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The Epidemiology and Burden of Pneumococcal Disease
Thomas Cherian
ISPPD 2014, Hyderabad2 |
Febrile bacteraemia Meningitis
ArthritisPeritonitis
Osteomyelitis
Pneumonia
Otitis
Sinusitis
Diseases caused by Streptococcus pneumoniae (Pneumococcus)
NP carriage
Invasive pneumococcal disease
ISPPD 2014, Hyderabad3 |
NP colonization occurs earlier in lower socioeconomic settings
0102030405060708090
100
Prop
ortio
n co
loni
zed
(%)
Age (months)
O’Brien et al. Pediatr Infect Dis J. 2003; 22(2): e1-11
Papua New Guinea Australian Aborigines
India Costa Rica
Sweden & Finland
Israeli Jews
ISPPD 2014, Hyderabad4 |
Surveillance for laboratory confirmed disease only provides part of the picture
Culture positive Spn disease
Culture negative meningitis and pneumonia
Identified by surveillance for invasive disease
Additional cases preventable with
vaccination
ISPPD 2014, Hyderabad5 |
Incidence of IPD
050
100150200250300350400450500
Finland Chile USA Kenya The Gambia Bangladesh -urban
Bangladesh-rural
Inci
denc
e/ 1
00,0
00 c
hild
ren
Incidence < 2 years Incidence < 5 years
Sources: Robinson KA JAMA 2001; Davidson M JID 1994; O’Dempsey TJ PIDJ 1996;Levine MM PIDJ 1998; Eskola J JAMA 1992; Berkley NEJM 2005; Brooks Am J Trop Med Hyg 2007; Arifeen SE CID 2009
ISPPD 2014, Hyderabad6 |
Invasive Pneumococcal Disease Rates, by Age, USA 1997
0
50
100
150
200
250
< 12 12–23 24–48 5–17 18–34 35–49 50–64 > 65
Available at: www.cdc.gov/ncidod/dbmd/abcs/survreports/spneu98.pdf. Age
Rat
e pe
r 100
,000
pe
rson
s
Months Years
ISPPD 2014, Hyderabad7 |
Age distribution of pneumococcal meningitis cases(Bangladesh, India)
Russel F et al. http://blogs.lshtm.ac.uk/vaccineschedules/files/6.-Russel-review-age-specific-epidemiology-PCV-schedules-session-nov11.pdf
ISPPD 2014, Hyderabad8 |
Pneumococcus is a significant cause of bacterial meningitis
05
101520253035404550
Mozambique(10)
Vietnam (11) Burkina Faso(12)
PneumococcusHibMeningococcus
Perc
ent o
f iso
late
s
1Peltola H. Clin Inf Dis 2001; 32: 64-75.2Ciana G, Parmar N, et al. J Trop Pediatr 1995; 41: 164-8.3Tram TT, Thinh LQ, et al. Ped Inf Dis J 1998; 17(9 Suppl): S192-S194.4du Chatelet IP, Traore Y, et al. Clin Inf Dis 2005; 40: 17-25.
In low-income countries about 45% of people with pneumococcal meningitis die, compared to 29% with Hib meningitis and 8% with meningococcal meningitis
ISPPD 2014, Hyderabad9 |
Proportion of meningitis caused by pneumococcus
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
Bangladesh (n=356) Pakistan (n=274) Burkina Faso(n=121)
Kenya (n=66) Nigeria (n=37)
Proportion of CSF specimens positive for S. pneumoniae, culture, latex or Binax ICT, children <5 y.o.
Binax ICTLatexCulture
17.2% 17.4%16.2% 16.2%
21.6%
Asia Africa
ISPPD 2014, Hyderabad10 |
Serotypes causing IPD in India, Nepal & Sri Lanka(n = 735)
0
10
20
30
40
50
60
70
80
90
100
0
2
4
6
8
10
12
14
16
18
20
146A
/B/C
/D 19F
23F
9A/V
18A/
B/C/
F 4 1 57A
/F 319
A15
B/C 2
23A 8
47F
12A
22A/
F11
A/D
25F 38
9N/L 13 15A 16 19B 20 39 10A
17F
19C
23B
24F 27 29 33C
33F 34
35,4
2 45 10F
11C 15 16A
16 F
24B 32 33 33B
35B
35C
PCV7 PCV10 PCV13 NVT
%
Cummlative
% V
accin
e Ty
pe
Vaccine Type Cummlative
Data for the period of 2005-2013
ISPPD 2014, Hyderabad11 |
Differences in serotype prevalence between India, Nepal & Sri Lanka
0
10
20
30
40
50
60
70
80
90
100
0
2
4
6
8
10
12
14
16
18
20
6A/B
/C/D 14 19
F 4
18A/
B/C/
F
23F
9A/V 5 1
7A/F
19A
15B/
C 27
11A/
D
22A/
F
33C
33F 8 29 34 39 10A
10F
16 F
17F
19B
19F
23A
24B
24F
47F
9N/L
PCV7 PCV10 PCV13 NVT
%
Cummlative
% V
accin
e Ty
pes
Vaccine Type Cummlative 0
10
20
30
40
50
60
70
80
90
100
0
4
8
12
16
20
24
28
32
36
40
14
9A/V
18A/
B/C/
F
23F
19F
6A/B
/C/D 4 1 5
7A/F 3
19A 2 8
12A
25F 16 20 39 45 19B
23A
23B
47F 13 32 33 34 38
12A
15A 10
A
PCV7 PCV10 PCV13 NVT
%
Cummlative
% V
accin
e Ty
pes
Vaccine Type Cummlative
0
10
20
30
40
50
60
70
80
90
100
0
2
4
6
8
10
12
14
16
18
20
14 19F
6A/B
/C/D 23
F
9A/V
18A/
B/C/
F 4 5 1 3
19A
15B/
C
23A
47F 38 13
11A/
D
15A
22A/
F 8 15 16 20 29 11C
16A
17F
19C
33B
35,4
2
35C
9N/L
PCV7 PCV10 PCV13 NVT
%
Cummlative
% V
acci
ne T
ypes
Vaccine Type Cummlative
INDIANEPAL
SRI LANKA
The image part with relationship ID rId2 was not found in the file.
-20 -10 0 10 20 30 40 50 60 70
114
56B
23F7F
19F18C6A
49V
19A2
12A18F
458
3818A12F10F
2033F
347B
10A11A11F
1315A15F16F17F23A24F25F28A33B35B35F22F
29212731
33C6C
Nonmenin
Meningitis Culture Positive
Meningitis Culture Negative
PCV
PCV-10 Coverage
Meningitis 44%
Non-Meningitis 47%
Overall 45%
Non-meningitis (N= 105) (Meningitis (N=336)
Figure: Distribution of Meningitis and Non-meningitis Cases with Their Vaccine Coverage(2007-2013)
Source: S K Saha, personal communication
ISPPD 2014, Hyderabad13 |
All Countries (India, Nepal, Sri Lanka) by Year
11.3
7.6
10.7
3.1 3.4
1.50.6
18.7
7.3
1.22.4
0.6
25.4
14.7
16.9
9.0
5.6
2.8 2.81.7
11.9
7.9
1.1
2.81.7
20.9
0.0
5.0
10.0
15.0
20.0
25.0
30.0
14 6A/B/C/D 19F 23F 9A/V 18A/B/C/F 4 1 5 7A/F 3 19A
PCV7 PCV10 PCV13 NVT
% V
accin
e Ty
pe
2005-2009 2010-2013
13
Figure: PCV-10 Coverage for IPD Cases in Bangladesh, 2007 - 2013
PCV-10 CoverageMeningitis 44%Non-Meningitis 47%Overall 45%
39% 40%
57%
29%
38%
54%
47%
0%
10%
20%
30%
40%
50%
60%
70%
80%
2007 2008 2009 2010 2011 2012 2013
PCV-10
PCV-10
Source: Samir Saha 14
ISPPD 2014, Hyderabad15 |
Outcome and age range (months)
India (cases per 1000 child-years)
Neighboring countries(per 1000)
Developingcountries globally(per 1000)
ALRI 0-59 290, 370 510 290
ALRI 1-59 310
Severe ALRI 0-59 50 20
Severe ALRI 1-59 165
Severe ALRI 2-59 10
Severe ALRI 0-35 43
Severe ALRI 1-23 27, 31, 79
Incidence of pneumonia
ISPPD 2014, Hyderabad16 |
S. pneumoniae—The Most Common Cause of Bacterial Pneumonia
0
10
20
30
40
50
60
Papua NewGuinea (1)
The Gambia(2)
Zimbabwe (3) The Gambia(4)
Perc
ent o
f asp
irate
s
% of bacterial isolates
S. pneumoniae
H. influenzae
Other bacteria
1Shann F, Gratten M, Germer S, et al. Lancet. 1984; 2(8402):537-541.2Wall RA, Corrah PT, Mabey DC, Greenwood BM. Bull World Health Org. 1986; 64(4):553-558.3Ikeogu MO. Arch Dis Child. 1989; 64(8):1207.4Forgie IM, Campbell H, Lloyd-Evans N, et al. Pediatr Infect Dis J. 1992; 11(6):466-473.
ISPPD 2014, Hyderabad17 |
Lung aspirate studies from S Asia
Author Year N No. pos S pneumo H inf S aureus Others
Sinha 1966 25 11 3 7 0 1
Hughes 1966 17 5 2 5 0 0Hughes 1969 18 7 2 6 0 0Kalra 1981 70 36 18 2 5 11
Tewari 1991 100 50 5 0 25 20
Prakash 1996 35 17 4 1 2 12
Patwari 1996 12 6 2 0 4 0All studies
1966-96 277 132 (48%) 36 (13%) 21 (8%) 36 (13) 44 (16)
Source: Vuori-Holopainen E, Peltola H. CID 2001Included older children
ISPPD 2014, Hyderabad18 |
Proportion of pneumonia attributable to pneumococcus, based on vaccine impact data
8 %
3 3 %
2 1 %
-30%
-20%
-10%
0%
10%
20%
30%
40%
50%
60%Cl
inica
l Pne
umon
ia
NCKP
Sout
h Afri
ca
Gamb
ia
Philip
pines
Seve
re Pn
eumo
nia
NCKP
Sout
h Afri
ca
Gamb
ia
Philip
pines
CXR+
Pne
umon
ia
NCKP
Sout
h Afri
ca
Gamb
ia
Philip
pines
Clinical Pneumonia
Severe Pneumonia
CXR+ Pneumonia
ISPPD 2014, Hyderabad19 |
Causes of death in children, 2010
Liu et al. Lancet 2012
ISPPD 2014, Hyderabad20 |
Pneumonia mortality trends, SEAR
Liu et al. Lancet 2012
ISPPD 2014, Hyderabad21 |
Country and age range (months)
Study design Outcome measure
Outcome-specific mortality reduction
India 0-47 Case-control, village randomized
Fatal pneumonia 54%
Pakistan 0-59 Observational, community based
Fatal ALRI 55%
Pakistan 0-59 Observational, hospital based
ARI case fatality rate
51%
Bangladesh 0-23 Case-control, village randomized
Fatal pneumonia 54%
Nepal 0-59 Observational, community based
Fatal ARI 69%
Etiology - bacterial “probe” studies
ISPPD 2014, Hyderabad22 |
Estimates of pneumococcal deaths(WHO, 2008 unofficial)
CountryPneumococcal deaths
Pneumonia Meningitis NPNM Total
Bangladesh 7165 1311 371 8846
Bhutan 82 7 2 91India 73292 9850 2786 85928
Maldives 6 3 3 12
Nepal 1378 278 79 1735
Pakistan 18799 1595 451 20845
Sri Lanka 133 10 10 153
TOTAL 100854 13054 3701 117609
ISPPD 2014, Hyderabad23 |
Top 10 high burden countriesPopulation size vs mortality rate
Feb/08 analysis
India
NigeriaEthiopia
DR Congo Afghanistan
China
Pakistan
AngolaBangladesh Uganda-10
10
30
50
70
90
110
130
150
0 200 400 600 800 1000
Pneumococcal deaths per 100,000 children under 5 years
Und
er 5
pop
ulat
ion
(mill
ion)
ISPPD 2014, Hyderabad24 |
Summary
Pneumococcus is an important cause of serious disease in children, especially pneumonia and meningitis.
Establishing pneumococcal etiology of childhood pneumonia is a challenge and limits the ability to get a direct estimation of burden of disease
Synthesis of available data shows that pneumococcal disease is an important cause of childhood morbidity and mortality worldwide, as well as in South Asia.
No reason to suspect that the epidemiology of pneumococcal disease in South Asia is different from that in other countries with similar socio-economic & mortality profile.
EXTRA SLIDES
ISPPD 2014, Hyderabad27 |
IPD serotypes, India (2005-213)(n=349)
0
10
20
30
40
50
60
70
80
90
100
0
2
4
6
8
10
12
14
16
18
20
6A/B
/C/D 14 19
F 4
18A/
B/C/
F
23F
9A/V 5 1
7A/F
19A
15B/
C 27
11A/
D
22A/
F
33C
33F 8 29 34 39 10A
10F
16 F
17F
19B
19F
23A
24B
24F
47F
9N/L
PCV7 PCV10 PCV13 NVT
%
Cummlative
% V
accin
e Ty
pes
Vaccine Type Cummlative
Data for the period of 2005-2013
ISPPD 2014, Hyderabad28 |
IPD serotypes, Nepal (2005-13)(n=210)
0
10
20
30
40
50
60
70
80
90
100
0
4
8
12
16
20
24
28
32
36
40
14
9A/V
18A/
B/C/
F
23F
19F
6A/B
/C/D 4 1 5
7A/F 3
19A 2 8
12A
25F 16 20 39 45 19B
23A
23B
47F 13 32 33 34 38
12A
15A 10
A
PCV7 PCV10 PCV13 NVT
%
Cummlative
% V
accin
e Ty
pes
Vaccine Type Cummlative
Data for the period of 2005-2013
ISPPD 2014, Hyderabad29 |
IPD serotypes, Sri Lanka (2005-13)( n=176)
0
10
20
30
40
50
60
70
80
90
100
0
2
4
6
8
10
12
14
16
18
20
14 19F
6A/B
/C/D 23
F
9A/V
18A/
B/C/
F 4 5 1 3
19A
15B/
C
23A
47F 38 13
11A/
D
15A
22A/
F 8 15 16 20 29 11C
16A
17F
19C
33B
35,4
2
35C
9N/L
PCV7 PCV10 PCV13 NVT
%
Cummlative
% V
accin
e Ty
pes
Vaccine Type Cummlative
Data for the period of 2005-2013
ISPPD 2014, Hyderabad30 |
India by Year
ISPPD 2014, Hyderabad31 |
Nepal by Year
3.1 3.11.9 1.3 1.9 1.9
0.6
35.8
12.6
2.5 2.50.6
32.1
7.8
3.9 3.95.9
2.00.0 0.0
33.3
11.8
0.0
5.9
2.0
23.5
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
40.0
14 9A/V 18A/B/C/F 23F 19F 6A/B/C/D 4 1 5 7A/F 3 19A
PCV7 PCV10 PCV13 NVT
% V
accin
e Ty
pe
2005-2009 2010-2013
Data for the period of 2005-2013
ISPPD 2014, Hyderabad32 |
Sri Lanka by Year
17.6
21.4
13.0
6.1
3.8
1.50.8
0.00.8
3.1
0.8
31.3
24.4
8.9
28.9
8.9
2.2
0.0 0.0
4.4
0.0
4.4
0.0
17.8
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
14 19F 6A/B/C/D 23F 9A/V 18A/B/C/F 4 5 1 3 19A
PCV7 PCV10 PCV13 NVT
% V
accin
e Ty
pe
2005-2009 2010-2013
Data for the period of 2005-2013