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Sir William Osler Streptococcus pneumonia (pneumococcus) the captain of all the men of death Pneumonia may well be called the friend of the aged. Taken off by it in an acute, short, not often painful illness, the old man escapes those cold gradations of decay so distressing of himself and to his friends

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Sir William Osler Streptococcus pneumonia (poneumococcus) the captain of all the men of death Pneumonia may well be called the friend of the aged. Taken off by it in an acute, short, not often painful illness, the old man escapes those cold gradations of decay so distressing of himself and to his friends Pneumonia 1-2 million deaths per year Half in children Commonest infectious cause of death in developed countries About 1 in 500 people age >55yr per annum

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1068 patients admitted to 3 hospitals 9% mortality at 30 days Pneumonia Severity : CURB 65 Lim Thorax 2008

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Pneumococcal disease and age

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Case control study Atlanta, Baltimore, Ontario 228 cases of Invasive pneumococcal disease Excluded immunosuppressed inc cancer OR (95%CI) Males2.7 (1.7-3.4) Smoker4.1 (2.4-7.3) Less than high school 2.8 (1.3-5.9)

Components of pneumococcal vaccines 23 valent Polysaccharide vaccine 78% of serotypes age group 18-49 76% of serotypes age group 50-64 66% of serotypes age group >64 13 valent conjugate vaccine 53% of serotypes age group 18-49 49% of serotypes age group 50-64 44% of serotypes age group >64

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Pneumococcal vaccine timelines 1977 14 valent polysaccharide vaccine 1983 current 23 valent polysaccharide vaccine 1992 vaccine recommended for at risk groups 2002conjugate vaccine 7 for at-risk children 5yr

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Emergence of non PCV-7 pneumococcal strains Public Health England Isolation of non- PCV-7 pneumococcal strains in those age >5yr

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Pneumococcal promiscuity

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Pneumococal vaccine in adults Effectiveness against pneumonia is uncertain Stops bacteraemia May just stop bacteraemia Duration of effectiveness is uncertain Changing epidemiology of pneumococcal disease

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Death from pneumonia in metal working occupations 1930-1963

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Death from pneumonia in metal working occupations 1970-1972

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Death from pneumonia in metal working occupations 1979-1990

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Pneumococcal and unspecified lobar pneumonia (ICD 481) Bronchopneumonia (ICD 481) Other pneumonias (ICD 480, 482-3, 486) Death from pneumonia in metal working occupations 1991-2000

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Effects of metal fume exposure Consistent x 2-3 increased risk of pneumonia Hasnt decreased since the 1930s Only when actively exposed Confined to lobar/ pneumococcal pneumonia WHY ?

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Iron and welding Iron facilitates bacterial growth Iron increases inflammation Iron is toxic to macrophages

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The Iron war during infection Pathogens adapt to obtain Iron Produce haemolysins which liberate iron from haem Produce proteolytic proteins that break down transferrin and lactoferrin producing their own low molecular weight iron chelators, Host organisms restrict iron availability during infection. Lactoferrin, ferratin bind iron Decreased binding to transferrin Macrophages ingest Fe-transferrin Reduced release of Fe from macrophages Decreased absorption of Iron ;" " while the amount of iron bound

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75,000 welders in the UK 40-50 hospital admissions pa because of fume 2 deaths pa Source : HSE Welding and pneumonia

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PPV (single 0.5ml dose in those who have not received PPV previously) should be considered for those at risk of frequent or continuous occupational exposure to metal fume (e.g. welders) taking into account the exposure control measures in place. Vaccination may reduce the risk of invasive pneumococcal disease but should not replace the need for measures to prevent or reduce exposure.

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Pneumococcal disease 1 in 5000 welders/yr Vaccine reduces risk by 75% Effect lasts 10 yr Vaccinating 600 welders will prevent 1 case pa If 1 in 8 die Vaccinating 5000 welders will prevent 1 death pa

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Number needed to treat Stopping smoking to prevent IHD death 8 Warfarin in AF to prevent stroke 25 Treat BP >/90 to prevent vasc event 700 Mammograms to save 1 cancer death1,600 Aspirin to prevent AMI/stroke1,667 Osteoporosis Rx to prevent # Fem > 60 yr1,945 Regular seat belt use to prevent death 50,000

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