Pneumococcal disease:

Epidemiology and Burden of

disease

Ari Prayitno

Dept. Child Health, Faculty of Medicine

University of Indonesia
 Topics

Burden of pneumonia and pneumococcal disease

Clinical manifestation of pneumococcal disease
Risk of pneumococcal disease in children
 Global Death Among Children Under Five

Pneumonia is the main killer in children

under 5
Pneumonia Pneumonia
(post-neonatal), 13% (neonatal), 3%

The United Nations Children's Fund (UNICEF). Comitting to Child Survival: A Progress Renewed. Progress Report 2015. UNICEF. September 2015.
http://www.unicef.org/publications/index_83078.html. Accessed January 22, 2016
 Global Death Among Children Under Five

UNICEF. One is too many: Ending child deaths from pneumonia and diarrhoea. November 2016.
 Indonesia and Pneumonia
Top countries with Pneumonia
Indonesia is one of the 10 countries with
the highest number of under-five deaths
in 2015
And 14% of death among children under
five in Indonesia due to Pneumonia

In Indonesia EVERY HOUR

2-3 children under-five died
due to pneumonia

The United Nations Children's Fund (UNICEF). Comitting to Child Survival: A Progress
Renewed. Progress Report 2015. UNICEF. September 2015.
http://www.unicef.org/publications/index_83078.html. Accessed January 22, 2016

Source: WHO and Maternal and Child Epidemiology Estimation Group (MCEE) provisional estimates 2015
Leading Underlying Causes of Death among Children
under five (aged 0-59 months) in Indonesia

Indonesia Sample Registration System, 2014

 What is the most common cause of
bacterial pneumonia in children?
Severe Pneumonia cases1

Others
(Fungi, Virus)
30%

S.Pneumonia
(Pneumococcus)
50%

H.Influenza tipe B
20%

Streptococcus pneumoniae, the most common cause of

bacterial pneumonia in children2

1. UNICEF; WHO. Pneumonia: The Forgotten Killer of Children. 2006.

2. Pneumonia. Fact Sheet No. 331. Updated November 2014. WHO.
 Pneumococcal Disease

CDC. Pneumococcal disease. In: Atkinson W, Wolfe S, Hamborsky J, eds. Epidemiology and Prevention of Vaccine-Preventable
Diseases. 12th ed. Washington DC: Public Health Foundation; 2011;217-230. 11th ed. 2009;217-230.
WHO. Acute Respiratory Infections (Update September 2009). http://www.who.int/vaccine_research/diseases/ari/en/print.html..
 The Burden of Pneumococcal Disease in Children

Meningitis Invasive
Bacteremia/sepsis Pneumococcal
Bacteremic pneumonia Disease (IPD)

Pneumonia

Otitis media

Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine-Preventable Diseases. In: Hamborsky J, Kroger A, Wolfe S,
eds. 13th ed. Washington D.C. Public Health Foundation, 2015. 9 11
 Contribution of specic pathogens to severe episodes of, and deaths
from, childhood diarrhoea and pneumonia, by WHO region

Walker CLF, Rudan I, Li L, et al. Lancet 2013;381:1405-16

Radiology of Severe Pneumonia
 Otitis Media
Otitis media is the most common illness seen
in pediatric practice in the US.
Peak incidence was age 611 months
By age 3 years, up to 85% of children will
have had one or more episodes
S. pneumoniae is the first or second most
common organism causing AOM for 26 to
36% of episodes Complications of
pneumococcal otitis media may include
mastoiditis and meningitis
1. Marom et al. JAMA Pediatr 2014;168:68-75
2. Casey et al. Pediatri Infect Dis J 2013;32:805-809
 Common Causes of Bacterial Meningitis

Age Group Causes

Newborns
Infants and Children
Adolescents and Young Adults
Group B Streptococcus, Escherichia coli,
Listeria monocytogenes
Streptococcus pneumoniae, Neisseria
meningitidis, Haemophilus influenzae
type b
Neisseria meningitidis, Streptococcus
pneumoniae

Streptococcus pneumoniae, Neisseria

Older Adults
meningitidis, Listeria monocytogenes

http://www.cdc.gov/meningitis/bacterial.html
Bacterial Meningitis in the United States
(1998 2007)

Thigpen et al. New England Journal of Medicine 2011:364:2016-2025

 Bacteremia
Bacteremia without a known site of infection
is the most common invasive clinical
presentation of pneumococcal infection
among children 2 years old or younger,
accounting for approximately 70% of invasive
disease in this age group.
Bacteremic pneumonia accounts for about
1216% of invasive pneumococcal disease
among children 2 years old or younger.

http://www.cdc.gov/pneumococcal/clnicians/clinical-features.html
Impact of Pneumococcal Disease

Mental
Death Paralysis
retardation

Learning Hearing
Seizure
disability Loss

Behavior Language Delayed Motor

Disorder Delay Development

1. Kornelisse RF, et al. Clin Infect Dis. 1995;21:1390-1397.

2. CDC. Morb Mortal Wkly Rep. 1997;46(RR-8):1-24.
3. Klein JO, et al. Textbook of Pediatric Infectious Diseases. 5th ed.; 2004:215-235.
4. Pikis A, et al. Clin Pediatr (Phila). 1996;35:72-78.
5. Dodge PR, et al. N Engl J Med. 1984;311:869-874. h
 Mortality of IPD Is High Regardless of Age

Case fatality rates for IPD are high, with overall rates
of approximately 20%1,2
In children, mortality is highest in young infants
In developing countries mortality can reach as high as
50% for meningitis
For those who survive, there is a significant risk of
long-term sequelae
As many as 58% of patients experience residual
effects of IPD such as hearing loss, mental retardation,
motor abnormalities, and seizures

1. Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine-Preventable Diseases. In: Hamborsky J, Kroger A, Wolfe S,
eds. 13th ed. Washington D.C. Public Health Foundation, 2015. 2. World Health Organization. Wkly Epidemiol Rec. 2012;87(14):129-144.
 Invasive pneumococcal disease (IPD)
Preferentially Affects the Young and Older Adults
Incidence of IPD per 100,000 Population, England and Wales, 1998-2006

80 1998 1999 2000

2001 2002 2003
2004 2005 2006

60

40

20

0
<2 mo 2-5 mo 6-11 mo 1-<2 2-4 5-9 10-14 15-44 45-64 65-74 75-79 80
Age (years)

Incidence of IPD creates a U-shaped curve with peaks at extremes of age

Adapted from: Kaye P et al. Poster presented at: ESPID Brussels, June 2009.
 Risk Factors for Pneumococcal Disease

Age group Underlying Medical Conditions Living Conditions

Children <2 years Congenital or acquired immunodeficiency Childcare outside of the

Sickle cell disease, asplenia, HIV home 4 hours per week,
Adults 65 years and in the presence of 2
Chronic heart, lung (including asthma), other children other than
renal, or liver disease siblings
Cancer Residence in a nursing
Cerebrospinal fluid (CSF) leak home or other long-term
Diabetes care facility
Chronic alcoholism or cigarette smoking
Organ or hematopoietic cell
transplantation
Cochlear implants

CDC. MMWR Recomm Rep. 1997;46(RR-8):1-24. WHO. Wkly Epidemiol Rec. 2008;83(42):373-384.
CDC. MMWR Recomm Rep. 2000;49(RR-9):1-38; CDC. MMWR Morb Mortal Wkly Rep. 2009;57(53):Q1-Q4.
Levine OS et al. Pediatrics. 1999;103(3):e28.
 Why are Younger Age Groups at Risk for
IPD and Pneumococcal Pneumonia?

Children <2 years of age

Weaning of protective antibodies acquired from
mother at birth
Immature immune systems
High rate of Streptococcus pneumoniae
colonization

CVD=cardiovascular disease; IPD=invasive pneumococcal disease.

1. Offit PA, et al. Pediatrics. 2002;109:124-129. 2. Garcia-Rodriguez JA, et al. J Antimicrob Chemother. 2002;50(S2):59-73. 3. Caruso C, et al. Immun Ageing. 2009;6:10. 4. Kyaw MH,
et al. J Infect Dis. 2005;192:377-386. 5. Musher DM. Streptococcus pneumoniae. In: Mandell GL, et al, eds. Mandell, Douglas, and Bennetts Principles and Practice of Infectious
Diseases. 7th ed. Philadelphia, PA; 2010:2623-2642.
6. Bewick T, et al. Thorax. 2012;67:540-545.
24
Global Pneumonia Disease Burden and Mortality
by Age

81% deaths from

pneumonia happen in
children < 2 years

Walker CLF, Rudan I, Li L, et al. Lancet 2013;381:1405-16

 To end most pneumonia deaths

UNICEF. One is too many: Ending child deaths from pneumonia and diarrhoea. November 2016.
 TAKE HOME MESSAGE
Pneumonia is the leading cause of death children under-
five globally including in Indonesia
Streptococcus pneumoniae, the most common cause of
pneumonia, also causes IPD (bacteremia, meningitis,
invasive pneumonia), and otitis media.
The risk of pneumococcal disease is highest in infants and
can cause sequelae
Protection against pneumococcal disease should start at
2 months of age
Be careful for children before 2 years old for IPD
Doctors play an important role in delivering awareness to
parents about pneumococcal disease protection
THANK YOU