RESUMO

Vaccinating children has been an unquestioned tradition for many years. However, there is now great concern over the growing rejection of childhood vaccination, as well as other less evident obstacles that affect vaccination coverage.Multiple factors are involved in the rejection of a specific vaccine or vaccination in general, including actions by anti-vaccination groups, as well as disinformation or the dissemination of erroneous information. In some countries, delays in completing the immunization schedule may be due to poor program management. These factors compromise effective vaccination coverage, constituting a serious threat to public health.Susceptible populations constantly change, due to epidemiological shifts determined by phenomena such as globalization and various conflicts that interfere in the operation of health services. In recent years there have been outbreaks of previously controlled diseases such as diphtheria, whooping cough, and measles, resulting both from imported cases and from deficiencies in national immunization programs.This paper explores different aspects of the increasing frequency of vaccine rejection. There is a need for a review of its causes and for the design of innovative strategies and approaches to regain acceptance of vaccination and its place as the most cost-effective tool in public health.

Durante muitos anos, vacinar os filhos foi uma tradição inquestionável; atualmente, porém, há grande preocupação com a crescente recusa das vacinas da infância, além de outros obstáculos mais difíceis de visualizar que afetam a cobertura vacinal.Múltiplos fatores concorrem para influenciar a recusa a uma vacina específica ou à vacinação em geral, seja pela ação de grupos antivacina ou pela desinformação ou divulgação de dados incorretos. Em alguns países, a situação é complicada por atrasos no cumprimento do calendário vacinal devido a possíveis falhas na gestão dos programas. Tudo isso compromete o nível efetivo das coberturas de vacinação e constitui grave ameaça à saúde pública.As populações suscetíveis a doenças imunopreveníveis estão em constante mutação devido a mudanças epidemiológicas, determinadas por fenômenos como a globalização ou diferentes conflitos que interferem com as ações de saúde. Recentemente, foram registrados surtos de doenças antes controladas, como a difteria, a coqueluche e o sarampo, seja por casos importados ou por falhas nos programas nacionais de imunização.Este artigo visa explorar os diferentes componentes que contribuem para a frequência crescente da recusa vacinal, o que exige uma reanálise dos fatores causais e o delineamento de estratégias e enfoques inovadores para recuperar a aceitação das vacinas e de seu papel como a mais custo-efetiva das ferramentas em saúde pública.

RESUMO

[RESUMEN]. Durante muchos años, vacunar a los niños era una tradición incuestionable; sin embargo, en la actualidad hay gran preocupación por el creciente rechazo a las vacunas de la infancia, además de otros obstáculos que no son fáciles de visualizar y que afectan las coberturas por vacunación. Se señalan múltiples factores intervinientes en los rechazos a una vacuna o a la vacunación en general por la acción de grupos antivacunas y por la desinformación o divulgación de datos erróneos. En algunos países, se agregan atrasos en el cumplimiento del esquema de inmunizaciones por posibles fallas en la gestión de los programas. Todo esto compromete el nivel efectivo de las coberturas de vacunación y constituye una seria amenaza para la salud pública. Las poblaciones susceptibles se modifican de manera constante por cambios epidemiológicos determinados por fenómenos como la globalización o diferentes conflictos que interfieren el accionar sanitario. En época reciente, se han registrado brotes de enfermedades antes controladas como la difteria, la tos ferina y el sarampión, ya sea por casos importados o por fallas en los programas nacionales de inmunización. Se intentó explorar distintos componentes que se suman a la frecuencia creciente de los rechazos a las vacunas, lo que obliga a una revisión de las causas y al diseño de estrategias y enfoques innovadores para recuperar la aceptación de la vacunación y su lugar como la herramienta más costo-efectiva en salud pública.

[ABSTRACT]. Vaccinating children has been an unquestioned tradition for many years. However, there is now great concern over the growing rejection of childhood vaccination, as well as other less evident obstacles that affect vaccination coverage. Multiple factors are involved in the rejection of a specific vaccine or vaccination in general, including actions by anti-vaccination groups, as well as disinformation or the dissemination of erroneous information. In some countries, delays in completing the immunization schedule may be due to poor program management. These factors compromise effective vaccination coverage, constituting a serious threat to public health. Susceptible populations constantly change, due to epidemiological shifts determined by phenomena such as globalization and various conflicts that interfere in the operation of health services. In recent years there have been outbreaks of previously controlled diseases such as diphtheria, whooping cough, and measles, resulting both from imported cases and from deficiencies in national immunization programs. This paper explores different aspects of the increasing frequency of vaccine rejection. There is a need for a review of its causes and for the design of innovative strategies and approaches to regain acceptance of vaccination and its place as the most cost-effective tool in public health.

[RESUMO]. Durante muitos anos, vacinar os filhos foi uma tradição inquestionável; atualmente, porém, há grande preocupação com a crescente recusa das vacinas da infância, além de outros obstáculos mais difíceis de visualizar que afetam a cobertura vacinal. Múltiplos fatores concorrem para influenciar a recusa a uma vacina específica ou à vacinação em geral, seja pela ação de grupos antivacina ou pela desinformação ou divulgação de dados incorretos. Em alguns países, a situação é complicada por atrasos no cumprimento do calendário vacinal devido a possíveis falhas na gestão dos programas. Tudo isso compromete o nível efetivo das coberturas de vacinação e constitui grave ameaça à saúde pública. As populações suscetíveis a doenças imunopreveníveis estão em constante mutação devido a mudanças epidemiológicas, determinadas por fenômenos como a globalização ou diferentes conflitos que interferem com as ações de saúde. Recentemente, foram registrados surtos de doenças antes controladas, como a difteria, a coqueluche e o sarampo, seja por casos importados ou por falhas nos programas nacionais de imunização. Este artigo visa explorar os diferentes componentes que contribuem para a frequência crescente da recusa vacinal, o que exige uma reanálise dos fatores causais e o delineamento de estratégias e enfoques inovadores para recuperar a aceitação das vacinas e de seu papel como a mais custo-efetiva das ferramentas em saúde pública.

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RESUMO

Resumen: Las vacunas conjugadas neumocóccicas (VCN) son efectivas para el control de las infecciones severas en niños y también limitan la colonización nasofaríngea por los serotipos que integran sus fórmulas. En Uruguay, no se dispone de publicaciones recientes sobre los serotipos albergados en el reservorio nasofaríngeo de los niños, ni antes ni luego de la introducción de las VCN. Con el objetivo de caracterizar la colonización nasofaríngea de niños menores de 2 años y describir los serotipos de S. pneumoniae identificados antes y después de la introducción de las vacunas conjugadas antineumocóccicas en el certificado esquema de vacunación (CEV) de Uruguay, se llevó a cabo un estudio descriptivo, retrospectivo, incluyendo tres períodos de tiempo: años 2002- 2003 y 2014-2015 en Paysandú, y 2012-2013 en Montevideo. Los aislamientos de S. pneumoniae se realizaron en laboratorios locales y la serotipificación por "quellung" se efectuó en el Departamento de Laboratorios de Salud Pública. Se procesaron 831 muestras, con 54,8% de recuperación de neumococos (n=456), de los cuales 223 fueron tipificados. El estudio previo a la vacunación mostró portación de serotipos invasores, con predominio de los serotipos 6A, 6B, 14 y 19F, todos incluidos en la vacuna 13-valente. En los niños de la policlínica de HIV, la colonización por neumococos invasores fue mucho menor, y el otro estudio, también posvacunación, evidenció la casi desaparición de cepas invasoras (6/93), con predominio de serotipos poco habituales, lo que constituyó un llamado de atención para instrumentar una vigilancia que monitorice la dinámica de la colonización infantil.

Summary: Pneumococcal conjugate vaccines (PCV) are effective against children's severe infections and they also constrain nasopharyngeal colonization due to the serotypes in their formulas. There are no recent publications in Uruguay regarding serotypes hosted in the children's nasopharyngeal reservoir, either from before or after the introduction of the PCV. With the purpose of characterizing nasopharyngeal colonization of children under 2 years of age and describing the S. pneumoniae serotypes before and after the pneumococcal conjugate vaccines in the Uruguayan National Vaccination Report, we carried out a descriptive retrospective study including three periods: 2002- 2003 and 2014-2015 in Paysandú, and 2012-2013 in Montevideo. S. pneumoniae was isolated in local laboratories and the "quellung" serotypification was carried out in the Laboratories of the Public Health Department. We processed 831 samples and recovered 54.8% pneumococci (n=456), of which 223 were typified. Prior to the vaccination, the study showed invasive serotype carriage, mainly of the 6A, 6B, 14 and 19F serotypes, all included in the 13-valent vaccine. At the HIV clinic, colonization from invasive pneumococci was much lower and the post vaccination study showed the almost complete disappearance of the invasive strains (6/93), mainly of the less common serotypes, which called the attention towards the increase of vigilance towards the monitoring of children colonization dynamics.

Resumo: As Vacinas Pneumocócicas Conjugadas (VPC) são eficazes contra infecções graves em crianças e também restringem a colonização nasofaríngea, devido aos sorotipos utilizados em suas fórmulas. Não há publicações recentes no Uruguai relativas aos sorotipos que incluem reservatório nasofaringeos nas crianças, nem de antes ou depois das vacinas VPN. Com o objetivo de caracterizar a colonização nasofaríngea de crianças menores de 2 anos de idade e descrevendo os sorotipos S. pneumoniae antes e depois das vacinas antipneumocócicas conjugadas no Relatório Nacional de Vacinação do Uruguai, realizou-se um estudo retrospectivo descritivo, incluindo três períodos: 2002- 2003 e 2014-2015 em Paysandú e 2012-2013 em Montevideo. S. pneumoniae foi isolada em laboratórios locais e a soro tipificação "quellung" foi realizada nos Laboratórios do Departamento de Saúde Pública. Foram processadas 831 amostras e recuperado 54,8% de pneumococo (n = 456), dos quais 223 foram tipificados. Antes da vacinação, o estudo mostrou transporte de sorotipos invasores, principalmente dos sorotipos 6A, 6B, 14, 19F, todos incluídos na vacina 13-valente. Na clínica de HIV, a colonização invasiva de pneumococos foi muito menor, e o estudo pós-vacinação mostrou o desaparecimento quase total das cepas invasivas (6/93), principalmente dos sorotipos menos comuns, o que sugere a necessidade de aumentar a vigilância no monitoramento da dinâmica de colonização de crianças.

RESUMO

La creciente resistencia a los antimicrobianos (RAM) es un problema apremiante que de no combatirse a tiempo puede comprometer la salud de las generaciones futuras, con un retorno a la era preantibiótica. Frente a esa amenaza, los organismos sanitarios internacionales convocaron a todos los países para coordinar renovadas estrategias de lucha contra la RAM, promoviendo el enfoque de "una salud" con la participación de diferentes actores e instituciones. Este manuscrito proporciona información actualizada, explicando que la RAM no es más un dilema médico sino un fenómeno complejo que además afecta la producción agroveterinaria, el desarrollo y la economía de los países. La exposición a antibióticos contribuye a la selección de mutantes resistentes y favorece la transferencia horizontal de elementos genéticos móviles como plásmidos, integrones y tranposones que portan varios genes de resistencia contra distintas familias de antibióticos. Las antibioticoterapias, aún en situaciones justificadas, ejercen presiones selectivas que favorecen el predominio de mutantes bacterianas resistentes, por lo que es preciso evitar las infecciones, optimizando la higiene y el empleo de vacunas. También se ensayan terapias alternativas, por ejemplo basadas en bacteriófagos o probióticos. El Plan de Acción Mundial para controlar la RAM propuesto por la Organización Mundial de la Salud, la Organización Mundial de Salud Animal y la Organización de las Naciones Unidas para la Alimentación y el Desarrollo comprende cinco objetivos: mejorar la conciencia y el conocimiento sobre la resistencia antimicrobiana; reforzar la vigilancia y la investigación; reducir la incidencia de la infección; optimizar el uso de antimicrobianos, y asegurar una financiación duradera que asegure la persistencia de las acciones de control.

The recent increase of antimicrobial resistance is a compelling problem that may compromise the health of future generations and result in us going back to the pre-antibiotic era, unless it is battled on time. In order to face this threat, global health organizations called countries to articulate new strategies to fight against antimicrobial resistance, by encouraging them to adopt a health centered approach that involves different actors and institutions. This report provides updated information, explaining the reasons why antimicrobial resistance is no longer a medical dilemma but rather a complex phenomenon that also affects agricultural and livestock production and the development and economy of countries. Antibiotic exposure contributes to the selection of resistant mutants and favors the horizontal transference of mobile genetic elements (MGE) such as plasmids, integrons and transposons, which carry several resistance genes against antibiotic families. Antibiotic therapy, still in justified situations, exerts selective pressure that favors the predominance of resistant bacteria mutants, and thus infections need to be avoided by optimizing hygiene conditions and relying on immunization. Also, alternative therapies are tried, as those based on bacteriophagists or probiotics. The Global Action Plan proposed by theWHO, theWorld Organization for Animal Health and the FAO to control antimicrobial resistance comprises five goals: to improve awareness and knowledge on antimicrobial resistance; to strengthen surveillance and research; to reduce the incidence of infection; to optimize the use of antimicrobial agents and to ensure a lasting funding that guarantees the continuation of control actions.

A crescente resistência aos antimicrobianos (RAM) é um problema grave que, se não for combatido rapidamente, pode comprometer a saúde das próximas gerações, com um retorno à era pré-antibiótica. Considerando esta ameaça, os organismos sanitários internacionais convocaram todos os países para coordenar novas estratégias de luta contra a RAM, promovendo um enfoque de saúde, com a participação de diferentes atores e instituições. Este manuscrito proporciona informação atualizada, explicando que a RAM não é mais um dilema médico, mas um fenómeno complexo que afeta também a produção agro veterinária, o desenvolvimento e a economia dos países. A exposição a antibióticos contribui para a seleção demutantes resistentes e favorece a transferência horizontal de elementos genéticos móviles como plasmídeos, integrons e tranposons que portam vários genes de resistência contra distintas famílias de antibióticos. As antibioticoterapias, mesmo emsituações justificadas, exercem pressões seletivas que favorecem o predomínio de mutantes bacterianos resistentes, e, portanto é preciso evitar as infeções, otimizando a higiene e o uso de vacinas. Também foram feitos ensaios com terapias alternativas, por exemplo, baseadas em bacteriófagos ou probióticos. O Plano de Ação Mundial para controlar a RAM, proposto pela OMS, OIE e FAO compreende cinco objetivos:melhorar a consciência e o conhecimento sobre resistência antimicrobiana; reforçar a vigilância e a pesquisa; reduzir a incidência das infecções; otimizar o uso de antimicrobianos, e garantir um financiamento duradouro que assegure a persistência das ações de controle.

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A fines del siglo XX, una gran diversidad de factores contribuyeron a la aparición de enfermedades infecciosas emergentes, con importante impacto en la salud pública. Estas enfermedades, en general, se caracterizan por ser de reciente aparición, provocar una inusual incidencia en una población o área geográfica, o reaparecer luego de haber cesado su actividad por largo tiempo(1). Algunas enfermedades emergentes, como VIH/SIDA, persisten por años, en tanto que otras, luego de su aparición, duran períodos limitados. Múltiples factores, además del agente infeccioso, intervienen en el complejo proceso que determina la emergencia de enfermedades infecciosas. Constantemente, miles de microorganismos potencialmente patógenos se diseminan en nuevas áreas geográficas, pero solo unos pocos llegan a sobrevivir y causar enfermedades, favorecidos por condicionantes socioeconómicas, ambientales y ecológicas. Este fenómeno mundial requiere una vigilancia epidemiológica constante, con una infraestructura nacional y regional que asegure una alerta temprana frente a la emergencia o reemergencia de esas enfermedades.

In the late 20th century, several different factors contributed to the appearance of emerging infectious diseases that had a great impact on public health. In general, these diseases are characterized by appearing for the first time, they rapidly increase in incidence in certain populations or geographical area, or they have been known for some time although they have disappeared for a long time. A few infectious diseases like HIV/AIDS have persisted for several years, while others, after appearing, last limited periods of time. Multiple factors, apart from the infectious agent, take part in the complex process that results in the emergence of an infectious disease. Thousands of potentially pathogenic microorganisms are constantly disseminated in new geographical areas, although just a few manage to survive and cause diseases, favored by social, economic, environment and ecologic factors. This global phenomenon requires continuous epidemiological surveillance, with a national and regional infrastructure that enables an early alert upon these diseases that emerge or re-emerge.

No final do século XX, muitos fatores diferentes contribuíram para o surgimento de doenças infecciosas emergentes, com importante impacto sobre a saúde pública. De maneira geral, estas doenças se caracterizam por haver surgido recentemente, provocar uma incidência pouco comum em uma população ou área geográfica, ou reaparecer depois de haver cessado sua atividade por um tempo prolongado (1). Algumas doenças emergentes, como VIH/SIDA, persistem por anos, enquanto outras têm uma duração limitada. Além do agente infeccioso, muitos outros fatores intervêm no complexo processo que determina o surgimento de doenças infecciosas. Constantemente, milhares de micro-organismos potencialmente patógenos se disseminam em novas áreas geográficas, mas somente poucos são capazes de sobreviver e causar doenças, favorecidos por condicionantes socioeconômicos, ambientais e ecológicos. Este fenômeno mundial requer uma vigilância epidemiológica constante, com una infraestrutura nacional e regional que garanta um alerta precoce frente à emergência ou reemergência de essas doenças.

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BACKGROUND: Data on the burden of pneumococcal disease and the most frequent serotypes demonstrated that invasive disease and pneumonia were important manifestations affecting children under 5 years of age. Therefore, pneumococcal diseases prevention became a public health priority. Uruguay was the first Latin American country to incorporate PCV7 into its National Immunization Program. The aim of this study is to compare the incidence rates for hospitalized pneumonia in children from the pre PCV introduction period and the following five years of PCVs application in Uruguay. METHODS AND FINDINGS: Population-based surveillance of pneumonia hospitalization rates, in children, less than 14 years of age, had been performed prior pneumococcal vaccination, and continued following PCV7 introduction and PCV13 replacement, using the same methodology. Hospitalized children with pneumonia were enrolled from January 1, 2009 through December 31st, 2012. The study was carried out in an area with a population of 238,002 inhabitants of whom 18, 055 were under five years of age. Patients with acute lower respiratory infections for whom a chest radiograph was performed on admission were eligible. Digitalized radiographs were interpreted by a reference radiologist, using WHO criteria. Pneumonia was confirmed in 2,697 patients, 1,267 with consolidated and 1,430 with non consolidated pneumonia of which incidence decrease, between 2009 and 2012, was 27.3% and 46.4% respectively. 2001-2004 and 2009-2012 comparison showed a significant difference of 20.4% for consolidated pneumonia hospitalizations. A significant incidence decline was recorded among children 6 to 35 months of age. CONCLUSIONS: An overall significant reduction in pneumonia hospitalizations was observed following the introduction of PCV7 and furthermore following the change to PCV13.

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INTRODUCTION: Streptococcus pneumoniae pneumonia burden in children was poorly defined in Uruguay. A three-year population-based surveillance demonstrated the impact of the pneumonia in hospitalized children of less than five years of age. To control these diseases in March 2008, Uruguayan health authorities decided to incorporate PCV7 to the National Immunization Program administered at 2, 4 and 12 months of age (2+1 schedule). OBJECTIVE: To compare the incidence of consolidated pneumonia hospitalization in children less than five years of age before and after pneumococcal conjugate vaccine implementation. METHODS: Same methodology of the prevaccination study was employed. The surveillance was carried out at the same four hospitals covering a population of 229,128 inhabitants (2004 Census) of whom 10.2% were under five years of age. Clinical data, vaccination status and digitization of their chest X-rays were recorded. A pediatric radiologist blinded to the clinical diagnosis interpreted the digital images according WHO definitions. Bacterial etiology was investigated in blood and/or in pleural fluid. RESULTS: Between January 1st 2009 and June 30th 2011 patients were enrolled. Out of 23,445 children<5 years of age, 1224 were hospitalized with pneumonia (430 consolidated pneumonias and 794 non consolidated pneumonias). Pleural effusion was recorded in 89 patients. In 48 consolidated pneumonias S. pneumoniae etiology was recognized. Post vaccination incidence rate of consolidated pneumonia in patients aged 12-23 months showed a significant reduction (44.9%) if we compare it with the incidence of pneumonia hospitalization in the previous study. In March 2010, PCV13 replaced PCV7. Compliance of PCV7/13 globally was 92% but the vaccination status varied among the surveyed patients because two catch-ups were carried out in addition to the routine cohort vaccination. From 2009 1st semester to 2011 1st semester incidence rates decline reached 59%. CONCLUSION: To date, the ongoing surveillance documented a significant decline on incidence of hospitalizations for consolidated pneumonia in children younger than 24 months of age, confirming the success of the 2+1 vaccination schedule.

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Introducción: en el Centro Hospitalario Pereira Rossell se registró un aumento progresivo de gestantes y recién nacidos (RN) con prueba de detección para sífilis (VDRL) reactivos. Frentea esa situación el Programa Nacional de Salud de la Niñez realizó una investigación para identificar los factores contribuyentes a la ocurrencia de sífilis congénita (SC) medianteauditorías de historias clínicas.Material y método: es un trabajo descriptivo cuya fuente de datos fueron la historia clínica del binomio madre-hijo complementada por el interrogatorio a madres y médicos tratantes. En cuatro meses de auditoría (octubre 2007 - enero 2008) se identificaron a todos los RN con VDRL reactivos y sus madres. La información se incorporó a una base de datos en EpiInfo 6.4. Resultados: se captaron 58 RN correspondientes a 56 madres. Los antecedentes maternospermitieron considerar la reactividad serológica de 12 RN como un recuerdo inmunológico. Diez gestantes infectadas no tuvieron controles prenatales y en otras 12 se comprobó la infección pero no fueron tratadas. Se infectaron o reinfectaron en el último trimestre 24(52,2%) de las gestantes. Relataron episodios de sífilis anteriores 41,9% y problemas tales como abortos, óbitos, bajo peso. Cinco de los RN presentaron manifestaciones clínicas o paraclínicas de SC. Estos y los RN con SC probable recibieron penicilina durante diez días.Los servicios responsables no lograron captar las parejas sexuales y sólo notificaron 44% de las SC.Conclusiones: las auditorías ampliaron la información, evidenciando debilidades en los registros, fallas en los controles prenatales, frecuencia de reinfecciones y subnotificación de los casos de SC.

Introduction: a progressive increase in VDRL positive pregnant women and newborns was registered at thePereira Rossell Hospital Center. For this reason the Programa Nacional de Salud de la Niñez (ChildrenÆs Health National Programme) conducted research to identify the factors that contribute to congenital syphilis by auditing medical histories. Method: we conducted a descriptive study based on the information arising from the mother-child binomial medical record and on interviews to mothers and treatingdoctors. For four months (October 2007-January 2008) we identified all VDRL positive newborns and their mothers.Data were analyzed with EpiInfo 6.4. software. Results: we found 58 newborns that corresponded to56 mothers. Maternal precedents led us to consider serologic activity in 12 newborns as an immune memory. Tenpregnant women had no prenatal controls and infection was proved in other 12 women, although they were nottreated. 24 (52.2%) were infected or re-infected in the last trimester. 41.9% informed about previous episodes ofsyphilis and problems such as abortions, fetal death or low weight. Five newborns presented clinical or para-clinical manifestations of congenital syphilis. The latter and the newborns with probable congenital syphilis weretreated with penicillin for ten days. Responsible services failed to reach sexual partners and only reported 44% of congenital syphilis. Conclusions: audits provided more information, evidencing weaknesses in records, failures in prenatal controls, re-infection frequency and the fact that CS is underreported.

Introdução: no Centro Hospitalar Pereira Rossell foi registrado um aumento progressivo de gestantes e recémnascidos (RN) com exames para diagnóstico de sífilis (VDRL) positivos. Por essa razão o Programa Nacional deSaúde da Criança realizou uma auditoria de prontuários de pacientes para identificar os fatores que favoreciam oaparecimento de casos de sífilis congênita (SC). Material e método: este é um estudo descritivo realizado com dados obtidos dos prontuários de paciente do binômio mãe-filho complementada com perguntas realizadas a mães e médicos. Foram identificados todos os RN com VDRL positivos e suas mães durante os quatro meses de auditoria (outubro 2007 - janeiro 2008). Os dados foram registrados em uma base de dados no programa EpiInfo 6.4. Resultados: foram identificados 58 RN correspondentesa 56 mães. Os antecedentes maternos possibilitaram considerar a reação sorológica de 12 RN como memóriaimunológica. Dez gestantes portadoras de sífilis não haviam realizado controles pré-natais e em outras 12 a infecção foi diagnosticada, porém não foram tratadas. Vinte e quatro gestantes (52,2%) foram infectadas ou reinfectadas no último trimestre de gestação. 41,9% informaram episódios anteriores de sífilis e problemas como abortos, mortes e baixo peso. Cinco RN apresentaram manifestações clínicas ou laboratoriais de SC. Estes RN e os que eram portadores prováveis de SC foram tratados com penicilina durante 10 dias. Os serviços de saúde não puderam captar os parceiros sexuais e somente 44% deles foram notificados.Conclusões: as auditorias permitiram ter acesso a mais informação mostrando debilidades nos registros, falhas nos controles pré-natais, freqüência de reinfecções e subnotificação de casos de SC.

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Introducción: en el Centro Hospitalario Pereira Rossell se registró un aumento progresivo de gestantes y recién nacidos (RN) con prueba de detección para sífilis (VDRL) reactivos. Frentea esa situación el Programa Nacional de Salud de la Niñez realizó una investigación para identificar los factores contribuyentes a la ocurrencia de sífilis congénita (SC) medianteauditorías de historias clínicas.Material y método: es un trabajo descriptivo cuya fuente de datos fueron la historia clínica del binomio madre-hijo complementada por el interrogatorio a madres y médicos tratantes. En cuatro meses de auditoría (octubre 2007 - enero 2008) se identificaron a todos los RN con VDRL reactivos y sus madres. La información se incorporó a una base de datos en EpiInfo 6.4. Resultados: se captaron 58 RN correspondientes a 56 madres. Los antecedentes maternospermitieron considerar la reactividad serológica de 12 RN como un recuerdo inmunológico. Diez gestantes infectadas no tuvieron controles prenatales y en otras 12 se comprobó la infección pero no fueron tratadas. Se infectaron o reinfectaron en el último trimestre 24(52,2%) de las gestantes. Relataron episodios de sífilis anteriores 41,9% y problemas tales como abortos, óbitos, bajo peso. Cinco de los RN presentaron manifestaciones clínicas o paraclínicas de SC. Estos y los RN con SC probable recibieron penicilina durante diez días.Los servicios responsables no lograron captar las parejas sexuales y sólo notificaron 44% de las SC.Conclusiones: las auditorías ampliaron la información, evidenciando debilidades en los registros, fallas en los controles prenatales, frecuencia de reinfecciones y subnotificación de los casos de SC.(AU)

Introduction: a progressive increase in VDRL positive pregnant women and newborns was registered at thePereira Rossell Hospital Center. For this reason the Programa Nacional de Salud de la Niñez (Childrenãs Health National Programme) conducted research to identify the factors that contribute to congenital syphilis by auditing medical histories. Method: we conducted a descriptive study based on the information arising from the mother-child binomial medical record and on interviews to mothers and treatingdoctors. For four months (October 2007-January 2008) we identified all VDRL positive newborns and their mothers.Data were analyzed with EpiInfo 6.4. software. Results: we found 58 newborns that corresponded to56 mothers. Maternal precedents led us to consider serologic activity in 12 newborns as an immune memory. Tenpregnant women had no prenatal controls and infection was proved in other 12 women, although they were nottreated. 24 (52.2%) were infected or re-infected in the last trimester. 41.9% informed about previous episodes ofsyphilis and problems such as abortions, fetal death or low weight. Five newborns presented clinical or para-clinical manifestations of congenital syphilis. The latter and the newborns with probable congenital syphilis weretreated with penicillin for ten days. Responsible services failed to reach sexual partners and only reported 44% of congenital syphilis. Conclusions: audits provided more information, evidencing weaknesses in records, failures in prenatal controls, re-infection frequency and the fact that CS is underreported.(AU)

Introdução: no Centro Hospitalar Pereira Rossell foi registrado um aumento progressivo de gestantes e recémnascidos (RN) com exames para diagnóstico de sífilis (VDRL) positivos. Por essa razão o Programa Nacional deSaúde da Criança realizou uma auditoria de prontuários de pacientes para identificar os fatores que favoreciam oaparecimento de casos de sífilis congênita (SC). Material e método: este é um estudo descritivo realizado com dados obtidos dos prontuários de paciente do binômio mãe-filho complementada com perguntas realizadas a mães e médicos. Foram identificados todos os RN com VDRL positivos e suas mães durante os quatro meses de auditoria (outubro 2007 - janeiro 2008). Os dados foram registrados em uma base de dados no programa EpiInfo 6.4. Resultados: foram identificados 58 RN correspondentesa 56 mães. Os antecedentes maternos possibilitaram considerar a reação sorológica de 12 RN como memóriaimunológica. Dez gestantes portadoras de sífilis não haviam realizado controles pré-natais e em outras 12 a infecção foi diagnosticada, porém não foram tratadas. Vinte e quatro gestantes (52,2%) foram infectadas ou reinfectadas no último trimestre de gestação. 41,9% informaram episódios anteriores de sífilis e problemas como abortos, mortes e baixo peso. Cinco RN apresentaram manifestações clínicas ou laboratoriais de SC. Estes RN e os que eram portadores prováveis de SC foram tratados com penicilina durante 10 dias. Os serviços de saúde não puderam captar os parceiros sexuais e somente 44% deles foram notificados.Conclusões: as auditorias permitiram ter acesso a mais informação mostrando debilidades nos registros, falhas nos controles pré-natais, freqüência de reinfecções e subnotificação de casos de SC.(AU)

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OBJETIVO. Determinar la evolución de la resistencia a la eritromicina, el cloranfenicol, el trimetoprim-sulfametozaxol (SXT) y la vancomicina de aislamientos invasores de Streptococcus pneumoniae obtenidos de niños de 10 países de América Latina y del Caribe en seis años de vigilancia. MÉTODOS. Se analizaron 8 993 aislamientos de S. pneumoniae recuperados entre 2000 y 2005 de niños menores de 6 años con infecciones invasoras, procedentes de Argentina, Brasil, Chile, Colombia, Cuba, México, Paraguay, República Dominicana, Uruguay y Venezuela. La sensibilidad a los antibióticos se determinó mediante los métodos establecidos y estandarizados en el proyecto SIREVA. La resistencia a múltiples antibióticos se definió como la resistencia a tres o más familias de antibióticos, de los no betalactámicos analizados en este estudio o de los betalactámicos evaluados en un estudio previo en el que 37,8% de estos aislamientos presentaron sensibilidad disminuida a la penicilina. RESULTADOS. Se encontró algún grado de resistencia al SXT y la eritromicina (56,4% y 15,4% de los aislamientos estudiados, respectivamente) y 4,6% presentó alta resistencia al cloranfenicol. Todos los aislamientos fueron sensibles a la vancomicina. Se observó la mayor frecuencia de resistencia al SXT en los aislamientos de neumonía y a la eritromicina en los casos de sepsis (61,6% y 25,5%, respectivamente; P < 0,01). La mayor frecuencia de resistencia al SXT se observó en Brasil (71,9%) y a la eritromicina en México (38,2%) y Venezuela (32,9%). Los serotipos 14, 6B, 19F y 23F fueron los que más frecuentemente se asociaron con la resistencia a los antibióticos estudiados. CONCLUSIONES. Se observó una elevada y creciente frecuencia de aislamientos resistentes al SXT y la eritromicina, y una disminución en la proporción de aislamientos resistentes al cloranfenicol. Estas tendencias mostraron diferencias entre los países estudiados.

OBJECTIVE. To examine the development of resistance to erythromycin, chloramphenicol, trimethoprim-sulfamethoxazole (TMP-SMZ), and vancomycin of the invasive isolates of Streptococcus pneumoniae obtained from children in 10 Latin American/Caribbean countries during six years of surveillance. METHODS. Analysis of 8 993 isolates of S. pneumoniae recovered in 2000­2005 from children with invasive infections, who were less than 6 years of age, and from Argentina, Brazil, Chile, Colombia, Cuba, Dominican Republic, Mexico, Paraguay, Uruguay, or Venezuela. Antibiotic susceptibility was determined through the methods established and standardized by the SIREVA project. Multidrug resistance was defined as: resistance to three or more antibiotics of the same class; to the non-beta-lactams analyzed by this study; or, to the beta-lactams evaluated by a previous study, in which 37.8% of these isolates showed decreased susceptibility to penicillin. RESULTS. Some degree of resistance was found to TMP-SMZ and erythromycin (56.4% and 15.4% of the isolates studied, respectively), with 4.6% highly resistant to chloramphenicol. All isolates were susceptible to vancomycin. The highest prevalence of TMP-SMZ resistance was observed in the pneumonia isolates; and that of erythromycin, in cases of sepsis (61.6% and 25.5%, respectively; P < 0.01). The highest prevalence of TMP-SMZ resistance was found in Brazil (71.9%), and that of erythromycin, in Mexico (38.2%) and Venezuela (32.9%). The 14, 6B, 19F, and 23F serotypes were most often associated with resistance to the antibiotics in the study. CONCLUSIONS. High and increasing rates of isolates resistant to TMP-SMZ and erythromycin were observed, as well as a decreasing percentage of isolates resistant to chloramphenicol. These trends highlight differences among the countries studied

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OBJECTIVES: To provide information on pneumococcal pneumonias, on their associated serotypes, and to estimate the coverage potentially afforded by antipneumococcal vaccines. STUDY DESIGN: A retrospective study (2000 to 2004) was performed of patients with pneumococcal pneumonia aged 0 to 14 years admitted to the National Reference Children's Hospital in Uruguay. Selected clinical data, radiographic interpretation, and microbiologic reports were obtained for analysis. RESULTS: Of 410 enrolled patients, 384 had consolidated pneumonia/pleural effusion and 26 had infiltrates without consolidation: Pneumococcus was identified in blood or in pleural fluid of 387 patients; 21 serotypes were identified. The most frequent serotypes in decreasing order were serotypes 14, 1, 5, 3, 9V, 6B, and 7F. Forty-eight percent of invasive Streptococcus pneumoniae isolates were obtained from children younger than 24 months. For this group, the 7-valent vaccine would cover 60%, but a 10-valent vaccine would cover 83.8%. CONCLUSIONS: This study provides information on pneumonia of proven S. pneumoniae causes and their associated serotypes, enabling estimation of potential effect of pneumococcal conjugate vaccines.

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BACKGROUND: Population-based studies on childhood community-acquired pneumonia are scarce in Latin America. Pneumococcal epidemiology is poorly defined, hence the World Health Organization recommended standardized chest radiograph interpretation to improve the approach to bacterial pneumonia. Therefore, our study aimed to estimate the burden of pneumonia in hospitalized children. METHODS: A three-year surveillance study was carried out in four hospitals covering a population of 229,128 inhabitants of whom 10.2% were under five years of age. Clinical records and digitization of their chest radiographs were obtained. A pediatrician and a pediatric radiologist blinded to the clinical diagnosis interpreted the digital images. RESULTS: Of 2034 patients, 826 (40.6%) had consolidated pneumonia, 941 (46.3%) had non-consolidated pneumonia, and 267 (13.1%) had no pneumonia. Children under two years of age predominated (66.9%). The average annual incidence rate for consolidated pneumonia over the three-year study period was 1175/10(5). Eighteen invasive Streptococcus pneumoniae were isolated from patients with consolidated pneumonia and two from those with non-consolidated pneumonia. Respiratory syncytial virus was evenly distributed between both X-ray groups. CONCLUSIONS: Patients younger than two years of age predominated, being the main targets for anti-pneumococcal conjugated vaccines. Incidence rates provided evidence of the burden of consolidated pneumonia for childhood, estimating the potential benefits of vaccination.

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Resumen Objetivos: determinar la demanda de atención de las infecciones respiratorias agudas (IRA) en el Departamento de Emergencia (DEP), y dentro de éstas analizar la frecuencia y manejo terapéutico de las neumonías adquiridas en la comunidad que se hospitalizan y aquellas que reciben tratamiento ambulatorio. Material y método: se realizó un estudio descriptivo: prospectivo de registro de consultas por IRA en los diferentes sectores del DEP y retrospectivo de revisión de historias de neumonías. Se incluyeron historias consecutivas de casos ocurridos en tres trimestres de verano y tres de invierno entre 2001 y 2003. Se analizó su frecuencia según edad, sexo, procedencia, características radiográficas y manejo hospitalizado o ambulatorio. Resultados: en el DEP se registró un promedio anual de 59.812 pacientes, de los cuales 31,2% cursaban algún tipo de IRA, correspondiendo 85,9% a infecciones altas y 14,1% a bajas. De éstas, se analizaron 2.053 historias de neumonía. La media de edad fue de tres años. La mayoría de los pacientes que residían en la capital o en su área de influencia (96,3%) fueron tratados ambulatoriamente (61,0%). La decisión de hospitalización se realizó en todos los casos de neumonía con derrame, en 34,8% de los pacientes con consolidación radiológica y en 24,8% de los pacientes con infiltrados. Se indicaron antibióticos en 87,4% de los casos. Conclusiones: las IRA y las neumonías representaron una demanda de atención importante, pero la mayoría de las neumonías, inclusive las con consolidación parenquimatosa, fueron tratadas ambulatoriamente. Futuros estudios confirmarán la efectividad de esos tratamientos, y el costo-efectividad de vacunas antineumococo.

Summary Objectives: to determine the demand of acute respiratory tract infections in the emergency department and analyze its frequency, treatment and the need of hospitalization. Methods: a descriptive prospective study registering respiratory tract infections consults at the emergency department was realized. A retrospective review analizing previous stories of pneumonias was also done. Consecutive cases which occured in three summers and winters trimesters between 2001 and 2003 were included. Frequency according to age, sex, chest x-ray characteristics, patients origin and management either ambulatory or hospitalized were analyzed. Results: in the emergency department there are 59.812 consultations anually, 31,2% had respiratory tract infections. 85,9% were upper tract infections and 14,1% were from the lower tract. 2.053 pneumonia stories were analyzed. The medium age was 3 years old. Most patients who resided at the urban area or its surroundings (96,3%) were treated ambulatory (61%). Hospitalized patients included all patients with pleural fluid; 34% who had in the chest x-ray a consolidated image and in 24,8% who had a diffuse infiltrate. Antibiotics were administered in 87,4% of the cases. Conclusions: pneumonias and respiratory tract infections represent an important demand but the majority even with a consolidated image were treated at home. Future studies are needed in order to conclude the effectiveness of the treatment and the benefits from the pneumococcal vaccine.

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Streptococcus pneumoniae serotype 5 is the third most common capsular type causing invasive diseases in children younger than 5 years in Latin America. Preliminary data on Colombian serotype 5 isolates indicated a common clonal origin associated with resistance to tetracycline (TET) and chloramphenicol (CHL). We studied 172 S. pneumoniae serotype 5 invasive isolates from Argentina, Brazil, Colombia, Guatemala, Mexico, and Uruguay and confirmed the presence of the Colombia(5)-19 clone throughout Latin America. Fifteen subtypes of a pulsed-field gel electrophoresis pattern and 4 electrophoretic types (ET) were obtained. Most of the isolates from different geographical regions belonged to pattern A (34.3%), subtype A5 (41.9%), and ET1 (91.1%). The A pattern (n = 59) was resistant to TET and had variable resistance to CHL; it was present in Brazil (10.2%), Colombia (78%), Guatemala (8.5%), and Mexico (3.4%). Subtype A5 with variable susceptibility to TET and sensitive to CHL was found in Argentina (29.2%), Mexico (8.3%), and Uruguay (62.5%). Subtypes A1-A4, A7-A8, and A9-A11 (closely related to A) also shared ET1, while subtype A6 was assigned to ET1, ET2, and ET3. Eleven subtypes (n = 21) were found to be specific for one country each. In summary, the S. pneumoniae serotype 5 isolates from Latin American are genetically closely related but show different patterns of antibiotic resistance, probably as a result of horizontal transfer.

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Muchas de las enfermedades prevalentes de la infancia han sido controladas con vacunas, y otras se encuentran en vías de lograrlo. El laboratorio de bacteriología tiene un papel fundamental en la caracterización feno y genotípica de las bacterias, contribuyendo con una vigilancia microbiológica antes y después de la aplicación de una vacuna. Por ese motivo, se revisó la información generada en el Departamento de Laboratorios de Salud Pública en relación a Haemophilus influenzae b, Neisseria meningitidis B y C, y Streptococcus pneumoniae, Aunque H. influenzae b es el patógeno dominante dentro de la especie, igualmente se realizaron estudios para su caracterización. La identificación y frecuencia de los aislamientos de N, meningitidis B y C resultaron fundamentales para decidir intervenciones con vacunas. La serotipificacion de los S. pneumoniae aislados de niños con neumococcias invasoras permitió determinar las potenciales coberturas que proporcionarían las fórmulas de las vacunas conjugadas, y también otras con antígenos proteicos. Los datos consignados confirman la necesidad de mantener la vigilancia microbiológica de las infecciones controladas con vacunas

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La neumonia adquirida en la comunidad es una de las principales causas de morbilidad y mortalidad en la infancia. Estudios realizados en paises en desarrollo indican que los cuadros de neumonia mas graves se asocian a causas bacterianas, con predominio de Streptococcus pneumoniae, seguido por Haemophilus influenzae tipo b. El manejo de esas infecciones en los menores de 2 años se ve dificultado por la carencia de vacunas apropiadas y por la disminucion de la susceptibilidad de S. pneumoniae a la penicilina y a otros antibioticos. En 1993, por iniciativa del Sistema Regional de Vacunas (SIREVA) de la Organizacion Panamericana de la Salud y con la financiacion de la Agencia Canadiense para el Desarrollo Internacional (Canadian International Development Agency: (CIDA), se diseño un estudio para identificar los tipos capsulares de S. pneumoniae que causan enfermedad invasora en los niños latinoamericanos menores de 5 años, con el proposito de determinar tanto la composicion ideal de una vacuna conjugada que pudiera emplearse en la Region como la susceptibilidad a la penicilina de los aislados de S. pneumoniae. La iniciativa fue aceptada por Argentina, Brasil, Colombia, Chile, Mexico y Uruguay. En este informe se analiza la informacion sobre la neumonia por S. pneumoniae generada en los paises participantes. Se captaron 3.393 niños con infecciones sistemicas por S. pneumoniae, de las cuales 1.578 correspondian a neumonias. El analisis se concentro en los 1.409 casos de neumonia de Argentina, Brasil, Colombia, Mexico y Uruguay. La distribucion por edades evidencio un franco predominio de los menores de 2 años (63.8 por ciento). Se identificaron 12 tipos capsulares prevalentes, de los cuales los serotipos 14, 5 y 1 ocuparon los tres primeros lugares en la mayoria de los paises

Community-acquired pneumonia is one of the leading causes of infant morbidity and mortality. Studies conducted in developing countries indicate that the most serious symptoms of pneumonia are associated with bacterial causes, mainly Streptococcus pneumoniae, followed by Haemophilus influenzae type b. Managing those infections in children under two years of age is hindered by the lack of appropriate vaccines and by the decreased susceptibility of S. pneumoniae to penicillin and other antibiotics. In 1993, at the initiative of the Regional System for Vaccines of the Pan American Health Organization, and with funding from the Canadian International Development Agency, a study was designed to identify the S. pneumoniae capsular types that cause invasive disease in Latin American children under 5 years of age. The objective of the study was to determine the ideal composition of a conjugate vaccine that could be used in Latin America, and the penicillin susceptibility of the S. pneumoniae isolates. The initiative was undertaken in Argentina, Brazil, Chile, Colombia, Mexico, and Uruguay. This report analyzes the information that the participating countries generated on pneumococcal pneumonia. A total of 3 393 children were found with systemic S. pneumoniae infections, of which 1 578 corresponded to pneumonias. The analysis focused on 1 409 cases of pneumonia in Argentina, Brazil, Colombia, Mexico, and Uruguay. Of the children, 63.8% of them were under two years of age. Twelve prevalent capsular types were identified, of which serotypes 14, 5, and 1 were the three most common in the majority of the countries. At the beginning of the study the highest level of penicillin resistance was found in Mexico (47.0%), and the lowest in Colombia (12.1%). Over the 1993­1998 period, resistance to penicillin increased in the five countries. Penicillin resistance was associated with a small number of capsular serotypes, mainly 14 and 23F. The first of those serotypes was resistant to penicillin and to trimethoprim-sulfamethoxazole, and the second was multiresistant. The frequency of resistance to trimethoprim-sulfamethoxazole was high in all of the countries; Argentina had the highest level, 58.0%. A decrease in susceptibility to chloramphenicol was uncommon, except in Colombia, where there was a resistance level of 23.4%. Resistance to erythromycin was low in all the countries, and all the isolates were susceptible to vancomycin.

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