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Background: Group A streptococcus (GAS) pharyngitis is associated with high rates of rheumatic heart disease in developing countries. We sought to identify guidelines for empiric treatment of pharyngitis in low-resource settings. To inform the design of GAS vaccines, we determined the emm types associated with pharyngitis among African schoolchildren., Methods: Surveillance for pharyngitis was conducted among children 5-16 years of age attending schools in Bamako, Mali. Students were encouraged to visit a study clinician when they had a sore throat. Enrollees underwent evaluation and throat swab for isolation of GAS. Strains were emm typed by standard methods., Results: GAS was isolated from 449 (25.5%) of the 1,759 sore throat episodes. Painful cervical adenopathy was identified in 403 children (89.8%) with GAS infection and was absent in 369 uninfected children (28.2%). Emm type was determined in 396 (88.2%) of the 449 culture-positive children; 70 types were represented and 14 types accounted for 49% of isolates. Based on the proportion of the 449 isolates bearing emm types included in the 30-valent vaccine (31.0%) plus nonvaccine types previously shown to react to vaccine-induced bactericidal antibodies (44.1%), the vaccine could protect against almost 75% of GAS infections among Bamako schoolchildren., Conclusions: Two promising strategies could reduce rheumatic heart disease in low-resource settings. Administering antibiotics to children with sore throat and tender cervical adenopathy could treat most GAS-positive children while reducing use of unnecessary antibiotics for uninfected children. Broad coverage against M types associated with pharyngitis in Bamako schoolchildren might be achieved with the 30-valent GAS vaccine under development.

Background: The population exposed to malaria within African cities has steadily increased. However, comprehensive data on life-threatening malaria features and risk factors in children from urban areas with seasonal malaria transmission, such as in Bamako (Mali), are lacking., Methods: Children admitted to the Gabriel Touré Hospital in Bamako with severe malarial anemia (SMA) and/or cerebral malaria (CM) were prospectively included in the study. Indicators of either SMA or CM were analyzed using logistic regression; and death hazard ratios (HRs) were estimated through survival analysis., Results: The study included 455 children: 66% presented with CM, 34% with SMA, 3% with hypoglycemia (HG); 5% with dehydration; 17% with respiratory distress (RD); 25% with splenomegaly; and 92% with hepatomegaly. The children with CM were older than those with SMA. CM was more often associated with dehydration, HG, and RD, whereas SMA was more often associated with splenomegaly. The overall case fatality rate was 16%, and 94% of the children who died had CM. HG [HR: 2.37; 95% confidence interval (CI): 1.04-5.39; P = 0.040], RD (HR: 4.23; 95% CI: 2.46-7.30; P < 10(-6)) and a deep coma with a Blantyre score of less than 3 (HR: 6.78, 95% CI: 2.43-18.91; P < 10(-3)), were all independent predictors of death., Conclusions: These findings delineate the patterns of severe malaria in children in a West African mesoendemic urban setting. They validate practicable prognostic indicators of life-threatening malaria for use in the limited facilities available in African health centers and provide a frame of reference for further research addressing life-threatening malaria in this setting.

Background: Population-based, bacteriologically confirmed disease burden data aid decision makers in African countries pondering whether to introduce Haemophilus influenzae type b (Hib) immunization for infants., Methods: A bacteriology laboratory was established in Hopital Gabriel Toure, serving Bamako, Mali. Children age 0-15 years with fever > or =39 degrees C or syndromes compatible with invasive bacterial disease (meningitis, etc.) were eligible. From 2 to 5 mL of blood or relevant body fluid were inoculated into Bactec Ped Plus/F medium for automated culture; body fluids were also inoculated directly onto solid media. Hib was confirmed by standard microbiologic techniques and antibiograms generated by disk diffusion., Results: From June 1, 2002 to May 31, 2004, 3592 (87.8%) of 4092 children admitted to Hopital Gabriel Toure with high fever or suspected invasive bacterial disease were cultured, including 1745 who were 0-11 months old, 1132 who were 1-4 years old and 715 who were 5-15 years old. Hib was isolated from 207 Bamako children, 81 from blood alone and 124 from cerebrospinal fluid (with or without positive blood culture). Of 207 cases 204 (98.5%) occurred in children younger than age 5 years (annual incidence, 45.2/10) and 159 (77%) in infants age 0-11 months (annual incidence, 158.4/10). Peak incidence (370.0 cases/10) and 12 of 21 Hib deaths occurred in 6- to 7-month-olds. Of the Hib isolates, 11.1% were resistant to ampicillin, 32% to chloramphenicol and 0.5% to ceftriaxone., Conclusions: The substantial burden of invasive Hib disease documented in Bamako has prompted the Malian government to introduce routine infant immunization with Hib conjugate.

Background: Prevention of invasive pneumococcal disease (IPD) in children is a global public health priority, and determination of the most common serotypes is crucial for vaccine development and implementation., Methods: We performed prospective surveillance for IPD in hospitalized children in Bamako, Mali. All febrile children and others suspected to have invasive bacterial disease had an admission blood culture and cultures of additional anatomic sites when indicated. Standard microbiologic methods were used to identify, serotype and determine antibiograms for pneumococcal isolates., Results: Of 2,049 children enrolled, 106 (5%) had an IPD, including 47 cases of meningitis and 44 bacteremic pneumonias. The incidence was highest in infants (84/100,000/year). The overall IPD case fatality rate was 24%. Only 2 of 96 isolates were nonsusceptible to penicillin. The serotypes isolated were 5 (54%), 2 (14%), 7F (10%), 19F (8%), 6A/B (3%), 9V (3%), 1 (2%) and 14 (1%)., Conclusions: IPD is common and frequently fatal among hospitalized children in Mali, but surprisingly little resistance has occurred. Notably, 91% of the serotypes causing IPD in Bamako children are found in the 11-valent pneumococcal conjugate vaccine.