HIV or AIDS.1 Whether pneumococcal conjugate vaccine use has created an opportunity for an increase in disease caused by S. aureus is unclear. Monitoring replacement disease from both nonvaccine pneumococcal serotypes and other bacteria is important and may direct the development of next-generation pneumococcal conjugate vaccines.

Moe H. Kyaw, Ph.D., M.P.H.
Cynthia G. Whitney, M.D., M.P.H.
Centers for Disease Control and Prevention, Atlanta, GA 30333
cwhitney@cdc.gov

for the Active Bacterial Core Surveillance Team

1 References

1. 1

   Flannery BL, Heffernan RT, Harrison LH, et al. Changes in invasive pneumococcal disease among HIV-infected adults living in the era of childhood pneumococcal immunization. Ann Intern Med 2006;144:1-9
   Web of Science | Medline

Citing Articles (4)

Citing Articles

1. 1

   Elisabeth Autret-Leca, Lamiae Grimaldi-Bensouda, Claire Daubin, Paula Poggi, Anne-Elisabeth Collignon, Annie-Pierre Jonville-Béra. (2011) Heptavalent Pneumococcal Conjugate Vaccine (PCV7): French Survey of Serious Adverse Reactions. Thérapie 66:1, 81-86
   CrossRef

2. 2

   J. J. Fitzsimons, A. L. Chong, M. T. Cafferkey, K. M. Butler. (2008) Invasive pneumococcal disease in children in Ireland—the anticipated benefit of conjugate pneumococcal vaccination. Irish Journal of Medical Science 177:3, 225-231
   CrossRef

3. 3

   Gili Regev‐Yochay, Debby Bogaert, Richard Malley, Peter W. M. Hermans, Reinier H. Veenhoven, Elisabeth A. M. Sanders, Marc Lipsitch, Ethan Rubinstein. (2008) Does Pneumococcal Conjugate Vaccine Influence Staphylococcus aureus Carriage in Children?. Clinical Infectious Diseases 47:2, 289-291
   CrossRef

4. 4

   Matthew E. Falagas, Petros I. Rafailidis, Gregory C. Makris. (2008) Bacterial interference for the prevention and treatment of infections. International Journal of Antimicrobial Agents 31:6, 518-522
   CrossRef