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COMMENTARY
Year : 2014  |  Volume : 140  |  Issue : 2  |  Page : 165-166

Pneumococcal disease in India: The dilemma continues


Advanced Pediatrics Centre Postgraduate Institute of Medical Education & Research Chandigarh 160 012, India

Date of Web Publication3-Oct-2014

Correspondence Address:
Sunit Singhi
Advanced Pediatrics Centre Postgraduate Institute of Medical Education & Research Chandigarh 160 012
India
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Source of Support: None, Conflict of Interest: None


PMID: 25297348

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How to cite this article:
Mathew JL, Singhi S. Pneumococcal disease in India: The dilemma continues . Indian J Med Res 2014;140:165-6

How to cite this URL:
Mathew JL, Singhi S. Pneumococcal disease in India: The dilemma continues . Indian J Med Res [serial online] 2014 [cited 2021 Sep 25];140:165-6. Available from: https://www.ijmr.org.in/text.asp?2014/140/2/165/142190

This issue carries a study by Ravi Kumar et al[1] on the Streptococcus pneumoniae nasopharyngeal carriage in a convenience sample of 190 apparently healthy infants and children [1] . They have also described the antimicrobial sensitivity pattern of the isolated bacteria. There are some methodological limitations in their study (such as small sample size, unclear recruitment criteria, hospital-based enrolment, recruitment of children presenting for vaccination, incomplete description of serotypes searched for, unclear cut-off for penicillin susceptibility, etc.). There are also some flaws in analysis and interpretation. For example, the point-prevalence in the age group 3-12 months (21/96) has been interpreted as 49.2 per cent giving the erroneous impression that there is an inverse correlation between age and pneumococcal carriage. Despite these limitations, the study adds to the Indian literature already available on the subject [2],[3],[4],[5],[6],[7],[8] . Against this backdrop, what additional value does this study provide?

Such a study could have clinical and public health significance since nasopharyngeal colonization with  S.pneumoniae Scientific Name Search  is an initial step leading to infection [9],[10],[11],[12],[13] and its clinical outcomes. It is also well known now that nasopharyngeal carriage may be associated with acquisition of viral upper respiratory infections [14] . Further, recent data from India [15] also suggest that early colonization at two months of age could be associated with growth faltering (detected at 6 months). If this observation is true (and not merely a statistical artefact), it is possible that S. pneumoniae carriage has implications wider than being one of the aetiologies for upper or lower respiratory tract infection.

Given this background, several important issues emerge. First, colonization is not synonymous with infection or invasive disease. Therefore, what could be the cause and mechanism whereby asymptomatic carriage results in clinically important outcomes (including pneumonia, meningitis, growth failure, etc.) in some infants? Second, is there a way to predict which individual infant/child could (or would) experience such adverse outcomes? Third and perhaps more important, unless these aspects are investigated satisfactorily, is it sensible to advocate universal infant pneumococcal vaccination? Fourth, if pneumococcal vaccination is considered an important tool to reduce childhood morbidity/mortality, should the goal be elimination of nasopharyngeal carriage or restricted to reduction in clinically significant disease as envisaged presently?

The latter issues gain importance because much of the current scientific discourse on S. pneumoniae is coloured by the hype around available (note emphasis) vaccines [16] . Traditionally, three prongs are used to advocate vaccination, viz. (i) estimated/extrapolated burden of invasive disease, (ii) penicillin (and sometimes other antibiotic) resistance rates, and (iii) nasopharyngeal carriage rate. Kumar et al[1] have also used their limited data to argue in favour of vaccination along these lines.

Targeting the elimination of nasopharyngeal carriage of vaccine serotypes may not be an appropriate strategy. Among Alaskan infants, vaccination with the 7-valent pneumococcal conjugate vaccine was highly efficacious in reducing invasive disease caused by vaccine serotypes [17] but had limited effectiveness in decreasing disease burden owing to serotype replacement [18],[19] . Serotype replacement and invasive disease caused by the non-vaccine serotypes, have raised significant issues in most developed countries also [20],[21] . This raises the additional issues of whether Indian research should focus more on clinical aspects such as identifying infants/children at high(er) risk of adverse outcomes from pneumococcal infection, and managing them; or whether to 'go with the flow' and target universal vaccination.

This study also suggests that there is emerging penicillin resistance among pneumococcal isolates [1] . This is an interesting finding because most Indian studies and the recent pan-Asian ANSORP study [22] do not corroborate this. It is unclear whether Kumar et al[1] used the recently prescribed minimum inhibitory concentration break points for penicillin resistance [23] which has resulted in the downward revision of penicillin resistance estimates. However, the more pertinent issue is not merely the potential for emerging penicillin resistance, but the causes thereof. In other words, we need to address rampant antibiotic (mis)use (including the empiric therapy of 'pneumonia' recommended by global agencies) and thereby decrease the potential for emergence of antimicrobial resistance.

To summarize, although this study by Kumar and colleagues [1] adds little additional information on pneumococcal carriage, it provides food for thought in various other directions.

 
   References Top

1.Ravi Kumar KL, Vandana A, Ganaie F, Ramesh AC. Nasopharyngeal carriage, antibiogram & serotype distribution of Streptococcus pneumoniae among healthy under five children. Indian J Med Res 2014; 140 : 216-20.  Back to cited text no. 1
    
2.Devi U, Borah PK, Mahanta J. The prevalence and antimicrobial susceptibility patterns of beta-hemolytic streptococci colonizing the throats of schoolchildren in Assam, India. J Infect Dev Ctries 2011; 5 : 804-8.  Back to cited text no. 2
    
3.Dhakal R, Sujatha S, Parija SC, Bhat BV. Asymptomatic colonization of upper respiratory tract by potential bacterial pathogens. Indian J Pediatr 2010; 77 : 775-8.   Back to cited text no. 3
    
4.Wattal C, Oberoi JK, Pruthi PK, Gupta S. Nasopharyngeal carriage of Streptococcus pneumoniae.Indian J Pediatr 2007; 74 : 905-7.  Back to cited text no. 4
    
5.Jain A, Kumar P, Awasthi S. High nasopharyngeal carriage of drug resistant Streptococcus pneumoniae and Haemophilus influenzae in North Indian schoolchildren. Trop Med Int Health 2005; 10 : 234-9.  Back to cited text no. 5
    
6.Coles CL, Rahmathullah L, Kanungo R, Thulasiraj RD, Katz J, Santosham M, et al. Nasopharyngeal carriage of resistant pneumococci in young South Indian infants. Epidemiol Infect 2002; 129 : 491-7.  Back to cited text no. 6
    
7.Kanungo R, d'Lima D, Rajalakshmi B, Natarajan MK, Badrinath S. Throat carriage of pneumococci in healthy school children in the Union Territory of Pondicherry. Indian J Med Res 2000; 112 : 100-3.  Back to cited text no. 7
    
8.Jebaraj R, Cherian T, Raghupathy P, Brahmadathan KN, Lalitha MK, Thomas K, et al. Nasopharyngeal colonization of infants in southern India with Streptococcus pneumoniae. Epidemiol Infect 1999; 123 : 383-8.  Back to cited text no. 8
    
9.Rupa V, Isaac R, Manoharan A, Jalagandeeswaran R, Thenmozhi M. Risk factors for upper respiratory infection in the first year of life in a birth cohort. Int J Pediatr Otorhinolaryngol 2012; 76 : 1835-9.  Back to cited text no. 9
    
10.Syrjanen RK, Auranen KJ, Leino TM, Kilpi TM, Makela PH. Pneumococcal acute otitis media in relation to pneumococcal nasopharyngeal carriage. Pediatr Infect Dis J 2005; 24 : 801-6.  Back to cited text no. 10
    
11.Garcia-Rodriguez JA, Fresnadillo Martinez MJ. Dynamics of nasopharyngeal clonization by potential respiratory pathogens. J Antimicrob Chemother 2002; 50 (Suppl S2) : 59-73.  Back to cited text no. 11
    
12.Bogaert D, de Groot R, Hermans PW. Streptococcus pneumoniae colonization: the key to pneumococcal disease. Lancet Infect Dis 2004; 4 : 144-54.  Back to cited text no. 12
    
13.Hill PC, Cheung YB, Akisanya A, Sankareh K, Lahai G, Greenwood BM, et al. Nasopharyngeal carriage of Streptococcus pneumoniae in Gambian infants: a longitudinal study. Clin Infect Dis 2008; 46 : 807-14.  Back to cited text no. 13
    
14.Sleeman KL, Daniels L, Gardiner M, Griffiths D, Deeks JJ, Dagan R, et al. Acquisition of Streptococcus pneumoniae and nonspecific morbidity in infants and their families: a cohort study. Pediatr Infect Dis J 2005; 24 : 121-7.  Back to cited text no. 14
    
15.Coles CL, Rahmathullah L, Kanungo R, Katz J, Sandiford D, Devi S, et al. Pneumococcal carriage at age 2 months is associated with growth deficits at age 6 months among infants in South India. J Nutr 2012; 142 : 1088-94.   Back to cited text no. 15
    
16.Mathew JL. Pneumococcal vaccination in developing countries: Where does science end and commerce begin? Vaccine 2009; 27 : 4247-51.  Back to cited text no. 16
[PUBMED]    
17.O'brien KL, Moulton LH, Reid R, Weatherholtz R, Oski J, Brown L, et al. Efficacy and safety of seven-valent conjugate pneumococcal vaccine in American Indian children: group randomised trial. Lancet 2003; 362 : 355-61.   Back to cited text no. 17
    
18.Hanage WP. Serotype-specific problems associated with pneumococcal conjugate vaccination. Future Microbiol 2008; 3 : 23-30.  Back to cited text no. 18
[PUBMED]    
19.Singleton RJ, Hennessy TW, Bulkow LR, Hammitt LL, Zulz T, Hurlburt DA, et al. Invasive pneumococcal disease caused by nonvaccine serotypes among alaska native children with high levels of 7-valent pneumococcal conjugate vaccine coverage. JAMA 2007; 297 : 1784-92.  Back to cited text no. 19
    
20.Steens A, Bergsaker MA, Aaberge IS, Rønning K, Vestrheim DF. Prompt effect of replacing the 7-valent pneumococcal conjugate vaccine with the 13-valent vaccine on the epidemiology of invasive pneumococcal disease in Norway. Vaccine 2013; 31 : 6232-8.  Back to cited text no. 20
    
21.Mehtälä J, Antonio M, Kaltoft MS, O'Brien KL, Auranen K. Competition between Streptococcus pneumoniae strains: implications for vaccine-induced replacement in colonization and disease. Epidemiology 2013; 24 : 522-9.  Back to cited text no. 21
    
22.Kim SH, Song JH, Chung DR, Thamlikitkul V, Yang Y, Wang H, et al. ANSORP Study Group. Changing trends in antimicrobial resistance and serotypes of Streptococcus pneumoniae isolates in Asian countries: an Asian Network for Surveillance of Resistant Pathogens (ANSORP) study. Antimicrob Agents Chemother 2012; 56 : 1418-26.   Back to cited text no. 22
    
23.Clinical and Laboratory Standards Institute. Performance standards for antimicrobial susceptibility testing; 18 th informational supplement. CLSI document M100 -S18. Wayne, PA: Clinical and Laboratory Standards Institute; 2008.  Back to cited text no. 23
    




 

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