Epidemiology of Chickenpox and Acute Bacterial Meningitis in India (idsurv data) Dr Suhas V. Prabhu IAP COI Meeting 24th-25th August 2012 Disclosure of conflict of interest Have received travel grants and honorarium from On Advisory Board of Wyeth (Pfizer) Sanofi Pasteur Wyeth (Pfizer) Own shares of various pharma companies GSK Cipla Ranbaxy The idsurv project data The Idsurv project data Data as available from the website is analyzed Analysis possible and valid for Age and sex distribution Seasonal variation Mortality Caveats: Due to selective reporting from doctors, conclusions of prevalence cannot be made Numbers are too small for valid statistical analysis Duration is too short to detect any secular trend Diagnosis (almost always) clinical so diagnosis may be suspect Clinical details are few so assessment of the actual morbidity cannot be made Chickenpox Data Collation Data for 569 days ending August 16, 2012 (~ 1 ½ year) Data reported by 22 pediatricians in 6 states Diagnosis was clinical in all cases ostensibly as per the following case definition: “Vesicular rash starting on trunk and spreading to extremities in multiple stages of evolution” Total 249 cases. i.e. Annual incidence of ~ 160 cases Age ranging from 1 month to 18 years Mean age 75 months (6 1/4 years) 153 male, 95 female. M:F ratio 1.6 : 1 Reporting Pediatricians Name District State No. of cases State Total Rupesh Sheth Bhimji Sachde Naveen Thacker Nitin Manish Chudasama J. Kesharani Vikas Goyal Tejaskumar Trivedi Ketan Shah Sandip Trivedi Suketu Shah Arun Shah Vipin Vasishta Vijay Yewale Uday Pai Tanu Singhal Harshal Nimkande Subhash Rao Pankaj Tardeja Ashok Gawdi Sharadkumar Pai-Raikar Neeta Pole Kutch Kutch Kutch Kutch Kutch Kutch Kutch Rajkot Surat Sabarkantha Gandhinagar Muzzafarpur Bijnour Thane Mumbai Mumbai Thane Thane Thane Thane North Goa Jabalpur Gujarat Gujarat Gujarat Gujarat Gujarat Gujarat Gujarat Gujarat Gujarat Gujarat Gujarat Bihar U.P. Maharashtra Maharashtra Maharashtra Maharashtra Maharashtra Maharashtra Maharashtra Goa M.P. 2 112 9 14 1 8 4 1 3 8 22 9 19 21 1 1 8 1 1 2 1 1 184 9 19 249 249 Total 35 1 1 Epidemiology Reporting states are Bihar, Gujarat, Uttar Pradesh and Maharashtra (and one case each from M.P. and Goa) Maximum Cases reported from Gujarat state (184) of which 150 were from Kutchh district Seasonal distribution: Dec to March 116 cases April to June 116 cases July to November 17 cases Crop of cases March – April 2011 End January to mid-February and May-June 2012 Medical details of Cases 8 patients were hospitalized (3.2%) Unknown whether the varicella or its complication was the reason for the hospitalization No deaths Immunization status 6 patients were ineligible for immunization (underage) (ages ranging from 1 month to 6 months) No cases between 6 and 12 months Only 2 cases were between 12 to 15 months 36 children were immunized (partially or completely) 17 “fully immunized” and 19 “partially immunized” Of the 17 “fully immunized” cases specific mention: One case of having received 1 dose One child reported to have received 2 doses Of the 19 “partially immunized” cases specific mention in 5 cases of having received 1 dose of the vaccine Conclusions from the data Chickenpox does occur in India Is a mild disease with no mortality and little morbidity Higher incidence in boys? Age distribution moving towards higher side – school age group is now the commonest affected Seasonal distribution – In late winter and early summer Vaccine coverage rates are low – only 36 of the 249 children had received partial or complete immunization Significant number of “breakthrough” cases after single dose of the vaccine do occur Age distribution of cases No. of cases 160 140 120 100 80 60 40 20 0 <6 6 months 1 year < 15 months 24 months 60 months 144 months < 1 year 15 months < 24 < 60 < 144 months months months months onwards More conclusions from the data Chickenpox is more a disorder of school-going rather than pre-school children Only 2 cases between 12 to 15 months; no justification for reducing minimum age for receiving the vaccine from 15 to 12. 4 % of cases occur in 1st 6 months of life; there is probably waning levels of antibodies in pregnant women, insufficient to offer adequate protection to the neonate from trans-placental transmission. This might be due to Immunized in childhood (not suffered natural disease) Lesser boosting effect from lack of exposure to cases after seroconversion due to reduction in prevalence of chickenpox Acute Bacterial Meningitis ACUTE BACTERIAL MENINGITIS – Case definition Acute onset of fever (usually > 38.5 °C rectal or 38.0 °C axillary and one of the following signs: Boggy fontanelle, seizures, neck stiffness, altered consciousness or other meningeal signs WITH Abnormal CSF Turbid appearance OR Leucocytosis (>100 cells / mm3) OR Leukocytosis (10 – 100 cells / mm3 ) with elevated proteins >100mg% or CSF sugar <40 mg% ACUTE BACTERIAL MENINGITIS – Etiological case definition ABM Pneumococcal ABM Haemophillus influenzae ABM with N. meningitidis +ve Gram stain / Latex / CSF or Blood culture ABM other organisms ABM with H. influenzae +ve Gram stain / Latex / CSF or Blood culture ABM Meningococcal ABM with Strep. pneumoniae +ve Gram stain / Latex / CSF or Blood culture ABM with organism other than P/H/N ABM with no microbial diagnosis ABM with no microbiological diagnosis Data Collation Data for 531 days ending August 13, 2012 (~ 1 yr and 5 months ) Data reported by 9 pediatricians in 4 states Total 61 cases Annual incidence = 42 cases / year Age range 1 month to 16 years Mean age 39 months (3 ¼ years) 48 male and 13 female Male : female ratio = ~ 3.7 : 1 Reporting Pediatricians Name District State No. of cases State Total Vipin Vashishta Bijnour U.P. 36 36 Rajesh Jasani Kutch Gujarat 1 Nehal Vaidya Smita Tewari Sandip Trivedi Vijay Yewale Jitendra Oswal Harshal Nimkande Sumanth Amperayani Kutch Vadodara Sabarkantha Thane Pune Gujarat Gujarat Gujarat Maharashtra Maharashtra 1 1 16 2 2 19 Thane Maharashtra 1 5 Chennai Tamil Nadu 1 1 61 61 Total Epidemiology Reporting states are only 3: Gujarat, Uttar Pradesh and Maharashtra (and one case from Tamil Nadu) Etiology Pneumococcus H. influenzae Meningococcus “Others” Unknown 11 cases (18.0%) 2 cases (3.3%) 1 case (1.6%) 13 cases (21.4%) 34 cases (55.7%) Method of etiological diagnosis Culture 8 cases Antigen detection 4 cases Gram staining 3 cases Uncertain 17 cases Proven diagnosis 10 cases Medical details of Cases 58 out of 61 (95%) were treated as inpatients 3 patients were NOT hospitalized 6 deaths = mortality rate of 9.8 % H. influenzae 2 cases Possible reason – Refused admission? One from Pune, age 8 months, diagnosis by antigen testing, also had empyema, survived One from Kutchh, age 12 months, “no microbiological diagnosis”, survived Meningococcus 1 case No microbiological diagnosis, age 13 months, survived Cases of Pneumoccocal meningitis Serial No. Age/Sex Method of Diagnosis Outcome Immunized? 1 192/M ? Survived No 2 8/M ? Died No 3 96/M ? Survived Partially (?) 4 84/M Culture Survived No 5 2/F ? Survived Partially (?) 6 84/M ? Survived No 7 144/M Culture Died No 8 192/M Gram stain + antigen+ culture Survived No 9 23/F ? Survived Partially (?) 10 15/F Gram stain + antigen Died No 11 32/M Culture Survived Partially (?) Immunization status Of the 11 cases due to Strep. Pneumoniae: Of the two cases with H. influenzae meningitis: 7 were not immunized 4 were “partially immunized” (No details available) Outcome in these 4 cases: All survived Of the 7 unimmunized cases, 3 died Both were unimmunized The one case of Meningococcal meningitis: Not immunized Conclusions from the data Acute bacterial meningitis does occur in India Occurs right from newborn period to adolescence Higher incidence in younger age group with mean age being 3¼ years Higher incidence in boys? Complete microbiological diagnosis is rarely available Pneumococcus is reported as the cause in 18% but diagnosis is confirmed in less than half of the cases Gram negative organisms are commonly seen esp. in younger infants Haemophilus and Meningococcus identified sporadically Conclusions from the data (contd.) None of the cases had reported receiving the full course of vaccines for Pneumococcus or Haemophilus 4 of the cases with Pneumococcal meningitis had been “partially immunized” All these 4 survived vs only 4 out of the 7 who were not immunized (? Partial protection?) Among the survivors there is no data about the nature of handicap if any Thank You!