The Saudi Thoracic Society pneumococcal vaccination guidelines-2016

The Saudi initiative for asthma - 2024 update: Guidelines for the diagnosis and management of asthma in adults and children

The Saudi Initiative for Asthma 2024 (SINA-2024) is the sixth version of asthma guidelines for the diagnosis and management of asthma for adults and children that was developed by the SINA group, a subsidiary of the Saudi Thoracic Society. The main objective of the SINA is to have guidelines that are up-to-date, simple to understand, and easy to use by healthcare workers dealing with asthma patients. To facilitate achieving the goals of asthma management, the SINA Panel approach is mainly based on the assessment of symptom control and risk for both adults and children. The approach to asthma management is aligned for age groups: adults, adolescents, children aged 5-12 years, and children aged <5 years. SINA guidelines have focused more on personalized approaches reflecting a better understanding of disease heterogeneity with the integration of recommendations related to biologic agents, evidence-based updates on treatment, and the role of immunotherapy in management. The medication appendix has also been updated with the addition of recent evidence, new indications for existing medication, and new medications. The guidelines are constructed based on the available evidence, local literature, and the current situation at national and regional levels. There is also an emphasis on patient-doctor partnership in the management that also includes a self-management plan.

Pneumococcal Disease: Global Disease Prevention Strategies with a Focus on the Challenges in Iraq

Pneumococcal disease is a global public health concern that significantly contributes to clinical disease burden and economic burden. Patients frequently afflicted are young children and older adults, as well as the immunocompromised population. Immunization is the most effective public health strategy to combat pneumococcal disease and several vaccine formulations have been developed in this regard. Although vaccines have had a significant global impact in reducing pneumococcal disease, there are several barriers to its success in Iraq. The war and conflict situation, increasing economic crises and poverty, poor vaccine accessibility in the public sector, and high vaccine costs are a few of the major obstacles that impede a successful immunization program. The last reported third dose pneumococcal conjugate vaccine coverage for Iraq was 37% in 2019, which is expected to reduce even further owing to the COVID-19 pandemic. Thus, strategies and policies to improve pneumococcal vaccine availability and coverage need to be strengthened to achieve maximum benefits of immunization. In the current review, we provide an overview of the existing knowledge on pneumococcal disease-prevention strategies across the globe. The main aim of this manuscript is to discuss the current status and challenges of pneumococcal vaccination in Iraq as well as the strategies to prevent pneumococcal infections.

Knowledge and healthcare professionals' perceptions of influenza vaccination in the Qassim region, Saudi Arabia (2019-2020)

Influenza is associated with a substantial economic burden owing to the extensive immediate and circuitous medicinal service costs at the individual and institutional levels. We aimed to evaluate healthcare workers' perceptions of the influenza vaccination in the Qassim region in Saudi Arabia. A cross-sectional study was conducted at selected hospitals from November to March 2020, in which healthcare workers completed a self-administered questionnaire. Of 327 participants, most were equally distributed between the ages 18-30 and 31-45 years (42.8% each), with 57.5% female and 42.5% male. Both Saudi (47.7%) and non-Saudi participants (52.3%) were included. The majority were physicians (29.7%), pharmacists (28.1%), and nurses (27.5%). Overall, 60.9% had good knowledge, 89% had positive perceptions, and 10.7% had negative perceptions. The primary reason for not getting vaccinated was a concern for complications. Moreover, 20.8% had never previously been vaccinated. Knowledge was positively correlated with nationality, educational level, and perception (p = .002, p = .047, and p = .021, respectively). Perceptions were significantly correlated with nationality (p =.009). Furthermore, 24.5% completely disagreed with compulsory vaccination and believe it would not improve coverage. Once fitted using a multinomial regression model, an r-square value of 0.026 indicated that nationality and history of previous vaccination significantly contributed to negative perceptions. We concluded that most healthcare workers had good knowledge and positive perceptions, and more than a third of the participants adhered to seasonal vaccination. Saudi patients and those who had never been vaccinated were more likely to have negative perceptions.

The Burden of Invasive Vaccine-Preventable Diseases in Adults in the Middle East and North Africa (MENA) Region

Implementing vaccination programmes at the national level is key to managing vaccine-preventable diseases (VPDs) in the overall population. Although paediatric immunization programmes have significantly reduced the burden of VPD, disease burden in adults still poses a substantial challenge, particularly in low- and middle-income countries such as those within the Middle East and North Africa (MENA) region. Invasive bacterial diseases (IBDs) are an important public health concern within this region, although vaccines are available to prevent the three most common causative organisms associated with IBD: Neisseria meningitidis (NM), Streptococcus pneumoniae (SP), and Haemophilus influenzae (HI). For this review, three separate PubMed searches were used to identify English-language publications describing the epidemiology of NM, SP, and HI in adults within the MENA region. Of the 161 total publications retrieved among all 3 literature searches, 39 were included in this review (NM: 8 publications; SP: 27 publications; HI: 4 publications). Publications describing epidemiology in paediatric or overall populations were excluded. Overall, these studies generally observed a high burden of IBD among adults in this region. Although NM, SP, and HI are communicable diseases in several countries, the surveillance systems in the MENA region are largely inadequate, resulting in poor responses to outbreaks and hindering improvement in outcomes of communicable diseases. Improving IBD surveillance would provide necessary estimates of disease burden, resulting in better vaccination strategies and improved outcomes. In conclusion, the present review provides a summary of the available information on the epidemiology of vaccine-preventable IBD in adults within the MENA region and highlights the need for increased disease surveillance and preventive strategies in these countries.

Physicians' awareness and practice toward influenza and pneumococcal vaccines for high-risk patients

Objectives:

The aim of the study is to assess the awareness of family medicine residents about influenza and pneumococcal vaccination for high-risk patients and to verify the most significant variables that might affect residents’ knowledge and the tools needed to enhance their practice.

Materials and Methods:

This cross-sectional study was conducted at four major hospitals in Riyadh, Saudi Arabia, during the period, October through December 2017. A pretested self-administered questionnaire was handed to 180 family residents. Descriptive statistics were used to analyze the study data. The Chi-square test was used to compare categorical variables data. The One-way ANOVA test was used to detect the significant difference.

Results:

The overall knowledge of physicians about influenza and pneumococcal vaccines was inadequate and was more toward pneumococcal vaccine, in spite their respectable knowledge about the target population. The main reasons for non- prescribing of vaccines were forgetfulness (59.4%), the availability of vaccines (33.9%), and the patients’ refusal (23.3%). The tools that might help for prescribing were the need for the presence of electronic reminder (69.4%) and the patients should follow a regular family physician (47.2%).

Conclusion:

Knowledge and practice of influenza and pneumococcal vaccination are inadequate. This is mainly because of forgetfulness owing to minimal guideline awareness, lack of vaccine availability, and patients’ refusal. The important recommendations to enhance vaccination practice among physicians are the implementation of electronic reminders, regular follow-up with the same physician in addition to educational programs during residency, and patient education about the importance of vaccinations as a means of disease prevention.

Trends in antimicrobial susceptibility patterns in King Fahad Medical City, Riyadh, Saudi Arabia

Objectives:

To describe and interpret local antibiograms from a single tertiary care center to monitor the trends of antimicrobial resistance (AMR) patterns and establish baseline data for further surveillance.

Methods:

We performed a retrospective descriptive review of antibiograms data between January 2010 and December 2015 from King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia.

Results:

A total of 51,491 isolates were identified, and most were gram-negative (76.2%). Escherichia coli was the most frequently isolated organism (36.8%), followed by Coagulase-negative Staphylococcus (28.4%) and Staphylococcus aureus (27.5%). The detection of antibiotic-resistant organisms, especially extended-spectrum beta-lactamase-producing Escherichia coli (31%-41%), increased over time. The sensitivity of Streptococcus pneumoniae to penicillin improved from 66% to 100% (p<0.001). Gram-negative isolates had excellent overall susceptibility to amikacin, variable susceptibility to piperacillin-tazobactam and carbapenems, and declining susceptibility to ceftazidime, ciprofloxacin, and cefepime.

Conclusion:

Streptococcus pneumoniae susceptibility to penicillin significantly improved over time, which might be because of the introduction of the pneumococcal vaccine. Conversely, the upward trend in resistant gram-negative organisms is worrisome and warrants the implementation of antimicrobial stewardship programs.

The prevalence of complications of pneumonia among adults admitted to a tertiary care center in Riyadh from 2010-2017

BACKGROUND

Pneumonia, the commonest lower respiratory tract infection, can result in respiratory and non-respiratory complications. Few studies have reported on the prevalence of many complications.

OBJECTIVES

Identify the prevalence of 18 complications of pneumonia and compare complication rates by age group and type of pneu.monia. Identify most prevalent comorbidities, the effect of the number of comorbidities on the presence of complications, and the association between specific comorbidities and specific complications.

DESIGN

Retrospective, cross-sectional prevalence study.

SETTING

Tertiary care center in Riyadh.

PATIENTS AND METHODS

The target population were patients aged 17 years and older, of different nationalities and both genders, diagnosed with pneumonia during the period of 2010 to 2017. Selection was by stratified sampling by year of admission.

MAIN OUTCOME MEASURES

Complications of pneumonia.

SAMPLE SIZE

800.

RESULTS

Complications were observed in 427 patients (53.4%). The complications were respiratory in 258 patients (32%), sepsis and septic shock in 186 (23%), cardiac in 125 (16%), neurological in 5 (0.6%), and cholestatic jaundice in 2 (0.3%). Pleural effusion was the commonest complication, observed in 230 patients. There was a significant difference (P less than .001) between the complication rates in older patients compared to younger (60% as compared to 41%). For the type of pneumonia, there was a significant difference (P less than .001) between community-acquired pneumonia and hospital-acquired pneumonia in the presence of complications (OR=2.41, 95% CI for OR=1.66, 3.49). The number of comorbidities was significantly associated with the presence of complications (P=.001) for those with multiple comorbidities (46% for patients with no comorbid illnesses versus 68% in patients with three or more comorbidities).

CONCLUSION

These results suggest that Saudi Arabia needs to establish better prevention and intervention programs, especially for the high-risk groups identified in this study: older patients, patients with hospital-acquired pneumonia and patients with two or more comorbidities.

LIMITATIONS

Retrospective design and single-centered.

CONFLICT OF INTEREST

None.

The Saudi Initiative for Asthma - 2019 Update: Guidelines for the diagnosis and management of asthma in adults and children

This is the fourth version of the updated guidelines for the diagnosis and management of asthma, developed by the Saudi Initiative for Asthma (SINA) group, a subsidiary of the Saudi Thoracic Society. The main objective of the SINA is to have guidelines that are up to date, simple to understand, and easy to use by healthcare workers dealing with asthma patients. To facilitate achieving the goals of asthma management, the SINA panel approach is mainly based on the assessment of symptom control and risk for both adults and children. The approach to asthma management is now more aligned for different age groups. The guidelines have focused more on personalized approaches reflecting better understanding of disease heterogeneity with integration of recommendations related to biologic agents, evidence-based updates on treatment, and role of immunotherapy in management. The medication appendix has also been updated with the addition of recent evidence, new indications for existing medication, and new medications. The guidelines are constructed based on the available evidence, local literature, and current situation at national and regional levels. There is also an emphasis on patient–doctor partnership in the management that also includes a self-management plan.

Mandatory meningococcal vaccine, and other recommended immunisations: Uptake, barriers, and facilitators among health care workers and trainees at Hajj

AIM

To evaluate the uptake of a mandatory meningococcal, a highly recommended influenza, and an optional pneumococcal vaccine, and to explore the key factors affecting vaccination rate among health care workers (HCWs) during the Hajj.

METHODS

An anonymous cross-sectional online survey was distributed among HCWs and trainees who worked or volunteered at the Hajj 2015-2017 through their line managers, or by visiting their hospitals and healthcare centres in Makkah and Mina. Overseas HCWs who accompanied the pilgrims or those who work in foreign Hajj medical missions were excluded. Pearson’s χ² test was used to compare categorical variables and odds ratio (OR) was calculated by “risk estimate” statistics along with 95% confidence interval (95%CI).

RESULTS

A total of 138 respondents aged 20 to 59 (median 25.6) years with a male to female ratio of 2.5:1 participated in the survey. Only 11.6% (16/138) participants reported receiving all three vaccines, 15.2% (21/138) did not receive any vaccine, 76.1% (105/138) received meningococcal, 68.1% (94/138) influenza and 13.8% (19/138) pneumococcal vaccine. Females were more likely to receive a vaccine than males (OR 3.6, 95%CI: 1.0-12.7, P < 0.05). Willingness to follow health authority’s recommendation was the main reason for receipt of vaccine (78.8%) while believing that they were up-to-date with vaccination (39.8%) was the prime reason for non-receipt.

CONCLUSION

Some HCWs at Hajj miss out the compulsory and highly recommended vaccines; lack of awareness is a key barrier and authority’s advice is an important motivator. Health education followed by stringent measures may be required to improve their vaccination rate.

Clinical respiratory infections and pneumonia during the Hajj pilgrimage: A systematic review

Background

The Islamic Hajj pilgrimage to Mecca is one of the world's largest annual mass gatherings. Inevitable overcrowding during the pilgrims' stay greatly increases the risk of acquiring and spreading infectious diseases, especially respiratory diseases.

Method

The MEDLINE/PubMed and Scopus databases were searched for all relevant papers published prior to February 2018 that evaluated the prevalence of clinical symptoms of respiratory infections, including pneumonia, among Hajj pilgrims, as well as their influenza and pneumococcal vaccination status.

Results

A total of 61 papers were included in the review. Both cohort- and hospital-based studies provide complementary data, and both are therefore necessary to provide a complete picture of the total burden of respiratory diseases during the Hajj. Respiratory symptoms have been common among Hajj pilgrims over the last 15 years. In cohorts of pilgrims, cough ranged from 1.9% to 91.5%. However, the prevalence rates of the most common symptoms (cough, sore throat, and subjective fever) of influenza-like illness (ILI) varied widely across the included studies. These studies have shown variable results, with overall rates of ILI ranging from 8% to 78.2%. These differences might result from differences in study design, study period, and rates of vaccination against seasonal influenza that ranged from 1.1% to 100% among study participants. Moreover, the definition of ILI was inconsistent across studies. In hospitalized Hajj pilgrims, the prevalence of pneumonia, that remains a major concern in critically ill patients, ranged from 0.2% to 54.8%.

Conclusions

Large multinational follow-up studies are recommended for clinic-based syndromic surveillance, in conjunction with microbiological surveillance. Matched cohorts ensure better comparability across studies. However, study design and data collection procedures should be standardized to facilitate reporting and to achieve comparability between studies. Furthermore, the definition of ILI, and of most common symptoms used to define respiratory infections (e.g., upper respiratory tract infection), need to be precisely defined and consistently used. Future studies need to address potential effect of influenza and pneumococcal vaccine in the context of the Hajj pilgrimage.

Bacterial respiratory carriage in French Hajj pilgrims and the effect of pneumococcal vaccine and other individual preventive measures: A prospective cohort survey

Background

Viral respiratory tract infections are known to be common in Hajj pilgrims while the role of bacteria is less studied.

Methods

Clinical follow-up, adherence to preventive measures and PCR-based pharyngeal bacterial carriage pre- and post-Hajj, were assessed in a cohort of 119 French Hajj pilgrims.

Results

55% had an indication for pneumococcal vaccination. Occurrence of respiratory symptoms was 76.5%, with cough (70.6%) and sore throat (44.5%) being the most frequent; fever was reported by 38.7% pilgrims and 42.0% took antibiotics. Respiratory symptoms, fever and antibiotic intake were significantly more frequent in pilgrims with indication for vaccination against pneumococcal infection. The prevalence of S. pneumoniae carriage (1.8% pre-, 9.8% post-Hajj), H. influenzae carriage (0.9%, 45.4%) and K. pneumoniae (2.8%, 9.8%) significantly increased post-Hajj. Pilgrims vaccinated with conjugate pneumococcal vaccine were seven time less likely to present S. pneumoniae carriage post-Hajj compared to those not vaccinated (3.2% vs. 18.0%, OR = 0.15; 95% CI [0.03–0.74], p = 0.02).

Conclusions

Pilgrims at risk for pneumococcal disease are more likely to suffer from febrile respiratory symptoms at the Hajj despite being immunized against pneumococcal disease and despite lowered S. pneumoniae carriage and should be targeted for reinforced prevention against respiratory infections.

Proportion of adult community-acquired pneumonia cases attributable to Streptococcus pneumoniae among Hajj pilgrims in 2016

•

The study evaluated the burden of pneumococcal community-acquired pneumonia (CAP) during Hajj 2016.

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The majority of CAP cases (70.6%) were admitted to hospitals in Mecca, and 53% were admitted after Hajj.

•

A large proportion of cases were older adult males and 45.4% of cases were treated in the intensive care unit (ICU).

•

The overall case-fatality rate was 10.1%, but was higher among those treated in the ICU and in those with invasive disease.

•

The proportion of CAP cases positive for Streptococcus pneumoniae was 18.0%.

Background

The Hajj mass gathering is a risk for pneumococcal disease. This study was performed to evaluate the proportion of adult community-acquired pneumonia (CAP) cases attributable to Streptococcus pneumoniae among Hajj pilgrims in 2016. To add sensitivity to etiological attribution, a urine antigen test was used in addition to culture-based methods.

Methods

Adult subjects hospitalized with X-ray-confirmed CAP were enrolled prospectively from all general hospitals designated to treat Hajj pilgrims in the holy cities of Mecca and Medina. Patients were treated according to local standard of care and administered the BinaxNow S. pneumoniae urine antigen test.

Results

From August 23 to September 23, 2016, a total of 266 patients with CAP were enrolled in the study, 70.6% of whom were admitted to hospitals in Mecca; 53% of the cases were admitted after the peak of Hajj. Patients originated from 43 countries. Their mean age was 65.3 years and the male to female ratio was 2:1. Just over 36% of the cases had diabetes, 10% declared that they were smokers, and 45.4% of cases were treated in the intensive care unit (ICU). The overall case-fatality rate was 10.1%, but was higher among those treated in the ICU and in those with invasive disease. The proportion of CAP cases positive for S. pneumoniae, based on culture or urine antigen test, was 18.0% (95% confidence interval 13.9–23.1%).

Conclusions

CAP during Hajj has an important clinical impact. A proportion of CAP cases among Hajj pilgrims were attributable to S. pneumoniae, a pathogen for which vaccines are available. Additional studies to determine the serotypes causing pneumococcal disease could further inform vaccine policy for Hajj pilgrims.

The Saudi Thoracic Society guidelines for diagnosis and management of noncystic fibrosis bronchiectasis

This is the first guideline developed by the Saudi Thoracic Society for the diagnosis and management of noncystic fibrosis bronchiectasis. Local experts including pulmonologists, infectious disease specialists, thoracic surgeons, respiratory therapists, and others from adult and pediatric departments provided the best practice evidence recommendations based on the available international and local literature. The main objective of this guideline is to utilize the current published evidence to develop recommendations about management of bronchiectasis suitable to our local health-care system and available resources. We aim to provide clinicians with tools to standardize the diagnosis and management of bronchiectasis. This guideline targets primary care physicians, family medicine practitioners, practicing internists and respiratory physicians, and all other health-care providers involved in the care of the patients with bronchiectasis.

Vaccinations against respiratory infections in Arabian Gulf countries: Barriers and motivators

AIM

To study the uptake, barriers and motivators of influenza, pneumococcal, meningococcal and pertussis vaccines among members of public in Arabian Gulf countries.

METHODS

A cross-sectional survey among the Gulf Cooperation Council (GCC) countries’ residents. Data collected electronically through a smartphone app. The survey variables aimed to investigate the respondents’ awareness about vaccines against influenza, pneumococcal, meningococcal and pertussis infections. Collected data concerning the respondents’ socio-demographic characteristics, their perception toward vaccine uptake and the factors that motivate or demotivate them from taking influenza vaccine. The data were analysed statistically using the SPSS v.23.0. Differences in the characteristics of users from different countries were quantified through bivariate analysis. Other important variables and controlling factors were studied using logistic regression.

RESULTS

A total of 1812 respondents participated in the study. Their mean age was 27 years, 82% were male and 24% had ≥ 1 chronic diseases. The overall uptake of influenza vaccine was 17% (21% among “at risk” people) and ranged from 15% in Saudi Arabia to 24% in Qatar. Doctor’s advice (23%) and a perception of having low body immunity (21%) were the main cited reasons for being vaccinated, whereas unawareness about the vaccine (43%) was the main barrier. The overall uptake of pneumococcal vaccine in the preceding three years was 22% (25% among “at risk” individuals) and ranged from 0% in Bahrain to 79% in Kuwait. The overall uptake of pertussis vaccine was 16% (31% among “vulnerable” people), and ranged from 7% in Saudi Arabia to 75% in Oman. The overall uptake of meningococcal vaccine was 20% (29% among the “at risk” people) and ranged from 3% in Oman to 50% in Bahrain.

CONCLUSION

The vaccination uptake across GCC countries is suboptimal and varies widely across the countries. Further research is needed to unearth the reasons and formulate action plan.

Phenotypic and molecular study of pneumococci causing respiratory tract infections. A 3-year prospective cohort

OBJECTIVES

To study serotype distribution and antimicrobial resistance to beta-lactams and macrolides in pneumococci causing respiratory diseases after the introduction of the 13-valent pneumococcal conjugate vaccine in Saudi Arabia. Methods: This is a hospital-based and a cross-sectional prospective surveillance study conducted at King Fahad Hospital of the University, AlKhobar, Kingdom  of Saudi Arabia, in which respiratory pneumococcal isolates collected between 2012 and 2014 were serotyped by multiplex sequential polymerase chain reaction (PCR) and Pneumotest-Latex. Resistance genes to beta-lactams and macrolides were detected by multiplex PCR. Results: The most common serotypes encountered were 11A, 19A, 17F, 23F, 3, and 19F, representing 64% of the typeable strains. Interestingly, 24% of the 94 isolates were not typeable and 18% were negative for the housekeeping gene cpsA. Among the 53 typeable pneumococci isolates, 36 (67.9%) carried genes encoding resistance to both penicillin and macrolides, 9 (17%) were penicillin-monoresistant, 3 (5.6%) were macrolide-monoresistant, and 5 (9.4%) were designated non-resistant. The high rate of resistance genes did not significantly differ according to serotype (p=0.76). Similarly, non-typeable pneumococci (cpsA+ and cpsA-) had high rates of resistance to both penicillin (62.5%) and macrolides (47%). Conclusion: These data highlight the emergence of a previously rare capsular type, 11A (mean patient age, 29 years; p=0.001). Moreover, the high percentage of non-typeable isolates shows the emergence of possible atypical pneumococcal serotypes not covered by available vaccines.

Vaccination in Hajj: An Overview of the Recent Findings

Background:

About two million people annually travel to Kingdom of Saudi Arabia to perform Hajj. The pilgrims may be at risk of exposure to communicable diseases in this mass gathering and their vaccination against contagious diseases can prevent many morbidities and mortalities. The aim of our study was to review the papers which evaluated effectiveness and compliance of the vaccines applied in Hajj.

Methods:

We used PubMed and Scopus to search international medical databases. The key words were as follows: Hajj, Haj, vaccine, vaccination, and immunization. The time interval of the search was from the beginning of 2010 to May 23, 2016. One hundred and thirty papers were extracted, and their contents were subsequently reviewed after title and abstract screenings. The original articles were included in the study and non-English articles were excluded from the study.

Results:

Considering the extracted papers, almost all pilgrims were vaccinated against meningococcal diseases. Using of influenza and pneumococcal vaccine rates were different among the pilgrims. The other vaccines have been taking according to specific conditions.

Conclusions:

The findings regarding influenza vaccine effectiveness are contradictory. A few studies confirmed the flu vaccine effectiveness while some others rejected its usefulness. Meningococcal immunization is an effective preventive tool with high compliance for Hajj pilgrims. Further investigations are recommended for the other vaccines.