Confronting the challenge: a regional perspective by the Latin American pediatric infectious diseases society (SLIPE) expert group on respiratory syncytial virus-tackling the burden of disease and implementing preventive solutions.

Respiratory syncytial virus (RSV) is the leading cause of acute lower respiratory infections in children around the world. The post-pandemic era has resulted in a notable increase in reported cases of RSV infections, co-circulation of other respiratory viruses, shifts in epidemiology, altered respiratory season timing, and increased healthcare demand. Low- and middle-income countries are responsible for the highest burden of RSV disease, contributing significantly to health expenses during respiratory seasons and RSV-associated mortality in children. Until recently, supportive measures were the only intervention to treat or prevent RSV-infection, since preventive strategies like palivizumab are limited for high-risk populations. Advances in new available strategies, such as long-acting monoclonal antibodies during the neonatal period and vaccination of pregnant women, are now a reality. As the Regional Expert Group of the Latin American Pediatric Infectious Diseases Society (SLIPE), we sought to evaluate the burden of RSV infection in Latin America and the Caribbean (LAC) region, analyze current strategies to prevent RSV infection in children, and provide recommendations for implementing new strategies for preventing RSV infection in children in LAC region.

Long-term sequelae secondary to snakebite envenoming: a single centre retrospective study in a Costa Rican paediatric hospital.

OBJECTIVES: Although devastating acute effects associated with snake envenoming are well described, the long-term sequelae resulting from these envenomings have not been adequately addressed, especially in the paediatric population. The aim of our study is to describe the clinical characteristics among paediatric patients in Costa Rica who developed long-term sequelae secondary to snakebite envenoming. DESIGN: Retrospective descriptive study of paediatric patients under 13 years who were admitted with a history of a recent snakebite at the National Children's Hospital in Costa Rica from January 2001 to December 2014. RESULTS: We enrolled 74 patients admitted to our centre due to envenoming, and separated those who did not develop sequelae (50 patients) from those who did (24 patients). Of those who presented acute complications during hospitalisation, local wound infection and clinically diagnosed compartmental syndrome were significantly higher in the group that developed sequelae thereafter. Hypertrophic scars (66.7%), functional limitation of affected limb (37.5%) and the need of skin graft (37.5%) were the most common sequelae. The median follow-up of patients with long-term sequelae after discharge was 25.4 months (5.6-59.4). No deaths were reported during this time period. CONCLUSIONS: Given the high economic, personal and healthcare burden that entails follow-up of these patients, efforts should be carried out to prevent the factors associated with sequelae among the affected population.

Snakebite envenoming in children: A neglected tropical disease in a Costa Rican pediatric tertiary care center.

BACKGROUND: Introduced in June 2017 by the World Health Organization (WHO) as a Neglected Tropical Diseases, snakebite envenoming is a global health problem. In Costa Rica, an incidence of 15 per 100,000 inhabitants and a mortality rate of 0.15 per 100,000 inhabitants per year were reported from 2005-2012. Children are also affected and prone to complications. METHODS: Retrospective descriptive 14-year study of children with envenomings by Viperidae snakebites managed at the tertiary pediatric hospital in Costa Rica. FINDINGS: 80 patients (pts) were included and classified as having mild (17 pts, 29.3%), moderate (58 pts, 72.5%) or severe (5 pts, 6.2%) envenoming. 52/80 (65%) patients received treatment within the first four hours, three (3.75%) between 5-8 h, three between 9-12 h, four (4%) between 13-16 h, two (2.5%) between 17-20 h, and seven (8.75%) after 20 h. Edema was documented in 76/80 (95%), pain in 58 (72.5%), local bleeding in 23 (28.8%), emesis in 10 (12.5%), bullae formation in 8 (10%), and tissue necrosis in three (3.8%) pts. Complications presented according with degree of envenoming, being more common in severe cases: wound infection occurred in 14/58 (24.1%) with moderate envenoming and 5/5 pts with severe envenoming (p < 0.0001), bleeding presented in 3/58 (5.2%) with moderate cases, and 2/5 (40%) in pts with severe envenoming (p = 0.004); and compartmental syndrome occurred in 3/17 (17.6%) pts with mild envenoming, in 33/58 (56.9%), and 5/5 of moderate and severe envenomed pts, respectively (p = 0.0014). Sequelae were documented 25/80 (31%).

Bacterial Infections Associated with Viperidae Snakebites in Children: A 14-Year Experience at the Hospital Nacional de Niños de Costa Rica†.

Secondary bacterial infections following Viperidae snakebite envenomation in children are common. Among 75 patients admitted because of snakebites at the only pediatric hospital in Costa Rica, 16 (21.3%) had a culture-confirmed secondary bacterial infection. Morganella morganii (37.5%), Aeromonas hydrophila (31.2%), and Providencia rettgeri (18.7%) were the most common pathogens. Empiric prophylaxis is still recommended and should be based on local etiological agents and antimicrobial susceptibilities.

Varicella prevention in Costa Rica: impact of a one-dose schedule universal vaccination.

INTRODUCTION: To describe the impact following a 1-dose Varicella vaccination schedule introduced in Costa Rica in September 2007. Areas covered: This is a retrospective review using epidemiologic surveillance national databases of varicella cases and hospitalizations, period 2000-2015. We analyzed age-related varicella incidence cases and hospitalization trends before and after the vaccine introduction. Expert commentary: Varicella vaccine coverage among children 16 months age increased from 76% in 2008 to 95% in 2015. During this period Costa Rica reached a 73.8% reduction of Varicella reported cases and 85.9% reduction of hospitalizations in the general population. Among children under 5 years of age, that reduction was 79.1% and 87%, respectively. Varicella complications in hospitalized patients decreased 98%, from n = 53 in 2008 to n = 1 in 2014. After 8-years post implementation of a 1-dose schedule of universal varicella vaccination, a dramatic overall disease reduction in incidence, hospitalizations and complicated cases has been observed in all age groups.

48th ICAAC/46th IDSA Annual Meeting: a pediatric perspective.

A combined meeting of the American Society of Microbiology and the Infectious Diseases Society of America was held recently in Washington, DC, USA, which gathered worldwide experts in the fields of infectious diseases, microbiology and the pharmaceutical industry, among others. Owing to its huge attendance and being among the largest conferences in the world during the year for infectious disease specialists, we focus only in the most relevant issues related to pediatric vaccines. Among others, we mention dengue, rotavirus, HIV, influenza virus, Streptococcus pneumoniae, Neisseria meningitidis, pertussis, measles and mumps. The case with mumps and measles illustrates the negative impact that vaccine refusal, fears and low coverage rates have on the resurgence of outbreaks produced by these two viruses. However, even with full vaccination schedules, other factors, such as waning immunity, influence the resurgence of these old diseases: pertussis, measles and mumps. This illustrates the importance of continuous surveillance in the epidemiology of vaccine-preventable diseases once a vaccine is licensed and introduced in a given population.

Pustular rash in Kawasaki syndrome.

The skin rash of Kawasaki syndrome is usually erythematous. A 23-month-old Costa Rican boy was admitted with a clinical picture compatible with Kawasaki syndrome, except for his skin lesions. He had diffuse, confluent, multiple sterile whitish pustular lesions on his chest, abdomen, neck, genitals, and thighs.

Immunogenicity and tolerability of inactivated flu vaccine in high risk and healthy children.

We conducted this open study to evaluate the immunogenicity and safety of the inactivated influenza vaccine, Imovax Gripe in 154 children between 6 and 36 months of age at high risk of influenza-related complications, and in a reference group of 64 healthy children. The study was conducted over two flu seasons, in which the vaccine contained the same A strains but different B strains. The results for the A/H3N2 and A/H1N1 strains from the two flu seasons were pooled, but those for the B strains were not. Anti-hemagglutinin (HA) antibody titers were determined before, and one month after each vaccination, and safety was evaluated based on diary card reporting any adverse event observed, either included or not in the list of "solicited events". Within each group of vaccines, the seroconversion rates, seroprotection rates, and ratio of post- to prevaccination geometric mean titers (GMTR) for the A/H3N2 and the A/H1N1 strains fulfilled all requirements of the criteria of the European Union Committee for Proprietary Medicinal Products (CPMP). The immune responses in high-risk and in healthy children were similar, and consistent with those observed in previous studies conducted in healthy children. The vaccine was equally well tolerated by all study groups. Reactogenicity was low and similar in both high-risk and healthy children. Overall from 9.5% to 15.4% of at-risk children and 12% of healthy children reported a solicited local reaction; 23.0 to 28.8% of high-risk and 25.3% of healthy children reported a solicited systemic reaction. The study results provide support for vaccination of children at high-risk of influenza related complications.

Immunogenicity and tolerability of inactivated flu vaccine In high risk and healthy children / Inmunogenicidad y tolerancia de la vacuna inactivada anti-influenza en niños en alto riesgo y en controles sanos

We conducted this open study to evaluate the immunogenicity and safety of the inactivated influenza vaccine, Imovax Gripe« in 154 children between 6 and 36 months of age at high risk of influenza- related complications, and in a reference group of 64 healthy children. The study was conducted over two flu seasons, in which the vaccine contained the same A strains but different B strains. The results for the A/H3N2 and A/H1N1 strains from the two flu seasons were pooled, but those for the B strains were not. Anti-hemagglutinin (HA) antibody titers were determined before, and one month after each vaccination, and safety was evaluated based on diary card reporting any adverse event observed, either included or not in the list of "solicited events". Within each group of vaccines, the seroconversion rates, seroprotection rates, and ratio of post- to prevaccination geometric mean titers (GMTR) for the A/H3N2 and the A/H1N1 strains fulfilled all requirements of the criteria of the European Union Committee for Proprietary Medicinal Products (CPMP). The immune responses in high-risk and in healthy children were similar, and consistent with those observed in previous studies conducted in healthy children. The vaccine was equally well tolerated by all study groups. Reactogenicity was low and similar in both high-risk and healthy children. Overall from 9.5% to 15.4% of at-risk children and 12% of healthy children reported a solicited local reaction; 23.0 to 28.8% of high-risk and 25.3% of healthy children reported a solicited systemic reaction. The study results provide support for vaccination of children at high-risk of influenza related complications.(AU)

Se realizó un estudio clínico abierto para evaluar la inmunogenícidad y la seguridad de la vacuna inactivada anti-influenza, Imovax Gripe«, en 154 niños entre 6 y 36 meses de edad con alto riesgo de complicaciones ligadas a la influenza, y en un grupo de referencia de 64 niños sanos. El estudio fue conducido en dos temporadas de gripe, durante las cuales la vacuna utilizada contenia las mismas cepas A pero diferentes cepas B. Los resultados para las cepas A/H3N2 y A/H1N1 de las dos temporadas de gripe fueron combinados ( pool de datos), pero no los de las cepas B. Los títulos de anticuerpos anti-hemaglutinina (HA) fueron determinados inmediatamente antes y un mes despues de cada vacunación, y la seguridad o tolerancia fue evaluada según la información de efectos adversos notificados, en cartillas para llenado diario, que incluían todos los eventos, figuraran o no en la lista de los "eventos solicitados". En cada grupo, las tasas de seroconversion y de seroprotección, y la razón de la media geométrica de títulos post-/ pre-vacunación (GMTR) para las cepas A/H3N2 y A/H1N1 cumplieron con todos los requisitos del Comité de Especialidades Farmacéuticas (CPMP) de la Unión Europea. Las respuestas inmunes fueron similares en los niños con alto riesgo y en los sanos, y consistentes con los resultados observados en los estudios anteriores en los niños sanos. La vacuna fue bien tolerada y la reactogenicidad fue baja y similar en los dos grupos de niños estudiados. Las reacciones locales listadas en la solicitud, fueron observadas en el 9.5 a 15.4% y en el 12% de niños con alto riego y sanos respectivamente; mientras que los síntomas sistémicos solicitados fueron observados en el 23.0 a 28.8% y el 25.3% de niños respectivamente. Los resultados de este estudio proveen informatión adicional a favor de la vacunación de niños con alto riesgo de complicaciones relacionadas con influenza.(AU)

Immunogenicity and tolerability of inactivated flu vaccine In high risk and healthy children / Inmunogenicidad y tolerancia de la vacuna inactivada anti-influenza en niños en alto riesgo y en controles sanos

We conducted this open study to evaluate the immunogenicity and safety of the inactivated influenza vaccine, Imovax Gripe® in 154 children between 6 and 36 months of age at high risk of influenza- related complications, and in a reference group of 64 healthy children. The study was conducted over two flu seasons, in which the vaccine contained the same A strains but different B strains. The results for the A/H3N2 and A/H1N1 strains from the two flu seasons were pooled, but those for the B strains were not. Anti-hemagglutinin (HA) antibody titers were determined before, and one month after each vaccination, and safety was evaluated based on diary card reporting any adverse event observed, either included or not in the list of "solicited events". Within each group of vaccines, the seroconversion rates, seroprotection rates, and ratio of post- to prevaccination geometric mean titers (GMTR) for the A/H3N2 and the A/H1N1 strains fulfilled all requirements of the criteria of the European Union Committee for Proprietary Medicinal Products (CPMP). The immune responses in high-risk and in healthy children were similar, and consistent with those observed in previous studies conducted in healthy children. The vaccine was equally well tolerated by all study groups. Reactogenicity was low and similar in both high-risk and healthy children. Overall from 9.5% to 15.4% of at-risk children and 12% of healthy children reported a solicited local reaction; 23.0 to 28.8% of high-risk and 25.3% of healthy children reported a solicited systemic reaction. The study results provide support for vaccination of children at high-risk of influenza related complications.

Se realizó un estudio clínico abierto para evaluar la inmunogenícidad y la seguridad de la vacuna inactivada anti-influenza, Imovax Gripe®, en 154 niños entre 6 y 36 meses de edad con alto riesgo de complicaciones ligadas a la influenza, y en un grupo de referencia de 64 niños sanos. El estudio fue conducido en dos temporadas de gripe, durante las cuales la vacuna utilizada contenia las mismas cepas A pero diferentes cepas B. Los resultados para las cepas A/H3N2 y A/H1N1 de las dos temporadas de gripe fueron combinados ( pool de datos), pero no los de las cepas B. Los títulos de anticuerpos anti-hemaglutinina (HA) fueron determinados inmediatamente antes y un mes despues de cada vacunación, y la seguridad o tolerancia fue evaluada según la información de efectos adversos notificados, en cartillas para llenado diario, que incluían todos los eventos, figuraran o no en la lista de los "eventos solicitados". En cada grupo, las tasas de seroconversion y de seroprotección, y la razón de la media geométrica de títulos post-/ pre-vacunación (GMTR) para las cepas A/H3N2 y A/H1N1 cumplieron con todos los requisitos del Comité de Especialidades Farmacéuticas (CPMP) de la Unión Europea. Las respuestas inmunes fueron similares en los niños con alto riesgo y en los sanos, y consistentes con los resultados observados en los estudios anteriores en los niños sanos. La vacuna fue bien tolerada y la reactogenicidad fue baja y similar en los dos grupos de niños estudiados. Las reacciones locales listadas en la solicitud, fueron observadas en el 9.5 a 15.4% y en el 12% de niños con alto riego y sanos respectivamente; mientras que los síntomas sistémicos solicitados fueron observados en el 23.0 a 28.8% y el 25.3% de niños respectivamente. Los resultados de este estudio proveen informatión adicional a favor de la vacunación de niños con alto riesgo de complicaciones relacionadas con influenza.

[Kikuchi-Fujimoto disease in pediatric population: a case report and a review of literature]. / Enfermedad de kikuchi-fujimoto en pediatría. Reporte de un caso y revisión de la literatura.

A 10 year-old child, with a history of a right cervical mass, is admitted to the Costa Rican National Children's Hospital for workup. The mass appeared approximately 4 weeks before admission. Laboratory tests were performed and malignity, infection and immunologic causes were ruled out. A biopsy was performed revealing granulomas characterized by central necrosis with abundant karyorrhexis, surrounded by histiocytes, lymphocytes and giant multinucleated cells, without neutrophils. Special stains showed no microorganisms. Once infectious and immunologic causes were excluded, and based on the biopsy's result, treatment was ruled out. Twelve months later, the patient is still asymptomatic; therefore, the diagnosis of a Kikuchi-Fujimoto syndrome was proposed. This report constitutes the first pediatric case diagnosed in our country.

Enfermedad de Kikuchi-Fujimoto en pediatría: Reporte de un caso y revisión de la literatura / Kikuchi-Fijimoto disease in pediatric population: a case report and a review of literature

Un niño de 10 años de edad fue ingresado al Hospital Nacional de Niños "Dr. Carlos Luis Sáenz Herrera" con una masa cervical derecha de aproximadamente cuatro semanas de evolución. Se realizaron pruebas de gabinete y laboratorio que descartaron malignidad, infecciones o procesos inmunológicos. Una biopsia a cielo abierto reportó la presencia de granulomas con necrosis central, abundante cariorrexis, histiocitos, linfocitos y células gigantes multinucleadas, sin neutrófilos. Las tinciones especiales no mostraron ningún microorganismo. En valoraciones posteriores al mes, a los seis y 12 meses el niño continuaba asintomático. Por no tener etiología precisa, no se administró ningún medicamento. Con base en la evolución clínica, los hallazgos de la biopsia y al excluirse causas infecciosas, tumorales e inmunológicas, se concluyó que el paciente presentó una enfermedad de Kikuchi Fujimoto, siendo el primer caso pediátrico reportado en nuestro país.

A 10 year-old child, with a history of a right cervical mass, is admitted to the Costa Rican National Children's Hospital for workup. The mass appeared approximately 4 weeks before admission. Laboratory tests were performed and malignity, infection and immunologic causes were ruled out. A biopsy was performed revealing granulomas characterized by central necrosis with abundant karyorrhexis, surrounded by histiocytes, lymphocytes and giant multi-nucleated cells, without neutrophils. Special stains showed no microorganisms. Once infectious and immunologic causes were excluded, and based on the biopsy's result, treatment was ruled out. Twelve months later, the patient is still asymptomatic; therefore, the diagnosis of a Kikuchi-Fujimoto syndrome was proposed. This report constitutes the first pediatric case diagnosed in our country.

Systemic host inflammatory and coagulation response in the Dengue virus primo-infection.

BACKGROUND: Dengue virus infection has been rising in tropical countries. Clinical manifestations range from fever and general malaise to hemorrhagic manifestations and death. The role of endothelial damage and cytokines has not been well established for dengue infection. OBJECTIVE: Determine the profile of the pro-inflammatory cytokines and several markers of coagulopathy of dengue infection. METHODS: Patients admitted between September 2000 and April 2001, who met the WHO dengue diagnosis criteria, were enrolled. Blood samples were collected at 0, 6, 12, 24, 48, 72 h and 5 and 7 days after hospitalization. Profile of pro-inflammatory cytokines, markers of coagulopathy, protein C, protein S, d-dimer, prothrombin time, activated partial thromboplastin time, fibrinogen and activated protein C levels were determined. RESULTS: Thirty-three patients were enrolled. Median (range) age was 31 (13-70) years; 51.5% (17/33) were female. Ten of 33 (30%) presented with hemorrhagic manifestations. Patients were classified: Grade 1: 23/33 (70%), Grade II: 10/33 (30%). At study entry IL-6 was the most elevated, followed by IL-8 and TNF alpha. IL-10 was not elevated. No significant differences (P < 0.05) were demonstrated in the levels of any of the haemostatic or cytokine markers by disease severity (Grade I versus Grade II patients). CONCLUSION: The systemic host inflammatory and coagulation activation response occurs early in patients with dengue viral infection in the absence of severe hemorrhagic manifestations, and provides the basis for considering future clinical study in the use of recombinant human activated protein C to treat patients with severe sepsis from dengue infection.