Estimates of the global, regional, and national morbidity, mortality, and aetiologies of lower respiratory infections in 195 countries, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016

Evaluation of the Safety and Immune Efficacy of Recombinant Human Respiratory Syncytial Virus Strain Long Live Attenuated Vaccine Candidates

Human respiratory syncytial virus (RSV) infection is the leading cause of lower respiratory tract illness (LRTI), and no vaccine against LRTI has proven to be safe and effective in infants. Our study assessed attenuated recombinant RSVs as vaccine candidates to prevent RSV infection in mice. The constructed recombinant plasmids harbored (5′ to 3′) a T7 promoter, hammerhead ribozyme, RSV Long strain antigenomic cDNA with cold-passaged (cp) mutations or cp combined with temperature-sensitive attenuated mutations from the A2 strain (A2cpts) or further combined with SH gene deletion (A2cptsΔSH), HDV ribozyme (δ), and a T7 terminator. These vectors were subsequently co-transfected with four helper plasmids encoding N, P, L, and M2-1 viral proteins into BHK/T7-9 cells, and the recovered viruses were then passaged in Vero cells. The rescued recombinant RSVs (rRSVs) were named rRSV-Long/A2cp, rRSV-Long/A2cpts, and rRSV-Long/A2cptsΔSH, respectively, and stably passaged in vitro, without reversion to wild type (wt) at sites containing introduced mutations or deletion. Although rRSV-Long/A2cpts and rRSV-Long/A2cptsΔSH displayed  temperature-sensitive (ts) phenotype in vitro and in vivo, all rRSVs were significantly attenuated in vivo. Furthermore, BALB/c mice immunized with rRSVs produced Th1-biased immune response, resisted wtRSV infection, and were free from enhanced respiratory disease. We showed that the combination of ΔSH with attenuation (att) mutations of cpts contributed to improving att phenotype, efficacy, and gene stability of rRSV. By successfully introducing att mutations and SH gene deletion into the RSV Long parent and producing three rRSV strains, we have laid an important foundation for the development of RSV live attenuated vaccines.

Estradiol resolves pneumonia via ERβ in regulatory T cells

Current treatments for pneumonia (PNA) are focused on the pathogens. Mortality from PNA-induced acute lung injury (PNA-ALI) remains high, underscoring the need for additional therapeutic targets. Clinical and experimental evidence exists for potential sex differences in PNA survival, with males having higher mortality. In a model of severe pneumococcal PNA, when compared with male mice, age-matched female mice exhibited enhanced resolution characterized by decreased alveolar and lung inflammation and increased numbers of Tregs. Recognizing the critical role of Tregs in lung injury resolution, we evaluated whether improved outcomes in female mice were due to estradiol (E2) effects on Treg biology. E2 promoted a Treg-suppressive phenotype in vitro and resolution of PNA in vivo. Systemic rescue administration of E2 promoted resolution of PNA in male mice independent of lung bacterial clearance. E2 augmented Treg expression of Foxp3, CD25, and GATA3, an effect that required ERβ, and not ERα, signaling. Importantly, the in vivo therapeutic effects of E2 were lost in Treg-depleted mice (Foxp3^DTR mice). Adoptive transfer of ex vivo E2-treated Tregs rescued Streptococcuspneumoniae–induce PNA-ALI, a salutary effect that required Treg ERβ expression. E2/ERβ was required for Tregs to control macrophage proinflammatory responses. Our findings support the therapeutic role for E2 in promoting resolution of lung inflammation after PNA via ERβ Tregs.

A Multicenter Evaluation of the US Prevalence and Regional Variation in Macrolide-Resistant S. pneumoniae in Ambulatory and Hospitalized Adult Patients in the United States

Macrolide resistance was found in 39.5% of 3626 nonduplicate Streptococcus pneumoniae isolates from adult ambulatory and inpatient settings at 329 US hospitals (2018–2019). Macrolide resistance was significantly higher for respiratory vs blood isolates and ambulatory vs inpatient settings. Despite geographic variation, S. pneumoniae macrolide resistance was >25% in most regions.

The potential of rapalogs to enhance resilience against SARS-CoV-2 infection and reduce the severity of COVID-19

COVID-19 disproportionately affects older people, with likelihood of severe complications and death mirroring that of other age-associated diseases. Inhibition of the mechanistic target of rapamycin complex 1 (mTORC1) has been shown to delay or reverse many age-related phenotypes, including declining immune function. Rapamycin (sirolimus) and rapamycin derivatives are US Food and Drug Administration-approved inhibitors of mTORC1 with broad clinical utility and well established dosing and safety profiles. Based on preclinical and clinical evidence, a strong case can be made for immediate large-scale clinical trials to assess whether rapamycin and other mTORC1 inhibitors can prevent COVID-19 infection in these populations and also to determine whether these drugs can improve outcomes in patients with severe COVID-19.

Early detection of drug-resistant Streptococcus pneumoniae and Haemophilus influenzae by quantitative flow cytometry

Early detection of drug resistance contributes to combating drug-resistant bacteria and improving patient outcomes. Microbial testing in the laboratory is essential for treating infectious diseases because it can provide critical information related to identifying pathogenic bacteria and their resistance profiles. Despite these clinical requirements, conventional phenotypic testing is time-consuming. Additionally, recent rapid drug resistance tests are not compatible with fastidious bacteria such as Streptococcus and Haemophilus species. In this study, we validated the feasibility of direct bacteria counting using highly sensitive quantitative flow cytometry. Furthermore, by combining flow cytometry and a nucleic acid intercalator, we constructed a highly sensitive method for counting viable fastidious bacteria. These are inherently difficult to measure due to interfering substances from nutrients contained in the medium. Based on the conventional broth microdilution method, our method acquired a few microliter samples in a time series from the same microplate well to exclude the growth curve inconsistency between the samples. Fluorescent staining and flow cytometry measurements were completed within 10 min. Therefore, this approach enabled us to determine antimicrobial resistance for these bacteria within a few hours. Highly sensitive quantitative flow cytometry presents a novel avenue for conducting rapid antimicrobial susceptibility tests.

Decreased number of hospitalized children with severe acute lower respiratory infection after introduction of the pneumococcal conjugate vaccine in the Eastern Democratic Republic of the Congo

Introduction

acute lower respiratory infections (ALRI) are a leading killer of children under five worldwide including the Democratic Republic of the Congo (DR Congo). We aimed to determine the morbidity and case fatality rate due to ALRI before and after introduction of the 13-valent pneumococcal conjugate vaccine (PVC13) in DR Congo 2013.

Methods

data were collected from medical records of children with a diagnosis of ALRI, aged from 2 to 59 months, treated at four hospitals in the Eastern DR Congo. Two study periods were defined; from 2010 to 2012 (before introduction of PCV13) and from 2014 to 2015 (after PCV13 introduction).

Results

out of 21,478 children admitted to the hospitals during 2010-2015, 2,007 were treated for ALRI. The case fatality rate among these children was 4.9%. Death was significantly and independently associated with malnutrition, severe ALRI, congenital disease and symptoms of fatigue. Among the ALRI hospitalised children severe ALRI decreased from 31% per year to 18% per year after vaccine introduction (p = 0.0002) while the fatality rate remained unchanged between the two study periods. Following introduction of PCV13, 63% of the children diagnosed with ALRI were treated with ampicillin combined with gentamicin while 33% received ceftriaxone and gentamicin.

Conclusion

three years after PCV13 introduction in the Eastern part of the DR Congo, we found a reduced risk of severe ALRI among children below five years. Broad-spectrum antibiotics were frequently used for the treatment of ALRI in the absence of any microbiological diagnostic support.

Epidemiological analysis of pneumococcal strains isolated at Yangon Children's Hospital in Myanmar via whole-genome sequencing-based methods

Streptococcus pneumoniae causes over one million deaths from lower respiratory infections per annum worldwide. Although mortality is very high in Southeast Asian countries, molecular epidemiological information remains unavailable for some countries. In this study, we report, for the first time, the whole-genome sequences and genetic profiles of pneumococcal strains isolated in Myanmar. We isolated 60 streptococcal strains from 300 children with acute respiratory infection at Yangon Children's Hospital in Myanmar. We obtained whole-genome sequences and identified the species, serotypes, sequence types, antimicrobial resistance (AMR) profiles, virulence factor profiles and pangenome structure using sequencing-based analysis. Average nucleotide identity analysis indicated that 58 strains were S. pneumoniae and the other 2 strains were Streptococcus mitis. The major serotype was 19F (11 strains), followed by 6E (6B genetic variant; 7 strains) and 15 other serotypes; 5 untypable strains were also detected. Multilocus sequence typing analysis revealed 39 different sequence types, including 11 novel ones. In addition, genetic profiling indicated that AMR genes and mutations spread among pneumococcal strains in Myanmar. A minimum inhibitory concentration assay indicated that several pneumococcal strains had acquired azithromycin and tetracycline resistance, whereas no strains were found to be resistant against levofloxacin and high-dose penicillin G. Phylogenetic and pangenome analysis showed various pneumococcal lineages and that the pneumococcal strains contain a rich and mobile gene pool, providing them with the ability to adapt to selective pressures. This molecular epidemiological information can help in tracking global infection and supporting AMR control in addition to public health interventions in Myanmar.

Inequalities and Inequities in Pediatric Respiratory Diseases

Social inequality refers to disparities in society that have the effect of limiting a group's socioeconomic, educational, and intellectual potential. Inequity in health means any limitation to access comprehensive health services that also hinders the achievement of well-being and favorable health outcomes. Strategies for more equitable growth to eradicate global poverty would contribute to reducing health inequities and improve health care outcomes. Coordinated efforts between governments, private sector, families, and interested stakeholders are needed. This article discusses inequality and inequity in pediatric respiratory diseases, the challenges confronted, and the strategies needed to mitigate these disparities.

Trends of inequalities in care seeking behavior for under-five children with suspected pneumonia in Ethiopia: evidence from Ethiopia demographic and health surveys (2005-2016)

Background

Pneumonia is a leading public health problem in under-five children worldwide and particularly in Africa. Unfortunately, progress in reducing pneumonia related mortality has been slow. The number of children with symptoms of pneumonia taken to health facilities for treatment is low in Ethiopia, and disparities among sub-groups regarding health seeking behavior for pneumonia have not been well explored in the region. This study assessed the trends of inequalities in care seeking behavior for children under five years of age with suspected pneumonia in Ethiopia.

Methods

Using cross-sectional data from the 2005, 2011 and 2016 Ethiopia Demographic and Health Surveys (DHS) and the World Health Organization’s (WHO) Health Equity Assessment Toolkit (HEAT), this study investigated the inequalities in health seeking behavior for children with suspected pneumonia. Four measures of inequality were calculated: Difference, Ratio, Slope Index of Inequality and Relative Index of Inequality. Results were disaggregated by wealth, education, residence, and sex with computed 95% Uncertainty Intervals for each point estimate to determine significance.

Results

The percentage of under-five children with symptoms of pneumonia who were taken to a health facility was significantly lower for children in the poorest families, 15.48% (95% UI; 9.77, 23.64) as compared to children in the richest families, 61.72% (95% UI; 45.06, 76.02) in 2011. Substantial absolute (SII = 35.61; 95% UI: 25.31, 45.92) and relative (RII = 4.04%; 95% UI: 2.25, 5.84) economic inequalities were also observed. Both educational and geographic inequalities were observed; (RII = 2.07; 95% UI: 1.08, 3.06) and (D = 28.26; 95% UI: 7.14, 49.37), respectively. Economic inequality decreased from 2011 to 2016. There was no statistically significant difference between male and female under-five children with pneumonia symptoms taken to health facility, in all the studied years.

Conclusions

Health care seeking behavior for children with pneumonia was lower among the poorest and non-educated families as well as children in rural regions. Policies and strategies need to target subpopulations lagging behind in seeking care for pneumonia treatment as it impedes achievement of key UN sustainable development goals (SDGs).

Decomposition of Improvements in Infant Mortality in Asian Developing Countries Over Three Decades

Low- and middle-income countries in Asia have seen substantial improvements in infant mortality over the last three decades. This study examines the factors contributing to the improvement in infant survival in their first year in six Asian countries: Bangladesh, India, Indonesia, Nepal, Pakistan, and the Philippines. I decompose the overall improvement in the infant survival rate in the respective countries from the 1990s to the 2010s into the part that can be explained by the improvements in circumstantial environments in which infants develop and the remaining part that is due to the structural change in the hazard functions. This decomposition is achieved by employing the random survival forest, allowing me to predict the counterfactual infant survival probability that infants in the 2010s would have under the circumstantial environments of the 1990s. The results show that large parts of the improvement are explained by the improvement in the environments in all the countries being analyzed. I find that the reduction in family size, increased use of antenatal care, longer pregnancy periods, and improved living standards were associated with the improvement of the infant mortality rate in all six countries.

Evolution, Clinical and Microbiological Characteristics of Invasive Pneumococcal Disease since the Introduction of the Pneumococcal Conjugate Vaccine 13-Valent in Adults over 18 Years Old

Invasive pneumococcal disease (IPD) presents high mortality in the population at risk. The aim of this work is to know the evolution, clinical and microbiological characteristics of IPD in the adult population of Majorca, since the introduction of a public funded program for pneumococcal conjugate vaccine (PCV-13) in the pediatric population in the Balearic Islands in 2016. For this purpose, a retrospective multicenter study was carried out in which all episodes of IPD in adult patients from the four hospitals of the public health system of Majorca were included, comparing the periods between 2012 and 2015 and between 2016 and 2019. Clinical variables, serotypes and antibiotic sensitivity were collected. There were 498 cases of IPD; 56.8% were male with a mean age of 67 (standard deviation: 16). Most infections were bacterial pneumonias (73.7%). Of the total cases, 264 (53%) presented complications. Of the 498 cases, 351 strains were obtained, of which 145 (41.3%) belong to vaccinal serotypes (included in the PCV-13 vaccine) and 206 (58.7%) to non-vaccinal serotypes (not included in the PCV-13 vaccine). The percentage of IPD caused by vaccinal serotypes was lower in the second period (47.8% vs. 34.5%; p = 0.012).

Vitamin D Modulation of the Innate Immune Response to Paediatric Respiratory Pathogens Associated with Acute Lower Respiratory Infections

Vitamin D is an essential component of immune function and childhood deficiency is associated with an increased risk of acute lower respiratory infections (ALRIs). Globally, the leading childhood respiratory pathogens are Streptococcus pneumoniae, respiratory syncytial virus and the influenza virus. There is a growing body of evidence describing the innate immunomodulatory properties of vitamin D during challenge with respiratory pathogens, but recent systematic and unbiased synthesis of data is lacking, and future research directions are unclear. We therefore conducted a systematic PubMed literature search using the terms “vitamin D” and “Streptococcus pneumoniae” or “Respiratory Syncytial Virus” or “Influenza”. A priori inclusion criteria restricted the review to in vitro studies investigating the effect of vitamin D metabolites on human innate immune cells (primary, differentiated or immortalised) in response to stimulation with the specified respiratory pathogens. Eleven studies met our criteria. Despite some heterogeneity across pathogens and innate cell types, vitamin D modulated pathogen recognition receptor (PRRs: Toll-like receptor 2 (TLR2), TLR4, TLR7 and nucleotide-binding oligomerisation domain-containing protein 2 (NOD2)) expression; increased antimicrobial peptide expression (LL-37, human neutrophil peptide (HNP) 1-3 and β-defensin); modulated autophagosome production reducing apoptosis; and modulated production of inflammatory cytokines (Interleukin (IL) -1β, tumour necrosis factor-α (TNF-α), interferon-ɣ (IFN-ɣ), IL-12p70, IFN-β, Regulated on Activation, Normal T cell Expressed (RANTES), IL-10) and chemokines (IL-8 and C-X-C motif chemokine ligand 10 (CXCL10)). Differential modulation of PRRs and IL-1β was reported across immune cell types; however, this may be due to the experimental design. None of the studies specifically focused on immune responses in cells derived from children. In summary, vitamin D promotes a balanced immune response, potentially enhancing pathogen sensing and clearance and restricting pathogen induced inflammatory dysregulation. This is likely to be important in controlling both ALRIs and the immunopathology associated with poorer outcomes and progression to chronic lung diseases. Many unknowns remain and further investigation is required to clarify the nuances in vitamin D mediated immune responses by pathogen and immune cell type and to determine whether these in vitro findings translate into enhanced immunity and reduced ALRI in the paediatric clinical setting.

[Virological diagnosis of lower respiratory tract infections]

INTRODUCTION

The etiological diagnosis of bronchopulmonary infections cannot be assessed with clinical, radiological and epidemiological data alone. Viruses have been demonstrated to cause a large proportion of these infections, both in children and adults.

BACKGROUND

The diagnosis of viral bronchopulmonary infections is based on the analysis of secretions, collected from the lower respiratory tract when possible, by techniques that detect either influenza and respiratory syncytial viruses, or a large panel of viruses that can be responsible for respiratory disease. The latter, called multiplex PCR assays, allow a syndromic approach to respiratory infection. Their high cost for the laboratory raises the question of their place in the management of patients in terms of antibiotic economy and isolation. In the absence of clear recommendations, the strategy and equipment are very unevenly distributed in France.

OUTLOOK

Medico-economic analyses need to be performed in France to evaluate the place of these tests in the management of patients. The evaluation of the role of the different viruses often detected in co-infection, especially in children, also deserves the attention of virologists and clinicians.

CONCLUSIONS

The availability of new diagnostic technologies, the recent emergence of SARS-CoV-2, together with the availability of new antiviral drugs are likely to impact future recommendations for the management of viral bronchopulmonary infections.

Clinical performance of the GenMark Dx ePlex respiratory pathogen panels for upper and lower respiratory tract infections

The GenMark Dx ePlex Respiratory Pathogen Panel (RP) is a multiplexed nucleic acid test for the qualitative detection of common viral and a few bacterial causes of respiratory tract infections. The ePlex RP has received FDA clearance for nasopharyngeal swab (NPS) specimens collected in viral transport media. In this study, we evaluated the performance of the ePlex RP panel in comparison to the NxTAG Respiratory Pathogen Panel (NxTAG-RPP) from Luminex in use in our laboratory, not only for NPS but also for bronchoalveolar lavage specimens (BAL). We also evaluated the impact of implementing the ePlex RP on the test turn-around time (TAT). The newest panel from GenMark Dx, the ePlex Respiratory Pathogen Panel 2 (RP2), which added the SARS-CoV-2 target to the RP was also evaluated for NPS. Verification of the performance of the ePlex RP for both NPS and BAL showed 93.3 % and 84.9 % total agreement with the NxTAG-RPP respectively. An overall comparison of the TAT after implementing the ePlex RP as compared to the NxTAG-RPP assay showed an average decrease of almost seven-fold.

Evaluation of a 'serious game' on nursing student knowledge and uptake of influenza vaccination

Background

Influenza is a serious global healthcare issue that is associated with between 290,000 to 650,000 deaths annually. The aim of this study is to evaluate the effect of a ‘serious game’ about influenza, on nursing student attitude, knowledge and uptake of the influenza vaccination.

Methods

1306 undergraduate nursing students were invited, via email, to play an online game about influenza between September 2018 and March 2019. 430 nursing students accessed the game and completed an 8-item questionnaire measuring their attitudes to influenza between September 2018 and March 2019. In April 2019, 356 nursing students from this sample completed a follow-up 2-item questionnaire about their uptake of the influenza vaccination. A larger separate 40-item knowledge questionnaire was completed by a year one cohort of 124 nursing students in August 2018 prior to receiving access to the game and then after access to the game had ended, in April 2019. This sample was selected to determine the extent to which the game improved knowledge about influenza amongst a homogenous group.

Results

In the year preceding this study, 36.7% of the sample received an influenza vaccination. This increased to 47.8% after accessing to the game. Nursing students reported perceived improvements in their knowledge, intention to get the vaccination and intention to recommend the vaccination to their patients after playing the game. Nursing students who completed the 40-item pre- and post-knowledge questionnaire scored an average of 68.6% before receiving access to the game and 85.2% after. Using Paired T-Tests statistical analysis, it was determined that this 16.6% increase was highly statistically significant (P < 0.001).

Conclusions

The research highlights that the influenza game can improve knowledge and intention to become vaccinated. This study suggests that improvement in influenza knowledge is likely to encourage more nursing students to receive the influenza vaccination.

Prevalence, distribution and antimicrobial susceptibility pattern of bacterial isolates from a tertiary Hospital in Malawi

Background

Bacterial infections are a significant cause of sickness and death in sub-Saharan Africa. This study aimed at establishing the prevalence, distribution and antimicrobial susceptibility pattern of major bacterial isolates from patients accessing medical care at a tertiary hospital in Malawi.

Methods

We retrospectively reviewed bacteria culture and antimicrobial susceptibility records for 4617 patients from 2002 to 2014 at Mzuzu Central Hospital (MCH). No inclusion and exclusion criteria were followed. Data was analysed using excel (Microsoft office, USA) and GraphPad prism 7 software programs.

Results

The most prevalent isolates were S. aureus (34.7%, n = 783), Klebsiella species (17.4%, n = 393) and Proteus species (11.4%, n = 256). Most microorganisms were isolated from adults (88.3%, n = 3889) and pus was the main source (69.3%, n = 1224). S. pneumoniae was predominantly isolated from cerebrospinal fluid (60.3%, n = 44) largely collected from children (88.2%, n = 64). Overall, most bacteria exhibited high resistance to all regularly used antimicrobials excluding ciprofloxacin.

Conclusions

Our report demonstrates an increase in bacterial infection burden in sites other than blood stream and subsequent increase in prevalence of antimicrobial resistance for all major isolates. Creating an epidemiological survey unit at MCH will be essential to help inform better treatment and management options for patients with bacterial infections.

Short-term exposure to air pollution and hospital admission for pneumonia: a systematic review and meta-analysis

BACKGROUND

Air pollution is a major issue that poses a health threat worldwide. Although several studies investigated the adverse effects of air pollution on various diseases, few have directly demonstrated the effects on pneumonia. Therefore, we performed a systematic review and meta-analysis on the associations between short-term exposure of air pollutants and hospital admission or emergency room (ER) visit for pneumonia.

METHODS

A literature search was performed using PubMed, Embase, and Web of Science up to April 10, 2020. Pooled estimates were calculated as % increase with 95% confidence intervals using a random-effects model. A sensitivity analysis using the leave-one-out method and subgroup analysis by region were performed.

RESULTS

A total of 21 studies were included in the analysis. Every 10 μg/m3 increment in PM2.5 and PM10 resulted in a 1.0% (95% CI: 0.5-1.5) and 0.4% (95% CI: 0.2-0.6) increase in hospital admission or ER visit for pneumonia, respectively. Every 1 ppm increase of CO and 10 ppb increase of NO2, SO2, and O3 was associated with 4.2% (95% CI: 0.6-7.9), 3.2% (95% CI: 1.3-5.1), 2.4% (95% CI: - 2.0-7.1), and 0.4% (95% CI: 0-0.8) increase in pneumonia-specific hospital admission or ER visit, respectively. Except for CO, the sensitivity analyses yielded similar results, demonstrating the robustness of the results. In a subgroup analysis by region, PM2.5 increased hospital admission or ER visit for pneumonia in East Asia but not in North America.

CONCLUSION

By combining the inconsistent findings of several studies, this study revealed the associations between short-term exposure of air pollutants and pneumonia-specific hospital admission or ER visit, especially for PM and NO2. Based on the results, stricter intervention policies regarding air pollution and programs for protecting human respiratory health should be implemented.

Direct and indirect effect of 10 valent pneumococcal vaccine on nasopharyngeal carriage in children under 2 years of age in Matiari, Pakistan

Background

Pakistan introduced Ten-valent pneumococcal-conjugate-vaccine PCV10 in 2012 as a 3 + 0 schedule without catch-up.

Methods

Children <2 years old in Matiari, Sindh provided nasopharyngeal swabs between 2014 and 2018, which were cultured for pneumococcus and serotyped through multiplex PCR at the Aga Khan University Hospital. Carriage rates over time for Vaccine-Type (VT) and Non-VT (NVT) serotypes were used to estimate direct, indirect, total and overall effects of vaccination. Regression analysis was used to determine factors associated with VT carriage.

Results

Pneumococcus was detected in 2370/3140 (75%). VT carriage decreased overall, 16.1–9.6% (p-trend <0.001); vaccinated (all 3 doses of PCV10 received) 11.3–8.1% (p-trend 0.031) and unvaccinated (no PCV10 dose received) 17.4–10.3% (p-trend 0.003) with a decline in serotypes 6B, 9V/9A and 19F. Immunization increased from 41.0% to 68.4% (p-trend 0.001). Direct effect of vaccine was 32.8% (95% CI 14.7–47.0%) and indirect effect 44.6%(95% CI 40.6–48.6%). Factors associated with decreased VT colonization were education 1–5 years (aOR 0.7, 95%CI 0.6–1.0), history of difficulty breathing (aOR 0.7, 95%CI 0.5–1.0), exposure to smoke (aOR 0.8, 95% CI 0.6–1.0), child fully immunized (aOR 0.7, 95%CI 0.5–1.0) and enrolled in 3rd (aOR 0.6, 95%CI 0.4–0.8) and 4th (aOR 0.6, 95%CI 0.5–0.9) year of the study whereas history of runny nose (aOR 1.5, 95% CI 1.2–1.9) was positively associated.

Conclusions

Decrease in VT pneumococcal carriage in vaccinated and unvaccinated children indicates herd immunity. Sustained increase in vaccine coverage and close long-term surveillance is warranted.

Epidemiology of Hypoxic Community-Acquired Pneumonia in Children Under 5 Years of Age: An Observational Study in Northern India

BACKGROUND

Community-acquired pneumonia (CAP) is the leading cause of under-five mortality in India. An increased risk of mortality has been reported in cases of hypoxic pneumonia.

METHODS

The primary objective of this study was to assess the proportion of children aged 2-59 months, hospitalized with hypoxic CAP, as well as socio-demographic, clinical, and radiological features associated with it. The secondary objective was to determine the risk of mortality among hospitalized cases of hypoxic CAP. This prospective, observational study was conducted in four districts of Northern India, between January 2015 and April 2021. A hospital-based surveillance network was established. Inclusion criteria were as follows: (a) child between 2 and 59 months, (b) hospitalization with symptoms of WHO-defined CAP, (c) resident of project district, (d) illness of <14 days, and (e) child had neither been hospitalized for this illness nor recruited previously. Children whose chest x-rays (CXRs) were either unavailable/un-interpretable and those that received any dose of pneumococcal conjugate vaccine-13 were excluded. Hypoxic pneumonia was defined as oxygen saturation <90% on pulse oximetry or requiring oxygen supplementation during hospital stay.

RESULTS

During the study period, 71.9% (7,196/10,006) children of severe pneumonia were eligible for inclusion, of whom 35.9% (2,580/7,196) were having hypoxic pneumonia. Female gender and use of biomass fuel for cooking increased the odds of hypoxic CAP. Clinical factors like wheezing, pallor, tachypnea, low pulse volume, presence of comorbidity, general danger signs, severe malnutrition, and radiological finding of primary end-point pneumonia ± other infiltrates (PEP±OI) also increased the odds of hypoxic CAP in a conditional logistic regression model. Adjusted odds ratio for mortality with hypoxia was 2.36 (95% CI: 1.42-3.92).

CONCLUSION

Almost one-third of cases hospitalized with severe CAP had hypoxia, which increased chances of mortality. Besides known danger signs, certain newer clinical signs such as pallor and wheezing as well as PEP+OI were associated with hypoxic CAP. Therefore, objective assessment of oxygen saturation must be done by pulse oximetry in all cases of CAP at the time of diagnosis.

Modeling COVID-19 scenarios for the United States

We use COVID-19 case and mortality data from 1 February 2020 to 21 September 2020 and a deterministic SEIR (susceptible, exposed, infectious and recovered) compartmental framework to model possible trajectories of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections and the effects of non-pharmaceutical interventions in the United States at the state level from 22 September 2020 through 28 February 2021. Using this SEIR model, and projections of critical driving covariates (pneumonia seasonality, mobility, testing rates and mask use per capita), we assessed scenarios of social distancing mandates and levels of mask use. Projections of current non-pharmaceutical intervention strategies by state-with social distancing mandates reinstated when a threshold of 8 deaths per million population is exceeded (reference scenario)-suggest that, cumulatively, 511,373 (469,578-578,347) lives could be lost to COVID-19 across the United States by 28 February 2021. We find that achieving universal mask use (95% mask use in public) could be sufficient to ameliorate the worst effects of epidemic resurgences in many states. Universal mask use could save an additional 129,574 (85,284-170,867) lives from September 22, 2020 through the end of February 2021, or an additional 95,814 (60,731-133,077) lives assuming a lesser adoption of mask wearing (85%), when compared to the reference scenario.

Disappearance of Seasonal Respiratory Viruses in Children Under Two Years Old During COVID-19 Pandemic: A Monocentric Retrospective Study in Milan, Italy

Background: The containment measures adopted during COVID-19 pandemic have influenced the epidemiology of other respiratory viruses. Aim: We analyzed the modification of the incidence and etiology of lower respiratory tract infections (LRTIs) in young children during COVID-19 pandemic. Methods: Case series of all children under 2 years old hospitalized at a tertiary care Hospital in the Center of Milan, Italy diagnosed with LRTIs in three consecutive winter seasons (from the 1st of November to the last day of February in 2018/2019, 2019/2020 and 2020/2021). We compared the number of hospitalizations and viral detections in the 2020/2021 with the average of 2018/2019 and 2019/2020 (pre-COVID-19) using the Poisson distribution. Results: we enrolled 178 patients (66 from 2018/2019, 96 from 2019/2020, 16 from 2020/2021) 94 males (53%) and 84 females (47%), with a median (IQR) age of 5 (2-13) months. The number of hospitalizations during the 2020/2021 season was 80% lower than the average of the pre-COVID-19 seasons (16 vs. 81, p<0.001). Overall, 171 (96%) patient's nasopharyngeal aspirate (NPA) detected at least one virus (110, 64%, single-detection, 61, 36%, co-detections). In 2020/2021 we observed the disappearance of Respiratory Syncytial virus (0 vs. 54, p < 0.001), Influenza virus (0 vs. 6.5, p = 0.002), Metapneumovirus (0 vs. 8, p < 0.001), Parainfluenza viruses (0 vs. 3.5, p = 0.03) and a significant reduction of Adenovirus (2 vs. 7, p = 0.03), Bocavirus (2 vs. 7.5, p = 0.02) and Enterovirus (1 vs. 5, p = 0.04). No significant difference was found for Rhinoviruses (14 cases vs. 17, p = 0.2), other Coronaviruses (0 vs. 2, p = 0.1), and Cytomegalovirus (1 vs. 1, p = 0.7). Conclusions: We observed a striking reduction in hospitalizations due to LRTIs and a modification of the etiology, with enveloped viruses mainly affected.

Liposomal Encapsulation of Polysaccharides (LEPS) as an Effective Vaccine Strategy to Protect Aged Hosts Against S. pneumoniae Infection

Despite the availability of licensed vaccines, pneumococcal disease caused by the bacteria Streptococcus pneumoniae (pneumococcus), remains a serious infectious disease threat globally. Disease manifestations include pneumonia, bacteremia, and meningitis, resulting in over a million deaths annually. Pneumococcal disease disproportionally impacts older adults aged ≥65 years. Interventions are complicated through a combination of complex disease progression and 100 different bacterial capsular polysaccharide serotypes. This has made it challenging to develop a broad vaccine against S. pneumoniae, with current options utilizing capsular polysaccharides as the primary antigenic content. However, current vaccines are substantially less effective in protecting the elderly. We previously developed a Liposomal Encapsulation of Polysaccharides (LEPS) vaccine platform, designed around limitations of current pneumococcal vaccines, that allowed the noncovalent coupling of polysaccharide and protein antigen content and protected young hosts against pneumococcal infection in murine models. In this study, we modified the formulation to make it more economical and tested the novel LEPS vaccine in aged hosts. We found that in young mice (2-3 months), LEPS elicited comparable responses to the pneumococcal conjugate vaccine Prevnar-13. Further, LEPS immunization of old mice (18-22 months) induced comparable antibody levels and improved antibody function compared to Prevnar-13. Importantly, LEPS protected old mice against both invasive and lung localized pneumococcal infections. In summary, LEPS is an alternative and effective vaccine strategy that protects aged hosts against different manifestations of pneumococcal disease.

Health and economic burden of invasive pneumococcal disease associated with 15-valent pneumococcal conjugate vaccine serotypes in children across eight European countries

AIMS

V114, a 15-valent pneumococcal conjugate vaccine (PCV15) currently approved in adults in the US, contains the 13 S. pneumoniae serotypes in PCV13 and two additional serotypes, 22 F and 33 F, which are important contributors to residual PD. This study quantified the health and economic burden of pediatric invasive pneumococcal disease (IPD) associated with V114 serotypes in eight countries in Europe.

MATERIALS AND METHODS

A Markov model estimated V114-type IPD cases and costs in hypothetical unvaccinated birth cohorts from Denmark, France, Germany, Italy, Norway, Spain, Switzerland, and the UK over 20 years. Inputs were obtained from published literature. IPD cases and costs were calculated for three time periods using time-specific epidemiological data: (a) pre-PCV7; (b) pre-PCV13; and (c) post-PCV13. Costs were estimated from a societal perspective (2018 Euros) and discounted at 3%.

RESULTS

The model estimated that 4,649 IPD cases in the pre-PCV7 period, 3,248 cases in the pre-PCV13 period, and 958 cases in the post-PCV13 period were attributable to V114 serotypes. Total discounted costs associated with V114 serotypes were €109.1 million (pre-PCV7 period), €65.7 million (pre-PCV13 period), and €18.7 million (post-PCV13 period).

LIMITATIONS

Post-meningitis sequelae, acute otitis media, and non-bacteremic pneumonia were not considered. Direct non-medical costs were not included. Conclusions on effectiveness of V114 or added value over existing infant vaccination programs cannot be drawn.

CONCLUSIONS

IPD cases and costs were estimated in hypothetical birth cohorts in eight European countries followed for 20 years during three time periods. Serotypes included in V114 were associated with significant morbidity and costs in pre-PCV7, pre-PCV13, and post-PCV13 periods. Future pediatric pneumococcal vaccines should maintain protection against serotypes in licensed vaccines while extending coverage to additional serotypes to ensure reductions in IPD burden are maintained.

Global burden of acute lower respiratory infection associated with human metapneumovirus in children under 5 years in 2018: a systematic review and modelling study

BACKGROUND

Human metapneumovirus is a common virus associated with acute lower respiratory infections (ALRIs) in children. No global burden estimates are available for ALRIs associated with human metapneumovirus in children, and no licensed vaccines or drugs exist for human metapneumovirus infections. We aimed to estimate the age-stratified human metapneumovirus-associated ALRI global incidence, hospital admissions, and mortality burden in children younger than 5 years.

METHODS

We estimated the global burden of human metapneumovirus-associated ALRIs in children younger than 5 years from a systematic review of 119 studies published between Jan 1, 2001, and Dec 31, 2019, and a further 40 high quality unpublished studies. We assessed risk of bias using a modified Newcastle-Ottawa Scale. We estimated incidence, hospital admission rates, and in-hospital case-fatality ratios (hCFRs) of human metapneumovirus-associated ALRI using a generalised linear mixed model. We applied incidence and hospital admission rates of human metapneumovirus-associated ALRI to population estimates to yield the morbidity burden estimates by age bands and World Bank income levels. We also estimated human metapneumovirus-associated ALRI in-hospital deaths and overall human metapneumovirus-associated ALRI deaths (both in-hospital and non-hospital deaths). Additionally, we estimated human metapneumovirus-attributable ALRI cases, hospital admissions, and deaths by combining human metapneumovirus-associated burden estimates and attributable fractions of human metapneumovirus in laboratory-confirmed human metapneumovirus cases and deaths.

FINDINGS

In 2018, among children younger than 5 years globally, there were an estimated 14·2 million human metapneumovirus-associated ALRI cases (uncertainty range [UR] 10·2 million to 20·1 million), 643 000 human metapneumovirus-associated hospital admissions (UR 425 000 to 977 000), 7700 human metapneumovirus-associated in-hospital deaths (2600 to 48 800), and 16 100 overall (hospital and community) human metapneumovirus-associated ALRI deaths (5700 to 88 000). An estimated 11·1 million ALRI cases (UR 8·0 million to 15·7 million), 502 000 ALRI hospital admissions (UR 332 000 to 762 000), and 11 300 ALRI deaths (4000 to 61 600) could be causally attributed to human metapneumovirus in 2018. Around 58% of the hospital admissions were in infants under 12 months, and 64% of in-hospital deaths occurred in infants younger than 6 months, of which 79% occurred in low-income and lower-middle-income countries.

INTERPRETATION

Infants younger than 1 year have disproportionately high risks of severe human metapneumovirus infections across all World Bank income regions and all child mortality settings, similar to respiratory syncytial virus and influenza virus. Infants younger than 6 months in low-income and lower-middle-income countries are at greater risk of death from human metapneumovirus-associated ALRI than older children and those in upper-middle-income and high-income countries. Our mortality estimates demonstrate the importance of intervention strategies for infants across all settings, and warrant continued efforts to improve the outcome of human metapneumovirus-associated ALRI among young infants in low-income and lower-middle-income countries.

FUNDING

Bill & Melinda Gates Foundation.

Critical Breaths in Transit: A Review of Non-invasive Ventilation (NIV) for Neonatal and Pediatric Patients During Transportation

Respiratory illnesses are a leading cause of death for children worldwide, with the majority of these cases occurring from preterm birth complications or acute respiratory infections. Appropriate respiratory intervention must be provided quickly to lower the chances of death or permanent harm. As a result, respiratory support given in prehospital and interfacility transport can substantially improve health outcomes for these patients, particularly in areas where transportation time to appropriate facilities is lengthy. Existing literature supports the use of non-invasive ventilation (NIV), such as nasal or bilevel continuous positive airway pressure, as a safe form of respiratory support for children under 18 years old in certain transportation settings. This mini review summarizes the literature on pediatric NIV in transport and highlights significant gaps that future researchers should address. In particular, we identify the need to: solidify clinical guidelines for the selection of eligible pediatric patients for transport on NIV; explore the range of factors influencing successful NIV implementation during transportation; and apply appropriate best practices in low and middle income countries.

Emergent Pneumonia in Children

In recent decades there have been multiple pathogens, viruses and bacteria, which have emerged as causal agents of pneumonia affecting adults, albeit less frequently, to children. For the purposes of this article we have classified emerging pathogens as follows: True emerging, to pathogens identified for the very first time affecting human population (SARS-CoV-1, SARS-CoV-2, MERS-CoV, avian influenza, and hantavirus); Re-emerging, to known pathogens which circulation was controlled once, but they have reappeared (measles, tuberculosis, antimicrobial resistant bacteria such as CA-MRSA, Mycoplasma pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, Stenotrophomonas maltophilia, and new serotypes of post-vaccine pneumococcal); and finally, those that we have called old known with new presentations, including common pathogens that, in particular condition, have changed their form of presentation (rhinovirus, and non-SARS coronavirus). We will review for each of them their epidemiology, forms of presentation, therapy, and prognosis in children compared to the adult with the aim of being able to recognize them to establish appropriate therapy, prognostics, and effective control measures.

Inhibition of Pneumolysin Cytotoxicity by Hydrolysable Tannins

Streptococcus pneumoniae causes invasive infections such as otitis media, pneumonia and meningitis. It produces the pneumolysin (Ply) toxin, which forms a pore onto the host cell membrane and has multiple functions in the pathogenesis of S. pneumoniae. The Ply C-terminal domain 4 mediates binding to membrane cholesterol and induces the formation of pores composed of up to 40 Ply monomers. Ply has a key role in the establishment of nasal colonization, pneumococcal transmission from host to host and pathogenicity. Altogether, 27 hydrolysable tannins were tested for Ply inhibition in a hemolysis assay and a tannin-protein precipitation assay. Pentagalloylglucose (PGG) and gemin A showed nanomolar inhibitory activity. Ply oligomerization on the erythrocyte surface was inhibited with PGG. PGG also inhibited Ply cytotoxicity to A549 human lung epithelial cells. Molecular modelling of Ply interaction with PGG suggests that it binds to the pocket formed by domains 2, 3 and 4. In this study, we reveal the structural features of hydrolysable tannins that are required for interaction with Ply. Monomeric hydrolysable tannins containing three to four flexible galloyl groups have the highest inhibitory power to Ply cytotoxicity and are followed by oligomers. Of the oligomers, macrocyclic and C-glycosidic structures were weaker in their inhibition than the glucopyranose-based oligomers. Accordingly, PGG-type monomers and oligomers might have therapeutic value in the targeting of S. pneumoniae infections.

Decoding capsule synthesis in Streptococcus pneumoniae

Streptococcus pneumoniae synthesizes more than one hundred types of capsular polysaccharides (CPS). While the diversity of the enzymes and transporters involved is enormous, it is not limitless. In this review, we summarized the recent progress on elucidating the structure-function relationships of CPS, the mechanisms by which they are synthesized, how their synthesis is regulated, the host immune response against them, and the development of novel pneumococcal vaccines. Based on the genetic and structural information available, we generated provisional models of the CPS repeating units that remain unsolved. In addition, to facilitate cross-species comparisons and assignment of glycosyltransferases, we illustrated the biosynthetic pathways of the known CPS in a standardized format. Studying the intricate steps of pneumococcal CPS assembly promises to provide novel insights for drug and vaccine development as well as improve our understanding of related pathways in other species.

Corrected and Republished from: A Nonfunctional Opsonic Antibody Response Frequently Occurs after Pneumococcal Pneumonia and Is Associated with Invasive Disease

Numerous reports on the dynamics of antipneumococcal immunity in relation to immunization with pneumococcal vaccines and on the prevalence of naturally acquired immunity in various populations have been published. In contrast, studies on the dynamics of the humoral immune response triggered by pneumococcal infection are scarce.

Naturally acquired opsonic antipneumococcal antibodies are commonly found in nonvaccinated adults and confer protection against infection and colonization. Despite this, only limited data exist regarding the adaptive immune response after pneumococcal exposure. To investigate the dynamics of naturally acquired antipneumococcal immunity in relation to an episode of infection, opsonic antibody activity was studied with paired acute-phase and convalescent-phase sera obtained from 54 patients with pneumococcal community-acquired pneumonia (CAP) using an opsonophagocytic assay (OPA). Results were compared with clinical characteristics and anticapsular immunoglobulin (Ig) concentrations. Interestingly, a nonfunctional opsonic antibody response (characterized by a decreased convalescent-phase serum OPA titer compared to that of the acute-phase serum or undetectable titers in both sera) was observed in 19 (35%) patients. The remaining individuals exhibited either an increased convalescent-phase OPA titer (n  =  24 [44%]) or a detectable, but unchanged, titer at both time points (n = 11 [20%]). Invasive pneumococcal disease (i.e., bacteremia) was significantly more common among patients with a nonfunctional convalescent-phase response than in patients with other convalescent-phase responses. Anticapsular Ig concentrations were higher among patients with detectable convalescent-phase OPA titers (P = 0.003), and the greatest Ig concentration increase was observed among patients with an increased convalescent-phase response (P = 0.002). Our findings indicate that an episode of pneumococcal infection may act as an immunizing event. However, in some cases when patients with CAP also suffer from bacteremia, a nonfunctional opsonic antibody response may occur. Furthermore, the results suggest that factors other than anticapsular Ig concentrations determine opsonic antibody activity in serum.

IMPORTANCE Numerous reports on the dynamics of antipneumococcal immunity in relation to immunization with pneumococcal vaccines and on the prevalence of naturally acquired immunity in various populations have been published. In contrast, studies on the dynamics of the humoral immune response triggered by pneumococcal infection are scarce. This study provides valuable information that will contribute to fill this knowledge gap. Our main results indicate that a functional immune response may fail after CAP, predominantly among patients with simultaneous bacteremia.

Which Current and Novel Diagnostic Avenues for Bacterial Respiratory Diseases?

Bacterial acute pneumonia is responsible for an extremely large burden of death worldwide and diagnosis is paramount in the management of patients. While multidrug-resistant bacteria is one of the biggest health threats in the coming decades, clinicians urgently need access to novel diagnostic technologies. In this review, we will first present the already existing and largely used techniques that allow identifying pathogen-associated pneumonia. Then, we will discuss the latest and most promising technological advances that are based on connected technologies (artificial intelligence-based and Omics-based) or rapid tests, to improve the management of lung infections caused by pathogenic bacteria. We also aim to highlight the mutual benefits of fundamental and clinical studies for a better understanding of lung infections and their more efficient diagnostic management.

Exploiting the pro-resolving actions of glucocorticoid-induced proteins Annexin A1 and GILZ in infectious diseases

For decades, glucocorticoids (GC) have been used to treat several inflammatory conditions, including chronic and autoimmune diseases, due to their potent anti-inflammatory properties. In the context of infectious diseases, the use of GCs may be effective as adjuvant to antibiotic therapy by controlling excessive inflammatory responses resulting in better outcome in some cases. However, the use of GCs has been associated with a vast number of side effects, including increased probability of immunosuppression and consequent risk of opportunistic infection. Glucocorticoid-induced leucine zipper (GILZ) and Annexin A1 (AnxA1) are GC-induced proteins intrinsically involved with the anti-inflammatory functions of GCs without the associated adverse metabolic effects. Recent studies have shown that these GC-proteins exhibit pro-resolving effects. An essential characteristic of pro-resolving molecules is their ability to coordinate the resolution of inflammation and promote host defense in most experimental models of infection. Although the role of GILZ and AnxA1 in the context of infectious diseases remain to be better explored, herein we provide an overview of the emerging functions of these GC-proteins obtained from pre-clinical models of infectious diseases.

Nasal high flow therapy introduction lowers reintubation risk in a Peruvian paediatric intensive care unit

AIM

We examined the impact of introducing high-flow nasal oxygen therapy (HFNT) on children under five with post-extubation respiratory failure in a paediatric intensive care unit (PICU) in Peru.

METHODS

This quasi-experimental study compared clinical outcomes before and after initial HFNT deployment in the PICU at Instituto Nacional de Salud del Niño in Lima in June 2016. We compared three groups: 29 received post-extubation HFNT and 17 received continuous positive airway pressure (CPAP) from 2016-17 and 12 historical controls received CPAP from 2012-16. The primary outcome was the need for mechanical ventilation. Adjusted hazard ratios (aHR) and 95% confidence intervals (95% CI) were calculated via survival analysis.

RESULTS

High-flow nasal oxygen therapy and CPAP did not alter the need for mechanical ventilation after extubation (aHR 0.47, 95% CI 0.15-1.48 and 0.96, 95% CI 0.35-2.62, respectively) but did reduce the risk of reintubation (aHR 0.18, 95% CI 0.06-0.57 and 0.14, 95% CI 0.03-0.72, respectively). PICU length of stay was 11, 18 and 37 days for CPAP, HFNT and historical CPAP and mortality was 12%, 7% and 27%, respectively. There was no effect on the duration of sedative infusions.

CONCLUSION

High-flow nasal oxygen therapy provided effective support for some children, but larger studies in resource-constrained settings are needed.

Reducing Aerosol-Related Risk of Transmission in the Era of COVID-19: An Interim Guidance Endorsed by the International Society of Aerosols in Medicine

National and international guidelines recommend droplet/airborne transmission and contact precautions for those caring for coronavirus disease 2019 (COVID-19) patients in ambulatory and acute care settings. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus, an acute respiratory infectious agent, is primarily transmitted between people through respiratory droplets and contact routes. A recognized key to transmission of COVID-19, and droplet infections generally, is the dispersion of bioaerosols from the patient. Increased risk of transmission has been associated with aerosol generating procedures that include endotracheal intubation, bronchoscopy, open suctioning, administration of nebulized treatment, manual ventilation before intubation, turning the patient to the prone position, disconnecting the patient from the ventilator, noninvasive positive-pressure ventilation, tracheostomy, and cardiopulmonary resuscitation. The knowledge that COVID-19 subjects can be asymptomatic and still shed virus, producing infectious droplets during breathing, suggests that health care workers (HCWs) should assume every patient is potentially infectious during this pandemic. Taking actions to reduce risk of transmission to HCWs is, therefore, a vital consideration for safe delivery of all medical aerosols. Guidelines for use of personal protective equipment (glove, gowns, masks, shield, and/or powered air purifying respiratory) during high-risk procedures are essential and should be considered for use with lower risk procedures such as administration of uncontaminated medical aerosols. Bioaerosols generated by infected patients are a major source of transmission for SARS CoV-2, and other infectious agents. In contrast, therapeutic aerosols do not add to the risk of disease transmission unless contaminated by patients or HCWs.

Pneumococcal carriage among children aged 4 - 12 years in Angola 4 years after the introduction of a pneumococcal conjugate vaccine

Children in Angola are affected by a high burden of disease caused by pneumococcal infections. The 13-valent pneumococcal conjugate vaccine (PCV13) was introduced in the childhood immunization programme in 2013 but the serotype distribution of Streptococcus pneumoniae and antimicrobial susceptibility patterns are unknown. We did a cross-sectional nasopharyngeal carriage study in Luanda and Saurimo, Angola (PCV13 3rd dose coverage 67% and 84%, respectively) during November to December 2017 comprising 940 children aged 4-12 years. The main objective was to assess vaccine serotype coverage and antimicrobial susceptibility rates for S. pneumoniae. Our secondary aim was to characterize colonizinig strains of Haemophilus influenzae and Moraxella catarrhalis. Pneumococcal colonization was found in 35% (95% CI 32-39%) of children (n = 332), with 41% of serotypes covered by PCV13. The most common serotypes were 3 (8%), 18C (6%), 23F (6%), 11A (6%), 34 (6%), 19F (5%) and 16 (5%). Carriage of H. influenzae and M. catarrhalis was detected in 13% (95% CI 11-15%) and 15% (95% CI 13-17%) of children, respectively. Non-susceptibility to penicillin was common among pneumococci (40%), particularly among PCV13-included serotypes (50% vs. 33%; p = 0.003), although the median minimal inhibitory concentration was low (0.19 µg/mL, IQR 0.13-0.25 µg/mL). Most pneumococci and H. influenzae were susceptible to amoxicillin (99% and 88%, respectively). Furthermore, resistance to trimethoprim-sulfamethoxazole was>70% among all three species. Multidrug-resistant pneumococci (non-susceptible to ≥ 3 antibiotics; 7% [n = 24]) were further studied with whole genome sequencing to investigate clonality as an underlying cause for this phenotype. No clearly dominating clone(s) were, however, detected. The results indicate that continued use of PCV13 may have positive direct and herd effects on pneumococcal infections in Angola as carriage of vaccine serotypes was common in the non-vaccinated age group. Finally, amoxicillin is assessed to be a feasible empirical treatment of respiratory tract infections in Angola.

Detection of Viruses by Multiplex Real-Time Polymerase Chain Reaction in Bronchoalveolar Lavage Fluid of Patients with Nonresponding Community-Acquired Pneumonia

Background

Nonresponding pneumonia is responsible for the most mortality of community-acquired pneumonia (CAP). However, thus far, it is not clear whether viral infection plays an important role in the etiology of nonresponding CAP and whether there is a significant difference in the clinical characteristics between viral and nonviral nonresponding CAP.

Methods

From 2016 to 2019, nonresponding CAP patients were retrospectively enrolled in our study. All patients received bronchoalveolar lavage (BAL) and virus detection in BAL fluid by multiplex real-time polymerase chain reaction (PCR), and clinical, laboratory, and radiographic data were collected.

Results

A total of 43 patients were included. The median age was 62 years, and 65.1% of patients were male. Overall, 20 patients (46.5%) were identified with viral infection. Of these viruses, influenza virus (n = 8) and adenovirus (n = 7) were more frequently detected, and others included herpes simplex virus, human enterovirus, cytomegalovirus, human coronavirus 229E, rhinovirus, and parainfluenza virus. Compared with nonviral nonresponding CAP, only ground-glass opacity combined with consolidation was a more common imaging manifestation in viral nonresponding CAP. However, no obvious differences were found in clinical and laboratory findings between the presence and the absence of viral infections.

Conclusions

Viral infections were particularly frequent in adults with nonresponding CAP. The ground-glass opacity combined with consolidation was a specific imaging manifestation for viral nonresponding CAP, while the clinical and laboratory data showed no obvious differences between viral and nonviral nonresponding CAP.

Capillary leakage provides nutrients and antioxidants for rapid pneumococcal proliferation in influenza-infected lower airways

Mechanisms for why influenza A virus (IAV) infections sensitize for pneumococcal infections are not clear. Here, we show that IAV-induced capillary leakage results in influx of nutrients and antioxidants to the lungs, thereby promoting pneumococcal growth in the lower respiratory tract. The evoked inflammation leads to redox imbalances that require bacterial adaptation to the oxidized environment, including induction of the pneumococcal chaperone/protease HtrA that protects the bacteria from clearance by the immune system. The results give us insight into the delicate interplay between the bacteria and the host environment during coinfections that needs to be explored in order to find novel therapeutic approaches.

Influenza A virus (IAV)-related mortality is often due to secondary bacterial infections, primarily by pneumococci. Here, we study how IAV-modulated changes in the lungs affect bacterial replication in the lower respiratory tract (LRT). Bronchoalveolar lavages (BALs) from coinfected mice showed rapid bacterial proliferation 4 to 6 h after pneumococcal challenge. Metabolomic and quantitative proteomic analyses demonstrated capillary leakage with efflux of nutrients and antioxidants into the alveolar space. Pneumococcal adaptation to IAV-induced inflammation and redox imbalance increased the expression of the pneumococcal chaperone/protease HtrA. Presence of HtrA resulted in bacterial growth advantage in the IAV-infected LRT and protection from complement-mediated opsonophagocytosis due to capsular production. Absence of HtrA led to growth arrest in vitro that was partially restored by antioxidants. Pneumococcal ability to grow in the IAV-infected LRT depends on the nutrient-rich milieu with increased levels of antioxidants such as ascorbic acid and its ability to adapt to and cope with oxidative damage and immune clearance.

Effect of ten-valent pneumococcal conjugate vaccine introduction on pneumonia hospital admissions in Fiji: a time-series analysis

BACKGROUND

In October, 2012, Fiji introduced routine infant immunisation with a ten-valent pneumococcal conjugate vaccine (PCV10) using three primary doses and no booster dose (3 + 0 schedule). Data are scarce for the effect of PCV in the Asia and Pacific region. We aimed to evaluate the effect of PCV10 on pneumonia hospital admissions in children younger than 5 years and adults aged 55 years and older in Fiji, 5 years after vaccine introduction.

METHODS

We did a time-series analysis assessing changes in pneumonia hospital admissions at three public tertiary hospitals in Fiji. Four pneumonia outcomes were evaluated: all-cause pneumonia, severe or very severe pneumonia, hypoxic pneumonia, and radiological pneumonia. Participants aged younger than 2 months, 2-23 months, 24-59 months, and 55 years and older were included. Data were extracted from the national hospital admission database according to International Classification of Diseases-tenth revision codes J10·0-18·9, J21, and J22 for all-cause pneumonia. Medical records and chest radiographs were reviewed for the main tertiary hospital to reclassify hospital admissions in children aged younger than 2 years as severe or very severe, hypoxic, or radiological pneumonia as per WHO definitions. Time-series analyses were done using the synthetic control method and multiple imputation to adjust for changes in hospital usage and missing data.

FINDINGS

Between Jan 1, 2007, and Dec 31, 2017, the ratio of observed cases to expected cases for all-cause pneumonia was 0·92 (95% CI 0·70-1·36) for children aged younger than 2 months, 0·86 (0·74-1·00) for children aged 2-23 months, 0·74 (0·62-0·87) for children aged 24-59 months, and 1·90 (1·53-2·31) in adults aged 55 years and older, 5 years after PCV10 introduction. These findings indicate a reduction in all-cause pneumonia among children aged 24-59 months and an increase in adults aged 55 years and older, but no change among children aged younger than 2 months. Among children aged 2-23 months, we observed declines of 21% (95% CI 5-35) for severe or very severe pneumonia, 46% (33-56) for hypoxic pneumonia, and 25% (9-38) for radiological pneumonia. Mortality reduced by 39% (95% CI 5-62) for all-cause pneumonia, bronchiolitis, and asthma admissions in children aged 2-23 months.

INTERPRETATION

The introduction of PCV10 was associated with a decrease in pneumonia hospital admissions in children aged 2-59 months. This is the first study in a middle-income country in the Asia and Pacific region to show the effect of PCV on pneumonia, filling gaps in the literature on the effects of PCV10 and 3 + 0 schedules. These data support decision making on PCV introduction for other low-income and middle-income countries in the region.

FUNDING

Department of Foreign Affairs and Trade of the Australian Government.

A hierarchical model for estimating the exposure-response curve by combining multiple studies of acute lower respiratory infections in children and household fine particulate matter air pollution

Adverse health effects of household air pollution, including acute lower respiratory infections (ALRIs), pose a major health burden around the world, particularly in settings where indoor combustion stoves are used for cooking. Individual studies have limited exposure ranges and sample sizes, while pooling studies together can improve statistical power.

Methods

We present hierarchical models for estimating long-term exposure concentrations and estimating a common exposure-response curve. The exposure concentration model combines temporally sparse, clustered longitudinal observations to estimate household-specific long-term average concentrations. The exposure-response model provides a flexible, semiparametric estimate of the exposure-response relationship while accommodating heterogeneous clustered data from multiple studies. We apply these models to three studies of fine particulate matter (PM_2.5) and ALRIs in children in Nepal: a case-control study in Bhaktapur, a stepped-wedge trial in Sarlahi, and a parallel trial in Sarlahi. For each study, we estimate household-level long-term PM_2.5 concentrations. We apply the exposure-response model separately to each study and jointly to the pooled data.

Results

The estimated long-term PM_2.5 concentrations were lower for households using electric and gas fuel sources compared with households using biomass fuel. The exposure-response curve shows an estimated ALRI odds ratio of 3.39 (95% credible interval = 1.89, 6.10) comparing PM_2.5 concentrations of 50 and 150 μg/m³ and a flattening of the curve for higher concentrations.

Conclusions

These flexible models can accommodate additional studies and be applied to other exposures and outcomes. The studies from Nepal provides evidence of a nonlinear exposure-response curve that flattens at higher concentrations.

Respiratory Syncytial Virus Infection: Its Propensity for Bacterial Coinfection and Related Mortality in Elderly Adults

Respiratory syncytial virus (RSV) is an increasingly recognized cause of acute respiratory infection (ARI) in adults. We compared the crude in-hospital mortality of patients with RSV infection alone with that of patients with RSV-bacterial coinfection. Overall, 12144 hospitalized patients with ARI were screened for RSV detection by polymerase chain reaction between February 2014 and April 2019. In total, 701 (5.8%) had a positive RSV result, including 85 (12.1%) with bacterial coinfection. RSV-bacterial coinfection was associated with an increase in crude in-hospital mortality in patients >65 years old (hazard ratio, 2.94; 95% CI, 1.30-6.60; P = .010). Optimized prevention and management strategies to reduce this burden are needed.

Apolipoprotein M inhibits proliferation and migration of larynx carcinoma cells

Prior studies have shown that apolipoprotein M (APOM) is involved in the development of some cancers. Here we investigated the effects of APOM on larynx cancer (LC). 20 patients with vocal cord polyps and 18 patients with LC were included in this study. The protein and mRNA levels of the samples were analysed using the Wes-ProteinSimple system (or traditional Western blot) and PCR technology, respectively. APOM protein level in cancer tissues was lower than that in paracarcinomatous (P = 0.0003) and polyp tissues (P < 0.0001). APOM overexpression significantly inhibited TU686 cell proliferation (P < 0.0001) and migration (P < 0.01), and increased expression of vitamin D receptor (VDR, P < 0.0001) as well as nuclear factor erythroid 2-like 3 (NFE2L3, P = 0.0215). In addition, matrix metalloproteinase-10 (MMP-10) mRNA level was significantly reduced in the APOM overexpression group (P = 0.0077). However, Western blot analysis showed that APOM overexpression did not change VDR, NFE2L3 and MMP-10 protein levels (P > 0.05). In summary, APOM inhibits the proliferation and migration of LC cells, but may not be related to VDR, NFE2L3 and MMP-10, which needs further study.

Demographic and socioeconomic patterns in healthcare-seeking behaviour for respiratory symptoms in England: a comparison with non-respiratory symptoms and between three healthcare services

OBJECTIVE

This study will analyse respiratory contacts to three healthcare services that capture more of the community disease burden than acute data sources, such as hospitalisations. The objective is to explore associations between contacts to these services and the patient's age, gender and deprivation. Results will be compared between healthcare services, and with non-respiratory contacts to explore how contacts differ by service and illness. It is crucial to investigate the sociodemographic patterns in healthcare-seeking behaviour to enable targeted public health interventions.

DESIGN

Ecological study.

SETTING

Surveillance of respiratory contacts to three healthcare services in England: telehealth helpline (NHS111); general practitioner in-hours (GPIH); and general practitioner out of hours unscheduled care (GPOOH).

PARTICIPANTS

13 million respiratory contacts to NHS111, GPIH and GPOOH.

OUTCOME MEASURES

Respiratory contacts to NHS111, GPIH and GPOOH, and non-respiratory contacts to NHS111 and GPOOH.

RESULTS

More respiratory contacts were observed for females, with 1.59, 1.73, and 1.95 times the rate of contacts to NHS111, GPOOH and GPIH, respectively. When compared with 15-44 year olds, there were 37.32, 18.66 and 6.21 times the rate of respiratory contacts to NHS111, GPOOH and GPIH in children <1 year. There were 1.75 and 2.70 times the rate of respiratory contacts in the most deprived areas compared with the least deprived to NHS111 and GPOOH. Elevated respiratory contacts were observed for males <5 years compared with females <5 years. Healthcare-seeking behaviours between respiratory and non-respiratory contacts were similar.

CONCLUSION

When contacts to services that capture more of the disease burden are explored, the demographic patterns are similar to those described in the literature for acute systems. Comparable results were observed between respiratory and non-respiratory contacts suggesting that when a wider spectrum of disease is explored, sociodemographic factors may be the strongest influencers of healthcare-seeking behaviour.

Using geo-spatial analysis for assessing the risk of hospital admissions due to community-acquired pneumonia in under-5 children and its association with socially vulnerable areas (Brazil)

Background

The concentration of under-5 child morbidity and mortality due to pneumonia in developing countries reflects the social inequities. This study aimed to map and assess the spatial risk for hospitalization due to Community-Acquired Pneumonia in children under 5 years of age and its association with vulnerable areas.

Methods

Ecological study in the city of Ribeirão Preto, state of São Paulo, Brazil. The study population consisted of hospitalized under-5 children, diagnosed with community-acquired pneumonia, in Ribeirão Preto-São Paulo-Brazil, from 2012 to 2013. Data were collected in different databases, by a trained team, between March 2012 and August 2013 and from the 2010 Demographic Census of the Brazilian Institute of Geography and Statistics. The 956 urban census tracts were considered as the units of analysis. The incidence of cases per 10,000 inhabitants was calculated by census tracts during the study period. For the identification of the spatial risk clusters, the Kernel density estimator and the Getis-Ord Gi* technique were performed. Generalized additive models were used to verify the association between areas with social vulnerability and the occurrence of childhood pneumonia.

Results

The study included 265 children under the age of five, hospitalized due to community-acquired pneumonia. A concentration of cases was identified in the regions with greater social vulnerability (low income, poor housing conditions and homelessness), as well as a lower occurrence of cases in the most developed and economically privileged area of the city. The majority of the children lived in territories served by traditional primary healthcare units, in which the health surveillance and family and community focus are limited. It is important to highlight that the tracts with the highest degrees of vulnerability, such as those identified as high vulnerability (urban) and very high vulnerability (subnormal urban clusters).

Conclusions

The results contribute to the comprehension of the social factors involved in child hospitalization due to pneumonia, based on the analysis of the spatial distribution. This approach revealed a strategic tool for diagnosing the disparities as well presenting evidences for the planning in health and strength health care system in achieving equity, welfare and social protection of children.

Supplementary Information

Supplementary information accompanies this paper at 10.1186/s12887-020-02398-x.

Risk factors for atopic diseases and recurrent respiratory tract infections in children

INTRODUCTION

The simultaneously increased prevalence of atopic diseases and decreased prevalence of infectious diseases might point to a link between the two entities. Past work mainly focused on either atopic diseases or recurrent infections. We aim to investigate whether risk factors for atopic diseases (ie, asthma, allergic rhinitis, atopic dermatitis, and/or food allergy) differ from risk factors for recurrent respiratory tract infections (RRTIs) in children.

METHODS

Cross-sectional data were used from 5517 children aged 1 to 18 years who participated in an Electronic Portal for children between 2011 and 2019. Univariable/multivariable logistic regression analyses were performed to determine risk factors for any atopic disease and RRTIs.

RESULTS

Children aged ≥5 years were more likely to have any atopic disease (adjusted odds ratio [OR]: 1.50-2.77) and less likely to have RRTIs (OR: 0.68-0.84) compared to children aged less than 5 years. Female sex (OR: 0.72; 95% confidence interval [CI]: 0.63-0.81), low birth weight (OR: 0.74; 95% CI: 0.57-0.97) and dog ownership (OR: 0.79; 95% CI: 0.66-0.95) reduced the odds of any atopic disease, but not of RRTIs. Daycare attendance (OR: 1.22; 95% CI: 1.02-1.47) was associated with RRTIs, but not with atopic diseases. A family history of asthma, allergic rhinitis, atopic dermatitis, and RRTIs was significantly associated with the same entity in children, with OR varying from 1.58 (95% CI: 1.35-1.85) in allergic rhinitis to 2.20 (95% CI: 1.85-2.61) in asthma.

CONCLUSION

Risk factors for atopic diseases are distinct from risk factors for RRTIs, suggesting that the changing prevalence of both entities is not related to shared risk factors.

Respiratory viral coinfection in a birth cohort of infants in rural Nepal

BACKGROUND

Acute respiratory illnesses are a leading cause of global morbidity and mortality in children. Coinfection with multiple respiratory viruses is common. Although the effects of each virus have been studied individually, the impacts of coinfection on disease severity are less understood.

METHODS

A secondary analysis was performed of a maternal influenza vaccine trial conducted between 2011 and 2014 in Nepal. Prospective weekly household-based active surveillance of infants was conducted from birth to 180 days of age. Mid-nasal swabs were collected and tested for respiratory syncytial virus (RSV), rhinovirus, influenza, human metapneumovirus (HMPV), coronavirus, parainfluenza (HPIV), and bocavirus by RT-PCR. Coinfection was defined as the presence of two or more respiratory viruses detected as part of the same illness episode.

RESULTS

Of 1730 infants with a respiratory illness, 327 (19%) had at least two respiratory viruses detected in their primary illness episode. Of 113 infants with influenza, 23 (20%) had coinfection. Of 214 infants with RSV, 87 (41%) had coinfection. The cohort of infants with coinfection had increased occurrence of fever lasting ≥ 4 days (OR 1.4, 95% CI: 1.1, 2.0), and so did the subset of coinfected infants with influenza (OR 5.8, 95% CI: 1.8, 18.7). Coinfection was not associated with seeking further care (OR 1.1, 95% CI: 0.8, 1.5) or pneumonia (OR 1.2, 95% CI: 0.96, 1.6).

CONCLUSION

A high proportion of infants had multiple viruses detected. Coinfection was associated with greater odds of fever lasting for four or more days, but not with increased illness severity by other measures.

Use of Pneumococcal and influenza vaccine in patients with COPD, asthma bronchiale and interstitial lung diseases in south east Germany

INTRODUCTION

The aim of this study was to analyse use of and adherence to influenza and pneumococcal vaccination in high-risk patients with chronic pulmonary disease.

METHODS

The study was initiated at the Centre of Pneumology in Donaustauf, Germany. All patients with asthma bronchiale (AB), chronic obstructive pulmonary disease (COPD) and interstitial lung disease (ILD) that were treated in a pneumological Non-ICU ward, in the sleep laboratory or in the outpatient's clinic between October 1st^, 2019 and March 26th^, 2020 and provided informed consent were included. Vaccination certificates and a vaccination-centred questionnaire were analysed in relation to vaccination status, risk factors, patient characteristics.

RESULTS

133 patients with COPD, 68 patients with AB and 104 patients with ILD were included. PCV13/PPSV23 vaccination only (no sequential vaccination) was performed in less than 10%/33% of all patients. Sequential vaccination of PCV13 and PPSV23 was performed in 12.8% of COPD, 7.4% of AB patients and 13.5% of ILD patients. Influenza vaccination was performed in less than 30% of all patients. Vaccinations were mainly performed by general practitioners (GPs) and rarely by specialists of pulmonary care (<6%). 67% of all patients were seen by a specialist in pulmonary care in the last 36 months, but in less than 15% the vaccination status was evaluated.

DISCUSSION

Use of and adherence for PPSV23 and influenza vaccinations is low in patients with COPD, AB and ILD in south east Germany.

State-of-the-art polymeric nanoparticles as promising therapeutic tools against human bacterial infections

Infectious diseases kill over 17 million people a year, among which bacterial infections stand out. From all the bacterial infections, tuberculosis, diarrhoea, meningitis, pneumonia, sexual transmission diseases and nosocomial infections are the most severe bacterial infections, which affect millions of people worldwide. Moreover, the indiscriminate use of antibiotic drugs in the last decades has triggered an increasing multiple resistance towards these drugs, which represent a serious global socioeconomic and public health risk. It is estimated that 33,000 and 35,000 people die yearly in Europe and the United States, respectively, as a direct result of antimicrobial resistance. For all these reasons, there is an emerging need to find novel alternatives to overcome these issues and reduced the morbidity and mortality associated to bacterial infectious diseases. In that sense, nanotechnological approaches, especially smart polymeric nanoparticles, has wrought a revolution in this field, providing an innovative therapeutic alternative able to improve the limitations encountered in available treatments and capable to be effective by theirselves. In this review, we examine the current status of most dangerous human infections, together with an in-depth discussion of the role of nanomedicine to overcome the current disadvantages, and specifically the most recent and innovative studies involving polymeric nanoparticles against most common bacterial infections of the human body.

The pneumococcal social network

Gram-positive bacteria employ an array of secreted peptides to control population-level behaviors in response to environmental cues. We review mechanistic and functional features of secreted peptides produced by the human pathogen Streptococcus pneumoniae. We discuss sequence features, mechanisms of transport, and receptors for 3 major categories of small peptides: the double-glycine peptides, the Rap, Rgg, NprR, PlcR, and PrgX (RRNPP)-binding peptides, and the lanthionine-containing peptides. We highlight the impact of factors that contribute to carriage and pathogenesis, specifically genetic diversity, microbial competition, biofilm development, and environmental adaptation. A recent expansion in pneumococcal peptide studies reveals a complex network of interacting signaling systems where multiple peptides are integrated into the same signaling pathway, allowing multiple points of entry into the pathway and extending information content in new directions. In addition, since peptides are present in the extracellular milieu, there are opportunities for crosstalk, quorum sensing (QS), as well as intra- and interstrain and species interactions. Knowledge on the manner that population-level behaviors contribute to disease provides an avenue for the design and development of anti-infective strategies.