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IB-VPD Surveillance data reporting period: January - June 2011 1

Global Invasive Bacterial Vaccine Preventable Diseases (IB-VPD) Information and Surveillance Bulletin Reporting Period: January through June 2011

Volume 5: February 2012 The World Health Organization (WHO) produces a global invasive bacterial vaccine preventable diseases (IB-VPD) surveillance bulletin twice a year to share information and data with partners at national, regional, and global levels. This bulletin presents surveillance data for January through June of 2011, as reported by Member States participating in the WHO-coordinated network for IB-VPD sentinel surveillance that targets children under 5 years of age hospitalized with suspected meningitis and/or pneumonia-sepsis.

Comments on this bulletin are welcome. Please Email to Dr. Mary Agócs ([email protected]) To subscribe for the bulletin please send an email to [email protected]

Table of Contents Page

Spotlight on Efforts to Improve IB-VPD Surveillance Data Quality

Establishment of Five (5) Criteria to Define Minimal Capacity for Effective IB-VPD Sentinel Site Surveillance

Dissemination of Standard Operating Procedures: Meningitis Laboratory Manual, Posters for Collecting Cerebrospinal Fluid and Laboratory Identification of Bacteria Causing Vaccine-Preventable Meningitis

Ensuring Sentinel Hospital Access to Advanced Laboratory Diagnostic Testing in Partnership with Regional Reference Laboratories

The WHO informal IB-VPD laboratory technical working group

Conducting Standardized Evaluation of Hospital Sentinel Sites Spotlight on the 2011 IB-VPD Laboratory External Quality Assessment Programme for Sentinel Hospitals as well as National and Regional Labs

2 2

5

5 5 5

Network of Global and Regional IB-VPD Reference Laboratories 6

Summary of January through June 2011 IB-VPD Surveillance Data 7

Annex: January through June 2011 IB-VPD Surveillance Data 8

The Global IB-VPD Surveillance Network 8

Tier 1: Meningitis surveillance, etiologic agents of meningitis 9

Tier 2: Meningitis-pneumonia-sepsis surveillance with aetiologic agents 12

Tier 3: Population based surveillance 14

Comments 15

Surveillance Data Reporting Calendar and Surveillance Websites 16

Acknowledgements 16

Photo: Cover of new laboratory manual

mailto:[email protected]


Spotlight on Efforts to Improve IB-VPD Surveillance Data Quality:

Establishment of Five (5) Criteria to Define Minimal Capacity for Effective IB-VPD Sentinel Site Surveillance

During 2010, WHO reviewed the status of both IB-VPD and rotavirus global surveillance networks which are used by Member States to make informed decisions regarding the introduction and benefits of Hib/PCV and rotavirus vaccines respectively. Following consultation with WHO's Strategic Advisory Group of Experts (SAGE), informal technical advisory group for new vaccines surveillance, and key partners during the 2011 September Global New Vaccines Surveillance Meeting, it was concluded that the rotavirus surveillance network is functioning to an overall high degree and is in general producing high quality data that is used by decision makers. However, the IB-VPD surveillance network has not yet matured and consequently is not yet providing data of such a high quality. WHO was advised by SAGE and partners to focus efforts on the IB-VPD surveillance network and to clearly signal the need to achieve and maintain high-quality surveillance by establishing clear criteria to identify sites that have existing minimal capacity and the required commitment to conduct effective quality IB-VPD surveillance.

These criteria are: 1. The Member State establishes a surveillance management team, consisting of the

following focal points: Ministry of Health, data manager and for each sentinel site a focal point hospital clinician and hospital laboratorian*;

2. Member States that are conducting only Tier 1 meningitis surveillance enrol at least 100 suspect meningitis cases per year into the surveillance system and investigate cases according to the established surveillance protocols;

3. The Member State reports data regularly to WHO according to the schedule agreed with the WHO Regional Office;

4. The sentinel sites and/or national laboratories (if applicable) in the Member State participate in the WHO laboratory IB-VPD external quality assessment programme; and

5. Member States conducting only Tier 1 meningitis surveillance will meet established quality indicators for Tier 1 before WHO provides funding for the Member State to establish Tier 2 (meningitis-pneumonia-sepsis) surveillance.

*Note: For AMR and WPR, a national laboratory focal point is an additional criteria.

WHO began notifying Member States of the criteria in January 2012, and Member States will be provided 12 months to meet the criteria. Member States that meet the criteria with the exception of number 2 above (enrolling >100 suspect meningitis cases) and are increasing the number of cases enrolled with time will be considered for inclusion in the network on a case-by-case basis.

Dissemination of Standard Operating Procedures including Meningitis Laboratory Manual and Visual Aides

Dissemination of WHO recommended operating procedures are critical to standardizing processes and improving data quality. WHO is now disseminating an updated laboratory manual for identifying bacteria causing vaccine preventable meningitis to all sentinel site and regional reference laboratories. This manual provides detailed guidance on laboratory diagnostic methods for identification of the bacteria. An accompanying poster summarizes the key methods via a one page visual aide (page 4). WHO is also disseminating a poster for clinicians that highlights the processes to collect cerebrospinal fluid from children with suspected meningitis (page 3.) These materials were developed in close collaboration with partners, with special inputs by U.S. Centers for Disease Control and Prevention, and are available on the WHO website link (see last page).


Tier 1: Meningitis Surveillance Poster: Process for Collecting Cerebrospinal Fluid

http://www.who.int/nuvi/surveillance/resources/en/index.html



Tier 1: Meningitis Surveillance Poster: Laboratory Diagnostic Process for

Identifying Bacteria Causing Vaccine-Preventable Meningitis




Ensuring Sentinel Hospital Access to Advanced Laboratory Diagnostic Testing for Meningitis in Partnership with Regional Reference Laboratories

In 2012, WHO is piloting an effort to ensure advanced laboratory diagnostic testing for children with suspected meningitis at all sentinel hospitals that will include two types of testing. First, rapid diagnostic test kits will be made available such as latex agglutination and immunochromatography kits. These kits are relatively easy to use and rapidly identify the presence of a vaccine preventable organism providing timely information to the treating physician. Second, WHO is establishing processes for cerebrospinal fluid to be frozen at sentinel hospitals and sent to a reference laboratory for polymerase chain reaction (PCR) testing. PCR can identify the disease causing organism and is an important method to determine the bacterial serotype or serogroup. It is hoped that the addition of these two forms of testing will improve yield of bacterial pathogens from cerebrospinal fluid specimens.

WHO Informal IB-VPD Laboratory Technical Working Group

During the September 2011 Global New Vaccines Surveillance Meeting, participants agreed that WHO should convene an informal technical laboratory advisory group to provide expert guidance to the WHO-coordinated IB-VPD surveillance network on specific priority issues. In response, WHO identified a group of experts that includes representation from the global and regional reference laboratories and a sentinel site. WHO convened the first meeting of this group on 7 February 2012, with WHO Regional Office participation. AS a first step, the informal technical working group is giving consideration to the upcoming 2012 External Quality Assessment (EQA) programme to ensure the best and most cost effective assessment of sentinel hospital laboratories.

Conducting Standardized Evaluation of Hospital Sentinel Sites

During 2012, WHO will begin a standardized evaluation of hospital sentinel sites, which has been noted by WHO and partners as a key activity to improve surveillance quality. Teams of trained personnel (clinician and laboratorian) will travel to Member States and hold discussions with the Ministry of Health, sentinel hospital management team, and assess all aspects of IB-VPD surveillance including case identification, enrolment, specimen collection and transport, laboratory processes, and data management. A standardized data collection tool will be used that has been extensively piloted. Furthermore, a standardized scoring and reporting system has been developed so that sentinel hospital performance can be tracked over time. WHO is prioritizing evaluation of IB-VPD surveillance in Member States planning to introduce PCV in 2013, to ensure time for implementation of recommendations prior to vaccine introduction.

Spotlight on Results of 2011 Sentinel Hospital Laboratory External Quality Assessment Programme(EQA) for the IB-VPD Surveillance Network

The previous IB-VPD information and surveillance bulletin described the launch of the global EQA programme in 2011. A subsequent November EQA round targeted all laboratories in the network, with 61 laboratories participating. Of these, 31 (51%) received an acceptable score, 26 (42.5%) received a non-acceptable score, and 4 (6.5%) participated but could not be evaluated because either the laboratory did not receive the shipments or could not perform the tests due to lack of reagents or equipment. Work is under way to technically improve the EQA programme, as described in the laboratory technical working group section of this bulletin. Support and training are being offered to laboratories that received a 'not acceptable' score. Another global EQA round is being planned for summer 2012.


Network of Global and Regional IB-VPD Reference Laboratories:

Table 1. WHO IB-VPD Surveillance Network Global and Regional Reference Laboratories, February 2012

Region Name of Laboratory

Location Member States Served

African Region (AFR)

Medical Research Council Laboratories, WHO Regional

Reference Laboratory for IB-VPD Banjul, Gambia

Benin, Burkina Faso, Cameroon, Côte d'Ivoire, DR Congo, Gambia, Ethiopia,

Ghana, Guinea, Mali, Niger, Nigeria, Senegal, Sierra Leone, Togo

KEMRI-Wellcome Trust Research Programme, WHO Regional Reference Laboratory for IB-VPD

Nairobi, Kenya Burundi, Eritrea, Kenya, Rwanda,

Tanzania, Uganda

National Institute for Communicable Diseases, WHO Regional Reference Laboratory for IB-VPD

Johannesburg, South Africa

Lesotho, Swaziland, Tanzania, Zambia,

Zimbabwe

Region of the Americas

(AMR)

Instituto Adolfo Lutz, WHO Regional Reference

Laboratory for IB-VPD Sao Paolo, Brazil

Argentina, Brazil, Chile, Cuba,

Dominican Republic, Paraguay, Uruguay, Venezuela

Instituto Nacional de Salud,, WHO Regional Reference Laboratory for IB-VPD

Bogota, Columbia

Bolivia, Costa Rica, Ecuador, El Salvador, Guatemala, Honduras,

Mexico, Nicaragua, Panama, Peru,

Trinidad & Tobago

Eastern Mediterranean Region

(EMR)

Central Puplic Health Laboratory, WHO Regional Reference Laboratory for IB-VPD

Cairo, Egypt Afghanistan, Iran, Iraq, Egypt, Libya,

Morocco, Pakistan, Sudan, Syria, Yemen

European Region (EUR)

Gabrichevsky Research Institute for Epidemiology and Microbiology, WHO Regional Reference Laboratory for IB-VPD

Moscow, Russia Azerbaijan, Belarus, Georgia, Ukraine,

Uzbekistan

South-East

Asia Region (SEAR)

Christian Medical College, WHO Regional Reference

Laboratory for IB-VPD

Vellore, India Nepal, Sri Lanka

Western Pacific Region

(WPR)

Department of Microbiology and Immunology, University of Melbourne, WHO Regional Reference Laboratory for

Rotavirus

Melbourne, Australia Papua New Guinea Philippines,

Vietnam

Korea Centers for Disease Control and Prevention (KCDC), WHO Regional Reference

Laboratory for IB-VPD

Seoul, Republic of Korea

Cambodia, Mongolia

Global Reference Laboratory

Centers for Disease Control and Prevention (CDC) Atlanta, USA Worldwide

Health protection Agency (HPA) Colindale, UK Worldwide

National Institute for Communicable Diseases (NICD) Johannesburg,

South Africa Worldwide

During 2012, the network (Table 1) of global and regional reference laboratories will continue to provide support to national and sentinel hospital laboratories. This includes training, on-site visits, quality control of specimen testing, and other activities as required and coordinated through WHO.


Summary of January through June 2011 IB-VPD Surveillance Data

Note: Data in this bulletin comes from a nascent IB-VPD surveillance network where quality assurance systems are only now being established. Thus, care needs to be taken in interpreting the data and drawing conclusions. The wide variation in data from different Member States reported in this bulletin may represent variation in surveillance quality, and laboratory testing methods used, rather than true epidemiological differences.

The global IB-VPD surveillance network collects data related to the detection of 3 vaccine-preventable organisms: Haemophilus influenzae (Hi), Streptococcus pneumoniae (Spn) and Neisseria meningitidis (Nm). Furthermore, the global IB-VPD sentinel surveillance utilizes a 3-tiered approach:

Tier 1 surveillance targets children under-five with suspected meningitis;

Tier 2 surveillance also targets children under-five with pneumonia and/or sepsis in

addition to meningitis;

Tier 3 surveillance seeks to determine incidence rates of IB-VPD, through surveillance

in a defined catchment population.

The current network, consisting mainly of Tier 1 sentinel sites, provides information that will be useful to monitor trends in disease occurrence, once high-quality data are obtained. However, information from Tier 1 sites should be bridged with data from Tier 2 and Tier 3 surveillance sites as well as from special studies in order to provide a comprehensive understanding of disease epidemiology.

This Bulletin presents IB-VPD surveillance data for January through June 2011. Summarized below are the main findings:

52 Member States reported IB-VPD surveillance data to WHO.

39 (75%) of 52 reporting Member States were GAVI funded Member States 1.

51 Member States reported Tier 1 data

1 Member State (Nicaragua) reported Tier 2 data only.

1 Member State (Mongolia) reported Tier 3 data in addition to Tiers 1 and 2

Tier 1 surveillance: Among children with meningitis:

For the first time during this reporting period, data was collected on identification of vaccine preventable organisms among suspect as well as probable meningitis cases, and 4 WHO Regions reported this data. Among these regions, this change resulted in substantially more reported cases. The total number of cases for Hi increased from 22 among just probable meningitis cases to 44 among suspected plus probable cases, for Spn the corresponding increase was from 75 to 157, and for Nm was from 47 to 73.

Spn, Hi or Nm were detected in a tested CSF specimen in 40 (78%) of the 51 reporting Member States.

Six (6) Member States identified > 10 Spn organisms: Brazil, Bangladesh, Cameroon, Malawi, Sierra Leone, and Vietnam. The scientific community is currently debating the minimum number of isolates that may be required to determine impact and for making assessments about serotype distribution. WHO is in the process of developing criteria for the type and quality of surveillance required to assess serotype replacement.

Tier 2 surveillance enrolled 9,913 children with suspected pneumonia, with a bacterial pathogen identified in 747 (14%) children. Of these, 105 (14%) were due to Spn and 10 (1%) were due to Hi.

1 1 The Member States that are funded by GAVI are those 76 that were at least once eligible for GAVI support


Annex: January through June 2011 IB-VPD Surveillance Data

The Global IB-VPD Surveillance Network

During the first semester of 2011, 52 Member States participated in the IB-VPD surveillance network, and reported data to WHO. This is a net gain of 4 Member States compared to the number of Member States that reported data in 2010: Benin, Bolivia (Plurinational State of), Mozambique, Nicaragua, Peru and Sierra Leone started to report IB-VPD data in 2011 while India and Nepal have not yet reported 2011 data.

Figure 1. WHO member states that reported to the global invasive bacterial vaccine preventable diseases (IB-VPD) surveillance network, January to June 2011.

Data Source: WHO/IVB Database Map production: Immunization Vaccines and Biologicals, (IVB), World Health Organization Date of map production: 01 February 2012

Among the 52 Member States globally, 115 hospital sentinel sites reported data, and 50% of reporting Member States were based in the WHO African Region (AFR), (Table 2). GAVI-funding was provided to 75% of Member States that reported to the WHO global surveillance network.

Table 2. Characteristics of WHO IB-VPD Surveillance Network by WHO Region, January to June 2011 .

WHO

Region*

Total number and

% of Member

States reporting

Number of GAVI-

funded Member

States reporting

% of all Member

States reporting who

are GAVI-funded

Total number and % of

sentinel sites reporting

AFR 26 (50%) 24 92% 30 (26%)

AMR 11 (21%) 3 27% 31 (27%)

EMR 6 (12%) 4 67% 31 (27%)

EUR 3 (6%) 3 100% ND

SEAR 2 (4%) 2 100% 2 (2%)

WPR 4 (8%) 3 75% 21 (18%)

Total 52 39 75% 115*The follow ing Member States participated in the global surveillance netw ork for IB VPD the f irst semester of 2011:

Benin, Burkina Faso, Burundi, Cameroon, Côte d'Ivoire, Democratic Republic of the Congo (the), Ethiopia, Gambia

(the), Ghana, Kenya, Lesotho, Malaw i, Mali, Mozambique, Namibia, Niger (the), Nigeria, Rw anda, Senegal, Sierra

Leone, Sw aziland, Togo, Uganda, United Republic of Tanzania (the), Zambia and Zimbabw e in the African Region

(AFR); Bolivia (Plurinational State of), Brazil, Ecuador, El Salvador, Guatemala, Honduras, Panama, Paraguay, Peru

and Venezuela (Bolivarian Republic of) in the Region of the Americas (AMR); Afghanistan, Iraq, Pakistan, Sudan

(the), Syrian Arab Republic (the) and Yemen in the Eastern Mediterranean Region (EMR); Azerbaijan, Georgia and

Ukraine in the European Region (EUR); Bangladesh and Sri Lanka in the South-East Asian Region (SEAR); Mongolia,

Papua New Guinea, Philippines (the) and Viet Nam in the Western Pacif ic Region (WPR).

Nicaragua in AMR is only reporting Tier 2 data

Table 1: Characteristics of WHO IB-VPD Surveillance Network by WHO Region, January to June 2011

1,800 0 1,800900 Kilometers

The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent

approximate border lines for which there may not yet be full agreement.

WHO 2012. All rights reserved

52 Member States reported clinical data

Not in the network


WHO has adopted a tiered approach to IB-VPD surveillance, with 3 reporting tiers as described on page 7, all enrolling children <5 years of age. All Member States are recommended to conduct Tier 1/meningitis surveillance at a minimum of 1-3 sentinel sites, depending on Member State size and population. Fewer sites with the required technical capacity undertake Tier 2 surveillance where, in addition to meningitis, cases of pneumonia and sepsis are investigated using blood culture. Tier 3 surveillance includes meningitis, pneumonia and sepsis in a well characterized catchment population that allows estimation of disease incidence. It is proposed to have at least one Tier 3 site in each WHO region or sub-region. Among the 52 Member States reporting data to WHO, 98% reported Tier 1 data, 16 (31%) reported Tier 2 data, and 1 (2%) Member State, Mongolia, collected population-based data (Table 3).

Table 3. Number of WHO Member States Reporting IB-VPD Data by Surveillance Tier and WHO Region, January - June 2011

Tier 1 - Meningitis Surveillance

During the first semester of 2011, 12,425 children <5 years of age hospitalized with suspected meningitis2 were enrolled in the WHO IB-VPD surveillance network (Table 4). Overall, 84% of suspected meningitis cases had a lumbar puncture (LP) performed.

Table 4. Number (No.) of children <5 years of age with suspected meningitis and percentage (%) of suspected meningitis cases with a lumbar puncture (LP) performed, by WHO region, January - June 2011

2 Any child 0-59 months of age admitted to a sentinel hospital with sudden onset of fever (>38.5°C axillary) and one of the following signs: necs stiffness, altered consciousness

with no other alternative diagnosis or other meningeal sign OR Signs and symptoms of bacterial meningitis as defined by the c linician, WHO Summary Report on Meeting to Standardize New Vaccines Surveillance Data to be Collected, Shared and Reported, 2008.

Tier I Tier 2 Tier 3

Meningitis +Pneumonia and/or Sepsis +Population-based

AFR 26 0 0

AMR 10 10 0

EMR 6 4 0

EUR 3 0 0

SEAR 2 1 0

WPR 4 1 1

Total 51 16 1

WHO Region

Type of IB VPD surveillance

Tier 1: Benin, Burkina Faso, Burundi, Cameroon, Côte d'Ivoire, Democratic Republic of the Congo (the),

Ethiopia, Gambia (the), Ghana, Kenya, Lesotho, Malawi, Mali, Mozambique, Namibia, Niger (the), Nigeria,

Rwanda, Senegal, Sierra Leone, Swaziland, Togo, Uganda, United Republic of Tanzania (the), Zambia and

Zimbabwe from AFR; Bolivia (Plurinational State of), Brazil, Ecuador, El Salvador, Guatemala, Honduras,

Panama, Paraguay, Peru and Venezuela (Bolivarian Republic of) from AMR; Afghanistan, Iraq, Pakistan, Sudan

(the), Syrian Arab Republic (the) and Yemen from EMR; Azerbaijan, Georgia and Ukraine from EUR;

Bangladesh and Sri Lanka from SEAR; Mongolia, Papua New Guinea, Philippines (the) and Viet Nam from

WPR; Tier 2: Bolivia (Plurinational State of), Ecuador, El Salvador, Guatemala, Honduras, Nicaragua, Panama,

Paraguay, Peru and Venezuela (Bolivarian Republic of) from AMR; Afghanistan, Pakistan, Syrian Arab Republic

and Yemen from EMR; Sri Lanka from SEAR; Mongolia from WPR; Tier 3: Mongolia from WPR;

WHO Region No. % of Total Range (by country)

AFR 3,404 27 6-551 96

AMR* 5,267 42 11-4,796 88

EMR 2,277 18 78-913 65

EUR 138 1 44-48 89

SEAR 1,173 9 3-1170 71

WPR 166 1 27-60 90

TOTAL 12,425 100 3-4,796 84

Suspected meningitis % Suspected meningitis

with a LP performed

* Brazil accounts for 91% of the suspected meningitis cases in the Americas, and 39% of the

global network, with 4,796 cases reported


Among children with suspected meningitis and LP performed, the percentage with probable bacterial meningitis3 varied widely between Member States, ranging from 2% in Côte d'Ivoire and Ethiopia to 100% in Ecuador (Figure 2). Five Member States reported probable meningitis constituting 80% or more of suspected meningitis: Ecuador (100%), El Salvador (97%), Ukraine (96%), Afghanistan (88%) and Guatemala (84%). The global IB-VPD surveillance network anticipated ~20% of probable bacterial meningitis cases among enrolled suspected meningitis cases. The global median of probable bacterial meningitis cases detected among suspected meningitis cases the first semester of 2011 was 29%. The percentage of probable bacterial meningitis varied by Region: AFR (15%), SEAR (24%), WPR (40%), EUR (42%), EMR (53%) and AMR (66%). Figure 2: Percent of suspected meningitis cases with probable bacterial meningitis, by Member State and WHO region - January through June 2011. The number of suspected meningitis cases (n= ) stated next to the Member State.

Tier 1 - Aetiologic agents The WHO IB-VPD surveillance system only gathers pathogen information as related to detection of one of the three vaccine preventable organisms, Haemophilus influenzae (Hi), Streptococcus pneumoniae (Spn), or Neisseria meningitides (Nm). Data must be cautiously interpreted, as sites varied in the use of antigen detection or polymerase chain reaction (PCR) for etiologic diagnosis with some sites using these tests for one or more of the three pathogens and other sites using only conventional culture.

3 Probable bacterial meningitis: A suspected case of meningitis with examination of cerebral spinal fluid showing at least one of the following: 1) turbid appearance, 2) WCC(>100

cells/mm3), 3) WCC (10-100 cells/mm

3) and either an elevated protein (>100mg/dl) or decreased glucose (<40 mg/dl).


For the first time during this reporting period, data was collected on identification of vaccine preventable organisms among suspect as well as probable meningitis cases, and 4 WHO Regions reported this data (Table 5). Among these regions, this change resulted in substantially more reported cases. The total number of cases for Hi increased from 22 among just probable meningitis cases to 44 among suspected plus probable cases, for Spn the corresponding increase was from 75 to 157, and it was from 47 to 73 for Nm.

Table 5. Number of children <5 years of age with suspected and probable bacterial meningitis and with Hi, Spn and Nm identified, by WHO region, January-June 2011

Figure 3 presents the total number of laboratory confirmed meningitis cases of Hi, Spn, and Nm reported by each Member State. Globally, the largest number of cases were identified by Brazil (which does not appear on the graph as the extremely large number of organisms identified by the Member State would distort the scale of the graph), followed by Bangladesh, the Niger, Ukraine, Sierra Leone, and Malawi.

Suspected Probable Suspected Probable Suspected Probable

AFR 27 6 110 33 41 16

EMR 6 6 18 18 5 5

EUR 2 2 4 4 27 26

WPR 9 8 25 20 0 0

Total 44 22 157 75 73 47

WHO RegionNo. of cases with Hi No. of cases withSpn No. of cases with Nm


Figure 3. Number of laboratory confirmed meningitis cases due to Streptococcus pneumonia (Spn), Haemophilius influenza (Hi) and Neisseria meningitis (Nm), by Member State, January through June 2011. Number of suspected cases of meningitis (n=) stated next to Member State

Brazil was removed from the graph because the reported identification of organisms was not comparable with the other Member States. For the same period of January through June 2011, Brazil reported 4,796 suspected cases of meningitis and identified 42 cases of Hi, 118 cases of Spn and 378 cases of Nm.

Tier 2 - Pneumonia and/or Sepsis Surveillance

During the first semester of 2011, Tier 2 data was reported by 16 Member States in 4 WHO Regions with 9,913 children < 5 years of age hospitalized with pneumonia4 and enrolled in the WHO IB-VPD surveillance network (Table 6). Overall, 2% of the 5,500 blood cultures obtained were found to contain a VPD, consistent with expected results of 1-4% positive blood cultures.

4 Any child <5 years of age hospitalized with signs and symptoms of pneumonia as defined by the clinician.

Number of identified organisms


Table 6: Number of children <5 years of age with pneumonia or sepsis enrolled in the WHO IB-VPD surveillance network, by WHO region, January - June 2011

Table 7: Blood culture results for the children <5 years of age with pneumonia enrolled in the WHO IB-VPD surveillance network, January through June 2011

Figures 4 and 5 present the percent of pneumonia and sepsis cases, due to Spn and HI.

Figure 4: Percent of pneumonia cases due to Streptococcus pneumoniae (Spn) and Haemophilus

influenzae (Hi), by Member State and WHO region - January through June 2011.

Number of sepsis cases with blood culture performed (n= ) stated next to Member State.

WHO Region

No. of

Member

States

reporting No. of children % of Total

Range (by

Member

State)

No. of

children % of Total

Range (by

Member

State)

AMR 10 7,182 72 102-2,065 NS NS NS

EMR 4 624 6 8-577 122 36 0-101

SEAR 1 73 1 -- 13 4 --

WPR 1 2,034 21 -- 207 61 --

TOTAL 16 9,913 100 8-2,065 342 100 0-207

Pneumonia Sepsis

Number of pneumonia cases 9,913

Number (%) with blood culture performed 5,500 (55%)

Number (%) of blood cultures with a bacterial pathogen identified 747 (14%)

Of those:

Number (%) due to HI 10 (1%)

Number (%) due to Spn 105 (14%)

Overall: positive blood cultures (10+105)/5500 2%


Figure 5: Percent of sepsis cases due to Streptococcus pneumoniae (Spn) and Haemophilus

influenzae (Hi), by Member State and WHO region - January through June 2011.

Number of sepsis cases with blood culture performed (n= ) stated next to Member State.

Tier 3 - Population based Surveillance

From January through June 2011, Mongolia reported population-based surveillance data for IB VPD. A total of 114,623 children under 5 years of age were enumerated in the catchment area of the six sentinel hospital sites; in order to accommodate surveillance data collected from the first semester of 2011, half of the child-years (57,312) of observation were used to calculate incidence rates for meningitis, pneumonia and sepsis, as well as Hi, Spn and Nm (Table 8).

Rates generated from sentinel site surveillance may be large under-estimates as they only reflect children under-five with access to the sentinel hospitals, and among those, children who are hospitalized with a syndrome under surveillance and tested for the pathogens of interest. Furthermore, pneumonia is the most common syndrome captured at sentinel sites in Mongolia, but the incidence rates reflected here only include cases of bacteraemic Hi and Spn pneumonia cases. Challenges in isolating these organisms must also be taken into consideration when interpreting these incidence rates.

Table 8: incidence rates of IB-VPD and aetiologic agents, Sentinel site surveillance – Mongolia, 2011

Incidence rate (per 100,000 child-years)

Syndrome (all-cause) Suspected meningitis 21

Pneumonia 3,549

Sepsis 361

Pathogen (all-syndrome) Hi 5

Spn 51

Nm 0


Comments

Tier 1/meningitis data included data from 51 Member States and >12,000 children <5 years of age with suspected meningitis. This was the first time Member States reported the identification of VPD bacteria in CSF of suspect as well as probable meningitis cases, and this resulted in almost doubling the number of laboratory confirmed cases reported to the surveillance network. This data combined with the information that the majority of suspected meningitis cases have a lumbar puncture preformed indicates that laboratory capacity to identify correctly probable bacterial meningitis needs to be further assessed globally. Following the 2011 global new vaccines surveillance meeting, WHO now recommends that CSF be tested with rapid kits at the sentinel hospital and frozen for PCR at the RRLs. These steps will hopefully reduce the considerable variation in laboratory confirmation of cases due to current variable laboratory practices. Additionally, the distribution of the standard operating procedures for the laboratory as described in this bulletin’s spotlight section may also improve quality. Globally, the quality of the IB-VPD surveillance network must be rapidly improved in order to assess any potential impact of the introduction of vaccine on meningitis.

Tier 2/pneumonia-sepsis data was reported by 16 Member States in 6 WHO Regions

and >9,900 children with pneumonia were enrolled. Haemophilus influenzae was isolated in about 6% of pneumonia cases. Streptococcus pneumoniae was isolated in about 20% of pneumonia cases and about 6% of sepsis case. Overall, Spn or HI were identified in 2% of blood cultures, falling within the expected rate of positive blood cultures among children <5 years of age with pneumonia of 1-4%.


Surveillance Data Reporting Calendar

The below reporting calendar is used for the surveillance network Reporting Frequency Site to national /regional WHO

At least Quarterly* January April July October

Site sends data from previous Oct-Dec to MOH and WHO CO**

Site sends data from previous Jan-Mar to MOH and WHO CO**

Site sends data from previous Apr-Jun to MOH and WHO CO**

Site sends data from previous Jul-Sept to MOH and

WHO CO**

Regional Reference Laboratory to WHO RO

6-Monthly Apr-May Oct-Nov

Annual data Jan-Dec of previous year Data from Jan-June of same year

Regions to countries (regional feedback bulletin)

Quarterly Jan Apr July Oct

RO prepares quarterly bulletin of country data from

Jul-Sept of previous year

RO prepares quarterly bulletin of country data

from Oct-Dec of previous year


Jan-Mar of previous year


Apr-Jun of previous year

Regions to WHO HQ (regional feedback bulletin)

6-Monthly May Nov

WHO RO sends aggregate regional data from Jan-Dec of the previous year to WHO HQ. These

data include serotype results from regional reference laboratories***

WHO RO sends regional data from Jan-Jun of previous year to WHO HQ

HQ to regions (global bulletin)

6-Monthly Sept Feb

WHO HQ drafts a global bulletin with data from Jan-Dec of the previous year to the regions which

includes serotype information***

WHO HQ drafts bulletin with data from Jan-June of the previous year to the regions

*Many sites are currently reporting to WHO monthly and this should be continued. Quarterly reporting is the minimum accepted and monthly reporting is preferred. **MOH - Ministry of Health, CO - country office, RO - Regional office (in AFRO this may be sub-regional office)

***Although regional reference laboratories should report serotype data to the regional office on a 6-montly basis this will only be shared with WHO HQ and the countries in the region annually

WHO IB-VPD Surveillance Websites Resources for surveillance: http://www.who.int/nuvi/surveillance/resources/en/index.html http://www.who.int/nuvi/rotavirus/en/index.html http://www.who.int/nuvi/surveillance/en/

Acknowledgements WHO gratefully acknowledges the dedicated efforts of the numerous individuals and organizations involved with compiling this surveillance information, including Ministries of Health, sentinel hospitals, as well as the network of global, regional and national reference laboratories.

http://www.who.int/nuvi/rotavirus/en/index.html

http://www.who.int/nuvi/surveillance/en/

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Global Invasive Bacterial Diseases Information and ... · IB-VPD Surveillance data reporting ... networks which are used by Member States to make informed decisions regarding the