title: Outbreaks of Streptococcus pneumoniae carriage in day care cohorts in Finland - implications for elimination of transmission.
abstract: BACKGROUND
  Day care centre (DCC) attendees play a central role in maintaining the circulation of Streptococcus pneumoniae (pneumococcus) in the population. Exposure within families and within DCCs are the main risk factors for colonisation with pneumococcal serotypes in DCC attendees.
  
  
  METHODS
  Transmission of serotype specific carriage was analysed with a continuous time event history model, based on longitudinal data from day care attendees and their family members. Rates of acquisition, conditional on exposure, were estimated in a Bayesian framework utilising latent processes of carriage. To ensure a correct level of exposure, non-participating day care attendees and their family members were included in the analysis. Posterior predictive simulations were used to quantify transmission patterns within day care cohorts, to estimate the basic reproduction number for pneumococcal carriage in a population of day care cohorts, and to assess the critical vaccine efficacy against carriage to eliminate pneumococcal transmission.
  
  
  RESULTS
  The model, validated by posterior predictive sampling, was successful in capturing the strong temporal clustering of pneumococcal serotypes in the day care cohorts. In average 2.7 new outbreaks of pneumococcal carriage initiate in a day care cohort each month. While 39% of outbreaks were of size one, the mean outbreak size was 7.6 individuals and the mean length of an outbreak was 2.8 months. The role of families in creating and maintaining transmission was minimal, as only 10% of acquisitions in day care attendees were from family members. Considering a population of day care cohorts, a child-to-child basic reproduction number was estimated as 1.4 and the critical vaccine efficacy against acquisition of carriage as 0.3.
  
  
  CONCLUSIONS
  Pneumococcal transmission occurs in serotype specific outbreaks of carriage, driven by within-day-care transmission and between-serotype competition. An amplifying effect of the day care cohorts enhances the spread of pneumococcal serotypes within the population. The effect of vaccination, in addition to reducing susceptibility to pneumococcal carriage in the vaccinated, induces a herd effect, thus creating a counter-effect to the amplifying effect of the cohort. Consequently, the critical vaccine efficacy against carriage, required for elimination of transmission, is relatively low. Use of pneumococcal conjugate vaccines is expected to induce a notable herd protection against pneumococcal disease.
authors: Department of Vaccination and Immune Protection, Division of Health Protection, National Institute for Health and Welfare (THL), Helsinki, Finland. fabian.hoti@thl.fi
authors: Fabian
authors: F
authors: Hoti
authors: Panu
authors: P
authors: Erästö
authors: Tuija
authors: T
authors: Leino
authors: Kari
authors: K
authors: Auranen
mesh_terms: D002353:Carrier State / Q000453:epidemiology / Q000635:transmission; D002648:Child; D002656:Child Day Care Centers; D003198:Computer Simulation; D004196:Disease Outbreaks; D005192:Family Health; D005387:Finland / Q000453:epidemiology; D006801:Humans; D008137:Longitudinal Studies; D015233:Models, Statistical; D011008:Pneumococcal Infections / Q000453:epidemiology* / Q000635:transmission*; D015995:Prevalence; D012307:Risk Factors; D012703:Serotyping