title: Streptococcus pneumoniae Serotypes and Mortality in Adults and Adolescents in South Africa: Analysis of National Surveillance Data, 2003 - 2008.
abstract: BACKGROUND
  An association between pneumococcal serotypes and mortality has been suggested. We aimed to investigate this among individuals aged ≥15 years with invasive pneumococcal disease (IPD) in South Africa.
  
  
  METHODS
  IPD cases were identified through national laboratory-based surveillance at 25 sites, pre-pneumococcal conjugate vaccine (PCV) introduction, from 2003-2008. We assessed the association between the 20 commonest serotypes and in-hospital mortality using logistic regression with serotype 4 (the third commonest serotype with intermediate case-fatality ratio (CFR)) as referent.
  
  
  RESULTS
  Among 3953 IPD cases, CFR was 55% (641/1166) for meningitis and 23% (576/2484) for bacteremia (p<0.001). Serotype 19F had the highest CFR (48%, 100/207), followed by serotype 23F (39%, 99/252) and serotype 1 (38%, 246/651). On multivariable analysis, factors independently associated with mortality included serotype 1 (OR 1.9, 95%CI 1.1-3.5) and 19F (OR 2.9, 95%CI 1.4-6.1) vs. serotype 4; increasing age (25-44 years, OR 1.8, 95%CI 1.0-3.0; 45-64 years, OR 3.6, 95%CI 2.0-6.4; ≥65 years, OR 5.2, 95%CI 1.9-14.1; vs. 15-24 years); meningitis (OR 4.1, 95%CI 3.0-5.6) vs. bacteremic pneumonia; and HIV infection (OR1.7, 95%CI 1.0-2.8). On stratified multivariate analysis, serotype 19F was associated with increased mortality amongst bacteremic pneumococcal pneumonia cases, while no serotype was associated with increased mortality in meningitis cases.
  
  
  CONCLUSIONS
  Mortality was increased in HIV-infected individuals, which may be reduced by increased antiretroviral therapy availability. Serotypes associated with increased mortality are included in the 10-and-13-valent PCV and may become less common in adults due to indirect effects following routine infant immunization.
authors.affiliation: Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases (NICD) of the National Health Laboratory Service (NHLS), Johannesburg, South Africa; School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg South Africa.
authors.forename: Cheryl
authors.initials: C
authors.lastname: Cohen
authors.affiliation: Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases (NICD) of the National Health Laboratory Service (NHLS), Johannesburg, South Africa; School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg South Africa.
authors.forename: Nireshni
authors.initials: N
authors.lastname: Naidoo
authors.affiliation: Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases (NICD) of the National Health Laboratory Service (NHLS), Johannesburg, South Africa.
authors.forename: Susan
authors.initials: S
authors.lastname: Meiring
authors.affiliation: Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases (NICD) of the National Health Laboratory Service (NHLS), Johannesburg, South Africa.
authors.forename: Linda
authors.initials: L
authors.lastname: de Gouveia
authors.affiliation: Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases (NICD) of the National Health Laboratory Service (NHLS), Johannesburg, South Africa; School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg South Africa.
authors.forename: Claire
authors.initials: C
authors.lastname: von Mollendorf
authors.affiliation: Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases (NICD) of the National Health Laboratory Service (NHLS), Johannesburg, South Africa; School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg South Africa.
authors.forename: Sibongile
authors.initials: S
authors.lastname: Walaza
authors.affiliation: Division of Medical Microbiology, University of Cape Town, Cape Town, South Africa.
authors.forename: Preneshni
authors.initials: P
authors.lastname: Naicker
authors.affiliation: Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases (NICD) of the National Health Laboratory Service (NHLS), Johannesburg, South Africa.
authors.forename: Shabir A
authors.initials: SA
authors.lastname: Madhi
authors.affiliation: Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg South Africa.
authors.forename: Charles
authors.initials: C
authors.lastname: Feldman
authors.affiliation: Hubert School of Public Health, Emory University, Atlanta, GA, United States of America.
authors.forename: Keith P
authors.initials: KP
authors.lastname: Klugman
authors.affiliation: Department of Internal Medicine, Faculty of Health Sciences, University of KwaZulu-Natal, Pietermaritzburg, South Africa.
authors.forename: Halima
authors.initials: H
authors.lastname: Dawood
authors.affiliation: Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases (NICD) of the National Health Laboratory Service (NHLS), Johannesburg, South Africa; School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg South Africa.
authors.forename: Anne
authors.initials: A
authors.lastname: von Gottberg
mesh_terms: D000293:Adolescent; D000328:Adult; D000367:Age Factors; D060085:Coinfection / Q000453:epidemiology / Q000382:microbiology / Q000821:virology; D003710:Demography; D005260:Female; D015658:HIV Infections / Q000453:epidemiology; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D015999:Multivariate Analysis; D011008:Pneumococcal Infections / Q000382:microbiology* / Q000401:mortality*; D011159:Population Surveillance; D012703:Serotyping; D013019:South Africa / Q000453:epidemiology; D013223:Statistics as Topic; D013296:Streptococcus pneumoniae / Q000145:classification*