Serotype 10A in Invasive Pneumococcal Disease (IPD) Surveillance in New Jersey, April – September 2009 Samantha Pitts, MD, MPH CDC/CSTE Applied Epidemiology Fellow New Jersey Department of Health and Senior Services (NJDHSS)

IPD in New Jersey In New Jersey, IPD is reportable in all age groups Case definition: documented S. pneumoniae infection from a normally sterile site and clinical symptoms Hospitals and local health departments report 600-800 confirmed cases annually

New Jersey vaccination requirements for child care and preschool entry Children 2-11 months: 2 doses of pneumococcal conjugate vaccine (PCV) Children 12-59 months: 1 dose of PCV after their first birthday

Background Emergence of serotype replacement following introduction of PCV-7 Increase in reported cases in multiple New Jersey counties in 2007-2008 Received anecdotal reports of severe IPD in persons at low risk Pilot study initiated to evaluate extent of serotype replacement in New Jersey

Methods Beginning April 1, 2009, NJDHSS requested that clinical laboratories submit all IPD specimens to state laboratory Serotyping done by PCR-based method Case reports were matched to laboratory samples for analysis Study case definition did not require documentation of clinical symptoms

Results: Case Ascertainment April – September 2009 150 (51%) case-persons with specimen for serotyping 143 (48%) case-persons used in analysis 6 (2%) failed to grow 1 (0.3%) not consistent with S. pneumoniae 296 reported IPD cases

1 Personal communication, Ruth Link-Gelles, CDC, 2011 Serotype Distribution in NJ vs. Active Bacterial Core Surveillance (ABCs) Data from 20091 PCV-13 PPSV-23 0% 5% 10% 15% 20% 25% 30% 19A 7F 3 10A 22F 33F 9N 6C 15A 23A 16F New Jersey ABCs Percent Serotype 1 Personal communication, Ruth Link-Gelles, CDC, 2011

Age Distribution of Serotype 10A Compared with Other Serotypes P=.10 by Fisher’s exact test

Geographic Distribution of 10A IPD in NJ

Geographic Distribution of All IPD in NJ Other

IPD serotype in NJ, April – September 2009, by MMWR week 5 10 15 20 25 30 35 13-15 16-18 19-21 22-24 25-27 28-30 31-33 34-36 37-39 MMWR week Count 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% Percent Other serotypes Serotype 10A Serotype 10A (percent of IPD)

Severity of cases in NJ, April – September 2009 ICU Admission Serotype 10A (n=36) Other serotypes (n=107) p value 28% 32% .58 Death Serotype 10A (n=23) Other serotypes (n=72) p value 26% 11% .10

Discussion Laboratory error Selection bias Outbreak Approximately 20% of 10A tested by conventional serotyping All were confirmed as 10A Selection bias Outbreak Seasonal phenomenon Regional difference in serotype distribution

Conclusions Serotype 10A represented 25% of IPD in NJ Serotype 10A has not been reported to represent a substantial percentage of IPD in the US May represent an opportunity for further prevention as serotype 10A is included in the polysaccharide vaccine State-based serotyping may be useful

Limitations Specimens were obtained during only 6 months of surveillance Only a subset (48%) of reported cases during this period had a specimen available for analysis Surveillance for IPD in NJ relies on passive reporting

Next Steps A case control study is underway to: Determine case vaccination eligibility and vaccination status Evaluate disease severity Continued serotype testing as part of IPD surveillance would help to determine if serotype 10A persists

Coauthors and Acknowledgements NJDHSS: Lisa McHugh Christina Tan Nelson Delgado Sarmila DasGupta Thomas Kirn Corey Robertson Cindy Gross Andria Apostolou NJDHSS, cont.: Barbara Montana Faye Sorhage Erica Rauch Amy Fink Stella Tsai Centers for Disease Control and Prevention: Matt Moore Ruth Link-Gelles