title: Ten years of surveillance for invasive Streptococcus pneumoniae during the era of antiretroviral scale-up and cotrimoxazole prophylaxis in Malawi.
abstract: OBJECTIVE
  To document trends in invasive pneumococcal disease (IPD) in a central hospital in Malawi during the period of national scale-up of antiretroviral therapy (ART) and cotrimoxazole prophylaxis.
  
  
  METHODS
  Between 1 January 2000 and 31 December 2009 almost 100,000 blood cultures and 40,000 cerebrospinal fluid (CSF) cultures were obtained from adults and children admitted to the Queen Elizabeth Central Hospital, Blantyre, Malawi with suspected severe bacterial infection.
  
  
  RESULTS
  4,445 pneumococcal isolates were obtained over the 10 year period. 1,837 were from children: 885 (19.9%) from blood and 952 (21.4%) from CSF. 2,608 were from adults: 1,813 (40.8%) from blood and 795 (17.9%) from CSF. At the start of the surveillance period cotrimoxazole resistance was 73.8% and at the end was 92.6%. Multidrug resistance (MDR) was present in almost one third of isolates and was constant over time. Free ART was introduced in Malawi in 2004. From 2005 onwards there was a decline in invasive pneumococcal infections with a negative correlation between ART scale-up and the decline in IPD (Pearson's correlation r = -0.91; p<0.001).
  
  
  CONCLUSIONS
  During 2004-2009, national ART scale-up in Malawi was associated with a downward trend in IPD at QECH. The introduction of cotrimoxazole prophylaxis in HIV-infected groups has not coincided with a further increase in pneumococcal cotrimoxazole or multidrug resistance. These data highlight the importance of surveillance for high disease burden infections such as IPD in the region, which will be vital for monitoring pneumococcal conjugate vaccine introduction into national immunisation programmes.
authors.affiliation: Malawi-Liverpool-Wellcome Trust Clinical Research Programme, College of Medicine, Chichiri, Blantyre, Malawi. Dean.Everett@liverpool.ac.uk
authors.forename: Dean B
authors.initials: DB
authors.lastname: Everett
authors.forename: Mavuto
authors.initials: M
authors.lastname: Mukaka
authors.forename: Brigitte
authors.initials: B
authors.lastname: Denis
authors.forename: Stephen B
authors.initials: SB
authors.lastname: Gordon
authors.forename: Enitan D
authors.initials: ED
authors.lastname: Carrol
authors.forename: Joep J
authors.initials: JJ
authors.lastname: van Oosterhout
authors.forename: Elizabeth M
authors.initials: EM
authors.lastname: Molyneux
authors.forename: Malcolm
authors.initials: M
authors.lastname: Molyneux
authors.forename: Neil
authors.initials: N
authors.lastname: French
authors.forename: Robert S
authors.initials: RS
authors.lastname: Heyderman
mesh_terms: D000328:Adult; D044966:Anti-Retroviral Agents / Q000627:therapeutic use*; D019072:Antibiotic Prophylaxis; D002648:Child; D004352:Drug Resistance, Microbial / Q000187:drug effects; D006801:Humans; D008295:Malawi / Q000453:epidemiology; D011008:Pneumococcal Infections / Q000097:blood / Q000188:drug therapy* / Q000453:epidemiology*; D011159:Population Surveillance; D011891:Rain; D012621:Seasons; D013296:Streptococcus pneumoniae / Q000187:drug effects / Q000472:pathogenicity*; D015662:Trimethoprim, Sulfamethoxazole Drug Combination / Q000494:pharmacology / Q000627:therapeutic use*
chemical_list: D044966:Anti-Retroviral Agents; D015662:Trimethoprim, Sulfamethoxazole Drug Combination