European enhanced surveillance of invasive pneumococcal disease in 2010: Data from 26 European countries in the post-heptavalent conjugate vaccine era
Introduction
Streptococcus pneumoniae infections are a major public health threat and cause high morbidity and mortality worldwide especially among children under 5 years and amongst the elderly [1], [2]. It is the leading cause of bloodstream infection (BSI), meningitis, upper respiratory tract infections and otitis media [2]. It is the most frequent causative agent of community acquired pneumonia (CAP), resulting in high case-fatality ratios (CFR) [3].
S. pneumoniae is surrounded by a polysaccharide capsule that protects the bacterium from phagocitosis and intracellular killing and therefore is an important virulence factor [4]. Based on differences in the capsule and recognition by different specific antibodies, 93 serotypes with different invasiveness and mortality potential have been identified [5], [6].
Different medical practices [7] and country differences in reporting and surveillance systems of IPD may well explain the large variation of IPD notification rates from 0.4 to 20 cases per 100 000 population per year [8] between European countries that have been reported previously [9].
The introduction of PCV7 targeting children less than 5 years of age has proven highly successful in reducing invasive and mucosal disease caused by the vaccine serotypes and in decreasing antibiotic resistance associated with vaccine serotypes [10]. An additional benefit of the PCV is the decrease in nasopharyngeal carriage of vaccine serotypes that confers a degree of herd immunity in the population [11]. Nevertheless, this success may be partially offset by an increase in non-vaccine serotypes [12], [13]. Furthermore, antimicrobial resistance has emerged and spreads in these non-vaccine serotypes [14].
In response, new pneumococcal conjugate vaccines (PCV10, PCV13) that include additional serotypes have been licensed and EU/EEA countries started introducing them gradually since 2010. The impact of pneumococcal conjugated vaccines and the burden of pneumococcal infections should be closely monitored and better quality data should be analysed in order to assess vaccine strategies throughout Europe. Moreover, it may prove useful to indicate where new expanded valency vaccines should be developed in response to serotype replacement observed after the implementation of PCV7 and as expected for PCV13 [15]. Here we report on the results from an analysis of data from the first enhanced surveillance programme for IPD set up by the European Centre for Disease Prevention and Control (ECDC) in collaboration with the EU/EEA Member States in order to assess the burden of IPD and the prevalence of the different serotypes across Europe.
Section snippets
Scope
Twenty-six European countries participated in the surveillance for IPD from 1st January to 31st December 2010 inclusive, namely Austria, Belgium, Bulgaria, Cyprus, Czech Republic, Denmark, Estonia, Finland, France, Greece, Hungary, Iceland, Ireland, Italy, Latvia, Lithuania, Malta, The Netherlands, Norway, Poland, Romania, Slovakia, Slovenia, Spain, Sweden, and the United Kingdom. This corresponded to approximately 82% of the total population of EU/EEA countries in 2010. A case of IPD was
Epidemiology
In 2010, 21 565 cases of IPD were reported by 26 EU/EEA countries. Notification rates ranged from 0.3 in Lithuania to 17.4 per 100 000 in Denmark (Table 2). The Nordic countries (Denmark, Norway, Finland and Sweden) and Belgium had the highest notification rates.
Of the 21 473 reported cases for which age information was provided, 45.3% were 65 years of age or older, 42.1% 15–64 years of age and 12.6% 0–14 years of age. The highest notification rates were reported among children below 1 year (18.5
Discussion
The 21 565 confirmed cases of IPD reported in the EU/EEA in 2010 showed a wide variation in notification rates. The variation in the notification rate of IPD in Europe may well be due to differences in case definitions of IPD, surveillance methods, medical practices (mainly blood culturing) and clinical presentation of IPD cases [17]. Therefore, a certain degree of under-diagnosis and under-reporting is suspected. Geographic variations in the distribution have been described elsewhere [19] and
Conclusions
European IPD pooled-data analysis is relevant to assess differences across the world and to help formulate policies at a European level. However, differing national surveillance systems and differing vaccination schedules make it difficult to compare data throughout Europe.
Despite these caveats, the establishment of the IPD enhanced surveillance at a European level has provided baseline information on the epidemiology of IPD and has allowed an estimate of the burden of the disease across Europe
Authors’ contributions
Adoración Navarro Torné coordinated the collection of data, performed the data analysis and wrote the manuscript.
Joana Gomes Dias, Chantal Quinten, and Marta Cecilia Busana contributed to the data analysis.
Frantiska Hruba, Pier Luigi Lopalco, Andrew J. Amato Gauci and Lucia Pastore-Celentano reviewed the manuscript.
The ECDC country experts for pneumococcal disease contributed to the data collection and reviewed the manuscript.
Conflict of interest
Authors declare no conflict of interest.
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See Appendix A.