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The unchecked pneumococcal reign over Indian children aged younger than 5 years
Comment
The most recent Global Burden of Disease report1 estimates that mortality of children aged younger than 5 years has decreased globally by 27·2% between 2005 and 2015, but that still nearly 6 million children aged younger than 5 years have died. Beyond the first month of life, lower respiratory tract infections are the leading cause of mortality, at 12·1%. The fraction of death attributable to pneumococcal pneumonia was observed to be 55·8% in children aged younger than 5 years. Estimates from the Maternal and Child Epidemiology Estimation group of WHO2 are marginally higher than those by the Global Burden of Disease reports, primarily due to methodological differences, but the picture remains the same. In the Maternal and Child Epidemiology Estimation report,2 India is included as one of the ten countries with the highest mortality of children aged younger than 5 years and the analysis of the causes of death notes acute respiratory infections as the commonest cause of death. Yadav and Awasthi3 report that 13–16% of mortality of children aged 5 years or younger in India is attributable to community-acquired pneumonia. The most common bacterial isolates for pneumonia reported are of Streptococcus pneumoniae, ranging from 13% to 40%.4–12 These reports were published between 1996 and 2016, but the pattern of pneumococcal isolation has not changed substantially between these dates. India is noted to have the largest number of deaths of children aged 1–59 months due to pneumococcal diseases.10 Besides causing pneumonia, the other pneumococcal clinical presentations include meningitis, which is the fourth-leading cause of death in children younger than 5 years of age (after diarrhoea and malaria).1 Additionally, other types of invasive pneumococcal disease might not cause death, but contribute to substantial morbidity.11 Studies of pneumococcal prevalence have been done in different parts of India, but either in small areas or with non-uniform case definitions or methods.3–13 With this background of pneumococcal disease in the Indian subcontinent, a need exists to have nationally representative data for pneumococcal morbidity, mortality, and seroprevalance. The Article by Anand Manoharan and colleagues14 in The Lancet Infectious
Diseases reporting the data collected by the Alliance for Surveillance of Invasive Pneumococci is very valuable. The data has been collected over 4·5 years in a both prospective and retrospective fashion through a network of institutions and laboratories across 11 Indian states. The results showed a S pneumoniae yield of 4%, which was higher than previous reports from the region.4,5 Pneumonia was the most common diagnosis made and the 1–11 month age group formed a majority of invasive pneumococcal disease. Overall mortality was 3%, for children with pneumonia it was 7%, and for those with invasive pneumococcal disease it was 12%. The results of this study endorse the reports of S pneumoniae being a substantial contributor to morbidity and mortality among children aged 5 years or younger.1 With effective vaccines available, the number of children dying with a vaccine-preventable disease is unfortunate and unnecessary. India has been lagging behind in achieving the targets for the under-5 mortality rate for 2015.2 To reach the Sustainable Development Goal 315 in the coming years, acute respiratory infections in children aged younger than 5 years of age have to be brought down. Tackling of pneumococcal infection will be a major step in improvement of survival of children younger than 5 years of age. Neighbouring Pakistan, Myanmar, Sri Lanka, and Bangladesh have either already instituted or planned inclusion of pneumococcal vaccine in their national immunisation schedules.9 India needs to move in this direction quickly as well along with other measures to reduce acute respiratory infections . The fact that the study by Manoharan and colleagues14 provides a larger picture of pneumococcal prevalence than did previous studies cannot be denied, but as mentioned by the authors, limitations exist of not adequately representing the various regions of the country and inadequate sampling from some participating sites. We still need comprehensive prospective data, not only for policy making, but also as a surveillance network for future once a vaccination programme is initiated. The issue of pneumococcal serotypes is a subject of constant review and discussion because besides geographical variations of
www.thelancet.com/infection Published online December 9, 2016 http://dx.doi.org/10.1016/S1473-3099(16)30543-6
Shaukat Ahmed /SIPA USA/PA Images
The unchecked pneumococcal reign over Indian children aged younger than 5 years
Lancet Infect Dis 2016 Published Online December 9, 2016 http://dx.doi.org/10.1016/ S1473-3099(16)30543-6 See Online/Articles http://dx.doi.org/10.1016/ S1473-3099(16)30466-2
1
Comment
seroprevalence, other factors like changes in vaccine practices and microbiological factors will continue to affect serotype prevalence, which might not remain constant in any region.12
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Jugesh Chhatwal
8
Department of Pediatrics, Christian Medical College, Ludhiana, Punjab 141008, India [email protected] I report grants to my institution (Christian Medical College) from the Alliance for Surveillance of Invasive Pneumococci Study Group during the conduct of the study by Manoharan and colleagues. 1
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GBD 2015 Mortality and Causes of Death Collaborators. Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet 2016; 388: 1459–544. Johns Hopkins Bloomberg School of Public Health. Maternal, newborn and child cause of death. http://www.jhsph.edu/research/centers-and-institutes/ institute-for-international-programs/current-projects/maternal-childepidemiology-estimation/maternal-newborn-and-child-cause-of-death (accessed Nov 23, 2016). Yadav KK, Awasthi S. The current status of community-acquired pneumonia management and prevention in children under 5 years age in India: a review. Ther Adv Infect Dis 2016; 3: 83–97. John TJ, Pai R, Lalitha MK, et al. Prevalence of pneumococcal serotypes in invasive diseases in southern India. Indian J Med Res 1996; 104: 205–07. Prospective multicentre hospital surveillance of Streptococcus pneumoniae disease in India. Invasive Bacterial Infection Surveillance (IBIS) Group, International Clinical Epidemiology Network (INCLEN). Lancet 1999; 353: 1216–21.
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Nisarga R, Premlatha R, Shivanan RK, et al. Hospital-based surveillance of invasive pneumococcal disease and pneumonia in South Bangalore, India. Indian Pediatr 2015; 52: 205–11. Rudan I, O’Brien KL, Nair H, et al, for the Child Health Epidemiology Reference Group (CHERG). Epidemiology and etiology of child health pneumonia in 2010: estimates of incidence, severe morbidity, mortality, underlying risk factors and causative pathogens for 192 countries. J Glob Health 2013; 3: 010401. Matthew JL, Singhi S, Ray P, et al. Etiology of community acquired pneumonia among children in India: prospective, cohort study. J Glob Health 2015; 5: 050418. Wijesinghe P. Invasive pneumococcal disease (IPD) surveillance in south east Asia region: successes and challenges. Pre 9th International Symposium on Pneumococci and Pneumococcal Diseases South Asia Symposium; Hyderabad, India; March 9–13, 2014. O’Brien KL, Wolfson LJ, Watt JP, et al, for the Hib and Pneumococcal Global Burden of Disease Study Team. Burden of disease caused by Streptococcus pneumoniae in children younger than 5 years: global estimates. Lancet 2009; 374: 893–902. Jaiswal N, Singh M, Thumburu KK, et al. Burden of invasive pneomococcal disease in children aged 1 month to 12 years living in south Asia: a systematic Review. PLoS One 2014; 9: e96282. Balaji V, Jayaraman R, Verghese VP, Baliga PR, Kurien T. Pneumococcal serotypes associated with invasive disease in under five children in India and implications for vaccine policy. Indian J Med Res 2015; 142: 286–92. Farooqui H, Jit M, Heymonn DL, Zodpey S. Burden of severe pneumonia, pneumococcal pneumonia, and pneumonia deaths in Indian states: modelling based estimates. PLoS One 2015; 10: e0129191. Manoharan A, Manchanda V, Sundaram B, et al. Invasive pneumococcal disease in children aged younger than 5 years in India: a surveillance study. Lancet Infect Dis 2016; published online Dec 9. http://dx.doi.org/10.1016/ S1473-3099(16)30466-2. UN Development Programme. Sustainable Development Goals. http://www.in.undp.org/content/india/en/home/post-2015/sdgoverview/goal-3.html (accessed Nov 23, 2016).
www.thelancet.com/infection Published online December 9, 2016 http://dx.doi.org/10.1016/S1473-3099(16)30543-6
The most recent Global Burden of Disease report1 estimates that mortality of children aged younger than 5 years has decreased globally by 27·2% between 2005 and 2015, but that still nearly 6 million children aged younger than 5 years have died. Beyond the first month of life, lower respiratory tract infections are the leading cause of mortality, at 12·1%. The fraction of death attributable to pneumococcal pneumonia was observed to be 55·8% in children aged younger than 5 years. Estimates from the Maternal and Child Epidemiology Estimation group of WHO2 are marginally higher than those by the Global Burden of Disease reports, primarily due to methodological differences, but the picture remains the same. In the Maternal and Child Epidemiology Estimation report,2 India is included as one of the ten countries with the highest mortality of children aged younger than 5 years and the analysis of the causes of death notes acute respiratory infections as the commonest cause of death. Yadav and Awasthi3 report that 13–16% of mortality of children aged 5 years or younger in India is attributable to community-acquired pneumonia. The most common bacterial isolates for pneumonia reported are of Streptococcus pneumoniae, ranging from 13% to 40%.4–12 These reports were published between 1996 and 2016, but the pattern of pneumococcal isolation has not changed substantially between these dates. India is noted to have the largest number of deaths of children aged 1–59 months due to pneumococcal diseases.10 Besides causing pneumonia, the other pneumococcal clinical presentations include meningitis, which is the fourth-leading cause of death in children younger than 5 years of age (after diarrhoea and malaria).1 Additionally, other types of invasive pneumococcal disease might not cause death, but contribute to substantial morbidity.11 Studies of pneumococcal prevalence have been done in different parts of India, but either in small areas or with non-uniform case definitions or methods.3–13 With this background of pneumococcal disease in the Indian subcontinent, a need exists to have nationally representative data for pneumococcal morbidity, mortality, and seroprevalance. The Article by Anand Manoharan and colleagues14 in The Lancet Infectious
Diseases reporting the data collected by the Alliance for Surveillance of Invasive Pneumococci is very valuable. The data has been collected over 4·5 years in a both prospective and retrospective fashion through a network of institutions and laboratories across 11 Indian states. The results showed a S pneumoniae yield of 4%, which was higher than previous reports from the region.4,5 Pneumonia was the most common diagnosis made and the 1–11 month age group formed a majority of invasive pneumococcal disease. Overall mortality was 3%, for children with pneumonia it was 7%, and for those with invasive pneumococcal disease it was 12%. The results of this study endorse the reports of S pneumoniae being a substantial contributor to morbidity and mortality among children aged 5 years or younger.1 With effective vaccines available, the number of children dying with a vaccine-preventable disease is unfortunate and unnecessary. India has been lagging behind in achieving the targets for the under-5 mortality rate for 2015.2 To reach the Sustainable Development Goal 315 in the coming years, acute respiratory infections in children aged younger than 5 years of age have to be brought down. Tackling of pneumococcal infection will be a major step in improvement of survival of children younger than 5 years of age. Neighbouring Pakistan, Myanmar, Sri Lanka, and Bangladesh have either already instituted or planned inclusion of pneumococcal vaccine in their national immunisation schedules.9 India needs to move in this direction quickly as well along with other measures to reduce acute respiratory infections . The fact that the study by Manoharan and colleagues14 provides a larger picture of pneumococcal prevalence than did previous studies cannot be denied, but as mentioned by the authors, limitations exist of not adequately representing the various regions of the country and inadequate sampling from some participating sites. We still need comprehensive prospective data, not only for policy making, but also as a surveillance network for future once a vaccination programme is initiated. The issue of pneumococcal serotypes is a subject of constant review and discussion because besides geographical variations of
www.thelancet.com/infection Published online December 9, 2016 http://dx.doi.org/10.1016/S1473-3099(16)30543-6
Shaukat Ahmed /SIPA USA/PA Images
The unchecked pneumococcal reign over Indian children aged younger than 5 years
Lancet Infect Dis 2016 Published Online December 9, 2016 http://dx.doi.org/10.1016/ S1473-3099(16)30543-6 See Online/Articles http://dx.doi.org/10.1016/ S1473-3099(16)30466-2
1
Comment
seroprevalence, other factors like changes in vaccine practices and microbiological factors will continue to affect serotype prevalence, which might not remain constant in any region.12
6
Jugesh Chhatwal
8
Department of Pediatrics, Christian Medical College, Ludhiana, Punjab 141008, India [email protected] I report grants to my institution (Christian Medical College) from the Alliance for Surveillance of Invasive Pneumococci Study Group during the conduct of the study by Manoharan and colleagues. 1
2
3
4 5
2
GBD 2015 Mortality and Causes of Death Collaborators. Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet 2016; 388: 1459–544. Johns Hopkins Bloomberg School of Public Health. Maternal, newborn and child cause of death. http://www.jhsph.edu/research/centers-and-institutes/ institute-for-international-programs/current-projects/maternal-childepidemiology-estimation/maternal-newborn-and-child-cause-of-death (accessed Nov 23, 2016). Yadav KK, Awasthi S. The current status of community-acquired pneumonia management and prevention in children under 5 years age in India: a review. Ther Adv Infect Dis 2016; 3: 83–97. John TJ, Pai R, Lalitha MK, et al. Prevalence of pneumococcal serotypes in invasive diseases in southern India. Indian J Med Res 1996; 104: 205–07. Prospective multicentre hospital surveillance of Streptococcus pneumoniae disease in India. Invasive Bacterial Infection Surveillance (IBIS) Group, International Clinical Epidemiology Network (INCLEN). Lancet 1999; 353: 1216–21.
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9
10
11
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Nisarga R, Premlatha R, Shivanan RK, et al. Hospital-based surveillance of invasive pneumococcal disease and pneumonia in South Bangalore, India. Indian Pediatr 2015; 52: 205–11. Rudan I, O’Brien KL, Nair H, et al, for the Child Health Epidemiology Reference Group (CHERG). Epidemiology and etiology of child health pneumonia in 2010: estimates of incidence, severe morbidity, mortality, underlying risk factors and causative pathogens for 192 countries. J Glob Health 2013; 3: 010401. Matthew JL, Singhi S, Ray P, et al. Etiology of community acquired pneumonia among children in India: prospective, cohort study. J Glob Health 2015; 5: 050418. Wijesinghe P. Invasive pneumococcal disease (IPD) surveillance in south east Asia region: successes and challenges. Pre 9th International Symposium on Pneumococci and Pneumococcal Diseases South Asia Symposium; Hyderabad, India; March 9–13, 2014. O’Brien KL, Wolfson LJ, Watt JP, et al, for the Hib and Pneumococcal Global Burden of Disease Study Team. Burden of disease caused by Streptococcus pneumoniae in children younger than 5 years: global estimates. Lancet 2009; 374: 893–902. Jaiswal N, Singh M, Thumburu KK, et al. Burden of invasive pneomococcal disease in children aged 1 month to 12 years living in south Asia: a systematic Review. PLoS One 2014; 9: e96282. Balaji V, Jayaraman R, Verghese VP, Baliga PR, Kurien T. Pneumococcal serotypes associated with invasive disease in under five children in India and implications for vaccine policy. Indian J Med Res 2015; 142: 286–92. Farooqui H, Jit M, Heymonn DL, Zodpey S. Burden of severe pneumonia, pneumococcal pneumonia, and pneumonia deaths in Indian states: modelling based estimates. PLoS One 2015; 10: e0129191. Manoharan A, Manchanda V, Sundaram B, et al. Invasive pneumococcal disease in children aged younger than 5 years in India: a surveillance study. Lancet Infect Dis 2016; published online Dec 9. http://dx.doi.org/10.1016/ S1473-3099(16)30466-2. UN Development Programme. Sustainable Development Goals. http://www.in.undp.org/content/india/en/home/post-2015/sdgoverview/goal-3.html (accessed Nov 23, 2016).
www.thelancet.com/infection Published online December 9, 2016 http://dx.doi.org/10.1016/S1473-3099(16)30543-6