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array:22 [ "pii" => "S2445146018300207" "issn" => "24451460" "doi" => "10.1016/j.vacune.2018.09.002" "estado" => "S300" "fechaPublicacion" => "2018-07-01" "aid" => "114" "copyrightAnyo" => "2018" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Vacunas. 2018;19:99-102" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "itemSiguiente" => array:18 [ "pii" => "S2445146018300232" "issn" => "24451460" "doi" => "10.1016/j.vacune.2018.12.001" "estado" => "S300" "fechaPublicacion" => "2018-07-01" "aid" => "118" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Vacunas. 2018;19:103-4" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "es" => array:8 [ "idiomaDefecto" => true "titulo" => "Preguntas y respuestas" "tienePdf" => "es" "tieneTextoCompleto" => "es" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "103" "paginaFinal" => "104" ] ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "L. 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"apellidos" => "Borràs" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S1576988718300578" "doi" => "10.1016/j.vacun.2018.11.001" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1576988718300578?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2445146018300232?idApp=UINPBA00004N" "url" => "/24451460/0000001900000002/v1_201901300630/S2445146018300232/v1_201901300630/es/main.assets" ] "itemAnterior" => array:18 [ "pii" => "S2445146018300256" "issn" => "24451460" "doi" => "10.1016/j.vacune.2018.10.001" "estado" => "S300" "fechaPublicacion" => "2018-07-01" "aid" => "116" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Vacunas. 2018;19:85-98" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Scientific Societies Consensus</span>" "titulo" => "Executive summary of the update and reflection document on influenza vaccination in Spain" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "85" "paginaFinal" => "98" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Resumen ejecutivo del documento de actualización y reflexión sobre vacunación antigripal en España" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "A. García, M. Fernández-Prada, J. Aristegui, D. Moreno, E. Redondo, I. Jimeno, M. García Cenoz, J.A. Lopez Trigo" "autores" => array:8 [ 0 => array:2 [ "nombre" => "A." "apellidos" => "García" ] 1 => array:2 [ "nombre" => "M." "apellidos" => "Fernández-Prada" ] 2 => array:2 [ "nombre" => "J." "apellidos" => "Aristegui" ] 3 => array:2 [ "nombre" => "D." "apellidos" => "Moreno" ] 4 => array:2 [ "nombre" => "E." "apellidos" => "Redondo" ] 5 => array:2 [ "nombre" => "I." "apellidos" => "Jimeno" ] 6 => array:2 [ "nombre" => "M." "apellidos" => "García Cenoz" ] 7 => array:2 [ "nombre" => "J.A." "apellidos" => "Lopez Trigo" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S157698871830044X" "doi" => "10.1016/j.vacun.2018.10.001" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S157698871830044X?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2445146018300256?idApp=UINPBA00004N" "url" => "/24451460/0000001900000002/v1_201901300630/S2445146018300256/v1_201901300630/en/main.assets" ] "en" => array:17 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Severe necrotising pneumonia in a fully immunised infant: A case of serotype 3 pneumococcal conjugate vaccine failure" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "99" "paginaFinal" => "102" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "G. Oligbu, L. Ahmed, G. Chia" "autores" => array:3 [ 0 => array:4 [ "nombre" => "G." "apellidos" => "Oligbu" "email" => array:1 [ 0 => "godwin.oligbu@nhs.net" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "L." "apellidos" => "Ahmed" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "G." "apellidos" => "Chia" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "London Northwest Healthcare Trust, London, UK" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St. George's, University of London, UK" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Neumonía necrotizante grave en un lactante completamente inmunizado: un caso de fracaso de la vacuna conjugada neumocócica serotipo 3" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1227 "Ancho" => 755 "Tamanyo" => 70636 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Chest X-ray (A) before treatment and (B) after treatment.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Streptococcus pneumoniae (SP)</span> is a major cause of bacterial pneumonia, and is responsible for almost a million childhood deaths worldwide, with 11% of all deaths occurring in <5 year-olds.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">1</span></a> In 2000, the 7-valent vaccine (PCV7) that protects against the seven most prevalent pneumococcal serotypes (4, 6B, 9V, 14, 18C, 19F, and 23F) causing invasive pneumococcal disease (IPD) in children was licensed. In 2010, PCV7 was replaced with a 13-valent vaccine (PCV13) and/or PCV 10 that aimed to protect against six additional serotypes (1,3, 5, 6A, 7F, and 19A) and 3 additional serotypes 1, 5, and 7F respectively.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">2</span></a> This conjugate vaccines are highly effective and led to a rapid decline in invasive pneumococcal disease (IPD) caused by vaccine-type across all age groups.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Nonetheless, the development of vaccine-type IPD (VT-IPD) after completing the recommended course of PCV immunisation (i.e. vaccine failure) do occur,<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">4</span></a> with serotype 3 (ST3) been one of the commonest serotype that has been reported.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">5</span></a> A number of factors have been adduced to be responsible, including the nasopharyngeal carriage and the capsular characteristics of this serotype.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">6,7</span></a> However, little is known about the characteristics of children who develop serotype-3 vaccine failure. Here we describe a case of severe necrotising pneumonia in an age appropriately immunised infant.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case summary</span><p id="par0015" class="elsevierStylePara elsevierViewall">16 month-old fit and well presented unwell to the accident and emergency with a 2-day history of fever, lethargy and increased work of breathing. She has no significant past medical history and the only child of non-consanguineous parents. She was born at term following an uneventful pregnancy and has been appropriately vaccinated for age</p><p id="par0020" class="elsevierStylePara elsevierViewall">On examination, her weight and height were within the 50<span class="elsevierStyleSup">th</span> centile. She was unwell, with temperature, 39.5<span class="elsevierStyleHsp" style=""></span>°C; respiratory rate, 52<span class="elsevierStyleHsp" style=""></span>breaths/min; heart rate 161<span class="elsevierStyleHsp" style=""></span>beats/min; blood pressure, 90/50<span class="elsevierStyleHsp" style=""></span>mmHg and saturation, 88% on room air, which improved to 96% on 3<span class="elsevierStyleHsp" style=""></span>L of oxygen via nasal cannula. She had a left-sided reduced air entry on auscultation. Other systemic examinations were unremarkable.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Her peak CRP was 300<span class="elsevierStyleHsp" style=""></span>mg/L (normal<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>1), and WBC 29/L (normal 5.0–15.0), Neutrophil 19/L (normal 1.5–8.5), Platelet 990/L (normal 150–410), Albumin 24<span class="elsevierStyleHsp" style=""></span>g/L (normal 35–50). Blood culture grew Streptococcus pneumoniae (SP), further immunological serotyping isolated serotype 3. There was significant left sided shadowing on CXR. Ultrasound showed loculated left pleural effusion and chest Computed Tomography was reported as large multilocular air cavity with mild mediastinal shift in keeping with necrosis secondary to infection (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>A). Her detailed immunological work-up were normal.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">She was admitted initially with intravenous cefuroxime. Vancomycin was added on D4 due to initial report of resistant to cephalosporin but extended testing in the reference laboratory showed susceptibility to penicillins, cephalosporins, carbapenems, and levofloxacin. Her clinical condition deteriorated on D9 with haematochezia and oedematous clinically. Haemoglobin dropped to 53<span class="elsevierStyleHsp" style=""></span>g/L, blood film showed toxic granulation and deranged renal function test. She was discussed with the renal team for possible haemolytic uraemic syndrome. She required blood transfusion and vancomycin was switched to Linezolid. She subsequently improved on Linezolid and was discharged on D20 for a further 2 weeks course of antibiotics and outpatient follow up. Her follow up CXR showed significant improvement and recruitment in her lung tissue with normalisation of her of renal functions (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>B).</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0035" class="elsevierStylePara elsevierViewall">This case described a rare case of vaccine failure in a previously healthy child who has been appropriately immunised for age. The development of vaccine-serotype IPD in a child who has been appropriately immunised with PCV (ie, vaccine failure) is rare.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">8</span></a> Our case is similar to that described by Conradi and colleague of a 15 month old infant who developed tension pneumothorax following serotype-3 necrotising pneumonia.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">9</span></a> This child had a severe necrotising pneumonia, requiring long-term hospitalisation and prolonged antibiotics. Serotype 3 has been particularly implicated in lower respiratory tract infection, complicated by empyema.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">10</span></a> The characteristics of these children, whether there are other associated underlying condition is usually unclear. An underlying immune deficiency is more likely in children who develop IPD after 2 years of age,<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">11</span></a> and those with recurrent IPD.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">12</span></a> This child had no associated co-morbidity and was fully evaluated for any possible immunodeficiency.</p><p id="par0040" class="elsevierStylePara elsevierViewall">A recent study looking at vaccine response after an episode of IPD in the United Kingdom, showed that, although a significant proportion of vaccinated children with vaccine-type IPD did not achieve protective antibody thresholds against the infecting serotype even after vaccination post-IPD, their IgG responses to the other vaccine serotypes remained intact, indicating that an underlying antibody deficiency was unlikely.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">13</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">In a cohort of 84 patient who had IPD in Catalonia after appropriate PCV13 vaccination, 6 were reported to be due to serotype 3.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">5</span></a> Similarly, this child developed pneumococcal serotype 3-vaccine failure with no previous IPD or hospital admission. Evidence have shown that individual pneumococcal serotypes have different propensities for invasiveness and disease, and since vaccine immunogenicity varies for the different serotypes.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">14</span></a> It is therefore most likely that the IPD in this case is due to low vaccine effectiveness for this serotype that has been reported in England and Wales.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">15</span></a> In infants, this serotype 3 elicited the lowest antibody response after primary and booster dose of PCV13 vaccine.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">16</span></a> It was therefore estimated that to confer some level of protection against serotype 3 IPD a very higher serum immunoglobulin G concentrations >2.83<span class="elsevierStyleHsp" style=""></span>μg/mL are required compared to the internationally accepted threshold of 0.35<span class="elsevierStyleHsp" style=""></span>μg/mL<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">15</span></a>; such high concentrations were rarely attained after vaccination.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">16</span></a> In addition to the low vaccine effectiveness, serotype 3 strains have been reported to form mucoid colonies, to be more heavily encapsulated with virulent potentials, and has been associated with increase in nasopharyngeal carriage following PCV13 introduction,<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">6,7,17</span></a> contributing to its prevalence.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusion and clinical implication</span><p id="par0050" class="elsevierStylePara elsevierViewall">Although, most IPD cases are currently not vaccine-preventable, clinician should therefore be careful with well immunised children with PCV13 because they can develop severe IPD due to serotype not included and also included in the vaccine, such as serotype 3. An underlying immune deficiency is more likely in children with recurrent IPD,<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">12</span></a> and the extent of immunological investigations should be at the discretion of the managing paediatrician. Additional strategies will be required to reduce this devastating disease.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Authors’ contributions</span><p id="par0055" class="elsevierStylePara elsevierViewall">G. O., L.A., and G.C. reviewed the literature, analysed the data, wrote the first draft, and coordinated the production of the manuscript. G.O. had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. All authors were involved in the interpretation of the data and writing of the report; all authors approved the final version</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Consent for publication</span><p id="par0060" class="elsevierStylePara elsevierViewall">Consent obtained from family for this publication, including the images.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conflicts of interest</span><p id="par0065" class="elsevierStylePara elsevierViewall">No external funding was received for this piece of work.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres1142659" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1073302" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1142660" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1073303" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case summary" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusion and clinical implication" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Authors’ contributions" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Consent for publication" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflicts of interest" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1073302" "palabras" => array:4 [ 0 => "Streptococcus pneumonia" 1 => "Pneumococcal conjugate vaccine" 2 => "Necrotising pneumonia" 3 => "Vaccine failure" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1073303" "palabras" => array:4 [ 0 => "Neumonía estreptocócica" 1 => "Vacuna conjugada neumocócica" 2 => "Neumonía necrotizante" 3 => "Falla de la vacuna" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">We describe a case of severe necrotising pneumonia in a fully immunised infant due to serotype 3 vaccine failure. A full immunological work up was unremarkable, and the child recovered fully with no residual complications.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Describimos un caso de neumonía necrosante grave en una fallo de la vacuna contra el serotipo 3 de un lactante completamente inmunizado. El trabajo inmunológico completo fue normal y el niño se recuperó completamente sin complicaciones residuales.</p></span>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1189 "Ancho" => 755 "Tamanyo" => 99978 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">(A & B) Crossectional CT showing large multilocular air cavity within the left lower lobe with mild mediastinal shift in keeping with necrosis secondary to infection.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1227 "Ancho" => 755 "Tamanyo" => 70636 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Chest X-ray (A) before treatment and (B) after treatment.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:17 [ 0 => array:3 [ "identificador" => "bib0090" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Burden of disease caused by Streptococcus pneumoniae in children younger than 5 years: global estimates" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "K.L. 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