Surveillance of pneumococcal-associated disease among hospitalized children in Khanh Hoa Province, Vietnam

BACKGROUND

To understand the epidemiology of childhood bacterial diseases, including invasive pneumococcal disease, prospective surveillance was conducted among hospitalized children in Nha Trang, Vietnam.

METHODS

From April 2005 through August 2006, pediatricians at the Khanh Hoa General Hospital used standardized screening criteria to identify children aged <5 years who had signs and symptoms of invasive bacterial disease. All cerebrospinal fluid (CSF) and blood specimens collected were tested by bacterial culture. Selected culture-negative specimens were tested for Streptococcus pneumoniae by antigen detection or for Haemophilus influenzae, Moraxella catarrhalis, Neisseria meningitidis, and S. pneumoniae by polymerase chain reaction (PCR).

RESULTS

A total of 987 children were enrolled (794 with pneumonia, 76 with meningitis, and 117 with other syndromes consistent with invasive bacterial disease); 84% of children were aged 0-23 months, and 57% were male. Seven (0.71%) of 987 blood cultures and 4 (15%) of 26 CSF cultures were positive for any bacterial pathogen (including 6 for H. influenzae type b and 1 for S. pneumoniae). Pneumococcal antigen testing and PCR identified an additional 16 children with invasive pneumococcal disease (12 by antigen testing and 4 by PCR). Among children aged <5 years who lived in Nha Trang, the incidence rate of invasive pneumococcal disease was at least 48.7 cases per 100,000 children (95% confidence interval, 27.9-85.1 cases per 100,000 children).

CONCLUSIONS

S. pneumoniae and H. influenzae type b were the most common causes of laboratory-confirmed invasive bacterial disease in children. PCR and antigen testing increased the sensitivity of detection and provided a more accurate estimate of the burden of invasive bacterial disease in Vietnam.

Survey of childhood empyema in Asia: implications for detecting the unmeasured burden of culture-negative bacterial disease

Background

Parapneumonic empyema continues to be a disease of significant morbidity and mortality among children despite recent advances in medical management. To date, only a limited number of studies have assessed the burden of empyema in Asia.

Methods

We surveyed medical records of four representative large pediatric hospitals in China, Korea, Taiwan and Vietnam using ICD-10 diagnostic codes to identify children <16 years of age hospitalized with empyema or pleural effusion from 1995 to 2005. We also accessed microbiology records of cultured empyema and pleural effusion specimens to describe the trends in the epidemiology and microbiology of empyema.

Results

During the study period, we identified 1,379 children diagnosed with empyema or pleural effusion (China, n = 461; Korea, n = 134; Taiwan, n = 119; Vietnam, n = 665). Diagnoses of pleural effusion (n = 1,074) were 3.5 times more common than of empyema (n = 305), although the relative proportions of empyema and pleural effusion noted in hospital records varied widely between the four sites, most likely because of marked differences in coding practices. Although pleural effusions were reported more often than empyema, children with empyema were more likely to have a cultured pathogen. In addition, we found that median age and gender distribution of children with these conditions were similar across the four countries. Among 1,379 empyema and pleural effusion specimens, 401 (29%) were culture positive. Staphylococcus aureus (n = 126) was the most common organism isolated, followed by Streptococcus pneumoniae (n = 83), Pseudomonas aeruginosa (n = 37) and Klebsiella (n = 35) and Acinetobacter species (n = 34).

Conclusion

The age and gender distribution of empyema and pleural effusion in children in these countries are similar to the US and Western Europe. S. pneumoniae was the second leading bacterial cause of empyema and pleural effusion among Asian children. The high proportion of culture-negative specimens among patients with pleural effusion or empyema suggests that culture may not be a sufficiently sensitive diagnostic method to determine etiology in the majority of cases. Future prospective studies in different countries would benefit from standardized case definitions and coding practices for empyema. In addition, more sensitive diagnostic methods would improve detection of pathogens and could result in better prevention, treatment and outcomes of this severe disease.

The Use of Typhoid Vaccines in Asia: The DOMI Experience

BACKGROUND

Two currently licensed typhoid vaccines have been evaluated in Asia, yet few Asian countries have considered including typhoid vaccines in their vaccination programs. The Diseases of the Most Impoverished (DOMI) Program was initiated to provide evidence to decide on the introduction of typhoid vaccines in Asian countries.

METHODS

The centerpiece of the program is a multidisciplinary demonstration project with Vi vaccine in 5 Asian countries. The project includes epidemiologic, economic, sociobehavioral, and policy studies.

RESULTS

Policy makers want evidence on which to base their vaccine-related decisions. The DOMI Program has provided updated information on the typhoid fever burden at several Asian sites. Cost-of-illness studies found high costs to governments and individuals. Sociobehavioral studies indicated a positive attitude toward typhoid vaccines. The results of the demonstration projects indicate that mass-immunization campaigns are feasible and acceptable.

CONCLUSIONS

The DOMI Program has begun to provide momentum for the evidence-based, rational introduction of typhoid vaccines into the public health programs of several Asian countries.

Haemophilus influenzae type B meningitis among children in Hanoi, Vietnam: epidemiologic patterns and estimates of H. Influenzae type B disease burden

From March 2000 to February 2002, a population-based study of Haemophilus influenzae type b (Hib) meningitis was conducted among children less than five years of age in Hanoi, Vietnam. Children with suspected bacterial meningitis were referred to hospitals and each patient underwent standardized clinical examination and microbiologic testing. In Hanoi, 580 children were evaluated for bacterial meningitis and 23 (4%) had confirmed or probable Hib meningitis. The incidence of all Hib meningitis was 12/100,000 child-years less than five years of age and 26/100,000 child-years less than two years of age. Nationally, an estimated 1,005 children less than five years of age are hospitalized for Hib meningitis and 5,107 are hospitalized for Hib pneumonia. Among children with Hib meningitis, at least 100 will develop severe neurologic sequelae and 40 will die. These data suggest there is a substantial burden of Hib disease in Vietnam. National leaders will be provided with these data to facilitate development of national vaccination policies for children in Vietnam.

Salmonella paratyphi A rates, Asia

Little is known about the causes of enteric fever in Asia. Most cases are believed to be caused by Salmonella enterica serovar Typhi and the remainder by S. Paratyphi A. We compared their incidences by using standardized methods from population-based studies in China, Indonesia, India, and Pakistan.

Introducing new vaccines into developing countries: obstacles, opportunities and complexities

Infectious diseases are thought to account for nearly 25% of all deaths worldwide, and extract a disproportionate toll in developing countries. Moreover, infectious diseases are now appreciated to be major causes of the poverty and economic underdevelopment that characterize the world's poorest countries. Development and deployment of new vaccines to prevent infectious diseases in developing countries have therefore become high priorities in the global health agenda.

Translational research to assist policy decisions about introducing new vaccines in developing countries

Few new-generation vaccines have found their way into public-health programmes for the poor in developing countries, and for those that have, delays of years or even decades after their licensure and introduction in industrialized countries have been the rule. Financial constraints and political obstacles have played major roles in delaying the introduction of the vaccines. Also contributing to this situation has been a dearth of needed research. While past analyses have identified inadequate support for conducting Phase 1 studies as an obstacle, other types of translational research are also needed. Vaccines may perform less well in impoverished populations in the developing world than in more affluent populations. Consequently, Phase 2 and Phase 3 trials of new vaccines in developing countries are a second essential type of translational research needed for the introduction of vaccines in developing countries. Moreover, even for vaccines that have performed well in pre-licensure human trials in developing countries, doubts often remain about whether the local disease burden justifies introduction of vaccine, whether the vaccine will be cost-effective, and whether introduction of vaccine will be programmatically feasible, acceptable, and financially sustainable. Because these residual doubts constitute obstacles to the introduction of vaccine, a third type of translational research is needed to provide this evidence required for policy. In this paper, these three types of translational research are illustrated with projects being undertaken in the Diseases of the Most Impoverished Programme. The Programme is conducting translational research to accelerate the rational introduction of new vaccines against cholera, shigellosis, and typhoid fever in developing countries affected by these diseases.

Technologies that make administration of vaccines safer

There is an ever-expanding technology that is aimed at making the administration of vaccines safer. Conventional ways of administering vaccines are being upgraded, modified or replaced by a wide variety of innovations. The paradigm of liquid vaccines, needles and syringes is slow to change, but already developments are occurring that will change for ever the way vaccines are administered and will improve the safety record of immunization. The oral route of vaccine administration has generally been thought of as safe, but until now only the polio vaccine has been widely used in this way. The conventional method of vaccine administration is by injection. Many ingenious devices have become available that now make injecting safer. Inventors are now looking imaginatively to alternative routes and technologies for delivering vaccines. Vaccines are generally manufactured to extremely high standards and rarely are shown to be the cause of safety issues. People remain the weakest safety link is vaccine administration. Technologies that bypasses the ability of man to make bad decisions or to behave incorrectly are of tremendous value. The vaccine world is in the middle of a radical re-think about how vaccines might best be administered. The presentation of the vaccine can be altered to fit new technologies such as powder jet guns, or skin patches. Even the conventional needle and syringe have evolved to much safer versions, and are set to continue this evolution. All this means even safer vaccines and their delivery.

Ensuring vaccine safety in immunization programmes--a WHO perspective

Ever since vaccines were firstly used against smallpox, adverse events following immunization have been reported. As immunization programmes expand to reach even the most remote communities in the poorest countries, it is likely that many more events will be temporally linked with vaccine administration. Furthermore, the profound shift in the general public and media interest in adverse events may lead to undue concerns and allegations which may ultimately jeopardize immunization programmes world-wide. While the health professional has understood this issue for some time, the public and the media have now also become all too aware of the significance of vaccine-related adverse events. The familiar vaccines, well-tested over decades, have not changed--but the perception regarding their safety has shifted. Claims outrageous or reasonable are being made against both the old and the newly-introduced vaccines. At the same time, the immunological and genetic revolution of the last decade may well bring to our notice some hypothetical risks that need to be addressed at pre-clinical level. WHO has been at the leading edge to guarantee vaccine safety for the last 30 years and will continue to do so. The Organization's plans for the next decade and beyond include the Safe Injection Global Network (SIGN), the development and introduction of safer technologies, and the prevention, early detection and management of AEFIs. The new technologies include needle-containing injection devices such as the autodisable syringe, as well as mucosal and transcutaneous immunization. Training will continue to be at the centre of WHO's efforts, limiting human error to a minimum. Mechanisms have been set in place to detect and respond to new and unforeseen events occurring. Above all, there is a willingness to respond to new climates and new technologies so that the Organization is in the best position to ensure safe immunization for all the world's children.

FS stress induces long-lasting memory facilitation: involvement of cholinergic pathways

We tested in vivo the hypothesis that foot-shock (FS) stress-induced prolongation of latencies in the one-trial step-through passive avoidance learning task in mice occurred through a long-term facilitation process. Whereas behavioral responses in control mice lasted for 24 h, decreasing progressively in the subsequent days, FS-stress exposure for 15 min before training (pretraining), immediately after training (posttraining), or 15 min before the test (pretest) resulted in a profound and sustained enhancement of test latencies that lasted for at least 96 h. These facilitating effects disappeared when FS exposure was delivered with a 2- or 3-h difference with respect to the training trial. Scopolamine (Scop) (1 mg/kg, intraperitoneally) 30 min before the training session caused impairment of test latencies in control and pretest stressed animals, but failed to affect both pre- and posttraining FS stress-induced enhancement. Our working hypothesis is that FS stress may increase the levels of acetylcholine in the presynaptic terminal or the firing rate of cholinergic input. Animals pretreated with FS stress daily for 1 or 4 days followed by the acute schedule described above showed no enhancements of test latencies. Pretraining Scop impaired test latencies in pre- and posttraining and pretest stressed animals, suggesting that unpredictability is a critical factor in activating behavioral long-term facilitation.

Synaptic plasticity: stairway to memory

Since the idea that memory is associated with alterations in synaptic strength was accepted, studies on the cellular and molecular mechanisms responsible for the plastic changes in neurons have attracted wide interest in the scientific community. Recent studies on memory processes have also pointed out some unifying themes emerging from a wide range of nervous systems, suggesting that regardless of the species or brain regions, a common denominator for memory may exist. Thus, the present review attempted to create a hypothetical and universal synaptic model valid for a variety of nervous systems, ranging from molluscs to mammals. The cellular and molecular events leading to short- and long-term modifications of memory have been described in a sequential order, from the triggering signals to the gene expression, synthesis of new proteins and neuronal growth. These events are thought to represent the late phases of memory consolidation leading to persistent modifications in synaptic plasticity, thereby facilitating the permanent storage of acquired information throughout the individual's life.

Inheritance of histiocytosis in Bernese mountain dogs

One hundred and twenty-seven cases of histiocytosis in Bernese mountain dogs (BMD) were evaluated to determine if the tumour is inherited. Family data ruled out autosomal recessive, autosomal dominant and sex-linked modes of inheritance. The trait was determined to be inherited with a polygenic mode of inheritance. The salient points permitting this conclusion are: pedigrees developed from independently selected propositi link up allowing the tracing of all cases through several generations; multiple cases occur in the same litter; multiple cases have been produced by given dams and sires; there is a higher frequency of the disease among offspring of affected parents when compared to offspring of normal parents that produced histiocytosis and all offspring in the general population of BMDs; the fact that histiocytosis is common in BMDs and rare in eight other breeds and accounts for 25.4 per cent of the 500 tumours studied in this breed. The heritability of this trait was calculated to be 0.298.

Effects of footshock-, psychological- and forced swimming-stress on the learning and memory processes: involvement of opioidergic pathways

Modulation of learning and memory acquisition, retention and retrieval in the one trial passive avoidance learning task in mice by three inescapable stresses, i.e., footshock (FS), psychological (PSY) and forced swimming (SW) were investigated. Pre-, post-training and pre-test FS-stress (2 mA, 0.2 Hz, 1 sec for 30 min) and pre-training PSY-stress (communication box, 5 min) resulted in enhanced test latencies. On the contrary, SW-stress (20 degrees C, 5 min) immediately or 1 hr after training impaired retention latencies that tended to recover after 2 hr post-training SW-stress, suggesting that at least 2 hr are required to consolidate newly acquired information. In contrast, pre-stress naloxone (Nx), which did not affect FS- and PSY-stress induced facilitatory effects, returned to control levels the impaired retention latencies induced by SW-stress. Taken collectively, these results imply the involvement of an opioid-dependent mechanism in the modulation of memory by SW-stress and non-opioid in the case of FS- and PSY-stress. Furthermore, they suggest that different mechanisms are involved in stress-induced memory modifications and the production of stress-induced analgesia (SIA) since in the latter, FS and PSY but not SW stress produce Nx-sensitive antinociception.

Trends in physiological role of opioids in psychoneuroendocrine-immune network

Extensive evidence suggests that opioid influences on the immune response are mediated through opioid receptors on the surface of immune cells. In addition, the binding of opioid agonists to centrally located opioid receptors appears also to alter immune activity through interactions with the neuroendocrine and the nervous systems. Finally, other findings summarized in this review provide evidence consistent with the hypothesis that under stressful stimuli, the immune system is altered through the interrelations among the neuroendocrine system, the sympathetic nervous system and central opioidergic pathways.