Diagnose en surveillance van infectieuze …– Partly hospital-acquired (48h definition) –...

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Centre Culturel et de Congrès de Woluwé-St-Pierre

Diagnose en surveillance van infectieuze aanDoeningen

Diagnostic et surveillance Des malaDies infectieuses

26Ste Seminarie > 25 november 201026e Séminaire > 25 novembre 2010

Cultureel en Congrescentrum van St.-Pieters-

Woluwe Programme | Programma

Diagnosis maLDi-toF

surveillance Ca-mrSa influenza

risk & Prevention rotavirus vaccinal cover Helicobacter pylori

infection control Shigella Food-borne outbreaks

information | informatie

t +32 2 642 57 77inscription avant le 10 novembre 2010inschrijving vóór 10 november 2010sur | op www.wiv-isp.be/epidemio/labo

Medewerking en financiële steunCollaboration et appui financier

ISP : DO Santé publique et Surveillance│WIV : OD Volksgezondheid en SurveillanceOrganiserend Comité│Comité OrganisateurStandsPublicités│AdvertentiesBVKB │SBBC

Dr J. Bots (GGC)Dr P. Butaye (CODA)Dr G. Daube (ULg)Dr K. De Schrijver (Vl. Gem.)Mrs G. Ducoffre (WIV-ISP)Dr P. Goubau (UCL)Dr G. Ieven (UZA)Dr N. Lambion (Com. fr.)

Dr P. Melin (ULg)Dr E. Padalko (UGent)

Dr D. Pierard (UZ Brussels)Dr C. Potvliege (CH Tivoli)Dr Y. Van Laethem(UMC St Peter)Dr H. Van Oyen (WIV-ISP)Dr J. Verhaegen (UZ Leuven)Dr K. Vernelen (WIV-ISP)

Voorzitter │Président : Dr. S. Quoilin (WIV-ISP)

Comité OrganisateurOrganiserend Comité

Becton DickinsonBiocodexBioMérieux BeneluxBioTradingBio-Rad LaboratoriesBopharBruker DaltonicsCSS/HGR

International Medical ProductsKiestraLamerisLucron BioproductsMeridian Bioscience EuropeOxoidSiemens Healthcare Diagnostics

Stands

Alere HealthBecton DickinsonBiocodexBioTradingMeridian Bioscience EuropeSiemens Healthcare Diagnostics

Advertenties│Publicités

Write in your agendaNext seminar

24/11/2011

Emergence of CA-MRSA USA 300 as a cause of severe infections in Belgium

Dr Olivier DenisLaboratoire de référence des MRSA

ULB, Hôpital Erasme Brussels

Woluwé-St-Pierre25/11/2010

1

HOSPITAL

Other hospitals

Nursing homes (NH)Long-term care facilities (MRS)

Community

MRSA transmission between different sectors

Animals

Hospital-associated (HA-)MRSA

Community-associated (CA-)MRSA

Livestock-associated (CA-)MRSA

Infections with PVL positive (MR)SA strains can be severe

Necrotizingpneumonia

NecrotizingOsteomyelitis

These cases are rare and need specific treatment

2

Global dissemination of CA-MRSA

Europe

Hawaii

Taiwan

Africa

Australia

World distribution of PVL positive CA-MRSA clones

ST8

ST8

ST8

ST8

ST80

ST80

ST80

ST30

ST30

ST30

ST30

ST30

ST1

ST1

ST1

ST5

ST5

ST59ST59

ST59

ST30

Tristan A. et al. EID 2007

3

World distribution of PVL positive CA-MRSA clones

ST8

ST8

ST8

ST80

ST80

ST30

ST30

ST30

ST30

ST1

ST1

ST1

ST5

ST5

ST59ST59

ST59

ST30

Tristan A. et al. EID 2007

ST8 ST80

ST30

Panton-Valentine leukocidin

• Two-component pore-forming protein encoded by lukF-PV and lukS-PV genes– Cell membranes and mitochondria

• Target cells : polymorphonuclear neutrophils, monocytes and macrophages

• Necrosis and abcess +++• < 5% of S. aureus• Genes located on phages

– ϕ108PVL, ϕPVL, ϕSTL, ϕSa2mw

Kanero J et al. Biosc. Biotechnol. Biochem 2004 68:981Gillet Y et al. The Lancet 2002 359:753

4

Other virulence factors

• USA 300-ST8– ⇑ expression of agr, searRS, sarA, α-toxin (hla), PVL– Arginine Catabolic Mobile Element

• Integrated into orfX closed to SCCmec element• Encoding arginine deiminase• Enhanced ability to colonize the skin and secondly dissemination

• ST80 S. aureus– ⇑ binding to collagens of types I and IV; and to laminin

• Other– Phenol-soluble modulin (PSM) peptides– Activation and lysis human neutrophils humains

Montgomery C. et al. JID 2008 198:561De Bentzmann S. et al. JID 2004 190:1506Wang R. et al. Nature Med 2007 13:1510

CA-MRSA USA 300

• Isolated from patients on all continents• Most prevalent CA-MRSA in the USA

– Major cause of SSTIs and invasive infections

– Asymptomatic colonisation (17%) in the general population

• Molecular characteristics– ST8-SCCmec IV– Virulence factors : PVL and ACME

Moran GJ et al. NEJM 2006

5

100

50 100.

00

120.

00

140.

00

160.

00

180.

00

200.

00

220.

00

240.

00

300.

00

350.

00

500.

00

600.

00

700.

00

800.

00

900.

00 PFGE SCCmec ST PVL

A1 Ia 247 -A20 IV 8 -A23 IV 8 +L1 IV 22 -B2 IV 45 -G10 II 5 -J4 IV 30 +J1 II 36 -X1 IV 80 +X1 IV 80 +X1 IV 80 +X2 IV 80 +

Clonal linkage of Community and Hospital MRSA strains in Belgium

Secular trends of MRSA clonal distribution National Surveillance, hospitals, Belgium 1992-2008

% o

f ins

titut

ions

Deplano et al. CMI 2000; Denis et al. JAC 2002; MDR 2003; AAC 2004; AAC 2006; 17th ECCMID 2007

0

10

20

30

40

50

60

70

80

90

100

1992(n=62)

1995(n=85)

1997(n=90)

1999(n=33)

2001(n=100)

2003(n=112)

2005(n=116)

2008(n=109)

A1-ST247-SCCmec I B2-ST45-SCCmec IV C3-ST5-SCCmec IV

A20-ST8-SCCmec IV G10-ST5-SCCmec II L1-ST22-SCCmec IV

Years (number of hospitals)

6

Differences between

HA-MRSA– Endemic clones in each

country– No specific toxins– Co-resistant to AB– Nosocomial infections – Older patients with co-

morbidities

CA-MRSA– Same clones in Europe– Specific toxins

• PVL • Toxic shock syndrome toxin

– Susceptible to AB– Skin and soft tissue infections – Young healthy people

Liassine N et al JCM 2004;42:825-8Naimi T et al JAMA. 2003;290:2976-84.Vandenesch et al. EID, 2003;9:978-84

Surveillance programme of CA-MRSA in Belgium

• 2004 – 1st semester 2008– Antimicrobial susceptibility profile of the MRSA strain

• Cipro-S, fusidic acid-R

– Clinical manifestations : furunculosis, necrotizing pneumonia, …

• Since 2nd semester 2008– If MRSA isolated from outpatients or from inpatients

but within the first 48 hours of hospital admission– Clinical manifestations

7

CA-MRSA collected for toxine gene detection, (n = 516, 2004-2009)

0

10

20

30

40

50

60

70

80

90

100

2004 2005 2006 2007 2008 2009

Num

ber o

f str

ains

PVL-neg MRSAPVL-pos MRSA

YearsReference laboratory for staphylococci and MRSA

Origins of CA-MRSA strains(n = 95, 2008)

0

5

10

15

20

25

30

35

Skin/softtissue

Screening ENT Blood Other

Num

ber o

f str

ains

PVL-neg MRSAPVL-pos MRSA

YearsReference laboratory for staphylococci and MRSA

8

0

10

20

30

40

50

60

2003-04 2005 2006 2007 2008 2009Years

Num

ber o

f str

ains

OtherST8-IV (USA 300)ST8-IVST30-IVST80-IV

Genotype distribution of CA-MRSA PVL positive (n = 188), Belgium, 2003 to 2009

Reference laboratory for staphylococci and MRSA

Denis et al. JAC 2005; Brauner J et al. 19th ECCMID 2009, Naesens R. et al. JMM 2009

0

10

20

30

40

50

60

2003-04 2005 2006 2007 2008 2009 2010Years

Num

ber o

f stra

ins

OtherST8-IV (USA 300)ST8-IVST30-IVST80-IV

Genotype distribution of CA-MRSA PVL positive (n = 242), Belgium, 2003 to 2010

Reference laboratory for staphylococci and MRSA

Denis et al. JAC 2005; Brauner J et al. 19th ECCMID 2009, Naesens R. et al. JMM 2009

9

Origins of PVL-positive CA-MRSA strains (n = 242, 2004 – 2010)

77%

7%3% 2% 3% 8%

Skin and soft tissueCarriageBloodSputumOtherUnkown

MRSA reference laboratory, unpublished data

Clinical and demographic characteristics of patients with CA-MRSA USA 300, 2008

# familial cluster

Patients Age Sample site Clinic Cluster Contact with the USA

Evolution

1 35 Blood Meningitis Yes Dead2 48 Sputum Bronchitis Recovery3 6 Nose Furuncle Yes Recovery4 5 Nose Furuncle Recovery5 50 Skin Anal abcess Recovery6 35 Skin Mastitis Recovery7 1 Skin Furuncle Recovery8 40 Nose Carriage Yes Yes Recovery9 1 Skin Skin abcess Yes Yes Recovery10 21 Skin Furuncle Recovery11 10 Skin Furuncle Recovery12 48 Skin Wound Yes Recovery13 40 Nose Carriage Yes Recovery14 37 Blood Endocarditis Recovery

#

10

History and contact with health-care facilities in MRSA patients at their hospital admission

(n = 42 hospitals, 2009)

38%

11%15%

9%

18%

9%MRSA history

Transfer from hospital

Transfer from NH

Transfer from hosp. and NH

Community

Unkown

Source: B.Jans et al IPH surveillance report 2009

Occurrence of CA-MRSA isolatesby strain characteristics, 2003-08

• National hospital surveys, 2003 – 08– 1153 MRSA collected from >110 hospitals

• PVL-positive CA-MRSA– Low & stable frequency (<2 %)– Partly hospital-acquired (48h definition)– PVL-positive CA-MRSA: 10 isolates belonging predominantly to the

European clone ST80-SCCmec IV

Vandendriessche S. et al. 20th ECCMID, Vienna, April 2010

11

MLST-SCCmec

spa-type

year Resistance profile Resistance genes

n

ST80- IV t044 20082005 200820052008

KANTET, KANTET, KANTET, KAN, ERYTET, KAN, ERY, CLI

aphA3tetK, aphA3tetK, aphA3tetK, aphA3, ermCtetK, aphA3, ermC

11211

ST30-IV t019 20032005

//

NANA

12

ST5-IV t3196 2008 TET tetK 1

Profile of PVL-positive MRSA strains


0

1

2

3

4

5

2003 2005 2008

% of MRSA

PVL-positve CA-MRSA

LA-MRSA

Trends in % PVL-positive CA-MRSA and LA-MRSA, 2003-2008

Years of survey

0.2

1.2 1.6

0.40.9 0.6


12

Nasopharyngeal carriage of S. aureusin healthy kindergarten children

• Screening for S. aureus– Children 3-6 years from 11 kindergarten– Sequential nasopharyngal aspirates (autumn/winter/spring)

• Results– 830 samples from 333 children– 286 (34%) culture positive for S. aureus from 185 (55%) carriers– 14 MRSA isolated from 11 children (3%)– MRSA isolates multi-resistant to antimicrobials– No PVL

Blumental S. et al. ESPID 2010

Conclusions

• CA-MRSA infections in young population associated with SSTI but severe infections recently reported

• Predominance of European CA-MRSA ST80 clone up to 2007

• Progressive replacement by CA-MRSA USA 300 ST8– Small familial clusters, importation from the USA

• Low prevalence of PVL-positive MRSA in hospitals and in healthy children

• Epidemiological surveillance across healthcare sectors and community

13

Prevention and control

• Guidelines for general practice management of staphylococcal infection– Document severe or recurrent skin and soft tissue

infections– Adapt antibiotic treatment based on susceptibility testing– Standard precaution during the care of wound infections

• Guidelines to patients and families– Hand hygiene– Avoid sharing of potentially contaminated objects

Surveillance of Influenza in a Pandemic:

What’s different?

Françoise Wuillaume – Scientific Institute of Public health26th Seminary: Diagnosis and Surveillance of Infectious diseasesBrussels 2010

1

2

Content

1. Key points about Influenza & the 2009 pandemic

2. Objectives of the surveillances

3. Epidemiology and virology results

4. Measure of impact

5. Lessons learned & perspectives

3

Reminder

•Swine flu

•Mexican flu

•A flu, H1N1 flu

Pandemic Influenza

•Bird flu

•H5N1

Avian Influenza

•Influenza A, Influenza B

•A/H1N1, A/H3N2

Seasonal influenza

ILI = Influenza Like Illness (flu syndrome, clinical flu)

ARI = Acute respiratory infection

SARI = Severe acute respiratory infection

2

4

Influenza virus

Familly Orthomyxoviridae…….Genus Influenza (80-100 nm)

8 RNA segments3 Types (A, B, C)2 surface glycoproteins (HA, NA)

Hemagglutinin (16) Neuraminidase (9)

5

WHO pandemic criteria

A pandemic can start when three conditions have been met:

1. a new influenza virus subtype emerges; 2. it infects humans, causing serious illness; 3. and it spreads easily and sustainably among

humans.

http://www.who.int/csr/disease/avian_influenza/avian_faqs/en/

Examples of pandemics:• Plague (14th century)• Cholera El Tor• HIV• Spanish flu (1918 – H1N1), Asian flu (1957 – H2N2), Hong Kong flu (1968 – H3N2)

3

6

WHO pandemic phases (2009 revision)

August 2010

June 2009

H5N1

7

Historic background

4

8

Content

1. Key points about the 2009 pandemic

2. Objectives of the surveillance




9

Surveillance of Influenza

INFLUENZA surveillance

Measure impact

Detect changes

•Population

•Health services

•Work force

• Virulence

• Resistance

•Transmission

Measure impactDescribe

0

250

500

750

1000

1250

35 37 39 41 43 45 47 49 51 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33

week

inci

dent

ie v

an g

riepa

le s

yndr

omen

(/1

00 0

00 in

won

ers)

+ Evaluation of Control Measures

•Virus: type, sub-type

5

10

Surveillance in a pandemic (WHO)

Characterize the geographical spread, trend, intensity, impact, changes

Monitoring

Characterize the virological and clinical features & the risk factors

Assessment

Detect sustain human-to-human transmissionEarly detection

11

Demand of information in a pandemic

Communication

People

Health authorities

Health professional

Epidemiologist

How many …cases, deaths, pregnant women, persons at risk,

person vaccinated, ...

International partners

6

12

Items of the Influenza surveillance

YesNoUse of Tamiflu

n.a.NoVaccine effectiveness

+/-No Burden on health servicesYesNoAbsenteeismYesYesMortality

YesNoPaediatricians: ILI + biol. sampling

+/-

Yes

Yes

YesP

YesGeneral practitioners: ILI – ARI + biological sampling

Describe

No

No

Yes

S

Vaccination coverage Evaluation of control measures

SARI + HospitalisationsMeasure impactVirological surveillanceDetect changes

13

Content






7

14

Epidemic Criteria

Yes-The neighbouring countries report an ILI activity

≥ 20 %QualitativeThe circulation of the virus is demonstrated

YesYesThe consultation rate is ≥ 141 ILI cases / 100,000 inhabitants / week during 2 consecutive weeks

PandemicSeasonal

15

Criteria 1 – ILI consultation rate ≥ 141/100,000 inh./week

ILI clinical Surveillance

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35

Trait. antiviraux

Grippe saisonnière

Grippe pandémique

ON

CasGroupes d'âge

Etat vaccinal

SYNDROMES GRIPPAUXUn syndrome grippal est une affection fébrile d’accès soudain, avec des symptômes respiratoires et des symptômes généraux

< 1 an1 - 4 ans

5 - 14 ans

15 - 19 ans

20 - 64 ans

65 - 84 ans

85 ans et +

ON

ON

Hospitalisation ON

8

16

Criteria 1 – ILI consultation rate ≥ 141/100,000 inh/week

Influenza Like Illnesses

Influenza – seasons 2009/2010 – Week 20/2010 - IPH

17

Criteria 1 – ILI consultation rate ≥ 141/100,000 inh/week

ILI per age groups

9

18

Criteria 2 – Proportion of positive samples ≥ 20 %

Proportion of positive samples

Exhaustive sampling

Systematic sampling

19

Criteria 3 – Neighbouring countries report ILI activity

International Notification – Week 40/2009

10

20

Season 2002-2003 B + H1N1 + H3N2

Season 2007-2008

Saison 2002-2003

Season 2005-2006

Season 2006-2007

Season 2004-2005

Season 2003-2004 H3N2

H3N2 + B B + H1N1

H3N2 H1N1 + B

Virology surveillance

21

Season 2008-2010 H3N2 + H1N1v

Virology surveillance

H3N2 + H1N1v

11

22

Content






23

SARI = Hospitalised cases

12

24

Workload in consultations and hospitals

0.0

5.0

10.0

15.0

20.0

25.0

40 43 46 49 52 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 2

Weeks

Mea

n nu

mbe

r of c

ases

Mean ILI per GP Mean ILI per Pedia Mean SARI per Hospital

0

100

200

300

400

500

600

700

800

900

Wee

k 35

Week 3

6

Week

37

Wee

k 38

Wee

k 39

Week

40

Week

41

Wee

k 42

Week 4

3

Week4

4

Week

45

Wee

k46

Wee

k47

Week

48

Week

49

Wee

k50

Week5

1

Week

52

Wee

k53

Week

1

Wee

k2

Number of positive tests reported

influenza A influenza B Parainfluenza Adenovirus RSV Mycoplasma

?

8.0 7.05.8

25.0

11.7

25

Mortality: Be-Momo

Mortality 1999-2008 All-age population

1500

2000

2500

3000

1999w1 2001w26 2004w1 2006w26 2009w1year,week

nb predul

13

26

1.5

2

2.5

3

3.5

4

01/09

/2008

01/10

/2008

01/11

/2008

01/12

/2008

01/01

/2009

01/02

/2009

01/03

/2009

01/04

/2009

01/05

/2009

01/06

/2009

01/07

/2009

01/08

/2009

01/09

/2009

01/10

/2009

01/11

/2009

01/12

/2009

01/01

/2010

01/02

/2010

01/03

/2010

01/04

/2010

01/05

/2010

Mor

talit

y ra

te/1

00,0

00 in

hab/

day

Mortality rate Predicted mortality rate upper limit

Mortality: Be-Momo

Mortality 2008/2009 & 2009/2010Daily mortality rate, General population

27

15

16

17

18

19

20

21

22

23

38 39 40 41 42 43 44 45 46 47 48 49 50 51

Both sexs

Mortality: Be-Momo

Weekly mortality rates - All ages

Men Women

15

16

17

18

19

20

21

22

23

38 39 40 41 42 43 44 45 46 47 48 49 50 5115

16

17

18

19

20

21

22

23

38 39 40 41 42 43 44 45 46 47 48 49 50 51

Mortality rate

Baseline mortality

Upper limit

14

28

Mortality: Be-Momo

Cumulative weekly excess of deaths– week 38 to week 51

-200

-150

-100

-50

0

50

100

150

200

250

300

38 39 40 41 42 43 44 45 46 47 48 49 50 51

Age < 65

Age 65 - 84

Age 85+

-200

-150

-100

-50

0

50

100

150

200

250

300

38 39 40 41 42 43 44 45 46 47 48 49 50 51

Both sexs

-300

-200

-100

0

100

200

300

400

38 39 40 41 42 43 44 45 46 47 48 49 50 51

Men Women

29

System 1: Be-Momo

Excess mortality during Flu epidemic, 1999-2009

2131049200940 20092,614910200922009503810200832008403610200752007-2018132006620062,118131220055320041,272922004462003-31813200362003

1,30811102002522001-30810620014920003,3931162000481999

WeekYearWeekYearExcess

mortalityNumber of

weeksEndStart

15

30

Mortality: Be-Momo

Cumulated excess of mortalityH3N2(2009) / H1N1(2009)

-200

-100

0

100

200

300

400

500

600

700

800

900

-1 0 1 2 3 4 5 6 7 8 9 10 11 12

Men (season 2009) Women (season 2009)Men (pandemic) Women (pandemic)

-500

0

500

1000

1500

2000

2500

3000

-1 0 1 2 3 4 5 6 7 8 9 10 11 12

Season 2008/2009 Pandemic 2009

31

Mortality: Hospital reporting

Deaths Specific Reporting

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

Week 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 1 2

Num

ber o

f dea

ths

0

100

200

300

400

500

600

700

800

900

ILI c

onsu

ltatio

n ra

te

nb deaths ILI consultation rate

16

32

… Could our epidemiologist calculate how many persons did get flu during the pandemic?

But finally….

33

Estimation of the number of infections

17 %5 %2 %Total

3 %1 %2 - 511 %65+

11 %4 %2 – 512 %15-64

53 %14 %2 – 51.3 – 25 %5-14

59 %16 %2 – 52 – 34 %< 5

% MaxEstimate

% Minestimate

Cor2(Asymp)

Cor1(consult)

GPsConsult

17

34

Content






35

Lessons learnedThe GP sentinel network is a powerful tool in a pandemic, for both virology and epidemiology surveillance

To be able to monitor PH crisis, it is important to monitor the same indicators in non crisis situations

importance of historic baselines

Importance of networking with data providers (ED, ICU, gyneco…)

Virology and epidemiology are complementary and cannot be dissociated

Relative failure of exhaustive surveillance systems validation of sentinels networks

Relative failure in measuring the severity of the pandemichospital sentinel network

validation of severity indicators

18

36

Perspectives

An effective pandemic surveillance system would be a system for which no additional surveillance item is necessary when the pandemic starts:

1. GP sentinel network (virology + clinic)2. Hospital ED network (virology + clinic)3. Sentinel network of laboratories4. Mortality5. Social impact indicator (absenteeism?)

Those surveillance items are useful in any PH crisis.

37

We wish you a safe 2010/2011 Influenza season …

Week 46 in 2010

Specimen collectionSpecimen collection

Specimen Specimen analysis: analysis: Relevant Relevant pathogenspathogens

IdentificationIdentification

PatientPatient’’s s optimized optimized

managementmanagement

Cost effective and timely!!

ASTAST!!! Physician /bacteriologistdiscussion!!!

Single evolutionover the years:

Automation and miniaturization

Microflex MALDI‐TOF MS (Bruker Daltonics) Axima (Shimadzu)

Ions production in gas phase

Ions separationdepending m/z

Mass spectrumIon currentelectric current

In vacuum

1. Sample is mixed with excess matrix and dried on a MALDI plate.

2. Laser flash ionizes matrix molecules.

3. Sample molecules are ionized by proton transfer from matrix:

MH+ + A M + AH+.

1. Build up of an electromagnetic field:

Acceleration of ions

2. Separation in the flight tube:

•Small ions reach the detector before large ones.

•Measures the time for ions to reach the detector

ion detector

+

+ +

+

++

template

matrix/analytecrystals

accelerationzone

field-freedrift range

grid electrode

desorption

ionization

acceleration

separation

detection

mz =

2eUL²

t²

m: massz: chargeU: accelaration voltageL: path lengtht: timee: elemetary charge

DHB:Irregular crystallization

Requires more laser shots for quality spectrum

Spectra with 100-200 mass signals

Spectra with many signalsm/z > 10kDa

HCCA:Regular crystallization

Requires less laser shots for qualityspectrum

Spectra with 80-150 mass signals

Spectra with fewer signalsm/z > 10kDa

3000 5000 7000 9000 11000 13000m/z

Escherichia coli

Hafnia alvei

Leclercia adecarboxylata

Klebsiella pneumoniae

Proteus mirabilis

Enterobacter aerogenes

Possibility of enrichment of the database

!!! Caution: Bad discrimination of bacteria with similar proteinic profiles

1. Direct application of a thin layer on the MALDI plate

2. To overlay withmatrix3. Dry on air4. Introduction into the

spectrometer

direct

culturesuspension

(McFarland 1‐2)

suspensionin 25%

formic acid

optional:on‐target extractionwith 25% formic acid

addition of0.5 µL matrix solution

solvent evaporationat room temperature

automatedMS analysis

MALDI target

The sample preparation is easy...

....but requires ‐ some training‐ a well lit workplace‐ a calm hand‐ appropriate equipment

* Joan Barenfanger et al, Decreased mortality associated with prompt Gram staining of blood cultures , Am J Clin Pathol 2008;130:870‐876

Bacterial group Number of testedstrains

Acceptedidentifications usingthe algorithm (%)

Enterobacteriaceae 541 98,7

Non fermentative Gram‐negative bacteria

207 95,6

Staphylococcus 83 97,5

Streptococcus 110 89

Haemophilus / Moraxella 42 97,6

Neisseria sp. 4 100

Campylobacter sp. 5 100

Anaerobes 21 95,2

TOTAL 1013 96,7

Species Number of tested strains Accepted identifications using the algorithm (%)

Gram negative (No extraction)

K. pneumoniae 4 4 (100%)

P. rettgeri 1 1 (100%)

S. marcescens 2 2 (100%)

E. cloacae 1 1 (100%)

E. coli 4 4 (100%)

TOTAL Gram negative 12 12 (100%)

Gram Positive (Extraction)

S. aureus 3 3 (100%)

S. epidermidis 5 4 (80%)

S. hominis 1 0 (0%)

S. capitis 2 2 (100%)

E. faecium 1 1 (100%)

S. pneumoniae 3 0 (0%) (No pellet)

TOTAL Gram positive 15 10 (66%)

TOTAL 27 22 (81%)

MALDI‐TOF MS Phenotypicidentifications using

biochemicalcharacteristics

Molecular biology

Direct application Extraction

Preparationtime

5 minutes 20 minutes 1 to 20 minutes 60 minutes

Identification time

2 minutes 2 minutes 5 to 48 hours 45 minutes to 48 hours

Cost(consumables)

0,1 €/sample 0,5 €/sample

Sepsityper kit: 4€/sample

5 €/sample 30‐50 €/sample

Possible identifications

aerobic/anaerobic bacteriaYeasts

MycobacteriaFilamentousfungi

Rather frequentclinically relevant

species

All ones in theory

Requiredcompetence

Basic Moderate High

Comparison: MALDI‐TOF mass spectrometry vs other identification methods

CHU IntranetHospital hygiene

* Decreased mortality associated with prompt Gram staining of bloodcultures. Am J Clin Pathol 2008;130:870‐876

Becomes the essential bacterial identification method in any clinical microbiology lab

Gastric non-Helicobacter pylori helicobacters: distribution in animals and

significance for human health

Bram Flahou, Richard Ducatelle, Koen Chiers, Miet Vermoote, Kim Van Deun, Annemieke Smet, Lien De Cooman, Frank Pasmans,

and Freddy Haesebrouck

Dept. of Pathology, Bacteriology and Avian DiseasesFaculty of Veterinary Medicine

Ghent University

[email protected]

H. pylori infections in humans

+/- 50% of world’spopulation

Developed countries

Less developedcountries

Source:http://www.steadyhealth.com/articles/Helicobacter_pylori__The_Bacteria_that_Cause_Ulcers_a71.html

H. pylori

H. pylori infections in humans

Very important role in gastric pathology!

Source:http://www.steadyhealth.com/articles/Persistent_pain_in_the_upper_abdomen__Dyspepsia__Indigestion__Symptoms_and_Treatment_a1151.html

Source: http://www.healthgiants.com/2009/11/28/what-is-peptic-ulcer/

Gastric Helicobacter infections in humans

+/- 50% of world’spopulation

0.1 - 6% of people undergoinga gastroscopy

H. pylori

Source:http://www.steadyhealth.com/articles/Helicobacter_pylori__The_Bacteria_that_Cause_Ulcers_a71.html

non- Helicobacter pylorihelicobacters (NHPH)

Source: Jalava et al., 1997

• Very fastidious organisms, with a typical morphology

• “H. heilmannii” gastric non-H. pylori helicobacters (NHPH)

• Several species, mainly infecting animals but also a minority of humans

• Like H. pylori, also associated with:- gastritis (Stolte et al., 1994; Debongnie et al., 1995;…)

- gastric ulcers (Debongnie et al., 1998; Sykora et al., 2003;…)

- MALT lymphoma (Morgner et al, 2000; Stolte et al, 2002,…)

Gastric non-H. pylori Helicobacter(NHPH) infections in humans

• Molecular sequencing of various genes (16S rRNA, 23S rRNA, hsp60, urease A and B):

“H. heilmannii”

“H. heilmannii” type 1: “H. heilmannii” type 2H. suis H. felis

H. bizzozeroniiH. salomonisH. heilmanniiH. cynogastricusH. baculiformis


“Helicobacter heilmannii” type 1 is identical to Helicobactersuis


Source:http://www.steadyhealth.com/articles/Persistent_pain_in_the_upper_abdomen__Dyspepsia__Indigestion__Symptoms_and_Treatment_a1151.html

http://www.treknature.com/gallery/Asia/India/photo2986.htm

Source:http://blogs.orlandosentinel.com/features_lifestyle_animal/2009/05/im-guessing-those-kissapig-fundraisers-are-on-hold.html

Helicobacter infections in pigs

- 1990: first characterization

- large spiral-shaped bacteria in the stomach of slaughterhouse pigs

- colonisation: glandular stomach

- urease +

- “Gastrospirillum suis”

- Further genetic characterization: “Candidatus H. suis”

- successful isolation: Helicobacter suis

H. suis infections in pigs: prevalence

0102030405060708090

100

1 2 3 4

antrum fundus

1 suckling pigs 3 grow – finisher pigs

2 nursery pigs 4 adult pigs

Percentage positivity

H. suis infections in pigs: importance

- One of the risk factors for developing lesions in pars oesophagea (non-glandular part of the stomach)

normal hyperkeratosis

High prevalence ECONOMIC SIGNIFICANCE:

reduced growth rate

mortality due to bleeding

erosions

H. suis infections in pigs: importance

- Induces chronic gastritis in glandular part (mainly antrum)

- Induces a reduction in daily weight gain (> 20 g/day)

Treatment/eradication interesting for profits in pigindustry

• Molecular sequencing of various genes (16S rRNA, 23S rRNA, hsp60, urease A and B):

“H. heilmannii”

“H. heilmannii” type 1: “H. heilmannii” type 2H. suis H. felis

H. bizzozeroniiH. salomonisH. heilmanniiH. cynogastricusH. baculiformis


“Helicobacter heilmannii” type 2

Different species colonizing mainly the canine and felinegastric mucosa:

H. felisH. bizzozeroniiH. salomonisH. heilmannii (previously “Candidatus H. heilmannii”)

culturable, however very fastidious

“”Helicobacter heilmannii” type 2

• One or more species of these helical bacteria in:

67 to 86% of clinically healthy dogs61 to 100 % of dogs showing chronic vomiting41 to 100 % of cats, slightly higher rate in animalspresented with chronic vomiting

Frequently mixed infections in dogs and catsAssociation with clinical symptoms species-dependent and still

controversial (H. felis: lymphocytic infiltrates )

Transmission between animals

• H. suis- Until now, no information concerning the epidemiologyof H. suis infections in pigs is available- Suggested routes of transmission:

gastric-oral route probably the main routes

oral-oral route

(faecal-oral): detection of H. suis in pig faeces

Prevalence in sows ↔ Prevalence in piglets (Protectiveeffect of milk???)

Transmission between animals• H. felis, H. bizzozeronii, H. salomonis, H. heilmannii

- Little information is available

- Transmission of H. salomonis from a dam to her puppies, as well as betweeninfected and non-infected pups (Hänninenet al., 1998)

- gastric/oral-oral transmission:

probably main route

- faecal-oral transmission:

probably NOT involved in transmission

(no isolation starting from faeces)Source: http://photobucket.com/images/cat%20licking/

Prevalence of NHPH in humans

• Percentage of patients undergoing gastroscopy:

- western populations: 0.1 % - 1.1 %, mostly around 0.3%

exceptions: Small Czech rural area : 2.0% ↕

More urban communities: 0.06% - 1.1 %

• Percentage of patients undergoing gastroscopy:

- eastern populations:

China: 1.73 % - 1. 9 % (Yang et al., 1998; Chen et al., 1993)

Thailand: 6.2 % (Yali et al., 1998)

- African populations: even higher?

Due to closer contact with animals?


Van den Bulck et al. (2005): as a percentage of NHPH-infected patients36.6%: H. suis most prevalent

In order of decreasing prevalence:

21.1%: H. salomonis14.6%: H. felis8.1%: H. heilmannii (provisionally)4%: H. bizzozeronii


Transmission NHPH animal man

• High NHPH prevalence in animals↔ animal reservoir?

Low NHPH prevalence in humans


Source:http://www.funnyfidos.com/category/funny-dog-pictures/

Transmission NHPH animal manEpidemiological evidence

• Still not much data available• Retrospective study (Stolte et al., 1994):

- ‘normal’ German population: 37% pets63 % animal-free

- ‘NHPH’-infected population: 70.3% animal contact29.7% animal-free

Difference is statistically significant

• Questionnaire-based study (Meining et al., 1998):

NHPH - infected group: 86.5% animal contact

H. pylori - infected controls:48.2% animal contact


• Questionnaire-based study (Meining et al., 1998):

- Contact with dogs, cats and especially pigs: risk factor for contracting NHPH (“H. heilmannii”) infection



• Presence of multiple “H. heilmannii” strains in an individual sufferingfrom ulcers and in his two cats (Dieterich et al., 1998)

• “H. heilmannii” gastritis caused by cat to child transmission (Van Loon et al., 2003)

genetic relatedness of human and feline strain• Acute gastritis associated with spiral organisms from cats (Lavelle et

al., 1994) • Transmission of “G. hominis” from a pet dog to a 12-year-old girl

(Thomson et al., 1994)

TEM + symptoms• Peptic ulcer disease associated with Helicobacter felis in a dog

owner (De Bock et al., 2007)

Transmission NHPH animal manCase studies

• Contamination of pig carcasses with H. suis:sampling in slaughterhouse

• 4 farms: 10 – 27% swabs: positive• Quantitative RT-PCR: 104 bacteria/swab• Transmission to humans through contaminated meat:

live bacteria? - On carcasses: yes- On meat products (raw mincedpork,…): to be investigated

Transmission NHPH animal manpork meat

Source: http://cric-projects.com/front/index.jsp?idProject=2

• Like H. pylori, also associated with:- gastritis, although less severe than that seen in a H. pylori infection (Stolte et al., 1994; Debongnie et al., 1995;…)

- gastric ulcers (Debongnie et al., 1998; Sykora et al., 2003;…)

- MALT lymphoma (Regimbeau et al, 1998, Morgner et al, 2000,…)

• Confirm in vitro and in vivo

Transmission NHPH animal manassociated pathologies

H. suis infection

Virulence of NHPHMongolian gerbils: chronic inflammation

Control

Virulence of NHPHMongolian gerbils: loss of parietal cells

H. suis

TEM In vivo: necrosis of parietal cells

Virulence of NHPHcell death

In vitro: H. suis-induced cell death in cell lines

Activated caspase-3: apoptosis

0

5

10

15

20

25

30

35

40

propidium iodide staining caspase-3 staining

% p

ositi

vity

in A

GS

cells

neg controlH. suis

Virulence of NHPHcell death

Important virulence factor: H. suis gamma-glutamyl transpeptidase, which degrades glutathione, generating pro-oxidant reactions

Research in our department

• Investigate virulence mechanisms

• Determine the current prevalence of NHPH in humans in Belgium and China (only just started)

• Identification up to the species and strain level

• Treatment/eradication of NHPH infections

Identification of NHPH to species level• Important for

- defining zoonoticimportance of different species- defining their association withdisease in humans and animals

• “H. heilmannii” type 2 bacteria: notdistinguishable based on 16S rRNAgene sequences

• Sequencing of urease A and B genes

• Multiplex PCR

H. felis

H. suis

Identification to species level: cultivation?

• Very fastidious organisms• “H. heilmannii” type 2:

- Succesful technique starting from gastric biopsiesfrom dogs and cats: H. felis, H. bizzozeronii, H.salomonis

- Only 2 isolates (H. bizzozeronii) from humangastric biopsies

• 2007: First succesful H. suis isolation starting from mucosalscrapings / mucus from the stomach of sows.

• 2010: First succesful H. heilmanniiisolation starting from mucosalscrapings / mucus from the stomach of cats.

• Important features- Activated charcoal- 20% serum- Acidic treatment of mucosa- Biphasic culture plates- Culturing at pH 4-6



H. suis


H. suis cultivation successful starting from mucosalscrapings

Gastric biopsies???

Identification to strain level

HS1 atpa (0.0000)HS2 atpa (0.0008)

HS3 atpa (0.0000)HS4 atpa (0.0000)

HS5 atpa (0.0000)HS9 atpa (0.0000)

HS6 atpa (0.0000)HS7 atpa (0.0000)HS8 atpa (0.0000)

StrainAlleletype

SequenceType

atpA efp mutY ppa trpC ureI vhpCHS1 1 1 1 1 1 1 1 ST1HS2 2 1 2 1 2 1 1 ST2HS3 1 2 2 1 2 1 3 ST3HS4 1 2 3 1 3 1 4 ST4HS5 3 2 4 1 2 2 2 ST5HS6 1 3 5 1 1 1 5 ST6HS7 1 3 6 1 1 1 6 ST7HS8 1 4 7 1 1 1 1 ST8HS9 3 2 8 1 1 3 2 ST9

Multi Locus Sequence Typing for isolates, biopsies,…

Research in our department

• Investigate virulence mechanisms

• Determine the current prevalence of NHPH in humans in Belgium and China (near future)

• Identification up to the species and strain level

• Treatment/eradication of NHPH infections

D0 D21 D42 D70 D119

D21 D42 D70 D119

H. suisstomachhomogenate euthanasia

SC

IN

Eradication H. suis: vaccination trial in mice

Average urease

OD

SC IN

P<0.05 P<0.05 P<0.05

P<0.05

P<0.05

H. suis: vaccination trial in miceResults: Urease OD

SC IN

% positive animals

H. suis: vaccination trial in miceResults: PCR

Treatment H. suis: in vitro antimicrobial susceptibility

Combined agar and broth dilution method, followed by evaluation of bacterial growth after 48 incubation (microaerobic, 37°C) using a H. suis specific qPCR

H. suis-containing broth

Treatment H. suis: in vitro antimicrobial susceptibility

Antimicrobial agent No. of strains with a MIC (µg/ml) of:

≤0.03 0.06 0.125 0.25 0.5 1 2 4 8 16 32 64 128Ampicillin 1 2 1 5

Ceftiofur 1 5 3

Clarithromycin 1 5 2 1

Enrofloxacin 4 4 1

Gentamicin 6 3

Lincomycin 1 2 5 1

Metronidazole 2 1 4 2

Tetracycline 3 3 2 1

Tylosine 4 5

Bimodal distribution: acquired resistance

Monomodal distribution with tailing: reduced susceptibility

Thank you for your kind attention!

HelicobacterHelicobacter pyloripylori infectioninfection

Fazia ManaKliniekhoofd gastro-enterologie

UZBrussel

1

25 November 2010

H. H. pyloripylori infectioninfection

TransmissionPrevalencePathologyTreatmentResistence

25 November 2010

About 50 % of world infected

Once aquired, lifelong

Only recognized and accepted reservoir = human stomach

H. H. pyloripylori infectioninfection: : introductionintroduction

2

25 November 2010

TransmissionTransmission

Still ?Infection primary in childhood

Schwarz S et al. PLOS pathogens 2008;4: e1000180

Vale F et al. Intern J Food Microbiol 2010

Perry S et al Emerg infect dis 2006

25 November 2010

TransmissionTransmission: : humanhuman to to humanhuman

Vertical person to person/horizontal person to person (sibling, outside family):

Gastro - oral (vomiting in childhood)Feco - oral (experiment with mice, after GE more infected)Oral - oral (controversial)

3

25 November 2010

Transmission: human environmentTransmission: human environment

Horizontal: environmentWater

Culture of HP from water, DNA en coccoid forms in water samplesMore infections if non-hygienic drinking water, no household bad and no sewage disposal facilitiesSurvival of HP in artificially contaminated water Coccoid form from water can colonize stomach of mice

Food (?, probably coccoid form survival in contaminated food, influence premastication)

25 November 2010

TransmissionTransmission

Rural areas: Horizontal transmission

Urban:Vertical transmission (Infection mother/child via genetic studies from HP)

4

25 November 2010

PrevalencePrevalence

Shangai 2009: 73 %serology, age 18-80

Guangzhou (China):1993: 62.5 %2003:49.3 %

Japan1993: 68.4 %2002: 52.5 %

South Korea1998: 66.9 %2005: 59.6 %

Alaska 2006: 24 %

25 November 2010

EpidemiologyEpidemiology childrenchildren 2121stst centurycentury

Belgium 2010: 9.4 %UBT, age 14 - 22

Brazil 2010: 28.7%Serology, age: 4–11

Uganda 2010: 44 %Stool test, age 0-11

Jordan 2006: 55 %Serology, age 6-9

Turkey 2006: 44 %Stool test, age 19-22

Germany 2003: 9 %Serology, age 7-20

Czech republic 2004: 7%Stool test, 0-15

Taiwan 12 %Serology, age 9-15

Saoudi Arabia 2006: 35 % UBT, medical students

Guangzhou (China): 19 %Children 1-5 y:1993: 30.82003:19.4

St-Petersburg: 13 %Children1995:44 %2005: 13 %

5

25 November 2010

PathologyPathology

H. pylori infection

Acute gastritis

Chronic gastritis

AsymptomaticAsymptomatic> 70 %> 70 %

Ulcer disease10 - 15 %

GastricCarcinoma

1 - 5 %

MALTlymphoma

< 1 %

25 November 2010

ExtradigestiveExtradigestive diseasesdiseases associatedassociated withwith H. H. pyloripylori infectioninfection

Vascular diseasesIschaemic heart diseasePrimary Raynaud's

phenomenonPrimary headache

Skin diseasesIdiopathic chronic

urticariaRosacea Alopecia areata

Autoimmune diseasesSjogren's syndromeAutoimmune thyroiditisAutoimmune

thrombocytopeniaHenoch-Schönlein

purpura

• Respiratory diseasesChronic bronchitisPulmonary tuberculosisBronchiectasisLung cancerBronchial asthma

• Other diseasesLiver cirrhosisGrowth retardationChronic idiopathicsideropeniaSudden infant deathDiabetes mellitus

6

25 November 2010

ITPITP IronIron deficiencydeficiencyanaemiaanaemia

dyspepsiadyspepsia

H. pylorigastritis

PathologyPathology

25 November 2010

Current concepts in the management of H. pylori infection: the Maastricht III Consensus report.

Malfertheiner P, Megraud F, O'Morain C, Bazzoli F, El-Omar E, Graham D, Hunt R, Rokkas T, Vakil N, Kuipers EJ.

2005 (published 2007)

ManagementManagement

7

25 November 2010

H. H. pyloripylori : diagnosis: diagnosis

Invasive tools

Histology

RUT

Culture

Non-invasivetools

UBT14C and 13C

Stool Ag test

Serology

Most efficient specand sens > 90 -95 %

Post treatment setting (monoclonal AB): +/- 92 % accuraat

Epidemiologicalstudies

25 November 2010

NonNon--invasiveinvasive tests tests UBT most accurate > 95 %Stool test (monoclonal AB): +/- 92 % accurate

Inconvenience of storage (-20°C), batch testing and acceptance of patients. Max 2 days room temperature ! New meridian rapid one-step test !

Serology only 80-85 % accurate. Locale validation necessary.

InvasiveInvasive teststestsRapid urea test (RUT): accuracy > 90 %


8

25 November 2010

Advantages serology:

Results of serology not influenced by intake of PPI, antibiotics or by bleeding.

more accurate if low bacterial load (atrofie, MALT)

Easy to use for epidemiology


25 November 2010

H. pylori: control after treatmentH. pylori: control after treatment

Control > 4 weeks

First choiceUBT

Second choicestool test (monoclonal > polyclonal)

9

25 November 2010

H. H. pyloripylori: : treatmenttreatment

whywhy ??

Recurrence of ulcers is decreased with + 90 %Healing of MALT lymphoma in early stagePrevention of gastric cancer if no precursor lesions of cancer are present at the moment of eradication

25 November 2010

Maastricht Maastricht guidelinesguidelines1996 1996 -- 2000 2000 -- 20052005

10

25 November 2010

A 11a Systematic review of randomised controlled trials (RCT) of good methodological quality and with homogenecity1b Individual RCT with narrow confidence interval1c Non-controlled studies

B 2 2a Systematic review of cohort studies (with homogenecity) 2b Individual cohort studies (including low quality RCT, eg <80%

follow-up) 2c Non-controlled cohort studies/ecological studies

33a Systematic review of case-control studies (with homogenicity)3b Individual case-control studies

C 4 Case series/poor quality cohort or case-control studies

D 5 Expert opinion without explicit critical appraisal or based on physiology, bench research or "first principles"

25 November 2010

Indications for treatment

11

25 November 2010

Maastricht III (2005) Maastricht III (2005) strong recommendations for eradication (unchanged))

A (5)Patients wishes

B (3b)First degree relatives of patients withgastric cancer

B (3b)After gastric cancer resection

B (2a)Atrophic gastritis

A (1C)MALToma

A (1a)DU/GU (active or not)

Recurrence of ulcers decrease with + 90 %

25 November 2010

Maastricht III (2005) Maastricht III (2005) unchanged recommendations for eradication


B (3b)First degree relatives of patients withgastric cancer



A (1C)Low grade MALToma


Healing of MALT lymphoma in early stage (mucosa or submucosa) in 62 %

Not efficient: t(11,18) (q21;Q21) with fusion of MALT1 and API2

12

25 November 2010



B (3b)First degree relatives of patientswith gastric cancer



A (1C)MALToma


25 November 2010



B (3b)First degree relatives of patientswith gastric cancer



A (1C)MALToma


13

25 November 2010

Maastricht III (2005)Maastricht III (2005)

HP and ITP

HP and iron deficiency anemia

HP and aspirine

A (1b)HP and acute NSAID use

B (2b)HP and long term PPI

A (1a)HP and dyspepsia

25 November 2010

HP and ITP


HP and aspirine





14

25 November 2010

HP and ITP


HP and aspirine





25 November 2010

1HP and ITP

1HP and iron deficiency anemia

HP and chronic low dose aspirine use





Chan Fk et al. N Eng J Med 2001

Lai KC et al. N Eng J Med 2002

15

25 November 2010

1HP and ITP

1HP and iron deficiency anemia

HP and aspirine





Fe is better absorbed in acid environement

Competition in use of iron between host and H. pylori

Low vitamine C concentrations in H. pylori gastritis

Mist erosions or ulcers

?

25 November 2010

Maastricht III: statementsMaastricht III: statements

H. pylori and H. pylori and chronicchronic NSAID NSAID useuseBoth independent risk factors for ulcersPPI is better than eradication in the prevention of reccuring complicated ulcers

H. pylori and GERDH. pylori and GERDEradication has no effect on the efficacy of PPINo indication for eradication if no chronic PPINegative association between H. pylori en GERD: reason ?

16

25 November 2010

Statement Statement concerningconcerning gastricgastric cancercancer

H. pylori is a proven risk factor for non cardiac gastriccancer (65 % of all stomach cancers worldwide)

The risk depends on genetics of bacteria and host.

Other possible factors: nutrition, environment, medication

H. pylori eradication prevents the development of premalignant lesions and so decreases the risk of gastric cancer (1b and 1c evidence)

25 November 2010


H. pylori is a proven risk factor for non cardiac gastriccancer (65 % of all stomach cancers worldwide)

The risk depends on genetics of bacteria and host.

Other possible factors: nutrition, environment, medication

H. pylori eradication prevents the development of premalignant lesions and so decreases the risk of gastric cancer (1b and 1c evidence)

17

25 November 2010


The best timing for eradication is before the development of pre-malignant lesions = young age.

H. pylori eradication in the prevention of gastric cancer should be considered in high risk populations (china, japan).

25 November 2010

WhatWhat does does thisthis meanmean forfor BelgiumBelgium ??

WomanWoman:Breast cancer + 37 % (n = 9405)Colonic cancer + 13 % (n = 3408)Lung cancer + 7 % (n = 1540)Gastric cancer + 3 % (n = + 500 ) (cardia en non-cardia)Cervix + 3 % (n = 651)Esophageal cancer + 1,3 % (n = 224) (adeno and spino)

Man:Man:Prostate + 30 % (n = 9510)Lung cancer + 17 % (n = 5268)Colonic cancer + 13 % (n = 4111)Gastric cancer + 3 % (n = 846)Esophageal cancer + 2,3 % (n = 664)

18

25 November 2010

TotalTotal amountamount of of cancerscancers in in BelgiumBelgium 20052005

01000200030004000500060007000

80009000

10000

prostaat long cervixborst maag slokdarm

25 November 2010

EvolutionEvolution of of gastricgastric cancercancer in in BelgiumBelgium

0

200

400

600

800

1000

1200

1400

1600

1999 2002 2005

MenWomanTotal

19

25 November 2010

Incidentie van kanker bij vrouwen in Incidentie van kanker bij vrouwen in BelgiBelgiëë, 2005, 2005

0

200

400

600

800

1000

1200

1400

25 30 35 40 45 50 55 60 65 70 75 80 >85

maagkankercolonborstslokdarmcervixlong

leeftijd

Abs

oluu

t aan

tal

25 November 2010

Mass screening ?

Mass screening and treatment would also have effect on:

DyspepsiaGastric and duodenal ulcers

De H. pylori prevalence decreases (< 10 % in children and adults)

Point of no return ?

20

25 November 2010

Treatment

25 November 2010

Maastricht Maastricht IIIIII: : treatmenttreatment

New :

Effective treatment should achieveintention-to-treat eradication rate > 80%

21

25 November 2010

Maastricht III : Maastricht III : treatmenttreatment

First line

PPI bid +

clarithromycin 500mg bid+

amoxicillin 1g or metronidazole 500mg bid

1 week to 2 weeks

R < 15-20%

25 November 2010


First line

PPI bid +

clarithromycin 500mg bid+

amoxicillin 1g or metronidazole 500mg bid

1 week to 2 weeks

R < 15-20%

XR < 40%

22

25 November 2010


Alternative: Bismuth quadruple therapy ifavailable

25 November 2010

First choice:Bismuth quadruple therapy 10-14 days(Bismuth, tetracycline, metronidazole, PPI) Pylera R

No Bismuth available:PPI/tetracycline/metronidazole


Second line:

23

25 November 2010

Maastricht III : Maastricht III : ““rescuerescue treatmenttreatment””

“Rescue treatment” depends onsusceptibility testing

Sequential therapy ? (further evaluationnecessary)

No advice on:levofloxacin (high and quick R)Rifampicin (only for TBC)Rifabutin (not in Belgium)

25 November 2010

SequentialSequential therapytherapy

Combination of the 3 currently usedantibiotics in a sequential way

Amoxi/clarithro/metro

10 days:PPI/ampi 5 daysPPI/ Clarithro/metro of tinidazole 5 days

24

25 November 2010

SequentialSequential therapytherapy: background: background

Combination ampi/PPI decreases the bacterial burden

Membrane distroyed by amoxi(decreases risk of developing R)

25 November 2010

Sequential therapy: efficiencySequential therapy: efficiency

RCT

first- line treatment versus sequential therapy: + 80 % versus + 90 %

If no R to clarithro: eradication rates =

10 day quadruple therapy (Amoxi/Metro/clarithro/PPI) versus sequential: both + 93 %

Wu DC, Clin Gastroenterol Hepatol. 2010 Jan;8(1):36-41

25

25 November 2010

SequentiSequentiëële therapiele therapie

Voordelen van de sequentiële behandeling ?

Betere eerste lijns resultaten (Minder nood aan 2de lijn)Compliantie =Niet meer neveneffecten

25 November 2010

SequentialSequential therapytherapy: : costscosts

Sequential: 37,5 euro

Classic (clarithro/metro/PPI 7 of 10 dagen):

34,5 euro

26

25 November 2010

FluoroquinoloneFluoroquinolone basedbased therapytherapy

Well tolerated, few side-effects, mixed results

1 st line: +/- 85 %2 nd line: 70 – 80 %3 rd line: 60 - 90 %

R is easily acquired R in Belgium: 25 % (Mana, Glupzcinsky, Miendje)

25 November 2010

OtherOther alternativesalternatives ??

27

25 November 2010

DoxicyclineDoxicycline basedbased therapytherapy

Different studies94 patients (cammarota et al 2004 – Rome-) 3rd line, R based116 patients (Realdi G et al.1999 – Italy -) 1line line270 patients (Perri et al 2002 – Italy) 1th line71 patients (Borody et al 1992 – australia-) 1 line189 patients, 3 groups (Taghavi SA et al 2008 –Iran-) 1 line

Success Respectively90 % / 58 % / 36 % / 65 % / 68 %

R testing,5 % tetra R, 0 % amoxi R, metro 100 %, claritro 95 %33 % doxi R, 26 % amoxi R, metro 30 %NDNDND

TreatmentOme, Amoxi 2 x 1 Bismuth, Doxi 2 x 100 mg 7 days -Ome, metro,Doxicycline 2 x 100 mg 7 daysLanso, Amoxi, doxi 2 x 100 14 daysBismuth citraat, metro, doxiDoxi, co-amoxiclav, ome

25 November 2010

Doxi, co-amoxiclav, ome

ND68 %189 (Iran)

Bismuth citraat, metro, doxi

ND65 %71(australia)

Lanso, Amoxi, doxi2 x 100 14 days

ND36 %270 (Italy)

Ome,metro,Doxicycline 2 x 100 mg 7 days

33 % doxi R, 26 % amoxi R, metro 30 %

58 %116 (Italy)

Ome, Amoxi 2 x 1 Bismuth, Doxi 2 x 100 mg 7 days

5 % tetra,, 100 %, metro 95 % claritro

90 %94 (Italy)

treatmentRresultspatients

Rabe, bismuth, doxy, furazolidone, 2x/d, 10 days

Only claritro failures83 %29 (Brazil)


28

25 November 2010


2 studies compared doxi with tetra(Realdi 1999 and Borody 1992)

Tetra > doxi91 % vs 58 %92 % vs 65 %

25 November 2010

IncreaseIncrease the the dosedose of PPI ?of PPI ?

Quick, intermediate and low metabolisers of PPI

Pos en negative studies

…….

Systemic review: omeprazole

A. VILLORIA et al. 2008. Aliment Pharmacol Ther 28, 868–877

29

25 November 2010

SituationSituation in in BelgiumBelgium ??

25 November 2010

R in R in adultsadults BelgiumBelgium

26 %28 %14 %Mana 2008

28 %-22 %Riga sept 2008Glupzcinsky)

16 %37 %15 %Miendje 2004-2007

17 %--Glupzcinsky 2003/4

-31 %3 %Aguemon 2002

levofloxacinmetronidazoleclarithromycin

30

25 November 2010

PrimPrim resistanceresistance in in childrenchildren BelgiumBelgium

6 – 16 %clarithro

18 %imidazole

Bontems1995 - 2000

Bontems P et al. Pediatr Infect Dis J 2001

25 November 2010

Algemene Algemene resitentieresitentie(multiple (multiple hospitalshospitals aroundaround BXL)BXL)

0

5

10

15

20

25

30

35

40

1997

2005

childrenclaritrochildrenmetroadultsclaritroadultsmetro

2005Y. Miendje

31

25 November 2010

International International resultsresults

1994-200522 %36 %(43 to 32 %)

France(children)

17 %35 %Korea

1989-’90 2005-’05

10 %20 %

Italy

1997-20021%(decreasing)

14 %Netherlands

200742 %90 %Cameroon

2000-200512 %36 %Wales

2000-20058,3 % (increasing)

28,6 % (increasing

England

200816 %TurkeyjaarR claritroR metroLand

25 November 2010

metameta--analysisanalysis standardstandard PAC 7PAC 7

81 %Untill 19981999Houben et al

Eradicationrate in %

Data rangePublicationAuthor

81 %Untill 19992000Gisbert et al

80 %1986 - 19981999Laheij et al

82 %Untill 19921992Chiba et al

32

25 November 2010

DISCUSSIE : DISCUSSIE : standardstandard PAC 7PAC 7

85 %S-Korea2009Jung et al

77 %Hungary2008Tulassay et al

92 %UK2008Ching et al

80 %Italie2007Zagari et al

86 %China2006Wang et al

79 %Finland2005Myllyluoma et al

85 %Australia1999Talley et al

82 %USA1999Schmid et al

92 %UK1998Stone et al

Eradicationrate in %

countryPublicationdate

Author

25 November 2010

DISCUSSIONDISCUSSION

Decreasing trends of eradication success ?

ITT > 90 % as a goal ?

Graham DY

Buzás GM, WJG, 2010

33

25 November 2010

DISCUSSIONDISCUSSION

Are cultures useful ?

Availability

expertise

Mixed resistanceCaristo E et al. Helicobacter 2008;13:557-563Kim J et al. Helicobacter 2003;8:202-206

Cost –benefit

Clinical relevance of metro R. Amoxi R ~ 0.rapid test clarithromycin resistance (FISH) ? - (spec en sens ?)

Before choosing levofloxacine based therapy

25 November 2010

ConclusionConclusion

Prevalence of Helicobacter pylori is falling dramatically in westernised countries Is decreasing in some developing countries

Transmission route is still not well known.

Mostly vertical in urban areas and horizontal in rural areas

34

25 November 2010


Most patients are asymptomatic and prevalence is falling but lethal pathologies like gastric cancer and ulcer disease are associated with H. pylori.

25 November 2010


Absolute indications for eradication

•DU/GU•Low-grade MALT•Pers or fam history of gastric cancer•Dyspepsia•Long term PPI use•IDA and ITP

35

25 November 2010


Prevention of gastric cancer

Eradication efficient if done before the development of pre-malignant lesions. Point of no return not known in other situations.

25 November 2010


Treatment:

First-line treatment efficacy has decreased but stays an acceptable treatment in Belgium.

Clarithromycin R has increased initially but seems to stabilize around 15 %

Metronidazole R is “relative” when translated to clinical practice.

36

25 November 2010


Treatment:

Levofloxacine R increases rapidly. Use in eradication only after culture and resistance profile.

In difficult situations: increase PPI, prolong treatment, find Bismuth, add H2-blokkers, culture (antrum and fundus).

25 November 2010

Don’t touch myHelicobacter ….

37

25 November 2010

Robin Warren and Barry Marshall1984

Nobel Nobel prizeprize medicinemedicine2005

Food-borne outbreaks caused by foodhandlers

Katelijne Dierick, DVM OD Communicable and Infectious diseasesNRL Food-borne outbreaksJuliette Wijtsmanstreet 141050 Brussels

Epilab, 25-11-2010

Rue Juliette Wytsmanstraat 14 | 1050 Brussels | BelgiumT +32 2 642 51 11 | F +32 2 642 50 01 | email: [email protected] | www.wiv-isp.be

1

Definitions

WHO definitions

Foodborne disease: a disease of an infectious or toxic nature caused by or thought to be caused by the consumption of foodor water

Outbreak: an incident in which 2 or more persons experience a similar illness after ingestion of the same food, or afteringestion of water from the same source, and whereepidemiological evidence implicates the food or water as the source of the illness.

The Zoonoses Directive (EC, 2003), transposed in KB-AR zoonoses22-5-2005, defines a food-borne outbreak as:

an incidence, observed under given circumstances, of two or more human cases of the same disease and/or infection, or a situation in which the observed number of human cases exceeds the expected number and where the cases are linked, or are probably linked, to the same food source’.

3 types

Food-borne infectionAfter ingestion of pathogen : direct interaction host-pathogen

• ex: SalmonellaFood-borne intoxication

After ingestion of toxine preformedin food: direct interaction host-toxin

• ex: StaphylococcusFood-borne toxi-infection

After ingestion of pathogen : Multiplication in the intestine of the

host with toxine production• ex: Clostridium perfringens

2

Trends and sources of zoonoses and zoonotic agents and food-borne outbreaksin the European union in 2008-april 2010

3

1032 436 37 154 48 175

48 134

2006

100709772

23

2008

851230383481057

6999

2007

10057 12 3 4 5

6 12

2006 persons affected% of total

43913Norovirus

841100Total17250unknown11810other

312Campylobacter109Bacillus cereus326Staphylococcus3910Salmonella20082007agent

% Reported food-borne outbreaks by agent and the total of affected persons in Belgium

Food is only a vehicle!Source:Infected animal

Infected raw material

Infected environment

Infected food handler

4

Toxi-infections caused byfood handler infection

PossibleSalmonellosisShigellosisHepatitis A

But most frequentlyNorovirusStaphylococcus aureus

Bacteria versus virusesBacteria : multiplication in food if favoral conditions

Viruses: need living cells: no multiplication

Stafylococcus aureusCoagulase positive staphylococci can produce enterotoxines:SET A, B, C, D,E, …… until O

Almost always S. aureus4 biotypes : A : human, B : poultry, pigs , C : cattle and sheep,D: hare

Origin of contaminationVery resistant , naturally occuring in air, water, soilmost important reservoir : humans, animals

Humans :• Healthy carriers ( throat, nose, skin: forehead, headskin,hands ) • Common cold infected with S.aureus• skin lesions : pus, acné, infected wounds ...

Animals:• pig : skin, nose, skin surrounding the eyes• milk : mastitis• Abcesses in meat( ex injection sites)

5

Stafylococcal intoxicationHealthy carriers milk – sick animalsdiseased people mastitis

Food preparation

Food-pH 7 -rich in protein -low AwContaminated food

multiplication of coagulase positive Staphylococci-Toxin (heatstable)production in food during exponential growrh phase(>105cfu/g)

Consumption of food

Absorption of the toxin preformed in the food

Food intoxication (nausea, vomiting, diarrhoea)Incubation time:2-4h

Duration: 24h

Stafylococcus

Food is contaminated by : • Poor personal hygiene during preparation• Contaminated milk or cream

Multiplication in food by:• non respect of cold or hot chain .

Sensitive food products : • Cooked product contaminated after preparation ( meat ,

fish, stews, vol au vent …• Crème patissière, ice cream, pastry• Products with low Aw : charcuterie, concentrated milk,

melkpowder

6

Case-study : Food-borne outbreak in a Barbecue in Brasschaat-1

22 out of 60 people sick and hospitalisedsevere vomiting.Food: steak, lamb chops, pork, chicken, sausage and potatoe salad.B.cereus: 104 – 107CFU/gcoagulase + Staphylococci: 103 -107CFU/g.

Food-borne outbreak in a Barbecue in Brasschaat-2:

BUT: •Presence of SET A in steak, pork, sausage and potatoe salad•SET toxin gen present in strains

PCR detection of the SET toxin genes sea, seb, sec and sed(toxines A-B-C-D-E detection with Vidas SET 2 – OxoidSET-RPLA) and the detection of the genes seg, seh, sei, sej, sek, sel, sem, seo and sen

PCR detection of the cereulide gen of B; cereus

•absence of cereulide gen in isolated strains•absence of emetic toxin cereulide

7

Norovirus

Very infectious• 100 virus particles can cause infection

Spread:• feco-orally• Person to person• Contaminated water or food water en voedsel (17% in NL)

Food at riskPrimary contamination

• Soft red fruits• Bivalve molluscs

Secundary contamination (by food handler)• Ready to eat meals• sandwiches• Complete meals (mixed)

Norovirus infections :seasonal influence

Foodborne outbreaks cumulative per month

0

5

10

15

20

25

1 2 3 4 5 6 7 8 9 10 11 12

month

cum

ulat

ive

num

ber

of fb

out

brea

k

Remaining outbreaks cumulative per month

0

20

40

60

80

100

120

140

1 2 3 4 5 6 7 8 9 10 11 12

month

cum

ulat

ive

num

ber

of o

utbr

eaks

not

rel

ate

to fo

od

FBO outbreaks Outbreaks not related to food

8

Zoönotic ??Primarycontamination

Food-handlers

Secondarycontamination

Contamination cycli of Norovirus

9

L. Baert et al , Epidemiol. Infect, 2009,137.316-325

10



11

Casus

Dilsen-Stokkem: VKSJ Vichte - 30/160 children illSunday 18/07/2010

Mon 19/07/2010: outbreak reported to NRL FBO by FAVV-AFSCA

Tue 20/07/2010: 5 food samples NRL FBO: start bacteriological analysis1 human sample: start bacteriological analysis and norovirus analysis

Thu 22/07/2010: first report human: positive norovirus GIIfood: bacteriology conform, start analysis norovirus

Mon 26/07/2010: final report human and food sampleshamburger positive for norovirus GII

Prevention

• Personal hygiene kitchen staff• T control of food before and after preparation

< 4° C > 65° C

• GMP (sector guide)• Vaccination (HAV)• Training!!!

12

Conclusion 1: Two parts in investigation:

Laboratory part : sampling very important!- Coproculture kitchen personnel- Swabs of nose or hands kitchen personnel- Environmental sampling- Leftovers of the meals- Ingredients-Raw materials

Epidemiological part- Food history- Disease history (also family, children, grand children)- Enquiry form!

Conclusion 2: Foodhandlers play an important role in the prevention of foodborne outbreaks

Foodhandler

Personal hygiene

Storage time/TemperatureAbuse

undercooking

Unprocessed orcontaminatedingredients

13

Thank you for your attention!

Thanks to our partners in Food-borne outbreakinvestigaton:

FAVV-AFSCAAgentschap Zorg en GezondheidSurveillance santé

Outbreak of Shigella sonneiinfections in the orthodox Jewish

community of AntwerpKoen De Schrijver, Sophie Bertrand, Ignacio Gutiérrez, Daniel Van den Branden, Jef Van

Schaeren

[email protected] Antwerpen

25 11 2010Diagnosis and surveillance Infectious Diseases WIV

Sint-Pieters-Woluwe

1

Onset

• In April 2008 informed on several isolatesof S. sonnei (notifiable disease)

• Young children, residing in Antwerp, members of the orthodox Jewishcommunity of Antwerp

Background I• 68% S. sonnei of 300 (2007)

– High antibiotic resistant strain• Shigellosis

– High infectiosity– Person to person– Mostly mild / dysentery– < 5 years

• Common source unfrequent– Sporadic cases – No custers before in Jewish

community in Antwerp

2

Background II

• Orthodox Jewishcommunity of Antwerp– Highly insular– Approx. 10,000 people– Frequent international

contact

Objectives of the study

• Describe the epidemic→Descriptive study• Detect the source of index patient and evaluate

relatedness of strains→Microbiological study• Assess riks factors for secondary transmission in

households→Secondary attack rate study in the households with identification of risk factors

• Stop spread of the epidemic→Control measures

3

Case definition• Confirmed case

– Person from Jewish community Antwerp– Culture confirmed S.sonnei– Ill between April-August 2008

• Probable case– Diarrhoea, and fever and abdominal cramps– Household of confirmed case– Within 7 days after index case– Same study period

• Secondary case– Within the week after contact with confirmed case in

the household

Descriptive study

– Standardized questionnaire• Demographical (… family contacts)• Clinical• Laboratorial• Exposure (travelling, family gatherings)

– Active case finding: visiting families and schools

4

Source tracing study

– Serotyping isolates (slide agglutination ) (Derbyshire UK)

– Susceptibility of strains (Disk diffusion Kirby-Bauer)(CLSI)

– PFGE (PulseNet method, XbaI) – Comparing strains from Israel 2000-2008) with strains

from Antwerp (FingerprintingII Informatix)– To compare the Israel strain we used the Dice

coefficient and unweighted – pair group method

Secondary attack rate study

– Identification of household contacts = 175– Secondary AR– Questionnaire and interview

• Number of children• Age of children• Presence of children with nappies• Children < 12 years assisting with cleansing other siblings• Antibiotics intake index Hospitalisation of index • Number of toilets• Hand washing after cleansing

– Uni- and multivariate RRs (95% CI) binomialregression model (StataCorp)

5

Patient data

• 42 cases (32 confirmed, 10 probable)• 32 cases notified and 10 case finding• 52% females• 55% < 5 years; 14% > 20 years• 43% dysentery type • 76% hospitalisation

N

10

5

17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 week 2008 2008

7

Secondary attack rate study

• 29 households• 175 household contacts• Secondary attack rate: (15/175) 8.5% (CI-

95% 4.3-12.7)

8

Control measures

• Parents were informed on need of handwashing.

• Schools informed on hygiene.• Symptomatic children excluded for a

minimum of 48 hours after clinicalrecovery, from day-care centres, pre-school and school attendance.

• Educational conference for parents, teachers, and caregivers.

9

Discussion and conclusion• 42 cases (32 S.sonnei) in Jewish community of Antwerp• Origine: Tel-Aviv

• Other outbreaks of S.sonnei in London, New York, Israel (1996-2008)– Calderon-Margalit et al.Epidemiol Infect. 2010;138:244-52

• Secondary attack rate: 8.5% comparable with other studies

• Risk factors: number of children (>3), young children (<5 y) and children (<12 y) helping parents independent risk factors

• High hospital admission rate 76%→ underdiagnosis

• Importance of collaboration between microbiology and epidemiology

• Importance of PFGE in comparing strains and in source tracing

Many thanksto

• Dr. Valinski ( Tel-Aviv)• Laboratories (Antwerp)

Vaccination coverage in Vaccination coverage in WalloniaWallonia

B. SwennenB. SwennenProvac Provac

ESPESP--ULBULB

Seminar : Diagnosis and surveillance of infectious diseases 25/11/2010

Immunization programme in Immunization programme in French community of BelgiumFrench community of Belgium

Target publicTarget public–– Children (0Children (0--18 y) in Wallonia18 y) in Wallonia–– Children (0Children (0--18 y) in Brussels followed by 18 y) in Brussels followed by

Private Private ““frenchfrench--speakingspeaking”” doctorsdoctorsPreventive structures Preventive structures

–– Office de la Naissance et de Office de la Naissance et de ll’’enfanceenfance (ONE)(ONE)–– Service Promotion santService Promotion santéé àà ll’é’écolecole (PSE)(PSE)

Vaccination Vaccination coveragecoverage

Impact Impact indicatorindicator : : –– proxy of the protection in the populationproxy of the protection in the population–– Vaccine Vaccine EfficacyEfficacy * vaccine * vaccine coveragecoverageProcessProcess indicatorindicator : : –– Is the programme Is the programme reachingreaching the the targettarget

population?population?–– Is Is immunizationimmunization scheduleschedule respectedrespected??

Immunization schedule in 2010:4 periods

Vaccination Vaccination coveragecoverage surveyssurveys in in French French communitycommunity of of BelgiumBelgiumChildrenChildren (18 (18 --24 24 monthsmonths) ) –– EveryEvery 3 3 yearsyears–– 8 8 surveyssurveys sincesince 19891989–– Last one in 2009Last one in 2009ScholarScholar population: 3 population: 3 yearsyears cyclecycle–– 2 2 th th elementaryelementary–– 6 6 th th elementaryelementary–– 4 4 th th secondarysecondary

Last Last SurveysSurveys

ChildrenChildren 18 18 -- 24 24 monthsmonths in in WalloniaWallonia 20092009ChildrenChildren 1818--28 28 monthsmonths in Brussels 2006in Brussels 2006AtAt SchoolSchool–– 4th 4th secondarysecondary in 2007in 2007--20082008–– 6th 6th elementaryelementary in in 20082008--20092009–– 2th 2th elementaryelementary inninn 20092009--20102010

Vaccination Vaccination coveragecoveragechildrenchildren 18 18 -- 24 24 monthsmonths in 2009in 2009

ChildrenChildren bornborn betweenbetween31 31 meimei and 30 and 30 novembernovember 20072007

ImmunizationImmunization scheduleschedule CSS 2007CSS 2007Age(1) 2 3 4 12 13 15 18 5-7 10-13 14-16

Vaccines month month month month month month month years years years

Polio(2) IPV IPV IPV IPV IPV

DiphteriaTetanus DTPa DTPa DTPa DTPa DTPa dTPertussis(3) dTpa

Haemophilus Hib Hib Hib Hibinfluenzae type b(4)

Hepatitis B(5) VHB VHB VHB VHB

MeaslesRubella RRO1 RRO1 RRO2 Mumps

Meningococcus C(7) MnC

Pneumococcus(8) Pn7V Pn7V Pn7V

Rotavirus ROTA ROTA (ROTA)

Range of period

Combined vzccine Control and catch-up if necessary

RRO2

12 vaccine preventable diseases

Modifications Modifications sincesince 20042004

Introduction Pn7VIntroduction Pn7V–– 3 3 dosisdosis regimenregimen–– Vaccine free of charge Vaccine free of charge sincesince januarijanuari 20072007RotavirusRotavirus vaccine vaccine recommendedrecommended–– InamiInami reimbursementreimbursement : 10,89: 10,89€€/dose for patient/dose for patient–– 2 vaccines 2 vaccines RotarixRotarix 2 doses, 2 doses, RotateqRotateq 3 doses3 dosesAtAt 12 12 monthmonth RRO + RRO + Pn7V 3Pn7V 3AtAt 15 15 monthmonth Hexa 4 + Hexa 4 + MenCMenC

MethodologyMethodology 1: the 1: the samplingsampling

Same methodolgy for 8 surveyssince1989Cluster sampling survey– 55 clusters of 12 children– 660 children

MethodologyMethodology 2: 2: data collectiondata collection

Home Home surveysurveyImmunizationImmunization information information notednoted fromfrom: : –– Carnet de lCarnet de l’’enfantenfant–– ImmunizationImmunization cardcardInterview of parents of the Interview of parents of the childrenchildrenInterviewers: Nurses Interviewers: Nurses fromfrom ONEONE

Distributed to all children bornsince 2000

660 Questionnaires

576 Contacts

526 Interviews

14 vaccinal Anamnesis

512 vaccinal charts

84 Non Contacts

50 Refusal

79.7%

8.7%

2.7%

12.7%87.3%

91.3%

97.3%

Taux de participationTaux de participation

Vaccine (n=512)

1 2 3 4

Hexavalent 98.0(502)96.9-99.2

98.0(502)96.9-99.2

96.9(496)95.5-98.3

90.0(461)87.4-92.7

MMR 92.4(473)90.2-94.6

/ / /

MéningococusC

91.2(467)88.7-93.7

0.2 (1)0-0.2

/ /

Pn7V 97.1(497)95.6-98.5

93.6(479)90.9-96.2

80.7(413)76.9-84.4

1.4 (7)0.4-2.4

Rotarix® 76.0(389)71.5-80.5

72.8(373)68.3-77.3

/ /

Rotateq® 6.1(31)4-8.1

5.7(29)3.7-7.7

4.5(23)2.6-6.3

/

DTaP-IPV 1.6(8)0.5-2.6

1.6(8)0.5-2.6

1.2(6)0.2-2.1

0.4(2)0-0.9

Hib 1.0(5)0.1-1.8

1.0(5)0.1-1.8

0.6(3)0-1.2

0.2(1)0-0.6

DTP 0.4(2)0-0.9

0.4(2)0-0.9

0.6(3)0-1.2

0.2(1)0-0.6

IPV / / / /

HBV 0.8(4)0-1.5

0.8(4)0-1.5

0.4(2)0-0.9

/

Vaccination coverage according vaccine disponible in FC

Vaccin (n=512) 1 2 3 4

Poliomyelitis 99.6 (510)99.1-100

99.6 (510)99.1-100

98 (502)(96.8-99.2)

90.4 (463)87.9-93

DiphtérieTetanus

Pertussis

100 (512) 100 (512) 98.6 (505) 97.6-99.6

90.6 (464)(88.1-93.1)

Hib 99.0 (507)98.2-99.9

99.0 (507)98.2-99.9

97.5 (499)96.1-98.8

90.2 (462)87.7-92.8

HBV 98.8 (506)97.6-99.8

98.8 (506)97.6-99.8

96.9 (496)95.4-98.4

90.4 (463)87.9-93

MMR 92.4(473)90.2-94.6

/ / /

Méningococcus C

91.2 (467)88.7-93.7

0.2 (1)0-0.2

/ /

Pn7V 97.1(497)95.6-98.5

93.6 (479)90.9-96.2

80.7 (413)76.9-84.4

1.4 (7)0.4-2.4

Rotavirus 82.0 (420)78.7-85.4

77.3 (396)*73.7-81.0

Vaccination coverage (%) in Wallonia in 2009

2006n= 493

2009n=512

n % IC 95% n % IC 95% dif férence2003-2006

Différence 2006-2009

Polio 4 dosis 468 94.9 93.0-96.9 463 90.4 87.9-93.0 2.6 -4.5 NS

DTP 4 dosis 467 94.7 92.8-96.7 464 90.6 88.1-93.1 2.0 -4.1 NS

Hib 4 dosis 461 93.7 91.6-95.8 462 90.2 87.7-92.8 6.3 -3.5 NS

VHB 3 dosis 456 92.7 90.2-94.8 462 90.2 87.7-92.8 27.9 -2.5 NS

MMR 439 89.0 86.3-91.8 473 92.4 90.2-94.6 6.5 +3.4 NS

Mén C 456 92.5 90.2-94.8 467 91.2 88.7-93.7 11.0 -1.3 NS

PN7V 145145 29.4 413 80.7 +51.3 **

Vaccine coverage evolution betwween 2006 et 2009 In WalloniaVaccine coverage evolution betwween 2006 et 2009 In Wallonia

8 surveys : 20 years of evolution8 surveys : 20 years of evolution

0

10

20

30

40

50

60

70

80

90

100

1989 1991 1993 1996 1999 2003 2006 2009

%

Polio complet

DTP-DT4

RRO

Hib

Hép. B

MénC

Prog.RROModif.RRO Hib

Recomm.Hib/VHB

Prog.VHB

OPV-IPVDTPa

Hib gratuit

MénC PnC

PnC

Evolution Evolution

In 2006 : increase due to hexavalent In 2006 : increase due to hexavalent vaccinevaccineIn 2009 : In 2009 : –– Stabilisation between 90% and 94% for Stabilisation between 90% and 94% for

hexavalenthexavalent–– MMR Progression (NS) but not yet 95%MMR Progression (NS) but not yet 95%–– Increase ** for Pn7V (3 dosis)Increase ** for Pn7V (3 dosis)–– Vaccine coverage decrease for the dose after Vaccine coverage decrease for the dose after

12 months of age 12 months of age

Vaccine coverage(%) : Vaccine coverage(%) : full schedule in 2009full schedule in 2009

Polio +DTPa + VHB +Hib + RRO + MenC+ Pn3

Polio +DTPa + VHB +Hib + RRO + MenC

74,1

84.0

70.0 -77.9

80.8– 87.2

Flanders2008

Wallonia2009

Brussels2006

Polio 95.3 90.4 90,0DTPa 95.2 90.6 90,0Hib 95.2 90.2 88,8HBV 95.1 90.2 88,4MMR 96.6 92.4 91,1MenC 95.6 91.2 91,7Pn7V 97.7 80.7 NA

Vaccine coverage in Belgium

Is the schedule right on time?Is the schedule right on time?

Before8 weeks

Between 8 – 10 weeks

Between 10 - 12 weeks

Between 12 - 16 weeks

After 16 weeks

Hexa1 1.2 57.8 26.8 9.8 4

14% 84,6%

Vaccinators in FCVaccinators in FCVaccinator MMR Rota1 Varicella*

n % n % n %

O.N.E.* 260 55.7 228 55.1 8 17.3

Pédiatere 170 36.4 152 36.7 30 65.2

GP 23 4.9 22 5.3 3 6.5

Hospi 14 3.0 12 2.9 5 10.9

Total 467 100 414 100 46 100

* 9% vaccine coverage for chickenpox

Bivariate analysis : study of the mother Bivariate analysis : study of the mother

Study Level Hexa 4 MMR

n % n

University 70 84.3 72 86.7

Other 385 91.4 395 93.8

* *

Bivariate analysis: Mother Bivariate analysis: Mother Nationality of originNationality of origin

Nationality Hexa 1 Rotavirus1 Rotavirus2

n % n % n %

Belgian 395 99 340 85.2 324 81.2Non belgian 100 94.3 76 71.7 74 69.8p value ** *** *

Bivariate analysis : Number Bivariate analysis : Number Chidren in the familyChidren in the family

Frères/ Sœurs

Rota1 Rota2 Pn7v (3)

n % n % n %

0 137 85.6 133 83.1 140 86.1

1 150 83.8 145 81.0 137 74.4

2 ou > 123 75.9 114 70.4 112 80.0

p value 0.055 * *

Bivariate analysis : Family IncomeBivariate analysis : Family Income

Income Rota1 Rota2n % n

0-1500 74 69.8 66 62.31500-3000 173 85.6 168 83.2>3000 117 85.4 114 83.2p value ** ***

Bivariate analysis: ParentsBivariate analysis: Parents’’s time s time at workat work

Rota1 Rota2

n % n

0-1 Full time 178 73.3 167 68.7

>1 Full time 238 90.5 233 88.3

p value *** ***

Day care Rota1 Rota2

n % n

Yes 268 86.7 259 83.9

No 150 75 141 70.5

p value *** ***

Bivariate analysis: Day care Bivariate analysis: Day care frequentationfrequentation

Bivariate analysis : ONE choice for Bivariate analysis : ONE choice for preventive carepreventive care

ONE (%)

Hexa4 RRO MénC Pn3 Rota1 Rota2

Yes 93.5 95.1 95.1 86.1 79.6 76.3

No 86.5 89.7 86.9 75.8 84.9 81

p value * * *** ** NS NS

Logistic regression for nonLogistic regression for non--vaccination factorsvaccination factors

Same model for Same model for –– Hexa 4Hexa 4–– MMRMMR–– Men CMen C–– Pn7V dose 3Pn7V dose 3–– RotavirusRotavirus

Vaccine free of charge

Hexavalent 4 MMR Men C PN7V 3 Rotavirus 2

Income>1500 1

< =1500 2.8(1.7-4.5) ***Rank in the fratry

1 1 1 1 1

>1 3.4 (1.5-8.5) ** 4.3 (1.5-12.7) ** 3.6 (1.4-8.9) ** 1.7(1-2.9) p=0.06

VaccinatorONE 1 1 1 1Other 3.6 (1.7-7.8) *** 2.2 (1- 4.8) * 3.7 (1.7-8) *** 2.4(1.4-4) ***

Study

High 1

≤secondary1.9 (0.9-4.2)

p=0.09

Day care

Nationality

Associated factors for non-vaccination (logistic regression, n=434,ORa)


Vaccine coverage remains stable since Vaccine coverage remains stable since 20062006Pn7V is well adoptedPn7V is well adoptedMMR1 still < 95% objectifMMR1 still < 95% objectifNo social inequities except for RotavirusNo social inequities except for RotavirusNo refusal for vaccination (cluster?)No refusal for vaccination (cluster?)Importance of the preventive structure Importance of the preventive structure ONE and free of charge vaccine to avoid ONE and free of charge vaccine to avoid inequitiesinequities

Vaccine coverage at school ageVaccine coverage at school age

MethodologyMethodology–– Random Sample of classes Random Sample of classes –– Information collected from medical chart in Information collected from medical chart in

school medical center (SPSE)school medical center (SPSE)–– April April ––mei each yearmei each year–– 3 year Cycle3 year CycleObjectivesObjectives–– Vaccine coverage, evolutionVaccine coverage, evolution–– Define new strategies for the programmeDefine new strategies for the programme

Immunization schedule in 2010:4 periods

Last Surveys Last Surveys

4th secondary in 20074th secondary in 2007--200820086th elementary in 6th elementary in 20082008--200920092th elementary inn 20092th elementary inn 2009--20102010

Vaccine coverage dT/dTaP Vaccine coverage dT/dTaP en 4 en 4 thth secondary (07secondary (07--08) 08)

before dTaP generalisationbefore dTaP generalisation

Vaccine coverage in 6th elementary

23,2225,24

30,53

44,8541,75

65,6

70,5

75,5

1,48

6,53 6,92

41,41

37,14

64,22

68,62

74,7

0

10

20

30

40

50

60

70

80

1996/1997 1997/1998 1998/1999 1999/2000 2000/2001 2003/2004 2005/2006 2008/2009

MMR2HBV

Vaccine coverage MMR2 Vaccine coverage MMR2 66th th Elementary / province in2009Elementary / province in2009

DTaPDTaP--IPV coverage evolution IPV coverage evolution 20042004--2010 in 2 Th elementary2010 in 2 Th elementary

69,173,1

74

0102030405060708090

100

2004-2005 2006-2007 2009-2010DTPaIPV

DTaPDTaP--IPV coverage /province IPV coverage /province and / vaccinator 2010 and / vaccinator 2010

14,3

55,7

10,1

2,4

58

9,1

8,8

50,5

9,7

14,6

47,3

16,4

1,5

59,1

8,4

9,5

49,8

13,1

0

10

20

30

40

50

60

70

80

90

Bruxelles Brabant Wallon Hainaut Liège Luxembourg NamurRégion/provinces

e

Identification non disponible

Autre vaccinateurMS

80,1

69,5 69

78,3

69 72,4

AcknowledgementsAcknowledgements

Provac Provac ––UlbUlb–– E RobertE Robert–– N da Costa MayaN da Costa Maya

Provac Provac ––UCL UCL –– A VermeerenA Vermeeren–– F GoffinF Goffin–– K LevieK Levie

Provac Provac ––ULGULG–– MC MiermansMC Miermans

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