Incidence and Risk of Pneumococcal Pneumonia in Adults with Distinct Underlying Medical Conditions: A Population-Based Study.

PURPOSE: This study investigated the incidence of pneumococcal pneumonia requiring hospitalisation among middle-aged and older adults with and without specific underlying medical conditions, evaluating the influence of these conditions in the risk of developing pneumonia. METHODS: Population-based prospective cohort study included 2,025,730 individuals ≥ 50 years around Catalonia, Spain. The Catalonian information system for the development of research in primary care (SIDIAP) was used to establish baseline characteristics of the cohort (comorbidities and underlying medical conditions). Hospitalisations from pneumococcal pneumonia occurred among cohort members between 01/01/2015 and 31/12/2015 were collected from hospital discharge codes of 68 reference Catalonian hospitals. Cox regression was used to estimate the association between baseline conditions and the risk of developing pneumonia. RESULTS: Global incidence rate (IR) of hospitalised pneumococcal pneumonia was 82.8 cases per 100,000 persons-year. Maximum IRs (per 100,000 persons-year) emerged among persons with haematological neoplasia (837.4), immunodeficiency (709.2), HIV infection (474.7), severe renal disease (407.5) and chronic pulmonary disease (305.7). In the multivariable analyses, apart from increasing age, HIV infection (hazard ratio [HR] 6.78), haematological neoplasia (HR 6.30), prior all-cause pneumonia (HR 5.27), immunodeficiency (HR 4.57) and chronic pulmonary disease (HR 2.89) were the conditions most strongly associated with an increasing risk. Pneumococcal vaccination did not emerge associated with a reduced risk in our study population (nor PPsV23 neither PCV13). CONCLUSION: Old age, immunocompromising conditions and chronic pulmonary/respiratory disease are major risk factors for pneumococcal pneumonia in adults. Our data underline the need for better prevention strategies in these persons.

Prevalence of high, medium and low-risk medical conditions for pneumococcal vaccination in Catalonian middle-aged and older adults: a population-based study.

BACKGROUND: Updated population-based data on the frequency and distribution of risk factors for pneumococcal disease is scarce. This study investigated the prevalence of distinct comorbidities and underlying risk conditions related to an increasing risk of pneumococcal disease among Catalonian middle-aged and older adults. METHODS: Cross-sectional population-based study including 2,033,465 individuals aged 50 years or older registered at 01/01/2015 in the Catalonian Health Institute (Catalonia, Spain). The clinical research database of the Information System for the Development of Research in Primary Care (SIDIAP database) was used to identify high-risk (asplenia and/or immunocompromising conditions) and other increased-risk conditions (chronic pulmonary, cardiac or liver disease, diabetes mellitus, alcoholism and/or smoking) among study subjects. RESULTS: Globally, 980,310 (48.2%) of the 2,033,465 study population had at least one risk condition of suffering pneumococcal disease (55.4% in men vs 42.0% in women, p < 0.001; 41.7% in people 50-64 years vs 54.7% in persons 65 years or older, p < 0.001). An amount of 176,600 individuals (8.7%) had high-risk conditions (basically immunocompromising conditions). On the other hand, 803,710 persons (39.5%) had one or more other risk conditions. In fact, 212,255 (10.4%) had chronic pulmonary diseases, 248,377 (12.2%) cardiac disease, 41,734 (2.1%) liver disease, 341,535 (16.8%) diabetes mellitus, 58,781 (2.9%) alcoholism and 317,558 (15.6%) were smokers. CONCLUSION: In our setting, approximately 50 % of overall persons 50 years or older may be considered at-risk population for pneumococcal disease (almost 10 % have high-risk conditions and 40 % have other risk conditions).

Incidence and risk conditions of ischemic stroke in older adults.

OBJECTIVE: The objective of this study was to investigate incidence and mortality from ischemic stroke in older adults with specific underlying chronic conditions, evaluating the influence of these conditions in developing stroke. MATERIALS & METHODS: Population-based cohort study involving 27,204 individuals ≥60 years old in Southern Catalonia, Spain. All cases of hospitalization from ischemic stroke (confirmed by neuro-imaging) were collected from 01/12/2008 until 30/11/2011. Incidence rates and 30-day mortality were estimated according to age, sex, chronic illnesses, and underlying conditions. Multivariable Cox regression analysis was used to calculate Hazards Ratio (HR) and estimate the association between baseline conditions and risk of developing stroke. RESULTS: Mean incidence rate reached 453 cases per 100,000 person-years. Maximum rates appeared among individuals with history of prior stroke (2926 per 100,000), atrial fibrillation (1815 per 100,000), coronary artery disease (1104 per 100,000), nursing-home residence (1014 per 100,000), and advanced age ≥80 years (1006 per 100,000). Thirty-day mortality was 13% overall, reaching 21% among patients over 80 years. Age [HR: 1.06; 95% confidence interval (CI): 1.04-1.07], history of prior stroke (HR: 5.08; 95% CI: 3.96-6.51), history of coronary artery disease (HR: 1.65; 95% CI: 1.21-2.25), atrial fibrillation (HR: 2.96; 95% CI: 2.30-3.81), diabetes mellitus (HR: 1.55; 95% CI: 1.23-1.95), and smoking (HR: 1.64; 95% CI: 1.15-2.34) emerged independently associated with an increased risk of ischemic stroke. CONCLUSION: Incidence and mortality from ischemic stroke remains considerable. Apart from age and history of atherosclerosis (prior stroke or coronary artery disease), atrial fibrillation, diabetes, and smoking were the underlying conditions most strongly associated with an increased risk.

Epidemiology of Streptococcus pneumoniae causing acute otitis media among children in Southern Catalonia throughout 2007-2013: Incidence, serotype distribution and vaccine's effectiveness.

OBJECTIVE: This study investigated incidence and serotype distribution of Streptococcus pneumoniae causing acute otitis media (AOM) in Catalonian children, evaluating vaccination effectiveness in the current era of extended valency pneumococcal conjugate vaccines (PCVs). METHODS: Population-based surveillance study that included all AOM cases with isolation of pneumococcus (from otic fluids/otorrea) identified among children ≤14 years in the region of Tarragona (Southern Catalonia, Spain) from 01/01/2007 to 31/12/2013. Prevalence of infections caused by serotypes covered by the different PCVs formulations were calculated for the periods before and after 30/06/2010 (date of PCV7/PCV13 replacement). The indirect cohort method was used to estimate PCV7/13 effectiveness against vaccine-type infections. RESULTS: A total of 78 children with a pneumococcal AOM were identified across study period, which meant an incidence rate of 23 cases per 100,000 population-year. Thirty-six cases (46.2%) occurred within the late PCV7 era and 42 cases (53.8%) during the early PCV13 era. Overall, the most common serotypes were type 19A (21.7%), type 3 (13.3%) and type 15B (6.7%). Prevalence of cases caused by serotypes included in PCV7 did not substantially change between the first and the second study period (from 10.3% to 12.9%), whereas prevalence of cases caused by PCV13 serotypes showed a decreasing trend between both periods (from 65.5% to 48.4%). The aggregate PCV7/13 effectiveness against vaccine-type infections was 72% (95% confidence interval: -26 to 94). CONCLUSION: Pneumococcal conjugate vaccination appears an acceptable preventive option to prevent pneumococcal AOM in infants. However, its serotype coverage and clinical effectiveness are not optimal.

Evaluating the clinical effectiveness of pneumococcal vaccination in preventing myocardial infarction: The CAPAMIS study, three-year follow-up.

BACKGROUND: Cardiovascular benefits using the 23-valent pneumococcal polysaccharide vaccine (PPV23) are controversial. This study assessed clinical effectiveness of PPV23 in preventing acute myocardial infarction in people over 60-years. METHODOLOGY: We conducted a population-based cohort study involving 27,204 individuals ≥60 years-old in Tarragona, Spain, who were prospectively followed from 01/12/2008 until 30/11/2011. Outcomes were hospitalization for AMI, 30-day mortality from AMI and all-cause death. Cox regression was used to evaluate the association between pneumococcal vaccination and the risk of each outcome. RESULTS: Cohort members were followed for a total of 76,033 person-years, of which 29,065 were for vaccinated subjects. Overall, 359 cases of AMI, 55 deaths from AMI and 2465 all-cause deaths were observed. Pneumococcal vaccination did not alter the risk of AMI (multivariable hazard ratio [HR]: 0.95; 95% confidence interval [CI]: 0.76-1.18; p=0.630), death from AMI (HR: 1.32; 95% CI: 0.76-2.28; p=0.321) and all-cause death (HR: 0.97; 95% CI: 0.89-1.05; p=0.448). In analyses focused on people with and without history of prior coronary artery disease, pneumococcal vaccination did not emerge effective in preventing any analyzed event. CONCLUSIONS: This study supports that PPV23 does not provide any relevant benefit against AMI in the general population over 60 years, as in primary as well as in secondary prevention, although it is underpowered to exclude a small benefit of vaccination against rare outcomes.

Validation of the CORB75 (confusion, oxygen saturation, respiratory rate, blood pressure, and age ≥ 75 years) as a simpler pneumonia severity rule.

PURPOSE: This study compares the ability of two simpler severity rules (classical CRB65 vs. proposed CORB75) in predicting short-term mortality in elderly patients with community-acquired pneumonia (CAP). METHODS: A population-based study was undertaken involving 610 patients ≥ 65 years old with radiographically confirmed CAP diagnosed between 2008 and 2011 in Tarragona, Spain (350 cases in the derivation cohort, 260 cases in the validation cohort). Severity rules were calculated at the time of diagnosis, and 30-day mortality was considered as the dependent variable. The area under the receiver operating characteristic curves (AUC) was used to compare the discriminative power of the severity rules. RESULTS: Eighty deaths (46 in the derivation and 34 in the validation cohorts) were observed, which gives a mortality rate of 13.1 % (15.6 % for hospitalized and 3.3 % for outpatient cases). After multivariable analyses, besides CRB (confusion, respiration rate ≥ 30/min, systolic blood pressure <90 mmHg or diastolic ≤ 60 mmHg), peripheral oxygen saturation (≤ 90 %) and age ≥ 75 years appeared to be associated with increasing 30-day mortality in the derivation cohort. The model showed adequate calibration for the derivation and validation cohorts. A modified CORB75 scoring system (similar to the classical CRB65, but adding oxygen saturation and increasing the age to 75 years) was constructed. The AUC statistics for predicting mortality in the derivation and validation cohorts were 0.79 and 0.82, respectively. In the derivation cohort, a CORB75 score ≥ 2 showed 78.3 % sensitivity and 65.5 % specificity for mortality (in the validation cohort, these were 82.4 and 71.7 %, respectively). CONCLUSIONS: The proposed CORB75 scoring system has good discriminative power in predicting short-term mortality among elderly people with CAP, which supports its use for severity assessment of these patients in primary care.

Incidence of pneumococcal infections among children under 15 years in southern Catalonia throughout the heptavalent conjugate vaccine era, 2002-2009.

PURPOSE: Updating epidemiological studies to document current incidences of pneumococcal diseases are greatly needed in the current era of new pneumococcal conjugate vaccines (PCVs). The aim of this study is to analyze the incidence and distribution of different serotypes causing pneumococcal infections among the pediatric population in southern Catalonia, Spain, throughout the 2002-2009 PCV7 eras. METHODS: A population-based surveillance study was conducted among children aged ≤ 14 years in the region of Tarragona (Catalonia, Spain) during the period 2002-2009. All cases of pneumococcal infections (invasive and non-invasive cases) were included in the study. Incidence rates (per 100,000 population-year) and prevalence of infections caused by serotypes included in different PCV formulations were calculated for the 2002-2005 and 2006-2009 periods. RESULTS: Globally, across the total 2002-2009 period, the incidence of pneumococcal infections was 48.2 per 100,000 children-year (22.4 and 25.8 for invasive and non-invasive infections, respectively). Between 2002-2005 and 2006-2009, the incidence rates largely decreased among children aged <2 years (from 171 to 111 per 100,000 children-year; p = 0.059), but they did not substantially vary among children aged 2-14 years. The percentages of cases caused by serotypes included in PCV7 (60.0 vs. 16.7 %; p < 0.001), PCV10 (75.0 vs. 47.4 %; p = 0.028), and PCV13 (85.0 vs. 70.5 %; p = 0.190) decreased in both periods. CONCLUSION: In this study, which was conducted in a setting with intermediate PCV7 uptakes, a considerable protective direct effect of vaccination occurred among young infants, but an indirect protective effect did not emerge in the rest of the pediatric population. Despite new PCVs with higher serotype coverage, an important proportion of pneumococcal infections is still not covered by these vaccines.

Comparison of three predictive rules for assessing severity in elderly patients with CAP.

AIM: This study compares the ability of the Pneumonia Severity Index (PSI) and the British Thoracic Society CURB-65 and CRB-65 rules in predicting short-term mortality among elderly patients with community-acquired pneumonia (CAP). METHODS: It is a population-based study including all people over 65 years old with a radiographically confirmed CAP in the region of Tarragona (Spain) between 2002 and 2008. Treatment setting and clinical variables were considered for each patient. PSI, CURB-65 and CRB-65 scores were calculated at the moment of diagnosis and 30-day mortality was considered as a main dependent variable. The rules were compared based on sensitivity, specificity and area under the receiver operating characteristic curve (AUC). RESULTS: Of the total 590 CAP cases, mortality rate was 13.6% (15.3% in hospitalised and 1.4% in outpatient cases; p = 0.001). Mortality increased with increasing PSI score (None in class II, 6,9% in class III, 14,4% in class IV and 29,5% in class V), CURB-65 score (7.5%, 14.5%, 26.7%, 53.3% and 100% for scores 1,2,3,4 and 5 respectively) and CRB-65 score (6.6%, 26.1%, 40.5% and 50% for scores 1,2,3 and 4 respectively). The three rules performed too similarly to predict 30-day mortality, with a ROC area of 0.727 [95% confidence interval (CI): 0.67-0.79] for the PSI, 0.672 (95% CI: 0.61-0.74) for the CURB-65, and 0.719 (95% CI: 0.65-0.78) for the CRB-65. CONCLUSION: Our data shows that the analysed rules perform equally well among elderly people with CAP which supports the recommendation for using the simplified CRB-65 severity score among elderly patients in primary care or emergency visits.

Protective effect of pneumococcal vaccine against death by pneumonia in elderly subjects.

The present study assessed the effectiveness of the 23-valent pneumococcal polysaccharide vaccine to prevent pneumonia and death in older adults in a first-time report between January and December 2002. A prospective cohort study was conducted including all individuals>or=65 yrs of age assigned to one of eight primary care centres in Tarragona, Spain (n=11,241). The primary outcomes were community-acquired pneumonia (hospitalised or outpatient) and death from pneumonia. All pneumonias were validated by checking clinical records. The association between the pneumococcal vaccination and the risk of each outcome was evaluated by means of multivariate Cox proportional-hazard models, adjusted by age, sex, influenza vaccination status, comorbidity and immunological status. Pneumococcal vaccination did not alter the risk of hospitalisation from pneumonia (hazard ratio (HR): 0.80; 95% confidence interval (CI): 0.50-1.28) or overall pneumonia (HR: 0.86; 95% CI: 0.56-1.31), but the vaccine was associated with considerable reductions of death risk from pneumonia (HR: 0.28; 95% CI: 0.09-0.83). In conclusion, these results suggest that pneumococcal polysaccharide vaccine may not be effective in reducing the incidence of pneumonia, but may be able to diminish the severity of the infection. These findings support the effectiveness of the pneumococcal polysaccharide vaccine to prevent mortality caused by pneumonia in older adults, providing a new argument to recommend systematic vaccination in the elderly.

[EVAN-65 project: evaluation of the effectiveness of pneumococcus vaccination in the elderly population over 65]. / Proyecto EVAN-65: evaluación de la efectividad de la vacuna antineumocócica en mayores de 65 años.

OBJECTIVE: To assess the effectiveness of systematic pneumococcus vaccination (PV) in the over-65s by comparing rates of incidence and severity of the cases of pneumonia caught in the community (PCC), in two cohorts-those vaccinated (VC) and those not (NVC). DESIGN: Multi-centre study of cohorts. SETTING: Primary Health Care. PARTICIPANTS: All those over 65 registered at 8 urban Health Districts and distributed into a VC (with PV) and an NVC. INTERVENTIONS: Active monitoring will be conducted for 3 years, with detection of all the PCC occurring during this period. Data sources will be the specific register of the PV programme and exhaustive review of primary Care and referral hospital clinical records (records of pneumonia cases admitted and records of pneumonia cases detected in Casualty). MAIN MEASUREMENT: Variables considered will be: age, sex, and presence or otherwise of risk factors linked to greater susceptibility to catching pneumonia (diabetes mellitus, low immunity levels, cardiopathy, COPD, tobacco dependency, alcoholism, splenectomy). To measure the effect, we will calculate the annual and overall accumulated (over 3 years) rates of incidence of pneumonia, as well as the relative and attributable risks. As measurements of its severity, we will analyse the mortality index and the "fine" ordinal scale of severity. DISCUSSION: The study will give a reply in terms of effectiveness and efficiency of the vaccine and will contribute to a definitive decision on the controversial question of the systematic indication of this vaccine for the over-65 population.