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Incidences of vaccine-preventable Haemophilus influenzae type b pneumonia and meningitis in Indonesian children: hamlet-randomised vaccine-probe trial. Comment

Identifieur interne : 001577 ( PascalFrancis/Curation ); précédent : 001576; suivant : 001578

Incidences of vaccine-preventable Haemophilus influenzae type b pneumonia and meningitis in Indonesian children: hamlet-randomised vaccine-probe trial. Comment

Auteurs : Bradford D. Gessner [France] ; Agustinus Sutanto [Indonésie] ; Mary Linehan [États-Unis] ; I. Gusti Gede Djelantik [Indonésie] ; Tracy Fletcher [États-Unis] ; I. Komang Gerudug [Indonésie] ; INGERANI [Indonésie] ; David Mercer [États-Unis] ; Vanda Moniaga [États-Unis] ; Lawrence H. Moulton [États-Unis] ; Kim Mulholland [Australie] ; Carib Nelson [États-Unis] ; Soewignjo Soemohardjo [Indonésie] ; Mark Steinhoff [États-Unis] ; Anton Widjaya [États-Unis] ; Philippe Stoeckel [France] ; James Maynard [États-Unis] ; Soemarjati Arjoso [Indonésie] ; Ana Lucia S. Sgambatti De Andrade [France] ; Celina M. Turchi Martelli [France]

Source :

RBID : Pascal:05-0068634

Descripteurs français

English descriptors

Abstract

Background Most studies of Haemophilus influenzae type b (Hib) disease in Asia have found low rates, and few Asian countries use Hib vaccine in routine immunisation programmes. Whether Hib disease truly is rare or whether many cases remain undetected is unclear. Methods To estimate incidences of vaccine-preventable Hib pneumonia and meningitis among children younger than 2 years in Lombok, Indonesia, during 1998-2002, we undertook a hamlet-randomised, controlled, double-blind vaccine-probe study (818 hamlets). Children were immunised (WHO schedule) with diphtheria, tetanus, pertussis (DTP) or DTP-PRP-T (Hib conjugate) vaccine. Vaccine-preventable disease incidences were calculated as the difference in rates of clinical outcomes between DTP and DTP-PRP-T groups. Analyses included all children who received at least one vaccine dose. Findings We enrolled 55 073 children: 28 147 were assigned DTP-PRP-T and 26 926 DTP. The proportion of pneumonia outcomes prevented by vaccine ranged from less than 0 to 4.8%. Calculated incidences of vaccine-preventable Hib disease (per 105 child-years of observation) for outcome categories were: substantial alveolar consolidation or effusion, less than zero (-43 [95% CI -185 to 98]); all severe pneumonia, 264 (95% CI less than zero to 629); all clinical pneumonia, 1561 (270 to 2853); confirmed Hib meningitis, 16 (1.4 to 31); meningitis with cerebrospinal-fluid findings consistent with a bacterial aetiology, 67 (22 to 112); and admission for suspected meningitis or presenting to a clinic with convulsions, 158 (42 to 273). Interpretation Hib vaccine did not prevent the great majority of pneumonia cases, including those with alveolar consolidation. These results do not support a major role for Hib vaccine in overall pneumonia-prevention programmes. Nevertheless, the study identified high incidences of Hib meningitis and pneumonia; inclusion of Hib vaccine in routine infant immunisation programmes in Asia deserves consideration.
pA  
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A02 01      @0 LANCAO
A03   1    @0 Lancet : (Br. ed.)
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A08 01  1  ENG  @1 Incidences of vaccine-preventable Haemophilus influenzae type b pneumonia and meningitis in Indonesian children: hamlet-randomised vaccine-probe trial. Comment
A11 01  1    @1 GESSNER (Bradford D.)
A11 02  1    @1 SUTANTO (Agustinus)
A11 03  1    @1 LINEHAN (Mary)
A11 04  1    @1 GEDE DJELANTIK (I. Gusti)
A11 05  1    @1 FLETCHER (Tracy)
A11 06  1    @1 GERUDUG (I. Komang)
A11 07  1    @1 INGERANI
A11 08  1    @1 MERCER (David)
A11 09  1    @1 MONIAGA (Vanda)
A11 10  1    @1 MOULTON (Lawrence H.)
A11 11  1    @1 MULHOLLAND (Kim)
A11 12  1    @1 NELSON (Carib)
A11 13  1    @1 SOEMOHARDJO (Soewignjo)
A11 14  1    @1 STEINHOFF (Mark)
A11 15  1    @1 WIDJAYA (Anton)
A11 16  1    @1 STOECKEL (Philippe)
A11 17  1    @1 MAYNARD (James)
A11 18  1    @1 ARJOSO (Soemarjati)
A11 19  1    @1 SGAMBATTI DE ANDRADE (Ana Lucia S.) @9 comment.
A11 20  1    @1 TURCHI MARTELLI (Celina M.) @9 comment.
A14 01      @1 Association Pour l'Aide à la Médecine Préventive @2 Paris @3 FRA @Z 1 aut. @Z 16 aut.
A14 02      @1 West Nusa Tenggara Provincial Government @2 Lombok @3 IDN @Z 2 aut. @Z 4 aut. @Z 6 aut. @Z 13 aut.
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A14 04      @1 Indonesian Ministry of Health @2 Jakarta @3 IDN @Z 7 aut. @Z 18 aut.
A14 05      @1 Department of International Health, Bloomberg School of Public Health, Johns Hopkins University @2 Baltimore, MD @3 USA @Z 10 aut. @Z 14 aut.
A14 06      @1 University of Melbourne @2 Melbourne @3 AUS @Z 11 aut.
A14 07      @1 Departamento de Saúde Coletiva, Universidade Federal de Goiás. S Universitário @2 Goiânia, 74605-050 @3 FRA @Z 19 aut. @Z 20 aut.
A20       @2 5-7,43-52 [13 p.]
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C01 01    ENG  @0 Background Most studies of Haemophilus influenzae type b (Hib) disease in Asia have found low rates, and few Asian countries use Hib vaccine in routine immunisation programmes. Whether Hib disease truly is rare or whether many cases remain undetected is unclear. Methods To estimate incidences of vaccine-preventable Hib pneumonia and meningitis among children younger than 2 years in Lombok, Indonesia, during 1998-2002, we undertook a hamlet-randomised, controlled, double-blind vaccine-probe study (818 hamlets). Children were immunised (WHO schedule) with diphtheria, tetanus, pertussis (DTP) or DTP-PRP-T (Hib conjugate) vaccine. Vaccine-preventable disease incidences were calculated as the difference in rates of clinical outcomes between DTP and DTP-PRP-T groups. Analyses included all children who received at least one vaccine dose. Findings We enrolled 55 073 children: 28 147 were assigned DTP-PRP-T and 26 926 DTP. The proportion of pneumonia outcomes prevented by vaccine ranged from less than 0 to 4.8%. Calculated incidences of vaccine-preventable Hib disease (per 105 child-years of observation) for outcome categories were: substantial alveolar consolidation or effusion, less than zero (-43 [95% CI -185 to 98]); all severe pneumonia, 264 (95% CI less than zero to 629); all clinical pneumonia, 1561 (270 to 2853); confirmed Hib meningitis, 16 (1.4 to 31); meningitis with cerebrospinal-fluid findings consistent with a bacterial aetiology, 67 (22 to 112); and admission for suspected meningitis or presenting to a clinic with convulsions, 158 (42 to 273). Interpretation Hib vaccine did not prevent the great majority of pneumonia cases, including those with alveolar consolidation. These results do not support a major role for Hib vaccine in overall pneumonia-prevention programmes. Nevertheless, the study identified high incidences of Hib meningitis and pneumonia; inclusion of Hib vaccine in routine infant immunisation programmes in Asia deserves consideration.
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<name sortKey="Steinhoff, Mark" sort="Steinhoff, Mark" uniqKey="Steinhoff M" first="Mark" last="Steinhoff">Mark Steinhoff</name>
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<name sortKey="Widjaya, Anton" sort="Widjaya, Anton" uniqKey="Widjaya A" first="Anton" last="Widjaya">Anton Widjaya</name>
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<name sortKey="Stoeckel, Philippe" sort="Stoeckel, Philippe" uniqKey="Stoeckel P" first="Philippe" last="Stoeckel">Philippe Stoeckel</name>
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<name sortKey="Maynard, James" sort="Maynard, James" uniqKey="Maynard J" first="James" last="Maynard">James Maynard</name>
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<name sortKey="Arjoso, Soemarjati" sort="Arjoso, Soemarjati" uniqKey="Arjoso S" first="Soemarjati" last="Arjoso">Soemarjati Arjoso</name>
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<name sortKey="Sgambatti De Andrade, Ana Lucia S" sort="Sgambatti De Andrade, Ana Lucia S" uniqKey="Sgambatti De Andrade A" first="Ana Lucia S." last="Sgambatti De Andrade">Ana Lucia S. Sgambatti De Andrade</name>
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<name sortKey="Turchi Martelli, Celina M" sort="Turchi Martelli, Celina M" uniqKey="Turchi Martelli C" first="Celina M." last="Turchi Martelli">Celina M. Turchi Martelli</name>
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<name sortKey="Moniaga, Vanda" sort="Moniaga, Vanda" uniqKey="Moniaga V" first="Vanda" last="Moniaga">Vanda Moniaga</name>
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<s1>Department of International Health, Bloomberg School of Public Health, Johns Hopkins University</s1>
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<name sortKey="Mulholland, Kim" sort="Mulholland, Kim" uniqKey="Mulholland K" first="Kim" last="Mulholland">Kim Mulholland</name>
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<inist:fA14 i1="06">
<s1>University of Melbourne</s1>
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<sZ>11 aut.</sZ>
</inist:fA14>
<country>Australie</country>
</affiliation>
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<name sortKey="Nelson, Carib" sort="Nelson, Carib" uniqKey="Nelson C" first="Carib" last="Nelson">Carib Nelson</name>
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<s1>Program for Appropriate Technology in Health</s1>
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<name sortKey="Soemohardjo, Soewignjo" sort="Soemohardjo, Soewignjo" uniqKey="Soemohardjo S" first="Soewignjo" last="Soemohardjo">Soewignjo Soemohardjo</name>
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<inist:fA14 i1="02">
<s1>West Nusa Tenggara Provincial Government</s1>
<s2>Lombok</s2>
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<sZ>2 aut.</sZ>
<sZ>4 aut.</sZ>
<sZ>6 aut.</sZ>
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<country>Indonésie</country>
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<name sortKey="Steinhoff, Mark" sort="Steinhoff, Mark" uniqKey="Steinhoff M" first="Mark" last="Steinhoff">Mark Steinhoff</name>
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<inist:fA14 i1="05">
<s1>Department of International Health, Bloomberg School of Public Health, Johns Hopkins University</s1>
<s2>Baltimore, MD</s2>
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<sZ>10 aut.</sZ>
<sZ>14 aut.</sZ>
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<name sortKey="Widjaya, Anton" sort="Widjaya, Anton" uniqKey="Widjaya A" first="Anton" last="Widjaya">Anton Widjaya</name>
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<name sortKey="Stoeckel, Philippe" sort="Stoeckel, Philippe" uniqKey="Stoeckel P" first="Philippe" last="Stoeckel">Philippe Stoeckel</name>
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<s1>Association Pour l'Aide à la Médecine Préventive</s1>
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<country>France</country>
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<name sortKey="Maynard, James" sort="Maynard, James" uniqKey="Maynard J" first="James" last="Maynard">James Maynard</name>
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<name sortKey="Arjoso, Soemarjati" sort="Arjoso, Soemarjati" uniqKey="Arjoso S" first="Soemarjati" last="Arjoso">Soemarjati Arjoso</name>
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<name sortKey="Sgambatti De Andrade, Ana Lucia S" sort="Sgambatti De Andrade, Ana Lucia S" uniqKey="Sgambatti De Andrade A" first="Ana Lucia S." last="Sgambatti De Andrade">Ana Lucia S. Sgambatti De Andrade</name>
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<inist:fA14 i1="07">
<s1>Departamento de Saúde Coletiva, Universidade Federal de Goiás. S Universitário</s1>
<s2>Goiânia, 74605-050</s2>
<s3>FRA</s3>
<sZ>19 aut.</sZ>
<sZ>20 aut.</sZ>
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<country>France</country>
</affiliation>
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<author>
<name sortKey="Turchi Martelli, Celina M" sort="Turchi Martelli, Celina M" uniqKey="Turchi Martelli C" first="Celina M." last="Turchi Martelli">Celina M. Turchi Martelli</name>
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<s1>Departamento de Saúde Coletiva, Universidade Federal de Goiás. S Universitário</s1>
<s2>Goiânia, 74605-050</s2>
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<country>France</country>
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<series>
<title level="j" type="main">Lancet : (British edition)</title>
<title level="j" type="abbreviated">Lancet : (Br. ed.)</title>
<idno type="ISSN">0140-6736</idno>
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<date when="2005">2005</date>
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<title level="j" type="main">Lancet : (British edition)</title>
<title level="j" type="abbreviated">Lancet : (Br. ed.)</title>
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<keywords scheme="KwdEn" xml:lang="en">
<term>Child</term>
<term>Clinical trial</term>
<term>Epidemiology</term>
<term>Haemophilus influenzae</term>
<term>Immunoprophylaxis</term>
<term>Incidence</term>
<term>Indonesia</term>
<term>Medicine</term>
<term>Meningitis</term>
<term>Pneumonia</term>
<term>Prevention</term>
<term>Probe</term>
<term>Vaccine</term>
</keywords>
<keywords scheme="Pascal" xml:lang="fr">
<term>Immunoprophylaxie</term>
<term>Incidence</term>
<term>Epidémiologie</term>
<term>Pneumonie</term>
<term>Prévention</term>
<term>Vaccin</term>
<term>Méningite</term>
<term>Haemophilus influenzae</term>
<term>Indonésie</term>
<term>Enfant</term>
<term>Essai clinique</term>
<term>Sonde</term>
<term>Médecine</term>
</keywords>
<keywords scheme="Wicri" type="geographic" xml:lang="fr">
<term>Indonésie</term>
</keywords>
<keywords scheme="Wicri" type="topic" xml:lang="fr">
<term>Vaccin</term>
<term>Enfant</term>
<term>Médecine</term>
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<front>
<div type="abstract" xml:lang="en">Background Most studies of Haemophilus influenzae type b (Hib) disease in Asia have found low rates, and few Asian countries use Hib vaccine in routine immunisation programmes. Whether Hib disease truly is rare or whether many cases remain undetected is unclear. Methods To estimate incidences of vaccine-preventable Hib pneumonia and meningitis among children younger than 2 years in Lombok, Indonesia, during 1998-2002, we undertook a hamlet-randomised, controlled, double-blind vaccine-probe study (818 hamlets). Children were immunised (WHO schedule) with diphtheria, tetanus, pertussis (DTP) or DTP-PRP-T (Hib conjugate) vaccine. Vaccine-preventable disease incidences were calculated as the difference in rates of clinical outcomes between DTP and DTP-PRP-T groups. Analyses included all children who received at least one vaccine dose. Findings We enrolled 55 073 children: 28 147 were assigned DTP-PRP-T and 26 926 DTP. The proportion of pneumonia outcomes prevented by vaccine ranged from less than 0 to 4.8%. Calculated incidences of vaccine-preventable Hib disease (per 10
<sup>5</sup>
child-years of observation) for outcome categories were: substantial alveolar consolidation or effusion, less than zero (-43 [95% CI -185 to 98]); all severe pneumonia, 264 (95% CI less than zero to 629); all clinical pneumonia, 1561 (270 to 2853); confirmed Hib meningitis, 16 (1.4 to 31); meningitis with cerebrospinal-fluid findings consistent with a bacterial aetiology, 67 (22 to 112); and admission for suspected meningitis or presenting to a clinic with convulsions, 158 (42 to 273). Interpretation Hib vaccine did not prevent the great majority of pneumonia cases, including those with alveolar consolidation. These results do not support a major role for Hib vaccine in overall pneumonia-prevention programmes. Nevertheless, the study identified high incidences of Hib meningitis and pneumonia; inclusion of Hib vaccine in routine infant immunisation programmes in Asia deserves consideration.</div>
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<s1>University of Melbourne</s1>
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<s0>Background Most studies of Haemophilus influenzae type b (Hib) disease in Asia have found low rates, and few Asian countries use Hib vaccine in routine immunisation programmes. Whether Hib disease truly is rare or whether many cases remain undetected is unclear. Methods To estimate incidences of vaccine-preventable Hib pneumonia and meningitis among children younger than 2 years in Lombok, Indonesia, during 1998-2002, we undertook a hamlet-randomised, controlled, double-blind vaccine-probe study (818 hamlets). Children were immunised (WHO schedule) with diphtheria, tetanus, pertussis (DTP) or DTP-PRP-T (Hib conjugate) vaccine. Vaccine-preventable disease incidences were calculated as the difference in rates of clinical outcomes between DTP and DTP-PRP-T groups. Analyses included all children who received at least one vaccine dose. Findings We enrolled 55 073 children: 28 147 were assigned DTP-PRP-T and 26 926 DTP. The proportion of pneumonia outcomes prevented by vaccine ranged from less than 0 to 4.8%. Calculated incidences of vaccine-preventable Hib disease (per 10
<sup>5</sup>
child-years of observation) for outcome categories were: substantial alveolar consolidation or effusion, less than zero (-43 [95% CI -185 to 98]); all severe pneumonia, 264 (95% CI less than zero to 629); all clinical pneumonia, 1561 (270 to 2853); confirmed Hib meningitis, 16 (1.4 to 31); meningitis with cerebrospinal-fluid findings consistent with a bacterial aetiology, 67 (22 to 112); and admission for suspected meningitis or presenting to a clinic with convulsions, 158 (42 to 273). Interpretation Hib vaccine did not prevent the great majority of pneumonia cases, including those with alveolar consolidation. These results do not support a major role for Hib vaccine in overall pneumonia-prevention programmes. Nevertheless, the study identified high incidences of Hib meningitis and pneumonia; inclusion of Hib vaccine in routine infant immunisation programmes in Asia deserves consideration.</s0>
</fC01>
<fC02 i1="01" i2="X">
<s0>002B01</s0>
</fC02>
<fC03 i1="01" i2="X" l="FRE">
<s0>Immunoprophylaxie</s0>
<s5>01</s5>
</fC03>
<fC03 i1="01" i2="X" l="ENG">
<s0>Immunoprophylaxis</s0>
<s5>01</s5>
</fC03>
<fC03 i1="01" i2="X" l="SPA">
<s0>Inmunoprofilaxia</s0>
<s5>01</s5>
</fC03>
<fC03 i1="02" i2="X" l="FRE">
<s0>Incidence</s0>
<s5>02</s5>
</fC03>
<fC03 i1="02" i2="X" l="ENG">
<s0>Incidence</s0>
<s5>02</s5>
</fC03>
<fC03 i1="02" i2="X" l="SPA">
<s0>Incidencia</s0>
<s5>02</s5>
</fC03>
<fC03 i1="03" i2="X" l="FRE">
<s0>Epidémiologie</s0>
<s5>03</s5>
</fC03>
<fC03 i1="03" i2="X" l="ENG">
<s0>Epidemiology</s0>
<s5>03</s5>
</fC03>
<fC03 i1="03" i2="X" l="SPA">
<s0>Epidemiología</s0>
<s5>03</s5>
</fC03>
<fC03 i1="04" i2="X" l="FRE">
<s0>Pneumonie</s0>
<s5>04</s5>
</fC03>
<fC03 i1="04" i2="X" l="ENG">
<s0>Pneumonia</s0>
<s5>04</s5>
</fC03>
<fC03 i1="04" i2="X" l="SPA">
<s0>Neumonía</s0>
<s5>04</s5>
</fC03>
<fC03 i1="05" i2="X" l="FRE">
<s0>Prévention</s0>
<s5>05</s5>
</fC03>
<fC03 i1="05" i2="X" l="ENG">
<s0>Prevention</s0>
<s5>05</s5>
</fC03>
<fC03 i1="05" i2="X" l="SPA">
<s0>Prevención</s0>
<s5>05</s5>
</fC03>
<fC03 i1="06" i2="X" l="FRE">
<s0>Vaccin</s0>
<s5>06</s5>
</fC03>
<fC03 i1="06" i2="X" l="ENG">
<s0>Vaccine</s0>
<s5>06</s5>
</fC03>
<fC03 i1="06" i2="X" l="SPA">
<s0>Vacuna</s0>
<s5>06</s5>
</fC03>
<fC03 i1="07" i2="X" l="FRE">
<s0>Méningite</s0>
<s5>07</s5>
</fC03>
<fC03 i1="07" i2="X" l="ENG">
<s0>Meningitis</s0>
<s5>07</s5>
</fC03>
<fC03 i1="07" i2="X" l="SPA">
<s0>Meningitis</s0>
<s5>07</s5>
</fC03>
<fC03 i1="08" i2="X" l="FRE">
<s0>Haemophilus influenzae</s0>
<s2>NS</s2>
<s5>08</s5>
</fC03>
<fC03 i1="08" i2="X" l="ENG">
<s0>Haemophilus influenzae</s0>
<s2>NS</s2>
<s5>08</s5>
</fC03>
<fC03 i1="08" i2="X" l="SPA">
<s0>Haemophilus influenzae</s0>
<s2>NS</s2>
<s5>08</s5>
</fC03>
<fC03 i1="09" i2="X" l="FRE">
<s0>Indonésie</s0>
<s2>NG</s2>
<s5>09</s5>
</fC03>
<fC03 i1="09" i2="X" l="ENG">
<s0>Indonesia</s0>
<s2>NG</s2>
<s5>09</s5>
</fC03>
<fC03 i1="09" i2="X" l="SPA">
<s0>Indonesia</s0>
<s2>NG</s2>
<s5>09</s5>
</fC03>
<fC03 i1="10" i2="X" l="FRE">
<s0>Enfant</s0>
<s5>11</s5>
</fC03>
<fC03 i1="10" i2="X" l="ENG">
<s0>Child</s0>
<s5>11</s5>
</fC03>
<fC03 i1="10" i2="X" l="SPA">
<s0>Niño</s0>
<s5>11</s5>
</fC03>
<fC03 i1="11" i2="X" l="FRE">
<s0>Essai clinique</s0>
<s5>12</s5>
</fC03>
<fC03 i1="11" i2="X" l="ENG">
<s0>Clinical trial</s0>
<s5>12</s5>
</fC03>
<fC03 i1="11" i2="X" l="SPA">
<s0>Ensayo clínico</s0>
<s5>12</s5>
</fC03>
<fC03 i1="12" i2="X" l="FRE">
<s0>Sonde</s0>
<s5>17</s5>
</fC03>
<fC03 i1="12" i2="X" l="ENG">
<s0>Probe</s0>
<s5>17</s5>
</fC03>
<fC03 i1="12" i2="X" l="SPA">
<s0>Sonda</s0>
<s5>17</s5>
</fC03>
<fC03 i1="13" i2="X" l="FRE">
<s0>Médecine</s0>
<s5>18</s5>
</fC03>
<fC03 i1="13" i2="X" l="ENG">
<s0>Medicine</s0>
<s5>18</s5>
</fC03>
<fC03 i1="13" i2="X" l="SPA">
<s0>Medicina</s0>
<s5>18</s5>
</fC03>
<fC07 i1="01" i2="X" l="FRE">
<s0>Pasteurellaceae</s0>
<s2>NS</s2>
</fC07>
<fC07 i1="01" i2="X" l="ENG">
<s0>Pasteurellaceae</s0>
<s2>NS</s2>
</fC07>
<fC07 i1="01" i2="X" l="SPA">
<s0>Pasteurellaceae</s0>
<s2>NS</s2>
</fC07>
<fC07 i1="02" i2="X" l="FRE">
<s0>Bactérie</s0>
</fC07>
<fC07 i1="02" i2="X" l="ENG">
<s0>Bacteria</s0>
</fC07>
<fC07 i1="02" i2="X" l="SPA">
<s0>Bacteria</s0>
</fC07>
<fC07 i1="03" i2="X" l="FRE">
<s0>Asie</s0>
<s2>NG</s2>
</fC07>
<fC07 i1="03" i2="X" l="ENG">
<s0>Asia</s0>
<s2>NG</s2>
</fC07>
<fC07 i1="03" i2="X" l="SPA">
<s0>Asia</s0>
<s2>NG</s2>
</fC07>
<fC07 i1="04" i2="X" l="FRE">
<s0>Homme</s0>
</fC07>
<fC07 i1="04" i2="X" l="ENG">
<s0>Human</s0>
</fC07>
<fC07 i1="04" i2="X" l="SPA">
<s0>Hombre</s0>
</fC07>
<fC07 i1="05" i2="X" l="FRE">
<s0>Appareil respiratoire pathologie</s0>
<s5>37</s5>
</fC07>
<fC07 i1="05" i2="X" l="ENG">
<s0>Respiratory disease</s0>
<s5>37</s5>
</fC07>
<fC07 i1="05" i2="X" l="SPA">
<s0>Aparato respiratorio patología</s0>
<s5>37</s5>
</fC07>
<fC07 i1="06" i2="X" l="FRE">
<s0>Poumon pathologie</s0>
<s5>38</s5>
</fC07>
<fC07 i1="06" i2="X" l="ENG">
<s0>Lung disease</s0>
<s5>38</s5>
</fC07>
<fC07 i1="06" i2="X" l="SPA">
<s0>Pulmón patología</s0>
<s5>38</s5>
</fC07>
<fC07 i1="07" i2="X" l="FRE">
<s0>Système nerveux central pathologie</s0>
<s5>39</s5>
</fC07>
<fC07 i1="07" i2="X" l="ENG">
<s0>Central nervous system disease</s0>
<s5>39</s5>
</fC07>
<fC07 i1="07" i2="X" l="SPA">
<s0>Sistema nervosio central patología</s0>
<s5>39</s5>
</fC07>
<fC07 i1="08" i2="X" l="FRE">
<s0>Système nerveux pathologie</s0>
<s5>40</s5>
</fC07>
<fC07 i1="08" i2="X" l="ENG">
<s0>Nervous system diseases</s0>
<s5>40</s5>
</fC07>
<fC07 i1="08" i2="X" l="SPA">
<s0>Sistema nervioso patología</s0>
<s5>40</s5>
</fC07>
<fN21>
<s1>038</s1>
</fN21>
<fN44 i1="01">
<s1>OTO</s1>
</fN44>
<fN82>
<s1>OTO</s1>
</fN82>
</pA>
</standard>
</inist>
</record>

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