Invasive group B streptococcal disease emerged in the 1970s as a leading cause of neonatal morbidity and mortality in the United States.
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In the 1990s, 4 to 6 percent of affected newborns died ...from the infection.
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Surviving infants often have developmental disabilities, including mental retardation and hearing or vision loss. The incidence of group B streptococcal disease is also high among pregnant women and the elderly.
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Clinical trials in the mid-1980s demonstrated that antibiotic prophylaxis administered during labor to mothers colonized with group B streptococci was highly effective in preventing disease in newborns.
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However, the medical community was . . .
Abstract The Strategic Group of Advisory Experts (SAGE) on immunization is an independent advisory committee with a mandate to advise the World Health Organization (WHO) on the development of vaccine ...and immunization related policies. SAGE working groups are established on a time-limited basis to review and provide evidence-based recommendations, together with their implications, for open deliberation and decision-making by SAGE. In making its recommendations, SAGE takes into consideration: the epidemiologic and clinical characteristics of the disease; vaccine and immunization characteristics; economic analysis; health system considerations; the existence of and interaction with other intervention and control strategies; costing and social impacts; and legal and ethical concerns. Since 1998, WHO has produced evidence-based vaccine position papers for use primarily by national public health officials and immunization programme managers. Since April 2006 all new or updated position papers have been based on SAGE recommendations. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach has been adopted by WHO and, since 2008, GRADE tables that rate the quality of evidence have been produced in support of key recommendations. SAGE previously expressed concern that GRADE was not ideally suited to many immunization-specific issues such as the vaccine population level effect and the inclusion of surveillance system data, particularly for vaccine safety. Extensive productive interactions with various advisory groups including the US Advisory Committee on Immunization Practices, the European Centres for Disease Control, the German Standing Committee on Vaccination (STIKO), WHO's Global Advisory Committee on Vaccine Safety and the GRADE working group resulted in key enhancements to accommodate vaccine-relevant evidence. This facilitated integration and acceptability of the GRADE approach in the development of immunization related SAGE and WHO recommendations. Ongoing utilisation should result in further fine-tuning of the approach to ensure that recommendations are based on the full range of appropriate evidence.
Few medical advances in recent decades have affected pediatric infectious diseases as much as conjugate vaccines against
Haemophilus influenzae
type b disease.
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In the United States, before the ...advent of conjugate vaccines,
H. influenzae
type b meningitis or invasive disease developed in nearly 1 in 200 children by five years of age,
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and 70 percent of bacterial meningitis among children under five was attributable to
H. influenzae.
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Now, reports of dramatic declines in the disease from several countries after conjugate vaccines entered routine use suggest that the elimination of the disease may be attainable.
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The near elimination of
H.
. . .
We conducted prospective, active population-based surveillance for candidemia (defined as any Candida species isolated from blood) in Atlanta and San Francisco (total population, 5.34 million) during ...1992–1993. The average annual incidence of candidemia at both sites was 8 per 100,000 population. The highest incidence (75 per 100,000) occurred among infants ⩽1 year old. In 19% of patients, candidemia developed prior to or on the day of admission. Underlying medical conditions included cancer (26%), abdominal surgery (14%), diabetes mellitus (13%), and human immunodeficiency virus infection (10%). In 47% of cases, species of Candida other than Candida albicans were isolated, most commonly Candida parapsilosis, Candida glabrata, and Candida tropicalis. Antifungal susceptibility testing of 394 isolates revealed minimal levels of azole resistance among C. albicans, C. tropicalis, and C. parapsilosis. These data document the substantial burden of candidemia and its changing epidemiology. Continued surveillance will be important to monitor the epidemiology of candidemia and to detect emergence of resistance to azoles.
Background. We explored the association between antituberculosis drug pharmacokinetics and treatment outcomes among patients with pulmonary tuberculosis in Botswana. Methods. Consenting outpatients ...with tuberculosis had blood samples collected 1, 2, and 6 h after simultaneous isoniazid, rifampin, ethambutol, and pyrazinamide ingestion. Maximum serum concentrations (Cmax) and areas under the serum concentration time curve were determined. Clinical status was monitored throughout treatment. Results. Of the 225 participants, 36 (16%) experienced poor treatment outcome (treatment failure or death); 155 (69%) were infected with human immunodeficiency virus (HIV). Compared with published standards, low isoniazid Cmax occurred in 84 patients (37%), low rifampin Cmax in 188 (84%), low ethambutol Cmax in 87 (39%), and low pyrazinamide Cmax in 11 (5%). Median rifampin and pyrazinamide levels differed significantly by HIV status and CD4 cell count category. Only pyrazinamide pharmacokinetics were significantly associated with treatment outcome; low pyrazinamide Cmax was associated with a higher risk of documented poor treatment outcome, compared with normal Cmax (50% vs. 16%; P<.01). HIV-infected patients with a CD4 cell count <200 cells/µL had a higher risk of poor treatment outcome (27%) than did HIV-uninfected patients (11%) or HIV-infected patients with a CD4 cell count ⩾200 cells/µL (12%; P=.01). After adjustment for HIV infection and CD4 cell count, patients with low pyrazinamide Cmax were 3 times more likely than patients with normal pyrazinamide Cmax to have poor outcomes (adjusted risk ratio, 3.38; 95% confidence interval, 1.84–6.22). Conclusions. Lower than expected antituberculosis drug Cmax occurred frequently, and low pyrazinamide Cmax was associated with poor treatment outcome. Exploring the global prevalence and significance of these findings may suggest modifications in treatment regimens that could improve tuberculosis cure rates.
Background. We conducted a pharmacokinetic study of antimycobacterial drugs involving a cohort of patients with pulmonary tuberculosis (TB) in Gaborone, Botswana, to assess the prevalence of and risk ...factors for low drug concentrations in serum. Methods. Adults participated if they had a history of cough ⩾2 weeks, had abnormal chest radiograph findings, consented to testing for human immunodeficiency virus (HIV), had sputum cultures positive for Mycobacterium tuberculosis, and were receiving antituberculous therapy for >7 days. Observed maximum serum concentrations were compared with published normal ranges. Results. Of 91 patients enrolled, 89 (98%) were outpatients, and 59 (68%) of 87 patients tested had HIV infection. The following numbers of patients had low serum concentrations of the following drugs: isoniazid, 27 (30%) of 90; rifampin, 71 (78%) of 91; ethambutol, 37 (41%) of 91; and pyrazinamide, 1 (1%) of 91. Low serum concentrations of both isoniazid and rifampin occurred in 23 (26%) of 90 patients. Low serum concentrations of rifampin were found in both HIV-infected and non–HIV-infected patients, and such patients were less likely to have >4 weeks of symptoms, more likely to have lymphadenopathy, and more likely to have low serum albumin levels (P < .05 for all). The associations with noncavitary pulmonary disease (P = .12) and HIV infection (P = .07) did not reach statistical significance. Delayed absorption was most common with ethambutol, followed by rifampin. Conclusions. These data, predominantly from HIV-infected patients with TB, suggest that low isoniazid, rifampin, and ethambutol concentrations are common in Botswana. In contrast, pyrazinamide usually is well absorbed.
Background. Widespread use of pneumococcal conjugate vaccine (PCV7) resulted in decreases in invasive disease among children and elderly persons. The benefits may be offset by increases in disease ...due to serotypes not included in the vaccine (hereafter, "nonvaccine serotypes"). We evaluated the effect of PCV7 on incidence of disease due to nonvaccine serotypes. Methods. Cases of invasive disease were identified in 8 geographic areas through the Centers for Disease Control and Prevention's Active Bacterial Core surveillance. Serotyping and susceptibility testing of isolates were performed. We calculated the incidence of disease for children aged <5 years and adults aged ⩾65 years. We compared rates of serotype-specific disease before and after PCV7 was licensed for use. Results. The annual incidence of disease due to nonvaccine serotypes increased from an average of 16.3 cases/100,000 population during prevaccine years (1998–1999) to 19.9 cases/100,000 population in 2004 for children aged <5 years (P=.01) and from 27.0 cases/100,000 population during prevaccine years to 29.8 cases/100,000 population in 2004 for adults aged ⩾65 years (P=.05). Significant increases in the incidences of disease due to serotypes 3, 15, 19A, 22F, and 33F were observed among children during this period (P<.05 for each serotype); serotype 19A has become the predominant cause of invasive disease in children. The incidence of disease due to these serotypes also increased among elderly persons. Conclusions. The incidence of pneumococcal disease caused by nonvaccine serotypes is increasing. Ongoing surveillance is needed to monitor the magnitude of disease caused by nonvaccine serotypes, to ensure that future vaccines target the appropriate serotypes.
•One in every two fatal injuries in the city of Sao Paulo is associated with acute substance use by the victim.•Alcohol-positive deaths are over-represented among road traffic injuries.•Drug-positive ...deaths are more prevalent among intentional injuries.•Acute substance use varies significantly according to victim’s social background and the spatial distribution of injury events.
Injury deaths have a major impact on public health systems, particularly in the Latin American region; however, little is known about how different drugs, in combination or not with alcohol, interact with each injury type. We tested an epidemiological protocol for investigating alcohol and other drug acute use among fatally injured victims taking into account the injury context for all injury causes in Sao Paulo, Brazil. Blood alcohol and drug content were fully screened and confirmed following a probability sample selection of decedents (n = 365) during 19 consecutive months (2014–2015). Drug concentrations, including benzodiazepines, cannabis, cocaine, and opioids were determined by gas chromatography-mass spectrometry (GC–MS) or liquid chromatography tandem mass spectrometry (LC–MS/MS). Toxicology data were interpreted in combination with injury context retrieved from police records regarding cause, place of injury, and victims’ criminal history. More than half of all fatally injured victims studied were under the influence of at least one substance (55.3%). Alcohol was the leading substance consumed before a fatal injury event (30.1%), followed by cocaine (21.9%) and cannabis (14%). Illicit drug use (cocaine and cannabis) comprised more than two thirds of all drug-related deaths. Alcohol-positive deaths are over-represented among road traffic injuries, while drug-positive deaths are more prevalent among intentional injuries. Victims who had previous criminal convictions were significantly more likely to have used illicit drugs compared to those who did not have a criminal background. We estimated that one in every two fatal injuries in the city of Sao Paulo is associated with acute substance use by the victim. The health burden attributed to alcohol- and drug-related fatal injury events has reached significant higher levels in Latin American cities such as Sao Paulo compared globally.
CONTEXT Streptococcus pneumoniae is a serious infection in young infants. A heptavalent pneumococcal conjugate vaccine (PCV7) was licensed in 2000 and recommended for all children aged 2 to 23 ...months. OBJECTIVE To determine the rates of invasive pneumococcal disease (IPD) in young infants before and after PCV7 was incorporated into the childhood immunization schedule in June 2000. DESIGN, SETTING, AND PARTICIPANTS A prospective, population-based study of infants aged 0 to 90 days who resided in areas in 8 US states with active laboratory surveillance for invasive S pneumoniae infections from July 1, 1997, to June 30, 2004. MAIN OUTCOME MEASURES Rates of laboratory-confirmed IPD before (July 1, 1997-June 30, 2000) and after (July 1, 2001-June 30, 2004) PCV7 introduction, excluding a transition year (July 1, 2000-June 30, 2001). RESULTS There were 146 cases of IPD, 89 before and 57 after PCV7 introduction. Isolated bacteremia occurred in 94 cases (64%), pneumonia in 27 (18%), meningitis in 22 (15%), and septic arthritis and/or osteomyelitis in 3 (2%). Mean rates of IPD for infants aged 0 to 90 days decreased 40% from 11.8 (95% confidence interval CI, 9.6-14.5) to 7.2 (95% CI, 5.6-9.4; P = .004) per 100 000 live births following PCV7 introduction. Among black infants, mean rates of IPD decreased significantly from 17.1 (95% CI, 11.9-24.6) to 5.3 (95% CI, 2.8-10.1; P = .001) per 100 000 live births, with a nonsignificant decrease from 9.6 (95% CI, 7.3-12.7) to 6.8 (95% CI, 4.9-9.4) per 100 000 live births for white infants. Rates of PCV7-serotype isolates decreased significantly from 7.3 (95% CI, 5.3-10.1) to 2.4 (95% CI, 1.6-3.8; P<.001) per 100 000 live births, while rates of non-PCV7 serotypes remained stable (P = .55). CONCLUSIONS Since PCV7 introduction, rates of IPD in young infants have decreased significantly, providing evidence that vaccinating children aged 2 to 23 months has led to changes in pneumococcal carriage in infants too young to receive PCV7. With a significant decrease in rates of IPD among black infants, the previous racial difference has been eliminated.
Human immunodeficiency virus (HIV) infection and AIDS increase the risk of invasive pneumococcal disease (IPD). We evaluated IPD among HIV-infected adults over a 10-year period in the US to identify ...opportunities for prevention of IPD among HIV-infected adults.
IPD and HIV surveillance in seven population-based and laboratory-based Active Bacterial Core surveillance areas.
IPD cases were adults 18-64 years old with pneumococcus isolated from a normally sterile site during 1998-2007. Isolates were serotyped using the Quellung reaction. HIV/AIDS status was determined by medical record review. We calculated incidence of IPD among adults with AIDS using national case-based surveillance data.
Of 13 812 IPD cases among 18-64-year-olds, 3236 (23%) occurred among HIV-infected adults (with or without AIDS) and 1313 (10%) occurred among the subset of HIV-infected adults with AIDS. Compared with the period (1998-1999) before childhood 7-valent pneumococcal conjugate vaccine (PCV7) introduction in the US, the overall incidence of IPD among adults with AIDS decreased 25% from 399 to 298 cases per 100 000 by 2007 (P = 0.008). In 2006-2007, 8, 39 and 55% of IPD cases among adults with AIDS were caused by serotypes included in the 7-valent PCV, 13-valent PCV and 23-valent pneumococcal polysaccharide vaccines, respectively.
Sustained declines in IPD have occurred among adults with AIDS in the US, but incidence remained high 7 years after PCV7 introduction. More aggressive efforts, including HIV-prevention measures and the use of new PCVs in children and possibly HIV-infected adults, are necessary to further reduce IPD among HIV-infected adults.
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