Letter to the Editor
Obsolete Anti-Pneumococcal Vaccination Recommendations in the Spanish Guidelines for the Management of Asthma (GEMA 4.0): The Authors Reply
La guía española del manejo del asma (GEMA 4.0) está obsoleta en lo que a vacunación antineumocócica se refiere. Respuesta de los autores
Vicente Plaza Morala,
, Cesáreo Álvarez Rodríguezb, Antonio Gómez-Outesc, Fernando Gómez Ruizd, Antolín López Viñae, Francisco Javier Pellegrini Belinchónf, Javier Plaza Zamorag, José Antonio Quintano Jiménezh, Santiago Quirce Gancedoi, José Sanz Ortegaj, Ramona Soler Vilarrasak, José Ramón Villa Asensil, en representación del Comité Ejecutivo de la Guía Española para el Manejo del Asma (GEMA)
Corresponding author
a Coordinador del Comité Ejecutivo de GEMA, Spain
b Sociedad Española de Medicina de Urgencias y Emergencias (SEMES), Spain
c Sociedad Española de Farmacología Clínica (SEFC), Spain
d Sociedad Española de Médicos Generales y de Familia (SEMG), Spain
e Sociedad Española de Neumología y Cirugía Torácica (SEPAR), Spain
f Sociedad Española de Pediatría Extrahospitalaria y Atención Primaria (SEPEAP), Spain
g Sociedad Española de Farmacia Familiar y Comunitaria (SEFAC), Spain
h Sociedad Española de Médicos de Atención Primaria (SEMERGEN), Spain
i Sociedad Española de Alergología e Inmunología Clínica (SEAIC), Spain
j Sociedad Española de Inmunología Clínica, Alergología y Asma Pediátrica (SEICAP), Spain
k Sociedad Española de Otorrinolaringología (SEORL), Spain
l Sociedad Española de Neumología Pediátrica (SENP), Spain
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"identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Sociedad Española de Neumología y Cirugía Torácica (SEPAR), Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Sociedad Española de Pediatría Extrahospitalaria y Atención Primaria (SEPEAP), Spain" "etiqueta" => "f" "identificador" => "aff0030" ] 6 => array:3 [ "entidad" => "Sociedad Española de Farmacia Familiar y Comunitaria (SEFAC), Spain" "etiqueta" => "g" "identificador" => "aff0035" ] 7 => array:3 [ "entidad" => "Sociedad Española de Médicos de Atención Primaria (SEMERGEN), Spain" "etiqueta" => "h" "identificador" => "aff0040" ] 8 => array:3 [ "entidad" => "Sociedad Española de Alergología e Inmunología Clínica (SEAIC), Spain" "etiqueta" => "i" "identificador" => "aff0045" ] 9 => array:3 [ "entidad" => "Sociedad Española de Inmunología Clínica, Alergología y Asma Pediátrica (SEICAP), Spain" "etiqueta" => "j" "identificador" => "aff0050" ] 10 => array:3 [ "entidad" => "Sociedad Española de Otorrinolaringología (SEORL), Spain" "etiqueta" => "k" "identificador" => "aff0055" ] 11 => array:3 [ "entidad" => "Sociedad Española de Neumología Pediátrica (SENP), Spain" "etiqueta" => "l" "identificador" => "aff0060" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "La guía española del manejo del asma (GEMA 4.0) está obsoleta en lo que a vacunación antineumocócica se refiere. Respuesta de los autores" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We read with great interest the letter to the Editor<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> contributed by Mascarós et al. on behalf the <span class="elsevierStyleItalic">Neumoexpertos en Prevención</span> group, which is supported by the Instituto de Investigación Sanitaria de Santiago, in collaboration with Pfizer (<a id="intr0010" class="elsevierStyleInterRef" href="http://neumoexpertos.org/conflicto-de-intereses">http://neumoexpertos.org/conflicto-de-intereses</a>). These authors question the lack of a recommendation for anti-pneumococcal vaccination in asthma patients in the latest edition of the Spanish Guidelines for the Management of Asthma (GEMA 4.0).<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> Their arguments hinge on recent consensus documents from experts recommending this intervention, and new studies that have shown its efficacy.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">3,4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Evidence-based clinical practice guidelines (CPG) propose recommendations when the scientific proof is available to support them. Unfortunately, in the case of the pneumococcal vaccine, the evidence is weak (or non-existent). Accordingly, it is not recommended by either the GEMA 4.0 or the most prestigious international guidelines, such as the Global Initiative for Asthma (GINA) or the British Thoracic Society (BTS). Of the 2 publications which Mascarós et al. claim provide new evidence for the efficacy of the vaccine, the study by Okapuu et al.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> is a simple arithmetic exercise based on a database crossover involving the calculation of a hypothetical number of cases needed to be treated (NNT), rather than the analysis of data gathered in a prospective clinical trial. The study by Bonten et al. (CAPITA study)<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> provides evidence for the indication of the PVC13 pneumococcal vaccine in patients over 65 years of age, but cannot be used as an argument to support its indication in the asthma population, since no specific subanalysis was performed in this group. Moreover, recommendations from expert groups published in recent consensus documents that lack the support of robust studies provide only low-level (or non-existent) evidence – the type of evidence which, in general, is avoided in CPGs.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Nevertheless, as the asthma population has a greater risk of presenting invasive pneumococcal disease,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> and pneumococcal vaccination is effective in preventing this infection in the general population, even if the evidence for its indication in the asthma population is weak (or non-existent), the Spanish National Health System (<a id="intr0015" class="elsevierStyleInterRef" href="http://www.msssi.gob.es/">http://www.msssi.gob.es</a>) has recently recommended its use in patients with severe asthma. We, the signatories of GEMA 4.0 (mostly clinical physicians), consider that pneumococcal vaccination in patients with severe asthma is probably beneficial, but as writers of evidence-based CPGs, we are obliged to limit our recommendation until rigorous proof of this indication is available. In view of these findings, it seems appropriate at the present time to go no further in recommending pneumococcal vaccination in the asthmatic population. The GEMA signatories will include this recommendation in the future, if new, robust evidence supporting this approach should emerge.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interests</span><p id="par0020" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interests related with the contents of this manuscript.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflict of interests" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Plaza Moral V, Álvarez Rodríguezb C, Gómez-Outesc A, Gómez Ruizd F, López Viñae A, Pellegrini Belinchónf FJ, et al. La guía española del manejo del asma (GEMA 4.0) está obsoleta en lo que a vacunación antineumocócica se refiere. Respuesta de los autores. Arch Bronconeumol. 2016;52:449.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Obsolete anti-pneumoccal vaccination recommendations in the Spanish guidelines for the management of asthma (GEMA 4.0)" "autores" => array:1 [ 0 => array:3 [ "colaboracion" => "en nombre de Neumoexpertos en Prevención" "etal" => false "autores" => array:3 [ 0 => "E. Mascarós" 1 => "D. Ocaña" 2 => "F. Martinón-Torres" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "Arch Bronconeumol" "fecha" => "2016" "volumen" => "52" "paginaInicial" => "448" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0035" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:1 [ "titulo" => "Guía Española para el Manejo del Asma (GEMA 4.0)" ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Arch Bronconeumol" "fecha" => "2015" "volumen" => "51" "numero" => "Suppl. 1" "paginaInicial" => "S1" "paginaFinal" => "S68" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0040" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "How many individuals with asthma need to be vaccinated to prevent one case of invasive pneumococcal disease?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J.M. Okapuu" 1 => "E. Chétrit" 2 => "B. Lefebvre" 3 => "C. Quach" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Can J Infect Dis Med Microbiol" "fecha" => "2014" "volumen" => "25" "paginaInicial" => "147" "paginaFinal" => "150" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25285110" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0045" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Polysaccharide conjugate vaccine against pneumococcal pneumonia in adults" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M.J. Bonten" 1 => "S.M. Huijts" 2 => "M. Bolkenbaas" 3 => "C. Webber" 4 => "S. Patterson" 5 => "S. Gault" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1056/NEJMoa1408544" "Revista" => array:6 [ "tituloSerie" => "N Engl J Med" "fecha" => "2015" "volumen" => "372" "paginaInicial" => "1114" "paginaFinal" => "1125" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25785969" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Asthma as a risk factor for invasive pneumococcal disease" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "T.R. Talbot" 1 => "T.V. Hartert" 2 => "E. Mitchel" 3 => "N.B. Halasa" 4 => "P.G. Arbogast" 5 => "K.A. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 2 | 0 | 2 |
| 2024 October | 41 | 13 | 54 |
| 2024 September | 46 | 15 | 61 |
| 2024 August | 64 | 36 | 100 |
| 2024 July | 44 | 16 | 60 |
| 2024 June | 57 | 34 | 91 |
| 2024 May | 59 | 28 | 87 |
| 2024 April | 38 | 22 | 60 |
| 2024 March | 48 | 19 | 67 |
| 2024 February | 35 | 27 | 62 |
| 2023 March | 8 | 4 | 12 |
| 2023 February | 34 | 20 | 54 |
| 2023 January | 23 | 36 | 59 |
| 2022 December | 49 | 31 | 80 |
| 2022 November | 61 | 33 | 94 |
| 2022 October | 44 | 30 | 74 |
| 2022 September | 39 | 25 | 64 |
| 2022 August | 29 | 45 | 74 |
| 2022 July | 25 | 42 | 67 |
| 2022 June | 33 | 34 | 67 |
| 2022 May | 24 | 38 | 62 |
| 2022 April | 39 | 31 | 70 |
| 2022 March | 41 | 37 | 78 |
| 2022 February | 27 | 33 | 60 |
| 2022 January | 31 | 43 | 74 |
| 2021 December | 32 | 28 | 60 |
| 2021 November | 31 | 51 | 82 |
| 2021 October | 39 | 44 | 83 |
| 2021 September | 24 | 47 | 71 |
| 2021 August | 34 | 44 | 78 |
| 2021 July | 21 | 23 | 44 |
| 2021 June | 36 | 38 | 74 |
| 2021 May | 43 | 58 | 101 |
| 2021 April | 80 | 149 | 229 |
| 2021 March | 42 | 33 | 75 |
| 2021 February | 31 | 22 | 53 |
| 2021 January | 30 | 25 | 55 |
| 2020 December | 24 | 23 | 47 |
| 2020 November | 34 | 20 | 54 |
| 2020 October | 20 | 17 | 37 |
| 2020 September | 22 | 10 | 32 |
| 2020 August | 27 | 19 | 46 |
| 2020 July | 31 | 25 | 56 |
| 2020 June | 22 | 7 | 29 |
| 2020 May | 25 | 19 | 44 |
| 2020 April | 35 | 31 | 66 |
| 2020 March | 30 | 15 | 45 |
| 2020 February | 44 | 27 | 71 |
| 2020 January | 29 | 23 | 52 |
| 2019 December | 32 | 19 | 51 |
| 2019 November | 48 | 21 | 69 |
| 2019 October | 25 | 23 | 48 |
| 2019 September | 17 | 8 | 25 |
| 2019 August | 24 | 19 | 43 |
| 2019 July | 19 | 15 | 34 |
| 2019 June | 25 | 22 | 47 |
| 2019 May | 30 | 29 | 59 |
| 2019 April | 35 | 28 | 63 |
| 2019 March | 28 | 23 | 51 |
| 2019 February | 37 | 16 | 53 |
| 2019 January | 37 | 11 | 48 |
| 2018 December | 31 | 23 | 54 |
| 2018 November | 46 | 16 | 62 |
| 2018 October | 93 | 18 | 111 |
| 2018 September | 20 | 11 | 31 |
| 2018 May | 6 | 2 | 8 |
| 2018 April | 31 | 4 | 35 |
| 2018 March | 18 | 3 | 21 |
| 2018 February | 18 | 4 | 22 |
| 2018 January | 31 | 7 | 38 |
| 2017 December | 28 | 5 | 33 |
| 2017 November | 29 | 4 | 33 |
| 2017 October | 30 | 4 | 34 |
| 2017 September | 22 | 15 | 37 |
| 2017 August | 21 | 10 | 31 |
| 2017 July | 23 | 15 | 38 |
| 2017 June | 29 | 17 | 46 |
| 2017 May | 34 | 10 | 44 |
| 2017 April | 30 | 15 | 45 |
| 2017 March | 17 | 10 | 27 |
| 2017 February | 17 | 8 | 25 |
| 2017 January | 6 | 4 | 10 |
| 2016 December | 33 | 16 | 49 |
| 2016 November | 44 | 35 | 79 |
| 2016 October | 2 | 3 | 5 |
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