Pneumococcal pneumonia continues to be an important disease in terms of prevalence, morbidity and mortality. With the discovery of penicillin and its wide clinical use, the overall mortality of pneumococcal pneumonia has been significantly reduced, but problems remain. These include: 1) death rate is uninfluenced by the antibiotic in the first five days of illness; 2) death rate in certain high risk groups and in patients infectecd with type 3 pneumococcus exceeds 25%; and 3) penicillin resistant strains of pneumococci have emerged. Because of these and other considerations, a modern 14-valent pneumococcal vaccine has been developed by Robert Austrian and his co-workers. The vaccine has been found to be immunogenic and effective in a number of populations studied. Additional efficacy studies are needed, however, particularly in certain high risk groups, such as the elderly and immunocompromised patients.

The economic techniques of cost-effectiveness and cost-benefit analysis have provided useful insights into the potential advantages of vaccination against pneumococcal pneumonia. They suggest that the cost of vaccinating persons 65 years and older and perhaps younger persons with high risk conditions would be reasonable when compared with the cost of treatment for pneumococcal pneumonia. These findings, together with other considerations, may guide physicians and health care policymakers in deciding which individuals might be expected to benefit from pneumococcal vaccination.

Many patients hospitalized for or dying of pneumococcal bacteremia have been discharged from a hospital with in the previous five years. In addition to age and underlying medical condition, previous hospital care, particularly for high risk conditions, is a useful marker for identifying individuals who are destined to develop serious pneumococcal infections. Relatively few patients, especially those with high risk conditions, would need to receive pneumococcal vaccine at the time of hospital discharge to prevent, within the next five years, each subsequent readmission or death from pneumococcal pneumonia. Although pneumococcal vaccine has not been widely used in the hospital setting, there are sound epidemiologic reasons to expect that organized programs for vaccine delivery in hospitals would be an effective approach to preventing many serious pneumococcal infections.

The Congress has authorized the Medicare program to pay for the cost of pneumococcal vaccine and its administration. The history of this legislation demonstrates that chance and political considerations quite separate from the scientific issues on vaccination played an important role in the development of this policy. It demonstrates both the need for and the difficulty of achieving more effective coordination of the activities related to national policies on vaccines and immunization.

The Advisory Committee on Immunization Practices (ACIP) of the U.S. Public Health Service is responsible for making recommendations on the use of new vaccines and periodically revising those for established vaccines. Recommendations for pneumococcal vaccine were first issued in 1978 and revised in 1981. The changes which appear in the revision reflect the continuing maturation of the Committee's judgment on the vaccine and are a good example of the process by which the ACIP develops its recommendations on national immunization practices.