Incidence, risk factors, and viral etiology of community-acquired acute lower respiratory tract infection among older adults in rural north India

P. G, Potdar V, Manna B, Amarchand R, Choudekar A, Gopal G, Sarda K, Lafond KE, Azziz-Baumgartner E, Saha S, Dar L, Krishnan A. Adverse outcomes in patients hospitalized with pneumonia at age 60 or more: A prospective multi-centric hospital-based study in India

BACKGROUND

Limited data exists regarding risk factors for adverse outcomes in older adults hospitalized with Community-Acquired Pneumonia (CAP) in low- and middle-income countries such as India. This multisite study aimed to assess outcomes and associated risk factors among adults aged ≥60 years hospitalized with pneumonia.

METHODS

Between December 2018 and March 2020, we enrolled ≥60-year-old adults admitted within 48 hours for CAP treatment across 16 public and private facilities in four sites. Clinical data and nasal/oropharyngeal specimens were collected by trained nurses and tested for influenza, respiratory syncytial virus (RSV), and other respiratory viruses (ORV) using the qPCR. Participants were evaluated regularly until discharge, as well as on the 7th and 30th days post-discharge. Outcomes included ICU admission and in-hospital or 30-day post-discharge mortality. A hierarchical framework for multivariable logistic regression and Cox proportional hazard models identified risk factors (e.g., demographics, clinical features, etiologic agents) associated with critical care or death.

FINDINGS

Of 1,090 CAP patients, the median age was 69 years; 38.4% were female. Influenza viruses were detected in 12.3%, RSV in 2.2%, and ORV in 6.3% of participants. Critical care was required for 39.4%, with 9.9% in-hospital mortality and 5% 30-day post-discharge mortality. Only 41% of influenza CAP patients received antiviral treatment. Admission factors independently associated with ICU admission included respiratory rate >30/min, blood urea nitrogen>19mg/dl, altered sensorium, anemia, oxygen saturation <90%, prior cardiovascular diseases, chronic respiratory diseases, and private hospital admission. Diabetes, anemia, low oxygen saturation at admission, ICU admission, and mechanical ventilation were associated with 30-day mortality.

CONCLUSION

High ICU admission and 30-day mortality rates were observed among older adults with pneumonia, with a significant proportion linked to influenza and RSV infections. Comprehensive guidelines for CAP prevention and management in older adults are needed, especially with the co-circulation of SARS-CoV-2.

Rates of Lower Respiratory Tract Illness in US Adults by Age and Comorbidity Profile

INTRODUCTION

While it is widely recognized that older adults, adults with chronic medical conditions (CMC), and adults with immunocompromising conditions (IC) are at increased risk of lower respiratory tract illness (LRTI), evidence of the magnitude of increased risk is limited. This study was thus undertaken to characterize rates of hospitalized and ambulatory LRTI among United States (US) adults by age and comorbidity profile.

METHODS

A retrospective cohort design and US healthcare claims database (2016-2019) were employed. Study population included adults aged ≥ 18 years and was stratified by age and comorbidity profile (CMC-, CMC+ , IC). LRTI was ascertained overall and by pathogen pathogen (e.g., respiratory syncytial virus [RSV]), and was classified by care setting (hospital, emergency department [ED], physician office/hospital outpatient [PO/HO]).

RESULTS

Relative rates (RR) of LRTI generally increased with older age across care settings (vs. 18-49 years), with the most marked increase for hospitalizations: for LRTI-hospitalized, RRs ranged from 3.3 for 50-64 years to 46.6 for ≥ 85 years; for LRTI-ED and LRTI-PO/HO, RRs ranged from 1.0 to 2.7 and from 1.3 to 1.5, respectively. Within age groups, LRTI rates were also consistently higher among CMC+ and IC adults (vs. CMC- adults). Age-specific RRs of LRTI patients hospitalized due to RSV were largely comparable to overall LRTI; age-specific RRs for other care settings, and RRs for CMC+ and IC adults (vs. CMC- adults), were generally higher for LRTI due to RSV.

CONCLUSIONS

Incidence of LRTI, including that due to RSV, especially for events requiring acute inpatient care, is markedly higher among older adults and adults of all ages with CMC or IC.

Economic burden of respiratory syncytial virus infection in adults: a systematic literature review

AIMS

Capture the economic and healthcare resource utilization (HCRU) burden in older adults due to respiratory syncytial virus (RSV) infection.

METHODS

An electronic literature search of PubMed, Embase, the Cochrane Library, PsycINFO, and EconLit was conducted for studies of the cost and HCRU outcomes of RSV infection in adult patients, with no language or country restrictions. Search dates for primary studies were January 1, 2002-May 18, 2022. The methodological quality of included studies was assessed using a modification of the Critical Appraisal Skills Programme (CASP) checklist for economic studies and the Drummond checklist.

RESULTS

42 studies were identified that reported cost or HCRU data associated with RSV infections, with geographic locations across North America, South America, Europe, Asia, and Oceania. Generally, hospitalization costs were highest in the United States (US). Driving factors of increased cost included older age, comorbidities, and length of stay. US studies found that the national direct cost burden of RSV hospitalizations was $1.3 billion for all adults and $1.5-$4.0 billion for adults aged ≥60 years (estimates for other countries were not identified). Studies estimating incremental costs for RSV cases versus controls and costs pre- and post-RSV infection demonstrated higher costs for RSV cases. Hospitalizations accounted for the majority of total costs.

Multisite surveillance for influenza and other respiratory viruses in India: 2016-2018

There is limited surveillance and laboratory capacity for non-influenza respiratory viruses in India. We leveraged the influenza sentinel surveillance of India to detect other respiratory viruses among patients with acute respiratory infection. Six centers representing different geographic areas of India weekly enrolled a convenience sample of 5-10 patients with acute respiratory infection (ARI) and severe acute respiratory infection (SARI) between September 2016-December 2018. Staff collected nasal and throat specimens in viral transport medium and tested for influenza virus, respiratory syncytial virus (RSV), parainfluenza virus (PIV), human meta-pneumovirus (HMPV), adenovirus (AdV) and human rhinovirus (HRV) by reverse transcription polymerase chain reaction (RT-PCR). Phylogenetic analysis of influenza and RSV was done. We enrolled 16,338 including 8,947 ARI and 7,391 SARI cases during the study period. Median age was 14.6 years (IQR:4-32) in ARI cases and 13 years (IQR:1.3-55) in SARI cases. We detected respiratory viruses in 33.3% (2,981) of ARI and 33.4% (2,468) of SARI cases. Multiple viruses were co-detected in 2.8% (458/16,338) specimens. Among ARI cases influenza (15.4%) were the most frequently detected viruses followed by HRV (6.2%), RSV (5%), HMPV (3.4%), PIV (3.3%) and AdV (3.1%),. Similarly among SARI cases, influenza (12.7%) were most frequently detected followed by RSV (8.2%), HRV (6.1%), PIV (4%), HMPV (2.6%) and AdV (2.1%). Our study demonstrated the feasibility of expanding influenza surveillance systems for surveillance of other respiratory viruses in India. Influenza was the most detected virus among ARI and SARI cases.

Respiratory Infections Prevention in Rural Older Adults: An Interventional Study

Respiratory tract infections are one of the major causes of morbidity and mortality in older adults. This quasi-experimental study aimed to evaluate the effect of an educational intervention on respiratory infections prevention (RIP) in rural older adults. The study sample composed of 80 older adults from a rural area, randomly assigned into two groups. The intervention group (n = 40) received ten 1-hour twice-weekly sessions and the control group (n = 40) received no intervention. Pre- and post-intervention assessments were done using measures of knowledge, attitudes, and practices regarding RIP. Chi-square test, Fisher's exact test, independent samples t-test, and paired t-test were used for data analysis. The study findings showed that the study intervention resulted in statistically significant improvements in the intervention group's knowledge, attitudes, and practices regarding RIP compared with the control group (p < .01). The educational intervention was effective and could be used to help rural older adults prevent respiratory infections.

Risk factors and medical resource utilization in US adults hospitalized with influenza or respiratory syncytial virus in the Hospitalized Acute Respiratory Tract Infection study

Background

Influenza and respiratory syncytial virus (RSV) are associated with substantial morbidity and mortality in the United States. We assessed risk factors for severe disease and medical resource utilization (MRU) among US adults hospitalized with influenza or RSV in the Hospitalized Acute Respiratory Tract Infection (HARTI) study.

Methods

HARTI was a prospective global (40 centers, 12 countries) epidemiological study of adults hospitalized with acute respiratory tract infections conducted across the 2017–2019 epidemic seasons. Patients with confirmed influenza or RSV were followed up to 3 months post‐discharge. Baseline characteristics, prevalence of core risk factors (CRFs) for severe disease (age ≥65 years, chronic heart or renal disease, chronic obstructive pulmonary disease, or asthma), and MRU were summarized descriptively.

Results

The US cohort included 280 influenza‐positive and 120 RSV‐positive patients. RSV patients were older (mean: 63.1 vs. 59.7 years) and a higher proportion had CRFs (87.5% vs. 81.4%). Among those with CRFs (influenza, n = 153; RSV, n = 99), RSV patients required longer hospitalizations (median length of stay: 4.5 days) and a greater proportion (79.8%) required oxygen supplementation during hospitalization compared with influenza patients (4.0 days and 59.5%, respectively). At 3 months post‐discharge, a greater proportion of RSV patients with CRFs reported use of antibiotics, antitussives, bronchodilators, and inhaled and systemic steroids versus those with influenza and CRFs. Many patients with CRFs reported hospital readmission at 3 months post‐discharge (RSV: 13.4%; influenza: 11.9%).

Conclusions

MRU during and post‐hospitalization due to RSV in adults is similar to or greater than that of influenza. Enhanced RSV surveillance and preventive and therapeutic interventions are needed.

Evaluating the Increased Burden of Cardiorespiratory Illness Visits to Adult Emergency Departments During Flu and Bronchiolitis Outbreaks in the Pediatric Population: Retrospective Multicentric Time Series Analysis

BACKGROUND

Cardiorespiratory decompensation (CRD) visits have a profound effect on adult emergency departments (EDs). Respiratory pathogens like respiratory syncytial virus (RSV) and influenza virus are common reasons for increased activity in pediatric EDs and are associated with CRD in the adult population. Given the seasonal aspects of such challenging pathology, it would be advantageous to predict their variations.

OBJECTIVE

The goal of this study was to evaluate the increased burden of CRD in adult EDs during flu and bronchiolitis outbreaks in the pediatric population.

METHODS

An ecological study was conducted, based on admissions to the adult ED of the Centre Hospitalier Universitaire (CHU) of Grenoble and Saint Etienne from June 29, 2015 to March 22, 2020. The outbreak periods for bronchiolitis and flu in the pediatric population were defined with a decision-making support tool, PREDAFLU, used in the pediatric ED. A Kruskal-Wallis variance analysis and a Spearman monotone dependency were performed in order to study the relationship between the number of adult ED admissions for the International Classification of Diseases (ICD)-10 codes related to cardiorespiratory diagnoses and the presence of an epidemic outbreak as defined with PREDAFLU.

RESULTS

The increase in visits to the adult ED for CRD and the bronchiolitis and flu outbreaks had a similar distribution pattern (CHU Saint Etienne: χ²₃=102.7, P<.001; CHU Grenoble: χ²₃=126.67, P<.001) and were quite dependent in both hospital settings (CHU Saint Etienne: Spearman ρ=0.64; CHU Grenoble: Spearman ρ=0.71). The increase in ED occupancy for these pathologies was also significantly related to the pediatric respiratory infection outbreaks. These 2 criteria gave an idea of the increased workload in the ED due to CRD during the bronchiolitis and flu outbreaks in the pediatric population.

CONCLUSIONS

This study established that CRD visits and bed occupancy for adult EDs were significantly increased during bronchiolitis and pediatric influenza outbreaks. Therefore, a prediction tool for these outbreaks such as PREDAFLU can be used to provide early warnings of increased activity in adult EDs for CRD visits.