title: Invasive pneumococcal disease among children in rural Bangladesh: results from a population-based surveillance.
abstract: BACKGROUND
  Streptococcus pneumoniae infection is recognized as a global priority public health problem, and conjugate vaccines have been shown to prevent vaccine-type invasive pneumococcal disease (IPD) in children. However, better estimates of the disease burden and reliable population-based data on serotype composition are needed for vaccine development and implementation in developing countries.
  
  
  METHODS
  We initiated a population-based surveillance in the rural Bangladesh community of Mirzapur, covering a population of approximately 144,000. Village health care workers made weekly visits to approximately 12,000 children 1-59 months of age in the study area. Children with reported fever, cough, or difficulty breathing were assessed by the village health care workers using a clinical algorithm and were referred to the hospital if required. Children from the study area who were seen in the hospital underwent clinical examination and laboratory testing if they met standardized case definitions. IPD was confirmed by blood and/or cerebrospinal fluid culture results. Isolates were identified, tested for susceptibility to antibiotics, and serotyped in accordance with standard laboratory methods. We present here the results from the first 3 years of the surveillance (July 2004-June 2007).
  
  
  RESULTS
  Village health care workers identified 5020 cases of possible severe pneumonia and/or very severe disease (165 cases per 1000 child-years)and 9411 cases of possible pneumonia (310 cases per 1000 child-years) as well as 2029 cases of suspected meningitis and/or very severe disease (67 cases per 1000 child-years) and 8967 cases of high fever and/or possible bacteremia (295 cases per 1000 child-years). Pneumonia was the single most common form of illness observed among 2596 hospitalizations (found in 977 [38%] of cases). We recovered 26 S. pneumoniae isolates (25 isolates from 6925 blood cultures and 1 isolate from 41 cerebrospinal fluid cultures), which gave an overall IPD incidence of 86 cases per 100,000 child-years. Invasive pneumococcal infection was common during infancy (with infants accounting for 23 of the 26 cases), and 50% of the total isolates were obtained from nonhospitalized patients who received a diagnosis of upper respiratory tract infection and fever. The most prevalent pneumococcal serotypes were serotypes 1, 5, 14, 18C, 19A, and 38. Ten of the 26 isolates were completely resistant to trimethoprim-sulfamethoxazole, and another 10 isolates had intermediate resistance.
  
  
  CONCLUSIONS
  IPD contributes substantially to childhood morbidity in rural Bangladesh. S. pneumoniae can cause invasive but nonsevere disease in children, and IPD incidence can be seriously under reported if such cases are overlooked. The emerging high resistance to trimethoprim-sulfamethoxazole should be addressed. Data on serotype distribution would help to guide appropriate pneumococcal conjugate vaccine formulation.
authors.affiliation: International Centre for Diarhoeal Disease Research, Dhaka, Bangladesh. shams@icddrb.org
authors.forename: Shams E
authors.initials: SE
authors.lastname: Arifeen
authors.forename: Samir K
authors.initials: SK
authors.lastname: Saha
authors.forename: Sayedur
authors.initials: S
authors.lastname: Rahman
authors.forename: Kazi Mizanur
authors.initials: KM
authors.lastname: Rahman
authors.forename: Syed Moshfiqur
authors.initials: SM
authors.lastname: Rahman
authors.forename: Sanwarul
authors.initials: S
authors.lastname: Bari
authors.forename: Aliya
authors.initials: A
authors.lastname: Naheed
authors.forename: Ishtiaq
authors.initials: I
authors.lastname: Mannan
authors.forename: M Habibur R
authors.initials: MH
authors.lastname: Seraji
authors.forename: Nawshad U
authors.initials: NU
authors.lastname: Ahmed
authors.forename: M Shameem
authors.initials: MS
authors.lastname: Hassan
authors.forename: Nazmul
authors.initials: N
authors.lastname: Huda
authors.forename: Ashraf Uddin
authors.initials: AU
authors.lastname: Siddik
authors.forename: Iftekhar
authors.initials: I
authors.lastname: Quasem
authors.forename: Maksuda
authors.initials: M
authors.lastname: Islam
authors.forename: Kaniz
authors.initials: K
authors.lastname: Fatima
authors.forename: Hassan
authors.initials: H
authors.lastname: Al-Emran
authors.forename: W Abdullah
authors.initials: WA
authors.lastname: Brooks
authors.forename: Abdullah H
authors.initials: AH
authors.lastname: Baqui
authors.forename: Robert F
authors.initials: RF
authors.lastname: Breiman
authors.forename: David
authors.initials: D
authors.lastname: Sack
authors.forename: Stephen P
authors.initials: SP
authors.lastname: Luby
mesh_terms: D000900:Anti-Bacterial Agents / Q000494:pharmacology; D016470:Bacteremia / Q000453:epidemiology / Q000382:microbiology; D015373:Bacterial Typing Techniques; D001459:Bangladesh / Q000453:epidemiology; D001769:Blood / Q000382:microbiology; D002555:Cerebrospinal Fluid / Q000382:microbiology; D002675:Child, Preschool; D017714:Community-Acquired Infections / Q000453:epidemiology* / Q000382:microbiology*; D006801:Humans; D015994:Incidence; D007223:Infant; D008586:Meningitis, Pneumococcal / Q000453:epidemiology; D008826:Microbial Sensitivity Tests; D011008:Pneumococcal Infections / Q000453:epidemiology*; D011018:Pneumonia, Pneumococcal / Q000453:epidemiology; D012424:Rural Population; D012703:Serotyping; D013296:Streptococcus pneumoniae / Q000145:classification / Q000302:isolation & purification*
chemical_list: D000900:Anti-Bacterial Agents