Table of Contents. 1 3 Update on Activities from Global and Regional Reference Laboratories. 3 The 2012 IB-VPD Laboratory External Quality Assessment

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1 Global Invasive Bacterial Vaccine Preventable Diseases (IB-VPD) Information and Surveillance Bulletin Reporting Period: January through December 2011 Volume 6: October 2012 The World Health Organization (WHO) produces a global invasive bacterial vaccine preventable diseases (IB-VPD) surveillance bulletin twice a year to share information and data with partners at national, regional, and global levels. This bulletin presents surveillance data for January through December of 2011, as reported by Member States participating in the WHO-coordinated network for IB-VPD sentinel surveillance that targets children under 5 years of age hospitalized with suspected meningitis and/or pneumonia-sepsis. Comments on this bulletin are welcome. Please to Dr. Mary Agócs (agocsm@who.int) To subscribe for the bulletin please send an to vpdata@who.int Table of Contents Page Spotlight on Detection of Pneumococcal Meningitis, Spotlight on the IB-VPD Laboratory Network 1 3 Update on Activities from Global and Regional Reference Laboratories 3 The 2012 IB-VPD Laboratory External Quality Assessment 7 Spotlight on Efforts to Improve Data Quality 8 Dissemination of Standard Operating Procedures: Data Management Pamphlet 8 Conducting Standardized Evaluation of Hospital Sentinel Sites (photos from Afghanistan, Gambia, Nepal, Pakistan, and Sri Lanka) 8 Summary of January through December 2011 IB-VPD Surveillance Data 12 Annex: January through December 2011 IB-VPD Surveillance Data 13 The Global IB-VPD Surveillance Network 13 Tier 1: Meningitis surveillance, etiologic agents of meningitis 15 Tier 2: Meningitis-pneumonia-sepsis surveillance with aetiologic agents 18 Tier 3: Population based surveillance 20 Serotype data 20 Comments 21 Network of Global and Regional IB-VPD Reference Laboratories 22 Surveillance Data Reporting Calendar and Surveillance Websites 23 Acknowledgements 23 Spotlight on Detection of Pneumococcal Meningitis, Photo: Data Management Pamphlet Figure A From 2008 to 2011, an increasing number of countries in the IB-VPD surveillance network identified > 20 pneumococcal (Spn) meningitis cases (Figure A, Table A.) During 2011, 16 countries identified at least 20 Spn meningitis cases, an increase from only 2 countries in This increase may be due in part to a change in reporting practice implemented in 2011 that requested all reporting sites to provide information on lab-confirmed cases identified in any suspect meningitis case, not just cases classified IB-VPD Surveillance data reporting period: January - December

2 as probable bacterial meningitis. Additional information is provided on page 17 related to the impact of this change. The increase may also be due to a recommendation from the September 2011 surveillance meeting that called for supplementary testing of CSF specimens using PCR and BINAX NOW (a chromatographic antigen detection test for S. pneumoniae) globally based on evidence of increased yield in laboratory confirmed cases over use of culture alone. Therefore, further increases in the number of reported cases of confirmed pneumococcal meningitis are expected in Serotype data is not available for all countries in the IB-VPD surveillance network, and thus it is not yet feasible to determine how many of these children s illness were due to a vaccine serotype. A recent publication estimated that a sentinel hospital should identify at least 20 cases of Spn meningitis due to the serotypes in PCV to measure the change in vaccine serotypes following PCV introduction. 1 During the global surveillance meeting in October 2012 in Washington DC, the IB-VPD network will discuss the need to increase availability of serotype data, explore reasons for this increasing Spn detection, and assess trends in data quality over time to identify any lessons learned that will be useful in further improving the network. Table A. Countries in the IB-VPD surveillance network that identified at least 20 annual pneumococcal meningitis cases during *. Country GAVI Eligible Yes/No Countries # of Suspect Meningitis Cases # Spn in Countries # of Suspect Meningitis Cases # Spn in Countries # of Suspect Meningitis Cases # Spn in Countries # of Suspect Meningitis Cases Bangladesh Yes , , , Benin Yes Not in Network Not in Network Not in Network Brazil No 7, , , ,476 No data Cameroon Yes Democratic Yes Not in Network Republic of Congo Gambia Yes Ghana Yes Malawi Yes , , , Morocco No No data No data 1, , Niger Yes Nigeria Yes Not in Network Not in Network Panama No Papua New Yes No data Guinea Senegal Yes Sierra Leone Yes Not in Network Not in Network Not in Network Togo Yes Uganda Yes , , , Viet Nam Yes 177** ,308 2 No data No data Yemen Yes , , Zambia Yes Zimbabwe Yes 1, , Total # of Reporting Countries Total # Spn reported 1, *Change in data reporting practices in 2011; all laboratory confirmed cases were reported in 2011 from AFR, EUR, and WPR; during only laboratory confirmed cases identified among cases classified as probable bacterial meningitis were reported **Viet Nam does not report suspected meningitis cases, thus the reported number of probable meningitis cases was used # Spn in Hampton et al. Sentinel versus population-based surveillance of pneumococcal conjugate vaccine effectiveness. Bull World Health Organ 2012;90: IB-VPD Surveillance data reporting period: January - December

3 Spotlight on the IB-VPD Laboratory Network Update on Activities from Global and Regional Reference Laboratories (RRL) WHO invited RRLs to share a short summary of their main activities in support of the IB- VPD surveillance network. The reports provided by the RRLs in AFR and EMR and the Global Reference Laboratory at CDC, Atlanta, USA are reproduced in this section of the bulletin to illustrate their important contribution to the IB-VPD network. The complete list of GRLs and RRLs with the countries served is on page 22 of this bulletin. RRL AFR Summary report submitted by the AFR RRL: National Institute for Communicable Diseases (NICD), Centre for Respiratory Diseases and Meningitis - Bacteriology, Johannesburg, South Africa. Note: NICD serves as a Global Reference Laboratory for the IB-VPD External Quality Assurance programme, as well as a RRL for Africa Working closely with WHO/AFRO, IST and country offices, three on-site visits have been carried out so far this year: Swaziland, (24 27 July), Zimbabwe, (15 17 August) and Namibia (28 31 August). All visits were made possible by efficient co-ordination through WHO/AFRO and included sentinel site assessments and refresher hands-on laboratory training of standardized methodologies for the isolation, identification and long-term storage of pathogens. Strengths and weaknesses at both clinical and laboratory level were identified and feedback was provided with suggestions for improvement. To date the RRL has received 261 culture negative CSF s for molecular testing, of which 36 (14%) were positive; 1 for N. meningitidis, 4 for H. influenzae and 31 for S. pneumoniae. Additionally 42 isolates were received, of which ~50% were viable. Serotypes and antimicrobial resistance results have been reported back to the sentinel sites. Some issues have been experienced with shipping of samples from sentinel sites to NICD, and many isolates are non-viable on receipt. We have attempted to resolve these issues directly with the sites concerned, and have also continued providing support and advice to the WHO/NICD IBD Proficiency Testing Programme. Photo: Zimbabwe, hands-on lab training Photo: Laboratory staff and NICD facilitator, Harare Central Hospital laboratory, Zimbabwe Photo: 3 participants of hands-on training at the Microbiology Laboratory Mbabane General Hospital, Swaziland Photo: Training at the Namibia Institute of Pathology, Windhoek, Namibia IB-VPD Surveillance data reporting period: January - December

4 Summary report submitted by AFR RRL: KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya. The East African RRL was in a transitional period in 2011 as the NetSPEAR programme came to an end and oversight of surveillance activities were handed over to WHO. In 2011, Uganda sent 33 isolates to the RRL for serotyping and antimicrobial susceptibility testing. Tanzania did not send any new isolates in From Kenyan sites, 3 isolates of Neisseria meningitidis were sent to the RRL but unfortunately these were not viable on receipt. From Kilifi District Hospital, there were 42 isolates of S. pneumoniae and 2 of H. influenzae from blood or CSF specimens that underwent serotyping and antimicrobial susceptibility testing in In 2011, the antimicrobial susceptibility testing method at the RRL changed from E-tests to a broth microdilution system from TREK Diagnostic Systems, in conjunction with the South African RRL. The pneumococcal serotyping method in place at the RRL is latex agglutination and Quellung typing initially, with multiplex conventional PCR (adapted from the CDC method) in use as an additional quality control. During 2011, the RRL conducted on site visits with the WHO team to St. Mary s Hospital, Lacor; Mbale Regional Referral Hospital, Mbarara Regional Referral Hospital and Mulago National Referral Hospital in Uganda from 18th to 28th July, and on site visits to Bugando Medical Centre, Mwanza; Mnazi Mmoja Hospital, Zanzibar; Bombo, Tanga; and Teule Hospital, Muheza in Tanzania from 29th May to 4th June. A meeting was held in Nairobi on 17th August to officially hand over surveillance activities to WHO and the Ministries of Health in Tanzania, Uganda and Kenya. This meeting was combined with a data management and laboratory workshop for site participants from the three countries in Kilifi from 18th to 20th August. Photo: Regional participants at the meeting on 17th August 2011 to hand over surveillance activities from NetSPEAR to the WHO and Ministries of Health. Photo: Regional Data Training Workshop for surveillance laboratory and data management personnel IB-VPD Surveillance data reporting period: January - December

5 Summary report submitted by AFR RRL: Medical Research Council (MRC), Banjul, The Gambia 1. RRL, The Gambia builds capacity in Diagnosis of Invasive Bacterial Vaccine Preventable Disease, focusing on Paediatric Bacterial Meningitis, in Africa. The 3rd annual training workshop of Paediatric Bacterial Meningitis Surveillance in West Africa took place from the April 2012 with the theme: Improving Laboratory Diagnosis of Bacterial Meningitis. The overall objective of the training workshop was to refresh microbiologists from 18 African Countries on laboratory identification of pathogens causing meningitis, with particular emphasis on use of rapid test kits (BINAX NOW and Pastorex latex agglutination) to diagnose disease. Photo: The Gambia Facilitators (in lab coats) with Lagos University Teaching Hospital Sentinel site lab staff during a site assessment in May Photo: Dr. Sheikh Jarju, Scientific Officer of the RRL, The Gambia training participants from Senegal and Guinea Bissau during the training Workshop, April Photo: Group photo of all participants and Facilitators who attended the 3 rd annual PneumoWAR training in The Gambia, Photo: Dr. Martin Antonio, Head, RRL, The Gambia, analysing some Real Time PCR data with a RRL staff using the ABI7500 machine. April The RRL, The Gambia conducts site visits to assess and onsite training. From 14 th -25 th May 2012, RRL, The Gambia participated in a technical support mission to The Federal Republic of Nigeria to support New Vaccines Surveillance in 5 sentinel sites. An assessment and training for three potential hospitals (Abubakar Tafewa Balewa University Teaching Hospital, Bauchi, University of Benin Teaching Hospital, Edo State and University of Ilorin Teaching Hospital, Kwara state) to conduct surveillance was undertaken. A detailed assessment using WHO questionnaire and training was also conducted for the two other existing sites (Lagos University Teaching Hospital, Lagos and University of Nigeria Teaching Hospital, Enugu). Photo: RRL, The Gambia Facilitators (in lab coats) with Lagos University Teaching Hospital Sentinel site lab staff during a site assessment in May IB-VPD Surveillance data reporting period: January - December

6 RRL EMR Summary report submitted by the RRL for EMR; Central Public Health Laboratory, Cairo, Egypt. During 2011, the EMR RRL supported the WHO IB-VPD network and: Established and ensured appropriate implementation of international standards for all bacteriological methods including culture, identification, and sensitivity procedures in Egypt, by training Egyptian governorate fever hospitals and national public health laboratory personnel on standard operating procedures especially for laboratory diagnosis of IB-VPD. Participated in the WHO external quality assessment programme in coordination with the National Institute for Communicable Diseases (NICD), Johannesburg on March, June, and October Undertook field visits to three sentinel sites in three provinces in Pakistan during December 2011; namely, King Edward University Mayo hospital and The Children s Hospital/Institute of Child Health, Lahore province, and National Institute of Children Health, Karachi province. In each hospital, the RRL supervised and reviewed technical performance to ensure a strict system of laboratory diagnosis of IB-VPD, quality control and quality assurance of bacterial meningitis surveillance. Conducted a Laboratory Training Workshop for Diagnosis of Invasive Bacterial Pathogens during June 2012, for staff from the three hospital laboratories that were visited in Pakistan. The training included laboratory biosafety and management, quality control and quality assurance, proper specimen handling, processing and recording, identification of IBD, specimen/isolate storage and shipment and an overview on the use of PCR in the diagnosis and serotyping of IB-VPD. Performed molecular serotyping of S. pneumoniae, H. influenzae and serogrouping of N.meningitidis for CSF specimens received from the regional network sentinel site laboratories involved in the clinical surveillance of IB-VPD. Summary report submitted by the GRL: U.S. Centers for Disease Control and Prevention (CDC), Atlanta, USA Since January 2012, the Centers for Disease Control and Prevention (CDC) GRL has provided valuable support to the IB-VPD Network, globally and in the U.S. CDC Subject Matter Experts participate in conference calls, provide technical advice to WHO on a regular basis, and serve as advisors on the IB-VPD Technical Working Group. The CDC GRL also played a key role in finalizing the IB-VPD laboratory and clinical posters and the laboratory manual for diagnosing meningitis, 2nd edition (Laboratory Methods for the Diagnosis of Meningitis caused by Neisseria meningitidis, Streptococcus pneumoniae, and Haemophilus influenzae, 2nd edition). CDC GRL also conducted QC of specimens and bacterial isolates sent to Atlanta from RRLs and collaborated with the Korea and Australia RRLs by reviewing results of QC analyses performed by these RRLs for their national laboratories. CDC GRL microbiologists continued activities toward building RRLs capacity through on-site assessments in Brazil, Australia, and Gambia, and conducted follow-up visits from past laboratory assessments at the India and Korea RRLs. Specific technical support was also provided during these visits, including training in molecular methods for detection and typing of the three IBD organisms from CSFs and isolates. Planning is underway to host one laboratorian from SEAR RRL for intensive training at CDC GRL this fall. IB-VPD Surveillance data reporting period: January - December

7 Photos: GRLvisit to RRL SEAR.. The 2012 IB-VPD Laboratory External Quality Assessment In addition to the technical support provided by WHO via RRLs to ensure and strengthen quality laboratory diagnostic capacity at the sentinel site laboratories, WHO supports laboratory external quality assessment (EQA) programmes. Via the EQA programme, participating laboratories receive simulated specimens and materials which may contain the vaccine preventable disease pathogens. The laboratories then seek to identify the presence or absence of the organism, and in some cases conduct specific testing to determine the serotype/serogroup. The IB-VPD global EQA programme was launched in 2011 and targets all network laboratories, including RRLs, National Laboratories, and sentinel hospital laboratories. The IB-VPD EQA programme is conducted by the Global Reference Laboratory for IB-VPD EQA, based at the National Institute for Communicable Diseases (NICD), South Africa. During 2012, the EQA GRL provided simulated cerebrospinal fluid (CSF) smears for Gram stain and corresponding lyophilized specimens for bacterial culture to a total of 73 laboratories participating in the IB-VPD surveillance network. A total of 73 laboratories were included in the EQA. Of these, 4 were not evaluated (see definitions below.) Of the remaining 69 laboratories, 47 (68%) passed the test and had an acceptable performance. Among non-acceptable laboratories were the 16 laboratories that did not respond to the survey. During 2011, 60 laboratories participated in the EQA, and 4 were also not evaluated. However, only 34 (59%) of laboratories had an acceptable performance. Among non-acceptable laboratories were 20 laboratories that did not respond to the survey without communicating any reason of non-response. Additional analysis of the data will be done to determine whether the improvement was seen in the labs already in the network, or due to high quality labs that have joined in Definitions: Acceptable: This category includes laboratories that provided answers that are accepted by the reviewing committee (responsible for data review and analysis) Not acceptable: This category includes laboratories that 1) failed the test, 2) did not submit results back, or 3) submitted late results with no communication that they were unable to participate in the survey. Non evaluated; This category includes laboratories that did not receive shipments or could not perform tests due to lack of reagents and/or equipment. IB-VPD Surveillance data reporting period: January - December

8 Spotlight on Efforts to Improve Data Quality Dissemination of Standard Operating Procedures: Pamphlet for Data Managers Use of WHO recommended operating procedures are critical to standardizing processes and improving data quality. WHO is now distributing a pamphlet for data managers, Data Management and Analysis Tips for Invasive Bacterial Vaccine Preventable Diseases (IB- VPD) Surveillance. This pamphlet is an accompanying document to the updated laboratory manual and poster for identifying bacteria causing vaccine preventable meningitis as well as the poster for clinicians that highlights the processes to collect cerebrospinal fluid from children with suspected meningitis. These materials were developed in close collaboration with partners, with special inputs by U.S. Centers for Disease Control and Prevention, and all are available on the WHO website link (see last page). Photo: Data Management Pamphlet Conducting Standardized Evaluation of Hospital Sentinel Sites During 2012, WHO began a standardized evaluation of hospital sentinel sites, which is considered to be a key activity to improve surveillance quality. By end 2012, at least 16 evaluations will have been conducted in Member States in all WHO Regions. Teams of trained personnel (clinician and laboratorian) travelled to Member States and held discussions with the Ministry of Health, sentinel hospital management team, and assessed all aspects of IB-VPD surveillance including case identification, patient enrolment, specimen collection and transport, laboratory processes, and data management. A standardized data collection tool was developed, piloted, and used (Figure B) that included a standardized scoring and reporting system that will enable tracking of sentinel hospital performance over time. WHO prioritized evaluation of IB-VPD surveillance in Member States that planned to introduce PCV in 2013, to ensure time for implementation of recommendations prior to vaccine introduction. WHO will work closely with Ministries of Health and RRLs to coordinate follow-up of recommendations made during these assessments. Figure B. WHO IB-VPD Data Collection Tool Photos from a Sample of Assessments follow: IB-VPD Surveillance data reporting period: January - December

9 Afghanistan Hospital emergency ward and CSF collection room with responsible clinicians and lab focal points CSF collection material Clinical Log-book Gambia WHO AFR briefing of IB-VPD sentinel site evaluators Royal Victoria Teaching Hospital Sentinel Site: WHO staff, evaluators, and microbiology laboratory IB-VPD Surveillance data reporting period: January - December

10 Nepal Patan sentinel hospital log book, Patan microbiology laboratory, and sheep kept to supply microbiology laboratory with blood Pakistan Hospital emergency ward and visual display of standard operating procedures Sri Lanka Ministry of Health and WHO discussion and ward log book at Lady Ridgeway sentinel hospital IB-VPD Surveillance data reporting period: January - December

11 Lady Ridgeway sentinel hospital specimen transport and microbiology laboratory Ukraine Site assessment at Donetsk City Hospital 1 IB-VPD Surveillance data reporting period: January - December

12 Summary of IB-VPD Surveillance Data from January through December 2011 Note: Because the IB-VPD surveillance network is in the process of establishing assurance systems and assurance of quality at all surveillance sites is not currently available, care needs to be taken in interpreting data and drawing conclusions. The wide variation in data from different Member States reported in this bulletin may represent variation in surveillance quality, and laboratory testing methods used, rather than true epidemiological differences. The global IB-VPD surveillance network collects data related to the detection of 3 vaccine-preventable organisms: Haemophilus influenzae (Hi), Streptococcus pneumoniae (Spn) and Neisseria meningitidis (Nm). Furthermore, the global IB-VPD sentinel surveillance utilizes a 3-tiered approach: Tier 1 surveillance targets children under-five with suspected meningitis; Tier 2 surveillance also targets children under-five with pneumonia and/or sepsis in addition to meningitis; Tier 3 surveillance seeks to determine incidence rates of IB-VPD, through surveillance in a defined catchment population. The current network, consisting mainly of Tier 1 sentinel sites, provides information that will be useful to monitor trends in disease occurrence, once high-quality data are obtained. However, information from Tier 1 sites should be bridged with data from Tier 2 and Tier 3 surveillance sites as well as from special studies to provide a comprehensive understanding of disease epidemiology. This Bulletin presents IB-VPD surveillance data for January through December Summarized below are the main findings: 57 Member States reported IB-VPD surveillance data to WHO. 43 (75%) of 57 reporting Member States were GAVI funded Member States Member States reported Tier 1 data 19 (33%) of 57 reporting Member States reported Tier 2 data 1 Member State (Mongolia) reported Tier 3 data in addition to Tiers 1 and 2 Tier 1: Globally, 22,516 suspected meningitis cases were enrolled into surveillance During 2011, WHO requested all laboratory confirmed cases to be reported. In the past, only laboratory confirmed cases among children classified as having probable meningitis were reported. Three WHO Regions (AFR, EUR, and WPR) were able to comply and this resulted in substantially increased detection of VPD organisms. In these Regions, the total number of Hi cases increased from 62 among just probable meningitis cases to 110 among suspected plus probable cases, for Spn the corresponding increase was from 249 to 1,091 and for Nm was from 125 to 303. Spn, Hi or Nm were detected in a tested CSF specimen in 52 (91%) of the 57 reporting Member States during Sixteen Member States identified > 20 Spn organisms in tested CSF: Benin, Brazil, Cameroon, DR Congo, Ghana, Malawi, Niger, Nigeria, Panama, Papua New Guinea, Senegal, Sierra Leone, Togo, Viet Nam, Zambia, and Zimbabwe. The scientific community is currently debating the minimum number of detected Spn that may be required to determine impact with 20 being a proposed annual number. Tier 2 surveillance enrolled 29,940 children with suspected pneumonia; a bacterial pathogen was identified in 1,567 (10%) of the 15,266 children with a blood culture performed. Among children with pneumonia who had a blood culture, 216 (1.4%) were due to Spn and 31 (0.2%) were due to Hi. 2 The Member States that are funded by GAVI are those 76 that were at least once eligible for GAVI support IB-VPD Surveillance data reporting period: January - December

13 Annex: IB-VPD Surveillance Data, January through December 2011 The Global IB-VPD Surveillance Network During 2011, 57 Member States reported data to the IB-VPD surveillance network (Figure 1.) Compared to 2010, this was a net gain of 8 Member States including Benin, Central African Republic, Mozambique and Sierra Leone in AFR, Bolivia (Plurinational State of), Nicaragua and Peru in AMR, Morocco in EMR, and Uzbekistan in EUR. Belarus in EUR did not report 2011 laboratory data during Figure 1. WHO member states that reported to the global invasive bacterial vaccine preventable diseases (IB- VPD) surveillance network, Member States reported data Not in the network Source: WHO/IVB New vaccine surveillance Database as of 10 August Map production: Immunization Vaccines and Biologicals, (IVB), World Health Organization. 194 WHO Member States. Date of slide: 20 Sept The 57 Member States that reported data comprised of 191 hospital sentinel sites; 47% of reporting Member States were based in the WHO African Region (AFR), (Table 1). 75% of Member States that reported data to WHO were GAVI-eligible and received financial support to conduct surveillance. Table 1: Characteristics of WHO IB-VPD Surveillance Network by WHO Region, 2011 The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. WHO All rights reserved WHO Region* Total number and % of Member States reporting Number of GAVIfunded Member States reporting % of all Member States reporting who are GAVI-funded Total number and % of sentinel sites reporting AFR 27 (47%) 25 93% 31 (16%) AMR 11 (19%) 3 27% 46 (24%) EMR** 7 (12%) 4 57% 92 (48%) EUR 4 (7%) 4 100% ND SEAR 4 (7%) 4 100% 7 (4%) WPR 4 (7%) 3 75% 15 (8%) Total % 191 *The follow ing Member States participated in the global surveillance netw ork for IB VPD in 2011: Benin, Burkina Faso, Burundi, Cameroon, Central African Republic, Côte d'ivoire, Democratic Republic of the Congo, Ethiopia, Gambia, Ghana, Kenya, Lesotho, Malaw i, Mali, Mozambique, Namibia, Niger, Nigeria, Rw anda, Senegal, Sierra Leone, Sw aziland, Togo, Uganda, United Republic of Tanzania, Zambia and Zimbabw e in the African Region (AFR); Bolivia (Plurinational State of), Brazil, Ecuador, El Salvador, Guatemala, Honduras, Nicaragua, Panama, Paraguay, Peru and Venezuela (Bolivarian Republic of) in the Region of the Americas (AMR); Afghanistan, Iraq, Morocco, Pakistan, Sudan, Syrian Arab Republic and Yemen in the Eastern Mediterranean Region (EMR); Azerbaijan, Georgia, Ukraine and Uzbekistan in the European Region (EUR); Bangladesh, India, Nepal and Sri Lanka in the South-East Asian Region (SEAR); Mongolia, Papua New Guinea, Philippines and Viet Nam in the Western Pacific Region (WPR). ** Morocco has 62 sentinel sites IB-VPD Surveillance data reporting period: January - December

14 Among the 57 Member States reporting clinical data to WHO, 57(100%) reported Tier 1 data, 19 (33%) reported Tier 2 data, and 1 (2%) Member State, Mongolia, collected population-based data (Table 2). Table 2. Number of WHO Member States Reporting IB-VPD Data by Surveillance Tier and WHO Region, January - December 2011 Type of IB VPD surveillance Tier I Tier 2 Tier 3 WHO Region Meningitis +Pneumonia and/or Sepsis +Population-based AFR AMR EMR EUR SEAR WPR Total Tier1: Benin, Burkina Faso, Burundi, Cameroon, Central Tier 2: Bolivia (Plurinational State of), Ecuador, El Tier 3: Mongolia from WPR African Republic, Côte d'ivoire, Salvador, Guatemala, Democratic Republic of the Congo, Ethiopia, Gambia, Ghana, Kenya, Lesotho, Malawi, Mali, Mozambique, Namibia, Niger, Nigeria, Rwanda, Senegal, Sierra Leone, Swaziland, Togo, Uganda, United Republic of Tanzania, Zambia and Zimbabwe from AFR; Bolivia Honduras, Nicaragua, Panama, Paraguay, Peru and Venezuela (Bolivarian Republic of) from AMR; Afghanistan, Pakistan, Syrian Arab Republic and Yemen from EMR; Bangladesh, India, Nepal and Sri Lanka from SEAR; Mongolia from WPR. (Plurinational State of), Brazil, Ecuador, El Salvador, Guatemala, Honduras, Nicaragua, Panama, Paraguay, Peru and Venezuela (Bolivarian Republic of) from AMR; Afghanistan, Iraq, Morocco, Pakistan, Sudan, Syrian Arab Republic and Yemen from EMR; Azerbaijan, Georgia, Ukraine and Uzbekistan from EUR; Bangladesh, India, Nepal and Sri Lanka from SEAR; Mongolia, Papua New Guinea, Philippines and Viet Nam from WPR. IB-VPD Surveillance data reporting period: January - December

15 Tier 1 - Meningitis Surveillance During 2011, 22,516 children <5 years of age hospitalized with suspected meningitis 3 were enrolled in the WHO IB-VPD surveillance network (Table 3). Overall, 90% of suspected meningitis cases had a lumbar puncture (LP) performed. Table 3: Number (No.) of children <5 years of age with suspected meningitis and percent of suspected meningitis that had a lumbar puncture performed, by WHO region, 2011 Suspected meningitis % Suspected meningitis WHO Region No. % of Total Range (by country) with a LP performed AFR 8, , AMR* 8, , EMR 3, , EUR SEAR 1, WPR TOTAL 22, , * Brazil accounts for 85% of the suspected meningitis cases in the Americas, and 36% of the global network, with 7,572 cases reported Note: For Viet Nam, the number of children with an LP performed was used to estimate the number of suspected meningitis cases Among children with suspected meningitis and LP performed, the percentage with probable bacterial meningitis 4 varied widely between Member States, ranging from 3% in Nepal to 92% in Guatemala (Figure 2). Five Member States reported probable meningitis constituting 80% or more of suspected meningitis: Guatemala (92%), Sierra Leone (91%), Pakistan (89%), Ukraine (88%) and El Salvador (87%). The global IB-VPD surveillance network anticipated ~20% of probable bacterial meningitis cases among enrolled suspected meningitis cases. The global median of probable bacterial meningitis cases detected among suspected meningitis in 2011 was 26%. The median percentage of probable bacterial meningitis for WHO Member States by Region varied: AFR (17%), SEAR (17%), WPR (35%), EUR (46%), EMR (53%) and AMR (66%). 3 Any child 0-59 months of age admitted to a sentinel hospital with sudden onset of fever (>38.5 C axillary) and one of the following signs: necs stiffness, altered consciousness with no other alternative diagnosis or other meningeal sign OR Signs and symptoms of bacterial meningitis as defined by the clinician, W HO Summary Report on Meeting to Standardize New Vaccines Surveillance Data to be Collected, Shared and Reported, Probable bacterial meningitis: A suspected case of meningitis with examination of cerebral spinal fluid showing at least one of the following: 1) turbid appearance, 2) WCC(>100 cells/mm 3 ), 3) WCC ( cells/mm 3 ) and either an elevated protein (>100mg/dl) or decreased glucose (<40 mg/dl). IB-VPD Surveillance data reporting period: January - December

16 Figure 2: Percent of suspected meningitis cases with probable bacterial meningitis, by Member State and WHO region - January through December The number of suspected meningitis cases (n= ) stated next to the Member State. Tier 1 - Aetiologic agents The WHO IB-VPD surveillance system only gathers pathogen information as related to detection of one of the three vaccine preventable organisms, Haemophilus influenzae (Hi), Streptococcus pneumoniae (Spn), or Neisseria meningitides (Nm). Data must be cautiously interpreted, as sites varied in the use of antigen detection or polymerase chain reaction (PCR) for etiologic diagnosis with some sites using these tests for one or more of the three pathogens and other sites using only conventional culture. During 2011, data was collected on identification of vaccine preventable organisms among suspect as well as probable meningitis cases. Three WHO Regions reported this data (Table 4) and this resulted in substantially increased detection of VPD organisms. The total number of Hi cases increased from 62 among just probable meningitis cases to 110 among suspected plus probable cases, for Spn the corresponding increase was from 249 to 1,091 and for Nm was from 125 to 303. IB-VPD Surveillance data reporting period: January - December

17 Table 4. Number of children <5 years of age with suspected and probable bacterial meningitis and with Hi, Spn and Nm identified, by WHO region, January-December 2011 No. of cases with Hi No. of cases with Spn No. of cases with WHO Region identified identified Nm identified Suspected Probable Suspected Probable Suspected Probable AFR EUR WPR Total Figure 3 presents the total number of laboratory confirmed meningitis cases of Hi, Spn, and Nm reported by each Member State. Globally, the largest number of cases were identified by Brazil (which does not appear on the graph as the extremely large number of organisms identified by the Member State would distort the scale of the graph), followed by Ghana, Benin, Senegal, Niger, and Papua New Guinea. Figure 3. Number of laboratory confirmed meningitis cases due to Streptococcus pneumonia (Spn), Haemophilus influenza (Hi) and Neisseria meningitis (Nm), by Member State, January through December Number of suspected cases of meningitis (n=) stated next to Member State Number of identified organisms Note: Brazil was removed from the graph because the country reported many more organisms than other Member States, and this would distort the graph. Brazil reported 7,572 suspected cases of meningitis and identified 77 cases of Hi, 265 cases of Spn and 845 cases of Nm. IB-VPD Surveillance data reporting period: January - December

18 Tier 2 - Pneumonia and/or Sepsis Surveillance During 2011, Tier 2 data was reported by 19 Member States in 4 WHO Regions with 29,940 children < 5 years of age hospitalized with pneumonia 5 and enrolled in the WHO IB-VPD surveillance network (Table 5). Overall, 1.6% of the 15,266 blood cultures obtained were found to contain a VPD, consistent with expected results of 1-4% positive blood culture (Table 6.) Table 5: Number of children <5 years of age with pneumonia or sepsis enrolled in the WHO IB-VPD surveillance network, by WHO region, January - December 2011 Pneumonia Sepsis No. of Member Range (by Range (by States Member No. of Member WHO Region reporting No. of children % of Total State) children % of Total State) AMR 10 22, ,303-3,815 NS NS NS EMR 4 1, , SEAR 4 3, , WPR 1 3, TOTAL 19 29, , NS: No Surveillance Table 6: Blood culture results for the children <5 years of age with pneumonia enrolled in the WHO IB-VPD surveillance network, January through December 2011 Number of pneumonia cases 29,940 Number (%) with blood culture performed 15,266 (51%) Number (%) of blood cultures with a bacterial pathogen identified 1,567 (10%) Of those: Number (%) due to HI 31 (0.2%) Number (%) due to Spn 216 (1.4% ) Overall: positive blood cultures (31+216)/ % Figures 4 and 5 present the percent of children with pneumonia and sepsis, respectively, with a blood culture performed and due to Spn and Hi. 5 Any child <5 years of age hospitalized with signs and symptoms of pneumonia as defined by the clinician. IB-VPD Surveillance data reporting period: January - December

19 Figure 4: Percent of pneumonia cases with a blood culture performed due to Streptococcus pneumoniae (Spn) and Haemophilus influenzae (Hi), by Member State and WHO region - January through December Number of pneumonia cases with blood culture performed (n= ) stated next to Member State. Figure 5: Percent of sepsis cases due to Haemophilus influenzae (Hi) and Streptococcus pneumoniae (Spn) by Member State and WHO region - January through December Number of sepsis cases with blood culture performed (n= ) stated next to Member State. IB-VPD Surveillance data reporting period: January - December

20 Tier 3 - Population based Surveillance From January through December 2011, Mongolia reported IB-VPD population-based surveillance data. A total of 114,623 children under 5 years of age were enumerated in the catchment area of the six sentinel hospital sites, and used to calculate incidence rates for meningitis, pneumonia and sepsis, as well as Hi, Spn and Nm (Table 7). Rates generated from sentinel site surveillance may be large under-estimates as they only reflect children under-five with access to the sentinel hospitals, and among those, children who are hospitalized with a syndrome under surveillance and tested for the pathogens of interest. Furthermore, pneumonia is the most common syndrome captured at sentinel sites in Mongolia, but the incidence rates reflected here only include cases of bacteraemic Hi and Spn pneumonia cases. Challenges in isolating these organisms must also be taken into consideration when interpreting these incidence rates. Table 7: incidence rates of IB-VPD and aetiologic agents, Sentinel site surveillance Mongolia, 2011 Incidence rate (per 100,000 child-years) Syndrome (all-cause) Suspected meningitis 38 Pneumonia 2,891 Sepsis 260 Pathogen (all-syndrome) Hi 5 Spn 38 Nm 8 Serotype Data During 2011, serotype data was reported by 5 Regions. The number of countries with serotype data increased from 28 in 2010 to 35 in In AFR, 89% of the 888 Spn organisms were serotyped, while 10% 191 isolates were serotyped in AMR, 66% of 47 in EMR, and 13% of 16 in EUR. IB-VPD Surveillance data reporting period: January - December

21 Comments Tier 1/meningitis data included data from 57 Member States and 22,516 children <5 years of age with suspected meningitis. Globally a marked increase was seen in identification of Spn meningitis cases, as exemplified by the increasing number of countries identifying at least 20 Spn meningitis cases from 2 countries in 2009 to 16 in Contributing to this was the effort of the data managers who revised the data collection protocols to include for the first time identification of VPD bacteria in CSF of suspect as well as probable meningitis cases, and this work resulted in the almost doubling of the number of laboratory confirmed cases reported to the surveillance network. Further improvement in the system is anticipated due to implementation of action items from the September 2011 global surveillance meeting, including: Enhanced efforts to visit sentinel sites; Strengthened role of the Regional Reference Laboratories; Recommendation that CSF be tested with rapid kits at the sentinel hospital and frozen for PCR at the RRLs; and Distribution of standard operating procedures including clinical and laboratory posters, laboratory manual, and upcoming data manager s pamphlet as described in this bulletin s spotlight section. Tier 2/pneumonia-sepsis data was reported by 19 Member States in 4 WHO Regions and 29,940 children with pneumonia were enrolled. Haemophilus influenzae was isolated in 0.2% of pneumonia cases. Streptococcus pneumoniae was isolated in 1.4% of pneumonia cases. Overall, Spn or HI were identified in 1.6% of blood cultures, falling within the expected rate of positive blood cultures among children <5 years of age with pneumonia of 1-4%. Serotype information is essential to monitor the changes in serotype distribution around the introduction of PCV. WHO and partners will discuss during the 2012 global surveillance meeting the serotypes reported during IB-VPD Surveillance data reporting period: January - December

22 Network of Global and Regional IB-VPD Reference Laboratories: Table 8. WHO IB-VPD Surveillance Network Global and Regional Reference Laboratories, September 2012 Region Name of Laboratory Location Member States Served Medical Research Council Laboratories, WHO Regional Reference Laboratory for IB-VPD Banjul, The Gambia Benin, Burkina Faso, Cameroon, Côte d'ivoire, DR Congo, Gambia, Ethiopia, Ghana, Guinea, Mali, Niger, Nigeria, Senegal, Sierra Leone, Togo African Region (AFR) KEMRI-Wellcome Trust Research Programme, WHO Regional Reference Laboratory for IB-VPD Nairobi, Kenya Burundi, Eritrea, Ethiopia, Kenya, Rwanda, Tanzania, Uganda National Institute for Communicable Diseases, WHO Regional Reference Laboratory for IB-VPD Johannesburg, South Africa Lesotho, Madagascar, Namibia, Swaziland, Tanzania, Zambia, Zimbabwe Region of the Americas (AMR) Instituto Adolfo Lutz, WHO Regional Reference Laboratory for IB-VPD Instituto Nacional de Salud,, WHO Regional Reference Laboratory for IB-VPD Sao Paolo, Brazil Bogota, Columbia Argentina, Brazil, Chile, Cuba, Dominican Republic, Paraguay, Uruguay, Venezuela Bolivia, Costa Rica, Ecuador, El Salvador, Guatemala, Honduras, Mexico, Nicaragua, Panama, Peru, Trinidad & Tobago Eastern Mediterranean Region (EMR) Central Puplic Health Laboratory, WHO Regional Reference Laboratory for IB-VPD Cairo, Egypt Afghanistan, Iran, Iraq, Egypt, Libya, Morocco, Pakistan, Sudan, Syria, Yemen European Region (EUR) Gabrichevsky Research Institute for Epidemiology and Microbiology, WHO Regional Reference Laboratory for IB-VPD Moscow, Russia Armenia, Azerbaijan, Belarus, Georgia, Ukraine, Uzbekistan South-East Asia Region (SEAR) Christian Medical College, WHO Regional Reference Laboratory for IB-VPD Vellore, India Nepal, Sri Lanka Western Pacific Region (WPR) Microbiological Diagnostic Unit-Public Health Laboratory, WHO Regional Reference Laboratory for IB- VPD Korea Centers for Disease Control and Prevention (KCDC), WHO Regional Reference Laboratory for IB-VPD Melbourne, Australia Chungcheongbukdo, Republic of Korea Papua New Guinea Philippines, Vietnam Cambodia, Mongolia U.S. Centers for Disease Control and Prevention (CDC) Atlanta, USA Worldwide Global Reference Laboratory Health protection Agency (HPA) Colindale, UK Worldwide National Institute for Communicable Diseases (NICD) Johannesburg, South Africa Worldwide During 2012, the network (Table 1) of global and regional reference laboratories will continue to provide support to national and sentinel hospital laboratories. This includes training, on-site visits, quality control of specimen testing, and other activities as required and coordinated through WHO. IB-VPD Surveillance data reporting period: January - December

23 Surveillance Data Reporting Calendar The below reporting calendar is used for the surveillance network Reporting Frequency Site to national /regional WHO At least Quarterly* January April July October Site sends data from previous Oct-Dec to MOH and WHO CO** Site sends data from previous Jan-Mar to MOH and WHO CO** Site sends data from previous Apr-Jun to MOH and WHO CO** Site sends data from previous Jul- Sept to MOH and WHO CO** Regional Reference Laboratory to WHO RO 6-Monthly Apr-May Oct-Nov Annual data Jan-Dec of previous year Data from Jan-June of same year Regions to countries (regional feedback bulletin) Quarterly Jan Apr July Oct RO prepares RO prepares RO prepares RO prepares quarterly quarterly bulletin of quarterly bulletin of quarterly bulletin of bulletin of country data country data from country data from country data from from Oct-Dec of previous Jul-Sept of previous Jan-Mar of previous Apr-Jun of year year year previous year Regions to WHO HQ (regional feedback bulletin) 6-Monthly July Nov WHO RO sends aggregate regional data from Jan-Dec of the previous year to WHO HQ. These data include serotype results from regional reference laboratories*** HQ to regions (global bulletin) WHO RO sends regional data from Jan-Jun of previous year to WHO HQ 6-Monthly Oct Feb WHO HQ drafts a global bulletin with data from WHO HQ drafts bulletin with data from Jan- Jan-Dec of the previous year to the regions which June of the previous year to the regions includes serotype information*** *Many sites are currently reporting to WHO monthly and this should be continued. Quarterly reporting is the minimum accepted and monthly reporting is preferred. **MOH - Ministry of Health, CO - country office, RO - Regional office (in AFRO this may be sub-regional office) ***Although regional reference laboratories should report serotype data to the regional office on a 6-montly basis this will only be shared with WHO HQ and the countries in the region annually WHO IB-VPD Surveillance Websites Resources for surveillance: Acknowledgements WHO gratefully acknowledges the dedicated efforts of the numerous individuals and organizations involved with compiling this surveillance information, including Ministries of Health, sentinel hospitals, as well as the network of global, regional and national reference laboratories. IB-VPD Surveillance data reporting period: January - December