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Lin W, Wang B, Wang M, Wang Y, Tuerdibieke Y, Qian C, Zhao G, Zhang T. The Unneglectable Disease Burden of Otitis Media Among Children in China: A Systematic Review and Meta-analysis. Pediatr Infect Dis J 2024; 43:403-409. [PMID: 38190644 DOI: 10.1097/inf.0000000000004239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Abstract
BACKGROUND Otitis media (OM) is one of the most commonly diagnosed infections among children yet with obscure disease burden. METHODS The literature published from 1980 to 2022 was retrieved in PubMed, Ovid-EMBASE, Web of Science, CNKI, Wanfang and VIP. Literature screening, quality assessment and data extraction were conducted by 2 independent reviewers. Heterogeneity and publication bias were detected by I2 , Egger's and Begg's tests. The data were pooled using the random-effects model. The number of OM cases was estimated by the multiplied model based on pooled results and the 2020 China census data. RESULTS A total of 28,378 literatures were identified with 67 finally included for data analysis. The OM incidence among children was 7.89% [95% confidence interval (CI): 5.43%-11.33%] and the prevalence of OM was 5.13% (95% CI: 3.49%-7.49%). The most common pathogen of the OM cases was Streptococcus pneumoniae ( S. pneumoniae ), with a positive rate of 33.52% (95% CI: 26.55%-41.29%). The most common serotypes of S. pneumoniae isolated from OM cases were serotypes 19F, 19A, 6B, 23F and 3, with 85.8% covered by the PCV13. We estimated that there were 8,950,797 (95% CI: 6,080,533-12,928,051) OM cases among under-fives in China in 2020, of which 3,374,451 (95% CI: 1,698,901-6,277,862) cases of OM were caused by S. pneumoniae . CONCLUSIONS The burden of OM in China was considerable yet neglected. To date, S. pneumoniae was the most frequently detected bacterial pathogen of OM. Vaccination may be effective to protect young children from OM.
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Affiliation(s)
- Wanjing Lin
- From the Department of Epidemiology, School of Public Health, Fudan University, Shanghai, China
- Key Laboratory of Public Health Safety, Ministry of Education, Shanghai, China
| | - Biying Wang
- From the Department of Epidemiology, School of Public Health, Fudan University, Shanghai, China
- Key Laboratory of Public Health Safety, Ministry of Education, Shanghai, China
| | - Mengzhen Wang
- From the Department of Epidemiology, School of Public Health, Fudan University, Shanghai, China
| | - Yujie Wang
- From the Department of Epidemiology, School of Public Health, Fudan University, Shanghai, China
| | - Yelina Tuerdibieke
- From the Department of Epidemiology, School of Public Health, Fudan University, Shanghai, China
| | - Chen Qian
- From the Department of Epidemiology, School of Public Health, Fudan University, Shanghai, China
- Key Laboratory of Public Health Safety, Ministry of Education, Shanghai, China
| | - Genming Zhao
- From the Department of Epidemiology, School of Public Health, Fudan University, Shanghai, China
- Key Laboratory of Public Health Safety, Ministry of Education, Shanghai, China
| | - Tao Zhang
- From the Department of Epidemiology, School of Public Health, Fudan University, Shanghai, China
- Key Laboratory of Public Health Safety, Ministry of Education, Shanghai, China
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Ricci Conesa H, Skröder H, Norton N, Bencina G, Tsoumani E. Clinical and economic burden of acute otitis media caused by Streptococcus pneumoniae in European children, after widespread use of PCVs-A systematic literature review of published evidence. PLoS One 2024; 19:e0297098. [PMID: 38564583 PMCID: PMC10986968 DOI: 10.1371/journal.pone.0297098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 12/21/2023] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Acute otitis media (AOM) is a common childhood disease frequently caused by Streptococcus pneumoniae. Pneumococcal conjugate vaccines (PCV7, PCV10, PCV13) can reduce the risk of AOM but may also shift AOM etiology and serotype distribution. The aim of this study was to review estimates from published literature of the burden of AOM in Europe after widespread use of PCVs over the past 10 years, focusing on incidence, etiology, serotype distribution and antibiotic resistance of Streptococcus pneumoniae, and economic burden. METHODS This systematic review included published literature from 31 European countries, for children aged ≤5 years, published after 2011. Searches were conducted using PubMed, Embase, Google, and three disease conference websites. Risk of bias was assessed with ISPOR-AMCP-NPC, ECOBIAS or ROBIS, depending on the type of study. RESULTS In total, 107 relevant records were identified, which revealed wide variation in study methodology and reporting, thus limiting comparisons across outcomes. No homogenous trends were identified in incidence rates across countries, or in detection of S. pneumoniae as a cause of AOM over time. There were indications of a reduction in hospitalization rates (decreases between 24.5-38.8% points, depending on country, PCV type and time since PCV introduction) and antibiotic resistance (decreases between 14-24%, depending on country), following the widespread use of PCVs over time. The last two trends imply a potential decrease in economic burden, though this was not possible to confirm with the identified cost data. There was also evidence of an increase in serotype distributions towards non-vaccine serotypes in all of the countries where non-PCV serotype data were available, as well as limited data of increased antibiotic resistance within non-vaccine serotypes. CONCLUSIONS Though some factors point to a reduction in AOM burden in Europe, the burden still remains high, residual burden from uncovered serotypes is present and it is difficult to provide comprehensive, accurate and up-to-date estimates of said burden from the published literature. This could be improved by standardised methodology, reporting and wider use of surveillance systems.
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Affiliation(s)
| | | | | | - Goran Bencina
- Center for Observational and Real-World Evidence, MSD, Madrid, Spain
| | - Eleana Tsoumani
- Center for Observational and Real-World Evidence, MSD, Athens, Greece
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Safari D, Daningrat WOD, Milucky JL, Khoeri MM, Paramaiswari WT, Tafroji W, Salsabila K, Winarti Y, Soebandrio A, Hadinegoro SR, Prayitno A, Childs L, Pimenta FC, Carvalho MDG, Pilishvili T. Nasopharyngeal carriage of Streptococcus pneumoniae among children <5 years of age in Indonesia prior to pneumococcal conjugate vaccine introduction. PLoS One 2024; 19:e0297041. [PMID: 38206916 PMCID: PMC10783721 DOI: 10.1371/journal.pone.0297041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 12/27/2023] [Indexed: 01/13/2024] Open
Abstract
Pneumococcal conjugate vaccines (PCVs) prevent nasopharyngeal colonization with vaccine serotypes of Streptococcus pneumoniae, leading to reduced transmission of pneumococci and stronger population-level impact of PCVs. In 2017 we conducted a cross-sectional pneumococcal carriage study in Indonesia among children aged <5 years before 13-valent PCV (PCV13) introduction. Nasopharyngeal swabs were collected during visits to community integrated health service posts at one peri-urban and one rural study site. Specimens were analyzed by culture, and isolates were serotyped using sequential multiplex polymerase chain and Quellung reaction. Antibiotic susceptibility was performed by broth microdilution method. We enrolled 1,007 children in Gunungkidul District, Yogyakarta (peri-urban) and 815 in Southwest Sumba, East Nusa Tenggara (rural). Pneumococcal carriage prevalence was 30.9% in Gunungkidul and 87.6% in Southwest Sumba (combined: 56.3%). PCV13 serotypes (VT) carriage was 15.0% in Gunungkidul and 52.6% in Southwest Sumba (combined: 31.8%). Among pneumococcal isolates identified, the most common VT were 6B (16.4%), 19F (15.8%), and 3 (4.6%) in Gunungkidul (N = 323) and 6B (17.6%), 19F (11.0%), and 23F (9.3%) in Southwest Sumba (N = 784). Factors associated with pneumococcal carriage were age (1-2 years adjusted odds ratio (aOR) 1.9, 95% CI 1.4-2.5; 3-4 years aOR 1.5, 95% CI 1.1-2.1; reference <1 year), other children <5 years old in the household (aOR 1.5, 95% CI 1.1-2.0), and presence of ≥1 respiratory illness symptom (aOR 1.8, 95% CI 1.4-2.2). Overall, 61.5% of the pneumococcal isolates were non-susceptible to ≥1 antibiotic class and 13.2% were multi-drug non-susceptible (MDNS) (non-susceptible to ≥3 classes of antibiotics). Among 602 VT isolates, 73.9% were non-susceptible and 19.9% were MDNS. These findings are critical to establish a pre-PCV13 carriage prevalence and demonstrate the complexity in evaluating the impact of PCV13 introduction in Indonesia given the wide variability in the carriage prevalence as shown by the two study sites.
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Affiliation(s)
- Dodi Safari
- Eijkman Research Center for Molecular Biology, National Research and Innovation Agency, Cibinong, West Java, Indonesia
| | - Wa Ode Dwi Daningrat
- Eijkman Research Center for Molecular Biology, National Research and Innovation Agency, Cibinong, West Java, Indonesia
- Centre for Genomic Pathogen Surveillance, Big Data Institute, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Jennifer L. Milucky
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Miftahuddin Majid Khoeri
- Eijkman Research Center for Molecular Biology, National Research and Innovation Agency, Cibinong, West Java, Indonesia
| | - Wisiva Tofriska Paramaiswari
- Eijkman Research Center for Molecular Biology, National Research and Innovation Agency, Cibinong, West Java, Indonesia
| | - Wisnu Tafroji
- Eijkman Research Center for Molecular Biology, National Research and Innovation Agency, Cibinong, West Java, Indonesia
| | - Korrie Salsabila
- Eijkman Research Center for Molecular Biology, National Research and Innovation Agency, Cibinong, West Java, Indonesia
| | - Yayah Winarti
- Eijkman Research Center for Molecular Biology, National Research and Innovation Agency, Cibinong, West Java, Indonesia
| | - Amin Soebandrio
- Eijkman Research Center for Molecular Biology, National Research and Innovation Agency, Cibinong, West Java, Indonesia
| | | | - Ari Prayitno
- Faculty of Medicine, University of Indonesia, Jakarta, Indonesia
| | - Lana Childs
- CDC Foundation, Atlanta, GA, United States of America
| | - Fabiana C. Pimenta
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Maria da Gloria Carvalho
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Tamara Pilishvili
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, United States of America
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Hu T, Podmore B, Barnett R, Beier D, Galetzka W, Qizilbash N, Heckl D, Boellinger T, Weaver J. Healthcare resource utilization and cost of pneumococcal disease in children in Germany, 2014-2019: a retrospective cohort study. Pneumonia (Nathan) 2023; 15:7. [PMID: 36964592 PMCID: PMC10039501 DOI: 10.1186/s41479-023-00105-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 01/05/2023] [Indexed: 03/26/2023] Open
Abstract
BACKGROUND Since the introduction of higher valency pneumococcal conjugate vaccines in 2009, recent estimates on the economic burden of pediatric pneumococcal disease (PD) in Germany have been lacking. This study estimates healthcare resource utilization (HCRU) and medical cost associated with PDs in children < 16 years old in Germany from 2014-2019. METHODS A nationally representative sample from the Institute for Applied Health Research (InGef) German claims database was used, covering approximately 5% of the total German population. Episodes of pneumococcal pneumonia (PP), all-cause pneumonia (ACP), invasive pneumococcal disease (IPD), and acute otitis media (AOM) in children aged < 16 years were identified using ICD-10-GM codes. HCRU was estimated from annual rates of outpatient visits, outpatient antibiotic prescriptions and inpatient admissions, divided by person-years (PY) at-risk. Average direct medical costs per episode were estimated as the total cost of all HCRU, divided by the total number of episodes. The Mann-Kendall test was used to assess monotonic time trends from 2014-2019. RESULTS During 2014-2019, 916,805 children aged < 16 years were followed up for a total of 3,608,716 PY. The average costs per episode for out-versus inpatient care associated with PP and ACP were €67 (95% CI 58-76) versus €2,606 (95% CI 1,338-3,873), and €63 (95% CI 62-63) versus €620 (95% CI 598-641), respectively. For IPD, the average medical cost per episode for out-versus inpatients were €30 (95% CI 19-42) versus €6,051 (95% CI 3,323-8,779), respectively. There were no significant trends in HCRU or costs for IPD or pneumonia over the study period, except for a significant reduction in ACP outpatient visits. A significant decrease in rate of outpatient visits and antibiotic prescribing for recurrent AOM was observed, in addition to an increase in rates of hospital admissions for simple AOM. This was paralleled by a significant increase in inpatient costs per episode for treating AOM overall, and simple AOM, over the study period. CONCLUSIONS The HCRU and cost per episode of pneumonia and IPD did not vary significantly from 2014-2019, but increased for AOM. The economic burden of pneumonia, IPD, and AOM remains substantial in Germany.
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Affiliation(s)
| | - Bélène Podmore
- OXON Epidemiology, London, UK
- London School of Hygiene & Tropical Medicine, London, UK
| | | | - Dominik Beier
- InGef - Institute for Applied Health Research Berlin GmbH, Berlin, Germany
| | - Wolfgang Galetzka
- InGef - Institute for Applied Health Research Berlin GmbH, Berlin, Germany
| | - Nawab Qizilbash
- OXON Epidemiology, London, UK
- London School of Hygiene & Tropical Medicine, London, UK
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Perdrizet J, Farkouh RA, Horn EK, Hayford K, Sings HL, Wasserman MD. The broader impacts of otitis media and sequelae for informing economic evaluations of pneumococcal conjugate vaccines. Expert Rev Vaccines 2022; 21:499-511. [PMID: 35191368 DOI: 10.1080/14760584.2022.2040989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Otitis media (OM) is a common childhood infection. Pneumococcal conjugate vaccines (PCVs) prevent OM episodes, thereby reducing short- and long-term clinical, economic, humanistic, and societal consequences. Most economic evaluations of PCVs focus on direct health gains and cost savings from prevented acute episodes but do not fully account for the broader societal impacts of OM prevention. AREAS COVERED This review explores the broader burden of OM on children, caregivers, and society to better inform future economic evaluations of PCVs. EXPERT OPINION OM causes a substantial burden to society through long-term sequelae, productivity losses, reduced quality of life for children and caregivers, and contribution to antimicrobial resistance from inappropriate antibiotic use. The effect of PCVs on acute OM has been recognized globally, yet the broader impact has not been consistently quantified, studied, or communicated. Economic evaluations of PCVs must evolve to include broader effects for patients, caregivers, and society from OM prevention. Future PCVs with broader coverage may further reduce OM incidence and antimicrobial resistance, but optimal uptake will depend on increasing the recognition and use of novel frameworks that include broader benefits. Communicating the full value of PCVs to decision makers may result in wider access and positive societal returns.
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Affiliation(s)
- Johnna Perdrizet
- Health Economics and Outcomes Research, Pfizer Inc, New York, NY, USA
| | - Raymond A Farkouh
- Health Economics and Outcomes Research, Pfizer Inc, New York, NY, USA
| | - Emily K Horn
- Health Economics and Outcomes Research, Pfizer Inc, New York, NY, USA
| | - Kyla Hayford
- Vaccines Medical Development and Scientific and Clinical Affairs, Pfizer, Inc., Toronto, Canada
| | - Heather L Sings
- Vaccines Medical Development and Scientific and Clinical Affairs, Pfizer, Inc., Collegeville, PA, USA
| | - Matt D Wasserman
- Health Economics and Outcomes Research, Pfizer Inc, New York, NY, USA
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Paker M, Pichkhadze E, Miron D, Shlizerman L, Mazzawi S, Shupak A. Two decades of otitis media in northern Israel: Changing trends in the offending bacteria and antibiotic susceptibility. Int J Pediatr Otorhinolaryngol 2022; 152:110940. [PMID: 34810003 DOI: 10.1016/j.ijporl.2021.110940] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 09/05/2021] [Accepted: 10/09/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Bacteriology and antibiotic resistance trends changed considerably following introduction of the pneumococcal conjugate vaccines (PCV) 7 and 13, with differences between geographic regions. The objective of this study was to evaluate changes in acute otitis media (AOM) bacteriology and antibiotic susceptibility from the pre-vaccination period (2002-2008) to after the introduction of PCV13 (2010-2019) in northern Israel. METHODS Data were collected from 3277 middle ear fluid (MEF) cultures and 4822 common AOM-generating pathogens of children aged <5 years with otitis media, taken during 2002-2019. Age of the child, bacteriology, and antibiotic resistance were compared between 2002 and 2008, the pre-vaccination period when no vaccination was available and 2010-2019 when PCV13 was introduced. RESULTS The mean age of the children in the pre-vaccination and the vaccination periods was 18.7 ± 13.7 and 15.7 ± 12.5 months, respectively (p < 0.001); the mean age of those with group A streptococcus (GAS) positive cultures was older, p < 0.001.The prevalence of Streptococcus pneumoniae (S. pneumoniae) decreased between those periods, from 47% to 25.8%, p < 0.001, Haemophilus influenzae (H. influenza) increased from 38.4% to 47.1%, p < 0.001, GAS increased from 12.9% to 23.8%, p < 0.001, and Moraxella catarrhalis (M. cat) increased but not statistically significant from 1.7% to 3.1%. The yearly number of positive MEF cultures decreased from 395.1 to 205.6, p < 0.001. The antibiotic sensitivity rate of almost all antibiotics increased between the two study periods. CONCLUSION The most common MEF bacteria in northern Israel today is H. influenzae. Comparing the pre-vaccination to the vaccination period, the incidence of S. pneumonia-positive cultures decreased while GAS and H. influenza cultures increased. The age of children with positive cultures increased, and the antibiotic sensitivity rate increased. Key This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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Affiliation(s)
- Miki Paker
- Department of Otolaryngology Head and Neck Surgery, Emek Medical Center, Afula, Israel.
| | - Elena Pichkhadze
- Department of Otolaryngology Head and Neck Surgery, Emek Medical Center, Afula, Israel.
| | - Dan Miron
- The Pediatric Infectious Disease Service. Emek Medical Center, Afula, Israel.
| | - Lev Shlizerman
- Department of Otolaryngology Head and Neck Surgery, Emek Medical Center, Afula, Israel.
| | - Salim Mazzawi
- Department of Otolaryngology Head and Neck Surgery, Emek Medical Center, Afula, Israel.
| | - Avi Shupak
- Unit of Otoneurology, Lin and Carmel Medical Centers, Haifa, Israel; Department of Communication Science and Disorders, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel; The Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel.
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7
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Ekinci E, Desmet S, Van Heirstraeten L, Mertens C, Wouters I, Beutels P, Verhaegen J, Malhotra-Kumar S, Theeten H. Streptococcus pneumoniae Serotypes Carried by Young Children and Their Association With Acute Otitis Media During the Period 2016-2019. Front Pediatr 2021; 9:664083. [PMID: 34291017 PMCID: PMC8286995 DOI: 10.3389/fped.2021.664083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 06/07/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Streptococcus pneumoniae (Sp) is a major cause of acute otitis media (AOM). Pneumococcal conjugate vaccine (PCV) programs have altered pneumococcal serotype epidemiology in disease and carriage. In this study, we used samples collected during a cross-sectional study to examine if the clinical picture of acute otitis media (AOM) in young children exposed to the PCV program in Belgium was related to the carried pneumococcal strains, and if their carriage profile differed from healthy children attending daycare centers. Material/Methods: In three collection periods from February 2016 to May 2018, nasopharyngeal swabs and background characteristics were collected from children aged 6-30 months either presenting at their physician with AOM (AOM-group) or healthy and attending day care (DCC-group). Clinical signs of AOM episodes and treatment schedule were registered by the physicians. Sp was detected, quantified, and characterized using both conventional culture analysis and real-time PCR analysis. Results: Among 3,264 collected samples, overall pneumococcal carriage and density were found at similar rates in both AOM and DCC. As expected non-vaccine serotypes were most frequent: 23B (AOM: 12.3%; DCC: 17.4%), 11A (AOM: 7.5%; DCC: 7.4%) and 15B (AOM: 7.5%; DCC: 7.1%). Serotypes 3, 6C, 7B, 9N, 12F, 17F, and 29 were more often found in AOM than in DCC (p-value < 0.05), whereas 23A and 23B were less often present in AOM (p-value < 0.05). Antibiotic non-susceptibility of Sp strains was similar in both groups. No predictors of AOM severity were identified. Conclusion: In the present study, overall carriage prevalence and density of S. pneumoniae were found similar in young children with AOM and in healthy children attending day-care centers in Belgium. Certain serotypes not currently included in the PCV vaccines were found to be carried more often in children with AOM than in DCC, a finding that might suggest a relationship between these serotypes and AOM.
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Affiliation(s)
- Esra Ekinci
- Centre for Evaluation of Vaccination, Vaccine and Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - Stefanie Desmet
- Reference Centre for Pneumococci, University Hospitals Leuven, Leuven, Belgium
| | - Liesbet Van Heirstraeten
- Laboratory of Medical Microbiology, Vaccine and Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - Colette Mertens
- Centre for Evaluation of Vaccination, Vaccine and Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - Ine Wouters
- Centre for Evaluation of Vaccination, Vaccine and Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - Philippe Beutels
- Centre for Health Economics Research and Modelling Infectious Diseases, University of Antwerp, Antwerp, Belgium
| | - Jan Verhaegen
- Reference Centre for Pneumococci, University Hospitals Leuven, Leuven, Belgium
| | - Surbhi Malhotra-Kumar
- Laboratory of Medical Microbiology, Vaccine and Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - Heidi Theeten
- Centre for Evaluation of Vaccination, Vaccine and Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
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Tin Tin Htar M, van Den Biggelaar AHJ, Sings H, Ferreira G, Moffatt M, Hall-Murray C, Verstraeten T, Gessner BD, Schmitt HJ, Jodar L. The impact of routine childhood immunization with higher-valent pneumococcal conjugate vaccines on antimicrobial-resistant pneumococcal diseases and carriage: a systematic literature review. Expert Rev Vaccines 2019; 18:1069-1089. [PMID: 31585049 DOI: 10.1080/14760584.2019.1676155] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Introduction: The introduction of 7-valent pneumococcal conjugate vaccine (PCV7) in childhood immunization programs reduced antimicrobial-resistant pneumococcal infections by vaccine serotypes. However, emerging antimicrobial-resistant non-vaccine serotypes, particularly serotype 19A, attenuated the overall effect. In 2010, higher-valent PCVs became available containing serotypes that are prone to become antimicrobial-resistant, like serotype 7F in PCV10 and PCV13, and serotype 19A in PCV13.Areas covered: This review evaluated literature published between June 1, 2008 and June 1, 2017 reporting on the effect of PCV10 or PCV13 implementation in routine infant immunization schedules on antimicrobial-resistant invasive pneumococcal disease (IPD), otitis media (OM), and nasopharyngeal carriage (NPC) in children and adults.Expert opinion: In countries with relatively high prior pneumococcal antimicrobial resistance (AMR), PCV13 childhood vaccination programs have reduced antimicrobial-resistant IPD, OM, and NPC in children and IPD in adults. The effectiveness of PCV13 against serotype 19A is likely an important contributing factor. Only few studies have documented the impact of PCV10 on AMR. Multiple factors may influence observed decreases in pneumococcal AMR including antimicrobial stewardship, case definition, time since PCV10/13 introduction, and pre-PCV10/13 AMR levels. This review emphasizes the importance of including impact on AMR when evaluating the full public health of pneumococcal vaccination programs.
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Affiliation(s)
| | | | - Heather Sings
- Vaccines Medical Development & Scientific/Clinical Affairs, Pfizer Inc, Collegeville, PA, USA
| | - Germano Ferreira
- Department of Epidemiology, P95 Epidemiology and Pharmacovigilance, Leuven, Belgium
| | - Margaret Moffatt
- Department of Health Economic & Outcomes Research, Pfizer Inc, New York, NY, USA
| | - Cassandra Hall-Murray
- Vaccines Medical Development & Scientific/Clinical Affairs, Pfizer Inc, Collegeville, PA, USA
| | - Thomas Verstraeten
- Department of Epidemiology, P95 Epidemiology and Pharmacovigilance, Leuven, Belgium
| | - Bradford D Gessner
- Vaccines Medical Development & Scientific/Clinical Affairs, Pfizer Inc, Collegeville, PA, USA
| | - Heinz-Josef Schmitt
- Vaccines Medical Development & Scientific/Clinical Affairs, Pfizer Inc, Paris, France
| | - Luis Jodar
- Vaccines Medical Development & Scientific/Clinical Affairs, Pfizer Inc, Collegeville, PA, USA
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9
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Gülhan B, Kanik-Yuksek S, Ozkaya-Parlakay A. Mastoiditis with Streptococcus pneumoniae serotype 19A in one-dose PCV13 vaccinated three-month-old infant. Hum Vaccin Immunother 2019; 15:2917-2918. [PMID: 31348728 DOI: 10.1080/21645515.2019.1627823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Pneumococcal conjugate vaccines (PCV) have been widely used in high-income countries for more than a decade, resulting in a dramatic reduction in pneumococcal disease caused by vaccine serotypes. PCV has been included in Turkey's National Immunization Programme since 2009 with PCV7 and continued with PCV13 from 2011. We presented a three-month-old infant who developed mastoiditis secondary to S. pneumoniae serotype 19A after acute otitis media.
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Affiliation(s)
- B Gülhan
- Department of Pediatric Infectious Diseases, University of Health Sciences, Ankara Child Health and Diseases Hematology Oncology Training and Research Hospital, Ankara, Turkey
| | - S Kanik-Yuksek
- Department of Pediatric Infectious Diseases, University of Health Sciences, Ankara Child Health and Diseases Hematology Oncology Training and Research Hospital, Ankara, Turkey
| | - A Ozkaya-Parlakay
- Department of Pediatric Infectious Diseases, University of Health Sciences, Ankara Child Health and Diseases Hematology Oncology Training and Research Hospital, Ankara, Turkey
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10
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Ubukata K, Takata M, Morozumi M, Chiba N, Wajima T, Hanada S, Shouji M, Sakuma M, Iwata S. Effects of Pneumococcal Conjugate Vaccine on Genotypic Penicillin Resistance and Serotype Changes, Japan, 2010-2017. Emerg Infect Dis 2019; 24:2010-2020. [PMID: 30334707 PMCID: PMC6200004 DOI: 10.3201/eid2411.180326] [Citation(s) in RCA: 94] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
To clarify year-to-year changes in capsular serotypes, resistance genotypes, and multilocus sequence types of Streptococcus pneumoniae, we compared isolates collected from patients with invasive pneumococcal disease before and after introductions of 7- and 13-valent pneumococcal conjugate vaccines (PCV7 and PVC13, respectively). From April 2010 through March 2017, we collected 2,856 isolates from children and adults throughout Japan. Proportions of PCV13 serotypes among children decreased from 89.0% in fiscal year 2010 to 12.1% in fiscal year 2016 and among adults from 74.1% to 36.2%. Although nonvaccine serotypes increased after introduction of PCV13, genotypic penicillin resistance decreased from 54.3% in 2010 to 11.2% in 2016 among children and from 32.4% to 15.5% among adults. However, genotypic penicillin resistance emerged in 9 nonvaccine serotypes, but not 15A and 35B. Multilocus sequence typing suggested that resistant strains among nonvaccine serotypes may have evolved from clonal complexes 156 and 81. A more broadly effective vaccine is needed.
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Midouni B, Mehiri E, Ghariani A, Draoui H, Essalah L, Bouzouita I, Raoult D, Slim-Saidi L, Fournier P. Genetic diversity of Streptococcus pneumoniae in Tunisia. Int J Antimicrob Agents 2019; 53:63-69. [DOI: 10.1016/j.ijantimicag.2018.09.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 09/26/2018] [Accepted: 09/29/2018] [Indexed: 12/16/2022]
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12
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Morales M, Ludwig G, Ercibengoa M, Esteva C, Sanchez-Encinales V, Alonso M, Muñoz-Almagro C, Marimón JM. Changes in the serotype distribution of Streptococcus pneumoniae causing otitis media after PCV13 introduction in Spain. PLoS One 2018; 13:e0209048. [PMID: 30562385 PMCID: PMC6298674 DOI: 10.1371/journal.pone.0209048] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 11/27/2018] [Indexed: 11/19/2022] Open
Abstract
One of the beneficial effects of pneumococcal conjugate vaccines (PCVs) has been a decrease in the incidence of non-invasive infections, such as otitis media (OM) caused by vaccine serotypes. In this study, we analyzed the epidemiology of pneumococcal OM before and after PCV13 introduction in 2010. Between 2008 and 2016, the middle ear exudates from 2653 children under 14 years of age with OM were studied in two Spanish provinces (Gipuzkoa and Barcelona), and S. pneumoniae was isolated in 235 (8.9%) of cases. The 204 available isolates were serotyped and distributed in three 3-year periods: one before and two after PCV13 introduction (early and late post-PCV13). A significant decrease in the rate of OM caused by S. pneumoniae was observed mainly due to a decrease in infections caused by all PCV13 serotypes, although exceptions were observed including the persistence of serotype 3 in Gipuzkoa and a weak re-emergence of serotype 19F in both regions. The rate and diversity of non-PCV13 serotypes increased in both regions and an emerging clone causing OM was detected in each region: serotype 23B ST2372 in Gipuzkoa and serotype 11A ST838/ST6521 in Barcelona. The introduction of PCV13 has been followed by a change in the epidemiology of pneumococcal OM, with a decrease in the rate of vaccine serotypes accompanied by an increase in the diversity of non-vaccine serotype and the clonal spreading of different single clones in each region.
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Affiliation(s)
- María Morales
- Donostia University Hospital–Biodonostia Health Research Institute, Donostia-San Sebastian, Spain
- CIBER Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Guillermo Ludwig
- Molecular Microbiology Department, Institut de Recerca Sant Joan de Déu, Sant Joan de Déu University Hospital, Barcelona, Spain
| | - Maria Ercibengoa
- CIBER Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Preventive Medicine and Health Public Department, University of the Basque Country (UPV/EHU), Donostia-San Sebastian, Spain
| | - Cristina Esteva
- Molecular Microbiology Department, Institut de Recerca Sant Joan de Déu, Sant Joan de Déu University Hospital, Barcelona, Spain
- CIBER de Epidemiología y Salud Pública (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain
| | | | - Marta Alonso
- Donostia University Hospital–Biodonostia Health Research Institute, Donostia-San Sebastian, Spain
- CIBER Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Carmen Muñoz-Almagro
- Molecular Microbiology Department, Institut de Recerca Sant Joan de Déu, Sant Joan de Déu University Hospital, Barcelona, Spain
- CIBER de Epidemiología y Salud Pública (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain
- School of Medicine, Universitat Internacional de Catalunya, Barcelona, Spain
| | - José Maria Marimón
- Donostia University Hospital–Biodonostia Health Research Institute, Donostia-San Sebastian, Spain
- CIBER Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
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13
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Satzke C, Dunne EM, Choummanivong M, Ortika BD, Neal EFG, Pell CL, Nation ML, Fox KK, Nguyen CD, Gould KA, Hinds J, Chanthongthip A, Xeuatvongsa A, Mulholland EK, Sychareun V, Russell FM. Pneumococcal carriage in vaccine-eligible children and unvaccinated infants in Lao PDR two years following the introduction of the 13-valent pneumococcal conjugate vaccine. Vaccine 2018; 37:296-305. [PMID: 30502068 DOI: 10.1016/j.vaccine.2018.10.077] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 10/11/2018] [Accepted: 10/23/2018] [Indexed: 01/27/2023]
Abstract
Pneumococcal carriage is a prerequisite for disease, and underpins herd protection provided by pneumococcal conjugate vaccines (PCVs). There are few data on the impact of PCVs in lower income settings, particularly in Asia. In 2013, the Lao People's Democratic Republic (Lao PDR) introduced 13-valent PCV (PCV13) as a 3 + 0 schedule (doses at 6, 10 and 14 weeks of age) with limited catch-up vaccination. We conducted two cross-sectional carriage surveys (pre- and two years post-PCV) to assess the impact of PCV13 on nasopharyngeal pneumococcal carriage in 5-8 week old infants (n = 1000) and 12-23 month old children (n = 1010). Pneumococci were detected by quantitative real-time PCR, and molecular serotyping was performed using DNA microarray. Post PCV13, there was a 23% relative reduction in PCV13-type carriage in children aged 12-23 months (adjusted prevalence ratio [aPR] 0.77 [0.61-0.96]), and no significant change in non-PCV13 serotype carriage (aPR 1.11 [0.89-1.38]). In infants too young to be vaccinated, there was no significant change in carriage of PCV13 serotypes (aPR 0.74 [0.43-1.27]) or non-PCV13 serotypes (aPR 1.29 [0.85-1.96]), although trends were suggestive of indirect effects. Over 70% of pneumococcal-positive samples contained at least one antimicrobial resistance gene, which were more common in PCV13 serotypes (p < 0.001). In 12-23 month old children, pneumococcal density of both PCV13 serotypes and non-PCV13 serotypes was higher in PCV13-vaccinated compared with undervaccinated children (p = 0.004 and p < 0.001, respectively). This study provides evidence of PCV13 impact on carriage in a population without prior PCV7 utilisation, and provides important data from a lower-middle income setting in Asia. The reductions in PCV13 serotype carriage in vaccine-eligible children are likely to result in reductions in pneumococcal transmission and disease in Lao PDR.
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Affiliation(s)
- Catherine Satzke
- Pneumococcal Research, Murdoch Children's Research Institute, Royal Children's Hospital, Flemington Road, Parkville, Australia; Department of Paediatrics, The University of Melbourne, Parkville, Australia; Department of Microbiology and Immunology, Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Parkville, Australia.
| | - Eileen M Dunne
- Pneumococcal Research, Murdoch Children's Research Institute, Royal Children's Hospital, Flemington Road, Parkville, Australia; Department of Paediatrics, The University of Melbourne, Parkville, Australia
| | | | - Belinda D Ortika
- Pneumococcal Research, Murdoch Children's Research Institute, Royal Children's Hospital, Flemington Road, Parkville, Australia
| | - Eleanor F G Neal
- Pneumococcal Research, Murdoch Children's Research Institute, Royal Children's Hospital, Flemington Road, Parkville, Australia; Department of Paediatrics, The University of Melbourne, Parkville, Australia; Centre for International Child Health, Department of Paediatrics, The University of Melbourne, Parkville, Australia
| | - Casey L Pell
- Pneumococcal Research, Murdoch Children's Research Institute, Royal Children's Hospital, Flemington Road, Parkville, Australia
| | - Monica L Nation
- Pneumococcal Research, Murdoch Children's Research Institute, Royal Children's Hospital, Flemington Road, Parkville, Australia
| | - Kimberley K Fox
- Expanded Programme on Immunization, World Health Organization Regional Office for the Western Pacific, Manila, Philippines
| | - Cattram D Nguyen
- Pneumococcal Research, Murdoch Children's Research Institute, Royal Children's Hospital, Flemington Road, Parkville, Australia; Department of Paediatrics, The University of Melbourne, Parkville, Australia
| | - Katherine A Gould
- Institute for Infection and Immunity, St. George's, University of London, London, UK; BUGS Bioscience, London Bioscience Innovation Centre, London, UK
| | - Jason Hinds
- Institute for Infection and Immunity, St. George's, University of London, London, UK; BUGS Bioscience, London Bioscience Innovation Centre, London, UK
| | - Anisone Chanthongthip
- Laos-Oxford-Mahosot Hospital Wellcome Trust Research Unit, Vientiane, Lao People's Democratic Republic
| | | | - E Kim Mulholland
- Pneumococcal Research, Murdoch Children's Research Institute, Royal Children's Hospital, Flemington Road, Parkville, Australia; Department of Paediatrics, The University of Melbourne, Parkville, Australia; Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Fiona M Russell
- Pneumococcal Research, Murdoch Children's Research Institute, Royal Children's Hospital, Flemington Road, Parkville, Australia; Department of Paediatrics, The University of Melbourne, Parkville, Australia; Centre for International Child Health, Department of Paediatrics, The University of Melbourne, Parkville, Australia
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14
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Agudelo CI, DeAntonio R, Castañeda E. Streptococcus pneumoniae serotype 19A in Latin America and the Caribbean 2010–2015: A systematic review and a time series analysis. Vaccine 2018; 36:4861-4874. [DOI: 10.1016/j.vaccine.2018.06.068] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 05/28/2018] [Accepted: 06/29/2018] [Indexed: 10/28/2022]
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15
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Etiology of Acute Otitis Media and Characterization of Pneumococcal Isolates After Introduction of 13-Valent Pneumococcal Conjugate Vaccine in Japanese Children. Pediatr Infect Dis J 2018; 37:598-604. [PMID: 29474258 DOI: 10.1097/inf.0000000000001956] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Acute otitis media is a leading cause of childhood morbidity and antibiotic prescriptions. We examined etiologic changes in acute otitis media after introduction of 13-valent pneumococcal conjugate vaccine as routine immunization for Japanese children in 2014. Serotypes, resistance genotypes, antibiotic susceptibilities and multilocus sequence typing of pneumococcal isolates were also characterized. METHODS Otolaryngologists prospectively collected middle ear fluid from 582 children by tympanocentesis or sampling through a spontaneously ruptured tympanic membrane between June 2016 and January 2017. Causative pathogens were identified by bacterial culture and real-time polymerase chain reaction for bacteria. Serotypes, resistance genotypes, sequence types and susceptibilities to 14 antimicrobial agents were determined for pneumococcal isolates. RESULTS At least 1 bacterial pathogen was identified in 473 of the samples (81.3%). Nontypeable Haemophilus influenzae (54.8%) was detected most frequently, followed by Streptococcus pneumoniae (25.4%), Streptococcus pyogenes (2.9%) and others. Pneumococci of current vaccine serotypes have decreased dramatically from 82.1% in 2006 to 18.5% (P < 0.001). Commonest serotypes were 15A (14.8%), 3 (13.9%) and 35B (11.1%). Serotype 3 was significantly less frequent among children receiving 13-valent pneumococcal conjugate vaccine compared with 7-valent pneumococcal conjugate vaccine (P = 0.002). Genotypic penicillin-resistant S. pneumoniae accounted for 28.7%, slightly less than in 2006 (34.2%; P = 0.393); the penicillin-resistant serotypes 15A and 35B had increased. Serotypes 15A, 3 and 35B most often belonged to sequence types 63, 180 and 558. CONCLUSIONS Our findings are expected to assist in development of future vaccines, and they underscore the need for appropriate clinical choice of oral agents based on testing of causative pathogens.
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Isturiz R, Sings HL, Hilton B, Arguedas A, Reinert RR, Jodar L. Streptococcus pneumoniae serotype 19A: worldwide epidemiology. Expert Rev Vaccines 2017; 16:1007-1027. [DOI: 10.1080/14760584.2017.1362339] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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17
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Pettigrew MM, Alderson MR, Bakaletz LO, Barenkamp SJ, Hakansson AP, Mason KM, Nokso-Koivisto J, Patel J, Pelton SI, Murphy TF. Panel 6: Vaccines. Otolaryngol Head Neck Surg 2017; 156:S76-S87. [PMID: 28372533 DOI: 10.1177/0194599816632178] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Objective To review the literature on progress regarding (1) effectiveness of vaccines for prevention of otitis media (OM) and (2) development of vaccine antigens for OM bacterial and viral pathogens. Data Sources PubMed database of the National Library of Science. Review Methods We performed literature searches in PubMed for OM pathogens and candidate vaccine antigens, and we restricted the searches to articles in English that were published between July 2011 and June 2015. Panel members reviewed literature in their area of expertise. Conclusions Pneumococcal conjugate vaccines (PCVs) are somewhat effective for the prevention of pneumococcal OM, recurrent OM, OM visits, and tympanostomy tube insertions. Widespread use of PCVs has been associated with shifts in pneumococcal serotypes and bacterial pathogens associated with OM, diminishing PCV effectiveness against AOM. The 10-valent pneumococcal vaccine containing Haemophilus influenzae protein D (PHiD-CV) is effective for pneumococcal OM, but results from studies describing the potential impact on OM due to H influenzae have been inconsistent. Progress in vaccine development for H influenzae, Moraxella catarrhalis, and OM-associated respiratory viruses has been limited. Additional research is needed to extend vaccine protection to additional pneumococcal serotypes and other otopathogens. There are likely to be licensure challenges for protein-based vaccines, and data on correlates of protection for OM vaccine antigens are urgently needed. Implications for Practice OM continues to be a significant health care burden globally. Prevention is preferable to treatment, and vaccine development remains an important goal. As a polymicrobial disease, OM poses significant but not insurmountable challenges for vaccine development.
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Affiliation(s)
- Melinda M Pettigrew
- 1 Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven Connecticut, USA
| | | | - Lauren O Bakaletz
- 3 Center for Microbial Pathogenesis, The Research Institute at Nationwide Children's Hospital, and Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | | | | | - Kevin M Mason
- 3 Center for Microbial Pathogenesis, The Research Institute at Nationwide Children's Hospital, and Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | | | - Janak Patel
- 7 University of Texas Medical Branch, Galveston, Texas, USA
| | - Stephen I Pelton
- 8 Boston University School of Medicine, Boston, Massachusetts, USA
| | - Timothy F Murphy
- 9 University at Buffalo, The State University of New York, Buffalo, New York, USA
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Ovnat Tamir S, Shemesh S, Oron Y, Marom T. Acute otitis media guidelines in selected developed and developing countries: uniformity and diversity. Arch Dis Child 2017; 102:450-457. [PMID: 27601361 DOI: 10.1136/archdischild-2016-310729] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 08/17/2016] [Accepted: 08/19/2016] [Indexed: 11/04/2022]
Abstract
BACKGROUND Acute otitis media (AOM) is a common childhood disease, with an enormous economic and healthcare-related burden. Guidelines and consensus papers for AOM diagnosis and management were published in many countries. Our objective was to study the differences and similarities between these protocols in developing and developed countries. METHODS The keywords: 'acute otitis media' AND 'children' AND ['treatment' or 'management'] AND ['guideline' or 'consensus'] were used in various electronic databases between 1 January 1989 through 31 December 2015. Overall, 99 sources from 62 countries were retrieved: 53 from 22 developed countries, and 46 from 40 developing countries. Representative guidelines from America (the USA, Argentina), Europe (Italy, Moldova), Africa (South Africa, Tanzania, Ethiopia), Asia (Japan, Afghanistan, Sri Lanka),and Oceania (South Australia, Fiji) were compared. RESULTS Paediatric societies publish guidelines in most developed countries; in developing countries, the Ministry of Health usually initiates guideline formulation. Most guidelines use the same diagnostic criteria and offer watchful waiting in mild-moderate scenarios. Amoxicillin is the suggested first-line antibiotic, whereas options for second-line and third-line therapies vary. Duration of therapy varies and is usually age dependent: 5-7 days for children <2 years and 10 days for children >2 years in developed countries, while duration and age groups vary greatly in developing countries. Reduction of AOM risk factors is encouraged in developed countries, but rarely in developing countries. CONCLUSIONS Guidelines for AOM from developing and developed countries are similar in many aspects, with variation in specific recommendations, due to local epidemiology and healthcare accessibility. Formulation of regional guidelines may help reduce AOM burden.
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Affiliation(s)
- Sharon Ovnat Tamir
- Department of Otolaryngology-Head and Neck Surgery, Edith Wolfson Medical Center, Tel Aviv University Sackler Faculty of Medicine, Holon, Israel
| | - Shay Shemesh
- Department of Otolaryngology-Head and Neck Surgery, Edith Wolfson Medical Center, Tel Aviv University Sackler Faculty of Medicine, Holon, Israel
| | - Yahav Oron
- Department of Otolaryngology-Head and Neck Surgery, Edith Wolfson Medical Center, Tel Aviv University Sackler Faculty of Medicine, Holon, Israel
| | - Tal Marom
- Department of Otolaryngology-Head and Neck Surgery, Assaf Harofeh Medical Center, Tel Aviv University Sackler Faculty of Medicine, Zerifin, Israel
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Hauser C, Kronenberg A, Allemann A, Mühlemann K, Hilty M. Serotype/serogroup-specific antibiotic non-susceptibility of invasive and non-invasive Streptococcus pneumoniae, Switzerland, 2004 to 2014. ACTA ACUST UNITED AC 2017; 21:30239. [PMID: 27254535 DOI: 10.2807/1560-7917.es.2016.21.21.30239] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 01/07/2016] [Indexed: 11/20/2022]
Abstract
Concurrent analysis of antibiotic resistance of colonising and invasive Streptococcus pneumoniae gives a more accurate picture than looking at either of them separately. Therefore, we analysed 2,129 non-invasive and 10,996 invasive pneumococcal isolates from Switzerland from 2004 to 2014, which spans the time before and after the introduction of the heptavalent (PCV7) and 13-valent (PCV13) conjugated pneumococcal polysaccharide vaccines. Serotype/serogroup information was linked with all antibiotic resistance profiles. During the study period, the proportion of non-susceptible non-invasive and invasive isolates significantly decreased for penicillin, ceftriaxone, erythromycin and trimethoprim/sulfamethoxazole (TMP-SMX). This was most apparent in non-invasive isolates from study subjects younger than five years (penicillin (p = 0.006), erythromycin (p = 0.01) and TMP-SMX (p = 0.002)). Resistant serotypes/serogroups included in PCV7 and/or PCV13 decreased and were replaced by non-PCV13 serotypes (6C and 15B/C). Serotype/serogroup-specific antibiotic resistance rates were comparable between invasive and non-invasive isolates. Adjusted odds ratios of serotype/serogroup-specific penicillin resistance were significantly higher in the west of Switzerland for serotype 6B (1.8; 95% confidence interval (CI): 1.4-4.8), 9V (3.4; 95% CI: 2.0-5.7), 14 (5.3; 95% CI: 3.8-7.5), 19A (2.2; 95% CI: 1.6-3.1) and 19F (3.1; 95% CI: 2.1-4.6), probably due to variations in the antibiotic consumption.
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Affiliation(s)
- Christoph Hauser
- Institute for Infectious Diseases, Faculty of Medicine, University of Bern, Bern, Switzerland
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20
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Impact of Pneumococcal Conjugate Vaccines on Selected Head and Neck Infections in Hospitalized Israeli Children. Pediatr Infect Dis J 2017; 36:314-318. [PMID: 27879558 DOI: 10.1097/inf.0000000000001425] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Streptococcus pneumoniae is a major pathogen of pediatric head and neck infections (HNIs), for example, acute otitis media (AOM), acute mastoiditis, acute bacterial sinusitis and meningitis. The aim of this study was to characterize the epidemiology of pneumococcal HNIs (pHNIs) before, during and after the introduction of pneumococcal conjugate vaccines (PCVs). METHODS Children 0-16 years of age, who were hospitalized with HNIs in the pediatrics department in a general hospital between January 1, 2007, and December 31, 2014, were retrospectively identified. Study years were categorized according to the PCV introduction timeline: 2007-2008: "pre-PCV years"; 2009-2011: "transition years" and 2012-2014: "post-PCV years." pHNIs episodes were defined if pneumococcal culture or urine antigen was positive. Children who received ≥2 doses of PCV7/PCV13 were considered as immunized. All other children were considered as unimmunized. RESULTS HNIs accounted for 2.5%-4.7% of the total admissions; 3%-17% of them were pHNIs. Eighty-seven pHNI episodes were identified: AOM (n = 42), acute mastoiditis (n = 28) and meningitis (n = 17). There was a downward trend in the overall incidence of HNIs, and particularly of pHNIs, in the post-PCV years. The average age and hospitalization duration of children with HNIs/pHNIs remained stable during the study years. In 2009-2010, pHNIs incidence sharply decreased, from 7 to 1.74/1000 hospitalized children/year, due to ~55% reduction of pneumococcal AOM episodes. An additional decrease was observed in the post-PCV years (1.62/1000 hospitalized children/year). Immunized children were less likely to present with pHNIs (P = 0.001) but were more likely to undergo surgery (P = 0.042). CONCLUSION We observed a reduction in pHNIs incidence after PCV program implementation.
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Han SB, Kim JH, Kang JH, Ma SH, Kim CS, Kim KH, Kim HM, Choi YY. Recent epidemiology of Streptococcus pneumoniae in nasopharynxes of Korean children with acute otitis media. J Infect Chemother 2016; 23:136-141. [PMID: 28024738 DOI: 10.1016/j.jiac.2016.10.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 10/18/2016] [Accepted: 10/22/2016] [Indexed: 11/24/2022]
Abstract
BACKGROUND This prospective study was performed to evaluate serotype distribution, multilocus sequence typing, and antibiotic susceptibility of Streptococcus pneumoniae identified in Korean children with acute otitis media (AOM) after the introduction of a 7-valent pneumococcal conjugate vaccine (PCV7). METHODS Nasopharyngeal aspirates were collected from children diagnosed with AOM in seven hospitals in Korea. The bacteria identified in these samples and the serotypes, sequence types (STs), and antibiotic susceptibilities of S. pneumoniae isolates were evaluated. RESULTS A total of 390 children were enrolled, and bacteria were identified in 376 (96.4%) children. S. pneumoniae, Haemophilus influenzae and Moraxella catarrhalis were identified in 155 (39.7%), 127 (32.6%) and 86 (22.1%) children, respectively. Serotype 19A (22.4%) was the most common S. pneumoniae serotype, with serogroups 11 (14.7%) and 15 (13.5%) following. ST320 (23.5%) was the most common ST; ST166 (17.0%) and ST83 (8.5%) followed. The overall susceptibility rates of S. pneumoniae to oral penicillin V and amoxicillin/clavulanate were 2.6% and 53.2%, respectively. The susceptibility rate to cefditoren was 91.0%; however, the rates for other cephalosporins were less than 10.0%. Compared with other serogroups, S. pneumoniae serogroups 19, 11, and 15 showed significantly lower susceptibility rates to all the antibiotics tested. CONCLUSION S. pneumoniae serotype 19A, serogroups 11 and 15 were the major nasopharyngeal-colonizing bacteria in Korean children with AOM after the introduction of PCV7. These relatively prevalent serotype/serogroups showed lower antibiotic susceptibility rates.
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Affiliation(s)
- Seung Beom Han
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea; The Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jong-Hyun Kim
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea; The Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jin Han Kang
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea; The Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
| | - Sang Hyuk Ma
- Department of Pediatrics, Fatima Hospital, Changwon, Republic of Korea
| | - Chun Soo Kim
- Department of Pediatrics, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Kyung-Hyo Kim
- Department of Pediatrics, Ewha Womans University School of Medicine, Seoul, Republic of Korea; Center for Vaccine Evaluation and Study, Medical Research Institute, Ewha Womans University School of Medicine, Seoul, Republic of Korea
| | - Hwang Min Kim
- Department of Pediatrics, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Young Youn Choi
- Department of Pediatrics, Chonnam National University Medical School, Gwangju, Republic of Korea
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Hays C, Vermee Q, Agathine A, Dupuis A, Varon E, Poyart C, Ploy MC, Raymond J. Demonstration of the herd effect in adults after the implementation of pneumococcal vaccination with PCV13 in children. Eur J Clin Microbiol Infect Dis 2016; 36:831-838. [DOI: 10.1007/s10096-016-2868-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Accepted: 12/06/2016] [Indexed: 01/21/2023]
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Cohen R, Biscardi S, Levy C. The multifaceted impact of pneumococcal conjugate vaccine implementation in children in France between 2001 to 2014. Hum Vaccin Immunother 2016; 12:277-84. [PMID: 26905678 DOI: 10.1080/21645515.2015.1116654] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
In 2003, France was the first European country to recommend 7-valent pneumococcal conjugate vaccine (PCV7) for a large proportion of healthy children. With complicated recommendations, the vaccine coverage during the first 4 y of implementation was low, then progressively increased to reach 90% in 2008. The aim of this review was to describe the particular impact of PCVs in a country where the vaccine coverage was initially suboptimal. After PCV7 implementation, the PCV7 serotypes nearly disappeared among pneumococci isolated from meningitis (-73%), other invasive pneumococcal disease (IPD; -90%) and pneumococcal carriage (-97%). Consequently, the rates of penicillin-resistant strains declined. However, because of important serotype replacement, the global effect on the incidence of meningitis (-31%) or other IPD (-14%) was modest and observed only in young children < 2 y old. After PCV13 transition, with immediate high vaccine coverage, the vaccine had an important impact on all pneumococcal disease: reduction of -20% for pneumococcal meningitis, -36% for non-meningitis IPD, -32% for community acquired pneumonia and -15% for S. pneumoniae carriage. These findings underline the complexity of pneumococcal epidemiology and the importance of high and fast vaccination coverage to obtain the optimal effect of PCVs.
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Affiliation(s)
- Robert Cohen
- a Université Paris Est ; IMRB- GRC GEMINI ; Créteil , France.,b ACTIV; Association Clinique et Thérapeutique Infantile du Val de Marne ; Saint-Maur des Fossés , France.,c Clinical Research Center (CRC) ; Centre Hospitalier Intercommunal de Créteil ; Créteil , France.,d Unité Court Séjour; Petits Nourrissons ; Service de Néonatologie; Centre Hospitalier Intercommunal de Créteil ; France.,e GPIP (Groupe de Pathologie Infectieuse Pédiatrique) de la SFP (Société Française de Pédiatrie) ; Paris , France
| | - Sandra Biscardi
- a Université Paris Est ; IMRB- GRC GEMINI ; Créteil , France.,c Clinical Research Center (CRC) ; Centre Hospitalier Intercommunal de Créteil ; Créteil , France.,e GPIP (Groupe de Pathologie Infectieuse Pédiatrique) de la SFP (Société Française de Pédiatrie) ; Paris , France.,f Service des urgences pédiatriques ; Centre Hospitalier Intercommunal de Créteil ; Créteil , France
| | - Corinne Levy
- a Université Paris Est ; IMRB- GRC GEMINI ; Créteil , France.,b ACTIV; Association Clinique et Thérapeutique Infantile du Val de Marne ; Saint-Maur des Fossés , France.,c Clinical Research Center (CRC) ; Centre Hospitalier Intercommunal de Créteil ; Créteil , France.,e GPIP (Groupe de Pathologie Infectieuse Pédiatrique) de la SFP (Société Française de Pédiatrie) ; Paris , France
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24
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Corrigendum. Hum Vaccin Immunother 2016; 12:2478-81. [DOI: 10.1080/21645515.2016.1229033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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25
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Lindstrand A, Galanis I, Darenberg J, Morfeldt E, Naucler P, Blennow M, Alfvén T, Henriques-Normark B, Örtqvist Å. Unaltered pneumococcal carriage prevalence due to expansion of non-vaccine types of low invasive potential 8years after vaccine introduction in Stockholm, Sweden. Vaccine 2016; 34:4565-4571. [PMID: 27473304 DOI: 10.1016/j.vaccine.2016.07.031] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2016] [Revised: 07/03/2016] [Accepted: 07/18/2016] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To evaluate the carriage prevalence, serotype distribution, and antibiotic resistance for pneumococcal carriage isolates collected 4-8years after introduction of pneumococcal conjugate vaccines (PCVs) in Stockholm, Sweden, and to identify risk factors for carriage and calculate the invasive disease potential for emerging serotypes. METHODS Nasopharyngeal aspirates were collected from 3024 children aged 0-<5years at regular visits at 23 Child Health Centers in Stockholm County in 2011-2015, and from 787 parents in 2014-2015. The invasive disease potential was calculated for serotypes using invasive disease isolates from 824 patients of all ages identified in the Stockholm County during the same time period as the carriage isolates. RESULTS A total carriage prevalence of 30% did not change during the study period. Non-vaccine types (NVT) dominated (94% by 2015) and the most common serotypes in descending order were 11A, 23B, 35F and 21. Risk factors for carriage were: age ⩾3months-<3years, having siblings, attending day-care and having travelled abroad the last 3months. Antibiotic resistance remained low. The invasive disease potential was high for NVT 8, 9N, 12F, and 22F, while low for a majority of emerging NVTs in carriage. CONCLUSION The carriage prevalence remained the same 4-8years after vaccine introduction, but serotype replacement became almost complete. A majority of emerging NVTs in carriage showed a low invasive disease potential. Carriage studies are an important complement to invasive disease surveillance to understand the full effect of PCV vaccine programs.
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Affiliation(s)
- Ann Lindstrand
- The Public Health Agency Sweden, SE-171 82, Solna, Sweden; Department of Public Health Sciences, Karolinska Institutet, SE-171 77 Stockholm, Sweden.
| | - Ilias Galanis
- The Public Health Agency Sweden, SE-171 82, Solna, Sweden
| | | | - Eva Morfeldt
- The Public Health Agency Sweden, SE-171 82, Solna, Sweden
| | - Pontus Naucler
- Department of Medicine, Unit of Infectious Diseases, Karolinska University Hospital, SE-171 76, Solna, Sweden
| | - Margareta Blennow
- Sachs' Children and Youth Hospital, South General Hospital, SE-118 83 Stockholm, Sweden; Department of Clinical Sciences and Education, Karolinska Institutet, SE-171 77 Stockholm, Sweden
| | - Tobias Alfvén
- Department of Public Health Sciences, Karolinska Institutet, SE-171 77 Stockholm, Sweden; Sachs' Children and Youth Hospital, South General Hospital, SE-118 83 Stockholm, Sweden
| | - Birgitta Henriques-Normark
- The Public Health Agency Sweden, SE-171 82, Solna, Sweden; Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, SE-171 77 Stockholm, Sweden; Department of Clinical Microbiology, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
| | - Åke Örtqvist
- Department of Medicine, Unit of Infectious Diseases, Karolinska University Hospital, SE-171 76, Solna, Sweden; Department of Communicable Disease Control and Prevention, SE-118 83, Stockholm County Council, Sweden
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26
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Li Y, Hill A, Beitelshees M, Shao S, Lovell JF, Davidson BA, Knight PR, Hakansson AP, Pfeifer BA, Jones CH. Directed vaccination against pneumococcal disease. Proc Natl Acad Sci U S A 2016; 113:6898-903. [PMID: 27274071 PMCID: PMC4922154 DOI: 10.1073/pnas.1603007113] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Immunization strategies against commensal bacterial pathogens have long focused on eradicating asymptomatic carriage as well as disease, resulting in changes in the colonizing microflora with unknown future consequences. Additionally, current vaccines are not easily adaptable to sequence diversity and immune evasion. Here, we present a "smart" vaccine that leverages our current understanding of disease transition from bacterial carriage to infection with the pneumococcus serving as a model organism. Using conserved surface proteins highly expressed during virulent transition, the vaccine mounts an immune response specifically against disease-causing bacterial populations without affecting carriage. Aided by a delivery technology capable of multivalent surface display, which can be adapted easily to a changing clinical picture, results include complete protection against the development of pneumonia and sepsis during animal challenge experiments with multiple, highly variable, and clinically relevant pneumococcal isolates. The approach thus offers a unique and dynamic treatment option readily adaptable to other commensal pathogens.
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Affiliation(s)
- Yi Li
- Department of Chemical and Biological Engineering, University at Buffalo, The State University of New York, Buffalo, NY 14260
| | | | - Marie Beitelshees
- Department of Chemical and Biological Engineering, University at Buffalo, The State University of New York, Buffalo, NY 14260
| | - Shuai Shao
- Department of Biomedical Engineering, University at Buffalo, The State University of New York, Buffalo, NY 14260
| | - Jonathan F Lovell
- Department of Biomedical Engineering, University at Buffalo, The State University of New York, Buffalo, NY 14260
| | - Bruce A Davidson
- Department of Anesthesiology, University at Buffalo, The State University of New York, Buffalo, NY 14260
| | - Paul R Knight
- Department of Anesthesiology, University at Buffalo, The State University of New York, Buffalo, NY 14260; Department of Microbiology and Immunology, University at Buffalo, The State University of New York, Buffalo, NY 14260
| | - Anders P Hakansson
- Department of Microbiology and Immunology, University at Buffalo, The State University of New York, Buffalo, NY 14260; Division of Experimental Infection Medicine, Department of Laboratory Medicine, Lund University, SE-221 00 Malmo, Sweden
| | - Blaine A Pfeifer
- Department of Chemical and Biological Engineering, University at Buffalo, The State University of New York, Buffalo, NY 14260; Abcombi Biosciences Inc., Buffalo, NY 14260;
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Hafen GM, Grenzbach AC, Moeller A, Rochat MK. Lack of concordance in parapneumonic effusion management in children in central Europe. Pediatr Pulmonol 2016; 51:411-7. [PMID: 26291694 DOI: 10.1002/ppul.23263] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Revised: 05/14/2015] [Accepted: 06/05/2015] [Indexed: 11/08/2022]
Abstract
Treatment of parapneumonic effusion in children remains controversial in the literature and in clinical practice. The aim of this study was to determine whether mutual consensus exists in the diagnosis and treatment of parapneumonic effusion in Central European countries. A questionnaire was sent to all directors of pediatric respiratory units in four adjacent Central European countries (Austria, France, Germany, Switzerland). The response rate was 61.8%. Responses reflected acceptable agreement regarding initial diagnostic procedures, as most centers performed chest X-ray and biological exams, followed by ultrasound, thoracocentesis, or computed tomography. However, antibiotic regimens were very heterogeneous, and the survey revealed complete lack of agreement on the indications and effusion volume threshold for invasive procedures, such as fibrinolytic instillation and thoracoscopy. In conclusion, apart from initial diagnostic procedures, this study showed a lack of mutual consensus among the four countries regarding the management of pediatric parapneumonic effusion. Multicenter prospective trials are clearly needed to acquire more evidence on the management of childhood parapneumonic effusion, enabling the development of evidence-based algorithms that could help to avoid unnecessary examinations with potential long-term side effects, such as radiation exposure at a young age.
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Affiliation(s)
- Gaudenz M Hafen
- Department of Pediatrics, Respiratory Unit, Lausanne University Hospital, Lausanne, Switzerland
| | - Andrea-Claudia Grenzbach
- Department of Pediatric Pulmonology, Clinic for Pediatric and Adolescent Medicine, University of Luebeck, Luebeck, Germany
| | - Alexander Moeller
- Division of Respiratory Medicine, University Children's Hospital Zurich, Zurich, Switzerland
| | - Mascha K Rochat
- Department of Pediatrics, Lausanne University Hospital, Lausanne, Switzerland
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Abstract
Acute otitis media (AOM) is a common problem facing general practitioners, paediatricians and otolaryngologists. This article reviews the aetiopathogenesis, epidemiology, presentation, natural history, complications and management of AOM. The literature was reviewed by using the PubMed search engine and entering a combination of terms including 'AOM', 'epidemiology' and 'management'. Relevant articles were identified and examined for content. What is the take-home message? AOM is a very common problem affecting the majority of children at least once and places a large burden on health care systems throughout the world. Although symptomatic relief is often enough for most children, more severe and protracted cases require treatment with antibiotics, especially in younger children.
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Affiliation(s)
- Helen Atkinson
- Department of Otolaryngology, Head and Neck Surgery, York Teaching Hospitals NHS Foundations Trust , York , UK
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29
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Dramatic decrease of Streptococcus pneumoniae infections in Marseille, 2003-2014. Eur J Clin Microbiol Infect Dis 2015. [PMID: 26210386 DOI: 10.1007/s10096-015-2455-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
We studied the evolution of the prevalence of pneumococcal infections in university hospitals in Marseille, France, from January 2003 to December 2014, and compared our observations and results to available international data. We collected data referring to patients hospitalised for Streptococcus pneumoniae infections in the four university hospitals of Marseille from January 2003 to December 2014. We then calculated percentages of positiveness to pneumococcal strains by dividing the annual number of patients infected by pneumococcal strains by the annual number of patients found to be infected by at least one bacterial species in the settings of interest throughout the study period. Overall, 2442 non-redundant patients were infected by S. pneumoniae strains throughout the study period. We observed that the annual percentage of patients infected by S. pneumoniae significantly decreased throughout the study period (from 1.99% in 2003 to 0.77% in 2014, p-value < 10(-4)). A significant correlation was obtained comparing the annual evolution of the percentage of patients positive to pneumococcal strains aged under 21 years to that of patients aged over 21 years (r = 0.93, p-value < 10(-5)). Our results allowed us to prove that national immunisation programmes effectively impact on the pneumococcal infection prevalence in young and elderly populations, even on the regional scale.
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