Risk of exacerbation following pneumonia in adults with heart failure or chronic obstructive pulmonary disease

Cost of invasive pneumococcal disease, all-cause pneumonia, and all-cause otitis media among commercial-insured US children

BACKGROUND

Invasive pneumococcal disease (IPD), pneumonia (PNE), and otitis media (OM) are significant causes of morbidity among children in the United States (US). While studies have evaluated the economic burden of these conditions, recent data on episodic costs of IPD, PNE, and OM requiring hospitalization or ambulatory care only among US children by age and comorbidity profile are currently not available. This study was undertaken to address this evidence gap.

METHODS

A retrospective observational cohort design and data (2015-2019) from Optum's de-identified Clinformatics® Data Mart Database were employed. Episodes of IPD, all-cause PNE, and all-cause OM were ascertained on a monthly basis during the follow-up period and stratified by care setting (hospital vs. ambulatory); all-cause OM was alternatively stratified by disease severity (acute, persistent, tympanostomy tube placement) and, for acute/persistent, by complexity (simple, complex). Mean episodic costs of disease were estimated for children aged <1, 1-<2, 2-<6, and 6-<18 years, respectively, overall and by comorbidity profile (with vs. without ≥1 medical condition).

RESULTS

Mean age-specific cost of IPD hospitalization ranged from $40,575-$95,607; IPD requiring care in an emergency department (ED), from $2,013-$5,606; and IPD requiring care in other ambulatory settings, from $619-$1,103. Mean cost of all-cause PNE ranged from $16,631-$21,429 for hospitalized cases; $2,462-$2,685 for ED cases; and $424-$473 for other ambulatory cases. Corresponding ranges for all-cause OM were $14,599-$16,341; $1,190-$2,083; and $253-$514. Children with (vs. without) comorbidities had higher mean costs of PNE episodes across all ages and care settings; mean cost of all-cause OM was largely invariant by comorbidity profile and was highest for episodes involving TTP.

CONCLUSIONS

Costs of IPD, all-cause PNE, and all-cause OM are high, particularly in the hospital setting. All-cause PNE, one of the most common causes of hospitalization for children, is particularly costly for children with comorbidities.

Short-term and Long-term Mortality Following Hospitalized and Ambulatory Lower Respiratory Tract Illnesses Among US Adults

Background

Lower respiratory tract illness (LRTI) is a significant cause of morbidity among adults, particularly older adults and adults with underlying medical conditions. Evidence on short- and long-term risks of mortality among adults requiring hospitalization or ambulatory care for LRTI, overall and within subgroups, is currently lacking.

Methods

A retrospective observational matched-cohort design and Optum's de-identified Clinformatics Data Mart Database (2012-2019) were used. The study population included adults who were hospitalized or received ambulatory care for LRTI and matched (1:1) comparison patients. All-cause mortality was ascertained during the 30-, 60-, 90-, 180-, and 360-day periods following the beginning of the LRTI episode. Risks of mortality were estimated for all LRTI patients and comparison patients as well as within age/comorbidity-specific subgroups.

Results

Among LRTI-hospitalized patients (n = 60.2K), 30-day mortality risk was 5.8% and 360-day risk was 18.3%, 7.5 and 2.6 times higher than corresponding values for comparison patients. Among LRTI-ambulatory patients (n = 2.4M), 30-day mortality risk was 1.2% and 360-day risk was 3.6%, 6.5 and 2.1 times higher than comparison patients. Among both LRTI-hospitalized and LRTI-ambulatory patients, mortality risk increased with increasing age and was higher for adults with chronic or immunocompromising conditions (vs without medical conditions).

Conclusions

Short- and long-term mortality were higher among patients who were hospitalized or received ambulatory care for LRTI vs matched comparison patients, and risks increased markedly with increasing age and worsening comorbidity profile. Strategies for preventing LRTI, especially among persons at elevated risk, may reduce premature deaths and yield important public health benefits.

Model-based cost-impact analysis of a diagnostic test for patients with community-acquired pneumonia in Canada

BACKGROUND

Antibiotics are broadly prescribed for community-acquired pneumonia (CAP) despite being only effective for bacterial infections. LIAISON® MeMed BV® (LMMBV) is a novel diagnostic test that can support clinicians in differentiating bacterial from viral infections and guide diagnostic-driven antibiotic prescribing.

METHODS

We developed a cost-impact model to compare the clinical and economic outcomes of using LMMBV with the current standard of care (SOC) versus SOC alone among a hypothetical cohort of 1,000 CAP patients presenting to the emergency department. The analysis was conducted from a Canadian public health payer's perspective. Outcomes of interest included antibiotic use (number of patients and days saved), hospital admission (admissions avoided and days saved), intensive care unit admission, adverse events, and clostridium difficile infection. One-way sensitivity analyses were conducted to explore parameter uncertainty. Scenario analyses were conducted according to age group, province, and impact of LMMBV on hospitalization.

RESULTS

In the base case, LMMBV plus SOC reduced the number of patients prescribed antibiotic treatment (429 patients avoided) and the total number of antibiotic treatment days (1,020 days avoided). The per-patient cost savings were $504.96 compared to SOC alone. These findings were consistent across all sensitivity and scenario analyses. Assuming full adoption of LMMBV, the per patient cost savings are projected to result in more than $163 million in total savings annually in Canada based on population estimates and published incidence data.

CONCLUSION

Considering the burden of CAP and antimicrobial resistance to the health care system, the use of LMMBV with SOC can offer both clinical and economic benefits to Canadian public payers.

Vaccination in Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD) is often exacerbated by various viruses and bacteria, leading to acute episodes of worsening respiratory symptoms, which contribute significantly to the morbidity and mortality associated with COPD. Consequently, vaccination against these pathogens is recommended by numerous guidelines to safeguard COPD patients from adverse health outcomes. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommendation advocates for vaccination against influenza, Streptococcus pneumoniae, respiratory syncytial virus (RSV), severe acute respiratory syndrome coronavirus (SARS-CoV2), pertussis, and varicella zoster. This review article will examine the current vaccination strategies recommended for adult COPD patients and will discuss the clinical benefits associated with these vaccines.

Adult vaccinations against respiratory infections

INTRODUCTION

Lower respiratory infections have a huge impact on global health, especially in older individuals, immunocompromised people, and those with chronic comorbidities. The COVID-19 pandemic highlights the importance of vaccination. However, there are lower rates of vaccination in the adult population that are commonly due to a missed opportunity to vaccinate. Vaccination offers the best strategy to prevent hospitalization, complications, and death caused by lower respiratory infections.

AREAS COVERED

In this review, the authors provide an overview of the vaccines for lower respiratory infections in the adult population. The review highlights the available data about the impact of vaccines on preventing respiratory infections, focusing on the pneumococcal vaccine, influenza vaccine, COVID-19 vaccines, and respiratory syncytial virus (RSV) vaccines. The authors discuss the currently available scientific evidence on the role of vaccines against respiratory infections. Finally, the authors review the current recommendations for vaccines in the adult population.

EXPERT OPINION

Scientific evidence on the effectiveness of vaccines against respiratory infections is important. An efficient implementation of adult immunization strategies will provide an opportunity to decrease the global burden of lower respiratory infections. Recognizing the existing vaccines and their recommendations for the adult population is essential to achieve a high vaccination rate in the population.

Association of Low Muscle Strength With Incident Pneumonia in Older Patients With Heart Failure

BACKGROUND

Patients with heart failure (HF) are at an increased risk of developing pneumonia, leading to a high mortality. A decrease in muscle strength due to aging or concomitant disease may contribute to the development of pneumonia in older adults. We sought to investigate the relationship between low muscle strength and pneumonia incidence in older patients hospitalized for worsening HF.

METHODS

We carried out a subanalysis of the FRAGILE-HF, a prospective multicenter observational study, including 1 266 consecutive older (≥65 years) patients hospitalized with HF (mean age 80.2 ± 7.8 years; 57.4% male; left ventricular ejection fraction 46% ± 17%) and information of incident pneumonia observed after discharge. Patients were followed up for 2 years post-discharge.

RESULTS

A total of 88 patients (7.0%) developed pneumonia after discharge, with an incidence of 42.7 per 1 000 person-years. A total of 893 patients with low muscle strength, defined as handgrip strength <28 kg for men and <18 kg for women according to international criteria, were more likely to develop pneumonia than those with normal muscle strength (p < .001; log-rank test). Low muscle strength was a significant predictor of incident pneumonia (adjusted hazard ratio with 95% confidence interval: 2.65 [1.31-5.35], p = .007). Furthermore, the mortality rates were 43.2% in patients who developed pneumonia and 19.3% in those who did not, indicating a heightened risk of death following the onset of pneumonia (adjusted hazard ratio: 4.25 [2.91-6.19], p < .001).

CONCLUSIONS

In older patients hospitalized for HF, low muscle strength was associated with incident pneumonia after discharge.

[Current and new vaccines against pneumococci]

Pneumococcal vaccination plays a crucial role in the prevention of bacterial respiratory infections caused by Streptococcus pneumoniae. Pneumococci are responsible for diseases such as pneumonia, sinusitis and acute otitis media and can cause serious invasive infections such as meningitis and bacteraemia. Pneumococcal pneumonia leads to increased morbidity and mortality, particularly in patients with chronic lung diseases such as chronic obstructive pulmonary disease (COPD). The introduction of 13-valent conjugate vaccines (pneumococcal conjugate vaccine 13 [PCV13]) has significantly reduced the burden of disease. However, infections caused by serotypes not covered by PCV13 continue to occur. Current vaccines such as the 20-valent conjugate vaccine (PCV20) provide extended serotype coverage and have shown a robust immune response in clinical trials. The recently updated recommendations of the German Standing Committee on Vaccination (Ständige Impfkommission, STIKO) include the use of PCV20 for all indication categories in adults, which represents a simplified and more effective vaccination strategy. Future developments include vaccines with even broader serotype coverage and improved immunological properties; these are expected to further reduce the burden of pneumococcal disease. Improving vaccination uptake and increasing vaccination rates, particularly among at-risk groups, remain key objectives to protect public health in the long term.

Coverage of influenza, pneumococcal and zoster vaccination and determinants of influenza and pneumococcal vaccination among adults with cardiovascular diseases in community

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of death and illness globally. Influenza, pneumococcal disease and herpes zoster infection may trigger acute cardiovascular events or cause complications among cardiac patients. Vaccination is recommended for adults with CVD. There is a gap in research evidence around determinants and uptake of influenza, pneumococcal and zoster vaccines in adults with CVD.

OBJECTIVE

The aim of this study is to examine the rate of the uptake of influenza, zoster and pneumococcal vaccines, factors associated with the uptake of influenza vaccine, and the perceptions of influenza and pneumococcal vaccination among people with CVD in the community.

METHOD

Cross-sectional survey data was analysed from three separate surveys carried out in Australia between October 2019 and September 2020 of 972 adults with CVD. We used descriptive statistics to describe data. Thematic analysis examined the reasons for taking influenza vaccine. Multivariable analysis was used to identify independent predictors of the influenza vaccine uptake and perceptions associated with the uptake of influenza and pneumococcal vaccines.

RESULTS

Out of 972 participants, a total of 661 (68 %) people said they had received influenza vaccine in the last 12 months; 361 (37 %) had ever received pneumococcal vaccine; 196 (20 %) had ever received zoster vaccine. Among 661 participants who said they received influenza vaccine within the 12 months prior to the study, 543 (82 %) participants received it from doctors or general practitioners (GPs) offices. Age 65 and older, being born in Australia, being employed or retired and having comorbidity were positive predictors of influenza vaccination. Doctors' recommendations to take the vaccine and awareness of free vaccines positively predicted influenza and pneumococcal vaccine uptake.

CONCLUSION

The uptake of recommended pneumococcal and zoster vaccines is low in people with CVD. Doctors' recommendations, targeted health promotion programs in general practice, and easy access to vaccination may optimise vaccination uptake in patients with CVD.

Diagnostic Discordance, Uncertainty, and Treatment Ambiguity in Community-Acquired Pneumonia : A National Cohort Study of 115 U.S. Veterans Affairs Hospitals

BACKGROUND

Evidence-based practice in community-acquired pneumonia often assumes an accurate initial diagnosis.

OBJECTIVE

To examine the evolution of pneumonia diagnoses among patients hospitalized from the emergency department (ED).

DESIGN

Retrospective nationwide cohort.

SETTING

118 U.S. Veterans Affairs medical centers.

PATIENTS

Aged 18 years or older and hospitalized from the ED between 1 January 2015 and 31 January 2022.

MEASUREMENTS

Discordances between initial pneumonia diagnosis, discharge diagnosis, and radiographic diagnosis identified by natural language processing of clinician text, diagnostic coding, and antimicrobial treatment. Expressions of uncertainty in clinical notes, patient illness severity, treatments, and outcomes were compared.

RESULTS

Among 2 383 899 hospitalizations, 13.3% received an initial or discharge diagnosis and treatment of pneumonia: 9.1% received an initial diagnosis and 10.0% received a discharge diagnosis. Discordances between initial and discharge occurred in 57%. Among patients discharged with a pneumonia diagnosis and positive initial chest image, 33% lacked an initial diagnosis. Among patients diagnosed initially, 36% lacked a discharge diagnosis and 21% lacked positive initial chest imaging. Uncertainty was frequently expressed in clinical notes (58% in ED; 48% at discharge); 27% received diuretics, 36% received corticosteroids, and 10% received antibiotics, corticosteroids, and diuretics within 24 hours. Patients with discordant diagnoses had greater uncertainty and received more additional treatments, but only patients lacking an initial pneumonia diagnosis had higher 30-day mortality than concordant patients (14.4% [95% CI, 14.1% to 14.7%] vs. 10.6% [CI, 10.4% to 10.7%]). Patients with diagnostic discordance were more likely to present to high-complexity facilities with high ED patient load and inpatient census.

LIMITATION

Retrospective analysis; did not examine causal relationships.

CONCLUSION

More than half of all patients hospitalized and treated for pneumonia had discordant diagnoses from initial presentation to discharge. Treatments for other diagnoses and expressions of uncertainty were common. These findings highlight the need to recognize diagnostic uncertainty and treatment ambiguity in research and practice of pneumonia-related care.

PRIMARY FUNDING SOURCE

The Gordon and Betty Moore Foundation.

Expert panel opinion on adult pneumococcal vaccination in the post-COVID era (NAP- EXPO Recommendations-2024)

INTRODUCTION

Pneumococcal diseases pose a significant public health concern in India, with substantial morbidity and mortality, with the elderly and those with coexisting medical conditions being most at risk. Pneumococcus was also seen to be one of the main reasons for co-infection, pneumonia and complications in COVID. Current guidelines recommend vaccination for specific adult populations, but there is a lack of uniformity and guidance on risk stratification, prioritisation and optimal timing.

METHODS

Nation Against Pneumococcal Infections - Expert Panel Opinion (NAP-EXPO) is a panel convened to review and update recommendations for adult pneumococcal vaccination in India. The panel of 23 experts from various medical specialties engaged in discussions and evidence-based reviews, discussed appropriate age for vaccination, risk stratification for COPD and asthma patients, vaccination strategies for post-COVID patients, smokers and diabetics, as well as methods to improve vaccine awareness and uptake.

OUTCOME

The NAP-EXPO recommends the following for adults: All healthy individuals 60 years of age and above should receive the pneumococcal vaccine; all COPD patients, regardless of severity, high-risk asthma patients, post-COVID cases with lung fibrosis or significant lung damage, should be vaccinated with the pneumococcal vaccine; all current smokers and passive smokers should be educated and offered the pneumococcal vaccine, regardless of their age or health condition; all diabetic individuals should receive the pneumococcal vaccine, irrespective of their diabetes control. Strategies to improve vaccine awareness and uptake should involve general practitioners (GPs), primary health physicians (PHPs) and physicians treating patients at high risk of pneumococcal disease. Advocacy campaigns should involve media, including social media platforms.

CONCLUSION

These recommendations aim to enhance pneumococcal vaccination coverage among high-risk populations in India in order to ensure a reduction in the burden of pneumococcal diseases, in the post-COVID era. There is a need to create more evidence and data to support the recommendations that the vaccine will be useful to a wider range of populations, as suggested in our consensus.

Cost-effectiveness analysis of adult pneumococcal conjugate vaccines for pneumococcal disease in Japan

BACKGROUND

The 23-valent pneumococcal polysaccharide vaccine (PPSV23) is used in the Japanese National Immunization Program for older adults and adults with increased risk for pneumococcal disease, however, disease incidence and associated burden remain high. We evaluated the cost-effectiveness of pneumococcal conjugate vaccines (PCVs) for adults aged 65 years and high-risk adults aged 60-64 years in Japan.

RESEARCH DESIGN AND METHODS

Using a Markov model, we evaluated lifetime costs using societal and healthcare payer perspectives and estimated quality-adjusted life-years (QALYs), and number of prevented cases and deaths caused by invasive pneumococcal disease (IPD) and non-IPD. The base case analysis used a societal perspective.

RESULTS

In comparison with PPSV23, the 20-valent PCV (PCV20) prevented 127 IPD cases 10,813 non-IPD cases (inpatients: 2,461, outpatients: 8,352) and 226 deaths, and gained more QALYs (+0.0015 per person) with less cost (-JPY22,513 per person). All sensitivity and scenario analyses including a payer perspective analysis indicated that the incremental cost-effectiveness ratios (ICERs) were below the cost-effectiveness threshold value in Japan (JPY5 million/QALY).

CONCLUSIONS

PCV20 is both cost saving and more effective than PPSV23 for adults aged 65 years and high-risk adults aged 60-64 years in Japan.

Pneumonia is not just pneumonia: Differences in utilization and costs with common comorbidities

We sought to explore the heterogeneity among patients hospitalized with pneumonia, a condition targeted in payment reform. In a retrospective cohort study of Medicare beneficiaries hospitalized for pneumonia, we compared postacute care utilization and costs of 90-day episodes of care among patients with and without comorbidities of chronic obstructive pulmonary disease (COPD) and/or heart failure. Of the 1,926,674 discharges, 28.1% had COPD, 14.3% had heart failure, and 14.6% carried both diagnoses. Patients with pneumonia were more likely to be discharged to a facility than those with pneumonia and COPD with or without heart failure, though less likely than those with pneumonia and heart failure only. Compared to patients with pneumonia only, patients with COPD and/or heart failure had higher episode payments. Acute conditions such as pneumonia may hold promise for episode-based care payment reform; however, the heterogeneity within this diagnosis indicates the need to consider other patient characteristics in interventions to improve value-based care.

The role of vaccination in COPD: influenza, SARS-CoV-2, pneumococcus, pertussis, RSV and varicella zoster virus

Exacerbations of COPD are associated with worsening of the airflow obstruction, hospitalisation, reduced quality of life, disease progression and death. At least 70% of COPD exacerbations are infectious in origin, with respiratory viruses identified in approximately 30% of cases. Despite long-standing recommendations to vaccinate patients with COPD, vaccination rates remain suboptimal in this population.Streptococcus pneumoniae is one of the leading morbidity and mortality causes of lower respiratory tract infections. The Food and Drug Administration recently approved pneumococcal conjugate vaccines that showed strong immunogenicity against all 20 included serotypes. Influenza is the second most common virus linked to severe acute exacerbations of COPD. The variable vaccine efficacy across virus subtypes and the impaired immune response are significant drawbacks in the influenza vaccination strategy. High-dose and adjuvant vaccines are new approaches to tackle these problems. Respiratory syncytial virus is another virus known to cause acute exacerbations of COPD. The vaccine candidate RSVPreF3 is the first authorised for the prevention of RSV in adults ≥60 years and might help to reduce acute exacerbations of COPD. The 2023 Global Initiative for Chronic Lung Disease report recommends zoster vaccination to protect against shingles for people with COPD over 50 years.

Acute organ injury and long-term sequelae of severe pneumococcal infections

Streptococcus pneumoniae (Spn) is a major public health problem, as it is a main cause of otitis media, community-acquired pneumonia, bacteremia, sepsis, and meningitis. Acute episodes of pneumococcal disease have been demonstrated to cause organ damage with lingering negative consequences. Cytotoxic products released by the bacterium, biomechanical and physiological stress resulting from infection, and the corresponding inflammatory response together contribute to organ damage accrued during infection. The collective result of this damage can be acutely life-threatening, but among survivors, it also contributes to the long-lasting sequelae of pneumococcal disease. These include the development of new morbidities or exacerbation of pre-existing conditions such as COPD, heart disease, and neurological impairments. Currently, pneumonia is ranked as the 9^th leading cause of death, but this estimate only considers short-term mortality and likely underestimates the true long-term impact of disease. Herein, we review the data that indicates damage incurred during acute pneumococcal infection can result in long-term sequelae which reduces quality of life and life expectancy among pneumococcal disease survivors.

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.

Burden of pneumococcal disease due to serotypes covered by the 13-valent and new higher-valent pneumococcal conjugate vaccines in the United States

The addition of pneumococcal conjugate vaccines (PCVs) to the United States (US) national immunization program led to significant reductions in incidence, mortality, and associated sequelae caused by pneumococcal disease (PD) in children and adults through direct and indirect protection. However, there remains clinical and economic burden due to PD caused by serotypes not included in the current 13-valent PCV (PCV13) formulation. To address this unmet need, 15-valent PCV (PCV15) and 20-valent PCV (PCV20), containing additional serotypes to PCV13, were recently approved in the US for adults and are anticipated for pediatrics in the near future. The study objective was to estimate the annual number of cases, deaths, and economic burden of PD due to serotypes included in PCV13, PCV15, and PCV20 for both US pediatric and adult populations. An Excel-based model was developed to calculate clinical and economic outcomes using published age-group specific serotype coverage; incidence of invasive PD, community-acquired pneumonia, and acute otitis media; case fatality rates; and disease-related costs. The results showed that across all age groups, the estimated annual PD cases and associated deaths covered by PCV13 serotypes were 914,199 and 4320, respectively. Compared with PCV13 serotypes, the additional 2 and 7 serotypes covered by PCV15 and PCV20 were attributed with 550,475 and 991,220 annual PD cases, as well as 1425 and 3226 annual deaths, respectively. This clinical burden translates into considerable economic costs ranging from $903 to $1,928 million USD that could be potentially addressed by PCV15 and PCV20. The additional serotypes included in PCV20 contribute substantially to the clinical and economic PD burden in the US pediatric and adult populations. Despite the success of the PCV13 pediatric national immunization program and increased adult uptake of PCV13 and 23-valent polysaccharide vaccine, broader PCV serotype coverage is needed across all ages to further reduce pneumococcal disease burden.

Vaccination and modern management of chronic obstructive pulmonary disease - a narrative review

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) carries a tremendous societal and individual burden, posing significant challenges for public health systems worldwide due to its high morbidity and mortality. Due to aging and multimorbidity but also in the wake of important progress in deciphering the heterogeneous disease endotypes, an individualized approach to the prevention and management of COPD is necessary.

AREAS COVERED

This article tackles relevant immunization strategies that are available or still under development with a focus on the latest evidence but also controversies around different regional immunization approaches. Further, we present the crossover between chronic lung inflammation and lung microbiome disturbance as well as its role in delineating COPD endotypes. Moreover, the article attempts to underline endotype-specific treatment approaches. Lastly, we highlight non-pharmacologic prevention and management programs in view of the challenges and opportunities of the COVID-19 era.

EXPERT OPINION

Despite the remaining challenges, personalized medicine has the potential to offer tailored approaches to prevention and therapy and promises to improve the care of patients living with COPD.

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.

Attributable Cost of Adult Hospitalized Pneumonia Beyond the Acute Phase

BACKGROUND

While much is known about the cost of community-acquired pneumonia (CAP) during the acute phase of illness, little is known about the potential attributable cost of CAP thereafter.

OBJECTIVE

The aim of this study was to assess long-term attributable costs associated with CAP among adults in US clinical practice.

METHODS

A retrospective matched cohort design and data from a US private healthcare claims repository were employed. In each month during the study period (2011-2016), adults who were hospitalized for CAP in that month ('CAP patients') were matched (1:1, without replacement) on demographic, clinical, and healthcare profiles to adults who did not develop CAP in that month ('comparison patients'). All-cause healthcare expenditures were tallied for the qualifying CAP hospitalization and during the 30-day period post-discharge (collectively, 'acute phase'), as well as from the end of the acute phase to the end of the 3-year follow-up period ('long-term phase').

RESULTS

The study population included 43,975 matched pairs of CAP patients and comparison patients. Expenditures averaged $33,380 (95% confidence interval [CI] $32,665-$34,161) for the CAP hospitalization and $4568 (95% CI $4385-$4749) during the 30-day period thereafter (vs. $2075 [95% CI $1989-$2167] in total for the comparison patients). During the long-term phase, all-cause expenditures averaged $83,463 (95% CI $81,318-$85,784) for CAP patients versus $51,017 (95% CI $49,553-$52,491) for comparison patients, and thus attributable expenditures during this phase totaled $32,446 (95% CI $29,847-$35,075). The majority of attributable CAP expenditures (53% of $68,319) occurred during the acute phase, while 21%, 14%, and 12% occurred during the first, second, and third years, respectively, after the acute phase.

CONCLUSIONS

Our findings provide additional evidence that the cost of CAP requiring hospitalization is high, and that the impact of CAP extends well beyond the expected time for resolution of acute inflammatory signs.

Mortality and readmission in the year following hospitalization for pneumonia among US adults

BACKGROUND

Increasing evidence suggests the impact of pneumonia persists beyond hospital discharge and the acute phase of respiratory symptoms. We characterized short-term and long-term risks of mortality and hospital readmission across the adult age span and spectrum of comorbidities.

METHODS

Retrospective cohort design and Optum's de-identified Integrated Claims-Clinical dataset (2012-2018) were employed. Study population comprised adults who had ≥1 pneumonia hospitalization; each hospitalization ≥365 days apart was considered. Cumulative risks of all-cause mortality (from pneumonia hospitalization through 360-day post-discharge period) and all-cause hospital readmission (during 360-day post-discharge period) were summarized on an overall basis as well as by age and comorbidity profile (i.e., healthy, at-risk, high-risk).

RESULTS

Study population totaled 37,006 patients who contributed 38,809 pneumonia hospitalizations; mean age was 71 years, 51% were female, and 88% had at-risk (33%) or high-risk (55%) conditions. Mortality was 3.5% in hospital, 8.2% from admission to 30 days post-discharge, and 17.7% from admission to 360 days post-discharge. Hospital readmission was 12.5% during the 30-day post-discharge period, and 42.3% during the 360-day post-discharge period. Mortality risk increased with age and severity of comorbidity profile; readmission risk was highest for persons aged 65-74 years and persons with high-risk conditions.

CONCLUSIONS

All-cause mortality up to 1 year following pneumonia hospitalization was substantial, and was associated with increasing age and worsening comorbidity profile. Both readmission and mortality were greater at all ages in at-risk and high-risk subgroups (vs. healthy counterparts). Strategies that prevent pneumonia and/or associated pathophysiologic changes, especially among individuals with comorbidities, have the potential to reduce morbidity and mortality.

The Prevalence of Anticholinergic Drugs and Correlation with Pneumonia in Elderly Patients: A Population-Based Study in Taiwan

Anticholinergic drugs may increase the risk of serious respiratory infection, especially in the elderly. The study aims to investigate the prevalence of anticholinergic drugs and the correlation of incident pneumonia associated with the use of anticholinergic drugs among the elderly in Taiwan. The study population was 275,005 elderly patients aged ≥65 years old, selected from the longitudinal health insurance database (LHID) in 2016. Among all the elderly patients, about 60% had received anticholinergic medication at least once. Furthermore, the study selected elderly patients who had not been diagnosed with pneumonia and had not received any anticholinergic drugs in the past year in order to evaluate the correlation between pneumonia and anticholinergic drugs. The study excluded elderly patients who died or had received related drugs of incident pneumonia during the study period and selected elderly patients receiving anticholinergic drugs as the case group. Propensity score matching (PSM) on a 1:1 scale was used to match elderly patients that were not receiving any anticholinergic drugs as the control group, resulting in a final sample of 32,215 patients receiving anticholinergic drugs and 32,215 patients not receiving any anticholinergic drugs. Conditional logistic regression was used to estimate the association between anticholinergic drugs and pneumonia after controlling for potential confounders. Compared with patients not receiving anticholinergic drugs, the adjusted odds ratio of patients receiving anticholinergic drugs was 1.33 (95% confidence interval: 1.18 to 1.49). Anticholinergic medication is common among elderly patients in Taiwan. Elderly patients receiving anticholinergic drugs may increase their risk of incident pneumonia. The safety of anticholinergic drugs in the elderly should be of concern in Taiwan.

Impact of 13Valent Vaccine for Prevention of Pneumococcal Diseases in Children and Adults at Risk: Possible Scenarios in Campania Region

BACKGROUND

Pneumonias are the most frequent infectious diseases, characterized by a high prevalence especially among children and adults at risk. The socio-economic impact caused by Streptococcus pneumoniae is evaluated in terms of morbidity, death rate and hospitalizations.

OBJECTIVE

The aim of the study was to demonstrate the potential economic advantages by implementation of an active anti-pneumococcal 13-valent vaccine strategy in Campania region (Southern Italy) in two different categories of subjects, children (aged 0-12), and adults (aged 50- 79) at risk (hypertension, nephropathies, COPD and heart diseases).

METHODS

Vaccination costs were compared with costs necessary to treat avoidable diseases in the presence and absence of a vaccination program.

RESULTS

Offering anti-pneumococcal 13-valent vaccine to the paediatric population was quantified as saving one million euros for Italian national health service in two years. In addition, offering anti-pneumococcal vaccine to adults at risk would generate a return of around 29 million euros.

CONCLUSION

In both cases, offering anti-pneumococcal 13-valent vaccine was proven to be a helpful political health strategy, not only in consideration of a reduction of cases but also in view of the favourable economic impacts.

The 1-year economic burden of community-acquired pneumonia (CAP) initially managed in the outpatient setting in the USA

Aim: To assess the annual economic burden of community-acquired pneumonia (CAP) initially managed in the outpatient setting. Patients & methods: Patients with an outpatient diagnosis of CAP between January 2012 and December 2016 were identified from the IQVIA (Danbury, CT & Durham, NC, USA) Real-World Data Adjudicated Claims – US Database. All-cause and CAP-related healthcare resource utilization and costs were assessed over the 1-year follow-up. Generalized linear model examined adjusted total cost. Results: Among 256,916 patients with outpatient CAP, a tenth (10.6%) had ≥1 hospitalization and, of these, 18.7% had ≥1 CAP-related hospitalization. The mean total cost per patient was US$14,372; 10.9% was CAP-related and 26.1% was due to inpatient care. The adjusted mean total all-cause cost was US$13,788. Conclusion: Patients with outpatient CAP incurred a substantial annual economic burden.

Pneumonia in young adults with asthma: impact on subsequent asthma exacerbations

Background: Recent studies of community-acquired pneumonia (CAP) have recognized acute cardiac complications-such as myocardial infarction, arrhythmia, or congestive heart failure (CHF)-as frequent complications during the acute process. As well, a prolonged vulnerability to exacerbations of underlying comorbidities-such as CHF and COPD-has been observed following CAP. We hypothesized that young adults with underlying asthma could also be adversely impacted over a prolonged time period following CAP.Methods: Using a retrospective matched-cohort design and data from a US private healthcare claims repository (>15 M persons annually), we selected all adults 18-49 years of age with evidence of asthma as their only comorbidity for inclusion in the source population. Then, from the source population, we matched one comparison patient to each CAP patient based on index date, age, sex, and selected markers for health status (eg, history of asthma-related healthcare encounters), and evaluated subsequent outpatient and inpatient encounters for asthma exacerbations.Results: Asthma exacerbations were identified twice as often in the 12 months subsequent to acute CAP. Cumulative incidence proportions for asthma exacerbations requiring hospitalization or emergency department care after 12 months of follow-up were 19.9% for those previously hospitalized with CAP versus 9.0% for matched comparison patients (difference, 10.9%; p<0.001), and were 12.4% for non-hospitalized CAP patients versus 7.7% for matched counterparts (difference, 4.7%; p<0.001).Conclusion: Our analysis provides further evidence that acute CAP has a prolonged impact on respiratory health.

Patient-Reported Consequences of Community-Acquired Pneumonia in Patients with Chronic Obstructive Pulmonary Disease

Community acquired pneumonia (CAP) carries high morbidity, mortality, and economic burden, which is even higher in adults diagnosed with chronic obstructive pulmonary disease (COPD). While several studies have assessed the clinical burden and mortality risk of CAP and COPD, very few studies focus on CAP burden from a COPD patient perspective. Individuals recently diagnosed with CAP and with pre-existing COPD were recruited through the COPD Foundation. The CAP Burden of Illness Questionnaire (CAP-BIQ), a content validated questionnaire assessing CAP symptomatology, duration of symptoms and CAP impact on work, activities and family, was administered at baseline and at 30-days follow-up. Of the 490 participants recruited, 481 had data sufficient for analysis. The prevalence of respiratory-related symptoms was very high (>90%) at the time of diagnosis with other generalized symptoms such as fatigue, trouble sleeping, headaches and confusion present in more than 60% of participants. Mean duration of symptoms varied from approximately 2 weeks for headaches and fever to more than a month for fatigue, wheezing, dyspnea, and cough. Employed participants missed an average of 21 days of work and those not employed missed 36 days of usual activities. Over 84% required help from family, friends or care givers. CAP is a serious and burdensome condition for people with COPD, a condition that can impair activities for weeks, frequently requires care from family or friends, and includes lingering symptoms. The patient-reported impact of CAP reported in this study underscores the need for prevention strategies in this population.

Effect of combination of pre- and postoperative pulmonary rehabilitation on onset of postoperative pneumonia: a retrospective cohort study based on data from the diagnosis procedure combination database in Japan

BACKGROUND

To examine the effect of rehabilitation on postoperative pulmonary complication when it is conducted in combination of both before and after lung cancer surgery, as compared with either before or after surgery and no rehabilitation.

METHODS

A retrospective cohort study was conducted to examine the effect of rehabilitation before and after lung cancer surgery on the causes of postoperative pneumonia. Data were collected from the diagnosis procedure combination (DPC) database. Patients admitted who received operative treatment for a new primary (ICD codes: C34) were selected. The inclusion criteria were patients who had pneumonectomy, malignant tumor surgery for the lung (thoracotomy), or thoracoscopic surgery (endoscopic; treatment code: K511-00, K513-00~03, and K514-00, 02). The exclusion criteria were patients who had a lung transplantation (treatment code: K514-03~06), suspected diagnosis, and a pneumonia within 3 months before being diagnosed as having lung cancer. Main outcome was onset of postoperative pneumonia.

RESULTS

Among 76,739 lung cancer patients, 15,146 who underwent lung cancer surgery were included in the analysis. In the combination of pre- and postoperative group, as compared with the preoperative [odds ratio (OR), 95% confidence interval (CI) 2.8, 1.8-4.4], postoperative (1.9, 1.6-2.3), and no rehabilitation group (2.5, 2.1-2.8), the onset of pneumonia was less frequent.

CONCLUSIONS

Combination of preoperative and postoperative rehabilitations significantly prevents postoperative pneumonia as compared with having preoperative, postoperative, or no rehabilitation.

Dynamic transmission modelling to address infant pneumococcal conjugate vaccine schedule modifications in the UK

The 13-valent pneumococcal conjugate vaccine (PCV) has been part of routine immunisation in a 2 + 1 schedule (two primary infant doses and one booster during the second year of life) in the UK since 2010. Recently, the UK's Joint Committee on Vaccination and Immunisation recommended changing to a 1 + 1 schedule while conceding that this will increase disease burden; however, uncertainty remains on how much pneumococcal burden – including invasive pneumococcal disease (IPD) and non-invasive disease – will increase. We built a dynamic transmission model to investigate this question. The model predicted that a 1 + 1 schedule would incur 8777–27 807 additional cases of disease and 241–743 more deaths over 5 years. Serotype 19A caused 55–71% of incremental IPD cases. Scenario analyses showed that booster dose adherence, effectiveness against carriage and waning in a 1 + 1 schedule had the most influence on resurgence of disease. Based on the model assumptions, switching to a 1 + 1 schedule will substantially increase disease burden. The results likely are conservative since they are based on relatively low vaccine-type pneumococcal transmission, a paradigm that has been called into question by data demonstrating an increase of IPD due to several vaccine serotypes during the last surveillance year available.