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Dynamics of Severe and Non-severe Invasive Pneumococcal Disease in Young Children in Israel Following PCV7/PCV13 Introduction

Glikman, Daniel, MD*,†; Dagan, Ron, MD; Barkai, Galia, MD§,¶; Averbuch, Diana, MD; Guri, Alex, MD**,††; Givon-Lavi, Noga, PhD‡,‡‡; Ben-Shimol, Shalom, MD‡,‡‡ on behalf of the Israel Bacteremia and Meningitis Active Surveillance Group

The Pediatric Infectious Disease Journal: October 2018 - Volume 37 - Issue 10 - p 1048–1053
doi: 10.1097/INF.0000000000002100
Vaccine Reports
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SDC

Background: The introduction of the pneumococcal conjugated vaccines (PCVs) resulted in a substantial reduction of invasive pneumococcal disease (IPD) rates. However, impact on nonsevere IPD (mostly occult bacteremia) has not yet been fully elucidated. We assessed severe and nonsevere IPD (SIPD and NSIPD, respectively) rate dynamics in children < 5 years in Israel before and after PCV7/PCV13 implementation.

Methods: A prospective, population-based, nationwide surveillance. All IPD episodes recorded from 1999 through 2015 were included. NSIPD was defined as IPD episodes without meningitis, pneumonia or mastoiditis in a child with a favorable outcome (not hospitalized or hospitalized in a nonintensive care unit < 5 days, without mortality). Three subperiods were defined: pre-PCV (1999–2008), PCV7 (2010–2011) and PCV13 (2013–2015). Incidence rate ratios (IRRs) were calculated.

Results: Overall, 4,457 IPD episodes were identified; 3,398 (76.2%) SIPD, 1,022 (22.9%) NSIPD and 37 (0.8%) unknown. In 90% of NSIPD episodes, no focus was identified. In the PCV7 period, NSIPD rates significantly declined by 52%, while SIPD rates declined less prominently by 24%. Following PCV13 introduction, compared with the PCV7 period, NSIPD rates declined nonsignificantly by 17% while SIPD rates declined significantly further by an additional 53%. These trends resulted in overall reductions (comparing PCV13 and pre-PCV periods) of NSIPD and SIPD of 60% (IRR = 0.4; 0.32–0.51) and 64% (IRR = 0.36; 0.32–0.42), respectively.

Conclusions: Following PCV7/PCV13 introduction, SIPD and NSIPD rates substantially declined, with differences in rate-dynamics, alluding to differences in serotype distribution between the 2 groups. Future surveillance is warranted when considering modification in treatment protocols for suspected occult bacteremia/NSIPD cases.

From the *Pediatric Infectious Diseases Unit, Galilee Medical Center, Nahariya, Israel

The Faculty of Medicine in the Galilee, Bar Ilan University, Safed, Israel

The Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel

§Pediatric Infectious Disease Unit, The Edmond and Lily Safra Children’s Hospital, Chaim Sheba Medical Center, Ramat Gan, Israel

The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel

Pediatric Infectious Diseases, Hadassah Hebrew University Medical Center, Jerusalem, Israel

**Division of Paediatrics, Kaplan Medical Center, Rehovot, Israel

††School of Medicine, The Hebrew University and Hadassah University Medical Center, Jerusalem, Israel

‡‡Pediatric Infectious Disease Unit, Soroka University Medical Center, Beer-Sheva, Israel.

Accepted for publication April 9, 2018.

Complete listing of Israel Bacteremia and Meningitis Active Surveillance Group is available at the end of the article.

Supported, in part, by a grant from Pfizer [grant no. 0887X1-4603].

Shalom Ben-Shimol has received speaker fees from Pfizer; Ron Dagan has received grants and consulting and speaker fees from Pfizer; grant and consulting fees from MSD and consulting fees from MeMed; all the other authors have nothing to declare.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (www.pidj.com).

Address for correspondence: Ron Dagan, MD, The Pediatric Infectious Disease Unit, Soroka University Medical Center, Beer-Sheva, Israel. E-mail: rdagan@bgu.ac.il.

Streptococcus pneumoniae is a leading cause of pediatric bacteremia and meningitis, with the highest incidence occurring in children < 5 years old.1,2 Occult bacteremia is defined as the presence of bacteria (90% are caused by S. pneumoniae) in the bloodstream of a febrile child (usually 3–36 months old) who looks well (nontoxic/nonseptic appearance) and has no obvious source of infection.3,4 Most children with occult pneumococcal bacteremia improve spontaneously, but ~25% of untreated patients have persistent bacteremia or develop new focal infections, including 3–6% who develop meningitis.3,4 Thus, in the clinical settings, children with suspected occult bacteremia are empirically treated with antibiotics to prevent those complications.3,4

The implementation of the 7-valent and 13-valent conjugate pneumococcal vaccines (PCV7 and PCV13) in National Immunization Programs (NIPs) resulted in a rapid and substantial reduction of invasive pneumococcal disease (IPD) rates in children.5–9 However, IPD is not a single clinical syndrome, and thus, PCV impact may not be similar in all outcomes within IPD.10–12

In Israel, of all IPD episodes in children < 5 years old in the pre-PCV era, 48.5% were diagnosed as sepsis/bacteremia (including septic/severe cases but also occult bacteremia cases).10 Other diagnoses included Bacteremic pneumonia (35.5%), meningitis (9.4%), bacteremic cellulitis, septic arthritis, peritonitis and sinusitis (2.9% grouped) and 3.7% had a missing diagnosis. Importantly, even in the Israeli setting, where all IPD episodes in children are monitored nationwide for > 25 years, it is hard to establish the diagnosis of occult bacteremia, as often clinical data regarding toxic/septic appearance and focal findings are missing.

Several studies reported reduction in occult bacteremia following PCVs introduction.13–17 However, these studies often had limitations in assessment of the real occult bacteremia incidence rate, as data regarding clinical presentation were usually not prospectively obtained, and consequently the prevalence (proportions) of pathogen-specific bacteremia out of all blood cultures obtained were reported. We previously evaluated PCV impact on incidence rates of different IPD end points10–12 and found that following PCV7/PCV13 introduction, dynamic rates of pneumococcal meningitis, bacteremic pneumonia and other (nonmeningitis, nonpneumonia) IPD episodes differed because of age and serotype distribution variability among the various IPD groups.

Occult bacteremia is essentially an IPD without a focus in a nontoxic child, mostly with a favorable outcome. To better understand PCVs impact on various IPD end points, we divided all IPD episodes into 2 groups: severe IPD (SIPD, including episodes with prolonged hospitalization, as well as cases with meningitis, pneumonia and mastoiditis as a focus) and nonsevere IPD (NSIPD, including episodes with a favorable outcome, without recognized meningitis, pneumonia and mastoiditis as a focus). These definitions were made to identify children with occult pneumococcal bacteremia and other nonsevere presentations of pneumococcal infections.

We assessed the dynamics of NSIPD and SIPD rates in children < 5 years in Israel before and after PCV7/PCV13 implementation.

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METHODS

This ongoing, prospective, nationwide, population-based, active surveillance, conducted by the Israeli Pediatric Bacteremia and Meningitis Group, was initiated in 1989. The current report describes data spanning over a 16-year period, from July 1999 through June 2015. The detailed methods were described previously5,children <5 years: an active prospective nationwide surveillance. Vaccine. 2014;32:3452–3459.','400');" onMouseOut="javascript:ImageWrapperControl_ImageMouseOut();">6,10–12 and will be presented here only briefly.

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Setting and Study Population

The study population comprised all children < 5 years old in Israel. As of 2004, 2009 and 2014, Israel had a population of ~699,000, 754,000 and 850,000 children < 5-years-old, respectively.18

The study has been conducted in all 27 medical health centers, which routinely obtain cerebrospinal fluid (CSF) and blood cultures from children: All 26 hospitals admitting children and 1 major outpatient health maintenance organization, Maccabi Healthcare Services central laboratory.5,children <5 years: an active prospective nationwide surveillance. Vaccine. 2014;32:3452–3459.','400');" onMouseOut="javascript:ImageWrapperControl_ImageMouseOut();">6 Less than 1% of all blood cultures in all ages and no CSF cultures are obtained outside these centers. This enabled us to practically collect all culture-confirmed blood and CSF pediatric IPD cases in Israel.

Local investigators in each center responded to a monthly distributed questionnaire sent by the principal investigator at the study headquarters located at the Pediatric Infectious Disease Unit of the Soroka University Medical Center.

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Case Definitions

An invasive pneumococcal disease episode was defined as an illness during which S. pneumoniae was isolated from blood, CSF or both. Nonculture diagnoses (polymerase chain reaction, antigen testing, Gram stain results or clinical diagnosis) were excluded. In Israel, < 5% of all IPD episodes are diagnosed by nonculture methods. Positive cultures from sterile sites other than blood or CSF (i.e., joint fluid, pleural fluid) were also excluded.

To identify children with occult pneumococcal bacteremia and other nonsevere presentations of pneumococcal infections, 2 criteria were used: (1) Lack of identification of meningitis, pneumonia or mastoiditis as IPD foci; and (2) outcome parameters suggesting nonsevere disease. Thus, NSIPD episodes were defined as IPD episodes without meningitis, pneumonia or mastoiditis in a child with a favorable outcome. Favorable outcome was defined as an episode of a child who was discharged from the emergency room or admitted for < 5 days and was neither hospitalized in an intensive care unit nor died. Nonsevere invasive pneumococcal disease episodes mostly (~90%) comprised pneumococcal bacteremia without focus, while other (focal) NSIPD episodes included cellulitis, sinusitis and arthritis.10

All IPD cases not included in the NSIPD group were defined as SIPD. Therefore, SIPD cases included all meningitis, pneumonia or mastoiditis episodes, as well as bacteremia episodes with prolonged hospitalization, intensive care unit hospitalization and/or mortality.

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PCV7/PCV13 Vaccine Uptake

The introduction of the 7-valent pneumococcal conjugate vaccine into the NIP was initiated in July 2009 with a catch-up campaign in children < 2 years.10,11 In November 2010, PCV13 replaced PCV7, without further catch-up.

Vaccine uptake evaluation methods were previously described.children <5 years: an active prospective nationwide surveillance. Vaccine. 2014;32:3452–3459.','400');" onMouseOut="javascript:ImageWrapperControl_ImageMouseOut();">6,11 By June 2011 and December 2012, ~80% and ~90%, respectively, of 7–11 month children received ≥ 2 PCV7 and/or PCV13 doses and ~95% received ≥ 2 PCV13 doses by June 2014 and June 2015.

By June 2011 and December 2012, 36% and 87%, respectively, of children 24–35 months, received ≥ 3 PCV7/PCV13 doses and > 90% received ≥ 3 PCV13 doses by June 2014 and June 2015.

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Data Analysis

Annual (July through June) incidence rates were calculated as the number of blood/CSF-positive culture cases divided by the total population at risk during each year of the study. The age-specific population at risk was estimated according to the Israeli Central Bureau of Statistics reports for the appropriate years.

For episodes in which serotype and/or serogroup were missing, a detailed extrapolation was conducted according to the distribution of serotypes in the age and ethnic groups during the same year, as described elsewhere.5

The proportion of isolates with serotype determination increased from ~60% in the pre-PCV period (2000–2008) to > 95% since 2009–2010.

To assess changes in NSIPD and SIPD incidence, we used annual rates. Three subperiods were defined, to allow better impact appreciation; (1) pre-PCV: July 1999–June 2008; (2) PCV7: July 2010–June 2011; and (3) PCV13: July 2013–June 2015. Mean incidences during PCV7 and PCV13 periods were compared with pre-PCV period.

Four age groups were defined; < 4, 4–11, 12–23 and 24–59 months. The subdivision of children < 12 months old group to < 4 and 4–11 months was done since children < 4 months are expected to have ≤ 1 PCV dose and thus can be counted as poorly or not vaccinated and are almost entirely dependent on indirect protection.

Incidences were calculated using the birth cohorts born in Israel, according to the Israeli Central Bureau of Statistics reports.18 Incidence rate ratios and 95% confidence intervals were calculated for NSIPD and SIPD and also analyzed by age groups.

Data were analyzed with SPSS 18.00 software. Univariate analyses were conducted using 2-tailed χ2 test or Student’s t test, where appropriate. P value < 0.05 was considered statistically significant.

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RESULTS

During the study period, from July 1999 through June 2015, 4,457 IPD episodes in children < 5 years old were identified. Of these, 3,398 (76.2%) were defined as severe episodes, 1,022 (22.9%) as nonsevere episodes and in 37 (0.8%) episodes severity could not be ascertained (Table, Supplemental Digital Content 1, http://links.lww.com/INF/D183). Among the overall study population, 59% were males; 78% and 22% were Jewish and non-Jewish children, respectively. Children < 4, 4–11, 12–23 and 24–59 months old constituted 11%, 24%, 38% and 27% of the study population, respectively.

Severe IPD episodes included pneumonia (49%), meningitis (14%), sepsis (35%) and mastoiditis (< 2%). The case fatality rate was < 2%. In 90% of NSIPD episodes, no focus was identified (foci identified included cellulitis, arthritis and sinusitis).

Overall, 35% of all isolates were extrapolated for missing serotypes during the study period. The proportion of isolates with serotype determination increased from 61% in the pre-PCV period (1999–2008) to > 95% in the PCV era in 2009 through 2015. Thus, data regarding overall, severe and nonsevere IPD rates are presented for the entire study period (1999 through 2015), but data regarding specific serotypes/serotype groups are only presented for the period between 2009 and 2015.

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Pre-PCV Period (July 1999 through June 2008) Characteristics

Children < 4, 4–11, 12–23 and 24–59 months old comprised 10.3%, 24.8%, 38.9% and 26.0% of all IPD, respectively.

The proportion of severe episodes in children < 4 months (84.9%) was significantly higher compared with children 4–11 months (72.3%; P < 0.001), 12–23 months (75.1%; P < 0.001) and 24–59 months (79.0%; P = 0.03).

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Overall Nonsevere and Severe IPD Rate Dynamics (July 1999 through June 2015)

In the PCV7 period, compared with the pre-PCV period, NSIPD rates significantly declined by 52% (IRR = 0.48; 0.35–0.65), while SIPD rates declined less prominently by 24% (IRR = 0.76; 0.66–0.88; Table 1, Figs. 1, 2). In contrast, following PCV13 introduction, compared with the PCV7 period, NSIPD rates declined nonsignificantly by 17% (IRR = 0.83 [0.57–1.22]), while SIPD rates declined significantly further by additional 53% (IRR = 0.47; 0.39–0.57).

TABLE 1

TABLE 1

FIGURE 1

FIGURE 1

FIGURE 2

FIGURE 2

These trends resulted in an overall reduction (comparing the PCV13 and the pre-PCV periods) in NSIPD and SIPD rates by 60% (IRR = 0.40; 0.32–0.51) and 64% (IRR = 0.36; 0.32–0.42), respectively.

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NSIPD and SIPD Rate Dynamics by Vaccine and Nonvaccine Serotypes (July 2009 through June 2015)

During the PCV13 period (2013–2015), for PCV7 serotypes and the 6 additional PCV13 serotypes, both SIPD and NSIPD rates substantially declined compared with the early-PCV period (2009–2010; Table 2). For PCV7 serotypes (7VT), NSIPD declined by 76% and for SIPD rates declined by 95%. For the 6 additional PCV13 serotypes (6VT), NSIPD declined by 92% and SIPD rates declined by 88% (IRR = 0.12 [0.07–0.18]). For non-PCV13 serotypes (non-VT13), both NSIPD and SIPD rates substantially increased during the PCV13 period; NSIPD rates increased by 74% and SIPD rates increased by 150%.

TABLE 2

TABLE 2

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Proportions of 7VT, 6VT and Non-VT13 in SIPD and NSIPD in Children < 60 Months in Israel, 2009–2015

In the early-PCV period (2009–2010), in both NSIPD and SIPD, proportions of IPD caused by PCV7 serotypes and the 6 additional PCV13 serotypes were similar (Fig. 3). In the PCV7 period, proportions of IPD caused by 7VT were similar in NSIPD and SIPD. In contrast, proportions of IPD caused by additional-6VT were lower in NSIPD than in SIPD (51.3% and 70.4%, respectively, P = 0.025)

FIGURE 3

FIGURE 3

The differences in the proportions of 7VT, additional-6VT and non-VT13 observed in the PCV7 period disappeared in the PCV13 period.

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Comparison of Rate Dynamics of NSIPD and SIPD Between Different Age Groups (July 1999 through June 2015)

Both NSIPD and SIPD rates declined significantly, comparing the pre-PCV period to the PCV13 period in all 4 age groups (Table, Supplemental Digital Content 2, http://links.lww.com/INF/D184). NSIPD and SIPD rates declined significantly also comparing the pre-PCV and PCV7 period for infants 4–11 and children 12–23 months of age, but not for infants < 4 months old and children 24–59 months old. Whereas significant reductions in SIPD rates comparing the PCV7 and the PCV13 periods were evident for children < 4, 12–23 and 24–59 months old, it was observed for NSIPD only in children 24–59 months old.

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DISCUSSION

In the current study, both SIPD and NSIPD rates significantly declined (by 64% and 60%, respectively) following PCV7/PCV13 sequential introduction. However, the dynamics of those reductions were different. Initially, following PCV7 introduction, the decline observed in SIPD rates was less prominent than that observed in NSIPD rates. Subsequently, following PCV13 introduction, both SIPD and NSIPD rates declined resulting in an overall similar impact in the 2 groups.

The discrepancy between SIPD and NSIPD rate dynamics was mainly driven by the differences in serotype distribution between SIPD and NSIPD. In the early PCV era, NSIPD episodes were “enriched” with VT7 serotypes. Similarly, in SIPD, higher proportion of IPD caused by additional PCV13 serotypes (VT6) was observed in the early PCV era (compared with NSIPD). Thus, it is not surprising that NSIPD rates declined substantially immediately following PCV7 introduction, while the decline in SIPD rates was more substantial following PCV13 introduction.

Age is an important factor, beyond serotype distribution, on PCVs observed impact. In early PCV years, unvaccinated age groups (< 4 and 24–59 months old) were less impacted by PCVs, as they did not benefit from direct vaccine impact. These trends changed with time, and in the PCV13 period, all age groups were similarly impacted, indicating both direct and indirect (herd) protection. Additionally, in the < 4 month age group SIPD proportion of overall IPD is higher than in other age groups (due to higher proportion of meningitis and prolonged hospitalization durations), and this also contributed to the delayed PCV impact on the < 4-month-old age group.

Nonsevere IPD is an important clinical entity. In the pre-PCV era, worldwide, occult bacteremia, caused mostly (~90%) by S. pneumoniae, was a major cause for antibiotic administration in the emergency room setting.3,4 This was derived from the high rates of occult bacteremia and physicians’ fear of missing this diagnosis; therefore, resulting in cases of sepsis and meningitis with mortality in a minority of the cases.3,4 Following PCVs introduction, several studies assessed the dynamics of occult bacteremia rates, with generally substantial reductions in disease rates observed.13,19,20 In the United States, where a significant proportion of blood cultures are obtained in the community setting and, consequently, many IPD episodes are diagnosed (generally NSIPD, as these cases have a favorable outcome), a substantial decline in IPD rates was observed early following PCV7 introduction.9 In contrast, in Israel where practically all blood cultures are obtained in the hospital setting (and thus reflect IPD episodes enriched with severe cases), IPD rates did not decline to the same extent following PCV7 introduction, but rather following PCV13 introduction.children <5 years: an active prospective nationwide surveillance. Vaccine. 2014;32:3452–3459.','400');" onMouseOut="javascript:ImageWrapperControl_ImageMouseOut();">6,10,11

In the current study, we assessed a different clinical syndrome, NSIPD (compared with SIPD), which we believe allows a better appreciation of PCVs impact on IPD. NSIPD, similarly to occult bacteremia, represents a group of IPD cases with favorable outcome. However, including other IPD episodes where a focus was identified (e.g., cellulitis) and also looking into outcome (e.g., hospitalization duration) allows a more complete understanding of the overall influence of PCVs on NSIPD.

It is important to be aware that the impressive decline in IPD rates (both severe and nonsevere), resulting from reduction in disease caused by vaccine serotypes (VT13), is accompanied by an increase in non-VT13 IPD rates. This phenomenon observed universally following PCVs introduction worldwide, derives from the replacement of vaccine serotypes carried in the nasopharynx by nonvaccine serotypes pneumococci.10,21–23 It is now well recognized that non-PCV13 serotypes are mostly of lower invasiveness compared with most PCV13 serotypes.21–23 However, as these nonvaccine serotypes become the predominant serotypes causing IPD, a continuous monitoring of their rates is mandated. Indeed, increased rates of IPD caused by serotype 12F and other nonvaccine serotypes have already been reported in Israel,24 as well as in the United Kingdom25 and Italy.26

Previous studies suggested, at least to some extent, physicians’ avoidance of prescribing antimicrobials in treatment protocols for febrile children 3–36 months old with leukocytosis, due to the reduction observed in occult bacteremia rates following PCVs introduction.13,19,27 We believe that physicians must be cautious when treating children with suspected occult bacteremia, and bear in mind that while disease rates are declining, nonvaccine serotype disease is increasing albeit not significantly. Furthermore, rates of meningitis, a possible complication of occult bacteremia, did not decline to the same extent as other IPD in Israel following PCV7/PCV13 sequential introduction, since most cases are caused by non-VT13 pneumococci.10 In consequence, a continuous surveillance is warranted to allow judicious modification, if any, to treatment protocols.

The main limitation of the current study is the relatively high rate of undetermined serotypes early in the pre-PCV period (missing ~40% of serotypes before 2009). However, in recent years, the rate of extrapolated serotypes has dropped to < 5% of all isolated pneumococci. Nevertheless, we acknowledge the possibility of secular trends and temporal fluctuations in pneumococcal serotypes in IPD, which may affect observed trends of SIPD and NSIPD, mainly in the pre-PCV era.

Additionally, some clinical data are missing not allowing the determination of “occult bacteremia” diagnosis. Nevertheless, we strongly believe that NSIPD definition is a more complete definition, which allows real appreciation of PCV impact on IPD episodes with favorable outcome.

We recognize the fact that SIPD and NSIPD are not always easy to define in the “real life setting.” It is conceivable that there is a “sliding scale” from NSIPD to severe and potentially fatal IPD, without a clear “cut-off” mark between the 2. Time is an important factor in this process, as a child with pneumococcal meningitis and pneumococcal bacteremia probably had “only” bacteremia a few hours earlier.

The main strengths of our study are the presence of long-term, nationwide pre-PCV IPD incidence data. Additionally, the relatively long time period that has elapsed since PCV13 introduction to the Israeli NIP (5 years) enables a genuine evaluation of PCV13 impact, as well as specific non-VT13 replacement rates.

In conclusion, following PCV7/PCV13 introduction, severe and nonsevere IPD rates were both substantially reduced. Different rate dynamics of the 2 groups were driven mainly by different serotype distribution, with PCV13 additional serotypes (additional-6VT) contributing in larger proportion to SIPD. These findings should be considered, and future surveillance studies are warranted when modification in treatment protocols for suspected occult bacteremia/IPD cases is contemplated.

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APPENDIX

The Israeli pediatric bacteremia and meningitis group

Ron Dagan, principal investigator, Beer Sheva; Jacob Amir, Petah-Tikva; Galia Barkai, Tel Hashomer; Diana Averbuch, Jerusalem; Shraga Aviner, Ashkelon; Ahuva Bachinski, Hadera; Maskit Bar-Meir, Jerusalem; Avihu Bar-Yochai, Zerifin; Ilana Benedikt, Jerusalem; Rita Bernstein, Rehovot; Tal Brosh-Nissimov, Ashdod; Nael Elias, Nazareth; Dan Engelhard, Jerusalem; Moshe Ephros, Haifa; Daniel Glikman, Nahariya; Giora Gottesman, Kfar-Saba; Galia Grisaru-Soen, Tel-Aviv; Alex Guri, Rehovot; Imad Kassis, Haifa; Nathan Keller, Tel Hashomer; Zina Korenman, Jerusalem; Hannah Leskes, Ashdod; Anthony Luder, Safed; Orli Megged, Jerusalem; Dan Miron, Afula; Meirav Mor, Petah-Tikva; Avi Peretz, Tveria; Uri Rubinstein, Netania; Yechiel Schlesinger, Jerusalem; David Schwartz, Tel-Aviv; Itamar Shalit, Petach Tikva; Eli Somekh, Holon; Isaac Srugo, Haifa; Michal Stein, Hadera; Yonatan Yeshayahu, Ashdod; Alvira Zbriger, Hadera; Miriam Zucker, Zfat.

Keywords:

pneumococcal conjugate vaccine (PCV); occult bacteremia; bacteremia without focus; children

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