The Epidemiology and Burden of
Pneumococcal Disease
Thomas Cherian
Diseases caused by Streptococcus pneumoniae
(Pneumococcus)
Febrile bacteraemia
Meningitis
Arthritis
Peritonitis
Osteomyelitis
Pneumonia
Sinusitis
Otitis
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Invasive
pneumococcal
disease
NP carriage
Proportion colonized (%)
NP colonization occurs earlier in lower
socioeconomic settings
100
90
80
70
60
50
40
30
20
10
0
Papua New Guinea
Australian Aborigines
India
Israeli Jews
Sweden & Finland
Age (months)
O’Brien et al. Pediatr Infect Dis J. 2003; 22(2): e1-11
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Costa Rica
Surveillance for laboratory confirmed
disease only provides part of the picture
Culture positive
Spn disease
Culture negative
meningitis and pneumonia
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Identified by
surveillance for
invasive disease
Additional cases
preventable with
vaccination
Incidence of IPD
Incidence/ 100,000 children
Incidence < 2 years
Incidence < 5 years
500
450
400
350
300
250
200
150
100
50
0
Finland
Chile
USA
Kenya
The Gambia Bangladesh - Bangladeshurban
rural
Sources: Robinson KA JAMA 2001; Davidson M JID 1994; O’Dempsey TJ PIDJ 1996;
Levine MM PIDJ 1998; Eskola J JAMA 1992; Berkley NEJM 2005; Brooks Am J Trop Med Hyg 2007; Arifeen SE CID 2009
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Invasive Pneumococcal Disease Rates, by Age, USA
1997
Rate per 100,000
persons
250
200
150
100
50
0
< 12
12–23
24–48
5–17
Months
Available at:
www.cdc.gov/ncidod/dbmd/abcs/survreports/spneu98.pdf.
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18–34
35–49
Years
Age
50–64
> 65
Age distribution of pneumococcal meningitis cases
(Bangladesh, India)
Russel F et al. http://blogs.lshtm.ac.uk/vaccineschedules/files/6.-Russel-review-age-specific-epidemiologyPCV-schedules-session-nov11.pdf
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Percent of isolates
Pneumococcus is a significant cause
of bacterial meningitis
50
45
40
35
30
25
20
15
10
5
0
Pneumococcus
Hib
Meningococcus
Mozambique
(10)
Vietnam (11)
Burkina Faso
(12)
In low-income countries about 45% of people with pneumococcal meningitis die,
compared to 29% with Hib meningitis and 8% with meningococcal meningitis
1Peltola
H. Clin Inf Dis 2001; 32: 64-75.
G, Parmar N, et al. J Trop Pediatr 1995; 41: 164-8.
3Tram TT, Thinh LQ, et al. Ped Inf Dis J 1998; 17(9 Suppl): S192-S194.
4du Chatelet IP, Traore Y, et al. Clin Inf Dis 2005; 40: 17-25.
2Ciana
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Proportion of meningitis caused by pneumococcus
Proportion of CSF specimens positive for S. pneumoniae, culture, latex or
Binax ICT, children <5 y.o.
30.0%
Binax ICT
Latex
25.0%
Culture
21.6%
20.0%
17.2%
17.4%
16.2%
16.2%
15.0%
10.0%
5.0%
0.0%
Bangladesh (n=356) Pakistan (n=274)
Asia
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Burkina Faso
(n=121)
Kenya (n=66)
Nigeria (n=37)
Africa
Serotypes causing IPD in India, Nepal & Sri
Lanka
20
100
18
90
16
80
%
14
70
12
60
10
50
8
40
6
30
4
20
C
u
m
m
l
a
t
i
v
e
2
10
0
0
14
6A/B/C/D
19F
23F
9A/V
18A/B/C/F
4
1
5
7A/F
3
19A
15B/C
2
23A
8
47F
12A
22A/F
11A/D
25F
38
9N/L
13
15A
16
19B
20
39
10A
17F
19C
23B
24F
27
29
33C
33F
34
35,42
45
10F
11C
15
16A
16 F
24B
32
33
33B
35B
35C
% Vaccine Type
(n = 735)
PCV7
PCV10 PCV13
NVT
Vaccine Type
Data for the period of 2005-2013
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Cummlative
Differences in serotype prevalence between
India, Nepal & Sri Lanka
20
100
18
90
16
80
14
70
12
60
10
50
% Vaccine Types
C
u
m
m
l
a
t
i
v
e
40
100
36
90
32
80
28
70
24
60
20
50
16
40
12
30
8
20
4
10
0
0
100
18
90
16
80
14
70
12
60
10
50
8
40
6
30
4
20
2
10
0
0
PCV10
ISPPD 2014, Hyderabad
NVT
Cummlative
35C
9N/L
33B
35,42
17F
19C
16A
11C
29
20
16
8
15
22A/F
15A
PCV13
Vaccine Type
11 |
11A/D
13
38
47F
23A
15B/C
19A
3
1
5
4
18A/B/C/F
23F
PCV7
9A/V
19F
6A/B/C/D
14
PCV7
%
SRI LANKA
NVT
Cummlative
10A
15A
38
12A
34
33
32
13
47F
23B
23A
45
19B
39
20
PCV13
Vaccine Type
C
u
m
m
l
a
t
i
v
e
16
25F
8
12A
2
3
19A
5
PCV10
7A/F
1
4
19F
6A/B/C/D
20
23F
Cummlative
18A/B/C/F
NVT
Vaccine Type
14
47F
%
0
9N/L
24F
24B
19F
23A
17F
19B
10F
16 F
39
PCV13
10A
34
8
29
33F
33C
22A/F
27
11A/D
19A
15B/C
1
PCV10
NEPAL
9A/V
PCV7
% Vaccine Types
0
7A/F
10
5
2
23F
20
9A/V
4
4
30
18A/B/C/F
6
14
40
19F
8
6A/B/C/D
% Vaccine Types
INDIA
%
C
u
m
m
l
a
t
i
v
e
Figure: Distribution of Meningitis and Non-meningitis Cases with Their Vaccine Coverage
(2007-2013)
-20
P
C
V
The image part with relationship ID rId2 was not found in the file.
-10
0
1
14
5
6B
23F
7F
19F
18C
6A
4
9V
19A
2
12A
18F
45
8
38
18A
12F
10F
20
33F
34
7B
10A
11A
11F
13
15A
15F
16F
17F
23A
24F
25F
28A
33B
35B
35F
22F
29
21
27
31
33C
6C
10
20
30
40
50
60
70
Non-meningitis (N= 105)
(Meningitis (N=336)
PCV-10 Coverage
Meningitis
44%
Non-Meningitis
47%
Overall
45%
Nonmenin
Meningitis Culture Positive
Meningitis Culture Negative
Source: S K Saha, personal communication
All Countries (India, Nepal, Sri Lanka) by
Year
30.0
25.4
25.0
20.9
% Vaccine Type
20.0
18.7
16.9
15.0
14.7
11.3
11.9
10.7
9.0
10.0
7.6
7.3
7.9
5.6
5.0
3.1
3.4
2.8
1.5
2.8
0.6
1.7
1.2 1.1
2.4 2.8
0.6
1.7
0.0
14
6A/B/C/D
19F
23F
9A/V
18A/B/C/F
4
PCV7
5
PCV10
2005-2009
13 |
1
7A/F
3
19A
PCV13
NVT
2010-2013
ISPPD 2014, Hyderabad
13
Figure: PCV-10 Coverage for IPD Cases in Bangladesh, 2007 - 2013
PCV-10 Coverage
PCV-10
80%
70%
60%
57%
Meningitis
44%
Non-Meningitis
47%
Overall
45%
54%
50%
40%
47%
39%
40%
PCV-10
38%
30%
29%
20%
10%
0%
2007
2008
2009
2010
2011
2012
2013
Source: Samir Saha
14
Incidence of pneumonia
Outcome and age
range (months)
India
(cases per 1000
child-years)
Neighboring
countries
(per 1000)
Developing
countries globally
(per 1000)
ALRI 0-59
290, 370
510
290
ALRI 1-59
310
Severe ALRI 0-59
50
Severe ALRI 1-59
165
Severe ALRI 2-59
10
Severe ALRI 0-35
43
Severe ALRI 1-23
27, 31, 79
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20
S. pneumoniae—The Most Common
Cause of Bacterial Pneumonia
% of bacterial isolates
Percent of aspirates
60
50
40
S. pneumoniae
H. influenzae
30
Other bacteria
20
10
0
Papua New
Guinea (1)
1Shann
The Gambia Zimbabwe (3) The Gambia
(2)
(4)
F, Gratten M, Germer S, et al. Lancet. 1984; 2(8402):537-541.
RA, Corrah PT, Mabey DC, Greenwood BM. Bull World Health Org. 1986; 64(4):553-558.
3Ikeogu MO. Arch Dis Child. 1989; 64(8):1207.
4Forgie IM, Campbell H, Lloyd-Evans N, et al. Pediatr Infect Dis J. 1992; 11(6):466-473.
2Wall
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Lung aspirate studies from S Asia
Author
Year
N
No. pos
S pneumo
H inf
S aureus
Others
Sinha
1966
25
11
3
7
0
1
Hughes
1966
17
5
2
5
0
0
Hughes
1969
18
7
2
6
0
0
Kalra
1981
70
36
18
2
5
11
Tewari
1991
100
50
5
0
25
20
Prakash
1996
35
17
4
1
2
12
Patwari
1996
All
studies
1966-96
12
277
6
2
132 (48%) 36 (13%)
Source: Vuori-Holopainen E, Peltola H. CID 2001
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0
21 (8%)
4
36 (13)
0
44 (16)
Included older children
Proportion of pneumonia attributable to
pneumococcus, based on vaccine impact data
60%
Clinical Pneumonia
50%
Severe Pneumonia
CXR+ Pneumonia
40%
33%
30%
21%
20%
10%
8%
0%
-10%
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Philippines
Gambia
South Africa
NCKP
CXR+ Pneumonia
Philippines
Gambia
South Africa
NCKP
Severe Pneumonia
Philippines
Gambia
South Africa
NCKP
-30%
Clinical Pneumonia
-20%
Causes of death in children, 2010
Liu et al. Lancet 2012
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Pneumonia mortality trends, SEAR
Liu et al. Lancet 2012
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Etiology - bacterial “probe” studies
Country and age
range (months)
Study design
Outcome
measure
Outcome-specific
mortality
reduction
India 0-47
Case-control,
village randomized
Fatal pneumonia
54%
Pakistan 0-59
Observational,
community based
Fatal ALRI
55%
Pakistan 0-59
Observational,
hospital based
ARI case fatality
rate
51%
Bangladesh 0-23
Case-control,
village randomized
Fatal pneumonia
54%
Nepal 0-59
Observational,
community based
Fatal ARI
69%
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Estimates of pneumococcal deaths
(WHO, 2008 unofficial)
Pneumococcal deaths
Country
Pneumonia
Bangladesh
Meningitis
NPNM
Total
7165
1311
371
8846
82
7
2
91
73292
9850
2786
85928
6
3
3
12
1378
278
79
1735
Pakistan
18799
1595
451
20845
Sri Lanka
133
10
10
153
100854
13054
3701
117609
Bhutan
India
Maldives
Nepal
TOTAL
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Top 10 high burden countries
Population size vs mortality rate
Under 5 population (million)
150
India
130
110
90
70
China
50
Nigeria
Ethiopia
30
Pakistan
DR Congo
10 Bangladesh
Uganda
Angola
-10 0
200
400
600
Afghanistan
800
Pneumococcal deaths per 100,000 children under 5 years
Feb/08 analysis
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1000
Summary
 Pneumococcus is an important cause of serious disease in
children, especially pneumonia and meningitis.
 Establishing pneumococcal etiology of childhood pneumonia
is a challenge and limits the ability to get a direct estimation of
burden of disease
 Synthesis of available data shows that pneumococcal disease is
an important cause of childhood morbidity and mortality
worldwide, as well as in South Asia.
 No reason to suspect that the epidemiology of pneumococcal
disease in South Asia is different from that in other countries
with similar socio-economic & mortality profile.
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EXTRA SLIDES
IPD serotypes, India (2005-213)
PCV7
PCV10
PCV13
NVT
Vaccine Type
Data for the period of 2005-2013
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Cummlative
9N/L
47F
24F
24B
23A
19F
19B
17F
16 F
10F
0
10A
0
39
10
34
2
29
20
8
4
33F
30
33C
6
22A/F
40
11A/D
8
27
50
15B/C
10
19A
60
7A/F
12
1
70
5
14
9A/V
80
23F
16
18A/B/C/F
90
4
18
19F
100
14
20
6A/B/C/D
% Vaccine Types
(n=349)
%
C
u
m
m
l
a
t
i
v
e
IPD serotypes, Nepal (2005-13)
PCV7
PCV10
PCV13
NVT
Vaccine Type
Data for the period of 2005-2013
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Cummlative
10A
15A
12A
38
34
33
32
13
47F
23B
0
23A
0
19B
10
45
4
39
20
20
8
16
30
25F
12
12A
40
8
16
2
50
19A
20
3
60
7A/F
24
5
70
1
28
4
80
6A/B/C/D
32
19F
90
23F
36
18A/B/C/F
100
9A/V
40
14
% Vaccine Types
(n=210)
%
C
u
m
m
l
a
t
i
v
e
IPD serotypes, Sri Lanka (2005-13)
PCV7
PCV10
PCV13
NVT
Vaccine Type
Data for the period of 2005-2013
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Cummlative
9N/L
35C
35,42
33B
19C
17F
16A
11C
29
20
0
16
0
15
10
8
2
22A/F
20
15A
4
11A/D
30
13
6
38
40
47F
8
23A
50
15B/C
10
19A
60
3
12
1
70
5
14
4
80
18A/B/C/F
16
9A/V
90
23F
18
6A/B/C/D
100
19F
20
14
% Vaccine Types
( n=176)
%
C
u
m
m
l
a
t
i
v
e
India by Year
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Nepal by Year
40.0
35.8
35.0
33.3
32.1
% Vaccine Type
30.0
25.0
23.5
20.0
15.0
12.6
11.8
10.0
7.8
5.9
5.0
3.1
3.1
3.9
5.9
3.9
1.9
1.3
1.9 2.0
0.0
0.0
14
9A/V
18A/B/C/F
23F
2.5
1.9
19F
6A/B/C/D
0.6 0.0
4
PCV7
Data for the period of 2005-2013
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2010-2013
0.6
0.0
1
5
PCV10
2005-2009
2.5
7A/F
3
2.0
19A
PCV13
NVT
Sri Lanka by Year
35.0
31.3
30.0
28.9
24.4
25.0
% Vaccine Type
21.4
20.0
17.8
17.6
15.0
13.0
10.0
8.9
8.9
6.1
5.0
4.4
3.8
2.2
1.5
0.0
0.0
14
19F
6A/B/C/D
23F
9A/V
18A/B/C/F
0.8
0.0
4
PCV7
Data for the period of 2005-2013
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0.8
0.0
5
2010-2013
0.8
0.0
1
PCV10
2005-2009
4.4
3.1
3
0.0
19A
PCV13
NVT