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PRESENTATION vaccine jab
Surveillance of Bacterial Pneumonia and Meningitis in Children under 5 A Practical Guide Preliminary version November 20, 2006 Pan American Health Organization Regional Office of the World Health Organization Washington, D.C. SURVEILLANCE OF BACTERIAL PNEUMONIA AND MENINGITIS IN CHILDREN UNDER 5 A Practical Guide Preliminary version November 20, 2006 Pan American Health Organization / World Health Organization Family and Community Health Area (FCH) / Immunization Unit (IM) and Area of Technology and Health Service Delivery (THS) / Essential Medicines, Vaccines and Health Technology Unit (EV) 1 Acknowledgements The Pan American Health Organization acknowledges the valuable contribution made by the health professionals of the Ministries of Health of the countries that have collaborated with FCH/IM and THS/EV officials in the production of this guide. 2 SUMMARY PRESENTATION ...................................................................................................... 6 I. BACTERIAL PNEUMONIA AND MENINGITIS IN CHILDREN UNDER FIVE .......... 7 1. Epidemiological situation in the Americas ........................................................ 7 1.1. Characterization of strains existing in the Region........................................... 7 2. Epidemiology of infectious agents ..................................................................... 8 2.1 Description of infectious agents ....................................................................... 8 2.2 Reservoir ........................................................................................................... 9 2.3 Transmission .................................................................................................... 9 2.4 Distribution........................................................................................................ 9 2.5 Susceptibility .................................................................................................... 9 2.6 Immunity ......................................................................................................... 10 2.7 The condition of the carrier............................................................................. 10 2.8 Disease burden .............................................................................................. 11 2.9 Economic studies ........................................................................................... 13 II. BACTERIAL PNEUMONIA (BP) ......................................................................... 13 1. Clinical aspects ................................................................................................ 13 1.1 Differential diagnosis ..................................................................................... 14 1.2 Complications ................................................................................................. 15 2. Radiological diagnosis ..................................................................................... 15 2.1 X-ray quality ................................................................................................... 16 3. Laboratory diagnosis ....................................................................................... 16 4. Treatment .......................................................................................................... 16 III. BACTERIAL MENINGITIS (MB) ........................................................................ 17 1. Clinical aspects ................................................................................................. 17 2. Laboratory diagnosis ........................................................................................ 17 2.1 Interpreting laboratory tests ........................................................................... 18 3. Complications ................................................................................................... 18 4. Treatment .......................................................................................................... 19 IV. LABORATORY DIAGNOSIS ............................................................................. 20 1. Collection, storage and transport of samples .................................................. 21 1.1 Steps for collecting CSF, blood and pleural fluid samples............................. 21 1.2 Storing samples .............................................................................................. 22 1.3 Transporting samples ..................................................................................... 23 2. General biosafety recommendations ................................................................ 23 3. Quality assurance ............................................................................................. 24 V. SURVEILLANCE OF BACTERIAL PNEUMONIA AND MENINGITIS ................... 25 1. Aims of the surveillance .................................................................................. 25 3 2. Surveillance strategies ..................................................................................... 25 2.1 Target population for surveillance .................................................................. 25 2.2 Type of surveillance ........................................................................................ 25 2.2.1 Criteria for selecting sentinel hospitals ....................................................... 26 3. Sentinel hospital surveillance of bacterial pneumonia..................................... 26 3.1 Definition ........................................................................................................ 26 4. Sentinel hospital surveillance of bacterial meningitis ...................................... 29 4.1 Definition ......................................................................................................... 29 5. Stages in sentinel hospital surveillance ........................................................... 31 6. Data necessary for surveillance........................................................................ 31 6.1 Sentinel hospital surveillance of bacterial pneumonia ................................... 31 6.2 Sentinel hospital surveillance of bacterial meningitis .................................... 32 7. Flow and frequency of information ................................................................... 33 8. Data analysis ..................................................................................................... 35 9. Functional structure of the surveillance system .............................................. 36 9.1 Function of the surveillance coordinators ...................................................... 36 10. Training ........................................................................................................... 39 11. Evaluation of the surveillance system ............................................................ 39 12. Feedback ......................................................................................................... 40 13. Investigating cases of meningitis ................................................................... 40 14. Intervention measures ................................................................................... 41 14.1 Protection of contacts ................................................................................... 41 14.1.1 Pneumoccocal pneumonia and meningitis ............................................... 41 14.1.2 Meningococcal and Hib meningitis ........................................................... 41 14.1.2 Chemoprophylaxis ..................................................................................... 42 14.1.4 Vaccination ................................................................................................. 42 VI. VACCINES........................................................................................................ 43 1. Vaccine against Haemophilus influenzae type b (Hib) ..................................... 43 2. Vaccines against pneumococcus ..................................................................... 44 2.1. Polysaccharide vaccine (23-valent) ............................................................... 45 2. 2. Conjugate vaccines ...................................................................................... 46 3. Vaccines against meningococcus .................................................................... 48 3.1. Polysaccharide vaccines ............................................................................... 48 3.2. Conjugate vaccines ........................................................................................ 49 Glossary ................................................................................................................ 51 References ............................................................................................................ 53 Annex 01: BACTERIAL PNEUMONIA INVESTIGATION FORM ............................. 62 Annex 02: BACTERIAL MENINGITIS INVESTIGATION FORM .............................. 63 4 Annex 03: Processing samples for cultures......................................................... 64 Annex 04: Data and indicator calculation sheets ................................................ 71 5 PRESENTATION Community-acquired bacterial pneumonia is responsible for 20% to 40% of all hospitalizations of children under 5. In the Region of the Americas, it is one of the three main causes of death among children. Bacterial meningitis, though not so frequent, is always serious because of the risk of sequels and its high mortality. Three bacteria, Streptococcus pneumoniae (pneumococcus), Haemophilus influenzae (Hi) type b (Hib) and Neisseria meningitidis (meningococcus), are responsible for the majority of episodes of these invasive infections in children under 5 and the three most important are pneumonia, meningitis and bacteriemia. This "Practical Guide for Surveillance of Bacterial Pneumonia and Meningitis in Children under 5" was produced by the Pan American Health Organization for health workers involved in the epidemiological surveillance of these two diseases. This guide presents the clinical and epidemiological aspects of bacterial pneumonia and meningitis, the role of radiology in pneumonia and laboratory tests to confirm the presence of these two diseases, the prevention and control measures needed and the epidemiological surveillance procedures for both events. The aim of this document is to standardize concepts and procedures for obtaining data on the disease burden to be used in the decision-making process, introducing new vaccines in national immunization schedules, evaluating the impact of the vaccines used and guiding the rational use of antimicrobial agents. Because these two diseases have high rates of morbidity and mortality, the introduction of new vaccines will be an important step in meeting one of the Millennium Development Goals, which is to reduce mortality by two thirds among children under 5 between 1990 and 2015. 6 I. BACTERIAL PNEUMONIA AND MENINGITIS IN CHILDREN UNDER FIVE 1. Epidemiological situation in the Americas Surveillance of bacterial pneumonia and meningitis is a priority for the Americas because of the importance of these diseases in the morbidity and mortality among children under five. Since 1993 the Region has had a surveillance network of regional laboratories, known as SIREVA (Regional System for Vaccines - RSV), supported by PAHO/WHO and by the Canadian Government through the Canadian International Development Agency - CIDA. This network, in which 20 countries currently participate, has infrastructure for identifying the three main bacterial agents responsible for bacterial pneumonia and meningitis in the Region (pneumococcus, Hi and meningococcus), determining the distribution of the circulating serotypes and serogroups of these bacteria, and establishing the susceptibility of the bacteria to the most frequently used antibiotics. Between 1993 and 2004 the network processed more than eleven thousand isolates of pneumococcus, obtained from invasive infections in children under 6; in addition to serotyping them and determining their susceptibility to antimicrobial agents, using quality laboratory procedures proven through the External Quality Assurance Program. At present, when new vaccines are available in the market, it is necessary to implement epidemiological surveillance of these infections in the Region to complement laboratory information with standardized epidemiological data broken down by person (age groups and most vulnerable people, for example), time and location. In addition, it is necessary to develop studies to determine the disease burden and carry out economic analyses. The SIREVA II Project was launched in 2005 as a PAHO initiative supported by the Global Alliance for Vaccines and Immunization - Pneumococcal Accelerated Development and Introduction Plan - GAVI's Pneumo ADIP. The acronym SIREVA now stands for Regional System for Surveillance of Bacterial Agents Responsible for Pneumonia and Meningitis (Sistema Regional de Red de Vigilancia de Agentes Bacterianos Responsables por Neumonías y Meningitis). 1.1. Characterization of strains circulating in the Region Surveillance of invasive processes through SIREVA has produced useful data on pneumococcus, Hi and meningococcus. 7 According to isolates obtained in Argentina, Brazil, Chile, Colombia, Mexico and Uruguay between 2000 and 2003, shown below in Graph 1, serotype 14 of pneumococcus predominates, with a total of 29,2%, followed by serotypes 6B, 5 and 1. Graph 1 Main pneumococcus serotypes isolated in invasive infections in children under six in six countries, Region of the Americas, 2000-2003 6B 7F 9.2% 6A 9V 2.5% 4.0% 5 3.0% 6.1% 4 1.7% 3 3.5% 1 6.0% 14 29.2% Otros 15.9% 18C 23F 4.2% 19A 19F 6.0% 3.1% 5.6% Source: Garcia S, Levine OS, Cherian T, Gabastou JM, Andrus J and the Working Group members. Pneumococcal disease and vaccination in the Americas; an agenda for accelerated vaccine introduction. Rev Panam Salud Pública/Pan Am J Public Health. 2006; 19(5): 340-8. Other important information was also collected: the proportion of pneumococcus that is not susceptible to penicillin has increased gradually from 14.7% in 1993 to 30.6% in 1999 and 39.8% in 2003. In addition to this laboratory data, mandatory reporting of meningitis cases and certain information on bacterial pneumonia in a number of countries in the Americas has enabled data from as far back as the 1970s to be compiled. Nevertheless, it is necessary to standardize concepts and procedures that will allow joint comparison and analysis, with the participation of all countries in a more homogenous and systematic manner. 2. Epidemiology of infectious agents 2.1 Description of infectious agents Streptococcus pneumoniae (pneumococcus) is a lance-shaped Gram-positive diplococcus. Ninety serotypes and more than 40 subgroups of pneumococcus have been identified; nevertheless, 11 of the most common serotypes cause approximately 75% of all invasive infections in children. 8 Haemophilus influenzae is a Gram-negative coccobacillus. Six encapsulated antigenic serotypes have been identified (classified from a to f). Both the encapsulated and non- encapsulated serotypes are potentially pathogenic in humans but their virulence and pathogenic mechanisms differ. Haemophilus influenzae serotype b (Hib) is the most pathogenic of these. Neisseria meningitidis (meningococcus) is a Gram-negative diplococcus. Thirteen serogroups of meningococcus have been identified, of which six cause the disease: A, B, C, W 135, Y and Z. The most common serogroups in the Americas are B and C. 2.2 Reservoir Only human beings are reservoirs of Hi, meningococcus and pneumococcus. 2.3 Transmission Transmission is from person to person through droplets of saliva and secretions from the respiratory tract. 2.4 Distribution The distribution of Hi, meningococcus and pneumococcus is universal. 2.5 Susceptibility Susceptibility to infection by Hib, meningococcus and pneumococcus is general. The three agents have common characteristics, such as a greater susceptibility by some people: Children under 5 Adults over 65 years of age Carriers of functional or surgical asplenia, nephrotic syndrome, diabetes mellitus, alcoholism, chronic hepatic, cardiovascular, pulmonary and renal disorders, hemoglobinopathies, acquired or congenital immunodeficiencies, hematological cancers and other generalized cancers, organ transplant patients or recipients of hematopoietic cells and those undergoing immunosuppressive therapy including systemic corticosteroids. The younger the child, the more susceptible her or she is to these bacteria, including invasive diseases. The highest risk for Hib is between 6-12 months, it then declines after the age of 2 and is infrequent in those over 5; for meningococcus, the highest rates of attack occur in children under one, with a peak between 3 and 5 months; pneumococcus is more frequent between the ages of 2 months and three years but declines after the age of 18 months. 9 2.6 Immunity Immunity against Hib, meningococcus and pneumococcus can be acquired passively through the placenta or actively through prior infection or immunization. Children may have antibodies against pneumococcus at birth, transmitted from their mothers, which disappear after a few months, coincident with an increase in the invasive disease. The incidence of the disease decreases after 18 months, when the child presents an immune response for most circulating pneumococcus serotypes through repeated exposure to them. At the age of 5, most unvaccinated children present anticapsular antibodies against Hib, which have arisen through exposure to the bacterium. As far as meningococcus is concerned, a group-specific immunity of unknown duration follows clinical and sub-clinical infections. 2.7 The condition of the carrier Pneumococcus, Hi and meningococcus usually colonize the nasopharynx of people without symptoms of any illness; these are considered carriers. The condition of the carrier is related to outbreaks of diseases such as otitis, sinusitis, meningitis, pneumonia and septicemia. The prevalence of pneumococcus carriers is higher in children, especially those attending kindergartens, and in adults who have close contact with them. It is estimated that up to 40% of children under two are colonized by this bacteria. The most frequently isolated pneumococcus serotypes in carriers and people with invasive disease are: 14, 6B and 23F. It is estimated that between 1% and 5% of those who have not been immunized are carriers of Hib. The percentage of carriers is higher among preschool children, probably because of the presence or absence of immunity. Hib can remain in the nasopharynx for months. Around 5 to 15% of adolescents and young adults may carry meningococcus in their nasopharynx. However, less than 1% progress to an invasive disease. Carriers of meningococcus are uncommon among children and rare in adults (1%). Table 1 below summarizes the epidemiological characteristics of these three etiological agents. 10 Table 1 Epidemiological Characteristics of the Main Bacteria Responsible for Pneumonia and Meningitis in Children Etiological agent Haemophilus Streptococcus Neisseria influenzae type B pneumoniae meningitidis Type of bacteria Gram-negative Lance-shaped Gram- Gram-negative coccobacillus positive diplococcus diplococcus Distribution universal Reservoir human beings Seasonality Autumn and Spring Winter and Spring (in Winter (in temperate not seasonal in some temperate countries) countries) countries Transmission Person to person through nasal and pharyngeal secretions Period of Whilst it is in the respiratory tract and up to 24 hours after the start of specific transmission antibiotic therapy. Carrier yes Incubation 2 to 4 days 1 to 3 days 1 to 10 days (usually < 4) Susceptibility People of all ages, but the most susceptible are children under 5 and adults over 60, and carriers of certain chronic diseases. Immunity Immunity can be acquired passively through the placenta or through prior infection or immunization th Source: Heymann DL editor. Control of Communicable Diseases Manual. 18 Edition, 2004. American Public Health Association. Washington DC, USA:700 p. 2.8 Disease burden Acute respiratory infections (ARI), particularly community-acquired pneumonia, are the main causes of hospitalization and death among children under five years of age in developing countries. In 2004, WHO estimated the incidence of clinical pneumonia in developing countries at 0,29 episodes per child each year (e/cy), equivalent to 29 episodes in each group of 100 children yearly. This is equivalent to an annual incidence of 150,7 million new cases, of which between 11 and 20 million (7% –13%) will require hospitalization. Various studies show that in the developed world the incidence of community-acquired pneumonia by children under five is approximately 0,026 e/cy. Therefore, more than 95% of all episodes of clinical pneumonia in young children throughout the world occur in developing countries. Several studies show that mortality due to ARI is directly associated with bacterial infections, principally by pneumococcus and Hib. Pneumococcus causes a range of infections from colonization of the nasopharynx to non- invasive infections of the mucous membranes of the middle ear, paranasal sinus, trachea, bronchi and lungs by direct dissemination of the microorganisms and/or dissemination 11 through the blood, causing only bacteriemia with no apparent focus of invasive infection of the central nervous system, pleura, joints, bones and heart valves. Figure 1 below shows the relation between pneumoccocal pneumonia (large circle) and invasive pneumoccocal disease (small circle). It is worth highlighting the fact that 20% of all hospitalized cases of pneumonia correspond to pneumonia with bacteriemia. Figure 1 Percentage distribution of invasive infections and pneumonia caused by pneumococcus Source: Adapted from Fedson DS, Musher DM. Pneumococcal Polysaccharide. In: Orenstein WA and Plotkin SA editors: Vaccines. Fourth edition, 2004, Elsevier Inv. Philadelphia, Pennsylvania. p. 538. Otitis media, defined as inflammation of the middle ear, is an example of a non-invasive bacterial infection occurring frequently in children between 6 and 36 months. Around three quarters of these will have at least one episode of otitis media during this period of their lives. Pneumococcus is usually found in 40% of positive cultures from middle ear secretions. Pneumococcus is the main cause of community-acquired pneumonia that requires hospitalization and of around 800.000 deaths of children under 5 each year. Before the introduction of the conjugate vaccine, Hib was the most important cause of bacterial meningitis among children in the Americas. At present, pneumococcus, followed by meningococcus, are the two most common causes of bacterial meningitis in the Region. More than 90% of meningitis cases in children under five are caused by these three bacteria. 12 2.9 Economic studies Economic studies should be conducted in the health field and their results used to guide decisions on the introduction of new vaccines or the expansion of the age group receiving the vaccines already used in the country. Cost studies can measure the economic burden for society of a disease that can be prevented by vaccination. As far as pneumococcus is concerned, the economic aspects are important for measuring the morbidity and mortality burden on health systems, families and society in general. The direct cost of treatment, hospitalization, consultation, diagnostic tests and treatment paid for by the health system, families or others, should be taken into account. Other direct costs arise from the families' expenditure on hospital visits, transport, meals and lodgings. To these should be added the cost of rehabilitation, in the event of sequels and disabilities, such as post-meningitis deafness. There are also indirect or social costs in terms of production lost through absence from work, as well as intangible costs (pain, suffering, and stigma). At the same time, studies are required to estimate the cost of introducing a new vaccine in a vaccination program and evaluate the costs in the medium and long term, in order to guarantee financial sustainability. This is an essential component of the decision-making process in National Immunization Programs. II - BACTERIAL PNEUMONIA (BP) 1. Clinical aspects Pneumonia is an infection of the pulmonary parenchyma and may be caused by various microorganisms such as virus, bacteria and others. Pneumonias with different etiologies can produce very similar clinical symptoms. According to the Integrated Management of Childhood Illnesses (IMCI) strategy, pneumonia is suspected when a child has a cough or respiratory distress as well as rapid breathing, during clinical examination: < 2 months: >60 breaths a minute 2-11 months: >50 breaths a minute 12 months to 5 years of age: >40 breaths a minute 13 Other signs are present during chest auscultation, such as reduction in the vesicular murmur on the affected side, crepitant rales not modified by cough, increased voc al resonance over lung consolidation. They are classified as very serious, serious or not serious, according to their clinical characteristics and each one has a specific treatment. Bacterial pneumonias are the most serious and are responsible for most hospitalizations and deaths among children under 5. Pneumonia is considered serious when the patient has a cough and respiratory distress in addition to at least one of the following symptoms: retraction of the lower chest wall nasal flaring expiratory wheezing (in young infants). In very serious pneumonia cases, one of the following symptoms must also be present: central cyanosis inability to suckle or drink vomiting of everything ingested convulsions, lethargy or loss of consciousness serious respiratory distress leading to head nodding. Possible pleural complications are identified by: pleural smear antalgic position secondary to chest pain reduced vocal resonance on auscultation. The hemogram is a non-specific test but can help to indicate the bacterial etiology of the infection. 1.1 Differential diagnosis Some common childhood illnesses can present symptoms similar to those of pneumonia. Bronchiolitis and asthma are some examples. Respiratory viral infections are common in children under 5. They usually present cough, fever, breathing through the mouth and nasal secretion. Rapid breathing, retraction of the chest wall and other signs of serious illness are absent. Wheezing may be present in young children. 14 Bronchiolitis is a viral infection of the lower tract which occurs frequently in children and is relatively serious. The most important cause of this illness is the respiratory syncytial virus. It is characterized by obstruction of the respiratory tract and wheezing, and does not respond much to the use of bronchodilators. There may be secondary bacterial infection. Asthma is a chronic inflammation with reversible obstruction of the respiratory tract. It is characterized by recurring episodes of wheezing and coughing; contraction of the lower chest wall and rapid breathing can be observed. If it is not associated with a viral or bacterial infection, there is no fever. It responds well to treatment with bronchodilators and anti-inflammatory agents. 1.2 Complications Complications with bacterial pneumonia include atelectasis, pleural effusion, empyema and hypertensive pneumothorax. . If a child with serious pneumonia is not treated promptly and adequately with specific antibiotics, respiratory insufficiency may develop, leading to death. 2. Radiological diagnosis Radiographic analysis is an important tool for diagnosing serious and very serious pneumonia, as it suggests whether the etiology is bacterial or viral and whether there are complications such as pleural effusion or atelectasis. According to WHO standards for interpreting chest X-rays, bacterial pneumonia produces one or more dense images, homogeneous or "cottony" in appearance, partially or totally affecting one or more segments of the pulmonary lobes or a complete lung, which are the condensations. It may contain air bronchogram (see glossary) and is sometimes associated with pleural effusion. Radiological changes typical of bacterial pneumonia are unifocal or multifocal condensations. Atelectasis shows on the X-ray as a reduction in the volume of the distal parenchyma and displacement of the sulcus, mediastinum and diaphragm towards the affected side (see glossary). 15 The effect on the pleura may appear as effusions of varying magnitudes. When the effusion is small, it may be difficult to see but it is evident when the mediastinum is displaced towards the contralateral side (right or left). Radiological signs appear after the clinical symptoms and may last for three months after remission. 2.1 X-ray quality A well-taken X-ray appropriately interpreted, is crucial to a radiographic diagnosis of pneumonia. The following points concerning the technical quality of the examination should be borne in mind when analyzing an X-ray. Adequate exposure - it should be possible to make out bones, mole tissue and lungs having different densities. Correct positioning - the terminals of the medial parts of the clavicles should be approximately equidistant from the mid line; Development – there should be a black space outside the body and extending to the end of the film while the densest areas, such as the most distal part of the spine behind the heart, should be white. 3. Laboratory diagnosis A blood sample should be taken for culture as soon as possible, before starting antibiotics, in order to isolate the etiological agent. The laboratory tests and samples to be taken are given in Chapter IV, "Laboratory Diagnosis". 4. Treatment Children with general pneumonia can be treated as outpatients with adequate precautions taken at home, in accordance with medical instructions. Serious and very serious cases of pneumonia in children must be referred to hospital. For more details on the treatments indicated, refer to the manuals of the IMCI strategy (Integrated Management of Childhood Illnesses). 16 III - BACTERIAL MENINGITIS (BM) 1. Clinical aspects Meningitis is an inflammation of the meninges, the membranes covering the brain. The most frequent clinical findings are signs of meningeal inflammation and fever. Children under one usually present certain symptoms that are commonly seen in other diseases such as reduced appetite and vomiting. Other more specific signs and symptoms are present, such as: irritability with no other justification or clinical cause lethargy convulsions bulging of the fontanelle Children one year old or more and adults present certain unspecific symptoms such as light sensitivity (photophobia) and headaches, as well as classic symptoms such as: stiffness of the neck and/or other signs of meningeal inflammation jet vomiting prominent signs of hyperactivity or lethargy. changes in state of consciousness In cases of meningococcemia, a skin rash is present which is initially erythematous and macular but quickly evolves into a petechial rash. Convulsions occur in 20% of cases. Various pathogens can cause meningitis, such as virus, bacteria and others. Although similar clinical symptoms are present, therapy is specific to the pathogen, therefore an etiological diagnosis from the cerebrospinal fluid (CSF) is essential. Given the crucial nature of an etiological diagnosis for meningitis, systematic collection of samples of the CSF is essential, as well as blood samples for complementary tests. 2. Laboratory diagnosis Laboratory tests for suspected cases of meningitis use CSF samples: cytochemical, direct examination (Gram staining) and culture. In addition to these diagnostic tests, other molecular or immunological tests may be performed on the CSF to complement the culture such as: polymerase chain reaction or PCR and latex microagglutination. Although these tests help to provide an immediate diagnosis, the culture is considered the gold standard, 17 not only because it reveals the characterization / serotyping of the etiological agent but also because it establishes the susceptibility of this agent to the most commonly used antimicrobial agents. The collection of CSF samples is considered mandatory and urgent if meningitis is suspected, to confirm the clinical and etiological diagnosis and start specific treatment, as well as to recommend control measures necessary to prevent secondary cases. Samples of blood and cutaneous lesions for culture are considered complementary and may help to establish the etiology of the infections. 2.1 Interpreting laboratory tests In cases of BM, cytochemical testing of the CSF presents the following characteristics: Increased leukocytes (equal to or greater than 200/mm 3) with neutrophils predominating. Elevated proteins Reduced glucose. In such cases, Gram staining of the CSF may identify the bacteria from their microscopic appearance. Gram-negative diplococcus, intra or extra-cellular (meningococcus) or Gram-negative coccobacillus (H. influenzae) or Lance-shaped Gram-positive diplococcus (pneumococcus) or Others. • The CSF testing establishes whether the findings are compatible with BM. • The Gram staining suggests the type of bacteria present. • The cultures confirm which bacteria is responsible for the disease. • The antibiogram establishes the susceptibility of the agent to the antibiotics tested. For more details on these tests, see Chapter IV of this guide, Laboratory Diagnosis. 3. Complications In general terms, 10-30% of all survivors of bacterial meningitis will have a permanent sequel. 18 The most frequent sequel of bacterial meningitis is sensorineural deafness. Other important sequels are: language disturbances, mental retardation, motor abnormalities and visual problems. Meningitis can rapidly produce stupor, coma and death. Meningitis caused by Hib has a mortality between 3% and 6%; when caused by meningococcus, mortality is between 8% and 15% and when caused by pneumococcus, it is between 10% and 30% 4. Treatment Treatment for meningitis requires the child to be admitted to the nearest hospital. For further details on the treatment of bacterial meningitis, refer to the manuals of the IMCI strategy (Integrated Management of Childhood Illnesses). 19 IV. LABORATORY DIAGNOSIS The main purpose of laboratory tests is to diagnose the etiology of bacterial pneumonia and meningitis and its susceptibility to antimicrobial agents. When a case of bacterial pneumonia or suspected meningitis in a child under 5 is detected, the technical team of all sentinel hospitals must: • Take samples of CSF and blood when meningitis is suspected • Take a blood sample for culture from all cases of bacterial pneumonia and pleural fluid samples when pleural effusion indicates thoracocentesis • Send samples immediately to the laboratory for processing. The hospital laboratory will process the samples, as shown in Figure 2. It will report the results to the hospital technical team as quickly as possible. When Hi, pneumococcus or meningococcus is isolated, the strains must be sent to the national reference laboratory to determine their serotype and minimum inhibitory concentration (MIC). The national reference laboratory will provide feedback to the sentinel hospital as quickly as possible, one to three months after receiving the strains. Figure 2 Flow diagram for laboratory diagnosis of bacterial pneumonia and meningitis 20 1. Collection, storage and transport of samples 1.1 Steps for collecting CSF, blood and pleural fluid samples Provided it is possible, the culture sample should be taken before starting treatment with antibiotics as false negative results might otherwise be produced. Samples should be obtained under standardized conditions of asepsis in all cases and the person taking them should use sterile gloves and a face mask. The optimum quantity of each type of sample for testing is: Children's blood: 1 to 3 ml CSF: 3 ml (1 ml for cytochemical tests and 2 ml for culture) Pleural fluid: 3 ml Wash the chosen part with soap and water. Using cotton wool, apply 70% alcohol in concentric rings working out from the sampling site to the periphery. Apply iodized alcohol solution to the sampling site. It is important to wait for the iodized compound to dry so the oxidizing function can take place and not to touch the sampling site with your fingers, or to speak or cough while the sample is being taken. In patients allergic to iodine, clean the skin twice with alcohol. The containers used must be sterile and specific to the type of sample: CSF containers must have a screw cap and contain no anticoagulant Pleural fluid containers must have a screw cap and contain anticoagulant Blood containers must not have screw caps and must contain specific anticoagulants Samples must be sent to the hospital laboratory no later than two hours after being taken. They should be accompanied by the investigation form containing the patient's identification data, such as name, age and sex, as well as data on the sample: type of sample, date and time taken, clinical suspicion. The container should be labeled with the patient's name and date. If bar codes are present take care not to damage them as they are necessary for the process. Collecting blood samples We recommend, if possible, taking two samples with an interval of one hour (minimum half an hour) between them. Select the most accessible peripheral vein and draw blood from it. 21 The blood will then inoculate rapidly in the container with the culture medium to prevent coagulation in the syringe (no more than 5 minutes). Disinfect the top of the container into which the blood will flow with 70% alcohol before drawing off the sample. The media to be used are Trypticase soy broth or brain-heart or Columbia. Whatever medium is chosen it should be mixed with sodium polyanethol sulphonate (SPS) at a final concentration of 0.025% to act as an anticoagulant. The needle should be inserted vertically and the vacuum incorporated in the containers will suck the contents rapidly from the syringe. There is no need to change the needle. The container is then tilted slowly to mix the blood with the medium. Sampling pleural fluid Given that a pleural puncture is an invasive procedure, it should be done only by experienced medical staff. Before carrying out the thoracocentesis, it is important to ensure that the operating room is equipped with everything necessary for pleural drainage, an oxygen supply and revival equipment (laryngoscope, tube or intubation cannula). To prevent the pleural fluid coagulating and the coagulation trapping the microorganisms present in it, a small amount of sodium polyanethol sulphonate (SPS) should be added in the sampling tube. Collecting CSF samples Direct CSF testing, orientation tests and cultures should be considered essential and extremely urgent procedures. The acquisition of LCR is an invasive procedure that should only be carried out by an experienced doctor in an environment with the minimum conditions for the procedure. It is a technique that requires similar precautions to surgery and adequate preparation of the sampling site. To avoid contamination of the CSF sample for culture, it should be taken separately in two sterile tubes with screw caps. One tube with at least 2 ml of CSF will be used for the bacteriological examination and the other, containing at least 1 ml, for the cytochemical tests. 1.2 Storing samples The sample for culture should be sent immediately to the laboratory. 22 The maximum time for delivering samples of blood, CSF and pleural fluid to the laboratory is two hours. Meanwhile, they must be kept at ambient temperature. If they have to be kept for longer they should be placed in an incubator at a temperature of 35 °C to 37° C They should never be kept in the freezer. CSF and pleural fluid samples should not be placed in any culture medium before they reach the laboratory. 1.3 Transporting samples Blood, CSF and pleural fluid samples for culture cannot be refrigerated or frozen during transport. Samples must be identified and accompanied by their epidemiological details during transport. The container must be wrapped in aluminum foil or sterile packing paper and placed in a box duly protected with foam or paper packing to protect it from bumps and breakages; an arrow should indicate the side they have been placed on so that they are not turned over. Mark the box with the sender's and recipient's details. Indicate on the box that it contains biological material. 2. General biosafety recommendations In order to reduce the risk of transmitting viral agents (HIV, hepatitis B, etc.), bacteria, protozoa and other parasites that may be present in all biological material, including blood, CSF and pleural fluid, the following recommendations should be followed: Be careful when collecting and transporting samples. Label the container with an indication that it contains biological material. Hermetically seal the sample containers. Clean the outside of the containers with disinfectant; for example, a hypochlorite solution with 0.1% available chlorine (1 g/liter, 1000 ppm), ensuring that it is not contaminated with blood or other biological material. In an emergency (tip over, etc.), available chlorine should be used, for example, sodium hypochlorite at 4 or 5 g/L. Use impermeable latex or vinyl gloves. Wash hands with soap and water immediately after taking off the gloves. Place used syringes and needles in a puncture-proof container. Wash the wound with abundant soap and water and in the case of needle punctures or other skin punctures, let it bleed. 23 Notify the supervisor and the health service of any case of contamination of hands or body with blood or other biological material, as well as any puncture or cut, so that you receive adequate treatment. 3. Quality assurance A key component of the SIREVA project is the Quality Assurance Program developed in response to the specific needs of the participants which includes: a monitoring process with remittance of specific isolates to the National Centre for Streptococcus (NCS) in Edmonton, Canada and the Instituto de Salud Carlos III in Madrid, Spain for confirmation and/or additional research. a quality control program to test the capacities of the participating laboratories. This program currently has two subregional reference centers: the Microbiology Group at the Instituto Nacional de Salud in Colombia and the Microbiology Department at the Instituto Adolfo Lutz in São Paulo, Brazil. Since October 2003 the Quality Assurance program of the SIREVA project has been called the External Quality Assurance Program (EQAP) with the corresponding updates and standardizations. The main functions of the national reference laboratories and subregional laboratories as quality control centers, include: To train professionals from the participating laboratories To secure the transport system for isolates to prevent the loss of viability and/or contamination To ensure storage of the isolates sent by participating laboratories To carry out serotyping and antimicrobial susceptibility testing of all isolates of S. pneumoniae, H. influenzae and N. meningitidis sent by the laboratories To carry out external quality assurance tests of inter-laboratory systems To participate in the External Quality Assurance Program of the subregional reference laboratory for national laboratories or the Canadian NCS and the Instituto de Salud Carlos III in Madrid, Spain, for the subregional laboratories To implement and maintain a system of continual communication to provide feedback to the participating laboratories 24 V. SURVEILLANCE OF BACTERIAL PNEUMONIA AND MENINGITIS 1. Aims of the surveillance General aim To generate standardized information on bacterial pneumonia and meningitis in children under 5, to support the future introduction of new vaccines, monitor their impact, and contribute to the rational use of antimicrobial agents. Specific aims To establish a sentinel hospital surveillance network for bacterial pneumonia and meningitis To identify pneumococcus, Hi and meningococcus, characterize the circulating strains of these agents and changes in serogroups/serotypes, and monitor antimicrobial susceptibility patterns To classify the etiology of bacterial pneumonia and meningitis To help establish standardized technical standards for the use of antimicrobial agents To contribute with information to justify the introduction of a new vaccine and monitor its impact. 2. Surveillance strategies 2.1 Target population for surveillance The target population for BP and BM surveillance is the group from 1 month to 4 years 11 months and 29 days. Given the magnitude of these infections and the vulnerability of these children, priority must be given to this age group. 2.2 Type of surveillance Sentinel hospital surveillance. All cases where hospital treatment is indicated are defined as hospitalized. The justification for the use of this form of surveillance is: 1. Hospitalization for serious bacterial pneumonia is frequent. 2. All cases of bacterial meningitis require hospitalization because of their severity. 25 3. Hospitalized cases are easier to find and require fewer resources than cases in the community. 4. These hospital laboratories ensure that the sample cultures are viable. 5. The hospitals' radiology services can confirm the suspicion of pneumonia. 2.2.1 Criteria for selecting sentinel hospitals According to the logistic and operational capacity of each country it is possible to establish the number of hospitals required to carry out sentinel surveillance The following criteria should be used to select hospitals: 1. They should be a reference for the population that is the target of the surveillance. 2. They should be geographically, economically and logistically accessible to the population, which means they treat a large number of patients. 3. They should have a radiology service 4. They should have a bacteriology laboratory that can isolate Hi, meningococcus and pneumococcus. 5. They should have the human and logistic resources necessary for surveillance. 6. There must be a commitment by the institution 3. Sentinel hospital surveillance of bacterial pneumonia 3.1 Definition Suspected case of pneumonia All patients, from 1 month to 4 years 11 months and 29 days, hospitalized because pneumonia has been diagnosed by a physician. Exclusion criteria Patients who have been ill for more than 15 days shall be excluded Confirmed case of bacterial pneumonia All suspected cases with a chest X-ray identifying a radiological pattern compatible with bacterial pneumonia. Confirmed case of bacterial pneumonia caused by Hib or pneumococcus All confirmed cases of bacterial pneumonia in which Hib or pneumococcus is isolated. Confirmed case of bacterial pneumonia with undetermined or other etiology All confirmed cases of bacterial pneumonia in which another bacteria has been isolated or no bacteria has been isolated 26 Cases in which bacterial pneumonia has been ruled out All suspected cases in which a chest X-ray has not identified a radiological pattern compatible with bacterial pneumonia. Cases of pneumonia that have been inadequately investigated All suspected cases that have not been given a chest X-ray. 27 Algorithm 1 Classification of a pneumonia case hospitalized at a sentinel site 28 4. Sentinel hospital surveillance of bacterial meningitis 4.1 Definition Suspected case of meningitis All children from one month to 4 years 11 months and 29 days hospitalized because of sudden febrile illness with at least one of the following signs: Stiffness of the neck and/or other signs of meningeal inflammation Bulging of the fontanelle in babies under one Jet vomiting Irritability with no other justification or clinical cause Convulsions Altered consciousness Lethargy or prominent hyperactivity Purpuric or petechial rash Confirmed case of bacterial meningitis All suspected cases in which cytochemical tests on the CSF reveal characteristics compatible with bacterial etiology and/or bacteria are identified in the Gram stain. Cases in which bacterial meningitis has been ruled out All suspected cases where cytochemical tests on the CSF are not compatible with bacterial etiology and nor are bacteria identified in the Gram stain and the culture is negative. Confirmed case of bacterial meningitis by Hib or pneumococcus or meningococcus All confirmed cases of bacterial meningitis with isolate in the culture, PCR diagnosis of cerebrospinal fluid for Hib, pneumococcus or meningococcus. Confirmed case of bacterial meningitis with undetermined or other etiology All confirmed cases of bacterial meningitis where the culture is negative for Hib, pneumococcus or meningococcus, or another bacteria has been isolated or none at all. Suspected case of meningitis inadequately investigated All suspected cases without CSF samples or with a sample that is insufficient for the laboratory tests. 29 Algorithm 2 Classification of a meningitis case hospitalized in a sentinel site 30 5. Stages in sentinel hospital surveillance a. Detect a BP or BM case in a sentinel hospital b. Manage every suspected case in accordance with the specific algorithm for surveillance of BP and BM c. Fill in the investigation form d. Order a pulmonary chest X-ray for suspected cases of BP e. Confirm BP case by clinical and radiological examination if X-ray reveals a pattern that suggests BP f. Take a blood sample for hemoculture in BP cases before starting antibiotic therapy and a pleural fluid sample for culture in the event of a pleural effusion, when thoracocentesis is indicated g. Order a sample of CSF and blood for laboratory tests before starting antibiotic therapy in cases of BM h. Send the samples immediately to the laboratory with a copy of the investigation form i. Confirm BM case by clinical and laboratory tests with cytochemical results and/or Gram stain of CSF suggestive of BM j. Complement information with laboratory test results: Gram stain of the two fluids; hemoculture, CSF or pleural fluid cultures with the etiological agent identified k. Send isolated strain of Hi or pneumococcus or meningococcus to the country's reference laboratory for characterization l. Complete the investigation form when the patient is discharged m. Send investigation form and relevant data to the epidemiologist, according to level in question. n. Provide periodic feedback with information. 6. Data necessary for surveillance 6.1 Sentinel hospital surveillance of bacterial pneumonia The following data should be collected weekly and consolidated monthly on the target population for surveillance: Number of hospitalizations for any reason (a) Number of hospitalizations for suspected pneumonia cases (b) Number of suspected pneumonia cases that have been adequately investigated; i.e. by chest X-ray and epidemiological forms filed in (c) Number of confirmed cases of bacterial pneumonia among adequately investigated cases (d) Number of confirmed cases of bacterial pneumonia with blood samples for culture (e) 31 Number of confirmed cases of bacterial pneumonia with pleural fluid samples for culture (f) Number of confirmed cases of bacterial pneumonia with isolation in blood of: Hib, pneumococcus, other, none (g') Number of confirmed cases of bacterial pneumonia with isolation in pleural fluid of: Hib, pneumococcus, other, none (h') Number of deaths caused by bacterial pneumonia among confirmed cases (i) The following indicators will be calculated from the data collected and consolidated: Percentage of hospitalizations to treat bacterial pneumonia among total hospitalizations of children from 1 month to < 5 years of age (d/a x 100) Percentage of suspected cases of pneumonia adequately investigated (c/b x 100) Percentage of confirmed cases of bacterial pneumonia among adequately investigated cases (d/b X 100) Percentage of confirmed cases of bacterial pneumonia with blood sample for culture (e/d x 100) Percentage of confirmed cases of bacterial pneumonia with pleural fluid sample for culture (f/d x 100) Percentage of isolates in blood samples (g'/e x 100) Percentage of isolates in pleural fluid samples (h'/f x 100) Mortality of confirmed cases of bacterial pneumonia (i/d x 100) 6.2 Sentinel hospital surveillance of bacterial meningitis The following data should be collected weekly and consolidated monthly on the target population for surveillance: Number of hospitalizations for any reason (a) Number of hospitalizations for suspected meningitis (j) Number of suspected meningitis cases that were adequately investigated; i.e. with CSF sample and epidemiological forms filled in (k) Number of confirmed cases of bacterial meningitis among adequately investigated cases (l) Number of confirmed cases of bacterial meningitis with CSF sample for culture (m) Number of confirmed cases of bacterial meningitis with blood sample for culture (n) 32 Number of confirmed cases of bacterial meningitis with isolates in the CSF samples of: Hib, meningococcus, pneumococcus, other, none (o') Number of confirmed cases of bacterial meningitis with isolates in blood samples of: Hib, meningococcus, pneumococcus, other, none (p') Number of deaths among confirmed cases of bacterial meningitis (q) The following indicators will be calculated from the data collected and consolidated: Percentage of hospitalizations caused by bacterial meningitis among total hospitalizations of children from 1 month to < 5 years of age (l/a x 100) Percentage of suspected cases of meningitis adequately investigated (k/j x 100) Percentage of confirmed cases of bacterial meningitis among adequately investigated cases (l/k x 100) Percentage of confirmed cases of bacterial meningitis with CSF sample for culture (m/l x 100) Percentage of confirmed cases of bacterial meningitis with blood sample for culture (n/l x 100) Percentage of isolates in CSF samples (o'/m x 100) Percentage of isolates in blood samples (p'/n x 100) Mortality of confirmed cases of bacterial meningitis (q/l x 100) 7. Flow and frequency of information The original epidemiological investigation form shall be sent to the hospital epidemiology department when the suspected case is entered into the database. Thereafter, when the patient is discharged, the fully completed form is sent with the final diagnosis and evolution. It is hoped that the final diagnosis will be available up to two weeks after hospitalization in each case. This office will send weekly the database and complementary data on hospitalizations of the target population under surveillance to the epidemiological office of the next level in the hierarchy. The municipal epidemiology office should send the data to the regional level. 33 The regional office will consolidate the data from its respective sentinel sites and send it to the regional office. In countries with no regional or departmental office, the municipalities should send the data directly to the national level. Each country should define its flow of information and the frequency at which it is sent by the different levels, depending on how their surveillance is organized. The national level will consolidate the data from all sentinel sites in the country and report monthly to PAHO on cases occurring during the month before the 10th of the following month. Annexes 04 to 07 contain the forms on which to consolidate the monthly data surveillance data on bacterial pneumonia and meningitis. PAHO will consolidate the data from the entire region and provide feedback to the whole system every six months. 34 Figure 3 Flow and frequency of information on sentinel hospital surveillance of pneumonia and meningitis 8. Data analysis Periodic analysis of data is aimed at understanding the behavior of the diseases and monitoring the surveillance system. Suspected and confirmed cases of each disease should be described, broken down by time, epidemiological weeks from the onset of the disease and monthly consolidate; according to children's ages and place of occurrence of the cases. It must also be established whether each case is isolated or whether it is part of an outbreak in a nursery or other institution or in the community. In addition to calculating and analyzing the indicators, other data should be analyzed such as the average number of days of hospitalization necessary for treating bacterial pneumonia and meningitis; and the susceptibility of the agents to the different antimicrobial agents tested. Also it is possible to establish other indicators, considering their importance in monitoring the surveillance of such disease. 35 9. Functional structure of the surveillance system The surveillance system for bacterial pneumonia and meningitis must be included in and integrated within each country's epidemiological surveillance system. This implies following the flow chart designed for reporting, sending the investigation form and biological samples for confirmation and feedback. Each country has its own functional structure. Nevertheless it is suggested that at least a national team and a local team (sentinel hospital) should be set up with their respective coordinators or supervisors. Teams may be set up at different levels, depending on the organization of each country's health network: municipal, regional or other. At the sentinel site the team should consist of a person responsible for each department: clinical, nursing, epidemiology and laboratory. The function of all of them should be well defined in order to generate and transmit data between the different levels. 9. 1 Function of surveillance coordinators National team General coordinator The coordinator of the surveillance system for bacterial pneumonia and meningitis in children under five throughout the country shall have the following functions and responsibilities: To organize training or awareness-raising for the sentinel teams when necessary, together with those responsible for epidemiology and the laboratory To monitor the actions taken in each of the sentinel hospitals, identifying future problems and helping to find solutions To periodically evaluate the data obtained To elaborate the national report, in conjunction with those responsible for epidemiology and the laboratory To disseminate this report widely among the different departments of the Ministry of Health To disseminate the information monthly through PAHO. Epidemiology supervisor To promote training and awareness-raising for the teams where necessary, in conjunction with the national coordinator To guarantee that the information generated in all sentinel hospitals in the country is consolidated and analyzed 36 To elaborate the national report, in conjunction with the coordinator and the person responsible for the laboratory To provide feedback to the country's network of sentinel hospitals. Laboratory supervisor To promote training or awareness-raising for the teams when necessary, in conjunction with the national coordinator To act as the national technical point of reference for the laboratory diagnosis of these diseases To ensure that laboratory supplies are always available so that the surveillance is not interrupted To coordinate with the hospital laboratories the correct flow of isolated strains To carry out quality control for the laboratories of the sentinel hospitals that process samples To perform serotyping of cultivated strains and the minimum inhibitory concentration (MIC). To evaluate the data obtained in conjunction with those responsible for the surveillance To participate in the drafting of the monthly report. It is recommended that teams be set up at every level with a structure and competences similar to those of the national team. Sentinel hospital team Each team should have a coordinator (preferably an epidemiologist) and consist of an epidemiologist or person responsible for the information, another responsible for clinical issues, another for nursing and another responsible for the local laboratory, with the following functions and responsibilities: Clinical issues supervisor To train the hospital team taking part in the surveillance and working on different shifts, together with those responsible for epidemiology, the laboratory and the nursing areas To ensure prompt and adequate data collection from the hospital wards To monitor the participation of the hospital's clinical personnel To monitor the percentage of suspected cases detected To participate in drafting the monthly report. Nursing supervisor 37 To train the hospital team taking part in the surveillance working on different shifts, together with the clinical, epidemiology and laboratory supervisors To monitor suspected cases detected, in conjunction with the clinical supervisor To guarantee adequate and timely collection of samples and chest X-rays To ensure that the data is entered on the investigation forms To monitor cases detected on the hospital wards To ensure that the data is entered on the investigation forms, in conjunction with the clinical supervisor To monitor the participation by the hospital nursing personnel To help in drafting the monthly report. Epidemiology supervisor To coordinate the sentinel hospital team To train the hospital team taking part in the surveillance and working on different shifts, in conjunction with the clinical, nursing and laboratory supervisors To collect information generated by the clinical department (hospital records) and the laboratory To enter the data in a specially-designed database To enter the laboratory results in the database To send the data to the highest level in the hierarchy (municipality, district, region or national level) at the frequency established in the country To consolidate data on suspected cases entering the system on the first day of each month To analyze the data monthly, including an evaluation of the surveillance indicators To elaborate a monthly report, in conjunction with the clinical, nursing and laboratory supervisors To send this report to the director of the hospital and the hospital technical team To send the local monthly report to the general coordinator of the epidemiological surveillance system for BP and BM at the next level in the hierarchy no later than the 5th of each month. Local laboratory supervisor To train the hospital technical team taking part in the surveillance and working on different shifts, in conjunction with the clinical, nursing, epidemiology and hospital technical team supervisors To receive samples of blood, pleural fluid and CSF To store these samples correctly 38 To perform timely diagnosis testing (cultures and antibiograms) To report the results of clinical tests to the clinical and epidemiological supervisors If Hi, meningococcus or pneumococcus is isolated, to send the positive strains to the reference laboratory for serotyping and MIC To guarantee adequate transport of the isolated strains to the reference laboratory To receive the results of these strains and inform the team To help in drafting the monthly report Each hospital team should: Meet monthly to discuss the weaknesses of the surveillance system, clarify any doubts and propose such changes as may be necessary to ensure the correct functioning of the system and to draft the monthly report 10. Training All healthcare personnel involved in surveillance at the different levels must receive training, especially the staff of the hospitals chosen for sentinel surveillance in each country. Continual communication, contact and support to the staff of these hospitals are important to achieve commitment and permanent participation by hospital medical personnel. Equally important are the monthly meetings of sentinel teams at the different levels, at which all data is shared. In addition, meetings are an opportunity for the entire team to clarify any doubts and make suggestions for solving difficulties. 11. Evaluation of the surveillance system The system should be evaluated monthly by the team at every sentinel site and by those responsible at the different levels. This evaluation should be consolidated by the national coordinator with the data from the whole country. This evaluation should analyze the results obtained and compare the results from the different sentinel hospitals, when more than one exists. 39 One of the indicators that can be used to evaluate the surveillance process is the percentage of cases of pneumonia or meningitis that are adequately investigated; i.e. with epidemiological forms for all; X-rays for pneumonia and CSF for meningitis. Other important points to be evaluated are: The frequency at which samples are taken from confirmed cases at every sentinel site The speed and regularity of information sent by each sentinel site These evaluations should be used to propose measures for implementing surveillance, when necessary. 12. Feedback There must be feedback at all levels. In other words. the information flow, which starts at the sentinel site up to PAHO, must return to the sentinel site. Equally, hospital laboratories must receive monthly consolidated information about their cases and those occurring in other sentinel sites in the country. Information from other countries should also reach each sentinel site every six months. Various mechanisms and measures can be used to provide feedback: meetings, Internet reports, websites, the normal surveillance bulletins and even specific bulletins. Only this way will all the components of the network feel that they are essential members of the system and be motivated to carry out their work. 13. Investigating cases of meningitis Bacterial meningitis represents a clinical emergency, but also an epidemiological emergency because the rapid transmission of Meningococcal or Hib meningitis to other people has to be prevented. The following steps should be taken in investigating a suspected case of meningitis: 1. Fill in the data on the investigation form 2. Analyze the preliminary results of the CSF to see whether there is an indication of the probable etiological agent 3. Establish the risk for close contacts in the family and institutions attended by the child such as nurseries or hospitals, if Hib or meningococcus is suspected 40 4. Also establish the risk for contacts with immunosuppressive diseases or at the extremes of the age spectrum (under two and equal to or older than 65 years of age) 5. Institute chemoprophylaxis for cases where this is indicated, if possible within 24 hours of identification 6. Identify the vaccination history of the case and contacts in order to establish the correct intervention to prevent further cases. If it is a case of meningitis caused by meningococcus, if there is a vaccine available for the meningococcus serogroup responsible, it should be used in the event of an outbreak. If it is a case of meningitis caused by Hib, if there are unvaccinated or inadequately vaccinated children among the victim's contacts, they should be considered for chemoprophylaxis. 7. Follow the steps in the algorithm established for classifying a case of meningitis (for final classification) 8. Search for other similar cases in the region or institution Identification of Hib cases in the Region of the Americas is important at this time. Considering the high effectiveness of the vaccine and the high coverage that has been reported, it is expected that very few cases of infection by this pathogen will occur in the countries of the Region. 14. Intervention measures 14.1 Protection of contacts 14.1.1 Pneumococcal pneumonia and meningitis For cases of pneumonia and meningitis caused by pneumococcus, respiratory isolation is not indicated as a general measure. Nevertheless, this isolation is necessary in institutions such as hospitals for 24 hours after the start of antibiotic therapy, to avoid transmission to people with a high risk of infection by pneumococcus. It is necessary to check domestic and other close contacts paying special attention to early signs or symptoms of the disease in children under five, adults 65 years or older and immunocompromised people in order to immediately start adequate treatment. 14.1.2 Meningococcal and Hib meningitis In cases of meningitis caused by meningococcus and Hib, respiratory isolation is indicated for all close contacts of the patient and in hospital wards to prevent secondary cases, for 24 hours after starting antibiotic therapy. Detailed monitoring of domestic and other close contacts is essential to detect early signs of the disease and start treatment without delay. Chemoprophylaxis is also indicated for these contacts. 41 Investigation of contacts and the source of the infection using pharyngeal exudate cultures is not indicated in order to decide who should receive prophylactic treatment. This may delay the administration of the correct prophylaxis measures. 14.1.2 Chemoprophylaxis Meningitis / meningococcemia caused by meningococcus Consider the need to administer an effective chemical agent as a prophylactic to intimate contacts, close family members or those sharing a bedroom, and also those exposed directly to the patient's oral secretions. This must start immediately, ideally in the first 24 hours after the case has been identified. According to the American Academy of Medicine and the United States Advisory Committee on Immunization Practices, ceftriaxone and rifampicin are equally effective drugs as prophylactics for infections caused by meningococcus and may be used in children and adults when indicated. The indicated dosage of rifampicin for adults is 600 mg twice a day (12/12 hours) orally for two days. Children over one month should receive 10 mg per kg of weight twice a day (12/12 hours) orally for two days; the maximum dose is 600 mg/day. Children under 1 month should be given 5 mg per kg of weight, also twice a day (12/12 hours) orally for two days. Rifampicin cannot be given to pregnant women. As far as ceftriaxone is concerned, the recommendation is to give a single intramuscular dose of 250 mg for adults and 125 mg for children under 15. Meningitis caused by Hib You should also consider the need to administer a prophylactic agent, especially to close contacts at the extremes of the age spectrum or very young children in nurseries that have not completed a Hib vaccination schedule or have not been vaccinated at all, or carriers of any immunodeficiency. Rifampicin can be used as a prophylactic for meningitis caused by Hib. Rifampicin must be used for four days; children should receive 20 mg per kg of weight/day of 24/24 hours (single daily dose) for 4 days; the maximum dose is 600 mg/day. Babies under 1 month should be given 10 mg per kg of weight/day (also 24/24 hours). The adult dosage is 600 mg per day (24/24 hours) for 4 days. 14.1.4 Vaccination Chapter V, "Vaccines", examines the vaccines available to prevent infection by these agents. 42 VI. VACCINES The first vaccines used against Hib, meningococcus and pneumococcus were polysaccharide vaccines. These vaccines suffer important limitations: They do not induce an immune response in children under two They have little effect on carriers There is a significant reduction in the level of protection in only a few years They do not generate a memory response and therefore do not have a booster effect. In the 1980s the first vaccines against these three bacteria appeared, consisting of polysaccharides conjugated to a protein which overcame the limitations of the existing polysaccharide vaccines. These vaccines are inactive and have a carrier protein bound or conjugated to the polysaccharide in the bacterial capsular (antigenically active). Many carrier proteins are used: diphtheria toxoid, tetanus toxoid, outer membranes of meningococcus or mutant diphtheria protein. This conjugation enables the immune system of children under two to identify the protein and produce a good response that will last. It has also been demonstrated that they produce group immunity since they reduce colonization of the respiratory tract among vaccinated children, thus reducing transmission to third parties, including adults. 1. Vaccine against Haemophilus influenzae type b (Hib) The Hib vaccine is the only conjugate vaccine widely used in expanded programs on immunization in the countries of the Americas. Table 2 below shows the three types of conjugate vaccines that are available in the market and are currently used. Table 2 Hib vaccines available Vaccine Description PRP-OMP OMP = conjugated to an outer membrane protein complex of N. Meningitidis PRP-T T = conjugated to tetanus toxoid PRP- CRM197 (HbOC) CRM197= conjugated to a mutant diphtheria protein. PRP means: Polyribosylribitol Phosphate Polysaccharide Adapted from: Wenger JD and Ward JI. Haemophilus influenzae Vaccine. In: Orenstein WA and Plotkin SA editors: Vaccines. Fourth edition, 2004, Elsevier Inv. Philadelphia, Pennsylvania: 229-268. Indications 43 The vaccine is indicated for all children under 5, principally those under 2 and for some 5 years old or more with risk factors such as anatomic or functional asplenia or with suppressed immune systems (including HIV / AIDS carriers). Contraindications Anaphylactic reaction to earlier doses: is an absolute contraindication to other doses. Acute febrile illness: it is best to wait until the patient has recovered. Immunization schedule Most countries in the Americas have used the three dosage schedule applied in the first year of life from the age of two months and with two month intervals between them, combined with the DTP and hepatitis B vaccines (pentavalent vaccine); nevertheless, some countries have applied a booster dose in the second year of life. Method of administration The vaccine must be applied intramuscular. Immune response The conjugate vaccines against Hib require between 2 and 3 doses to reach a good level of antibodies and titres between 83% and 99% considered protective after three doses. In addition to individual protection there is a group protection: mucous protection reduces colonization of the oropharynx, thus reducing the number of carriers in the community and, consequently, the transmission of bacteria to other people. Adverse events Hib conjugate vaccines are notably safe and well tolerated. The frequency of systemic reactions such as fever is from 3% to 10%, less than 1% may show irritability, vomiting and somnolence. When administered concomitant to or combined with the DTP vaccine, conjugate vaccines do not increase the frequency of reactions attributable to the DTP vaccine. 2. Vaccines against pneumococcus The first trials of a polysaccharide vaccine against pneumococcus were carried out in 1945 and the first hexavalent vaccine was introduced in the United States but quickly withdrawn. In the 1970s, a polysaccharide vaccine with 14 serotypes was introduced and in the 1980s one with 23 serotypes, which is still in use today. 44 As far as pneumococcal conjugate vaccines are concerned, in addition to the available heptavalent conjugate vaccine, other vaccines are being developed by different laboratories with 9, 10, 11 and 13 serotypes. 2.1. Polysaccharide vaccine (23-valent) The 23-valent polysaccharide vaccine has the following serotypes: 1, 2, 3, 4, 5, 6B, 7F, 8, 9V, 10A, 11A, 12F, 14,15B, 17F, 18C, 19A, 19F, 20, 22F, 23F and 33F. Indications The 23-valent polysaccharide vaccine is recommended for: People aged 65 or older. People at increased risk of invasive diseases caused by pneumococcus such as those with a clinical history of suspected or confirmed pneumonia, carriers of functional or surgical asplenia, nephrotic syndrome, diabetes mellitus, alcoholism, chronic hepatic, cardiovascular, pulmonary and renal diseases, hemoglobinopathies, acquired or congenital immunodeficiencies, hematological or other generalized cancers, organ transplant patients or recipients of hematopoietic cells and those undergoing immunosuppressive therapy including systemic corticosteroids. This vaccine is not recommended for children under 2 because of the low immunogenicity of this group. Such children, as well as those in the 2-5 age group with these diseases, should be given the conjugate vaccine. Contraindications Anaphylactic reaction to earlier doses Acute febrile illness Pregnant women: the safety of this vaccine has still not been well established, therefore women at high risk of infections caused by pneumococcus should be vaccinated before becoming pregnant. Immunization schedule The general recommendation is a single dose for immunocompetitive people, except for those aged 65 or older who received the first dose 5 years ago or more. A second dose is recommended for immunocompromised patients; children under 10 years of age should receive the second dose 3 years after the first; children over 10 and adults should be revaccinated after 5 years. Method of administration 45 Preferably intramuscular although it can also be applied subcutaneously. Immune response The vaccine induces the production of specific antibodies for every serotype in more than 80% of healthy young adults and prevents between 60% and 70% of invasive infections. The response in immunocompromised patients is generally poorer. Its effectiveness at preventing invasive diseases in adults over 65 is between 50% and 80%. Adverse events The most frequent adverse reactions are pain, induration and erythema at the injection site in the 48 hours following use in 30% to 50% of patients. Anaphylaxis is extremely infrequent. 2. 2. Conjugate vaccines A heptavalent pneumococcal conjugate vaccine is available and has been licensed in various countries. This vaccine contains the following 7 serotypes: 4, 6B, 9V, 14, 18C, 19F, 23F. Nevertheless, given the serotypes isolated in the Americas by the SIREVA network in the period 2000-03, this vaccine only covers an average of approximately 60% of the circulating serotypes. It does not cover some important serotypes such as 5 and 1. Others pneumococcal conjugate vaccines are being developed and contain the following serotypes: 9-valent: heptavalent with the addition of serotypes 1 and 5 10-valent: heptavalent with the addition of serotypes 1, 5 and 7F 11-valent: heptavalent with the addition of serotypes 1, 5, 7F and 3 13-valent: heptavalent with the addition of serotypes 1, 5, 7F, 3, 6A and 19A There is unpublished information that 9 and 11-valent types will be discontinued and that a 10-valent may be available by 2008. Indications The indication is to vaccinate mainly children under 2. If possible, children under 5 should also receive the vaccine. It is recommended that priority be given to using this vaccine on the following children at increased risk of invasive disease caused by pneumococcus: those with a clinical history of suspected or confirmed pneumonia, carriers of functional or surgical asplenia, nephrotic syndrome, diabetes mellitus, chronic hepatic, cardiovascular, pulmonary and renal diseases, hemoglobinopathies, acquired or congenital immunodeficiencies, hematological and other 46 generalized cancers, organ transplant patients and those receiving immunosuppressive therapy, including systemic corticosteroids. Contraindications Anaphylactic reaction to earlier doses: is an absolute contraindication to other doses. Acute febrile illness: it is best to wait until the patient has recovered. Immunization schedule According to the recommendations of the United States Advisory Committee on Immunization Practices, the vaccine should be administered after two months from birth and three doses are necessary in the first year of life at intervals of two months (minimum 4 weeks). A booster dose is also recommended at 12-15 months. For more information on when to vaccinate children of different ages, see Table 3 below. Table 3 Recommended immunization schedule for the heptavalent pneumococcal conjugate vaccine in children not previously vaccinated by age on receiving first dose Age at first dose Immunization schedule Booster dose (months) 2-6 3 doses at 2 month intervals* One dose at 12-15 months† 7 - 11 2 doses at 2 month intervals* One dose at 12-15 months† 12 – 23 2 doses at 2 month intervals** - 24 – 59 Healthy 1 dose - Children with: 2 doses at intervals of 2 months - drepanocytosis, asplenia, HIV infection, chronic diseases or ¶ immunocompromised *For those vaccinated before they reached one, the minimum interval between doses is 4 weeks † The booster dose must be given > 8 weeks after completing the immunization schedule ** The minimum interval between doses is 8 weeks ¶ Recommendations do not cover children who have recently received bone marrow transplants Source: Centers for Disease Control and Prevention. Preventing Pneumococcal Disease Among Infants and Young Children: Recommendations of the Advisory Committee on Immunization Practices. MMWR. 2000; 49(RR -9). Method of administration Intramuscular. Immune response 90% to 100% of infants develop titres considered protective after receiving three doses of the heptavalent vaccine at age 2, 4 and 6 months. The response is not the same for all serotypes, being least for serotypes 4, 9V and 23F. The response in premature and under weight babies is similar to that in those born after the full term. 47 The effectiveness of the vaccine at preventing invasive diseases in vaccinated children is greater than 95% and appears to remain for an extended period of time. It is less effective against non-invasive disease, especially in children over two. Its effectiveness against Acute Otitis Media (AOM) is estimated at 57%. Adverse events The most frequent adverse events are local reactions at the injection site: erythema, induration, fever >38.5° (15% after the first dose and 20% after subsequent doses) in the first two days after vaccination. Neither convulsions nor neurological changes have been reported. 3. Vaccines against meningococcus The first vaccines against meningococcus were developed more than 30 years ago. However, there is still no vaccine that protects against all pathogenic serotypes. At present, two types of meningococcal vaccines are available: polysaccharide vaccines and conjugate vaccines. 3.1. Polysaccharide vaccines The polysaccharide vaccines are monovalent or bivalent and protect against serogroups A and C, or tetravalent which protect against serogroups A, C, W135 and Y. There is also a vaccine against serogroups B and C produced in Cuba. Indications These vaccines are recommended solely for controlling outbreaks produced by specific serogroups, or in hyperendemic areas. Contraindications There are no specific contraindications; the contraindications are general for all the vaccines: Acute febrile illness Serious reaction to previous doses of the vaccine. Pregnant women may be vaccinated when the risk of infection by meningococcus is high, that is, when vaccination is more important than the possible risk to the fetus. Immunization schedule A single dose. Method of administration 48 Intramuscular or subcutaneous. Immune response The immune response in children under two is very poor for serogroup C. Effectiveness is low in children between 2 and 5 years of age, who develop protective antibody titres in 40%. The immunity produced by the vaccine is maintained for a period of 3 years and diminishes more rapidly the younger the child is vaccinated. There are indications that this vaccine may produce immunological tolerance or hypo-response to the antigen with a successive vaccination, especially when the first vaccination is given at a very early age. The immune response is earlier and more effective for serogroup A but the antibodies also diminish rapidly and two doses are necessary to immunize children under 18 months old. The effectiveness of the tetravalent vaccine against serogroups Y and W135 has not been established. Adverse events Adverse events are infrequent. Minor and transient local reactions such as pain, erythem a and induration may occur 24-48 hours after vaccination in 2,5% to 26% of those vaccinated. Mild to moderate systemic reactions are rare, fewer than 5% present fever. Anaphylactic reactions are exceptional. 3.2. Conjugate vaccines Three monovalent conjugate vaccines are available against serogroup C, two are conjugated with non-toxic CRM197 derived from diphtheria toxoid and the third is conjugated with the tetanus toxoid. A tetravalent meningococcal vaccine with serogroups A, C, Y and W135 has been licensed in the United States since 2005, conjugated to a diphtheria toxoid. At the moment there is no conjugate vaccine available against serogroup B meningococcus. Indications WHO recommends that these conjugate vaccines be used in regular immunization programs to protect people at high risk or in the event of outbreaks, depending on the epidemiological position, public health priorities and the economic conditions in each country. Vaccination of close contacts in the event of an outbreak, when a vaccine against the specific serogroup is available, should be carried out at the same time as the use of chemoprophylaxis. 49 Contraindications Anaphylactic or serious reaction to previous doses. Acute febrile illness Pregnant women Table 4 Meningococcal conjugate vaccines available Vaccine Description C conjugated with tetanus toxoid C conjugated with CRM197 A, C, W135, Y conjugated with diphtheria toxoid Sources: Harrison LH. Prospects for Vaccine Prevention of Meningococcal Infection. Clin. Microbiol. Rev. Jan 2006: 142-164.Asociación Española de Pediatría. Module II a. Vacunas habituales contenidas en calendario.5 Vacunas contra el Meningococo serial on the Internet. quoted 2006 July 11 about 13 p. Available from:http://www.aeped.es/vacunas/pav/modulo2/PDFs/Modulo2_5.pdf Immunization schedule In the United Kingdom, the monovalent meningococcal conjugate vaccine directed at serogroup C was included in the routine immunization schedule in 1999 and is applied to children when they reach two months, three doses with a one month interval between doses. For children over one and adults a single dose is recommended. The tetravalent conjugate vaccine against serogroups A, C, W135 and Y is licensed in the United States for application in a single dose to people between 11 and 55 years of age. Method of administration Meningococcal conjugate vaccines should be given as an intramuscular injection. Immune response Effectiveness studies on the serogroup C meningococcal conjugate vaccine carried out in the United Kingdom demonstrate an effectiveness between 88% and 98% among the different age groups in the first year after vaccination. The application of three doses in the first year of life at 2, 3 and 4 months resulted in a drop in effectiveness to 81% in one year. An immunological memory was also observed after a booster dose applied at 12 months together with a reduction in bacteria carriers and a consequent decline in the incidence of the disease in people who had not been vaccinated, which indicates a herd immunity. The immunogenicity of the tetravalent vaccine is not less than that of the polysaccharide vaccine. Adverse events 50 Adverse events are rare and similar to those occurring with other conjugate vaccines and generally disappear in 48 hours. Glossary Air bronchogram: A reduced radiolucid ("black") linear image produced by the contrast between the air content of a bronchus and the density produced by the infiltrated alveoli surrounding it. Alveolar infiltrate: Dense pulmonary infiltrate, spongy or cottony and homogeneous in appearance showing that the alveolar air space is filled with liquid (pus, edema). Alveolus: Tiny air sacs in the lungs where the exchange of O2 and CO2 takes place. Atelectasis: Loss of lung volume due to absorption of air in the lung tissue distal to an obstruction in the airway (e.g. mucus plug). The lung tissue collapses like a fan and the radiographic image shows a dense area, generally triangular in shape, with its apex towards the hilar zone. Bacteriemia: Temporary presence of bacteria in the blood. Condensation: Dense, usually homogeneous alveolar infiltrate of cotton-wool appearance, affecting an entire lobe, a segment or part of a lung segment. It usually contains air bronchograms and is accompanied by the silhouette sign (+). Occasionally associated with pleural effusion. CSF: Cerebrospinal fluid EQAP: External Quality Assurance Program Head nodding: A movement of the head synchronous with inspiration indicating use of accessory muscles in severe respiratory distress. Hib: Haemophilus influenzae type b IAL: Instituto Adofo Lutz de São Paulo, Brasil Infiltrate: Any pathological density in the lungs that appears on a chest X-ray. INS: Instituto Nacional de Salud de Bogotá, Colombia ISC III: Instituto de Salud Carlos III de España Interstice: Lung tissue located outside the alveoli and bronchi; includes suspensory tissue, blood and lymphatic vessels. Interstitial infiltrate: Radiologically dense area, linear or reticular which follows the path of the vessels and bronchi and reveals a process compromising the structures of the pulmonary interstice. It is generally diffuse, giving the chest X-ray a "dirty" appearance. MIC: Minimum inhibitory concentration NCS: National Centre for Streptococcus in Edmonton, Alberta, Canada Nm: Neisseria meningitidis PCR: Polymerase chain reaction 51 Rapid breathing: Respiratory frequency: infants < 2 months: > 60 breaths / minute; from 2 - 11 months: >50 breaths / minute and for children from 12 months to 5 years: 40 breaths / minute. Septicemia: Presence and multiplication of microorganisms associated with clinical signs and symptoms. Silhouette sign: Blurring of an edge or line that is usually well defined, for example, the edge of the diaphragm in a process affecting the lower lobe. SIREVA: Regional System for Vaccines (also RSV) SIREVA II: Regional System for Surveillance of Bacterial Agents Responsible for Pneumonia and Meningitis. Spn: Streptococcus pneumoniae SXT: Sulfamethoxazole + trimethoprim 52 References Agudelo CI, Moreno J, Sanabria OM, Ovalle MV, Di Fabio JL, Castañeda E, Grupo Colombiano de Trabajo en Streptococcus pneumoniae. Streptococcus pneumoniae: evolución de los serotipos y los patrones de susceptibilidad antimicrobiana en aislamientos invasores en 11 años de vigilancia en Colombia (1994-2004). Biomedica. 2006;26:234-49. Almeida AECC, de Filippis I, Abreu AO, Ferreira DG, Gemal AL, Marzochi KBF. Occurrence of Haemophilus influenzae strains in three Brazilian states since the introduction of a conjugate Haemophilus influenzae type b vaccine. Brazilian Journal of Medical and Biological Research. 2005;38:777-81. American Academy of Pediatrics. Recommendations for Care of Children in Special Circumstances. In Pickering LK, ed. Red Book 2003– Report of the Committee on Infectious Diseases .26th Edition. Elk Grove Village, IL: American Academy of Pediatrics; 2003.129 p. American Society of Microbiology. Manual de Pruebas de Susceptibilidad Antimicrobiana. Coyle MB Editor, 2005. 241p. Amieta JME y De León JM. Sensibilidad y especificidad de la frecuencia respiratoria aumentada y el tiraje subcostal en el diagnóstico de neumonía en el hospital infantil "Napoleón Franco Pareja" de Cartagena, Colombia. In: Investigaciones operativas sobre el control de las infecciones respiratorias agudas (IRA) en niños en América Latina y el Caribe. Benguigue Y, Valenzuela C Editores. Pan American Health Organization, Washington DC 1998. p.67-75. Anderson MS, Glodé MP, Smith AL. Meningococcal Disease. In: Textbook of Pediatrics Infectious Diseases. Feigin RD et al ed. 5th edition. Elsevier Inc., Philadelphia, Pennsylvania, 2004. p.1265-79. Asociación Española de Pediatría. Módulo II a. Vacunas habituales contenidas en calendario. 5 Vacunas contra el Meningococo serial on the Internet.cited 2006 July 11 about 13 p. Available from: http://www.aeped.es/vacunas/pav/modulo2/PDFs/Modulo2_5.pdf Borrow R, Goldblatt D, Andrews N, Southern J, Ashton L, Deane S and al. Antibody Persistence and Immunological Memory at Age 4 Years after Meningococcal Group C Conjugate Vaccination in Children in the United Kingdom. JID 2002;186:1353–7. 53 Brandileone MCC, Vieira VSD, Zanella RC, Landgraf IM, Melles CEA, Taunay AE et al. Distribution of Serotypes of Streptococcus pneumoniae Isolated from Invasive Infections over a 16 Year Period in the Greater Sao Paulo Area, Brazil. J Clin Microbiol. 1995; 33(10):2789-91. Brandileone MCC, Andrade ALSS, Di Fabio JL, Guerra MLLS,Austrian R. Appropiateness of a Pneumococcal Conjugate Vaccine in Brazil: Potencial Impact of Age and Clinical Diagnosis, with Enphasis on Meningitis. JID. 2003;187:1206-12. Brandileone MCC, Casagrande ST, Guerra MLLS, Zanella RC, Andrade ALSS, Di Fabio JL et al. Impact in numbers of lactam-resistant invasive Streptococcus pneumoniae in Brazil and the impact of vaccine coverage. Journal of Medical Microbiology. 2006;55:567-74. Brandileone MCC, Vieira VSD, Zanella RC, Landgraf IM, Melles CEA, Taunay AE et al. Distribution of Serotypes of Streptococcus pneumoniae Isolated from Invasive Infections over a 16 Year Period in the Greater Sao Paulo Area, Brazil. J Clin Microbiol. 1995; 33(10):2789-91. Bricks LF, Berezin E. Impact of pneumococcal conjugate vaccines on the prevention of invasive pneumoccocal diseases. J Pediatr (Rio J). 2006; 82 (3 Supl):S67-S74. Centers for Disease Control and Prevention. Department of Health and Human Services. Pneumococcal Disease. In: Atkinson, W and Wolfe, C, ed. Epidemiology and Prevention of Vaccine-Preventable Diseases. 7th edition January 2002. Atlanta (USA), CDC;2002. p. 205- 16. Centers for Disease Control and Prevention. Department of Health and Human Services. Haemophilus b Conjugate vaccines for Prevention of Haemophilus influenza Type B Disease Among Infants and Children Two Months of Age and Older. Recommendations of the Advisory Committee on Immunization Practices. MMWR. 1991;40(RR-1). Centers for Disease Control and Prevention. Department of Health and Human Services. Haemophilus influenza type B. In: Atkinson, W and Wolfe, C, ed. Epidemiology and Prevention of Vaccine-Preventable Diseases. 7th edition January 2002. Atlanta (USA), CDC; 2002. p.83-95. Centers for Disease Control and Prevention. Preventing and Control of Meningococcal and Meningococcal Disease and College Students. Recommendations of the Advisory Committee on Immunization Practices. MMWR. 2000;49(RR-7). 54 Centers for Disease Control and Prevention. Preventing and Control of Meningococcal Disease. Recommendations of the Advisory Committee on Immunization Practices. MMWR. 2005;54(RR-7). Centers for Disease Control and Prevention. Preventing Pneumococcal Disease Among Infants and Young Children: Recommendations of the Advisory Committee on Immunization Practices. MMWR. 2000;49(RR-9). Dagan R, Greenberg M, Jacobs MR. Pneumococcal Infections. In: Textbook of Pediatrics Infectious Diseases. Feigin RD et al ed. 5th edition. Elsevier Inc., Philadelphia, Pennsylvania, 2004. p.1204-58. de Filippis I, Nascimento CRS, Clementino MBM, Sereno AB, Rebelo C, Souza NNF, Riley LW. Rapid detection of Neisseria meningitidis in cerebrospinal fluid by one-step polymerase chain reaction of the nspA gene. Diagnostic Microbiology and Infectious Disease. 2005; 51:85-90 Di Fabio JL, Castañeda E, Agudelo MI, De La Roz F, Hortal M, Camou T et al. Evolution of Streptococcus pneumoniae serotypes and penicilin susceptibility in Latin America, Sireva- Vigía Group, 1993 to 1999. Pediatr Infect Dis J. 2001;20(10):959-67. Di Fabio JL, Hortal M. Invasive pneumococcal diseases in Uruguayan children: Comparison between serotype distribution and conjugate vaccine formulations. Vaccine. 2003;21:2093-6. Eskola J, Black S, Shinefield H. Pneumococcal Conjugated Vaccines. In: Orenstein WA and Plotkin SA editors:Vaccines. Fourth edition, 2004, Elsevier Inv. Philadelphia, Pennsylvania. p.589-624. Faccone D, Andres P, Galas M, Tokumoto M, Rosato A, Corsoi A. Emergence of a Streptococcus pneumoniae Clinical Isolate Highly Resistent to Telithromycin and Fluoroquinolones. Clin. Microbiol. Rev. Nov. 2006; 43(11):5800-3. Fedson DS, Musher DM. Pneumococcal Polysaccharide. In: Orenstein WA and Plotkin SA editors: Vaccines. Fourth edition, 2004, Elsevier Inv. Philadelphia, Pennsylvania. p.529-88. Ferreira OS, Britto MCA. Pneumonia aguda – tema que todos devemos estudar. J Pediatr (Rio J). 2003; 79 (6):478-9. 55 Gamboa L, Camou T, Hortal M, Castañeda E and the SIREVA-Vigía Working group. Dissemination of Streptococcus pneumoniae Clone Colombia5-19 en Latin America. J Clin Microbiol. 2003; 40(11) 3942-50. Garcia S, Levine OS, Cherian T, Gabastou JM, Andrus J and the Working Group members. Pneumococcal disease and vaccination in the Americas; an agenda for accelerated vaccine introduction. Rev Panam Salud Pública/Pan Am J Public Health. 2006;19(5):340-8. Gomes FMS, Valente MH. Pneumonias Bacterianas Agudas. In: Pediatria na Atenção Primária. Isler H, Leone Claudio, Marcondes E, Editores . Sarvier São Paulo, 2002. p286- 92. Granoff DM, Feavers JM, Borrow R. Meningococcal Vaccines. In: Orenstein WA and Plotkin SA editors: Vaccines. Fourth edition, 2004, Elsevier Inv. Philadelphia, Pennsylvania. p959- 88. Harrison LH. Prospects for Vaccine Prevention of Meningococcal Infection. Clin. Microbiol. Rev. Jan 2006;19(1):142-64. Heymann DL editor. Control of Communicable Diseases Manual. 18th Edition, 2004. American Public Health Association. Washington DC, USA. 700 p. Hortal M, Contera M, Mogdasy C, Russi JC. Acute respiratory infections in children from a deprived urban population from Uruguay. Tev Inst Med trop S Paulo. 1994;36(1):51-7. Hortal M, Camou T, Palacio R, Didarboure H, García A. Ten Year Review of Invasive Pneumococal Diseases in children and Adults from Uruguay: Clinical Spectrum, Serotypes, and Antimicrobial Resistance. Int J Infect Dis.2000;4(2):91-95. Hortal M, Ruvinsky R, Rossi A, Agudelo CI, Castañeda E, Brandileone C et al. Impacto de Streptococcus pneumoniae en las neumonías del niño latinoamericano. Grupo SIREVA- Vigía Rev Panam Salud Pública/Pan Am J Public Health. 2000;8(3):185-95. Instituto Nacional de Salud de Colombia. Manual de Procedimientos de Laboratorio. Área Microbiología. Bogotá, Colombia 2005. Lagos RZ, San Martin OB, Erazo AL, Avendaño B, Levine MM, Grupo de Trabajo Colaborativo para el diagnóstico de Infecciones Pneumocóccicas del niño. Rev Chil Infect. 2001;18(Supl.1):15-21. 56 Hemophilus Meningitis. In: Control of Communicable Diseases Manual. Heymann DL , Editor.18th Edition. American Health Association. Washington DC,2004:366-68. Hortal M, Camou T. Molecular Epidemiology of Streptococcus pneumoniae. Rev Chil Infect. 2001;18(Supl.1):25-30. Instituto Nacional de Salud. Área Microbiología. Manual de Procedimientos de Laboratorio. Bogotá, Colombia. Año 2005. Kertesz DA, Di Fabio JL, Brandileone MCC, Castañeda E, Echaniz-Aviles G, Heitmann I. Invasive Streptococcus pneumoniae Infection in Latin American Children: Results of the Pan American Health Organization Surveillance Study. CID.1998;26:1355-61 Laforce FM. Conjugate Meningoccocal Vaccines for Africa. In: Quadros CA editor. Pan American Health Organization, Washington DC 2004:99-103. Lagos R, Di Fabio JL, Moënne K, Muñoz AM, Wasserman S, de Quadros Ciro. El uso de la radiografía de tórax para la vigilancia de neumonías bacterianas en niños latinoamericanos. Rev Panam Salud Pública/Pan Am J Public Health. 2003;13(5):294-302. Lagos R, Muñoz A, Valenzuela MT, Heitmann I, Levine MM. Population-based surveillance for hospitalized and ambulatory pediatric invasive pneumococcal disease in Santiago, Chile. Pediatr Infect Dis J. 2002; 21(12):115-23. Lin J, kaltof MS, Brandao AP, Echaniz-Aviles G, Brandileone MCC, Hollingshead SK, Benjamin WH, Nahm MH. Validation of a Multiplex Pneumococcal Serotyping Assay with Clinical Samples. J. Med. Microbiol. Feb2006: 44(2):383-8 Lucarevschi B, Baldacci ER, Bricks LF, Bertoli CJ, Teixeira LM, Mendes CMF, Oplustil C. oropharyngeal carriage of Streptococcus pneumoniae by children attending day care centers in Taubaté, SP: correlation between serotypes and conjugated heptavalent pneumococcal vaccine. J Pediatr (Rio J). 2003; 79(3l):215-20. Mantese OC, Paula A, Moraes AB, Moreira TA, Guerra MLLS. Brandileone MCC. Prevalencia de sorotipos e resistência antimicrobiana de cepas invasivas de Streptococcus pneumoniae. J Pediatr (Rio J). 2003; 79(6):537-42 Meningoccocal Infection. In: Control of Communicable Diseases Manual. Heymann DL , Editor.18th Edition. American Health Association. Washington DC, 2004:356-66. 57 Mesa Española de Normalización de la Sensibilidad y Resistencia a los Antimicrobianos (MENSURA). Recomendaciones del grupo MENSURA para la selección de antimicrobianos en el estudio de la sensibilidad y criterios para la interpretación del antibiograma. Rev Esp Quimioter. 2000;13:73-86. Ministerio de Salud Pública y Bienestar Social. Laboratorio Central de Salud Pública. Departamento Bacteriología Referencial. Proyecto de Fortalecimiento de la Vigilancia de Meningitis y Neumonías Bacterianas (VIMENE). Asunción, Paraguay Ministerio de Salud Pública y Bienestar Social. Laboratorio Central de Salud Pública. Departamento Bacteriología Referencial. Manual de Procedimientos de Laboratorio. Asunción, Paraguay. Año 2005. Ministerio de Salud. Vigilancia Epidemiológica Centinela del Haemophilus influenzae y Streptococcus pneumoniae en menores de cinco años. Lima, Perú. 2001. Ministério de Saúde. Secretaria de Vigilância em Saúde. Guia de Vigilância Epidemiológica. 6a Edição. Brasília, Brasil. 2005: 816 p. Mulholand K, Levine O, Nohynek H, Greenwood BM. Evaluation of Vaccines for the Prevention of Pneumonia in Children in Developing Countries. Epidemiol Rev. 1999;21(1): 43-55. Nascimento-Carvalho CM, Lopes AA, Gomes MDBS, Magalhaes MP, Oliveira JR, Vilas- Boas AL et al Community Acquired Pneumonia Among Pediatric Outpatients in Salvador. BJID. February 2001,5:13-20. Nascimento-Carvalho CM, Freitas-Souza LS, Moreno-Carvalho OA, Alves NN, Barberino MG, Duarte J et al. Invasive pneumococcal strains isolated from children and adolescents in Salvador. J Pediatr (Rio J).2003;209-14. Nascimento-Carvallho CM, Andrade ALS. Haemophilus influenza type b vaccination: long term protection. J Pediatr (Rio J). 2006; 82 (3 Supl):S109-S14. Organización Panamericana de la Salud. Programa AIEPI. Organización Mundial de la Salud. UNICEF. Neumonía. In: Diagnóstico y tratamiento de enfermedades prevalentes graves de la infancia. Washington DC: OPS;2004. p.33-48. 58 Organización Panamericana de la Salud. Programa AIEPI. Organización Mundial de la Salud. UNICEF. Meningitis. In: Diagnóstico y tratamiento de enfermedades prevalentes graves de la infancia Washington DC: OPS;2004. p.69-73. Organización Panamericana de la Salud. Programa AIEPI. Organización Mundial de la Salud. Referencia Urgente. In: Manual de atención integrada a las enfermedades prevalentes de la infancia. Washington DC: WHO;2004. p.233-9. Organización Panamericana de la Salud. Instituto Nacional de Salud de Colombia. Programa de Vigilancia de los Serotipos y Resistencia Antimicrobiana de Streptococcus pneumoniae y Haemophilus influenzae. Manual de Procedimientos. Revisión Junio 2004. Bogotá, Colombia, 2004. 177 p. Oselka G. Prevencao da doenca pneumocócica no Brasil. J pediatr (Rio J). 2003;79 (3):195- 6. Pio A. Standard case management of pneumonia in children in developing countries: the cornerstone of the acute respiratory infection program. Bull World Health Organ.2003; 81(4):298-300. Popovic, T, Ajello, G W, Facklam, RR. Laboratory methods for the diagnosis of meningitis caused by Neisseria meningitidis, Streptococcus pneumoniae and Haemophilus influenzae. Atlanta, GA (USA): Centers for Disease Control, World Health Organization,1998. Proposal for an Epidemiological surveillance System for Bacterial Meningitis and Pneumonia in the Region. XIII Meeting of the PAHO technical advisory group on vaccine preventable diseases. Hull, Quebec, Canada. April 12 – 16 de 1999. Jose Luis Di Fabio, Claudio Silveira, Ciro de Quadros, Carlos J. Castillo, Salvador Garcia, Luis Gerardo Castellanos, Claudia Schmidt. Rudan I, Tomaskovic L, Boschy Pinto, Campbell C on behalf of WHO Child Health Epidemiology Reference Work Group. Global estimative of the incidence of clinical pneumonia among children under five years of age. Bull World Health Organ.2004;82(12): 895-903, A-F. Rodriguez R. Infecções Respiratórias Agudas sa Vias Superiores. In: Infecções Respiratórias em Crianças. Benguigui Y, Antuñano FJL, Schmunis G, Yunes J, Editores. Organización Panamericana de la Salud, Washington, D.C, 1998: p.190-4. 59 Ruvisnky R and Balanzat AMC. Neumonías Bacterianas y Virales. In: Infecciones respiratorias en niños. Benguigui Y, Antuñano FJL, Schmunis G, Yunes J, Editores. Organización Panamericana de la Salud, Washington, D.C,1997: p.215-43. Ruvinsky R, Gentile A, Regueira M et al. Infecciones invasivas por Streptococcus pneumoniae: Estudio epidemiológico e importancia del desarrollo de un sistema de vigilancia. Rev. chil. pediatr. [serial on the internet]. 2004Jan [cited 2006 August 08];75(1) [about 3 p.]. Available from: www:scielo.cl/scielo.php?script=sci_arttext&pid=S0370- 41062004000100013&lng=pt&nrm=iso>. ISSN 0370-4106. Sarria E, Fisher GB, Lima JAB, Barreto SSM, Flores JAM, Sukiennik R. Interobserver agreement in the radiological tract infections in children. J Pediatr (Rio J). 2003; 79(6):497- 503. Sáfadi MAP, Barros AP. Meningococcal conjugate vaccines: efficacy and new combinations. J Pediatr (Rio J). 2006; 82 (3 Supl):S35-S44. Sociedad Latinoamericana de Infectología Pediátrica. Manual de Vacunas de Latinoamérica. Tercera Edición Latinoamericana 2005. Capítulo 7 y 8. p 148 – 257. Solórzano-Santos F, Ortiz-Ocampo LA, Miranda-Novales MC, Echániz-Avilés G, Soto- Noguerón A, Guiscafré-Gallardo H. Serotipos prevalentes de Streptococcus pneumoniae colonizadores de nasofaringe en niños del Distrito Federal. Salud Pública de México. Julio- agosto 2005; 47(4) 276-281. Swingler G, Fransman D, Hussey G. Vacunas conjugadas para prevenir infecciones por Haemophilus influenzae tipo B (Revisión Cochrane traducida). In: La Biblioteca Cochrane Plus [serial on the internet] 2006 [cited 2006 August 03]:2[about 2 p.]. Available from:http://www.update-software.com. Vela MC, Fonseca N, Di Fabio JL, Castañeda E. Presence of International Multiresistant Clones of Streptococcus pneumoniae in Colombia. Microb Drug Resist. 2001; 7(2):153-63. Ward J. Haemophilus influenzae. In: Textbook of Pediatrics Infectious Diseases. Feigin RD et al editors. 5th edition. Elsevier Inc., Philadelphia, Pennsylvania, 2004:p1636-54. Wedege E, Hoiby EA, Rosenqvist E, Froholm LO. Serotyping and subtyping of Neisseria meningitidis isolates by co-agglutination, dot-blotting and ELISA. J. Med. Microbiol. 1990; 31:195-201. 60 Wenger JD and Ward JI. Haemophilus influenzae Vaccine. In: Orenstein WA and Plotkin SA editors:Vaccines. Fourth edition, 2004, Elsevier Inv. Philadelphia, Pennsylvania: 229-68. William MJ, Joan SK. Neisseria and Moraxella catarrhalis. In: Murray PR, Baron EJ, Jorgensen JH, Pealler MA, Yolken RH, eds. Manual of Clinical Microbiology 8th edition. Washington, DC; 2003. p. 585-608. World Health Organization Pneumonia Vaccine Investigator's Group. Department of Vaccines and Biologicals. Standardization of interpretation of chest radiographs for the diagnosis of pneumonia in children. WHO, Geneva; 2001. 32 p. World Health Organization. Pneumococcal Vaccines. WHO position paper. Weekly Epidemiological Record. [serial on the internet]. 2003 [cited 2006 November 19]; 14:[about 20 p.]. Available from: http://www.who.int/immunization/wer7814pneumococcal_Apr03_position_paper.pdf World Health Organization. Meningococcal vaccines: polysaccharide and polysaccharide conjugate vaccines. WHO position paper. Weekly Epidemiological Record. [serial on the internet]. 2002[cited 2006 November 20]; 40(77):[about 9 p.]. Available from: http://www.who.int/immunization/wer7740meningococcal_Oct02_position_paper.pdf 61 Annex 01: BACTERIAL PNEUMONIA INVESTIGATION FORM HOSPITAL: N° Case: Date of hospitalization: ……/……../…….. No. Clinical Record: Date of case detection: ……/……../…….. 1. PATIENT'S DETAILS Full name: Sex M( ) F( ) Date of birth:…../….../…..Age: Years: Months: Days: From: Dept. Prov. / Dept: Municipality: Address & Telephone N°: Detection: Emergency ( ) Ward ( ) Diagnosis on admission: Date symptoms started:....../........./...... Vaccination history: Hib: YES ( ) Dose: 1 ( ) 2 ( ) 3 ( ) Booster ( ) NO ( ) Not known ( ) Meningococcal: YES ( ) which_______________ Dose: 1( ) 2( ) 3( ) NO ( ) Not known ( ) Pneumococcal: YES ( ) which_________________ Dose:1( ) 2( ) 3( ) NO ( ) Not known ( ) Use of antibiotics over last week: YES ( ) Oral ( ) Parenteral ( ) Both ( ) NO ( ) Not known ( ) If "YES", which antibiotic? Date of first dose:......../…....../….... Date of latest dose:......../…....../….... Total dose _____________________ 2. RADIOLOGY RESULTS: Mark with an X if the following detected: Consolidated lobe ( ) Pleural effusion ( ) Air bronchogram ( ) Others - describe: 3. LABORATORY DATA 3.1. SAMPLE OBTAINED: Mark tests requested with an X Blood ( ) Date taken:.. …./… …../….. Culture YES ( ) NO ( ) Pleural fluid ( ) Date taken....../......../ …. Culture YES ( ) NO ( ) 3.2 Results Gram stain of hemoculture Gram stain of pleural fluid: Hemoculture: Hib( ) Spn( ) Other bacteria: Date isolated….../….…/……. Pleural fluid: Hib( ) Spn( ) Other bacteria: Date isolated:…../ ……./……. 3.3. ANTIMICROBIAL SUSCEPTIBILITY: Note antimicrobial agents according to susceptibility Sensitive: Intermediate: Resistant: 4. EVOLUTION OF PATIENT Discharged cured: ( ) Diagnosis on discharge: ___________________Date:……../……../……. Self discharge: ( ) Date:……../……../……. Deceased: ( ) Date:......../......../........ Person responsible for filling in the form: 62 Annex 02: BACTERIAL MENINGITIS INVESTIGATION FORM HOSPITAL: N° Case: Date of hospitalization: ……/……../…….. No. Clinical Record Date of case detection: ……/……../…….. 1. PATIENT'S DETAILS Full name: Sex M( ) F( ) Date of birth:…../….../…..Age: Years: Months: Days: From: Dept. Prov. / Dept: Municipality: Address & Telephone N°:__________________________________________________________ Are there any other cases that could establish an epidemiological link with this one? YES ( ) Who?__________________________________________________________________________ NO ( ) Don't know ( ) Detection: Emergency ( ) Ward ( ) Diagnosis on admission: Date symptoms started:....../........./... Vaccination history: Hib: YES ( ) Dose: 1 ( ) 2 ( ) 3 ( ) Booster ( ) NO ( ) Not known ( ) Meningococcal: YES ( ) which ____________Dose: 1( ) 2( ) 3( ) NO ( ) Not known ( ) Pneumococcal: YES ( ) which_____________Dose: 1 ( ) 2( ) 3( ) NO ( ) Not known ( ) Use of antibiotics over last week: YES ( ) Oral ( ) Parenteral ( ) Both ( ) NO ( ) Not known ( ) If "YES", which antibiotic? Date of first dose:......../…....../….... Date of latest dose:......../…....../….... Total dose _____________________ 2. LABORATORY DATA 2.1. Sample obtained: Mark tests requested with an X Blood ( ) Date taken:.. …./… …../….. …/ Culture YES ( ) NO ( ) Cerebrospinal fluid ( ) Date taken …../……./ … Culture YES ( ) NO ( ) 2.2 Results: Note results of the tests requested Gram stain of CSF: CSF cytochemical Glucose: Leukocytes test: Proteins Red blood count Hemoculture: Hib( ) Spn( ) Nm( ) Other bacteria: Date isolated….../….…/…… CSF culture: Hib( ) Spn( ) Nm( ) Other bacteria: Date isolated….../….…/…… 2.4. ANTIMICROBIAL SUSCEPTIBILITY: Note antimicrobial agents according to susceptibility Sensitive: Intermediate: Resistant: 3. EVOLUTION OF PATIENT: Discharged cured: ( ) Diagnosis on discharge: ____________________Date:……../……../……. Self discharge: ( ) Date:……../……../……. Deceased: ( ) Date:......../......./......... Person responsible for filling in the form: 63 Annex 03: Processing samples for cultures 1. Hemocultures 1.1 Inoculation of hemoculture bottles The procedures for inoculating hemoculture bottles are as follows: Disinfect with 70% alcohol or with iodized alcohol and inject blood into the medium, if the hemoculture bottle has a diaphragm. Shake the bottle gently several times to dilute blood well. Dispose of syringe and needle in a puncture-proof container. Clean the diaphragm again Label the bottle with the patient's name and code, date, time and the approximate amount of blood inoculated (this is sometimes difficult and sometimes less blood than required is taken but it should not be disposed of). To neutralize the normal antimicrobial properties of the blood and possible antimicrobial agents, we recommend using media containing resin inhibitors or other chemical inhibitors. Hemocultures for children > 2 should be diluted at 1-2 ml of blood to 20 ml of culture broth (1:10 to 1:20). 1.2 Incubation of hemocultures For hemocultures it is necessary to: Immediately incubate the inoculated broths from 35° C to 37° C Subculture after 18 h, for ordinary hemoculture bottles. Then continue incubating the bottle, observing daily for 5 days. Any turbidity or lysis of the erythrocytes indicates growth, in which case sub-cultures should be made. As S. pneumoniae tends to self- lysis, the sub-cultures should be made early (8 h) and repeated on the sixth day regardless of the appearance of the hemoculture bottle. Observe the hemocultures daily When making sub-cultures you should: Clean the rubber stopper of the hemoculture bottle with iodized alcohol Take out a small quantity of material with a syringe (approximately 0,5 ml) Inoculate Subculture in chocolate agar, incubate in an atmosphere with 5% CO2, if positive, turbidity, gas and hemolysis will be produced 64 In addition, prepare a smear for the Gram stain test Continue observing hemocultures daily Devices exist which enable daily inoculation. Table 1 below contains a summary of the hemoculture process. Table 1 Processing hemocultures Samples 18 hours 48 hours 72 hours 4th day 5th day 6th day Gram Observe Gram I Subculture Observe Observe Observe Report Subculture in ChA Gram Observe Observe Observe Observe Gram II Subculture Report Subculture 1. 3 Results of the hemocultures If there is bacterial growth proceed as indicated in the algorithm for identifying the bacterial agent and perform an antimicrobial susceptibility test according to international standards established by the CLSI (Clinical and Laboratory Standards Institute) which are available from www.clsi.org. Then send the isolated strain to the national reference laboratory and the corresponding regional laboratory. 65 Algorithm 1 Processing blood samples for culture from children under five 66 2. Pleural fluid culture 2.1 Processing pleural fluid samples Sample processing consists of the following stages: Centrifuge for 15 minutes at 10.000 rpm or 20 minutes at 5.000 rpm, then process the sediment; purulent samples must be examined directly. Prepare two smears, Gram stain one and leave the other unstained. The Gram stain is a critical test for a presumptive and rapid diagnosis of infectious agents and is also useful for valuing the quality of the sample. Inoculate the samples on supplemented chocolate agar slides; incubate in candle jars with 5% to 7% CO2, for 24 to 48 hours. It is also possible to incubate the tube with the sample and after a few hours subculture the material. Continue observing the cultures daily. 2.2 Results of pleural fluid cultures If there is bacterial growth proceed as indicated in the algorithm for identifying the bacterial agent and perform an antimicrobial susceptibility test according to international standards established by the CLSI. Then send the isolated strain to the national reference laboratory and the corresponding regional laboratory. The procedure for processing pleural fluid samples is given below. 67 Algorithm 2 Processing pleural fluid samples for bacterial pneumonia from children under 5 68 3. Tests on CSF All samples must be processed in the laboratory without delay, no more than two hours after being taken. Table 2 below gives the type of tests to be performed on the sample collected Table 2 Recommended tests for laboratory diagnosis of meningitis Sample Type of Volume Bottle Keep until sent to laboratory to be collected examination necessary Send to laboratory immediately, or keep at room temperature for up to 3 hours. Cytochemical and 1-2 ml 1 sterile tube microscopic test More than 3 hours – keep at 4 °C CSF (Gram) Culture 0,5-1 ml 1 tube MH Seed immediately/3h chocolate Keep at 35-36 °C Latex 0.5 ml 1 sterile tube Keep at 4 °C for up to 5 days PCR 0,5 ml 1 sterile tube Keep at -20 °C Subculture immediately Hemoculture Blood Culture 10-20% bottle Keep sub-cultures at 36 °C (BHI or TSB/SPS) Up to 5-7 days at 35-36 °C 3.1 Processing cerebrospinal fluid samples for culture The sample must be processed as follows immediately upon reception: Centrifuge the CSF for 15 minutes at 10.000 rpm, remove supernatant and perform two smears with the sediment for Gram stain. Culture the sample in chocolate agar. Incubate at 35 °C from 18 to 48 hours in an atmosphere with 5% to 7% CO 2. If any microorganisms grow, identify them using traditional techniques and test for susceptibility to antimicrobial agents; the results of this test will indicate any adjustment to the initial or empirical therapy or that based on direct examination. 69 Algorithm 3 Procedure for processing CSF samples from children under 5 with suspected meningitis 70 Annex 04: Data and indicator calculation sheets 71 72
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