Submitted by Marlene Santos (marlene.bc.ufg@gmail.com) on 2016-04-20T19:18:23Z No. of bitstreams: 2 Tese - Eliane Terezinha Afonso - 2015.pdf: 3480407 bytes, checksum: db146d8884a4aedac166a73ef268d89d (MD5) license_rdf: 19874 bytes, checksum: 38cb62ef53e6f513db2fb7e337df6485 (MD5) / Approved for entry into archive by Luciana Ferreira (lucgeral@gmail.com) on 2016-04-25T15:00:31Z (GMT) No. of bitstreams: 2 Tese - Eliane Terezinha Afonso - 2015.pdf: 3480407 bytes, checksum: db146d8884a4aedac166a73ef268d89d (MD5) license_rdf: 19874 bytes, checksum: 38cb62ef53e6f513db2fb7e337df6485 (MD5) / Made available in DSpace on 2016-04-25T15:00:31Z (GMT). No. of bitstreams: 2 Tese - Eliane Terezinha Afonso - 2015.pdf: 3480407 bytes, checksum: db146d8884a4aedac166a73ef268d89d (MD5) license_rdf: 19874 bytes, checksum: 38cb62ef53e6f513db2fb7e337df6485 (MD5) Previous issue date: 2015-08-19 / BACKGROUND: Pneumonia causes substantial morbidity and mortality in all age groups around the world. The 10-valent pneumococcal conjugate vaccine (PCV10) was introduced into the routine infant immunization in Brazil, free of charge, in March 2010. The aim of this study was to evaluate the impact PCV10 vaccination on rates of all cause pneumonia hospitalizations one year and three years after its introduction in Brazil. METHODS: We conducted two interrupted time series analysis studies. The first evaluated only the direct effect of PCV10 vaccination, in five Brazilian cities (Belo Horizonte, Curitiba, Porto Alegre, São Paulo and Recife), and was conducted one year after starting the vaccination. The second study evaluated the direct and indirect impact (individuals not vaccinated) of PCV10 vaccination in Brazil, and was conducted three years after vaccination. We used data from the Brazilian Hospitalization System from 2005-2013. The main outcome was monthly rates of all-cause pneumonia hospitalizations identified by ICD-10 codes J12-J18. We used hospitalization rates for congenital malformations and non-respiratory causes as a comparison groups. The time-series analysis was based on a generalized linear model. Pneumonia rates observed in the pre-vaccination period were used to estimate the hospitalization rates in the post-vaccination period of each study, adjusting for seasonality and secular trends. To estimate the direct (2-23 months of age) and indirect (≥5 years of age) impact of PCV10 vaccination, we calculated the percentage change in hospitalization rates, as the observed divided by the predicted rates of hospitalization in the post-intervention period minus one, with respective 95% CI and p values. The number of all-cause pneumonia hospitalizations averted by vaccination was calculated taking into account the difference between the predicted and observed number in the PCV10 post vaccination period. RESULTS: One year after introduction of PCV10 in Brazil, significant declines in hospitalizations for pneumonia in children aged 2-23 months were noted in Belo Horizonte (28.7%), Curitiba (23.3%), and Recife (27.4%). After three years of the introduction of PCV10, 461,519 pneumonia hospitalizations were averted in Brazil, and a significant decrease in rates of pneumonia hospitalization was observed in unvaccinated individuals aged 5-39 years, ranging from 14.1-17.4% (p<0.05). In contrast, an increased trend in pneumonia hospitalizations (p=0·004) was observed for elderly (≥ 65 years). CONCLUSION: Vaccination with PCV10 in Brazil was associated with reduction of pneumonia hospitalizations in vaccinated individuals. Herd effect was observed in individuals aged 5-39 years after three years of vaccination. Potential reasons for the increased trend in pneumonia hospitalization rates in the elderly should be investigated. / INTRODUÇÃO: As pneumonias contribuem com alta carga de morbimortalidades em todo mundo. No Brasil, a vacina pneumocócica conjugada 10 valente (PCV10) foi introduzida na rotina de imunização da infância em março de 2010. Este estudo teve como objetivo avaliar o impacto da vacinação nas taxas de hospitalizações por pneumonia no Brasil no curto e médio prazo do início da vacinação. METODOLOGIA: Dois estudos de séries temporais interrompidas foram conduzidos. O primeiro avaliou o efeito direto da vacinação em cinco capitais brasileiras (Belo Horizonte, Curitiba, Porto Alegre, São Paulo e Recife) e foi conduzido após um ano de introdução da PCV10 no país. O segundo estudo avaliou o impacto direto e indireto (população não vacinada) da vacinação em todo país e foi conduzido três anos após sua introdução. Os dados de hospitalizações foram obtidos do Sistema de Informações Hospitalares (SIH-SUS) de 2005 a 2013. O desfecho principal foi a taxa mensal de hospitalização por pneumonia definida pelos códigos J12-J18 da CID10. As taxas de hospitalizações por malformações congênitas e causas não respiratórias foram utilizadas como grupos de comparações. A análise de série temporal utilizou um modelo de regressão linear generalizado. As taxas de hospitalizações por pneumonia observadas no período pré-PCV10, ajustadas por tendência secular e sazonalidade, foram utilizadas para estimar as taxas no período pós-PCV10. O impacto da vacinação para cada faixa etária foi calculado como o percentual de mudança nas taxas de hospitalizações, dividindo-se as taxas observadas pelas taxas preditas do período pós PCV10, menos um. Os respectivos IC95% e os valores de p foram apresentados. O número de hospitalizações por pneumonia evitadas após três anos de vacinação foi estimado pela diferença entre os números de hospitalizações por pneumonia preditos e observados no período pós-vacinação. RESULTADOS: Após um ano de introdução da PCV10 no Brasil, observou-se significativo declínio nas taxas de hospitalizações por pneumonia em crianças de 2 a 23 meses em três das cinco capitais estudadas: Belo Horizonte (28,7%), Curitiba (23,3%), e Recife (27,4%). Após três anos da introdução da PCV10, 461.519 hospitalizações por pneumonia foram evitadas no Brasil e um significativo declínio nas taxas de pneumonia foi observado em indivíduos não vacinados de 5 a 39 anos variando de 14,1% a 17,4% (p<0,05). No entanto, observou-se um aumento significativo (9,9%, p=0,004) nas taxas de hospitalizações por pneumonia para idosos ≥65 anos. CONCLUSÕES: A vacinação com a PCV10 foi associada à significativa redução das hospitalizações por pneumonia na infância. Adicionalmente, o estudo evidenciou importante redução das hospitalizações por pneumonia em grupos etários não vacinados, sinalizando efeito indireto conferida pela vacina. A tendência de aumento das hospitalizações por pneumonias em idosos necessita de investigações para elucidação dos fatores envolvidos nesse fenômeno.

A proteína A de superfície de pneumococo (PspA) é encontrada na superfície de todas as cepas de Streptococcus pneumoniae e candidata promissora para novas vacinas pneumocócicas. Foi desenvolvido um processo de purificação da PspA4Pro cujas etapas iniciais foram: ruptura da biomassa celular, precipitação do homogenato obtido com o detergente brometo de cetiltrimetilamônio (CTAB) e remoção do precipitado por centrifugação. Foram avaliadas cromatografias de troca iônica (aniônica, catiônica), afinidade por metais, interação hidrofóbica e mista de troca catiônica e hidrofóbica. Utilizando precipitação com CTAB, cromatografia de troca aniônica, crioprecipitação em pH4,0 e cromatografia de troca catiônica atingiu-se a pureza requerida de PspA4Pro (>95%) com recuperação entre 14% e 33%. O processo alcançou níveis aceitáveis de endotoxina no produto final e a PspA4Pro purificada foi reconhecida por anticorpos anti-PspA4, manteve sua atividade e sua estrutura secundária. / Pneumococcal surface protein A (PspA) is found in all Streptococcus pneumoniae strains and is a promising candidate to be used in new pneumococcal vaccines. A purification process for PspA4Pro which inicial steps were: cell disruption, precipitation of the homogenate with the cationic detergent cetyltrimethylammonium bromide (CTAB) and pellet removal by centrifugation. The chromatographic techniques tested were ion exchange (anionic and cationic), immobilized metal affinity, hydrophobic interaction and mix mode with hydrophobic and cationic ligands. Using CTAB precipitation, anion exchange chromatography, crioprecipitation in pH4.0 and cation exchange chromatography the PspA reached the required purity (>95%) with recovery between 14% and 33% . The process reached acceptable levels of endotoxin in the final product and the purified PspA4Pro was recognized by anti-PspA4 antibodies and manteined its activity and secondary structure.

Diversas proteínas pneumocócicas têm sido estudadas como candidatos vacinais. Entre elas, PspA e Ply induzem anticorpos essenciais para a proteção contra sepse, enquanto, SP 0148 e SP 2108 induzem IL-17 e protegem camundongos contra a colonização. Esse trabalho teve como objetivo principal desenvolver vacinas pneumocócicas baseadas em proteínas. Primeiramente, foi selecionada uma molécula de PspA com ampla reatividade cruzada. Em seguida, esta PspA foi fusionada com PdT, um pneumolisóide derivado da Ply. Essa proteína de fusão mostrou-se capaz de induzir resposta imunológica humoral e celular e protegeu camundongos contra desafio letal. Vacinas baseadas em BCG, que possui diversas propriedades adjuvantes, foram desenvolvidas expressando as proteínas pneumocócicas rPspA-PdT, SP 0148 e SP 2108. A imunização com o rBCG 0148/rSP 0148 induziu IL-17 e levou a proteção contra colonização. A combinação das três vacinas de rBCG mostrou-se mais eficiente na proteção contra desafio de colonização. Esses resultados sugerem um uso promissor do rBCG como vacina pneumocócica. / Several pneumococcal proteins have been proposed as vaccine candidates. PspA and Ply induce protective antibodies against sepse, while SP 0148 and SP 2108, induce IL-17 and protect mice against pneumococcal colonization. The major aim of this study was to produce pneumococcal vaccines based on proteins. First, we selected one PspA molecule able to induce broad-ranging cross-reactivity. Second, we constructed a hybrid protein containing a PspA fused to PdT, a detoxified form of Ply. The hybrid protein was able to induce humoral and cellular responses and protected mice against lethal challenge. Finally, due the adjuvant properties of BCG, we constructed recombinant BCG strains expressing PspA-PdT, SP 0148 and SP 2108. The immunization with rBCG-0148/rSP 0148 induced IL-17 and IFN-, and pneumococcal colonization in mice. Interestingly, the combination of all rBCG vaccines was more efficient in protecting mice against pneumococcal colonization. These results suggesting a promising use of rBCG as pneumococcal vaccine.

Streptococcus pneumoniae é uma bactéria encapsulada causadora de doenças infecciosas como pneumonia, bacteremia e meningite, infecções essas que estão entre as principais causas de morte entre crianças, idosos e imunodeprimidos, indivíduos que constituem o grupo de risco para tais infecções. A vacinação tem sido a mais eficaz forma de conter tais infecções. A vantagem das vacinas conjugadas em comparação às polissacarídicas é a capacidade de indução de uma resposta imune T-dependente o que garante proteção mesmo ao grupo de risco para infecções por S. pneumonia. A proposta do projeto foi estabelecer um protocolo para obtenção de um conjugado constituído pelo polissacarídeo capsular de S. pneumonia sorotipo 1 (PS1) e pela proteína de superfície pneumocócica A (PspA). A síntese do conjugado empregou uma metodologia inédita para o sorotipo 1. A avaliação da resposta imune humoral induzida pelo conjugado mostrou a indução de IgG anti-PS1 gerada pelas imunizações com o conjugado PS1-PspA. / Streptococcus pneumoniae is an encapsulated bacteria causing infectious diseases such as pneumonia, bacteremia and meningitis, these infections are among the leading causes of death among children, elderly and immunocompromised, who constituting individuals of risk group. The vaccination has been the more effective form to counter these infection. The advantage of conjugated vaccines compared to vaccines polysaccharide, is the ability to induce a T-dependent immune response which provides protection even at risk groups for infection by S. pneumoniae. The project proposal was establish a protocol for obtaining a conjugate consisting of the capsular polysaccharide of S. pneumoniae serotype 1 (PS1) and the pneumococcal surface protein A (PspA). The synthesis of conjugate employed a new methodology for serotype 1. The evaluation of humoral immune response induced by the conjugate showed anti-PS1 IgG induction generated by immunization with the PS1-PspA.

<p><em>Streptococcus pneumoniae</em> (pneumokok) je&nbsp; jedan&nbsp; od&nbsp; vodećih&nbsp; uzroka morbiditeta i mortaliteta &scaron;irom sveta, kada su u pitanju infektivne bolesti. Pretežno izaziva infekcije gornjih respiratornih puteva (sinuzitis, otitis) i konjunktivitis. Vodeći je uzročnih vanbolničkih pneumonija, bakterijskog meningitisa i sepse. Lekovi izbora u terapiji pneumokoknih bolesti su beta laktamski antibiotici i makrolidi. Iako se makrolidni antibiotici uveliko koriste u lečenju pneumokoknih infekcija &scaron;irom sveta, porast rezistencije na makrolide&nbsp; bi&nbsp; mogao&nbsp; da&nbsp; kompromituje&nbsp; njihovu&nbsp; upotrebu. Rezistencija pneumokoka na makrolide je posredovana putem dva glavna mehanizma: modifikacija ciljnog mesta delovanja leka&nbsp; i aktivni efluks leka. Metilaciju 23S ribozomalne ribonukleinske kiseline (rRNK) obavlja enzim metilaza, čiju sintezu kodira<em> ermB</em> gen. Kod ovog tipa rezistencije dolazi do ukr&scaron;tene rezistencije na makrolide (M), linkozamide (L) i streptogramine B (Sb). Ovakav vid rezistencije se ispoljava kao MLS_b - fenotip i karakteri&scaron;e ga visok nivo rezistencije. Može se javiti kao konstitutivni (cMLS) i inducibilni (iMLS). Drugi mehanizam rezistencije na makrolide je aktivni efluks leka, kodiran od strane <em>mefA</em>&nbsp; gena. Efluks antibiotik a determini&scaron;e rezistenciju samo na 14-člane i 15-člane makrolide, bez ukr&scaron;tene rezistencije. Ispoljava se kao M-fenotip, a karakteri&scaron;e ga niži stepen rezistencije. Cilj ove studije je bio&nbsp; da&nbsp; se&nbsp; odredi u čestalost&nbsp; makrolidne&nbsp; rezistencije <em>Streptococcus pneumoniae</em> među invazivnim i neinvazivnim izolatima kod dece i odraslih, da se odrediti u čestalost korezistencije i multiple rezistencije kod makrolid rezistentnih sojeva&nbsp; <em>Streptococcus pneumoniae</em>, da se fenotipski odredi tip rezistencije na makrolide i da se ispita genska osnova makrolidne rezistencije (detektovati prisustvo <em>ermB</em> i <em>mefA</em> gena). Analizirani su podaci o 326 sojeva <em>Streptococcus pneumoniae</em> rezistentnih na makrolide (MRSP) sakupljenih &scaron;irom&nbsp; Srbije&nbsp; u&nbsp; periodu&nbsp; od&nbsp; januara&nbsp; 2010.&nbsp; do&nbsp; decembra&nbsp; 2012.&nbsp; godine. Sakupljeni&nbsp; MRSP&nbsp; izolati&nbsp; su&nbsp; transportovani&nbsp; u&nbsp; Nacionalnu&nbsp; referentnu laboratoriju za streptokok radi daljih ispitivanja. Identifikacija je vr&scaron;ena na osnovu mikroskopskih, kulturelnih i biohemijskih osobina. Konzervacija je vr&scaron;ena u moždano-srčanom bujonu sa 10% sadržajem glicerola na -80&deg;C. Dvostruki&nbsp; disk&nbsp; difuzioni&nbsp; test,&nbsp; kombinovani&nbsp; difuzion odilucioni&nbsp; test&nbsp; i automatizovani VITEK 2 sistem su kori&scaron;ćeni za određivanje fenotipova rezistencije na makrolide. Geni koji kodiraju rezistenciju na makrolide su detektovani PCR metodom. Ukupna rezistencija sojeva <em>S.pneumoniae</em> na makrolide u Srbiji je iznosila 34%. Sojevi <em>S.pneumoniae</em> rezistentni na makrolide su če&scaron;će bili izolovani kod dece (36%) u odnosu na odrasle (29%) osobe, i če&scaron;će su izolovani iz neinvazivnih (35,5%) u odnosu na invazivne (27,4%) materijale. Dominantan fenotip rezistencije na makrolide je bio MLS_b fenotip (78,5%). Konstitutivan MLS fenotip je bio zastupljen kod 73,9%, a inducibilan MLS kod 4,6% MRSP izolata. Potvrđena je udruženost <em>mefA</em>&nbsp; gena i M fenotipa; <em>ermB</em> gena i iMLS fenotipa, kao i <em>ermB</em> gena i cMLS fenotipa. Prisustvo oba ermB i mefA gena rezistencije je potvrđeno kod 43,9 % izolata. Svi izolati sa koji su imali oba gena rezistencije su ispoljili&nbsp; MLS_b fenotip.&nbsp; Istovremena&nbsp; neosetljivost&nbsp; na&nbsp; penicilin&nbsp; je bila zastupljena kod 16% MRSP sojeva. Visok nivo rezistencije na penicilin je imalo svega 5,8% MRSP izolata. Među MRSP sojevima je bio prisutan visok nivo&nbsp; rezistencije&nbsp; na&nbsp; tetraciklin&nbsp; (81,3%)&nbsp; i&nbsp; trimetoprim-sulfametoksazol (74,3%). Multirezistenti sojevi, koji su bili rezistentni na tetracikline i trimetoprim-sulfametoksazol su predstavljali dve trećine (66,1%) MRSP izolata.&nbsp; Zastupljenost&nbsp; udružene&nbsp; rezistencije&nbsp; MRSP&nbsp; na&nbsp; tetraciklin i trimetoprim-sulfametoksazol je bila veća kod sojeva sa MLS fenotipom (73,1%)&nbsp; u&nbsp; odnosu&nbsp; na&nbsp; sojeve&nbsp; sa&nbsp; M&nbsp; fenotipom&nbsp; (36,7%). Zastupljenost istovremene rezistencije na makrolide i druge antibiotike među kojima su penicilin, amoksicilin, cefotaksim, tetraciklin, trimetoprim-sulfametoksazol, kao&nbsp; i&nbsp; multirezistentnih&nbsp; sojeva&nbsp; je&nbsp; bila&nbsp; veća&nbsp; kod pedijatrijskih&nbsp; izolata pneumokoka&nbsp; u&nbsp; odnosu&nbsp; na&nbsp; sojeve&nbsp; dobijene&nbsp; kod&nbsp; odraslih.&nbsp; U čestalost istovremene rezistencije na makrolide i druge antibiotike među kojima su tetraciklin i ofloksacin je bila vi&scaron;e prisutna među neinvazivnim u odnosu na invazivne MRSP izolate. Invazivni MRSP izolati iz likvora su pokazivali veću rezistenciju na beta laktamske antibiotike u odnosu neinvazivne sojeve. MRSP sojevi su pokazali veoma visok nivo osetljivosti na levofloksacin (99,6), telitromicin (98,4%), cefotaksim (93,5%), i mipenem (97,3%). MRSP sojevi su u potpunosti bili osetljivi na vankomicin, linezolid, moksifloksacin, sparfloksacin, rifampicin&nbsp; i&nbsp; pristinamicin.&nbsp; Među&nbsp; invazivnim&nbsp; sojevima <em>S.pneumoniae</em> rezistentnim na makrolide je nađeno 12 različitih serotipova. Polovina izolata je pripadala serotipovima 19F (25%) i 14 (23%), dok su sledeći po učestalosti bili 6A (10,4%) i 23F (8,3%). Istovremena rezistencija na makrolide, penicilin, tetracikline i trimetoprim-sulfametoksazol je nađena kod serotipova 19F, 14 i 23F, dok su serotpovi 12F i 31 bili neosetljivi samo na makrolide. Na&scaron;e istraživanje predstavlja prvu detaljnu analizu fenotipskih i&nbsp; genotipskih&nbsp; osobina&nbsp; sojeva&nbsp; pneumokoka&nbsp; rezistentnih&nbsp; na&nbsp; makrolidne antibiotike u Srbiji. Dobijeni rezultati ukazuju na&nbsp; potrebu za aktivnim nadzorom nad pneumokoknim infekcijama u Srbiji.</p> / <p><em>Streptococcus pneumoniae</em> (pneumococcus) is one of the leading morbidity and&nbsp; mortality&nbsp; causes&nbsp; all&nbsp; over&nbsp; the&nbsp; world&nbsp; with&nbsp; respect&nbsp; to&nbsp; infectious&nbsp; diseases. <em>Streptococcus&nbsp; pneumoniae</em> is&nbsp; a&nbsp; leading&nbsp; cause&nbsp; of upper&nbsp; respiratory&nbsp; tract infections&nbsp; (&nbsp; sinusitis,&nbsp; otitis)&nbsp; and&nbsp; conjunctivitis. It&nbsp; is&nbsp; also&nbsp; the&nbsp; most&nbsp; common cause&nbsp; of&nbsp; community-acquired&nbsp; pneumonia, bacterial&nbsp; meningitis&nbsp; and&nbsp; sepsis. Beta lactam and&nbsp; macrolide antibiotics remained a first choice for empirical treatment of pneumococcal infections. Although macrolides are widely used for&nbsp;&nbsp; treatment&nbsp;&nbsp; of&nbsp;&nbsp; pneumococcal&nbsp;&nbsp; infections, an&nbsp;&nbsp; increase&nbsp;&nbsp; in&nbsp;&nbsp; macrolide resistance&nbsp; might compromise&nbsp; their use. Pneumococcal&nbsp; macrolide resistance is&nbsp; mediated&nbsp; by&nbsp; two&nbsp; major&nbsp; mechanisms:&nbsp; target&nbsp; site&nbsp; modification&nbsp; and&nbsp; active drug&nbsp; efflux.&nbsp; Methylation&nbsp; of&nbsp; the&nbsp; 23S&nbsp; ribosomal&nbsp; ribonucleic&nbsp; acid&nbsp; (rRNA)&nbsp; is performed&nbsp;&nbsp; by&nbsp;&nbsp; the&nbsp;&nbsp; enzyme&nbsp;&nbsp; methylase,&nbsp;&nbsp; encoded&nbsp;&nbsp; by&nbsp;&nbsp; the<em> ermB </em>gene. Modification&nbsp; of&nbsp; ribosomal&nbsp; targets&nbsp; leads&nbsp; to&nbsp; cross-resistance to&nbsp; macrolides (M),&nbsp; lincosamides&nbsp; (L)&nbsp; and&nbsp; streptogramins&nbsp; B&nbsp; (Sb). It&nbsp; is&nbsp; expressed&nbsp; as&nbsp; the MLS_b &ndash;phenotype,&nbsp; which&nbsp; confers&nbsp; a&nbsp; high-level&nbsp; resistance. This&nbsp; phenotype&nbsp; can&nbsp;&nbsp; be&nbsp;&nbsp; either&nbsp;&nbsp; constitutively&nbsp;&nbsp; (cMLS)&nbsp;&nbsp; or&nbsp;&nbsp; inducibly&nbsp;&nbsp; (iMLS). expressed. Another macrolide resistance mechanism is the active drug efflux, encoded by&nbsp; the <em>mefA&nbsp;</em> gene.&nbsp; The&nbsp; drug&nbsp; efflux&nbsp; confers&nbsp; resistance&nbsp; to&nbsp; 14-&nbsp; and&nbsp; 15-membered&nbsp; macrolides&nbsp; only,&nbsp; with&nbsp; no&nbsp; cross-resistance.&nbsp; It&nbsp; is&nbsp; expressed&nbsp; as&nbsp; the M-phenotype,&nbsp; which&nbsp; confers&nbsp; low-level&nbsp; resistance.&nbsp; The&nbsp; objective of&nbsp; this study&nbsp;&nbsp; was&nbsp;&nbsp; :&nbsp;&nbsp; 1) to&nbsp;&nbsp; examine&nbsp;&nbsp; the&nbsp;&nbsp; prevalence of&nbsp;&nbsp; macrolide&nbsp;&nbsp; resistant <em>Streptococcus&nbsp;&nbsp; pneumoniae </em>(MRSP) among&nbsp;&nbsp; invasive&nbsp;&nbsp; and&nbsp;&nbsp; noninvasive isolates in children and adults, 2) to examine the prevalence of coresistance and multiple-resistance among MRSP strains, 3) to examine the prevalence of&nbsp; macrolide&nbsp; resistant&nbsp; phenotypes,&nbsp; and&nbsp; 4)&nbsp; to&nbsp; examine&nbsp; the&nbsp; prevalence&nbsp; of macrolide&nbsp; resistant&nbsp; genotypes&nbsp; (detect&nbsp; the&nbsp; presence of&nbsp; the <em>ermB</em>&nbsp;&nbsp; and <em>mefA</em> gene).&nbsp; A&nbsp; total&nbsp; of&nbsp;&nbsp; 326&nbsp; MRSP&nbsp; strains&nbsp; were&nbsp; analyzed,&nbsp; which&nbsp; were&nbsp; collecte dall&nbsp; over&nbsp; Serbia&nbsp; in&nbsp; the&nbsp; period&nbsp; from&nbsp; January,&nbsp; 2010&nbsp; - December,&nbsp; 2012.&nbsp; The collected&nbsp;&nbsp; MRSP&nbsp;&nbsp; isolates&nbsp;&nbsp; were&nbsp;&nbsp; referred&nbsp;&nbsp; to&nbsp;&nbsp; the&nbsp;&nbsp; National&nbsp; Reference Laboratory&nbsp; for&nbsp; streptococci&nbsp; and&nbsp; pneumococci for&nbsp; further&nbsp; investigation. Identification based on microscopic, culture and biochemical features of the isolates. Conservation was performed in the brain-heart infusion broth with a&nbsp; 10%&nbsp; glycerol&nbsp; content&nbsp; at&nbsp; -80&deg;C.&nbsp; Macrolide&nbsp; resistance&nbsp; phenotypes&nbsp; were determined by a double disc diffusion test, combine d diffusion-dilution test and&nbsp;&nbsp; automatized&nbsp;&nbsp; VITEK&nbsp; 2 system. Macrolide&nbsp;&nbsp; resistance&nbsp;&nbsp; genes&nbsp;&nbsp; were&nbsp; determined by PCR. Overall, macrolide nonsusceptibility rate in Serbia was 34%.&nbsp; MRSP&nbsp; isolates&nbsp; were&nbsp; more&nbsp; prevale nt&nbsp; among&nbsp; children&nbsp; (36%)&nbsp; than adults&nbsp; (29%),&nbsp; and&nbsp; were&nbsp; more&nbsp; prevalent&nbsp; among&nbsp;&nbsp; noninvasive&nbsp; (35.5%)&nbsp; than invasive&nbsp; (27.4%)&nbsp; samples.&nbsp; Predominant&nbsp; macrolide&nbsp; resistance&nbsp; phenotype was&nbsp; the&nbsp; MLS b&nbsp; phenotype&nbsp; (78.5%),&nbsp; from&nbsp; which&nbsp; 73.9 %&nbsp; belonged&nbsp; to&nbsp; cMLS and&nbsp; 4.6%&nbsp; to&nbsp; iMLS&nbsp; phenotype.&nbsp; All&nbsp; the&nbsp; strains&nbsp; assigne d&nbsp; to&nbsp; the&nbsp; MLS_b phenotype harbored<em> ermB</em> gene, while all the strains with M phenotype had the mefA gene.&nbsp; The&nbsp; presence&nbsp; of&nbsp; both ermB and mefA resistance&nbsp; genes&nbsp; was confirmed&nbsp; in&nbsp; 43.9&nbsp; %&nbsp; of&nbsp; isolates. All&nbsp; the&nbsp; isolates&nbsp; which&nbsp; harbored&nbsp; both resistance genes expressed the MLS_b phenotype. Among macrolide resistant strains,&nbsp; penicillin&nbsp; nonsusceptiblility&nbsp; was&nbsp; observed&nbsp;&nbsp; in&nbsp; 16% .&nbsp; A&nbsp; high&nbsp; level resistance was confirmed in 5. 8% of MRSP isolates. MRSP strains showed high&nbsp; resistance rates to tetracyclin&nbsp; (81.3%) and&nbsp; trimethoprim-sulfamethoxazole&nbsp; (74.3%).&nbsp; Multiresistant&nbsp; strains,&nbsp; resistant&nbsp; to&nbsp; tetracyclines and&nbsp; trimethoprim-sulfamethoxazole,&nbsp; made&nbsp; two&nbsp; thirds&nbsp; (66.1&nbsp; %)&nbsp; of&nbsp; MRSP isolates.&nbsp; Among&nbsp; MRSP,&nbsp; co-resistance&nbsp; to&nbsp; tetracycline&nbsp; and&nbsp; trimethoprim-sulfamethoxazole&nbsp; was&nbsp; more&nbsp; prevalent&nbsp; among&nbsp; MLS&nbsp; phenotypes&nbsp; (73.1%) than&nbsp; M&nbsp; phenotypes&nbsp; (36.7%).&nbsp; Co-resistance&nbsp; strains&nbsp; to&nbsp; macrolides&nbsp; and&nbsp; other antibiotics including&nbsp;&nbsp;&nbsp; penicillin,&nbsp;&nbsp; amoxicillin,&nbsp;&nbsp;&nbsp; cefotaxime,&nbsp; tetracyclin, trimethoprim-sulfamethoxazole and multiresistant&nbsp; strains&nbsp; were more prevalent among children than adult. Coresistance to macrolides and other antibiotics&nbsp; including&nbsp; tetracycline&nbsp; and&nbsp; ofloxacin&nbsp; was&nbsp; more&nbsp; prevalent&nbsp; among noninvasive&nbsp;&nbsp; than&nbsp;&nbsp; invasive&nbsp;&nbsp; strains.&nbsp;&nbsp; Invasive&nbsp;&nbsp; MRSP&nbsp;&nbsp; isolates&nbsp;&nbsp; from&nbsp;&nbsp; the cerebrospinal fluid showed a higher resistance rate to beta lactam antibiotics than&nbsp; noninvasive&nbsp; strains.&nbsp; MRSP&nbsp; strains&nbsp; had&nbsp; a&nbsp; high&nbsp; susceptibility&nbsp; rates&nbsp; to levofloxacin&nbsp;&nbsp; (99.6),&nbsp;&nbsp; telithromycin&nbsp;&nbsp; (98.4%),&nbsp;&nbsp; cefotak sime&nbsp;&nbsp; (93.5%)&nbsp;&nbsp; and imipenem&nbsp; (97.3%).&nbsp; MRSP&nbsp; strains&nbsp; were&nbsp; fully&nbsp; susceptible&nbsp; to&nbsp; vancomycin, linezolid, moxifloxacin, sparfloxacin, rifampicin a nd pristinamycin. Among macrolide&nbsp;&nbsp; resistant <em>S.pneumoniae</em> strains,&nbsp;&nbsp; 12 different&nbsp;&nbsp; serotypes&nbsp;&nbsp; were identified.&nbsp; One&nbsp; half&nbsp; of&nbsp; these&nbsp; isolates&nbsp; belonged&nbsp; to the&nbsp; 19F&nbsp; (27.1%)&nbsp; and&nbsp; 14 (22.&nbsp; 9%)&nbsp; serotype,&nbsp; followed&nbsp; in&nbsp; frequency&nbsp; by&nbsp; the&nbsp; 6A&nbsp; (10.41%)&nbsp; and&nbsp; 23F (8.3%)&nbsp; serotype .&nbsp; Multiresistant&nbsp; strains&nbsp; (macrolides,&nbsp; penicillin,&nbsp; tetracyclines and&nbsp; trimethoprim-sulfamethoxazole)&nbsp; belonged&nbsp; to&nbsp; serotypes 19F,&nbsp; 14&nbsp; and 23F, while the 12F and 31 serotype were resistant to macrolides only. This in vestigation&nbsp;&nbsp; represents&nbsp;&nbsp; the&nbsp;&nbsp; first&nbsp;&nbsp; detailed&nbsp;&nbsp; analysis of&nbsp;&nbsp; phenotypes&nbsp;&nbsp; and genotypes&nbsp; of&nbsp; macrolide&nbsp; resistant&nbsp; pneumococcal&nbsp; strains&nbsp; in&nbsp; Serbia.&nbsp; The obtained&nbsp; results suggest&nbsp; the need for an active surveillance&nbsp; of pneumococcal infections in Serbia.</p>

ortalidad en niños menores de 5 años, a pesar de contar con medidas preventivas como la vacunación.  Objetivo: Evaluar el impacto de la vacuna antineumocócica conjugada sobre la incidencia de neumonía en niños menores de 5 años, a nivel nacional y departamental, así como las hospitalizaciones y mortalidad a nivel nacional, desde 2001-2019 en el Perú. Además, realizar un análisis entre departamentos con coberturas altas de vacunación y aquellos que alcanzan coberturas bajas.  Metodología: Diseño: Series de tiempo definidas por la introducción de la vacuna antineumocócica heptavalente (PCV7) en el periodo de tiempo entre 2009 y 2011 a nivel nacional y departamental. Posteriormente, se realizó un análisis multivariado contrastando la incidencia de casos entre los departamentos con alta y baja cobertura de vacunación. Procedimiento de obtención de datos: Los datos agrupados sobre la incidencia, hospitalización y mortalidad por neumonía fue obtenida de la CDC (Centro de Enfermedades Contagiosas); la cobertura de vacunación fue obtenida como base de datos del Ministerio de Salud (MINSA) Análisis específicos: se realizó un análisis multivariado contrastando la incidencia de casos de neumonía entre los departamentos con alta y baja cobertura de vacunación.  Resultados: Para las hospitalizaciones a nivel nacional, la tendencia de cambio post vacunación fue negativa y significativa (p <0.001). La incidencia y mortalidad tuvieron cambios no significativos. A nivel regional, Callao, Lima, Moquegua, Cusco, Huancavelica, Pasco, Loreto, San Martín y Ucayali tuvieron tendencia de cambio post vacunación negativa y significativa (p <0.001). Conclusiones: La vacunación ha demostrado ser efectiva para disminuir hospitalizaciones por neumonía en algunos departamentos y a nivel nacional. Sin embargo, existen factores individuales que pueden alterar la efectividad de la intervención, propias de la estrategia aplicada y del tipo de estudio utilizado. / Introduction: Pneumonia is an acute respiratory infection, the most common bacterial cause is Streptococcus pneumoniae and represents one of the major causes of mortality in children under 5 years of age, despite preventive measures. Objective: Assess the impact of the pneumococcal vaccine on the incidence of pneumonia in children under 5 years of age, at the national and departmental level, as well as hospitalizations and mortality at the national range, over 2001-2019 in Peru. In addition, perform an analysis between departments that achieve high vaccination coverage and those with low coverage.  Methodology: Study design: Time series interrupted by the inclusion of the heptavalent pneumococcal vaccine (PCV7) in the period between 2009 and 2011 at the national and departmental level. Multivariate analysis, contrasting the incidence of cases between departments with high and low vaccination coverage. Data collection procedure: Pooled data on pneumonia incidence, hospitalization, and mortality obtained from the CDC (Center for Communicable Diseases); vaccination coverage obtained as a database from the Ministry of Health (MINSA) Specific analyzes: multivariate contrasting the incidence of pneumonia cases between departments with high and low vaccination coverage. Results: Hospitalizations at the national level had a negative trend of change after vaccination (p <0.001). At regional level, Callao, Lima, Moquegua, Cusco, Huancavelica, Pasco, Loreto, San Martín and Ucayali had a negative and significant change trend post vaccination (p <0.001). Conclusions: Vaccination has proven to be effective in some departments and at the national level. However, there are individual factors and limitations of the study that may affect the outcome. / Tesis

Streptococcus pneumoniae est une bactérie cocci gram positif commensale de la flore oropharyngée qui colonise le rhinopharynx de l’Homme et dont près de 100 sérotypes sont connus. Les nourrissons et les jeunes enfants représentent son réservoir principal. Le pneumocoque peut être à l’origine d’infections graves, telles que la méningite, les bactériémies et la pneumonie, et moins graves mais plus courantes comme la sinusite et l’otite moyenne aiguë. Deux vaccins anti-pneumococciques conjugués ont été introduits en France : le PCV7 (couvrant contre 7 sérotypes) en 2003 et le PCV13 (couvrant contre 6 sérotypes supplémentaires) en 2010. L’objectif général de ce travail de thèse est d’évaluer l’impact des politiques vaccinales sur les infections invasives à pneumocoque en France, en s’intéressant principalement aux évolutions temporelles et géographiques des plus graves : les méningites à pneumocoque (MP). Un premier travail a étudié les dynamiques temporelles des MP sur la période 2001–2014 afin d’identifier l’impact de l’introduction des vaccins conjugués. Des techniques statistiques de modélisations adaptées aux séries temporelles ont été utilisées. Les résultats de ce travail retrouvent des effets rapportés dans la littérature : une réduction des MP à sérotypes vaccinaux mais aussi une augmentation des MP dues aux sérotypes non inclus dans le vaccin (phénomène de « remplacement sérotypique »).Par conséquent, le premier bénéfice, à l’échelle de la population générale, de l’introduction de cette vaccination a été observé seulement onze ans après l’introduction du PCV7, et principalement suite à l’introduction du PCV13 en 2010, avec une diminution de 25% du nombre de MP en 2014. La composante géographique a ensuite été prise en compte afin d’étudier le rôle de la de couverture vaccinale dans la variabilité des MP annuelles entre les départements sur la période 2001-2016. Les résultats confirment l’efficacité des deux formulations du vaccin sur les MP dues aux sérotypes vaccinaux et suggèrent une certaine homogénéité de cet effet entre les différents départements. Inversement, le remplacement sérotypique a été confirmé mais uniquement suite à l’introduction de la première formulation du vaccin et ces effets présentent une répartition géographique hétérogène et variable. La variabilité de la couverture vaccinale entre les départements n’explique pas celle observée dans le nombre de MP, ce qui suggère l’intervention d’autres facteurs tel que la densité géographique. Enfin, une modélisation dynamique, permettant de prendre en compte des aspects fondamentaux des dynamiques de transmission et d’infection du pneumocoque non intégrés dans les méthodes de modélisation statique, a été proposée afin de prédire l’impact de différentes stratégies de vaccination pour les adultes de 65 ans et plus et ainsi évaluer leur rapport coût-utilité. / Streptococcus pneumoniae is a Gram-positive commensal bacterium of the oropharyngeal flora usually colonizing human’s rhino pharynx, of which almost 100 serotypes are known. Infants and young children constitute its main reservoir. Pneumococcus may cause serious infections, such as meningitis, bacteremia and pneumonia, or less serious but more common such as sinusitis and acute otitis media (AOM). Two conjugate pneumococcal vaccines have been introduced in France: PCV7 (covering 7 serotypes) in 2003 and PCV13 (covering 6 additional serotypes) in 2010. The overall objective of this thesis is to assess the impact of vaccination policy on invasive pneumococcal diseases in France, by focusing on temporal and geographical trends of the most serious of them: pneumococcal meningitis (PM). An initial study of PMs temporal dynamics over the 2011-2014 period assessed the impact of conjugate vaccines’ introduction. Statistical modeling techniques were used for time series analysis. The results confirm the effects found in literature: a reduction of vaccine serotypes PMs but at the same time an increase of PMs, due to non-vaccine serotypes (effect of “serotype replacement”). Therefore, the first benefit of vaccine introduction at population scale has been observed no less than 11 years after PCV7 introduction, and then principally after PCV13 was introduced in 2010, with a 25% decrease in PMs in 2014. The geographic component was then implemented to analyze the role of vaccine coverage in annual PM variability between geographic units over the 2001-2016 period. Results confirm the effectiveness of both vaccine compositions on vaccine serotypes PMs and suggest homogeneity of this effect among geographic units. Conversely the serotype replacement has been confirmed only after the first vaccine composition was introduced and presents a variable and heterogeneous geographical repartition. Variability in vaccine coverage among geographic units doesn’t explain the differences in PMs, which could suggest the role of others factors such as demographic density. Finally, a dynamic modeling capable of taking into consideration fundamental aspects of pneumococcus transmission and infection mechanisms not integrated in static modeling has been proposed in order to predict the impacts of different vaccination strategies for 65+ adults and therefore assess their cost-utility ratios.

Made available in DSpace on 2014-07-29T15:26:24Z (GMT). No. of bitstreams: 1 tese caritas medicina tropical.pdf: 1784866 bytes, checksum: b85c7ab5508fd90ff809159f179430cc (MD5) Previous issue date: 2009-02-17 / Objectives: (i) to identify risk factors for S. pneumoniae penicillin nonsusceptible isolates (PNSp) in children attending day-care centers (DCCs) in Goiânia, Brazil and to assess the genetic patterns of pneumococcal isolates; (ii) to estimate the coverage for carriage serotypes for the 7-valente (PCV7) pneumococcal conjugate vaccine, and for the investigational 10 (PCV10) and 13-valent (PCV13) vaccines; (iii) to assess the genetic relatedeness between isolates expressing capsular type 14 and those non(sero)- typeable isolates (NTPn); (iv) to investigate if carriage isolates match genetically to any international pneumococcal clone (PMEN network). Methods: A cross-sectional survey of carriage PNSp was conducted among 1.192 children, 2 months to 5 years of age, attending 62 DCCs in Central Brazil. Capsular typing was performed in PNSp isolates (CLSI, 2007) and in a sample of isolates susceptible to penicillin (PSSp) matched to PNSp and DCCs whenever possible. Serotyping was performed by Quellung reactions and confirmed by multibead assay. NTPn isolates and serotype 14 were tested by PCR for capsule genes. Odds ratio for PNSp carriage and respective 95% confidence interval (95%CI) were assessed by logistic regression. Pulsed field gel electrophoresis (PFGE) was applied to assess the genetic similarity between PNSp serotype 14 and NTPn isolates. PCR was performed for the presence of pneumococcal capsule gene locus. For comparison purpose we also evaluated the genetic profile of PNSp serotype 14 invasive strains derived from the current pneumococcal invasive disease surveillance for the same pediatric population. Isolates were epidemiologically related if they shared &#8805;80% similarity on the dendrogram (Dice coefficient). A cluster was defined as three or more related isolates. Results: A total of 686 pneumococci were isolated for a colonization rate of 57.6% and 178 (25.8%) were PNSp. Among the PNSp isolates the usual common types were found: 14 (53%), 23F (10.2%), 6B (6%), 19F (4.8%) and 19A (4.2%). PSSp isolates displayed 30 different serotypes although serotype 14 was the most common. Overall a high prevalence of NTPn (11.1%) was observed with 62.9% PNSp. Serotypes coverage xvi for the PCV7, PCV10 and PCV13 vaccines were 55.2%, 55.9% and 65.1%, respectively. Being less than 24 months of age (OR=1.79; p=0.006), hospitalization in the previous three months (OR=2.19; p=0.025), and recurrent acute otitis media (OR=2.89; p=0.013) were independently associated with PNSp in a multivariate model. Among the 123 PNSp submitted to PFGE (106/carriage and 17/ invasive isolates) a major group of 34 serotype 14 strains (8 invasive and 26 carriage) was identified and found to be genetically related to the global pneumococcal clone Spain 9V-3 (82.7% similarity). All NTPn presented capsule gene locus and 10 (45.4%) of them presented capsule gene locus to type 14. Conclusions: (i) DCC attendees with history of recurrent AOM could significantly contribute to the spread of nasopharyngeal PNSp strains into the community; (ii) epidemiologic and molecular evidences support the findings that pneumococcal nonypeable carriage isolates are genetically similar to carriage and invasive isolates expressing capsular type 14; (iii) carriage and invasive isolates circulating in Goiânia belong to a serotype 14 variant of the Spain 9V -3 clone and play a critical role in the spread of PNSp strains to the entire pediatric community of Goiânia / Objetivo: (i) identificar fatores associados à colonização nasofaríngea por S. pneumoniae não suscetíveis à penicilina em crianças que frequentam creches no município de Goiânia-GO e caracterizar geneticamente as cepas não suscetíveis; (ii) determinar a cobertura das vacinas conjugadas pneumocócicas 7, 10 e 13 valente; (iii) avaliar o relacionamento genético entre cepas do sorotipo 14 e pneumococos não tipáveis (PnNT); (iv) identificar a presença de cepas colonizadoras relacionadas geneticamente aos clones internacionais de S. pneumoniae. Metodologia: Um estudo de prevalência de portador de pneumococo não suscetível à penicilina (SpNP) foi conduzido de agosto a dezembro de 2005, em 1192 crianças de dois a 59 meses de idade, atendidas em 62 creches em Goiânia. Os testes de suscetibilidade antimicrobiana seguiram as recomendações do CLSI de 2007 e a sorotipagem foi realizada pela reação de Quellung e confirmada por ensaio multibead. Isolados PnNT e do sorotipo 14 foram analisados por reação de PCR. Odds ratio para portador de SpNP e respectivos intervalos de 95% de confiança foram estimados por regressão logística. Para avaliar a similaridade genética entre os isolados de portador (sorotipo 14 e PnNT) e isolados invasivos (sorotipo 14) obtidos de crianças de Goiânia utilizou-se amostras de isolados invasivos de um estudo maior de vigilância populacional que vem sendo conduzido desde 2007. Assim, eletroforese em campo pulsado (PFGE) foi utilizada para a tipagem molecular. Definiu-se como linhagem a presença de três ou mais cepas resistentes com similaridade genética &#8805; 80%. Resultados: S. pneumoniae foi isolado de 686 (57,6%) crianças das creches e 178 (25,9%) dessas eram portadoras de SpNS. Sorotipo 14 (53%), 23F (10,2%), 6B (6%), 19F (4,8%) e 19A (4,2%) estavam presentes em 78,2% dos PnNS. Detectou-se alta prevalência (11,1%) de isolados não tipáveis, dos quais 62.9% eram resistentes à penicilina. A cobertura dos sorotipos colonizadores para as vacinas 7-valente, 10- valente e 13-valente foi respectivamente 55,2%, 55,9% e 65,1%. Crianças menores de 24 meses de idade (OR=1,79; p=0,006), hospitalização nos últimos três meses (OR=2,19; p=0,025), e otite média aguda recorrente (OR=2,89; p=0,013) foram fatores xiv independentemente associados com SpNS na análise multivariada. Entre os 123 isolados submetidos à PFGE, 106 eram de nasofaringe de crianças das creches, dos quais 84 expressavam a cápsula tipo 14 e 22 eram isolados PnNT. Todas as cepas invasivas eram sorotipo 14. A maior linhagem agrupou 34 pneumococos do sorotipo 14, com 82,7% de similaridade, os quais foram geneticamente relacionados ao clone Spain 9V-3. Todas as cepas PnNT apresentaram locus para o gene da cápsula para o tipo 14. Houve uma diferença estatisticamente significante entre os valores da CIM para a penicilina entre as três principais linhagens (Krukal-Wallis, p<0,001). Conclusões: (i) crianças com otite média recorrente podem exercer papel importante na disseminação de pneumococos resistentes para a comunidade; (ii) Evidências genéticas apóiam os achados de que cepas de pneumococo não tipáveis assemelham-se ao genótipo das cepas do sorotipo 14; (iii) isolados de portadores e invasivos que circulam em Goiânia pertencem a um sorotipo 14 variante do clone Spain9V-3, responsável pela disseminação da resistência do pneumococo na população pediátrica de Goiânia

Submitted by Cássia Santos (cassia.bcufg@gmail.com) on 2015-11-12T12:16:48Z No. of bitstreams: 2 Tese - Sabrina Sgambatti - 2015.pdf: 2847998 bytes, checksum: 069ae0ef61790cc3dd2564c3e7fa9120 (MD5) license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) / Approved for entry into archive by Luciana Ferreira (lucgeral@gmail.com) on 2015-11-12T12:21:22Z (GMT) No. of bitstreams: 2 Tese - Sabrina Sgambatti - 2015.pdf: 2847998 bytes, checksum: 069ae0ef61790cc3dd2564c3e7fa9120 (MD5) license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) / Made available in DSpace on 2015-11-12T12:21:22Z (GMT). No. of bitstreams: 2 Tese - Sabrina Sgambatti - 2015.pdf: 2847998 bytes, checksum: 069ae0ef61790cc3dd2564c3e7fa9120 (MD5) license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) Previous issue date: 2015-07-17 / Background. Anticipating the introduction of the 10-valent pneumococcal conjugate vaccine (PCV10) on childhood National Immunization Program (NIP), an active population-based surveillance on pneumonia hospitalizations was conducted as a baseline, enabling a vaccination impact study. The objectives of the present research were: (i) to assess the reliability of the Hospital Information System of the Unified Health System (SIH-SUS) as a data source for assessing PCV10 impact on pneumonia; (ii) to measure the impact of vaccination with PCV10 in reducing the incidence of clinical and X-Ray confirmed pneumonia, in children residing in Goiânia municipality. Methods. In this study, we conducted an active prospective population-based surveillance on pneumonia in the post PCV10 vaccination period (2011-2013), in all 17 pediatric hospitals of Goiânia, with similar methodology used in the previous pneumonia surveillance during the pre vaccination period (2007-2009). Children aged 2-35 months of age, admitted to hospitalization with suspected diagnosis of pneumonia, were elegible for the survey. Clinical pneumonia and X-Ray confirmed pneumonia were the outcomes. The intervention was the PCV10, introduced in June 2010 in Goiania. Probabilistic linkage was performed between the SIH-SUS database (secondary data) and the active population surveillance (primary data) for the year 2012, to measure the agreement of case identification on pneumonia hospitalization rates between both data sources. To assess the impact of PCV10, annual incidence of clinical pneumonia and X-Ray confirmed pneumonia (per 100,000 population) and respective 95% confidence interval (95%CI) was estimated for the post vaccinations period and compared to the rates obtained for the pre vaccination period. The relative risk for pneumonia and respective 95%CI were calculated based on Poisson distribution. The percentage change in rates (1-relative risk) between pre and post vaccination periods was calculated. Results. Pneumonia incidence rates obtained by the SIH-SUS were statistically similar to those obtained by active population surveillance for children 2-23meses (p = 0.184). On the PCV10 impact evaluation study, the rates of hospitalization for clinical and RXT confirmed pneumonia in children under 24 months decreased 13.1% (from 5,728/100,000 to 4,976/100,000) and 25.4% (from 2,497/100,000 to 1,862/100,000), respectively, after routine immunization. / Introdução. Antecipando a introdução da vacina pneumocócica conjugada 10-valente (PCV10) no calendário de vacinação infantil do Programa Nacional de Imunizações (PNI), um estudo de vigilância de base populacional ativa foi conduzido como linha de base, possibilitando, assim, avaliar o impacto da vacinação nas hospitalizações por pneumonia. Assim, os objetivos desta investigação foram: (i) avaliar a confiabilidade do Sistema de Informações Hospitalares do Sistema Único de Saúde (SIH-SUS) como fonte de dados para estudos de avaliação de impacto da PCV10 nas pneumonias; (ii) avaliar o impacto da vacinação com a PCV10 na redução da incidência de hospitalizações de crianças com pneumonia clínica e confirmada por Raio-X de tórax (RXT), residentes no município de Goiânia. Métodos. Neste estudo, conduzimos uma vigilância populacional prospectiva, ativa, de pneumonias no período pós vacinal (2011-2013) em 17 hospitais pediátricos de Goiânia, com metodologia similar à conduzida em estudo anterior, no período pré vacinal (2007-2009). Foram elegíveis para o estudo crianças de 2 a 35 meses de idade, admitidas com com diagnóstico inicial de pneumonia. Os desfechos foram pneumonia clínica e pneumonia confirmada por RXT. A intervenção foi a PCV10, introduzida em junho de 2010 em Goiânia. A técnica de linkage probabilístico foi utilizada para vincular o banco de dados do SIH-SUS (dados secundários) e o da vigilância populacional ativa (dados primários) referentes ao ano de 2012, e desta forma, avaliar a concordância no diagnóstico e nas taxas de hospitalização por pneumonia entre as duas fontes de dados. Para avaliar o impacto da PCV10, calculou-se a incidência anual de pneumonia clínica e confirmada por RXT (por 100.000 habitantes) e respectivos intervalos de 95% de confiança (IC95%) para o período pós vacinal, e comparou-se com as taxas do período pré vacinal. O risco relativo para pneumonia e respectivos IC95% foram calculados com base na distribuição de Poisson. O percentual de mudança entre as taxas pré e pós vacinal foi calculado como 1-risco relativo. Resultados. As taxas de pneumonia obtidas pelo SIH-SUS foram estatisticamente similares às obtidas por vigilância populacional ativa para as crianças de 2-23meses (p=0,184). No estudo de avaliação do impacto da PCV10, as taxas de hospitalização por pneumonia clínica e confirmada por RXT em crianças menores de 24 meses reduziram 13.1% (de 5,728/100,000 para 4,976/100,000) e 25.4% (de 2,497/100,000 para 1,862/100,000), respectivamente, após a vacinação de rotina. Conclusões. Dados do SIH-SUS podem ser utilizados para avaliar o impacto da PCV10 nas hospilazações por pneumonia na infância. Após 3 anos de vacinação com a PCV10 em Goiânia, observou-se significante queda das taxas de hospitalização por pneumonia clinica e confirmada por RXT em crianças alvo do PNI.

Streptococcus pneumoniae is a significant cause of mortality and morbidity in both children and older adults, with infection resulting in invasive disease, pneumonia and otitis media. The inclusion of pneumococcal conjugate vaccines in routine infant immunisation programmes has had a major impact on disease rates. Vaccine-induced protection against pneumococcal infection is thought to be mediated by the generation of persistent serotype-specific functional antibodies and antigen-specific memory B cells, the latter capable of generating a rapid secondary antibody response on re-exposure to antigen. Although many studies have investigated the immunogenicity of pneumococcal vaccines in different age groups by measuring serotype-specific antibodies, there is more limited information about the B cells underlying such an immune response. Important areas to investigate include the identity of the B cell subsets involved in antibody production and the potential link between memory B cells (B_MEM) and persistent antibody production by long-lived plasma cells. In this thesis I have investigated in detail the immune response to pneumococcal vaccines given to children and adults by a variety of different methods. By examining the variability of a B_MEM ELISpot method, it was shown that this assay is robust and reproducible and can be performed on fresh or frozen samples and in different laboratories. Using this technique, in a study of pre-school children, it was demonstrated for the first time that the level of pre-existing serotype 3-specific antibody is negatively correlated with, and may directly impair the B_MEM response to a booster dose of 13-valent pneumococcal conjugate vaccine (PCV-13) containing serotype 3 glycoconjugate. In the same study, it was shown that antibody persistence against most vaccine serotypes can be expected until the age of 3.5 years. A novel antigen-labelling technique was used in a detailed kinetics study of antigen-specific B cell subsets in response to either PCV-13 or 23-valent pneumococcal polysaccharide vaccine in adults. The results of this study revealed distinct B cell subset response patterns that were observed in all study participants indicating that IgM B_MEM seem to play a major role in the immune response to pneumococcal vaccines. In addition, in the same study, genome wide analysis of gene expression was performed and it was shown that vaccination with either a pneumococcal conjugate or polysaccharide vaccine results in a marked difference in numbers of differentially expressed genes 8 days following vaccination. A further tool likely to be of use in investigating B cell responses is the analysis of the antibody repertoire using next-generation sequencing techniques. In order to test the ability of these methods to detect vaccine responses, a large dataset of high-throughput B cell receptor sequences was analysed and revealed convergence of antigen-specific complementary-determining region (CDR)₃ amino acid (AA) sequences following vaccination and identified antigen-specific sequences. It was further demonstrated that for sequences directed against the H. influenzae type b (Hib) polysaccharide, diversity of immunoglobulin gene rearrangements is much greater than previously recognised. Frequencies of Hib-specific CDR₃ AA sequences were linked with anti-Hib avidity indices highlighting the potential of this method as an alternative (functional) measure of vaccine immunogenicity. These data suggest that studying the B cells and antibody repertoire post-vaccination can give novel insights into the biology that underlies the immune responses.