“…The causes of the decreased efficacy of pneumococcal vaccination among Native Americans are multifactorial and involve unusually high rates of endemic disease, malnutrition, obesity, diabetes, smoking, alcoholism, and other effects of poverty [ 139 , 157 , 158 , 159 ]. Other U.S. minorities, such as African Americans and Latinos [ 139 , 159 , 160 , 161 , 162 , 163 , 164 , 165 ], also experience lower vaccine efficacy than is found among Whites and for similar reasons. Because poverty, malnutrition, endemic disease, and substance use vary widely by geographical region, significant differences in pneumococcal vaccine efficacy also exist at a global level [ 174 ], so that simply using vaccination rates, as has been performed here, and in most of the other studies cited in this paper, is only an approximation for actual efficacy.…”