Severity assessment of lower respiratory tract infection in elderly patients in primary care.

BACKGROUND: Simple markers for evaluating the severity of lower respiratory tract infections (LRTI) in primary care are lacking. It is of value to examine whether the information available to the primary care physician during a patient's initial visit can be used to assess the severity of LRTI. METHODS: The associations between different baseline variables and outcomes (survival within or more than 30 days) were investigated prospectively in a series of 950 home-living patients 65 years or older with severe LRTI that their primary care physicians suspected to be pneumonia. RESULTS: Twenty-one men and 17 women died (4.1%) within 30 days. According to univariate analysis, the following parameters differed (P < .01) between the fatalities and survivors: acute aggravation of a coexisting illness, age, respiratory rate, white blood cell count, and C-reactive protein (CRP) level. According to Cox forward stepwise regression analysis (P = .01 for entry and.05 for removal), acute aggravation of a concurrent illness, respiratory rate (> or = 25/min), and CRP concentration (> or = 100 mg/L) were independently associated with death. The mortality rate was 2.2% if the patients had none or only 1 of the independent risk factors and 20% if they had all 3 risk factors. CONCLUSIONS: Preceding aggravation of a concurrent illness and respiratory rate of 25/min or higher, together with an elevated serum CRP level (> or = 100 mg/L), can be used as simple markers for identifying patients with the highest risk for LRTI and improve management decisions among elderly people in primary care.

Incremental effectiveness of pneumococcal vaccine on simultaneously administered influenza vaccine in preventing pneumonia and pneumococcal pneumonia among persons aged 65 years or older.

The effectiveness of simultaneously administered influenza and pneumococcal vaccines vs. influenza vaccine alone in preventing pneumonia, pneumococcal pneumonia and pneumococcal bacteraemia among the elderly was studied. The vaccines were offered to all persons aged 65 years or older (N=43,500) living in 35 administrative districts in Northern Finland. A total of 26,925 persons (62%) decided to participate. Allocation to the vaccination groups took place by year of birth (odd/even). The total follow-up of those vaccinated consisted of 38,037 person years. The incremental effectiveness of the pneumococcal vaccine was -20 (95% CI -50- + 10%) for pneumonia, -20 (95% CI -90- + 20%) for pneumococcal pneumonia and + 60% (95% CI -40- +90%) for pneumococcal bacteraemia. Thus the pneumococcal polysaccharide vaccine did not offer any additional protection from pneumonia among elderly people in Finland although it reduced the incidence of bacteraemia.

Pneumococcal vaccination in the elderly: an underused option?

Pneumococcal infections, especially pneumococcal pneumonia and pneumococcal bacteraemia are leading causes of morbidity and mortality among the elderly. The emergence of penicillin-resistant pneumococcal strains together with the growing number of old people have emphasised the need for prevention of pneumococcal infections. Prospective cohort studies with pneumonia as the endpoint have so far left open the question of the rationale of vaccinating the risk groups with pneumococcal vaccine. Pneumococcal vaccine has been proven effective against pneumococcal bacteraemia, but the incidence of that disease and thus its importance to the individuals themselves and to the healthcare system is small. Adverse events associated with pneumococcal vaccine are quite frequent but, especially in the elderly, mild and do not limit its use. Clinicians should keep the pneumococcal vaccine in mind and discuss its use with their patients at increased risk for pneumococcal infection. However, before pneumococcal vaccine can be included in national vaccination programmes, its cost-effectiveness in preventing invasive infections must be assured or definitive evidence obtained of its effectiveness against non-invasive pneumococcal infection.

Persistence of antibodies to pneumococcal capsular polysaccharide vaccine in the elderly.

Persistence of antibodies to 23-valent pneumococcal vaccine was assessed among 62 subjects aged 65-88 years. IgG antibodies were measured by standardized EIA to serotypes 4, 6B, 9V, 14, 19F, and 23F before and 1 month, 1 year, and 3 years after vaccination. After satisfactory antibody responses (fold increases from 2.6 to 5.3), 3-year geometric mean concentrations (GMCs) had waned to close (for types 4, 9V, and 23F) or similar (for types 6B and 19F) to their prevaccination values. Type 14 was exceptional: 1-month GMC was 7.7-fold and 3-year GMC was 3.0-fold in comparison to the prevaccination GMC. Antibody concentrations decreased at an equal rate irrespective of serotype and age or sex of the vaccinee. The major factor predicting the persistence of antibodies above the prevaccination level was the magnitude of the original antibody response. Present results suggest that pneumococcal revaccination of the elderly may be needed as early as 3-4 years after the initial vaccination.

Associations of prevaccination antibody levels with adverse reactions to pneumococcal and influenza vaccines administered simultaneously in the elderly.

The association of prevaccination antibodies with the adverse reactions seen after vaccination was studied in 85 elderly subjects (65-90 years) vaccinated simultaneously with pneumococcal and influenza vaccines. The subjects with a temperature rise (9% of vaccinees) had significantly higher prevaccination antibody levels to pneumococcal capsular polysaccharides (PPSs) than those without a temperature rise; no difference was seen in their haemagglutination inhibiting (HI) influenza virus antibody levels. Pain in the left arm (the pneumococcal vaccine injection site) occurred in 45% of the subjects and was likewise associated with elevated PPS antibody levels. Pain at the site of influenza vaccine injection (the right arm) seen in 33% of the vaccinees was significantly more common among those who had previously received influenza vaccine, but was not associated with elevated HI antibody levels. In conclusion, prevaccination pneumococcal but not influenza antibodies were associated with both systemic and local reactions following vaccination.

Hospital discharges for pneumonia in Finland between 1972 and 1993 in the population aged 65 years or over.

AIM: to describe the use of hospital services by Finnish adults aged 65 or over with pneumonia from 1972 to 1993. MATERIAL AND METHODS: the study was based on nation-wide hospital discharge records. Patients in hospital for over 150 days were excluded. The number of persons aged 65 or over was 458,156 in 1972 and 707,341 in 1993. RESULTS: pneumonia caused 237,330 periods of hospital treatment and a total of 3,826,986 hospitalization days in elderly people during the 22-year period. Annual hospital treatment periods increased from 15.5 to 23.9 per 1000 of population aged 65 years or over within this interval. The average annual change in the age-adjusted rate of hospital admissions for pneumonia was 1.45% [95% confidence interval (CI) 1.03 to 1.87] for males and 0.83% (95% CI 0.39 to 1.28) for females. The increase was highest in the oldest male group, those aged 85 years or over. In 1972 the number of hospitalization days recorded was 126,690 (277 per 1000) and in 1993 it was 242,638 (343 per 1000), implying an absolute increase of 91.5%. However, the average annual change in the age-adjusted rate of hospitalization days for pneumonia showed a decrease of 0.62% (95% CI 1.04 to 0.19). CONCLUSION: the recorded increase in the use of hospital services by elderly patients with pneumonia, combined with the current increase in size of the elderly population, suggests that the prevention and treatment of pneumonia in this sector of the population will pose a challenge for the health service in the future.

Hospitalization for pneumonia in the Finnish working-age population.

The aim of this investigation was to describe the use of hospital services among the Finnish working-age population aged 15 to 64 years on account of pneumonia. The study was based on nationwide hospital discharge records maintained by the National Research and Development Centre for Welfare and Health. Pneumonia caused 63,414 periods of hospital treatment and a total of 568,861 hospitalization days among working-age people in Finland from 1984 to 1993. The mean annual age-specific rate of pneumonia-related hospital treatment periods per 1000 persons among men was 2.67 (SD 0.17) and among women 1.10 (SD 0.08). The men had more treatment periods than the women in every 5-year age group, the greatest difference being in the youngest age groups and in the oldest ones. In men the mean annual rate of treatment periods increased rapidly after the age of 40 years (from 1.54 per 1000 persons in age group 40-45 years to 7.86 per 1000 in age group 60-64 years). In women the increase in corresponding age groups was more moderate (from 0.77 to 3.19). The increasing number of pneumonia-related hospital treatment periods after the age of 40 is facing the challenge for the occupational health care in the future.

The impact of vaccination strategy and methods of information on influenza and pneumococcal vaccination coverage in the elderly population.

We compared the coverage achieved with either an age-based, free-of-charge vaccination program offering influenza vaccine alone or with pneumococcal vaccine with a restricted risk disease-based influenza vaccination program supplemented by self-funded immunization. We also compared two means of informing the public, either using mailed personal reminders or through the mass media only. Forty-one administrative districts with a total of 41,500 persons aged 65 years or older participated in the study during three consecutive seasons from 1992 to 1994. The average vaccination coverage achieved by the risk disease-based program was 20%, by the age-based program with mass media information, 52%, and by the age-based program with mailed personal reminders 82%. The availability of free-of-charge vaccines is thus not sufficient to ensure a high vaccination rate. The effect of the personal reminders was restricted to the year they were sent. The addition of pneumococcal vaccine to the age-based influenza vaccination program had little influence on the acceptance rate.

Factors associated with influenza vaccination coverage among the elderly: role of health care personnel.

Factors associated with acceptance of influenza vaccination in an elderly population were investigated in order to find ways of improving vaccination coverage. Three administrative districts with different vaccination coverages were selected, and a random sample of 10 percent (N = 497) of the elderly population living outside institutions was taken from the official lists maintained by the Central Statistical Office. The data were collected by means of a postal questionnaire. The questionnaire inquired about influenza vaccination status during the autumn 1992 campaign, demographic factors, health status, previous experiences and beliefs about influenza vaccination and influenza as a disease, and source of information about the vaccination campaign. The highest positive associations were found between a high influenza vaccination acceptance rate and the perceived need for vaccination (Relative risk (RR) 4.6, 95% confidence interval (CI) 2.7-7.9), belief in its effectiveness (RR 3.6, 95% CI 2.1-6.1) and information received from health visitors (RR 2.2, 95% CI 1.8-2.6). Vaccination acceptance was negatively associated with a belief in its adverse effects, (RR 0.4, 95% CI 0.2-0.6). Information received from health visitors was associated with more frequent occurrence of positive beliefs about influenza vaccination and with higher acceptance of vaccination irrespective of positive or negative beliefs regarding it. In order to obtain high vaccination coverage health care personnel should be carefully informed about the importance of influenza vaccination and encouraged to inform the public.

Antibody response to pneumococcal capsular polysaccharide vaccine in the elderly.

Antibody response to 23-valent pneumococcal vaccine was assessed in 350 subjects (131 men, 219 women) aged 65-91 years. IgG antibodies to pneumococcal serotypes 4, 6B, 9V, 14, 19F, and 23F were measured by EIA after blocking of antibodies to cell wall polysaccharide. Antibody concentrations in both pre- and postvaccination sera (mean interval, 35 days) were higher in elderly men than women; in the women, the concentrations decreased significantly with increasing age, but not in the men. Antibody fold increases were good in the elderly, including those > or = 85 years old. The overall percentage of the elderly with antibody concentrations > 1 microgram/mL to the 6 antigens increased by vaccination from 61% to 87%, but in the women > or = 85 years old, only to 75%. Antibody response to 23-valent pneumococcal vaccine was satisfactory in the elderly.

Reactions following administration of influenza vaccine alone or with pneumococcal vaccine to the elderly.

BACKGROUND: Even though the efficacy of pneumococcal vaccine against invasive pneumococcal infections and other closely related infections has been established, its use in the United States is only one quarter of that of influenza vaccine. The simultaneous administration of the two vaccines could be expected to raise the coverage of pneumococcal vaccination to a considerable degree. There is a paucity of data regarding the reactions associated with the simultaneous administration of pneumococcal and influenza vaccines. METHODS: All persons aged 65 years or older living in 29 administrative districts in Northern Finland were offered influenza vaccine alone or influenza and pneumococcal vaccines. A total of 9336 persons (49.6% of the target population) accepted vaccination: 4581 persons born in odd years received influenza vaccine, and 4755 persons born in even years received influenza and pneumococcal vaccines. Local reactions were recorded in a diary by vaccines on the day of vaccination and for 4 days afterward according to the following scale: no reaction, mild reaction, strong reaction, and disabling reaction. The participants who felt feverish were asked to measure and record their temperature. Ninety-three percent of those vaccinated returned the diary. RESULTS: No serious reactions were observed. The incidence of local reactions was 284 per 1000 vaccinations in the influenza-vaccinated group and 441 per 1000 vaccinations in the influenza-pneumococcal-vaccinated group, a difference of 157 (95% confidence interval, 137 to 176), and that of fever (temperature, at least 37.5 degrees C) was 10 and 24 per 1000, respectively, for a difference of 14 (95% confidence interval, 9 to 19). The frequency of local reactions decreased with advancing age. CONCLUSION: Because the adverse reactions to the pneumococcal and influenza vaccines when given together were mild, we conclude that the simultaneous administration of the two vaccines to the elderly population, irrespective of age, is safe.