Paediatric snakebite envenoming: recognition and management of cases.

Snakebite in children can often be severe or potentially fatal, owing to the lower volume of distribution relative to the amount of venom injected, and there is potential for long-term sequelae. In the second of a two paper series, we describe the pathophysiology of snakebite envenoming including the local and systemic effects. We also describe the diagnosis and management of snakebite envenoming including prehospital first aid and definitive medical and surgical care.

Paediatric snakebite envenoming: the world's most neglected 'Neglected Tropical Disease'?

Snakebite disproportionally affects children living in impoverished rural communities. The WHO has recently reinstated snakebites on its list of Neglected Tropical Diseases and launched a comprehensive Strategy for the Prevention and Control of Snakebite Envenoming. In the first of a two paper series, we describe the epidemiology, socioeconomic impact and key prevention strategies. We also explore current challenges and priorities including the production and distribution of safe and effective antivenom.

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.

Epidemiological burden of invasive pneumococcal disease in children and adolescents with predisposing risk factors.

OBJECTIVE: Some medical conditions constitute important risk factors for the development of invasive pneumococcal diseases in children and adolescents aged from 5 to 19 years. Conjugate vaccines have potential efficacy in this scenario, but are not available in many Latin American public healthcare systems for this age group. This study aimed to estimate the preventable fraction of invasive pneumococcal diseases among individuals aged from 5 to 19 years with associated risk factors for its development. METHODS: Data regarding the Latin America population, risk factors prevalence and conjugate vaccines efficacy were obtained from the literature. RESULTS: Total population at risk ranged from 17.3 to 64.6 million of individuals and asthma was the most impacting risk factor. According to SIREVA, PCV13 provided a 62.9% serotypes coverage in individuals from 5 to 29 years in 2012, potentially increasing the covered population from [8,338,457-31,057,620] with PCV10 to [10,906,356-40,622,078] with PCV13. To date, according to available efficacy data, the hypothetically immunized population ranged from 11.4 to 42.4 million, representing 7.0% to 26.0% of the total population in this age group. CONCLUSIONS: Vaccination in risk groups should be encouraged, as it potentially contributes to the reduction in the number of cases of invasive pneumococcal disease.

The challenge of changing the inactivated poliomyelitis vaccine in Latin America: declaration of the Latin American Society of Pediatric Infectious Diseases (SLIPE).

Even though we have already covered 99% of the path to eradicate poliomyelitis from the world, this disease is still causing paralysis in children. Its eradication means not only the end of wild poliovirus circulation, but vaccine-derived poliovirus circulation as well. Taking into account different factors such as: current epidemiological data, adverse events of the attenuated oral poliomyelitis vaccine (OPV), the availability of an injectable inactivated vaccine (IPV) without the potential of causing the severe adverse events of the oral vaccine (OPV), the efficacy and effectiveness of the IPV in several countries of the world where it has been used for several years, the rationale of changing the vaccination schedule in different Latin American countries; the Latin American Society of Pediatric Infectious Diseases (SLIPE) announces its recommendation of switching to IPV in Latin America, by this Declaration, with an Action Plan for 2014-2015 period as regards vaccination against polio policies in Latin America. 1. The optimal proposed schedule consists of four IPV doses (three doses in the primary schedule plus a booster dose), whether IPV is combined or not with other indicated vaccines in the immunization program of the country. During the OPV to IPV transition phase, an alternative schedule is acceptable; 2. Countries should set optimal strategies in order to maintain and improve vaccination coverage, and implement a nominal immunization registry; 3. Improving the Epidemiological Surveillance of Acute Flaccid Paralysis (AFP) and setting up an environmental surveillance program; 4. Setting up strategies for introducing IPV in National Immunization Programs, such as communicating properly with the population, among others; 5. Bringing scientific societies closer to decision makers; 6. Ensuring optimal supply and prices for IPV introduction; 7. Training vaccination teams; 8. Enhancing the distribution and storing logistics of vaccines. In addition to the scientific evidence, the countries that have not yet decided to switch to IPV should consider the implications of equity and social justice.

Hepatitis A as an etiologic agent of acute liver failure in Latin America.

BACKGROUND: This prospective, multicenter study examined the importance of hepatitis viruses as etiological agents of acute liver failure (ALF) and the outcome of ALF cases in Latin American children and adolescents. METHODS: The study was conducted for minimum 12 months in 9 centers in Argentina, Brazil, Chile, Colombia, Costa Rica, and Mexico during 2001-2002. Hospitalized patients aged 1-20 years with a suspected diagnosis of ALF were included in the study and tested for serologic markers for hepatitis A, B, and C viruses. RESULTS: Of the 106 patients enrolled, 88 were included in the analysis. Median age was 5 years, and 55% with ALF were aged 1-5 years. A total of 37 individuals (43%) tested positive for anti-hepatitis A virus (HAV) immunoglobulin M (IgM) as marker of acute HAV infection; one was positive for anti-hepatitis B core antigen IgM and negative for hepatitis B surface antigen. None had markers of hepatitis C virus infection. Mortality rates in the overall study cohort (45%) and for those who tested anti-HAV IgM positive (41%) were similar. Forty-one percent of all patients and 46% of those positive for anti-HAV IgM underwent transplantation. The mortality rate in those with liver transplantation was half of that in patients who were not transplanted (28% versus 57%). CONCLUSIONS: HAV was the main etiologic agent of ALF in the population studied.

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.

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.

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)

Prospective multinational study of pertussis infection in hospitalized infants and their household contacts.

BACKGROUND: Increased incidence of pertussis has been noted among infants too young to be immunized. We studied the disease burden of pertussis in pediatric intensive care units and the source of infection in several Asian, European and Latin American countries. METHODS: The study was conducted in 7 countries from September 2001 to January 2004. Children <1 year of age were enrolled from pediatric intensive care units (PICU) and pediatric wards if they presented with respiratory failure, apnea, bradycardia, or cough accompanied by paroxysms, vomiting, whoop or cyanosis. Household members of pertussis-positive index cases were asked to answer a questionnaire and provide diagnostic specimens. RESULTS: Pertussis was confirmed in 99 infants (12%) of 823 infants included in the analysis: 10 of 90 (11%) in Brazil, 9 of 88 (10%) in Costa Rica, 11 of 145 (8%) in Germany, 13 of 147 (9%) in Singapore, 29 of 67 (43%) in Spain, 2 of 86 (2%) in Taiwan and 25 of 200 (13%) in Uruguay. However, sensitivity analysis indicated that these figures were conservative. The mean (+/- SD) average age of infection was 2.6 +/- 2.2 months. Pertussis was found among 96 of 269 (36%) of household contacts investigated. At least one household contact was identified as the source of infection in 24 of 88 (27%) of the PICU cases and mothers were identified as being the most frequent source of infection. CONCLUSION: Although regional differences exist, severe pertussis represents a considerable global disease burden. Since most infants are infected before vaccination and concomitant protection is completed, household contacts should be targeted for booster vaccination to reduce the pertussis reservoir.

Neumología por Streptococus pneumoniae resistente a penicilina y cefalosporinas de tercera generación: reporte del primer caso en el HNN / Pneumonia by Streptococus pneumoniae resistant a penicilin and cephalosporins of third generation: Report of the first case in the HNN

Se describe el caso de una niña de seis años que consultó en varias ocasiones por presentar tos, fiebre alta, dificultad respiratoria y esputo purulento. Recibió multiples tratamientos antibióticos, vía intramuscular y endovenosa con penicilinas, siendo la respuesta inadecuada. Se documentó clínica y radiológicamente la presencia de una neumonía, razón por la cual se amplió cobertura antibiótica a cefotaxime. Se aisló Streptococcus pneumoniae del cultivo de esputo, mostrando resistencia a penicilina y cefalosporinas de tercera generación. En nuestro medio, constituye el primer caso reportado de neumonía por neumococo con un patrón de resistencia múltiple a penicilina y cefalosporinas de tercera generación.