La enfermedad meningocócica por bacteria infecciosa en Ecuador

Introducción: La meningitis puede ocurrir a cualquier edad y en individuos previamente sanos; concierne a la inflamación de las meninges por bacterias piógenas. La enfermedad meningocócica bacteriana prevalece en todo el mundo y constituye una emergencia médica con una alta morbilidad y mortalidad. Objetivo: Evaluar la sintomatología de la enfermedad meningocócica en Ecuador. Método: Se realizó una investigación de tipo cualicuantitativa, se llevó a cabo una revisión bibliográfica exhaustiva en buscadores bibliográficos con la búsqueda de palabras claves: enfermedad meningocócica por bacteria infecciosa. Se estudió el universo constituido por 151 pacientes afectados. Las variables edad en años de los afectados, factores de riesgo dependientes y síntomas presentes permitió a los autores plantear las conclusiones. Resultados: El 56,30 % de la población es de sexo masculino, con una edad promedio de aproximadamente 10 meses. El 63,58 % población de estudio es menor de 1 año de edad, la cantidad de síntomas presentados fue variable, del 11 % con 4 o más síntomas y el 47 % con un síntoma. La mala higiene en las personas se presentó en un 35,20 %. La sintomatología está relacionada con el consumo de caracoles y agua sin hervir. Conclusiones: La enfermedad meningocócica ocasiona daños a nivel del cerebro y medula espinal y su número de infecciones ha incrementado en los últimos años. La limpieza inadecuada de los alimentos supone un riesgo para adquirir la enfermedad. Los síntomas más frecuentes son: afectación neurológica, convulsiones, vómitos y náuseas, además la presencia de eosinófilos en sangre y líquido cefalorraquídeo.

Introduction: Meningitis can affect at any age and healthy individuals; it´s the inflammation of the meninges caused by the infection with pyogenic bacteria. Meningococcal disease is prevalent worldwide and constitutes a medical emergency with high morbidity and mortality. Objective: To assess the symptomatology of meningococcal disease in Ecuador. Method: A qualitative-quantitative research was carried out, an exhaustive bibliographic review was conducted in bibliographic search engines with the use of keywords: meningococcal disease caused by infectious bacteria. A total of 151 affected patients (as universe) were studied. The variables: age of those affected patients, dependent risk factors and symptoms present, helped in the authors final conclusions. Results: The 56.30% of the studied population was male, with an average age of approximately 10 months. The 63.58% of the studied population is under 1 year of age, the number of symptoms presented was variable, 11% with 4 or more symptoms and 47% with one symptom. Poor hygiene was presented in 35.20%. Symptomatology is related to the consumption of snails and unboiled water. Conclusions: Meningococcal disease causes damage to the brain and spinal cord, and infections has increased in recent years. Inadequate food sanitation is one of the risks for acquiring the disease. The most frequent symptoms are: neurological involvement, convulsions, vomiting and nausea, as well as the presence of eosinophils in blood and cerebrospinal fluid.

Introdução: A meningite pode ocorrer em qualquer idade e em indivíduos previamente saudáveis; diz respeito à inflamação das meninges por bactérias piogênicas. A doença meningocócica bacteriana é prevalente em todo o mundo e constitui uma emergência médica com alta morbidade e mortalidade. Objetivo: Avaliar os sintomas da doença meningocócica no Equador. Método: Realizou-se uma investigação quali-quantitativa, realizou-se uma revisão bibliográfica exaustiva em buscadores bibliográficos com a busca das palavras-chave: doença meningocócica por bactéria infecciosa. Foi estudado o universo constituído por 151 pacientes acometidos. As variáveis idade em anos dos afetados, fatores de risco dependentes e sintomas presentes permitiram aos autores tirar conclusões. Resultados: 56,30% da população é do sexo masculino, com idade média de aproximadamente 10 meses. 63,58% da população estudada é menor de 1 ano, o número de sintomas apresentados foi variável, 11% com 4 ou mais sintomas e 47% com um sintoma. A má higiene das pessoas foi apresentada em 35,20%. Os sintomas estão relacionados ao consumo de caracóis e água não fervida. Conclusões: A doença meningocócica causa danos ao cérebro e à medula espinhal e o número de infecções aumentou nos últimos anos. A limpeza inadequada dos alimentos representa um risco para a aquisição da doença. Os sintomas mais frequentes são: comprometimento neurológico, convulsões, vômitos e náuseas, além da presença de eosinófilos no sangue e líquido cefalorraquidiano.

Serogrupos y resistencia antimicrobiana de Neisseria meningitidis causantes de enfermedad invasiva en Paraguay

RESUMEN La enfermedad meningocócica representa un problema de salud pública y una de las principales causas de morbilidad y mortalidad en todo el mundo. Los serogrupos que causan la mayor carga de enfermedad a nivel global son A, B, C, W e Y. El objetivo del estudio fue describir los serogrupos y la resistencia antimicrobiana de Neisseria meningitidis aisladas de enfermedad invasiva en Paraguay durante el periodo 2010-2020. Se estudiaron todas las muestras de líquido cefalorraquídeo y sangre con aislamientos o detección de ADN por PCR de N. meningitidis de pacientes de diversas edades, que fueron remitidas al Laboratorio Central de Salud Pública durante el periodo 2010-2020, dentro del marco de la vigilancia epidemiológica de meningitis (n=163) en Paraguay. La mayor frecuencia de hallazgos de N. meningitidis se observó en el grupo de edad de < 1 año. El 25,7% de los casos correspondió al serogrupo B, el 52,1% al serogrupo C, 18,4% al serogrupo W y 3,7% al serogrupo Y. En el 2018, se evidenció la mayor cantidad de casos por serogrupo C (n=27). La menor frecuencia de sensibilidad disminuida a penicilina G fue en el 2010 (12,5%) y la mayor en el 2014 (100,0%). Se registró un aumento de casos por serogrupo C a partir del 2017, posicionándose como serogrupo prevalente hasta el 2020, y además, un aumento de la sensibilidad disminuida a la penicilina. La vigilancia es de importancia en el control de la enfermedad meningocócica para detección de brotes, estimación de la carga de enfermedad, análisis de resistencia antimicrobiana, distribución de serogrupos y evaluaciones de estrategias de control.

ABSTRACT Meningococcal disease represents a public health problem and one of the main causes of morbidity and mortality worldwide. The serogroups that cause the highest burden of disease globally are A, B, C, W, and Y. The aim of the study was to describe serogroups and antimicrobial resistance of Neisseria meningitidis isolated from invasive disease in Paraguay during the 2010-2020 period. Samples of cerebrospinal fluid and blood with isolates or detection of DNA by PCR of N. meningitidis from patients of different ages referred to the Central Public Health Laboratory during the period 2010-2020 within the framework of the epidemiological surveillance of meningitis (n = 163) in Paraguay were studied. The highest frequency of N. meningitidis findings was observed in the <1 year age group, 25.7% of the cases corresponded to serogroup B, 52.1% to serogroup C, 18.4% to serogroup W and 3.7% to serogroup Y. In 2018, the highest number of cases by serogroup C (n = 27) was found. The lowest frequency of decreased sensitivity to penicillin G was in 2010 (12.5%) and the highest in 2014 (100.0%). There was an increase in cases due to serogroup C in 2017, positioning itself as the prevalent serogroup until 2020, in addition, there was an increase in decreased sensitivity to penicillin. Surveillance is important in the control of meningococcal disease for outbreak detection, estimation of the burden of disease, analysis of antimicrobial resistance, serogroup distribution, and evaluations of control strategies.

Evolución de la vacunación frente al meningococo del serogrupo B: ¿qué ha cambiado a lo largo de 5 años? / Evolution of vaccination against serogroup B meningococcus: what has changed over 5 years?

Introducción: la infección por meningococo del serogrupo B puede provocar enfermedad meningocócica invasiva, con un 20-30% de secuelas y hasta un 10% de mortalidad. Material y métodos: estudio observacional, descriptivo y retrospectivo de vacunación frente al meningococo del serogrupo B en la población pediátrica del Sector I de Zaragoza desde octubre de 2015 hasta diciembre de 2019. Se estudió: edad de inicio de la vacunación, edad a la fecha de la primera dosis (≤3 meses, 4-11 meses, 12-23 meses, 2-9 años, 10-16 años), sexo, centro de salud (CS) y número de dosis recibidas. Resultados: se vacunó a 11 776 pacientes, de los cuales un 51,6% fueron varones. Presentaron una edad media de inicio de vacunación a los 5,0 ± 4,4 años y 2,2 ± 0,6 dosis recibidas. La distribución del total de vacunados fue muy variada, con una diferencia del 17,8% entre el CS con más vacunados y el CS con menos vacunados. El 0,7% recibieron primera dosis en 2015, el 23,8% en 2016, el 38% en 2017, el 26,7% en 2018 y el 10,8% en 2019. El 12% tenía ≤3 meses al inicio de la vacunación, el 11,5% tenía 4-11 meses, el 6,7% tenía 12-23 meses, el 50,4% 2-9 años y el 19,5% 10-16 años, existiendo diferencias en relación con la fecha de primera dosis (p = 0,000). El 2017 cuenta con mayor incidencia de vacunación global (12,2%), aunque en lactantes fue superior en 2018 (42,1%) y en los grupos de 2-9 años y adolescentes en 2017: el 15,8 y el 5,4% respectivamente. La incidencia global acumulada fue 32,5%, siendo en lactantes de 133,5%. Conclusiones: a pesar de las prometedoras cifras de incidencia acumulada, encontramos numerosas diferencias de vacunación entre grupos de edad y CS, por lo que resulta interesante la vacunación sistemática y financiada de meningococo B (AU)

Introduction: infection by serogroup B meningococcus can cause invasive meningococcal disease, with development of sequelae in 20-30% of cases and a mortality of up to 10%.Material and methods: observational, descriptive and retrospective study of vaccination against serogroup B meningococcus in the paediatric population of health sector I of Zaragoza between October 2015 and December 2019. We analysed the age at primary vaccination, age group at time of first dose (≤3 months, 4-11 months, 12-23 months, 2-9 years, 10-16 years), sex, primary care centre (PCC) and number of received doses.Results: 11 776 patients were vaccinated, of who 51.6% were male. The mean age at initiation of vaccination was 5.0 ± 4.4 years, and they received a mean of 2.2 ± 0.6 doses. The distribution of vaccinated patients by PCC was heterogeneous, with a difference of 17.8% between the centre with the most vaccinated patients and the centre with the least. Of all patients, 0.7% received the first dose in 2015, 23.8% in 2016, 38% in 2017, 26.7% in 2018 and 10.8% in 2019. Twelve percent were aged 3 months or less when they received the first dose, 11.5% 4-11 months, 6.7% 12-23 months, 50.4% 2-9 years and 19.5% 10-16 years, with differences based on the date of the first dose (p = 0.000). The highest frequency of overall vaccination corresponded to 2017 (12.2%), although in children under 2 years it was higher in 2018 (42.1%) and in children aged 2-9 years and adolescents it was highest in 2017: 15.8% and 5.4%, respectively. The cumulative frequency of vaccination was 32.5% in the overall sample and 133.5% in the group aged less than 2 years.Conclusions: although we found promising cumulative vaccination rates, there were numerous differences in vaccination between age groups and PCCs, which is why publicly funded routine vaccination against meningococcus B is worth contemplating. (AU)

[Serogroup C invasive meningococcal disease in the post-vaccine era and vaccine failures]. / Enfermedad meningocócica invasiva por serogrupo C en la era posvacunal y fallos vacunales.

INTRODUCTION: The incidence of serogroup C invasive meningococcal disease (IMD) has decreased since the introduction of systematic vaccination in 2000. The aim of this study is to determine the number of serogroup C IMD cases diagnosed since then and the vaccine failures. PATIENTS AND METHODS: A retrospective analysis was performed on patients diagnosed with IMD by culture or polymerase chain reaction (PCR) in a maternity and childhood hospital in Barcelona between 2001 and 2018. An analysis was made of the number of vaccine doses and the age received, as well as on the medical records and vaccine cards. RESULTS: There were 128 confirmed cases of IMD (7.1 cases/year; 70.3 in <5 years). The serogroup was studied in 125 (97.6%) cases, in which 103 (82.4%) were B, 10 (8%) were C, one (0.8%) was 29E, and one (0.8%) was Y, and only 10 (8%) were not able to be serogrouped. Of the 10 patients with serogroup C, 4 were not vaccinated, and in 3, the course was not complete as regards the number of doses. The other 3 received the complete course according to age and current calendar, and thus were considered vaccine failures. A total of 6 patients died (mortality rate: 4.7%), 5 due to serogroup B (mortality: 4.8%), and one due to serogroup C (mortality: 10%). CONCLUSIONS: Serogroup C only represented 8% of IMD cases in the period studied, with 30% of cases due to this serogroup being vaccine failures.

Priorización de nuevas vacunas e innovación al servicio de estrategias de vacunación / New vaccines prioritization and immunization-related innovation

La vacunación es el medio más efectivo para controlar la morbilidad y mortalidad relacionadas con enfermedades infecciosas. Para lograr esto, necesitamos vacunas inmunogénicas y seguras que faciliten y mejoren sus condiciones de transporte, almacenamiento y administración. Gracias a los avances en inmunología y bioinformática, es posible impulsar el descubrimiento de nuevas vacunas para enfrentar la tuberculosis, el virus respiratorio sincicial, el Streptococcus agalactiae, la enfermedad meningocócica invasora, entre otros. Así también, nuevas tecnologías, como la producción de vacunas utilizando plantas transgénicas y parches de microagujas, los cuales podrían facilitar la producción, disminuir los costos y efectos adversos. Sin embargo, no solo necesitamos las vacunas, sino que debemos conocer la epidemiología de las enfermedades prevenibles con vacuna para tomar decisiones fundadas, con el objetivo de planificar estrategias sanitarias, medir su impacto y evaluar la seguridad de su utilización, para alcanzar las metas de salud pública y la confianza de la población.

Vaccination is the most effective strategy to avoid morbidity and mortality related to infectious diseases. To achieve this, we need immunogenic and safe vaccines that facilitate and improve its transport, storage and administration conditions. Thanks to current advances in immunology and bioinformatics, it is possible to boost the discovery of new vaccines to deal with tuberculosis, the respiratory syncytial virus, Streptococcus agalactiae, meningococcal invasive disease, among others. In addition to new technologies such as the production of plant-based vaccines, and microneedles patches, which can facilitate its production, reducing costs and adverse effects. However, vaccines is not the only thing that we need, because we must know the epidemiology and burden of disease to take informed decisions to design optimal strategies, measuring their impact and assessing the safety of their use in order to achieve the goals health and population confidence.

Vacuna cubana antimeningocócica VA-MENGOC-BC®: Treinta años de uso y potencialidades vigentes / Cuban Meningococcal Vaccine VA-MENGOC-BC®: 30 Years of Use and Future Potential

La enfermedad meningocócica provoca cada año más de 500.000 casos y 85.000 muertes en el mundo y un 20 por ciento de los sobrevivientes sufre secuelas. En Cuba, en 1980, la incidencia llegó a 14,4 por 100.000 habitantes para todas las edades y fue declarada como el principal problema de salud del país. En niños menores de 1 año se reportaron más de 120 casos por 100.000 habitantes en algunas provincias. En 1989, investigadores en La Habana, Cuba desarrollaron una vacuna contra meningococo B y C; VA-MENGOC-BC®, la primera en el mundo eficaz contra el meningococo del serogrupo B. Su eficacia de 83 por ciento se demostró en un estudio de campo prospectivo a doble ciegas, aleatorizado, contra placebo. En su producción se empleó por primera vez la tecnología vesicular o proteoliposómica. Esta vacuna se usó en una campaña de vacunación masiva y posteriormente fue incluida en el Programa Ampliado de Inmunización en Cuba y tuvo un impacto acumulado sobre la incidencia de la enfermedad meningocócica del serogrupo B superior a 95 por ciento (93 por ciento-98 por ciento). La vacunación masiva y sistemática cambió el espectro de cepas del meningococo en los portadores asintomáticos sanos y la circulación de cepas en las poblaciones hacia fenotipos no virulentos. La enfermedad dejó de ser un problema de salud en el país. VA-MENGOC-BC® es la vacuna contra la enfermedad meningocócica del serogrupo B que se aplicó en el mayor número de susceptibles en el mundo. En América Latina se administraron más de 60 millones de dosis. En varios países donde se ha usado VA-MENGOC-BC®, circulan cepas diferentes a la vacunal y contra todas ellas se demostró un elevado porcentaje de efectividad (55%-98 por ciento en menores de 4 años y 73 por ciento-100 por ciento en mayores de 4 años). VA-MENGOC-BC® y su tecnología proteoliposómica han tenido impacto y mantienen su potencialidad, no solo en la enfermedad meningocócica, sino en el desarrollo de otras vacunas y adyuvantes(AU)

Every year, meningococcal infection by Neisseria meningitidis causes over 500,000 cases and 85,000 deaths in the world, with 20 percent of survivors suffering sequelae. In Cuba its incidence in 1980 reached 5.9 cases per 100,000 population; about 80 percent of cases were serogroup B, prompting health authorities to declare meningococcal disease the country's main public health problem. Several provinces reported over 120 cases per 100,000 children aged <1 year, overwhelmingly serogroup B. At that time, no vaccines existed with proven efficacy against N. meningitidis serogroup B, nor was there a vaccine candidate that could be successful in the short term. By 1989, researchers in Havana had developed a Cuban meningococcal B and C vaccine, VA-MENGOC-BC®, the world's first against serogroup B meningococcal disease. Its efficacy of 83 percent was demonstrated in a prospective, randomized, double-blind, placebo-controlled field study. Vaccine production used vesicle or proteoliposome technology for the first time. The same year, the World Intellectual Property Organization awarded its gold medal to the main authors of the VA-MENGOC-BC® patent. The vaccine was used in a mass vaccination campaign and later included in Cuba's National Immunization Program, with a cumulative impact on incidence of serogroup B meningococcal disease greater than 95 percent (93 percent-98 percent). Mass, systematic vaccination shifted the spectrum of meningococcal strains in healthy asymptomatic carriers and strains circulating among population groups toward nonvirulent phenotypes. The disease ceased to be a public health problem in the country. VA-MENGOC-BC® is the most widely applied vaccine against serogroup B meningococcal disease in the world. Over 60 million doses have been administered in Latin America. In several countries where it has been applied, in which strains other than the vaccine-targeted strains circulate, VA-MENGOC-BC® has demonstrated effectiveness against all (55 percent-98 percent in children aged ≥4 years and 73 percent-100 percent in children aged >4 years). The vaccine and its proteoliposome technology have had an impact and continue to have potential, not only for meningococcal disease, but also for development of other vaccines and adjuvants(AU)

Genotipos de Neisseria meningitidis aislados de pacientes con enfermedad meningocócica en Paraguay, 1996-2015 / Genotypes of Neisseria meningitidis isolates in patients with meningococcal meningitis in Paraguay, 1996-2015 / Genótipos de Neisseria meningitidis isolados de pacientes com doença meningocócica no Paraguai, 1996-2015

RESUMEN Objetivo Describir las características fenotípicas y genotípicas de cepas de Neisseria meningitidis aisladas de enfermedad meningocócica en Paraguay entre 1996 y 2015. Métodos Se estudiaron por métodos microbiológicos convencionales y técnicas moleculares 114 aislamientos de N. meningitidis y 12 muestras clínicas sin aislamiento confirmadas por reacción en cadena de la polimerasa (PCR) que fueron remitidas por los diferentes centros centinelas y centros colaboradores de Paraguay. Resultados El grupo de edad más afectado fue el de menores de 1 año (19,0%), seguido por el de 1 a 5 años (17,5%). Un mayor porcentaje de las cepas se aisló de casos de meningitis (81,7%) y el serogrupo B se encontró en 60,3% de los casos. Los fenotipos más frecuentes fueron B:4:P1.14 (16,0%), B:15:P1.5, C:NT:NST y W:NT:P1.2 (10,5%), respectivamente. Los complejos clonales prevalentes fueron ST-11/ET37 complex 29,6% (8/27) con predominio del serogrupo W (6/8), ST-35 complex 18,5% (5/27) en el serogrupo B (4/4), y ST-32/ET5 complex 14,8% (4/16) en el serogrupo B (5/5). Conclusiones En Paraguay la enfermedad meningocócica es relativamente infrecuente. Los análisis de distribución de serogrupo muestran que el más frecuente es el B y en los últimos dos años aumentaron los casos de enfermedad meningocócica por C y W. Los complejos clonales encontrados se correlacionan con los hallados en la región del Cono Sur. Debido al alto nivel de virulencia de N. meningitidis, su vigilancia debe constituir una prioridad estratégica de los sistemas de salud pública nacionales y regionales para prevenir brotes epidémicos y apoyar la toma de decisiones en salud pública.

ABSTRACT Objective Describe the phenotypical and genotypical characteristics of Neisseria meningitidis isolates from cases of meningococcal disease in Paraguay between 1996 and 2015. Methods Conventional microbiological methods and molecular techniques were used to study 114 isolates of N. meningitidis and 12 clinical samples without isolation (confirmed by polymerase chain reaction), provided by various sentinel centers and collaborating centers in Paraguay. Results The most affected age group was children under 1 year (19.0%), followed by 1-5-year-olds (17.5%). The highest percentage of strains was isolated in meningitis cases (81.7%) and serogroup B was found in 60.3% of cases. The most frequent phenotypes were B:4:p1.14 (16.0%), B:15:p1.5, C:nt:nst, and W:nt:p1.2 (10.5%), respectively. The prevalent clonal complexes were: ST-11/ET37 complex, 29.6% (8/27), predominantly serogroup W (6/8); ST-35 complex, 18.5% (5/27), in serogroup B (4/4); and ST-32/ET5 complex, 14.8% (4/16), in serogroup B (5/5). Conclusions Meningococcal meningitis is relatively uncommon in Paraguay. Distribution analysis showed that serogroup B is the most common and that the number of cases of meningococcal disease caused by serogroups C and W increased in the last two years. The identified clonal complexes were correlated with those found in the Southern Cone region. Due to the high virulence of N. meningitidis, its surveillance should be a strategic priority of national and regional public health systems to prevent epidemic outbreaks and support public health decision-making.

RESUMO Objetivo Descrever as características fenotípicas e genotípicas de cepas de Neisseria meningitidis isoladas de casos de doença meningocócica no Paraguai entre 1996 e 2015. Métodos Foram estudados por métodos microbiológicos convencionais e técnicas moleculares 114 isolados de N. meningitidis e 12 amostras clínicas sem isolamento confirmadas por reação em cadeia da polimerase (PCR) enviados por diferentes centros-sentinela e centros colaboradores do Paraguai. Resultados A faixa etária mais afetada foi a de crianças menores de 1 ano (19,0%) e crianças de 1 a 5 anos (17,5%). Uma maior porcentagem de cepas foi isolada de casos de meningite (81,7%) e o sorogrupo B foi identificado em 60,3% dos casos. Os fenótipos mais comuns foram B:4:P1.14 (16,0%), B:15:P1.5, C:NT:NST e W:NT:P1.2 (10,5%), respectivamente. Os complexos clonais mais prevalentes foram o complexo ST-11/ET37 (29,6%, 8/27) com predomínio no sorogrupo W (6/8), complexo ST-35 (18,5%, 5/27) no sorogrupo B (4/4) e complexo ST-32/ET5 (14,8%, 4/16) no sorogrupo B (5/5). Conclusões A doença meningocócica é relativamente pouco comum no Paraguai. A análise da distribuição dos sorogrupos demonstrou que o sorogrupo B é o mais prevalente e, nos últimos dois anos, ouve um aumento nos casos de doença meningocócica pelos sorogrupos C e W. Os complexos clonais encontrados se correlacionam com os achados na região do Cone Sul. Devido à alta virulência da N. meningitidis, a vigilância deste agente deve ser uma prioridade estratégica dos sistemas de saúde pública nacionais e regionais para prevenir surtos epidêmicos e subsidiar a tomada de decisão em saúde pública.

Púrpura en los pies: Meningococcemia? Reporte de caso clínico y revisión de la literatura / Purpura in the feet: Meningococcemia? Clinical case report and literature review

Neisseria meningitidis es la etiología de infecciones severas incluso letales, afectando principalmente a la población joven. No obstante, dado que el único reservorio es la nasofaringe humana, hay portadores asintomáticos. El meningococo es sensible a los antibióticos de uso habitual, como: cefalosporinas de tercera generación y quinolonas, pero el retraso en el diagnóstico por presentaciones clínicas infrecuentes y la administración tardía de la terapia, se asocian a elevada morbimortalidad. Presentamos una paciente de 18 años, con un cuadro de rápida evolución, con parámetros inflamatorios de laboratorio alterados, asociado a lesiones cutáneas purpúricas, que evolucionó con falla multiorgánica y desenlace fatal, lográndose la confirmación etiológica por el Instituto de Salud Pública. Reportamos el caso para tener en consideración el diagnóstico de meningococcemia, frente a pacientes con cuadro clínico y exámenes de laboratorio sugerentes de sepsis, que presentan lesiones cutáneas compatibles.

Neisseria meningitidis is the etiology of severe, even lethal infections, affecting mainly the young population. However, since the only reservoir is the human nasopharynx, there are asymptomatic carriers. Meningococcus is sensitive to commonly used antibiotics such as third generation cephalosporins and quinolones, but delayed diagnosis due to infrequent clinical presentation and delayed therapy are associated with high morbidity and mortality. We present an 18-year-old female patient with a rapid evolution, with altered inflammatory laboratory parameters, associated with purpuric skin lesions, which evolved with multiorgan failure and fatal outcome, and the etiological confirmation was obtained by the Public Health Institute. We report the case to take into account the diagnosis of meningococcemia in patients with clinical symptoms and laboratory tests suggestive of sepsis and compatible skin lesions.

Pros and cons of vaccination against serogroup B meningococcal disease. / Pros y contras de la vacunación frente a la enfermedad por meningococo B.

A vaccine has recently been approved in the EU against meningococcal serogroup B, the main cause of meningococcal disease. There is a fierce debate about the decision regarding a universal vaccination in infants older than 2 months, as recommended by the majority of scientific societies. In western Europe the only country to have included the universal vaccination is the United Kingdom, with a lower incidence of the disease than Ireland. Other countries have also adopted it, such as the Czech Republic, Cuba and certain regions of Italy. Numerous cost-effectiveness studies have been published regarding the vaccination with different assumptions, which have supported the decision not to implant the universal vaccination because it exceeds the will to pay for a health benefit. We discuss the pros and cons of the universal vaccination against meningococcal B, recommended by the Sociedad Española de Pediatría (Spanish Society of Paediatrics), which as yet has not been implemented.

[Invasive meningococcal disease in Navarra in the era of a meningococcal C vaccine]. / Enfermedad meningocócica invasiva en Navarra en la era de la vacuna conjugada antimeningocócica C.

INTRODUCTION: Systematic childhood vaccination against meningococcus C has had a considerable impact on meningococcal invasive disease (MID). The aim of this study is to perform an analysis on the epidemiology, the clinical features, and the factors associated with a worse prognosis of MID, in the era of a meningococcal C vaccine. MATERIAL AND METHODS: The study included confirmed cases of MID in children less than 15 years of age in Navarra, Spain, between 2008 and 2014. The risk of death or permanent sequelae was evaluated according to the presence of clinical features and analytical parameters at diagnosis. RESULTS: The average annual incidence was 7.9 cases per 100,000 children, with the highest attack rate in children < 1 year. Of 53 cases analysed, 87% were due to meningococcus B. Fever (100%), rash (91%), and elevation of procalcitonin (94%) were the most frequent findings at diagnosis. Some sign of shock was observed in 70% upon arrival at the hospital. The case-fatality rate was 3.8% and 10 % survived with permanent sequelae. Glasgow coma scale < 15 (odds ratio [OR]= 9.2), seizure (OR=8.3), sepsis without meningitis (OR=9.1), thrombocytopenia (OR=30.5), and disseminated intravascular coagulation (OR= 10.9) showed a greater association with a worse prognosis. CONCLUSION: The MID continues to be a significant cause of morbidity and mortality in children. Therefore, new advances are needed in the prevention, early diagnosis, and detection of the factors associated with poor prognosis.

Enfermedad meningocóccica invasora por serogrupo B en dos niños chilenos vacunados contra serogrupos ACWY / Meningococcal invasive disease caused by serogroup B in two Chilean children vaccinated against ACWY serogroups

Invasive meningococcal disease (IMD) by serogroup W has become predominant in Chile since 2012, prompting vaccination with conjugate ACWY. We reported two pediatric cases in patients already vaccinated, which evolved with IMD by serogroup B. This should remind us to keep the alertness with this pathology, despite the current vaccination system in Chile, emphasizing in improve our epidemiological case definition and its diagnosis.

La Enfermedad Meningocóccica Invasora (EMI) por serogrupo W ha llegado a ser predominante en Chile desde el 2012, motivando estrategias de inmunización con vacunas conjugadas contra los serogrupos ACWY. Presentamos dos casos pediátricos de pacientes vacunados contra meningococo ACWY que evolucionaron con EMI por serogrupo B, lo que debe recordarnos la alerta y sospecha de esta patología, inclusive con el esquema de vacunación actual chileno, poniendo énfasis en mejorar nuestra definición epidemiológica de caso sospechoso para optimizar su diagnóstico.

[Meningococcal C conjugate vaccine: Impact of a vaccination program and long-term effectiveness in Navarra, Spain, 2000-2014]. / Vacuna conjugada frente al meningococo C: impacto del programa de vacunación y efectividad a largo plazo en Navarra, 2000-2014.

BACKGROUND: Since 2000, when the meningococcal serogroupC conjugate vaccine (MenCC) was introduced in the childhood immunization schedule in Spain, several changes in the schedule and catch-up campaigns have been performed. We aim to estimate the impact and effectiveness of this vaccine in Navarra up to 2014. METHODS: The impact of the vaccination program was analysed by comparing incidence, mortality and lethality rates of disease before (1995-1999) and after (2004-2014) the introduction of the MenCC. Vaccine effectiveness was estimated using the screening method (Farrington) and the indirect cohort method (Broome). Data on cases were obtained from the active surveillance of meningococcal disease. RESULTS: During 1995-1999 the mean annual incidence of meningococcalC disease was 1.32 per 100,000, and 7.18 per 100,000 in children younger than 15years. The fall of meningococcalC disease incidence was significant in cohorts targeted for vaccination from the beginning and progressive in the general population. No cases were reported between 2011 and 2014. The estimated vaccine effectiveness was 96% by the screening method, and 99% by the indirect cohort method. CONCLUSION: The MenCC vaccination program has been successful in decreasing the incidence rate of serogroupC meningococcal disease in Navarra, and schedule changes have maintained high vaccine effectiveness throughout the study period.

Efectividad de la vacuna VA-MENGOC-BC® contra cepas heterólogas de meningococo B / Effectiveness of VA-MENGOC-BC® vaccine against heterologous strains of meningococcus B

La efectividad de las vacunas de vesículas de membrana externa de Neisseria meningitidis serogrupo B ha sido cuestionada por algunos investigadores, limitándola a la cepa vacunal. VA-MENGOC-BC® es una vacuna antimeningocócica basada en dicha tecnología. Presentamos un metaanálisis de estudios realizados en diferentes contextos epidemiológicos, evaluando su efectividad contra cepas heterólogas de meningococo B en varios grupos de edades. Se demuestra que la vacuna es efectiva contra cepas homólogas, heterólogas y de diferentes complejos clonales(AU)

Vaccines based on outer membrane vesicles of Neisseria meningitidis serogroup B strains have been questioned by some researchers, who limit its effectiveness to the vaccine strain. VA-MENGOC-BC® is a meningococcal vaccine based on this technology. A meta-analysis of independent studies in different epidemiological contexts is used to assess the clinical effectiveness of the vaccine against heterologous serogroup B strains in several age groups. In this paper we provide evidence supporting its effectiveness against homologous and heterologous strains from different clonal complexe(AU)

[Meningococcal vaccines. Global epidemiological situation and strategies for prevention by vaccination]. / Vacunas antimeningocócicas. Situación epidemiológica mundial y estrategias de prevención mediante la vacunación.

N. meningitidis is a major cause of meningitis and septicemia and a major public health problem in many countries. The disease, that can be fulminant, has a high mortality and may cause serious sequelae, even in cases of apparently optimal medical treatment. Chemoprophylaxis may prevent secondary cases among those in close contact with the ill, but, since secondary cases represent only 1%-2% of all meningococcal disease, chemoprophylaxis has a small impact when fighting most of endemic and epidemic forms. Given that al least 5% -15% of children and young adults are carriers, the fight against meningococcal disease based on chemotherapeutic elimination of nasopharyngeal colonization is virtually impossible. Therefore, immunization is the only rational way to combat this disease.

[The use of polymerase chain reaction in the diagnosis of invasive meningococcal disease]. / La reacción en cadena de la polimerasa en el diagnóstico de la enfermedad meningocócica invasiva.

INTRODUCTION AND OBJECTIVES AND AIMS: Invasive meningococcal disease (IMD) remains a serious public health problem. Although culture is the gold standard, previous antibiotic therapy reduces its sensibility. The aim of this study is the epidemiological analysis of IMD in our area, to assess the usefulness of polymerase chain reaction (PCR) to increase its diagnostic accuracy,and to show the association of antibiotic administration with the negative result of the culture. PATIENTS AND METHODS: A retrospective study was conducted on all children younger than 16 years with microbiologically (positive culture and/or PCR) confirmed IMD, admitted to our hospital between 2004-2012. RESULTS: Seventy-five patients were included, of whom 52% had sepsis, 30.7% meningitis, and 17.3% with both of them. PCR was positive in all samples, whereas a positive was seen 50.7% of the cultures. Previously administered antibiotic was documented in 40 patients (53.3%), and 40% of them were confirmed by PCR only. CONCLUSIONS: PCR was the only test providing evidence for IMD diagnosis and serogroup determination in almost 39% of cases.

[Vaccination against meningococcal B disease. Public statement of the Advisory Committee on Vaccines of the Spanish Association of Paediatrics (CAV-AEP)]. / Vacunación frente al meningococo B. Posicionamiento del Comité Asesor de Vacunas de la Asociación Española de Pediatría.

Meningococcal invasive disease, including the main clinical presentation forms (sepsis and meningitis), is a severe and potentially lethal infection caused by different serogroups of Neisseria meningitidis. Meningococcal serogroup B is the most prevalent in Europe. Most cases occur in children, with a mortality rate of 10% and a risk of permanent sequelae of 20-30% among survivors. The highest incidence and case fatality rates are observed in healthy children under 2-3 years old, followed by adolescents, although it can occur at any age. With the arrival in Spain of the only available vaccine against meningococcus B, the Advisory Committee on Vaccines of the Spanish Association of Paediatrics has analysed its preventive potential in detail, as well as its peculiar administrative situation in Spain. The purpose of this document is to publish the statement of the Committee as regards this vaccination and the access to it by the Spanish population, taking into account that it has been only authorized for people at risk. The vaccine is available free in the rest of Europe for those who want to acquire it, and in some countries and regions it has been introduced into the systematic immunisation schedules. The Committee considers that Bexsero® has a profile of a vaccine to be included in the official schedules of all the Spanish autonomous communities and insists on the need for it to be available in pharmacies for its administration in all children older than 2 months.

[Polyvalent meningococcal vaccines: within or outside our agenda?]. / Vacunas multivalentes frente a enfermedad meningocócica: ¿dentro o fuera de nuestras agendas?

The development of tetravalent vaccines against Invasive Meningococcal Disease (IMD) has been driven mainly due to the increase of the prevalence and geographic expansion of several serogroups considered unusual, but also because of the need for vaccines that offer broad spectrum protection in a devastating disease such as IMD. These changes in serogroups considered usual (B and C) have been detected for both serogroup Y and W, which has led to the multivalent vaccines being used by a number of countries with different strategies that will be discussed in the article. Epidemiological data in Spain, currently do not justify its use in immunization schedules, but there is a potential risk for the introduction of virulent clones of those uncommon serogroups (Y and W), and this would lead us to open a discussion of their potential use, particularly in the adolescent/pre-teen population as a target group for intervention.

Enfermedad invasiva por Neisseria Meningitidis, alerta epidemiológica / Neisseria Meningitidis invasive disease, epidemiological alert

En países que han incorporado vacunas conjugadas contra Streptococcus pneumoniae y Haemophilus influenzae, la Neisseria meningitidis es el principal patógeno bacteriano causante de enfermedad invasiva. La enfermedad invasiva por meningoco se asocia con una alta tasa de letalidad. Objetivos. Describir una agregación inesperada de casos de enfermedad invasiva por Neisseria meningitidis en los Municipio Salmeron Acosta y Sucre, Estado Sucre,Venezuela. Metodos. Cohorte de inicio. Casos con diagnóstico definido o probable de infección por Neisseria meningitidis. Se registraron datos pertinentes acerca del paciente, de su enfermedad, del agente causal y del medio ambiente. Se determinó la tasa de incidencia por grupos de edad y municipio de residencia, serogrupos de Neisseria meningitidis, y patron de susceptibilidad a antibióticos. Resultados. Entre las semanas epidemiológicas 1-41 de 2012 se detectaron 15 casos de enfermedad invasiva por meningococo en niños menores de 15 años con residencia en el Estado Sucre, Venezuela. La tasa de incidencia para los Municipios Cruz Salmerón Acosta y Sucre del Estado Sucre fue 33,7 x 105 y 6,7 x 105 niños <15 años respectivamente. La enfermedad muestra mayor dispersión en la tasa de ataque de niños de 5-14 años, agregación en espacio y tiempo así como tendencia cíclica. Los casos confirmados fueron 10 de 15, Neisseria meningitidis serogrupo B, 4 casos y Neisseria meningitidis serogrupo C, 6 casos. La letalidad observada fue 6 de 15; se observaron secuelas en un tercio de los sobrevivientes. Conclusiones. Se describe una frecuencia inesperada de enfermedad invasiva por Neisseria meningitidis en los Municipio Salmeron Acosta y Sucre, Estado Sucre,Venezuela. La información generada puede orientar el diseño de medidas de intervención y control.

In countries were conjugate vaccines against Streptococcus pneumoniae and Haemophilus influenzae, have been incorporated, Neisseria meningitidis is the major bacterial pathogen causing invasive disease. Invasive meningococcal disease is associated with a high mortality rate. Objectives. To describe unexpected aggregation of invasive meningococcal disease. Methods. Inception cohort: Definite or probable cases of infection with Neisseria meningitidis. Information about the patient and his disease, the causative agent and the environment was registered. Incidence rate by age and municipality of residence, serogroups of Neisseria meningitidis, and antibiotic susceptibility pattern were determined. Results. Between the epidemiological weeks 1-41 of 2012, 15 cases of invasive meningococcal disease in children under 15 years of age, living in the state of Sucre, Venezuela were identified. The incidence rate for Cruz Salmerón Acosta and Sucre municipalities was 33.7 x 105 and 6.7 x 105 children <15 years of age, respectively. The disease shows greater dispersion in incidence by age group, aggregation in space and time and a cyclical trend. Confirmed cases were 10 of 15, 4 cases of Neisseria meningitidis serogroup B and 6 cases of Neisseria meningitidis serogroup C. Overall mortality rate was 6 of 15; sequelae were present in one third of the survivors. Conclusions. This study describes an unexpected frequency of invasive meningococcal disease in the Sucre and Salmeron Acosta Municipalities, Sucre State, Venezuela. This information may be useful to guide intervention measures design.

Enfermedad meningocócica: epidemiología, diagnóstico y vacunación / Meningococcal disease: epidemiology, diagnosis and vaccination

La enfermedad meningocócica invasiva causada por N. meningitidis es un problema global de salud pública, por su alta morbilidad y mortalidad. Esta patología es causada en su mayoría por los serogrupos A,B,C, W-135 e Y. La prevención mediante la vacunación es la mejor herramienta para disminuir la carga mundial de esta enfermedad. Las vacunas no conjugadas que toman como base solo el polisacárido externo, aun cuando son beneficiosas en epidemias, producen pobre inmunogenicidad a largo plazo en los niños menores de dos años de edad, que representan la población de mayor riesgo. Las vacunas de nueva generación, en donde el polisacárido es conjugado con proteína transportadoras, producen respuestas inmune en niños menores de 2 años, lo cual podría producir una reducción importante de la enfermedad en esta población de alto riesgo. Las nuevas técnicas de detección están constituyendo a mejorar el pronóstico de la enfermedad, al permitir un diagnóstico más temprano y específico, conducentes a un tratamiento más oportuno. La creación de vacunas que confieran una protección más amplia, especialmente contra el serogrupo B, y protejan a la población en mayor riesgo, sigue siendo un reto...

Avaliação dos fatores de risco para óbito em pacientes com doença meningocócica, Salvador, Bahia / Assessment of risk factors for death in patients with meningococcal disease, Salvador, Bahia / Evaluación de los factores de riesgo de muerte en pacientes com enfermedad meningocócica, Salvador, Bahia

A doença meningocócica (DM) apresenta relevância pela elevada incidência e mortalidade que apresenta. O objetivo deste artigo foi avaliar os fatores de risco para óbito em pacientes com doença meningocócica numa população de Salvador, Bahia. Trata-se de estudo de coorte histórica envolvendo 98 pacientes internados num hospital de referência no estado da Bahia de junho/2008 a maio/2009. Os dados clínicos, demográficos, epidemiológicos e laboratoriais foram obtidos por pesquisa nos prontuários e nas fichas do Núcleo de Vigilância Epidemiológica. Os resultados indicam a idade média de 15,6 (± 13,9) anos, 50 (51por cento) eram do sexo masculino e 68 (69,4por cento) procediam da capital. Evoluíram paraalta 85 (86,7por cento) pacientes e 13 (13,3por cento) para óbito. O tempo médio da doença foi de 48,2 horas. Meningite Meningocócica ocorreu em 54 (55,1por cento) casos, Meningite Meningocócica com Meningococcemia, em 28 (28,6por cento) e Meningococcemia, em 16 (16,3por cento). O sorogrupo C (57,74por cento) foi o mais prevalente. Concluiu-se que o tempo de doença foi menor nos pacientes que evoluíram para óbito e que a presença de irritação meníngea foi maior nos pacientes que evoluíram para alta. A presença de lesão de pele elevou o risco de evolução para óbito. Quanto maiores as alterações observadas no líquor e hemograma, maior a chance deevolução para alta hospitalar, sendo também estas alterações fatores de proteção de evolução para óbito.

Meningococcal disease (MD) has relevance for its high incidence and mortality rates. The purpose of this article was to evaluate risk factors for death in patients with meningococcal disease in a selected population of Salvador, Bahia. This is historical cohort study conducted with 98 patients hospitalized in a center of excellence hospital in the state of Bahia from June/2008 to May/2009. The clinical, demographic, epidemiological and laboratory data of the research were obtained from medical records and from the records of the Epidemiological Surveillance Center. The results indicate an average age of 15.6 (± 13.9) years, 50 (51percent) were male and 68 (69.4percent lived in the capital. The percentage of 86.7percent (85) patients were discharged from the hospital and 13 (13.3percent) died. The average length of time of the disease was 48.2 hours. Meningococcal meningitis occurred in 54 (55.1percent) cases, with Meningococcal Meningitis Meningococcemia, 28 (28.6percent) and Meningococcemia, 16 (16.3percent). The serogroup C (57,74percent) was the most prevalent. It was concluded that the disease duration was shorter in patients who died; the presence of meningeal irritation was higher in patients who were discharged.The presence of skin lesions increased the risk of progression to death. As to laboratory, CSF and hemogram, demonstrated that the greater the change observed the greater the chance of progression to discharge, these changes are also protective factors of progression to death.

La enfermedad meningocócica (MD) presenta relevancia por su elevadaincidencia y mortalidad. El objetivo de este artículo fue evaluar los factores de riesgo de muerte en pacientes con enfermedad meningocócica en la población de Salvador, Bahía. Estudio de enfoque histórico, realizado con 98 pacientes internos, de junio de 2008 a mayode 2009, en un hospital de referencia en el estado de Bahía. Los datos clínicos, demográficos, epidemiológicos y de laboratorio se obtuvieron a través de los históricos médicos y en los registros del Núcleo de Vigilancia Epidemiológica. Los resultados indican una edad media de 15,6 (±13,9) años, 50 (51por ciento) eran hombres y 68 (69,4por ciento) procedían de la capital. Un total de 85 (86,7por ciento) evolucionaron para alta y 13 pacientes (13,3por ciento) fallecieron. La duración media de la enfermedad fue de 48,2 horas. En 54 (55,1por ciento) de los casos se produjo meningitis meningocócica, en 28 (28,6por ciento) meningitis meningocócica con meningococcemia, y en 16(16,3por ciento) meningococcemia. El serogrupo C (57/74por ciento) fue el más frecuente. Se concluye que el tiempo de enfermedad fue menor en los pacientes que fueron a óbito y que la presencia de irritación meníngea fue mayor en los pacientes que evolucionaron para alta. La presencia delesiones en la piel aumenta el riesgo de óbito. Mientras mayor sean las alteraciones observadas en el LCR y en el hemograma, mayor será la probabilidad de evolucionar para alta hospitalaria representando, también, factores de protección con relación a la muerte.