Pneumococcal disease burden final

Pneumococcal disease burden: 

Pneumococcal disease burden Dr.H.K.Takvani, MD Ped., FIAP IPP, NNF, Gujarat State Chapter 2009-2010 National Executive Board Member. IAP 4 terms President IAP, Gujarat State Branch, 2001 President IMA Jamnagar City Branch 2008-09 drtakvani@gmail.com www.takvanidr.multiply.com "We do not guarantee cure, but what we can guarantee is an honest and transparent effort ".

Diease Burden-How do we find? : 

Diease Burden-How do we find? Identifying the causative bug from tissue, blood, body fluids. Not possible every time so we do a sample size survey Estimates from a sample size Extrapolate in similar areas Calculate from the effect of vaccine on the incidence of disease

S. pneumoniae: 

S. pneumoniae 15-50% of community acquired pneumonia, 30-50% of acute otitis media Significant proportion of bacterial meningitis and bacteremia. 50% of the 2 million deaths due to pneumonia globally every year are attributable to S pneumoniae .

Pneumococcal Disease Remains a Serious Risk in Children1-3: 

Pneumococcal Disease Remains a Serious Risk in Children 1-3 4 WHO. http://www.who.int/immunization_monitoring/data/GlobalImmunizationData.pdf. Accessed September 3, 2009. WHO. Wkly Epidemiol Rec. 2007;82:93-104. UNICEF/WHO 2006. http://www.unicef.org/publications/files/Pneumonia_The_Forgotten_ Killer_of_Children.pdf. Accessed September 6, 2009. Pneumococcal Disease is the #1 vaccine-preventable cause of death worldwide 1 Streptococcus pneumoniae is a leading cause of severe pneumonia, especially in the developing world 3 Est. deaths in 2002 In children aged <5 years:

We are missing the target (Millennium Development Goal 4): 

We are missing the target (Millennium Development Goal 4) AAR =average annual rate of reduction MDG=millennium development goal U5MR in 2015 at current AAR MDG Target U5MR in 2015 85 38 Under-five mortality ratio (U5MR) projections 60 priority countries Source: UN Population Division World Population Prospects, 2004. 5

Countries with the greatest number of pneumococcal deaths among children under 5 years: 

Countries with the greatest number of pneumococcal deaths among children under 5 years O,Brien K, et al. Lancet. 2009;374:893-902. PNEUMOCOCCAL DISEASE BURDEN TOP TEN 1

Pneumonia: Global Disease Burden: 

Pneumonia: Global Disease Burden Pneumonia report card, November 9-12, 2010 PREPARED BY THE INTERNATIONAL VACCINE ACCESS CENTER (IVAC) AT THE JOHNS HOPKINS UNIVERSITY BLOOMBERG SCHOOL OF PUBLIC HEALTH 3 / 4 of all Worldwide Pneumonia Deaths among children under age 5 occur in the 15 report card countries (1.17 million / 1.57 million Deaths) Children in the top 15 Countries are anywere from 17 to 400 times more likely to die from pneumonia than a child living in the United States

Pneumonia: Global Disease Burden Treatment: 

Pneumonia: Global Disease Burden Treatment Pneumonia report card, November 9-12, 2010 PREPARED BY THE INTERNATIONAL VACCINE ACCESS CENTER (IVAC) AT THE JOHNS HOPKINS UNIVERSITY BLOOMBERG SCHOOL OF PUBLIC HEALTH

Asia Pacific Incidence of Pneumonia Cases 2004 (Children <5 Years): 

9 UNICEF Region/ Country Number of Children <5 yrs (Millions) Number of Childhood Pneumonia Deaths (Thousands) Incidence of Pneumonia Cases (Episodes/Child-yr) Pneumonia Episodes (Millions) South Asia* 169 702 0.36 61 East Asia & Pacific* 146 158 0.24 35 China 86 72 0.21 18 India 120 410 0.37 44 Indonesia 21 25 0.29 6 Thailand 5 2 NA NA Philippines ~10 9 0.30 3 TOTAL 557 1,378 1.77 167 * Countries included within regional listing are noted in the slide notes Asia Pacific Incidence of Pneumonia Cases 2004 (Children <5 Years) UNICEF/WHO. Pneumonia: The Forgotten Killer of Children . 2006. Slide courtesy of Dr. Nitin Shah.

Asia Pacific Penicillin and Erythromycin Resistance : 

10 Asia Pacific Penicillin and Erythromycin Resistance Song J-H, et al. Antimicrob Agents Chemother . 2004;48:2101-2107. S. pneumoniae Isolates From Jan 2000-June 2001 in Asia Increasing resistance in Asia may be due to spread of Taiwan 19F and Spain 23F

S. pneumoniae: 

S. pneumoniae Ninety serotypes A handful are responsible for most cases of invasive pneumococcal disease (IPD). Seven 1, 5, 6A, 6B, 14, 19F, 23F most common globally. Also in Africa and Asia, and account for 58%-66% of IPD in every region.

S. pneumoniae: 

S. pneumoniae Serotype 14 most common accounting for 12%-29% of IPD in each region. Serotype 6B ranked second in every region, except Africa (ranked fifth); when combined with serotype 6A, this serogroup accounted for 14%-18% of IPD.

S. pneumoniae: 

S. pneumoniae Serotypes 1, 5, and 14 together 28%-43% of IPD Serotypes 23F and 19F for 9%-18% of IPD Based on year 2000 incidence and mortality estimates, these seven serotypes accounted for 300,000 deaths in Africa and 200,000 deaths in Asia.

S. pneumoniae: 

S. pneumoniae Children under the age of 2 yrs are at greatest risk for IPD. Estimates of IPD incidence for developing countries are difficult to obtain. It is estimated that for every case of meningitis, there are 10 times more cases of bacteremia, 100 times more cases of non-invasive pneumonia and 1000 times more cases of acute otitis media (AOM).

S. pneumoniae: 

S. pneumoniae 90% of bacteremia, 30-50% of severe community acquired pneumonia, 30-45% of pyogenic meningitis and 30-60% of all bacterial AOM are estimated to be caused by pneumococcus. The mortality rate of invasive disease is 6% - 20% and there are long term sequels like CNS squeal in survivors of meningitis and deafness in children with recurrent AOM

Asia Pacific Pneumococcal Disease Burden (India): 

16 Asia Pacific Pneumococcal Disease Burden (India) Invasive Bacterial Infection Surveillance (IBIS) Group and International Clinical Epidemiology Network. (INCLEN). Lancet. 1999;353:1216-1221. N=314 patients <2 months to ≥12 years of age with pneumococcal disease Data are for all ages Meningitis and septicemia have the highest fatality rates among pneumococcal diseases

S. pneumoniae: 

S. pneumoniae Prevalence of pneumococcal disease in India - Data is scanty

Mortality: 

Mortality In 2009, Total 8,26,000 Under five children died of pneumococcal disease. 4,49,000 (61%) occurred in ten African and Asian countries. WHO Around 1,42,000 under five children died of pneumococcal diseases among this list of ten countries.

Mortality: 

Mortality Pneumonia mortality in under five children (WHO estimates: 2005-06) 18% of 8.795 million i.e. 1.575 million globally 20.3% of 1.829 million deaths i.e. 0.371 million in India WHO estimates that 50% of these pneumonia deaths occur due to pneumococcus i.e. 0.8-1.0 million deaths every year

Pneumococcal serotype distribution: 

Pneumococcal serotype distribution Sparse India specific data has been published since Invasive Bacterial Infection Surveillance (IBIS) study done in 1993-1997. Results of the IBIS study in patients with Invasive Pneumococcal Disease (IPD) indicate that serotypes 6, 1, 19, 14, 4, 5, 45, 12, 7, 23 are the most prevalent with serotypes 1 and 5 accounting for 29% of invasive pneumococcal disease. The same study now continues as South Asian Pneumococcal Alliance (SAPNA) project and the serotype distribution has not changed much with time.

Pneumococcal serotype distribution: 

Pneumococcal serotype distribution According to this study, the most prevalent serotypes in India are 6B, 20, 16 and 1. The results of SAPNA study were based only on the report of 11 samples from India taken between October 2006 to March 2007. Further, serotypes 20 and 16 form the miniscule group. Even in IBIS study, they did not get any mention below 5 yrs of age and constituted only 1-4% above 5yrs of age.

Each of the serotypes has its own ‘personality’.: 

Each of the serotypes has its own ‘personality’. Serotype 1 may be responsible for more than 10% of all IPD cases in children less than 5 years of age. Serotype 1 is often reported as the leading cause of pneumonia and pneumonia with empyema. In the least-developed countries of the world, outbreaks of serotypes 1 and 5 (so-called epidemic serotypes) are important causes of childhood disease. These two serotypes account for 29% of IPD in India (18.9% in underfive children).

Each of the serotypes has its own ‘personality’.: 

Each of the serotypes has its own ‘personality’. The pediatric serotypes, such as 6A and 19A, are characterized by their ability to colonize the nasopharynx of young children. These serotypes have a tendency to develop reduced susceptibility to commonly used antibiotics, such as penicillin G and macrolides 6A and 19A constitute around 10% of all pneumococcal serotypes even in India. Serotype 6A has become more complex with the newly identified 6C and 6D, and according to few reports 6A provides better cross protection against the entire 6 group than 6B alone.

Each of the serotypes has its own ‘personality’.: 

Each of the serotypes has its own ‘personality’. According to 2008 ANSORP data, 19A is on rise in most Asian countries. Amongst 1637 invasive S. pneumoniae isolates collected from 10 Asian countries, 91 were serotype 19A. Of the 91 samples of 19A, only 3 were from India and constituted 13% of the pneumococcal isolates causing invasive pneumococcal disease from India. In the USA, Active Bacterial Core surveillance (ABCs) data showed that the incidence of IPD due to serotype 19A increased from 0.8 to 2.5 cases per 100,000 population between 1998 and 2005. Increasing rates of 19A infection, often by multi-antibioticresistant strains, are now reported from many regions in the world

Each of the serotypes has its own ‘personality’.: 

Each of the serotypes has its own ‘personality’. Serotype 3, invasive infections caused by this serotype are more commonly seen in older children than in the very young and it is often associated with pulmonary necrosis and severe pneumonia. Serotype 3 is a hard nut to crack for PCV developers due to its poor immunogenicity and non-boostability.

Each of the serotypes has its own ‘personality’.: 

Each of the serotypes has its own ‘personality’. Serotype 3 pneumococci are abundantly capsulated, making the bacteria less sensitive to immune interactions. Attempts are made to make it more immunogenic with the use of better adjuvants. Serotype 7F IPD rates are currently increasing in some countries. This serotype is only rarely resistant to commonly used antibiotics.

Slide 27: 

17/09/2011 Takvani 27 drtakvani@gmail.com www.takvanidr.multiply.com Dr.H.K.Takvani MD (Pediatrics), FIAP Children Hospital and Neonatal Care Centre Valkeshwari Nagari Indira Marg JAMNAGAR-361008, Gujarat, India Friends…. Please Share your views