Catching up on some older Fortnights, and the discussion about the pneumococcal vaccine was really interesting! I'd love to see similar reviews of other common vaccines.
Love the addition of Dr. Foy. One of the best moments start at 39:04. They way Dr. Foy lays out the real benefits of the pneumococcal vaccine is comical. Yes, what are "we doing here" :) Keep them coming SM
The crew here sure likes to take shots at my specialty of Preventive (not preventative) Medicine.
In general, part of the argument for vaccination is public health. Sterilizing immunity, herd immunity, and so on. It could be the case that even if an individual patient is not benefited, they are prevented from becoming a reservoir for a bacteria that may ultimately infect other people, develop antimicrobial resistance, and so on. Of course, this argument was deployed heavily relative to the COVID mRNA vaccines despite the fact that the technology could in no way deliver on those premises. Most vaccines are not the smallpox vaccine.
I could imagine it being the case that pneumococcal vaccinations actually reduced the overall dangerousness of bacteria in the community, but I doubt that this is actually the case and it would be an uphill sled to prove it. These arguments are very disease-specific and vaccine-specific, and unfortunately in the eyes of some people, this is not the case and all vaccines are interchangeable.
Another conceivable downstream effect of marginally effective vaccines might be psychological. If a certain sort of person is actually afraid of getting pneumonia, having a vaccine in their system might cause them to behave differently, for better or for worse. The patient might be more inclined to spend time with friends and experience reduced loneliness, or the patient might ignore a cough thinking it can't be pneumonia and delay medical care. This effect of course relies on some combination of the patient's ignorance and irrationality, because the clinical effect of vaccination appears to be trivial. Again, I don't know that the pneumonia vaccines will have a ton of effects in the psychological realm, but for other vaccines, the psychological effect may outstrip the antimicrobial effect. This might well be the case for the COVID shots, and possibly other prophylactic treatments of various sorts.
Thank you for sharing this study. I hadn't seen the adult data and sadly found it unsurprising. The more I read vaccine RCTs, the more I see how small the ARR's are, and the less enthusiasm I have for them. And I am a family medicine doctor!
This is a great example of "right vaccine, wrong time." The same pneumococcal vaccine series in kids has a VE 27% for all-cause radiologic-defined pneumonia with NNT 60. I reviewed these vaccines in kids on my substack for anyone's interest:
With respect to the BP trial I think that Andrew made the salient point in that like most thinks in medicine one needs to individualize and one needs to individualize beyond just looking at the granular data in the chart. You could have two patients with exactly the same medical profile but due to issues that may not be included in the medical record, it might be appropriate to treat one person's hypertension one way and the other another way. Too many physicians become slaves to clinical guidelines which is sad because a robot can probably do a better job with adherence to clinical guidelines. It is the physician's job to decide when a clinical guideline does not apply to the patient
Thank you for reviewing the Pneumonia vaccine trial. I have often struggled to adequately discuss the risks and benefits of this vaccine. The ARR and NNV numbers are exactly what I was looking for. Unfortunately it appears that this vaccine reduces a very small risk not very much. Thank you for having the courage to clearly discuss trials such as these.
My point concerns the assessment of the BP trial. The commentators, like many doctors and scientists, are barking up the wrong tree. The question of whether to treat or not treat truly frail patients (based on official scores) or adjusted scores (as the authors did in this analysis) remains unanswered by the trial's findings. It’s clear that treatment reduces cardiovascular outcomes in these individuals, but the patient, family, and clinician should decide if it’s worthwhile. If my grandpa (metaphorically, I am 75 years old) were frail but cognitively preserved and wanted to live, I would prefer him to be frail but without the risk of another stroke. My main concern, however, is some complacency regarding the risks of high BP, as the decision to tailor treatment involves other factors beyond just high BP. High BP has the highest area under the curve as a risk for CVD, even if these calculations include 140/90 in the equations and don't include the long-term consequences like atrial fibrillation or aortic valve stenosis, among others. And it is the only risk factor for CVD that has a mathematical endorsement of causality. I have posted a similar comment and sent two of our manuscripts on this topic to John. I am not interested in promoting them for my own ego, but I, along with Paul Whelton and others, truly want to reduce the incidence of CVD worldwide. Sadly, there has been little change in the diagnosis and control of high BP over the past 20 years. The DOIs of our two main studies are included. The third manuscript, "One Hundred to Live, One Hundred," has been prepared. I am pleased to be a member of Sensible Medicine, and I am confident that this comment adheres to the spirit of the blog. DOIs: 10.1161/HYPERTENSIONAHA.119.14240; 10.1161/HYPERTENSIONAHA.124.21361
Must again commend the three of you for another excellent and informative discussion. I liked Dr Prasad and agreed with most everything he said, but the pace of his speech was quite rapid and sometimes he got a little too far away from the microphone, Dr. Foy is an excellent replacement. He brings a healthy skepticism as well as an outstanding attention to detail to the discussion.
On the vaccine question, I recall that during my decades of medical practice pneumococcal infections maintained a high degree of sensitivity to penicillin and a couple of other antibiotics. The cases where pneumonia served as the "old man's friend" were only with those who literally had one foot in the grave. Wouldn't this realistically make the whole issue of pneumococcal vaccine moot?
I'm always surprised at how many people don't understand or believe that people can and will die of infections! Typically see this with very elderly patients who are really in the stage of pure focus on quality of life. After treating recurrent UTI until they are resistant to everything, if you raise the idea that we don't need to keep treating UTIs, people look at you in horror.
I often bring up the notion of the "old man's friend" to help illustrate.
I have a friend in a nursing home. Wait and see for an UTI, no treating right away is considered an irresponsible attitude. Last month my friend was told she had a UTI. She also had a cough and a high fever. Turned out that she didn't have a UTI (cultures came back negative) but a seriously bad case of flue.
As an aside she had the flue vaccine four days prior to getting sick. Correlation is not causation... but in this case I wonder if it could be?
Great show. Many clinicians Intuit the risk exposure with aggressive surrogate marker titration. I doubt many will read a study like this and change their mind. They might doubt themselves and worry that maybe they aren't being aggressive enough.
But worse, most clinicians are losing faith in the research process and its publication. I shouldn't need 3 astute docs like yourselves to make sense of papers. The level of scrutiny that's needed these days forces most doctors to just blindly follow guidelines.
I don't have a proposed solution, but I also know that protocolized medicine is AI medicine, which is ineffective, costly, and riddled with unmeasurable harm.
Thanks so much for reviewing this. You should look at the 5 year FDA vaccine committee review of prevnar 13 which I believe was June 2019. As I recall the presentation from the infectious disease society stated that the 13 strains in the vaccine were NO LONGER prevalent in the US adult population due to childhood vaccination. They debated pulling the recommendation to use the vaccine then settled on keeping the vaccine and having doctors do a risk benefit discussion with patients.
Also would appreciate a comment on the CAPVAXIVE website information
So should the pneumonia vaccine be on the childhood schedule? Or is the childhood vaccine different…..or are children different so we can’t use this study to make a recommendation for children.
What is your opinion on HiB vaccines for children, and if so, at what age? Epiglottitis (much less frequent since the vaccine), meningitis, and other invasive infections are not insignificant concerns.
Catching up on some older Fortnights, and the discussion about the pneumococcal vaccine was really interesting! I'd love to see similar reviews of other common vaccines.
Love the addition of Dr. Foy. One of the best moments start at 39:04. They way Dr. Foy lays out the real benefits of the pneumococcal vaccine is comical. Yes, what are "we doing here" :) Keep them coming SM
The crew here sure likes to take shots at my specialty of Preventive (not preventative) Medicine.
In general, part of the argument for vaccination is public health. Sterilizing immunity, herd immunity, and so on. It could be the case that even if an individual patient is not benefited, they are prevented from becoming a reservoir for a bacteria that may ultimately infect other people, develop antimicrobial resistance, and so on. Of course, this argument was deployed heavily relative to the COVID mRNA vaccines despite the fact that the technology could in no way deliver on those premises. Most vaccines are not the smallpox vaccine.
I could imagine it being the case that pneumococcal vaccinations actually reduced the overall dangerousness of bacteria in the community, but I doubt that this is actually the case and it would be an uphill sled to prove it. These arguments are very disease-specific and vaccine-specific, and unfortunately in the eyes of some people, this is not the case and all vaccines are interchangeable.
Another conceivable downstream effect of marginally effective vaccines might be psychological. If a certain sort of person is actually afraid of getting pneumonia, having a vaccine in their system might cause them to behave differently, for better or for worse. The patient might be more inclined to spend time with friends and experience reduced loneliness, or the patient might ignore a cough thinking it can't be pneumonia and delay medical care. This effect of course relies on some combination of the patient's ignorance and irrationality, because the clinical effect of vaccination appears to be trivial. Again, I don't know that the pneumonia vaccines will have a ton of effects in the psychological realm, but for other vaccines, the psychological effect may outstrip the antimicrobial effect. This might well be the case for the COVID shots, and possibly other prophylactic treatments of various sorts.
re: Pneumococcal vaccine.
Thank you for sharing this study. I hadn't seen the adult data and sadly found it unsurprising. The more I read vaccine RCTs, the more I see how small the ARR's are, and the less enthusiasm I have for them. And I am a family medicine doctor!
This is a great example of "right vaccine, wrong time." The same pneumococcal vaccine series in kids has a VE 27% for all-cause radiologic-defined pneumonia with NNT 60. I reviewed these vaccines in kids on my substack for anyone's interest:
https://open.substack.com/pub/kennoguchi/p/pneumococcal-vaccine-in-kids?r=1nyk1f&utm_campaign=post&utm_medium=web&showWelcomeOnShare=true
With respect to the BP trial I think that Andrew made the salient point in that like most thinks in medicine one needs to individualize and one needs to individualize beyond just looking at the granular data in the chart. You could have two patients with exactly the same medical profile but due to issues that may not be included in the medical record, it might be appropriate to treat one person's hypertension one way and the other another way. Too many physicians become slaves to clinical guidelines which is sad because a robot can probably do a better job with adherence to clinical guidelines. It is the physician's job to decide when a clinical guideline does not apply to the patient
Thank you for reviewing the Pneumonia vaccine trial. I have often struggled to adequately discuss the risks and benefits of this vaccine. The ARR and NNV numbers are exactly what I was looking for. Unfortunately it appears that this vaccine reduces a very small risk not very much. Thank you for having the courage to clearly discuss trials such as these.
My point concerns the assessment of the BP trial. The commentators, like many doctors and scientists, are barking up the wrong tree. The question of whether to treat or not treat truly frail patients (based on official scores) or adjusted scores (as the authors did in this analysis) remains unanswered by the trial's findings. It’s clear that treatment reduces cardiovascular outcomes in these individuals, but the patient, family, and clinician should decide if it’s worthwhile. If my grandpa (metaphorically, I am 75 years old) were frail but cognitively preserved and wanted to live, I would prefer him to be frail but without the risk of another stroke. My main concern, however, is some complacency regarding the risks of high BP, as the decision to tailor treatment involves other factors beyond just high BP. High BP has the highest area under the curve as a risk for CVD, even if these calculations include 140/90 in the equations and don't include the long-term consequences like atrial fibrillation or aortic valve stenosis, among others. And it is the only risk factor for CVD that has a mathematical endorsement of causality. I have posted a similar comment and sent two of our manuscripts on this topic to John. I am not interested in promoting them for my own ego, but I, along with Paul Whelton and others, truly want to reduce the incidence of CVD worldwide. Sadly, there has been little change in the diagnosis and control of high BP over the past 20 years. The DOIs of our two main studies are included. The third manuscript, "One Hundred to Live, One Hundred," has been prepared. I am pleased to be a member of Sensible Medicine, and I am confident that this comment adheres to the spirit of the blog. DOIs: 10.1161/HYPERTENSIONAHA.119.14240; 10.1161/HYPERTENSIONAHA.124.21361
Must again commend the three of you for another excellent and informative discussion. I liked Dr Prasad and agreed with most everything he said, but the pace of his speech was quite rapid and sometimes he got a little too far away from the microphone, Dr. Foy is an excellent replacement. He brings a healthy skepticism as well as an outstanding attention to detail to the discussion.
On the vaccine question, I recall that during my decades of medical practice pneumococcal infections maintained a high degree of sensitivity to penicillin and a couple of other antibiotics. The cases where pneumonia served as the "old man's friend" were only with those who literally had one foot in the grave. Wouldn't this realistically make the whole issue of pneumococcal vaccine moot?
I was looking for the chance to throw out the "old man's friend" moniker.
I like that one as well!
I'm always surprised at how many people don't understand or believe that people can and will die of infections! Typically see this with very elderly patients who are really in the stage of pure focus on quality of life. After treating recurrent UTI until they are resistant to everything, if you raise the idea that we don't need to keep treating UTIs, people look at you in horror.
I often bring up the notion of the "old man's friend" to help illustrate.
I have a friend in a nursing home. Wait and see for an UTI, no treating right away is considered an irresponsible attitude. Last month my friend was told she had a UTI. She also had a cough and a high fever. Turned out that she didn't have a UTI (cultures came back negative) but a seriously bad case of flue.
As an aside she had the flue vaccine four days prior to getting sick. Correlation is not causation... but in this case I wonder if it could be?
I notice that, though you imply it, you guys stop short of saying, "I won't take it, and I won't recommend it."
May I suggest a similar episode regarding the Flu vaccine? Shingles vaccine?
Great show. Many clinicians Intuit the risk exposure with aggressive surrogate marker titration. I doubt many will read a study like this and change their mind. They might doubt themselves and worry that maybe they aren't being aggressive enough.
But worse, most clinicians are losing faith in the research process and its publication. I shouldn't need 3 astute docs like yourselves to make sense of papers. The level of scrutiny that's needed these days forces most doctors to just blindly follow guidelines.
I don't have a proposed solution, but I also know that protocolized medicine is AI medicine, which is ineffective, costly, and riddled with unmeasurable harm.
Thanks so much for reviewing this. You should look at the 5 year FDA vaccine committee review of prevnar 13 which I believe was June 2019. As I recall the presentation from the infectious disease society stated that the 13 strains in the vaccine were NO LONGER prevalent in the US adult population due to childhood vaccination. They debated pulling the recommendation to use the vaccine then settled on keeping the vaccine and having doctors do a risk benefit discussion with patients.
Also would appreciate a comment on the CAPVAXIVE website information
https://www.merckvaccines.com/capvaxive/ipd-case-coverage/
scrolling down just below the comments on the 8 unique serotypes there is the following comment:
"There are currently no studies comparing the efficacy of CAPVAXIVE and PCV20."
So should the pneumonia vaccine be on the childhood schedule? Or is the childhood vaccine different…..or are children different so we can’t use this study to make a recommendation for children.
There is a much much better case to be made for childhood pneumococcal vaccination.
What is your opinion on HiB vaccines for children, and if so, at what age? Epiglottitis (much less frequent since the vaccine), meningitis, and other invasive infections are not insignificant concerns.
This was great! thank you so much. I enjoy how Andrew breaks down the absurdity of the pneumococcal vaccine!