ReviewEpidemiology of invasive pneumococcal disease in the Arabian Peninsula and Egypt
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.
References (41)
- et al.
Streptococcus pneumoniae in Saudi Arabia: antibiotic resistance and serotypes of recent clinical isolates
Int J Antimicrob Agents
(2004) - et al.
Childhood bacterial meningitis in Saudi Arabia
J Infect
(1998) Distribution of serotypes and antibiotic resistance of invasive pneumococcal disease isolates among children less than five years old in Saudi Arabia (2000–2004)
Clin Microbiol Infect
(2008)- et al.
Etiology, antimicrobial susceptibility profiles, and mortality associated with bacterial meningitis among children in Egypt
Ann Epidemiol
(2004) - et al.
Epidemiological, clinical and prognostic profile of acute bacterial meningitis among children in Alexandria, Egypt
Indian J Med Microbiol
(2005) - et al.
Epidemiology of meningitis in Al-Ain, United Arab Emirates, 2000–2005
Int J Infect Dis
(2007) - et al.
Pattern of meningitis in Al-Ain Medical District, United Arab Emirates—a decadal experience (1990–99)
J Infect
(2002) The epidemiology of pneumococcal, meningococcal, and Haemophilus disease in the Middle East and North Africa (MENA) region—current status and needs
Vaccine
(2007)- et al.
Phase 1 trial of a 13-valent pneumococcal conjugate vaccine in healthy adults
Vaccine
(2007) - Pneumococcal conjugate vaccine for childhood immunization—WHO position paper. Wkly Epidemiol Rec...
Use of antiserum-coated latex particles for serotyping Streptococcus pneumoniae
Microbiol Immunol
Site-specific disease of individual Streptococcus pneumoniae serotypes in pediatric invasive disease, acute otitis media and acute conjunctivitis
Pediatr Infect Dis J
Increasing prevalence of multidrug-resistant Streptococcus pneumoniae in the United States
N Engl J Med
Penicillin resistance in serogroups/serotypes of Streptococcus pneumoniae causing invasive infections in Central Saudi Arabia
Saudi Med J
Streptococcus pneumoniae serotypes/serogroups causing invasive disease in Riyadh, Saudi Arabia: extent of coverage by pneumococcal vaccines
Ann Saudi Med
Childhood pneumococcal bacteraemia in Riyadh, Saudi Arabia
Ann Trop Paediatr
Bacterial meningitis in Saudi Arabia: the impact of Haemophilus influenzae type b vaccination
J Chemother
Antibiotic resistance of pediatric isolates of Streptococcus pneumoniae in a Saudi Arabian hospital from 1999 to 2004
Med Sci Monit
Haemophilus type B meningitis in Saudi children under 5 years old
J Trop Pediatr
A retrospective epidemiological study of invasive pneumococcal disease in children aged 0–5 years in the Kingdom of Saudi Arabia
Cited by (25)
Epidemiology of bacterial meningitis in Lebanon from 2011 to 2019
2020, Journal of Clinical NeurosciencePneumococcal Vaccines
2018, Indian Journal of Medical MicrobiologyEffect of the introduction of pneumococcal conjugate vaccines on serotype prevalence in Kuwait and Saudi Arabia
2018, VaccineCitation Excerpt :The Gulf region in the Middle East has a high pneumococcal disease burden, with risk factors similar to those occurring globally, as well as regional risk factors, such as those associated with the Hajj pilgrimage [2]. However, pneumococcal disease epidemiology in this region continues to be elucidated, with most data derived from individual studies rather than from large data sets [8]. In a systematic review of literature from 1990 to 2007, IPD incidence within the region was 3.4–53.5 per 100,000 children aged <5 years and 0.7–2.5 per 100,000 individuals aged <20 years; 61–100% of all bacteremia cases and 3–25% of all meningitis cases occurring in children aged <2 years were caused by S pneumoniae [8].
A retrospective epidemiological study of invasive pneumococcal infections in children aged 0-5 years in Bahrain from 1 January 1999 to 31 December 2003
2012, VaccineCitation Excerpt :This is higher than incidence rates in children <5 years old in Switzerland (7.61 per 100,000; 1985–1994) [8], Finland (24.2 per 100,000; 1985–1989) [9], Spain (34.5 per 100,000; 1991–2001) [10], Sydney (31.7 per 100,000; 1991–1996) [11], Germany (10.6 per 100,000; 1997–1998) [12] and the United States (36.9 and 33.2 per 100,000 in 1998 and 1999, respectively) [13,14]. This is also higher than the incidence in other countries in the Arabian Peninsula and Egypt, which ranged from 3.4 to 53.5 per 100,000 in children aged <5 years old [7]. The true incidence and burden of IPD in Bahrain is expected to be higher, as many cases were missed owing to previous antibiotic treatment, lack of microbiological confirmation, death at home and the refusal of parents to allow their infants to undergo lumbar puncture.