Elsevier

Vaccine

Volume 24, Issue 9, 27 February 2006, Pages 1408-1412
Vaccine

Response to pneumococcal vaccine in chronic obstructive lung disease—The effect of ongoing, systemic steroid treatment

https://doi.org/10.1016/j.vaccine.2005.09.020Get rights and content

Abstract

Forty-nine patients with chronic obstructive lung disease (COPD) were block-randomized in four groups to investigate, if different degrees of steroid-load influenced the effect of pneumococcal-vaccination on antibody level and clinical variables during 6 months of follow-up. The groups included 13 patients without systemic steroids for the previous 3 months, all vaccinated at entrance in the study and treated with steroids for 4 weeks. Nine patients had chronic steroid treatment both before and during the investigation; they were vaccinated at the entrance in the study. Fifteen patients without systemic steroids for the previous 3 months were vaccinated after the end of a 4-week steroid treatment. Twelve patients served as controls, and were not vaccinated.

Totally, 60%–78% of vaccinated patients in the three groups had a rise in antibody level, and a later decrease compared to two of the 12 control patients (p < 0.01). This difference was also significant (p < 0.05) for the patients vaccinated at entrance in the hospital. No differences were observed among the clinical variables: pneumonia, exacerbations, admittance to hospital, increase in the use of steroids or β-agonists, and the use of antibiotics.

We conclude that a rise in antibody level after pneumococcal vaccination can be expected in patients with COPD despite of the use of systemic steroids. The clinical effect of vaccination is debatable.

Introduction

Immunization with pneumococcal vaccine has been recommended for many years for patients with chronic respiratory diseases. The reason for this has mainly been the fact that pneumococci are the most frequent bacteria in exacerbation in patients with chronic obstructive lung disease (COPD) [1], although it may not influence the risk of pneumonia, but only the risk of invasive disease [2]. The benefit of the procedure has recently been questioned based on a meta-analysis [3], but this question has not been finally answered yet, as conclusions are jeopardized by few patients included, and difficulty in the measurements of the patient-benefits.

In children after splenectomy the vaccination-response was normal if doses of prednisolone was below 1.5 mg/kg/day, but weakened if larger [4]. In patients with nephrotic syndrome, steroids did not influence the vaccination-response [5] as in patients with steroid-dependent asthma [6]. Patients with chronic obstructive lung disease have not been investigated.

We wanted to investigate if ongoing treatment with systemic steroids hampered the immune response after a vaccination with 23-polyvalent pneumococcal vaccine. Our clinical problem was if we should vaccinate the patient at entrance in the hospital, or wait until the treatment with systemic steroids has stopped.

Section snippets

Materials and methods

Forty-nine patients with COPD were included and block-randomized to vaccination or not. COPD was defined according to the GOLD-guideline [7], i.e., FEV1/FVC <70%, FEV1 reversibility-test <200 ml.

The grouping was chosen to simulate the different clinical problems in relation to systemic treatment with steroids and timing of vaccination. Randomization was carried out by means of closed and non-transparent envelopes marked with group no. 2 (ongoing steroid treatment) or group nos. 1/4 (no steroids

Antibodies

Every patient had antibodies present at entrance in the study with no difference in the median and summarized antibody levels between groups (Table 3). Only patients vaccinated and then treated with systemic steroids showed a significant rise in titres, when all serotypes were considered together (group 1). In the vaccinated groups (Table 4) the majority of the patients experienced a rise and later a fall in titres, whereas two of the unvaccinated control patients had a slight development in

Discussion

Pneumococcal infection is the most frequent cause of bacterial pneumonia acquired outside hospitals, and patients older than 65 years carries a higher risk of invasive disease. Accordingly, there is a higher mortality in the older age groups. A beneficial effect of vaccination has been shown in Stockholm [3], [10] in patients older than 65 years concerning hospital admissions with pneumonia, invasive pneumococcal disease and mortality. Nichol et al. [2] documented a lower rate of hospital

Acknowledgements

The study has been supported by grants from: Boehringer Ingelheim Denmark and The Medical Association of Storstroem County. None of the participants had any financial connections to sponsors or any other commercial company involved.

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