Pneumococcal vaccine

In William Osler's day (turn of the 20th century), pneumonia was called "the old man's friend," because it took the elderly away quietly and with relatively little fuss. It was most often caused by the pneumococcal organism, now called Streptococcus pneumoniae. When penicillin came on the scene in the mid 20th century, there was at last a treatment for pneumonia with this organism, but soon resistant strains developed. S. pneumoniae is a frequent resident of the human respiratory tract and usually causes no problems. But if it gets into the wrong place it can also cause sepsis, otitis media, meningitis, sinusitis, peritonitis and arthritis. And it can also take advantage of ground prepared for it by a viral infection. It is the most prevalent secondary bacterial infection complicating influenza and a major cause of mortality in flu cases. Fortunately there is something we can do to prevent that: vaccination. The vaccine isn't to the flu virus but to many of the strains (called serotypes) of S. pneumoniae. CDC has just issued interim guidance on the use of pneumococcal vaccine during a flu pandemic. In case you haven't noticed, we are having a flu pandemic at the moment:.

Influenza predisposes individuals to bacterial community-acquired pneumonia. During the 20th century influenza pandemics, secondary bacterial pneumonia was an important cause of illness and death and Streptococcus pneumoniae (pneumococcus) was reported as the most common etiology. Severe pneumococcal pneumonia associated with inter-pandemic influenza also has been reported, and S. pneumoniae remains a leading cause of vaccine-preventable illness and death in the United States. The current novel influenza A (H1N1) outbreak is evolving rapidly, and CDC continues to compile key information regarding risk of influenza, severity of illness and attack rate of secondary bacterial pneumonia among influenza patients. (CDC guidance document)

I got the pneumovax vaccine about a year ago. At the time I got it because I was in the recommended group (over 65), but now with swine flu amongst us CDC has extended its recommendation of the single dose 23-valent pneumococcal vaccine (of which Pneumovax is an example) to anyone over the age of 2 with a high risk condition. You can see their list of conditions in the Table at the bottom of the page here, but it includes things like COPD, congestive failure and diabetes. It also includes adults who smoke or have asthma, so this extends the recommendation to perhaps a third of all adults. If you aren't in these categories and are between the ages of 2 and 64, CDC is not saying you should get the pneumococcal vaccine to protect you from pneumococcal pneumonia secondary to flu -- but I am. As far as I know there is no shortage of this vaccine and it is very effective and seems equally safe. You only need to get it once.

Most children now get another pneumococcal vaccine that covers the 7 most common serotypes for the under 5 age group. This was mainly to protect them against middle ear infections and bacterial meningitis, but in a flu pandemic where children are at high risk it would partially protect them from pneumonia. Unfortunately there are other causes of secondary bacterial pneumonia not covered by the vaccine implicated in pediatric flu mortality (e.g., MRSA staph infections), but this removes a chunk of them.

The pneumococcal vaccines (and another childhood vaccine against Haemophilus influenzae type B, a different bug) are extremely effective. Given the severe cases reported among Manitoba's First Nation communities, it's of some interest that S. pneumoniae infections have been a special problem among the Alaskan Native population, where it is a leading causes of meningitis, pneumonia, middle ear infection and sinusitis. There the vaccine has had notable success:

Although polysaccharide pneumococcal vaccines have been available for many years, they are not effective in young children. In 2000, a 7-valent protein-polysaccharide pneumococcal vaccine (Prevnar®), which is effective in young children, was licensed by the Food and Drug Administration. In January 2001, the State of Alaska made this vaccine available for children CDC; cites omitted)

We don't know exactly why influenza infection predisposes to secondary bacterial infections (see some good discussion of the biology over at Vincent Racaniello's excellent Virology Blog). The influenza virus itself can cause a serious pneumonia (primary viral pneumonia), also a significant cause of mortality when it occurs. Then there is the dysregulation of the immune response called a cytokine storm. So the flu virus can do mortal damage in a number of different ways.

The pneumococcal vaccine will likely prevent one of the more common serious complications. Ask your doctor to give it to you

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Amazing. You summed up today in one post what I spent two hours surfing for yesterday afternoon! A nurse at my son's pediatrician's office told me that my son "should be covered" having had the Prevnar series; is there any advantage to adding the Pneumovax though? He's 5 and has a history of mild Reactive Airway (they still won't call it asthma) that still occasionally flares during viral infections.

Thanks for all the wonderful info, Revere!

Max: I wouldn't. Children didn't react much to the adult vaccine so the Prevnar version was designed to elicit antibodies by conjugating the polysaccharide antigen to various proteins. It covers fewer serotypes, but for adults it isn't recommended to get it more than once (unless you've had it longer than five years before when you were under 65) because of sometimes strong reactions to a second administration. I'm not sure about children getting the adult version later. Maybe a reader has some experience or knowledge about this. It's a reasonable question that, off hand, I don't know the answer to.

It is amazing that we can live so long with all these bacteria around. This means that most of the time our body is able to fight off all these baddies without ever having a vaccine. Most of the time the immune system is strong enough to win these battles. I believe the greatest enemy of a healthy immune system is malnutrition. If you want to know why so many people need medical intervention to fight these infections just look at what they are eating. Nutrition could be the deciding factor between a mild flu and a severe flu with secondary infections.

My children have not been vaccinated for this and are 7 and 8. My understanding is the Prevnar is until 2 years old?? And they won't react to the adult vaccine? What is my best course of action in this case?

makes perfect sense...thanks

Both my kids have asthma. One is 14 and the other 6. I'm always very careful to get them the seasonal flu vaccine, but -- of course -- there isn't a novel H1N1 vaccine yet. Is the CDC planning to provide guidance on the use of Pneumovax for high risk kids? Both my husband and I have had it, since we're caregivers for his elderly parents. I'll discuss it with our pediatrician, but I know in the past it's helped to have latest guidance/research to point to, and I'd really like to know what the CDC recommends under pandemic circumstances. My son had an allergic reaction (possibly to the adjuvant) in his 3 yr. old flu shot, so when he was 4 they wouldn't give him a shot (the rest of the family got their shots early instead). So when he was 5, I found research studies showing that Flumist was safe in asthmatic kids and perhaps protected them better. This persuaded our pediatrician to go ahead and give it to him, though their office policy was normally not to give it to asthmatic kids. He did fine and had flumist again this year. Which is all a long way of saying that pediatricians may not be up on the latest info on how being in a pandemic changes the risk/benefit equation.

Amy: CDC is recommending the adult version for those between 2 and 64 who are at special risk. If your child is in that group (e.g., asthma, diabetes) they are recommending it, but not for normal healthy people in those age groups -- yet. They left the door open as this pandemic evolves. I'd ask your pediatrician.

Perhaps the current required (at least in my state) Prevnar immunization schedule for children has something to do with why H1N1 mortality is currently lower for children compared to adults (25-55) who likely did not receive Prevnar as children?

So much for my last hypothesis. CDC just said highest rate of hospitalization was in kids under 5.

Wheras, WHO just said that 2% of cases are rapidly progressing to pneumonia; in adults between 30-50 years old.

Unless I got that wrong.
http://www.cdc.gov/h1n1flu/press/

By phytosleuth (not verified) on 11 Jun 2009 #permalink

can you receive the vaccine while pregnant?

Doug said: It is amazing that we can live so long with all these bacteria around.

Actually, we ARE mostly bacteria. Recent research has revealed that about 90% of the cells in our bodies are actually bacteria. Which I think throws a big spanner in the works regarding human-centric conceptions of the "tree of life." There's an NIH-funded research program now called the Human Microbiome Project, http://nihroadmap.nih.gov/hmp/, to try to characterize the bacterial population in the human organism, which is now being dubbed a "superorganism" by many.

Our microbial partners probably have a huge influence on how and why we get sick, including with flu, and some day our medical treatments will reflect this - I'm very interested in tracking the data that are starting to come out about this whole thing.

K--there are no studies of pneumococcal vaccine during pregnancy.

So far as I know, there are no case reports of bad effects from the vaccine during pregnancy either.

You and your doc would have to decide which you think is a greater risk in your situation--vaccine or post-flu bacterial infection.

We do know that flu in general tends to hit pregnant women harder than the general population, which means the risk of complications from flu is higher.

It's your call. The data on risks doesn't yet exist. The vaccine falls in the category of killed vaccines (contains no live bacteria). In most cases killed vaccines have lower risks. But again, applied to *this* vaccine, the risk level falls into the category of 'educated guess', because there is no data.

By Lisa the GP (not verified) on 11 Jun 2009 #permalink

This says that what most people die of, in severe cases of the current swine flu in particular, is viral pneumonia and not bacterial pneumonia:
http://blogs.webmd.com/breaking-news/2009/05/pneumona-vaccine-for-swine…

In which case getting the vaccine would be a nice gesture, just in case you happen to become infected with bacterial pneumonia, and because historically that's what people have died of, but not necessarily a big deal with this particular flu? Thoughts?

sylvia; read it again. Most people who die of flu die of secondary infections, but a significant number do die of primary viral pneumonia. The pneumococcal vaccine won't help them or those that die of secondary infections from other bacterial, like MRSA. As noted in the post, it is only a portion, but a significant portion of the complications. So far we don't have any evidence this flu is clinically different. We await data, of course.

Thanks Revere!

I'm telling all my (adult) friends to get the vaccine. I made an appointment for my husband and I to get it at our primary care physician's office next week. I did check with my insurance company, and they cover it.

I checked with my kid's pediatrician (he's 3), and apparently he's gotten a series of 4 different pneumococcal vaccines, just as a part of his regular immunizations. I assume that's all he needs...

We live in NYC, so we've been paying close attention to all the swine flu news, and trying to keep up on everything we can do about it.

Many, many thanks for your blog, Revere.

These two links provide many answers about Prevnar and pneumovax. Enjoy......

http://aappolicy.aappublications.org/cgi/content/full/pediatrics;106/2/…

"A single dose of 23PS vaccine has been recommended since 1985 for children 2 years or older who are at risk of pneumococcal disease.1,2 The 23PS vaccine provides potential protection against an expanded number of serotypes, and the cost of 23PS vaccine is considerably less than that of PCV7."

and

http://aappolicy.aappublications.org/cgi/content/full/pediatrics;106/2/…

"In 1 trial, 24 children 2 years or older with SCD were given 2 doses of PVC7 at an 8-week interval, followed 8 weeks later by a single dose of 23-valent pneumococcal polysaccharide (23PS) vaccine with or without a third dose of PCV7.62 Antibody levels to all 7 antigens were higher after the combined dosing regimen (eg, PCV7 plus 23PS vaccine as the third dose), compared with the regimen of the 23PS vaccine given alone as the third dose"

By Brian Geers (not verified) on 11 Jun 2009 #permalink

I'm in my mid-50's and I've had the vaccine twice, once in my thirties and once in my forties. At the time, the recommendation was for once every 10 years. The second shot (which, if I recall correctly, protects against more strains) had fewer side effects that the first.

Interesting, I stopped getting strep throat, which I had previously gotten almost every year.

This is very useful information. I'll have to make sure my kids have had these (I think they both have, if it's on the vaccination schedule for a 4 and 7 year old), and also to make sure my wife and I get it.

Are there other things that would be sensible to do to prepare, in case this next flu season is especially nasty? Would there be any advantage to getting antibiotics appropriate for treating bacterial pneumonia ahead of time, in case the health care system is completely slammed come flu season?

By albatross (not verified) on 11 Jun 2009 #permalink

This isn't about the pneumovax in pregnancy, but about the virus itself. It may help pregnant folk make a better ballpark assessment of their risks.

I think the take home message is 'don't catch this flu' and if you do, seek medical care earlier rather than later.

Evidence of swine flu risk to pregnant women rises; experts urge early treatment

By Helen Branswell â 1 day ago

TORONTO â There are mounting and troubling signs that swine flu and pregnancy don't mix well.

Six pregnant women in Manitoba are reportedly on ventilators because they are severely ill with the virus. And at least two pregnant women in the United States have died of swine flu complications after delivering babies by C-section.

A pregnant teenager in the Dominican Republic died, as did a pregnant woman in Scotland. A woman in St. Theresa Point, a First Nations community in Manitoba, miscarried after contracting swine flu.

Humankind's relationship with the new swine H1N1 virus is still in its infancy. But people who've studied the issue of pregnancy during flu pandemics don't like the signs they are seeing.

Dr. Denise Jamieson, an obstetrician-gynecologist with the U.S. Centers for Disease Control's division of reproductive health, says she finds the evidence to date "very unsettling."

"I am concerned about this," Jamieson said in an interview from Atlanta.

"There does seem to be increased severity in pregnancy. We don't have hard and fast numbers but there are enough reports that are concerning."

Data released by the CDC last month said at that point, 17 per cent of Americans hospitalized for severe swine flu infections were pregnant women.

A report a couple of weeks back in the World Health Organization's journal, Weekly Epidemiologic Record, noted of 30 swine flu patients hospitalized in California, five were pregnant women. Of those, two developed severe complications - spontaneous abortion and premature rupture of membranes.

Jamieson said the numbers are still small but seem to be pointing to a pattern seen in previous pandemics, when pregnant women were disproportionately harder hit than non-pregnant peers.

more at:

http://www.google.com/hostednews/canadianpress/article/ALeqM5jiEhxWUiH_…

By Lisa the GP (not verified) on 11 Jun 2009 #permalink

As a health care provider with asthma, my asthma specalist gave me a presciption for the vaccine a month ago. I wasn't to thrilled about this flu and my chances with it. I got the prescription from her to avoid an office visit at my primary care provider since the asthma doc dosn't do vaccines even though all her patients should have the Pneumovax 23. I have a nurse visit today, I hope insurance picks it up but I don't care, I'm high risk and I have seen H1N1 in my practice. Think about your risk, and act now in the summer if you need to.

By spitting in the wind (not verified) on 12 Jun 2009 #permalink

Albatross: Regarding your questions in your posting on 6/11:

Are there other things that would be sensible to do to prepare, in case this next flu season is especially nasty? Would there be any advantage to getting antibiotics appropriate for treating bacterial pneumonia ahead of time, in case the health care system is completely slammed come flu season?

In 2007, I bought and read 7 books about preparing for a pandemic, and the Bird Flu Manual by Grattan Woodson was by far the best. In the book, Dr. Woodson gives detailed information about which medicines (including antibiotics for bacterial pneumonia and antivirals for flu) to stockpile for a flu pandemic (any flu pandemic--not just bird flu) and how to administer these yourself medicines at home, since that is where you will likely need to be treated if (and more likely when) the health care system is overwhelmed by a pandemic. In the book, Dr. Woodson recommends getting the pneumococcal vaccine, and I'd have to say he was way ahead of the game with this recommendation, judging by Revere's posting about the pneumococcal vaccine. I got our whole family the pneumococcal vaccine in 2007, and when the swine flu broke out this year, my friends finally listened to me and got their families vaccinated, too. In terms of stockpiling the medications, you may need to find some time finding a doctor willing to write you prescriptions. Our family doctor was really good about it. I brought in the Bird Flu Manual book the Monday morning after the swine flu broke out and she wrote prescriptions for the whole family for all of the medications listed in it (including Tamiflu); however, I've talked to my doctor since and she said that her medical group and the CDC have told her she can no longer write a prescription for Tamiflu unless the patient has flu symptoms. In any case, if you run into the problem about Tamiflu, you can at least fill the prescriptions for all of the other medications. A friend of mine did find an online pharmacy (with an MD on staff) in which she was able to get Tamiflu, since she wasn't able to get it from her doctor: DrugDelivery.ca. In any case, I highly recommend Dr. Woodson's book as essential for your family's pandemic planning, as it also includes a lot of information about how to prepare for the pandemic in a variety of ways (ex: what to have on hand if/when there are major infrastructure problems like the power grid going down or food becoming unavailable for stretches of time). My husband thought I was crazy when I bought all of the supplies recommended in the book back in 2007, but now he is grateful for my foresight and we feel much better about our ability to survive the pandemic and its potential effect on U.S. infrastructure over the year or two in which the pandemic will likely play out. I pray that I will never need these supplies, but they have given me tremendous peace of mind despite the considerable expense of stocking up; our family forewent luxury items over the last two years in order to establish this stockpile. After all, you can't eat a plasma t.v. if there is no food on the grocery store shelves; you won't even be able to watch it if the power goes out.

By Christina (not verified) on 17 Jun 2009 #permalink

Albatross: Regarding your questions in your posting on 6/11:

Are there other things that would be sensible to do to prepare, in case this next flu season is especially nasty? Would there be any advantage to getting antibiotics appropriate for treating bacterial pneumonia ahead of time, in case the health care system is completely slammed come flu season?

In 2007, I bought and read 7 books about preparing for a pandemic, and the Bird Flu Manual by Grattan Woodson was by far the best. In the book, Dr. Woodson gives detailed information about which medicines (including antibiotics for bacterial pneumonia and antivirals for flu) to stockpile for a flu pandemic (any flu pandemic--not just bird flu) and how to administer these yourself medicines at home, since that is where you will likely need to be treated if (and more likely when) the health care system is overwhelmed by a pandemic. In the book, Dr. Woodson recommends getting the pneumococcal vaccine, and I'd have to say he was way ahead of the game with this recommendation, judging by Revere's posting about the pneumococcal vaccine. I got our whole family the pneumococcal vaccine in 2007, and when the swine flu broke out this year, my friends finally listened to me and got their families vaccinated, too. In terms of stockpiling the medications, you may need to find some time finding a doctor willing to write you prescriptions. Our family doctor was really good about it. I brought in the Bird Flu Manual book the Monday morning after the swine flu broke out and she wrote prescriptions for the whole family for all of the medications listed in it (including Tamiflu); however, I've talked to my doctor since and she said that her medical group and the CDC have told her she can no longer write a prescription for Tamiflu unless the patient has flu symptoms. In any case, if you run into the problem about Tamiflu, you can at least fill the prescriptions for all of the other medications. A friend of mine did find an online pharmacy (with an MD on staff) in which she was able to get Tamiflu, since she wasn't able to get it from her doctor: DrugDelivery.ca. In any case, I highly recommend Dr. Woodson's book as essential for your family's pandemic planning, as it also includes a lot of information about how to prepare for the pandemic in a variety of ways (ex: what to have on hand if/when there are major infrastructure problems like the power grid going down or food becoming unavailable for stretches of time). My husband thought I was crazy when I bought all of the supplies recommended in the book back in 2007, but now he is grateful for my foresight and we feel much better about our ability to survive the pandemic and its potential effect on U.S. infrastructure over the year or two in which the pandemic will likely play out. I pray that I will never need these supplies, but they have given me tremendous peace of mind despite the considerable expense of stocking up; our family forewent luxury items over the last two years in order to establish this stockpile. After all, you can't eat a plasma t.v. if there is no food on the grocery store shelves; you won't even be able to watch it if the power goes out.

By Christina (not verified) on 17 Jun 2009 #permalink

Kudos to Christina for having the foresight to plan for this. When this thing started several months ago, I felt it would wane over the Summer and allow us to prepare. Given the growing number of cases (which seems to grow exponentially each day) and the reported deaths, I feel that we need to move from planning to executing. IMO, the first thing to do is to get the Pneumovax vaccine. There is a variety of literature that supports the idea that the overwhelming majority of previous deaths during pandemics was due to Streptococcus Pneumonia. The CDC might as well encourage everyone to roll up their sleeve for this vaccine.

As for stockpiling antibiotics and Tamiflu, it probably wouldn't be very difficult in obtaining a broad spectrum or one of the antibiotics that target Strep (Amoxicillin,Cefprozil). Tamiflu is a different story. If you are willing to shell out a few hundred dollars its available in tablet and liquid suspension from one of the online pharmacies...I think DrugCA..google it and it will come up.
I plan on going the extra step the next few weeks by building up enough food and water for 6-8 weeks in case of supply disruption. I still feel that's not enough, but its a start.

Christina, a few years ago my company joined the affiliate program of DrugDelivery.ca - which means we put a link to them on our website, expecting a commission from resulting sales - and they would not pay us the commission (a little over $100, if I remember correctly) which the program stats said we were due, simply ignoring our emails about it. So I do not trust that company and would feel funny about buying tamiflu from them, as it could possibly be counterfeit.

A company I personally would trust a lot more is antiaging-systems.com - although I might have some doubts about their tamiflu as well, especially if it comes to be in great demand as the pandemic proceeds. It's hard to trust anyone you don't know, unfortunately, when there's a lot of money to be made.

By Jon Schultz (not verified) on 17 Jun 2009 #permalink

Brian and Jon:

Thanks for responding to my posting about preparing for a pandemic.

Brian: Although you may feel that stocking up enough food and water for 6-8 weeks is not enough, it is much better than most Americans are doing and it should help you to get through a wave of the pandemic in your area. Personally, I have stockpiled enough food for one year, but that may be excessive and probably not practical for you at this point. Regarding stockpiling water (which obviously takes a lot of space at the recommended 2 gallons per person per day), in my readings about the pandemic's potential impact on infrastructure, it seems more likely that municipalities will continue to pump water into homes even if the water is not treated (background: there are only enough treatment chemicals on hand in most cities for a few days of water treatment) than for the municipalities to turn the water off to homes for any length of time (unless, of course, the power goes off for long periods and they can't pump the water, but I think that power supplies to water plants will be a high priority of government in a pandemic). Given that, I decided to invest in a good water filter, a recommendation per the Crisis Preparedness Handbook, which is also excellent. After much investigation, I decided on a water filter from General Ecology because of its superior capabilities for filtering out both microbes and toxins: http://www.generalecology.com/category_products.php?category_name_url=i…. I stockpiled a bunch of extra filters and also the company's emergency pump kit (in case water pressure goes out for a time in a pandemic). Of course, if you want to go the cheaper route, you can just buy a bunch of bleach at Costco to do your own water treatment (you can find info on the web about how to do this), but I worried about exposing our family to too much bleach and so opted for the relatively more expensive water filter. If you are going to start stockpiling, I would recommend getting your local friends and family on board about it, because if they don't have their own stockpiles, you are going to be in a difficult position of sharing your limited resources with friends and loved ones. In regard to your comment about Tamiflu being "available in tablet and liquid suspension", per the Bird Flu Manual I would highly recommend the tablet form of Tamiflu, because it can last much, much longer than the liquid suspension; if stored correctly (i.e., low humidity--not in the bathroom-- and mild temperatures) Tamiflu tablets can potentially last years beyond the expiration date. In the Bird Flu Manual (which you really should get if you will be stockpiling meds), Dr. Woodson tells you how to make your own liquid suspension from the Tamiflu tablets you have if/when a liquid suspension is needed to administer to children. Dr. Woodson also gives information on making your own Tamiflu suppositories from cocoa butter and crushed Tamiflu tablets, which I think is a very good idea to prevent the Tamiflu being lost orally through a bout of nausea (nausea is a side effect of both the flu and Tamiflu).

Jon: I'm sorry to hear about your experience with DrugDelivery.ca. It's so hard to know who to trust on the Internet. For what it's worth, my friend compared the Tamiflu pills she got from them with info available on another web site (can't find the link right now) that shows pictures of what Tamiflu tablets and package should look like if they are not counterfeit, and it looked like the Tamiflu she got was legitimate. I did a web search on spotting fake Tamiflu and actually found a previous posting by Revere on this topic: http://scienceblogs.com/effectmeasure/2008/03/how_to_test_for_counterfe…. Please read the posting because it has some interesting info on a test done to investigate the authenticity of Tamiflu purchased online. In any case, I've recently read and heard some allusions to the fact that this virus will likely become Tamiflu-resistant over the course of this pandemic, and in that case the only things we have left to combat it are a vaccine (which will be in extremely short supply initially) and possibly Relenza (which is also available at DrugDelivery.ca). At this point, I think that it would be wise to have some Relenza on hand, if you can get it. By the way, I have no affiliation with any of the companies or authors I've talked about; I'm just a layperson who has spent a lot of time researching this over the last few years.

Good luck to both of you.

By Christina (not verified) on 18 Jun 2009 #permalink

Thank you, Christina. That's good to know.

(Note you have to remove the period from the end of Christina's links.)

By Jon Schultz (not verified) on 18 Jun 2009 #permalink

Hi can someone tell me what adverse reactions can occur if you give pneumovax 23 to infants. My daughter got it accidentally and she is 4 months old but it was 1 1/2 weeks ago and she has had no problems so far. what should I do should she get another dose of prevenar or not.I will be grateful if anyone can reply

Ommar: Ask you pediatrician about the dose schedule. I think it is very worthwhile to get this vaccine.

Hi, my baby was vaccinated by Previnar on 2nd april 2010. He is 15 months old now. After that he is continuously suffering from loose stool and vomitting....Can any one please put comments on this!!! this was his third dose of previnar...In previous two dose, I don't face any issue..

Are you kidding me? Showing a carrot going down the conveyer without being packaged? How much bactreia on it? How stupid is this drug company? Won't take its drugs no matter what happens to me.