Vaccination against pertussis in Latin American preterm and low-birth weight infants: experts opinion position for a neglected childhood age group

BACKGROUND

Pertussis remains as one of the oldest leading vaccine-preventable diseases of childhood, despite many decades of primary vaccine doses' and boosters' implementation. Although the epidemiology is well understood in infants and children, premature babies and low-birth weight infants remain a special group where the disease incidence is unknown, severity of the disease is considerable, and specific vaccination recommendations are scarce.

RESEARCH DESIGN AND METHODS

A retrospective review of the available evidence of pertussis vaccination in premature and low birth weight infants was analyzed from January 2000 to December 2022 in six selected countries: Argentina, Mexico, Colombia, Panamá, Costa Rica, and Chile.

RESULTS

Chile had reports of adverse effects associated with vaccination of premature infants with the pentavalent vaccine, and their rationale to switching to the hexavalent vaccine. Colombia had reports of the justification for the use of hexavalent vaccine in prematures in the Neonatal Units and Kangaroo Mother Programs throughout the country. Mexico had selected publications of the vaccination status in prematures and low-birth weight infants.

CONCLUSION

Despite its importance, increased morbidity, and highest risk of complications in premature babies, there is a paucity of information of vaccine recommendations and coverage rates among selected Latin American infants.

Epidemiology of pertussis in Costa Rica and the impact of vaccination: A 58-year experience (1961-2018)

Costa Rica is an upper middle-income country in Central America with a vigorous public health system. We have studied the number of cases, hospitalizations, and deaths due to pertussis from 1961 to 2018, in relation to vaccine coverage. Following the introduction of the fourth and fifth doses of DTP (booster doses) in 1973 there was a marked reduction of reported pertussis. In 2002 pertussis surveillance and laboratory diagnosis were improved. In 2007, Tdap post-partum immunization was introduced and then switched to intrapartum Tdap immunization in 2011. Of these two strategies post-partum vaccination seemed to have a greater effect in decreasing hospitalizations and deaths, nevertheless, since 2011 there has been only 4 infant deaths due to pertussis.

Congenital rubella syndrome: progress and future challenges

Since 1941, when Gregg first described the triad of deafness, cataracts and cardiac disease as the classical clinical manifestations of congenital rubella syndrome (CRS), strong efforts have been implemented around the world to achieve effective preventive strategies. In Costa Rica, vaccination against rubella started in 1972 and in 1986, the combined measles, mumps and rubella vaccine was introduced in the national schedule among 1-year-old children. This vaccination strategy shifted the susceptibility to other groups at child-bearing age. To protect this age group, in 2001 Costa Rica implemented a successful national immunization campaign targeting both men and women aged 15-39 years, followed by postpartum vaccination of women who were pregnant when the campaign was implemented. The epidemiological surveillance system of rubella and CRS cases was strengthened and it was integrated with the investigation and notification system of febrile eruptive diseases. We describe the Costa Rican experience, which has led to similar actions in other countries in Latin America. Challenges and strategies in the elimination of rubella and CRS are also discussed.

Síndrome de rubéola congénita en Costa Rica: importancia de reforzar la vigilancia activa

OBJECTIVE

To identify cases of congenital rubella syndrome (CRS) and their form of presentation in children aged < 3 months in the National Children's Hospital of Costa Rica between 1996 and 2000.

METHODS

Between 1996 and 2000, patients aged 1 day to 3 months with positive IgM serology for rubella, identified by means of the computerized database of the National Children's Hospital Laboratory, were selected. Their corresponding medical records were reviewed and the characteristics of these patients were analyzed.

RESULTS

Sixty-six children with positive serology were identified, of which 49 had a complete medical record that allowed review. Of these, 29 (60 %) were boys. The mean age at which IgM serology was requested was 33 days. The principal manifestations leading to serology were hepatosplenomegaly, microcephaly and multiple congenital anomalies. The initial diagnosis was TORCH infection. Of the 49 patients, 45 were classified as CRS and four as infection with rubella.

CONCLUSIONS

The present study highlights the need to increase active surveillance of CRS. Greater vigilance in applying the criteria for clinical diagnosis is required to allow an adequate degree of suspicion and early reporting of cases.

[Kikuchi-Fujimoto disease in pediatric population: a case report and a review of literature]

A 10 year-old child, with a history of a right cervical mass, is admitted to the Costa Rican National Children's Hospital for workup. The mass appeared approximately 4 weeks before admission. Laboratory tests were performed and malignity, infection and immunologic causes were ruled out. A biopsy was performed revealing granulomas characterized by central necrosis with abundant karyorrhexis, surrounded by histiocytes, lymphocytes and giant multinucleated cells, without neutrophils. Special stains showed no microorganisms. Once infectious and immunologic causes were excluded, and based on the biopsy's result, treatment was ruled out. Twelve months later, the patient is still asymptomatic; therefore, the diagnosis of a Kikuchi-Fujimoto syndrome was proposed. This report constitutes the first pediatric case diagnosed in our country.

Ganciclovir therapy in cytomegalovirus (CMV) infection in immunocompetent pediatric patients

OBJECTIVES

To evaluate the outcome of immunocompetent pediatric patients who had positive cytomegalovirus (CMV) antigenemia and received ganciclovir.

METHODS

A retrospective review was done of patients who had a CMV infection based on positive antigenemia. Medical charts were reviewed for the following information: age, sex, underlying disease, symptoms and signs, laboratory results, complementary diagnostic procedures, duration and dose of ganciclovir therapy, concomitant medications, complications, and outcome.

RESULTS

Sixty-four patients with positive CMV antigenemia were identified; 15 patients were excluded from the study because of their underlying diseases. Of the remaining 49 patients, 26 (53%) were female; the median age was 11.5 months (range 0.3-132 months). Sixty-one percent (30/49) of these patients received ganciclovir (5-10 mg/kg/day) for a median of 14 days (range 7-42 days). Clinical findings included: fever, anemia, hepatomegaly, failure to thrive, elevated liver enzymes, splenomegaly, seizures, and thrombocytopenia. Sixty-three percent (19/30) of the treated patients had negative antigenemia at the end of therapy. CMV antigenemia remained positive in six (20%) patients. Nine patients received a second course of ganciclovir.

CONCLUSIONS

Ganciclovir was effective in 80% of patients, as determined by negative antigenemia at the end of therapy.

Epidemiological observations of the judicious use of antibiotics in a pediatric teaching hospital

OBJECTIVE

This study in a tertiary care teaching center with 361 beds was conducted to assess use, misuse, and abuse of antibiotics.

MATERIALS AND METHODS

Every day of the study, a computer program was used to compile a list of patients' bedside records. On a specific day, the bedside charts of selected patients were reviewed to determine whether: (1) a justification for antibiotic prescription was recorded; (2) duration of antibiotic therapy had been defined; (3) suitable cultures had been obtained; and (4) treatment was appropriate for the infection to be treated. For 6 months, charts were evaluated 3 days per week.

RESULTS

Of 750 bedside charts 500 (67%) were selected for review. Of the 500 patients, 175 (35%) did not receive antibiotics. The abuses or misuses of antibiotics most frequently observed among the 325 treated patients were no record of justification for the antibiotic prescribed (130/325, 40%); no appropriate blood or fluid samples obtained for culture (45/325, 14%); no subsequent control cultures or cultures obtained before modifying therapy (80/175, 46%); no indication of a planned duration of therapy (180/325, 55%); and improper dosage prescribed in relation to weight (25/325, 8%). Abuse or misuse of antibiotics was more frequently observed among surgical patients than among nonsurgical patients (P<0.05).

CONCLUSION

Rational use of antibiotics should be emphasized in every training program as a main strategy to control the increase in drug resistance and to prolong the usefulness of antibiotics.

Systemic cytokine response in children bitten by snakes in Costa Rica

BACKGROUND

To characterize the host response to venom from snakes of the family Viperidae in Costa Rica, we investigated the release of cytokines: IL-1, IL-6, IL-8, TNF-alpha, MIP-1beta, and RANTES in pediatric patients who were bitten by a snake.

METHODS

Patients were included in this study if they were admitted to the hospital within 24 hours of the snakebite. Blood samples were taken immediately on admission to the hospital, and then at intervals of 3, 12, and 24 hours, and on days 3, 5, and 7 after the accident. Patients received gentamicin plus clindamycin or gentamicin plus penicillin intravenously for a minimum of 3 days or longer if necessary. IL-1, IL-8, TNF-alpha, MIP-1beta, and RANTES were determined by monoclonal antibody-based ELISAs, while IL-6 was determined by bioassay.

RESULTS

Eighteen patients were included in this study; 15 were bitten by Bothrops asper and three by B. lateralis. Eleven patients were male. Median (range) age was 9 (1-12) years. Nine patients had detectable serum concentrations of IL-6 (200 pg/ mL) and IL-8 (51 pg/mL) on admission, increasing to 500 pg/mL and 115 pg/mL for IL-6 and IL-8, respectively, during the first 12-24 hours. Cytokine concentrations returned to normal or undetectable ranges by 72 hours. TNF-alpha concentrations peaked at 12 hours (mean: 48 pg/mL). Low, but detectable concentrations of MIP-1beta were observed in some patients at various time intervals (48 pg/mL), whereas IL-1 was not detectable at any time point. Regulated on Activation Normal T cell Expressed and Secreted (RANTES) concentrations were evaluated in only five patients, being elevated in all of them. Patients with elevated cytokine concentrations required early fasciotomy (<24 hours after the accident) more often than those who had normal or undetectable cytokine concentrations (P < 0.05). There were no statistically significant associations between severity of envenomation, or outcome, and elevated serum cytokine concentrations (P > 0.05).

CONCLUSIONS

Bothrops sp snake venoms induce clinical and pathophysiologic alterations similar to acute trauma, with release of proinflammatory cytokines. A better understanding of the role of the inflammatory response could lead to the development of new therapeutic strategies to improve the outcome in snakebitten patients.

[Diagnosis of acute hematogenous osteomyelitis by ultrasound in pediatric patients]

OBJECTIVE

The objective of this study was to evaluate the efficacy of ultrasound in the diagnosis of acute hematogenous osteomyelitis of long bones in pediatric patients.

PATIENTS AND METHODS

A prospective study was performed in a tertiary care pediatric hospital. During 12 months we prospectively studied 46 patients with the clinical diagnosis of acute hematogenous osteomyelitis (AHO) of long bones at the Hospital Nacional de Niños in Costa Rica. In all patients ultrasound (US) was performed within 24-36 hours of admission, before any invasive diagnosis or therapeutic procedure was begun.

RESULTS

In those without US findings, but with strongly suspected (AHO), a bone scan was done. Of these patients, 26/46 (57%) was female. The mean age was 6.8 years. Sixty-five percent (30/46) had US findings compatible with AHO affecting the tibia (13), femur (11), humerus (4), and radius (2). The findings included subperiostic fluid (10), periosteal thickening (14), subperiostic abscess (6) and thickening of subcutaneous tissues (26). Patients were surgically drained and puss was obtained from the bone in all 30. Two patients with negative US, but strongly suspected AHO had a bone scan that was negative. Patients with AHO were followed with US within 5-7 days of surgery and all 30 showed marked improvement.

CONCLUSIONS

In this study, US showed 100% sensitivity and specificity for the diagnosis of AHO of long bones in pediatric patients. US are a sensitive and non-invasive procedure for the diagnosis and follow-up of AOH of long bones.

Handwashing practices in a tertiary-care, pediatric hospital and the effect on an educational program

OBJECTIVE

To study the frequency of handwashing and the effects of an educational program.

DESIGN

A prospective study.

SETTING

A tertiary-care, pediatric hospital.

PARTICIPANTS

Three divisions (two general pediatric wards and one infectious disease ward). The personnel observed included 60 medical staff (interns, residents, and attending, including consulting, physicians), 37 nurses, and 15 paramedical staff.

INTERVENTIONS

The study was carried out in 5 phases: (1) unobtrusive observation to obtain a baseline handwashing rate; (2) observation after written notification; (3) observation after providing motivating devices: movies, brochures, posters; (4) discontinuation of observation and motivation; (5) unobtrusive observation, to obtain a residual handwashing rate.

RESULTS

During this study, 1,123 patient contacts were observed. The baseline handwashing rates before and after patient contact were 52% and 49%, respectively. During phase 2, handwashing rates before and after patient contact increased slightly to 56% and 52%, respectively. During phase 3, rates increased to 74% and 69% (P < .01). However, rates fell during the final phases to 49% and 52%, respectively (P < .01). There were no significant differences among hospital staff in any phase of this study (P > .05).

CONCLUSIONS

Constant motivation, using movies, brochures, and posters, transiently increased the frequency of handwashing among the house staff of a tertiary-care facility; however, to be effective, this motivation needs to be sustained.