The unmet need for critical care at a quaternary paediatric intensive care unit in South Africa.

BACKGROUND: Paediatric intensive care, a valuable resource that improves the outcomes of critically ill children, is often scarce. OBJECTIVE: To evaluate the need for paediatric intensive care beds and compare the outcomes of admitted and non-admitted deserving cases. METHODS: A prospective evaluation of all bed requests, in terms of need for intensive care and outcomes of those admitted and not admitted to a paediatric intensive care unit (PICU), was performed between July 2017 and June 2018. Factors for refusal and for poor outcomes were evaluated. RESULTS: Of the 811 bed requests, 32.6% (n=264, p<0.001) were denied access. Of the 231 deserving cases who were denied access, 85.7% (n=198) were due to unavailability of a PICU bed. Patients not admitted to PICU had a twofold increased risk of dying compared with those admitted (34.4% v. 15.5% respectively, p<0.001), even though the patient characteristics of both groups were similar (age, gender and nutritional status). In those admitted, risk factors for mortality were requiring transfusion of blood and platelets (56.0%, p<0.001), requiring two or more inotropes (52.5%, p<0.001), instability on admission (41.3%, p<0.001), prior cardiac arrest (32.0%, p=0.021), severe acute malnutrition (26.9%, p=0.043), fungal infection (22.2%, p=0.004) and emergency admission (18.0%, p<0.001). In those not admitted, prior cardiac arrest (100%, p<0.001) and emergency referral (42.3%, p<0.001) were associated with adverse outcomes. CONCLUSION: The need for PICU beds exceeds availability, with a consequent twofold increase in mortality among cases not admitted to PICU. Paediatric critical care services have increased at appropriate sites of need following completion of this study.

Invasive fungal infections in a paediatric intensive care unit in a low-to middle-income country.

Background: Paediatric intensive care units (PICUs) are high-risk settings for healthcare-associated infections. Invasive fungal infection (IFI) is one of the common causes of healthcare-associated infections. Objectives: To describe the prevalence and short-term outcomes of children with IFI, and to offer a basis for the efficient prevention and treatment of IFI. Methods: A retrospective study was conducted in children under the age of 12 years over a two-year period. Participants were categorised according to pre-defined microbiology criteria into IFI if they had a positive culture from blood or other sterile sites. Data collected included demographics, invasive procedures, length of stay and mortality. Results: One thousand and forty-two children were admitted during the study period. Of the total, 56.8% (n=592) were male. Median length of stay was 18 days (mean±SE 18.6±8.9). IFI was identified in 35 cases per 1 000 admissions, with 77.7% of these infants under the age of one year. The mean length of stay was 18.6 days compared with 7.5 days for children with bacterial infections. The in-hospital mortality for invasive fungal infection was 36% compared with 16% for all admissions. Findings confirmed that colonisation was more prevalent than IFI. Conclusion: IFIs are common among infants, and these patients have a higher mortality rate and prolonged hospital stay. Therefore we recommend early diagnosis and timely treatment with high-performance antifungal drugs to improve the prognosis in children with IFI.

Effect of short-term exposure to ambient nitrogen dioxide and particulate matter on repeated lung function measures in infancy: A South African birth cohort.

BACKGROUND: The developing lung is highly susceptible to environmental toxicants, with both short- and long-term exposure to ambient air pollutants linked to early childhood effects. This study assessed the short-term exposure effects of nitrogen dioxide (NO2) and particulate matter (PM10) on lung function in infants aged 6 weeks, 6, 12 and 24 months, the early developmental phase of child growth. METHODS: Lung function was determined by multiple breath washout and tidal breathing measurement in non-sedated infants. Individual exposure to NO2 and PM10 was determined by hybrid land use regression and dispersion modelling, with two-week average estimates (preceding the test date). Linear mixed models were used to adjust for the repeated measures design and an age*exposure interaction was introduced to obtain effect estimates for each age group. RESULTS: There were 165 infants that had lung function testing, with 82 of them having more than one test occasion. Exposure to PM10 (µg/m3) resulted in a decline in tidal volume at 6 weeks [-0.4 ml (-0.9; 0.0), p = 0.065], 6 months [-0.5 ml (-1.0; 0.0), p = 0.046] and 12 months [-0.3 ml (-0.7; 0.0), p = 0.045]. PM10 was related to an increase in respiratory rate and minute ventilation, while a decline was observed for functional residual capacity for the same age groups, though not statistically significant for these outcomes. Such associations were however less evident for exposure to NO2, with inconsistent changes observed across measurement parameters and age groups. CONCLUSION: Our study suggests that PM10 results in acute lung function impairments among infants from a low-socioeconomic setting, while the association with NO2 is less convincing.

The unmet need for critical care at a quaternary paediatric intensive care unit in South Africa

Paediatric intensive care, a valuable resource that improves the outcomes of critically ill children, is often scarce. Objective. To evaluate the need for paediatric intensive care beds and compare the outcomes of admitted and non-admitted deserving cases. Methods. A prospective evaluation of all bed requests, in terms of need for intensive care and outcomes of those admitted and not admitted to a paediatric intensive care unit (PICU), was performed between July 2017 and June 2018. Factors for refusal and for poor outcomes were evaluated. Results. Of the 811 bed requests, 32.6% (n=264, p<0.001) were denied access. Of the 231 deserving cases who were denied access, 85.7% (n=198) were due to unavailability of a PICU bed. Patients not admitted to PICU had a twofold increased risk of dying compared with those admitted (34.4% v. 15.5% respectively, p<0.001), even though the patient characteristics of both groups were similar (age, gender and nutritional status). In those admitted, risk factors for mortality were requiring transfusion of blood and platelets (56.0%, p<0.001), requiring two or more inotropes (52.5%, p<0.001), instability on admission (41.3%, p<0.001), prior cardiac arrest (32.0%, p=0.021), severe acute malnutrition (26.9%, p=0.043), fungal infection (22.2%, p=0.004) and emergency admission (18.0%, p<0.001). In those not admitted, prior cardiac arrest (100%, p<0.001) and emergency referral (42.3%, p<0.001) were associated with adverse outcomes. Conclusion. The need for PICU beds exceeds availability, with a consequent twofold increase in mortality among cases not admitted to PICU. Paediatric critical care services have increased at appropriate sites of need following completion of this study

An evaluation of challenges with the South African PMTCT HIV programme seen from the perspective of HIV-positive children admitted to the PICU

Background. Mother-to-child transmissions (MTCT) accounts for 90% of the 370 000 new HIV-positive children, globally. Despite progress in the prevention of mother-to-child transmission (PMTCT) of HIV, children still acquire HIV infection. Objective. To identify and describe the prevalence of maternal, infant and/or health system-related risk factors gleaned from the literature for HIV transmission in HIV-positive children admitted to the paediatric intensive care unit (PICU) at Inkosi Albert Luthuli Central Hospital (IALCH), Durban, South Africa. Method. A retrospective electronic chart review identifying all HIV-positive children under 2 years admitted to the PICU at IALCH between January 2017 and December 2019 was undertaken. Individual patient records were analysed using a standardised template. Results. Of the 80 mothers and children with HIV enrolled in the present study, 38.8% (n=31/80) of mothers were diagnosed prior to pregnancy, 42.5% (n=34/80) were diagnosed during pregnancy (unsure when exactly transmission occurred), and 18.8% (n=15/80) of mothers were diagnosed after delivery. The median (range) time of antiretroviral treatment (ART) was 225 (30 - 365) days for mothers. More than half of mothers (56.3%, n=45/80) whose babies became HIV-positive had poor adherence to antiretroviral drugs (HIV viral load >1 000 copies/mL). An HIV-positive diagnosis in the children of these mothers occurred throughout infancy and early childhood, especially in the first 6 months (87.5%, n=70/80). A third of mothers practised mixed feeding. Health system deficiency, mainly via cancellation of tests without notifying healthcare workers, was typical in infants (33%; n=26/80) and mothers (68.8%, n=55/80). All others (100%) were not counselled about the importance of PMTCT and 93.8% of mothers were not counselled about the importance of follow-up. Almost all HIV-positive infants (95%, n=76) presented with severe respiratory illness, mainly severe acute respiratory distress syndrome (62.5%, n=50/80) and pneumonia with hypoxic respiratory failure (32.5%, n=26/80). The overall mortality of the cohort was 22.5% (n=18/80), and most deaths were associated with cytomegalovirus (CMV), Pneumocystis jirovecii pneumonia (PJP) or both (61.1%, n=11/18). Conclusion. This present study confirmed that a new diagnosis of HIV positivity occurs throughout pregnancy and early childhood in infants. Poor adherence to ART in mothers and their infants, poor counselling, failure to attend antenatal and postnatal care, mixed feeding, and challenged laboratory services were common modifiable factors that need addressing.

Disseminated nocardiosis in an immunocompetent patient.

Nocardiosis is a rare opportunistic bacterial infection. We describe an 8-year-old immunocompetent patient who presented with constitutional symptoms suggestive of probable tuberculosis (TB) in whom we confirmed a diagnosis of nocardiosis. Nocardia is a Gram-positive bacterium that is ubiquitous in soil and decaying vegetable matter. N. asteroides is the most common species. Despite the traditional description of nocardiosis as an opportunistic infection, case reports and case series of pulmonary nocardiosis have recently been reported in immunocompetent patients. Three clinical presentations of nocardiosis have been described; acute, subacute and chronic suppurative infections with episodes of exacerbations and remissions. We describe the presentation, diagnosis, management and prognosis of a rare case of disseminated nocardiosis managed initially as disseminated TB with no improvement.

Red blood cell concentrate transfusion strategies utilised at a tertiary-level paediatric intensive care unit: A descriptive study on impact and cost

Background. Optimal haemoglobin threshold for red blood cell (RBC) transfusions in critically ill anaemic children in a paediatric intensive care unit (PICU) is uncertain.Objective. To describe outcomes and costs associated with different RBC transfusion strategies in anaemic patients admitted to a tertiary PICU in Durban, South Africa.Methods. Transfusion data gathered over a 1-year period were analysed retrospectively. RBC transfusion strategies were classified as restrictive, 'modified liberal' or mixed. The 'modified liberal' group was subdivided into haemodynamically stable or unstable clusters.Transfusion-related effects, comorbidities and mortality were described. Costs associated with RBC transfusions in the various strategy groups were analysed.Results. Over the 118 transfusion records analysed, a restrictive strategy was adopted in 27 cases (22.9%) and a modified liberal strategy was used in 68 cases (57.6%). A mixed strategy was followed in 23 (19.5%) cases. Although mortality was higher in the modified liberal group than in the restrictive group (27.9% v. 11.1%), the difference was not statistically different (p=0.09). There were no differences in the duration of intermittent positive pressure ventilation, length of PICU stay or post-transfusion effects between the restrictive and modified liberal transfusion strategies. A saving of R155 280.15 could have been realised if a restrictive transfusion strategy had been used for haemodynamically stable patients assigned to the modified liberal group. A further R28 988.67 was spent on avoidable after-hours transfusions levies.Conclusion. Adopting a restrictive daytime strategy for RBC transfusions at a PICU could introduceconsiderable cost savings without affecting outcomes

The significance of cytomegalovirus in children with pneumonia admitted for mechanical ventilation.

BACKGROUND: The pathogenic role of cytomegalovirus (CMV) among children with pneumonia is not clear. OBJECTIVES AND DESIGN: We describe the outcome of children on mechanical ventilation with 'probable' CMV-related pneumonitis (CMV DNA polymerase chain reaction [PCR] positive as well as clinical and imaging features of CMV on ganciclovir) and children with pneumonia and CMV infection (CMV DNA PCR-positive without clinical and imaging features of CMV and not on ganciclovir therapy) at a paediatric intensive care unit in South Africa between 2011 and 2013. CMV viral loads were measured in non-bronchoscopic bronchoalveolar lavage fluid (NBBALF), plasma and whole-blood samples. RESULTS: Of the 97 children enrolled, 38 had CMV-related pneumonitis, 27 had pneumonia and CMV infection and 32 had pneumonia without CMV infection (negative CMV DNA PCR). Survival in the three groups was respectively 73.7% (P < 0.05), 92.6% (P < 0.05) and 88.0%. The difference in outcome could be accounted for by variance in the prevalence of human immunodeficiency virus (HIV) infection (respectively 60.5% and 29.6%, P < 0.05). A higher CMV viral load in NBBALF and plasma was seen in cases of CMV-related pneumonitis than in pneumonia with CMV infection: respectively log 5.20 vs. log 4.10 (P < 0.05) and 4.56 vs. 3.47 (P < 0.05). CONCLUSIONS: HIV-infected children on mechanical ventilation with CMV-related pneumonitis on ganciclovir have poor outcomes. Randomised placebo-controlled studies on ganciclovir are required.

Iatrogenic medication errors in a paediatric intensive care unit in Durban, South Africa.

BACKGROUND: Iatrogenic medication errors due to calculation errors are an under-reported concern in children. OBJECTIVE: To determine the incidence and source of iatrogenic medication errors in a paediatric intensive care unit (PICU). METHODS: A prospective study was conducted in the PICU at Inkosi Albert Luthuli Hospital, Durban, South Africa, over a 3-month period in 2014. Medication-related calculation skills of medical practitioners and nurses were assessed through the voluntary anonymous completion of a questionnaire. Medication errors were recorded either spontaneously or by review of all electronic records of admissions. Errors were classified as delays in the decision to prescribe, prescribing mistakes, dispensing errors and administration issues. RESULTS: Of 25 staff members sampled, only 6 (24.0%) were able to complete all medication calculations accurately, while 44.0% (n=11) were unable to answer three or more questions correctly. Errors most frequently encountered included failure to calculate rates of infusion and the conversion of mL to mEq or mL to mg for potassium, phenobarbitone and digoxin. Of the 117 children admitted, 111 (94.9%) were exposed to at least one medication error. Two or more medication errors occurred in 34.1% of cases. Of the errors, 73.8% were detected on chart review and 26.2% by spontaneous reporting. Overall, 89.2% of errors occurred during prescribing, with 10.0% having a ≥10-fold increase or decrease in dosage calculations. Only 2.7% of medication errors were reported as resulting in adverse events. CONCLUSION: Therapeutic skills of healthcare professionals working in the PICU need to be improved to decrease iatrogenic medication errors.

Childhood tuberculosis and exposure to indoor air pollution: a systematic review and meta-analysis.

BACKGROUND: Indoor air pollution (IAP) from environmental tobacco smoke (ETS) and biomass fuel smoke (BMS) poses respiratory health risks, with children and women bearing the major burden. OBJECTIVES: We used a systematic review and meta-analysis to investigate the relation between childhood tuberculosis (TB) and exposure to ETS and BMS. METHODS: We searched three databases for epidemiological studies that investigated the association of childhood TB with exposure to ETS and BMS. We calculated pooled estimates and heterogeneity for studies eligible for inclusion in the meta-analysis and stratified studies on ETS by outcome. RESULTS: Five case-control and three cross-sectional studies were eligible for inclusion in the meta-analysis and quality assessment. Pooled effect estimates showed that exposure to ETS is associated with tuberculous infection and TB disease (OR 1.9, 95%CI 1.4-2.9) among exposed compared to non-exposed children. TB disease in ETS studies produced a pooled OR of 2.8 (95%CI 0.9-4.8), which was higher than the OR for tuberculous infection (OR 1.9, 95%CI 0.9-2.9) for children exposed to ETS compared to non-exposed children. Studies on BMS exposure were too few and too small to permit a conclusion. CONCLUSION: Exposure to ETS increases the risk of childhood TB disease or tuberculous infection.

Paediatric spirometry guideline of the South African Thoracic Society: Part 1.

Spirometry forms an important component in the diagnosis and management of pulmonary diseases in children. In the paediatric setting, there are different challenges in terms of performance and interpretation of good quality and reliable tests. An awareness of the physiological and developmental aspects that exist in children is necessary to improve the quality and reliability of spirometry. We reviewed the recommendations on the technical aspects of performing spirometry in children, from the available guidelines and clinical trials. The focus was on the indications, methods and the interpretation of lung function tests in children <12 years of age. Reliable lung function testing can be performed in children, but an awareness of the limitations, the use of incentives and a dedicated lung function technologist are necessary. 

Guideline for the management of acute asthma in children: 2013 update.

BACKGROUND: Acute asthma exacerbations remain a common cause of hospitalisation and healthcare utilisation in South African children. AIM: To update the South African paediatric acute asthma guidelines according to current evidence, and produce separate recommendations for children above and below 2 years of age. METHODS: A working group of the South African Childhood Asthma Group was established to review the published literature on acute asthma in children from 2000 to 2012, and to revise the South African guidelines accordingly. RECOMMENDATIONS: Short-acting inhaled bronchodilators remain the first-line treatment of acute asthma. A metered-dose inhaler with spacer is preferable to nebulisation for bronchodilator therapy to treat mild to moderate asthma. Two to four puffs of a short-acting bronchodilator given every 20 - 30 minutes, depending on clinical response, should be given for mild attacks; up to 10 puffs may be needed for more severe asthma. Children with severe asthma or oxygen saturation (SpO2) <92% should receive oxygen and frequent doses of nebulised beta-2-agonists, and be referred to hospital. Nebulised ipratropium bromide (via nebulisation or multidosing via pMDI-spacer combination) should be added if there is a poor response to three doses of ß2-agonist or if the symptoms are severe. Early use of corticosteroids reduces the need for hospital admission and prevents relapse; oral therapy is preferable. Assessment of acute asthma in children below the age of 2 years can be difficult, and other causes of wheezing must be excluded. Treatment of acute asthma in this age group is similar to that of older children. CONCLUSION: Effective therapy for treatment of acute asthma - primarily inhaled short-acting ß2-agonists, oral corticosteroids and oxygen with appropriate delivery systems - should be available in all healthcare facilities and rapidly instituted for treatment of acute asthma in children. ENDORSEMENT: The guideline document was endorsed by the Allergy Society of South Africa (ALLSA), the South African Thoracic Society (SATS), the National Asthma Education Programme (NAEP), the South African Paediatric Association (SAPA) and the South African Academy of Family Practice.

Clinical manifestations and outcome in HIV-infected young infants presenting with acute illness in Durban, South Africa.

OBJECTIVES: In young infants, early development of symptomatic HIV infection increases the risk of morbidity and mortality. A prospective study was conducted over a 1-year period in a region with a high burden of HIV in order to describe the clinical presentation of HIV infection in infants aged between 0 and 59 days on attendance at hospital and the factors associated with the need for urgent hospital management. METHODS: Sick young infants presenting to the King Edward VIII Hospital, Durban between February 2003 and January 2004 were enrolled. After systematic evaluation by a primary health worker, an experienced paediatrician determined the primary diagnosis and need for urgent hospital management. Comparisons of these assessments were stratified by HIV status. Children were classified as HIV-uninfected (HIV ELISA-negative), HIV-exposed-but-uninfected (HIV ELISA-positive and HIV RNA PCR-negative), HIV-infected (HIV ELISA-positive and HIV viral load >400 copies/ml). RESULTS: Of 925 infants enrolled, 652 (70·5%) had their HIV status determined: 70 (10·7%) were HIV-infected, 271 (41·6%) HIV-exposed-but-uninfected, and 311 (47·7%) HIV-uninfected. Factors associated with an increased probability of being HIV-infected included if the mother had children from more than one sexual partner, if the infant had had contact with a tuberculosis-infected person or if the HIV-infected mother and/or her exposed infant failed to receive nevirapine prophylaxis. Signs of severe illness were more frequently encountered in HIV-infected than in HIV-exposed-but-uninfected infants, including the prevalence of chest in-drawing (20·3% vs 8·8%, p = 0·004) and severe skin pustules (18·6% vs 8·6%, p = 0·01). Among infants requiring urgent hospital management, observed or reported feeding difficulties and severe skin pustules were more common in HIV-infected than uninfected infants. More HIV-infected infants (12·9%) required hospitalisation than those who were HIV-exposed-but-uninfected (7·7%) or uninfected (7·4%). Primary diagnoses of pneumonia, sepsis or oral thrush were more frequently seen in HIV-infected than exposed-but-uninfected or HIV-uninfected children. CONCLUSION: Early recognition and triaging of infants suspected of having HIV infection provides an opportunity for early diagnosis and treatment which could prevent the adverse impact of rapidly progressive HIV disease.

Guideline for the diagnosis, prevention and treatment of paediatric ventilator-associated pneumonia.

OBJECTIVE: Ventilator-associated pneumonia (VAP) has been poorly studied in South Africa, but is likely to be a significant problem, with resulting increased morbidity and mortality in the paediatric intensive care unit population. This guideline is intended to review the evidence and recommendations for prevention and management of VAP in children and to provide, where possible, clear advice to aid the care of these children, to limit costly and unnecessary therapies and--importantly--limit inappropriate use of antimicrobial agents, EVIDENCE: The Working Group was constituted. Literature on the aetiology, prevention and management of paediatric VAP is reviewed. RECOMMENDATIONS: Evidence-based clinical practice guidelines are provided for VAP diagnosis and prevention in South Africa. In addition, the current status of antimicrobial use has been reviewed and clear recommendations are set out.

Clinical profile and predictors of severe illness in young South African infants (<60 days).

BACKGROUND: Most childhood deaths occur within the first 2 months of life. Simple symptoms and signs that reliably indicate the presence of severe illness that would warrant urgent hospital management are of major public health importance. OBJECTIVES: To describe the disease profile of sick young infants aged 0-59 days presenting at King Edward VIII Hospital, Durban, and to assess the association between clinical features assessed by primary health workers and the presence of severe illness. METHODS: Specific clinical signs were evaluated in young infants by a health worker (nurse), using a standardised list. These signs were compared with an assessment by an experienced paediatrician for the need for urgent hospital- or clinic-based care. RESULTS: Nine hundred and twenty-five young infants were enrolled; 61 were <7 days old, 477 were 7-27 days old, and 387 were 28-59 days old. Illnesses needing urgent hospital management in the age group <7 days were hyperbilirubinaemia (43%) and sepsis (43%); in the age group 7-27 days they were pneumonia (26%), sepsis (17%) and hyperbilirubinaemia (15%), and in the age group 28-59 days they were pneumonia (54%) and sepsis (15%). The clinical sign most consistently predictive of needing urgent hospital care across all groups was not feeding well. Among those over 7 days old, a history of difficult feeding, temperature 237.5 degrees C and respiratory rate > or =60 per minute were also important. CONCLUSIONS: The simple features of feeding difficulties, pyrexia, tachypnoea and lower chest in-drawing are useful predictors of severity of illness as well as effective and safe tools for triaging of young infants for urgent hospital management at primary care centres. Neonatal hyperbilirubinaemia, pneumonia and sepsis are the common conditions for which young infants require urgent hospital-based management.

Impact of HIV-1 status on the radiological presentation and clinical outcome of children with WHO defined community-acquired severe pneumonia.

AIMS: We compared the radiological features and outcome of WHO defined severe pneumonia among HIV infected and exposed uninfected children randomised to receive penicillin or oral amoxicillin in Durban, South Africa. METHODS: Of 425 children aged between 3 and 59 months with WHO defined severe pneumonia, 366 had anonymous HIV testing performed. Outcome was assessed by failure to improve at 48 h after enrolment or deterioration within 14 days. Chest radiographs were evaluated according to WHO defined radiological criteria for pneumonia and internationally standardised radiological criteria. Findings were stratified for HIV status. RESULTS: 82 (22.4%) children were HIV infected, 40 (10.9%) were HIV exposed and 244 (66.7%) were HIV uninfected. The day 14 outcome in children <12 months of age was significantly worse in HIV-1 infected than HIV uninfected children (OR 2.8 (95% CI 1.35 to 3.5), p = 0.002), while HIV-1 infected and uninfected children aged > or =12 months had equivalent outcomes. Parental penicillin and oral amoxicillin had equivalent response rates in all HIV groups. According to the WHO radiological classification, children who failed WHO standard antimicrobial treatment had significantly higher "other consolidates/infiltrates" than "endpoints for consolidation" in the HIV infected group (OR 5.45 (95% CI 1.58 to 21.38), p<0.002), while the reverse was true for HIV exposed uninfected children (OR 4.13 (95% CI 0.88 to 20.57), p<0.036). CONCLUSIONS: The WHO standard treatment guideline for severe pneumonia is inadequate for HIV-1 infected infants. The increased prevalence of "other consolidates/infiltrates" among HIV-1 infected children who failed standard treatment supports the addition of co-trimoxazole to WHO standard treatment.

The burden of pneumococcal disease in children advances in the fight of this epidemic

Streptococcus pneumoniae; the most important cause of acute otitis media; pneumonia; septicaemia and meningitis worldwide; comes in 90 different serotypes. Only a few serotypes cause most of the serious disease. Different serotypes are distinguished by differences in the complex sugars that made up the bacteria's capsule that provide protection against the host's specific defenses. The burden of invasive pneumococcal disease in South Africa subjects is estimated to be 100 - 200 per 100 000. The conjugate pneumococcal vaccine has been shown to be effective in reducing invasive pneumococcal disease due to vaccine serotypes in all countries where it has been introduced. This benefit has extended to unvaccinated subjects. Reduction in penicillin resistant pneumococcus related to vaccine serotypes has been recorded. Replacement disease by non vaccine serotype has eroded the benefit of the vaccine. Industry; donors and governments need to interact to ensure accelerated implementation of this vaccine in developing countries