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..........................................................................4

2 RESPIRATORY INFECTIONS.....................................................5
2.1 Introduction........................................................................5
2.2 Search methodology.............................................................6
2.3 Prevalence..........................................................................7
2.4 Hospital admissions..............................................................9

3 PRIMARY PREVENTION INTERVENTIONS..............................11

4 SECONDARY PREVENTION INTERVENTIONS..........................13

5 FURTHER INFORMATION.......................................................14

6 REFERENCES..........................................................................14

© 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.

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Public Health Wales Primary and secondary prevention of
respiratory infections

1 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 include 2: 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.

Date: 3 Sep 2010 Version: 1 Page: 3 of 10

Public Health Wales 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 cold 2.

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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Public Health Wales Primary and secondary prevention of
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2.4 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

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

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Public Health Wales 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 Unitary Authority Admissions

Betsi Cadwaladr University Isle of Anglesey 949
Gwynedd 1559
Conwy 1431
Denbighshire 1223
Flintshire 1549
Wrexham 1370
Powys Powys 1373
Hywel Dda Ceredigion 550
Pembrokeshire 1183
Carmarthenshire 1927
Abertawe Bro Morgannwg Swansea 2915
Neath Port Talbot 1585
Bridgend 1444
Cardiff and Vale University The Vale of Glamorgan 1425
Cardiff 3415
Cwm Taf Rhondda Cynon Taff 3388
Merthyr Tydfil 817
Aneurin Bevan Caerphilly 1927
Blaenau Gwent 863
Torfaen 1073
Monmouthshire 801
Newport 1335
Total 34102
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 population 4.
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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Public Health Wales Primary and secondary prevention of
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There is guidance on the primary prevention of H1N1 influenza in non-

healthcare settings. The recommendations for prevention H1N1 influenza
are similar to those for controlling the spread of seasonal influenza 5.

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 conditions 6.

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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Public Health Wales Primary and secondary prevention of
respiratory infections

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 References

1. 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-tract-
infection/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/best-
practice/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 self-
limiting 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.brit-
thoracic.org.uk/Portals/0/Clinical
%20Information/Pneumonia/Guidelines/CAPGuideline-full.pdf
[Accessed 16th Apr 2010]

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