The results of Dr Gruer's survey are certainly interesting. Although the design of his group's study was not identical to ours,1 the case fatality rates observed among his patients parallel those reported by others.2 It would be useful for Dr Gruer to characterize those parameters (eg, duration of illness prior to hospitalization, pneumococcal serotype) that may have contributed to the high mortality rates. Such an analysis might identify reasons for the differences in the mortality data between his study and our own.
Finally, I share Dr Gruer's pessimism on the usefulness of pneumococcal vaccines in reducing attack or case-fatality rates among elderly and debilitated patients. In persons of advanced age who have substantial underlying disease, the contemporary vaccine has not been shown to be either consistently immunogenic or protective.3-5 Further, it must be emphasized that factors other than antibody levels certainly contribute to protection from sporadic pneumococcal