Incidence and risk factors of pneumococcal pneumonia in adults: a population-based study.

BACKGROUND: Infection caused by Streptococcus pneumoniae, mainly invasive pneumococcal disease (IPD) and pneumococcal pneumonia (PP), are a major public health problem worldwide. This study investigated population-based incidence and risk of PP among Catalonian persons ≥ 50 years-old with and without specific underlying conditions/comorbidities, examining the influence of single and multi-comorbidities in the risk of suffering PP. METHODS: Population-based cohort study involving 2,059,645 persons ≥ 50 years-old in Catalonia, Spain, who were retrospectively followed between 01/01/2017-31/12/2018. The Catalonian information system for development of research in primary care (SIDIAP) was used to establish baseline characteristics of the cohort (comorbidities/underlying conditions), and PP cases were collected from discharge codes (ICD-10: J13) of the 68 referral Catalonian hospitals. RESULTS: Global incidence rate (IR) was 90.7 PP cases per 100,000 person-years, with a 7.6% (272/3592) case-fatality rate (CFR). Maximum IRs emerged among persons with history of previous IPD or all-cause pneumonia, followed by haematological neoplasia (475.0), HIV-infection (423.7), renal disease (384.9), chronic respiratory disease (314.7), liver disease (232.5), heart disease (221.4), alcoholism (204.8), solid cancer (186.2) and diabetes (159.6). IRs were 42.1, 89.9, 201.1, 350.9, 594.3 and 761.2 in persons with 0, 1, 2, 3, 4 and ≥ 5 comorbidities, respectively. In multivariable analyses, HIV-infection (hazard ratio [HR]: 5.16; 95% CI: 3.57-7.46), prior all-cause pneumonia (HR: 3.96; 95% CI: 3.45-4.55), haematological neoplasia (HR: 2.71; 95% CI: 2.06-3.57), chronic respiratory disease (HR: 2.66; 95% CI: 2.47-2.86) and prior IPD (HR: 2.56; 95% CI: 2.03-3.24) were major predictors for PP. CONCLUSION: Apart of increasing age and immunocompromising conditions (classically recognised as high-risk conditions), history of prior IPD/pneumonia, presence of chronic pulmonary/respiratory disease and/or co-existing multi-comorbidity (i.e., two or more underlying conditions) are major risk factors for PP in adults, with an excess risk near to immunocompromised subjects. Redefining risk categories for PP, including all the above-mentioned conditions into the high-risk category, could be necessary to improve prevention strategies in middle-aged and older adults.

[Epidemiology of pneumococcal pneumonia among middle-aged and older adults in Catalonia, 2017-2018]. / Epidemiología de la neumonía neumocócica en adultos mayores de 50 años: estudio de cohortes en Cataluña, 2017-2018.

OBJECTIVE: To analyse population-based incidence and lethality of pneumococcal pneumonia (PP) requiring hospitalisation among Catalonian adults after universal vaccination implementation in infants. DESIGN: Population-based cohort study. SETTING: Primary care/hospital, Catalonia. PARTICIPANTS: 2,059,645 individuals ≥50 years old affiliated to the Institut Catala de la Salut retrospectively followed between 01/01/2017 and 31/12/2018. MAIN OUTCOME MEASURES: The Catalonian information system for the development of research in primary care (SIDIAP, Sistema de Información para el Desarrollo de la Investigación en Atención Primaria) was used to establish baseline characteristics and risk-strata of cohort members at study start: low-risk (immunocompetent persons without risk conditions), intermediate-risk (immunocompetent persons with at-risk condition) and high-risk (immunocompromising conditions). PP requiring hospitalisation among cohort members across study period were collected from CMBD (Conjunto Mínimo Básico de Datos) discharge data of 64 reference Catalonian hospitals. RESULTS: An amount of 3592 episodes of HPP were observed, with an incidence density of 90.7 cases per 100,000 person-years (95% CI: 85.2-96.5), being 11.9 bacteremic (95% CI: 10.8-13.1) and 78.8 non-bacteremic (95% CI: 74.0-83.8). Incidence rates substantially increased by age (37.3 in 50-64 years vs. 98.3 in 65-79 years vs. 259.8 in ≥80 years) and baseline-risk stratum (42.1, 120.7 and 238.6 in low-, intermediate- and high-risk stratum, respectively). Overall case-fatality rate was 7.6% (10.8% in invasive cases vs. 7.1% in non-invasive cases; pP=.004). In multivariable analyses, high-risk stratum and oldest age were the strongest predictors for invasive and non-invasive cases, respectively. CONCLUSION: Incidence and lethality of PP remained moderate among adults >50 years in Catalonia during 2017-2018 (earlier period after universal vaccination introduction for infants).

Evaluating clinical effectiveness and impact of anti-pneumococcal vaccination in adults after universal childhood PCV13 implementation in Catalonia, 2017-2018.

Background: At present, because of indirect effects derived from routine childhood immunisation, clinical benefits vaccinating adults with the 23-valent pneumococcal polysaccharide vaccine (PPsV23) and/or the 13-valent pneumococcal conjugate vaccine (PCV13) are uncertain. This study investigated clinical effectiveness for both PPsV23/PCV13 in preventing pneumonia among Catalonian adults during an earlier 2-year period post-PCV13 free (publicly funded) approval for infants. Methods: We conducted a Population-based cohort study involving 2,059,645 adults ≥ 50 years in Catalonia, Spain, who were followed between 01/01/2017-31/12/2018. Primary outcomes were hospitalisation from pneumococcal pneumonia (PP) or all-cause pneumonia (ACP) and main explanatory variable was PCV13/PPsV23 vaccination status. Cox regression models were used to estimate vaccination effectiveness adjusted by age/sex and underlying-risk conditions. Results: Cohort members were followed for 3,958,528 person-years (32,328 PCV13-vaccinated, 1,532,186 PPsV23-vaccinated), observing 3592 PP (131 in PCV13-vaccinated vs 2476 in PPsV23-vaccinated) and 24,136 ACP (876 in PCV13-vaccinated vs 17,550 in PPsV23-vaccinated). Incidence rates (per 100,000 person-years) were 90.7 for PP (394.2 in PCV13-vaccinated vs 161.6 in PPsV23-vaccinated) and 609.7 for ACP (2636.3 in PCV13-vaccinated vs 1145.4 in PPsV23-vaccinated). The PCV13 was associated with an increased risk of PP (hazard ratio [HR]: 1.24; 95% CI: 1.00-1.52; p = 0.046) and ACP (HR: 1.38; 95% CI: 1.28-1.49; p < 0.001) whereas the PPsV23 did not alter the risk of PP (HR: 1.07; 95% CI: 0.98-1.18; p = 0.153) and slightly increased the risk of ACP (HR: 1.14; 95% CI: 1.10-1.18; p < 0.001). In supplementary analyses focused on at-risk individuals (i.e., elderly persons, immunocompromissing and other chronic illnesses) protective effects of vaccination did not emerge either. Conclusions: Data does not support clinical benefits from pneumococcal vaccination (nor PCV13 neither PPsV23) against pneumonia among Catalonian middle-aged and older adults in the current era of universal PCV13 childhood immunisation in our setting. New extended valency PCVs are greatly needed.

Susceptibility and risk of SARS-COV-2 infection among middle-aged and older adults in Tarragona area, Spain.

Objective: To analyse susceptibility/risk of suffering COVID-19 among adults with distinct underlying medical conditions. Methods: Population-based cohort study involving 79,083 individuals ≥50 years old in Tarragona (Southern Catalonia, Spain). Baseline cohort characteristics (demographic, pre-existing comorbidities, chronic medications and vaccinations history) were established at study start (01/03/2020) and primary outcome was laboratory-confirmed COVID-19 occurred among cohort members throughout 01/03/2020-30/06/2020. Risk of suffering COVID-19 was evaluated by Cox regression, estimating multivariable hazard ratios (HRs) adjusted for age/sex and pre-existing comorbidities. Results: Across study period, 536 laboratory-confirmed COVID-19 cases were observed (mean incidence: 39.5 cases per 100,000 persons-week). In multivariable-analysis, increasing age/years (HR: 1.01; 95% CI: 1.00-1.02), nursing-home (HR: 20.19; 95% CI: 15.98-25.51), neurological disease (HR: 1.35; 95% CI: 1.03-1.77), taking diuretics (HR: 1.39; 95% CI: 1.10-1.75), antiplatelet (HR: 1.36; 95% CI: 1.05-1.76) and benzodiazepines (HR: 1.24; 95% CI: 1.00-1.53) increased risk; conversely, taking angiotensin-converting-enzyme inhibitors (HR: 0.78; 95% CI: 0.61-1.00), angiotensin-receptor-blockers (HR: 0.70; 95%CI: 0.51-0.96) and statins (HR: 0.75; 95% CI: 0.58-0.96) were associated with reduced risk. Among community-dwelling individuals, pre-existing cancer, renal and cardiac disease appeared also related with an increased risk, whereas influenza vaccination was associated with reduced risk. Conclusion: In a setting with relatively low incidence of COVID-19 across the first wave of pandemic period, increasing age, nursing-home residence and multiple comorbidities appear predisposing for COVID-19 among middle-aged/older adults. Conversely, statins, angiotensin-receptor blockers/inhibitors and influenza vaccination were related with decreased risk.

Objetivo: Analizar incidencia y riesgo/susceptibilidad de sufrir la COVID-19 en adultos según distintas condiciones médicas preexistentes. Métodos: Cohorte de base poblacional que incluyó 79.083 personas ≥50 años en Tarragona. Características basales de la cohorte (edad/sexo, comorbilidades, medicaciones crónicas) se establecieron a 01-03-2020 y se registraron todos los casos de COVID-19 confirmada ocurridos en miembros de la cohorte hasta el 30-06-2020. Para estimación de riesgos se realizó regresión de Cox, con cálculo de hazard ratio (HR) ajustados por edad, sexo y comorbilidad. Resultados: Se observaron 536 casos confirmados de COVID-19 (incidencia media: 39,5 casos por 100.000 personas-semana). En análisis multivariante, edad/años (HR: 1,01; IC el 95%: 1,00-1,02; p = 0,050), estar institucionalizado/residencia (HR: 20,19; IC 95%: 15,98-25,51; p<0,001), enfermedad neurológica (HR: 1,35; IC el 95%: 1,03-1,77), diuréticos (HR: 1,39; IC 95%: 1,10-1,75), antiagregantes plaquetarios (HR: 1,36; IC 95%: 1,05-1,76) y benzodiacepinas (HR: 1,24; IC 95%: 1,00-1,53) se asociaron con un riesgo aumentado de la COVID-19 analizando la totalidad de la cohorte; contrariamente, medicación IECA (HR: 0,78; IC el 95%: 0,61-1,00), ARA-II (HR: 0,70; IC el 95%: 0,51-0,96) y estatinas (HR: 0,75; IC el 95%: 0,58-0,96) se asociaron con menor riesgo. Entre personas no institucionalizadas, cáncer, nefropatía y cardiopatía se asociaron con mayor riesgo y vacunación antigripal con menor riesgo. Conclusión: En un área con relativamente baja incidencia de COVID-19, edad, institucionalización y múltiples comorbilidades aumentaron el riesgo/susceptibilidad de sufrir la COVID-19. Contrariamente, estatinas, inhibidores del sistema renina-angiotensina y vacunación antigripal se asociaron con menor riesgo.

Susceptibility and risk of SARS-COV-2 infection among middle-aged and older adults in Tarragona area, Spain.

OBJECTIVE: To analyse susceptibility/risk of suffering COVID-19 among adults with distinct underlying medical conditions. METHODS: Population-based cohort study involving 79,083 individuals ≥50 years old in Tarragona (Southern Catalonia, Spain). Baseline cohort characteristics (demographic, pre-existing comorbidities, chronic medications and vaccinations history) were established at study start (01/03/2020) and primary outcome was laboratory-confirmed COVID-19 occurred among cohort members throughout 01/03/2020-30/06/2020. Risk of suffering COVID-19 was evaluated by Cox regression, estimating multivariable hazard ratios (HRs) adjusted for age/sex and pre-existing comorbidities. RESULTS: Across study period, 536 laboratory-confirmed COVID-19 cases were observed (mean incidence: 39.5 cases per 100,000 persons-week). In multivariable-analysis, increasing age/years (HR: 1.01; 95% CI: 1.00-1.02), nursing-home (HR: 20.19; 95% CI: 15.98-25.51), neurological disease (HR: 1.35; 95% CI: 1.03-1.77), taking diuretics (HR: 1.39; 95% CI: 1.10-1.75), antiplatelet (HR: 1.36; 95% CI: 1.05-1.76) and benzodiazepines (HR: 1.24; 95% CI: 1.00-1.53) increased risk; conversely, taking angiotensin-converting-enzyme inhibitors (HR: 0.78; 95% CI: 0.61-1.00), angiotensin-receptor-blockers (HR: 0.70; 95%CI: 0.51-0.96) and statins (HR: 0.75; 95% CI: 0.58-0.96) were associated with reduced risk. Among community-dwelling individuals, pre-existing cancer, renal and cardiac disease appeared also related with an increased risk, whereas influenza vaccination was associated with reduced risk. CONCLUSION: In a setting with relatively low incidence of COVID-19 across the first wave of pandemic period, increasing age, nursing-home residence and multiple comorbidities appear predisposing for COVID-19 among middle-aged/older adults. Conversely, statins, angiotensin-receptor blockers/inhibitors and influenza vaccination were related with decreased risk.

COVID19-related and all-cause mortality risk among middle-aged and older adults across the first epidemic wave of SARS-COV-2 infection: a population-based cohort stuJune 2020.dy in Southern Catalonia, Spain, March-

BACKGROUND: Direct and indirect COVID19-related mortality is uncertain. This study investigated all-cause and COVID19-related deaths among middle-aged and older adults during the first wave of COVID-19 pandemic period, assessing mortality risks by pre-existing socio-demographic and medical underlying conditions. METHODS: Population-based cohort study involving 79,083 individuals ≥50 years-old in Tarragona (Southern Catalonia, Spain). Baseline cohort characteristics (age/sex, comorbidities and medications/vaccinations history) were established at study start (01/03/2020) and main outcomes were COVID19-related deaths (those occurred among patients with laboratory-confirmed COVID19) and all-cause deaths occurred among cohort members between 01/03/2020-30/06/2020. Mortality risks were assessed by Cox regression analyses. RESULTS: Cohort members were followed for 1,356,358 persons-weeks, occurring 576 all-cause deaths (124 COVID19-related deaths). Of the 124 deceased patients with a laboratory-confirmed COVID19, 112 (90.3%) died by (due to) COVID-19, while 12 (9.7%) died with COVID-19 (but likely due to other concomitant causes). All-cause mortality rate among cohort members across study period was 42.5 deaths per 100,000 persons-week, being 22.8 among healthy/unrelated-COVID19 subjects, 236.4 in COVID19-excluded/PCR-negative subjects, 493.7 in COVID19-compatible/PCR-unperformed subjects and 4009.1 in COVID19-confirmed patients. Increasing age, sex male, nursing-home residence, cancer, neurologic, cardiac or liver disease, receiving diuretics, systemic corticosteroids, proton-pump inhibitors and benzodiazepines were associated with increased risk of all-cause mortality; conversely, receiving renin-angiotensin inhibitors and statins were associated with reduced risk. Age/years (hazard ratio [HR]: 1.08; 95% confidence interval [CI]: 1.06-1.10), sex male (HR: 1.82; 95% CI: 1.24-2.70), nursing-home residence (HR: 12.56; 95% CI: 8.07-19.54) and number of pre-existing comorbidities (HR: 1.14; 95% CI: 1.01-1.29) were significant predictors for COVID19-related mortality, but none specific comorbidity emerged significantly associated with an increased risk in multivariable analysis evaluating it. CONCLUSION: COVID19-related deaths represented more than 20 % of all-cause mortality occurred among middle-aged and older adults during the first wave of the pandemic in the region. A considerable proportion (around 10 %) of these COVID19-related deaths could be attributed to other concomitant causes. Theoretically COVID19-excluded subjects (PCR-negative) suffered ten-times greater all-cause mortality than healthy/unrelated-COVID19 subjects, which points to the existence of considerable number of false negative results in earlier PCR testing and could explain part of the global excess all-cause mortality observed during the pandemic.

[Treatment setting, symptomatology, clinical course, severity degree and case-fatality rate in 536 adults over 50 years with laboratory-confirmed COVID-19 in Tarragona, Spain, March-June 2020.] / Lugar de atención, sintomatología y curso clínico, gravedad y letalidad en 536 casos confirmados de COVID-19 en adultos mayores de 50 años en el área de Tarragona, marzo-junio de 2020.

OBJECTIVE: Population-based clinical data on COVID-19 is scarce. This study analyzed distinct clinical characteristics of COVID-19 and relationships with lethality among adults. METHODS: Retrospective cohort that included all population ≥50 years with a laboratory-confirmed COVID-19 in Tarragona, Spain, during 01/03/2020-30/06/2020. Treatment setting (outpatient/hospital/nursing-home), pre-existing comorbidities, signs/symptoms, clinical course, severity and lethality (death from any cause in-hospital or within the first 30-day after the diagnosis) were determined. Chi squared and Fisher's test were used to compare percentages. RESULTS: Of the 536 overall cases (mean age: 74 years; 43.8% male), 150 (28%) were outpatient, 179 (33.4%) were hospitalised and 207 (38.6%) happened in nursing-home/social-health centres. The most prevalent symptoms were fever (57.9%), cough (49.8%), dyspnea (41.5%), general discomfort (36.2%), fatigue (24.4%), diarrhea (19.6%), myalgias (17.3%), headache (14.6%), confusion/lethargy (14.6%), thoracic pain (10%), anosmia (9.8%), disgeusia/ageusia (8.1%) and sore throat (7.7%). Global lethality was 23.1% (1.7% in 50-64 years vs 25.5% in 65-79 years vs 38.7% in ≥80 years, p<0.001; 26.8% in men vs 20.3% in women, p=0.075; 3.3% in outpatient vs 29.6% in hospitalised vs 31.9% in nursing-home/social-health centres, p<0.001). By symptomatology, maximum lethality was observed among patients with confusion/lethargy (77.6%) and minimum among those with ageusia/disgeusia (4.8%), anosmia (3.9%) or myalgias (1.1%). By pre-existing comorbidities, greater lethality happened among patients with neurologic (36.7%), renal (35.4%) and cardiac disease (35.3%). CONCLUSIONS: There was a relatively great lethality of COVID-19 among the general population ≥50 years across the first epidemic wave in the study setting. Increasing age, male sex, nursing-home residence and several signs/symptoms and comorbidities were associated with higher mortality.

OBJETIVO: Los datos clínicos de ámbito poblacional sobre COVID-19 son escasos. Este estudio analizó distintas características de presentación de la enfermedad y su relación con letalidad en adultos de 50 años y más. METODOS: Cohorte retrospectiva que incluyó todas las personas mayores o con 50 años con diagnóstico confirmado de COVID-19 en Tarragona del 01/03/2020 al 30/06/2020 (n=536). Se valoró el lugar de atención/tratamiento (ambulatorio/hospital/residencia), las comorbilidades previas, los signos/síntomas de presentación, el curso clínico, la gravedad y la letalidad (muerte por cualquier causa en 30 días post-diagnóstico). Chi cuadrado y test exacto de Fisher se usaron para la comparación de proporciones. RESULTADOS: De los 536 casos (edad media 74 años, 43,8% varones), 150 (28%) fueron ambulatorios, 179 (33,4%) hospitalizados y 207 (38,6%) ocurrieron en residencias/sociosanitarios. Los síntomas más prevalentes fueron fiebre (57,9%), tos (49,8%), disnea (41,5%, malestar general (36,2%), fatiga (24,4%), diarrea (19,6%), mialgias (17,3%), cefalea (14,6%), confusión/letargia (14,6%), dolor torácico (10%), anosmia (9,8%), disgeusia/ageusia (8,1%) y odinofagia (7,7%). La letalidad global fue 23,1% (1,7% en 50-64 años, 25,5% en 65-79 años y 38,7% en ≥80 años, p<0,001; 26,8% en hombres vs 20,3% en mujeres, p=0,075; 3,3% en ambulatorio/domicilio vs 29,6% en hospitalizados vs 31,9% en residencias/sociosanitarios, p<0,001). Según sintomatología, la máxima letalidad se observó en pacientes con confusión/letargia (77,6%) y la mínima en aquellos con ageusia/disgeusia (4,8%), anosmia (3,9%) o mialgias (1,1%). Según la comorbilidad, la máxima letalidad apareció en pacientes con enfermedad neurológica (36,7%), renal (35,4%) y cardiaca (35,3%). CONCLUSIONES: Se constata una relativamente alta letalidad de la COVID-19 en la población general mayor o de 50 años durante la primera ola epidémica. La edad avanzada, el sexo varón, la institucionalización y la presencia de algunos signos/síntomas y/o comorbilidades se asociaron con mayor mortalidad.

Development of a predictive prognostic rule for early assessment of COVID-19 patients in primary care settings.

OBJECTIVE: To investigate possible early prognostic factors among middle-aged and older adult and explore prognostic rules stratifying risk of patients. DESIGN: Community-based retrospective cohort. SETTING: Primary Health Care Tarragona region. PARTICIPANTS: 282 community-dwelling symptomatic patients ≥50 years with laboratory-confirmed COVID-19 (hospitalised and/or outpatient) during March-June 2020 in Tarragona (Southern Catalonia, Spain). MAIN OUTCOME MEASUREMENTS: Relationship between demographics, pre-existing comorbidities and early symptomatology (first 5-days) and risk of suffering critical outcome (ICU-admission/death) across clinical course was evaluated by logistic regression analyses, and simple predictive models were developed. RESULTS: Of the 282 cases (mean age: 65.9 years; 140 men), 154 (54.6%) were hospitalised (30 ICU-admitted) and 45 (16%) deceased. Median time follow-up in clinical course was 31 days (range: 30-150) for survivors and 14 days (range: 1-81) for deceased patients. In crude analyses, increasing age, male sex, some comorbidities (renal, respiratory or cardiac disease, diabetes and hypertension) and symptoms (confusion, dyspnoea) were associated with an increased risk to suffer critical outcome, whereas other symptoms (rinorrhea, myalgias, headache, anosmia/disgeusia) were related with reduced risk. After multivariable-adjustment only age/years (OR: 1.04; 95% CI: 1.01-1.07; p=0.004), confusion (OR: 5.33; 95% CI: 1.54-18.48; p=0.008), dyspnoea (OR: 5.41; 95% CI: 2.74-10.69; p<0.001) and myalgias (OR: 0.30; 95% CI: 0.10-0.93; p=0.038) remained significantly associated with increased or reduced risk. A proposed CD65-M prognostic rule (acronym of above mentioned 4 variables) showed a good correlation with the risk of suffering critical outcome (area under ROC curve: 0.828; 95% CI: 0.774-0.882). CONCLUSION: Clinical course of COVID-19 is early unpredictable, but simple clinical tools as the proposed CD65-M rule (pending external validation) may be helpful assessing these patients in primary care settings.

Influence of prior comorbidities and chronic medications use on the risk of COVID-19 in adults: a population-based cohort study in Tarragona, Spain.

OBJECTIVE: To investigate possible relationships between pre-existing medical conditions (including common comorbidities and chronic medications) and risk for suffering COVID-19 disease in middle-aged and older adults. DESIGN: Population-based retrospective cohort study. SETTING: Twelve primary care centres (PCCs) in Tarragona (Spain). PARTICIPANTS: 79 083 people (77 676 community-dwelling and 1407 nursing-home residents), who were all individuals aged >50 years affiliated to the 12 participating PCCs. OUTCOMES: Baseline cohort characteristics (age, sex, vaccinations, comorbidities and chronic medications) were established at study start (1st. March 2020) and primary outcome was time to COVID-19 confirmed by PCR among cohort members throughout the epidemic period (from 1st. March 2020 to 23rd. May 2020). Risk for suffering COVID-19 was evaluated by Cox regression, estimating multivariable HRs adjusted for age, sex, comorbidities and medications use. RESULTS: During the study period, 2324 cohort members were PCR-tested, with 1944 negative and 380 positive results, which means an incidence of 480.5 PCR-confirmed COVID-19 cases per 100 000 persons-period. Assessing the total study cohort, only age (HR 1.02; 95% CI 1.01 to 1.03; p=0.002), nursing-home residence (HR 21.83; 95% CI 16.66 to 28.61; p<0.001) and receiving diuretics (HR 1.35; 95% CI 1.04 to 1.76; p=0.026) appeared independently associated with increased risk. Smoking (HR 0.62; 95% CI 0.41 to 0.93; p=0.022), ACE inhibitors (HR 0.68; 95% CI 0.47 to 0.99; p=0.046) and antihistamine (HR 0.47; 95% CI 0.22 to 1.01; p=0.052) were associated with a lower risk. Among community-dwelling individuals, cancer (HR 1.52; 95% CI 1.03 to 2.24; p=0.035), chronic respiratory disease (HR 1.82; 95% CI 1.08 to 3.07; p=0.025) and cardiac disease (HR 1.53; 95% CI 1.06 to 2.19; p=0.021) emerged to be also associated with an increased risk. Receiving ACE inhibitors (HR 0.66; 95% CI 0.44 to 0.99; p=0.046) and influenza vaccination (HR 0.63; 95% CI 0.44 to 0.91; p=0.012) was associated with decreased risk. CONCLUSION: Age, nursing-home residence and multiple comorbidities appear predisposing for COVID-19. Conversely, receiving ACE inhibitors, antihistamine and influenza vaccination could be protective, which should be closely investigated in further studies specifically focused on these concerns.

Use of distinct anti-hypertensive drugs and risk for COVID-19 among hypertensive people: A population-based cohort study in Southern Catalonia, Spain.

The use of some anti-hypertensive drugs in the current COVID-19 pandemic has become controversial. This study investigated possible relationships between anti-hypertensive medications use and COVID-19 infection risk in the ambulatory hypertensive population. This is a population-based retrospective cohort study involving 34 936 hypertensive adults >50 years in Tarragona (Southern Catalonia, Spain) who were retrospectively followed through pandemic period (from 01/03/2020 to 30/04/2020). Two data sets including demographic/clinical characteristics (comorbidities and cardiovascular medications use) and laboratory PCR codes for COVID-19 were linked to construct an anonymized research database. Cox regression was used to calculate multivariable hazard ratios (HRs) and estimate the risk of suffering COVID-19 infection. Across study period, 205 PCR-confirmed COVID-19 cases were observed, which means an overall incidence of 586.8 cases per 100 000 persons-period. In multivariable analyses, only age (HR: 1.03; 95% CI: 1.02-1.05; P < .001) and nursing home residence (HR: 19.60; 95% CI: 13.80-27.84; P < .001) appeared significantly associated with increased risk of COVID-19. Considering anti-hypertensive drugs, receiving diuretics (HR: 1.22; 95% CI: 0.90-1.67; P = .205), calcium channel blockers (HR: 1.29; 95%CI: 0.91-1.82; P = .148), beta-blockers (HR: 0.97; 95% CI: 0.68-1.37; P = .844), and angiotensin-converting enzyme inhibitors (HR: 0.83; 95% CI: 0.61-1.13; P = .238) did not significantly alter the risk of PCR-confirmed COVID-19, whereas receiving angiotensin II receptor blockers was associated with an almost statistically significant reduction risk (HR: 0.67; 95% CI: 0.44-1.01; P = .054). In conclusion, our data support that receiving renin-angiotensin-aldosterone system inhibitors does not predispose for suffering COVID-19 infection in ambulatory hypertensive people. Conversely, receiving angiotensin II receptor blockers could be related with a reduced risk.

[Evaluation of incidence and risk profile for suffering Covid-19 infection by underlying conditions among middle-aged and older adults in Tarragona.] / Evaluación de la incidencia y perfil de riesgo de Covid-19 según comorbilidad previa en adultos ≥50 años del área de Tarragona.

OBJECTIVE: Population-based data on the current Covid-19 pandemic is scarce. This study investigated incidence and risk to suffer Covid-19 by baseline underlying conditions in people ≥50 years in Tarragona region across march-april 2020. METHODS: Population-based retrospective cohort study involving 79,071 adults ≥50 years-old in Tarragona region (Southern Catalonia, Spain). Cohort characteristics (age, sex, residence, vaccinations history and comorbidities) were established at baseline, and Covid-19 cases occurring between 01/03/2020-30/04/2020 were registered. Cox regression analysis calculating Hazard ratios (HRs) adjusted by age, sex and comorbidities was used to estimate risk for Covid-19. RESULTS: Across study period, 1,547 cohort members were PCR tested (22.6% positive) and 367 were presumptive cases without PCR tested. Considering PCR-confirmed Covid-19, incidence (per 100,000 persons-period) was 441 overall (248, 141, 424, 1,303 and 3,135 in 50-59, 60-69, 70-79, 80-89 and ≥90 years-old, respectively; 380 in men and 497 in women; 259 in community-dwelling and 10,571 in nursing-home). By comorbidities, maximum incidence emerged among persons with neurological disease (2,723), atrial fibrillation (1,348), chronic renal failure (1,050), cardiac disease (856), respiratory disease (798) and diabetes (706). Lower incidence appeared in rheumatic diseases (230) and smokers (180). In multivariable analysis focused on community-dwelling individuals (N=77,671), only cardiac disease (HR: 1.47; 95% CI: 1.01-2.15; p=0.045) and respiratory disease (HR: 1.75; 95% CI: 1.00-3.02; p=0.051) were associated with an increased risk, whereas smoking (HR:0.43; 95% CI: 0.25-0.74; p=0.002) and influenza vaccinated (HR: 0.63; 95% CI: 0.43-0.92; p=0.015) appeared associated with a decreased risk. CONCLUSIONS: Apart of increasing age and nursing-home residence, chronic respiratory and cardiac disease appear at increased risk for suffering covid19. This study investigated population-based incidence of Covid-19 infection by underlying conditions among adults ≥50 years in Tarragona (Southern Catalonia, Spain) across two first months pandemic period.

OBJETIVO: Los datos clínico-epidemiológicos de base poblacional durante la actual pandemia de Covid-19 son escasos. Este estudio investigó la incidencia y riesgo de sufrir Covid-19 según condiciones basales subyacentes en la población ≥50 años de Tarragona durante marzo-abril 2020. METODOS: Estudio de cohortes retrospectivo que incluyó a 79.071 personas ≥50 años en el área de Tarragona. Se establecieron características basales de la cohorte (edad, sexo, residencia, vacunaciones y comorbilidades previas), y se registró la ocurrencia de Covid-19 entre 01/03/2020-30/04/2020. Para la estimación de riesgos se realizó regresión de Cox, con cálculo de Hazard ratios (HRs) ajustados por edad, sexo y comorbilidad. RESULTADOS: Se realizaron PCR-tests en 1.547 personas (22,6% positivos) y 367 fueron codificados como presuntos casos sin realizarse PCR-test. Considerando Covid-19 confirmada (PCR positivo), la incidencia (por 100.000 personas-periodo) fue de 441 (248, 141, 424, 1.303 y 3.135 en 50-59, 60-69, 70-79, 80-89 y ≥90 años, respectivamente; 380 en hombres frente a 497 en mujeres; 259 residentes en la comunidad respecto a 10.571 en institucionalizados). Según comorbilidades, las máximas incidencias aparecieron en enfermedad neurológica (2.723), fibrilación auricular (1.348), insuficiencia renal crónica (1.050), cardiopatía (856), enfermedad respiratoria (798) y diabetes (706). Menores incidencias aparecieron en enfermedad reumatológica (230) y fumadores (180). En personas no institucionalizadas (N=77.671), solo la enfermedad cardiaca (HR: 1,47; IC95%: 1,01-2,15; p=0,045) y respiratoria (HR: 1,75; IC95%: 1,00-3,02; p=0,051) se asociaron con incremento del riesgo, mientras que ser fumador (HR: 0,43; IC95%: 0,25-0,74; p=0,002) y vacunación antigripal en otoño previo (HR: 0,63; IC95%: 0,43-0,92; p=0,015) se asociaron con menor riesgo. CONCLUSIONES: Aparte de la edad y la institucionalización, la existencia de enfermedad respiratoria y/o cardiaca crónicas se asocia con una mayor incidencia de Covid-19 en adultos.

[Epidemiology of invasive pneumococcal disease in Tarragona, Spain, 2012-2015: incidence, lethality and serotype-coverage for distinct antipneumococcal vaccine formulations]. / Epidemiología de la enfermedad neumocócica invasiva en la región de Tarragona, 2012-2015: Incidencia, letalidad y cobertura de serotipos para las distintas formulaciones vacunales antineumocócicas.

OBJECTIVE: Nowadays, after licensure of the second generation new pneumococcal conjugate vaccines (PCV10/PCV13). The epidemiology of the pneumococcal disease must be re-evaluated. The present study described incidence, lethality and serotype distribution of invasive pneumococcal disease (IPD) in the general population of Tarragona's region (Spain) after licensure of these vaccines. METHODS: Retrospective study that included all cases of IPD (pneumococcus isolated in sterile sites) diagnosed among all-age individuals in the Spanish region of Tarragona (Tarragonés, Alt Camp and Baix Penedés counties) from 01/01/2012 to 31/12/2015. Incidence and lethality rates were estimated by age strata and globally. Similarly, it was determined the prevalence of IPD cases caused by serotypes included in the distinct formulations of multivalent conjugate vaccines (pcv7), PCV10 and PCV13) or 23-valent polysaccharide vaccine (PPV23). RESULTS: A total of 171 IPD cases were observed, which means a global incidence (per 100,000 persons-year) of 10.82 (7.86 in ≤14 years, 5.94 in 15-64 years and 36.46 in ≥65 years; p<0.001). Overall lethality rate was 6.8% (none in children, 9,3% in people 15-64 years and 6.9% in people ≥65 years). A serotype was identified in 132 (77.2%) of the 171 studied samples. Serotype-vaccine coverages (cases due to vaccine-type serotypes) were 14.4%, 26.5%, 42.4% and 78.8% for the PCV7, PCV10, PCV13 and PPV23, respectively (p<0.001). CONCLUSIONS: Incidence and lethality of IPD were intermediate-low in the region of Tarragona throughout 2012-2015. During this period, Serotype- vaccine coverage was almost double for the 23-valent than for the 13-valent vaccine.

OBJETIVO: En la actualidad, tras la comercialización de las nuevas vacunas neumocócicas conjugadas de segunda generación (VNC10/VNC13), la epidemiología de la enfermedad neumocócica debe ser reevaluada. El presente estudio tuvo como objetivo describir la incidencia, letalidad y distribución serotípica de la enfermedad neumocócica invasiva (ENI) en la población general del área de Tarragona durante el cuatrienio posterior a la introducción de estas vacunas. METODOS: Estudio observacional retrospectivo que incluyó todos los casos de ENI (Streptococcus pneumoniae aislado en sangre, líquido cefalorraquídeo, líquido pleural/articular/peritoneal o muestras de tejidos profundos obtenidas de forma estéril mediante punción-aspiración o biopsia) diagnosticados en el área de Tarragona (comarcas del Tarragonés, Alt Camp y Baix Penedés) entre 01/01/2012 y 31/12/2015. Se estimaron tasas de incidencia y letalidad (globalmente y por estratos etarios) y se determinó la prevalencia de casos causados por serotipos incluidos en las distintas formulaciones de vacunas antineumocócicas conjugadas heptavalente (VNC7), decavalente (VNC10), tridecavalente (VNC13) y polisacárida tricosavalente (VNP23). RESULTADOS: Se observaron 171 casos de ENI, lo que representó una incidencia (por 100.000 personas-año) de 10,82 (7,86 en ≤14 años, 5,94 en 15-64 años y 36,46 en ≥65 años; p<0,001). La letalidad fue del 6,8% (ninguna en niños, 9,3% en 15-64 años y 6,9% en personas ≥65 años; p<0,001). El serotipo responsable fue identificado en 132 (77,2%) de las 171 muestras estudiadas. La cobertura serotípica (casos causados por serotipos vacunales) fue del 14,4%, 26,5%, 42,4% y 78,8% para la VNC7, VNC10, VNC13 y VNP23, respectivamente (p<0,001). CONCLUSIONES: Durante el periodo 2012-2015 la incidencia y letalidad por ENI fue intermedia-baja en el área de Tarragona, destacando que la cobertura serotípica fue casi doble para la vacuna 23-valente que para la 13-valente.

[Incidence and lethality of ischaemic stroke among people 60 years or older in the region of Tarragona (Spain), 2008-2011]. / Incidencia y letalidad del ictus isquemico en la poblacion mayor de 60 años del area de Tarragona, España (2008-2011).

INTRODUCTION: Data available about the epidemiology of stroke is limited. This study investigated incidence and lethality of ischaemic stroke among the general population over 60 years in the region of Tarragona. PATIENTS AND METHODS: Population-based cohort study that included 27,204 individuals >= 60 years assigned to nine Primary Care Centers in the Tarragones county (Catalonia, Spain), who were prospectively followed between December 1st, 2008 and November 30th, 2011. During follow-up, all episodes of ischaemic stroke were recruited among cohort members. Only confirmed ischaemic cases (confirmed by neuroimaging and validated alter checking hospital medical records) were included. RESULTS: An amount of 343 confirmed cases of ischaemic stroke were observed, which means a global incidence rate of 453 episodes per 100,000 persons/year (95% confidence interval = 408-504). Incidence was higher among men than in women (531 vs 392 per 100,000; p < 0.001) and increases substantially with increasing age (195 vs 517 vs 1,006 per 100,000 in 60-69 years, 70-79 years and >= 80 years, respectively; p < 0.001). Incidence was eight times greater among persons with history of prior ictus as compared with those without history of ictus (2,962 vs 340 per 100,000; p < 0.001). Overall lethality rate was 13%, reaching 21% among patients >= 80 years. CONCLUSION: Morbid-mortality by ischaemic ictus remains considerable among our population. Preventive measures and more efficacious therapies are imperative.

TITLE: Incidencia y letalidad del ictus isquemico en la poblacion mayor de 60 años del area de Tarragona, España (2008-2011).Introduccion. La informacion existente sobre la epidemiologia del ictus en nuestro pais es limitada. Este estudio analizo la incidencia y mortalidad por ictus isquemico en la poblacion general mayor de 60 años del area de Tarragona. Pacientes y metodos. Estudio de cohortes de base poblacional que incluyo a 27.204 personas de 60 o mas años adscritas a nueve areas basicas de salud en la comarca del Tarragones. Se realizo un seguimiento prospectivo durante tres años, en los que se seleccionaron todos los episodios de ictus isquemicos ocurridos entre los miembros de la cohorte desde el 1 de diciembre de 2008 hasta el 30 de noviembre de 2011. Se incluyeron exclusivamente episodios con diagnostico validado tras la revision de la historia clinica y se excluyeron aquellos casos sin confirmacion diagnostica por neuroimagen. Resultados. Se observo un total de 343 casos confirmados de ictus isquemico, lo cual supuso una incidencia de 453 episodios por 100.000 personas/año (intervalo de confianza del 95% = 408-504). La incidencia fue mayor en hombres que en mujeres (531 frente a 392 por 100.000 personas/año; p < 0,001) y aumento sustancialmente con la edad (195 frente a 517 y frente a 1.006 por 100.000 personas/año en 60-69, 70-79 y >= 80 años, respectivamente; p < 0,001). La incidencia fue mas de ocho veces superior entre las personas con antecedentes de ictus previo en comparacion con aquellas sin historia de ictus previo (2.962 frente a 340 por 100.000 personas/año; p < 0,001). El indice de letalidad global fue del 13%, y alcanzo el 21% entre las personas de 80 o mas años. Conclusiones. La morbimortalidad por ictus es considerable en nuestra poblacion. Medidas preventivas y tratamientos mas eficaces son imperativos.

Evaluating clinical effectiveness of pneumococcal vaccination in preventing stroke: the CAPAMIS Study, 3-year follow-up.

BACKGROUND: Cerebrovascular benefits using the 23-valent pneumococcal polysaccharide vaccine (PPV23) are controversial. This study assessed clinical effectiveness of PPV23 in preventing ischemic stroke in people older than 60 years. METHODS: We conducted a population-based cohort study involving 27,204 individuals of 60 years or older in Tarragona, Spain, who were prospectively followed from December 01, 2008, until November 30, 2011. Outcomes were neuroimaging-confirmed ischemic stroke, 30-day mortality from stroke, and all-cause death. Pneumococcal vaccination effectiveness was evaluated by Cox regression analyses, estimating hazard ratios (HRs) adjusted for age, sex, comorbidities, and influenza vaccine status. RESULTS: Cohort members were followed for a total of 76,033 person-years, of which 29,065 were for vaccinated subjects. Overall, 343 cases of stroke, 45 deaths from stroke, and 2465 all-cause deaths were observed. Pneumococcal vaccination did not alter the risk of stroke (multivariable HR: 1.04; 95% confidence interval [CI]: .83-1.30; P=.752), death from stroke (HR: 1.14; 95% CI: .61-2.13; P=.686), and all-cause death (HR: .97; 95% CI: .89-1.05; P=.448). In analyses focused on people with and without a history of cerebrovascular disease, the PPV23 did not emerge effective in preventing any analyzed event, but influenza vaccine emerged independently associated with a reduced risk of death from stroke (HR: .51; 95% CI: .28-.93; P=.029) and all-cause death (HR: .73; 95% CI: .67-.81; P<.001). CONCLUSIONS: Our data support that the PPV23 does not provide benefit against ischemic stroke, but it also supports a beneficial effect of influenza vaccine in reducing specific- and all-cause mortality risk in the general population older than 60 years.

[Ability of the modified CRB75 severity scale in assessing elderly patients with community acquired pneumonia]. / Utilidad de la escala de severidad modificada CRB75 en el manejo del paciente anciano con neumonía adquirida en la comunidad.

OBJECTIVE: To compare the ability of the classic CRB65 (confusion, respiratory rate, blood pressure and age ≥65 years) vs the modified CRB-75 for the severity assessment of patients 65 years or older with community acquired pneumonia (CAP). DESIGN: Prospective cohort study. SETTING: Tarragona Health Region. PARTICIPANTS: A total of 350 patients ≥65 years with a radiographically confirmed CAP (hospitalized or outpatient) during 2008-2010. MAIN OUTCOME MEASURES: The CRB-65 score (confusion; respiratory rate ≥30; systolic blood pressure <90 mmHg or diastolic ≤ 60 mmHg; age ≥65 years) and the modified CRB-75 (similar criteria but age ≥75 years) were calculated at the time of diagnosis, and 30-day mortality was considered as the main dependent variable. RESULTS: The overall 30-day mortality rate was 13.1% (4% in outpatient CAP and 15% in hospitalized CAP). According to CRB-65, mortality was 7,7% with a score of 1, 22.5% with a score of 2, and 50% with a score of 3 (no cases with a score of 4). Mortality also directly increased according to CRB-75, being 3,2% with a score of 0, 9,7% with a score of 1, 30.0% with a score of 2, and 45.5% with a score of 3. The discriminative value of both CRB65 and CRB75 rules to classify risk of short-term mortality among our study population was acceptable, with a better area under receive operating characteristic curve (ROC) for CRB75 than for CRB-65 (0,735 vs 0,681; P<.01). CONCLUSION: Both CRB-65 and CRB-75 scales are an acceptable tool to classify mortality risk among elderly patients with CAP. However, CRB-75 can be more useful for evaluating patients over 65 years with CAP.

[Evolution of the antipneumococcal vaccination coverage among children in the region of Tarragona, Spain, 2002-2011]. / Evolución de las coberturas de vacunación antineumocócica en la población infantil de Tarragona, 2002-2011.

BACKGROUND: In Catalonia, as in most Spanish regions, the conjugate pneumococcal vaccine is not publicly funded, except for immunocompromised or high-risk children. This study assessed current vaccine coverage in the region of Tarragona, analyzing trends in vaccine uptakes throughout the 2002-2011 period by analyzing uptakes by year of birth. METHODS: Cross-sectional multicenter study that included all children <10 years attended between 01/12/2011 and 02/12/2011 in pediatric ambulatory visits in 9 Primary Care Centers in the region of Tarragona (N=521 children). Pneumococcal vaccine status was determined after clinical record review. Vaccine coverages were compared by chi-squared test. RESULTS: Among the total 521 children, 45.1% (95% confidence interval [CI]: 40.8-49.5) had received CPV. Vaccine coverages were 18.5% (95% CI: 9.3-31.4) for children born between 2002-2003, 38.6% (95% CI: 27.2-51.0) in 2004-2005, 62.5% (95% CI: 51.0-73.0) in 2006-2007, 50.8% (95% CI: 41.7-59.8) in 2008-2009 and 44.6% (95% CI: 36.8-51.3) in 2010-2011 (p<0.001). CONCLUSIONS: Vaccine coverage can be considered as intermediate/low. In our population, after a rapid initial increase, vaccination uptakes have decreased in the last 4 years, coinciding with the current economic crisis. In our population, after a rapid initial increase, vaccination uptakes have decreased in the last 4 years.

[Incidence and clinical characteristics of community-acquired pneumonia managed as outpatient among elderly people in Tarragona-Valls, Spain]. / Incidencia y características clínicas de las neumonías tratadas ambulatoriamente en las personas mayores de 65 años del área de Tarragona-Valls, 2002-2005.

BACKGROUND: Few information exists about community-acquired pneumonia (CAP) not hospitalized. This study assessed incidence and clinical characteristics of community-acquired pneumonia (CAP) managed as outpatient among elderly population. METHODS: Prospective cohort study that included 11,240 individuals 65 years or older who were assigned to 8 Primary Care Centers in the region of Tarragona-Valls, Spain. All cases of CAP managed as outpatient occurred among cohort members from January 1, 2002 to April 30, 2005 were included. All cases were x-ray proved and validated by checking clinical records. RESULTS: An amount of 118 cases of CAP managed as outpatient were observed (45 diagnosed in Primary Care and 73 diagnosed in Emergence Units) which means an incidence of 34.8 cases per 10,000 elderly persons-year (95% CI: 28.8-41.7). Incidence was greater among males (41.9 per 10,000) and among those aged 75 years or older (47.5 per 10,000). When diagnosis, 68.6% of patients had fever, (80% in 65-74 years and 60.3 in 75 years or older, p=0.037), 36.4% dyspnea, 44.9% pleural pain, 77.1% cough, 50.0% expectoraton and 5.7% had altered mental state. The combination of "fever, cough and pleural pain" occurred in 27.1% of cases (95% CI: 19.3-36.1). CONCLUSIONS: The incidence of outpatient CAP among elderly people is considerable. A great proportion of cases, specially older patients, had not typical clinical manifestations of pneumonia.