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.

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.

Blood-biomarkers and devices for atrial fibrillation screening: Lessons learned from the AFRICAT (Atrial Fibrillation Research In CATalonia) study.

BACKGROUND AND OBJECTIVE: AFRICAT is a prospective cohort study intending to develop an atrial fibrillation (AF) screening program through the combination of blood markers, rhythm detection devices, and long-term monitoring in our community. In particular, we aimed to validate the use of NT-proBNP, and identify new blood biomarkers associated with AF. Also, we aimed to compare AF detection using various wearables and long-term Holter monitoring. METHODS: 359 subjects aged 65-75 years with hypertension and diabetes were included in two phases: Phase I (n = 100) and Phase II (n = 259). AF diagnosis was performed by baseline 12-lead ECG, 4 weeks of Holter monitoring (NuuboTM), and/or medical history. An aptamer array including 1310 proteins was measured in the blood of 26 patients. Candidates were selected according to p-value, logFC and biological function to be tested in verification and validation phases. Several screening devices were tested and compared: AliveCor, Watch BP, MyDiagnostick and Fibricheck. RESULTS: AF was present in 34 subjects (9.47%). The aptamer array revealed 41 proteins with differential expression in AF individuals. TIMP-2 and ST-2 were the most promising candidates in the verification analysis, but none of them was further validated. NT-proBNP (log-transformed) (OR = 1.934; p<0.001) was the only independent biomarker to detect AF in the whole cohort. Compared to an ECG, WatchBP had the highest sensitivity (84.6%) and AUC (0.895 [0.780-1]), while MyDiagnostick showed the highest specificity (97.10%). CONCLUSION: The inclusion and monitoring of a cohort of primary care patients for AF detection, together with the testing of biomarkers and screening devices provided useful lessons about AF screening in our community. An AF screening strategy using rhythm detection devices and short monitoring periods among high-risk patients with high NT-proBNP levels could be feasible.

Predictive model for atrial fibrillation in hypertensive diabetic patients.

BACKGROUND: Several scores to identify patients at high risk of suffering atrial fibrillation have been developed. Their applicability in hypertensive diabetic patients, however, remains uncertain. Our aim is to develop and validate a diagnostic predictive model to calculate the risk of developing atrial fibrillation at five years in a hypertensive diabetic population. METHODS: The derivation cohort consisted of patients with both hypertension and diabetes attended in any of the 52 primary healthcare centres of Barcelona; the validation cohort came from the 11 primary healthcare centres of Terres de l'Ebre (Catalonia South) from January 2013 to December 2017. Multivariable Cox regression identified clinical risk factors associated with the development of atrial fibrillation. The overall performance, discrimination and calibration of the model were carried out. RESULTS: The derivation data set comprised 54 575 patients. The atrial fibrillation rate incidence was 15.3 per 1000 person/year. A 5-year predictive model included age, male gender, overweight, heart failure, valvular heart disease, peripheral vascular disease, chronic kidney disease, number of antihypertensive drugs, systolic and diastolic blood pressure, heart rate, thromboembolism, stroke and previous history of myocardial infarction. The discrimination of the model was good (c-index = 0.692; 95% confidence interval, 0.684-0.700), and calibration was adequate. In the validation cohort, the discrimination was lower (c-index = 0.670). CONCLUSIONS: The model accurately predicts future atrial fibrillation in a population with both diabetes and hypertension. Early detection allows the prevention of possible complications arising from this disease.