Ghassan Ddaibo - Sabin Vaccine Institute

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Ghassan Ddaibo - Sabin Vaccine Institute

Lebanese Inter-hospital

Pneumococcal Surveillance

Program (LIPSP)

Ghassan Dbaibo, M.D.

Professor

Department of Pediatrics

American University of Beirut


GAVI’s PneumoADIP at Johns Hopkins

(Global Alliance For Vaccines and Immunizations: Pneumococcal Vaccine

Accelerated Development and Introduction Plan)

Mission: To improve child health by accelerating

the evaluation of and access to new, life-saving

pneumococcal vaccines for the world’s children.


Established a Pilot Surveillance Program for

Invasive Pneumococcal Disease in Lebanon

• Cooperation between 7 hospitals in different areas of

Lebanon as of October 1, 2005

• Increased to 74 hospitals as of October, 2007.

• Coordinated at the American University of Beirut with

dedicated space, Research Assistants, Filing system as

well as laboratory support for storage and isolate

handling.

• Collect pneumococcal isolates from blood, CSF, or other

normally sterile sites.


Objectives of the program:

Objectives of the program:

Primary Objective:

• To determine the serotypes of Streptococcus

pneumoniae causing invasive disease in Lebanon in

order to determine the most appropriate vaccine for

coverage and protection

Secondary Objectives:

1) To determine the susceptibility patterns and emerging trends of

pneumococcal penicillin resistance in Lebanon

2) To determine the correlation of resistance with specific serotypes


Methods: Active Surveillance

Methods: Active Surveillance

• Weekly contact initiated by Research Assistant to

remind labs about the program

• Identification of pneumococcus from culture of

blood, CSF, or otherwise sterile site

• Alert surveillance coordinator within 24 hours

• Subculture for back-up, freeze if possible

• Dispatch courier (Research Assistant) by car to

transport the culture plate

• Obtain relevant clinical information


Methods

• Subculture and freeze after proper labeling and

identification in the computer database

• When 20-25 samples become available: thaw, grow

on chocolate agar slants, and ship to NAMRU-3

(Cairo) for serotyping

• Do MIC’s on isolates to correlate with serotypes

• Provide program members with results on a periodic

basis


Lebanon: Population

Lebanon: Population

• Estimated Lebanese population : 4 million

• Greater Beirut: 1.2 million

• Average birth cohort in last 5 years:

75,000/year

• GNI per capita (US$): 5,490

• PCV7 price per dose: (US$) 100


Lebanon: Hospital System

Lebanon: Hospital System

• No. of hospitals: 170 ( public + private )

• No. of beds: 15609

• Average no. of beds per hospital: 92

beds/hospital

• Range of bed no.’s: 10 - 907

• Sick patients tend to be transported to coastal

cities

• Percentage of hospitals in LIPSP: 74/170=44%

• No. of beds in LIPSP: 9738

• Percentage of beds in LIPSP: 9738/15609=

63%


Results

• Total valid samples to date: 117

• Lost samples: 8

• Serotyped samples: 71

• Additional samples sent: 13

• Samples waiting to be sent or resent: 25


Sources of Isolates of IPD

100

90

80

70

60

50

40

30

20

10

0

90

14

7

Blood CSF Pleural

Fluid

Source

4 2

MEF

Others


Distribution of IPD according to Sex

Number

80

70

60

50

40

30

20

10

0

77

Males

Sex

40

Females


Distribution of IPD by Age

Number

45

40

35

30

25

20

15

10

5

0

41

28

19

17

11

60y

Age


Clinical Syndromes Associated with

Streptococcus pneumoniae

6%

2%

5%

25%

48%

Peumonia

Meningitis

Sepsis

Mastoiditis

Sinusitis

Others

14%


Outcome of IPD

Number

100

90

80

70

60

50

40

30

20

10

0

90

14

13

Recovered Deceased Unknown


Distribution of IPD according to serotype

(All Ages, n = 71)

12

10

8

Pneumonia

Bacteremia/Sepsis

Meningitis

Mastoiditis

Sinusitis

Others

6

4

2

0

14 18C 19F 6B 23F 4 9V 5 1 7F 3 19A 6A 9A 11A 22F 28A 29 8 9N 15C 24 15A 10A 42 UT

47%

58%

68%


Serotypes causing IPD for children under

5y

7

6

5

4

Pneumonia

Bacteremia/Sepsis

Meningitis

Mastoiditis

Sinusitis

Others

3

2

1

0

14 18C 19F 6B 23F 4 9V 5 1 7F 3 19A 6A 9A 28A 15C 42

72%

76%

84%


Serotype Distribution by Districts

{ 19F(3), 18C(2), 4, 6B,

5, 6A, 8, 14, 9A, 42, 19A,

9N }

{ 19F(2), 9A, 22F,

14, 15A, 23F }

{ 6B(7), 14(5), 19F(5),

3(4), 1(4), 9N(3), 7F(3),

22F(2), 19A(2), 15C,

9A, 11A, 28A, 12F, 8,

15A, 29, 10A }


Serotype Distribution by Districts

cases


Vaccine Coverage by District

Vaccine Coverage by District

North

. Beirut

Mount Lebanon

Lebanon

Children

Children

Children

All Ages

All Ages

All Ages

Vaccine

< 5y

< 5y

< 5y

(n = 45)

(n = 16)

(n = 7)

(n = 15)

(n = 5)

(n = 4)

PCV7

42%

80%

62%

60%

57%

50%

PCV10

57%

80%

69%

80%

57%

50%

PCV13

68%

87%

75%

100%

57%

50%


Year-to-Year Changes in Coverage

Year-to-Year Changes in Coverage

2006

2007*

Age

All Ages

( n= 24 )

< 5 y

( n= 11 )

All Ages

(n = 32)

< 5

(n = 7)

Prevenar

Doses Sold

6000

13000

Estimate of

Vaccinated

(%)

2000

(0.5-3%)

4300

(1.1-6%)

PCV7

50%

63%

31%

71%

PCV10

50%

73%

47%

71%

PCV13

63%

82%

59%

86%

* Serotyping Data from 2007 is not complete, results from 23 samples are pending


Antimicrobial Resistance

Antimicrobial Resistance

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

E

PG

Sensitive Intermediate No Result Resistant

-There was a 25% resistance to

erythromycin.

- 47% of resistant strains were

serotype 19F.

- 8 out of the 10 samples of

serotype 19F were resistant to

E in our pool.

- There was a 15% resistance

to PCN.

- Out of the 10 PCN-resistant

strains found, serotypes 19F(4)

and 14(3) combined to account

for 70% of resistant strains.

- 7 strains were found to be

resistant to both PCN and E:

19F(4), 14(2), 12F.


Prevention of Resistant Strains with Vaccination

Strains Resistant

to Erythromycin

Strains Resistant

to Penicillin

Strains

Resistant

to both

PCV7

70%

70%

86%

PCV10

83%

70%

86%

PCV13

88%

70%

86%


Preliminary Conclusions for Lebanon:

Preliminary Conclusions for Lebanon:

• IPD distribution peaks in very young and very

old

• Potential PCV7 coverage is 47% (all ages) and

72% (< 5y)

• Potential PCV13 coverage would be 68% (all

ages) and 84% (


Acknowledgements:

- PneumoADIP

- WHO-EMRO

- Dr. George Araj

(AUB-Laboratory Medicine)

- Dr. Guillermo Pimentel

(NAMRU-3, Cairo)

- Research Team at AUB:

Charbel Salem (2005)

Mohamad El-Sayyad (2005)

Elie Abu Jawdeh (2006)

Georges Karam(2006)

Sahar Koubar (2006)

Omar Salam (2007)

Maya Saad (2007)

Rita Semaan (2007)

Thank you

Thank you

LIPSP

Member Hospitals

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