Malaysian Healthy Ageing Society Adul dult t im immu muni nizat - PowerPoint PPT Presentation

Organised by: Co-Sponsored: Malaysian Healthy Ageing Society

Adul dult t im immu muni nizat atio ion: n: The e val alue ue of of preven enti tion on Dr Chris istoph pher er Lee ee Infectious ctious Diseases ases Uni Unit Depar artme tment nt of Medicine ine Hospi spita tal l Sungai ai Buloh

Microbial exposures & diseases throughout life Prenatal Neonatal < 5 years 5-18 Adult Elderly RSV HSV Measles-virus Rubella Influenza HBV Influenza HPV Mumps-virus CMV PIV HPV RSV HIV Rubella-Virus VZV AV HIV HAV HBV HPV RV C.diphtheriae H. influenzae b GBS S.pneumoniae N.meningitidis Mycoplasma Listeria Enterobacteria B.pertussis M.tuberculosis S.pneumoniae B. pertussis C.tetani B. pertussis Salmonella B. pertussis Toxoplasma Plasmodium Schmitt: Based on Mandell, Bennett Dolin 7th ed, 2010

Infectious pressure, colonization, immune response & burden of disease

Immunity: B cells and age

Guideline for Adults

Infections: a major concern in the elderly • Infectious diseases account for 1/3 of all deaths in people > 65 yrs . • Early detection more difficult in elderly because typical signs & symptoms, eg. fever and leukocytosis, are frequently absent. A change in mental status or decline in function may be only presenting problem. • An estimated 90% of deaths resulting from pneumonia occur in people > 65 yrs. • Mortality resulting from influenza also occurs primarily in the elderly. Mouton CP et al. American Family Physician, Jan 15, 2001 / VOL 63, No 2

LRTI (the majority of which includes CAP in adults) are a leading cause of death worldwide Leading Causes of Death, All Ages, 2004 8 7 6 Deaths (millions) 5 4 3 2 1 0 1 2 3 4 5 6 7 8 9 10 Rank LRTIs=lower respiratory tract infections WHO Global Burden of Disease Report, 2004 Update. http://www.who.int/healthinfo/global_burden_disease/GBD_report_2004update_full.pdf.

Pneumonia in Elderly • 3 rd common site of infection after UTI & pressure sores. • Mortality rate 30-50% • Risk factors: emphysema, chronic bronchitis, COPD • Pathogens:  Pneumococcus, most common bacterial cause  H. influenzae , other H.spp, S.aureus  Gram- bacilli (Enterobacteriaceae, Pseudomonas, K. pneumoniae) Legionella & other atypicals  Viruses esp. influenza • Transmission  Endogenous flora /aspiration: S. aureus , pneumococci  Droplet: eg influenza  L. pneumophila if aerosolized: air conditioning, cooling towers, showerheads

Strept pneumoniae The old bug that won’t go away …

Risk factors for pneumococcal disease Age 1 Underlying Medical Conditions 2-4 Living Conditions 3-5 • Childcare outside of the • Children <2 years • Congenital or acquired home ≥4 hours per immunodeficiency • Adults >65 years week, and in the • Sickle cell disease, asplenia, HIV presence of ≥2 other • Chronic heart, lung (including children other than asthma), renal, or liver disease siblings • Cancer • Residence in a nursing home or other long-term • Cerebrospinal fluid (CSF) leak care facility • Diabetes • Chronic alcoholism or cigarette smoking • Organ or hematopoietic cell transplantation • Cochlear implants Age is the most important risk factor for pneumococcal disease 1 CDC. Morb Mortal Wkly Rep. 1997;46(RR-8):1-24. WHO. Wkly Epidemiol Rec . 2008;83:373-384. CDC. Morb Mortal Wkly Rep. 2000;49(RR-9):1-35. CDC. Morb Mortal Wkly Rep. 2009;57(53):Q1-Q4. Levine OS et al. Pediatrics. 1999;103:1-5.

Incidence of IPD is used as a surrogate indicator • Pneumococcal disease can be classified as either invasive (IPD) or mucosal 1 o IPD is defined as any condition in which S. pneumoniae is present in the blood, cerebrospinal fluid, or another normally sterile body site 2 • IPD is less common than pneumococcal pneumonia; however, its microbiological diagnosis is unambiguous 2 • The incidence of IPD is therefore frequently used as an indicator of the overall burden of pneumococcal disease 2 1. World Health Organization (WHO). Acute Respiratory Infections (Update February 2009). http://www.who.int/vaccine_research/diseases/ari/en/print.html. Accessed May 27, 2009. 12 2. WHO. Wkly Epidemiol Rec . 2008;83:373-384.

Incidence is greatest at the extremes of age 20 IPD by Age (China, 18.8 Hong Kong, 1995-2004) 18 Rate/100,000 persons/year 16 14 12.8 12 10.2 10 8 6 4 2 1.0 0.5 1.2 0 ≥65 0-2 3-5 6-14 15-34 35-64 Age (years) Ho PL et al. Pediatr Infect Dis J . 2006;25:454-455.

More bacteremia in the young and more pneumonia in older adults Active Surveillance a of Manifestations of IPD by Age, Metropolitan New South Wales, 1997-2001 1200 Cases by Disease (Total No.) 1105 b 1000 Other focal Meningitis Pneumonia Bacteremia 800 617 600 482 376 400 319 200 100 0 ≥65 0-1 2-4 5-14 15-39 40-64 Age (years) a Active: specific activities to identify cases (eg, telephone calls) vs passive (review of routine reports from healthcare facilities). b Other focal diseases included cellulitis, arthritis, and epiglottitis. McIntyre P et al. NSW Public Health Bull . 2003;14:85-89.

Risk of invasive pneumococcal disease in elderly adults, by age group and chronic illness category. Blue bars, aged 65 – 79 years; red Plotkin S et al. Clin Infect Dis. 2008;47:1328-1338 bars, aged >80 years

Influenza: Virus of the Year 2009 !

Influenza-related Mortality in the U.S. • Between 1976 and 2006, estimates of flu-associated deaths range from a low of about 3,000 to a high of about 49,000 people. • During 2009-10, the novel 2009 Influenza A/ H1N1 spread worldwide causing the 1 st . flu pandemic in > 40 yrs. • It is estimated that the 2009 H1N1 pandemic resulted in more than 12,000 flu-related deaths in the U.S. In contrast to seasonal flu, nearly 90% of the deaths occurred among people younger than 65 yrs of age. CDC

Sever ere e Res espi pirator ory y Dis isea ease e Concurre rrent t wit ith the e Cir ircul ulation ation of Influen enza za Gerardo Chowell et al NEJM, No 7; Volume 361:674-679, 2009 % Distribution of Deaths from Severe Pneumonia during the 2009 Study Period, as Compared with Influenza Seasons from 2006 to 2008, in Mexico, According to Age Group.

Estimated Annual Influenza-associated Mortality Rates per 100,000 Person-yrs from 1990 to 1999 seasons Age Mortality Rate per 100,000 person-years Group Underlying Underlying resp. All-cause (years) Pneumonia & & circulatory deaths Influenza deaths deaths < 1 0.3 0.6 2.2 1-4 0.2 0.4 1.1 5-49 0.2 0.5 1.5 50-64 1.3 7.5 12.5 > 65 22.1 98.3 132.5 Total 3.1 13.8 19.6 Thompson WW, Shay DK, Weintraub E, et al. JAMA . 2003;289(2):176-186

Influenza in Tropics Influenza-associated mortality rate / 100,000 person-years Author Country All cause Underlying Underlying pneumonia & circulatory & influenza resp deaths deaths S’pore Chow et All ages: 14.8 All ages: 2.9 All ages: 11.9 al * > 65yrs: 167.8 > 65yrs: 46.9 > 65yrs: 155.4 Wong et Hong All ages: 16.4 All ages: 4.1 All ages: 12.4 al ** Kong > 65yrs: 136.1 > 65yrs: 39.3 > 65yrs: 102.0 * Chow et al. Emerging Infectious Diseases, Vol 12, No 1, Jan 2006. Pg. 114-121 ** Wong et al. Clinical Infectious Diseases 2004; 39: 1611-7

The Cost of Pneumonia!

Mortality from pneumonia, including CAP, starts to increase around age 45 years United Kingdom, Mortality Rate by Age Group, 2005 70 61.2 Female Male 60 Rate/100,000 population 50 40.6 40 30 18.6 20 12 6.6 2.7 5.2 1.1 3.9 4.2 10 0.3 0.1 0.5 1.5 0.7 0.2 0.4 1 0 <1 1-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 Age (years) The rates for age group 75+ years (609.9 for females and 570.9 for males) are not shown to facilitate examination of the trend in rates for younger age groups WHO Statistics. Mortality Database. http://apps.who.int/whosis/database/mort/table1_process.cfm. Accessed June 10, 2009.

Hospital treatment for pneumonia has a substantial economic impact Estimated Total Charges, United States 20 19,603 Diagnosis-related Group 89: Simple Pneumonia and Pleurisy, >17 years of age with CC 18,734 18 17,897 Average 16,435 16 length of 14,951 14 stay=5.0 days 13,241 Thousands of dollars 12 12,219 10,885 10 10,535 9,945 9,749 9,593 9,585 9,550 8 Average length of 6 stay=7.5 days 4 Estimated cost per day has increased 207% since 1993 2 0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 There has been an upward trend in total costs per pneumonia hospitalization, despite a downward trend in total inpatient days per hospitalization CC=cell culture Health Care Cost and Utilization Project Nationwide Inpatient Sample (NIS), Agency for Healthcare Research and Quality (AHRQ). Based on data collected, and provided to the AHRQ, by individual states. http://hcupnet.ahrq.gov/HCUPnet.jsp. Accessed June 10, 2009.