Healthcare Service Improvement Team
Primary and secondary
prevention of
respiratory infections
Author:
Norma Prosser, Dr Mary Webb, Public Health Specialists
Date:
3 September 2010
Version:
1
Publication/ Distribution:

Public (Internet)
Review Date: A review of this document is not planned by Public Health
Wales NHS Trust
Purpose and Summary of Document:
This is an evidence-based summary of effective interventions for primary
and secondary prevention of respiratory infections. It has been produced to
assist local health boards to implement Designed for people with chronic
condition, Service development and commissioning directives, Chronic
respiratory conditions, and should be read in conjunction with that
publication.
Influenza and pneumococcal vaccination (in accordance with national
guidelines) are shown to be effective.
Work Plan reference: HS04
Public Health Wales
Primary and secondary prevention of
respiratory infections
CONTENTS
1
BACKGROUND ......................................................................... 3
2
RESPIRATORY INFECTIONS .................................................... 3
2.1 Introduction ......................................................................... 3
2.2 Search methodology ............................................................. 3
2.3 Prevalence ........................................................................... 4
2.4 Hospital admissions .............................................................. 5
3
PRIMARY PREVENTION INTERVENTIONS ............................... 6
4
SECONDARY PREVENTION INTERVENTIONS ........................... 7
5
FURTHER INFORMATION ........................................................ 7
6
REFERENCES ........................................................................... 8
© 2010 Public Health Wales NHS Trust.
Material contained in this document may be reproduced without prior permission
provided it is done so accurately and is not used in a misleading context.
Acknowledgement to Public Health Wales NHS Trust to be stated.
Date: 3 Sep 2010
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Public Health Wales
1
Primary and secondary prevention of
respiratory infections
Background
This document has been produced to assist local health boards to
implement the Welsh Assembly Government’s, Designed for people with
chronic condition, Service development and commissioning directives,
Chronic respiratory conditions1, and should be read in conjunction with
that publication.
A key action identified in chapter 2: Prevention – reducing the risks (p.
22) of the publication is evidence-based primary and secondary
prevention1.
To supplement the evidence–base, and provide an overview of the topic,
information with regard to prevalence (where available); hospital
admissions (where information is available from Patient Episode Database
Wales - PEDW); and links to additional information resources have been
included. The links to the additional information resources is included to
indicate where further details, or management and treatment guidance
can be sought.
The information contained in this document is not exhaustive.
2
Respiratory infections
2.1
Introduction
Respiratory infection is any infection that occurs in the respiratory system.
A distinction is made between the upper respiratory tract, and the lower
respiratory tract2.
Common upper respiratory tract infections include2: the common cold;
sore throat; tonsillitis; sinusitis; laryngitis. Common lower respiratory
tract infections include2: bronchitis; pneumonia.
Infection such as influenza can affect both the upper and lower respiratory
tract2.
2.2
Search methodology
Search terms used: primary prevention, secondary prevention, respiratory
infections.
Search terms were kept broad to maximise retrieval of literature and
search limits set to retrieve papers published between January 2003 to
January 2010.
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Primary and secondary prevention of
respiratory infections
Electronic databases: Medline; Embase; Cochrane Database of Systematic
Reviews; Database of Abstracts of Reviews of Effects; Cochrane Central
Register of Controlled Trials and British Nursing Index.
Meta search engines: Turning Research Into Practice (TRIP); Google
Scholar; SUMsearch.
Websites: NHS Evidence; International Network of Agencies for Health
Technology Assessment (INAHTA); National Institute for Health and
Clinical Excellence (NICE); National Horizon Scanning Centre and Map of
Medicine; UpToDate.
2.3
Prevalence
The respiratory tract is more vulnerable to infection than other parts of
the body, and a common cause of illness. They are believed to be one of
the leading reasons why people visit their GP or pharmacist. The most
widespread respiratory tract infection is the common cold2.
Respiratory tract infections are more common during the winter, possibly
due to the tendency for people to remain indoors in close proximity with
each other2.
Children tend to get more upper respiratory tract infections than adults,
such as colds, probably because they have yet to build up immunity to the
many viruses that can cause infections2.
Most respiratory tract infections are self-limiting and outcomes are
generally good2. The at-risk groups who may be more vulnerable to
infection include1:
 very young;
 elderly;
 people with a pre-existing lung condition;
 people with a weakened immune system.
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2.4
Primary and secondary prevention of
respiratory infections
Hospital admissions
Figure 1: Persons admitted to hospital in Wales in 2008 with a principal
diagnosis of respiratory infection (ICD-10, J00-J06, J10-J18, J20, J22,
J30-J39, J40-J43) by Unitary Authority
Number of people admitted to hospital with a principal diagnosis of respiratory infection
2008
ys
er
ed
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ig
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en
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am
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le
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A
Admissions
4000
3500
3000
2500
2000
1500
1000
500
0
Unitary Authority
Figure 2: Persons admitted to hospital in Wales in 2008 with a principal
diagnosis of respiratory infection (ICD-10, J00-J06, J10-J18, J20, J22,
J30-J39, J40-J43) by Local Health Board
Number of people admitted to hospital with a principal diagnosis of respiratory infection
2008
9000
Admissions
8000
7000
6000
5000
4000
3000
2000
1000
0
Betsi
Cadwaladar
University
Powys
Hywel Dda
Abertawe Bro
Morganwwg
Cardiff and Vale
University
Cwm Taf
Aneurin Bevan
Local Health Board
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Primary and secondary prevention of
respiratory infections
Table 1: Persons admitted to hospital in Wales in 2008 with a principal
diagnosis of respiratory infection (ICD-10, J00-J06, J10-J18, J20, J22,
J30-J39, J40-J43)
Local Health Board
Betsi Cadwaladr University
Powys
Hywel Dda
Abertawe Bro Morgannwg
Cardiff and Vale University
Cwm Taf
Aneurin Bevan
Admission
s
949
1559
1431
1223
1549
1370
1373
550
1183
1927
2915
1585
1444
1425
3415
3388
817
1927
863
1073
801
1335
34102
Unitary Authority
Isle of Anglesey
Gwynedd
Conwy
Denbighshire
Flintshire
Wrexham
Powys
Ceredigion
Pembrokeshire
Carmarthenshire
Swansea
Neath Port Talbot
Bridgend
The Vale of Glamorgan
Cardiff
Rhondda Cynon Taff
Merthyr Tydfil
Caerphilly
Blaenau Gwent
Torfaen
Monmouthshire
Newport
Total
Source: PEDW
3
Primary prevention interventions
Studies of influenza infection have shown that vaccination of healthy
adults result in marked reductions in serologically confirmed influenza and
smaller reductions in clinical influenza3.
Most influenza-associated deaths occur in the elderly population and
studies have demonstrated effectiveness of vaccination in this population4.
A systematic review found that benefits of vaccination were more evident
on health-related outcomes of residents in long-term care facilities than in
healthy elderly individuals in the community. A pooled cohort study
published after the meta-analyses demonstrated a significant reduction in
mortality in vaccinated elderly individuals4.
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Primary and secondary prevention of
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There is guidance on the primary prevention of H1N1 influenza in nonhealthcare settings. The recommendations for prevention H1N1 influenza
are similar to those for controlling the spread of seasonal influenza5.
Vaccination for preventing pneumococcal infection has shown to be
effective in the prevention of pneumococcal infection in healthy adults, but
might not afford as much protection in adults with chronic conditions6.
In studies of pneumococcal vaccine for children and adults with
bronchiectasis, the authors conclude that given the limitations of the
evidence available, adults and children (when age appropriate) should be
vaccinated as per national guidelines7 - 9.
Cases and survivors of tuberculosis and HIV infections are increasing and
effective methods for notification, prevention, diagnosis and treatment are
required.
There are national guidelines available from the National
Institute of Health and Clinical Excellence (NICE)10.
A framework document for tuberculosis infections is currently being
produced by Public Health Wales NHS Trust.
4
Secondary prevention interventions
Secondary prevention is aimed at preventing the complications of
respiratory infections11.
Recurrent upper respiratory tract infections in children have an important
socioeconomic impact, with consequences on both the quality of life of the
children, the possible medical sequelae and the inherent direct and
indirect costs; they are also of significance in adults. The possibility to
prevent these infections is limited in the absence of specific vaccines
against micro-organisms responsible for most of the respiratory tract
infections (i.e. respiratory synctial virus, adenovirus, rhinovirus)11.
The early identification of pneumonia is vital to prevent sequelae of
infection. The classic symptoms and signs of pneumonia are however, less
likely in elderly patients and non-specific features, especially confusion,
are more likely. The 2009 British Thoracic Society (BTS) guidelines on
community acquired pneumonia provide guidance on validated methods
for the early recognition of pneumonia12.
5
Further information
British Lung Foundation
 Flu
http://www.lunguk.org/
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Primary and secondary prevention of
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British Thoracic Society:
 Guidelines for the management of community acquired pneumonia
in adults: 2009 update;
 Guidelines for the management of community acquired pneumonia
in children;
 Pandemic flu: clinical management of patients with influenza-like
illness during an influenza pandemic:
http://www.brit-thoracic.org.uk/library-guidelines.aspx
The Cochrane Organisation:
 Acute Respiratory infections Group:
http://www.cochrane.org/reviews/en/topics/48.html.
Map of Medicine:
 Community-acquired pneumonia:
http://nhsevidence.mapofmedicine.com/evidence/map/index.html
National electronic Library of Infection (NeLI):
 Factsheets and guidelines:
http://www.neli.org.uk/IntegratedCRD.nsf/NeLI_Home1?OpenForm
National Institute for Health and Clinical Excellence (NICE):
 Prescribing of antibiotics for self-limiting respiratory tract infections
in adults and children in primary care:
http://guidance.nice.org.uk/CG69/Guidance
 Clinical diagnosis and management of tuberculosis, and measures
for its prevention and control:
http://www.nice.org.uk/nicemedia/live/10980/30018/30018.pdf
Scottish Intercollegiate Guidelines Network (SIGN)
 Community management of lower respiratory tract infection in
adults.
http://www.sign.ac.uk/guidelines/fulltext/59/index.html
6
1.
References
Welsh Assembly Government. Designed for people with chronic
conditions. Service development and commissioning directive.
Chronic respiratory conditions. Cardiff: WAG; 2007. Available at:
http://wales.gov.uk/dhss/publications/health/strategies/chronicrespir
atory/respiratorye.pdf;jsessionid=2T6fLNkJTBJcQ0ZzBLgcJfCjsXtmc0K
0JKQvB4X1JnQp1hHbqZsG!-330498905?lang=en [Accessed 11th Mar
2010]
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2.
NHS choices. [Website]. Respiratory tract infection. Available at:
http://www.nhs.uk/conditions/Respiratory-tractinfection/Pages/Introduction.aspx[Accessed 16th Aug 2010]
3.
Jefferson T et al. Vaccines for preventing influenza in healthy adults.
Cochrane Database Syst Rev 2007, Issue 2. Art. No.: CD001269.
DOI: 10.1002/14651858.CD001269.pub3. Available at:
http://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD0012
69/pdf_fs.html [Accessed 16th Apr 2010]
4.
Nichol KL, Nordic JD, Nelson DB et al. Effectiveness of influenza
vaccine in the community-dwelling elderly. N Engl J Med 2007; 357:
1373-81
5.
BMJ Clinical Evidence. [Website]. BMJ Best Practice. 2009 Influenza A
(H1N1) virus. Primary prevention. Available at:
http://bestpractice.bmj.com/bestpractice/monograph/1178/prevention.html [Accessed 16th Apr 2010]
6.
Moberley S et al. Vaccines for preventing pneumococcal infection in
adults. Cochrane Database Syst Rev 2008, Issue 1. Art. No.:
CD000422. DOI: 10.1002/14651858.CD000422.pub2. Available at:
http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/C
D000422/pdf_fs.html [Accessed 16th Apr 2010]
7.
Chang CC et al. Pneumococcal vaccines for children and adults with
bronchiectasis. Cochrane Database Syst Rev 2009, Issue 2. Art. No.:
CD006316. DOI: 10.1002/14651858.CD006316.pub3. Available at:
http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD006316
/pdf_fs.html [Accessed 16th Apr 2010]
8.
Health Protection Agency. [Website]. Pneumococcal vaccination
recommendations. Who should be vaccinated? Available at:
http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/Pneu
mococcal/ [Accessed 16th Aug 2010]
9.
Public Health Wales NHS Trust. [Website]. Public Health Wales
Immunisation & Vaccine Preventable Disease Programme.
Pneumococcal disease. Available at:
http://howis.wales.nhs.uk/sites3/page.cfm?orgid=474&pid=21248
10. The National Collaborating Centre for Chronic Conditions.
Tuberculosis. Clinical diagnosis and management of tuberculosis, and
measures for its prevention and control. CG33. London: NICE; 2007.
Available at:
http://www.nice.org.uk/nicemedia/pdf/CG033FullGuideline.pdf
[Accessed 16th Apr 2010]
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11. National Institute for Health and Clinical Excellence. Respiratory tract
infections – antibiotic prescribing. Prescribing of antibiotics for selflimiting respiratory tract infections in adults and children in primary
care. CG69. London: NICE; 2008. Available at:
http://guidance.nice.org.uk/CG33 [Accessed 16th Apr 2010]
12. British Thoracic Society. Guidelines for the management of
community acquired pneumonia in adults: 2009 update. Thorax
2009; 64: Suppl. 111. Available at: http://www.britthoracic.org.uk/Portals/0/Clinical%20Information/Pneumonia/Guidelin
es/CAPGuideline-full.pdf [Accessed 16th Apr 2010]
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