We reviewed retrospectively all invasive Haemophilus influenzae (Hi) infections in adults ascerta... more We reviewed retrospectively all invasive Haemophilus influenzae (Hi) infections in adults ascertained from reference laboratory records and notifications from five NHS regions over the 5 years from 1 October 1990, a period encompassing the introduction of routine Hib childhood immunization (October 1992). A total of 446 cases were identified, a rate of 0n73 infections per 10& adults per annum. Though numbers of Hib infections in adults fell after the introduction of Hib vaccines for children (P l 0n035), and there was no increase in infections caused by other capsulated Hi serotypes, total numbers of invasive Hi infections increased due to a large rise in infections caused by non-capsulated Hi (ncHi) strains (P l 0n0067). There was an unexpectedly low rate of infections in those aged 75 years or more (P 0n0001). The commonest clinical presentations were pneumonia with bacteraemia (227\350, 65 %) and bacteraemia alone (62\350, 18 %) and the highest rates of disease were in the 65-74 years age group (P 0n0001). Clinical presentation was not influenced by the capsulation status of the invading Hi strain. 103\350 cases (29 %) died within 1 month, and 207\350 (59 %) within 6 months of their Hi infection. Case fatality rates were high in all age groups. Pre-existing diseases were noted in 220\350 cases and were associated with a higher case fatality rate (82 % s. 21%, P 0n0001). After the introduction of Hib immunization in children, invasive Hib infections in unimmunized adults also declined, but the overall rate of invasive Hi disease in adults increased, with most infections now caused by non-capsulated strains. Physicians and microbiologists should be aware of the changing epidemiology, the high associated mortality and high risk of underlying disease. Invasive haemophilus infections in adults should be investigated and treated aggressively.
To describe the presentation, management, and outcome of 43 cases of pneumococcal-associated hemo... more To describe the presentation, management, and outcome of 43 cases of pneumococcal-associated hemolytic uremic syndrome (P-HUS). An increased incidence of P-HUS has been noted in the United Kingdom between January 1998 and May 2005. Cases with microangiopathic hemolytic anemia (Hb <10 g/dL with fragmented RBCs), thrombocytopenia (platelet count < 130 x 10(9)/L), acute renal impairment with oliguria and elevated plasma creatinine for age, confirmed or suspected pneumococcal infection and/or T-activation were included. The median age at presentation was 13 months (range, 5-39 months). Pneumococcus was identified in 34 of 43 cases; T-activation was identified in 36 of 37 cases. Twelve strains were serotyped: serotypes 3 (n = 2), 6A (n = 2), 12F (n = 1), 14 (n = 1), 19A (n = 6). Empyema was present in 23 of 35 pneumonia cases; 13 cases had confirmed (9) or suspected (4) pneumococcal meningitis; 36 cases required dialysis (median, 10 days; range, 2-240 days). The mortality rate was 11%, comprising 3 cases of meningitis, 1 case of sepsis and 1 case of pulmonary embolism at 8 months follow up while on dialysis. Follow-up data were available for 35 of 38 patients who survived (median follow-up period, 9 months; range, 1-63 months); of these, 10 patients had renal dysfunction, 1 patient was dialysis-dependent, 5 patients had hypertension and 8 patients had at least 1+ proteinuria on urinalysis. P-HUS has increased compared with historic surveys (0/288 in 1985-1988; 8/413 in 1997-2001, 43/315 in 1998-May 2005). Early mortality remains high (8-fold that of VTEC-induced HUS). Ten of 12 strains identified would not be covered by the PCV7 vaccine.
Background The clinical and economic costs of an episode of hospitalised pneumonia are usually as... more Background The clinical and economic costs of an episode of hospitalised pneumonia are usually assumed to be short-lived with patients subsequently returning to their previous health-state. We hypothesised that a diagnosis of hospitalised pneumonia in an individual within a specific risk group would have clinical and economic implications that would go beyond the initial episode. Aim Determine, within the NHS context, the clinical and financial burden of hospitalised pneumonia in 6 risk groups over a 4 year period utilising the Hospital Episodes Statistics (HES) database, which incorporates the entire population of England that visit a hospital. Method We retrospectively analysed HES data on individuals≥18 years. Those with a specified risk group diagnosis were tracked from 2012 to 2015. Individuals developing hospitalised pneumonia in the year following their risk group diagnosis were matched through propensity scoring to an individual within that risk group who did not go on to develop hospitalised pneumonia. Hospital activity, costs and mortality were compared between the two groups over the next 3 years. Results Table. No title available. Conclusion This study utilises an entire adult population to ascertain the impact of hospitalised pneumonia in patients with certain underlying comorbidities. Hospitalised pneumonia has a significant long term impact on those within specific risk groups, resulting in additional hospital admissions and associated costs, and the initial pneumonia episode appears to significantly increase the likelihood of mortality.
Background. The introduction of the Haemophilus influenzae serotype b (Hib) conjugate vaccine int... more Background. The introduction of the Haemophilus influenzae serotype b (Hib) conjugate vaccine into national immunization has led to rapid and sustained declines in invasive Hib disease incidence across all age groups. In industrialized countries with established Hib vaccination programs, however, little is known about individuals who develop invasive Hib disease. This study describes the epidemiology of invasive Hib disease in England and Wales during 2000-2012 and the clinical characteristics of laboratory-confirmed Hib cases diagnosed during 2009-2012. Methods. Public Health England (PHE) conducts enhanced national surveillance of invasive Hib disease in England and Wales. Detailed clinical information was obtained for all laboratory-confirmed Hib cases diagnosed during 2009-2012. Results. Invasive Hib disease in England and Wales has been declining since 2002, reaching its lowest incidence of 0.02 per 100 000 (14 cases) in 2012. In children aged <5 years of age, Hib incidence was 0.06 per 100 000 (2 cases), compared with 35.5 per 100 000 prior to routine Hib vaccination. Follow-up of all 106 case patients over the 4-year period revealed that most cases occurred in adults (73%) who often had preexisting medical conditions (77%) and presented with pneumonia (56%). The Hib-associated case fatality rate was 9.4% (10/106 cases). Conclusions. Control of Hib disease in England and Wales is currently the best that has been achieved since the introduction of routine Hib vaccination in 1992. Invasive Hib disease is no longer a major cause of acute bacterial meningitis in children but, instead, cases are more likely to present as pneumonia in older adults with comorbidities, similar to the less virulent nonencapsulated H. influenzae.
Introduction/background Specific risk groups are at increased risk of hospitalisation and death f... more Introduction/background Specific risk groups are at increased risk of hospitalisation and death from non-invasive pneumococcal disease. Evidence showing the increased odds ratio in these risk groups for developing hospitalised pneumonia in England is missing. Aim To quantify the odds of developing hospitalised pneumonia for 6 key risk groups as defined by The Green Book (UK vaccination policy guide) compared to ‘healthy controls’, with no risk group diagnosis, using the Hospital Episodes Statistics (HES) database. Materials and methods We retrospectively analysed the Hospital Episodes Statistics database, which includes analysed data on the entire ≥18 years population of England for episodes of hospitalised pneumonia over a period of 3 years. Patients and controls were identified by ICD-10 codes. Healthy controls were in-patient admissions for tooth extraction. Odds ratios were calculated while simultaneously adjusting for gender, age, Charlson Comorbidity Index, ethnicity, geography and deprivation. Results Odds ratio of developing hospitalised pneumonia for specific risk groups compared to healthy controls.Abstract P33 Table 1 Risk Group Odds ratio (95% CI) Chronic Heart Disease (CHD) 1.87 (1.80–1.94) Chronic Liver Disease (CLD) 3.43 (3.29–3.59) Chronic Respiratory Disease (CRD) 5.47 (5.28–5.70) Chronic Kidney Disease (CKD) 2.20 (2.13–2.32) Diabetes 1.18 (1.13–1.23) Bone Marrow Transplant recipients (BMT) 5.46 (5.05–5.90) Conclusion This is the first study of an entire adult population quantifying the increased odds of hospitalised pneumonia among patients with these underlying risk factors. These individuals are at a significant increased risk of developing hospitalised pneumonia and that the odds are substantially higher for those with CRD, CLD and BMT. These data support the potential benefit of adopting a targeted prevention strategy among specific risk groups.
Results There was a 90-fold variation in expenditure on stop smoking products across London secon... more Results There was a 90-fold variation in expenditure on stop smoking products across London secondary care trusts (graph 1). Some of the highest expenditure was in trusts dealing with mental health. Comparing similar sized organisations to correct for bed numbers; within major teaching hospital groups, there was a 3-fold variation (£96 k vs £29 k). There was a 10-fold difference in smaller acute Trusts (£32 k vs £3 k) and specialist trusts (£14 k vs £1.4 k). Discussion It is important to stress that expenditure does not equate to prescribing or use of these products. Also, this expenditure does not include any products bought in a hospital shop or provided by any on site external stop smoking services. Being unwell and admitted to hospital offers a unique opportunity for sick smokers to stop smoking. Heightened health concerns and being in an environment where smoking is not permitted enhances the motivation to quit. However, it appears that not all secondary care Trusts in London are providing the tools to help sick smokers quit, This may also reflect the lack of skilled advisors to provide support within these trusts. Hopefully, the variation in expenditure will narrow with the introduction of a national CQUIN for offering stop smoking products in secondary care coming into force for 2017-2019.
In August 2012, an explosive outbreak of severe lower respiratory tract infection (LRTI) due to S... more In August 2012, an explosive outbreak of severe lower respiratory tract infection (LRTI) due to Streptococcus pneumoniae serotype-8 occurred in a highly vaccinated elderly institutionalized population in England. Fifteen of 23 residents developed LRTI over 4 days (attack rate 65%); 11 had confirmed S. pneumoniae serotype-8 disease, and two died. Following amoxicillin chemoprophylaxis and pneumococcal polysaccharide vaccine (PPV) re-vaccination no further cases occurred in the following 2 months. No association was found between being an outbreakassociated case and age (P = 0•36), underlying comorbidities [relative risk (RR) 0•84 95% confidence interval (CI) 0•34-2•09], or prior receipt of PPV (RR 1•4, 95% CI 0•60-3•33). However, the median number of years since PPV was significantly higher for cases (n = 15, 10•2 years, range 7•3-17•9 years) than non-cases (n = 8, 7•2 years, range 6•8-12•8 years) (P = 0•045), provided evidence of waning immunity. Alternative vaccination strategies should be considered to prevent future S. pneumoniae outbreaks in institutionalized elderly populations.
The 13-valent pneumococcal conjugate vaccine (PCV) has been part of routine immunisation in a 2 +... more 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 burdenincluding invasive pneumococcal disease (IPD) and non-invasive diseasewill 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.
TO THE EDITOR—We read with interest the article by Kent et al [1]. The authors note that the burd... more TO THE EDITOR—We read with interest the article by Kent et al [1]. The authors note that the burden of invasive pneumococcal disease (IPD) in UK infants aged <1 year is substantial and that the incidence of IPD in this age group increased over the study period (2013–2016). Although the majority of IPD cases (369/454, 71.4%) were due to non–13-valent pneumococcal conjugate vaccine (PCV13) serotypes, disease also was caused by PCV13 (vaccine type [VT]) serotypes (85/454, 16.4%), with a limited reduction in VT IPD from 36 cases in 2013 to 28 cases in 2016. Serotype 3 was the most common VT serotype identified; however, 9 other VT (plus 6C) serotypes also caused infant IPD, in particular, 19A, 7F, and 19F. This suggests ongoing transmission of VT pneumococci with risk of disease to children with insufficient immunity. While premature infants and those with clinical risk factors for IPD were most at risk of developing IPD (13.0% and 28.6%, respectively), full-term infants with no identified risk factors were also at risk.
We reviewed retrospectively all invasive Haemophilus influenzae (Hi) infections in adults ascerta... more We reviewed retrospectively all invasive Haemophilus influenzae (Hi) infections in adults ascertained from reference laboratory records and notifications from five NHS regions over the 5 years from 1 October 1990, a period encompassing the introduction of routine Hib childhood immunization (October 1992). A total of 446 cases were identified, a rate of 0n73 infections per 10& adults per annum. Though numbers of Hib infections in adults fell after the introduction of Hib vaccines for children (P l 0n035), and there was no increase in infections caused by other capsulated Hi serotypes, total numbers of invasive Hi infections increased due to a large rise in infections caused by non-capsulated Hi (ncHi) strains (P l 0n0067). There was an unexpectedly low rate of infections in those aged 75 years or more (P 0n0001). The commonest clinical presentations were pneumonia with bacteraemia (227\350, 65 %) and bacteraemia alone (62\350, 18 %) and the highest rates of disease were in the 65-74 years age group (P 0n0001). Clinical presentation was not influenced by the capsulation status of the invading Hi strain. 103\350 cases (29 %) died within 1 month, and 207\350 (59 %) within 6 months of their Hi infection. Case fatality rates were high in all age groups. Pre-existing diseases were noted in 220\350 cases and were associated with a higher case fatality rate (82 % s. 21%, P 0n0001). After the introduction of Hib immunization in children, invasive Hib infections in unimmunized adults also declined, but the overall rate of invasive Hi disease in adults increased, with most infections now caused by non-capsulated strains. Physicians and microbiologists should be aware of the changing epidemiology, the high associated mortality and high risk of underlying disease. Invasive haemophilus infections in adults should be investigated and treated aggressively.
To describe the presentation, management, and outcome of 43 cases of pneumococcal-associated hemo... more To describe the presentation, management, and outcome of 43 cases of pneumococcal-associated hemolytic uremic syndrome (P-HUS). An increased incidence of P-HUS has been noted in the United Kingdom between January 1998 and May 2005. Cases with microangiopathic hemolytic anemia (Hb &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;10 g/dL with fragmented RBCs), thrombocytopenia (platelet count &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 130 x 10(9)/L), acute renal impairment with oliguria and elevated plasma creatinine for age, confirmed or suspected pneumococcal infection and/or T-activation were included. The median age at presentation was 13 months (range, 5-39 months). Pneumococcus was identified in 34 of 43 cases; T-activation was identified in 36 of 37 cases. Twelve strains were serotyped: serotypes 3 (n = 2), 6A (n = 2), 12F (n = 1), 14 (n = 1), 19A (n = 6). Empyema was present in 23 of 35 pneumonia cases; 13 cases had confirmed (9) or suspected (4) pneumococcal meningitis; 36 cases required dialysis (median, 10 days; range, 2-240 days). The mortality rate was 11%, comprising 3 cases of meningitis, 1 case of sepsis and 1 case of pulmonary embolism at 8 months follow up while on dialysis. Follow-up data were available for 35 of 38 patients who survived (median follow-up period, 9 months; range, 1-63 months); of these, 10 patients had renal dysfunction, 1 patient was dialysis-dependent, 5 patients had hypertension and 8 patients had at least 1+ proteinuria on urinalysis. P-HUS has increased compared with historic surveys (0/288 in 1985-1988; 8/413 in 1997-2001, 43/315 in 1998-May 2005). Early mortality remains high (8-fold that of VTEC-induced HUS). Ten of 12 strains identified would not be covered by the PCV7 vaccine.
Background The clinical and economic costs of an episode of hospitalised pneumonia are usually as... more Background The clinical and economic costs of an episode of hospitalised pneumonia are usually assumed to be short-lived with patients subsequently returning to their previous health-state. We hypothesised that a diagnosis of hospitalised pneumonia in an individual within a specific risk group would have clinical and economic implications that would go beyond the initial episode. Aim Determine, within the NHS context, the clinical and financial burden of hospitalised pneumonia in 6 risk groups over a 4 year period utilising the Hospital Episodes Statistics (HES) database, which incorporates the entire population of England that visit a hospital. Method We retrospectively analysed HES data on individuals≥18 years. Those with a specified risk group diagnosis were tracked from 2012 to 2015. Individuals developing hospitalised pneumonia in the year following their risk group diagnosis were matched through propensity scoring to an individual within that risk group who did not go on to develop hospitalised pneumonia. Hospital activity, costs and mortality were compared between the two groups over the next 3 years. Results Table. No title available. Conclusion This study utilises an entire adult population to ascertain the impact of hospitalised pneumonia in patients with certain underlying comorbidities. Hospitalised pneumonia has a significant long term impact on those within specific risk groups, resulting in additional hospital admissions and associated costs, and the initial pneumonia episode appears to significantly increase the likelihood of mortality.
Background. The introduction of the Haemophilus influenzae serotype b (Hib) conjugate vaccine int... more Background. The introduction of the Haemophilus influenzae serotype b (Hib) conjugate vaccine into national immunization has led to rapid and sustained declines in invasive Hib disease incidence across all age groups. In industrialized countries with established Hib vaccination programs, however, little is known about individuals who develop invasive Hib disease. This study describes the epidemiology of invasive Hib disease in England and Wales during 2000-2012 and the clinical characteristics of laboratory-confirmed Hib cases diagnosed during 2009-2012. Methods. Public Health England (PHE) conducts enhanced national surveillance of invasive Hib disease in England and Wales. Detailed clinical information was obtained for all laboratory-confirmed Hib cases diagnosed during 2009-2012. Results. Invasive Hib disease in England and Wales has been declining since 2002, reaching its lowest incidence of 0.02 per 100 000 (14 cases) in 2012. In children aged <5 years of age, Hib incidence was 0.06 per 100 000 (2 cases), compared with 35.5 per 100 000 prior to routine Hib vaccination. Follow-up of all 106 case patients over the 4-year period revealed that most cases occurred in adults (73%) who often had preexisting medical conditions (77%) and presented with pneumonia (56%). The Hib-associated case fatality rate was 9.4% (10/106 cases). Conclusions. Control of Hib disease in England and Wales is currently the best that has been achieved since the introduction of routine Hib vaccination in 1992. Invasive Hib disease is no longer a major cause of acute bacterial meningitis in children but, instead, cases are more likely to present as pneumonia in older adults with comorbidities, similar to the less virulent nonencapsulated H. influenzae.
Introduction/background Specific risk groups are at increased risk of hospitalisation and death f... more Introduction/background Specific risk groups are at increased risk of hospitalisation and death from non-invasive pneumococcal disease. Evidence showing the increased odds ratio in these risk groups for developing hospitalised pneumonia in England is missing. Aim To quantify the odds of developing hospitalised pneumonia for 6 key risk groups as defined by The Green Book (UK vaccination policy guide) compared to ‘healthy controls’, with no risk group diagnosis, using the Hospital Episodes Statistics (HES) database. Materials and methods We retrospectively analysed the Hospital Episodes Statistics database, which includes analysed data on the entire ≥18 years population of England for episodes of hospitalised pneumonia over a period of 3 years. Patients and controls were identified by ICD-10 codes. Healthy controls were in-patient admissions for tooth extraction. Odds ratios were calculated while simultaneously adjusting for gender, age, Charlson Comorbidity Index, ethnicity, geography and deprivation. Results Odds ratio of developing hospitalised pneumonia for specific risk groups compared to healthy controls.Abstract P33 Table 1 Risk Group Odds ratio (95% CI) Chronic Heart Disease (CHD) 1.87 (1.80–1.94) Chronic Liver Disease (CLD) 3.43 (3.29–3.59) Chronic Respiratory Disease (CRD) 5.47 (5.28–5.70) Chronic Kidney Disease (CKD) 2.20 (2.13–2.32) Diabetes 1.18 (1.13–1.23) Bone Marrow Transplant recipients (BMT) 5.46 (5.05–5.90) Conclusion This is the first study of an entire adult population quantifying the increased odds of hospitalised pneumonia among patients with these underlying risk factors. These individuals are at a significant increased risk of developing hospitalised pneumonia and that the odds are substantially higher for those with CRD, CLD and BMT. These data support the potential benefit of adopting a targeted prevention strategy among specific risk groups.
Results There was a 90-fold variation in expenditure on stop smoking products across London secon... more Results There was a 90-fold variation in expenditure on stop smoking products across London secondary care trusts (graph 1). Some of the highest expenditure was in trusts dealing with mental health. Comparing similar sized organisations to correct for bed numbers; within major teaching hospital groups, there was a 3-fold variation (£96 k vs £29 k). There was a 10-fold difference in smaller acute Trusts (£32 k vs £3 k) and specialist trusts (£14 k vs £1.4 k). Discussion It is important to stress that expenditure does not equate to prescribing or use of these products. Also, this expenditure does not include any products bought in a hospital shop or provided by any on site external stop smoking services. Being unwell and admitted to hospital offers a unique opportunity for sick smokers to stop smoking. Heightened health concerns and being in an environment where smoking is not permitted enhances the motivation to quit. However, it appears that not all secondary care Trusts in London are providing the tools to help sick smokers quit, This may also reflect the lack of skilled advisors to provide support within these trusts. Hopefully, the variation in expenditure will narrow with the introduction of a national CQUIN for offering stop smoking products in secondary care coming into force for 2017-2019.
In August 2012, an explosive outbreak of severe lower respiratory tract infection (LRTI) due to S... more In August 2012, an explosive outbreak of severe lower respiratory tract infection (LRTI) due to Streptococcus pneumoniae serotype-8 occurred in a highly vaccinated elderly institutionalized population in England. Fifteen of 23 residents developed LRTI over 4 days (attack rate 65%); 11 had confirmed S. pneumoniae serotype-8 disease, and two died. Following amoxicillin chemoprophylaxis and pneumococcal polysaccharide vaccine (PPV) re-vaccination no further cases occurred in the following 2 months. No association was found between being an outbreakassociated case and age (P = 0•36), underlying comorbidities [relative risk (RR) 0•84 95% confidence interval (CI) 0•34-2•09], or prior receipt of PPV (RR 1•4, 95% CI 0•60-3•33). However, the median number of years since PPV was significantly higher for cases (n = 15, 10•2 years, range 7•3-17•9 years) than non-cases (n = 8, 7•2 years, range 6•8-12•8 years) (P = 0•045), provided evidence of waning immunity. Alternative vaccination strategies should be considered to prevent future S. pneumoniae outbreaks in institutionalized elderly populations.
The 13-valent pneumococcal conjugate vaccine (PCV) has been part of routine immunisation in a 2 +... more 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 burdenincluding invasive pneumococcal disease (IPD) and non-invasive diseasewill 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.
TO THE EDITOR—We read with interest the article by Kent et al [1]. The authors note that the burd... more TO THE EDITOR—We read with interest the article by Kent et al [1]. The authors note that the burden of invasive pneumococcal disease (IPD) in UK infants aged <1 year is substantial and that the incidence of IPD in this age group increased over the study period (2013–2016). Although the majority of IPD cases (369/454, 71.4%) were due to non–13-valent pneumococcal conjugate vaccine (PCV13) serotypes, disease also was caused by PCV13 (vaccine type [VT]) serotypes (85/454, 16.4%), with a limited reduction in VT IPD from 36 cases in 2013 to 28 cases in 2016. Serotype 3 was the most common VT serotype identified; however, 9 other VT (plus 6C) serotypes also caused infant IPD, in particular, 19A, 7F, and 19F. This suggests ongoing transmission of VT pneumococci with risk of disease to children with insufficient immunity. While premature infants and those with clinical risk factors for IPD were most at risk of developing IPD (13.0% and 28.6%, respectively), full-term infants with no identified risk factors were also at risk.
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Papers by Mary Slack