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Editor,—Kyaw et al 1 highlight the importance of advice from general practitioners in the immunisation of patients with pneumococcal vaccine. However, greater knowledge regarding pneumococcal immunisation is required among GPs and doctors in general before patients in the target groups are likely to be vaccinated. I performed a postal questionnaire survey of the awareness of the indications for, and practice of pneumococcal immunisation among GPs in one inner London borough. Questions explored knowledge of the guidelines for pneumococcal immunisation with six real and six factitious indications, and GPs' immunisation practice. One hundred and fifty six GPs were mailed the questionnaire. The response rate was 56 of 156. The responses are summarised in table 1.
Respondents may represent those GPs interested in immunisation. However, few GPs seem to have a clear understanding of the Department of Health guidelines and some seem to confuse indications with those for influenza and meningococcal vaccines. On the other hand some GPs are aware of the indications but do not immunise accordingly, possibly because of the workload implications, lack of remuneration for the service or because of doubt regarding the vaccine's efficacy.2 3 For some patients there may be uncertainty as to whether hospitals or primary care should be taking the lead. The guidelines may be difficult to integrate into routine practice; current indications vary from those for influenza immunisation and there is a need to avoid re-immunising in most patients. Communication between hospital departments and patients' GPs is important in this regard.
Local immunisation campaigns can be effective but may not be seen as a priority by health authorities. In the future the indications for pneumococcal immunisation will need to be reviewed as conjugate pneumococcal vaccines are further evaluated and licensed.
We accept the point made by James that many GPs may be uncertain about the indications for pneumococcal vaccine. Indeed, earlier work we performed demonstrated the existence of similar uncertainty in the early 1990s, regarding the indications for influenza vaccine.1-1 With regard to pneumococcal vaccine, the situation is probably worsened by the fact that the evidence in support of effectiveness in high risk elderly persons is restricted to the prevention of invasive disease (bacteraemia).1-2 We also agree that GPs face many issues around appropriate workload and remuneration. Nevertheless, we cannot accept that pneumococcal vaccination is too difficult to incorporate into routine practice. The indications for influenza and pneumococcal vaccines overlap considerably.1-3 The UK Department of Health recommends that patients recalled annually for influenza vaccination, are offered pneumococcal vaccine simultaneously (on a “once only” basis and at a different injection site),1-3 thereby delivering two preventive measures for the same consultation and administrative costs. We agree that the availability of new conjugate vaccines, which offer the hope of reducing nasopharyngeal carriage, may bring about the need to review policy.1-4 However, until these become available, efforts to improve the uptake of polysaccharide pneumococcal vaccine in high risk persons should continue.