We share the frustration of Hirschmann and Lipsky1 in the dearth of large prospective studies of pneumococcal vaccine in various populations. However, we disagree with the conclusions reached in their article. As clinicians, we must consider the risk-benefit ratio and keep in mind health care costs in our interventions. The risks of pneumococcal vaccine are extremely low. As described by the authors, the magnitude of the benefits will vary depending on the underlying immune status of the host.
We would like to expand on the example cited by the authors. If 100 000 elderly subjects were immunized at $20 each for an initial cost of $2 million, only 74 cases (15 bacteremic and 59 nonbacteremic) of pneumococcal disease would be prevented. The mean length of stay for patients in our community-based pneumonia incidence study2 was 13 days for pneumococcal bacteremia and 10 days for nonbacteremic pneumococcal pneumonia (J.F.P.