Updated recommendations of the International Dengue Initiative expert group for CYD-TDV vaccine implementation in Latin America.

Dengue disease represents a large and growing global threat to public health, causing a significant burden to health systems of endemic countries. For countries considering vaccination as part of their Integrated Management Strategy for Prevention and Control of Dengue, the World Health Organization currently recommends the first licensed dengue vaccine, CYD-TDV for: individuals aged 9 years or above from populations with high transmission rates, based on either seroprevalence criteria or pre-vaccination screening strategies, and for persons with confirmed prior exposure to infection in moderate to lower transmission settings. This paper describes the main conclusions of the Sixth Meeting of the International Dengue Initiative (IDI) held in June 2018, following release of a new product label by the manufacturer, updated WHO-SAGE recommendations, additional scientific evidence on vaccine performance, and reports of experiences by implementing countries. Considerations were made regarding the need for improving the quality of epidemiological and surveillance data in the region to help define the convenience of either of the two vaccination strategies recommended by WHO-SAGE. Extensive discussion was dedicated to the pros and cons of implementing either of such strategies in Latin America. Although, in general, a seroprevalence-based approach was preferred in high transmission settings, when cost-effectivity is favorable pre-vaccination screening is a convenient alternative. Cost-effectiveness evaluations can assist with the decisions by public health authorities of whether to introduce a vaccine. Where implemented, vaccine introduction should be part of a public health strategy that includes the participation of multiple sectors of society, incorporating input from scientific societies, ministries of heath, and civil society, while ensuring a robust communication program.

Bordetella pertussis en Latinoamérica: ¿estamos reconociendo el problema? / Bordetella pertussis (Whooping Cough) in Latin America: Are we aware of the problem?

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Ataxia aguda cerebelosa posvaricela en niños costarricenses / Postvaricella cerebellar ataxia in children in Costa Rica

Introducción. La ataxia cerebelosa aguda posvaricela (ACAPV) y la meningoencefalitis son las complicaciones neurológicas agudas más comunes de la varicela. El objetivo del estudio es describir la presentación clínica, el tratamiento médico y el pronóstico de la ACAPV en niños costarricenses hospitalizados en el único hospital pediátrico de nuestro país, donde la vacunación contra la varicela aún no es sistemática. Métodos. Estudio descriptivo retrospectivo; se incluyeron pacientes de entre 1 y 12 años de edad, egresados del Hospital de Nacional Niños de Costa Rica entre enero de 1997 y junio de 2004, con el diagnóstico de ACAPV. Resultados. De los 441 pacientes inmunocompetentes que fueron hospitalizados por presentar complicaciones asociadas a virus varicela zóster durante este período, 37 pacientes (8,4 %) tuvieron ACAPV, y 24/37 (64,9 %) fueron varones. La edad media (rango) fue de 5 años (1-10 años). La media (rango) de aparición de la ataxia tras el inicio del brote fue de 2 días (1-30). El análisis del líquido cefalorraquídeo (LCR) se realizó en 22 pacientes (59,5 %) y en todos fue normal. La tomografía computarizada (TC) mostró edema cerebral en 6/18 pacientes (33,3 %). Un total 23 niños de 37 recibieron aciclovir intravenoso, aunque no se observaron diferencias significativas (p > 0,05) entre ambos grupos en cuanto a beneficio con la terapia. La duración media (rango) de la ataxia fue de 4 días (1-10) y 7 pacientes (19 %) fueron dados de alta atáxicos. La estancia hospitalaria media (rango) fue de 4,4 días (2-11). Se documentaron secuelas menores en 13/24 pacientes (54,2 %) durante las visitas de seguimiento y contactos telefónicos. Conclusiones. La ACAPV usualmente se asocia con un pronóstico favorable; sin embargo, pueden producirse secuelas neurológicas. La utilidad real del aciclovir y de realizar estudios de imágenes cerebrales en estos niños es controvertida

Introduction. Postvaricella cerebellar ataxia (PVCA) and meningoencephalitis are the most common acute neurological complications of chickenpox. The objective of this study was to describe the clinical presentation, management, and outcome of children hospitalized with PVCA in the only pediatric hospital of this developing country, where routine varicella immunization is not yet available. Methods. We performed a retrospective chart review of children aged 1-12 years old admitted to the National Children's Hospital of Costa Rica from January 1997 to June 2004 with a diagnosis of PVCA. Results. Among the 441 immunocompetent patients admitted for varicella zoster virus-associated complications during this period, 37 (8.4 %) had PVCA. Twenty-four of the 37 (64.9 %) patients were boys. The mean (range) age was 5 (1-10) years. The median (range) interval from rash onset to admission was 2 (1-3) days. Cerebrospinal fluid analysis was available in 22 (59.5 %) patients and was normal in all. Head computed tomography showed cerebral edema in six out of 18 patients (33.3 %). Intravenous acyclovir was administered to 23 patients but no significant differences in clinical manifestations or outcomes were observed in treated versus untreated patients. The mean (range) length of ataxia was 4 (1-10) days, and seven (19 %) patients were still ataxic on discharge. The mean (range) length of hospital stay was 4.4 (2-11) days. Minor sequelae were documented in 13 out of 24 (54.2 %) patients during follow-up visits and telephone contacts. Conclusions. PVCA is usually associated with a favorable prognosis; however, neurological sequelae can occur. The real utility of acyclovir treatment and brain imaging studies in these children remains controversial

Síndrome de rubéola congénita en Costa Rica: importancia de reforzar la vigilancia activa / Congenital rubella syndrome in Costa Rica: importance of active surveillance

Objetivo: Identificar los casos de síndrome de rubéola congénita(SRC) y su forma de presentación en niños menores de3 meses atendidos en el Hospital Nacional de Niños de1996 a 2000. Métodos: En el período de 1996 a 2000 se seleccionaron los pacientes de un día de edad a 3 meses, con un positivo de serologíaI gM por rubéola, identificados por medio del registro computarizado del laboratorio. Se revisó la historia clínica correspondiente, analizando las características delos pacientes. Resultados: Se identificaron 66 niños con serología positiva, 49 tenían historia clínica completa que permitió la revisión. De éstos, 29 (60 %) eran varones. La edad media en que se solicitó la serología fue de 33 días. La hepatosplenomegalia, la microcefalia y las polimalformaciones fueron las tres principales manifestaciones por las cuales se solicitó la serología. El diagnóstico inicial que predominó fue el TORCHS (toxoplasmosis, rubéola, citomegalovirus, herpes,sífilis). Tras la revisión final de los 49 casos, 45 pacientes se clasificaron como SRC y cuatro como infección por rubéola. Conclusiones: El presente estudio pone de manifiesto la necesidad dereforzar la vigilancia activa permanente del SRC. Se debe reforzar la búsqueda de signos y síntomas, así como los antecedentes maternos que permitan la sospecha adecuada y la comunicación oportuna de los casos de SRC

Objective: To identify cases of congenital rubella syndrome (CRS)and their form of presentation in children aged < 3 months in the National Children’s Hospital of Costa Rica between1996 and 2000.MethodsBetween 1996 and 2000, patients aged 1 day to 3 months with positive IgM serology for rubella, identified by means of the computerized database of the National Children’s Hospital Laboratory, were selected. Their corresponding medical records were reviewed and the characteristics of these patients were analyzed. Results: Sixty-six children with positive serology were identified, of which 49 had a complete medical record that allowed review. Of these, 29 (60 %) were boys. The mean age at which IgM serology was requested was 33 days. The principal manifestations leading to serology were hepatospleno megaly, microcephaly and multiple congenital anomalies. The initial diagnosis was TORCH infection. Of the 49 patients, 45 were classified as CRS and four as infection with rubella. Conclusions: The present study highlights the need to increase active surveillance of CRS. Greater vigilance in applying the criteria for clinical diagnosis is required to allow an adequate degree of suspicion and early reporting of cases

Systemic cytokine response in children bitten by snakes in Costa Rica.

BACKGROUND: To characterize the host response to venom from snakes of the family Viperidae in Costa Rica, we investigated the release of cytokines: IL-1, IL-6, IL-8, TNF-alpha, MIP-1beta, and RANTES in pediatric patients who were bitten by a snake. METHODS: Patients were included in this study if they were admitted to the hospital within 24 hours of the snakebite. Blood samples were taken immediately on admission to the hospital, and then at intervals of 3, 12, and 24 hours, and on days 3, 5, and 7 after the accident. Patients received gentamicin plus clindamycin or gentamicin plus penicillin intravenously for a minimum of 3 days or longer if necessary. IL-1, IL-8, TNF-alpha, MIP-1beta, and RANTES were determined by monoclonal antibody-based ELISAs, while IL-6 was determined by bioassay. RESULTS: Eighteen patients were included in this study; 15 were bitten by Bothrops asper and three by B. lateralis. Eleven patients were male. Median (range) age was 9 (1-12) years. Nine patients had detectable serum concentrations of IL-6 (200 pg/ mL) and IL-8 (51 pg/mL) on admission, increasing to 500 pg/mL and 115 pg/mL for IL-6 and IL-8, respectively, during the first 12-24 hours. Cytokine concentrations returned to normal or undetectable ranges by 72 hours. TNF-alpha concentrations peaked at 12 hours (mean: 48 pg/mL). Low, but detectable concentrations of MIP-1beta were observed in some patients at various time intervals (48 pg/mL), whereas IL-1 was not detectable at any time point. Regulated on Activation Normal T cell Expressed and Secreted (RANTES) concentrations were evaluated in only five patients, being elevated in all of them. Patients with elevated cytokine concentrations required early fasciotomy (<24 hours after the accident) more often than those who had normal or undetectable cytokine concentrations (P < 0.05). There were no statistically significant associations between severity of envenomation, or outcome, and elevated serum cytokine concentrations (P > 0.05). CONCLUSIONS: Bothrops sp snake venoms induce clinical and pathophysiologic alterations similar to acute trauma, with release of proinflammatory cytokines. A better understanding of the role of the inflammatory response could lead to the development of new therapeutic strategies to improve the outcome in snakebitten patients.

Venomous snakebites in children and adolescents: a 12 year retrospective review

Snakebite envenomation is a worldwide problem and in Costa Rica. The following is a retrospective review of 79 patients admitted to the Hospital Nacional de Ninos (HNN) from January 1985 to September 1996. Child's age ranged from 9 months to 14 years. The M: F ratio was 1.5:1. Sixty percent of the patients lived in remote rural areas. The most common clinical signs at the time of hospitalization were pain and edema. Fifty patients (63.29 per cent) showed moderate to severe envenomation grades. Fifty-one (64,55 per cent) was caused by Bothrops asper. Complications during hospitalization were compartment syndrome and secondary infection. Three children died, one from disseminated intravascular coagulation, another from renal insufficiency, and the third from a perforated duodenal ulcer. Patients who underwent early fasciotomy had signficantly less hospitalization and fewer infectious complications, (p<0.001). There was no relationship between the envenomation grade and length of hospitalization (p=0.4). The most common pathogen isolated was S. aureus. Early fasciotomy seemed to reduce the complications seen in these patients. Further studies are necessary to identify the factors that may clinicians to decide those who should undergo fasciotomy, as well as the best moment to perform it

Abscess secondary to facial snakebite

In Costa Rica, approximately 700 snakebite cases occur each year, 5 to 10 of which result in death. At the Hospital Nacional de Ninos (HNN), 6 to 10 cases are reported annually, more than half of these cases and nearly all deaths are result from Bothrops asper snakebite. This venomous snake, popularly known as the "terciople", most often attacks the lower upper limbs and characteristically produces local tissue damage, which can be severe. The following is a report of the first case of a non-fatal and unusual facial bite caused by Bothrops asper in our country.

[Diagnosis of acute hematogenous osteomyelitis by ultrasound in pediatric patients]. / Diagnóstico de osteomielitis aguda hematógena por ultrasonido en el paciente pediátrico.

OBJECTIVE: The objective of this study was to evaluate the efficacy of ultrasound in the diagnosis of acute hematogenous osteomyelitis of long bones in pediatric patients. PATIENTS AND METHODS: A prospective study was performed in a tertiary care pediatric hospital. During 12 months we prospectively studied 46 patients with the clinical diagnosis of acute hematogenous osteomyelitis (AHO) of long bones at the Hospital Nacional de Niños in Costa Rica. In all patients ultrasound (US) was performed within 24-36 hours of admission, before any invasive diagnosis or therapeutic procedure was begun. RESULTS: In those without US findings, but with strongly suspected (AHO), a bone scan was done. Of these patients, 26/46 (57%) was female. The mean age was 6.8 years. Sixty-five percent (30/46) had US findings compatible with AHO affecting the tibia (13), femur (11), humerus (4), and radius (2). The findings included subperiostic fluid (10), periosteal thickening (14), subperiostic abscess (6) and thickening of subcutaneous tissues (26). Patients were surgically drained and puss was obtained from the bone in all 30. Two patients with negative US, but strongly suspected AHO had a bone scan that was negative. Patients with AHO were followed with US within 5-7 days of surgery and all 30 showed marked improvement. CONCLUSIONS: In this study, US showed 100% sensitivity and specificity for the diagnosis of AHO of long bones in pediatric patients. US are a sensitive and non-invasive procedure for the diagnosis and follow-up of AOH of long bones.

Handwashing practices in a tertiary-care, pediatric hospital and the effect on an educational program.

OBJECTIVE: To study the frequency of handwashing and the effects of an educational program. DESIGN: A prospective study. SETTING: A tertiary-care, pediatric hospital. PARTICIPANTS: Three divisions (two general pediatric wards and one infectious disease ward). The personnel observed included 60 medical staff (interns, residents, and attending, including consulting, physicians), 37 nurses, and 15 paramedical staff. INTERVENTIONS: The study was carried out in 5 phases: (1) unobtrusive observation to obtain a baseline handwashing rate; (2) observation after written notification; (3) observation after providing motivating devices: movies, brochures, posters; (4) discontinuation of observation and motivation; (5) unobtrusive observation, to obtain a residual handwashing rate. RESULTS: During this study, 1,123 patient contacts were observed. The baseline handwashing rates before and after patient contact were 52% and 49%, respectively. During phase 2, handwashing rates before and after patient contact increased slightly to 56% and 52%, respectively. During phase 3, rates increased to 74% and 69% (P < .01). However, rates fell during the final phases to 49% and 52%, respectively (P < .01). There were no significant differences among hospital staff in any phase of this study (P > .05). CONCLUSIONS: Constant motivation, using movies, brochures, and posters, transiently increased the frequency of handwashing among the house staff of a tertiary-care facility; however, to be effective, this motivation needs to be sustained.