BACKGROUND:Abundant, indirect epidemiological evidence indicates that influenza contributes to all-cause mortality and cardiovascular hospitalisations with studies showing increases in acute myocardial infarction (AMI) and death during the influenza season. OBJECTIVE:To investigate whether influenza is a significant and unrecognised underlying precipitant of AMI. DESIGN:Case-control study. SETTING:Tertiary referral hospital in Sydney, Australia, during 2008 to 2010. PATIENTS:Cases were inpatients with AMI and controls were outpatients without AMI at a hospital in Sydney, Australia. MAIN OUTCOME MEASURES:Primary outcome was laboratory evidence of influenza. Secondary outcome was baseline self-reported acute respiratory tract infection. RESULTS:Of 559 participants, 34/275 (12.4%) cases and 19/284 (6.7%) controls had influenza (OR 1.97, 95% CI 1.09 to 3.54); half were vaccinated. None were recognised as having influenza during their clinical encounter. After adjustment, influenza infection was no longer a significant predictor of recent AMI. However, influenza vaccination was significantly protective (OR 0.55, 95% CI 0.35 to 0.85), with a vaccine effectiveness of 45% (95% CI 15% to 65%). CONCLUSIONS:Recent influenza infection was an unrecognised comorbidity in almost 10% of hospital patients. Influenza did not predict AMI, but vaccination was significantly protective but underused. The potential population health impact of influenza vaccination, particularly in the age group 50-64 years, who are at risk for AMI but not targeted for vaccination, should be further explored. Our data should inform vaccination policy and cardiologists should be aware of missed opportunities to vaccinate individuals with ischaemic heart disease against influenza.

Background: There is abundant indirect epidemiologic evidence that influenza contributes to all-cause mortality and to cardiac hospitalisations. Rates of acute myocardial infarction (AMI) and death also increase during the influenza season. In retrospective studies, influenza vaccination is protective against AMI, cardiac death and stroke. However, prospective studies are lacking hence an absence of any direct evidence for a role of influenza in precipitating heart disease and stroke. We hypothesise that influenza is a significant precipitant of acute ischaemic vascular events. Aim: To determine if influenza is a significant and unrecognised underlying precipitant of acute ischaemic cardiac events during the winter season. Methods: Cases admitted with AMI to a large teaching hospital were compared to time-matched controls from outpatient clinics. Baseline sera and viral nasal/throat swabs were collected followed by convalescent sera four to six weeks post recruitment to determine antibody titres. Vaccinated subjects with high antibody titres at baseline were only excluded if titres were high at baseline, unless they tested positive on PCR or had a four-fold rise in titres. Results: In 561 subjects, comprising of 275 cases and 286 controls, 60 subjects had evidence of influenza infection. There were 37 positive for influenza among cases and 23 among controls (OR 1.79, 95% CI: 1.0–3.1, p = 0.04). Conclusion: There was a significantly higher rate (close to two times the increased risk) of influenza in patients admitted with ischaemic cardiac events than in control subjects. This supports a case for vaccination as a primary prevention strategy against acute ischaemic cardiac events.

Background: Rates of acute myocardial infarction (AMI) and death increase during the influenza season. Retrospective studies suggest that influenza vaccination is protective against AMI and cardiac death. Currently, healthy Australians aged ≤65 are not provided with seasonal influenza vaccination. Aim: To examine seasonal influenza vaccination uptake of study participants, including the association with demographic characteristics, co-morbidities and lifestyle factors. Method: A prospective case–control study was conducted in the Australian winters of 2008–2009. Cases admitted with AMI to a large teaching hospital were compared to matched controls from outpatient clinics. Participants were asked to report their vaccination status for influenza vaccine for the current season and previous season and responses were verified with their general practitioner. Results: Participants reported similar vaccine uptake rates (80.9%) compared to the national average (79.1%; AIHW 2003/4). Cases had significantly lower vaccination rates compared to controls for those aged 65+ years (p = 0.03) and those <65 years (p = 0.001). Controls aged 65+ years were more likely to report the 2008 influenza vaccine (76.1%) than cases aged 65+ years (63.1%, OR 1.86 95% CI: 1.1–3.3, p = 0.03). Controls aged <65 years were more likely to report the 2008 influenza vaccine (37.5%) than cases aged <65 years (14.8%, OR 3.44 95% CI: 1.6–7.4, p = 0.001). Vaccine acceptance rates appeared to be influenced by markers of socio-economic status but not the number of co-morbidities or medical risk factors to coronary heart disease. Conclusion: Social-economic status (SES) may play a role in vaccine uptake. Publicly funded vaccination programs may also increase acceptance rates and could provide a cost-effective solution in preventing influenza related morbidity and mortality.

There have been few surveys of Streptococcus pneumoniae and Neisseria meningitidis carriage in sick or frail elderly people who, with the very young, comprise the group who are at highest risk for pneumococcal disease. We studied pneumococcal carriage among participants in a pneumococcal immunisation study in the frail elderly.Methods: Subjects aged >= 60 years were recruited from a large tertiary referral hospital in Sydney, Australia. Nose and throat swabs were collected at the time of enrolment and 12 months after immunisation. Results: Before immunisation, only 1 of 315 participants was identified as a nasal carrier of S. pneumoniae; another was identified as throat carrier of N. meningitidis. None of the participants examined after immunisation was carrying either S. pneumoniae or N. meningitidis.Conclusion: The low rate of pneumococcal carriage in this population of hospitalised elderly patients was unexpected. The most likely reason is that long-term carriage is rare in this population and suggests that pneumococcal disease primarily follows recent acquisition of S. pneumoniae types not associated with carriage. (C) 2010 Elsevier Ltd. All rights reserved.

Many studies show that rates of acute myocardial infarction (AMI) and death increase during the influenza season. In retrospective studies, influenza vaccination is protective against AMI, cardiac death and stroke. However, prospective studies are lacking.

a National Centre for Immunization Research and Surveillance Sydney, NSW, Australia b The University of Sydney, Sydney, NSW, Australia c Discipline of Medicine, Geriatric Medicine, Westmead Hospital, Sydney, NSW, Australia d School of Public Health and Community Medicine, The University of New South Wales, Australia e The Australian Red Cross Blood Services, Sydney, NSW, Australia f Research Unit of Transfusion Medicine and Immunogenetics, Faculty of Medicine, University of Sydney, Australia

Limited information exists regarding optimal methods for the recruitment and retention of older people in clinical trials. The aim of this review is to identify common barriers to the recruitment of older people in clinical trials and to propose solutions to overcome these barriers. A review of literature was performed to identify common difficulties in recruiting older people. This in combination with our experience during recruitment for a randomized control trial, have highlighted numerous barriers. Population-specific recruitment strategies, simple informed-consent processes, and effective communication between the researcher and subject are effective strategies to overcome these barriers.

Pneumococcal vaccine is now recommended for all people aged 65 years and over in Australia, yet many in this age group remain unvaccinated, especially those from Non-English Speaking Backgrounds (NESB). Aim: Our aim was to assess some of the perceived beliefs. benefits and barriers to pneumococcal immunisation in older people.Design and setting: We conducted qualitative open-ended interviews among elderly hospital inpatients aged receiving care in the geriatric, cardiology, and orthopaedic departments of a large, 800-bed tertiary referral hospital.Methods: 24 participants who had not received pneumococcal immunisation, and who were aged 60 years and over, were mentally competent and well enough to be interviewed were selected for our study. Results: Three topics were addressed: patient attitudes towards vaccination, knowledge of vaccines and their purpose, and accessibility of patient education materials about vaccines and their purpose. Patients who accepted pneumococcal immunisation (acceptors) generally were unaware of the vaccine or did not know it was recommended for them.Patients who refused the pneumococcal vaccine (refusers) either would not consider it without the recommendation of their general practitioner or they maintained the belief that the vaccination would Cause illness or symptoms. Knowledge about the availability and purpose of the pneumococcal vaccine was poor amongst our group.Conclusion: Poor knowledge of the availability and purpose of pneumococcal immunisation was prevalent in our subjects. Appropriate education campaigns and trusting and positive relationships with the general practitioners are likely to improve immunisation uptake. (C) 2009 Elsevier Ltd. All rights reserved.

Pneumococcal disease and influenza are major causes of morbidity and mortality particularly among the elderly. Influenza and pneumococcal vaccination are recommended for people aged 65 years and older or persons with chronic illness. However, despite the burden of disease related to pneumococcus and influenza and the availability safe, efficacious and cost-effective vaccines, health care providers continue to have doubts about these vaccines. Little is known about barriers for pneumococcal vaccination in the health care providers particularly in the primary health care setting.Since 2005 a publicly funded program offering free pneumococcal vaccine for elderly people over 65 years has been implemented in Australia. Aim: To investigate knowledge, attitudes and practices around vaccination of elderly patients among hospital health care workers and community general practitioners and to explore the difference between hospital doctors and GRMethods: A self-reported questionnaire survey distrubuted March and June 2007 to General physicians (GP's) whose practices are located in Western Sydney and health care staff consisting of Hospital Doctors (HD), hospital nurses (HN) and allied health care workers at a tertiary referral hospital in Western Sydney. Descriptive analyses were conducted; bivariate analyses were performed to investigate associations between variables.Results: Completed surveys were obtained for 56.3% (335/595) GPs and 42.1% (346/822) for HHCWs. The HHCWs comprised 37.5% (130/346) HD, 57.8% (200/346) HN and 4.6% (16/346) allied health care workers. GP's are more likely to support elderly vaccination than hospital doctors (98.8% compared to 93%, P = 0.0007). GPs reported that the reason for not vaccinating patients in 88% (295/335) of the cases was due to patient refusal. GP's and HHCW both agreed that pneumococcal disease is a serious illness and that vaccination is an important preventive measure for the elderly. However, the majority 68.2% (88/129) of hospital doctors report that vaccinations are difficult to address due to multiple competing priorities compared to only 34.6% (116/335) of GPs, P < 0.0001. Hospital doctors are more likely than GPS (24% vs. 17%) to report that patients often complain of adverse effects from pneumococcal vaccine. Hospital doctors 20% (104/130) are significantly less likely than GPs < 1% (3/335) to have access to guidelines and other information regarding vaccination in the elderly.Conclusions: GPs and hospital health care workers in our study were aware of, agreed with, immunization recommendation for the pneumococcal vaccine. Physician barriers to vaccination were patient's refusals and competing priorities, particularly for hospital health care workers, who were less likely to see vaccination as a priority. Hospitalisation is an opportunity for vaccination, but utilisation of this opportunity is reduced by lack of access to information about immunization for hospital health care workers and competing priorities. These could be areas to target for improved uptake of the elderly immunization. (C) 2008 Elsevier Ltd. All rights reserved.

Advanced age has been associated with a wide range of defects in both the innate and adaptive immune systems including diminished specific antibody responses that increase the risk of invasive pneumococcal disease (IPD) and limit the effectiveness of vaccines. However, the elderly are a heterogeneous group and measures of overall frailty may be a better indicator of disease susceptibility (or vaccine response) than chronological age alone.Aim: To evaluate the immunogenicity of the 7-valent conjugated pneumococcal vaccine (PCV7) versus 23-valent polysaccharide vaccine (23vPPV) and compare the immune response to four serotypes (4, 68,18C and 19F), with respect to age or frailty in an elderly population of previously unvaccinated hospitalized patients.Method: 241 patients aged 60 years and over, recruited between 16 May 2005 and 20 February 2006, were randomised to 23PPV or PCV7 vaccine. We measured Frailty Index (FI), Barthel index and the MiniMental State. Serotype-specific IgG was measured by ELISA at base line and 6 months after vaccination. Antibody responses were defined by the ratio of post-vaccination to pre-vaccination IgG antibody concentration (poor < 2-fold increase, acceptable >= 2.0 to 3.99-fold and strong >= 4.0-fold increase).Results: Pre-immunization IgG was generally low and did not differ significantly by age or frailty. Post-immunization, IgG increased to all four serotypes; acceptable or strong response ranged between 29% for (613) and 57% for (18C). There was no significant difference between the two vaccine types (23PPV versus PCV7). At 6 months post-vaccination, the highest geometric mean IgG concentrations (GMCs) were seen for serotype 19F and the lowest for serotype 4. Although there was some variation by serotype, responses after vaccination were lowest in the most frail or aged subjects.Conclusions: Pneumococcal vaccines are perceived to offer low protection in the frail elderly, but our study showed that the proportion of this vulnerable population with acceptable responses is encouraging. Frailty, as measured by the Frailty Index, appears to be a better predictor of immune response to pneumococcal vaccines than age alone. (C) 2008 Elsevier Ltd. All rights reserved.

Introduction: The elderly, despite being most at risk for invasive pneumococcal disease, respond poorly to polysaccharide vaccine. Conjugated vaccine technology overcomes this problem in children aged <2 years, but conjugated vaccines are not licensed for use in adults. Clinical predictors of response to vaccines other than chronological age may assist in targeting adults in most need of a more immunogenic vaccine. An index of frailty (FI) has gained support as a measurement tool, but has not been examined as a predictor of immune responsiveness. Aims: To determine the response to 23 valent polysaccharide (PPV) and 7-valent conjugate (PCV7) pneumococcal vaccines in the elderly by level of frailty. Methods: A randomized controlled clinical trial of hospitalized elderly was conducted. Subjects were randomised to receive PPV or PCV7; those who received PCV7 received PPV 6 months later. Serology was measured by enzyme immunoassay (ELISA) against four serotypes, 4, 6B, 18C and 19F. Results: For all four sero types there were statistically significant increases in geometric mean concentrations after immunization; however there were no difference between 23PPV and PCV7. There association between frailty scores and geometric mean concentrations (GMC) varied by serotype. For serotype 4, there was a clear relationship between response and frailty - responses decreased with increasing frailty. This relationship was seen to a lesser degree for serotypes 18C and 19F. Type 6B is considered to be a poor immunogenic and there were very little change in both groups from baseline to 6 months. Conclusions: We demonstrated the more frail patients had a poorer immune response to polysaccharide and conjugate pneumococcal vaccines, except for serotype 6B, where responses were poor in all groups. The use of a frailty index may be more suitable than age alone to determine people at risk of poor vaccine responses.

Aim: To investigate attitudes, perceptions and knowledge of elderly hospital patients in regard to vaccination in general and pneumococcal vaccination in particular.Setting: A hospital-based patient survey in Sydney, Australia.Participants: Patients aged 60 years and older who are admitted to selected wards in an 800-bed tertiary referral hospital in Sydney, Australia.Methods: A face-to-face interview administered to 200 inpatients.Results: Approximately half (49%) of the patients had a positive attitude to vaccination whereas 59% had less positive perception. There were 35% of the patients who were unvaccinated against influenza and pneumococcal disease. Positive perception (OR 2.9, 95% C.I. = 1.3-6.5) and attitude (OR 4.4, 95% C.I. = 2.0-9.4) significantly predicted vaccination with both vaccines. Similarly the odds of receiving pneumococcal vaccination for those who had a more positive attitude and more correct knowledge were significant (OR = 2.3, 95% C.I. = 1.0-5.4; OR = 2.7, 95% C. I. = 1.1-6.8). We explored reasons for non-vaccination. Physician recommendation was listed as an important factor by patients.Conclusions: Positive perception and attitude towards vaccination are significant factors associated with immunisation status. For the pneumococcal vaccination, having influenza vaccination is related to pneumococcal vaccination. (c) 2007 Elsevier Ltd. All rights reserved.