[Paediatric Invasive Pneumococcal Disease Before Universal Vaccination: 1995 - 2015]. / Doença Invasiva Pneumocócica Pediátrica Antes da Vacinação Universal: 1995 - 2015.

INTRODUCTION: Pneumococcal conjugate vaccine was introduced in the private market in Portugal in 2001, reaching over the years a moderately high coverage. In July 2015, it was included in the National Immunisation Program. The aim of this study was to characterize invasive pneumococcal disease in a pediatric hospital before universal use of the vaccine. MATERIAL AND METHODS: Retrospective analysis of medical records of all children with Streptococcus pneumoniae identified by culture and/or molecular biology (available since 2008), in products obtained from sterile sites, from January 1995 to June 2015. We evaluated demographic, clinical and microbiological data. Serotype results are available since 2004. RESULTS: Over those 20 years, 112 invasive pneumococcal disease cases were identified, with a median age of 15 months (1 month - 15 years). The median number of cases /year was 4, the highest between 2001 - 2002 (8/year) and 2007 - 2012 (7 - 11/year). The identification occurred mostly in blood culture (72), cerebrospinal fluid (24), pleural fluid (11) an others (5). The most frequent diagnoses were pneumonia (38%), occult bacteraemia (34%) and meningitis (21%). Over the period under review, there was an increase of pneumonia and slight increase of OB, with meningitis cases remaining relatively unchanged. DISCUSSION: In the last two decades, there was no reduction in the number of cases of invasive pneumococcal disease. There was an increase in isolates from pneumonia and occult bacteraemia that might be due to the introduction of molecular biological methods for Streptococcus pneumoniae detection. Vaccine serotypes were predominant. CONCLUSION: This retrospective analysis before universal vaccination will contribute to evaluate the impact of vaccination in the Portuguese pediatric population.

Introdução: A vacina conjugada pneumocócica foi introduzida no mercado privado português em 2001, atingindo ao longo dos anos coberturas moderadamente elevadas. Em julho de 2015 foi integrada no Programa Nacional de Vacinação. O objetivo deste estudo foi caracterizar a doença invasiva pneumocócica num hospital pediátrico antes da vacinação universal. Material e Métodos: Análise retrospetiva dos processos clínicos de todas as crianças com identificação de Streptococcus pneumoniae por cultura e/ou por biologia molecular (disponível desde 2008), em produtos obtidos de locais estéreis, de janeiro 1995 a junho 2015, avaliando dados demográficos, clínicos e microbiológicos. Os serotipos estão disponíveis desde 2004. Resultados: Ao longo destes 20 anos identificámos 112 casos de doença invasiva pneumocócica, com idade mediana de 15 meses (1 mês - 15 anos). A mediana de casos/ano foi 4, com valores máximos entre 2001 - 2002 (8/ano) e 2007 - 2012 (7 - 11/ano). A identificação ocorreu maioritariamente em hemocultura (72), líquido cefalorraquidiano (24), líquido pleural (11) e outros (5). Os diagnósticos mais frequentes foram pneumonia (38%), bacteriemia oculta (34%) e meningite (21%). Ao longo do período em análise, observou-se um aumento do diagnóstico de pneumonia e aumento ligeiro de bacteriemia oculta, tendo-se mantido relativamente constante o de meningite. Discussão: Nas últimas duas décadas não se observou redução do número de casos de doença invasiva pneumocócica, tendo ocorrido um aumento da identificação de pneumococo em pneumonia e bacteriemia oculta, para o qual poderão ter contribuído a introdução dos métodos de biologia molecular e a realização de mais hemoculturas. Os serotipos vacinais foram predominantes. Conclusão: Esta analise retrospetiva pré vacinação universal, contribuirá para avaliar o impacto da vacinação na população pediátrica portuguesa.

Congenital Milium of the Nipple.

A 12-month-old girl presented with an asymptomatic, pearly nodule on the left nipple that had been present from birth and was currently 3 mm in diameter and growing. Assuming the diagnosis of congenital primary milium of the nipple, we took a "wait and see" approach. After 3 months, the pearl disappeared without any scarring.

Pneumococcal Serotypes Colonise the Nasopharynx in Children at Different Densities.

Prevalence of pneumococcal serotypes in carriage and disease has been described but absolute serotype colonisation densities have not been reported. 515 paediatric nasal swab DNA extracts were subjected to lytA qPCR and molecular serotyping by microarray. Absolute serotype densities were derived from total pneumococcal density (qPCR cycle threshold and standard curve) and relative abundance (microarray) and varied widely. Compared to all serotype densities observed, the strongest evidence of differences was seen for serotypes 21 and 35B (higher) and 3, 38 and non-typeables (lower) (p<0.05) with a similar hierarchy when only a single serotype carriage was assessed. There was no evidence of any overall density differences between children with single or multiple serotypes detected but serotypes with mid-range densities were more prevalent. The hierarchy of distinct pneumococcal serotype carriage densities described here for the first time, may help explain the dynamics of transmission between children.

Density Distribution of Pharyngeal Carriage of Meningococcus in Healthy Young Adults: New Approaches to Studying the Epidemiology of Colonization and Vaccine Indirect Effects.

BACKGROUND: Improved understanding of Neisseria meningitidis (Nm) carriage biology and better methods for detection and quantification would facilitate studies of potential impact of new vaccines on colonization and transmission in adolescents. METHODS: We performed plate cultures on 107 oropharyngeal swabs stored frozen in skim milk tryptone glucose glycerol (STGG) broth and previously positive for Nm. We compared quantitative polymerase chain reaction (qPCR) detection of Nm in 601 STGG-swabs with culture. Using qPCR (n = 87), a log-phase broth culture standard curve and semiquantitative plate cultures (n = 68), we measured density of carriage. We compared qPCR genogrouping of DNA extracts from STGG-swabs and from plate culture lawns (n = 110) with purified isolates (n = 80). RESULTS: Swab storage resulted in only 10% loss of culture sensitivity. Direct sodC qPCR Nm detection yielded more positives (87/601, 14.5%) than culture (80/601, 13.3%). Most samples (57/110) positive by culture were also positive by qPCR and vice versa, but discrepancies (single positives) were frequent among low-density samples. sodC qPCR was positive in 79/80 isolates but in only 65 by ctrA qPCR. Density both by culture and qPCR varied across 4 orders of magnitude with the majority being low (<50 bacteria-gene copies/mL) and a minority being high (>1000). Genogrouping qPCRs yielded more positive results when performed on DNA extracts from lawn cultures. CONCLUSIONS: We provide the first description of the distribution of Nm carriage density. This could be important for understanding transmission dynamics and population-level effectiveness of adolescent vaccine programs. Storage of swabs frozen in STGG for batched laboratory analysis facilitates carriage studies and direct sodC qPCR for Nm combined with qPCR genogrouping of lawn culture extracts provides accurate, detailed description of colonization.

Mumps Outbreak among Highly Vaccinated Teenagers and Children in the Central Region of Portugal, 2012-2013.

INTRODUCTION: Mumps vaccine was introduced in the National Immunization Program in Portugal in 1987, rapidly reaching a national coverage > 92%, with important reduction in the annual incidence of the disease. We report a mumps outbreak in the Central Region of Portugal, occurred in the winter 2012-13. MATERIAL AND METHODS: Cases of salivary-gland swelling and other symptoms compatible with mumps were investigated. Geodemographics, clinical, laboratory and vaccination data were analyzed. RESULTS: Over six months, 148 outbreak-related cases were reported: 87.8% occurred in three of the 16 affected counties and 78.4% had a known epidemiological link. Median age was 14.5 years (2-62) and 70.3% were 11-20 years old; 61.5% were male. The mean duration of disease was seven days (2-20). The disease was generally mild; 80.4% had fever and in 55.4% there was unilateral involvement of the parotid gland. Seven cases had orchitis, one oophoritis and one had nephritis. Two cases were hospitalized. School transmission predominated and class attack rates were < 30%. Most of the cases occurred in vaccinated individuals (92%) of whom 86.8% had received 2 doses; 17.7% had received one dose of the vaccine containing the Rubini strain. Mumps virus genotype G was identified in 4 cases. DISCUSSION: This mumps outbreak among a highly vaccinated population, occurring mostly in teenagers at school, could be due to the partial effectiveness of the vaccine against the disease (particularly in the group vaccinated with Rubini strain), waning immunity overtime and genotype mismatch. CONCLUSIONS: This outbreak report shows the importance of discussion about the need of more booster dose of the actual vaccine or new vaccine including more genotypes to improve immunogenicity.

Introdução: A vacina contra o sarampo, parotidite epidémica e rubéola foi introduzida no Programa Nacional de Vacinação em 1987, atingindo rapidamente uma cobertura vacinal > 92% para duas doses, com redução importante da incidência anual da doença. Reportamos um surto de parotidite na Região Centro de Portugal ocorrido entre outubro de 2012 e março de 2013. Material e Métodos: Foram investigados os casos de tumefação de glândulas salivares e sintomas compatíveis com parotidite. Para cada caso foram analisados dados demográficos, clínicos, laboratoriais e vacinais. Resultados: Ao longo de seis meses foram notificados 148 casos: 87,8% ocorreram em três dos 16 concelhos afetados e 78,4% tinham uma relação epidemiológica conhecida. A idade mediana foi de 14,5 anos (2-62) e 70,3% tinham entre 11 e 20 anos; 61,5% eram do sexo masculino. Na maioria dos casos a doença foi ligeira, com uma duração média de sete dias (2-20). A febre ocorreu em 80,4% e a glândula parótida apresentou envolvimento unilateral em 55,4%; sete casos tiveram orquite, um ooforite e uma nefrite. Dois doentes foram internados. A transmissão da doença ocorreu predominantemente em ambiente escolar, com taxas de ataque < 30%. A maioria dos casos ocorreu em indivíduos vacinados (92%), dos quais 86,8% com duas doses. Em 17,7% foi identificada uma dosede vacina contendo a estirpe Rubini. Foi identificado o genótipo G do vírus da parotidite em quatro casos. Discussão: Este surto de parotidite numa população com coberturas vacinais elevadas, atingindo principalmente adolescentes em meio escolar, poderá dever-se à efetividade parcial da vacina contra a doença (especialmente no grupo vacinado com a estirpe Rubini), à perda de imunidade ao longo do tempo ou ainda à discordância entre os genótipos vacinal e circulante causador de doença. Conclusões: O relato deste surto releva a importância da discussão sobre a necessidade de mais doses de reforço da vacina atual ou de uma nova vacina incluindo mais genótipos para melhorar a imunogenicidade.

Oropharyngeal Carriage of Meningococcus in Portugal by Group and Clonal Complex 6 Years After Adolescent Vaccine Campaign.

Portugal introduced (2+1) conjugate Meningococcal group C vaccine in 2006 with high coverage catch up to 18 years and has given only 1 dose at 1 year since 2012. Among 601 student oropharyngeal swabs, meningococcal carriage rate was 13.3% (A-0%, B-5.3%, C-0.3%, W-0.2%, X-0.2% and Y-1.7%). C and W strains were of potentially disease-causing clonal complexes (cc) but not the hyperinvasive cc11.

Case control study of rotavirus vaccine effectiveness in Portugal during 6 years of private market use.

BACKGROUND: Although recommended by the vaccine committee of the Portuguese Paediatric Society, rotavirus vaccines have not been included in the routine immunization schedule. They have been available privately since 2006 with estimated coverage reaching approximately 30%. However, unlike other European countries using the vaccine, sentinel surveillance has detected fluctuations but no clear trends in the rate of gastrointestinal disease presentations. In this study, we set out to establish the real world effectiveness of rotavirus immunization in this low vaccine coverage setting. METHODS: We carried out a test-negative case control study on a population of children attending a regional pediatric hospital, between 2006 and 2012, with symptoms of acute gastroenteritis and producing a stool sample for routine rotavirus testing. We calculated exposure odds ratio (ratio of odds of antecedent vaccination among cases compared with controls) to derive vaccine effectiveness ([1 - adjusted odds ratio]/100) against both hospital attendance and admission. RESULTS: Vaccine effectiveness against attendance with rotavirus acute gastroenteritis was 83.7% (95% confidence interval: 73.9-89.8) and against hospital admission was 96.1% (95% confidence interval: 83.8-99.1). No significant difference between the 2 available vaccines was detected. CONCLUSION: Both rotavirus vaccines offer a high degree of individual protection in this population.

[Hemoglobin: simply a laboratory value or a powerful predictor of risk in patients with acute coronary syndrome?]. / Hemoglobina: um mero valor analítico ou um poderoso preditor de risco em doentes com síndromes coronárias agudas?

INTRODUCTION: Anemia has been shown to be associated with a worse prognosis, especially higher mortality in various pathological conditions. However, few studies have specifically examined its impact in acute coronary syndrome (ACS) patients. The purpose of our study was to assess the association between different quartiles of hemoglobin on admission and short- and long-term prognosis in patients with ACS. METHODS: We performed a retrospective analysis of 1303 consecutive ACS patients admitted to a coronary care unit and analyzed the association between baseline hemoglobin and morbidity and mortality, in-hospital and at 12-month follow-up. The population was divided into groups according to quartiles of hemoglobin concentration (Hb): Q1: <10.8g/dl; Q2: 10.8-12.2g/dl; Q3: 12.3-13.2g/dl; Q4: ≥13.3g/dl. Logistic regression analysis was used to identify independent predictors of short- and long-term mortality. RESULTS: Hypertension and diabetes mellitus were more common in the lower Hb quartiles, while the prevalence of smoking and physical inactivity increased with higher Hb. A higher proportion of patients in the lower quartiles had congestive heart failure, peripheral artery disease and previous stroke or transient ischemic attack. Anemic patients tended to be older, with worse renal function and left ventricular systolic function. Patients in Q1 had significantly higher levels of troponin I and blood glucose on admission. Anemic patients showed significantly higher in-hospital mortality (Q1: 9.8%; Q2: 6.3%; Q3: 4.1%; Q4: 3.6%, p<0.001), longer hospital stay (Q1: 6.1±4.4; Q2: 5.2±3.0; Q3: 4.9±2.7; Q4 4.3±2.1 days, p<0.001) and higher 1-year mortality (Q1: 23.6%; Q2: 11.6%; Q3: 10.6%; Q4: 5.5%, p<0.001). In multivariate analysis, the only independent predictor of in-hospital mortality was Killip class >1 at admission. The independent predictors of long-term mortality were age ≥69.5 years, Killip class >1 at admission, diabetes mellitus, ST-segment depression on admission ECG and Hb <10.8g/dl. DISCUSSION AND CONCLUSIONS: Low baseline hemoglobin is associated with more comorbidities and can accurately predict 1-year mortality after an acute coronary syndrome.