Pathogens responsible for blood stream infections according to age group^*.

*<p>Data are no. (%) or no. unless stated otherwise. Percents shown for column totals only for bacterial isolates by blood culture.</p>†<p>Pathogens isolated by blood culture unless indicated otherwise.</p>‡<p>Median age in months.</p>††<p>4 patients with <i>S.</i> Typhi and 1 patient with <i>S.</i> Paratyphi A were PCR positive for <i>R. typhi.</i></p

Etiological agents identified in febrile children presenting to the Pediatric Outpatient Department at Patan Hospital, Nepal, during the summer and winter study periods.

†<p>4 <i>R. typhi</i> PCR positive patients had <i>S</i>. Typhi and 1 had <i>S</i>. Paratyphi A in blood culture.</p

Demographic, clinical and laboratory features of patients with culture-confirmed enteric fever and their comparison with all the other patients in the cohort^*.

*<p>Data are no. (%) unless stated otherwise. SD, standard deviation; IQR, interquartile range.</p

Clinical characteristics of febrile children presenting to the Pediatric Outpatient Department at Patan Hospital, Nepal, during the summer and winter study periods.

<p>Clinical characteristics of febrile children presenting to the Pediatric Outpatient Department at Patan Hospital, Nepal, during the summer and winter study periods.</p

<i>Streptococcus pneumoniae</i> Carriage Prevalence in Nepal: Evaluation of a Method for Delayed Transport of Samples from Remote Regions and Implications for Vaccine Implementation

<div><p>Background</p><p>Pneumococcal disease is a significant cause of morbidity and mortality in young children in Nepal, and currently available pneumococcal conjugate vaccines offer moderate coverage of invasive disease isolates.</p><p>Methods</p><p>A prevalence study of children aged 1.5 to 24 months in urban and rural Nepal was conducted. In the urban group, nasopharyngeal swabs (NPS) were transported using silica desiccant packages (SDP) with delayed processing (2 weeks), or skim-milk-tryptone-glucose-glycerin (STGG) with immediate processing (within 8 hours). Pneumococcal nasopharyngeal carriage prevalence, serogroup/type distribution and isolate genotypes (as defined by multilocus sequence typing) were determined.</p><p>Results</p><p>1101 children were enrolled into the study: 574 in the urban group and 527 in the rural group. Overall carriage prevalence based on culture from specimens transported and stored in STGG was 58.7% (337/574), compared to 40.9% (235/574) in SDP. There was concordance of detection of pneumococcus in 67% of samples. Using the SDP method, pneumococcal carriage prevalence was higher in the rural population (69.2%; 364/526) compared to the urban population (40.9%; 235/574). Serogroup/type distribution varied with geographical location. Over half of the genotypes identified in both the urban and rural pneumococcal populations were novel.</p><p>Conclusion</p><p>The combination of delayed culture and transport using SDP underestimates the prevalence of pneumococcal carriage; however, in remote areas, this method could still provide a useful estimate of carriage prevalence and serogroup/type distribution. Vaccine impact is unpredictable in a setting with novel genotypes and limited serotype coverage as described here. Consequently, continued surveillance of pneumococcal isolates from carriage and disease in Nepali children following the planned introduction of pneumococcal conjugate vaccines introduction will be essential.</p></div

Clonal complexes identified in each study location.

<p>a. Clonal complexes are named with the sequence type (ST) predicted to be the ancestral ST. When the ancestral ST could not be determined, all STs in the clonal complex are indicated (e.g. 6025/7595). When an ST had no related variants it is marked as “STxx_Single”. The first 10 CCs listed were considered to be major CCs and the remainder were minor CCs.</p><p>b. KAT  =  Kathmandu; OKH  =  Okhaldhunga.</p><p>c. One serotype was unknown because the isolate was PCR-negative for the serotyping primers and the culture was nonviable (and thus unavailable for serotyping by Quellung).</p><p>d. Clonal complexes with: 4 isolates each, n = 15; 3 isolates each, n = 18; 2 isolates each, n = 30; and 1 isolate each, n = 123.</p

Frequency of pneumococcal serogroups/types in urban STGG samples compared to urban SDP samples.

<p>Frequency of pneumococcal serogroups/types in urban STGG samples compared to urban SDP samples.</p

Baseline demographic characteristics of participants.

<p>a. N = number of children.</p><p>b. Nasopharyngeal swab missing from one child in rural cohort.</p

Age-specific pneumococcal carriage rates.

<p>Age-specific pneumococcal carriage rates.</p

Serogroup/type concordance between the different swab transport methods.

<p>The size of data points is proportional to the frequency of isolates. Spn = <i>Streptococcus pneumoniae</i>, NT = nontypeable, NG = no growth.</p