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Pneumococcal pneumonia in adults 60 years or older: Incidence, mortality and prevention
Neumonía neumocócica en adultos mayores de 60 años: incidencia, mortalidad y prevención
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Pneumonia is the most common presentation of pneumococcal infection in adults, but the true burden of the disease is not well known because of difficulties to characterize nonbacteremic cases.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">This study describes the epidemiology (incidence, mortality and serotype distribution) of pneumococcal pneumonia (bacteremic and nonbacteremic cases) among Southern Catalonian people 60 years or older. This work is part of the CAPAMIS Study,<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> a cohort study conducted in Tarragona (Southern Catalonia, Spain) whose results of the effectiveness of antipneumococcal vaccination have been published.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><p id="par0015" class="elsevierStylePara elsevierViewall">Population-based prospective cohort study that included 27,204 individuals, who were all people 60 years or older registered in any of nine primary care centers (PCCs) of the Institut Catala de la Salut in the Tarragones county (a mixed industrial–residential urban area in the Mediterranean coast of Southern Catalonia) with an overall population of 337,289 all-age inhabitants at study start. Design and study population have been extensively described elsewhere.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Cohort members were followed since study start (01/Dec/2008) until the occurrence of a first event, enrolment from the PCC ceased, death, or until the end of the study (30/Nov/2011). Presumptive cases of pneumonia were initially identified on the basis of primary hospital discharge ICD-9 diagnosis codes for pneumonia (480–486). All presumptive cases were further reviewed by two trained physician investigators who checked the hospital medical records, only being definitively included if, on conclusion of the medical record review, the diagnosis was verified according to classical criteria previously described.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> Death from pneumonia (case-fatality) was considered when the patient died (in-hospital or not) within the first 30 days after the diagnosis.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Conventional diagnostic workup included blood culture, sputum culture and <span class="elsevierStyleItalic">S. Pneumoniae</span> urinary antigen test (Binax-NOW),<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> which were performed as indicated by the attending physician in each case. The isolates of <span class="elsevierStyleItalic">S. pneumoniae</span> were identified from blood and sputum samples by standard methods in the microbiology laboratory of two hospitals in the study area (Joan XXIII and Santa Tecla). Strains were serotyped in the Pneumococci Reference Laboratory of the Instituto de Salud Carlos III (Majadahonda, Madrid).</p><p id="par0030" class="elsevierStylePara elsevierViewall">Incidence rates were calculated as person-years, considering in the denominator the sum of the person-years contributed by each individual during the study period. The 95% confidence intervals (CIs) were calculated assuming a Poisson distribution. Chi-squared or Fisher's test and Nonparametric equality-of-medians test were used to compare proportions and quantitative data as appropriate. Statistical significance was set at <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05 (two-tailed).</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0035" class="elsevierStylePara elsevierViewall">The 27,204 cohort members (mean age 71.7 years; 44.6% male) were followed for a total of 75,360 person-years. Across study period, 125 cohort members suffered pneumococcal pneumonia (16 bacteremic and 109 nonbacteremic cases). Of the 109 nonbacteremic cases, 14 were identified by positive sputum culture, 5 by positive sputum culture plus urinary antigen test and 90 by positive urinary antigen test alone. Incidence rates (per 1000 person-years) were 0.21 (95% CI: 0.13–0.35) for bacteremic pneumococcal pneumonia, 1.45 (95% CI: 1.20–1.75) for nonbacteremic pneumococcal pneumonia and 1.66 (95% CI: 1.39–1.98) for all pneumococcal pneumonia.</p><p id="par0040" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the study population, time followed, absolute number of events and incidence rates for all pneumococcal pneumonia according to age strata, sex and type of residence.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">The median days of hospitalization were 8 days (interquartile range [IQR]: 5–11). No statistical differences were observed when comparing length-stay according to age strata and sex. Ten (8%) of 125 cases (three bacteremic and seven nonbacteremic) were admitted into the Intensive Care Unit (ICU), with a median stay of 3 days (IQR: 2–4) in the ICU and 9 days (IQR: 6–13) in the total hospital-stay.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Thirty-day case-fatality rate was 10.4% (12.5% in bacteremic cases and 10.1% of nonbacteremic cases; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.885). Case-fatality was 3.2% in people 60–69 years, 7.3% in people 70–79 years and 17% in people 80 years or more; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.101. Case-fatality rate was 8.7% for community-dwelling individuals and 30% of nursing-home residents (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.069).</p><p id="par0055" class="elsevierStylePara elsevierViewall">Serotypes 3 and 19A (with 5 cases each one) were the most commonly identified serotypes, accounting for 35.7% of the total 28 serotyped isolates. The remaining identified serotypes were type 22F and 35B with 3 cases each one, 6C in two cases and types 1, 4, 6A, 7F, 8, 9N, 16F, 19F, 23B and 29 in one case. <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> compares prevalence of infections caused by serotypes contained in the 13-valent and 23-valent pneumococcal vaccines.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0060" class="elsevierStylePara elsevierViewall">This study investigated the burden of pneumococcal pneumonia among the general population 60 years or older in a well defined geographical area in Southern Catalonia. Our data show an intermediate incidence rate (21 episodes per 100,000 person-year) and mortality (10.4%).</p><p id="par0065" class="elsevierStylePara elsevierViewall">Incidence largely varied by sex (double in men than in women) and age strata (approximately 4-fold greater in people 80 years or more than in people 60–69 years). A similar trend has been reported in prior epidemiological studies, considering that the frequent association between increasing age and presence of underlying diseases accounts for an increased morbidity–mortality due to pneumococcal pneumonia in the oldest adults.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> Moreover, the incidence was dramatically greater among nursing-home residents (who suffered an incidence 8-fold greater than community-dwelling individuals).</p><p id="par0070" class="elsevierStylePara elsevierViewall">The reported incidences of pneumococcal infections vary widely in different settings.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> It is believed that these differences largely reflect differences in surveillance methods and blood culture practices, but they could also reflect geographical and epidemiological differences. Considering bacteremic pneumococcal pneumonia, the incidence rate observed in our study is within the range of 12–76 cases per 100,000 person-year reported for invasive pneumococcal diseases (mainly bacteremic pneumococcal pneumonia) among older adults in distinct European countries.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> We note that an incidence of 19 cases of bacteremic pneumococcal pneumonia per 100,000 population-year was reported among Catalonian elderly people during 1997–1999.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> According to our data, incidence has slightly increased ten years after. Although this data possibly reflects a greater frequency of blood cultures performed in the contemporary period, our results showing a small increase in the incidence of invasive pneumococcal infections among older adults in recent years are not unique and merit further investigations.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Regarding nonbacteremic pneumococcal pneumonia, there are scarce data about its incidence given the difficulties to achieve a reliable etiological diagnosis. In this study, we used Binax-NOW <span class="elsevierStyleItalic">S. pneumoniae</span> urinary antigen test for the detection of nonbacteremic pneumococcal pneumonias and 90 of 109 nonbacteremic cases were diagnosed by this test, which has shown acceptable sensitivity and specificity.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> The incidence rate for nonbacteremic cases reached 145 episodes per 100,000 person-years, being the observed ratio of nonbacteremic to bacteremic pneumococcal pneumonia approximately 6.8 (109/16). In a recent meta-analysis the ratio of nonbacteremic to bacteremic pneumococcal pneumonia was estimated to be approximately 3.75 (95% CI: 2.51–5.59).<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">We note that, although the potential impact of both 13-valent and 23-valent pneumococcal vaccines is considerable (vaccine-serotype coverage of 53.6% and 73.1%, respectively), it still remains an important proportion of infections not covered by these vaccines.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Our study has several strengths. The study design was population-based and included a large cohort followed for a long 36-month consecutive period. In addition, the studied outcomes, which were primarily collected from the local hospital discharge diagnoses databases, were later extensively reviewed for further accuracy diagnosis. On the other hand, our study has some limitations. The total burden of the disease was not determined since the study did not include possible cases managed as outpatient. Rates were based on the first episode of hospitalization from pneumonia occurring during the study period and they do not include multiple events per person; thus, the overall cumulative incidence is slightly underestimated. Finally, the relatively low number of events makes it difficult to generalize results.</p><p id="par0090" class="elsevierStylePara elsevierViewall">We conclude that the burden of pneumococcal pneumonia remains considerable among our study population (despite a publicly funded anti-pneumococcal vaccination program working since 2000). Large incidence and mortality rates appear among the oldest people and nursing home residents, which underline the need for an effective preventive strategy for these high-risk subjects.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Role of the funding source</span><p id="par0120" class="elsevierStylePara elsevierViewall">Funding for the study was provided, in part, by grants from the “Fondo de Investigación Sanitaria” of the <span class="elsevierStyleGrantSponsor" id="gs1">Instituto de Salud Carlos III</span> (Exps 09/00043 and 15/01230). This study sponsor had no role in the design or implementation of the study, analysis of data, or reporting of the results.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Contributors</span><p id="par0095" class="elsevierStylePara elsevierViewall">A. Vila-Corcoles, X. Ansa and O. Ochoa-Gondar designed the study, assessed outcomes, and wrote and edited the paper; X. Ansa, E. Satue and C. de Diego obtained the data; O. Ochoa-Gondar and T. Rodriguez-Blanco did statistical analyses; A. Vila-Corcoles coordinated the study. The two first listed authors contributed similarly to the work.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflict of interest</span><p id="par0105" class="elsevierStylePara elsevierViewall">All the authors declare that they have not conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:3 [ "identificador" => "xres676845" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec682884" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres676844" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Fundamento" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec682885" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0045" "titulo" => "Role of the funding source" ] 9 => array:2 [ "identificador" => "sec0025" "titulo" => "Contributors" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflict of interest" ] 11 => array:2 [ "identificador" => "xack228335" "titulo" => "Acknowledgments" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-03-30" "fechaAceptado" => "2015-09-10" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec682884" "palabras" => array:5 [ 0 => "Epidemiology" 1 => "Incidence" 2 => "Mortality" 3 => "Pneumococcal pneumonia" 4 => "<span class="elsevierStyleItalic">Streptococcus pneumoniae</span>" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec682885" "palabras" => array:5 [ 0 => "Epidemiología" 1 => "Incidencia" 2 => "Letalidad" 3 => "Neumonía neumocócica" 4 => "S<span class="elsevierStyleItalic">treptococcus pneumoniae</span>" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">This study investigated the burden (incidence, mortality and serotype distribution) of pneumococcal pneumonia among older adults in the region of Tarragona (Spain).</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Population-based cohort study involving 27,204 individuals ≥60 years in Tarragonès county (Southern Catalonia), who were prospectively followed between 01/12/2008 and 30/11/2011. Bacteremic and nonbacteremic (positive sputum culture and/or urinary antigen test) pneumococcal pneumonias were recruited.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A total of 125 pneumococcal pneumonias (16 bacteremic and 109 nonbacteremic) was observed. Incidence rates (per 1000 person-years) were 0.21 (95% confidence interval [CI]: 0.13–0.35) for bacteremic cases and 1.45 (95% CI: 1.20–1.75) for nonbacteremic cases. Case-fatality rate was 10.4% (12.5% in bacteremic and 10.1% in nonbacteremic cases). Five serotypes (types 3, 6C, 19A, 22F and 35B) were the most common serotypes, accounting for 64.3% of overall isolated serotypes. 73.1% of cases were due to the strains included in the 23-valent vaccine whereas 53.6% were due to the strains included in the 13-valent vaccine.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The burden of pneumococcal pneumonia remains considerable (especially among oldest people and nursing-home residents) despite a publicly funded anti-pneumococcal vaccination program operative for several years.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Fundamento</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Este estudio analiza la epidemiología (incidencia, letalidad y distribución de serotipos) de la neumonía neumocócica en adultos mayores de Tarragona.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Cohorte de base poblacional que incluyó 27.204 individuos<span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>60 años en la comarca del Tarragonès, con seguimiento prospectivo entre 1-12-2008 y 30-11-2011 y selección de todos los casos de neumonía neumocócica bacteriémica y no-bacteriémica (cultivo de esputo y/o antigenuria positiva).</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se observaron 125 neumonías neumocócicas (16 bacteriémicas y 109 no bacteriémicas). Las tasas de incidencia (por 1.000 personas-año) fueron 0,21 (intervalo de confianza [IC] 95%: 0,13-0,35) para casos bacteriémicos y 1,45 (IC 95%: 1,20-1,75) para casos no bacteriémicos. La letalidad global fue del 10,4% (12,5% en casos bacteriémicos y 10,1% en no bacteriémicos). Cinco serotipos (3, 6C, 19A, 22F y 35B) fueron los más comunes, representando un 64,3% del total de serotipos aislados. Un 73,1% de los casos fueron debidos a serotipos incluidos en la vacuna 23-valente, mientras que un 53,6% fueron debidos a serotipos incluidos en la vacuna 13-valente.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusión</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La incidencia de neumonía neumocócica es considerable (especialmente en personas mayores y/o institucionalizadas) a pesar del programa público de vacunación antineumocócica implementado desde hace años.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Fundamento" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:3 [ "apendice" => "<p id="par0115" class="elsevierStylePara elsevierViewall">The following investigators members of the EPIVAC Research Team contributed to this work: Angel Vila-Córcoles, Xabier Ansa, Olga Ochoa-Gondar, Cinta de Diego, Eva Satue, Imma Hospital, Elisabet Salsench, Jordi Bladè and Francisca Ramos (Primary Care Service of Camp de Tarragona, Institut Catala de la Salut); Frederic Gomez-Bertomeu (Department of Laboratory and Microbiology, Hospital Joan XXIII), Ramón Magarolas, Leonardo Esteban (Department of Pneumology, Hospital Joan XXIII); Xavier Raga (Department of Laboratory and Microbiology, Hospital Santa Tecla), Frederic Ballester Bastardie (Department of Laboratory and Microbiology, Hospital Sant Joan de Reus); Maria Mar Olga Perez Moreno (Department of Laboratory and Microbiology, Hospital de Tortosa Verge de la Cinta); Jorge Alexis Guzmán Avalos (Emergency Department, Hospital Joan XXIII).</p>" "etiqueta" => "Appendix A" "identificador" => "sec0040" ] ] ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No. of subjects \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Follow-up (person-years) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No. of events \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">IR<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> (95% CI) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Age strata</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>60–69 yrs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12,401 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">35,690 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">31 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.87 (0.59–1.23) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>70–79 yrs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9284 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">26,041 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">41 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.57 (1.13–2.14) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>≥80 yrs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5519 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13,629 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">53 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.89 (2.91–5.09) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Sex</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12,137 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33,341 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">78 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.34 (1.85–2.92) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Female \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15,067 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">42,019 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">47 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.12 (0.82–1.49) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Residence</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Nursing-home \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">375 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">780 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12.82 (6.15–23.58) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Community-dwelling \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">26,829 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">74,580 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">115 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.54 (1.27–1.85) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Overall population \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">27,204 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">75,360 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">125 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.66 (1.38–1.98) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1110599.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">IR denotes incidence rates and are presented per 1000 person/years.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Incidence rates of hospitalization from pneumococcal pneumonia according to age strata, sex and type of residence.</p>" ] ] 1 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Note</span>: PCV13, serotypes included in the 13-valent pneumococcal conjugate vaccine; PPV23, serotypes included in the 23-valent pneumococcal polysaccharide vaccine.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Type of isolate \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">PCV13<br><span class="elsevierStyleItalic">N</span> (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">PPV23<br><span class="elsevierStyleItalic">N</span> (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span> value \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Invasive (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>12) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (41.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 (75.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.214 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Non-invasive (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>16) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 (62.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 (62.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.715 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Overall (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>28) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 (53.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19 (73.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.412 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1110598.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Prevalence of infections caused by serotypes included in the current antipneumococcal vaccines for adult population.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The burden of pneumococcal disease among adults in developed and developing countries: what is and is not known" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "D.S. 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The authors also thank Angel Vila-Rovira (research on mortality data) for his assistance.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000014600000005/v1_201606230528/S2387020616300572/v1_201606230528/en/main.assets" "Apartado" => array:4 [ "identificador" => "44146" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Brief report" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000014600000005/v1_201606230528/S2387020616300572/v1_201606230528/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020616300572?idApp=UINPBA00004N" ]
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