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CLINICAL INTRODUCTION Why a book on pneumonia? The epidemiological significance of pneumonia and its treatment in the world at the start of the 21st century Pneumonia and pleurisy still belong to the most common diseases AND also are still the most common acute causes of death in many countries in the world: Incidence Community Aquired Pneumonia (CAP) · USA: App. 5.6 million cases annually 1 · Germany: App. 500.000 cases annually 2 · India: 2015 - Pneumonia in children younger than 5 years of age - 49,8 million cases (403 out of 1000 children) 3 Hospital Aquired Pneumonia (HAP) · USA - 0.5-1% of all hospital-patients 4 · UK - 1.5% of all hospital patients - with a mortality rate of 30-70% 5 · Germany 75.000 - 112.000 cases per year 6 · China 1.4% of all hospital patients 7 Mortality · USA 2021 - app. 41.300 deaths (1.8% of total deaths) Pneumonia is the 8th leading cause of death in the USA and first among infectious diseases. 8 (CDC 2021) · Germany 2020 - app. 15.900 deaths. 9 · Globally we have 2,49 Million deaths due to Lower Respiratory Tract Infection (LRTI) per year. 10 · Pneumonia is still the world-wide leading cause of death for children under 5 years of age - 2017 800.000 children died due to pneumonia (15% of all deaths) 11 · The greatest risk factors for developing pneumonia are malnutrition, air pollution, and smoking. 11 · Since 1990 we have seen a 3-fold reduction of global child-mortality-rates caused by pneumonia. 11 · The global mortality rates of older people have remained unchanged since 1990 11 (WHO, 2021) · Nowadays many of these cases are due to viral infections not to bacterial ones, though we could not find accurate statistics on this. 12 · There is also a rising concern regarding antibiotic-resistance in bacteria which cause pneumonia. (See our reference to a veterinary study addressing this topic.) 13 Development of mortality since the age of Antibiotics The mortality rate for pneumonia varies greatly and must always be seen in the context of concomitant diseases, age, and the type of pneumonia. It is difficult to obtain or interpret reliable data from the time period before antibiotics. We rely on these two orthodox authorities on the topic: Osler, 1909 and Murray 2016: Ed. Osler: In bronchopneumonia, children under 5 years of age are reported to have a mortality rate of 30-50%. The mortality rate for lobar pneumonia varies greatly. From 3.6% in the German army to 60-80% in over 60-year-olds. osl1,1909 Murray: Community-acquired pneumonia (CAP) is a frequent infectious respiratory disease. Although many patients with CAP can be treated as outpatients, the mortality of CAP in those who do require hospitalization ranges from 5% to 15% and increases to 20% to 50% in patients who require intensive care unit (ICU) care. Hospital-acquired pneumonia (HAP) is the second most common and most frequently fatal nosocomial infection. mur1,2016 Epidemiological specifics for pleurisy mur1,2016 There have been a number of recent reports from the United States, Canada, Europe, and Asia, all showing a dramatic increase in the incidence of pleural infection. This seems to be the case for both children and adults and, although most data are derived from developed-world populations, this pattern has been replicated around the globe. The incidence of pleural infection began to rise in the mid to late 1990s. This was captured by Grijalva and colleagues, who recently examined the trends in parapneumonic empyema in the United States over a 13-year period, demonstrating a doubling in the rates of empyema hospitalizations between 1996 and 2008, from 3.04 to 5.98 per 100,000. similar results were demonstrated by a Canadian study, which also confirmed the significant disparity in empyema incidence between those 65 years of age and older (17 to 20 per 100,000) and those 19 years of age or younger (2 to 4 per 100,000). Mortality rates from empyema also seem to be on the rise. A study looking at the population of Utah showed a sixfold rise in mortality from the period 1950-1975 to the period 2000-2005. In a large series, inpatients were found to have a mortality up to 18% in the short term, with those in intensive care experiencing mortality as high as 41%. In a large multicenter trial from the United Kingdom, patients with an average age of 59 were shown to have a mortality rate 1 year after treatment for empyema between 8% and 20%. The explanation for the increase in empyema incidence is not clear. With the introduction of the heptavalent pneumococcal conjugate vaccine* in 2000, a reduction in pneumococcal empyema in children from serotypes covered by the vaccine may have led to an increase of cases caused by nonvaccine serotypes. This may account for an increase in adult infection with these serotypes. This, however, does not explain the increase in staphylococcal empyema seen in the series by Grijalva and associates. mur1,2016 *Current scientific data on effectiveness of pneumococcal vaccines against pneumonia There are many studies suggesting relevant impact of pneumococcal vaccines for the reduction of pneumonia and mortality in different populations (countries, age, chronically diseased, etc.). With the knowledge that vaccine studies often blend out serotype-replacement, severe side-effects, conflict of interest and overall (in-)effectiveness on the diseases addressed, we searched for papers in which this bias was tried to be avoided: We found interesting scientific data on this from: 1. Manitoba, Canada (Sallaheddin, 2017 16): "Despite the introduction of several vaccination programs, overall rates of Invasive Pneumococcal Disease have not declined in Manitoba in the last decade, due to increase in incidence of non-PCV7 serotypes." 1. Worldwide - (WHO, Chowdhary, 2008 17): "Incidence of pneumonia is not reduced by pneumococcal conjugate vaccine." 2. United Kingdom (UK Health Security Agency,2023 18): "During the 2022 to 2023 epidemiological year, the cumulative number of cases [Ed. of Invasive Pneumococcal Disease IPD] was higher than in any year since the 2017 to 2018 epidemiological year for all age groups." Conclusion Ed.: After a reduction of Invasive Pneumococcal Disease-cases for a few years epidemiological data from all over the world shows that incidence and mortality rates have once again gone back up to at least the level before pneumococcal vaccination. In this case the main reason seems to be serotype-replacement with other serotypes of pneumococcus, but further reasons seem probable. Tuberculosis Although Tuberculosis causes a specific form of pneumonia in about 90% of the cases, it is nowadays counted as an independent disease-entity. Tuberculosis has been one of the most frequent causes of death in the 19th and 20th centuries. It still is a very common disease and cause of death in many countries. [According to the WHO - in 2021, an estimated 10.6 million people fell ill with tuberculosis (TB) worldwide. Six million men, 3.4 million women and 1.2 million children. TB is present in all countries and age groups. The most people affected live on the African and Asian continents and in some South-American regions. Around 87% of new TB cases occurred in the 30 high TB burden countries, with more than two thirds of the global total in Bangladesh, China, the Democratic Republic of the Congo, India, Indonesia, Nigeria, Pakistan, and the Philippines. A total of 1.6 million people died from TB in 2021 (including 187 000 people with HIV). Worldwide, TB is the 13th leading cause of death. Multidrug-resistant TB (MDR-TB) remains a public health crisis and a health security threat. Only approximately one in three people with drug resistant TB accessed treatment in 2021.] (WHO, Global Tuberculosis Report 2022) |