Najwa Khuri-Bulos

Guillain-Barré syndrome and Fisher syndrome: case definitions and guidelines for collection, analysis, and presentation of immunization safety data.

ames J. Sejvara,∗, Katrin S. Kohla, Jane Gidudua, Anthony Amatob, Nandini Bakshic, Roger Baxterc, ale R. Burwend, David R. Cornblathe, Jan Cleerbout f, Kathryn M. Edwardsg, Ulrich Heiningerh, ichard Hughes i, Najwa Khuri-Bulos j, Rudolf Korinthenbergk, Barbara J. Lawl, Ursula Munrom, elena C. Maltezoun, Patricia Nello,1, James Oleskep, Robert Sparksq, Priscilla Velentgasr, atricia Vermeers, Max Wiznitzer t, The Brighton Collaboration GBS Working Group2

Human rhinovirus C associated with wheezing in hospitalised children in the Middle East.

BACKGROUND Few studies have investigated the disease burden and genetic diversity of human rhinoviruses (HRVs) in developing countries. OBJECTIVES To assess the burden of HRV in Amman, Jordan, and to characterise clinical differences between HRV groups. STUDY DESIGN We prospectively studied children <5 years, hospitalised with respiratory symptoms and/or fever in Amman, Jordan. Viruses were identified by real-time reverse transcriptase polymerase chain reaction (RT-PCR). VP4/VP2 gene sequencing was performed on HRV-positive specimens. RESULTS Of the 728 enrolled children, 266 (37%) tested positive for picornaviruses, 240 of which were HRV. Of the HRV-positive samples, 62 (26%) were of the recently identified group HRVC, 131 (55%) were HRVA and seven (3%) were HRVB. The HRVC strains clustered into at least 19 distinct genotypes. Compared with HRVA-infected children, children with HRVC were more likely to require supplemental oxygen (63% vs. 42%, p=0.007) and, when co-infections were excluded, were more likely to have wheezing (100% vs. 82%, p=0.016). CONCLUSIONS There is a significant burden of HRV-associated hospitalisations in young children in Jordan. Infection with the recently identified group HRVC is associated with wheezing and more severe illness.

Treatment of childhood brucellosis: results of a prospective trial on 113 children.

Treatment of childhood brucellosis is controversial and is currently dependent on inclusion of aminoglycoside antibiotics which are both costly and potentially toxic. Hence an alternate mode of therapy preferably dependent exclusively on oral agents is desirable because this decreases medical cost. In this study we prospectively treated 113 children with a combination of two oral agents, trimethoprim-sulfamethoxazole (10 to 12 mg/kg trimethoprim, 50 to 60 mg/kg sulfamethoxazole and rifampin 15 to 20 mg/kg in two divided doses for 6 weeks. The treatment was well-tolerated and all patients responded by defervescence of fever and resolution of all symptoms within 1 to 3 weeks. Relapse after 6 months occurred in four children all of whom responded to repeat therapy by the same agents. We conclude that the combination of trimethoprim-sulfamethoxazole and rifampin is both cost-effective and safe for the treatment of childhood brucellosis.

Foodhandler-associated Salmonella outbreak in a university hospital despite routine surveillance cultures of kitchen employees.

OBJECTIVE To describe an outbreak of salmonella food poisoning that probably was due to contamination of mashed potatoes by a foodhandler, which occurred despite a policy for routine surveillance stool cultures of kitchen employees. DESIGN A case control study of 223 individuals who ate the lunch meal on September 23, 1989, at the Jordan University Hospital (JUH) cafeteria. SETTING Tertiary care university hospital in Amman, the capital of Jordan. PATIENTS Individuals who developed loose stool or vomiting 6 to 72 hours after eating the lunch meal of September 23, 1989, at the JUH cafeteria. RESULTS Of 619 individuals, 183 fit the case definition (attack rate, 19.6%); 150 were employees, 26 were inpatients, and seven were visitors. Twelve other employees became sick 4 to 6 days later and probably were infected secondarily. The incubation period ranged from 16 to 72 hours in 183 instances. Symptoms included diarrhea (88%), fever (71%), abdominal pain (74%), dehydration (34%), and bloody stool (5%). Eighty-four were hospitalized. Cultures of eight food items were negative, but stool culture on 90 of 180 patients and 11 of 61 kitchen employees yielded Salmonella enteritidis group D. A cohort study of 223 individuals revealed a food-specific attack rate of 72% for the steak and potato meal and 18% for the rice and meat meal (RR, 4; CI95, 2.62 to 6.24; P < 0.01). Stratified analysis of the steak and potato meal revealed that the potatoes were implicated most strongly (RR, 1.93; CI95, 1.42 to 2.64; P < 0.01). Cultures were obtained from all kitchen employees, and 11 of 61 grew Salmonella enteritidis group D. One asymptomatic, culture-positive employee prepared the mashed potatoes on September 23. All of these employees had negative stool cultures 3 months earlier. CONCLUSION This outbreak probably was caused by massive contamination of mashed potatoes by the contaminated hands of the foodhandler. Routine stool culture of foodhandlers is not cost-effective and should not be used as a substitute for health education and proper hygienic practices.

Nosocomial infections in the intensive care units at a university hospital in a developing country: comparison with National Nosocomial Infections Surveillance intensive care unit rates.

OBJECTIVE As a measure of the quality of care provided to patients in the intensive care unit, comparison of nosocomial infection rates with those of the National Nosocomial Infection surveillance was completed during a 3-year observation period. DESIGN The study design was a prospective study during 3 years between 1993 and 1995. During that period, patients at the medical/surgical and neurosurgical intensive care units and the high-risk nursery were surveyed for nosocomial infections. Device use, bloodstream infection, urinary tract infection, and ventilator-associated pneumonia nosocomial infection rates were calculated and compared with the National Nosocomial Infection Surveillance published rates for the same period. SETTING The study setting was the medical/surgical intensive care unit, the neurosurgical intensive care unit, and the high-risk nursery at the Jordan University Hospital. RESULTS Overall infection rates were 17.2 per 100 patients in the medical/surgical intensive care unit, 14.2 to 18.5 per 100 patients in the neurosurgical intensive care unit, and 13.4 to 73.5 per 100 patients in the high-risk nursery. When compared with the weight of the infants, these rates were 61.9 to 94 per 100 in infants weighing <1500 g, 26 to 30.8 per 100 patients in infants weighing >1500 g to 2500 g, and 11.7 to 14.4 per 100 in infants weighing >2500 g. Whereas device use was moderate, bloodstream infection and ventilator-associated pneumonia rates were >90th percentile for National Nosocomial Infection Surveillance in the high-risk nursery, and urinary tract infection was >90th percentile in the medical/surgical and neurosurgical intensive care units. Nosocomial infections at the intensive care units in developing countries need further investigation and control.

The Remaining Challenge of Pneumonia The Leading Killer of Children

Despite a drop in overall child mortality cases since 2000, pneumonia still killed nearly 1.6 million children less than 5 years of age this year, and it remains the leading cause of death in this age group—more than AIDS, malaria, and measles combined. In developing countries, the disease burden among children is particularly high, because implementation of life-saving interventions such as vaccination, exclusive breast-feeding during the first 6 months of life, good nutrition for older children, handwashing, and reducing indoor air pollution from cook stovesand tobacco smoke, continues to be limited. Two of the most common pneumonia-causing pathogens, Haemophilus influenzae type b (Hib) and Streptococcus pneumoniae, can be prevented through vaccination. Previous Hib vaccination efforts in developing countries have shown dramatic reductions in disease burden. A large 1997 trial in the Gambia demonstrated vaccine efficacy of 95% against invasive Hib disease. In the same Gambia study, efficacy of the (9-valent) vaccine was 77% against pneumococcal disease caused by the serotypes targeted by the vaccine and 37% against all types of severe pneumonia which are often fatal. Yet, despite these findings and recommendations from the World Health Organization (WHO) that both Hib and PCVs be included in routine infant immunization programs in all countries, many developing countries have yet to adopt these life-saving interventions. Of the 2008 global cohort of 129 million (surviving) newborn children, 93 million (71% of all born) were not immunized with Hib vaccines and 121 million (93% of all born) were not immunized with PCVs. Vaccine cost remains a major deterrent in vaccine adoption as well as concern over the fact that an earlier version—the 7-valent PCV—did not cover key serotypes found in low-income settings, but the stage has been set for a revolution in pneumococcal vaccine delivery and access. Financing is now available for low-income countries to introduce life-saving vaccines that have, until now, been out of reach for overstretched developing country health budgets. In June 2009, the governments of Italy, the United Kingdom, Canada, the Russian Federation, and Norway, and the Bill and Melinda Gates Foundation launched the pilot pneumococcal Advance Market Commitment (AMC)—an innovative financing mechanism designed to stimulate the development, manufacture, and uptake of affordable vaccines that meet the needs of developing countries—with a collective US

Mass psychogenic illness following tetanus-diphtheria toxoid vaccination in Jordan

1.5 billion commitment. In addition, the Global Alliance for Vaccine and Immunization will help fund the total cost of these vaccines by contributing up to US

Guidelines for collection, analysis and presentation of vaccine safety data in pre-and post-licensure clinical studies

1.3 billion between 2010 and 2015. Acting on the Gates Foundation’s call to make this the “decade of vaccines,” in March of this year, GlaxoSmithKline and Pfizer Inc, the 2 makers of the new 10and 13-valent PCVs (PCV10 and PCV13), confirmed their commitment by signing an agreement to become the first companies to supply pneumococcal vaccines through the AMC. Two other companies with products in development have also signed on. This means that the newest pneumococcal vaccines will be available for developing countries, where they are urgently needed, and at a fraction of the price charged in industrialized countries. New vaccines available through the AMC stand to protect against more strains of pneumococcal disease prevalent in the developing world. Although serotypes included in PCV7 covered 65% to 80% of serotypes associated with invasive pneumococcal disease in western industrialized countries, the coverage varied in developing countries and was anticipated to be lower. This left leaders outside of the western industrialized world hesitant to invest in PCV7, despite the urging of the World Health Organization. Many countries decided to hold their decisions to implement pneumococcal vaccines until newer vaccines with broader coverage were available. The time has come for all countries to act. In addition to the “older” vaccines such as Hib vaccine and PCV7, the new generation vaccines—PCV10 and PCV 13—are available now and expected to cover 50% to 80% of invasive pneumococcal disease not just in industrialized countries, but worldwide. In addition to the PCV7 serotypes (4, 6B, 9V, 14, 18C, 19F, and 23F), PCV10 covers against strains 1, 5, and 7F, while PCV13 also includes serotypes 1, 3, 5, 6A, 7F, and 19A, offering broader coverage against strains prevalent throughout Africa and Asia. As we mark the second World Pneumonia Day, developing countries must seize the moment to eliminate the leading causes of pneumonia in the world. As pediatricians and researchers, we can Accepted for publication September 7, 2010. From the *The Pediatric Infectious Disease Unit, Soroka University Medical Center and the Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel; †Division of Maternal and Child Health, Aga Khan University, Karachi, Pakistan; ‡Sabin Vaccine Institute, Washington, DC; §European Society of Clinical Microbiology and Infectious Diseases, Barcelona, Spain; ¶William H. Foege Chair in Global Health, Rollins School of Public Health, Emory University, Atlanta, GA; Division of Infectious Disease, Jordan University Hospital, Amman, Jordan; **International Vaccine Access Center, Johns Hopkins University, Baltimore, MD; ††Department of Microbiology, Bangladesh Institute of Child Health, Dhaka Shishu Hospital, Dhaka, Bangladesh; ‡‡Center for Vaccine Development, Bamako, Mali; §§Kenya Paediatric Association, Nairobi, Kenya; and ¶¶Pediatrics, Beijing Children’s Hospital, Beijing, China. Supported by Sabin Vaccine Institute, Pneumococcal Awareness Council of Experts. Address for correspondence: Ron Dagan, MD, Pediatric Infectious Disease Unit, Soroka University Medical Center, POB 15, Beer-Sheva 84101 Israel. E-mail: rdagan@bgu.ac.il. Copyright

Guidelines for collection, analysis and presentation of vaccine safety data in surveillance systems

In September 1998, more than 800 young people in Jordan believed they had suffered from the side-effects of tetanus-diphtheria toxoid vaccine administered at school; 122 of them were admitted to hospital. For the vast majority, their symptoms did not result from the vaccine but arose from mass psychogenic illness. The role played by the media, the childrens parents, and the medical profession in the escalation of this mass reaction appeared, at first sight, to be unusual and even unique to the circumstances in Jordan at the time. A review of the literature showed, however, that this mass reaction was similar in many ways to previous outbreaks, even though the underlying causes varied. There are about 200 published accounts of mass responses to situations involving suspected poisoning or other events. Because such mass reactions are relatively rare and the triggers so diverse, individuals faced with responding to them are unlikely to have prior experience in how to handle them and are unlikely to take bold steps to prevent their escalation. Indeed they may be unaware that such events have been recorded before. The lessons learned from this incident in Jordan may help other immunization programme managers to handle crisis situations elsewhere.

Investigation of Burkholderia cepacia Nosocomial Outbreak with High Fatality in Patients Suffering from Diseases other than Cystic Fibrosis

Jan Bonhoeffer, Adwoa Bentsi-Enchill, Robert T. Chen, Margaret C. Fisher, Michael S. Gold, Katharina Hartman, Ulrich Heininger, Bernard Hoet, Thomas Jefferson, Najwa Khuri-Bulos, Katrin S. Kohl, S. Michael Marcy, David Nalin, Robert Pless, Hernan Sanabria-Rojas, Karen Sleeman, Robert Wise and The Brighton Collaboration Methods Working Group