Roberto Debbag

The cost-effectiveness of universal vaccination of children against hepatitis A in Argentina: results of a dynamic health-economic analysis.

BackgroundSocioeconomic improvements can reduce levels of endemic hepatitis A, but conversely increase the burden of disease. Routine childhood vaccination can rapidly control hepatitis A infection rates through the induction of herd immunity, although such programs can be costly.MethodsWe evaluated the healthcare benefits and cost-effectiveness of a routine childhood vaccination program against hepatitis A in Argentina, using a dynamic model that incorporated the changing epidemiology of infection and the impact of vaccine-induced herd immunity. Demographic, disease, and economic data from Argentina were used where available.ResultsAt 95% coverage, the program would reduce the number of hepatitis A infections by 352 405 annually, avoiding 121 587 symptomatic cases and 428 deaths. Substantial healthcare benefits were also observed with vaccination coverage as low as 70%, which would prevent 295 826 infections. Economically, the program would save US

Decline in HAV-associated fulminant hepatic failure and liver transplant in children in Argentina after the introduction of a universal hepatitis A vaccination program.

23 989 963 annually at 95% coverage, equivalent to US

Long-term immunity after two doses of inactivated hepatitis A vaccine, in Argentinean children.

3 429 per life-year gained. The program remained cost-saving in response to variation in factors, including disease-related costs, discount rate, herd immunity level, and rate of decrease of force of infection. The break-even cost per vaccine dose for the society was US

Esquemas atrasados de vacunación y oportunidades perdidas de vacunación en niños de hasta 24 meses: estudio multicéntrico

25 in the base-case, more than three times the current public cost of US

Ceftriaxone therapy of bacterial meningitis: cerebrospinal fluid concentrations and bactericidal activity after intramuscular injection in children treated with dexamethasone.

7 per dose.ConclusionsRoutine childhood vaccination against hepatitis A showed both health benefits and robust economic benefits in this analysis, supporting the recent decision of the Argentine government to implement such a program.

Enfermedad meningocóccica: siempre presente. Cambios en los serogrupos en el Cono Sur

Introduction Hepatitis A virus (HAV) infection is a vaccine-preventable disease. The most severe complication in children is fulminant hepatic failure (FHF), estimated to occur in 0.4% of cases; patients with FHF often require a liver transplant (LT). Following another outbreak of HAV infection in Argentina during 2003–2004, a one-dose HAV universal immunization (UI) program was started in 2005, resulting in a reduction in the incidence of HAV infection. We have investigated the impact of HAV UI on the trends in the occurrence of FHF and LT in children. Methods All pediatric cases of FHF admitted to four pediatric centers in Buenos Aires during March 1993–July 2005 were retrospectively reviewed, and data of cases during August 2005–December 2008 were collected. Information about demography, HAV infections and vaccination status, diagnostic data for FHF using the Pediatric Acute Liver Failure criteria, clinical laboratory results, encephalopathy, the severity of liver disease using the Pediatric End Stage Liver Disease score, assessment of patients on the LT waiting list using King’s College Criteria for LT, treatment given for FHF (pre- and post-transplant), and clinical outcome were collected using a case report form. The frequency and outcomes of HAV-associated FHF and LT cases before and after UI were analyzed. Results During the pre-immunization period, March 1993–July 2005, 54.6% (N = 165) of FHF cases were caused by HAV; HAV-associated FHF cases peaked during 2003–2004. During the post-immunization period, August 2005–December 2008, only 27.7% (N = 18) of FHF cases were caused by HAV infection; only one of these patients had received the HAV vaccine (one dose only). The number of HAV-associated FHF cases decreased from 2005, and no cases were reported from November 2006–December 2008. Multivariate analyses showed that the association of FHF with HAV infection rather than other etiologies decreased with increasing age (P = 0.03), UI against HAV (P = 0.002), and anti-actin antibodies (P = 0.002), and increased with increasing weight (P = 0.0004). Conclusions The number of children with HAV-associated FHF in Argentina has strongly decreased since the initiation of the UI program. Further monitoring is required to confirm the long-term health and economic benefits of UI against HAV infection.

Análisis clínico y de los factores de riesgo de mortalidad de 86 casos de endocarditis infecciosa en niños y adolescentes en Argentina (1988-2000)

We examined long-term anti-hepatitis A virus antibody persistence in Argentinean children 10 years after the initial study in which they received 2 doses of inactivated hepatitis A vaccine (Avaxim 80U). Of the 111 children, 48 from the initial trial were enrolled. Of 48, 47 (97.9%) participants had serum anti-hepatitis A virus antibody titers ≥20 mIU/mL, with the geometric mean concentration of 390.91 (±370.14) mIU/mL; (95% confidence interval, 282.2–499.5 mIU/mL), range, 36 to 1860.

Oral ciprofloxacin in the management of children with cancer with lower risk febrile neutropenia

INTRODUCTION Delayed vaccine schedule (DVS) and missed opportunities of vaccination (MOV) are some of the main causes of low coverage in children ≤24 month in Argentina. OBJECTIVES To determine the prevalence of DVS and the rate of MOV during the frst 24 months of life and risk factors for their occurrence. POPULATION AND METHODS We conducted a survey among children ≤24 months caregivers at five hospitals in different departments, between August-December/2008. RESULTS Total enrolled: 1591 children; 54.2% male, median of age 8 months (0-24 months). Eighty percent concurred with vaccine-card, 75.9% consulted by pathology. Overall DVS rate: 39.7%. Most common DVS reason: the current mild disease: 38.5%. Overall MOV rate: 19.8%. Most common MOV reason: no detection of the need to vaccinate 47.8%. DTPHib and OPV vaccines had a higher risk of DVS and MOV. DVS independent predictors: age ≥6 months, administration for additionally recommended vaccines and prolonged waiting in the last vaccination. MOV independent predictors were: age ≥6 months, no compliance with prior care, and not asking for vaccines. CONCLUSION We found a high proportion of MOV and mainly of DVS; they were associated mostly to false contraindications, lack of questioning on vaccines and difficulties in the quality of care provided to parents.

Oral ciprofloxacin in the management of children with cancer with lower risk febrile neutropenia: A randomized controlled trial

Antibiotic therapy is administered intravenously to children with bacterial meningitis to achieve the highest possible blood and cerebrospinal fluid (CSF) concentrations. However, intravenous access for the entire duration of therapy may be difficult in some children. Intramuscular therapy offers a more versatile option; however, CSF concentrations and bactericidal activity following im injection in children concurrently treated with dexamethasone have not been studied. We prospectively evaluated 37 children given an im dose of ceftriaxone on either the 3rd, 6th or 9th day of antibiotic therapy while receiving dexamethasone for the first 4 days of treatment. All children were required to have normal peripheral perfusion at the time of im injection. Four to 6 hours after im injection CSF was obtained. The average age of study patients was 28 months; Neisseria meningitidis, Streptococcus pneumoniae and Haemophilus influenzae type b were responsible for 95% of all infections. All children studied had detectable CSF ceftriaxone concentrations, with mean (± SD) concentrations (μg/ml) on Days 3, 6 and 9 of therapy of 5.7 ± 5.5 (n = 12), 5.2 ± 5.0 (n = 14) and 2.0 ± 2.6 (n = 10), respectively. All CSF bactericidal titers for N. meningitidis, S. pneumoniae and H. influenzae type b, regardless of day of im injection, were ≥1:64. Intramuscular ceftriaxone therapy of bacterial meningitis may be a reasonable therapeutic option for the convalscing child with good peripheral perfusion.

Infecciones invasivas por Streptococcus B-hemolítico del Grupo A

Meningococcal disease (MD) caused by Neisseria meningitidis is a condition with high mortality rates in childhood. Serogroup W135 N. meningitidis (MenW135) is usually associated with 1 to 8% of MD cases worldwide, and with a low carriage rate. During March 2000, an increase in the number of cases of MenW135 in Saudi Arabia was reported that coincided with the Hajj pilgrimage (Hajj-2000 strain). Mayer et al studied MenW135 strains from outbreaks related with this pilgrimage and found that all had been caused by the same hypervirulent clone (ST-11/complex ET-37). The circulation of this strain could also be documented in Latin America. In the last years, changes in serogroup prevalence have been observed in the region, the increase of MenW135 in the Southern Cone being the most significant. N. meningitidis infections of several serogroups including MenW135 may be prevented with chemoprophylaxis with antibiotics and quadrivalent vaccines. Better knowledge of the global epidemiology through the new molecular techniques, jointly with the availability of vaccines are the most relevant tools to control hyperendemic or epidemic periods of MD.