the United States in which a greater association with HIV exists.7
In our demographics analysis, we also found that both the mother
and the father of HCV-positive infants reported a level of educa-
tion below than that found from parents of HCV-negative infants.
The reasons for this association are not clear, and it was not
possible to collect additional epidemiologic data that might have
provided insight into this risk factor.
Although some authorities have indicated that routine
screening of all pregnant women is not cost-effective and therefore
is not advocated.9Centers for Disease Control and Prevention and
American College of Obstetrics and Gynecology have both rec-
ommended that pregnant women with HCV risk factors, including
injection drug use or receipt of blood transfusion before July 1992,
be targeted for screening and counseling.13Unfortunately, selec-
tive HCV screening of high-risk pregnant women may not identify
all pregnant women with HCV infection as documented in Scot-
land where selective antenatal screening failed to identify 72% of
HCV infections.14Routine screening of pregnant women for HCV
at the prenatal visit may provide a potential means to prevent
transmission for that pregnancy and identify women who may choose
to undergo treatment for HCV infection at the end of the pregnancy.
Infants who become infected can be identified and can benefit from
newer antiviral therapy regimens that are more effective and better
tolerated than regimens currently used for children.15,16
The data from this study can be used to help assess the overall
cost-effectiveness of screening and early treatment for hepatitis C for
both mothers and their offsprings. Given a rate of infection of at least
rate of approximately 5%, the prevalence of actual HCV infection in
newborn infants in southern California can be estimated to be approx-
imately 0.0125% from this 2003 birth cohort. Of the approximately
540,000 live births in California in 2003, 70 infants will develop
hepatitis C infection. Of infants who develop perinatal infection,
about one-fourth will experience a spontaneous clearing of infection,
but 50 infants may develop chronic HCV infection annually, repre-
senting a significant illness burden to the California healthcare system
for liver failure and hepatocellular carcinoma later in life.15,17The
ability to detect asymptomatic HCV infection in pregnant women and
to treat both mothers (postpartum) and their infants to prevent chronic
liver disease are compelling reasons to reassess the benefits of routine
prenatal screening for HCV.
The authors thank Donald E. Mosier, MD, PhD (The
Scripps Research Institute) for collaboration on the study of
vertical transmission of HCV infection; John G. McHutchison, MD
(The Scripps Clinic) for collaboration on development of the filter
paper assay from adult HCV patients; Linda M. Bradley, PhD
(The Sidney Kimmel Cancer Center) and Evan S. Bradley for
performing the HCV EIA antibody assays, and the State of Cali-
fornia Department of Public Health, Retrovirus Diagnostic Sec-
tion, Viral and Rickettsial Diseases Laboratory for performing
testing for HIV on HCV-positive samples.
1. Recommendations for prevention and control of hepatitis C virus (HCV)
infection and HCV-related chronic disease. Centers for Disease Control and
Prevention. MMWR Recomm Rep. 1998;47:1–39.
2. Centers for Disease Control and Prevention. National Hepatitis C Preven-
tion Strategy (CDC 2001). Available at: http://www.cdc.gov/hepatitis/
HCV/Strategy/PDFs/NatHepCPrevStrategy.pdf. Accessed September 20,
3. Centers for Disease Control and Prevention. HCV guidelines and recom-
mendations for health professionals. Available at: http://www.cdc.gov/
hepatitis/HCV/GuidelinesC.htm. Accessed September 20, 2010.
4. Centers for Disease Control and Prevention. Third National Health and
Nutrition Examination Survey (NHANES III) Public-Use Data Files. Avail-
able at: http://www.cdc.gov/nchs/products/elec_prods/subject/nhanes3.htm.
Accessed September 20, 2010.
5. Centers for Disease Control and Prevention. Disease burden from viral
hepatitis A, B and C in the United States. Available at: http://www.cdc.gov/
hepatitis/PDFs/disease_burden.pdf. Accessed September 20, 2010.
6. American Academy of Pediatrics. Hepatitis C. In: Pickering L, ed. 2009
Red Book: Report of the Committee on Infectious Diseases. 28th ed. Elk
Grove Village, IL: American Academy of Pediatrics; 2009:357–360.
7. Polis CB, Shah SN, Johnson KE, et al. Impact of maternal HIV coinfection
on the vertical transmission of hepatitis C virus: a meta-analysis. Clin Infect
8. Mast EE, Hwang LY, Seto DS, et al. Risk factors for perinatal transmission
of hepatitis C virus (HCV) and the natural history of HCV infection
acquired in infancy. J Infect Dis. 2005;192:1880–1889.
9. Plunkett BA, Grobman WA. Routine hepatitis C virus screening in pregnancy:
a cost-effectiveness analysis. Am J Obstet Gynecol. 2005;192:1153–1161.
10. Pappaioanou M, Kashamuka M, Behets F, et al. Accurate detection of
maternal antibodies to HIV in newborn whole blood dried on filter paper.
11. Wise M, Bialek S, Finelli L, et al. Changing trends in hepatitis C-related
mortality in the United States, 1995–2004. Hepatology. 2008;47:1128–1135.
12. Resti M, Azzari C, Galli L, et al. Maternal drug use is a preeminent risk
factor for mother-to-child hepatitis C virus transmission: results from a
multicenter study of 1372 mother-infant pairs. J Infect Dis. 2002;185:567–
13. Gonik B. The role of obstetrician/gynecologists in the management of
hepatitis C virus infection. Infect Dis Obstet Gynecol. 2008;2008:374517.
14. Hutchinson SJ, Goldberg DJ, King M, et al. Hepatitis C virus among
childbearing women in Scotland: prevalence, deprivation, and diagnosis.
15. Hu J, Doucette K, Hartling L, et al. Treatment of hepatitis C in children: a
systematic review. PLoS One. 2010;5:e11542.
16. Lemon SM, McKeating JA, Pietschmann T, et al. Development of novel
therapies for hepatitis C. Antiviral Res. 2010;86:79–92.
17. Jhaveri R, Grant W, Kauf TL, et al. The burden of hepatitis C virus
infection in children: estimated direct medical costs over a 10-year period.
J Pediatr. 2006;148:353–358.
ETIOLOGY OF MENINGITIS AMONG PATIENTS
ADMITTED TO A TERTIARY REFERRAL HOSPITAL
Paul C. Mullan, MD,*
Andrew P. Steenhoff, MB BCH, DCH, FCPAED,†
Heather Draper, MS,* Tara Wedin, MD,† Margaret Bafana,‡
Gabriel Anabwani, MB CHB, MMED, MSCE,§
Haruna Jibril, MB BS, FCMPAED, MSc,‡ Machacha Tshepo, MD,¶
and Gordon E. Schutze, MD*
Abstract: This retrospective review evaluated records of cerebrospinal
fluid samples between 2000 and 2008 at Princess Marina Hospital in
Gaborone, Botswana. Of the 7501 cerebrospinal fluid samples reviewed,
Streptococcus pneumoniae (n ? 125) and Haemophilus influenzae (n ?
60) were the most common bacteria cultured. There were also 1018
cryptococcal and 44 tuberculous meningitis cases. Antimicrobial suscep-
tibilities are described. Public health interventions could decrease the
burden of meningitis in Botswana.
Key Words: meningitis, tuberculosis, Africa, vaccine, Pneumococcus,
Accepted for publication December 16, 2010.
From the *Department of Pediatrics, Baylor College of Medicine, Houston, TX;
†Department of Pediatrics, Division of Infectious Diseases, University of
Pennsylvania, Philadelphia, PA; ‡Botswana Ministry of Health, Gaborone,
Botswana; §Botswana-Baylor Children’s Clinical Centre of Excellence,
Gaborone, Botswana; and ¶Department of Paediatrics, Princess Marina
Hospital, Gaborone, Botswana.
Mullan et al
The Pediatric Infectious Disease Journal • Volume 30, Number 7, July 2011
© 2011 Lippincott Williams & Wilkins
620 | www.pidj.com
Address for correspondence: Paul C. Mullan, MD, 6621 Fannin, MC1-1481,
Houston, TX 77030. E-mail: email@example.com.
50%.1Descriptive meningitis data have been published in other
countries in Sub-Saharan Africa1but are incomplete in Botswana.
We retrospectively reviewed the laboratory records of cerebrospi-
nal fluid (CSF) samples that were collected at the nation’s largest
public hospital in Gaborone, Botswana, to help guide empirical
therapy decisions, to inform decisions about antibiotic availability
in specific regions, and to advocate for the introduction of appro-
eningitis is a major cause of mortality and morbidity in
developing countries, with mortality rates as high as 30% to
MATERIALS AND METHODS
Setting. Laboratory data from CSF samples collected between
January 1, 2000 and May 31, 2008 at the Princess Marina Hospital
in Gaborone were retrospectively reviewed.
Laboratory Methods. After collection, CSF samples were pro-
cessed at the Botswana National Health Laboratory. They were plated
onto sheep blood agar, chocolate agar, and Sabouraud dextrose agar
and incubated at 35°C in 5% CO2(Sabouraud and chocolate agar) or
ambient air (Sabouraud). Plates were checked daily for 72 hours. Any
growth of organisms was subsequently speciated and antibiotic sus-
ceptibility testing was determined by disk diffusion method.2All
supplies were checked routinely for contamination and known Amer-
ican Type Culture Collection strains were used for quality control.
The CSF leukocyte count was performed using an improved Neu-
bauer counting chamber.
If requested, samples sent to the National Tuberculosis
Reference Laboratory (NTRL) were acid-fast stained and exam-
ined by fluorescent microscopy. They were also cultured for up to
12 weeks on Lowenstein-Jensen media and susceptibilities to
isoniazid, rifampin, ethambutol, streptomycin, and para nitroben-
zoic acid were determined.
Case Identification. Laboratory record books and electronic data-
bases from the Botswana National Health Laboratory were re-
viewed. Any sample received from a patient who had a second
sample submitted within 3 weeks of the first sample was counted
as a single positive case. Any positive CSF culture that was
suspicious for a contaminant was excluded if the sample had ?10
leukocytes/mL. Cryptococcal meningitis was defined by a positive
cryptococcal culture. India ink testing was performed on all sam-
ples and results were reviewed. Additionally, laboratory record
books from the National Tuberculosis Reference Laboratory were
reviewed to capture all samples that were processed for workup of
tuberculous meningitis (TBM).
Data Management and Statistical Analysis. Data were entered into
Microsoft Excel 2004 and analyzed by STATA statistical software,
v9.2 (College Station, TX). Descriptive and summary statistics
were reported for all variables. A P value of ?0.05 was deemed
statistically significant. This study was approved by the Health
Research Unit in Botswana, the Institutional Review Board at
Princess Marina Hospital, and Baylor College of Medicine in
Houston, TX. Due to the retrospective nature of this study, in-
formed consent was waived for study subjects.
Study Profile. There were 7501 CSF samples received during the
study period. Overall numbers and age ranges of each organism are
listed in Table 1. Due to absent record books at National Health
Laboratory and NTRL, 17% and 25% of the months were not
available, respectively, for analysis.
Bacterial Causes. Although Streptococcus pneumoniae was the
most common bacterial organism overall, Haemophilus influ-
enzae was the most frequent organism in the ?12-year-olds and
?5-year-olds, and made up 50% and 55% of the cases, respec-
tively. H. influenzae was seen most commonly between April
and September (P?0.01), whereas S. pneumoniae was seen
most commonly between May and October (P?0.001). Suscep-
tibility of S. pneumoniae samples was 64% to penicillin G (n ?
110 samples), 88% to cefotaxime (n ? 8), 95% to chloram-
phenicol (n ? 120), 97% to ampicillin (n ? 76), and 99% to
vancomycin (n ? 86). Susceptibility of H. influenzae samples
was 38% to amoxicillin/clavulanate (n ? 26), 74% to chloram-
phenicol (n ? 42), and 94% to cefotaxime (n ? 18). Between
the early and latter halves of the study, there was a significant
decrease in H. influenzae and S. pneumoniae susceptibility to
Tuberculous Meningitis. Of the 7501 study samples, 876 (12%)
were sent to the NTRL for workup of tuberculosis. Of the 44 cases
of TBM identified, 14 samples were positive for acid-fast bacilli
and 34 were culture-positive. The susceptibilities to streptomycin,
isoniazid, rifampin, ethambutol, and para nitrobenzoic acid were
81%, 96%, 96%, 100%, and 100%, respectively.
Organisms Isolated From Cerebrospinal Fluid Samples From Princess Marina Hospital in
Organism All Ages
Cases With Patient
of Unknown Age
Group B Streptococcus
Total positive cultures per age group
Total negative cultures per age group
*For M. tuberculosis, culture positive and/or acid-fast bacilli positive cases are included in this number.
†Other (total): Staphylococcus epidermidis (3), other Streptococcus spp. (3), Acinetobacter (1), Citrobacter (1), Neisseria meningitidis (1), nonlactose fermenter (1), Pseudomonas
aeruginosa (1). In certain settings, these organisms may be contaminants. Except for Cryptococcus, a positive culture with ?9 leucocytes/mm3in the CSF of any of the listed cultures
was defined as a contaminant and excluded.
The Pediatric Infectious Disease Journal • Volume 30, Number 7, July 2011Meningitis in Botswana
© 2011 Lippincott Williams & Wilkins
www.pidj.com | 621
Cryptococcal Meningitis. There were 1155 cases of cryptococcal
meningitis during the study period. India ink results were recorded
on 7499 of the 7501 samples. India ink testing had a sensitivity of
91% (95% confidence interval: 89, 93) and a negative predictive
value of 98.6% (95% confidence interval: 98.3, 98.9). A higher
proportion of Cryptococcus cases were reported between the May
and October months than in the months between November and
These results have provided new data describing the burden
of meningitis seen in Botswana. A retrospective review in nearby
Pretoria, South Africa,3showed similar findings to our data, with
57% of cases being caused by H. influenzae and 33% caused by S.
pneumoniae. The Integrated Management of Childhood Illness
(IMCI) standard recommendation for empiric meningitis treatment
in the absence of known resistance is chloramphenicol plus either
ampicillin or benzylpenicillin.4When considering the H. influen-
zae and S. pneumoniae pediatric (?12 years) cases in this study,
these regimens had antimicrobial susceptibilities of 87% (66/76)
and 79% (64/81); a third generation cephalosporin (eg, cefo-
taxime) would have provided 100% (17/17) coverage. The Bo-
tswana-specific IMCI committee is now recommending cefo-
taxime as empiric meningitis coverage for pediatric patients more
than 2 months of age.
With increasingly drug-resistant S. pneumoniae and H.
influenzae, the implementation of effective vaccines assumes even
greater priority. The vaccine program of Botswana is very effec-
tive, with coverage rates as high as 96% for the third DTP
vaccine.5This study should prove useful to national decision
makers as they prioritize vaccinations in Botswana—-neither the
H. influenzae type b (Hib) nor pneumococcal vaccine are included
in current national guidelines. After the introduction of a nonava-
lent pneumococcal conjugate vaccine in South Africa, first inva-
sive pneumococcal disease events in children were reduced by
65% to 83%.6A S. pneumoniae nasopharyngeal carriage study in
Botswana found that 4 of the invasive serotypes found in the
population are present in the nonavalent pneumococcal vaccine.7
Commencing pneumococcal vaccination in children would also
likely lead to decreased invasive pneumococcal disease in the adult
population.8Similarly, the introduction of Hib vaccines in South
Africa precipitated a 65% decrease in the absolute number of
invasive Hib cases seen in children.9Given our proximity to South
Africa, one could estimate that Hib is likely to be responsible for
97% of H. influenzae meningitis cases.10
Other regional studies have described higher rates of TBM
than this study’s finding that 3.1% of all causes of meningitis were
TBM.11This was surprising given the high rates of immune
suppression and tuberculosis in Botswana. Our results could be
due to patient (or caregiver) refusals of lumbar punctures, the
cumbersome physician ordering process that currently exists, or
the substandard handling of specimens that might limit the yield of
cultures. With increasing rates of resistance to first-line antituber-
culosis therapy in Southern Africa, clinicians should prioritize
sending CSF samples for TB culture and susceptibility studies.
Our study had a number of limitations that likely limited
the magnitude of meningitis cases. First, we were missing 21%
of the study period’s laboratory books. Laboratory personnel
have now been trained to use Microsoft Excel for electronic
record keeping. Second, the number of CSF samples may have
been affected by patients declining lumbar puncture due to the
misperception that the procedure is what causes the patient’s
death. Additionally, many clinical meningitis cases may have
been pretreated before hospital CSF analysis, thereby limiting
culture yield. S. pneumoniae and H. influenzae were the leading
causes of bacterial meningitis. Public health measures could
combat these vaccine-preventable diseases to limit sequelae and
mortalities. Early diagnosis, improved lay public knowledge,
enhanced antibiotic availability, and adherence to Botswana-
specific IMCI empiric antibiotic choices will also improve the
outcome for those who do become infected. The variance in
specific patterns of meningitic organisms across Africa high-
lights the need for continued local surveillance to determine
appropriate healthcare interventions.
The authors thank the Botswana National Health Labora-
tory and the National Tuberculosis Reference Laboratory for their
assistance. The authors also thank Dr. Edward Mason and Dr. Sue
Torrey for reviewing the manuscript.
1. Peltola H. Burden of meningitis and other severe bacterial infections of
children in Africa: implications for prevention. Clin Infect Dis. 2001;32:
2. Standards NCfCL. Performance Standards for Antimicrobial Disk Suscep-
tibility Tests: Approved Standard. 8th ed, M2-A8. Wayne, PA: NCCLS;
3. Grobler AC, Hay IT. Bacterial meningitis in children at Kalafong Hospital,
1990–1995. S Afr Med J. 1997;87:1052–1054.
4. World Health Organization. Integrated Management of Childhood Illness
Handbook. 2008. Available at: http://whqlibdoc.who.int/publications/2008/
9789241597289_eng.pdf. Accessed October 8, 2010.
5. UNICEF. Info by country - Botswana statistics. 2008. Available at: http://
www.unicef.org/infobycountry/botswana_statistics.html. Accessed October
6. Klugman KP, Madhi SA, Huebner RE, et al. A trial of a 9-valent pneumo-
coccal conjugate vaccine in children with and those without HIV infection.
N Engl J Med. 2003;349:1341–1348.
7. Huebner RE, Wasas A, Mushi A, et al. Nasopharyngeal carriage and
antimicrobial resistance in isolates of Streptococcus pneumoniae and Hae-
mophilus influenzae type b in children under 5 years of age in Botswana. Int
J Infect Dis. 1998;3:18–25.
8. Centers for Disease Control and Prevention. Direct and indirect effects of
routine vaccination of children with 7-valent pneumococcal conjugate
vaccine on incidence of invasive pneumococcal disease–United States,
1998–2003. Morb Mortal Wkly Rep. 2005;54:893–897.
9. von Gottberg A, de Gouveia L, Madhi SA, et al. Impact of conjugate
Haemophilus influenzae type b (Hib) vaccine introduction in South Africa.
Bull World Health Organ. 2006;84:811–818.
10. Hussey G, Hitchcock J, Schaaf H, et al. Epidemiology of invasive Haemo-
philus influenzae infections in Cape Town, South Africa. Ann Trop Paedi-
11. Donald PR, Cotton MF, Hendricks MK, et al. Pediatric meningitis in the
Western Cape Province of South Africa. J Trop Pediatr. 1996;42:256–261.
2009 INFLUENZA A H1N1 INFECTIONS
DELAYS IN STARTING TREATMENT WITH OSELTAMIVIR
WERE ASSOCIATED WITH A MORE SEVERE DISEASE
Cristian Launes, MD,* Juan-Jose ´ García-García, MD, PhD,*
Iolanda Jorda ´n, MD, PhD,† Aina Martínez-Planas, MD,*
Laura Selva, MSc,‡ and Carmen Mun ˜oz-Almagro, MD, PhD‡
Abstract: Respiratory failure has been the main severe complication
described in pediatric patients with influenza A H1N1 2009 (pandemic
H1N1) infection. We describe the pandemic H1N1 2009 disease in children
who required hospital admission and the patients’ data associated with
pediatric intensive care unit admission. Respiratory failure was the main
complication. Extrapulmonary manifestations were also observed. Of the
Launes et al
The Pediatric Infectious Disease Journal • Volume 30, Number 7, July 2011
© 2011 Lippincott Williams & Wilkins
622 | www.pidj.com