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Review| Volume 17, ISSUE 9, e673-e677, September 2013

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Morbidity and mortality of pneumonia in adults in six Latin American countries

Open AccessPublished:April 03, 2013DOI:https://doi.org/10.1016/j.ijid.2013.02.006
Morbidity and mortality of pneumonia in adults in six Latin American countries
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      Summary

      Objective

      To estimate the morbidity and mortality of pneumonia in adults over 50 years of age in Argentina, Brazil, Chile, Colombia, Mexico, and Venezuela.

      Methods

      Local data sources were queried to estimate the number of hospitalized and outpatient pneumonia cases and deaths in the year 2009. Pneumonia cases were identified in adults aged ≥50 years using ICD-10 codes. The hospital case fatality rate (HCFR) by age corresponds to the percentage of mortality per hospitalization.

      Results

      Cases of hospitalized pneumonia (incidence per 100 000 inhabitants/year) in adults ≥50 years were: Argentina 39 674 (401.1); Brazil 225 341 (611.6); Chile 30 434 (738.5); Colombia 26 955 (326.6); Mexico 82 397 (413.1); Venezuela 31 601 (640.1). The number of hospital deaths (CFR%) were: Argentina 5099 (13%); Brazil 47 287 (21%); Chile 3072 (10%); Colombia 2981 (11%); Mexico 13 312 (16%); Venezuela 11 101 (35%). Cases of outpatient pneumonia (incidence per 100 000 inhabitants/year) were: Argentina 54 093 (546.8); Brazil 260 277 (706.4); Chile 33 173 (804.9); Colombia 27 713 (335.8); Mexico 83 354 (417.9); Venezuela 39 645 (803.0). The percentage of episodes treated as outpatient was 64% (range 57–80%) among those aged 50–64 years and 39% (range 8–56%) among those ≥85 years. Across countries, 51% of hospitalizations (range 42–63%) and 69% of deaths (range 65–72%) were in adults ≥75 years.

      Conclusions

      Pneumonia is a common cause of hospitalization and mortality in adults in Latin America. Incidence increases substantially with increasing age, as does the likelihood of hospitalization and mortality.

      Keywords

      1. Introduction

      Lower respiratory tract infections, including pneumonia, are the third leading cause of death worldwide, responsible for an estimated 3.8 million deaths in 2008.

      World Health Organization. WHO factsheet: top 10 causes of death. Geneva: WHO;. Available at: http://www.who.int/mediacentre/factsheets/fs310/en/index.html (accessed September 21, 2010).

      The incidence of pneumonia is greatest among children aged ≤5 years and adults aged ≥50 years, with incidence increasing with each decade in adults over 50 years of age.
      • Berezin E.N.
      • Morales J.C.
      • Hong T.
      • Todd M.
      • Seljan M.P.
      Pneumonia hospitalization in Brazil from 2003 to 2007.
      Int J Infect Dis. 2012; 16: e583-e590
      Incidence is also increased in persons with chronic disease, including chronic obstructive pulmonary disease (COPD), kidney failure, congestive heart failure, coronary artery disease, chronic neurological diseases, alcoholism, neoplastic diseases, and immunosuppressive treatments.
      • Mandell L.A.
      Epidemiology and etiology of community acquired pneumonia.
      Infect Dis Clin North Am. 2004; 18: 761-776
      , 
      • Jackson M.L.
      • Neuzil K.M.
      • Thompson W.W.
      • Shay D.K.
      • Yu O.
      • Hanson C.A.
      • Jackson L.A.
      The burden of community-acquired pneumonia in seniors: results of a population-based study.
      Clin Infect Dis. 2004; 39: 1642-1650
      , 
      • Díaz A.
      • Barria P.
      • Niederman M.
      • Restrepo M.I.
      • Dreyse J.
      • Fuentes G.
      • et al.
      Etiology of community-acquired pneumonia in hospitalized patients in Chile: the increasing prevalence of respiratory viruses among classic pathogens.
      Chest. 2007; 131: 779-787
      Among the elderly, the burden of pneumonia on healthcare systems is likely to become more significant over time given that the number of persons over the age of 60 years in the world will triple, from 673 million in 2005 to two billion in 2050. This will be most evident in developed countries, where it is estimated that this age group will increase from 64% (2005) to 80% (2050) of the total population,

      United Nations. World population prospects: the 2006 revision. Report No. ST/ESA/SER.A/261/ES. New York, NY: United Nations; 2007.

      representing a significant health problem throughout the world, and an important clinical and economic burden due to the significant use of healthcare resources associated with each case.
      • Isturiz R.E.
      • Luna C.M.
      • Ramirez J.
      Clinical and economic burden of pneumonia among adults in Latin America.
      Int J Infect Dis. 2010; 14: e852-e856
      It is estimated that approximately two million cases of pneumonia are diagnosed each year in Argentina, Brazil, and Chile.
      • Isturiz R.E.
      • Luna C.M.
      • Ramirez J.
      Clinical and economic burden of pneumonia among adults in Latin America.
      Int J Infect Dis. 2010; 14: e852-e856
      The mortality related to lower respiratory tract infections (LRTIs) in Latin America is reported to be 6%, compared with 4% in developed regions, and LRTIs were the third most frequent cause of death in adults in 31 Latin American countries in 2001–2003.
      • Murray C.J.
      • Lopez A.D.
      Mortality by cause for eight regions of the world: Global Burden of Disease Study.
      Lancet. 1997; 349: 1269-1276
      , 
      Pan American Health Organization
      The ten leading causes of death in countries of the Americas 2006 ed.
      PAHO, Washington, DC2006
      In Brazil, case fatality rates (CFR) of hospitalized pneumonia increase steadily with advancing age, with CFRs in adults ≥80 years of age several fold higher than those of children 5–9 years, making it a top cause of mortality.
      The public health burden of pneumonia in children is significant and is the focus of many global and regional analyses.
      • Gentile A.
      • Bardach A.
      • Ciapponi A.
      • Garcia-Marti S.
      • Aruj P.
      • Glujovsky D.
      • et al.
      Epidemiology of community-acquired pneumonia in children of Latin America and the Caribbean: a systematic review and meta-analysis.
      Int J Infect Dis. 2012; 16: e5-e15
      , 
      • Liu L.
      • Johnson H.
      • Cousens P.
      • Perin J.
      • Scott S.
      • Lawn J.
      • et al.
      Global, regional, and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2000.
      Lancet. 2012; 379: 2151-2161
      , 
      • Theodoratou E.
      • Zhang J.S.
      • Kolcic I.
      • Davis A.M.
      • Bhopal S.
      • Nair H.
      • et al.
      Estimating pneumonia deaths of post-neonatal children in countries of low or no death certification in 2008.
      PLoS One. 2011; 6: e25095
      However, there is little reliable information on the specific incidence and mortality of pneumonia in adults across Latin America, despite recognition of the relative burden it places on healthcare systems. Therefore, the objective of this study was to estimate the morbidity and mortality burden of pneumonia in adults over 50 years of age in Argentina, Brazil, Chile, Colombia, Mexico, and Venezuela in 2009.

      2. Methods

      2.1 Description

      A retrospective analysis of local data sources was conducted to estimate the burden of pneumonia in Argentina, Brazil, Colombia, Chile, Mexico, and Venezuela among adults. Data were stratified by age groups of 50–64, 65–74, 75–84, and ≥85 years, to report the incidence rates (inpatient and outpatient), the reported hospital deaths, and the total annual burden of the disease in each country.

      2.2 Data sources

      To obtain pneumonia cases detected by the different healthcare systems and in-hospital mortality information, specific databases and queries of reported pneumonia cases were used in each country, using as search criteria the cases reported in 2009 by ICD-10 codes J12–J18, ICD-9 codes 480–486, gender, and age group.
      Since pneumonia is a reportable disease in Mexico and in Latin American countries, pneumonia cases were obtained from the national epidemiological surveillance bulletins from week 1 through week 52 of the year 2009 for each country. In the case of Brazil, the information was obtained from the Portal da Saúde – Secretariat of Health Surveillance;

      Secretaria de Vigilância em Saúde—Semana Epidemiológica (SE) 1–52. Portal da Saúde. Brazil: Secretaria de Vigilância em Saúde;. Available at: http://portalsaude.saude.gov.br/portalsaude/index.cfm?portal=pagina.visualizarArea&codArea=376 (accessed October 5, 2010).

      for Mexico, pneumonia cases were obtained from the Epidemiological Bulletin Yearbook 2009 of the National Epidemiological Surveillance Center;

      Anuario Estadístico del Boletín Epidemiológico 2009. Mexico: SUIVE/DGE/Secretaría de Salud/Estados Unidos Mexicanos; 2009. Available at: http://www.dgepi.salud.gob.mx/2010/plantilla/inicio_anuarios.html (accessed September 23, 2010).

      in the case of Argentina, from the Health Ministry Epidemiological Bulletin 2009 for Acute Respiratory Diseases;

      Boletín Epidemiológico Periódico, Enfermedades Respiratorias Agudas 2009. Argentina: Ministerio de Salud, Presidencia de la Nación;. Available at: http://msal.gov.ar/htm/site/sala_situacion/boletines_ultimos.asp (accessed October 1, 2010).

      for Chile, the information was obtained from the epidemiological surveillance monthly electronic bulletins of 2009 of the Department of Epidemiology, Ministry of Health of Chile;

      Boletín Electrónico Mensual de Vigilancia Epidemiológica 2009, semana 1–52. Chile: Ministerio de Salud de Chile, Departamento de Epidemiologia;. Available at: http://epi.minsal.cl/evigant/evganter.htm (accessed October 7, 2010).

      for Venezuela the information was obtained from the Epidemiological Bulletin 2009 of the Ministry of Popular Power for Health;

      Boletín Epidemiológico 2009, semana 1–52. Venezuela: Ministerio del Poder Popular para la Salud;. Available at: http://www.mpps.gob.ve/?option=com_phocadownload&view=category&id=8:2009 (accessed October 8, 2010).

      and finally in Colombia the information was obtained through the 2009 Epidemiological Bulletin of the National Institute of Health.

      Boletín Epidemiológico 2009, semana 1–52. Colombia: Instituto Nacional de Salud;. Available at: http://www.ins.gov.co/boletin-epidemiologico/Paginas/default.aspx (accessed October 8, 2010).

      Subsequently the following databases were consulted for each specific country in order to obtain inpatient cases of pneumonia: for Argentina the information was obtained from the Statistics and Information Department of Health (DEIS),

      Dirección de Estadísticas e Información en Salud (DEIS). Anuarios Estadísticos de Morbilidad y Mortalidad (Egresos Hospitalarios) 2005, 2006 y 2007. Argentina: DEIS; 2007. Available at: http://www.deis.gov.ar/ (accessed October 1, 2010).

      for Colombia the information was provided by the National Institute of Health (INS),

      Instituto Nacional de Salud (INS). Estadísticas de la Vigilancia en Salud Pública. Boletines Estadísticos Semanales 2010. Colombia: INS; 2010. Available at: http://www.ins.gov.co/?idcategoria=1729 (accessed October 8, 2010).

      for Mexico the information was available from the National System of Health Information (SINAIS) and the National Epidemiological Surveillance Center (CENEVACE),

      Sistema Nacional de Información en Salud (SINAIS). Egresos hospitalarios Morbilidad 2004–2008. Mexico: SINAIS; 2008. Available at: http://www.sinais.salud.gob.mx/basesdedatos/ (accessed September 23, 2010).

      , 

      Centro Nacional de Vigilancia Epidemiológica y Control de Enfermedades (CENAVECE). Anuarios de Morbilidad 2004–2008. Boletín epidemiológico 2009–2010. Mexico: CENAVECE; 2009. Available at: http://www.dgepi.salud.gob.mx/2010/plantilla/intd_boletin.html (accessed September 23, 2010).

      for Brazil reported cases were obtained from the Database of the Unified Healthcare System (DATASUS),

      Departamento de Informática do SUS (DATASUS). Informações de Saúde. Epidemiológicas e Morbidade. Morbidade e Mortalidade Hospitalar do SUS 2004–2010. Brazil: DATASUS; 2010. Available at: http://www2.datasus.gov.br/DATASUS/index.php?area=0203 (accessed October 5, 2010).

      , 

      Agencia Nacional de Vigilância Sanitaria (ANVISA). Brazil: ANVISA; 2009. Available at: http://www.anvisa.gov.br/esp/index.htm (accessed October 5, 2010).

      for Chile the cases were reported by the Department of Statistics and Health Information of the Ministry of Health of Chile (DEIS),

      Departamento de Estadística e Información en Salud Chile (DEIS). Estadísticas de Morbilidad. Egresos Hospitalarios 2004–2008. Chile: DEIS; 2008. Available at: http://webdeis.minsal.cl/estadisticas-egresoshospitalarios (accessed October 7, 2010).

      , 

      Departamento de Estadística e Información en Salud Chile (DEIS). Estadísticas de Atención en Salud. Estadísticas Hospitalarias 2004–2008. Chile: DEIS; 2008. Available at: http://www.deis.cl/todas-las-categorias (accessed October 7, 2010).

      , 
      Ministerio de Salud de Chile
      Encuesta Nacional en Salud.
      Ministerio de Salud de Chile, Chile2010
      , 

      Compendio Estadístico de Salud Chile. Estadísticas en Salud. Chile: Instituto Nacional de Estadísticas de Chile; 2010. Available at: http://www.ine.cl/canales/menu/publicaciones/compendio_estadistico/compendio_estadistico2010.php (accessed October 7, 2010).

      and for Venezuela the statistical database of the Ministry of Popular Power for Health (MPPS) was consulted.

      Ministerio del Poder Popular para la Salud. Planes y Proyectos. Dirección del MPPS. Venezuela: MPPS; 2009. Available at: http://www.mpps.gob.ve/index.php?option=com_content&view=article&id=549&Itemid=915 (accessed October 8, 2010).

      To identify the total pneumonia cases treated as outpatients, the difference between the cases reported by epidemiological bulletins and the inpatient cases was determined, and the result was considered as the cases that did not require hospitalization.

      2.3 Incidence

      The incidence was calculated based on the total cases of pneumonia (ICD-10 codes J12–J18 and ICD-9 codes 480–486) reported by the various local sources of epidemiological notification in each country during 2009,

      Boletín Epidemiológico Periódico, Enfermedades Respiratorias Agudas 2009. Argentina: Ministerio de Salud, Presidencia de la Nación;. Available at: http://msal.gov.ar/htm/site/sala_situacion/boletines_ultimos.asp (accessed October 1, 2010).

      , 

      Boletín Electrónico Mensual de Vigilancia Epidemiológica 2009, semana 1–52. Chile: Ministerio de Salud de Chile, Departamento de Epidemiologia;. Available at: http://epi.minsal.cl/evigant/evganter.htm (accessed October 7, 2010).

      , 

      Boletín Epidemiológico 2009, semana 1–52. Venezuela: Ministerio del Poder Popular para la Salud;. Available at: http://www.mpps.gob.ve/?option=com_phocadownload&view=category&id=8:2009 (accessed October 8, 2010).

      , 

      Boletín Epidemiológico 2009, semana 1–52. Colombia: Instituto Nacional de Salud;. Available at: http://www.ins.gov.co/boletin-epidemiologico/Paginas/default.aspx (accessed October 8, 2010).

      , 

      Dirección de Estadísticas e Información en Salud (DEIS). Anuarios Estadísticos de Morbilidad y Mortalidad (Egresos Hospitalarios) 2005, 2006 y 2007. Argentina: DEIS; 2007. Available at: http://www.deis.gov.ar/ (accessed October 1, 2010).

      , 

      Instituto Nacional de Salud (INS). Estadísticas de la Vigilancia en Salud Pública. Boletines Estadísticos Semanales 2010. Colombia: INS; 2010. Available at: http://www.ins.gov.co/?idcategoria=1729 (accessed October 8, 2010).

      , 

      Sistema Nacional de Información en Salud (SINAIS). Egresos hospitalarios Morbilidad 2004–2008. Mexico: SINAIS; 2008. Available at: http://www.sinais.salud.gob.mx/basesdedatos/ (accessed September 23, 2010).

      , 

      Centro Nacional de Vigilancia Epidemiológica y Control de Enfermedades (CENAVECE). Anuarios de Morbilidad 2004–2008. Boletín epidemiológico 2009–2010. Mexico: CENAVECE; 2009. Available at: http://www.dgepi.salud.gob.mx/2010/plantilla/intd_boletin.html (accessed September 23, 2010).

      , 

      Departamento de Informática do SUS (DATASUS). Informações de Saúde. Epidemiológicas e Morbidade. Morbidade e Mortalidade Hospitalar do SUS 2004–2010. Brazil: DATASUS; 2010. Available at: http://www2.datasus.gov.br/DATASUS/index.php?area=0203 (accessed October 5, 2010).

      , 

      Agencia Nacional de Vigilância Sanitaria (ANVISA). Brazil: ANVISA; 2009. Available at: http://www.anvisa.gov.br/esp/index.htm (accessed October 5, 2010).

      , 

      Departamento de Estadística e Información en Salud Chile (DEIS). Estadísticas de Morbilidad. Egresos Hospitalarios 2004–2008. Chile: DEIS; 2008. Available at: http://webdeis.minsal.cl/estadisticas-egresoshospitalarios (accessed October 7, 2010).

      both for hospitalized patients as well as non-hospitalized patients. Data were collected within age groups (age 50–64, 65–74, 75–84, and ≥85 years), which were then divided by the population × 100 000 inhabitants, respectively, to obtain the incidence rate per 100 000 person-years.

      2.4 Mortality

      The total numbers of deaths due to the ICD codes listed above were obtained from data published by different local sources in each country in regards to the reported deaths that required hospital attention by age group (ages 50–64, 65–74, 75–84, and ≥85 years).

      Dirección de Estadísticas e Información en Salud (DEIS). Anuarios Estadísticos de Morbilidad y Mortalidad (Egresos Hospitalarios) 2005, 2006 y 2007. Argentina: DEIS; 2007. Available at: http://www.deis.gov.ar/ (accessed October 1, 2010).

      , 

      Instituto Nacional de Salud (INS). Estadísticas de la Vigilancia en Salud Pública. Boletines Estadísticos Semanales 2010. Colombia: INS; 2010. Available at: http://www.ins.gov.co/?idcategoria=1729 (accessed October 8, 2010).

      , 

      Sistema Nacional de Información en Salud (SINAIS). Egresos hospitalarios Morbilidad 2004–2008. Mexico: SINAIS; 2008. Available at: http://www.sinais.salud.gob.mx/basesdedatos/ (accessed September 23, 2010).

      , 

      Centro Nacional de Vigilancia Epidemiológica y Control de Enfermedades (CENAVECE). Anuarios de Morbilidad 2004–2008. Boletín epidemiológico 2009–2010. Mexico: CENAVECE; 2009. Available at: http://www.dgepi.salud.gob.mx/2010/plantilla/intd_boletin.html (accessed September 23, 2010).

      , 

      Departamento de Informática do SUS (DATASUS). Informações de Saúde. Epidemiológicas e Morbidade. Morbidade e Mortalidade Hospitalar do SUS 2004–2010. Brazil: DATASUS; 2010. Available at: http://www2.datasus.gov.br/DATASUS/index.php?area=0203 (accessed October 5, 2010).

      , 

      Agencia Nacional de Vigilância Sanitaria (ANVISA). Brazil: ANVISA; 2009. Available at: http://www.anvisa.gov.br/esp/index.htm (accessed October 5, 2010).

      , 

      Departamento de Estadística e Información en Salud Chile (DEIS). Estadísticas de Morbilidad. Egresos Hospitalarios 2004–2008. Chile: DEIS; 2008. Available at: http://webdeis.minsal.cl/estadisticas-egresoshospitalarios (accessed October 7, 2010).

      , 

      Departamento de Estadística e Información en Salud Chile (DEIS). Estadísticas de Atención en Salud. Estadísticas Hospitalarias 2004–2008. Chile: DEIS; 2008. Available at: http://www.deis.cl/todas-las-categorias (accessed October 7, 2010).

      , 
      Ministerio de Salud de Chile
      Encuesta Nacional en Salud.
      Ministerio de Salud de Chile, Chile2010
      , 

      Compendio Estadístico de Salud Chile. Estadísticas en Salud. Chile: Instituto Nacional de Estadísticas de Chile; 2010. Available at: http://www.ine.cl/canales/menu/publicaciones/compendio_estadistico/compendio_estadistico2010.php (accessed October 7, 2010).

      , 

      Ministerio del Poder Popular para la Salud. Planes y Proyectos. Dirección del MPPS. Venezuela: MPPS; 2009. Available at: http://www.mpps.gob.ve/index.php?option=com_content&view=article&id=549&Itemid=915 (accessed October 8, 2010).

      Hospital deaths divided by the overall number of hospitalizations were used to estimate a case fatality rate (percent mortality per hospitalization) by age.

      3. Results

      In 2009, the total number of hospitalized cases (incidence per 100 000 inhabitants/year) for pneumonia in adults aged ≥50 years in the various Latin American countries was: Mexico 82 397 (413.1); Brazil 225 341 (611.6); Colombia 26 955 (326.6); Venezuela 31 601 (640.1); Chile 30 434 (738.5); and Argentina 39 674 (401.1) (Table 1). The incidence of hospitalized pneumonia increased similarly in each country with each increasing age category. Outpatient cases (incidence per 100 000 inhabitants/year) of pneumonia in adults aged ≥50 years were: Mexico 83 354 (417.9); Brazil 260 277 (706.4); Colombia 27 713 (335.8); Venezuela 39 645 (803.0); Chile 33 173 (804.9); and Argentina 54 093 (546.8). In general, the proportion of outpatient to inpatient cases decreased with advancing age. In the age group 50–64 years, the cases treated on an outpatient basis represented 64% (range 57–80%) of total cases, compared to the age group ≥85 years where cases of outpatient care represented 39% (range 8–56%) of total cases. The average death rate reported in 2009 for adults aged ≥50 years in the six countries studied was 17.7% (Table 2). The total cases of hospital deaths reported (death rate, %) in each country was as follows: Mexico 13 312 (16.2%); Brazil 47 287 (20.9%); Colombia 2981 (11.0%); Venezuela 11 101 (35.1%); Chile 3072 (10.1%); and Argentina 5099 (12.9%). A majority of deaths occurred in persons aged ≥75 years, who accounted for 69.2% (range 64.6–72.0%) of total deaths in adults.
      Table 1Total pneumonia hospitalizations, deaths, and outpatient visits for adults over 50 years of age, 2009
      MexicoBrazilColombiaVenezuelaChileArgentina
      Hospitalizations82 397225 34126 95531 60130 43439 674
      Outpatient visits83 354260 27727 71339 64533 17354 093
      Deaths13 31247 287298111 10130725099
      Incidence rates (per 100 000)
      Pneumonia hospitalizations413.1611.6326.6640.1738.5401.0
      Pneumonia outpatient visits417.9706.4335.8803.0804.9546.8
      Hospital case fatality rate (%)16.2%21.0%11.1%35.1%10.1%12.9%
      Table 2Pneumonia inpatient and outpatient incidence and hospital case fatality rates by age, 2009
      CountryAge, years
      50–6465–7475–84≥85
      InpatientOutpatientInpatientOutpatientInpatientOutpatientInpatientOutpatient
      Mexico
       Cases12 50049 81117 87221 53224 101967927 9242332
       Incidence
      Incidence per 100 000 person years.
      		104.0414.3326.6393.41304.0523.74656.4388.9
       HCFR (%)
      Hospital case fatality rate (percent).
      		12.412.616.519.8
      Brazil
       Cases70 67995 69659 29767 15264 06266 56031 30330 869
       Incidence
      Incidence per 100 000 person years.
      		292.2395.6733.0830.11700.91767.23922.93868.5
       HCFR (%)
      Hospital case fatality rate (percent).
      		10.213.630.240.4
      Colombia
       Cases570111 320558969248194610874713361
       Incidence
      Incidence per 100 000 person years.
      		102.2203.0325.2402.91028.5766.74636.32085.7
       HCFR (%)
      Hospital case fatality rate (percent).
      		6.99.512.713.6
      Venezuela
       Cases622114 4646767984910 51110 00381025329
       Incidence
      Incidence per 100 000 person years.
      		184.5429.1687.81001.12213.02106.07552.44967.5
       HCFR (%)
      Hospital case fatality rate (percent).
      		19.528.432.156.6
      Chile
       Cases496512 2356404875610 635779984304383
       Incidence
      Incidence per 100 000 person years.
      		193.9477.9657.9899.52252.91652.17295.53793.2
       HCFR (%)
      Hospital case fatality rate (percent).
      		7.78.69.413.6
      Argentina
       Cases881411 588897812 06112 14918 143973412 301
       Incidence
      Incidence per 100 000 person years.
      		159.9210.2367.4493.6849.51268.61916.02421.2
       HCFR (%)
      Hospital case fatality rate (percent).
      		8.412.013.217.2
      a Incidence per 100 000 person years.
      b Hospital case fatality rate (percent).

      4. Discussion

      Pneumonia is a frequent cause of physician visits, hospitalization, and death among older adults in Latin America. Increasing age was associated with a substantial increase in the overall incidence of pneumonia, the likelihood of hospitalization, and the likelihood of mortality. Among the studied population, 51% of hospitalizations (range 42–63%) and 69% of deaths (range 65–72%) were in adults ≥75 years, who represented only 13% of the population above 50 years of age.
      Our findings are similar to other reports globally and regionally. In Europe the incidence of hospitalized pneumonia in adults has been reported with rates of 1.5–9.8 per 1000 population in persons aged 65 years and older,
      • Welte T.
      • Torres A.
      • Nathwani D.
      Clinical and economic burden of community-acquired pneumonia among adults in Europe.
      Thorax. 2012; 67: 71-79
      which is lower than the 7.0–16.3 per 1000 persons aged 65 years and older across the countries in our analysis. Our estimates are more aligned with an observational study in Brazil, which reported the incidence of pneumonia from 2000 to 2007, resulting in an annual incidence in the age group 70–79 years of 1134–1193 cases per 100 000 inhabitants, and in the age group 80 years and over of 2177–2895 cases per 100 000 inhabitants.
      • Isturiz R.E.
      • Luna C.M.
      • Ramirez J.
      Clinical and economic burden of pneumonia among adults in Latin America.
      Int J Infect Dis. 2010; 14: e852-e856
      With regard to the hospital death rate, Caberlotto et al. prospectively studied patients diagnosed with community-acquired pneumonia (CAP) in two hospitals in Argentina and found death rates of 13.5% and 13%, respectively,
      • Caberlotto O.J.
      • Cadario M.E.
      • Garay J.E.
      • Copacastro C.A.
      • Cabot A.
      • Savy V.L.
      Neumonía Adquirida en la Comunidad en dos Poblaciones Hospitalarias.
      Medicina (Buenos Aires). 2003; 63: 1-8
      and the average age at death was 58–68.31 years. In our study, the average death rate was 17.69% (10.10–35.11%) for adults aged ≥50 years, with a rate of 12.5% in Argentina. Jardim et al., carried out a multicenter clinical study in five Latin American countries to evaluate the efficacy and safety of treatments with moxifloxacin or amoxicillin in patients 18 years of age and older suspected of having CAP due to pneumococcus; the study showed that the hospitalization rate of the patients studied was 52.8%.
      • Jardim J.R.
      • Rico G.
      • Roza C.
      • Obispo E.
      • Urueta J.
      • Wolff M.
      • et al.
      Moxifloxacino frente a amoxicilina en el tratamiento de la neumonía adquirida en la comunidad en América Latina. Resultados de un ensayo clínico multicéntrico.
      Arch Bronconeumol. 2003; 39: 387-393
      In our study, the average hospitalization rate in the different Latin American countries for adults aged ≥50 years was 46.7% (range 42.3–49.3%).
      Hospitalized CAP may be caused by many organisms, with Streptococcus pneumoniae (20–60%) being the most commonly identified pathogen in Latin America.
      • Alfageme I.
      • Aspa J.
      • Bello S.
      • Blanquer J.
      • Blanquer R.
      • Borderías L.
      • et al.
      Guidelines for the diagnosis and treatment of community-acquired pneumonia. Spanish Society of Pulmonology and Thoracic Surgery (SEPAR).
      Arch Bronconeumol. 2005; 41: 272-289
      , 
      • Luna C.M.
      • Famiglietti A.
      • Absi R.
      • Videla A.J.
      • Nogueira F.J.
      • Fuenzalida A.D.
      • Gené R.J.
      Community-acquired pneumonia: etiology, epidemiology, and outcome at a teaching hospital in Argentina.
      Chest. 2000; 118: 1344-1354
      , 
      • Díaz A.
      • Barria P.
      • Niederman M.
      • Restrepo M.I.
      • Dreyse J.
      • Fuentes G.
      • et al.
      Etiology of community-acquired pneumonia in hospitalized patients in Chile: the increasing prevalence of respiratory viruses among classic pathogens.
      Chest. 2007; 131: 779-787
      Vaccination of adults against pneumococcal disease has the potential to reduce the incidence of hospitalizations and associated costs of disease.
      • Smith K.J.
      • Wateska A.R.
      • Nowalk M.P.
      • Raymund M.
      • Nuorti J.P.
      • Zimmerman R.K.
      Cost-effectiveness of adult vaccination strategies using pneumococcal conjugate vaccine compared with pneumococcal polysaccharide vaccine.
      JAMA. 2012; 307: 804-812
      , 
      • Castaneda-Orjuela C.
      • Alvis-Guzman N.
      • Paternina A.J.
      • De la Hoz-Restrepo F.
      Cost-effectiveness of the introduction of the pneumococcal polysaccharide vaccine in elderly Colombian population.
      Vaccine. 2011; 29: 7644-7650
      , 
      • Rozenbaum M.H.
      • Hak E.
      • van der Werf T.S.
      • Postma M.J.
      Results of a cohort model analysis of the cost-effectiveness of routine immunization with 13-valent pneumococcal conjugate vaccine of those aged > or =65 years in the Netherlands.
      Clin Ther. 2010; 32: 1517-1532
      , 
      • Weycker D.
      • Sato R.
      • Strutton D.
      • Edelsberg J.
      • Atwood M.
      • Jackson L.A.
      Public health and economic impact of 13-valent pneumococcal conjugate vaccine in US adults aged >/=50 years.
      Vaccine. 2012; 30: 5437-5444
      A 23-valent polysaccharide vaccine (PPV23) is available in several countries and is generally recommended for use in the elderly based on its effectiveness in reducing invasive pneumococcal disease.
      World Health Organization
      23-valent pneumococcal polysaccharide vaccine. WHO position paper.
      Wkly Epidemiol Rec. 2008; 83: 373-384
      Guidelines for the use of PPV23 often recommend use in adults over the ages of 50, 60, or 65 years, in recognition of their heightened risk and the relative value of disease prevention.

      World Health Organization. WHO vaccine-preventable diseases: monitoring system 2012 global summary. Immunization schedules by antigen, October 2012 update. Geneva: WHO; 2012. Available at: http://apps.who.int/immunization_monitoring/en/globalsummary/scheduleselect.cfm (accessed October 9, 2010).

      A 13-valent pneumococcal conjugate vaccine (PCV13) is now approved in many countries for use in adults to prevent pneumococcal disease caused by vaccine serotypes. A large clinical trial is currently underway to investigate the efficacy PCV13 in reducing CAP in adults ≥65 years of age, which may further clarify the potential role of this vaccine in clinical practice.
      • Hak E.
      • Grobbee D.E.
      • Sanders E.A.
      • Verheij T.J.
      • Bolkenbaas M.
      • Huijts S.M.
      • et al.
      Rationale and design of CAPITA: a RCT of 13-valent conjugated pneumococcal vaccine efficacy among older adults.
      Neth J Med. 2008; 66: 378-383
      Given the high burden of pneumonia, the increase in morbidity and mortality with increasing age, and the demographic aging of the population, understanding the opportunity for disease prevention is of increasing importance.
      Pneumonia can impose significant financial costs due to hospitalization, outpatient treatment, and lost productivity. In this study we were limited to the identification of pneumonia cases through ICD-9 and ICD-10 registries, which are general codes that often include unconfirmed cases, nosocomial pneumonias, readmissions, and hospitalizations due to other causes.
      • Nelson J.C.
      • Jackson M.
      • Yu O.
      • Whitney C.G.
      • Bounds L.
      • Bittner R.
      • et al.
      Impact of the introduction of pneumococcal conjugate vaccine on rates of community acquired pneumonia in children and adults.
      Vaccine. 2008; 26: 4947-4954
      , 
      • Jackson L.A.
      • Neuzil K.M.
      • Yu O.
      • Benson P.
      • Barlow W.E.
      • Adams A.L.
      • et al.
      Effectiveness of pneumococcal polysaccharide vaccine in older adults.
      N Engl J Med. 2003; 348: 1747-1755
      , 
      • Guevara R.E.
      • Butler J.C.
      • Marston B.J.
      • Plouffe J.F.
      • File Jr., T.M.
      • Breiman R.F.
      Accuracy of ICD-9-CM codes in detecting community-acquired pneumococcal pneumonia for incidence and vaccine efficacy studies.
      Am J Epidemiol. 1999; 149: 282-289
      , 
      • Yu O.
      • Nelson J.C.
      • Bounds L.
      • Jackson L.A.
      Classification algorithms to improve the accuracy of identifying patients hospitalized with community-acquired pneumonia using administrative data.
      Epidemiol Infect. 2011; 139: 1296-1306
      , 
      • Skull S.A.
      • Andrews R.M.
      • Byrnes G.B.
      • Campbell D.A.
      • Nolan T.M.
      • Brown G.V.
      • et al.
      ICD-10 codes are a valid tool for identification of pneumonia in hospitalized patients aged > or = 65 years.
      Epidemiol Infect. 2008; 136: 232-240
      However, ICD-coded cases can be useful as a relative metric to health utilization that can facilitate comparison within a country, over time, in relation to other ICD-coded events, and across demographic groups. Given this utility, studies have applied ICD-based studies as a measure of pneumonia disease burden in other parts of the world,
      • Gil-Prieto R.
      • Garcia-Garcia L.
      • Alvaro-Meca A.
      • Mendez C.
      • Garcia A.
      • de Miguel A.G.
      The burden of hospitalizations for community-acquired pneumonia (CAP) and pneumococcal pneumonia in adults in Spain (2003–2007).
      Vaccine. 2011; 29: 412-416
      , 
      • Ochoa-Gondar O.
      • Vila-Córcoles A.
      • de Diego C.
      • Arija V.
      • Maxenchs M.
      • Grive M.
      • et al.
      The burden of community-acquired pneumonia in the elderly: the Spanish EVAN-65 study.
      BMC Public Health. 2008; 8: 222
      and have evaluated ICD-based pneumonia indicators over time as a metric for monitoring pneumococcal vaccine impact.
      • Grijalva C.G.
      • Nuorti J.P.
      • Arbogast P.G.
      • Martin S.W.
      • Edwards K.M.
      • Griffin M.R.
      Decline in pneumonia admissions after routine childhood immunization with pneumococcal conjugate vaccine in the USA: a time-series analysis.
      Lancet. 2007; 369: 1179-1186
      , 
      • Jardine A.
      • Menzies R.I.
      • McIntyre P.B.
      Reduction in hospitalizations for pneumonia associated with the introduction of a pneumococcal conjugate vaccination schedule without a booster dose in Australia.
      Pediatr Infect Dis J. 2010; 29: 607-612
      , 
      • Chang Y.C.
      • Chou Y.J.
      • Liu J.Y.
      • Yeh T.F.
      • Huang N.
      Additive benefits of pneumococcal and influenza vaccines among elderly persons aged 75 years or older in Taiwan—a representative population-based comparative study.
      J Infect. 2012; 65: 231-238
      When ICD-coded all-cause hospitalized pneumonia data have been compared against clinical records to identify radiographically confirmed CAP in adults, between 54% and 71% of coded cases meet these criteria.
      • Nelson J.C.
      • Jackson M.
      • Yu O.
      • Whitney C.G.
      • Bounds L.
      • Bittner R.
      • et al.
      Impact of the introduction of pneumococcal conjugate vaccine on rates of community acquired pneumonia in children and adults.
      Vaccine. 2008; 26: 4947-4954
      , 
      • Jackson L.A.
      • Neuzil K.M.
      • Yu O.
      • Benson P.
      • Barlow W.E.
      • Adams A.L.
      • et al.
      Effectiveness of pneumococcal polysaccharide vaccine in older adults.
      N Engl J Med. 2003; 348: 1747-1755
      , 
      • Guevara R.E.
      • Butler J.C.
      • Marston B.J.
      • Plouffe J.F.
      • File Jr., T.M.
      • Breiman R.F.
      Accuracy of ICD-9-CM codes in detecting community-acquired pneumococcal pneumonia for incidence and vaccine efficacy studies.
      Am J Epidemiol. 1999; 149: 282-289
      , 
      • Yu O.
      • Nelson J.C.
      • Bounds L.
      • Jackson L.A.
      Classification algorithms to improve the accuracy of identifying patients hospitalized with community-acquired pneumonia using administrative data.
      Epidemiol Infect. 2011; 139: 1296-1306
      , 
      • Skull S.A.
      • Andrews R.M.
      • Byrnes G.B.
      • Campbell D.A.
      • Nolan T.M.
      • Brown G.V.
      • et al.
      ICD-10 codes are a valid tool for identification of pneumonia in hospitalized patients aged > or = 65 years.
      Epidemiol Infect. 2008; 136: 232-240
      Coding practices may vary by country and region, and similar data are not currently available from Latin American countries, therefore the transferability of these data is uncertain. Further research into the validation of administrative coded pneumonia cases in Latin America with regard to cause and etiology would significantly benefit our understanding of the nature of pneumonia in adults.
      In conclusion, we found a population weighted average incidence of hospitalized pneumonia in persons over 50 years of age of 519.6 hospitalizations per 100 000 person years, with an average fatality rate of 19.0 per 100 hospitalizations, representing 436 402 hospitalizations and 82 852 deaths in 2009. Assuming the same disease behavior for the 1.03 billion population over 50 across Latin American countries,

      Economic Commision for Latin America and the Caribbean (ECLAC), Latin American and Caribbean Center of Demography (CELADE) - Population Division, Long term population estimates and projections 150-2100. Available at: http://www.eclac.cl/celade/proyecciones/basedatos_BD.htm (accessed October 8, 2010).

      this represents an estimated 533 083 hospitalizations and 101 283 deaths per year. Extrapolating forward to 2020, with a projected adult population of 1.49 billion, pneumonia could account for up to 617 993 hospitalizations and 112 680 deaths in a single year. Pneumonia represents a significant health burden in adults, which may continue to grow as the population ages.
      Conflict of interest: This study was conducted with the financial support of Pfizer Inc. New York, without generating any kind of legal compromise and/or the results thereof. At the time of the study, Craig Roberts and Joaquin Mould-Quevedo were employees of Pfizer Inc., New York.

      References

      1. World Health Organization. WHO factsheet: top 10 causes of death. Geneva: WHO;. Available at: http://www.who.int/mediacentre/factsheets/fs310/en/index.html (accessed September 21, 2010).

        View in Article
        • Berezin E.N.
        • Morales J.C.
        • Hong T.
        • Todd M.
        • Seljan M.P.
        Pneumonia hospitalization in Brazil from 2003 to 2007.
        Int J Infect Dis. 2012; 16: e583-e590
        View in Article
        • Mandell L.A.
        Epidemiology and etiology of community acquired pneumonia.
        Infect Dis Clin North Am. 2004; 18: 761-776
        View in Article
        • Jackson M.L.
        • Neuzil K.M.
        • Thompson W.W.
        • Shay D.K.
        • Yu O.
        • Hanson C.A.
        • Jackson L.A.
        The burden of community-acquired pneumonia in seniors: results of a population-based study.
        Clin Infect Dis. 2004; 39: 1642-1650
        View in Article
        • Díaz A.
        • Barria P.
        • Niederman M.
        • Restrepo M.I.
        • Dreyse J.
        • Fuentes G.
        • et al.
        Etiology of community-acquired pneumonia in hospitalized patients in Chile: the increasing prevalence of respiratory viruses among classic pathogens.
        Chest. 2007; 131: 779-787
        View in Article

      6. United Nations. World population prospects: the 2006 revision. Report No. ST/ESA/SER.A/261/ES. New York, NY: United Nations; 2007.

        View in Article
        • Isturiz R.E.
        • Luna C.M.
        • Ramirez J.
        Clinical and economic burden of pneumonia among adults in Latin America.
        Int J Infect Dis. 2010; 14: e852-e856
        View in Article
        • Murray C.J.
        • Lopez A.D.
        Mortality by cause for eight regions of the world: Global Burden of Disease Study.
        Lancet. 1997; 349: 1269-1276
        View in Article
        • Pan American Health Organization
        The ten leading causes of death in countries of the Americas 2006 ed.
        PAHO, Washington, DC2006
        View in Article
        • Gentile A.
        • Bardach A.
        • Ciapponi A.
        • Garcia-Marti S.
        • Aruj P.
        • Glujovsky D.
        • et al.
        Epidemiology of community-acquired pneumonia in children of Latin America and the Caribbean: a systematic review and meta-analysis.
        Int J Infect Dis. 2012; 16: e5-e15
        View in Article
        • Liu L.
        • Johnson H.
        • Cousens P.
        • Perin J.
        • Scott S.
        • Lawn J.
        • et al.
        Global, regional, and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2000.
        Lancet. 2012; 379: 2151-2161
        View in Article
        • Theodoratou E.
        • Zhang J.S.
        • Kolcic I.
        • Davis A.M.
        • Bhopal S.
        • Nair H.
        • et al.
        Estimating pneumonia deaths of post-neonatal children in countries of low or no death certification in 2008.
        PLoS One. 2011; 6: e25095
        View in Article

      13. Secretaria de Vigilância em Saúde—Semana Epidemiológica (SE) 1–52. Portal da Saúde. Brazil: Secretaria de Vigilância em Saúde;. Available at: http://portalsaude.saude.gov.br/portalsaude/index.cfm?portal=pagina.visualizarArea&codArea=376 (accessed October 5, 2010).

        View in Article

      14. Anuario Estadístico del Boletín Epidemiológico 2009. Mexico: SUIVE/DGE/Secretaría de Salud/Estados Unidos Mexicanos; 2009. Available at: http://www.dgepi.salud.gob.mx/2010/plantilla/inicio_anuarios.html (accessed September 23, 2010).

        View in Article

      15. Boletín Epidemiológico Periódico, Enfermedades Respiratorias Agudas 2009. Argentina: Ministerio de Salud, Presidencia de la Nación;. Available at: http://msal.gov.ar/htm/site/sala_situacion/boletines_ultimos.asp (accessed October 1, 2010).

        View in Article

      16. Boletín Electrónico Mensual de Vigilancia Epidemiológica 2009, semana 1–52. Chile: Ministerio de Salud de Chile, Departamento de Epidemiologia;. Available at: http://epi.minsal.cl/evigant/evganter.htm (accessed October 7, 2010).

        View in Article

      17. Boletín Epidemiológico 2009, semana 1–52. Venezuela: Ministerio del Poder Popular para la Salud;. Available at: http://www.mpps.gob.ve/?option=com_phocadownload&view=category&id=8:2009 (accessed October 8, 2010).

        View in Article

      18. Boletín Epidemiológico 2009, semana 1–52. Colombia: Instituto Nacional de Salud;. Available at: http://www.ins.gov.co/boletin-epidemiologico/Paginas/default.aspx (accessed October 8, 2010).

        View in Article

      19. Dirección de Estadísticas e Información en Salud (DEIS). Anuarios Estadísticos de Morbilidad y Mortalidad (Egresos Hospitalarios) 2005, 2006 y 2007. Argentina: DEIS; 2007. Available at: http://www.deis.gov.ar/ (accessed October 1, 2010).

        View in Article

      20. Instituto Nacional de Salud (INS). Estadísticas de la Vigilancia en Salud Pública. Boletines Estadísticos Semanales 2010. Colombia: INS; 2010. Available at: http://www.ins.gov.co/?idcategoria=1729 (accessed October 8, 2010).

        View in Article

      21. Sistema Nacional de Información en Salud (SINAIS). Egresos hospitalarios Morbilidad 2004–2008. Mexico: SINAIS; 2008. Available at: http://www.sinais.salud.gob.mx/basesdedatos/ (accessed September 23, 2010).

        View in Article

      22. Centro Nacional de Vigilancia Epidemiológica y Control de Enfermedades (CENAVECE). Anuarios de Morbilidad 2004–2008. Boletín epidemiológico 2009–2010. Mexico: CENAVECE; 2009. Available at: http://www.dgepi.salud.gob.mx/2010/plantilla/intd_boletin.html (accessed September 23, 2010).

        View in Article

      23. Departamento de Informática do SUS (DATASUS). Informações de Saúde. Epidemiológicas e Morbidade. Morbidade e Mortalidade Hospitalar do SUS 2004–2010. Brazil: DATASUS; 2010. Available at: http://www2.datasus.gov.br/DATASUS/index.php?area=0203 (accessed October 5, 2010).

        View in Article

      24. Agencia Nacional de Vigilância Sanitaria (ANVISA). Brazil: ANVISA; 2009. Available at: http://www.anvisa.gov.br/esp/index.htm (accessed October 5, 2010).

        View in Article

      25. Departamento de Estadística e Información en Salud Chile (DEIS). Estadísticas de Morbilidad. Egresos Hospitalarios 2004–2008. Chile: DEIS; 2008. Available at: http://webdeis.minsal.cl/estadisticas-egresoshospitalarios (accessed October 7, 2010).

        View in Article

      26. Departamento de Estadística e Información en Salud Chile (DEIS). Estadísticas de Atención en Salud. Estadísticas Hospitalarias 2004–2008. Chile: DEIS; 2008. Available at: http://www.deis.cl/todas-las-categorias (accessed October 7, 2010).

        View in Article
        • Ministerio de Salud de Chile
        Encuesta Nacional en Salud.
        Ministerio de Salud de Chile, Chile2010
        View in Article

      28. Compendio Estadístico de Salud Chile. Estadísticas en Salud. Chile: Instituto Nacional de Estadísticas de Chile; 2010. Available at: http://www.ine.cl/canales/menu/publicaciones/compendio_estadistico/compendio_estadistico2010.php (accessed October 7, 2010).

        View in Article

      29. Ministerio del Poder Popular para la Salud. Planes y Proyectos. Dirección del MPPS. Venezuela: MPPS; 2009. Available at: http://www.mpps.gob.ve/index.php?option=com_content&view=article&id=549&Itemid=915 (accessed October 8, 2010).

        View in Article
        • Welte T.
        • Torres A.
        • Nathwani D.
        Clinical and economic burden of community-acquired pneumonia among adults in Europe.
        Thorax. 2012; 67: 71-79
        View in Article
        • Caberlotto O.J.
        • Cadario M.E.
        • Garay J.E.
        • Copacastro C.A.
        • Cabot A.
        • Savy V.L.
        Neumonía Adquirida en la Comunidad en dos Poblaciones Hospitalarias.
        Medicina (Buenos Aires). 2003; 63: 1-8
        View in Article
        • Jardim J.R.
        • Rico G.
        • Roza C.
        • Obispo E.
        • Urueta J.
        • Wolff M.
        • et al.
        Moxifloxacino frente a amoxicilina en el tratamiento de la neumonía adquirida en la comunidad en América Latina. Resultados de un ensayo clínico multicéntrico.
        Arch Bronconeumol. 2003; 39: 387-393
        View in Article
        • Alfageme I.
        • Aspa J.
        • Bello S.
        • Blanquer J.
        • Blanquer R.
        • Borderías L.
        • et al.
        Guidelines for the diagnosis and treatment of community-acquired pneumonia. Spanish Society of Pulmonology and Thoracic Surgery (SEPAR).
        Arch Bronconeumol. 2005; 41: 272-289
        View in Article
        • Luna C.M.
        • Famiglietti A.
        • Absi R.
        • Videla A.J.
        • Nogueira F.J.
        • Fuenzalida A.D.
        • Gené R.J.
        Community-acquired pneumonia: etiology, epidemiology, and outcome at a teaching hospital in Argentina.
        Chest. 2000; 118: 1344-1354
        View in Article
        • Smith K.J.
        • Wateska A.R.
        • Nowalk M.P.
        • Raymund M.
        • Nuorti J.P.
        • Zimmerman R.K.
        Cost-effectiveness of adult vaccination strategies using pneumococcal conjugate vaccine compared with pneumococcal polysaccharide vaccine.
        JAMA. 2012; 307: 804-812
        View in Article
        • Castaneda-Orjuela C.
        • Alvis-Guzman N.
        • Paternina A.J.
        • De la Hoz-Restrepo F.
        Cost-effectiveness of the introduction of the pneumococcal polysaccharide vaccine in elderly Colombian population.
        Vaccine. 2011; 29: 7644-7650
        View in Article
        • Rozenbaum M.H.
        • Hak E.
        • van der Werf T.S.
        • Postma M.J.
        Results of a cohort model analysis of the cost-effectiveness of routine immunization with 13-valent pneumococcal conjugate vaccine of those aged > or =65 years in the Netherlands.
        Clin Ther. 2010; 32: 1517-1532
        View in Article
        • Weycker D.
        • Sato R.
        • Strutton D.
        • Edelsberg J.
        • Atwood M.
        • Jackson L.A.
        Public health and economic impact of 13-valent pneumococcal conjugate vaccine in US adults aged >/=50 years.
        Vaccine. 2012; 30: 5437-5444
        View in Article
        • World Health Organization
        23-valent pneumococcal polysaccharide vaccine. WHO position paper.
        Wkly Epidemiol Rec. 2008; 83: 373-384
        View in Article

      40. World Health Organization. WHO vaccine-preventable diseases: monitoring system 2012 global summary. Immunization schedules by antigen, October 2012 update. Geneva: WHO; 2012. Available at: http://apps.who.int/immunization_monitoring/en/globalsummary/scheduleselect.cfm (accessed October 9, 2010).

        View in Article
        • Hak E.
        • Grobbee D.E.
        • Sanders E.A.
        • Verheij T.J.
        • Bolkenbaas M.
        • Huijts S.M.
        • et al.
        Rationale and design of CAPITA: a RCT of 13-valent conjugated pneumococcal vaccine efficacy among older adults.
        Neth J Med. 2008; 66: 378-383
        View in Article
        • Nelson J.C.
        • Jackson M.
        • Yu O.
        • Whitney C.G.
        • Bounds L.
        • Bittner R.
        • et al.
        Impact of the introduction of pneumococcal conjugate vaccine on rates of community acquired pneumonia in children and adults.
        Vaccine. 2008; 26: 4947-4954
        View in Article
        • Jackson L.A.
        • Neuzil K.M.
        • Yu O.
        • Benson P.
        • Barlow W.E.
        • Adams A.L.
        • et al.
        Effectiveness of pneumococcal polysaccharide vaccine in older adults.
        N Engl J Med. 2003; 348: 1747-1755
        View in Article
        • Guevara R.E.
        • Butler J.C.
        • Marston B.J.
        • Plouffe J.F.
        • File Jr., T.M.
        • Breiman R.F.
        Accuracy of ICD-9-CM codes in detecting community-acquired pneumococcal pneumonia for incidence and vaccine efficacy studies.
        Am J Epidemiol. 1999; 149: 282-289
        View in Article
        • Yu O.
        • Nelson J.C.
        • Bounds L.
        • Jackson L.A.
        Classification algorithms to improve the accuracy of identifying patients hospitalized with community-acquired pneumonia using administrative data.
        Epidemiol Infect. 2011; 139: 1296-1306
        View in Article
        • Skull S.A.
        • Andrews R.M.
        • Byrnes G.B.
        • Campbell D.A.
        • Nolan T.M.
        • Brown G.V.
        • et al.
        ICD-10 codes are a valid tool for identification of pneumonia in hospitalized patients aged > or = 65 years.
        Epidemiol Infect. 2008; 136: 232-240
        View in Article
        • Gil-Prieto R.
        • Garcia-Garcia L.
        • Alvaro-Meca A.
        • Mendez C.
        • Garcia A.
        • de Miguel A.G.
        The burden of hospitalizations for community-acquired pneumonia (CAP) and pneumococcal pneumonia in adults in Spain (2003–2007).
        Vaccine. 2011; 29: 412-416
        View in Article
        • Ochoa-Gondar O.
        • Vila-Córcoles A.
        • de Diego C.
        • Arija V.
        • Maxenchs M.
        • Grive M.
        • et al.
        The burden of community-acquired pneumonia in the elderly: the Spanish EVAN-65 study.
        BMC Public Health. 2008; 8: 222
        View in Article
        • Grijalva C.G.
        • Nuorti J.P.
        • Arbogast P.G.
        • Martin S.W.
        • Edwards K.M.
        • Griffin M.R.
        Decline in pneumonia admissions after routine childhood immunization with pneumococcal conjugate vaccine in the USA: a time-series analysis.
        Lancet. 2007; 369: 1179-1186
        View in Article
        • Jardine A.
        • Menzies R.I.
        • McIntyre P.B.
        Reduction in hospitalizations for pneumonia associated with the introduction of a pneumococcal conjugate vaccination schedule without a booster dose in Australia.
        Pediatr Infect Dis J. 2010; 29: 607-612
        View in Article
        • Chang Y.C.
        • Chou Y.J.
        • Liu J.Y.
        • Yeh T.F.
        • Huang N.
        Additive benefits of pneumococcal and influenza vaccines among elderly persons aged 75 years or older in Taiwan—a representative population-based comparative study.
        J Infect. 2012; 65: 231-238
        View in Article

      52. Economic Commision for Latin America and the Caribbean (ECLAC), Latin American and Caribbean Center of Demography (CELADE) - Population Division, Long term population estimates and projections 150-2100. Available at: http://www.eclac.cl/celade/proyecciones/basedatos_BD.htm (accessed October 8, 2010).

        View in Article

      Article info

      Publication history

      Published online: April 03, 2013
      Accepted: February 6, 2013
      Received in revised form: January 31, 2013
      Received: April 13, 2012
      Corresponding Editor: Eskild Petersen, Aarhus, Denmark

      Identification

      DOI: https://doi.org/10.1016/j.ijid.2013.02.006

      Copyright

      © 2013 International Society for Infectious Diseases. Published by Elsevier Inc.

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