51
|
King C, Banda M, Bar-Zeev N, Beard J, French N, Makwenda C, McCollum ED, Mdala M, Bin Nisar Y, Phiri T, Ahmad Qazi S, Colbourn T. Care-seeking patterns amongst suspected paediatric pneumonia deaths in rural Malawi. Gates Open Res 2021; 4:178. [PMID: 33537557 DOI: 10.12688/gatesopenres.13208.1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2020] [Indexed: 02/03/2023] Open
Abstract
Background: Pneumonia remains a leading cause of paediatric deaths. To understand contextual challenges in care pathways, we explored patterns in care-seeking amongst children who died of pneumonia in Malawi. Methods: We conducted a mixed-methods analysis of verbal autopsies (VA) amongst deaths in children aged 1-59 months from 10/2011 to 06/2016 in Mchinji district, Malawi. Suspected pneumonia deaths were defined as: 1. caregiver reported cough and fast breathing in the 2-weeks prior to death; or, 2. the caregiver specifically stated the child died of pneumonia; or 3. cause of death assigned as 'acute respiratory infection' using InterVA-4. Data were extracted from free-text narratives based on domains in the 'Pathways to Survival' framework, and described using proportions. Qualitative analysis used a framework approach, with pre-specified themes. Results: We analysed 171 suspected pneumonia deaths. In total, 86% of children were taken to a healthcare facility during their final illness episode, and 44% sought care more than once. Of children who went to hospital (n=119), 70% were admitted, and 25% received oxygen. Half of the children died within a healthcare setting (43% hospital, 5% health centre and 2% private clinics), 64 (37%) at home, and 22 (13%) in transit. Challenges in delayed care, transport and quality of care (including oxygen), were reported. Conclusions: Healthcare was frequently sought for children who died of suspected pneumonia, however several missed opportunities for care were seen. Sustained investment in timely appropriate care seeking, quick transportation to hospital and improved case management at all levels of the system is needed.
Collapse
Affiliation(s)
- Carina King
- Department of Global Public Health, Karolinska Institute, Stockholm, Sweden.,Institute for Global Health, University College London, London, UK
| | - Masford Banda
- Parent and Child Health Initiative, Lilongwe, Malawi.,Centres for Disease Control and Prevention, Lilongwe, Malawi
| | - Naor Bar-Zeev
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - James Beard
- Institute for Global Health, University College London, London, UK
| | - Neil French
- Institute of Infection, University of Liverpool, Liverpool, UK
| | | | - Eric D McCollum
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA.,Department of Pediatrics, Johns Hopkins Medicine, Baltimore, USA
| | | | - Yasir Bin Nisar
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Tambosi Phiri
- Parent and Child Health Initiative, Lilongwe, Malawi
| | - Shamim Ahmad Qazi
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Tim Colbourn
- Institute for Global Health, University College London, London, UK
| |
Collapse
|
52
|
Simkovich SM, Thompson LM, Clark ML, Balakrishnan K, Bussalleu A, Checkley W, Clasen T, Davila-Roman VG, Diaz-Artiga A, Dusabimana E, Fuentes LDL, Harvey S, Kirby MA, Lovvorn A, McCollum ED, Mollinedo EE, Peel JL, Quinn A, Rosa G, Underhill LJ, Williams KN, Young BN, Rosenthal J. A risk assessment tool for resumption of research activities during the COVID-19 pandemic for field trials in low resource settings. BMC Med Res Methodol 2021; 21:68. [PMID: 33845785 PMCID: PMC8040756 DOI: 10.1186/s12874-021-01232-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 02/17/2021] [Indexed: 12/14/2022] Open
Abstract
RATIONALE The spread of severe acute respiratory syndrome coronavirus-2 has suspended many non-COVID-19 related research activities. Where restarting research activities is permitted, investigators need to evaluate the risks and benefits of resuming data collection and adapt procedures to minimize risk. OBJECTIVES In the context of the multicountry Household Air Pollution Intervention (HAPIN) trial conducted in rural, low-resource settings, we developed a framework to assess the risk of each trial activity and to guide protective measures. Our goal is to maximize the integrity of reseach aims while minimizing infection risk based on the latest scientific understanding of the virus. METHODS We drew on a combination of expert consultations, risk assessment frameworks, institutional guidance and literature to develop our framework. We then systematically graded clinical, behavioral, laboratory and field environmental health research activities in four countries for both adult and child subjects using this framework. National and local government recommendations provided the minimum safety guidelines for our work. RESULTS Our framework assesses risk based on staff proximity to the participant, exposure time between staff and participants, and potential viral aerosolization while performing the activity. For each activity, one of four risk levels, from minimal to unacceptable, is assigned and guidance on protective measures is provided. Those activities that can potentially aerosolize the virus are deemed the highest risk. CONCLUSIONS By applying a systematic, procedure-specific approach to risk assessment for each trial activity, we were able to protect our participants and research team and to uphold our ability to deliver on the research commitments we have made to our staff, participants, local communities, and funders. This framework can be tailored to other research studies conducted in similar settings during the current pandemic, as well as potential future outbreaks with similar transmission dynamics. The trial is registered with clinicaltrials.gov NCT02944682 on October 26. 2016 .
Collapse
Affiliation(s)
- Suzanne M Simkovich
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, USA.
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, USA.
- MedStar Health Research Institute, Hyattsville, USA.
| | - Lisa M Thompson
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, USA
| | - Maggie L Clark
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, USA
| | - Kalpana Balakrishnan
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Institute for Higher Education and Research (Deemed University), Chennai, India
| | - Alejandra Bussalleu
- A.B. PRISMA, San Miguel, Peru
- CLIMA - Latin American Center of Excellence in Climate Change and Health; and Intercultural Citizenship and Indigenous Health Unit, Faculty of Public Health and Administration, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - William Checkley
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, USA
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Thomas Clasen
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, USA
| | - Victor G Davila-Roman
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, USA
| | - Anaite Diaz-Artiga
- Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala
| | | | - Lisa de Las Fuentes
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, USA
| | - Steven Harvey
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, USA
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
| | - Miles A Kirby
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Amy Lovvorn
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, USA
| | - Eric D McCollum
- Global Program for Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences, Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Erick E Mollinedo
- Department of Environmental Health Science, College of Public Health, University of Georgia, Athens, USA
| | - Jennifer L Peel
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, USA
| | - Ashlinn Quinn
- Division of International Epidemiology and Population Studies, Fogarty International Center, National Institutes of Health, Bethesda, USA
| | - Ghislaine Rosa
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Lindsay J Underhill
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, USA
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Kendra N Williams
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, USA
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Bonnie N Young
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, USA
| | - Joshua Rosenthal
- Division of International Epidemiology and Population Studies, Fogarty International Center, National Institutes of Health, Bethesda, USA
| |
Collapse
|
53
|
Ginsburg AS, Mvalo T, Hwang J, Phiri M, McCollum ED, Maliwichi M, Schmicker R, Phiri A, Lufesi N, May S. Malawian children with fast-breathing pneumonia with and without comorbidities. Pneumonia (Nathan) 2021; 13:3. [PMID: 33627192 PMCID: PMC7905626 DOI: 10.1186/s41479-021-00081-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 02/15/2021] [Indexed: 01/03/2023] Open
Abstract
Background Due to high risk of mortality, children with comorbidities are typically excluded from trials evaluating pneumonia treatment. Understanding heterogeneity of outcomes among children with pneumonia and comorbidities is critical to ensuring appropriate treatment. Methods We explored whether the percentage of children with fast-breathing pneumonia cured at Day 14 was lower among those with selected comorbidities enrolled in a prospective observational study than among those enrolled in a concurrent randomized controlled trial evaluating treatment with amoxicillin in Lilongwe, Malawi. Results Among 79 children with fast-breathing pneumonia in the prospective observational cohort, 57 (72.2%) had HIV infection/exposure, 20 (25.3%) had malaria, 2 (2.5%) had severe acute malnutrition, and 17 (21.5%) had anemia. Treatment failure rate was slightly (not significantly) lower in children with comorbidities (4.1%, 3/73) compared to those without comorbidities (4.5%, 25/552) similarly treated. There was no significant difference in clinical cure rates by Day 14 (95.8% with vs 96.7% without comorbidity). Conclusions Children with fast-breathing pneumonia excluded from a concurrent clinical trial due to comorbidities did not fare worse. Children at higher risk whose caregivers seek care early and who receive appropriate risk assessment (e.g., pulse oximetry, hemoglobin, HIV/malaria testing) and treatment, can achieve clinical cure by Day 14. Trial registration ClinicalTrials.govNCT02960919; registered November 8, 2016. Supplementary Information The online version contains supplementary material available at 10.1186/s41479-021-00081-y.
Collapse
Affiliation(s)
- Amy Sarah Ginsburg
- University of Washington Clinical Trial Center, Building 29, Suite 250, 6200 NE 74th Street, Seattle, WA, 98115, USA.
| | - Tisungane Mvalo
- University of North Carolina Project, Lilongwe Medical Relief Fund Trust, Lilongwe, Malawi
| | - Jun Hwang
- University of Washington Clinical Trial Center, Building 29, Suite 250, 6200 NE 74th Street, Seattle, WA, 98115, USA
| | - Melda Phiri
- University of North Carolina Project, Lilongwe Medical Relief Fund Trust, Lilongwe, Malawi
| | | | - Madalitso Maliwichi
- University of North Carolina Project, Lilongwe Medical Relief Fund Trust, Lilongwe, Malawi
| | - Robert Schmicker
- University of Washington Clinical Trial Center, Building 29, Suite 250, 6200 NE 74th Street, Seattle, WA, 98115, USA
| | - Ajib Phiri
- College of Medicine, University of Malawi, Blantyre, Malawi
| | | | - Susanne May
- University of Washington Clinical Trial Center, Building 29, Suite 250, 6200 NE 74th Street, Seattle, WA, 98115, USA
| |
Collapse
|
54
|
McCollum ED, Higdon MM, Fancourt NSS, Sternal J, Checkley W, De Campo J, Shet A. Training physicians in India to interpret pediatric chest radiographs according to World Health Organization research methodology. Pediatr Radiol 2021; 51:1322-1331. [PMID: 33704543 PMCID: PMC8266794 DOI: 10.1007/s00247-021-04992-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 11/19/2020] [Accepted: 01/26/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND Chest radiography is the standard for diagnosing pediatric lower respiratory infections in low-income and middle-income countries. A method for interpreting pediatric chest radiographs for research endpoints was recently updated by the World Health Organization (WHO) Chest Radiography in Epidemiological Studies project. Research in India required training local physicians to interpret chest radiographs following the WHO method. OBJECTIVE To describe the methodology for training Indian physicians and evaluate the training's effectiveness. MATERIALS AND METHODS Twenty-nine physicians (15 radiologists and 14 pediatricians) from India were trained by two WHO Chest Radiography in Epidemiological Studies members over 3 days in May 2019. Training materials were adapted from WHO Chest Radiography in Epidemiological Studies resources. Participants followed WHO methodology to interpret 60 unique chest radiographs before and after the training. Participants needed to correctly classify ≥80% of radiographs for primary endpoint pneumonia on the post-training test to be certified to interpret research images. We analyzed participant performance on both examinations. RESULTS Twenty-six of 29 participants (89.7%) completed both examinations. The average score increased by 9.6% (95% confidence interval [CI] 5.0-14.1%) between examinations (P<0.001). Participants correctly classifying ≥80% of images for primary endpoint pneumonia increased from 69.2% (18/26) on the pretraining to 92.3% (24/26) on the post-training examination (P=0.003). The mean scores of radiologists and pediatricians on the post-training examination were not statistically different (P=0.43). CONCLUSION Our results demonstrate this training approach using revised WHO definitions and tools was successful, and that non-radiologists can learn to apply these methods as effectively as radiologists. Such capacity strengthening is important for enabling research to support national policy decision-making in these settings. We recommend future research incorporating WHO chest radiograph methodology to consider modelling trainings after this approach.
Collapse
Affiliation(s)
- Eric D. McCollum
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA ,Department of Pediatrics, Johns Hopkins Global Program in Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences, Johns Hopkins School of Medicine, 200 North Wolfe St., Baltimore, MD 21287 USA
| | - Melissa M. Higdon
- Department of International Health, International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | - Nicholas S. S. Fancourt
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia ,Murdoch Children’s Research Institute, Melbourne, Australia
| | - Jack Sternal
- Department of International Health, International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | - William Checkley
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD USA ,Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD USA
| | - John De Campo
- Murdoch Children’s Research Institute, Melbourne, Australia ,Department of Radiology, Melbourne University, Melbourne, Australia
| | - Anita Shet
- Department of International Health, International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| |
Collapse
|
55
|
van der Zalm MM, Walters E, Claassen M, Palmer M, Seddon JA, Demers AM, Shaw ML, McCollum ED, van Zyl GU, Hesseling AC. High burden of viral respiratory co-infections in a cohort of children with suspected pulmonary tuberculosis. BMC Infect Dis 2020; 20:924. [PMID: 33276721 PMCID: PMC7716283 DOI: 10.1186/s12879-020-05653-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 11/24/2020] [Indexed: 11/16/2022] Open
Abstract
Background The presentation of pulmonary tuberculosis (PTB) in young children is often clinically indistinguishable from other common respiratory illnesses, which are frequently infections of viral aetiology. As little is known about the role of viruses in children with PTB, we investigated the prevalence of respiratory viruses in children with suspected PTB at presentation and follow-up. Methods In an observational cohort study, children < 13 years were routinely investigated for suspected PTB in Cape Town, South Africa between December 2015 and September 2017 and followed up for 24 weeks. Nasopharyngeal aspirates (NPAs) were tested for respiratory viruses using multiplex PCR at enrolment, week 4 and 8. Results Seventy-three children were enrolled [median age 22.0 months; (interquartile range 10.0–48.0); 56.2% male and 17.8% HIV-infected. Anti-tuberculosis treatment was initiated in 54.8%; of these 50.0% had bacteriologically confirmed TB. At enrolment, ≥1 virus were detected in 95.9% (70/73) children; most commonly human rhinovirus (HRV) (74.0%). HRV was more frequently detected in TB cases (85%) compared to ill controls (60.6%) (p = 0.02). Multiple viruses were detected in 71.2% of all children; 80% of TB cases and 60.6% of ill controls (p = 0.07). At follow-up, ≥1 respiratory virus was detected in 92.2% (47/51) at week 4, and 94.2% (49/52) at week 8. Conclusions We found a high prevalence of viral respiratory co-infections in children investigated for PTB, irrespective of final PTB diagnosis, which remained high during follow up. Future work should include investigating the whole respiratory ecosystem in combination with pathogen- specific immune responses.
Collapse
Affiliation(s)
- M M van der Zalm
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
| | - E Walters
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.,Department of Paediatrics, Great North Children's Hospital, Newcastle-Upon-Tyne Health Trust, Newcastle upon Tyne, UK
| | - M Claassen
- Division of Medical Virology, Faculty of Medicine and Health Sciences, Stellenbosch University and National Health Laboratory Service, Tygerberg Hospital, Cape Town, South Africa
| | - M Palmer
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - J A Seddon
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.,Department of Infectious Diseases, Imperial College London, London, UK
| | - A M Demers
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - M L Shaw
- Department of Medical Biosciences, University of the Western Cape, Cape Town, South Africa.,Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - E D McCollum
- Eudowood Division of Pediatric Respiratory Sciences, School of Medicine, Johns Hopkins University, Baltimore, USA.,Global Program in Respiratory Sciences, Department of Pediatrics, Johns Hopkins University, Baltimore, MD, USA.,Health Systems Program, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - G U van Zyl
- Division of Medical Virology, Faculty of Medicine and Health Sciences, Stellenbosch University and National Health Laboratory Service, Tygerberg Hospital, Cape Town, South Africa
| | - A C Hesseling
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| |
Collapse
|
56
|
McCollum ED, Park DE, Watson NL, Fancourt NSS, Focht C, Baggett HC, Brooks WA, Howie SRC, Kotloff KL, Levine OS, Madhi SA, Murdoch DR, Scott JAG, Thea DM, Awori JO, Chipeta J, Chuananon S, DeLuca AN, Driscoll AJ, Ebruke BE, Elhilali M, Emmanouilidou D, Githua LP, Higdon MM, Hossain L, Jahan Y, Karron RA, Kyalo J, Moore DP, Mulindwa JM, Naorat S, Prosperi C, Verwey C, West JE, Knoll MD, O'Brien KL, Feikin DR, Hammitt LL. Digital auscultation in PERCH: Associations with chest radiography and pneumonia mortality in children. Pediatr Pulmonol 2020; 55:3197-3208. [PMID: 32852888 PMCID: PMC7692889 DOI: 10.1002/ppul.25046] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 08/15/2020] [Accepted: 08/17/2020] [Indexed: 01/16/2023]
Abstract
BACKGROUND Whether digitally recorded lung sounds are associated with radiographic pneumonia or clinical outcomes among children in low-income and middle-income countries is unknown. We sought to address these knowledge gaps. METHODS We enrolled 1 to 59monthold children hospitalized with pneumonia at eight African and Asian Pneumonia Etiology Research for Child Health sites in six countries, recorded digital stethoscope lung sounds, obtained chest radiographs, and collected clinical outcomes. Recordings were processed and classified into binary categories positive or negative for adventitial lung sounds. Listening and reading panels classified recordings and radiographs. Recording classification associations with chest radiographs with World Health Organization (WHO)-defined primary endpoint pneumonia (radiographic pneumonia) or mortality were evaluated. We also examined case fatality among risk strata. RESULTS Among children without WHO danger signs, wheezing (without crackles) had a lower adjusted odds ratio (aOR) for radiographic pneumonia (0.35, 95% confidence interval (CI): 0.15, 0.82), compared to children with normal recordings. Neither crackle only (no wheeze) (aOR: 2.13, 95% CI: 0.91, 4.96) or any wheeze (with or without crackle) (aOR: 0.63, 95% CI: 0.34, 1.15) were associated with radiographic pneumonia. Among children with WHO danger signs no lung recording classification was independently associated with radiographic pneumonia, although trends toward greater odds of radiographic pneumonia were observed among children classified with crackle only (no wheeze) or any wheeze (with or without crackle). Among children without WHO danger signs, those with recorded wheezing had a lower case fatality than those without wheezing (3.8% vs. 9.1%, p = .03). CONCLUSIONS Among lower risk children without WHO danger signs digitally recorded wheezing is associated with a lower odds for radiographic pneumonia and with lower mortality. Although further research is needed, these data indicate that with further development digital auscultation may eventually contribute to child pneumonia care.
Collapse
Affiliation(s)
- Eric D McCollum
- Global Program in Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland, USA.,Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Daniel E Park
- Department of International Health, International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, George Washington University, Washington, District of Columbia, USA
| | | | - Nicholas S S Fancourt
- Department of International Health, International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | - Henry C Baggett
- Global Disease Detection Center, US Centers for Disease Control and Prevention Collaboration, Thailand Ministry of Public Health, Mueang Nonthaburi, Nonthaburi, Thailand.,Division of Global Health Protection, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - W Abdullah Brooks
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka and Matlab, Bangladesh
| | - Stephen R C Howie
- Medical Research Council Unit, Basse, The Gambia.,Department of Paediatrics, University of Auckland, Auckland, New Zealand.,Centre for International Health, University of Otago, Dunedin, New Zealand
| | - Karen L Kotloff
- Division of Infectious Disease and Tropical Pediatrics, Department of Pediatrics, Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Maryland
| | - Orin S Levine
- Department of International Health, International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,Bill & Melinda Gates Foundation, Seattle, Washington, USA
| | - Shabir A Madhi
- Medical Research Council: Respiratory and Meningeal Pathogens Research Unit, University of the Witwatersrand, Johannesburg, South Africa.,Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases Unite, University of the Witwatersrand, Johannesburg, South Africa
| | - David R Murdoch
- Department of Pathology and Biomedical Science, University of Otago, Christchurch, New Zealand.,Microbiology Unit, Canterbury Health Laboratories, Christchurch, New Zealand
| | - J Anthony G Scott
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya.,Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Donald M Thea
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Juliet O Awori
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - James Chipeta
- Department of Paediatrics and Child Health, University Teaching Hospital, Lusaka, Zambia
| | - Somchai Chuananon
- Global Disease Detection Center, US Centers for Disease Control and Prevention Collaboration, Thailand Ministry of Public Health, Mueang Nonthaburi, Nonthaburi, Thailand
| | - Andrea N DeLuca
- Department of International Health, International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Amanda J Driscoll
- Department of International Health, International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Bernard E Ebruke
- Medical Research Council Unit, Basse, The Gambia.,International Foundation Against Infectious Disease in Nigeria, Abuja, Nigeria
| | - Mounya Elhilali
- Department of Electrical and Computer Engineering, Johns Hopkins University, Baltimore, Maryland, USA
| | - Dimitra Emmanouilidou
- Department of Electrical and Computer Engineering, Johns Hopkins University, Baltimore, Maryland, USA
| | | | - Melissa M Higdon
- Department of International Health, International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Lokman Hossain
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka and Matlab, Bangladesh
| | - Yasmin Jahan
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka and Matlab, Bangladesh
| | - Ruth A Karron
- Department of International Health, Center for Immunization Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Joshua Kyalo
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - David P Moore
- Medical Research Council: Respiratory and Meningeal Pathogens Research Unit, University of the Witwatersrand, Johannesburg, South Africa.,Department of Paediatrics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Justin M Mulindwa
- Department of Paediatrics and Child Health, University Teaching Hospital, Lusaka, Zambia
| | - Sathapana Naorat
- Global Disease Detection Center, US Centers for Disease Control and Prevention Collaboration, Thailand Ministry of Public Health, Mueang Nonthaburi, Nonthaburi, Thailand
| | - Christine Prosperi
- Department of International Health, International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Charl Verwey
- Medical Research Council: Respiratory and Meningeal Pathogens Research Unit, University of the Witwatersrand, Johannesburg, South Africa.,Department of Paediatrics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - James E West
- Department of Electrical and Computer Engineering, Johns Hopkins University, Baltimore, Maryland, USA
| | - Maria Deloria Knoll
- Department of International Health, International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Katherine L O'Brien
- Department of International Health, International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Daniel R Feikin
- Department of International Health, International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Laura L Hammitt
- Department of International Health, International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| |
Collapse
|
57
|
Graceffo S, Husain A, Ahmed S, McCollum ED, Elhilali M. Validation of Auscultation Technologies using Objective and Clinical Comparisons. Annu Int Conf IEEE Eng Med Biol Soc 2020; 2020:992-997. [PMID: 33018152 DOI: 10.1109/embc44109.2020.9176456] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Technology is rapidly changing the health care industry. As new systems and devices are developed, validating their effectiveness in practice is not trivial, yet it is essential for assessing their technical and clinical capabilities. Digital auscultations are new technologies that are changing the landscape of diagnosis of lung and heart sounds and revamping the centuries old original design of the stethoscope. Here, we propose a methodology to validate a newly developed digital stethoscope, and compare its effectiveness against a market-accepted device, using a combination of signal properties and clinical assessments. Data from 100 pediatric patients is collected using both devices side by side in two clinical sites. Using the proposed methodology, we objectively compare the technical performance of the two devices, and identify clinical situations where performance of the two devices differs. The proposed methodology offers a general approach to verify a new digital auscultation device as clinically-viable; while highlighting the important consideration for clinical conditions in performing these evaluations.
Collapse
|
58
|
Kala A, Husain A, McCollum ED, Elhilali M. An objective measure of signal quality for pediatric lung auscultations. Annu Int Conf IEEE Eng Med Biol Soc 2020; 2020:772-775. [PMID: 33018100 DOI: 10.1109/embc44109.2020.9176539] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
A stethoscope is a ubiquitous tool used to 'listen' to sounds from the chest in order to assess lung and heart conditions. With advances in health technologies including digital devices and new wearable sensors, access to these sounds is becoming easier and abundant; yet proper measures of signal quality do not exist. In this work, we develop an objective quality metric of lung sounds based on low-level and high-level features in order to independently assess the integrity of the signal in presence of interference from ambient sounds and other distortions. The proposed metric outlines a mapping of auscultation signals onto rich low-level features extracted directly from the signal which capture spectral and temporal characteristics of the signal. Complementing these signal-derived attributes, we propose high-level learnt embedding features extracted from a generative auto-encoder trained to map auscultation signals onto a representative space that best captures the inherent statistics of lung sounds. Integrating both low-level (signal-derived) and high-level (embedding) features yields a robust correlation of 0.85 to infer the signal-to-noise ratio of recordings with varying quality levels. The method is validated on a large dataset of lung auscultation recorded in various clinical settings with controlled varying degrees of noise interference. The proposed metric is also validated against opinions of expert physicians in a blind listening test to further corroborate the efficacy of this method for quality assessment.
Collapse
|
59
|
Colbourn T, King C, Beard J, Phiri T, Mdala M, Zadutsa B, Makwenda C, Costello A, Lufesi N, Mwansambo C, Nambiar B, Hooli S, French N, Bar Zeev N, Qazi SA, Bin Nisar Y, McCollum ED. Predictive value of pulse oximetry for mortality in infants and children presenting to primary care with clinical pneumonia in rural Malawi: A data linkage study. PLoS Med 2020; 17:e1003300. [PMID: 33095763 PMCID: PMC7584207 DOI: 10.1371/journal.pmed.1003300] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 09/11/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The mortality impact of pulse oximetry use during infant and childhood pneumonia management at the primary healthcare level in low-income countries is unknown. We sought to determine mortality outcomes of infants and children diagnosed and referred using clinical guidelines with or without pulse oximetry in Malawi. METHODS AND FINDINGS We conducted a data linkage study of prospective health facility and community case and mortality data. We matched prospectively collected community health worker (CHW) and health centre (HC) outpatient data to prospectively collected hospital and community-based mortality surveillance outcome data, including episodes followed up to and deaths within 30 days of pneumonia diagnosis amongst children 0-59 months old. All data were collected in Lilongwe and Mchinji districts, Malawi, from January 2012 to June 2014. We determined differences in mortality rates using <90% and <93% oxygen saturation (SpO2) thresholds and World Health Organization (WHO) and Malawi clinical guidelines for referral. We used unadjusted and adjusted (for age, sex, respiratory rate, and, in analyses of HC data only, Weight for Age Z-score [WAZ]) regression to account for interaction between SpO2 threshold (pulse oximetry) and clinical guidelines, clustering by child, and CHW or HC catchment area. We matched CHW and HC outpatient data to hospital inpatient records to explore roles of pulse oximetry and clinical guidelines on hospital attendance after referral. From 7,358 CHW and 6,546 HC pneumonia episodes, we linked 417 CHW and 695 HC pneumonia episodes to 30-day mortality outcomes: 16 (3.8%) CHW and 13 (1.9%) HC patients died. SpO2 thresholds of <90% and <93% identified 1 (6%) of the 16 CHW deaths that were unidentified by integrated community case management (iCCM) WHO referral protocol and 3 (23%) and 4 (31%) of the 13 HC deaths, respectively, that were unidentified by the integrated management of childhood illness (IMCI) WHO protocol. Malawi IMCI referral protocol, which differs from WHO protocol at the HC level and includes chest indrawing, identified all but one of these deaths. SpO2 < 90% predicted death independently of WHO danger signs compared with SpO2 ≥ 90%: HC Risk Ratio (RR), 9.37 (95% CI: 2.17-40.4, p = 0.003); CHW RR, 6.85 (1.15-40.9, p = 0.035). SpO2 < 93% was also predictive versus SpO2 ≥ 93% at HC level: RR, 6.68 (1.52-29.4, p = 0.012). Hospital referrals and outpatient episodes with referral decision indications were associated with mortality. A substantial proportion of those referred were not found admitted in the inpatients within 7 days of referral advice. All 12 deaths in 73 hospitalised children occurred within 24 hours of arrival in the hospital, which highlights delay in appropriate care seeking. The main limitation of our study was our ability to only match 6% of CHW episodes and 11% of HC episodes to mortality outcome data. CONCLUSIONS Pulse oximetry identified fatal pneumonia episodes at HCs in Malawi that would otherwise have been missed by WHO referral guidelines alone. Our findings suggest that pulse oximetry could be beneficial in supplementing clinical signs to identify children with pneumonia at high risk of mortality in the outpatient setting in health centres for referral to a hospital for appropriate management.
Collapse
Affiliation(s)
- Tim Colbourn
- Institute for Global Health, University College London, London, United Kingdom
| | - Carina King
- Institute for Global Health, University College London, London, United Kingdom
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - James Beard
- Institute for Global Health, University College London, London, United Kingdom
| | - Tambosi Phiri
- Parent and Child Health Initiative, Lilongwe, Malawi
| | | | | | | | - Anthony Costello
- Institute for Global Health, University College London, London, United Kingdom
| | | | | | | | - Shubhada Hooli
- Department of Pediatrics, Section of Emergency Medicine, Baylor College of Medicine, Houston, Texas, United States of America
| | - Neil French
- Institute of Infection & Global Health, University of Liverpool, Liverpool, United Kingdom
| | - Naor Bar Zeev
- Institute of Infection & Global Health, University of Liverpool, Liverpool, United Kingdom
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Shamim Ahmad Qazi
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | - Yasir Bin Nisar
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Eric D. McCollum
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
| |
Collapse
|
60
|
McCollum ED. Longitudinally Evaluating the Lung Function of Children in Low- and Middle-income Countries: It's About Time. Clin Infect Dis 2020; 70:491-492. [PMID: 30918951 DOI: 10.1093/cid/ciz260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 03/25/2019] [Indexed: 11/14/2022] Open
Affiliation(s)
- Eric D McCollum
- Eudowood Division of Pediatric Respiratory Sciences, Department of Pediatrics, School of Medicine, Baltimore, Maryland.,Global Program in Respiratory Sciences, Department of Pediatrics, School of Medicine, Baltimore, Maryland.,Health Systems, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| |
Collapse
|
61
|
McCollum ED, Ahmed S, Roy AD, Chowdhury NH, Schuh HB, Rizvi SJR, Hanif AAM, Khan AM, Mahmud A, Pervaiz F, Harrison M, Reller ME, Simmons N, Quaiyum A, Begum N, Santosham M, Checkley W, Moulton LH, Baqui AH. Effectiveness of the 10-valent pneumococcal conjugate vaccine against radiographic pneumonia among children in rural Bangladesh: A case-control study. Vaccine 2020; 38:6508-6516. [PMID: 32873404 PMCID: PMC7520553 DOI: 10.1016/j.vaccine.2020.08.035] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 08/13/2020] [Accepted: 08/14/2020] [Indexed: 11/05/2022]
Abstract
Background Pneumococcal conjugate vaccine (PCV) effectiveness against radiographic pneumonia in South Asia is unknown. Bangladesh introduced PCV10 in 2015 using a three dose primary series (3 + 0). We sought to measure PCV10 effectiveness for two or more vaccine doses on radiographic pneumonia among vaccine-eligible children in rural Bangladesh. Methods We conducted a matched case-control study over two years from 2015 to 2017 using clinic and community controls in three subdistricts of Sylhet, Bangladesh. Cases were vaccine eligible 3–35 month olds at Upazila Health Complex outpatient clinics with World Health Organization-defined radiographic primary endpoint pneumonia (radiographic pneumonia). Clinic controls were matched to cases within a one week time window by age, sex, and clinic and had an illness unlikely to be Streptococcus pneumoniae; community controls were healthy and similarly matched within a one week time window by age and sex, and distance from the clinic. We estimated adjusted vaccine effectiveness (aVE) using conditional logistic regression. Results We matched 1262 cases with 2707 clinic and 2461 community controls. Overall, aVE using clinic controls was 21.4% (95% confidence interval, −0.2%, 38.4%) for ≥2 PCV10 doses and among 3–11 month olds was 47.3% (10.5%, 69.0%) for three doses. aVE increased with higher numbers of doses in clinic control sets (p = 0.007). In contrast, aVE using community controls was 7.6% (95% confidence interval, −22.2%, 30.0%) for ≥2 doses. We found vaccine introduction in the study area faster and less variable than expected with 75% coverage on average, which reduced power. Information bias may also have affected community controls. Conclusions Clinic control analyses show PCV10 prevented radiographic pneumonia in Bangladesh, especially among younger children receiving three doses. While both analyses were underpowered, community control enrollment – compared to clinic controls – was more difficult in a complex, pluralistic healthcare system. Future studies in comparable settings may consider alternative study designs.
Collapse
Affiliation(s)
- Eric D McCollum
- Global Program in Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences, Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, USA; Health Systems Program, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA.
| | | | - Arun D Roy
- Johns Hopkins University - Bangladesh, Dhaka, Bangladesh
| | | | - Holly B Schuh
- Health Systems Program, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Syed J R Rizvi
- Johns Hopkins University - Bangladesh, Dhaka, Bangladesh
| | - Abu A M Hanif
- Johns Hopkins University - Bangladesh, Dhaka, Bangladesh
| | - Ahad M Khan
- Johns Hopkins University - Bangladesh, Dhaka, Bangladesh
| | - Arif Mahmud
- Johns Hopkins University - Bangladesh, Dhaka, Bangladesh
| | - Farhan Pervaiz
- Global Disease Epidemiology and Control Program, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA; Division of Pulmonary and Critical Care, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Meagan Harrison
- Health Systems Program, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Megan E Reller
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, NC, USA; Duke Hubert-Yeargan Center for Global Health, Durham, NC, USA; Duke Global Health Institute, Durham, NC, USA
| | - Nicole Simmons
- Global Disease Epidemiology and Control Program, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Abdul Quaiyum
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Nazma Begum
- Johns Hopkins University - Bangladesh, Dhaka, Bangladesh
| | - Mathuram Santosham
- Health Systems Program, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - William Checkley
- Global Disease Epidemiology and Control Program, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA; Division of Pulmonary and Critical Care, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Lawrence H Moulton
- Global Disease Epidemiology and Control Program, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Abdullah H Baqui
- Health Systems Program, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| |
Collapse
|
62
|
Ginsburg AS, Mvalo T, Nkwopara E, McCollum ED, Phiri M, Schmicker R, Hwang J, Ndamala CB, Phiri A, Lufesi N, Izadnegahdar R, May S. Amoxicillin for 3 or 5 Days for Chest-Indrawing Pneumonia in Malawian Children. N Engl J Med 2020; 383:13-23. [PMID: 32609979 PMCID: PMC7233470 DOI: 10.1056/nejmoa1912400] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Evidence regarding the appropriate duration of treatment with antibiotic agents in children with pneumonia in low-resource settings in Africa is lacking. METHODS We conducted a double-blind, randomized, controlled, noninferiority trial in Lilongwe, Malawi, to determine whether treatment with amoxicillin for 3 days is less effective than treatment for 5 days in children with chest-indrawing pneumonia (cough lasting <14 days or difficulty breathing, along with visible indrawing of the chest wall with or without fast breathing for age). Children not infected with human immunodeficiency virus (HIV) who were 2 to 59 months of age and had chest-indrawing pneumonia were randomly assigned to receive amoxicillin twice daily for either 3 days or 5 days. Children were followed for 14 days. The primary outcome was treatment failure by day 6; noninferiority of the 3-day regimen to the 5-day regimen would be shown if the percentage of children with treatment failure in the 3-day group was no more than 1.5 times that in the 5-day group. Prespecified secondary analyses included assessment of treatment failure or relapse by day 14. RESULTS From March 29, 2016, to April 1, 2019, a total of 3000 children underwent randomization: 1497 children were assigned to the 3-day group, and 1503 to the 5-day group. Among children with day 6 data available, treatment failure had occurred in 5.9% in the 3-day group (85 of 1442 children) and in 5.2% (75 of 1456) in the 5-day group (adjusted difference, 0.7 percentage points; 95% confidence interval [CI], -0.9 to 2.4) - a result that satisfied the criterion for noninferiority of the 3-day regimen to the 5-day regimen. Among children with day 14 data available, 176 of 1411 children (12.5%) in the 3-day group and 154 of 1429 (10.8%) in the 5-day group had had treatment failure by day 6 or relapse by day 14 (between-group difference, 1.7 percentage points; 95% CI, -0.7 to 4.1). The percentage of children with serious adverse events was similar in the two groups (9.8% in the 3-day group and 8.8% in the 5-day group). CONCLUSIONS In HIV-uninfected Malawian children, treatment with amoxicillin for chest-indrawing pneumonia for 3 days was noninferior to treatment for 5 days. (Funded by the Bill and Melinda Gates Foundation; ClinicalTrials.gov number, NCT02678195.).
Collapse
Affiliation(s)
| | - Tisungane Mvalo
- University of North Carolina Project, Lilongwe Medical
Relief Fund Trust, Tidziwe Centre, Private Bag A-104, Lilongwe, Malawi
| | | | - Eric D. McCollum
- Eudowood Division of Pediatric Respiratory Sciences,
Department of Pediatrics, Johns Hopkins School of Medicine and Department of International
Health, Johns Hopkins Bloomberg School of Public Health, 200 N Wolfe Street, Baltimore,
MD, 21287, USA
| | - Melda Phiri
- University of North Carolina Project, Lilongwe Medical
Relief Fund Trust, Tidziwe Centre, Private Bag A-104, Lilongwe, Malawi
| | - Robert Schmicker
- Department of Biostatistics, University of Washington
Clinical Trial Center, Building 29, Suite 250, 6200 NE 74 Street, Seattle,
WA, 98115, USA
| | - Jun Hwang
- Department of Biostatistics, University of Washington
Clinical Trial Center, Building 29, Suite 250, 6200 NE 74 Street, Seattle,
WA, 98115, USA
| | - Chifundo B. Ndamala
- University of North Carolina Project, Lilongwe Medical
Relief Fund Trust, Tidziwe Centre, Private Bag A-104, Lilongwe, Malawi
| | - Ajib Phiri
- Department of Pediatrics and Child Health, College of
Medicine, University of Malawi, Private Bag 360, Chichiri, Blantyre, Malawi
| | - Norman Lufesi
- Acute Respiratory Infection and Emergency Triage
Assessment and Treatment, Malawi Ministry of Health, Private Bag 65, Lilongwe,
Malawi
| | - Rasa Izadnegahdar
- Bill & Melinda Gates Foundation, 500 Fifth Avenue
N, Seattle, WA, 98109, USA
| | - Susanne May
- Department of Biostatistics, University of Washington
Clinical Trial Center, Building 29, Suite 250, 6200 NE 74 Street, Seattle,
WA, 98115, USA
| |
Collapse
|
63
|
Gupta M, Wahl B, Adhikari B, Bar-Zeev N, Bhandari S, Coria A, Erchick DJ, Gupta N, Hariyani S, Kagucia EW, Killewo J, Limaye RJ, McCollum ED, Pandey R, Pomat WS, Rao KD, Santosham M, Sauer M, Wanyenze RK, Peters DH. The need for COVID-19 research in low- and middle-income countries. Glob Health Res Policy 2020; 5:33. [PMID: 32617414 PMCID: PMC7326528 DOI: 10.1186/s41256-020-00159-y] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 06/11/2020] [Indexed: 12/21/2022] Open
Abstract
In the early months of the pandemic, most reported cases and deaths due to COVID-19 occurred in high-income countries. However, insufficient testing could have led to an underestimation of true infections in many low- and middle-income countries. As confirmed cases increase, the ultimate impact of the pandemic on individuals and communities in low- and middle-income countries is uncertain. We therefore propose research in three broad areas as urgently needed to inform responses in low- and middle-income countries: transmission patterns of SARS-CoV-2, the clinical characteristics of the disease, and the impact of pandemic prevention and response measures. Answering these questions will require a multidisciplinary approach led by local investigators and in some cases additional resources. Targeted research activities should be done to help mitigate the potential burden of COVID-19 in low- and middle-income countries without diverting the limited human resources, funding, or medical supplies from response activities.
Collapse
Affiliation(s)
- Madhu Gupta
- Department of Community Medicine and School of Public Health, Postgraduate Institute of Medical Education and Research, Madhya Marg, Sector 12, Chandigarh, 160012 India
| | - Brian Wahl
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA.,International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Binita Adhikari
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA.,Health Foundation Nepal, Kathmandu, Nepal
| | - Naor Bar-Zeev
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA.,International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Sudip Bhandari
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | | | - Daniel J Erchick
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Nidhi Gupta
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Shreya Hariyani
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - E Wangeci Kagucia
- Epidemiology and Demography Department, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Japhet Killewo
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Rupali Jayant Limaye
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA.,International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Eric D McCollum
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA.,Eudowood Division of Pediatric Respiratory Sciences, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, USA
| | - Raghukul Pandey
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - William S Pomat
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Krishna D Rao
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Mathuram Santosham
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA.,International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Molly Sauer
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA.,International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | | | - David H Peters
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| |
Collapse
|
64
|
Ahmed S, Mvalo T, Akech S, Agweyu A, Baker K, Bar-Zeev N, Campbell H, Checkley W, Chisti MJ, Colbourn T, Cunningham S, Duke T, English M, Falade AG, Fancourt NS, Ginsburg AS, Graham HR, Gray DM, Gupta M, Hammitt L, Hesseling AC, Hooli S, Johnson AWB, King C, Kirby MA, Lanata CF, Lufesi N, Mackenzie GA, McCracken JP, Moschovis PP, Nair H, Oviawe O, Pomat WS, Santosham M, Seddon JA, Thahane LK, Wahl B, Van der Zalm M, Verwey C, Yoshida LM, Zar HJ, Howie SR, McCollum ED. Protecting children in low-income and middle-income countries from COVID-19. BMJ Glob Health 2020; 5:bmjgh-2020-002844. [PMID: 32461228 PMCID: PMC7254117 DOI: 10.1136/bmjgh-2020-002844] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 05/08/2020] [Indexed: 02/03/2023] Open
Affiliation(s)
- Salahuddin Ahmed
- Projahnmo Research Foundation, Dhaka, Bangladesh.,NIHR Global Health Unit on Respiratory Health (RESPIRE), London, United Kingdom
| | - Tisungane Mvalo
- University of North Carolina Project Malawi, Lilongwe, Malawi.,Department of Pediatrics, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina, USA
| | - Samuel Akech
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | | | | | - Naor Bar-Zeev
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Harry Campbell
- NIHR Global Health Unit on Respiratory Health (RESPIRE), London, United Kingdom.,Center for Global Health, Usher Institute, University of Edinburgh Medical School, Edinburgh, United Kingdom
| | - William Checkley
- Division of Pulmonary and Critical Care, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Mohammod Jobayer Chisti
- Dhaka Hospital, Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease and Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Tim Colbourn
- Global Health Institute, University College London, London, United Kingdom
| | - Steve Cunningham
- NIHR Global Health Unit on Respiratory Health (RESPIRE), London, United Kingdom.,Centre for Inflammation Research, University of Edinburgh, Edinburgh, United Kingdom
| | - Trevor Duke
- Paediatric Intensive Care Unit, Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,School of Medicine and Health Sciences, University of Papua New Guinea, Goroka, Papua New Guinea
| | - Mike English
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxfordshire, United Kingdom
| | - Adegoke G Falade
- Division of Paediatric Pulmonology, Department of Paediatrics, College of Medicine and University College Hospital, Ibadan, Nigeria
| | - Nicholas Ss Fancourt
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Amy S Ginsburg
- Clinical Trial Center, University of Washington, Seattle, United States
| | - Hamish R Graham
- Centre for International Child Health, MCRI, University of Melbourne, Melbourne, Victoria, Australia.,Department of Paediatrics, University College Hospital Ibadan, Ibadan, Nigeria
| | - Diane M Gray
- Division Paediatric Pulmonology, Department of Paediatrics, University of Cape Town, Cape Town, South Africa
| | - Madhu Gupta
- Department of Community Medicine and School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Laura Hammitt
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Anneke C Hesseling
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Shubhada Hooli
- Department of Pediatrics, Section of Pediatric Emergency Medicine, Baylor College of Medicine, Houston, United States
| | - Abdul-Wahab Br Johnson
- Pulmonology & Infectious Disease Unit, Department of Paediatrics & Child Health, University of Ilorin/University of Ilorin Teaching Hospital, Ilorin, Nigeria
| | - Carina King
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Miles A Kirby
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States.,Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, United States
| | - Claudio F Lanata
- Instituto de Investigación Nutricional, Lima, Peru.,Department of Pediatrics, School of Medicine, Vanderbilt University, Nashville, Tennessee, United States
| | - Norman Lufesi
- Community Health Sciences Unit, Malawi Ministry of Health, Lilongwe, Malawi
| | - Grant A Mackenzie
- MRC Unit, The Gambia at LSHTM, Fajara, Gambia.,Faculty of Infectious & Tropical Diseases, LSHTM, London, United Kingdom.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - John P McCracken
- Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala
| | - Peter P Moschovis
- Divisions of Pulmonary Medicine and Global Health, Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Harish Nair
- NIHR Global Health Unit on Respiratory Health (RESPIRE), London, United Kingdom.,Center for Global Health, Usher Institute, University of Edinburgh Medical School, Edinburgh, United Kingdom
| | - Osawaru Oviawe
- Department of Child Health, University of Benin Teaching Hospital, Benin City, Nigeria
| | - William S Pomat
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Mathuram Santosham
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - James A Seddon
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.,Department of Infectious Diseases, Imperial College London, London, United Kingdom
| | - Lineo Keneuoe Thahane
- Baylor College of Medicine Children's Foundation - Lesotho, Maseru, Lesotho.,Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA.,The International Pediatric AIDS Initiative (BIPAI) at Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Brian Wahl
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Marieke Van der Zalm
- Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Charl Verwey
- Division of Paediatric Pulmonology, Department of Paediatrics, Chris Hani Baragwanath Academic Hospital, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Respiratory and Meningeal Pathogens Research Unit, Medical Research Council, University of the Witwatersrand, Johannesburg, South Africa
| | - Lay-Myint Yoshida
- Department of Pediatric Infectious Diseases, Institute of Tropical Medicine, Nagasaki University, Nagasaki, Japan
| | - Heather J Zar
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa.,SA-MRC Unit on Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Stephen Rc Howie
- Department of Paediatrics: Child & Youth Health, University of Auckland, Auckland, New Zealand
| | - Eric D McCollum
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA .,Johns Hopkins Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| |
Collapse
|
65
|
Bakare AA, Graham H, Agwai IC, Shittu F, King C, Colbourn T, Iuliano A, Aranda Z, McCollum ED, Isah A, Bahiru S, Valentine P, Falade AG, Burgess RA. Community and caregivers' perceptions of pneumonia and care-seeking experiences in Nigeria: A qualitative study. Pediatr Pulmonol 2020; 55 Suppl 1:S104-S112. [PMID: 31985894 DOI: 10.1002/ppul.24620] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 12/17/2019] [Indexed: 11/08/2022]
Abstract
BACKGROUND Appropriate and timely care seeking can reduce pneumonia deaths, but are influenced by caregivers and community norms of health and illness. We explore caregiver and community perceptions, and care-seeking experience, of childhood pneumonia, to understand contexts that drive pediatric service uptake in Nigeria. METHODS Community group discussions and qualitative interviews with caregivers in Lagos and Jigawa states were completed between 1 November 2018 and 31 May 2019. Participants were recruited from purposively sampled health facility catchment areas with assistance from facility staff. We used episodic interviews, asking caregivers (Jigawa = 20; Lagos = 15) to recount specific events linked to quests for therapy. Community group discussions (n = 3) used four vignettes from real pneumonia cases to frame a discussion around community priorities for healthcare and community-led activities to improve child survival. Data were analyzed using the framework method. RESULTS We found poor knowledge of pneumonia-specific symptoms and risk factors among caregivers and community members, with many attributing pneumonia to cold air exposure. Interviews highlighted that care-seeking decision making involved both husbands and wives, but men often made final decisions. In Lagos, older female relatives also shaped quests for therapy. Cost was a major consideration. In both states, there were accounts of dissatisfaction with health workers' attitudes and a general acceptance of vaccination services. CONCLUSION There is a need for community-based approaches to improve caregiver knowledge and care seeking for under-five children with pneumonia. Messaging should attend to knowledge of symptoms, risk factors, family dynamics, and community responsibilities in healthcare service delivery and utilization.
Collapse
Affiliation(s)
- Ayobami A Bakare
- Department of Community Medicine, University College Hospital, Ibadan, Nigeria.,Department of Community Medicine, College of Medicine, University of Ibadan, Ibadan, Nigeria.,Department of Global Public Health, Karolinska Institute, Stockholm, Sweden
| | - Hamish Graham
- Centre for International Child Health, University of Melbourne, Melbourne, VIC, Australia.,Department of Paediatrics, University College Hospital, Ibadan, Nigeria
| | - Imaria C Agwai
- Department of Epidemiology and Medical Statistics, Faculty of Public Health, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Funmilayo Shittu
- Department of Health Promotion and Education, Faculty of Public Health, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Carina King
- Department of Global Public Health, Karolinska Institute, Stockholm, Sweden.,Institute for Global Health, University College London, London, UK
| | - Tim Colbourn
- Institute for Global Health, University College London, London, UK
| | - Agnese Iuliano
- Institute for Global Health, University College London, London, UK
| | - Zeus Aranda
- Institute for Global Health, University College London, London, UK
| | - Eric D McCollum
- Eudowood Division of Respiratory Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Adamu Isah
- Save the Children International, Abuja, Nigeria
| | | | | | - Adegoke G Falade
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria.,Department of Paediatrics, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | | | | |
Collapse
|
66
|
King C, Iuliano A, Burgess RA, Agwai I, Ahmar S, Aranda Z, Bahiru S, Bakare AA, Colbourn T, Shittu F, Graham H, Isah A, McCollum ED, Falade AG. A mixed-methods evaluation of stakeholder perspectives on pediatric pneumonia in Nigeria-priorities, challenges, and champions. Pediatr Pulmonol 2020; 55 Suppl 1:S25-S33. [PMID: 31985139 DOI: 10.1002/ppul.24607] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 11/28/2019] [Indexed: 11/07/2022]
Abstract
BACKGROUND Interventions to reduce pneumonia mortality exist; however, stakeholder engagement is needed to prioritize these. We explored diverse stakeholder opinions on current policy challenges and priorities for pediatric pneumonia in Nigeria. METHODS We conducted a mixed-methods study, with a web-survey and semi-structured interviews, to explore stakeholder roles, policy barriers, opportunities, and priorities. Web-survey participants were identified through stakeholder mapping, including researchers' networks, academic and grey literature, and "Every Breath Counts" coalition membership. Stakeholders included actors involved in pediatric pneumonia in Nigeria from non-governmental, government, academic, civil society, private, and professional organizations. Stakeholder interviews were conducted with local government, healthcare managers, professional associations, and local leaders in Lagos and Jigawa states. Quantitative data were analyzed descriptively; qualitative data were analyzed using a thematic framework. RESULTS Of 111 stakeholders, 38 (34%) participated in the web-survey and 18 stakeholder interviews were conducted. Four thematic areas emerged: current policy, systems barriers, intervention priorities, and champions. Interviewees reported a lack of pneumonia-specific policies, despite acknowledging guidelines had been adopted in their settings. Barriers to effective pneumonia management were seen at all levels of the system, from the community to healthcare to policy, with key issues of resourcing and infrastructure. Intervention priorities were the strengthening of community knowledge and improving case management, focused on primary care. While stakeholders identified several key actors for pediatric pneumonia, they also highlighted a lack of champions. CONCLUSION Consistent messages emerged to prioritize community and primary care initiatives, alongside improved access to oxygen, and pulse oximetry. There is a need for clear pneumonia policies, and support for adoption at a state level.
Collapse
Affiliation(s)
- Carina King
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden.,Institute for Global Health, University College London, London, UK
| | - Agnese Iuliano
- Institute for Global Health, University College London, London, UK
| | | | - Imaria Agwai
- Department of Epidemiology and Medical Statistics, Faculty of Public Health, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | | | - Zeus Aranda
- Institute for Global Health, University College London, London, UK
| | | | - Ayobami A Bakare
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden.,Department of Community Medicine, University College Hospital, Ibadan, Nigeria
| | - Tim Colbourn
- Institute for Global Health, University College London, London, UK
| | - Funmilayo Shittu
- Department of Health Promotion and Education, Faculty of Public Health, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Hamish Graham
- International Child Health, Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Adamu Isah
- Save the Children International, Abuja, Nigeria
| | - Eric D McCollum
- Eudowood Division of Pediatric Respiratory Sciences, Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Adegoke G Falade
- Department of Paediatrics, University of Ibadan and University College Hospital, Ibadan, Nigeria
| |
Collapse
|
67
|
Shittu F, Agwai IC, Falade AG, Bakare AA, Graham H, Iuliano A, Aranda Z, McCollum ED, Isah A, Bahiru S, Ahmed T, Burgess RA, King C, Colbourn T, On Behalf Of The Inspiring Project Consortium. Health system challenges for improved childhood pneumonia case management in Lagos and Jigawa, Nigeria. Pediatr Pulmonol 2020; 55 Suppl 1:S78-S90. [PMID: 31990146 PMCID: PMC7977681 DOI: 10.1002/ppul.24660] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 01/09/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND Case fatality rates for childhood pneumonia in Nigeria remain high. There is a clear need for improved case management of pneumonia, through the sustainable implementation of the Integrated Management of Childhood Illnesses (IMCI) diagnostic and treatment algorithms. We explored barriers and opportunities for improved case management of childhood pneumonia in Lagos and Jigawa states, Nigeria. METHODS A mixed-method analysis was conducted to assess the current health system capacity to deliver quality care. This was done through audits of 16 facilities in Jigawa and 14 facilities in Lagos, questionnaires (n = 164) and 13 focus group discussions with providers. Field observations provided context for data analysis and triangulation. RESULTS There were more private providers in Lagos (4/8 secondary facilities) and more government providers in Jigawa (4/8 primary, 3/3 secondary, and 1/1 tertiary facilities). Oxygen and pulse oximeters were available in two of three in Jigawa and six of eight in Lagos of the sampled secondary care facilities. None of the eight primary facilities surveyed in Jigawa had oxygen or pulse oximetry available while in Lagos two of three primary facilities had oxygen and one of three had pulse oximeters. Other IMCI and emergency equipment were also lacking including respiratory rate timers, particularly in Jigawa state. Health care providers scored poorly on knowledge of IMCI, though previous IMCI training was associated with better knowledge. Key enabling factors in delivering pediatric care highlighted by health care providers included accountability procedures and feedback loops, the provision of free medication for children, and philanthropic acts. Common barriers to provide care included the burden of out-of-pocket payments, challenges in effective communication with caregivers, delayed presentation, and lack of clear diagnosis, and case management guidelines. CONCLUSION There is an urgent need to improve how the prevention and treatment of pediatric pneumonia is directed in both Lagos and Jigawa. Priority areas for reducing pediatric pneumonia burden are training and mentoring of health care providers, community health education, and introduction of oximeters and oxygen supply.
Collapse
Affiliation(s)
- Funmilayo Shittu
- Department of Health Promotion and Education, Faculty of Public Health, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Imaria C Agwai
- Department of Epidemiology and Medical Statistics, Faculty of Public Health, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Adegoke G Falade
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria
| | - Ayobami A Bakare
- Department of Community Medicine, University College Hospital, Ibadan, Nigeria
| | - Hamish Graham
- Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Agnese Iuliano
- Institute for Global Health, University College London, London, UK
| | - Zeus Aranda
- Institute for Global Health, University College London, London, UK
| | - Eric D McCollum
- Eudowood Division of Pediatric Respiratory Sciences, Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Adamu Isah
- Save the Children International, Abuja, Nigeria
| | | | | | | | - Carina King
- Institute for Global Health, University College London, London, UK.,Department of Global Public Health, Karolinska Institute, Stockholm, Sweden
| | - Tim Colbourn
- Institute for Global Health, University College London, London, UK
| | | |
Collapse
|
68
|
Iuliano A, Aranda Z, Colbourn T, Agwai IC, Bahiru S, Bakare AA, Burgess RA, Cassar C, Shittu F, Graham H, Isah A, McCollum ED, Falade AG, King C, On Behalf Of The Inspiring Project Consortium. The burden and risks of pediatric pneumonia in Nigeria: A desk-based review of existing literature and data. Pediatr Pulmonol 2020; 55 Suppl 1:S10-S21. [PMID: 31985170 DOI: 10.1002/ppul.24626] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 12/22/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND Pneumonia is a leading killer of children under-5 years, with a high burden in Nigeria. We aimed to quantify the regional burden and risks of pediatric pneumonia in Nigeria, and specifically the states of Lagos and Jigawa. METHODS We conducted a scoping literature search for studies of pneumonia morbidity and mortality in under-5 children in Nigeria from 10th December 2018 to 26th April 2019, searching: Cochrane, PubMed, and Web of Science. We included grey literature from stakeholders' websites and information shared by organizations working in Nigeria. We conducted multivariable logistic regression using the 2016 to 2017 Multiple Cluster Indicators Survey data set to explore factors associated with pneumonia. Descriptive analyses of datasets from 2010 to 2019 was done to estimate trends in mortality, morbidity, and vaccination coverage. RESULTS We identified 25 relevant papers (10 from Jigawa, 8 from Lagos, and 14 national data). None included data on pneumonia or acute respiratory tract infection burden in the health system, inpatient case-fatality rates, severity, or age-specific pneumonia mortality rates at state level. Secondary data analysis found that no household or caregiver socioeconomic indicators were consistently associated with self-reported symptoms of cough and/or difficulty breathing, and seasonality was inconsistently associated, dependant on region. CONCLUSION There is a clear evidence gap around the burden of pediatric pneumonia in Nigeria, and challenges with the interpretation of existing household survey data. Improved survey approaches are needed to understand the risks of pediatric pneumonia in Nigeria, alongside the need for investment in reliable routine data systems to provide data on the clinical pneumonia burden in Nigeria.
Collapse
Affiliation(s)
- Agnese Iuliano
- Institute for Global Health, University College London, London, UK
| | - Zeus Aranda
- Institute for Global Health, University College London, London, UK
| | - Tim Colbourn
- Institute for Global Health, University College London, London, UK
| | - Imaria C Agwai
- Department of Epidemiology and Medical Statistics, Faculty of Public Health, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | | | - Ayobami A Bakare
- Department of Community Medicine, University College Hospital, Ibadan, Nigeria
| | | | | | - Funmilayo Shittu
- Department of Health Promotion and Education, Faculty of Public Health, University of Ibadan, Ibadan, Nigeria
| | - Hamish Graham
- Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Adamu Isah
- Save the Children International, Abuja, Nigeria
| | - Eric D McCollum
- Eudowood Division of Pediatric Respiratory Sciences, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Adegoke G Falade
- Department of Paediatrics, University of Ibadan and University College Hospital, Ibadan, Nigeria
| | - Carina King
- Institute for Global Health, University College London, London, UK.,Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | | |
Collapse
|
69
|
Lenahan JL, Nkwopara E, Phiri M, Mvalo T, Couasnon MT, Turner K, Ndamala C, McCollum ED, May S, Ginsburg AS. Repeat assessment of examination signs among children in Malawi with fast-breathing pneumonia. ERJ Open Res 2020; 6:00275-2019. [PMID: 32494572 PMCID: PMC7248340 DOI: 10.1183/23120541.00275-2019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 03/04/2020] [Indexed: 01/04/2023] Open
Abstract
Background As part of a randomised controlled trial of treatment with placebo versus 3 days of amoxicillin for nonsevere fast-breathing pneumonia among Malawian children aged 2–59 months, a subset of children was hospitalised for observation. We sought to characterise the progression of fast-breathing pneumonia among children undergoing repeat assessments to better understand which children do and do not deteriorate. Methods Vital signs and physical examination findings, including respiratory rate, arterial oxygen saturation measured by pulse oximetry (SpO2), chest indrawing and temperature were assessed every 3 h for the duration of hospitalisation. Children were assessed for treatment failure during study visits on days 1, 2, 3 and 4. Results Hospital monitoring data from 436 children were included. While no children had SpO2 90–93% at baseline, 7.4% (16 of 215) of children receiving amoxicillin and 9.5% (21 of 221) receiving placebo developed SpO2 90–93% during monitoring. Similarly, no children had chest indrawing at enrolment, but 6.6% (14 of 215) in the amoxicillin group and 7.2% (16 of 221) in the placebo group went on to develop chest indrawing during hospitalisation. Conclusion Repeat monitoring of children with fast-breathing pneumonia identified vital and physical examination signs not present at baseline, including SpO2 90–93% and chest indrawing. This information may support providers and policymakers in developing guidance for care of children with nonsevere pneumonia. This study characterised the progression of fast-breathing pneumonia among children in Malawi. Repeat monitoring of children identified vital and physical exam signs not present at baseline, including oxygen saturation of 90–93% and chest indrawing.http://bit.ly/2vUlckS
Collapse
Affiliation(s)
- Jennifer L Lenahan
- International Programs, Save the Children Federation Inc., Westport, CT, USA
| | - Evangelyn Nkwopara
- International Programs, Save the Children Federation Inc., Westport, CT, USA
| | - Melda Phiri
- Dept of Pediatrics, University of North Carolina Project, Lilongwe Medical Relief Fund Trust, Lilongwe, Malawi
| | - Tisungane Mvalo
- Dept of Pediatrics, University of North Carolina Project, Lilongwe Medical Relief Fund Trust, Lilongwe, Malawi
| | - Mari T Couasnon
- International Programs, Save the Children Federation Inc., Westport, CT, USA
| | - Kali Turner
- International Programs, Save the Children Federation Inc., Westport, CT, USA
| | - Chifundo Ndamala
- Dept of Pediatrics, University of North Carolina Project, Lilongwe Medical Relief Fund Trust, Lilongwe, Malawi
| | - Eric D McCollum
- Dept of Pediatrics, Eudowood Division of Pediatric Respiratory Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Susanne May
- Dept of Biostatistics, University of Washington, Seattle, WA, USA
| | - Amy Sarah Ginsburg
- International Programs, Save the Children Federation Inc., Westport, CT, USA
| |
Collapse
|
70
|
Hooli S, King C, Zadutsa B, Nambiar B, Makwenda C, Masache G, Lufesi N, Mwansambo C, Malla L, Costello A, Colbourn T, McCollum ED. The Epidemiology of Hypoxemic Pneumonia among Young Infants in Malawi. Am J Trop Med Hyg 2020; 102:676-683. [PMID: 31971153 DOI: 10.4269/ajtmh.19-0516] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
We describe hypoxemic pneumonia prevalence in outpatient and inpatient settings, in-hospital mortality, and clinical guideline performance for identifying hypoxemia in young infants in Malawi. In this retrospective analysis of a prospective cohort study, we investigate infants younger than 2 months participating in pneumonia surveillance at seven hospitals and 18 outpatient health centers in Malawi between 2011 and 2014. Logistic regression, multiple imputation with chained equations, and pattern mixture modeling were used to determine the association between peripheral capillary oxyhemoglobin saturation (SpO2) levels and hospital mortality. We describe outpatient clinician hospital referral recommendations based on clinical characteristics and SpO2 distributions. Among 1,879 analyzed cases, SpO2 < 90% was more prevalent among outpatient health center cases compared with hospitalized cases (22.6% versus 13.5%, 95% CI: 17.6-28.4% and 12.0-15.3%, respectively). A larger proportion of hospitalized infants had signs of respiratory distress compared with infants at health centers (67.7% versus 56.6%, P < 0.001) and most hospitalized infants were boys (56.7% versus 40.6%, P < 0.001). An SpO2 of 90-92% and < 90% was associated with similarly increased odds of in-hospital mortality (adjusted odds ratio [aOR]: 4.3 and 4.4, 95% CI: 1.7-11.1 and 1.8-10.5, respectively). Unrecorded, or unobtainable, SpO2 was highly associated with mortality (n = 127, aOR: 18.1; 95% CI: 7.6-42.8). Four of 22 (18%) infants at health centers who did not meet clinical referral criteria had an SpO2 ≤ 92%. Clinicians should consider hospital referral in young infants with a SpO2 ≤ 92%. Infants with unobtainable SpO2 readings should be considered a high-risk group, and hospital referral of these cases may be appropriate.
Collapse
Affiliation(s)
- Shubhada Hooli
- Department of Pediatrics, Section of Emergency Medicine, Baylor College of Medicine, Houston, Texas
| | - Carina King
- Institute for Global Health, University College London, London, United Kingdom.,Department of Global Public Health, Karolinksa Institutet, Stockholm, Sweden
| | | | - Bejoy Nambiar
- Institute for Global Health, University College London, London, United Kingdom
| | | | | | - Norman Lufesi
- Republic of Malawi Ministry of Health, Lilongwe, Malawi
| | | | - Lucas Malla
- Kenya Medical Research Institute-Wellcome Trust, Nairobi, Kenya
| | - Anthony Costello
- Institute for Global Health, University College London, London, United Kingdom
| | - Tim Colbourn
- Institute for Global Health, University College London, London, United Kingdom
| | - Eric D McCollum
- Division of Pulmonology, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland.,Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| |
Collapse
|
71
|
Sessions KL, Ruegsegger L, Mvalo T, Kondowe D, Tsidya M, Hosseinipour MC, Lufesi N, Eckerle M, Smith AG, McCollum ED. Focus group discussions on low-flow oxygen and bubble CPAP treatments among mothers of young children in Malawi: a CPAP IMPACT substudy. BMJ Open 2020; 10:e034545. [PMID: 32404389 PMCID: PMC7228516 DOI: 10.1136/bmjopen-2019-034545] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To determine the acceptability of bubble continuous positive airway pressure (bCPAP) and low-flow oxygen among mothers of children who had received either therapy. SETTING A district hospital in Salima, Malawi. PARTICIPANTS We conducted eight focus group discussions (FGDs) with a total of 54 participants. Eligible participants were mothers of children 1 to 59 months of age with severe pneumonia and a comorbidity (HIV-infection, HIV-exposure, malnutrition or hypoxaemia) who, with informed consent, had been enrolled in a randomised clinical trial, CPAP IMPACT (Improving Mortality for Pneumonia in African Children Trial), comparing low-flow oxygen and bCPAP treatments (ClinicalTrials.gov, NCT02484183). PRIMARY AND SECONDARY OUTCOME MEASURES FGDs assessed mothers' attitudes and feelings towards oxygen and bCPAP before and after therapy along with general community perceptions of respiratory therapies. Data was analysed using inductive thematic analysis to assess themes and subthemes of the transcripts. RESULTS Community perceptions of oxygen and bCPAP were widely negative. Mothers recounted that they are told that 'oxygen kills babies'. They are often fearful of allowing their child to receive oxygen therapy and will delay treatment or seek alternative therapies. Mothers report limiting oxygen and bCPAP by intermittently removing the nasal cannulas or mask. After oxygen or bCPAP treatment, regardless of patient outcome, mothers were supportive of the treatment their child received and would recommend it to other mothers. CONCLUSION There are significant community misconceptions around oxygen and bCPAP causing mothers to be fearful of either treatment. In order for low-flow oxygen treatment and bCPAP implementation to be effective, widespread community education is necessary.
Collapse
Affiliation(s)
- Kristen L Sessions
- Pediatrics, McGaw Medical Center of Northwestern University, Chicago, Illinois, United States
| | - Laura Ruegsegger
- Project Malawi, University of North Carolina System, Lilongwe, Malawi
| | - Tisungane Mvalo
- University of North Carolina Project Malawi, Lilongwe, Malawi
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States
| | - Davie Kondowe
- University of North Carolina Project Malawi, Lilongwe, Malawi
| | - Mercy Tsidya
- University of North Carolina Project Malawi, Lilongwe, Malawi
| | - Mina C Hosseinipour
- University of North Carolina Project Malawi, Lilongwe, Malawi
- Infectous Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States
| | - Norman Lufesi
- Acute Respiratory Infection Unit, Ministry of Health, Lilongwe, Malawi
| | - Michelle Eckerle
- Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
- University of Cincinnati College of Medicine, Cincinnati, Ohio, United States
| | - Andrew Gerald Smith
- Pediatric Critical Care Medicine, University of Utah, Salt Lake City, Utah, United States
| | - Eric D McCollum
- Eudowood Division of Pediatric Respiratory Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland, United States
- International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States
| |
Collapse
|
72
|
Clasen T, Checkley W, Peel JL, Balakrishnan K, McCracken JP, Rosa G, Thompson LM, Barr DB, Clark ML, Johnson MA, Waller LA, Jaacks LM, Steenland K, Miranda JJ, Chang HH, Kim DY, McCollum ED, Davila-Roman VG, Papageorghiou A, Rosenthal JP. Design and Rationale of the HAPIN Study: A Multicountry Randomized Controlled Trial to Assess the Effect of Liquefied Petroleum Gas Stove and Continuous Fuel Distribution. Environ Health Perspect 2020; 128:47008. [PMID: 32347766 PMCID: PMC7228119 DOI: 10.1289/ehp6407] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 02/07/2020] [Accepted: 02/11/2020] [Indexed: 05/05/2023]
Abstract
BACKGROUND Globally, nearly 3 billion people rely on solid fuels for cooking and heating, the vast majority residing in low- and middle-income countries (LMICs). The resulting household air pollution (HAP) is a leading environmental risk factor, accounting for an estimated 1.6 million premature deaths annually. Previous interventions of cleaner stoves have often failed to reduce exposure to levels that produce meaningful health improvements. There have been no multicountry field trials with liquefied petroleum gas (LPG) stoves, likely the cleanest scalable intervention. OBJECTIVE This paper describes the design and methods of an ongoing randomized controlled trial (RCT) of LPG stove and fuel distribution in 3,200 households in 4 LMICs (India, Guatemala, Peru, and Rwanda). METHODS We are enrolling 800 pregnant women at each of the 4 international research centers from households using biomass fuels. We are randomly assigning households to receive LPG stoves, an 18-month supply of free LPG, and behavioral reinforcements to the control arm. The mother is being followed along with her child until the child is 1 year old. Older adult women (40 to < 80 years of age) living in the same households are also enrolled and followed during the same period. Primary health outcomes are low birth weight, severe pneumonia incidence, stunting in the child, and high blood pressure (BP) in the older adult woman. Secondary health outcomes are also being assessed. We are assessing stove and fuel use, conducting repeated personal and kitchen exposure assessments of fine particulate matter with aerodynamic diameter ≤ 2.5 μ m (PM 2.5 ), carbon monoxide (CO), and black carbon (BC), and collecting dried blood spots (DBS) and urinary samples for biomarker analysis. Enrollment and data collection began in May 2018 and will continue through August 2021. The trial is registered with ClinicalTrials.gov (NCT02944682). CONCLUSIONS This study will provide evidence to inform national and global policies on scaling up LPG stove use among vulnerable populations. https://doi.org/10.1289/EHP6407.
Collapse
Affiliation(s)
- Thomas Clasen
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - William Checkley
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Jennifer L. Peel
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, Colorado, USA
| | - Kalpana Balakrishnan
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Institute for Higher Education and Research (Deemed University), Chennai, Tamil Nadu, India
| | - John P. McCracken
- Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala
| | - Ghislaine Rosa
- Department of Disease Control, Faculty of Infections and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Lisa M. Thompson
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia, USA
| | - Dana Boyd Barr
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Maggie L. Clark
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, Colorado, USA
| | | | - Lance A. Waller
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Lindsay M. Jaacks
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Kyle Steenland
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - J. Jaime Miranda
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Howard H. Chang
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Dong-Yun Kim
- Office of Biostatistics Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Eric D. McCollum
- Eudowood Division of Respiratory Sciences, Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Victor G. Davila-Roman
- Cardiovascular Imaging and Clinical Research Core Laboratory, Cardiovascular Division, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Aris Papageorghiou
- Nuffield Department of Women’s and Reproductive Health, University of Oxford, Oxford, UK
| | - Joshua P. Rosenthal
- Division of Epidemiology and Population Studies, Fogarty International Center, National Institutes of Health, Bethesda, Maryland, USA
| | - HAPIN Investigators
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, Colorado, USA
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Institute for Higher Education and Research (Deemed University), Chennai, Tamil Nadu, India
- Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala
- Department of Disease Control, Faculty of Infections and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia, USA
- Berkeley Air Monitoring Group, Berkeley, California, USA
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
- Office of Biostatistics Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
- Eudowood Division of Respiratory Sciences, Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
- Cardiovascular Imaging and Clinical Research Core Laboratory, Cardiovascular Division, Washington University School of Medicine, St. Louis, Missouri, USA
- Nuffield Department of Women’s and Reproductive Health, University of Oxford, Oxford, UK
- Division of Epidemiology and Population Studies, Fogarty International Center, National Institutes of Health, Bethesda, Maryland, USA
| |
Collapse
|
73
|
Crocker ME, Hossen S, Goodman D, Simkovich SM, Kirby M, Thompson LM, Rosa G, Garg SS, Thangavel G, McCollum ED, Peel J, Clasen T, Checkley W. Effects of high altitude on respiratory rate and oxygen saturation reference values in healthy infants and children younger than 2 years in four countries: a cross-sectional study. Lancet Glob Health 2020; 8:e362-e373. [PMID: 32087173 PMCID: PMC7034060 DOI: 10.1016/s2214-109x(19)30543-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 12/10/2019] [Accepted: 12/16/2019] [Indexed: 01/04/2023]
Abstract
BACKGROUND In resource-limited settings, pneumonia diagnosis and management are based on thresholds for respiratory rate (RR) and oxyhaemoglobin saturation (SpO2) recommended by WHO. However, as RR increases and SpO2 decreases with elevation, these thresholds might not be applicable at all altitudes. We sought to determine upper thresholds for RR and lower thresholds for SpO2 by age and altitude at four sites, with altitudes ranging from sea level to 4348 m. METHODS In this cross-sectional study, we enrolled healthy children aged 0-23 months who lived within the study areas in India, Guatemala, Rwanda, and Peru. Participants were excluded if they had been born prematurely (<37 weeks gestation); had a congenital heart defect; had history in the past 2 weeks of overnight admission to a health facility, diagnosis of pneumonia, antibiotic use, or respiratory or gastrointestinal signs; history in the past 24 h of difficulty breathing, fast breathing, runny nose, or nasal congestion; and current runny nose, nasal congestion, fever, chest indrawing, or cyanosis. We measured RR either automatically with the Masimo Rad-97, manually, or both, and measured SpO2 with the Rad-97. Trained staff measured RR in duplicate and SpO2 in triplicate in children who had no respiratory symptoms or signs in the past 2 weeks. We estimated smooth percentiles for RR and SpO2 that varied by age and site using generalised additive models for location, shape, and scale. We compared these data with WHO RR and SpO2 thresholds for tachypnoea and hypoxaemia to determine agreement. FINDINGS Between Nov 24, 2017, and Oct 10, 2018, we screened 2027 children for eligibility. 335 were ineligible, leaving 1692 eligible participants. 30 children were excluded because of missing values and 92 were excluded because of measurement or data entry errors, leaving 1570 children in the final analysis. 404 participants were from India (altitude 1-919 m), 389 were from Guatemala (1036-2017 m), 341 from Rwanda (1449-1644 m), and 436 from Peru (3827-4348 m). Mean age was 7·2 months (SD 7·2) and 796 (50·7%) of 1570 participants were female. Although average age was mostly similar between settings, the average participant age in Rwanda was noticeably younger, at 5·5 months (5·9). In the 1570 children included in the analysis, mean RR was 31·9 breaths per min (SD 7·1) in India, 41·5 breaths per min in Guatemala (8·4), 44·0 breaths per min in Rwanda (10·8), and 48·0 breaths per min in Peru (9·4). Mean SpO2 was 98·3% in India (SD 1·5), 97·3% in Guatemala (2·4), 96·2% in Rwanda (2·6), and 89·7% in Peru (3·5). Compared to India, mean RR was 9·6 breaths per min higher in Guatemala, 12·1 breaths per min higher in Rwanda, and 16·1 breaths per min higher in Peru (likelihood ratio test p<0·0001). Smooth percentiles for RR and SpO2 varied by site and age. When we compared age-specific and site-specific 95th percentiles for RR and 5th percentiles for SpO2 against the WHO cutoffs, we found that the proportion of false positives for tachypnoea increased with altitude: 0% in India (95% CI 0-0), 7·3% in Guatemala (4·1-10·4), 16·8% in Rwanda (12·9-21·1), and 28·9% in Peru (23·7-33·0). We also found a high proportion of false positives for hypoxaemia in Peru (11·6%, 95% CI 7·0-14·7). INTERPRETATION WHO cutoffs for fast breathing and hypoxaemia overlap with RR and SpO2 values that are normal for children in different altitudes. Use of WHO definitions for fast breathing could result in misclassification of pneumonia in many children who live at moderate to high altitudes and show acute respiratory signs. The 5th percentile for SpO2 was in reasonable agreement with the WHO definition of hypoxaemia in all regions except for Peru (the highest altitude site). Misclassifications could result in inappropriate management of paediatric respiratory illness and misdirection of potentially scarce resources such as antibiotics and supplemental oxygen. Future studies at various altitudes are needed to validate our findings and recommend a revision to current guidelines. Substantiating research in sick children is still needed. FUNDING US National Institutes of Health, Bill & Melinda Gates Foundation.
Collapse
Affiliation(s)
- Mary E Crocker
- Department of Paediatrics, School of Medicine, University of Washington, Seattle, WA, USA; Division of Pulmonary and Sleep Medicine, Seattle Children's Hospital, Seattle, WA, USA
| | - Shakir Hossen
- Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Centre for Global Non-Communicable Disease Research and Training, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Dina Goodman
- Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Centre for Global Non-Communicable Disease Research and Training, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Suzanne M Simkovich
- Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Centre for Global Non-Communicable Disease Research and Training, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Miles Kirby
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Lisa M Thompson
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
| | - Ghislaine Rosa
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | - Sarada S Garg
- Department of Environmental Health Engineering, ICMR Centre for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Institute of Higher Education and Research (SRIHER), Chennai, India
| | - Gurusamy Thangavel
- Department of Environmental Health Engineering, ICMR Centre for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Institute of Higher Education and Research (SRIHER), Chennai, India
| | - Eric D McCollum
- Eudowood Division of Paediatric Respiratory Sciences, Department of Paediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of International Health, Bloomberg School of Public Health, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jennifer Peel
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, CO, USA
| | - Thomas Clasen
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - William Checkley
- Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Centre for Global Non-Communicable Disease Research and Training, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of International Health, Bloomberg School of Public Health, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| |
Collapse
|
74
|
Simkovich SM, Underhill LJ, Kirby MA, Goodman D, Crocker ME, Hossen S, McCracken JP, de León O, Thompson LM, Garg SS, Balakrishnan K, Thangavel G, Rosa G, Peel JL, Clasen TF, McCollum ED, Checkley W. Design and conduct of facility-based surveillance for severe childhood pneumonia in the Household Air Pollution Intervention Network (HAPIN) trial. ERJ Open Res 2020; 6:00308-2019. [PMID: 32211438 PMCID: PMC7086071 DOI: 10.1183/23120541.00308-2019] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 02/06/2020] [Indexed: 12/20/2022] Open
Abstract
Pneumonia is both a treatable and preventable disease but remains a leading cause of death in children worldwide. Household air pollution caused by burning biomass fuels for cooking has been identified as a potentially preventable risk factor for pneumonia in low- and middle-income countries. We are conducting a randomised controlled trial of a clean energy intervention in 3200 households with pregnant women living in Guatemala, India, Peru and Rwanda. Here, we describe the protocol to ascertain the incidence of severe pneumonia in infants born to participants during the first year of the study period using three independent algorithms: the presence of cough or difficulty breathing and hypoxaemia (≤92% in Guatemala, India and Rwanda and ≤86% in Peru); presence of cough or difficulty breathing along with at least one World Health Organization-defined general danger sign and consolidation on chest radiography or lung ultrasound; and pneumonia confirmed to be the cause of death by verbal autopsy. Prior to the study launch, we identified health facilities in the study areas where cases of severe pneumonia would be referred. After participant enrolment, we posted staff at each of these facilities to identify children enrolled in the trial seeking care for severe pneumonia. To ensure severe pneumonia cases are not missed, we are also conducting home visits to all households and providing education on pneumonia to the mother. Severe pneumonia reduction due to mitigation of household air pollution could be a key piece of evidence that sways policymakers to invest in liquefied petroleum gas distribution programmes.
Collapse
Affiliation(s)
- Suzanne M. Simkovich
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Lindsay J. Underhill
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Miles A. Kirby
- Dept of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Dina Goodman
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Mary E. Crocker
- Division of Pulmonary and Sleep Medicine, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, USA
| | - Shakir Hossen
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - John P. McCracken
- Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala
| | - Oscar de León
- Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala
| | - Lisa M. Thompson
- Dept of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
| | - Sarada S. Garg
- Dept of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Institute for Higher Education and Research (Deemed to be University), Chennai, India
| | - Kalpana Balakrishnan
- Dept of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Institute for Higher Education and Research (Deemed to be University), Chennai, India
| | - Gurusamy Thangavel
- Dept of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Institute for Higher Education and Research (Deemed to be University), Chennai, India
| | - Ghislaine Rosa
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Jennifer L. Peel
- Dept of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, CO, USA
| | - Thomas F. Clasen
- Dept of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Eric D. McCollum
- Eudowood Division of Pediatric Respiratory Sciences, Dept of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- Global Program on Pediatric Respiratory Sciences, Dept of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- These authors contributed equally
| | - William Checkley
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- These authors contributed equally
| |
Collapse
|
75
|
Goodman D, Crocker ME, Pervaiz F, McCollum ED, Steenland K, Simkovich SM, Miele CH, Hammitt LL, Herrera P, Zar HJ, Campbell H, Lanata CF, McCracken JP, Thompson LM, Rosa G, Kirby MA, Garg S, Thangavel G, Thanasekaraan V, Balakrishnan K, King C, Clasen T, Checkley W. Challenges in the diagnosis of paediatric pneumonia in intervention field trials: recommendations from a pneumonia field trial working group. Lancet Respir Med 2019; 7:1068-1083. [PMID: 31591066 PMCID: PMC7164819 DOI: 10.1016/s2213-2600(19)30249-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 06/27/2019] [Accepted: 07/03/2019] [Indexed: 12/14/2022]
Abstract
Pneumonia is a leading killer of children younger than 5 years despite high vaccination coverage, improved nutrition, and widespread implementation of the Integrated Management of Childhood Illnesses algorithm. Assessing the effect of interventions on childhood pneumonia is challenging because the choice of case definition and surveillance approach can affect the identification of pneumonia substantially. In anticipation of an intervention trial aimed to reduce childhood pneumonia by lowering household air pollution, we created a working group to provide recommendations regarding study design and implementation. We suggest to, first, select a standard case definition that combines acute (≤14 days) respiratory symptoms and signs and general danger signs with ancillary tests (such as chest imaging and pulse oximetry) to improve pneumonia identification; second, to prioritise active hospital-based pneumonia surveillance over passive case finding or home-based surveillance to reduce the risk of non-differential misclassification of pneumonia and, as a result, a reduced effect size in a randomised trial; and, lastly, to consider longitudinal follow-up of children younger than 1 year, as this age group has the highest incidence of severe pneumonia.
Collapse
Affiliation(s)
- Dina Goodman
- Division of Pulmonary and Critical Care, Johns Hopkins University, Baltimore, MD, USA; Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA
| | - Mary E Crocker
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA; Division of Pediatric Pulmonology, School of Medicine, University of Washington, Seattle, WA, USA
| | - Farhan Pervaiz
- Division of Pulmonary and Critical Care, Johns Hopkins University, Baltimore, MD, USA; Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA
| | - Eric D McCollum
- Eudowood Division of Pediatric Respiratory Sciences, Department of Pediatrics, Johns Hopkins University, Baltimore, MD, USA; School of Medicine, and Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Kyle Steenland
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Suzanne M Simkovich
- Division of Pulmonary and Critical Care, Johns Hopkins University, Baltimore, MD, USA; Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA
| | - Catherine H Miele
- Division of Pulmonary and Critical Care, Johns Hopkins University, Baltimore, MD, USA; Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA
| | - Laura L Hammitt
- School of Medicine, and Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Phabiola Herrera
- Division of Pulmonary and Critical Care, Johns Hopkins University, Baltimore, MD, USA; Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA
| | - Heather J Zar
- Department of Pediatrics and Child Health, SA-MRC Unit on Child & Adolescent Health, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Harry Campbell
- Centre for Global Health Research, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Claudio F Lanata
- Instituto de Investigación Nutricional, Lima, Peru; Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - John P McCracken
- Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala
| | - Lisa M Thompson
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA; Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Ghislaine Rosa
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
| | - Miles A Kirby
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Sarada Garg
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Medical College & Research Institute (Deemed University), Chennai, India
| | - Gurusamy Thangavel
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Medical College & Research Institute (Deemed University), Chennai, India
| | - Vijayalakshmi Thanasekaraan
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Medical College & Research Institute (Deemed University), Chennai, India
| | - Kalpana Balakrishnan
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Medical College & Research Institute (Deemed University), Chennai, India
| | - Carina King
- Institute for Global Health, University College London, London, UK
| | - Thomas Clasen
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - William Checkley
- Division of Pulmonary and Critical Care, Johns Hopkins University, Baltimore, MD, USA; Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA; School of Medicine, and Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA.
| |
Collapse
|
76
|
King C, McCollum ED. Trends in the global burden of paediatric lower respiratory infections. Lancet Infect Dis 2019; 20:4-5. [PMID: 31678028 PMCID: PMC7952014 DOI: 10.1016/s1473-3099(19)30557-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Accepted: 08/06/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Carina King
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden; Institute for Global Health, University College London, London WC1N 1EH, UK.
| | - Eric D McCollum
- Eudowood Division of Pediatric Respiratory Sciences, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA; Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| |
Collapse
|
77
|
Pervaiz F, Hossen S, Chavez MA, Miele CH, Moulton LH, McCollum ED, Roy AD, Chowdhury NH, Ahmed S, Begum N, Quaiyum A, Santosham M, Baqui AH, Checkley W. Training and standardization of general practitioners in the use of lung ultrasound for the diagnosis of pediatric pneumonia. Pediatr Pulmonol 2019; 54:1753-1759. [PMID: 31432618 PMCID: PMC6899663 DOI: 10.1002/ppul.24477] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 08/20/2019] [Accepted: 07/09/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Pneumonia is a leading cause of death in children of low-resource settings. Barriers to care include an early and accurate diagnosis. Lung ultrasound is a novel tool for the identification of pediatric pneumonia; however, there is currently no standardized approach to train in image acquisition and interpretation of findings in epidemiological studies. We developed a training program for physicians with limited ultrasound experience on how to use ultrasound for the diagnosis of pediatric pneumonia and how to standardize image interpretation using a panel of readers. METHODS Twenty-five physicians participating in the training program conducted lung ultrasounds in all children with suspected pneumonia, aged 3 to 35 months, presenting to three subdistrict hospitals in Sylhet, Bangladesh, between June 2015 and September 2017. RESULTS A total of 9051 pediatric lung ultrasound assessments were conducted through 27 months of data collection. Study physicians underwent training and all were successfully standardized, achieving 91% agreement and maintained a sensitivity and specificity of 88% and 92%, respectively, when their diagnosis was compared with experts. Overall kappa between two readers was high (0.86, 95% confidence interval [CI], 0.84-0.87), and remained high when a third expert reader was included (0.80, 95% CI, 0.79-0.81). Agreement and kappa statistics were similarly high when stratified by age, sex, presence of danger signs, or hypoxemia. CONCLUSIONS Lung ultrasound is a novel tool for the diagnosis of pediatric pneumonia with evidence supporting its validity and feasibility of implementation. Here we introduced a training program that resulted in a high level of inter-sonographer agreement.
Collapse
Affiliation(s)
- Farhan Pervaiz
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Shakir Hossen
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Miguel A. Chavez
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Catherine H. Miele
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Lawrence H. Moulton
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
- Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Eric D. McCollum
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
- Eudowood Division of Pediatric Respiratory Sciences, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Arun D. Roy
- Johns Hopkins University‐Bangladesh, Dhaka, Bangladesh
| | | | | | - Nazma Begum
- Johns Hopkins University‐Bangladesh, Dhaka, Bangladesh
| | - Abdul Quaiyum
- Reproductive Health Unit, icddr,b, Dhaka, Bangladesh
| | - Mathuram Santosham
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Abdullah H. Baqui
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - William Checkley
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| |
Collapse
|
78
|
McCollum ED, Mvalo T, Eckerle M, Smith AG, Kondowe D, Makonokaya D, Vaidya D, Billioux V, Chalira A, Lufesi N, Mofolo I, Hosseinipour M. Bubble continuous positive airway pressure for children with high-risk conditions and severe pneumonia in Malawi: an open label, randomised, controlled trial. Lancet Respir Med 2019; 7:964-974. [PMID: 31562059 PMCID: PMC6838668 DOI: 10.1016/s2213-2600(19)30243-7] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 07/08/2019] [Accepted: 07/09/2019] [Indexed: 12/14/2022]
Abstract
Background Pneumonia is the leading cause of death among children globally. Most pneumonia deaths in low-income and middle-income countries (LMICs) occur among children with HIV infection or exposure, severe malnutrition, or hypoxaemia despite antibiotics and oxygen. Non-invasive bubble continuous positive airway pressure (bCPAP) is considered a safe ventilation modality that might improve child pneumonia survival. bCPAP outcomes for high-risk African children with severe pneumonia are unknown. Since most child pneumonia hospitalisations in Africa occur in non-tertiary district hospitals without daily physician oversight, we aimed to examine whether bCPAP improves severe pneumonia mortality in such settings. Methods This open-label, randomised, controlled trial was done in the general paediatric ward of Salima District Hospital, Malawi. We enrolled children aged 1–59 months old with WHO-defined severe pneumonia and either HIV infection or exposure, severe malnutrition, or an oxygen saturation of less than 90%. Children were randomly assigned 1:1 to low-flow nasal cannula oxygen or nasal bCPAP. Non-physicians administered care; the primary outcome was hospital survival. Primary analyses were by intention-to-treat and interim and adverse events analyses per protocol. This trial is registered with ClinicalTrials.gov, number NCT02484183, and is closed. Findings We screened 1712 children for eligibility between June 23, 2015, and March 21, 2018. The data safety and monitoring board stopped the trial for futility after 644 of the intended 900 participants were enrolled. 323 children were randomly assigned to oxygen and 321 to bCPAP. 35 (11%) of 323 children who received oxygen died in hospital, as did 53 (17%) of 321 who received bCPAP (relative risk 1·52; 95% CI 1·02–2·27; p=0·036). 13 oxygen and 17 bCPAP patients lacked hospital outcomes and were considered lost to follow-up. Suspected adverse events related to treatment occurred in 11 (3%) of 321 children receiving bCPAP and 1 (<1%) of 323 children receiving oxygen. Four bCPAP and one oxygen group deaths were classified as probable aspiration episodes, one bCPAP death as probable pneumothorax, and six non-death bCPAP events included skin breakdown around the nares. Interpretation bCPAP treatment in a paediatric ward without daily physician supervision did not reduce hospital mortality among high-risk Malawian children with severe pneumonia, compared with oxygen. The use of bCPAP within certain patient populations and non-intensive care settings might carry risk that was not previously recognised. bCPAP in LMICs needs further evaluation before wider implementation for child pneumonia care. Funding Bill & Melinda Gates Foundation, International AIDS Society, Health Empowering Humanity.
Collapse
Affiliation(s)
- Eric D McCollum
- Eudowood Division of Pediatric Respiratory Sciences, Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA.
| | - Tisungane Mvalo
- University of North Carolina Project Malawi, Lilongwe, Malawi; Department of Pediatrics, School of Medicine, University of North Carolina at Chapel Hill, NC, USA
| | - Michelle Eckerle
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Andrew G Smith
- University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Davie Kondowe
- University of North Carolina Project Malawi, Lilongwe, Malawi
| | - Don Makonokaya
- University of North Carolina Project Malawi, Lilongwe, Malawi
| | | | | | | | | | - Innocent Mofolo
- University of North Carolina Project Malawi, Lilongwe, Malawi
| | - Mina Hosseinipour
- University of North Carolina Project Malawi, Lilongwe, Malawi; Division of Infectious Disease, University of North Carolina at Chapel Hill, NC, USA
| |
Collapse
|
79
|
Boyd N, King C, Walker IA, Zadutsa B, Bernstein M, Ahmed S, Roy A, Hanif AAM, Saha SC, Majumder K, Nambiar B, Colbourn T, Makwenda C, Baqui AH, Wilson I, McCollum ED. Usability Testing of a Reusable Pulse Oximeter Probe Developed for Health-Care Workers Caring for Children < 5 Years Old in Low-Resource Settings. Am J Trop Med Hyg 2019; 99:1096-1104. [PMID: 30141389 PMCID: PMC6159595 DOI: 10.4269/ajtmh.18-0016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Hypoxemia measured by pulse oximetry predicts child pneumonia mortality in low-resource settings (LRS). Existing pediatric oximeter probes are prohibitively expensive and/or difficult to use, limiting LRS implementation. Using a human-centered design, we developed a low-cost, reusable pediatric oximeter probe for LRS health-care workers (HCWs). Here, we report probe usability testing. Fifty-one HCWs from Malawi, Bangladesh, and the United Kingdom participated, and seven experts provided reference measurements. Health-care workers and experts measured the peripheral arterial oxyhemoglobin saturation (SpO2) independently in < 5 year olds. Health-care worker measurements were classed as successful if recorded in 5 minutes (or shorter) and physiologically appropriate for the child, using expert measurements as the reference. All expert measurements were considered successful if obtained in < 5 minutes. We analyzed the proportion of successful SpO2 measurements obtained in < 1, < 2, and < 5 minutes and used multivariable logistic regression to predict < 1 minute successful measurements. We conducted four testing rounds with probe modifications between rounds, and obtained 1,307 SpO2 readings. Overall, 67% (876) of measurements were successful and achieved in < 1 minute, 81% (1,059) < 2 minutes, and 90% (1,181) < 5 minutes. Compared with neonates, increasing age (infant adjusted odds ratio [aOR]; 1.87, 95% confidence interval [CI]: 1.16, 3.02; toddler aOR: 4.33, 95% CI: 2.36, 7.97; child aOR; 3.90, 95% CI: 1.73, 8.81) and being asleep versus being calm (aOR; 3.53, 95% CI: 1.89, 6.58), were associated with < 1 minute successful measurements. In conclusion, we designed a novel, reusable pediatric oximetry probe that was effectively used by LRS HCWs on children. This probe may be suitable for LRS implementation.
Collapse
Affiliation(s)
- Nicholas Boyd
- Great Ormond Street Hospital, UCL Institute of Child Health, London, United Kingdom
| | - Carina King
- Institute for Global Health, University College London, London, United Kingdom
| | - Isabeau A Walker
- Lifebox Foundation, London, United Kingdom.,Great Ormond Street Hospital, UCL Institute of Child Health, London, United Kingdom
| | | | | | | | | | - Abu A M Hanif
- Johns Hopkins University-Bangladesh, Dhaka, Bangladesh
| | - Subal C Saha
- Johns Hopkins University-Bangladesh, Dhaka, Bangladesh
| | | | - Bejoy Nambiar
- Institute for Global Health, University College London, London, United Kingdom
| | - Tim Colbourn
- Institute for Global Health, University College London, London, United Kingdom
| | | | - Abdullah H Baqui
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | | | - Eric D McCollum
- Eudowood Division of Pediatric Respiratory Sciences, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland.,Johns Hopkins University-Bangladesh, Dhaka, Bangladesh
| |
Collapse
|
80
|
Nkwopara E, Schmicker R, Mvalo T, Phiri M, Phiri A, Couasnon M, McCollum ED, Ginsburg AS. Analysis of serious adverse events in a paediatric fast breathing pneumonia clinical trial in Malawi. BMJ Open Respir Res 2019; 6:e000415. [PMID: 31548894 PMCID: PMC6733335 DOI: 10.1136/bmjresp-2019-000415] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 07/01/2019] [Accepted: 08/09/2019] [Indexed: 11/25/2022] Open
Abstract
Introduction Pneumonia is the leading infectious killer of children. We conducted a double-blind, randomised controlled non-inferiority trial comparing placebo to amoxicillin treatment for fast breathing pneumonia in HIV-negative children aged 2–59 months in Malawi. Occurrence of serious adverse events (SAEs) during the trial were examined to assess disease progression, co-morbidities, recurrence of pneumonia and side effects of amoxicillin. Methods Enrolled children with fast breathing for age and a history of cough <14 days or difficult breathing were randomised to either placebo or amoxicillin for 3 days, and followed for 14 days to track clinical characteristics and outcomes. Medical history, physical exam, laboratory results and any chest radiographs collected at screening, enrolment and during hospitalisation were evaluated. All SAE reports were reviewed for additional information regarding hospitalisation, course of treatment and outcome. Results In total, 102/1126 (9.0%) enrolled children with fast breathing pneumonia were reported to have a SAE. Seventy-five per cent (n=77) of SAEs were pneumonia-related (p<0.01). Children<2 years of age represented the greatest proportion (61/77, 79.2%) of those with a pneumonia-related SAE. In the amoxicillin group, there were 46 SAEs and 5 (10.9%) cases were identified as possibly related to study drug (4 gastroenteritis and 1 fever). There were no life-threatening pneumonia SAEs or deaths in either group, and by the time of exit from the study, all children recovered without sequelae. Discussion In this fast breathing pneumonia clinical trial, SAEs occurred infrequently in both the amoxicillin and placebo groups, and amoxicillin was well tolerated. Trial registration number NCT02760420. https://clinicaltrials.gov/ct2/show/NCT02760420?term=ginsburg&rank=9.
Collapse
Affiliation(s)
- Evangelyn Nkwopara
- International Programs, Save the Children Federation Inc, Fairfield, Connecticut, USA
| | - Robert Schmicker
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Tisungane Mvalo
- Department of Pediatrics, University of North Carolina Project, Lilongwe Medical Relief Fund Trust, Lilongwe, Malawi
| | - Melda Phiri
- Department of Pediatrics, University of North Carolina Project, Lilongwe Medical Relief Fund Trust, Lilongwe, Malawi
| | - Ajib Phiri
- Department of Pediatrics and Child Health, University of Malawi College of Medicine, Blantyre, Malawi
| | - Mari Couasnon
- International Programs, Save the Children Federation Inc, Fairfield, Connecticut, USA
| | - Eric D McCollum
- Eudowood Division of Pediatric Respiratory Sciences, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Amy Sarah Ginsburg
- International Programs, Save the Children Federation Inc, Fairfield, Connecticut, USA
| |
Collapse
|
81
|
Ginsburg AS, May S, Nkwopara E, Ambler G, McCollum ED, Mvalo T, Phiri A, Lufesi N. Title Correction: Clinical Outcomes of Pneumonia and Other Comorbidities in Children Aged 2-59 Months in Lilongwe, Malawi: Protocol for the Prospective Observational Study “Innovative Treatments in Pneumonia”. JMIR Res Protoc 2019; 8:e16007. [PMID: 31452518 PMCID: PMC6732970 DOI: 10.2196/16007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 08/26/2019] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - Susanne May
- Department of BiostatisticsUniversity of WashingtonSeattle, WAUnited States
| | | | | | - Eric D McCollum
- Eudowood Division of Pediatric Respiratory SciencesJohn Hopkins School of MedicineBaltimore, MDUnited States
| | - Tisungane Mvalo
- University of North Carolina Project: Lilongwe, Central RegionLilongweMalawi
| | - Ajib Phiri
- Department of Paediatrics and Child HealthCollege of MedicineUniversity of MalawiBlantyreMalawi
| | - Norman Lufesi
- Ministry of Health, Republic of MalawiLilongweMalawi
| |
Collapse
|
82
|
Sessions KL, Mvalo T, Kondowe D, Makonokaya D, Hosseinipour MC, Chalira A, Lufesi N, Eckerle M, Smith AG, McCollum ED. Bubble CPAP and oxygen for child pneumonia care in Malawi: a CPAP IMPACT time motion study. BMC Health Serv Res 2019; 19:533. [PMID: 31366394 PMCID: PMC6668155 DOI: 10.1186/s12913-019-4364-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 07/22/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In some low-resource settings bubble continuous positive airway pressure (bCPAP) is increasingly used to treat children with pneumonia. However, the time required for healthcare workers (HCWs) to administer bCPAP is unknown and may have implementation implications. This study aims to compare HCW time spent administering bCPAP and low-flow nasal oxygen care at a district hospital in Malawi during CPAP IMPACT (Improving Mortality for Pneumonia in African Children Trial). METHODS Eligible participants were 1-59 months old with WHO-defined severe pneumonia and HIV-infection, HIV-exposure, severe malnutrition, or hypoxemia and were randomized to either bCPAP or oxygen. We used time motion techniques to observe hospital care in four hour blocks during treatment initiation or follow up (maintenance). HCW mean time per patient at the bedside over the observation period was calculated by study arm. RESULTS Overall, bCPAP required an average of 34.71 min per patient more than low-flow nasal oxygen to initiate (bCPAP, 118.18 min (standard deviation (SD) 42.73 min); oxygen, 83.47 min (SD, 20.18 min), p < 0.01). During initiation, HCWs spent, on average, 12.45 min longer per patient setting up bCPAP equipment (p < 0.01) and 11.13 min longer per patient setting up the bCPAP nasal interface (p < 0.01), compared to oxygen equipment and nasal cannula set-up. During maintenance care, HCWs spent longer on average per patient adjusting bCPAP, compared to oxygen equipment (bCPAP 4.57 min (SD, 4.78 min); oxygen, 1.52 min (SD, 2.50 min), p = 0.03). CONCLUSION Effective bCPAP implementation in low-resource settings will likely create additional HCW burden relative to usual pneumonia care with oxygen. TRIAL REGISTRATION Clinicaltrials.gov NCT02484183 , June 29, 2015.
Collapse
Affiliation(s)
- Kristen L. Sessions
- Mayo Clinic School of Medicine, 200 1st Street SW, Rochester, MN USA
- Northwestern University, Lurie Children’s Hospital, 225 E, Chicago, IL 60611 USA
| | - Tisungane Mvalo
- University of North Carolina Project Malawi, Tidziwe Centre, 100 Mzimba Road, Lilongwe, Malawi
| | - Davie Kondowe
- University of North Carolina Project Malawi, Tidziwe Centre, 100 Mzimba Road, Lilongwe, Malawi
| | - Donnie Makonokaya
- University of North Carolina Project Malawi, Tidziwe Centre, 100 Mzimba Road, Lilongwe, Malawi
| | - Mina C. Hosseinipour
- University of North Carolina Project Malawi, Tidziwe Centre, 100 Mzimba Road, Lilongwe, Malawi
| | - Alfred Chalira
- Community Health Science Unit, Private Bag, 65 Lilongwe, Malawi
| | - Norman Lufesi
- Community Health Science Unit, Private Bag, 65 Lilongwe, Malawi
| | - Michelle Eckerle
- University of Cincinnati College of Medicine, 3333 Burnet Ave, Cincinnati, OH 45229 USA
| | - Andrew G. Smith
- University of Utah, P.O. Box 581289, Salt Lake City, UT 84158 USA
| | - Eric D. McCollum
- Johns Hopkins School of Medicine, Rubenstein Child Health Building, #3150, 200 North Wolfe Street, Baltimore, MD 21287 USA
| |
Collapse
|
83
|
Ginsburg AS, May S, Nkwopara E, Ambler G, McCollum ED, Mvalo T, Phiri A, Lufesi N. Clinical Outcomes of Pneumonia and Other Comorbidities in Children Aged 2-59 Months in Lilongwe, Malawi: Protocol for the Prospective Observational Study "Innovative Treatments in Pneumonia". JMIR Res Protoc 2019; 8:e13377. [PMID: 31359870 PMCID: PMC6690162 DOI: 10.2196/13377] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 04/12/2019] [Accepted: 04/30/2019] [Indexed: 01/29/2023] Open
Abstract
Background Pneumonia is the leading infectious cause of death worldwide among children below 5 years of age. Clinical trials are conducted to determine optimal treatment; however, these trials often exclude children with comorbidities and severe illness. Conclusions Given the paucity of data from Africa, African-based research is necessary to establish optimal management of childhood pneumonia in malaria-endemic settings in the region. An expanded evidence base that includes children with pneumonia and other comorbidities, who are at high risk for mortality or have other complications and are therefore typically excluded from childhood pneumonia clinical trials, can contribute to future iterations of the World Health Organization Integrated Management of Childhood Illness guidelines. Methods The study enrolled 1000 children with pneumonia presenting to the outpatient departments of Kamuzu Central or Bwaila District Hospitals in Lilongwe, Malawi, who were excluded from concurrent randomized controlled clinical trials investigating fast breathing and chest indrawing pneumonia and who met the inclusion criteria for this prospective observational study. Each child received standard care for their illnesses per Malawian guidelines and hospital protocol and was prospectively followed up with scheduled study visits on days 1, 2 (if hospitalized), 6, 14 (in person), and 30 (by phone). Our primary objectives are to describe the clinical outcomes of children who meet the inclusion criteria for this study and to investigate whether the percentages of children cured at day 14 among those with either fast breathing or chest indrawing pneumonia and comorbidities such as severe malaria, anemia, severe acute malnutrition, or HIV are lower than those in children without these comorbidities in the standard care groups in concurrent clinical trials. This study was approved by the Western Institutional Review Board, Malawi College of Medicine Research and Ethics Committee, and the Malawi Pharmacy, Medicines and Poisons Board. Objective This prospective observational study aimed to assess the clinical outcomes of children aged 2-59 months with both pneumonia and other comorbidities in a malaria-endemic region of Malawi. Results The Innovative Treatments in Pneumonia project was funded by the Bill and Melinda Gates Foundation (OPP1105080) in April 2014. Enrollment in this study began in 2016, and the primary results are expected in 2019. International Registered Report Identifier (IRRID) DERR1-10.2196/13377
Collapse
Affiliation(s)
| | - Susanne May
- Department of Biostatistics, University of Washington, Seattle, WA, United States
| | | | | | - Eric D McCollum
- Eudowood Division of Pediatric Respiratory Sciences, John Hopkins School of Medicine, Baltimore, MD, United States
| | - Tisungane Mvalo
- University of North Carolina Project: Lilongwe, Central Region, Lilongwe, Malawi
| | - Ajib Phiri
- Department of Paediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Norman Lufesi
- Ministry of Health, Republic of Malawi, Lilongwe, Malawi
| |
Collapse
|
84
|
King C, Mvalo T, Sessions K, Wilson I, Walker I, Zadutsa B, Makwenda C, Phiri T, Boyd N, Bernstein M, McCollum ED. Performance of a novel reusable pediatric pulse oximeter probe. Pediatr Pulmonol 2019; 54:1052-1059. [PMID: 30912314 PMCID: PMC6591029 DOI: 10.1002/ppul.24295] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 01/23/2019] [Accepted: 02/04/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To assess the performance of reusable pulse oximeter probe and microprocessor box combinations, of varying price-points, in the context of a low-income pediatric setting. METHODS A prospective, randomized cross-over study comparing time to biologically plausible oxygen saturation (SpO2 ) between: (1) Lifebox LB-01 probe with Masimo Rad-87 box (L + M) and (2) a weight-appropriate reusable Masimo probe with Masimo Rad-87 box (M + M). A post hoc secondary analysis comparison with historical usability testing data with the Lifebox LB-01 probe and Lifebox V1.5 box (L + L) was also conducted. Participants, children aged 0 to 35 months, were recruited from pediatric wards and outpatient clinics in the central region of Malawi. The primary outcome was time taken to achieve a biologically plausible SpO 2 measurement, compared using t tests for equivalence. RESULTS We recruited 572 children. Plausible SpO2 measurements were obtained in less than 1 minute, 71%, 70%, and 63% for the M + M, L + M, and L + L combinations, respectively. A similar pattern was seen for less than 2 minutes, however, this effect disappeared at less than 5 minutes with 96%, 96%, and 95% plausible measurements. Using a ±10 second threshold for equivalence, we found L + M and M + M to be equivalent, but were under-powered to assess equivalence for L + L. CONCLUSIONS The novel reusable pediatric Lifebox probe can achieve a quality SpO2 measurement within a pragmatic time range of weight-appropriate Masimo equivalent probes. Further research, which considers the cost of the devices, is needed to assess the added value of sophisticated motion tolerance software.
Collapse
Affiliation(s)
- Carina King
- Institute for Global Health, University College London, London, UK.,Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Tisungane Mvalo
- University of North Carolina Project Malawi, Lilongwe, Malawi.,Department of Pediatrics, University of North Carolina, Chapel Hill, North Carolina
| | | | | | - Isabeau Walker
- Lifebox Foundation, London, UK.,Great Ormond Street Hospital, London, UK.,Institute for Child Health, University College London, London, UK
| | | | | | - Tambosi Phiri
- Parent and Child Health Initiative, Lilongwe, Malawi
| | - Nicholas Boyd
- King's Sierra Leona Partnership, Freetown, Sierra Leone
| | | | - Eric D McCollum
- Department of Pediatrics, Eudowood Division of Pediatric Respiratory Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland.,Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| |
Collapse
|
85
|
McCollum ED, Brown SP, Nkwopara E, Mvalo T, May S, Ginsburg AS. Development of a prognostic risk score to aid antibiotic decision-making for children aged 2-59 months with World Health Organization fast breathing pneumonia in Malawi: An Innovative Treatments in Pneumonia (ITIP) secondary analysis. PLoS One 2019; 14:e0214583. [PMID: 31220085 PMCID: PMC6586284 DOI: 10.1371/journal.pone.0214583] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 03/14/2019] [Indexed: 01/19/2023] Open
Abstract
Background Due to increasing antimicrobial resistance in low-resource settings, strategies to rationalize antibiotic treatment of children unlikely to have a bacterial infection are needed. This study’s objective was to utilize a database of placebo treated Malawian children with World Health Organization (WHO) fast breathing pneumonia to develop a prognostic risk score that could aid antibiotic decision making. Methods We conducted a secondary analysis of children randomized to the placebo group of the Innovative Treatments in Pneumonia (ITIP) fast breathing randomized, controlled, noninferiority trial. Participants were low-risk HIV-uninfected children 2–59 months old with WHO fast breathing pneumonia in Lilongwe, Malawi. Study endpoints were treatment failure, defined as either disease progression at any time on or before Day 4 of treatment or disease persistence on Day 4, or relapse, considered as the recurrence of pneumonia or severe disease among previously cured children between Days 5 and 14. We utilized multivariable linear regression and stepwise model selection to develop a model to predict the probability of treatment failure or relapse. Results Treatment failure or relapse occurred in 11.5% (61/526) of children included in this analysis. The final model incorporated the following predictors: heart rate terms, mid-upper arm circumference, malaria status, water source, family income, and whether or not a sibling or other child in the household received childcare outside the home. The model’s area under the receiver operating characteristic score was 0.712 (95% confidence interval 0.66, 0.78) and it explained 6.1% of the variability in predicting treatment failure or relapse (R2, 0.061). For the model to categorize all children with treatment failure or relapse correctly, 77% of children without treatment failure or relapse would require antibiotics. Conclusion The model had inadequate discrimination to be appropriate for clinical application. Different strategies will likely be required for models to perform accurately among similar pediatric populations.
Collapse
Affiliation(s)
- Eric D. McCollum
- Eudowood Division of Pediatric Respiratory Sciences, Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
- * E-mail:
| | - Siobhan P. Brown
- Department of Biostatistics, University of Washington Clinical Trial Center, Seattle, Washington, United States of America
| | | | - Tisungane Mvalo
- University of North Carolina Project, Lilongwe Medical Relief Fund Trust, Lilongwe, Malawi
- Department of Pediatrics, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Susanne May
- Department of Biostatistics, University of Washington Clinical Trial Center, Seattle, Washington, United States of America
| | | |
Collapse
|
86
|
Ginsburg AS, McCollum ED, May SJ. World Health Organization Treatment Recommendations for Nonsevere Fast-Breathing Pneumonia Need to Be Updated-Reply. JAMA Pediatr 2019; 173:608-609. [PMID: 30985898 DOI: 10.1001/jamapediatrics.2019.0641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
|
87
|
McCollum ED, Ahmed S, Chowdhury NH, Rizvi SJR, Khan AM, Roy AD, Hanif AA, Pervaiz F, Ahmed ANU, Farrukee EH, Monowara M, Hossain MM, Doza F, Tanim B, Alam F, Simmons N, Reller ME, Harrison M, Schuh HB, Quaiyum A, Saha SK, Begum N, Santosham M, Moulton LH, Checkley W, Baqui AH. Chest radiograph reading panel performance in a Bangladesh pneumococcal vaccine effectiveness study. BMJ Open Respir Res 2019; 6:e000393. [PMID: 31179000 PMCID: PMC6530497 DOI: 10.1136/bmjresp-2018-000393] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 02/13/2019] [Indexed: 01/07/2023] Open
Abstract
Introduction To evaluate WHO chest radiograph interpretation processes during a pneumococcal vaccine effectiveness study of children aged 3–35 months with suspected pneumonia in Sylhet, Bangladesh. Methods Eight physicians masked to all data were standardised to WHO methodology and interpreted chest radiographs between 2015 and 2017. Each radiograph was randomly assigned to two primary readers. If the primary readers were discordant for image interpretability or the presence or absence of primary endpoint pneumonia (PEP), then another randomly selected, masked reader adjudicated the image (arbitrator). If the arbitrator disagreed with both primary readers, or concluded no PEP, then a masked expert reader finalised the interpretation. The expert reader also conducted blinded quality control (QC) for 20% of randomly selected images. We evaluated agreement between primary readers and between the expert QC reading and the final panel interpretation using per cent agreement, unadjusted Cohen’s kappa, and a prevalence and bias-adjusted kappa. Results Among 9723 images, the panel classified 21.3% as PEP, 77.6% no PEP and 1.1% uninterpretable. Two primary readers agreed on interpretability for 98% of images (kappa, 0.25; prevalence and bias-adjusted kappa, 0.97). Among interpretable radiographs, primary readers agreed on the presence or absence of PEP in 79% of images (kappa, 0.35; adjusted kappa, 0.57). Expert QC readings agreed with final panel conclusions on the presence or absence of PEP for 92.9% of 1652 interpretable images (kappa, 0.75; adjusted kappa, 0.85). Conclusion Primary reader performance and QC results suggest the panel effectively applied the WHO chest radiograph criteria for pneumonia.
Collapse
Affiliation(s)
- Eric D McCollum
- Eudowood Division of Pediatric Respiratory Sciences, Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA.,Global Program in Respiratory Sciences, Department of Pediatrics, Johns Hopkins University, Baltimore, Maryland, USA.,Health Systems, Department of International Health, Johns Hopkins Hospital and Health System, Baltimore, Maryland, USA
| | | | | | - Syed J R Rizvi
- Johns Hopkins University - Bangladesh, Dhaka, Bangladesh
| | - Ahad M Khan
- Johns Hopkins University - Bangladesh, Dhaka, Bangladesh
| | - Arun D Roy
- Johns Hopkins University - Bangladesh, Dhaka, Bangladesh
| | - Abu Am Hanif
- Johns Hopkins University - Bangladesh, Dhaka, Bangladesh
| | - Farhan Pervaiz
- Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA.,Division of Pulmonary and Critical Care, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA.,Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Asm Nawshad U Ahmed
- Department of Pediatrics, Dhaka Shishu Hospital, Dhaka, Bangladesh.,Child Health Research Foundation, Dhaka, Bangladesh
| | | | - Mahmuda Monowara
- Department of Radiology and Imaging, Dhaka Shishu Hospital, Dhaka, Bangladesh
| | - Mohammad M Hossain
- Department of Radiology and Imaging, Dhaka Shishu Hospital, Dhaka, Bangladesh
| | - Fatema Doza
- Department of Radiology and Imaging, National Institute of Cardiovascular Diseases, Dhaka, Bangladesh
| | - Bidoura Tanim
- Department of Radiology and Imaging, National Institute of Ophthalmology, Dhaka, Bangladesh
| | - Farzana Alam
- Department of Radiology and Imaging, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Nicole Simmons
- Health Systems, Department of International Health, Johns Hopkins Hospital and Health System, Baltimore, Maryland, USA
| | - Megan E Reller
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA.,Duke Hubert-Yeargan Center for Global Health, Durham, North Carolina, USA.,Duke Global Health Institute, Durham, North Carolina, USA
| | - Meagan Harrison
- Health Systems, Department of International Health, Johns Hopkins Hospital and Health System, Baltimore, Maryland, USA
| | - Holly B Schuh
- Health Systems, Department of International Health, Johns Hopkins Hospital and Health System, Baltimore, Maryland, USA
| | - Abdul Quaiyum
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Samir K Saha
- Child Health Research Foundation, Dhaka, Bangladesh
| | - Nazma Begum
- Johns Hopkins University - Bangladesh, Dhaka, Bangladesh
| | - Mathuram Santosham
- Health Systems, Department of International Health, Johns Hopkins Hospital and Health System, Baltimore, Maryland, USA
| | - Lawrence H Moulton
- Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - William Checkley
- Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA.,Division of Pulmonary and Critical Care, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA.,Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Abdullah H Baqui
- Health Systems, Department of International Health, Johns Hopkins Hospital and Health System, Baltimore, Maryland, USA
| |
Collapse
|
88
|
Ginsburg AS, Mvalo T, Nkwopara E, McCollum ED, Ndamala CB, Schmicker R, Phiri A, Lufesi N, Izadnegahdar R, May S. Placebo vs Amoxicillin for Nonsevere Fast-Breathing Pneumonia in Malawian Children Aged 2 to 59 Months: A Double-blind, Randomized Clinical Noninferiority Trial. JAMA Pediatr 2019; 173:21-28. [PMID: 30419120 PMCID: PMC6583426 DOI: 10.1001/jamapediatrics.2018.3407] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
IMPORTANCE Pneumonia is the leading infectious killer of children. Rigorous evidence supporting antibiotic treatment of children with nonsevere fast-breathing pneumonia in low-resource African settings is lacking. OBJECTIVE To assess whether treatment with placebo for nonsevere fast-breathing pneumonia is substantively less effective than 3 days of treatment with amoxicillin. DESIGN, SETTING, AND PARTICIPANTS This double-blind, 2-arm, randomized clinical noninferiority trial with follow-up of 14 days screened 1343 HIV-uninfected children aged 2 to 59 months with nonsevere fast-breathing pneumonia at outpatient departments of hospitals in Lilongwe, Malawi, Africa, between June 2016 and June 2017. INTERVENTIONS Placebo or amoxicillin dispersible tablets administered twice daily for 3 days. MAIN OUTCOMES AND MEASURES The primary end point was the proportion of children failing treatment by day 4 with a relative noninferiority margin of 1.5 times the failure rate in the amoxicillin group. Primary analyses were performed based on the intention-to-treat principle. Planned secondary analyses included treatment failure or relapse by day 14. RESULTS In total, 1126 children were randomized to 3 days of amoxicillin (n = 564) or placebo (n = 562) therapy. Baseline demographic and clinical characteristics were similar between the groups. For the entire study population, the mean (SD) age was 21.3 (15.1) months, and 601 (53.4%) were female. After an interim analysis, the data safety monitoring board stopped the study because children receiving amoxicillin had a 4.0% (22 of 552 with outcome data) treatment failure rate by day 4, whereas children receiving placebo had a 7.0% (38 of 543) treatment failure rate (adjusted relative risk, 1.78; 95% CI, 1.07%-2.97%; adjusted absolute difference, 3.0%; 95% CI, 0.4%-5.7%). Among children with known day 14 outcomes, 56 of 552 (10.1%) receiving amoxicillin and 64 of 543 (11.8%) receiving placebo had either treatment failure by day 4 or relapse by day 14 (relative risk, 1.16; 95% CI, 0.83%-1.63%; absolute difference, 1.6%; 95% CI, -2.1% to 5.4%). There were no deaths. CONCLUSIONS AND RELEVANCE In HIV-uninfected children aged 2 to 59 months in a malaria-endemic region of Malawi, placebo treatment of nonsevere fast-breathing pneumonia was significantly inferior to treatment with amoxicillin. However, by day 4, approximately 93% of children receiving placebo were without treatment failure, and there was no significant difference between groups in treatment failure or relapse by day 14. The number of children with nonsevere fast-breathing pneumonia that needed amoxicillin treatment for 1 child to benefit was 33. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02760420.
Collapse
Affiliation(s)
| | - Tisungane Mvalo
- University of North Carolina Project, Lilongwe Medical Relief Fund Trust, Tidziwe Centre, Lilongwe, Malawi
| | | | - Eric D. McCollum
- Eudowood Division of Pediatric Respiratory Sciences, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland,Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Chifundo B. Ndamala
- University of North Carolina Project, Lilongwe Medical Relief Fund Trust, Tidziwe Centre, Lilongwe, Malawi
| | - Robert Schmicker
- Department of Biostatistics, University of Washington Clinical Trial Center, Seattle
| | - Ajib Phiri
- Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Chichiri, Blantyre
| | - Norman Lufesi
- Acute Respiratory Infection and Emergency Triage Assessment and Treatment, Malawi Ministry of Health, Lilongwe
| | | | - Susanne May
- Department of Biostatistics, University of Washington Clinical Trial Center, Seattle
| |
Collapse
|
89
|
Pervaiz F, Chavez MA, Ellington LE, Grigsby M, Gilman RH, Miele CH, Figueroa-Quintanilla D, Compen-Chang P, Marin-Concha J, McCollum ED, Checkley W. Building a Prediction Model for Radiographically Confirmed Pneumonia in Peruvian Children: From Symptoms to Imaging. Chest 2018; 154:1385-1394. [PMID: 30291926 PMCID: PMC6335257 DOI: 10.1016/j.chest.2018.09.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 08/18/2018] [Accepted: 09/05/2018] [Indexed: 11/30/2022] Open
Abstract
Background Community-acquired pneumonia remains the leading cause of death in children worldwide, and current diagnostic guidelines in resource-poor settings are neither sensitive nor specific. We sought to determine the ability to correctly diagnose radiographically confirmed clinical pneumonia when diagnostics tools were added to clinical signs and symptoms in a cohort of children with acute respiratory illnesses in Peru. Methods Children < 5 years of age with an acute respiratory illness presenting to a tertiary hospital in Lima, Peru, were enrolled. The ability to predict radiographically confirmed clinical pneumonia was assessed using logistic regression under four additive scenarios: clinical signs and symptoms only, addition of lung auscultation, addition of oxyhemoglobin saturation (Spo2), and addition of lung ultrasound. Results Of 832 children (mean age, 21.3 months; 59% boys), 453 (54.6%) had clinical pneumonia and 221 (26.6%) were radiographically confirmed. Children with radiographically confirmed clinical pneumonia had lower average Spo2 than those without (95.9% vs 96.6%, respectively; P < .01). The ability to correctly identify radiographically confirmed clinical pneumonia using clinical signs and symptoms was limited (area under the curve [AUC] = 0.62; 95% CI, 0.58-0.67) with a sensitivity of 66% (95% CI, 59%-73%) and specificity of 53% (95% CI, 49%-57%). The addition of lung auscultation improved classification (AUC = 0.73; 95% CI, 0.69-0.77) with a sensitivity of 75% (95% CI, 69%-81%) and specificity of 53% (95% CI, 49%-57%) for the presence of crackles. In contrast, the addition of Spo2 did not improve classification (AUC = 0.73; 95% CI, 0.69-0.77) with a sensitivity of 40% (95% CI, 33%-47%) and specificity of 72% (95% CI, 68%-75%) for an Spo2 ≤ 92%. Adding consolidation on lung ultrasound was associated with the largest improvement in classification (AUC = 0.85; 95% CI, 0.82-0.89) with a sensitivity of 55% (95% CI, 48%-63%) and specificity of 95% (95% CI, 93%-97%). Conclusions The addition of lung ultrasound and auscultation to clinical signs and symptoms improved the ability to correctly classify radiographically confirmed clinical pneumonia. Implementation of auscultation- and ultrasound-based diagnostic tools can be considered to improve diagnostic yield of pneumonia in resource-poor settings.
Collapse
Affiliation(s)
- Farhan Pervaiz
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD
| | - Miguel A Chavez
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD; Biomedical Research Unit, A.B. PRISMA, Lima, Peru
| | - Laura E Ellington
- Department of Pulmonary and Sleep Medicine, Seattle Children's Hospital, University of Washington, Seattle, WA
| | - Matthew Grigsby
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD
| | - Robert H Gilman
- Biomedical Research Unit, A.B. PRISMA, Lima, Peru; Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | - Catherine H Miele
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD
| | | | | | | | - Eric D McCollum
- Department of Pediatrics, Eudowood Division of Pediatric Respiratory Sciences, School of Medicine Johns Hopkins University, Baltimore, MD
| | - William Checkley
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD; Biomedical Research Unit, A.B. PRISMA, Lima, Peru.
| |
Collapse
|
90
|
Bondo A, Nambiar B, Lufesi N, Deula R, King C, Masache G, Makwenda C, Costello A, Rhoda D, McCollum ED, Colbourn T. An assessment of PCV13 vaccine coverage using a repeated cross-sectional household survey in Malawi. Gates Open Res 2018; 2:37. [PMID: 30569035 PMCID: PMC6266718 DOI: 10.12688/gatesopenres.12837.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2018] [Indexed: 11/20/2022] Open
Abstract
Background: The 13-valent pneumococcal conjugate vaccine (PCV13) was introduced in Malawi from November 2011 using a three dose primary series at 6, 10, and 14 weeks of age to reduce Streptococcus pneumoniae-related diseases. To date, PCV13 paediatric coverage in Malawi has not been rigorously assessed. We used household surveys to longitudinally track paediatric PCV13 coverage in rural Malawi. Methods: Samples of 60 randomly selected children (30 infants aged 6 weeks to 4 months and 30 aged 4-16 months) were sought in each of 20 village clinic catchment 'basins' of Kabudula health area, Lilongwe, Malawi between March 2012 and June 2014. Child health information was reviewed and mothers interviewed to determine each child's PCV13 dose status and vaccine timing. The survey was completed six times in 4-8 month intervals. Survey inference was used to assess PCV13 dose coverage in each basin for each age group. All 20 basins were pooled to assess area-wide vaccination coverage over time, by age in months, and adherence to the vaccination schedule. Results: We surveyed a total of 8,562 children in six surveys; 82% were in the older age group. Overall, in age-eligible children, two-dose and three-dose coverage increased from 30% to 85% and 10% to 86%, respectively, between March 2012 and June 2014. PCV13 coverage was higher in the older age group in all surveys. Although it varied by basin, PCV13 coverage was consistently delayed: median ages at first, second and third doses were 9, 15 and 21 weeks, respectively. Conclusion: In our rural study area, PCV13 introduction did not meet the Malawi Ministry of Health one-year three-dose 90% coverage target, but after 2 years reached levels likely to reduce the prevalence of both invasive and non-invasive paediatric pneumococcal diseases. Better adherence to the PCV13 schedule may reduce pneumococcal disease in younger Malawian children.
Collapse
Affiliation(s)
- Austin Bondo
- Parent and Child Health Initiative (PACHI) Trust, Lilongwe, Malawi
| | - Bejoy Nambiar
- UCL Institute for Global Health, London, WC1N 1EH, UK
| | - Norman Lufesi
- Acute Respiratory Infections Unit, Ministry of Health, Lilongwe, Malawi
| | - Rashid Deula
- Parent and Child Health Initiative (PACHI) Trust, Lilongwe, Malawi
| | - Carina King
- UCL Institute for Global Health, London, WC1N 1EH, UK
| | - Gibson Masache
- Parent and Child Health Initiative (PACHI) Trust, Lilongwe, Malawi
| | - Charles Makwenda
- Parent and Child Health Initiative (PACHI) Trust, Lilongwe, Malawi
| | | | - Dale Rhoda
- Biostat Global Consulting, Worthington, OH, 43085, USA
| | - Eric D McCollum
- UCL Institute for Global Health, London, WC1N 1EH, UK.,Department of Pediatrics, Eudowood Division of Pediatric Respiratory Sciences, Johns Hopkins School of Medicine, Baltimore, USA.,Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Tim Colbourn
- UCL Institute for Global Health, London, WC1N 1EH, UK
| |
Collapse
|
91
|
McCollum ED, Ginsburg AS. Outpatient Management of Children With World Health Organization Chest Indrawing Pneumonia: Implementation Risks and Proposed Solutions. Clin Infect Dis 2018; 65:1560-1564. [PMID: 29020216 PMCID: PMC5850637 DOI: 10.1093/cid/cix543] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 06/08/2017] [Indexed: 02/03/2023] Open
Abstract
This Viewpoints article details our recommendation for the World Health Organization Integrated Management of Childhood Illness guidelines to consider additional referral or daily monitoring criteria for children with chest indrawing pneumonia in low-resource settings. We review chest indrawing physiology in children and relate this to the risk of adverse pneumonia outcomes. We believe there is sufficient evidence to support referring or daily monitoring of children with chest indrawing pneumonia and signs of severe respiratory distress, oxygen saturation <93% (when not at high altitude), moderate malnutrition, or an unknown human immunodeficiency virus (HIV) status in an HIV-endemic setting. Pulse oximetry screening should be routine and performed at the earliest point in the patient care pathway as possible. If outpatient clinics lack capacity to conduct pulse oximetry, nutritional assessment, or HIV testing, then we recommend considering referral to complete the evaluation. When referral is not possible, careful daily monitoring should be performed.
Collapse
Affiliation(s)
- Eric D McCollum
- Eudowood Division of Pediatric Respiratory Sciences, Johns Hopkins School of Medicine and Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | | |
Collapse
|
92
|
Baqui AH, McCollum ED, Saha SK, Roy AK, Chowdhury NH, Harrison M, Hanif AAM, Simmons N, Mahmud A, Begum N, Ahmed S, Khan AM, Ahmed ZB, Islam M, Mitra D, Quaiyum A, Chavez MA, Pervaiz F, Miele CH, Schuh HB, Khanam R, Checkley W, Moulton LH, Santosham M. Pneumococcal Conjugate Vaccine impact assessment in Bangladesh. Gates Open Res 2018; 2:21. [PMID: 29984359 PMCID: PMC6030398 DOI: 10.12688/gatesopenres.12805.1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2018] [Indexed: 12/28/2022] Open
Abstract
The study examines the impact of the introduction of 10-valent Pneumococcal Conjugate Vaccine (PCV10) into Bangladesh’s national vaccine program. PCV10 is administered to children under 1 year-old; the scheduled ages of administration are at 6, 10, and 18 weeks. The study is conducted in ~770,000 population containing ~90,000 <5 children in Sylhet, Bangladesh and has five objectives: 1) To collect data on community-based pre-PCV incidence rates of invasive pneumococcal diseases (IPD) in 0-59 month-old children in Sylhet, Bangladesh; 2) To evaluate the effectiveness of PCV10 introduction on Vaccine Type (VT) IPD in 3-59 month-old children using an incident case-control study design. Secondary aims include measuring the effects of PCV10 introduction on all IPD in 3-59 month-old children using case-control study design, and quantifying the emergence of Non Vaccine Type IPD; 3) To evaluate the effectiveness of PCV10 introduction on chest radiograph-confirmed pneumonia in children 3-35 months old using incident case-control study design. We will estimate the incidence trend of clinical and radiologically-confirmed pneumonia in 3-35 month-old children in the study area before and after introduction of PCV10; 4) To determine the feasibility and utility of lung ultrasound for the diagnosis of pediatric pneumonia in a large sample of children in a resource-limited setting. We will also evaluate the effectiveness of PCV10 introduction on ultrasound-confirmed pneumonia in 3-35 month-old children using an incident case-control design and to examine the incidence trend of ultrasound-confirmed pneumonia in 3-35 month-old children in the study area before and after PCV10 introduction; and 5) To determine the direct and indirect effects of vaccination status on nasopharyngeal colonization on VT pneumococci among children with pneumonia
. This paper presents the methodology. The study will allow us to conduct a comprehensive and robust assessment of the impact of national introduction of PCV10 on pneumococcal disease in Bangladesh.
Collapse
Affiliation(s)
- Abdullah H Baqui
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, 21205, USA
| | - Eric D McCollum
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, 21205, USA.,Department of Pediatrics, Eudowood Division of Pediatric Respiratory Sciences, School of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA
| | - Samir K Saha
- Child Health Research Foundation, Dhaka, Bangladesh
| | - Arun K Roy
- Johns Hopkins University, Bangladesh, Dhaka, Bangladesh
| | | | - Meagan Harrison
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, 21205, USA
| | | | - Nicole Simmons
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, 21205, USA
| | - Arif Mahmud
- Johns Hopkins University, Bangladesh, Dhaka, Bangladesh
| | - Nazma Begum
- Johns Hopkins University, Bangladesh, Dhaka, Bangladesh
| | | | - Ahad M Khan
- Johns Hopkins University, Bangladesh, Dhaka, Bangladesh
| | | | | | | | - Abdul Quaiyum
- International Centre For Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Miguel A Chavez
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD, 21287, USA
| | - Farhan Pervaiz
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD, 21287, USA
| | - Catherine H Miele
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD, 21287, USA
| | - Holly B Schuh
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, 21205, USA
| | - Rasheda Khanam
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, 21205, USA
| | - William Checkley
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, 21205, USA
| | - Lawrence H Moulton
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, 21205, USA
| | - Mathuram Santosham
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, 21205, USA
| |
Collapse
|
93
|
Hooli S, King C, Makwenda C, Zatudsa B, Lufesi N, Costello A, Nambiar B, Mwansambo C, Colbourn T, McCollum ED. Incidence and degree of hypoxaemia in Malawian infants under 2 months of age presenting to district hospitals and its correlation with mortality: a retrospective analysis. The Lancet Global Health 2018. [DOI: 10.1016/s2214-109x(18)30151-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
|
94
|
Hooli S, Colbourn T, Lufesi N, Costello A, Nambiar B, Thammasitboon S, Makwenda C, Mwansambo C, McCollum ED, King C. Correction: Predicting Hospitalised Paediatric Pneumonia Mortality Risk: An External Validation of RISC and mRISC, and Local Tool Development (RISC-Malawi) from Malawi. PLoS One 2018; 13:e0193557. [PMID: 29470524 PMCID: PMC5823457 DOI: 10.1371/journal.pone.0193557] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
|
95
|
Affiliation(s)
- Carina King
- Institute for Global Health, University College London, London WC1N 1EH, UK.
| | - Eric D McCollum
- Eudowood Division of Pediatric Respiratory Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA; Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| |
Collapse
|
96
|
King C, Boyd N, Walker I, Zadutsa B, Baqui AH, Ahmed S, Islam M, Kainja E, Nambiar B, Wilson I, McCollum ED. Opportunities and barriers in paediatric pulse oximetry for pneumonia in low-resource clinical settings: a qualitative evaluation from Malawi and Bangladesh. BMJ Open 2018; 8:e019177. [PMID: 29382679 PMCID: PMC5829842 DOI: 10.1136/bmjopen-2017-019177] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE To gain an understanding of what challenges pulse oximetry for paediatric pneumonia management poses, how it has changed service provision and what would improve this device for use across paediatric clinical settings in low-income countries. DESIGN Focus group discussions (FGDs), with purposive sampling and thematic analysis using a framework approach. SETTING Community, front-line outpatient, and hospital outpatient and inpatient settings in Malawi and Bangladesh, which provide paediatric pneumonia care. PARTICIPANTS Healthcare providers (HCPs) from Malawi and Bangladesh who had received training in pulse oximetry and had been using oximeters in routine paediatric care, including community healthcare workers, non-physician clinicians or medical assistants, and hospital-based nurses and doctors. RESULTS We conducted six FGDs, with 23 participants from Bangladesh and 26 from Malawi. We identified five emergent themes: trust, value, user-related experience, sustainability and design. HCPs discussed the confidence gained through the use of oximeters, resulting in improved trust from caregivers and valuing the device, although there were conflicts between the weight given to clinical judgement versus oximeter results. HCPs reported the ease of using oximeters, but identified movement and physically smaller children as measurement challenges. Challenges in sustainability related to battery durability and replacement parts, however many HCPs had used the same device longer than 4 years, demonstrating robustness within these settings. Desirable features included back-up power banks and integrated respiratory rate and thermometer capability. CONCLUSIONS Pulse oximetry was generally deemed valuable by HCPs for use as a spot-check device in a range of paediatric low-income clinical settings. Areas highlighted as challenges by HCPs, and therefore opportunities for redesign, included battery charging and durability, probe fit and sensitivity in paediatric populations. TRIAL REGISTRATION NUMBER NCT02941237.
Collapse
Affiliation(s)
- Carina King
- Institute for Global Health, University College London, London, UK
| | - Nicholas Boyd
- UCL Institute of Child Health, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Isabeau Walker
- UCL Institute of Child Health, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | | | - Abdullah H Baqui
- International Center for Maternal and Newborn Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Salahuddin Ahmed
- International Center for Maternal and Newborn Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Mazharul Islam
- Department of Anthropology, Shahjalal University of Science and Technology, Sylhet, Bangladesh
| | - Esther Kainja
- Parent and Child Health Initiative, Lilongwe, Malawi
| | - Bejoy Nambiar
- Institute for Global Health, University College London, London, UK
| | | | - Eric D McCollum
- Eudowood Division of Pediatric Respiratory Diseases, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| |
Collapse
|
97
|
McCollum ED, Smith AG, Eckerle M, Mvalo T, O'Brien KL, Baqui AH. CPAP treatment for children with pneumonia in low-resource settings. Lancet Respir Med 2017; 5:924-925. [PMID: 29133034 DOI: 10.1016/s2213-2600(17)30347-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Accepted: 09/04/2017] [Indexed: 01/08/2023]
Affiliation(s)
- Eric D McCollum
- Eudowood Division of Pediatric Respiratory Sciences, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA; Department of International Health, International Center for Maternal and Newborn Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MA, USA.
| | - Andrew G Smith
- Paediatric Critical Care Medicine, University of Utah, Salt Lake City, UT, USA
| | - Michelle Eckerle
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | - Katherine L O'Brien
- Department of International Health, International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, MA, USA
| | - Abdullah H Baqui
- Department of International Health, International Center for Maternal and Newborn Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MA, USA
| |
Collapse
|
98
|
Smith AG, Eckerle M, Mvalo T, Weir B, Martinson F, Chalira A, Lufesi N, Mofolo I, Hosseinipour M, McCollum ED. CPAP IMPACT: a protocol for a randomised trial of bubble continuous positive airway pressure versus standard care for high-risk children with severe pneumonia using adaptive design methods. BMJ Open Respir Res 2017; 4:e000195. [PMID: 28883928 PMCID: PMC5531309 DOI: 10.1136/bmjresp-2017-000195] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 05/16/2017] [Accepted: 06/09/2017] [Indexed: 01/24/2023] Open
Abstract
Introduction Pneumonia is a leading cause of mortality among children in low-resource settings. Mortality is greatest among children with high-risk conditions including HIV infection or exposure, severe malnutrition and/or severe hypoxaemia. WHO treatment recommendations include low-flow oxygen for children with severe pneumonia. Bubble continuous positive airway pressure (bCPAP) is a non-invasive support modality that provides positive end-expiratory pressure and oxygen. bCPAP is effective in the treatment of neonates in low-resource settings; its efficacy is unknown for high-risk children with severe pneumonia in low-resource settings. Methods and analysis CPAP IMPACT is a randomised clinical trial comparing bCPAP to low-flow oxygen in the treatment of severe pneumonia among high-risk children 1–59 months of age. High-risk children are stratified into two subgroups: (1) HIV infection or exposure and/or severe malnutrition; (2) severe hypoxaemia. The trial is being conducted in a Malawi district hospital and will enrol 900 participants. The primary outcome is in-hospital mortality rate of children treated with standard care as compared with bCPAP. Ethics and dissemination CPAP IMPACT has approval from the Institutional Review Boards of all investigators. An urgent need exists to determine whether bCPAP decreases mortality among high-risk children with severe pneumonia to inform resource utilisation in low-resource settings. Trial registration number NCT02484183; Pre-results.
Collapse
Affiliation(s)
- Andrew G Smith
- Paediatric Critical Care Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Michelle Eckerle
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | | | - Brian Weir
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | | | | | | | - Mina Hosseinipour
- Division of Infectious Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Eric D McCollum
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA.,Eudowood Division of Pediatric Respiratory Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| |
Collapse
|
99
|
McCollum ED, Park DE, Watson NL, Buck WC, Bunthi C, Devendra A, Ebruke BE, Elhilali M, Emmanouilidou D, Garcia-Prats AJ, Githinji L, Hossain L, Madhi SA, Moore DP, Mulindwa J, Olson D, Awori JO, Vandepitte WP, Verwey C, West JE, Knoll MD, O'Brien KL, Feikin DR, Hammit LL. Listening panel agreement and characteristics of lung sounds digitally recorded from children aged 1-59 months enrolled in the Pneumonia Etiology Research for Child Health (PERCH) case-control study. BMJ Open Respir Res 2017; 4:e000193. [PMID: 28883927 PMCID: PMC5531306 DOI: 10.1136/bmjresp-2017-000193] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Revised: 05/25/2017] [Accepted: 05/25/2017] [Indexed: 01/14/2023] Open
Abstract
INTRODUCTION Paediatric lung sound recordings can be systematically assessed, but methodological feasibility and validity is unknown, especially from developing countries. We examined the performance of acoustically interpreting recorded paediatric lung sounds and compared sound characteristics between cases and controls. METHODS Pneumonia Etiology Research for Child Health staff in six African and Asian sites recorded lung sounds with a digital stethoscope in cases and controls. Cases aged 1-59 months had WHO severe or very severe pneumonia; age-matched community controls did not. A listening panel assigned examination results of normal, crackle, wheeze, crackle and wheeze or uninterpretable, with adjudication of discordant interpretations. Classifications were recategorised into any crackle, any wheeze or abnormal (any crackle or wheeze) and primary listener agreement (first two listeners) was analysed among interpretable examinations using the prevalence-adjusted, bias-adjusted kappa (PABAK). We examined predictors of disagreement with logistic regression and compared case and control lung sounds with descriptive statistics. RESULTS Primary listeners considered 89.5% of 792 case and 92.4% of 301 control recordings interpretable. Among interpretable recordings, listeners agreed on the presence or absence of any abnormality in 74.9% (PABAK 0.50) of cases and 69.8% (PABAK 0.40) of controls, presence/absence of crackles in 70.6% (PABAK 0.41) of cases and 82.4% (PABAK 0.65) of controls and presence/absence of wheeze in 72.6% (PABAK 0.45) of cases and 73.8% (PABAK 0.48) of controls. Controls, tachypnoea, >3 uninterpretable chest positions, crying, upper airway noises and study site predicted listener disagreement. Among all interpretable examinations, 38.0% of cases and 84.9% of controls were normal (p<0.0001); wheezing was the most common sound (49.9%) in cases. CONCLUSIONS Listening panel and case-control data suggests our methodology is feasible, likely valid and that small airway inflammation is common in WHO pneumonia. Digital auscultation may be an important future pneumonia diagnostic in developing countries.
Collapse
Affiliation(s)
- Eric D McCollum
- Eudowood Division of Pediatric Respiratory Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland, USA,Department of International Health, Johns Hopkins Bloomberg School of Public Health, Dhaka, Bangladesh,Department of International Health, International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Daniel E Park
- Department of International Health, International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | - W Chris Buck
- Department of Pediatrics, University of California Los Angeles, Maputo, Mozambique
| | - Charatdao Bunthi
- International Emerging Infections Program, Global Disease Detection Center, Thailand Ministry of Public Health – US Centers for Disease Control and Prevention Collaboration, Nonthaburi, Thailand
| | | | | | - Mounya Elhilali
- Department of Electrical and Computer Engineering, Johns Hopkins University, Baltimore, USA
| | - Dimitra Emmanouilidou
- Department of Electrical and Computer Engineering, Johns Hopkins University, Baltimore, USA
| | - Anthony J Garcia-Prats
- Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg, South Africa
| | - Leah Githinji
- Division of Paediatric Pulmonology, University of Cape Town, Cape Town, South Africa
| | - Lokman Hossain
- Respiratory Vaccines, Center for Vaccine Sciences, icddr,b, Dhaka, Bangladesh
| | - Shabir A Madhi
- Medical Research Council, Respiratory and Meningeal Pathogens Research Unit, University of the Witwatersrand, Johannesburg, South Africa,Department of Science and Technology/National Research Foundation, South African Research Chair: Vaccine Preventable Diseases, University of the Witwatersrand, Johannesburg, South Africa
| | - David P Moore
- Medical Research Council, Respiratory and Meningeal Pathogens Research Unit, University of the Witwatersrand, Johannesburg, South Africa,Department of Paediatrics, University of the Witwatersrand, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
| | - Justin Mulindwa
- Department of Paediatrics and Child Health, University Teaching Hospital, Lusaka, Zambia
| | - Dan Olson
- Department of Pediatrics, Section of Infectious Disease, Center for Global Health, University of Colorado, Colorado, USA
| | - Juliet O Awori
- Kenya Medical Research Institute Wellcome Trust Research Programme, Kilifi, Kenya
| | - Warunee P Vandepitte
- Queen Sirikit National Institute of Child Health, Rangsit University, Bangkok, Thailand
| | - Charl Verwey
- Medical Research Council, Respiratory and Meningeal Pathogens Research Unit, University of the Witwatersrand, Johannesburg, South Africa,Department of Paediatrics, University of the Witwatersrand, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
| | - James E West
- Department of Electrical and Computer Engineering, Johns Hopkins University, Baltimore, USA
| | - Maria D Knoll
- Department of International Health, International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Katherine L O'Brien
- Department of International Health, International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Daniel R Feikin
- Department of International Health, International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA,Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Laura L Hammit
- Kenya Medical Research Institute Wellcome Trust Research Programme, Kilifi, Kenya
| |
Collapse
|
100
|
Abstract
GOAL Chest auscultations offer a non-invasive and low-cost tool for monitoring lung disease. However, they present many shortcomings, including inter-listener variability, subjectivity, and vulnerability to noise and distortions. This work proposes a computer-aided approach to process lung signals acquired in the field under adverse noisy conditions, by improving the signal quality and offering automated identification of abnormal auscultations indicative of respiratory pathologies. METHODS The developed noise-suppression scheme eliminates ambient sounds, heart sounds, sensor artifacts, and crying contamination. The improved high-quality signal is then mapped onto a rich spectrotemporal feature space before being classified using a trained support-vector machine classifier. Individual signal frame decisions are then combined using an evaluation scheme, providing an overall patient-level decision for unseen patient records. RESULTS All methods are evaluated on a large dataset with 1000 children enrolled, 1-59 months old. The noise suppression scheme is shown to significantly improve signal quality, and the classification system achieves an accuracy of 86.7% in distinguishing normal from pathological sounds, far surpassing other state-of-the-art methods. CONCLUSION Computerized lung sound processing can benefit from the enforcement of advanced noise suppression. A fairly short processing window size ( s) combined with detailed spectrotemporal features is recommended, in order to capture transient adventitious events without highlighting sharp noise occurrences. SIGNIFICANCE Unlike existing methodologies in the literature, the proposed work is not limited in scope or confined to laboratory settings: This work validates a practical method for fully automated chest sound processing applicable to realistic and noisy auscultation settings.
Collapse
|