Review
Epidemiology of invasive pneumococcal disease in the Arabian Peninsula and Egypt

https://doi.org/10.1016/j.ijantimicag.2008.08.012Get rights and content

Abstract

Invasive pneumococcal disease (IPD) causes considerable morbidity and mortality among children worldwide. This review describes the burden of disease and pneumococcal serotypes/serogroups causing disease in children in the Arabian Peninsula and Egypt identified from a literature search from 1990 to 2007. The incidence of IPD in children aged ≤5 years ranged from 3.4 to 53.5 per 100 000. Bacteraemia cases were responsible for 61–100% (children <2 years) of total IPD. Pneumococcal meningitis cases ranged from 3% to 25% (<2 years) and from 7% to 30% (≤5 years). The most common IPD serotypes/serogroups were 14, 23F, 6B, 19F and 6A (≤5 years). Circulating serotypes/serogroups causing IPD potentially covered by the 7-valent pneumococcal conjugate vaccine (PCV-7) ranged from 49% to 83% (<2 years) and from 61% to 69% (≤5 years). Penicillin resistance among invasive isolates ranged from 0% to 78%. Case fatality and morbidity rates for pneumococcal meningitis were 0–22% and 10–62%, respectively. Incidence and morbidity data for meningitis and bacteraemia demonstrate a substantial vaccine-preventable burden of IPD in young children. Standardisation of definitions and development of improved regional surveillance/reporting would enable the region to measure better the impact of prevention strategies for IPD, such as infant-based immunisation programmes.

Introduction

Streptococcus pneumoniae is a significant cause of morbidity and mortality worldwide, accounting for more than one million deaths in children in developing countries each year [1]. The pneumococcus causes a spectrum of localised, non-invasive infections such as pneumonia, otitis media and sinusitis as well as more severe invasive infections including bacteraemic pneumonia, meningitis and bacteraemia. There are currently more than 90 serotypes of S. pneumoniae described based on differences in capsular polysaccharides, which have been categorised into 46 different serogroups based on immunological cross-reactivity [2]. Although not all serotypes cause disease, some have a greater capacity for invasion resulting in bacteraemic disease, others are more frequently associated with respiratory tract disease but not bacteraemia, and some are limited to nasopharyngeal colonisation [3]. In addition, the emergence of antibiotic resistance continues to impact on the treatment of pneumococcal infections [4].

The Arabian Peninsula and Egypt are areas with a considerable burden of pneumococcal disease. The burden of disease has been reported in individual studies in the Kingdom of Saudi Arabia (KSA) [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], Egypt [15], [16], [17], United Arab Emirates (UAE) [18], [19], Qatar [20], Kuwait [21], [22], [23] and Yemen [24], and has also been summarised in Jordan, Lebanon and Oman [25]. However, a comprehensive analysis of burden and serotype distribution is lacking.

This review examines existing data on pneumococcal disease in the Arabian Peninsula and Egypt in order to detail the epidemiology of invasive pneumococcal disease (IPD) within these countries. Characteristic aspects of the region, such as demographics of the population studied, clinical syndromes, serotypes/serogroups and antimicrobial susceptibility of the clinical isolates, and morbidity and mortality data are included to help delineate the overall burden of disease.

Section snippets

Materials and methods

The published data were obtained using a Medline/OldMedline database search for relevant papers in the English language from 1990 through January 2007. Search terms included pneumococcal infection, Streptococcus pneumoniae, Egypt, Bahrain, Jordan, Kuwait, Middle East, Saudi Arabia, MENA, Qatar, Yemen and Lebanon. Additional relevant studies were identified by review of the reference lists of all identified studies. During development of the manuscript, four recent studies [13], [14], [21], [23]

Epidemiology by country

Table 1, Table 2, Table 3 summarise abstracted data from the existing published literature from six countries within the region of the Arabian Peninsula and Egypt. Each table identifies the location, the time period covered and the age distribution of the children studied. Table 1 also includes the number of isolates, serotypes/serogroups and potential coverage by PCV-7, if available. In addition to the demographic data, Table 2 also includes any available antimicrobial susceptibility data and

Discussion

IPD is a pervasive infection in the Arabian Peninsula and Egypt, particularly in children <5 years of age. Our reported surveillance numbers of pneumococcal meningitis incidence were in the moderate range (0.7–14.4/100 000) [11], [14], [19], [20] compared with that reported in developing nations (20/100 000) [32]. In a recent 5-year study [14], the incidence of IPD (24.4–53.5/100 000 population) was in the range expected for developing nations (10 to ∼100/100 000) [32], [33]. It is likely that

Acknowledgments

The authors would like to thank Deborah Matour for preparation of the manuscript, and Daniel Isaacman and Mark Fletcher for their editorial assistance.

Funding: Wyeth Pharmaceuticals.

Competing interests: SP: advisory board member of Wyeth (Prevnar®) and GlaxoSmithKline (Synflorix) and Investigator Initiated Grant from Wyeth. The other authors declare no competing interests.

Ethical approval: Not required.

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