Invasive Haemophilus influenza Type b in an Infant During the COVID-19 Pandemic: The Return of Diseases We Hoped Never to See Again….

To the Editors:

A 7-month-old previously healthy female was admitted to our hospital with generalized tonic-clonic seizures, 4 days history of fever (102.9 F) and nonbilious nonbloody emesis. Meningitis was diagnosed with a lumbar puncture that revealed pleocytosis. Brain magnetic resonance imaging with and without contrast showed subdural collections over both convexities. Hemophilus influenzae type b was isolated from blood and cerebrospinal fluid cultures.

On hospital day (HD) 8 and HD 26, the patient underwent transfontanel subdural taps for the persistence of the subdural collections. On HD 44, a magnetic resonance imaging (Fig. 1) revealed a loculated subdural empyema with a markedly worsened midline shift. The patient underwent a craniotomy with the removal of the pyogenic membrane and drainage of the fluid.

FIGURE 1.

MRI brain with and without contrast (HD 44) showing right subdural empyema that was more loculated and organized, exerting more mass effect leading to increased leftward midline shift compared with MRI brain with and without contrast (HD 25), communicating hydrocephalus. MRI indicates magnetic resonance imaging.

Before the availability of vaccinations, H. influenzae type b was the leading cause of bacterial meningitis in the United States. Following widespread vaccination, the disease virtually disappeared with the annual incidence of Hib decreasing to an estimated annual incidence of 0.27 cases per 100,000 children <5 years of age since 2001.[1]

Risk factors for invasive Hib disease in our patient included her age and, most important, lack of Hib vaccination. Routine immunization services faced stark challenges in 2020, with the coronavirus disease 2019 (COVID-19) pandemic causing the most widespread and most significant global disruption in recent history. Supply and facility constraints, fear of severe acute respiratory syndrome coronavirus 2 exposure in healthcare settings, as was the case in our patient, might explain why routine immunization was among the most affected health services. Globally, estimated coverage in 2020 fell to 76.7% for third-dose diphtheria-tetanus-pertussis vaccine while first-dose measles-containing vaccine dropped to 78.9%.[2] A recent study suggests a potential 10% increase in mortality from vaccine-preventable diseases due to pandemic-related disruptions to routine immunization.[3] The second half of 2020 showed signs of recovery; nevertheless, recovery efforts were far from complete.

While COVID-19 remains a formidable threat in 2021, even when the pandemic wants gaps in vaccine coverage increase, the risk of vaccine-preventable disease outbreaks.

Many current US trainees have likely never seen or managed Hib meningitis. Due to falling vaccination rates related to COVID-19, providers should be alert to the presence of vaccine-preventable infections and their management. In addition, strengthening routine immunization data systems and efforts to target resources and outreach, reaching children who missed regular vaccine doses during the pandemic will be essential to minimize the risk of vaccine-preventable disease outbreaks; otherwise the world’s fragile progress could easily give way to vaccine-preventable disease outbreaks in 2021 and beyond.