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Epidemiology of Chickenpox and Acute Bacterial Meningitis in India (idsurv data) Dr Suhas V. Prabhu IAP COI Meeting 24 th -25 th August 2012.

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Presentation on theme: "Epidemiology of Chickenpox and Acute Bacterial Meningitis in India (idsurv data) Dr Suhas V. Prabhu IAP COI Meeting 24 th -25 th August 2012."— Presentation transcript:

1 Epidemiology of Chickenpox and Acute Bacterial Meningitis in India (idsurv data) Dr Suhas V. Prabhu IAP COI Meeting 24 th -25 th August 2012

2 Disclosure of conflict of interest  Have received travel grants and honorarium from  Wyeth (Pfizer)  Sanofi Pasteur  On Advisory Board of  Wyeth (Pfizer)  Own shares of various pharma companies  GSK  Cipla  Ranbaxy

3 The idsurv project data

4 The Idsurv project data  Data as available from the website is analyzed  Analysis possible and valid for  Age and sex distribution  Seasonal variation  Mortality  Caveats:  Due to selective reporting from doctors, conclusions of prevalence cannot be made  Numbers are too small for valid statistical analysis  Duration is too short to detect any secular trend  Diagnosis (almost always) clinical so diagnosis may be suspect  Clinical details are few so assessment of the actual morbidity cannot be made

5 Chickenpox

6 Data Collation  Data for 569 days ending August 16, 2012 (~ 1 ½ year)  Data reported by 22 pediatricians in 6 states  Diagnosis was clinical in all cases ostensibly as per the following case definition:  “Vesicular rash starting on trunk and spreading to extremities in multiple stages of evolution”  Total 249 cases. i.e. Annual incidence of ~ 160 cases  Age ranging from 1 month to 18 years  Mean age 75 months (6 1/4 years)  153 male, 95 female.  M:F ratio 1.6 : 1

7 Reporting Pediatricians NameDistrictStateNo. of casesState Total Rupesh ShethKutchGujarat2 Bhimji SachdeKutchGujarat112 Naveen ThackerKutchGujarat9 NitinKutchGujarat14 Manish ChudasamaKutchGujarat1 J. KesharaniKutchGujarat8 Vikas GoyalKutchGujarat4 Tejaskumar TrivediRajkotGujarat1 Ketan ShahSuratGujarat3 Sandip TrivediSabarkanthaGujarat8 Suketu ShahGandhinagarGujarat22184 Arun ShahMuzzafarpurBihar99 Vipin VasishtaBijnourU.P.19 Vijay YewaleThaneMaharashtra21 Uday PaiMumbaiMaharashtra1 Tanu SinghalMumbaiMaharashtra1 Harshal NimkandeThaneMaharashtra8 Subhash RaoThaneMaharashtra1 Pankaj TardejaThaneMaharashtra1 Ashok GawdiThaneMaharashtra235 Sharadkumar Pai-RaikarNorth GoaGoa11 Neeta PoleJabalpurM.P.11 Total249

8 Epidemiology  Reporting states are Bihar, Gujarat, Uttar Pradesh and Maharashtra (and one case each from M.P. and Goa)  Maximum Cases reported from Gujarat state (184) of which 150 were from Kutchh district  Seasonal distribution:  Dec to March 116 cases  April to June 116 cases  July to November 17 cases  Crop of cases  March – April 2011  End January to mid-February and May-June 2012

9 Medical details of Cases  8 patients were hospitalized (3.2%)  Unknown whether the varicella or its complication was the reason for the hospitalization  No deaths

10 Immunization status  6 patients were ineligible for immunization (underage) (ages ranging from 1 month to 6 months)  No cases between 6 and 12 months  Only 2 cases were between 12 to 15 months  36 children were immunized (partially or completely)  17 “fully immunized” and 19 “partially immunized”  Of the 17 “fully immunized” cases specific mention:  One case of having received 1 dose  One child reported to have received 2 doses  Of the 19 “partially immunized” cases specific mention in 5 cases of having received 1 dose of the vaccine

11 Conclusions from the data  Chickenpox does occur in India  Is a mild disease with no mortality and little morbidity  Higher incidence in boys?  Age distribution moving towards higher side – school age group is now the commonest affected  Seasonal distribution – In late winter and early summer  Vaccine coverage rates are low – only 36 of the 249 children had received partial or complete immunization  Significant number of “breakthrough” cases after single dose of the vaccine do occur

12 Age distribution of cases

13 More conclusions from the data  Chickenpox is more a disorder of school-going rather than pre-school children  Only 2 cases between 12 to 15 months; no justification for reducing minimum age for receiving the vaccine from 15 to 12.  4 % of cases occur in 1 st 6 months of life; there is probably waning levels of antibodies in pregnant women, insufficient to offer adequate protection to the neonate from trans-placental transmission.  This might be due to  Immunized in childhood (not suffered natural disease)  Lesser boosting effect from lack of exposure to cases after sero- conversion due to reduction in prevalence of chickenpox

14 Acute Bacterial Meningitis

15 ACUTE BACTERIAL MENINGITIS – Case definition  Acute onset of fever (usually > 38.5 °C rectal or 38.0 °C axillary and one of the following signs: Boggy fontanelle, seizures, neck stiffness, altered consciousness or other meningeal signs WITH  Abnormal CSF  Turbid appearance OR  Leucocytosis (>100 cells / mm 3 ) OR  Leukocytosis (10 – 100 cells / mm 3 ) with elevated proteins >100mg% or CSF sugar <40 mg%

16 ACUTE BACTERIAL MENINGITIS – Etiological case definition  ABM Pneumococcal  ABM with Strep. pneumoniae  +ve Gram stain / Latex / CSF or Blood culture  ABM Haemophillus influenzae  ABM with H. influenzae  +ve Gram stain / Latex / CSF or Blood culture  ABM Meningococcal  ABM with N. meningitidis  +ve Gram stain / Latex / CSF or Blood culture  ABM other organisms  ABM with organism other than P/H/N  ABM with no microbial diagnosis  ABM with no microbiological diagnosis

17 Data Collation  Data for 531 days ending August 13, 2012 (~ 1 yr and 5 months )  Data reported by 9 pediatricians in 4 states  Total 61 cases  Annual incidence = 42 cases / year  Age range 1 month to 16 years  Mean age 39 months (3 ¼ years)  48 male and 13 female  Male : female ratio = ~ 3.7 : 1

18 Reporting Pediatricians NameDistrictStateNo. of casesState Total Vipin VashishtaBijnourU.P.36 Rajesh JasaniKutchGujarat1 Nehal VaidyaKutchGujarat1 Smita TewariVadodaraGujarat1 Sandip TrivediSabarkanthaGujarat1619 Vijay YewaleThaneMaharashtra2 Jitendra OswalPuneMaharashtra2 Harshal Nimkande ThaneMaharashtra15 Sumanth Amperayani ChennaiTamil Nadu11 Total61

19 Epidemiology  Reporting states are only 3: Gujarat, Uttar Pradesh and Maharashtra (and one case from Tamil Nadu)  Etiology  Pneumococcus 11 cases (18.0%)  H. influenzae 2 cases (3.3%)  Meningococcus 1 case (1.6%)  “Others” 13 cases (21.4%)  Unknown 34 cases (55.7%)  Method of etiological diagnosis  Culture 8 cases  Antigen detection 4 cases  Gram staining 3 cases  Uncertain17 cases  Proven diagnosis 10 cases

20 Medical details of Cases  58 out of 61 (95%) were treated as inpatients  3 patients were NOT hospitalized  Possible reason – Refused admission?  6 deaths = mortality rate of 9.8 %  H. influenzae 2 cases  One from Pune, age 8 months, diagnosis by antigen testing, also had empyema, survived  One from Kutchh, age 12 months, “no microbiological diagnosis”, survived  Meningococcus 1 case  No microbiological diagnosis, age 13 months, survived

21 Cases of Pneumoccocal meningitis Serial No.Age/SexMethod of DiagnosisOutcomeImmunized? 1192/M?SurvivedNo 28/M?DiedNo 396/M?SurvivedPartially (?) 484/MCultureSurvivedNo 52/F?SurvivedPartially (?) 684/M?SurvivedNo 7144/MCultureDiedNo 8192/MGram stain + antigen+ culture SurvivedNo 923/F?SurvivedPartially (?) 1015/FGram stain + antigenDiedNo 1132/MCultureSurvivedPartially (?)

22 Immunization status  Of the 11 cases due to Strep. Pneumoniae:  7 were not immunized  4 were “partially immunized” (No details available)  Outcome in these 4 cases: All survived  Of the 7 unimmunized cases, 3 died  Of the two cases with H. influenzae meningitis:  Both were unimmunized  The one case of Meningococcal meningitis:  Not immunized

23 Conclusions from the data  Acute bacterial meningitis does occur in India  Occurs right from newborn period to adolescence  Higher incidence in younger age group with mean age being 3¼ years  Higher incidence in boys?  Complete microbiological diagnosis is rarely available  Pneumococcus is reported as the cause in 18% but diagnosis is confirmed in less than half of the cases  Gram negative organisms are commonly seen esp. in younger infants  Haemophilus and Meningococcus identified sporadically

24 Conclusions from the data (contd.)  None of the cases had reported receiving the full course of vaccines for Pneumococcus or Haemophilus  4 of the cases with Pneumococcal meningitis had been “partially immunized”  All these 4 survived vs only 4 out of the 7 who were not immunized (? Partial protection?)  Among the survivors there is no data about the nature of handicap if any

25 Thank You!


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