23-Valent Pneumococcal Polysaccharide Vaccine in HIV-1-Infected Ugandan Adults: Double-Blind, Randomised and Placebo Controlled Trial [French N, et al. Lancet 2000;355:2106]: This study from Uganda was conducted to determine the efficacy of the 23-valent pneumococcal vaccine in patients with HIV infection. There were 1,392 patients enrolled, including 697 vaccine recipients and 695 placebo recipients. The results showed an increased risk of invasive pneumococcal disease and a statistically significant increase in all-cause pneumonia for vaccine recipients.

Pneumococcal vaccine trial in Uganda
	Vaccine n = 697	Placebo n = 695	OR for vaccine
Invasive pneumococcal infection	15	10	1.47
All-cause pneumonia	40	21	1.41

The authors conclude that pneumococcal polysaccharide vaccination is not effective in HIV-infected Ugandan adults, and they further suggest that the increased risk of pneumococcal infection associated with vaccination may necessitate reappraisal of the vaccine in other settings.
Comment: There is increasing concern about the value of pneumococcal vaccine, and this study certainly fuels the debate at this time when the CDC is pushing hard for the use of Pneumovax as a method to help deal with pneumococcal antibiotic resistance. Jerome Hirshman recently reviewed the results of six prospective studies of pneumococcal vaccine in the U.S. and concluded that meta-analysis of these reports shows no evidence of efficacy based on the frequency of pneumococcal pneumonia, pneumococcal infections, or all-cause pneumonia [ASM News 2000;66:326]. The Ugandan study shows similar results, but also shows an unexplained risk for the vaccine with a possible enhanced susceptibility to pneumococcal infection and all-cause pneumonia. It should also be noted that the USPHS/IDSA has recently eliminated pneumococcal vaccination as a performance standard for HIV providers due to weak data to support efficacy. posted 7/3/2000