Rates of pneumonia among children and adults with chronic medical conditions in Germany

Prevalence of and Risks for Bacterial Infections in Hospitalized Children With Bronchiolitis

BACKGROUND AND OBJECTIVES

Viral bronchiolitis is a common pediatric illness. Treatment is supportive; however, some children have concurrent serious bacterial infections (cSBIs) requiring antibiotics. Identifying children with cSBI is challenging and may lead to unnecessary treatment. Improved understanding of the prevalence of and risk factors for cSBI are needed to guide treatment. We sought to determine the prevalence of cSBI and identify factors associated with cSBI in children hospitalized with bronchiolitis.

METHODS

We performed a retrospective cohort study of children <2 years old hospitalized with bronchiolitis at a free-standing children's hospital from 2012 to 2019 identified by International Classification of Diseases codes. cSBI was defined as bacteremia, urinary tract infection, meningitis, or pneumonia. Risk factors for cSBI were identified using logistic regression.

RESULTS

We identified 7871 admissions for bronchiolitis. At least 1 cSBI occurred in 4.2% of these admissions; with 3.5% meeting our bacterial pneumonia definition, 0.4% bacteremia, 0.3% urinary tract infection, and 0.02% meningitis. cSBI were more likely to occur in children with invasive mechanical ventilation (odds ratio [OR] 2.53, 95% confidence interval [CI] 1.78-3.63), a C-reactive protein ≥4 mg/dL (OR 2.20, 95% CI 1.47-3.32), a concurrent complex chronic condition (OR 1.67, 95% CI 1.22-2.25) or admission to the PICU (OR 1.46, 95% CI 1.02-2.07).

CONCLUSIONS

cSBI is uncommon among children hospitalized with bronchiolitis, with pneumonia being the most common cSBI. Invasive mechanical ventilation, elevated C-reactive protein, presence of complex chronic conditions, and PICU admission were associated with an increased risk of cSBI.

Hospital Burden of All-Cause Pneumonia and Nonbacteremic Pneumococcal Pneumonia in Adults in France Between 2013 and 2019

Background

Community-acquired pneumonia (CAP) is associated with significant morbidity and mortality. The study objective was to describe the hospital burden of pneumonia in the adult population in France.

Methods

This retrospective study was conducted from the National Health Insurance Database. All hospitalizations for pneumonia (all-cause) between 2013 and 2019 were included. Different risk categories for patients were established based on pneumococcal vaccine recommendations by French health authorities.

Results

A total of 2 199 240 episodes of CAP were registered over the study period (annual mean, 314 177 [standard deviation, 17 818.6]); 75% occurred in patients aged ≥65 years, among whom 47% were not classified in the moderate- or high-risk categories recommended for French pneumococcal vaccination. The incidence of CAP increased with age (117.9, 395.3, and 1916.7 per 100 000 for the age groups 18-49, 50-64, and ≥65 years, respectively, in 2019). Furthermore, being at risk of pneumococcal disease resulted in more severe outcomes, including longer episode duration (mean, 14 days in low-risk vs 17 days in high-risk patients) and higher risk of referral to critical care units (from 20% to 27%), of rehospitalization up to 180 days (from 39% to 67%), of in-hospital death (from 12% to 19%), and of 1-year mortality (from 26% to 49%).

Conclusions

This study establishes the incidence of CAP in adults in France, describes the significant burden of disease, and highlights the need for better prevention policies.

Host genetic variants associated with susceptibility and severity of pneumococcal pneumonia in adult patients

BACKGROUND

Pneumococcal community-acquired pneumonia (P-CAP) is a major cause of morbidity and hospitalization. Several host genetics factors influencing risk of pneumococcal disease have been identified, with less information about its association with P-CAP. The aim of the study was to assess the influence of single nucleotide polymorphisms (SNP) within key genes involved in the innate immune response on the susceptibility to P-CAP and to study whether these polymorphic variants were associated with the severity and outcome of the episodes in a cohort of adult Caucasian patients.

METHODS

Seventeen SNPs from 7 genes (IL-R1, IL-4, IL-10, IL-12B, NFKBIA, NFKBIE, NFKBIZ) were analyzed. For susceptibility, a case-control study including a cohort of 57 adult with P-CAP, and 280 ethnically matched controls was performed. Genetic influence on clinical severity and outcome was evaluated in a prospective observational study including all consecutive adult P-CAP patients from November 2015 to May 2017.

RESULTS

The NFKBIA polymorphism rs696 and a haplotype combination were associated with susceptibility to P-CAP (OR = 0.62, p = 0.005 and OR = 0.63, p = 0.008, respectively). The SNP IL4 rs2227284 was associated with severe P-CAP (OR = 2.17, p = 0.04). IL-R1 (rs3917267) and IL-10 (rs3024509) variants were related with respiratory failure (OR = 3.31, p = 0.001 and OR = 0.18, p = 0.003, respectively) as well as several haplotype combinations in NFKBIA, NFKBIZ, IL-R1 and IL-10 (p = 0,02, p = 0,01, p = 0,001, p = 0,03, respectively). CURB-65 values were associated with the IL-10 rs3024509 variant (beta = - 0.4, p = 0.04), and with haplotype combinations of NFKBIZ and IL-10 (p = 0.05, p = 0.04, respectively). Genetic variants in IL-10 (rs3024509) and in IL-12B (rs730691) were associated with PSI values (beta = - 0.54, p = 0.01, and beta = - 0.28, p = 0.04, respectively), as were allelic combinations in IL-R1 (p = 0.02) and IL-10 (p = 0.01). Finally, several polymorphisms in the IL-R1 gene (rs13020778, rs2160227, & rs3917267) were associated with the time elapsed until clinical stability (beta = - 0.83, p = 0.03; beta = - 1, p = 0.02 and beta = 1.07, p = 0.008, respectively).

CONCLUSIONS

A genetic variant in NFKBIA was associated with susceptibility to P-CAP in adult Caucasian patients and genetic variants from key cytokines of the innate immune response (Il-4, IL-10, IL-R1 and IL-12B) and NF-κB inhibitors were associated with different phenotypes of severe P-CAP. If validated, these SNPs may help to identify people at risk of P-CAP or severe P-CAP on which preventive measures could be applied.

S100A9 is indispensable for survival of pneumococcal pneumonia in mice

S100A8/A9 has important immunomodulatory roles in antibacterial defense, but its relevance in focal pneumonia caused by Streptococcus pneumoniae (S. pneumoniae) is understudied. We show that S100A9 was significantly increased in BAL fluids of patients with bacterial but not viral pneumonia and correlated with procalcitonin and sequential organ failure assessment scores. Mice deficient in S100A9 exhibited drastically elevated Zn2+ levels in lungs, which led to bacterial outgrowth and significantly reduced survival. In addition, reduced survival of S100A9 KO mice was characterized by excessive release of neutrophil elastase, which resulted in degradation of opsonophagocytically important collectins surfactant proteins A and D. All of these features were attenuated in S. pneumoniae-challenged chimeric WT→S100A9 KO mice. Similarly, therapy of S. pneumoniae-infected S100A9 KO mice with a mutant S100A8/A9 protein showing increased half-life significantly decreased lung bacterial loads and lung injury. Collectively, S100A9 controls central antibacterial immune mechanisms of the lung with essential relevance to survival of pneumococcal pneumonia. Moreover, S100A9 appears to be a promising biomarker to distinguish patients with bacterial from those with viral pneumonia. Trial registration: Clinical Trials register (DRKS00000620).

Healthcare resource utilization and cost of pneumococcal disease in children in Germany, 2014-2019: a retrospective cohort study

BACKGROUND

Since the introduction of higher valency pneumococcal conjugate vaccines in 2009, recent estimates on the economic burden of pediatric pneumococcal disease (PD) in Germany have been lacking. This study estimates healthcare resource utilization (HCRU) and medical cost associated with PDs in children < 16 years old in Germany from 2014-2019.

METHODS

A nationally representative sample from the Institute for Applied Health Research (InGef) German claims database was used, covering approximately 5% of the total German population. Episodes of pneumococcal pneumonia (PP), all-cause pneumonia (ACP), invasive pneumococcal disease (IPD), and acute otitis media (AOM) in children aged < 16 years were identified using ICD-10-GM codes. HCRU was estimated from annual rates of outpatient visits, outpatient antibiotic prescriptions and inpatient admissions, divided by person-years (PY) at-risk. Average direct medical costs per episode were estimated as the total cost of all HCRU, divided by the total number of episodes. The Mann-Kendall test was used to assess monotonic time trends from 2014-2019.

RESULTS

 During 2014-2019, 916,805 children aged < 16 years were followed up for a total of 3,608,716 PY. The average costs per episode for out-versus inpatient care associated with PP and ACP were €67 (95% CI 58-76) versus €2,606 (95% CI 1,338-3,873), and €63 (95% CI 62-63) versus €620 (95% CI 598-641), respectively. For IPD, the average medical cost per episode for out-versus inpatients were €30 (95% CI 19-42) versus €6,051 (95% CI 3,323-8,779), respectively. There were no significant trends in HCRU or costs for IPD or pneumonia over the study period, except for a significant reduction in ACP outpatient visits. A significant decrease in rate of outpatient visits and antibiotic prescribing for recurrent AOM was observed, in addition to an increase in rates of hospital admissions for simple AOM. This was paralleled by a significant increase in inpatient costs per episode for treating AOM overall, and simple AOM, over the study period.

CONCLUSIONS

 The HCRU and cost per episode of pneumonia and IPD did not vary significantly from 2014-2019, but increased for AOM. The economic burden of pneumonia, IPD, and AOM remains substantial in Germany.

Prevalence of and Spending on Ear, Nose, Throat, and Respiratory Infections Among Children With Chronic Complex Conditions

OBJECTIVE

Ear, nose, throat, and respiratory infections (ENTRI) may affect children with complex chronic conditions (CCC) differently than their peers. We compared ENTRI prevalence and spending in children with and without CCCs.

METHODS

Retrospective analysis of 3,880,456 children ages 0-to-18 years enrolled in 9 US state Medicaid programs in 2018 contained in the IBM Watson Marketscan Database. Type and number of CCCs were distinguished with Feudtner's system. ENTRI prevalence, defined as ≥1 healthcare encounters for ENTRI, and Medicaid spending on ENTRI were compared by CCC using chi-square tests and logistic regression.

RESULTS

ENTRIs were greater in children with vs. without a CCC (57.7% vs 43.5% [P < .001]). Children with a CCC (5.5%, n = 213,425) accounted for nearly one-fourth ($145.8 million [US]) of total spending on ENTRI. Aside from throat and sinus infection, ENTRI prevalence increased with number of CCCs (P < .001). For example, as number of CCCs increased from zero to ≥3, lower-airway infection increased from 12.5% to 37.5%, P < .001 (OR 4.10; 95% CI 3.95-4.26). ENTRI spending attributable to inpatient care increased from 9.7% to 92.8% (P < .001) as the number of CCCs increased from zero to ≥3.

CONCLUSION

Most children with a CCC pursued care for ENTRI in 2018 and these children accounted for a disproportionate share of ENTRI spending. Children with multiple CCCs had a high prevalence of lower-airway infection; most of their ENTRI spending was for inpatient care. Providers can use these findings to counsel patients and families and to inform future investigations on how best to manage ENTRI in children with CCCs.

Cost-effectiveness of use of 20-valent pneumococcal conjugate vaccine among adults in Germany

OBJECTIVES

Despite national recommendations for use of pneumococcal vaccines, rates of community-acquired pneumonia (CAP) and invasive pneumococcal disease (IPD) remain high in Germany. New pneumococcal conjugate vaccines (PCVs) with expanded coverage have the potential to reduce the pneumococcal disease burden among adults.

METHODS

Using a Markov model, we evaluated the lifetime outcomes/costs comparing 20-valent PCV (PCV20) with standard of care (SC) vaccinations for prevention of CAP and IPD among adults aged ≥60 years and at-risk adults aged 18-59 years in Germany. PCV20 also was compared with sequential vaccination with 15-valent PCV (PCV15) followed by PPSV23 in a scenario analysis.

RESULTS

Over the course of a lifetime (82 years), use of PCV20vs. SC would prevent 54,333 hospitalizations, 26368 outpatient CAP cases, 10946 disease-related deaths yield 74,694 additional life-years (LYs), while lowering total medical costs by 363.2 M €. PCV20 remained cost saving (i.e. dominant) versus SC even in numerous sensitivity analyses, including a sensitivity analysis assuming moderate effectiveness of the SC pneumococcal polysaccharide vaccine against noninvasive pneumococcal CAP. In several scenario analyses and a probabilistic sensitivity analysis, PCV20 was also cost-saving compared toPCV15 PPSV23 vaccination.

CONCLUSIONS

One dose of PCV20 among adults aged ≥60 years and adults aged 18-59 years with moderate- and high-risk conditions wouldsubstantially reduce pneumococcal disease, save lives, and be cost saving compared with SC.

A review of evidence for pneumococcal vaccination in adults at increased risk of pneumococcal disease: risk group definitions and optimization of vaccination coverage in the United Kingdom

INTRODUCTION

Pneumococcal disease (PD) significantly contributes to morbidity and mortality, carrying substantial economic and public health burden. This article is a targeted review of evidence for pneumococcal vaccination in the UK, the definitions of groups at particular risk of PD and vaccine effectiveness.

AREAS COVERED

Relevant evidence focusing on UK data from surveillance systems, randomized controlled trials, observational studies and publicly available government documents is collated and reviewed. Selected global data are included where appropriate.

EXPERT OPINION

National vaccination programs have reduced the incidence of vaccine-type PD, despite the rising prominence of non-vaccine serotypes in the UK. The introduction of higher-valency conjugate vaccines provides an opportunity to improve protection against PD for adults in risk groups. Several incentives are in place to encourage general practitioners to vaccinate risk groups, but uptake is low-suboptimal particularly among at-risk individuals. Wider awareness and understanding among the public and healthcare professionals may increase vaccination uptake and coverage. National strategies targeting organizational factors are urgently needed to achieve optimal access to vaccines. Finally, identifying new risk factors and approaches to risk assessment for PD are crucial to ensure those at risk of PD can benefit from pneumococcal vaccination.

Increased risk of death from pneumonia among cancer survivors: A propensity score‐matched cohort analysis

BACKGROUND

The repeated global pandemic of the new virus has led to interest in the possibility of severe pneumonia among cancer patients and survivors. Here, we aimed to assess the association between incident cancer and risk of death from pneumonia in Japanese in a large population-based cohort study.

METHODS

We used the data from The Japan Public Health Center-based Prospective Study (JPHC Study), which enrolled subjects aged 40 to 69 between 1990 and 1994 and followed their cancer incidence and mortality until 2013. After identifying 103,757 eligible subjects for analysis and imputing missing data on covariates by the chained equations approach, we conducted propensity score-matched analysis for 1:4 matching, leaving 14,520 cases diagnosed with cancer and 48,947 controls without cancer during the study period for final analysis. A Cox proportional hazards regression model was used to estimate the hazard ratio (HR) and corresponding confidence interval (CI) for the risk of death from pneumonia with comparison of cancer cases and cancer-free controls.

RESULTS

Compared to cancer-free individuals, risk of death from pneumonia was significantly higher among those who had any diagnosed cancer (HR, 1.41; 95%CI, 1.08-1.84); those within 1 year of diagnosis (HR, 23.0; 95% CI, 2.98-177.3); within 1 to <2 years (HR, 3.66; 95% CI, 1.04-12.9); and those with regional spread or distant metastatic cancer at initial diagnosis (HR, 2.01; 95% CI, 1.26-3.21). A history of lung, oesophageal, and head and neck cancer conferred the higher risk among site-specific cancers.

CONCLUSION

We found a positive association between incident cancer and risk of death from pneumonia in this study. These results imply the possibility that the immunocompromised status and respiratory failure due to antitumor treatment may have resulted in a more severe outcome from pneumonia among cancer survivors than the general population.

Clinical and economic burden of pneumococcal disease among individuals aged 16 years and older in Germany

This study assessed the incidence rate of all-cause pneumonia (ACP) and invasive pneumococcal disease (IPD) and associated medical costs among individuals aged ≥16 in the German InGef database from 2016 to 2019. Incidence rate was expressed as the number of episodes per 100 000 person-years (PY). Healthcare resource utilisation was investigated by age group and by risk group (healthy, at-risk, high-risk). Direct medical costs per ACP/IPD episode were estimated as the total costs of all inpatient and outpatient visits. The overall incidence rate of ACP was 1345 (95% CI 1339-1352) and 8.25 (95% CI 7.76-8.77) per 100 000 PY for IPD. For both ACP and IPD, incidence rates increased with age and were higher in the high-risk and at-risk groups, in comparison to the healthy group. ACP inpatient admission rate increased with age but remained steady across age-groups for IPD. The mean direct medical costs per episode were €8075 (95% CI 7121-9028) for IPD and €1454 (95% CI 1426-1482) for ACP. The aggregate direct medical costs for IPD and ACP episodes were estimated to be €8.5 million and €248.9 million respectively. The clinical and economic burden of IPD and ACP among German adults is substantial regardless of age.

Building on a Strong Foundation to Address a New Era to Help Protect Against Pneumococcal Disease

Antoni Torres, Respiratory Intensive Care Unit, Department of Pneumology and Respiratory Allergy, Hospital Clinic of Barcelona, University of Barcelona, Spain, opened the symposium, noting that pneumococcal conjugate vaccines (PCV) have reduced pneumococcal disease through direct and indirect effects. However, the burden of pneumococcal disease remains substantial in adults, supporting the importance of further reducing vaccine-preventable disease and its impact on healthcare resource utilisation and public health. Mário Ramirez, Faculty of Medicine, University of Lisbon, Portugal, and Molecular Microbiology and Infection Laboratory, Institute of Molecular Medicine, University of Lisbon, Portugal, reviewed the changing serotype epidemiology of pneumococcal disease in Europe, and described important differences between pneumococcal polysaccharide vaccines and PCVs. He detailed the dramatic direct impact of PCVs in children in decreasing the burden of vaccine-type (VT) pneumococcal disease, as well as indirect effects in unvaccinated populations, particularly adults. Residual VT-disease and increases in non-PCV13 disease underscore the need for additional disease coverage that may be afforded by higher-valent PCVs. Charles Feldman, Department of Internal Medicine, University of the Witwatersrand, Johannesburg, South Africa, reviewed the considerable worldwide burden of lower respiratory tract infections (LRTI), including pneumococcal pneumonia. He noted that indirect effects in adults may be suboptimal, and herd effects may have reached their limit. Feldman described adult populations that should be prioritised for pneumococcal vaccination based on risk factors, and stressed the importance of a comprehensive approach to increase adult vaccination. Finally, Wendy Watson, Vaccines Clinical Research, Pfizer, Collegeville, USA, described the adult PCV20 clinical development programme, emphasising that it was built on the well-established PCV13 platform. In the Phase III clinical trial programme, PCV20 was well tolerated, with a safety profile similar to PCV13, regardless of prior pneumococcal vaccination history. Importantly, it was immunogenic across all ages studied and in those with chronic medical conditions. Wendy Watson concluded that PCV20 has the potential to simplify adult vaccination and help reduce the burden of adult pneumococcal disease.

Pneumococcal vaccination coverage in individuals (16-59 years) with a newly diagnosed risk condition in Germany

Background

Despite recommendations from the German Standing Committee on Vaccination (STIKO), pneumococcal vaccination coverage remains low in vulnerable populations. This study estimated the pneumococcal vaccination coverage rate (VCR) and timing among individuals aged 16–59 years in Germany who were recommended to receive pneumococcal vaccination, according to STIKO.

Methods

A retrospective cohort analysis was conducted using the German InGef database. Individuals aged 16 to 59 years diagnosed with at least one “at-risk” (chronic disease) or “high-risk” (e.g., immunocompromising) condition considered to be at-risk of pneumococcal infection were identified at the time of first diagnosis, between January 1, 2016 and December 31, 2018, and followed up until December 31, 2019. The percentage of cumulative pneumococcal VCR with 95% confidence interval (CI) was reported for each calendar year of follow-up.

Results

There were 334,292 individuals followed for a median of 2.38 (interquartile range (IQR) 1.63–3.13) person years. For individuals aged 16–59 years diagnosed with an incident risk condition in 2016, pneumococcal VCR increased from 0.44% (95% CI 0.41–0.48) in 2016 to 1.24% (95% CI 1.18–1.30) in 2019. In 2019, VCRs were higher in individuals with high-risk conditions compared with at-risk conditions (2.24% (95% CI 2.09–2.40) vs. 0.90% (95% CI 0.85–0.96)). In 2019, VCRs were higher in individuals aged 50 to 59 years compared with individuals aged 16 to 49 years (2.25% (95% CI 2.10–2.41) vs. 0.90% (95% CI 0.84–0.96)). Similar trends were observed in individuals with newly diagnosed risk conditions identified in 2017 and in 2018. Older age, influenza vaccination and increasing number of risk conditions increased the likelihood of pneumococcal vaccination. Median time to vaccination from diagnosis of the risk condition was shorter for high-risk conditions (369.5 days (IQR 155.8–702.0)) compared to at-risk conditions (435.5 days (IQR 196.3–758.8)).

Conclusion

Despite recommendations from STIKO, pneumococcal vaccination coverage remains very low and with long delays in vulnerable individuals aged 16–59 in Germany. Further efforts are required to increase immunization levels and shorten time to vaccination among individuals 16–59 years of age developing conditions with higher susceptibility to pneumococcal infection.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-022-07736-1.

The remarkable history of pneumococcal vaccination: an ongoing challenge

Although it varies with age and geographical distribution, the global burden of infection with Streptococcus pneumoniae (pneumococcus) remains considerable. The elderly, and younger adults with comorbid conditions, are at particularly high risk of pneumococcal infection, and this risk will increase as the population ages. Vaccination should be the backbone of our current strategies to deal with this infection.

Main body: This manuscript reviews the history of the development of pneumococcal vaccines, and the impact of different vaccines and vaccination strategies over the past 111 years. It documents the early years of vaccine development in the gold mines of South Africa, when vaccination with killed pneumococci was shown to be effective, even before the recognition that different pneumococci were antigenically distinct. The development of type-specific vaccines, still with whole killed pneumococci, showed a high degree of efficacy. The identification of the importance of the pneumococcal capsule heralded the era of vaccination with capsular polysaccharides, although with the advent of penicillin, interest in pneumococcal vaccine development waned. The efforts of Austrian and his colleagues, who documented that despite penicillin therapy, patients still died from pneumococcal infection in the first 96 h, ultimately led to the licensing first of a 14-valent pneumococcal polysaccharide in 1977 followed by the 23-valent pneumococcal polysaccharide in 1983. The principal problem with these, as with other polysaccharide vaccines, was that that they failed to immunize infants and toddlers, who were at highest risk for pneumococcal disease. This was overcome by chemical linking or conjugation of the polysaccharide molecules to an immunogenic carrier protein. Thus began the era of pneumococcal conjugate vaccine (PCV), starting with PCV7, progressing to PCV10 and PCV13, and, most recently, PCV15 and PCV20. However, these vaccines remain serotype specific, posing the challenge of new serotypes replacing vaccine types. Current research addresses serotype-independent vaccines which, so far, has been a challenging and elusive endeavor.

Conclusion: While there has been enormous progress in the development of pneumococcal vaccines during the past century, attempts to develop a vaccine that will retain its efficacy for most pneumococcal serotypes are ongoing.

52-year follow-up of a birth cohort reveals a high pneumonia incidence among young men

Background

Knowledge of pneumonia incidence and risk factors in adults is mainly based on clinical studies of selected patient data and registers with ageing populations. Prospective population-based investigations, such as birth cohort studies, are needed to understand pneumonia incidence and risk factors among young and working-age populations.

Methods

Northern Finland Birth Cohort (NFBC) 1966 data (n=6750) were analysed for pneumonia incidence and risk factors. Incidence analysis was replicated using data from an independent NFBC 1986 cohort (n=9207). Pneumonia in relation to chronic conditions and lifestyle factors was analysed.

Results

A peak with a maximum of 227 pneumonia episodes per 10 000 among men between the ages of 19 and 21 years was found in two independent cohorts. Pneumonia was associated with male sex (relative risk 1.72, 95% CI 1.45-2.04; p<0.001), low educational level (relative risk 2.30, 95% CI 1.72-3.09; p<0.001), smoking (relative risk 1.55, 95% CI 1.31-1.84; p<0.001), asthma (relative risk 2.19, 95% CI 1.73-2.75; p<0.001), cardiovascular diseases (relative risk 2.50, 95% CI 2.04-3.07; p=0.001), kidney diseases (relative risk 4.14, 95% CI 2.81-6.10; p<0.001), rheumatoid arthritis (relative risk 2.69, 95% CI 1.80-4.01; p<0.001), psoriasis (relative risk 2.91, 95% CI 1.92-4.41; p<0.001) and type II diabetes (relative risk 1.80, 95% CI 1.34-2.42; p<0.001). Men with excessive alcohol consumption at age 31 years were at risk of future pneumonia (relative risk 2.40, 95% CI 1.58-3.64; p<0.001).

Conclusions

Birth cohort data can reveal novel high-risk subpopulations, such as young males. Our study provides understanding of pneumonia incidence and risk factors among young and working age populations.

Pneumococcal vaccination rates in immunocompromised patients in Germany: A retrospective cohort study to assess sequential vaccination rates and changes over time

Background

Pneumococcal vaccination is recommended by the German Standing Committee on Vaccination (STIKO) for infants, elderly 60+ years and patients at risk. In 2016, a sequential pneumococcal vaccination schedule (conjugate vaccine followed by polysaccharide vaccine 6–12 months later) supplemented this recommendation for immunocompromised patients ≥2 years of age. Previous research showed low pneumococcal vaccination rates (pnc-VR) in this vulnerable group. Moreover, no evidence is available on adherence to the newer sequential schedule. This study aimed to analyze the development of pnc-VRs in immunocompromised patients and rates of sequential vaccinations according to the STIKO recommendations.

Methods

Using a representative health claims database, we assigned incident immunocompromised patients ≥2 years of age to one of two successive cohorts to observe trends over time: cohort A (first diagnosis of immunocompromised condition between 01/2013 and 12/2014), and cohort B (first diagnosis between 01/ 2015 and 12/2017). Pnc-VR within two years after first diagnosis and cumulative pnc-VR was compared among both cohorts. In cohort B, we assessed sequential pnc-VR within 15 months of the first vaccination. For additional analyses, patients were stratified by age, gender and immunocompromising condition.

Results

Cohort A and B comprised 193,521 and 289,279 patients, respectively. Overall pnc-VR increased over time from 4.3% (cohort A; 95%-confidence interval: 4.3%-4.4%) to 6.0% (cohort B; 5.9%-6.1%), with highest pnc-VRs in men ≥60 years (11.3%: 11.1%-11.6%) and HIV patients (15.2%: 13.1%-17.4%). Cumulative pnc-VRs in cohort B were higher in any quarter following diagnosis when compared with cohort A. Overall sequential pnc-VR in cohort B was 4.0% (3.7%-4.3%), with a higher rate observed in patients aged 16–59 (6.8%: 6.0%-7.7%) vs. patients aged ≥60 years (3.1%: 2.8%-3.4%).

Conclusion

While some improvements were seen over time, pnc-VRs remain very low in immunocompromised patients, as did sequential vaccination rates. Current recommendations to protect immunocompromised patients from pneumococcal infections are not being sufficiently implemented.

Risk factors for pneumococcal disease in persons with chronic medical conditions: Results from the LIFE Study

OBJECTIVES

This study aimed to identify the risk factors for pneumococcal disease.

METHODS

The study was performed using insurance claims data from the residents of 12 Japanese municipalities. Based on recorded diagnoses, we identified chronic medical conditions in each patient between April 2015 and March 2016 and examined the subsequent occurrence of a pneumococcal disease from April 2016 onward. Cox proportional hazards models were used to estimate the hazard ratio of each chronic medical condition for a pneumococcal disease occurrence.

RESULTS

The study was conducted on 732,235 patients, of whom, 61,306 (8.4%) were aged 0-18 years, 184,367 (25.2%) were aged 19-49 years, 126,078 (17.2%) were aged 50-64 years, and 360,484 (49.2%) were aged ≥65 years. A higher number of conditions was associated with a higher incidence of pneumococcal disease. Significant risk factors for pneumococcal disease in all patients included chronic heart disease, chronic lung disease, diabetes mellitus, cancer, and chronic renal disease. Furthermore, chronic lung disease, diabetes mellitus, aspiration pneumonia, and immunosuppressant use were risk factors among patients aged 50-64 years.

CONCLUSIONS

Persons aged 50-64 years with multiple chronic medical conditions or with specific conditions are at a higher risk of developing pneumococcal disease, indicating a need to consider their inclusion in routine vaccination programs.

Risk of infections and mortality in Danish patients with cancer diagnosed with bone metastases: a population-based cohort study

OBJECTIVES

Risk of infections in patients with solid cancers and bone metastases (BM) and the subsequent impact on prognosis is unclear. We examined the risk of infections among patients with cancer diagnosed with BM and the subsequent impact of infections on mortality.

DESIGN

Population-based cohort study.

SETTING

Danish medical databases holding information on all hospital contacts in Denmark.

PARTICIPANTS

Adult patients with solid cancers and BM between 1 January 1994 and 30 November 2013.

OUTCOME MEASURES

In the risk analyses, the outcome was time to hospitalisation for common severe infections, pneumonia, sepsis and urinary tract infections. In the mortality analysis, we used Cox regression to compute HRs of death, modelling infection as time-varying exposure, stratifying for primary cancer type and adjusting for age, sex and comorbidities.

RESULTS

Among 23 336 patients with cancer and BM, cumulative incidences of common severe infections were 4.6%, 14.0% and 20.0% during 1 month, 1 year and 10 years follow-up. The highest incidence was observed for pneumonia, followed by urinary tract infections and sepsis. Infection was a strong predictor of 1 month mortality (adjusted HR: 2.1 (95% CI 1.8 to 2.3)) and HRs increased after 1 and 10 years: 2.4 (95% CI 2.3 to 2.6) and 2.4 (95% CI 2.4 to 2.6). Sepsis and pneumonia were the strongest predictors of death. Results were consistent across cancer types.

CONCLUSION

Patients with cancer and BM were at high risk of infections, which was associated with a more than twofold increased risk of death for up to 10 years of follow-up. The findings underscore the importance of preventing infections in patients with cancer and BM.

Clinical and Economic Burden of Pneumococcal Disease Due to Serotypes Contained in Current and Investigational Pneumococcal Conjugate Vaccines in Children Under Five Years of Age

INTRODUCTION

The widespread implementation of pneumococcal conjugate vaccines (PCVs) has significantly reduced the burden of pneumococcal disease around the world. Although licensed 10-valent (PCV10) and 13-valent (PCV13) vaccines have considerably reduced mortality and morbidity, a sizeable disease burden attributable to serotypes not contained in these PCVs remains. This study aimed to estimate the annual clinical and economic burden of pneumococcal disease attributable to licensed (PCV10 and PCV13) and investigational PCVs, notably 15-valent (PCV15) and 20-valent (PCV20) vaccines, in 13 countries in children under 5 years of age.

METHODS

A decision-analytic model was created to aggregate total cases [inclusive of invasive pneumococcal disease (IPD), pneumonia, and otitis media (OM)], deaths, and direct costs in each country of interest [stratified by PCV10/PCV13 countries, depending on national immunization programs (NIPs)] over 1 year, using up to the three most recent years of available serotype coverage data. Data inputs were sourced from local databases, surveillance reports, and published literature.

RESULTS

In 5 PCV10 NIPs (Austria, Finland, Netherlands, New Zealand, Sweden), most remaining PCV20-type disease was due to PCV13-unique serotypes (30-85%), followed by PCV20-unique (9-50%), PCV15-unique (4-15%), and PCV10-unique (2-14%) serotypes. In 8 PCV13 NIPs (Australia, Canada, France, Germany, Italy, South Korea, Spain, United Kingdom), most remaining PCV20-type disease was caused by PCV20-unique serotypes (16-69%), followed by PCV13-unique (11-54%), PCV15-unique (2-33%), and PCV10-unique serotypes (3-19%). Across all countries, PCV20 serotypes caused 3000 to 345,000 cases of disease and cost between $1.3 and $44.9 million USD annually with variability driven by population size, NIP status, and epidemiologic inputs. In aggregate, PCV20 serotypes caused 1,234,000 cases and $213.5 million in annual direct medical costs in children under 5 years of age.

CONCLUSION

Despite the success of PCV10 and PCV13 in reducing pneumococcal disease, a substantial clinical and economic burden remains due to serotypes contained in investigational vaccines.

Liver-Dependent Lung Remodeling during Systemic Inflammation Shapes Responses to Secondary Infection

Systemic duress, such as that elicited by sepsis, burns, or trauma, predisposes patients to secondary pneumonia, demanding better understanding of host pathways influencing this deleterious connection. These pre-existing circumstances are capable of triggering the hepatic acute-phase response (APR), which we previously demonstrated is essential for limiting susceptibility to secondary lung infections. To identify potential mechanisms underlying protection afforded by the lung-liver axis, our studies aimed to evaluate liver-dependent lung reprogramming when a systemic inflammatory challenge precedes pneumonia. Wild-type mice and APR-deficient littermate mice with hepatocyte-specific deletion of STAT3 (hepSTAT3-/-), a transcription factor necessary for full APR initiation, were challenged i.p. with LPS to induce endotoxemia. After 18 h, pneumonia was induced by intratracheal Escherichia coli instillation. Endotoxemia elicited significant transcriptional alterations in the lungs of wild-type and hepSTAT3-/- mice, with nearly 2000 differentially expressed genes between genotypes. The gene signatures revealed exaggerated immune activity in the lungs of hepSTAT3-/- mice, which were compromised in their capacity to launch additional cytokine responses to secondary infection. Proteomics revealed substantial liver-dependent modifications in the airspaces of pneumonic mice, implicating a network of dispatched liver-derived mediators influencing lung homeostasis. These results indicate that after systemic inflammation, liver acute-phase changes dramatically remodel the lungs, resulting in a modified landscape for any stimuli encountered thereafter. Based on the established vulnerability of hepSTAT3-/- mice to secondary lung infections, we believe that intact liver function is critical for maintaining the immunological responsiveness of the lungs.

Public health impact of pneumococcal conjugate vaccination: a review of measurement challenges

INTRODUCTION

Modeling analyses have attempted to quantify the global impact of pneumococcal conjugate vaccines (PCVs) on pneumococcal disease (PD), however these pediatric models face several challenges in obtaining comprehensive impact measurements.

AREAS COVERED

We present several measurement challenges and discuss examples from recently published pediatric modeling evaluations. Challenges include estimating the number of infants fully or partially vaccinated with PCVs, inclusion of indirect effects of vaccination, accounting for various dosing schedules, capturing effect of PCVs on nonspecific, noninvasive PD, and inclusion of adult PCV use.

EXPERT OPINION

The true impact of PCVs has been consistently underestimated in published analyses due to multiple measurement challenges. Nearly 100 million adults are estimated to have received PCV13 over the last decade globally, potentially preventing up to 662 thousand cases of PD. Approximately 4.1 million cases of invasive PD alone may have been averted through indirect protection. Estimates of PCV impact on noninvasive PD remain a challenge due to altered epidemiology. Program switches, incomplete vaccination, and private market uptake among children also confound PD impact estimates. Taken together, the number of averted PD cases from PCV use in the last ten years may be up to three times higher than estimated in previous studies.

Adults at risk of pneumococcal disease in France

BACKGROUND

Immunocompromised patients and those with certain underlying medical conditions are at risk of pneumococcal disease, but in France their vaccine coverage is largely unknown. We aimed to assess the number of adult patients eligible for pneumococcal vaccination in France.

METHODS

We conducted an annual cross-sectional study based on retrospective data from the French National Health Data System. Over 2014-2018, we included all adults continuously affiliated to the General health insurance scheme (covering 76% of the population), at risk of pneumococcal disease. Patients were identified with published or newly developed algorithms using diagnoses and reimbursements for hospital stays, medical procedures, and specific treatments, laboratory tests, or medical devices.

RESULTS

On January 1, 2018, we identified 4,045,021 at-risk patients (11% increase since 2014). Mean age was 66.1years (55.1% were aged≥65), 51% were men, and 18% had at least two conditions. Of these, 3,634,594 had a chronic medical condition (including 2,617,921 patients treated for diabetes, 616,003 for chronic respiratory disease, 424,223 for heart failure, and 285,214 for chronic liver disease) and 570,035 were immunocompromised (of these, 191,527 were treated with immunosuppressive drugs or biotherapy, 152,255 with chemotherapy for cancer, and 100,604 for HIV).

CONCLUSION

These published or newly developed algorithms - which can be used to address other public health issues - identified more than 4 million adults eligible for pneumococcal vaccination in the main health insurance scheme (10% of the studied adult population). This is a first step towards ensuring patients get vaccinated as part of their chronic condition management.

Cost-effectiveness analysis for PCV13 in adults 60 years and over with underlying medical conditions which put them at an elevated risk of pneumococcal disease in Japan

Background: The objective of this study was to conduct a cost-effectiveness analysis of PCV13 vs. PPV23 and no vaccination and PPV23 vs. no vaccination in adults aged ≥ 60 years with underlying medical conditions which put them at an elevated risk of pneumococcal disease in a Japanese healthcare setting.Research design and methods: A natural history model was developed with a life-long time horizon and 1-year cycle length, with microsimulation as a modeling technique. The expected costs from a public payer's and societal perspective, quality-adjusted life-years (QALYs), and prevented cases and deaths caused by IPD (invasive pneumococcal disease) and NBP (non-bacteremic pneumococcal pneumonia) were estimated.Results: In the base-case scenario, the cost per QALY gained from a public payer's perspective for PCV13 vs, PPV23 and no vaccination were 500,255JPY and 1,139,438JPY, respectively, The cost per QALY gained for PPV23 vs no vaccination was 1,687,057JPY. Over the life-long time horizon for 1 million patients, when compared to PPV23, PCV13 resulted in 65 fewer IPD cases, 2,894 fewer NBP cases, and 384 fewer deaths caused by pneumococcal disease.Conclusions: In adults aged 60 years and over with underlying medical conditions, PCV13 was shown to be a more cost-effective alternative to PPV23.

The epidemiologic and biologic basis for classifying older age as a high-risk, immunocompromising condition for pneumococcal vaccine policy

INTRODUCTION

Immunosenescence is a normal biologic process involving deterioration of protective immune responses. Consequently, older adults experience increased risk of infectious diseases, particularly pneumonia, and its leading bacterial cause, Streptococcus pneumoniae. Pneumococcal vaccine recommendations are often limited to adults with specific medical conditions despite similar disease risks among older adults due to immunosenescence.

AREAS COVERED

This article reviews epidemiologic, biologic, and clinical evidence supporting the consideration of older age due to immunosenescence as an immunocompromising condition for the purpose of pneumococcal vaccine policy and the role vaccination can play in healthy aging.

EXPERT OPINION

Epidemiologic and biologic evidence suggest that pneumococcal disease risk increases with age and is comparable for healthy older adults and younger adults with immunocompromising conditions. Because immunocompromising conditions are already indicated for pneumococcal conjugate vaccines (PCVs), a comprehensive public health strategy would also recognize immunosenescence. Moreover, older persons should be vaccinated before reaching the highest risk ages, consistent with the approach for other immunocompromising conditions. To facilitate PCV use among older adults, vaccine technical committees (VTCs) could classify older age as an immunocompromising condition based on the process of immunosenescence. With global aging, VTCs will need to consider immunosenescence and vaccine use during healthy aging.

Population-based incidence and mortality of community-acquired pneumonia in Germany

Background

Little information on the current burden of community-acquired pneumonia (CAP) in adults in Germany is available.

Methods

We conducted a retrospective cohort study using a representative healthcare claims database of approx. 4 million adults to estimate the incidence rates (IR) and associated mortality of CAP in 2015. IR and mortality were stratified by treatment setting, age group, and risk group status. A pneumonia coded in the primary diagnosis position or in the second diagnosis position with another pneumonia-related condition coded in the primary position was used as the base cases definition for the study. Sensitivity analyses using broader and more restrictive case definitions were also performed.

Results

The overall IR of CAP in adults ≥18 years was 1,054 cases per 100,000 person-years of observation. In adults aged 16 to 59 years, IR for overall CAP, hospitalized CAP and outpatient CAP was 551, 96 and 466 (with a hospitalization rate of 17%). In adults aged ≥60 years, the respective IR were 2,032, 1,061 and 1,053 (with a hospitalization rate of 52%). If any pneumonia coded in the primary or secondary diagnosis position was considered for hospitalized patients, the IR increased 1.5-fold to 1,560 in the elderly ≥60 years. The incidence of CAP hospitalizations was substantially higher in adults ≥18 years with at-risk conditions and high-risk conditions (IR of 608 and 1,552, respectively), compared to adults without underlying risk conditions (IR 108). High mortality of hospitalized CAP in adults ≥18 was observed in-hospital (18.5%), at 30 days (22.9%) and at one-year (44.5%) after CAP onset. Mortality was more than double in older adults in comparison to younger patients.

Conclusion

CAP burden in older adults and individuals with underlying risk conditions was high. Maximizing uptake of existing vaccines for respiratory diseases may help to mitigate the disease burden, especially in times of strained healthcare resources.

Etiology of Community-Acquired Pneumonia Requiring Hospital Admission in Adults with and Without Cancers: A Single-Center Retrospective Study in China

Background

The etiology and distribution of community-acquired pneumonia (CAP) vary periodically and geographically. The clinical evaluation of CAP among patients with cancers remains unknown.

Patients and Methods

This retrospective hospital-based study on adult CAP was conducted in Tang Du Hospital, China, from September 2018 to August 2019. The demographic characteristics, clinical manifestations and laboratory data were extracted from medical records and compared between CAP patients with and without cancers. Univariable and multivariable logistic regression methods were used to explore risk factors associated with CAP patients with and without cancers.

Results

Data from 149 CAP patients with cancers and 268 CAP patients without cancers were analyzed. Patients without cancers were more likely to show fever, cough and yellow sputum, higher level of neutrophil count than the cancer patients. Klebsiella pneumoniae (K. pneumoniae 14.77% vs 9.33%, p = 0.093) and Streptococcus pneumoniae (S. pneumoniae 16.11% vs 11.57%, p = 0.189) were among the most commonly encountered pathogens in both the groups. Pseudomonas aeruginosa (P. pneumoniae 26.50% vs 11.41%, p < 0.001), Mycoplasma pneumoniae (M. pneumoniae 8.21% vs 1.34%, p = 0.003), and filamentous fungi (10.82% vs 4.7%, p = 0.033) were predominant in CAP patients without cancers. Haemophilus influenzae (H. influenzae 22.15% vs 14.18%, p = 0.038) and methicillin-resistant Staphylococci (MRS 23.49 vs 15.68, p = 0.049) were more prevalent for CAP cancer patients. Certain pathogens were increasing in a cold season. In patients without cancers, MRS, H. influenzae and P. aeruginosa were associated with central nervous system (CNS) disease, connective tissue disease, bronchiectasis, respectively. In addition, healthy adults were likely to be infected with M. pneumoniae showing fever.

Conclusion

CAP patients with cancers had atypical clinical manifestations and showed no distinct increase in inflammatory markers. The predominant pathogens differed as well as similar between the CAP patients with and without cancers. Certain pathogens follow a seasonal pattern. CNS disease, connective tissue disease and bronchiectasis were associated with the predominant pathogens in patients without cancers.

Higher Hospitalization Rate for Lower Airway Infection in Transfusion-Naïve Thalassemia Children

Few studies have addressed the risk of infection in transfusion-naïve thalassemia patients. We aimed to investigate whether transfusion-naïve thalassemia population has higher hospitalization rates for lower airway infection-related diseases than non-thalassemia population in children. A nationwide population-based retrospective cohort study was conducted using detailed medical records of the Taiwan National Health Insurance Research Database. Transfusion-naïve thalassemia patients were compared with a matched cohort at a ratio of 1:4. Data of the selected patients were adjusted for age, sex, and related comorbidities. We recorded the frequency of admissions or outpatient clinic visits for patients with a diagnosis of pneumonia or acute bronchitis/bronchiolitis. Based on our results, the hospitalization rates and incidence rate ratios of bronchitis/bronchiolitis and pneumonia for transfusion-naïve thalassemia children were all higher than those for non-thalassemia controls. Therefore, we conclude that transfusion-naïve thalassemia children are more likely to experience lower airway infections and have a higher probability of hospitalization for these conditions.

Influence of Older Age and Other Risk Factors on Pneumonia Hospitalization in Switzerland in the Pneumococcal Vaccine Era

Background: Pneumococcal pneumonia is a disease of the extremes of age. However, as other traditional risk factors for pneumococcal pneumonia also increase with older age, it is unclear if older age itself should be an indication for pneumococcal vaccination. Therefore, we assessed the effect of age on risk for hospitalization for pneumonia and for pneumococcal pneumonia. Methods: Using a national hospitalization dataset, all patients ≥16 years hospitalized in a Swiss hospital with a diagnosis of pneumonia or pneumococcal pneumonia between 2002 and 2015 were included. Multivariable logistic regression analysis was used to test the association between age (≥50 or ≥65 years) and hospitalization for pneumonia or pneumococcal pneumonia after adjusting for pneumococcal vaccine indications. Similar analyses were performed for effect of age on length of stay (LOS) and mortality. Results: Among a total of 17,619,016 hospitalizations a diagnosis of pneumonia was present in 421,760 (2.4%) and a diagnosis of pneumococcal pneumonia in 21,610 (0.12%). Age ≥50 years (OR: 3.52 and 2.12, respectively; p for both <0.001) and age ≥65 years (OR: 2.98 and 1.80, respectively; p for both <0.001) as well as most Swiss pneumococcal vaccine indications were independent predictors of hospitalization with a pneumonia and pneumococcal pneumonia diagnosis, respectively. Older age with both age cut-offs were associated with increased LOS (≥50 years: aRR: 1.19 and 1.24, respectively; age ≥65 years: aRR: 1.60 and 1.20, respectively; p < 0.001 for all) and mortality (≥50 years: aOR: 4.73 and 2.84, respectively; age ≥65 years: aOR: 2.38 and 2.69, respectively, p < 0.001 for all) in patients with a pneumonia and pneumococcal pneumonia diagnosis, respectively. The effects of pneumococcal vaccine indications decreased with older age. The incidences of hospitalizations with a pneumonia diagnosis and a pneumococcal pneumonia diagnosis increased significantly from the pre-vaccine era to the PCV7 era and the PCV13 era (p for trend for both analyses <0.001). Conclusion: This study confirms the Swiss indications for pneumococcal vaccination as independent risk factors for pneumonia hospitalizations. Older age itself should be considered as an additional vaccine indication. Pneumonia and pneumococcal pneumonia in adults have increased despite pneumococcal vaccination in children.

Decreasing trend in the incidence of serious pneumonias in Finnish children with juvenile idiopathic arthritis

OBJECTIVES

Children with juvenile idiopathic arthritis (JIA) may be predisposed to serious pneumonia due to modern disease-modifying anti-rheumatic treatment. In this nationwide retrospective study with clinical data, we describe the pneumonia episodes among children with JIA.

METHODS

Patients under 18 years of age with JIA and pneumonia during 1998-2014 were identified in the National Hospital Discharge Register in Finland. Each individual patient record was reviewed, and detailed data on patients with JIA and pneumonia were retrieved, recorded, and analyzed. If the patient was hospitalized or received intravenous antibiotics, the pneumonia was considered serious.

RESULTS

There were 157 episodes of pneumonia among 140 children with JIA; 111 episodes (71%) were serious (80% in 1998-2006 and 66% in 2007-2014). The mean age of the patients was 9 years. Forty-eight percent had active JIA and 46% had comorbidities. Disease-modifying anti-rheumatic drugs (DMARD) were used at the time of 135 episodes (86%): methotrexate (MTX) by 62% and biologic DMARDs (bDMARD) by 30%. There was no significant difference in the use of bDMARDs, MTX and glucocorticoids between the patient groups with serious and non-serious pneumonia episodes. During six of the episodes, intensive care was needed. Two patients (1.3%) died, the remaining ones recovered fully.

CONCLUSIONS

Although the incidence of pneumonia and the use of immunosuppressive treatment among children with JIA increased from 1998 to 2014, the proportion of serious pneumonias in these patients decreased. There was no significant difference in the use of anti-rheumatic medication between patients with serious and non-serious pneumonia.Key Points• The incidence of serious pneumonias decreased from 1998 to 2014 among children with juvenile idiopathic arthritis (JIA).• There was no significant difference in the use of the disease-modifying anti-rheumatic medication between JIA patients with serious and non-serious pneumonias.• Active JIA, comorbidities, and combination medication were associated with nearly half of the pneumonias.

The impact of certain underlying comorbidities on the risk of developing hospitalised pneumonia in England

Background

UK specific data on the risk of developing hospitalised CAP for patients with underlying comorbidities is lacking. This study compared the likelihood of hospitalised all-cause community acquired pneumonia (CAP) in patients with certain high-risk comorbidities and a comparator group with no known risk factors for pneumococcal disease.

Methods

This retrospective cohort study interrogated data in the Hospital Episodes Statistics (HES) dataset between financial years 2012/13 and 2016/17. In total 3,078,623 patients in England (aged ≥18 years) were linked to their hospitalisation records. This included 2,950,910 individuals with defined risk groups and a comparator group of 127,713 people who had undergone tooth extraction with none of the risk group diagnoses. Risk groups studied were chronic respiratory disease (CRD), chronic heart disease (CHD), chronic liver disease (CLD), chronic kidney disease (CKD), diabetes (DM) and post bone marrow transplant (BMT). The patients were tracked forward from year 0 (2012/13) to Year 3 (2016/17) and all diagnoses of hospitalised CAP were recorded. A Logistic regression model compared odds of developing hospitalised CAP for patients in risk groups compared to healthy controls. The model was simultaneously adjusted for age, sex, strategic heath authority (SHA), index of multiple deprivation (IMD), ethnicity, and comorbidity. To account for differing comorbidity profiles between populations the Charlson Comorbidity Index (CCI) was applied. The model estimated odds ratios (OR) with 95% confidence intervals of developing hospitalised CAP for each specified clinical risk group.

Results

Patients within all the risk groups studied were more likely to develop hospitalised CAP than patients in the comparator group. The odds ratios varied between underlying conditions ranging from 1.18 (95% CI 1.13, 1.23) for those with DM to 5.48 (95% CI 5.28, 5.70) for those with CRD.

Conclusions

Individuals with any of 6 pre-defined underlying comorbidities are at significantly increased risk of developing hospitalised CAP compared to those with no underlying comorbid condition. Since the likelihood varies by risk group it should be possible to target patients with each of these underlying comorbidities with the most appropriate preventative measures, including immunisations.

Vaccine strategies for prevention of community-acquired pneumonia in Canada: Who would benefit most from pneumococcal immunization?

OBJECTIVE

To describe the burden of pneumococcal disease and associated risk factors in the Canadian adult population, delineate available pneumococcal vaccines and associated efficacy and effectiveness data, and review current pneumococcal vaccine recommendations and community-acquired pneumonia (CAP) prevention strategies in Canada.

QUALITY OF EVIDENCE

Pneumococcal vaccination guidelines from the Canadian National Advisory Committee on Immunization in 2013 and 2016 constitute level III evidence for CAP prevention in the Canadian adult population.

MAIN MESSAGE

It is recommended that immunosuppressed adults of all ages receive the 13-valent pneumococcal conjugate vaccine (PCV13) (grades A and B recommendations). In 2016, the National Advisory Committee on Immunization also recommended that all adults aged 65 years and older receive PCV13 (grade A recommendation) on an individual basis, followed by the 23-valent pneumococcal polysaccharide vaccine (grade B recommendation). This update is based on a large clinical study that demonstrated PCV13 efficacy against vaccine-type CAP in this population.

CONCLUSION

Physicians should focus on improving pneumococcal vaccination rates among adults, which remain low. Vaccination with PCV13 should also be considered for adults with chronic conditions, whose baseline risk is often higher than that for healthy individuals aged 65 years and older.

Pneumococcal vaccination rates in immunocompromised patients-A cohort study based on claims data from more than 200,000 patients in Germany

Background

The German Committee on Vaccination recommends pneumococcal vaccination for infants, seniors 60+ years and patients at risk with defined underlying diseases. Aim of this study was to assess the pneumococcal vaccination rate (pnc-VR) in patients with certain incident inherited or acquired immunodeficiency or immunosuppression and to understand who vaccinates these patients who are particularly at high risk to develop a pneumococcal infection.

Methods

We conducted a cohort study in patients aged 2 years or older, with a first episode of a “high-risk” condition between January 2013 and December 2014 based on a representative sample of German claims data. Pnc-VR was calculated as the proportion of patients receiving any pneumococcal vaccine within two years after first episode of “high-risk” condition. Further analyses cover pnc-VR stratified by high risk conditions and region, time to vaccination, and physician specialty administering the pneumococcal vaccination.

Results

The study population comprised 204,088 incident “high-risk” patients (56% female). The overall pnc-VR within two years was 4.4% (95%-confidence interval: 4.3%-4.5%). Within specific high-risk conditions, we found the highest vaccination rate of 11.5% (10.1%-13.0%) among patients starting immunosuppressants with underlying rheumatoid arthritis followed by 9.9% (7.8%-12.4%) in HIV patients. Stratification by region revealed a slightly higher vaccination rate in Eastern (6.5%: 6.0%-6.9%) compared to Western Germany (4.2%: 4.1–4.3%). Median time to vaccination within the first two years in vaccinated patients was 332.5 days (Q1 142 days, Q3 528 days). The majority of patients (92.6%) got vaccinated by a general practitioner.

Conclusion

Although these vulnerable patients need protection most, our study suggests that the overall pnc-VR after a first episode of a high-risk condition for pneumococcal disease is very low and vaccination is far too late. To prevent pneumococcal disease in patients at high risk, further efforts are needed to increase awareness and improve the timeliness of pneumococcal vaccination.

Burden of community-acquired pneumonia, predisposing factors and health-care related costs in patients with cancer

BACKGROUND

Data on the burden of community-acquired pneumonia (CAP) and health-care related costs in patients with cancer is scarce. We aimed to estimate the CAP incidence rate, mortality, and healthcare-related costs of CAP patients with different cancer subtypes in Germany.

METHODS

We used German health claims data of a representative sample of 4 million subjects to conduct cohort studies in patients with a new diagnosis of lung, hematological, breast, gastro-intestinal tract and renal/urinary-tract cancer and a comparator cohort without cancer between 2011 and 2015. CAP cases were identified in both the hospital and ambulatory care setting. Crude and age- and sex-standardized incidence rates (sIR) of CAP and mortality after CAP were calculated. To compare the health care-related costs of cancer patients with and without a diagnosis of CAP, a propensity-score (PS) matched control group was created.

RESULTS

The study population comprised of 89,007 patients with cancer. In lung cancer patients, the sIR was increased 21-fold compared to the control cohort. For the other cancer subtypes, the sIR was increased 4.3-fold (hematological malignancies) to 1.7-fold (breast cancer) compared to the control cohort. The 30-day mortality in CAP cases was highest in lung cancer patients with 20.0% and ranged from 7.2 to 18.5% in CAP cases with other cancer subtypes. The highest costs were observed in CAP cases with hematological malignancies with 28,969 € (SD 37,142 €) and the lowest in patients with renal/urinary tract cancer with 17,432 € (SD 19,579 €). The absolute difference in the mean overall costs between CAP cases and controls without CAP ranged from 4,111€ to 9,826€, depending on the cancer type. CAP-related costs were predominantly triggered by substantially elevated hospital costs in CAP cases.

CONCLUSIONS

The incidence rate of CAP and related mortality is high in patients with cancer with strong variations by cancer subtype. Furthermore, CAP in cancer patients is associated with substantial direct excess costs.

Pneumonia hospitalisation and case-fatality rates in older Australians with and without risk factors for pneumococcal disease: implications for vaccine policy

Community-acquired pneumonia (CAP) results in substantial numbers of hospitalisations and deaths in older adults. There are known lifestyle and medical risk factors for pneumococcal disease but the magnitude of the additional risk is not well quantified in Australia. We used a large population-based prospective cohort study of older adults in the state of New South Wales (45 and Up Study) linked to cause-specific hospitalisations, disease notifications and death registrations from 2006 to 2015. We estimated the age-specific incidence of CAP hospitalisation (ICD-10 J12-18), invasive pneumococcal disease (IPD) notification and presumptive non-invasive pneumococcal CAP hospitalisation (J13 + J18.1, excluding IPD), comparing those with at least one risk factor to those with no risk factors. The hospitalised case-fatality rate (CFR) included deaths in a 30-day window after hospitalisation. Among 266 951 participants followed for 1 850 000 person-years there were 8747 first hospitalisations for CAP, 157 IPD notifications and 305 non-invasive pneumococcal CAP hospitalisations. In persons 65-84 years, 54.7% had at least one identified risk factor, increasing to 57.0% in those ⩾85 years. The incidence of CAP hospitalisation in those ⩾65 years with at least one risk factor was twofold higher than in those without risk factors, 1091/100 000 (95% confidence interval (CI) 1060-1122) compared with 522/100 000 (95% CI 501-545) and IPD in equivalent groups was almost threefold higher (18.40/100 000 (95% CI 14.61-22.87) vs. 6.82/100 000 (95% CI 4.56-9.79)). The CFR increased with age but there were limited difference by risk status, except in those aged 45 to 64 years. Adults ⩾65 years with at least one risk factor have much higher rates of CAP and IPD suggesting that additional risk factor-based vaccination strategies may be cost-effective.

Integrative Physiology of Pneumonia

Pneumonia is a type of acute lower respiratory infection that is common and severe. The outcome of lower respiratory infection is determined by the degrees to which immunity is protective and inflammation is damaging. Intercellular and interorgan signaling networks coordinate these actions to fight infection and protect the tissue. Cells residing in the lung initiate and steer these responses, with additional immunity effectors recruited from the bloodstream. Responses of extrapulmonary tissues, including the liver, bone marrow, and others, are essential to resistance and resilience. Responses in the lung and extrapulmonary organs can also be counterproductive and drive acute and chronic comorbidities after respiratory infection. This review discusses cell-specific and organ-specific roles in the integrated physiological response to acute lung infection, and the mechanisms by which intercellular and interorgan signaling contribute to host defense and healthy respiratory physiology or to acute lung injury, chronic pulmonary disease, and adverse extrapulmonary sequelae. Pneumonia should no longer be perceived as simply an acute infection of the lung. Pneumonia susceptibility reflects ongoing and poorly understood chronic conditions, and pneumonia results in diverse and often persistent deleterious consequences for multiple physiological systems.

Estimating the cost-effectiveness of a sequential pneumococcal vaccination program for adults in Germany

Introduction

In Germany, a 23-valent polysaccharide pneumococcal vaccine (PPSV23) is recommended for elderly (60+) and patients 16+ with chronic diseases not associated with immune suppression. For all other patients at risk, sequential immunization with a 13-valent pneumococcal conjugate vaccine (PCV13) first, followed by PPSV23 is recommended. Repeated vaccination with PPSV23 is recommended every 6 years after individual assessment by the physician. This was adopted into the vaccination directive with binding reimbursement and funding. However, additional voluntary services allow statutory health insurances to differentiate from each other. Aim of this study is to estimate the cost-effectiveness of voluntary service scenarios compared to the strategy in place to support informed decision making.

Methods

A microsimulation framework with Markov-type process of a population susceptible to pneumococcal disease over a lifetime horizon was developed to compare effectiveness and cost-effectiveness of different vaccination strategies. We simulated 1,000 iterations for seven scenarios. Assumptions were derived from published literature and probabilistic sensitivity analysis was run to show the robustness of the model.

Results

Our study indicates that all voluntary service strategies could prevent further clinical cases compared to the existing policy. Depending on the scenario, 48–142 invasive pneumococcal disease (IPD), 24,000–45,000 hospitalized all-cause nonbacteremic pneumonia (NBP), 15,000–45,000 outpatient NBP cases, and 4,000–8,000 deaths could be avoided on average. This refers to potential savings of €115 Mio. - €187 Mio. for medical and non-medical costs. Additional costs per patient for the payer are €2.48 to €7.13 and for the society €2.20 to €6.85. The ICER per LYG ranged from €3,662 to €23,061 (payer) and €3,258 to €29,617 (societal). All but one scenario was cost-effective in ≥60% of the generated 1,000 simulations.

Conclusion

Compared to the vaccination strategy in place, the different hypothetical scenarios can be considered cost-effective and suitable as additional voluntary services.

Risk of pneumococcal diseases in adults with underlying medical conditions: a retrospective, cohort study using two Japanese healthcare databases

OBJECTIVES

To quantify the risk of pneumococcal pneumonia (PP) and invasive pneumococcal disease (IPD) in adults aged ≥19 years with underlying medical conditions compared with healthy adults of the same age in Japan.

DESIGN

An observational, retrospective, cohort study using two healthcare claims databases in Japan: Japan Medical Data Center (JMDC) and Medical Data Vision (MDV) databases.

PARTICIPANTS

A total of 10.4 million individuals, representing 9.3 million person-years of follow-up, were included in the analysis. Eleven medical conditions as well as PP and IPD were identified by the International Statistical Classification of Diseases and Related Health Problems version 10 diagnostic codes and/or local disease codes used in Japan.

PRIMARY OUTCOME MEASURES

Adjusted rate ratios (RRs) for PP and IPD in adults with a medical condition versus adults without any medical condition were calculated using multivariate Poisson regression models with age and/or sex as covariates.

RESULTS

In the JMDC and MDV databases, respectively, adults ≥19 years with a medical condition (RRs for PP: 3.3 to 13.4, 1.7 to 5.2; RRs for IPD: 12.6 to 43.3, 4.4 to 7.1), adults with two or more medical conditions (PP: 11.6, 2.8; IPD: 18.7, 5.8) and high-risk adults (PP: 12.9, 1.8; IPD: 29.7, 4.0) were at greater risk of PP and IPD compared with their healthy counterparts. Adults aged 50-64 years with an underlying medical condition (PP rate: 38.6 to 212.1 per 100 000 person-years) had a higher rate of PP than those aged ≥65 years without any condition (PP rate: 13.2 to 93.0 per 100 000 person-years).

CONCLUSIONS

Adults of all ages with an underlying medical condition are at greater risk of PP and IPD compared with adults without any medical condition. This risk increases with the number of underlying medical conditions. Our results support extending pneumococcal vaccination to younger adults with an underlying medical condition, especially those aged 50-64 years.

Burden of pneumococcal community-acquired pneumonia in adults across Europe: A literature review

BACKGROUND

The burden of community-acquired pneumonia (CAP) caused by Streptococcus pneumoniae (pneumococcus) among adults in Europe is poorly defined.

METHODS

Structured searches of PubMed were conducted to identify the incidence of pneumococcal CAP among adults across Europe.

RESULTS

The overall incidence rates for CAP was 68-7000 per 100,000 and the incidence in hospitalised CAP cases of all causes was 16-3581 per 100,000. In general the incidence of CAP increased consistently with age. Available data indicated higher burdens of pneumococcal CAP caused in groups with more comorbidities. Most cases of pneumococcal CAP (30%-78%) were caused by serotypes covered by PCV13 vaccine; the incidence of PCV13-related pneumonia decreased after the introduction of childhood vaccination.

CONCLUSIONS

We observed a high burden adult pneumococcal CAP in Europe despite use of the 23-valent pneumococcal polysaccharide vaccine, particularly in elderly patients with comorbidities. CAP surveillance presented wide variations across Europe. Pneumococcal CAP has to be monitored very carefully due to the possible effect of current vaccination strategies.

Post hoc analysis of the efficacy of the 13-valent pneumococcal conjugate vaccine against vaccine-type community-acquired pneumonia in at-risk older adults

BACKGROUND

Individuals with certain chronic medical conditions are at higher risk of developing pneumonia and pneumococcal disease than those without. Using data from the Community-Acquired Pneumonia Immunization Trial in Adults (CAPiTA), this post hoc analysis assessed the efficacy of the 13-valent pneumococcal conjugate vaccine (PCV13) in adults aged ≥65 years with at-risk conditions.

METHODS

The Community-Acquired Pneumonia Immunization Trial in Adults (CAPiTA) was a double-blind, parallel-group, randomized, placebo-controlled study in the Netherlands in which adults aged ≥65 years received either PCV13 or placebo. Outcomes of interest were identified using prespecified clinical criteria, radiographic confirmation, routine microbiologic testing, and a serotype-specific urinary antigen detection assay. In this post hoc analysis, participants were classified by at-risk status based on self-reporting of any of the following chronic medical conditions: heart disease, lung disease, asthma, diabetes, liver disease, and smoking. The objective of this analysis was to assess PCV13 vaccine efficacy (VE) against a first episode of vaccine-serotype community-acquired pneumonia (VT-CAP) in at-risk participants.

RESULTS

Of the 84,496 adults enrolled in the study, 41,385 (49.2%) were considered at risk owing to chronic medical conditions. Of the 139 VT-CAP cases, 115 (82.7%) occurred in these participants. VE of PCV13 against a first episode of VT-CAP among participants with at-risk conditions was 40.3% (95.2% CI: 11.4%, 60.2%). Average duration of follow-up since vaccination was 3.95 years for at-risk participants; protection did not wane over the study period.

CONCLUSIONS

This post hoc analysis of the Community-Acquired Pneumonia Immunization Trial in Adults (CAPiTA) showed significant and persistent efficacy of PCV13 against VT-CAP in at-risk older adults. ClinicalTrials.gov identifier: NCT00744263.

Disease burden of hospitalized community-acquired pneumonia in South Korea: Analysis based on age and underlying medical conditions

Pneumonia is a leading cause of hospitalization and mortality worldwide. Despite recognition of the importance of community-acquired pneumonia (CAP) in adults, limited epidemiologic information is available in South Korea. This study aimed to evaluate the disease burden of hospitalized CAP in adults aged ≥19 years and its epidemiologic trend using Health Insurance and Review Assessment (HIRA) data.This is a retrospective study using the HIRA database from year 2009 to 2013. We estimated the incidence rate and direct medical cost of hospitalized CAP in adults aged ≥19 years in South Korea. These were further analyzed with respect to age and underlying medical conditions.During 2009 to 2013, 1216,916 hospitalizations were recorded. On average, the annual age-adjusted incidence rate of hospitalized CAP was 626 per 100,000 persons, with the rate increasing with age. When stratified by age- and risk groups, elderly people ≥75 years showed the highest incidence rate of hospitalized CAP over 5-year study periods. With respect to the risk groups based on underlying medical conditions, incidence rate ratios were 2.04 to 5.86 for the high-risk group versus the low-risk group and 1.28 to 5.49 for the moderate-risk group versus the low-risk group. Overall, mean direct medical cost for hospitalized CAP was 1851 USD per capita during the 5-year period: 1263 USD in the low-risk group, 2353 USD in the moderate-risk group, and 2841 USD in the high-risk group.This study shows that the incidence and medical cost of hospitalized CAP were consistently high over the 5-year study period. In particular, elderly people and adults with underlying medical conditions were at increased risk for hospitalized CAP.

Risk stacking of pneumococcal vaccination indications increases mortality in unvaccinated adults with Streptococcus pneumoniae infections

BACKGROUND

Several chronic disease states have been identified as pneumococcal vaccination indications due to their ability to increase pneumococcal disease development and subsequent mortality. However, the risk of mortality according to the number of these disease states present is unknown. We sought to determine the impact of concomitant, multiple risk factors (stacked risks) for pneumococcal disease on 30-day mortality in adults.

METHODS

This was a national case-control study of unvaccinated older Veterans (≥50years of age) admitted to Veterans Affairs medical centers from 2002 to 2011 with serious pneumococcal infections (pneumonia, bacteremia, meningitis) based on positive S. pneumoniae blood, cerebrospinal fluid, or respiratory cultures, respectively. Cases were those not alive 30days following culture, while controls were alive. Using logistic regression, we quantified risk of 30-day mortality among patients with stacked risk factors, including age ≥65years, alcohol abuse, chronic heart disease, chronic liver disease, chronic respiratory disease, diabetes mellitus, immunodeficiency, and smoking.

RESULTS

We identified 9730 serious pneumococcal infections, with an overall 30-day mortality rate of 18.6% (1764 cases, 7966 controls). Infection types included pneumonia (62%), bacteremia (26%), and bacteremic pneumonia (11%). Along with eight individual risk factors, we assessed 247 combinations of risk factors. Most cases (85%) and controls (74%) had at least two risk factors. Mortality increased as risks were stacked, up to six risk factors (one: OR 1.5, CI 1.08-2.07; two: OR 2.01, CI 1.47-2.75; three: OR 2.71, CI 1.99-3.69; four: OR 3.27, CI 2.39-4.47; five: OR 3.63, CI 2.60-5.07; six: OR 4.23, CI 2.69-6.65), with each additional risk factor increasing mortality an average of 55% (±13%).

CONCLUSIONS

Among adults ≥50years with serious pneumococcal disease, mortality risk increased approximately 55% as vaccination indications present increased. Mortality with six stacked indications was double that of two indications.