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      Burden of bacterial meningitis in India: Preliminary data from a hospital based sentinel surveillance network

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          Abstract

          Background

          Worldwide, acute bacterial meningitis is a major cause of high morbidity and mortality among under five children, particularly in settings where vaccination for H. influenzae type b, S. pneumoniae and N. meningitidis is yet to be introduced in the national immunization programs. Estimation of disease burden of bacterial meningitis associated with these pathogens can guide the policy makers to consider inclusion of these newer vaccines in the immunization programs. A network of hospital based sentinel surveillance was established to generate baseline data on the burden of bacterial meningitis among children aged less than 5 years in India and to provide a platform for impact assessment following introduction of the Pentavalent and Pneumococcal Conjugate Vaccines (PCV).

          Methods

          During surveillance carried out in select hospitals across India in 2012–2013, information regarding demographics, immunization history, clinical history, treatment details and laboratory investigations viz. CSF biochemistry, culture, latex agglutination and PCR was collected from children aged 1 to 59 months admitted with suspected bacterial meningitis.

          Results

          A total of 3104 suspected meningitis cases were enrolled from 19,670 children admitted with fever at the surveillance hospitals. Of these, 257 cases were confirmed as cases of meningitis. They were due to S. pneumoniae (82.9%), H. influenzae type b (14.4%) and N. meningitidis (2.7%). Highest prevalence (55.3%) was observed among children 1 to 11 months. Antimicrobial susceptibility testing revealed considerable resistance among S. pneumoniae isolates against commonly used antibiotics such as cotrimoxazole, erythromycin, penicillin, and cefotaxime. More commonly prevalent serotypes of S. pneumoniae in circulation included 6B, 14, 6A and 19F. More than 90% of serotypes identified were covered by Pneumococcal Conjugate Vaccine 13.

          Conclusions

          We observed that S. pneumoniae was the commonest cause of bacterial meningitis in hospitalized children under five years of age in India. Continued surveillance is expected to provide valuable information and trends in future, to take an informed decision on introduction of pneumococcal vaccination in Universal Immunization Programme in India and will also eventually help in post-vaccination impact evaluation.

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          Most cited references26

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          Pneumococcal conjugate vaccine for childhood immunization--WHO position paper.

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            The diagnosis and management of acute bacterial meningitis in resource-poor settings.

            Acute bacterial meningitis is more common in resource-poor than resource-rich settings. Survival is dependent on rapid diagnosis and early treatment, both of which are difficult to achieve when laboratory support and antibiotics are scarce. Diagnostic algorithms that use basic clinic and laboratory features to distinguish bacterial meningitis from other diseases can be useful. Analysis of the CSF is essential, and simple techniques can enhance the yield of diagnostic microbiology. Penicillin-resistant and chloramphenicol-resistant bacteria are a considerable threat in resource-poor settings that go undetected if CSF and blood can not be cultured. Generic formulations of ceftriaxone are becoming more affordable and available, and are effective against meningitis caused by penicillin-resistant or chloramphenicol-resistant bacteria. However, infection with Streptococcus pneumoniae with reduced susceptibility to ceftriaxone is reported increasingly, and alternatives are either too expensive (eg, vancomycin) or can not be widely recommended (eg, rifampicin, which is the key drug to treat tuberculosis) in resource-poor settings. Additionally, improved access to affordable antibiotics will not overcome the problems of poor access to hospitals and the fatal consequences of delayed treatment. The future rests with the provision of effective conjugate vaccines against S pneumoniae, Haemophilus influenzae, and Neisseria meningitides to children in the poorest regions of the world.
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              Acute respiratory infection and pneumonia in India: a systematic review of literature for advocacy and action: UNICEF-PHFI series on newborn and child health, India.

              Scaling up of evidence based management of childhood acute respiratory infection/pneumonia, is a public health priority in India, and necessitates robust literature review, for advocacy and action. To identify, synthesize and summarize current evidence to guide scaling up of management of childhood acute respiratory infection/pneumonia in India, and identify existing knowledge gaps. A set of ten questions pertaining to the management (prevention, treatment, and control) of childhood ARI/pneumonia was identified through a consultative process. A modified systematic review process developed a priori was used to identify, synthesize and summarize, research evidence and operational information, pertaining to the problem in India. Areas with limited or no evidence were identified as knowledge gaps. Childhood ARI/pneumonia is a significant public health problem in India, although robust epidemiological data is not available on its incidence. Mortality due to pneumonia accounts for approximately one-fourth of the total deaths in under five children, in India. Pneumonia affects children irrespective of socioeconomic status; with higher risk among young infants, malnourished children, non-exclusively breastfed children and those with exposure to solid fuel use. There is lack of robust nation-wide data on etiology; bacteria (including Pneumococcus, H. influenzae, S. aureus and Gram negative bacilli), viruses (especially RSV) and Mycoplasma, are the common organisms identified. In-vitro resistance to cotrimoxazole is high. Wheezing is commonly associated with ARI/pneumonia in children, but difficult to appreciate without auscultation. The current WHO guidelines as modified by IndiaCLEN Task force on Penumonia (2010), are sufficient for case-management of childhood pneumonia. Other important interventions to prevent mortality are oxygen therapy for those with severe or very severe pneumonia and measles vaccination for all infants. There is insufficient evidence for protective or curative effect of vitamin A; zinc supplementation could be beneficial to prevent pneumonia, although it has no therapeutic benefit. There is insufficient evidence on potential effectiveness and cost-effectiveness of Hib and Pneumococcal vaccines on reduction of ARI specific mortality. Case-finding and community-based management are effective management strategies, but have low coverage in India due to policy and programmatic barriers. There is a significant gap in the utilization of existing services, provider practices as well as family practices in seeking care. The systematic review summarizes current evidence on childhood ARI and pneumonia management and provides evidence to inform child health programs in India.
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                Author and article information

                Contributors
                Role: ConceptualizationRole: Formal analysisRole: Funding acquisitionRole: InvestigationRole: MethodologyRole: Project administrationRole: ResourcesRole: SupervisionRole: ValidationRole: VisualizationRole: Writing – original draftRole: Writing – review & editing
                Role: InvestigationRole: MethodologyRole: VisualizationRole: Writing – review & editing
                Role: VisualizationRole: Writing – original draftRole: Writing – review & editing
                Role: Formal analysisRole: VisualizationRole: Writing – original draftRole: Writing – review & editing
                Role: Formal analysisRole: Visualization
                Role: ConceptualizationRole: Funding acquisition
                Role: Funding acquisitionRole: Project administration
                Role: ConceptualizationRole: Funding acquisitionRole: InvestigationRole: MethodologyRole: Project administrationRole: ResourcesRole: SupervisionRole: ValidationRole: VisualizationRole: Writing – original draftRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                16 May 2018
                2018
                : 13
                : 5
                : e0197198
                Affiliations
                [1 ] ICMR-National Institute of Epidemiology, Chennai, Tamil Nadu, India
                [2 ] Christian Medical College, Vellore, Tamil Nadu, India
                [3 ] Indian Council of Medical Research, New Delhi, India
                Wadsworth Center, UNITED STATES
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                ¶ Network Investigators details are provided in the Acknowledgments.

                Author information
                http://orcid.org/0000-0002-2191-4034
                Article
                PONE-D-17-44664
                10.1371/journal.pone.0197198
                5955554
                29768458
                057d051a-9363-4a49-9b8d-7ee3d00b5825
                © 2018 Jayaraman et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 22 December 2017
                : 27 April 2018
                Page count
                Figures: 6, Tables: 2, Pages: 13
                Funding
                This project was funded by Government of India, as Grant in Aid, (G.27017/02/2011-CC&V).
                Categories
                Research Article
                Medicine and Health Sciences
                Infectious Diseases
                Bacterial Diseases
                Bacterial Meningitis
                Medicine and Health Sciences
                Infectious Diseases
                Infectious Diseases of the Nervous System
                Meningitis
                Bacterial Meningitis
                Medicine and Health Sciences
                Neurology
                Infectious Diseases of the Nervous System
                Meningitis
                Bacterial Meningitis
                Medicine and Health Sciences
                Inflammatory Diseases
                Meningitis
                Bacterial Meningitis
                Biology and Life Sciences
                Organisms
                Bacteria
                Streptococcus
                Pneumococcus
                Biology and Life Sciences
                Microbiology
                Medical Microbiology
                Microbial Pathogens
                Bacterial Pathogens
                Streptococcus
                Pneumococcus
                Medicine and Health Sciences
                Pathology and Laboratory Medicine
                Pathogens
                Microbial Pathogens
                Bacterial Pathogens
                Streptococcus
                Pneumococcus
                Medicine and Health Sciences
                Infectious Diseases
                Infectious Diseases of the Nervous System
                Meningitis
                Medicine and Health Sciences
                Neurology
                Infectious Diseases of the Nervous System
                Meningitis
                Medicine and Health Sciences
                Inflammatory Diseases
                Meningitis
                Medicine and Health Sciences
                Pediatrics
                People and Places
                Geographical Locations
                Asia
                India
                Biology and Life Sciences
                Microbiology
                Medical Microbiology
                Microbial Pathogens
                Bacterial Pathogens
                Haemophilus Influenzae
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                Pathology and Laboratory Medicine
                Pathogens
                Microbial Pathogens
                Bacterial Pathogens
                Haemophilus Influenzae
                Biology and Life Sciences
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                Bacteria
                Haemophilus
                Haemophilus Influenzae
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                Disease Surveillance
                Infectious Disease Surveillance
                Medicine and Health Sciences
                Infectious Diseases
                Infectious Disease Control
                Infectious Disease Surveillance
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