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In 1999, all individuals > or = 65 yrs of age (n=258,754) in Stockholm County, Sweden, were offered influenza and pneumococcal vaccination in a prospective study on the effectiveness of these vaccines in reducing the need for hospital treatment and death due to influenza, pneumonia and invasive pneumococcal disease (IPD). Data on hospitalisation and mortality during 1 yr were obtained from the administrative database in Stockholm County Council. Vaccination was performed in 124,702 (48%) subjects; 72,107 had both vaccines, 29,346 only had the influenza vaccine and 23,249 only had the pneumococcal vaccine. Compared with the unvaccinated cohort, a lower incidence of hospitalisation for all endpoint diagnoses was seen in vaccinated persons. An additive effectiveness of vaccination was seen when both vaccines were given, with a reduction of hospital admissions for influenza (37%), pneumonia (29%) and IPD (44%). In-hospital mortality for pneumonia was significantly lower in those who received both vaccines, than in unvaccinated persons. To conclude, vaccination with influenza and pneumococcal vaccines together was effective in reducing the need for hospital admission for influenza and pneumonia. There was a strong indication that pneumococcal vaccination alone, was effective not only in the prevention of invasive pneumococcal disease, but also of pneumonia overall, although to a low degree.

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To assess the effectiveness of influenza and pneumococcal vaccination in reducing hospitalisation and deaths in elderly people, the population aged > or =65 years in Stockholm County, Sweden (n = 259627) were invited to take part in a vaccination campaign with influenza and 23-valent pneumococcal vaccine (PV). A no. of persons (100,242) (vaccinated cohort) were vaccinated with one or both vaccines during the campaign. The incidence of hospital admissions during 1 year after the vaccination campaign, adjusted for sex and age, was significantly lower in the vaccinated than in the unvaccinated cohort for influenza (relative risk [RR] 0.68), pneumonia (RR 0.78), and invasive pneumococcal disease (RR 0.46). In the vaccinated cohort, the in-hospital mortality was lower for pneumonia (RR 0.55), COPD (RR 0.53) and cardiac failure (RR 0.72).

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This study characterizes possible confounders that might make cohorts vaccinated and unvaccinated against influenza and pneumococcal infection different at baseline, with the hypothesis that the two cohorts are comparable. The similarity between health and demographic data was analysed by a randomized, multivariant study addressed to 10,000 persons aged 65 years and older in Stockholm County and was carried out in the form of a postal inquiry during the period December 2000 to May 2001. The study-population response rate was 78%. Of these, 66% (5,120 persons) had been given at least one influenza vaccination during the 3-year study period (1998-2000), 50% (3,780) had received one pneumococcal vaccination and 78% had received both vaccines during the period. The vaccination rate was lower in the age group 65-69 years (60%), compared with elderly cohorts aged over 70 years (67-72%, P < 0.001). Elderly persons living in nursing homes or institutions had higher vaccination rates than persons living in their own households (72 vs. 67%). Persons with underlying chronic diseases had higher vaccination rates (71%, P < 0.001) than those without underlying chronic diseases. Vaccine recipients had fewer days in hospital, compared with non-recipients. Unvaccinated persons with myocardial disease had nine times more days in hospital than vaccinated persons with myocardial disease. Vaccination against pneumococcal infection had an additional effect with influenza vaccination in reducing hospitalization for chronic lung diseases; influenza vaccination alone did not have this effect. In conclusion, the influenza and pneumococcal-vaccine recipients were older and had significantly more chronic lung and heart conditions than the unvaccinated cohort.

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In order to minimize the emergence of antibiotic-resistant strains among common pathogens seen in primary care in Stockholm County, the County Medical Officer in 1995 established a multidisciplinary regional STRAMA-group (Swedish Strategic Programme for the Rational Use of Antimicrobial Agents and Surveillance of Resistance). The group started out by studying antibiotic sensitivity for common pathogens in the County and in Sweden. Then the group analyzed the use of antibiotic drugs and differences in prescribing patterns among different groups of physicians in the County. In order to minimize resistance and achieve the goal of optimal use of antibiotics the group decided to publish guidelines for primary care physicians treating patients with respiratory tract infections (printed in 1997) and urinary tract infections (printed in 1999). In this article we present the guideline for urinary tract infections.

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In 1999 the County Medical Officer in Stockholm County established the third regional STRAMA-group (Swedish Strategic Programme for The Rational Use of Antimicrobial Agents and Surveillance of Resistance) to deal with skin and soft tissue infections. The group decided to publish guidelines for physicians in the county, and this third book was distributed among the 7,000 physicians in Stockholm County.

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BACKGROUND: The effectiveness of influenza and pneumococcal vaccination in the prevention of hospital admissions and death has not been assessed prospectively. We have therefore examined the effects of influenza and pneumococcal vaccination in individuals aged 65 years and older in a 3-year prospective study, between Dec 1, 1998 and May 31, 1999. METHODS: All individuals in Stockholm County aged 65 years or older (259,627) were invited to take part in a vaccination campaign against influenza and pneumococcal infection. We recorded for all vaccine recipients (100,242) name, and date of birth, and whether they had been given both or one of the vaccines. All individuals (> or = 65 years) admitted to hospital in Stockholm County with influenza and pneumonia related diagnoses were identified between Dec 1, 1998, and May 31, 1999. FINDINGS: The incidence (per 100,000 inhabitants per year) of hospital treatment was lower in the vaccinated than in the unvaccinated cohort for all diagnoses: 263 versus 484 (-46% [95% CI 34-56]) for influenza; 2199 versus 3097 (-29% [24-34)) for pneumonia; 64 versus 100 (-36% [3-58]) for pneumococcal pneumonia; and 20 versus 40 (-52% [1-77]) for invasive pneumococcal disease. The total mortality was 57% (55-60) lower in vaccinated than in unvaccinated individuals (15.1 vs 34.7 deaths per 1000 inhabitants). INTERPRETATION: These findings show that general vaccination leads to substantial health benefits and to a reduction of mortality from all causes in this age group.

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PIP: The HIV situation in Africa was very dismal in 1994, with about 10 million people infected. The causes of the rapid spread were the high incidence of sexually transmitted diseases (STDs), urbanization, and breakup of families because of migrations, since men often seek work at other places. In the age group of 15-19 years in Malawi, Uganda, and Zimbabwe, there were 5 HIV-infected women for 1 infected man, but in the 30-39 year age group, there 3 infected men for every 1 woman. A report from Kenya showed that 69% of boys and 25% of girls were sexually active, while 50% had more than 4 partners. Among 15-24 year old pregnant women, 36% had STDs. A study from the Ivory Coast indicated that HIV prevalence increased from 27% in 1987 to 53% in 1992 among patients who were seeking care for an STD in Abidjan. Among tuberculosis (TB) patients this increased from 16% to 35%, and among pregnant women from 7% in 1987 to 14% in 1992. Another group, 745 prostitutes, were also studied in Abidjan. 48% were infected with HIV and 34% were infected both with HIV-1 and HIV-2. It is estimated that 50-75% of HIV-infected people in Africa also had STDs, compared to 20% of the HIV-infected in Thailand and India and 5% in Brazil. It has been proven in a US cohort study that the treatment of STDs reduces the spread of HIV. In Gambia, Rwanda, Zaire, and Kenya, 50-100% of gonococcal isolates were resistant to penicillin and tetracycline, and 40% of women with symptoms of STD infection did not receive adequate treatment. A study from England indicated that both HIV and TB follow the same epidemiological patterns among men 30-39 and among women 20-29 years old. In developing countries HIV is the main risk factor for developing TB. About 4-5 million people have TB as a cofactor for HIV infection, of whom 80% are in Africa. In 1994 about 3% of TB cases were associated with HIV, which will increase to 10% by the year 2000.^ieng

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PIP: In a reply to Sven Britton's concern about references to Africans and their differing sexual views, it is stated that in recent years 40% of asylum seekers from Uganda were infected by HIV. The explosive spread of AIDS and other sexually transmitted diseases can be traced to a pattern of multiple sex partners as among homosexuals in the United States. According to the World Health Organization, in 1992, 211,032 AIDS cases were reported from Africa and 242,146 from the US. WHO estimated in 1993 that there were 7.5 million HIV-infected people in Africa and 2 million in the US. However, there is massive under-reported of AIDS cases in Africa, where, the disease is spread mainly through heterosexual contact. Among a total of 264 HIV-infected Africans reported in Sweden, 50 (19%) were persons who violated the law on infection prevention. There are about people in Stockholm county aged 18-49 who originate from African countries, of whom 131 are known to be infected with HIV (1 of 25). The risk of HIV infection is 122 times higher with an African through sexual contact than with other foreigners (29 HIV-infected out of 81,000). The risk of 3009 times higher with an African man than with a Swedish man (56 HIV-infected out of 400,000 men). Heterosexual transmission is more disconcerting than homosexual transmission, because the latter represents only a small part of the world's 10 million HIV-infected. In Sweden more heterosexually than homosexually transmitted cases are reported. The patients treating physician reports him/her to the infection prevention doctor. 8 of Sweden's 24 infection prevention doctors have admitted problems with HIV-infected Africans, and 4 counties confined HIV-infected Africans on account of violating the law. Swedish citizens who break the law of other countries are deported to Sweden; consequently, foreigners can be deported to their countries if they violate Swedish law.^ieng

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