Indian Pediatr 2015;52: 200-201
Invasive Pneumococcal Disease and India
*#Meenu Singh and
#Department of Pediatrics, Advanced Pediatrics
Centre, and *ICMR Advanced Centre of Evidence Based Child Health;
PGIMER, Chandigarh, India.
In this issue of Indian Pediatrics, Nisarga
and colleagues have surveyed for the pneumococcal disease in Bangalore
through the Pneumonet Programme , and have attempted to curtail the
knowledge gap regarding the burden of invasive pneumococcal disease and
distribution of pneumococcal serotypes in India. Many other surveillance
programmes like SAPNA, INCLEN, IBIS and ASAP are also working to assess
the invasive pneumococcal disease burden in India. Knowing disease
burden is important to make decisions regarding the introduction of
pneumococcal vaccine in National immunization program. Many
multi-centric  and single-site studies [3,4] have previously shown
the significant presence of invasive pneumococcal diseases amongst
Indian children, but these are now more than a decade old. The changes,
which have occurred during these years, are not fully known. Skimpy data
hinder the decision regarding introduction of vaccine. The Pneumonet
study published in Indian Pediatrics is a two-year multi-centric
hospital-based surveillance for pneumonia and invasive pneumococcal
diseases in children under five years of age. Though it is a
multi-centric study, the representation is for Bangalore only. It is
difficult to generalize the findings but the study has tried to
demonstrate every aspect of the disease. The investigators have worked
on the isolation, identification, serotyping and antibiotic resistance
patterns of pneumococcus.
The surveillance of over 9000 children from Bangalore
has found 40 confirmed cases of invasive pneumococcal disease and shows
the presence of non- vaccine serotypes. Albeit, the serotyping was not
performed for all the isolates, it still can pinpoint the change
occurring in serotype distribution and hint towards the potential of
non-vaccine pneumococcal serotypes causing severe invasive diseases.
According to Nisarga and colleagues , serotype 6A is the most
commonly encountered serotype, which is in contrast with the findings of
a systematic review of surveillance studies , where it was found that
the most prevalent vaccine serotypes were 14, 5, 1, 19F and 6B. This
finding also highlights the changing trends of the serotypes over the
Nisarga, et al. found pneumococcus being most
resistant against the antibiotic trimethoprim/sulphmethoxazole that is
similar to the findings of a recent systematic review [5,6]. The studyís
selective preference for using non-culture methods like polymerase chain
reaction (PCR) and antigen testing is another shortcoming. Obtaining
positive cultures in a pediatric population is difficult, and if prior
antibiotic has been administered it is even more difficult to isolate
the organism. The study population was children under five years of age
of which 20% had received prior antibiotics which affects the isolation
rate. The study has not used the latex agglutination test and has made
limited use of PCR for identifying the organisms.
The current study also lacks in updating the
information on economic burden for invasive pneumococcal disease, which
is an important factor for determining the disease burden and deciding
upon the policy decisions regarding future actions. Nisarga, et al.
demonstrated the highest serotype coverage by the 13-valent
pneumococcal vaccine which is consistent with the findings of the
systematic review , and an earlier study from CMC, Vellore .
Though the later has shown that a new 15-valent vaccine will cover most
of the disease causing serotypes but the vaccine is not yet available.
The current surveillance is a positive attempt
towards answering the question on having or not having pneumococcal
conjugate vaccines in Indian National immunization schedule? India hopes
to see more of these surveys performed on a large-scale, community-based
studies from different regions so as to have most precise estimate of
the disease to plan the strategy against it. This has rightly been
called for by the authors. A countrywide population-based prospective
study to understand the disease burden, epidemiology, serotype
distribution and also economic burden will more closely aid in
recommending a country-specific vaccine.
Funding: None; Competing interests: None
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