Transcript Hot Topics in Pediatric ID - The Department of Pediatrics

Hot Topics
in Pediatric ID
Robert J. Leggiadro, MD
Chairman
Department of Pediatrics
Lincoln Medical Center
Professor of Clinical Pediatrics
Weill Medical College of Cornell University
NY Times Headline
10/14/08
• Worrisome Infection Eludes a
leading Children’s Vaccine
Emergence of Pneumococcal
Serotype 19A
• Most common invasive serotype
• Largest proportion resistant IPD
JID 2008; 197:1016-27.
From The Journal of Infectious Diseases 197(7):1016–1027.
© 2008 by the Infectious Diseases Society of America.
For permission to reuse, contact [email protected].
Figure 1. Age-specific incidence of invasive pneumococcal disease caused by serotype 19A, 1998–2005
Native Alaska Children
less than 2 yrs.
•
•
•
•
PCV7 coverage 90%
Since 2004 140% ↑ in NV strains
30% 19A; others 3, 6A, 7F
Vaccine covered strains ↓ 96%.
Cases of Invasive Pneumococcal Disease by Serotype Among Alaskan Children Younger Than 2
Years, 1995-2000 and 2001-2006
Singleton, R. J. et al. JAMA 2007;297:1784-1792.
Copyright restrictions may apply.
FIGURE 1 Histogram of the annual number of cases of pneumococcal mastoiditis, and
the proportion that were serotype 19A, among children at Texas Children's Hospital
between 1995 and June 2007
Ongkasuwan, J. et al. Pediatrics 2008;122:34-39
Copyright ©2008 American Academy of Pediatrics
FIGURE 4 Histogram of the annual number of total pneumococcal isolates, and the
proportion that were serotype 19A, recovered from middle ear fluid cultures obtained
from children at Texas Children's Hospital between 1995 and June 2007
Ongkasuwan, J. et al. Pediatrics 2008;122:34-39
Copyright ©2008 American Academy of Pediatrics
Emergence of Pneumococcal
Serotype 19A
• Equally capable of IPD, NP colonization
and AOM.
• 9th most common IPD serotype pre-PCV7;
common NP carriage pre-PCV 7
• High rate of resistance
• PCV7 ineffective against 19A
Emergence of Pneumococcal
Serotype 19A
• Clonal expansion
• Capsular switching
• Selective advantages
Emergence of Pneumococcal
Serotype 19A
• PCV7 may not be the only factor
• Antibiotic (especially macrolide)
use impacts serotype distribution
• Alaska, Barcelona, Israel, China,
Belgium
• White Mountain Apache population
has not seen 19A increase
Pneumococcal Meningitis
Epidemiology in the PCV7 Era
• 2001 – 2004 compared with 1994 – 1999
• 2/3 reduction in rates of PM in children less than
2 yrs old
• 1/3 reduction in rates of PM in adults 65 yrs and
older
• Median age ↑ to 46 yrs from 37 yrs.
• Overall 3,300 cases, 394 deaths of PM
prevented.
Clin Infect Dis 2008; 46:1664
Epidemic Pneumococcal Meningitis
in Africa
•
•
•
•
Ghana, Burkina Faso
Concurrent with meningococcal epidemics
Dry season
Serotype 1 most common
Epidemic Pneumococcal Meningitis
in Africa
• Underappreciated burden of
pneumococcal disease in sub-Saharan
Africa.
• Unique propensity of serotype 1 S.
pneumoniae to cause serious infection
and out breaks.
• Opportunity for prevention through
pneumococcal vaccination.
Bacteremia among children in
Rural Kenya
•
•
•
•
Hospital deaths in children between 60 d and 5 y
8.7% due to pneumococcal bacteremia
4.9% due to H. flu bacteremia
Highlights need for prevention through
immunization
N Engl J Med 2005; 352:39-47.
Childhood Bacteremia in
Rural Kenya
•28% children hospitalized with
bacteremia died
•26% hospital deaths associated with
bacteremia
•Bacteremia responsible for more
deaths than malaria (22%)
PCV Worldwide
• Only 26 (14%) of 193 WHO
members have introduced PCV7 into
their national immunization
programs.
• Primarily high-income countries with
relatively few childhood deaths
secondary to IPD.
IPD Mortality Indicators in
Children less than 5 years old
•More than 50 deaths/1,000 live births
•50,000 deaths annually
•More than 10% deaths secondary to
Pn
•Greater than 1% HIV incidence in
adults
Pneumococcal Conjugate Vaccines
• PCV7; 14, 6B, 19F, 9V, 23F, 18C, 4
• PCV10; 7 plus 1, 5, 7F
• PCV 13; 10 plus 3, 6A 19A
Role of Bacterial Pneumonia
1918 – 1919 Influenza Pandemic
•Bacterial pneumonia on autopsy
•Typical pneumonia features
•Picture similar to measles 1917-1918
•Most influenza typical, including full recovery
•Mortality reflected bacterial pneumonia rates
•Higher rates in U.S. military camps
•Time of onset (10 d) consistent with bacteria pneumonia
•Early bed rest effective in isolation from bacterial carriers
JID 2008; 198:962-70
Bacterial Pneumonia and
Pandemic Influenza Planning
•
•
•
•
Shift in focus
Basic research
Pneumocococcal vaccines
Source, supply, surge capacity of important
antibiotics
• Inclusion of vancomycin
• Implications for developing countries
Emerg Infect Dis 2008; 14:1187-92