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• W2000272634 abstract "To the Editor: Streptococcus pneumoniae is the major cause of pneumonia in the elderly adults.1 The vast majority of pneumococcal pneumonia cases are sporadic, although outbreaks of pneumococcal disease in crowded settings such as daycare centers,2 nursing homes,3 and military camps4 have been reported. In mid-April 2013, a local hospital in Kanagawa, Japan, identified a series of cases of pneumococcal pneumonia in nursing home unit residents aged 80 and older. The hospital physicians and local health center staff investigated the outbreak to confirm the etiological pathogen and to prevent disease transmission. Demographic and clinical data of the residents were extracted from nursing home and hospital records using a standardized form. Confirmed pneumonia was defined as an episode of acute respiratory symptoms and evidence of a new infiltrate on chest radiography. Confirmed pneumonia was considered to be S. pneumoniae infection if S. pneumoniae was isolated from sputum or if a rapid urinary antigen test (Binax NOW S. pneumoniae, Binax, Portland, ME) was positive. Influenza-like illness (ILI) was defined as an episode of respiratory symptoms and sudden fever. Thirty-one residents with physical disabilities and cognitive impairment resided in the nursing home unit at the end of March. Most were female aged 80 and older and bedridden. Twenty-seven (87%) residents had been vaccinated for influenza in the 2012–13 season, but only two (7%) had been vaccinated with the 23-valent polysaccharide pneumococcal vaccine (PPV23). The index case presented symptoms on March 28. From that date until late April, 10 confirmed cases of pneumonia and 16 ILI cases were identified in residents. The attack rates of pneumonia and ILI were 32.2% and 83.9%, respectively. All individuals with pneumonia were hospitalized, and one died from heart failure. The characteristics of the residents with confirmed pneumonia were nearly identical to those of other residents; the median age was 87.5, and none had been vaccinated with PPV23. In the same period, six of 28 (attack rate = 21%) staff members presented with ILI; none developed pneumonia. The last case was recorded on April 25. Sputum samples were available for seven of 10 confirmed pneumonia cases, five of which revealed S. pneumoniae. The other two confirmed pneumonia cases were positive for the urinary antigen, for a total of seven cases of pneumococcal pneumonia (Table 1). Eight of the 10 residents with confirmed pneumonia underwent a rapid influenza diagnostic test, and none was positive. Nasopharyngeal swab samples were also obtained from three residents with ILI on April 19, and one was S. pneumoniae culture positive. All six S. pneumoniae isolates (five from residents with pneumonia patients one from a resident with ILI) were identified as serotype 3, and multilocus sequence typing demonstrated that these isolates belonged to sequence type (ST) 180. All isolates showed identical pulsed-field gel electrophoresis patterns. These isolates were susceptible to penicillins, cephalosporins, carbapenems, and vancomycin and resistant to erythromycin and clindamycin. Previous studies have documented pneumococcal disease outbreaks caused by various serotypes,2-6 but no serotype 3 outbreak has been reported. Although systematic data on S. pneumoniae serotype and ST distributions are lacking in Japan, several studies have suggested that serotype 3 is one of the major pneumococcal pneumonia serotypes in adults7, 8 and that the ST180 clone is dominant in this serotype.9 We believe that this outbreak became obvious because it occurred in the most vulnerable group; nearly all of the residents with patients were extremely old people with underlying diseases. Swallowing disturbances and impaired immunity increase the risk of pneumonia in this age group.1 Nursing home residents in crowded living conditions are at an especially high risk of S. pneumoniae infection.10 At the time of the study, no national recommendation for PPV23 vaccination existed in Japan. Although local governments partially or fully subsidize the cost of PPV23, vaccine coverage remained less than 20% for people aged 65 and older in 2012, and the figure was lower in very elderly people. In the current study, only 7% of residents had received PPV23, and none with pneumonia had been vaccinated. Japan has the world's most rapidly aging population, and the number of elderly people who require long-term care is rising. Given that the pneumonia burden is expected to rise substantially in the coming decades, effective vaccination programs for adults, and particularly for extremely elderly people, must be implemented in Japan. We thank the nursing home staff for assistance with data collection. Conflict of Interest: None. This work was supported by the Institute of Tropical Medicine, Nagasaki University, Japan. Author Contributions: Study concept and design: Kuroki, Ishida, Suzuki, Furukawa, Ohya, Watanabe, Konnai, Aiharam, Morimoto. Acquisition of participants and data: Kuroki, Ishida, Suzuki, Furukawa, Ohya, Watanabe, Konnai, Aiharam, Chang, Ohnishi. Analysis and interpretation of data: Kuroki, Ishida, Suzuki, Ariyoshi, Morimoto. Preparation of manuscript: Kuroki, Ishida, Suzuki, Ariyoshi, Oishi, Ohnishi, Morimoto. Sponsor's Role: None." @default.
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• W2000272634 date "2014-06-01" @default.
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• W2000272634 title "Outbreak of Streptococcus Pneumoniae Serotype 3 Pneumonia in Extremely Elderly People in a Nursing Home Unit in Kanagawa, Japan, 2013" @default.
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