Cigarette Smoking and Invasive Pneumococcal Disease
J. Pekka Nuorti, M.D., Jay C. Butler, M.D., Monica M. Farley, M.D., Lee H. Harrison, M.D., Allison McGeer, M.D., Margarette S. Kolczak, Ph.D., Robert F. Breiman, M.D., for The Active Bacterial Core Surveillance Team
Background Approximately half of otherwise healthy adults withinvasive pneumococcal disease are cigarette smokers. We conducteda population-based case–control study to assess the importanceof cigarette smoking and other factors as risk factors for pneumococcalinfections.
Methods We identified immunocompetent patients who were 18 to64 years old and who had invasive pneumococcal disease (as definedby the isolation of Streptococcus pneumoniae from a normallysterile site) by active surveillance of laboratories in metropolitanAtlanta, Baltimore, and Toronto. Telephone interviews were conductedwith 228 patients and 301 control subjects who were reachedby random-digit dialing.
Results Fifty-eight percent of the patients and 24 percent ofthe control subjects were current smokers. Invasive pneumococcaldisease was associated with cigarette smoking (odds ratio, 4.1;95 percent confidence interval, 2.4 to 7.3) and with passivesmoking among nonsmokers (odds ratio, 2.5; 95 percent confidenceinterval, 1.2 to 5.1) after adjustment by logistic-regressionanalysis for age, study site, and independent risk factors suchas male sex, black race, chronic illness, low level of education,and living with young children who were in day care. There weredose–response relations for the current number of cigarettessmoked per day, pack-years of smoking, and time since quitting.The adjusted population attributable risk was 51 percent forcigarette smoking, 17 percent for passive smoking, and 14 percentfor chronic illness.
Conclusions Cigarette smoking is the strongest independent riskfactor for invasive pneumococcal disease among immunocompetent,nonelderly adults. Because of the high prevalence of smokingand the large population attributable risk, programs to reduceboth smoking and exposure to environmental tobacco smoke havethe potential to reduce the incidence of pneumococcal disease.
The incidence of invasive pneumococcal disease is highest amongyoung children and the elderly. Although the rates are loweramong nonelderly adults, the absolute numbers of infectionsare highest in these adults, who may be at increased risk ifthey have chronic illness.1 The data on conditions predisposingnonelderly adults to pneumococcal infection have come from clinicalcase series and community-based surveillance studies and werenot adjusted for multiple risk factors.2,3 Up to one third ofadults with invasive pneumococcal disease have no recognizedrisk factors.4
Cigarette smoking and exposure to environmental tobacco smokeincrease the risk of certain respiratory tract infections.5,6,7,8,9Smokers account for approximately half of otherwise healthyadult patients with invasive pneumococcal disease.4,10 Characteristicsassociated with pneumococcal disease among adults, particularlybehavioral and socioeconomic factors, have not been evaluatedin controlled, population-based studies. To assess the contributionof active and passive smoking and other factors to the riskof invasive pneumococcal disease, we conducted a population-basedcase–control study.
Methods
Definition and Ascertainment of Cases
A case of invasive pneumococcal disease was defined as an illnessin which Streptococcus pneumoniae was isolated from a normallysterile site, such as blood or cerebrospinal fluid. Cases wereidentified prospectively among residents of metropolitan Atlanta,metropolitan Baltimore, and the Peel region of Toronto (aggregatepopulation in 1995, 8.3 million) through ongoing laboratory-basedsurveillance, as described previously.11 The study patientswere residents of the surveillance area who were 18 to 64 yearsof age, who had a telephone, and in whom an illness that metthe case definition of invasive pneumococcal disease developedbetween January 1995 and May 1996. Only community-acquired caseswere included. Patients were excluded if they had a recognizedcondition or treatment that led to immunocompromise or immunosuppression1(asplenia, immunoglobulin deficiency, dialysis, organ transplantation,the nephrotic syndrome, human immunodeficiency virus infection,the acquired immunodeficiency syndrome, hematologic cancer,radiation therapy, or immunosuppressive chemotherapy, includingcorticosteroids) or if they were residents of an institution,such as a correctional facility or a nursing home.
Selection of Patients
Each month we systematically selected a sample of approximately25 percent of all cases reported in each surveillance area.Of 513 patients included in the samples, 42 percent were ineligiblefor the following reasons: immunocompromise (25 percent), notelephone (16 percent), or residence in an institution (1 percent).Of 297 eligible patients, 228 (77 percent) agreed to participatein the study, 24 declined (8 percent), 6 had died (2 percent),and 39 were unreachable (13 percent). The rates of participationwere similar in all three areas. The patients who were interviewedwere similar with respect to age, race, and sex to the eligiblepatients who were not enrolled in the study.
Selection of Control Subjects
Control subjects were selected from the general population ineach surveillance area by random-digit telephone dialing.12They were frequency-matched to the patients according to themonth of positive culture (to account for seasonal variationin the incidence of invasive pneumococcal disease), area, andage group (18 to 29, 30 to 49, and 50 to 64 years), on the basisof the number of patients in each age group in the previousmonth. Each month, we attempted to enroll an equal number ofcontrol subjects and patients, using the same exclusion criteria.We called 7267 telephone numbers, of which 1367 were residentialnumbers. The respondents in 26 percent of the residences declinedto participate, and there was no eligible respondent in 52 percentof the residences. A total of 301 control subjects were interviewed.
Data Collection
Trained investigators obtained informed consent from the studysubjects and conducted interviews using a standard questionnaire.Participants were asked about chronic illnesses, environmentaland occupational exposures, and socioeconomic factors. Questionsconcerning cigarette smoking and alcohol consumption were adaptedfrom the Behavioral Risk Factor Surveillance System of the Centersfor Disease Control and Prevention (CDC).13 All questions referredto the month before the patient's illness. The median numberof days between a positive culture and the interview with thesubject was 47 days for patients and 58 days for controls. Thestudy was approved by the CDC and by the review board of eachinstitution.
Definitions of Cigarette Smoking
The study subjects were classified according to their smokingstatus.13 Current smokers reported having smoked at least 100cigarettes in their lifetime and still smoked or had quit smokingwithin the preceding year. Former smokers had smoked at least100 cigarettes in their lifetime but had quit smoking more thanone year earlier. Subjects who had smoked less than 100 cigarettesor who had never smoked were considered never to have smoked.For former smokers and those who had never smoked, exposureto environmental tobacco smoke was estimated by determiningthe number of people living in the household who smoked at home,the number of cigarettes smoked in the home each day, and thenumber of hours the subject spent daily outside the home ina place where people were smoking. We divided the subjects intofour categories of smoking status: current smokers, former smokers(with no passive exposure to smoke), persons with passive exposureto smoke (those who had never smoked or former smokers exposedto tobacco smoke for more than one hour daily), and personswho had never smoked and had no passive exposure to smoke (thereference group).
Statistical Analysis
Data were analyzed with SAS software (version 6.12, SAS Institute,Cary, N.C.) and Epi Info software (version 6.04). We used theMantel–Haenszel method to calculate summary odds ratiosafter adjustment for the frequency-matching variables age andstudy area.14 To control for confounding and to identify independentrisk factors, we used unconditional logistic-regression analysis.After assessing two-way interactions and collinearity amongvariables, we used hierarchical backward elimination to determinethe best fit for the model.15
Smoking status was the main variable analyzed. The followingcovariates included in the initial model were significantlyassociated with illness in the primary analysis or were consideredpotential confounders: study site, age, sex, race, level ofeducation, household income, presence or absence of chronicillness (heart failure, cirrhosis, diabetes, and chronic obstructivepulmonary disease, including chronic bronchitis and emphysema),presence or absence of asthma, level of alcohol consumption,presence or absence of children under six years of age in thehousehold, presence or absence of household crowding, and healthinsurance status. The likelihood-ratio test was used to assessthe statistical significance of each variable. All reportedP values are two-sided.
We calculated adjusted population attributable risks for independentrisk factors in the multivariable model.16 To examine whetherthere was a dose–response relation, we included both dichotomousand continuous components for each variable related to smoking(the number of cigarettes smoked, pack-years of smoking, andthe time since quitting) in the final model, simultaneouslytesting for an effect associated with smoking status (yes orno) and a dose–response relation.17 These models provideda much better fit than did models that used only the continuousvariables.
Results
Characteristics of Patients and Control Subjects
Between January 1995 and May 1996, a total of 2888 cases ofinvasive pneumococcal disease were identified, of which 1248(43 percent) occurred among persons who were 18 to 64 yearsof age. The annual incidence of invasive pneumococcal diseaseranged from 7.5 per 100,000 in Toronto to 21.8 per 100,000 inBaltimore (Table 1). In Atlanta and Baltimore, where the surveillancedata included information on race, the rates were 5 to 8 timesas high among blacks as among nonblacks and 1.7 times as highamong men as among women.
Table 1. Incidence of Invasive Pneumococcal Disease Overall and among Persons 18 to 64 Years Old, According to Race and Sex in Three Population-Based Surveillance Areas in 1995.
Among the 228 patients enrolled, 216 (95 percent) had bacteremia,10 (4 percent) had meningitis, and 2 (1 percent) had infectionsat other normally sterile sites. The patients were similar tothe 301 control subjects in age, but were more likely to bemale or black (Table 2). Overall, 23 percent of patients hadchronic illnesses (Table 3), and the proportion increased to44 percent among patients who were 50 to 64 years of age. Whenpersons classified as heavy drinkers were included (those whoconsumed 25 or more drinks per week), 28 percent of patientshad an indication for the receipt of pneumococcal vaccine.1Current smokers accounted for 58 percent of all patients, 57percent of the 164 patients who did not have an indication forthe receipt of pneumococcal vaccine, and 24 percent of the controlsubjects. Although chronic obstructive pulmonary disease (P<0.001)and chronic illness (P<0.001) were strongly associated withsmoking, only 13 percent of all smokers had chronic lung disease;23 percent had at least one chronic illness. Among persons whohad an indication for vaccination, six patients (9 percent)and three control subjects (11 percent) reported having receivedthe vaccine.
Table 3. Demographic, Medical, and Socioeconomic Characteristics Associated with Invasive Pneumococcal Disease in Immunocompetent Adults 18 to 64 Years Old.
Among the patients, 57 percent of the men, 59 percent of thewomen, 64 percent of the nonblacks, and 51 percent of the blackswere current smokers. Among the control subjects, 26 percentof the men, 26 percent of the women, 24 percent of the blacks,and 25 percent of the nonblacks were current smokers. Patientswere as likely as control subjects to be former smokers (Table 3),but the average time since patients had stopped smokingwas 11.3 years, as compared with 17.0 years for the controlsubjects (P= 0.005). Among 318 nonsmokers, 33 percent of patientsand 17 percent of control subjects were exposed to environmentaltobacco smoke. These patients and control subjects were similarwith respect to the mean daily duration of passive exposureto smoke outside the home (3.7 vs. 3.1 hours, P=0.48) and themean number of cigarettes smoked daily by others in their home(14 vs. 16, P=0.42).
Stratified Analysis
After adjustment for age and study area, current smoking wasstrongly associated with pneumococcal disease (Table 3). Passivesmoking was also associated with illness, but the point estimatewas lower; the odds ratios were similar for persons who wereexposed to smoke only at home and those who were exposed tosmoke only outside the home. Other characteristics associatedwith pneumococcal disease included chronic illness, particularlychronic obstructive pulmonary disease and cirrhosis, livingwith children under the age of six years who attended day-carecenters, and characteristics associated with low socioeconomicstatus (low educational level and low income, lack of healthinsurance [or only Medicaid coverage], and household crowding).Patients were less likely than control subjects to consume moderateamounts of alcohol and were more likely to be heavy drinkers.
Multivariable Analysis
Covariates that were not significant (by the likelihood-ratiotest) were removed from the initial model in the following sequence:household crowding, health insurance status, annual householdincome, level of alcohol consumption, and presence or absenceof asthma. The elimination of these variables did not appreciablychange the regression coefficients for the independent riskfactors included in the final model (Table 4). Patients were4.1 times as likely as control subjects to be current smokers(95 percent confidence interval, 2.4 to 7.3). Nonsmoking patientswere 2.5 times as likely to be exposed to environmental tobaccosmoke as nonsmoking controls (95 percent confidence interval,1.2 to 5.1). When they were entered into the model individually,the effects of chronic obstructive pulmonary disease, heartfailure, cirrhosis, and diabetes were not significant. However,when these variables were incorporated into the predefined variableof chronic illness, the presence of chronic illness was a significantindependent risk factor (P=0.005). In addition, male sex, blackrace, and a low level of education were significantly associatedwith pneumococcal disease. Patients were 3.0 times as likelyas control subjects to live in a household with children underthe age of six years who were in day care (95 percent confidenceinterval, 1.5 to 6.2). This association was strongest amongpatients who were 18 to 49 years of age. The population attributablerisks for independent risk factors in the multivariable modelwere 51 percent for cigarette smoking, 17 percent for passivesmoking (among nonsmokers), 14 percent for chronic illness,57 percent for chronic illness and smoking combined, and 11percent for living with young children who were in day care.
Table 4. Independent Risk Factors for Invasive Pneumococcal Disease among Immunocompetent Adults 18 to 64 Years Old.
Dose–Response Relations
Among current smokers, the adjusted odds ratios for invasivepneumococcal disease increased steadily from 2.3 to 5.5 withincreases in the number of cigarettes smoked daily, suggestinga dose–response relation (Table 5). As compared with notsmoking, an increased risk of invasive pneumococcal diseasewas observed for smoking cigarettes, and the risk increasedlinearly with increases in the number of cigarettes smoked (P<0.001).Among current and former smokers, the multivariate adjustedodds ratios increased from 1.5 to 3.2 with increasing numberof pack-years of smoking (P=0.002), a finding also consistentwith a dose–response relation. Although former smokerswere not at increased risk overall, an association was observedwith the length of time since quitting (P= 0.001). The riskof pneumococcal disease decreased by 14 percent per year afterthe subjects quit smoking, returning to the level of those whohad never smoked after approximately 13 years. Among nonsmokers,the risk increased with an increasing duration of passive exposureto smoke.
Table 5. Relation of the Intensity of Cigarette Smoking, Cumulative Exposure, Reversible Exposure, and Passive Smoking to the Risk of Invasive Pneumococcal Disease.
Discussion
Our results indicate that cigarette smoking is the strongestindependent risk factor for invasive pneumococcal disease amongimmunocompetent, nonelderly adults and that 51 percent of thedisease burden in this population group can be attributed statisticallyby this modifiable risk factor. We found that the current numberof cigarettes smoked per day, the number of pack-years of smoking,and the time since quitting showed clear dose–responserelations with the risk of pneumococcal disease. Increased riskwas also independently associated with exposure to environmentaltobacco smoke, chronic illness, a low level of education, blackrace, male sex, and living with young children who were in daycare.
Differences in the distribution of factors associated with bothsmoking and pneumococcal disease, such as chronic illness (particularlychronic lung disease), alcohol consumption, and low socioeconomicstatus, could confound the association with smoking. However,adjustment for multiple demographic, medical, and socioeconomiccharacteristics did not appreciably change the crude estimates,suggesting that confounding by these factors was relativelyminor.
In most areas of the United States, more than 90 percent ofadults live in households with telephones, and control subjectsselected by random-digit dialing have been shown to be representativeof the general population in most respects.18 However, thismethod necessarily excludes people without telephones, suchas the homeless. Although random-digit dialing may have resultedin overrepresentation of women, the selection of controls wasunlikely to depend on exposure status, and the missing informationon the sex of the control subjects was probably nondifferential.The effects of sex and race were controlled for in multivariableanalysis. Among selected control subjects, the proportions ofblacks, current smokers, former smokers, and persons who hadnever smoked (with stratification according to sex and race)were similar to those among adults in the general populationof the surveillance areas,13 suggesting that the sample wasrepresentative. In addition, the estimates of the effects ofsmoking were consistently similar in different demographic groups(data not shown). The prevalence of moderate alcohol consumptionand of abstinence among the controls was also similar to thatin the general-population estimates,13 but underreporting andmisclassification are possible, particularly among heavy drinkers.Heavy use of alcohol has been associated with pneumococcal infectionsin other studies.3,10 Because of the small number of personswho reported heavy drinking, our study did not have the statisticalpower to assess the relation between smoking and heavy consumptionof alcohol.
The rates of disease in our study and in other studies2,4,10were higher among men and blacks. Male sex and black race remainedindependent risk factors even after adjustment for possibleconfounders. The reasons for geographic variation in the reportedincidence of pneumococcal disease are unclear. Because the surveillancemethods in each study area were standardized and had a highsensitivity,11 the differences in rates between the U.S. sitesand the Canadian site may reflect differences in clinical practice(such as the frequency of obtaining blood for cultures frompatients with pneumonia) or the racial or ethnic compositionof the populations.
Exposure to environmental tobacco smoke is widespread in boththe home and the workplace.19 Among children, parental smokinghas been linked with certain respiratory illnesses.5,20,21,22Among adults, passive smoking has also been implicated as arisk factor for meningococcal disease, but the association withpneumococcal disease has not been reported.23,24
The specific biologic mechanisms by which exposure to tobaccosmoke increases the risk of pneumococcal disease are poorlyunderstood. Cigarette smoke impairs mucociliary clearance, enhancesbacterial adherence, and disrupts the respiratory epithelium.25,26,27,28In some studies, smokers had serum immunoglobulin levels thatwere 10 to 20 percent lower than those of nonsmokers.29,30 However,smokers also had increased levels of pneumococcal antibodies,possibly as a consequence of frequent respiratory tract infectionsor higher rates of carriage.31
Higher rates of nasopharyngeal colonization with meningococcushave been observed among active and passive smokers than amongnonsmokers.32,33 Exposure to pneumococcus is common, and insome studies, smokers had higher rates of pneumococcal carriagethan nonsmokers.34,35 Smokers may be more susceptible than nonsmokersto viral infections of the respiratory tract, such as influenza,36,37and a recent history of an upper respiratory tract illness ora coexisting illness may increase the risk of invasive pneumococcaldisease.38,39
Young children who attend day-care centers are at increasedrisk for invasive pneumococcal disease.40,41 We found an increasedrisk of disease among adults who lived with children who attendedday-care centers, and the risk is probably associated with increasedexposure to colonizing bacteria. The carriage rates of S. pneumoniaeare highest among young children and are higher among adultswith preschool children than among adults without preschoolchildren.42 In some studies, children attending day-care centershad higher rates of carriage than those who were not in daycare.43,44
The rates of pneumococcal disease are higher in low-income censustracts than in those with high incomes.2,10,45,46 After adjustmentfor other covariates in the multivariable model, a low householdincome was not significantly associated with the risk of illness,but a low level of education was a strong independent risk factor.The prevalence of smoking varies inversely with the level ofeducation,47,48,49 which is the most commonly used measure ofsocioeconomic status.50 The level of education is more consistentlyassociated with illness and risk factors (such as cigarettesmoking) than is income or occupation.51
Smoking is the most common cause of chronic obstructive pulmonarydisease, and the rate of pneumococcal disease is high amongpatients with chronic obstructive pulmonary disease,10,52 probablybecause of defective clearance mechanisms. Although chroniclung disease is an important confounder, the numbers of studysubjects with chronic obstructive pulmonary disease or otherspecific chronic medical conditions were too small for an independentanalysis in the multivariable model. In our study, only 13 percentof current smokers had chronic lung disease. The presence ofany chronic illness for which pneumococcal vaccine is recommendedwas an independent risk factor for invasive pneumococcal disease,but the population attributable risk was relatively low becauseof the low prevalence in the age group studied.
Fewer than one third of the patients had a condition for whichpneumococcal vaccine is recommended.1 Although our study wasnot specifically designed to ascertain vaccination status orevaluate the efficacy of vaccination,53 the self-reported prevalenceof pneumococcal vaccination was similar to that in nationalsurveys in this age group (CDC: unpublished data). Because thevaccine is effective against bacteremia among immunocompetentadults,53,54 persons with underlying chronic illnesses shouldbe vaccinated.1 Our results support the evaluation of persons50 years of age for indications for pneumococcal vaccine,1,55because of the high prevalence of risk factors in this group.Although the risk of pneumococcal disease decreased with timesince quitting smoking, former smokers appear to be at increasedrisk for at least 10 years after they quit. Therefore, it maybe reasonable to incorporate the pneumococcal vaccine into smoking-cessationprograms as well as to consider vaccinating those who continueto smoke.
Our study documents yet another example of an adverse healtheffect linked to active and passive smoking. In 1995, 47 millionadult Americans, about one fourth of the U.S. adult population,smoked cigarettes.49 Because of the high prevalence of smokingand the high population attributable risk for smoking, the implicationsof our results for prevention are important. Reducing the prevalenceof cigarette smoking to 15 percent56 could reduce the incidenceof invasive pneumococcal disease among nonelderly adults byapproximately 18 percent, preventing approximately 4000 casesin the United States annually (CDC: unpublished data). Studiesshould be conducted to determine how the incidence of pneumococcaldisease is affected by programs to prevent people from startingsmoking and to encourage smoking cessation,57 as well as byregulatory approaches intended to reduce both smoking and exposureto environmental smoke.19 Our findings may also be of interestto advisory bodies that are responsible for formulating recommendationsfor pneumococcal vaccination.
Supported in part by the National Vaccine Program Office andthe National Center for Infectious Diseases Emerging InfectionsProgram, Centers for Disease Control and Prevention, Atlanta.
We are indebted to Marc Fischer, Ramon Guevara, Malinda Kennedy,Orin Levine, and Carolyn Wright of the Centers for Disease Controland Prevention in Atlanta for their assistance in the investigationand to the staffs of the hospitals and laboratories and theinfection-control practitioners in the surveillance areas fortheir assistance in identifying cases.
* The members of the Active Bacterial Core Surveillance Team arelisted in the Appendix.
Source Information
From the Respiratory Diseases Branch, Division of Bacterial and Mycotic Diseases, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta (J.P.N., J.C.B., M.S.K., R.F.B.); Emory University School of Medicine and Atlanta Veterans Affairs Medical Center, Atlanta (M.M.F.); Johns Hopkins University School of Hygiene and Public Health, Baltimore (L.H.H.); and Mount Sinai Hospital, Toronto (A.M.).
Address reprint requests to Dr. Butler at the Arctic Investigations Program, National Center for Infectious Diseases, Centers for Disease Control and Prevention, 4055 Tudor Centre Dr., Anchorage, AK 99508-5902, or at jcb3{at}cdc.gov.
References
Prevention of pneumococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep 1997;46:1-24. [Medline]
Breiman RF, Spika JS, Navarro VJ, Darden PM, Darby CP. Pneumococcal bacteremia in Charleston County, South Carolina: a decade later. Arch Intern Med 1990;150:1401-1405. [Free Full Text]
Burman LA, Norrby R, Trollfors B. Invasive pneumococcal infections: incidence, predisposing factors, and prognosis. Rev Infect Dis 1985;7:133-142. [Medline]
Plouffe JF, Breiman RF, Facklam RR. Bacteremia with Streptococcus pneumoniae: implications for therapy and prevention. JAMA 1996;275:194-198. [Free Full Text]
Hirschtick RE, Glassroth J, Jordan MC, et al. Bacterial pneumonia in persons infected with the human immunodeficiency virus. N Engl J Med 1995;333:845-851. [Free Full Text]
Fischer M, Hedberg K, Cardosi P, et al. Tobacco smoke as a risk factor for meningococcal disease. Pediatr Infect Dis J 1997;16:979-983. [CrossRef][Medline]
Imrey PB, Jackson LA, Ludwinski PH, et al. An outbreak of serogroup C meningococcal disease associated with campus bar patronage. Am J Epidemiol 1996;143:624-630. [Free Full Text]
Stanwell-Smith RE, Stuart JM, Hughes AO, Robinson P, Griffin MB, Cartwright K. Smoking, the environment and meningococcal disease: a case control study. Epidemiol Infect 1994;112:315-328. [Medline]
Straus WL, Plouffe JF, File TM Jr, et al. Risk factors for domestic acquisition of legionnaires' disease. Arch Intern Med 1996;156:1685-1692. [Free Full Text]
Pastor P, Medley F, Murphy TV. Invasive pneumococcal disease in Dallas County, Texas: results from population-based surveillance in 1995. Clin Infect Dis 1998;26:590-595. [Medline]
Schuchat A, Robinson K, Wenger JD, et al. Bacterial meningitis in the United States in 1995. N Engl J Med 1997;337:970-976. [Free Full Text]
Hartge P, Brinton LA, Rosenthal JF, Cahill JI, Hoover RN, Waksberg J. Random digit dialing in selecting a population-based control group. Am J Epidemiol 1984;120:825-833. [Free Full Text]
State- and sex-specific prevalence of selected characteristics -- Behavioral Risk Factor Surveillance System, 1994 and 1995. Mor Mortal Wkly Rep CDC Surveill Summ 1997;46:1-29.
Schlesselman JJ. Case-control studies: design, conduct, analysis. New York: Oxford University Press, 1982:181-200.
Kleinbaum DG, Kupper LL, Morgenstern H. Epidemiologic research: principles and quantitative methods. Belmont, Calif.: Lifetime Learning, 1982:320-76.
Bruzzi P, Green SB, Byar DP, Brinton LA, Schairer C. Estimating the population attributable risk for multiple risk factors using case-control data. Am J Epidemiol 1985;122:904-914. [Free Full Text]
Gwinn ML, Lee NC, Rhodes PH, Layde PM, Rubin GL. Pregnancy, breast feeding, and oral contraceptives and the risk of epithelial ovarian cancer. J Clin Epidemiol 1990;43:559-568. [CrossRef][Medline]
Olson SH, Kelsey JL, Pearson TA, Levin B. Evaluation of random digit dialing as a method of control selection in case-control studies. Am J Epidemiol 1992;135:210-222. [Free Full Text]
Pirkle JL, Flegal KM, Bernert JT, Brody DJ, Etzel RA, Maurer KR. Exposure of the US population to environmental tobacco smoke -- the Third National Health and Nutrition Examination Survey, 1988 to 1991. JAMA 1996;275:1233-1240. [Free Full Text]
Margolis PA, Keyes LL, Greenberg RA, Bauman KE, LaVange LM. Urinary cotinine and parent history (questionnaire) as indicators of passive smoking and predictors of lower respiratory illness in infants. Pediatr Pulmonol 1997;23:417-423. [CrossRef][Medline]
O'Dempsey TJD, McArdle TF, Morris J, et al. A study of risk factors for pneumococcal disease among children in a rural area of West Africa. Int J Epidemiol 1996;25:885-893. [Free Full Text]
Stuart JM, Cartwright KAV, Dawson JA, Rickard J, Noah ND. Risk factors for meningococcal disease: a case control study in southwest England. Community Med 1988;10:139-146. [Medline]
Tappero JW, Reporter R, Wenger JD, et al. Meningococcal disease in Los Angeles County, California, and among men in the county jails. N Engl J Med 1996;335:833-840. [Free Full Text]
Fainstein V, Musher D. Bacterial adherence to pharyngeal cells in smokers, nonsmokers, and chronic bronchitics. Infect Immun 1979;26:178-182. [Free Full Text]
Dye JA, Adler KB. Effects of cigarette smoke on epithelial cells of the respiratory tract. Thorax 1994;49:825-834. [Free Full Text]
Green GM, Carolin D. The depressant effect of cigarette smoke on the in vitro antibacterial activity of alveolar macrophages. N Engl J Med 1967;276:421-427.
Raman AS, Swinburne AJ, Fedullo AJ. Pneumococcal adherence to the buccal epithelial cells of cigarette smokers. Chest 1983;83:23-27. [Free Full Text]
Holt PG. Immune and inflammatory function in cigarette smokers. Thorax 1987;42:241-249. [Free Full Text]
Mili F, Flanders WD, Boring JR, Annest JL, Destefano F. The associations of race, cigarette smoking, and smoking cessation to measures of the immune system in middle-aged men. Clin Immunol Immunopathol 1991;59:187-200. [CrossRef][Medline]
Sankilampi U, Isoaho R, Bloigu A, Kivela S-L, Leinonen M. Effect of age, sex and smoking habits on pneumococcal antibodies in an elderly population. Int J Epidemiol 1997;26:420-427. [Free Full Text]
Stuart JM, Cartwright KAV, Robinson PM, Noah ND. Effect of smoking on meningococcal carriage. Lancet 1989;2:723-725. [Medline]
Thomas JC, Bendana NS, Waterman SH, et al. Risk factors for carriage of meningococcus in the Los Angeles County men's jail system. Am J Epidemiol 1991;133:286-295. [Free Full Text]
Janoff EN, O'Brien J, Thompson P, et al. Streptococcus pneumoniae colonization, bacteremia, and immune response among persons with human immunodeficiency virus infection. J Infect Dis 1993;167:49-56. [Medline]
Rodriguez-Barradas MC, Tharapel RA, Groover JE, et al. Colonization by Streptococcus pneumoniae among human immunodeficiency virus-infected adults: prevalence of antibiotic resistance, impact of immunization, and characterization by polymerase chain reaction with BOX primers of isolates from persistent S. pneumoniae carriers. J Infect Dis 1997;175:590-597. [Medline]
Finklea JF, Sandifer SH, Smith DD. Cigarette smoking and epidemic influenza. Am J Epidemiol 1969;90:390-399. [Free Full Text]
Kark JD, Lebiush M, Rannon L. Cigarette smoking as a risk factor for epidemic A(H1N1) influenza in young men. N Engl J Med 1982;307:1042-1046. [Abstract]
Musher DM, Groover JE, Reichler MR, et al. Emergence of antibody to capsular polysaccharides of Streptococcus pneumoniae during outbreaks of pneumonia: association with nasopharyngeal colonization. Clin Infect Dis 1997;24:441-446. [Medline]
Kim PE, Musher DM, Glezen WP, Rodriguez-Barradas MC, Nahm WK, Wright CE. Association of invasive pneumococcal disease with season, atmospheric conditions, air pollution, and the isolation of respiratory viruses. Clin Infect Dis 1996;22:100-106. [Medline]
Takala AK, Jero J, Kela E, Ronnberg P-R, Koskenniemi E, Eskola J. Risk factors for primary invasive pneumococcal disease among children in Finland. JAMA 1995;273:859-864. [Free Full Text]
Levine OS, Farley M, Harrison LH, Lefkowitz L, McGeer A, Schwartz B. Risk factors for invasive pneumococcal disease in children: a population-based case-control study in North America. Pediatrics 1999;103:656-656.http://www.pediatrics.org/cgi/content/full/103/3/e28abstract
Hendley JO, Sande MA, Stewart PM, Gwaltney JM Jr. Spread of Streptococcus pneumoniae in families. I. Carriage rates and distribution of types. J Infect Dis 1975;132:55-61. [Medline]
Henderson FW, Gilligan PH, Wait K, Goff DA. Nasopharyngeal carriage of antibiotic-resistant pneumococci by children in group day care. J Infect Dis 1988;157:256-263. [Medline]
Dagan R, Melamed R, Muallem M, Piglansky L, Yagupsky P. Nasopharyngeal colonization in southern Israel with antibiotic-resistant pneumococci during the first 2 years of life: relation to serotypes likely to be included in pneumococcal conjugate vaccines. J Infect Dis 1996;174:1352-1355. [Medline]
Chen FM, Breiman RF, Farley M, Plikaytis B, Deaver K, Cetron MS. Geocoding and linking data from population-based surveillance and the US Census to evaluate the impact of median household income on the epidemiology of invasive Streptococcus pneumoniae infections. Am J Epidemiol 1998;148:1212-1218. [Free Full Text]
Nuorti JP, Butler JC, Gelling L, Kool JL, Reingold AL, Vugia DJ. Epidemiologic relation between HIV and invasive pneumococcal disease in San Francisco County, California. Ann Intern Med 2000;132:182-190. [Free Full Text]
Zhu B, Giovino GA, Mowery PD, Eriksen MP. The relationship between cigarette smoking and education revisited: implications for categorizing persons' educational status. Am J Public Health 1996;86:1582-1589. [Erratum, J Public Health 1997;87:168.] [Free Full Text]
Escobedo LG, Zhu B-P, Giovino GA, Eriksen MP. Educational attainment and racial differences in cigarette smoking. J Natl Cancer Inst 1995;87:1552-1553. [Free Full Text]
Cigarette smoking among adults -- United States, 1995. MMWR Morb Mortal Wkly Rep 1997;46:1217-1220. [Medline]
Liberatos P, Link BG, Kelsey JL. The measurement of social class in epidemiology. Epidemiol Rev 1988;10:87-121. [Free Full Text]
Winkleby MA, Jatulis DE, Frank E, Fortmann SP. Socioeconomic status and health: how education, income, and occupation contribute to risk factors for cardiovascular disease. Am J Public Health 1992;82:816-820. [Free Full Text]
Lipsky BA, Boyko EJ, Inui TS, Koepsell TD. Risk factors for acquiring pneumococcal infections. Arch Intern Med 1986;146:2179-2185. [Free Full Text]
Shapiro ED, Berg AT, Austrian R, et al. The protective efficacy of polyvalent pneumococcal polysaccharide vaccine. N Engl J Med 1991;325:1453-1460. [Abstract]
Butler JC, Breiman RF, Campbell JF, Lipman HB, Broome CV, Facklam RR. Pneumococcal polysaccharide vaccine efficacy: an evaluation of current recommendations. JAMA 1993;270:1826-1831. [Free Full Text]
ACP Task Force on Adult Immunization, Infectious Diseases Society of America. Guide for adult immunization. 3rd ed. Philadelphia: American College of Physicians, 1994:107-14.
Public Health Service. Healthy People 2000: national health promotion and disease prevention objectives. Washington, D.C.: Government Printing Office, 1991. (DHHS publication no. (PHS) 91-50212.)
Cigarette smoking-attributable mortality and years of potential life lost -- United States, 1990. MMWR Morb Mortal Wkly Rep 1993;42:645-649. [Medline]
Appendix
The members of the Active Bacterial Core Surveillance Team areas follows: Atlanta Veterans Affairs Medical Center, Atlanta— W.S. Baughman and L. Rhodes; Johns Hopkins UniversitySchool of Hygiene and Public Health, Baltimore — L. Billmann;Maryland Department of Health and Mental Hygiene, Baltimore— D.M. Dwyer; Princess Margaret Hospital, Toronto —E. Goldenberg; Centers for Disease Control and Prevention, Atlanta— A. Kraus, B. Plikaytis, K. Robinson, and A. Schuchat.
Suzuki, M, Thiem, V D, Yanai, H, Matsubayashi, T, Yoshida, L-M, Tho, L H, Minh, T T, Anh, D D, Kilgore, P E, Ariyoshi, K
(2009). Association of environmental tobacco smoking exposure with an increased risk of hospital admissions for pneumonia in children under 5 years of age in Vietnam. Thorax
64: 484-489
[Abstract][Full Text]
Giebelen, I. A. J., Leendertse, M., Florquin, S., van der Poll, T.
(2009). Stimulation of acetylcholine receptors impairs host defence during pneumococcal pneumonia. Eur Respir J
33: 375-381
[Abstract][Full Text]
Herr, C, Beisswenger, C, Hess, C, Kandler, K, Suttorp, N, Welte, T, Schroeder, J-M, Vogelmeier, C, Group, R B. f. t. C. S.
(2009). Suppression of pulmonary innate host defence in smokers. Thorax
64: 144-149
[Abstract][Full Text]
Poland, G. A., Schaffner, W.
(2009). Immunization Guidelines for Adult Patients: An Annual Update and a Challenge. ANN INTERN MED
150: 53-54
[Full Text]
Severance, E. G., Bossis, I., Dickerson, F. B., Stallings, C. R., Origoni, A. E., Sullens, A., Yolken, R. H., Viscidi, R. P.
(2008). Development of a Nucleocapsid-Based Human Coronavirus Immunoassay and Estimates of Individuals Exposed to Coronavirus in a U.S. Metropolitan Population. CVI
15: 1805-1810
[Abstract][Full Text]
Simell, B., Lahdenkari, M., Reunanen, A., Kayhty, H., Vakevainen, M.
(2008). Effects of Ageing and Gender on Naturally Acquired Antibodies to Pneumococcal Capsular Polysaccharides and Virulence-Associated Proteins. CVI
15: 1391-1397
[Abstract][Full Text]
Kroening, P. R., Barnes, T. W., Pease, L., Limper, A., Kita, H., Vassallo, R.
(2008). Cigarette Smoke-Induced Oxidative Stress Suppresses Generation of Dendritic Cell IL-12 and IL-23 through ERK-Dependent Pathways. J. Immunol.
181: 1536-1547
[Abstract][Full Text]
Benfield, T., Lange, P., Vestbo, J.
(2008). COPD Stage and Risk of Hospitalization for Infectious Disease. Chest
134: 46-53
[Abstract][Full Text]
Almirall, J., Bolibar, I., Serra-Prat, M., Roig, J., Hospital, I., Carandell, E., Agusti, M., Ayuso, P., Estela, A., Torres, A., the Community-Acquired Pneumonia in Catalan Countr,
(2008). New evidence of risk factors for community-acquired pneumonia: a population-based study. Eur Respir J
31: 1274-1284
[Abstract][Full Text]
Bliss, S. J., Larzalere-Hinton, F., Lacapa, R., Eagle, K. R., Frizzell, F., Parkinson, A., Reid, R., Craig, M., Santosham, M., O'Brien, K. L.
(2008). Invasive Pneumococcal Disease Among White Mountain Apache Adults, 1991-2005. Arch Intern Med
168: 749-755
[Abstract][Full Text]
Cardozo, D. M., Nascimento-Carvalho, C. M., Andrade, A.-L. S. S., Silvany-Neto, A. M., Daltro, C. H. C., Brandao, M.-A. S., Brandao, A. P., Brandileone, M.-C. C.
(2008). Prevalence and risk factors for nasopharyngeal carriage of Streptococcus pneumoniae among adolescents. J Med Microbiol
57: 185-189
[Abstract][Full Text]
Watt, J. P., O'Brien, K. L., Benin, A. L., McCoy, S. I., Donaldson, C. M., Reid, R., Schuchat, A., Zell, E. R., Hochman, M., Santosham, M., Whitney, C. G.
(2007). Risk Factors for Invasive Pneumococcal Disease among Navajo Adults. Am J Epidemiol
166: 1080-1087
[Abstract][Full Text]
Lyytikainen, O., Klemets, P., Ruutu, P., Kaijalainen, T., Rantala, M., Ollgren, J., Nuorti, J. P.
(2007). Defining the Population-Based Burden of Nosocomial Pneumococcal Bacteremia. Arch Intern Med
167: 1635-1640
[Abstract][Full Text]
Woodhead, M.
(2007). Inhaled Corticosteroids Cause Pneumonia ...or Do They?. Am. J. Respir. Crit. Care Med.
176: 111-112
[Full Text]
Benowitz, N. L.
(2007). Cigarette Smoking and the Personalization of Irinotecan Therapy. JCO
25: 2646-2647
[Full Text]
Diaz, A., Barria, P., Niederman, M., Restrepo, M. I., Dreyse, J., Fuentes, G., Couble, B., Saldias, F.
(2007). Etiology of Community-Acquired Pneumonia in Hospitalized Patients in Chile: The Increasing Prevalence of Respiratory Viruses Among Classic Pathogens. Chest
131: 779-787
[Abstract][Full Text]
Tonnesen, P., Carrozzi, L., Fagerstrom, K. O., Gratziou, C., Jimenez-Ruiz, C., Nardini, S., Viegi, G., Lazzaro, C., Campell, I. A., Dagli, E., West, R.
(2007). Smoking cessation in patients with respiratory diseases: a high priority, integral component of therapy. Eur Respir J
29: 390-417
[Abstract][Full Text]
Booy, R., Iskander, M., Viner, R., Senanayake, S. N., Gardner, P.
(2007). Prevention of Meningococcal Disease. NEJM
356: 524-526
[Full Text]
Jaakkola, M. S., Jaakkola, J. J. K.
(2006). Impact of smoke-free workplace legislation on exposures and health: possibilities for prevention.. Eur Respir J
28: 397-408
[Abstract][Full Text]
de Roux, A., Cavalcanti, M., Marcos, M. A., Garcia, E., Ewig, S., Mensa, J., Torres, A.
(2006). Impact of Alcohol Abuse in the Etiology and Severity of Community-Acquired Pneumonia. Chest
129: 1219-1225
[Abstract][Full Text]
Kum-Nji, P., Meloy, L., Herrod, H. G.
(2006). Environmental Tobacco Smoke Exposure: Prevalence and Mechanisms of Causation of Infections in Children. Pediatrics
117: 1745-1754
[Abstract][Full Text]
Kyaw, M. H., Lynfield, R., Schaffner, W., Craig, A. S., Hadler, J., Reingold, A., Thomas, A. R., Harrison, L. H., Bennett, N. M., Farley, M. M., Facklam, R. R., Jorgensen, J. H., Besser, J., Zell, E. R., Schuchat, A., Whitney, C. G., Active Bacterial Core Surveillance of the Emerging,
(2006). Effect of Introduction of the Pneumococcal Conjugate Vaccine on Drug-Resistant Streptococcus pneumoniae. NEJM
354: 1455-1463
[Abstract][Full Text]
Coen, P. G, Tully, J., Stuart, J. M, Ashby, D., Viner, R. M, Booy, R.
(2006). Is it exposure to cigarette smoke or to smokers which increases the risk of meningococcal disease in teenagers?. Int J Epidemiol
35: 330-336
[Abstract][Full Text]
Tully, J., Viner, R. M, Coen, P. G, Stuart, J. M, Zambon, M., Peckham, C., Booth, C., Klein, N., Kaczmarski, E., Booy, R.
(2006). Risk and protective factors for meningococcal disease in adolescents: matched cohort study. BMJ
332: 445-450
[Abstract][Full Text]
Palmer, K. T., McNeill-Love, R., Poole, J. R., Coggon, D., Frew, A. J., Linaker, C. H., Shute, J. K.
(2006). Inflammatory responses to the occupational inhalation of metal fume. Eur Respir J
27: 366-373
[Abstract][Full Text]
Fry, A. M., Shay, D. K., Holman, R. C., Curns, A. T., Anderson, L. J.
(2005). Trends in Hospitalizations for Pneumonia Among Persons Aged 65 Years or Older in the United States, 1988-2002. JAMA
294: 2712-2719
[Abstract][Full Text]
File, T. M. Jr, Tan, J. S.
(2005). Pneumonia in Older Adults: Reversing the Trend. JAMA
294: 2760-2763
[Full Text]
Woodhead, M., Blasi, F., Ewig, S., Huchon, G., Leven, M., Ortqvist, A., Schaberg, T., Torres, A., van der Heijden, G., Verheij, T. J. M.
(2005). Guidelines for the management of adult lower respiratory tract infections. Eur Respir J
26: 1138-1180
[Abstract][Full Text]
Talbot, T. R., Hartert, T. V., Mitchel, E., Halasa, N. B., Arbogast, P. G., Poehling, K. A., Schaffner, W., Craig, A. S., Griffin, M. R.
(2005). Asthma as a Risk Factor for Invasive Pneumococcal Disease. NEJM
352: 2082-2090
[Abstract][Full Text]
Birtles, A., McCarthy, N., Sheppard, C. L., Rutter, H., Guiver, M., Haworth, E., George, R. C.
(2005). Multilocus Sequence Typing Directly on DNA from Clinical Samples and a Cultured Isolate To Investigate Linked Fatal Pneumococcal Disease in Residents of a Shelter for Homeless Men. J. Clin. Microbiol.
43: 2004-2008
[Abstract][Full Text]
Arcavi, L., Benowitz, N. L.
(2004). Cigarette Smoking and Infection. Arch Intern Med
164: 2206-2216
[Abstract][Full Text]
Flannery, B., Schrag, S., Bennett, N. M., Lynfield, R., Harrison, L. H., Reingold, A., Cieslak, P. R., Hadler, J., Farley, M. M., Facklam, R. R., Zell, E. R., Whitney, C. G.
(2004). Impact of Childhood Vaccination on Racial Disparities in Invasive Streptococcus pneumoniae Infections. JAMA
291: 2197-2203
[Abstract][Full Text]
Wernich Thomsen, R., Holmager Hundborg, H., Lervang, H.-H., Paaske Johnsen, S., Schonheyder, H. C., Toft Sorensen, H.
(2004). Risk of Community-Acquired Pneumococcal Bacteremia in Patients With Diabetes: A population-based case-control study. Diabetes Care
27: 1143-1147
[Abstract][Full Text]
O'Brien, K. L., Santosham, M.
(2004). Potential Impact of Conjugate Pneumococcal Vaccines on Pediatric Pneumococcal Diseases. Am J Epidemiol
159: 634-644
[Abstract][Full Text]
Elssner, A., Carter, J. E., Yunger, T. M., Wewers, M. D.
(2004). HIV-1 Infection Does Not Impair Human Alveolar Macrophage Phagocytic Function Unless Combined With Cigarette Smoking. Chest
125: 1071-1076
[Abstract][Full Text]
Klugman, K. P., Madhi, S. A., Huebner, R. E., Kohberger, R., Mbelle, N., Pierce, N., the Vaccine Trialists Group,
(2003). A Trial of a 9-Valent Pneumococcal Conjugate Vaccine in Children with and Those without HIV Infection. NEJM
349: 1341-1348
[Abstract][Full Text]
Reefhuis, J., Honein, M. A., Whitney, C. G., Chamany, S., Mann, E. A., Biernath, K. R., Broder, K., Manning, S., Avashia, S., Victor, M., Costa, P., Devine, O., Graham, A., Boyle, C.
(2003). Risk of Bacterial Meningitis in Children with Cochlear Implants. NEJM
349: 435-445
[Abstract][Full Text]
Wernette, C. M., Frasch, C. E., Madore, D., Carlone, G., Goldblatt, D., Plikaytis, B., Benjamin, W., Quataert, S. A., Hildreth, S., Sikkema, D. J., Kayhty, H., Jonsdottir, I., Nahm, M. H.
(2003). Enzyme-Linked Immunosorbent Assay for Quantitation of Human Antibodies to Pneumococcal Polysaccharides. CVI
10: 514-519
[Full Text]
Sisk, J. E., Whang, W., Butler, J. C., Sneller, V.-P., Whitney, C. G.
(2003). Cost-Effectiveness of Vaccination against Invasive Pneumococcal Disease among People 50 through 64 Years of Age: Role of Comorbid Conditions and Race. ANN INTERN MED
138: 960-968
[Abstract][Full Text]
Gardner, P.
(2003). A Need To Update and Revise the Pneumococcal Vaccine Recommendations for Adults. ANN INTERN MED
138: 999-1000
[Full Text]
Yamaguchi, H., Friedman, H., Yamamoto, Y.
(2003). Involvement of Nicotinic Acetylcholine Receptors in Controlling Chlamydiapneumoniae Growth in Epithelial HEp-2 Cells. Infect. Immun.
71: 3645-3647
[Abstract][Full Text]
Whitney, C. G., Farley, M. M., Hadler, J., Harrison, L. H., Bennett, N. M., Lynfield, R., Reingold, A., Cieslak, P. R., Pilishvili, T., Jackson, D., Facklam, R. R., Jorgensen, J. H., Schuchat, A., the Active Bacterial Core Surveillance of the Emer,
(2003). Decline in Invasive Pneumococcal Disease after the Introduction of Protein-Polysaccharide Conjugate Vaccine. NEJM
348: 1737-1746
[Abstract][Full Text]
Simoni, M., Jaakkola, M.S., Carrozzi, L., Baldacci, S., Di Pede, F., Viegi, G.
(2003). Indoor air pollution and respiratory health in the elderly. Eur Respir J
21: 15S-20s
[Abstract][Full Text]
Artz, A. S., Ershler, W. B., Longo, D. L.
(2003). Pneumococcal Vaccination and Revaccination of Older Adults. Clin. Microbiol. Rev.
16: 308-318
[Abstract][Full Text]
Gordon, S B, Read, R C
(2002). Macrophage defences against respiratory tract infections: The immunology of childhood respiratory infections. Br Med Bull
61: 45-61
[Abstract][Full Text]
Jaakkola, M.S.
(2002). Environmental tobacco smoke and health in the elderly. Eur Respir J
19: 172-181
[Abstract][Full Text]
Matsunaga, K., Klein, T. W., Friedman, H., Yamamoto, Y.
(2001). Involvement of Nicotinic Acetylcholine Receptors in Suppression of Antimicrobial Activity and Cytokine Responses of Alveolar Macrophages to Legionella pneumophila Infection by Nicotine. J. Immunol.
167: 6518-6524
[Abstract][Full Text]
Lim, W S, Macfarlane, J T, Colthorpe, C L
(2001). Respiratory diseases in pregnancy {bullet} 2: Pneumonia and pregnancy. Thorax
56: 398-405
[Full Text]
HUTCHINSON, D, MOOTS, R, HELIÖVAARA, M, AHO, K, KNEKT, P, REUNANEN, A, AROMAA, A, IMPIVAARA, O
(2001). Coffee consumption, RF, and the risk of RA. Ann Rheum Dis
60: 540a-541
[Full Text]
Robinson, K. A., Baughman, W., Rothrock, G., Barrett, N. L., Pass, M., Lexau, C., Damaske, B., Stefonek, K., Barnes, B., Patterson, J., Zell, E. R., Schuchat, A., Whitney, C. G., for the Active Bacterial Core Surveillance /Emergi,
(2001). Epidemiology of Invasive Streptococcus pneumoniae Infections in the United States, 1995-1998: Opportunities for Prevention in the Conjugate Vaccine Era. JAMA
285: 1729-1735
[Abstract][Full Text]
Nelson, E.
(2001). The miseries of passive smoiong. Hum Exp Toxicol
20: 61-83
[Abstract]
Breiman, R. F., Keller, D. W., Phelan, M. A., Sniadack, D. H., Stephens, D. S., Rimland, D., Farley, M. M., Schuchat, A., Reingold, A. L.
(2000). Evaluation of Effectiveness of the 23-Valent Pneumococcal Capsular Polysaccharide Vaccine for HIV-Infected Patients. Arch Intern Med
160: 2633-2638
[Abstract][Full Text]
Fleming, C. A., Craven, D. E., Nuorti, J. P., Butler, J. C., Breiman, R. F.
(2000). Smoking and Pneumococcal Disease. NEJM
343: 219-220
[Full Text]
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