The Chicago Journal

The Impact of a ‘High Severity’ Flu Season on Children and the Urgency of Vaccination

Jason Robinson Jason Robinson on December 4, 2023

In the realm of public health, the recent release of the CDC’s comprehensive report on the 2022–23 flu season serves as a clarion call, directing attention to the resurfacing threat of influenza. This resurgence, marked by an early onset in October and a return to pre-pandemic levels, triggers concerns and prompts a deeper exploration of its ramifications, especially among children and adolescents. Coupled with the concurrent presence of COVID-19 and respiratory syncytial virus, this season ushers in what the CDC aptly terms a “triple-demic,” challenging the resilience of healthcare systems on a global scale.

Pediatric Hospitalization Rates

Early Onset and Peak Activity of the Flu Season

The flu season’s early ignition, transpiring before the widespread vaccination of children and adolescents, significantly contributed to the surge in hospitalization rates. As the report unfolds, late November and early December emerge as the focal points of peak influenza-associated outpatient and hospitalization activity.

Severity Classifications

Delving into the intricacies of the CDC’s severity classifications, the 2022–23 season attains the alarming status of “high severity” concerning children and adolescents. This categorization hinges on meticulous evaluations encompassing outpatient visits, hospitalizations, and deaths attributed to influenza.

Vaccination Disparities

Lower Vaccination Rates

Alarming statistics reveal a disconcerting decline in vaccination rates among hospitalized children and adolescents during the 2022–23 season (18.3%) compared to the relatively robust figures of previous seasons (35.8%–41.8%). This stark difference underscores the pressing need for a robust and accessible immunization strategy.

Contributing Factors

The report intricately weaves a narrative suggesting that the early circulation of influenza, transpiring before the vaccination of a substantial cohort of children, stands as a key contributor to the heightened hospitalization rates. This insight not only underscores the urgency of vaccination campaigns but also prompts a critical examination of the temporal dynamics of vaccination programs.

Medical Visits and Hospitalizations

Age Disparities

The pages of the report unfold a story of age disparities, with children under 5 experiencing higher rates of flu-associated medical visits, hospitalizations, and mortality compared to their counterparts aged 5–17. The statistics reach their zenith during the 2022-2023 season, marking the highest levels since the 2016-2017 period.

Underlying Conditions

Within the nuanced data, a predominant theme emerges — the majority of hospitalized children bear the weight of underlying conditions. Asthma, neurologic disorders, and obesity reign as the most common precursors to severe influenza outcomes. Noteworthy is the revelation that a significant proportion of pediatric hospitalizations occurred during the initial throes of the flu season in October and November 2022.

Takeaway

In the twilight of this comprehensive exploration, the 2022–23 flu season stands revealed as the fourth-highest severity season for children and adolescents since the 2009 influenza A(H1N1) pandemic. The report’s parting words echo a resounding call to action, emphasizing the paramount importance of prompt vaccination and antiviral treatment for symptomatic patients. Aligning with the CDC’s staunch recommendation, the conclusive note asserts that every individual aged ≥6 months should receive the annual influenza vaccine, ideally concluding this crucial preventive measure by the end of October.

Trends in Childhood Cancer Mortality: A Closer Look at Disparities

Nicholas Alexander Nicholas Alexander on December 4, 2023

In the ever-evolving landscape of childhood cancer mortality within the United States, a recent report from the US Centers for Disease Control and Prevention (CDC) has shed light on the dynamic shifts over the past two decades. While an overall positive trajectory in reducing the death rate is evident, an in-depth examination reveals disparities among various demographic groups, underscoring the need for targeted interventions.

Declining Rates, Unequal Progress:

The report brings to the forefront a notable 24% decrease in the overall childhood cancer death rate, marking a decline from 2.8 in 2001 to 2.1 per 100,000 children under 20 in 2021. However, this positive trend is not uniformly experienced across all ethnicities and age groups, emphasizing the nuanced nature of the progress.

Ethnic Disparities Unveiled:

The initial period between 2001 and 2011 witnessed Black, White, and Hispanic children benefiting from parallel reductions in cancer death rates, with no significant differences among them. However, the subsequent decade unfolds a concerning pattern. While White children continued to experience decreasing mortality rates, Black and Hispanic children faced a 20% higher cancer death rate in 2021 compared to their White counterparts, marking a disturbing divergence that demands targeted intervention and analysis.

Age-Specific Patterns:

A closer examination of age-specific trends reveals a shifting landscape. The significant decline in childhood cancer mortality observed from 2001 to 2011 was not uniformly sustained across all age groups. Notably, the progress continued predominantly among children under 10 in the subsequent decade, highlighting a nuanced pattern that necessitates a thoughtful and tailored approach.

Teens Bucking the Trend:

Despite historical challenges in teen mortality rates, the report brings a glimmer of hope. In 2021, the cancer death rate among teens was 23% lower than in 2001, indicating a positive turn in a demographic that has historically faced higher mortality rates than their younger counterparts. This positive deviation prompts further exploration into the contributing factors and potential avenues for continued improvement.

Changing Faces of Childhood Cancer:

The landscape of childhood cancer causes has experienced a remarkable transformation. Leukemia, once the predominant cause of childhood cancer death in the US, has witnessed a notable reduction, with death rates nearly halved between 2001 and 2021. However, brain cancer has now emerged as the primary contributor to childhood cancer mortality, constituting a quarter of all cancer deaths among those under 20. This shift underscores the dynamic nature of childhood cancer and the importance of adaptive strategies in combating it.

Takeaway:

In conclusion, while there is an overall positive trend in reducing childhood cancer mortality in the US, the disparities uncovered by the CDC report demand a comprehensive and targeted examination. Understanding the divergent patterns among ethnicities and age groups is crucial for developing precise and effective interventions to ensure equitable progress in the ongoing battle against childhood cancer.

Addressing the Escalating Crisis of Congenital Syphilis: A Unified Front for Urgent Action

Leah Cooper Leah Cooper on December 4, 2023

The Alarming Rise in Congenital Syphilis Cases

Within the landscape of public health in the United States, a deeply concerning surge in congenital syphilis cases has emerged, particularly among the most vulnerable demographic—newborns. This once-rare and preventable condition has undergone an alarming 32% increase in 2022, marking a tenfold rise since 2012. The gravity of the situation is further emphasized by the distressing revelation that more than 3,700 babies were born with syphilis in the same year. Shockingly, nearly 300 of these newborns faced dire consequences such as stillbirth or succumbing to the infection, painting a harrowing picture of the current public health crisis.

The Urgent Call for a Collective Response

In response to this burgeoning crisis, the Centers for Disease Control and Prevention (CDC) has sounded a resounding call to action, categorizing the current situation as both “dire” and “alarming.” The urgency of the matter is underscored by the CDC’s assertion that the situation has reached unprecedented levels, necessitating not only the attention of obstetrician/gynecologists but also a comprehensive response from the entire medical community. The pressing need to swiftly identify and treat infected individuals is emphasized as a critical measure to safeguard the health and well-being of newborns, urging a unified front against this escalating threat.

Challenges and Threats to Prevention Efforts

As the call for action reverberates, a myriad of challenges looms large, threatening the effectiveness of prevention efforts. The report sheds light on a perfect storm of factors contributing to this alarming rise. These include significant budget cuts to state health departments and a concurrent shortage of the essential drug, Bicillin, crucial in the treatment of syphilis during pregnancy. The shortage of resources and funding, coupled with a notable lack of testing and treatment in a significant number of cases, poses a severe and immediate threat to the comprehensive combat against congenital syphilis, demanding innovative solutions and strategic interventions.

Navigating the Complex Landscape of Missed Treatments

Delving deeper into the report, it becomes evident that missed opportunities for testing or treatment of birth parents contribute significantly to the rising congenital syphilis cases. Shockingly, in 88% of cases, there were instances of overlooked chances for intervention. Furthermore, racial disparities cast a shadow over these distressing statistics, with babies born to Black, Hispanic, and American Indian or Alaska Native mothers being eight times more likely to have congenital syphilis than their counterparts born to White mothers. This complex landscape of missed treatments requires a nuanced approach, acknowledging and addressing the underlying factors contributing to this concerning trend.

A Promising Breakthrough in Meningitis Prevention

Nicholas Alexander Nicholas Alexander on December 4, 2023

In a world where medical science continually advances, the story of Patti Wukovits and her daughter, Kimberly Coffey, serves as a poignant reminder of the urgency for improved protection against deadly diseases. Kimberly’s tragic battle with meningitis B, despite adhering to the CDC’s recommendations for vaccination, sheds light on a new turning point in the fight against this debilitating ailment. This article explores the significance of Pfizer’s pentavalent meningococcal vaccine, Penbraya, and how it has the potential to transform the landscape of meningitis vaccinations.

Kimberly’s Tragic Tale

Kimberly’s journey into the world of meningitis began with a high fever and body aches. She described it as feeling like her ankles were bleeding, a sensation that led to her mother, Patti Wukovits, rushing her to the emergency room. Tragically, Kimberly was diagnosed with meningitis B, a strain not covered by the existing MenACWY vaccine recommended by the CDC. Despite her mother’s best efforts, Kimberly lost her life to the disease, leaving her family forever changed.

The Inadequacy of Existing Vaccines

The MenACWY vaccine, which adolescents are advised to receive when they turn 11 or 12, offers protection against four groups of meningococcal bacteria. However, it falls short when it comes to the group that includes meningitis B. In Kimberly’s case, this inadequacy proved fatal. At the time, there was no vaccine to safeguard against meningitis B. The inadequacies of the existing vaccines called for a new, more comprehensive solution.

A Beacon of Hope: Penbraya

On a promising note, Pfizer’s Penbraya vaccine has emerged as a potential game-changer in the fight against meningococcal disease. Unlike its predecessors, Penbraya safeguards against not one, but five kinds of bacteria, making it a beacon of hope for individuals seeking broader protection with fewer shots.

Understanding Meningococcal Disease

Meningococcal disease, inclusive of meningitis, is a rare yet devastating illness caused by the bacteria neisseria meningitidis. It can lead to severe consequences such as infections in the lining of the brain and spinal cord, memory and concentration issues, seizures, balance problems, hearing loss, and even blindness. In some cases, it can escalate into a life-threatening blood infection known as septicemia or blood poisoning. Alarmingly, statistics reveal that approximately one in ten cases of bacterial meningitis results in fatality.

The Challenges of Early Diagnosis

Early diagnosis is critical in fighting meningococcal disease, but it’s often delayed due to symptoms that can mimic other infections like Covid-19 or the flu. Symptoms include fever, headache, nausea or vomiting, trouble waking, stiff neck, a distinctive skin rash, sensitivity to light, and brain fog. Swift action is essential, as the infection can spread rapidly, as seen in Kimberly’s case.

Transmission and Outbreaks

The disease is highly contagious and can be transmitted through coughing, sneezing, or sharing drinks with an infected person. While outbreaks are rare, they can be devastating, particularly in settings where people operate in close quarters, such as schools or dormitories.

Current Vaccine Recommendations

Presently, the CDC recommends two types of meningococcal vaccines in the United States. The MenACWY vaccine, which protects against A, C, W, and Y variations, is administered to preteens and teens. There is also the MenB vaccine, designed to combat the strain that claimed Kimberly’s life. The existing vaccination schedule requires multiple shots, which can be burdensome.

The Promise of a Simpler Vaccination Schedule

Recognizing the complexity of the current vaccination schedule, the CDC’s independent vaccine advisors have recommended Pfizer’s Penbraya vaccine, a pentavalent solution that protects against the majority of meningococcal disease in young people. It offers the prospect of increased vaccine coverage by streamlining the vaccination process with just two doses, administered six months apart.

The Road Ahead

While the committee’s vote on Penbraya is a significant step, it awaits final approval from the CDC. As we celebrate this turning point in the fight against meningitis, it’s crucial to ensure easy access to Pfizer’s groundbreaking vaccine to save lives and provide comprehensive protection.

Takeaway

Pfizer’s Penbraya vaccine signifies a new hope in the battle against meningococcal disease, especially for young adults and adolescents. Kimberly Coffey’s tragic story underscores the urgency for comprehensive protection, and Penbraya’s potential to simplify the vaccination process is a significant step forward. As we await the CDC’s final decision, this new vaccine offers a brighter future in safeguarding our youth against this deadly disease.

Fentanyl contributed to teen deaths in the US, studies found

Claire Peterson Claire Peterson on June 12, 2023

Fentanyl — Fentanyl is an extremely strong synthetic opioid that has been linked to a recent increase in drug overdose deaths among adults in the United States.

According to the Centers for Disease Control and Prevention, 36,000 people died from drug overdoses using synthetic opioids such as fentanyl in 2019 alone, which represents more than 60% of all opioid-related overdose deaths.

Fentanyl’s potency, along with its widespread availability and low cost, has resulted in its domination in the illicit drug market, ending in a public health crisis that is currently causing devastation across the country.

Affecting the youth

While fentanyl has mostly been linked to adult deaths, it has recently been linked to the deaths of a large number of children and teenagers in the United States.

Over 1,500 children under the age of 20 will die from fentanyl in 2021, according to Julie Gaither, an epidemiologist at Yale School of Medicine.

The number of deaths has risen by four since 2018.

Fentanyl fatalities accounted for nearly all opioid-related deaths in this age group in 2021.

The drug

Fentanyl is a synthetic opioid that is used to treat cancer patients’ acute pain.

It is also manufactured and supplied illegally as a street drug.

The drug is significantly more potent than other opioids such as morphine and heroin, making it very dangerous for recreational users.

The opioid fentanyl is manufactured in laboratories, primarily in China, and then smuggled into other countries.

Illicit fentanyl is commonly mixed with other opioids, such as heroin or cocaine, without the user’s knowledge, increasing the risk of overdose.

Fentanyl trafficking has worsened a serious public health issue in several countries, most notably the United States, where fentanyl overdose deaths have surged in recent years.

Replacing prescription drugs

Because it is less expensive and easier to obtain illegally, fentanyl is rapidly replacing prescription opioids such as oxycodone.

As a result, there has been an increase in overdoses since patients may not realize they are taking fentanyl instead of the prescribed prescription.

Because traffickers frequently mix fentanyl with other opiates to boost their potency or imitate the effects of other prescription medications, counterfeit prescription drugs are being infected with illicit fentanyl.

As a result, people seeking pain treatment with authorized prescription medications may be unintentionally ingesting a lethal dose of fentanyl.

“That’s primarily the story of what’s happening among teenagers,” said Sarah Bagley, the pediatrician and addiction provider of the Boston University Chobanian & Avedisian School of Medicine.

Bagley believes that teenagers purchase and use drugs or substances without recognizing it is fentanyl.

“People are not anticipating that they are going to be exposed to fentanyl, and then they are, and that results in overdose.”

Read also: Beyond the Obvious: How Your Gut Microbiome Impacts Your Mood and Other Surprising Signs of Imbalance

Overdoses

Some of the symptoms of a drug overdose include:

  • Falling asleep
  • Losing consciousness
  • Gurgling
  • Choking sounds
  • Weak/no breathing

“This change in the drug supply, where you have a much more potent opioid, is really driving it all,” said Bagley.

The bulk of fentanyl deaths among adolescents and teens, according to Gaither, happened at home.

“For smaller kids, kids who are mobile, they would be taking a drug that’s off the floor,” she said.

Gaither also emphasized the significance of more education to assist parents understand how dangerous fentanyl is and the importance of keeping drugs out of the reach of children.

Mortality rate

Julie Gaither reviewed pediatric mortality statistics from the Centers for Disease Control and Prevention from 1999 through 2021.

The fentanyl death rate more than quadrupled during that time period, rising from 0.47 to 1.92 per 100,000 children.

In 2021, fentanyl suffocated 40 babies and 93 children aged one to four.

Adult overdose deaths have also increased.

In 2021, synthetic opioids, mostly fentanyl, were responsible for more than 70,000 deaths in the United States, with more than 106,000 drug overdose deaths expected in 2022.

A counter to overdose

The US Food and Drug Administration approved Naloxone, an opioid overdose reversal medication, for over-the-counter use in March.

In late summer, it will be sold at a number of retailers.

Some communities teach residents how to use nasal spray medications and distribute them to victims.

Narcan, an opiate antidote that is safe for children of all ages, is the medication, according to Gaither.

Parents who have Narcan on hand can counteract the effects of opioids rapidly.

Bagley, on the other hand, stressed the need of educating teenagers about Narcan.

She has spoken with teenagers who have asked how they can keep their friends safe.

Addressing overdoses with children, according to Bagley, entails discussing the hazards as well as how they care for others in their lives and respond in a crisis.

Insomnia linked to heart attacks in new studies

Edward Anderson Edward Anderson on April 24, 2023

Insomnia – Although sleep is an essential component of one’s day, some people struggle with falling asleep in bed at times.

Insomnia is defined as difficulty falling, staying, or gaining adequate sleep, and a recent study suggests that insomniacs may be at danger.

Sleep deprivation may have an influence on people’s hearts, in addition to interfering with daily functioning.

The news

Insomnia has been linked to an increased risk of heart attack in studies.

The most prevalent sleep issue, according to their research, affects 10% to 15% of all Americans.

According to the report’s findings, which were published in the journal Clinical Cardiology, the possible association between sleeplessness and heart attack is more likely to impact women.

According to Dr. Martha Gulati, chief of preventive services at Cedars-Sinai Smidt Heart Center, the majority of her patients are women, and sleeplessness is a risk factor for those with ischemic heart disease.

Although not being a participant in the study, Gulati shared her thoughts: “Insomnia is actually quite common.”

“We see it probably in 1 in 10 patients in the United States. It is my impression that almost everyone experiences insomnia at some point in their life.”

“The estimate is that 1 in 2 adults experience it at some point in their life, maybe in the short term because of stressful moments.”

Analysis

The analysis of the study is based on more than 11 decades of information collected from 1,184,256 people in the following countries:

  • China
  • Germany
  • Norway
  • Taiwan
  • The United States
  • The United Kingdom

The study was undertaken by researchers from Egypt, Saudi Arabia, Pakistan, and the United States, and it classified insomnia as a sleep disorder with three major diagnoses:

  • Difficulty falling asleep
  • Difficulty staying asleep
  • Waking up early but restlessness that makes it hard to sleep again

There were 1,030,375 people who did not suffer from insomnia and 153,881 who did.

Sleep deprivation is 1.69 times more likely to cause a heart attack, according to research.

Despite this, the number of heart attacks was quite modest, occurring in around 1.6% of individuals who had insomnia and 1.2% of those who did not.

Hours of sleep

The researchers observed a link between a higher risk of heart attack and the amount of time participants spent sleeping at night.

Individuals who slept for five hours or less were 1.56 times more likely to suffer a heart attack than those who slept for seven or eight hours.

Getting more sleep, however, does not ensure safety.

According to the study, those who slept for six hours or more each night had a lower risk of having a heart attack.

“A lot of studies have pointed somewhere between seven and eight hours of sleep being the magic number for us,” said Gulati.

“There is obviously variability for everyone, but too much sleep is rarely the issue.”

The study discovered that insomniacs of any age or gender had the same risk of having a heart attack.

Read also: Teenagers using social media should be older than 13

How insomnia affects the body

A lack of sleep, according to Dr. Martha Gulati, increases the risk of a heart attack in a variety of ways, with a focus on cortisol control.

Cortisol is a stress hormone that regulates how the body reacts to stress.

The higher a person’s blood pressure, the more stressed he or she is.

People’s blood pressure drops when they receive enough sleep.

“What really happens when you’re not getting enough sleep is that your cortisol gets out of whack,” Gulati explained.

“If you are having sleep problems, we know that your blood pressure is more elevated at night.”

Gulati observed that having high nighttime blood pressure might be a risk factor for heart disease induced by cortisol imbalance.

Meanwhile, the study’s authors suggested that sleep deprivation be included as a risk factor in cardiovascular disease preventive recommendations.

Dr. Hani Aiash, a cardiologist and associate dean of interprofessional research at Upstate Medical University’s College of Health Professions, is one of the study’s senior authors.

Sleep, he argues, is more useful than most people realize: “Now we have evidence that sleep is medicine. So good sleep is prevention.”

“If you don’t sleep well… below five hours or six hours, you’re exposing yourself to a higher risk of myocardial infarction. The pattern of sleep is very important.”

Aiash also feels that nine hours is too long: “Above nine hours is harmful also.”

Mitigation

After the release of the report, the Centers for Disease Control and Prevention in the United States recommended five methods for minimizing insomnia:

  • Keep consistent sleeping and waking hours, including on weekends.
  • Make your bedroom a relaxing, dark, and comfortable retreat.
  • Remove any electrical devices from the room (smartphones, TVs, computers)
  • To enhance your chances of getting a good night’s sleep, avoid big meals, coffee, and alcohol.
  • Keep an active lifestyle throughout the day.

If your sleeplessness persists, the CDC advises you to contact a doctor.

…

Pfizer cleared of stroke risks, CDC and experts claim

Edward Anderson Edward Anderson on January 16, 2023

…

Pfizer: Despite the necessity of Covid-19 booster doses and vaccinations in general, some people still opt not to get the shots due to fear of getting sick.

Seniors, in particular, are anxious about the injections’ potential side effects since many have developed a phobia of strokes.

However, the Centers for Disease Control and Prevention has conducted studies to dispel such concerns.

Surveillance

The discovery prompted the implementation of a CDC surveillance system that Pfizer’s omicron Covid variant booster dose was linked to an increased risk of stroke in adults 65 and older.

In collaboration with networks across the US, the CDC’s Immunization Safety offices, and a comprehensive healthcare organization, the Vaccine Safety Datalink (VSD) system was developed.

It monitors and evaluates the safety of vaccinations using electronic health data from affiliate facilities.

It includes information on the type administered, the vaccination date, and any other vaccines received on the same day.

The VSD also utilizes information on health problems identified during doctor visits, ER visits, urgent care visits, and hospital stays.

Statement

The CDC issued a press release on its website on Friday.

“Following the availability and use of the updated (bivalent) COVID-19 vaccines, CDC’s Vaccine Safety Datalink (VSD), a near real-time surveillance system, met the statistical criteria to prompt additional investigation into whether there was a safety concern for ischemic stroke in people ages 65 and older who received the Pfizer-BioNTech COVID-19 Vaccine, Bivalent.“

“Rapid-response investigation of the signal in the VSD raised a question of whether people 65 and older who have received the Pfizer-BioNTech COVID-19 Vaccine, Vivalent were more likely to have an ischemic stroke in the 21 days following vaccination compared with days 22-42 following the vaccination.“

A review of the Centers for Medicare and Medicaid Services database found that there was no increased risk of stroke as a result of the modified vaccines.

Additionally, Pfizer-BioNTech’s global safety database has not discovered any signs of stroke in connection with the updated injections.

Read also: Covid-19 surges among senior citizens or ‘senior waves’

Detection

A CDC spokesperson said the problem was first brought up in late November.

The CDC began looking into the possibility of seniors suffering a stroke 21 days after receiving the Pfizer injection when it was discovered in the middle of December, and worries persisted.

For Moderna boosters, the initial signal and results were the same.

The representative stated that 130 patients 65 and older who had the Pfizer omicron booster injection suffered strokes within 21 days.

More than 550,000 seniors who had their booster injection reported the data.

According to the CDC, no other monitoring system has so far detected any issues with the Pfizer booster.

Data

No extra stroke risk was noted when researchers examined the data from the following sources:

  • Center for Medicare and Medicaid Services
  • The Department of Veterans Affairs
  • The Vaccine Adverse Reporting System
  • Pfizer’s global safety database

“Although the totality of the data currently suggests that it is very unlikely that the signal in VSD represents a true clinical risk, we believe it is important to share this information with the public, as we have in the past, when one of our safety monitoring systems detects a signal,” the CDC wrote.

The CDC asserts that the monitoring system picks up signals from sources unrelated to immunization.

The agency spokesperson noted that the investigations should provide a clearer view and additional facts in the upcoming weeks.

Investigation

The Food and Drug Administration will convene a panel discussion with independent immunization authorities on January 26 to tackle the issue.

Furthermore, Pfizer said in a statement made on Friday that there is no proof between the Covid vaccination and ischemic strokes.

Pfizer, BioNTech, the CDC, and the FDA have not discovered any connections between the different monitoring systems in the United States, claims company spokesperson Kit Longley.

“Compared to published incidence rates of ischemic stroke in this older population, the companies to date have observed a lower number of reported ischemic strokes following the vaccination with the omicron BA.4/BA.5-adapted bivalent vaccine,” said Longley.

The omicron injection from Pfizer is still prescribed by the CDC.

Those who have finished the primary vaccine series and are five years of age or older are eligible for the booster.

Ages six months to four years old are the youngest children that can receive an omicron injection.

Reference:

CDC says it’s ‘very unlikely’ Pfizer booster carries stroke risk for seniors after launching review

CDC & FDA identify preliminary COVID-19 vaccine safety signal for persons aged 65 years and older