Infection and infection prevention in alpha-1 antitrypsin deficiency

Influenza viruses are highly adaptable. They change the structures on their surface from year to year. The influenza vaccine targets proteins located on the surface of the viruses. It's like the race between the hare and the hedgehog: if the virus changes, the vaccine must be adapted accordingly. If the virus and vaccine are a very good match, vaccinations provide protection of up to 70%.
Given that the peak of the flu season has been in February and March in recent years, the best time for a flu vaccination is October and November. The protection provided by the vaccine only lasts about six to eight months.

Research into new vaccines is exciting. While the surface of the influenza virus is constantly changing, structures in the core of the pathogen remain the same. An experimental vaccine, which has so far only been tested in mice, targets one such structure, the hemagglutinin. All of the tested animals survived the influenza virus infection. The extent to which this approach can also be successful in humans will be revealed by research over the next 10-15 years.

For people with AATD, influenza vaccination is essential. Vaccination is also recommended for everyone over 60. In addition, there are other risk groups that are particularly vulnerable to influenza infection. Pregnant women are at the highest risk because their specific hormonal situation affects certain aspects of their immune system, making them more susceptible to severe illness.

Influenza vaccination can be administered throughout pregnancy. It protects not only the mother but also the child, who is born without any immunity to influenza. The newborn benefits from receiving antibodies from the vaccinated mother via the placenta. However, in Germany, only 81% of pregnant women are vaccinated against influenza. This presents a significant challenge for obstetricians.

Seniors in nursing homes are also particularly vulnerable and should be vaccinated annually. This simultaneously reduces the risk of infection for other residents. Respiratory infections caused by viruses are especially common in early childhood. While this is inconvenient for the whole family, it's beneficial for the child's immune system. Frequent infections build up a young child's defenses. If a child gets sick often before starting school, they will be better able to cope with viral infections at school. However, this poses a problem for grandparents, who are at risk of infection when caring for their sick grandchildren. Therefore, older people should try to keep some distance from their grandchildren if they have a severe infection.

As mentioned above, bacterial infections can occur following a viral infection. Everyone should be vaccinated against pneumococcal bacteria with AATM. There are different vaccines, belonging to two main groups: the longer-acting conjugate vaccine and the less expensive polysaccharide vaccine. The official recommendation for people over 60 in Germany is the polysaccharide vaccine Pneumovax®, primarily for economic reasons. The speaker, however, clearly advocates for the conjugate vaccine, marketed under the name Prevenar 13®. One dose costs around €60, which is usually paid out of pocket. Researchers are working on an improved version of this vaccine, which is expected to be available in two years. Pneumococcal vaccinations need to be boosted every few years.

In addition to pneumococcal disease, pertussis (whooping cough) should also be considered. In the 1960s, many infants were vaccinated with a highly effective cellular vaccine against pertussis. However, it had numerous side effects, so it was later replaced by a better-tolerated, but less effective, acellular vaccine. Its protection only lasts 10-15 years. For this reason, many adults no longer have immunity against pertussis, and more and more cases are being reported. Even having had pertussis does not provide lifelong protection. The pertussis vaccine is administered as a three-in-one vaccine along with diphtheria and tetanus. Those with AATD should also check their vaccination record for this vaccination.

The German Bronchiectasis Registry has been established at Hannover Medical School (MHH) since 2015. Patients are enrolled in the registry after an initial consultation at the center. Their average age is currently 59, and 591 of the participants are women. A significant proportion of patients have bacterial infections. A particularly important and common pathogen is Pseudomonas aeruginosa (381), followed by Staphylococcus aureus (161) and Haemophilus influenzae (121). Pseudomonas infection, in particular, is crucial for the prognosis and must be treated appropriately. In addition to MHH (which manages the registry), many other private practitioners and hospitals participate in the German Bronchiectasis Registry. Registration is possible at any of these institutions. The participating institutions can be found on the website www.bronchiektasen-register.de/. Besides the German registry, there are various other registries for bronchiectasis worldwide, for example in Europe, the USA, India, and China. Researchers hope that the analysis of this data from thousands of patients will yield new insights into the course of the disease.

The bacteria primarily colonize and multiply in the mucus that adheres to the walls of the bronchi. Therefore, the most important therapeutic principle for bronchiectasis is to remove the mucus from the airways. This is achieved through daily respiratory physiotherapy and secretion drainage, which patients can learn from specially trained physiotherapists and have regularly reviewed. For doctors in Hanover, it is always a shock when nine out of ten newly presented patients have never heard of respiratory physiotherapy and secretion drainage. Medical exercise therapy, including movement and sports, also helps to clear mucus from the airways.

Another important method is the inhalation of expectorant medications using a special electric nebulizer. Saline solution with a concentration of 3% is particularly suitable. Inhaling this saline solution for ten minutes significantly loosens the mucus, making it easier to cough up and clearing the lungs.

Several months ago, some pulmonologists in Germany did people a disservice by questioning the importance of air pollutants for health. Statements from European and international professional societies subsequently clarified the role of air pollutants in health.

Inhaled particles can be classified according to their size. Larger, heavier particles are usually deposited in the throat during inhalation. Smaller particles (under 2.5 µm), which can enter the lungs with the inhaled air, are more dangerous. Current research focuses on ultrafine particles (under 1 µm), which can even penetrate the walls of the alveoli and enter the bloodstream. They can then be detected throughout the body, even in the brain. Some of these particles also contain metals. For example, metals found exclusively in aircraft turbines have been detected in many lung tissue samples. These metals are released with every aircraft movement, inhaled by people, and then deposited in the body. The effects they have there are not yet known.
Significantly more air pollutants and particles can be detected in winter than in summer. Asthma attacks occur much more frequently in patients with bronchial asthma in connection with elevated pollutant concentrations.

Researchers also found that exacerbations in patients with AATM were more frequent on days with high pollutant concentrations.
In Germany, the situation is still relatively favorable compared to many Asian countries. For example, we are currently discussing NO2 concentrations of 40 ppm, while in Beijing, NO2 levels of 2000 ppm are commonplace. Nevertheless, it is essential to improve in Europe as well and to protect the most vulnerable, especially children and the sick. The air should be as clean as possible. Although the automotive industry is capable of building low-emission cars, it rejects this for economic reasons.