Trends in lower respiratory tract infection hospitalizations among American Indian/Alaska Native children and the general US child population

"You can feel the fresh air … " Rural Alaska Native household perceptions of home air purifiers and health

Alaska Native and American Indian children experience frequent respiratory illness. Indoor air quality is associated with the severity and frequency of respiratory infections in children. High efficiency particulate air (HEPA) purifiers effectively improve indoor air quality and may protect respiratory health. In 2019, the Yukon-Kuskokwim Health Corporation implemented a pilot programme that provided education and HEPA purifiers to households of children with chronic lung conditions. The team evaluated HEPA purifier acceptability and use by interviewing representatives from 11 households that participated in the pilot programme. All interviewees reported improvement in their child's health, and some believed that the health of other household members was also improved because of the HEPA purifier. Interviewees reported that the HEPA purifiers were easy to use, quiet, and not expensive to run. Five of 11 households were still using the HEPA purifier at the time of the interview, which was about three years after receipt of the unit. The most common reasons for discontinuing use were equipment failure and lack of replacement filter, suggesting that programme support could increase sustainability. Our evaluation suggests that HEPA purifiers are acceptable and feasible for use in rural Alaska Native households.

Social determinants of respiratory health from birth: still of concern in the 21st century?

Respiratory symptoms are ubiquitous in children and, even though they may be the harbinger of poor long-term outcomes, are often trivialised. Adverse exposures pre-conception, antenatally and in early childhood have lifetime impacts on respiratory health. For the most part, lung function tracks from the pre-school years at least into late middle age, and airflow obstruction is associated not merely with poor respiratory outcomes but also early all-cause morbidity and mortality. Much would be preventable if social determinants of adverse outcomes were to be addressed. This review presents the perspectives of paediatricians from many different contexts, both high and low income, including Europe, the Americas, Australasia, India, Africa and China. It should be noted that there are islands of poverty within even the highest income settings and, conversely, opulent areas in even the most deprived countries. The heaviest burden of any adverse effects falls on those of the lowest socioeconomic status. Themes include passive exposure to tobacco smoke and indoor and outdoor pollution, across the entire developmental course, and lack of access even to simple affordable medications, let alone the new biologicals. Commonly, disease outcomes are worse in resource-poor areas. Both within and between countries there are avoidable gross disparities in outcomes. Climate change is also bearing down hardest on the poorest children. This review highlights the need for vigorous advocacy for children to improve lifelong health. It also highlights that there are ongoing culturally sensitive interventions to address social determinants of disease which are already benefiting children.

Population-based birth cohort study on diabetes in pregnancy and infant hospitalisations in Cree, other First Nations and non-Indigenous communities in Quebec

OBJECTIVES

Diabetes in pregnancy, whether pre-gestational (chronic) or gestational (de novo hyperglycaemia), increases the risk of adverse birth outcomes. It is unclear whether gestational diabetes increases the risk of postnatal morbidity in infants. Cree First Nations in Quebec are at high risk for diabetes in pregnancy. We assessed whether pre-gestational or gestational diabetes may increase infant hospitalisation (an infant morbidity indicator) incidence, and whether this may be related to more frequent infant hospitalisations in Cree and other First Nations in Quebec.

DESIGN

Population-based birth cohort study through administrative health data linkage.

SETTING AND PARTICIPANTS

Singleton infants (≤1 year) born to mothers in Cree (n=5070), other First Nations (9910) and non-Indigenous (48 200) communities in rural Quebec.

RESULTS

Both diabetes in pregnancy and infant hospitalisation rates were much higher comparing Cree (23.7% and 29.0%) and other First Nations (12.4% and 34.1%) to non-Indigenous (5.9% and 15.5%) communities. Compared with non-diabetes, pre-gestational diabetes was associated with an increased risk of any infant hospitalisation to a greater extent in Cree and other First Nations (relative risk (RR) 1.56 (95% CI 1.28 to 1.91)) than non-Indigenous (RR 1.26 (1.15 to 1.39)) communities. Pre-gestational diabetes was associated with increased risks of infant hospitalisation due to diseases of multiple systems in all communities. There were no significant associations between gestational diabetes and risks of infant hospitalisation in all communities. The population attributable risk fraction of infant hospitalisations (overall) for pre-gestational diabetes was 6.2% in Cree, 1.6% in other First Nations and 0.3% in non-Indigenous communities.

CONCLUSIONS

The study is the first to demonstrate that pre-gestational diabetes increases the risk of infant hospitalisation overall and due to diseases of multiple systems, but gestational diabetes does not. High prevalence of pre-gestational diabetes may partly account for the excess infant hospitalisations in Cree and other First Nations communities in Quebec.

Impact of health disparity on pediatric infections

PURPOSE OF REVIEW

The COVID-19 pandemic highlighted the health disparities among minoritized children due to structural racism and socioeconomic inequalities. This review discusses how health disparities affect pediatric infections and how they can be addressed.

RECENT FINDINGS

In addition to disparities in healthcare access due to poverty, geography, and English-language proficiency, implicit and explicit bias affects the healthcare quality and subsequent outcomes in children and adolescents with infections. Disparities in clinical trial enrollment affect the generalizability of research findings. Physicians who understand their patients' languages and the contexts of culture and socioeconomic conditions are better equipped to address the needs of specific populations and the health disparities among them.

SUMMARY

Addressing disparities in pediatric infections requires prioritization of efforts to increase physician workforce diversity in Pediatric Infectious Diseases, as well as education in bias reduction and culturally sensitive clinical practice, in addition to socioeconomic interventions that improve healthcare access, delivery, and outcomes.

Structural and Social Determinants of Inequitable Environmental Exposures in the United States

American Indian (AI)/Alaskan Natives, African Americans, and Latino Americans have disproportionally high exposure to harmful environmental conditions as a consequence of unjust laws and policies, systemic racism, residential segregation, and discrimination. In this review, we draw connections between historical policies and social movements in the United States' history that have been rooted in racism and classism, leading to social isolation and marginalization of AIs, African Americans, and Latino Americans. We then discuss the structural factors that stem from the aforementioned inequities and that contribute to the inequitable distribution of environmental hazards.

Evaluation of indoor PM2.5 concentrations in a Native American Community: a pilot study

BACKGROUND

Indoor air pollution is associated with adverse health effects; however, few studies exist studying indoor air pollution on the Navajo Nation in the southwest U.S., a community with high rates of respiratory disease.

METHODS

Indoor PM_2.5 concentration was evaluated in 26 homes on the Navajo Nation using real-time PM_2.5 monitors. Household risk factors and daily activities were evaluated with three metrics of indoor PM_2.5: time-weighted average (TWA), 90th percentile of concentration, and daily minutes exceeding 100 μg/m³. A questionnaire and recall sheet were used to record baseline household characteristics and daily activities.

RESULTS

The median TWA, 90th percentile, and daily minutes exceeding 100 μg/m³ were 7.9 μg/m³, 14.0 μg/m³_, and 17 min, respectively. TWAs tended to be higher in autumn and in houses that used fuel the previous day. Other characteristics associated with elevated PM exposure in all metrics included overcrowded houses, nonmobile houses, and houses with current smokers, pets, and longer cooking time.

CONCLUSIONS

Some residents of the Navajo Nation have higher risk of exposure to indoor air pollution by Environmental Protection Agency (EPA) standards. Efforts to identify the causes and associations with adverse health effects are needed to ensure that exposure to risks and possible health impacts are mitigated.

Disparities in Outcomes During Lower Respiratory Tract Infection in American Indian Children: A 9-Year Retrospective Analysis in a Rural Population in South Dakota

BACKGROUND

American Indian (AI) children are at increased risk for severe disease during lower respiratory tract infection (LRTI). The reasons for this increased severity are poorly understood. The objective of this study was to define the clinical presentations of LRTI and highlight the differences between AI and non-AI previously healthy patients under the age of 24 months.

METHODS

We performed a retrospective chart review between October 2010 and December 2019. We reviewed 1245 patient charts and 691 children met inclusion criteria for this study. Data records included demographics, clinical, laboratory data, and illness outcomes.

RESULTS

Of 691 patients, 120 were AI and 571 were non-AI. There was a significant difference in breast-feeding history (10% of AI vs. 28% of non-AI, P < 0.0001) and in secondhand smoke exposure (37% of AI vs. 21% of non-AI, P < 0.0001). AI children had increased length of hospitalization compared with non-AI children (median of 3 vs. 2 days, P < 0.001). In addition, AI children had higher rates of pediatric intensive unit admission (30%, n = 37) compared with non-AI children (11%; n = 67, P < 0.01). AI children also had higher rates (62.5%, n = 75) and duration of oxygen supplementation (median 3 days) than non-AI children (48%, n = 274, P = 0.004; median 2 days, P = 0.0002). On a multivariate analysis, AI race was an independent predictor of severe disease during LRTI.

CONCLUSIONS

AI children have increased disease severity during LRTI with longer duration of hospitalization and oxygen supplementation, a higher rate of oxygen requirement and Powered by Editorial Manager and ProduXion Manager from Aries Systems Corporation pediatric intensive care unit admissions, and a greater need for mechanical ventilation. These results emphasize the need for improvement in health policies and access to health care in this vulnerable population.

Is viral coinfection a risk factor for severe lower respiratory tract infection? A retrospective observational study

OBJECTIVE

To determine whether viral coinfection is a risk for severe lower respiratory tract infection (LRTI).

WORKING HYPOTHESIS

Children with viral coinfection had a higher risk for admission to the intensive care unit (ICU) than those with a single virus infection.

STUDY DESIGN

Retrospective, observational study for 10 years.

PATIENT-SUBJECT SELECTION

Children between 1 and 60 months of age hospitalized with LRTI.

Racial/Ethnic Disparities in the Incidences of Bronchiolitis Requiring Hospitalization

BACKGROUND

Race/ethnicity is currently not considered a risk factor for bronchiolitis, except for indigenous populations in Western countries. A better understanding of the potential impact of race/ethnicity can inform programs, policies, and practices related to bronchiolitis.

METHODS

We performed a population-based, longitudinal, observational study using the State Inpatient Database from New York State in the United States. Infants born between 2009 and 2013 at term without comorbidities were followed for the first 2 years of life, up to 2015. We calculated the cumulative incidences among different race/ethnicity groups, and evaluated the risks by developing logistic regression models.

RESULTS

Of 877 465 healthy, term infants, 10 356 infants were hospitalized with bronchiolitis. The overall cumulative incidence was 11.8 per 1000 births. The cumulative incidences in non-Hispanic White, non-Hispanic Black, Hispanic, and Asian infants were 8.6, 15.4, 19.1, and 6.5 per 1000 births, respectively. In a multivariable analysis adjusting for socioeconomic status, the risks remained substantially high among non-Hispanic Black (odds ratio, 1.42; 95% confidence interval [CI], 1.34-1.51) and Hispanic infants (odds ratio, 1.77; 95% CI, 1.67-1.87), whereas being of Asian race was protective (odds ratio, .62; 95% CI, .56-.69).

CONCLUSIONS

The risks of bronchiolitis hospitalization in the first 2 years of life were substantially different by race/ethnicity, with Hispanic and Black infants having the highest rates of hospitalization. Further research is needed to develop and implement culturally appropriate public health interventions to reduce racial and ethnic health disparities in bronchiolitis.

Environmental Health Consults in Children Hospitalized with Respiratory Infections

Indoor air pollutants contribute to respiratory infections and asthma exacerbations in children. Rural Alaska Native children experience some of the highest U.S. rates of respiratory hospitalizations, which are associated with lack of in-home running water, household crowding, and woodstove use. In our previous study, in-home education and modifications reduced respiratory symptoms, and medical visits. In this study, we evaluated the feasibility of providing in-hospital environmental health consults for parents/guardians of children < 5 years old hospitalized at the Alaska Native Medical Center with respiratory infections or asthma. Environmental health specialists conducted 92 in-hospital consults and mailed Healthy Homes Toolkits to households. Local housing authorities completed low-cost home modifications in 47 eligible households. Participants reported changes in household behaviors that were specifically addressed in the consult or included in the Toolkit (e.g. allergen-impermeable pillow covers). Reported respiratory symptoms were decreased at the 6-month follow-up. Over a 2 year period the median overall medical costs for respiratory illness in study children were $70,500. Children with in-home piped water had half the daily overall medical costs than children without in-home piped water ($74 compared to $144). In this study, we demonstrate that it is feasible to provide environmental consults, mail Toolkits, and arrange home modifications to the homes of children hospitalized with respiratory illness. These findings, along with the high costs of medical care for these children, suggest in-hospital environmental health consults are a cost-effective intervention.

Feasibility of a Low-Fidelity Pediatric Simulation-Based Continuing Education Curriculum in Rural Alaska

Introduction

Simulation-based continuing education (SBCE) is a widely used tool to improve healthcare workforce performance. Healthcare providers working in geographically remote and resource-limited settings face many challenges, including the development and application of SBCE. Here, we describe the development, trial, and evaluation of an SBCE curriculum in an Alaska Native healthcare system with the aim to understand SBCE feasibility and specific limitations.

Methods

The perceived feasibility and efficacy of incorporating a low-fidelity medical simulation curriculum into this Native Alaskan healthcare system was evaluated by analyzing semi-structured interviews, focus groups, and surveys over a 15-month period (August 2018 - October 2019). Subjects were identified via both convenience and purposive sampling. Included were 40 healthcare workers who participated in the simulation curriculum, three local educators who were trained in and subsequently facilitated simulations, and seven institutional leaders identified as “key informants.” Data included surveys with the Likert scale and dichotomous positive or negative data, as well as a thematic analysis of the qualitative portion of participant survey responses, focus group interviews of educators, and semi-structured interviews of key informants. Based on these data, feasibility was assessed in four domains: acceptability, demand, practicality, and implementation.

Results

Stakeholders and participants had positive buy-in for SBCE, recognizing the potential to improve provider confidence, standardize medical care, and improve teamwork and communication, all factors identified to optimize patient safety. The strengths listed support feasibility in terms of acceptability and demand. A number of challenges in the realms of practicality and implementation were identified, including institutional buy-in, need for a program champion in a setting of staff high turnover, and practicalities of scheduling and accessing participants working in one system across a vast and remote geographic region. Participants perceived the simulations to be effective and feasible.

Conclusion

While simulation participants valued an SBCE program, institutional leaders and educators identified veritable obstacles to the practical implementation of a structured program. Given the inherent challenges of this setting, a traditional simulation curriculum is unlikely to be fully feasibly integrated. However, due to the overall demand and social acceptability expressed by the participants, innovative ways to deliver simulation should be developed, trialed, and evaluated in the future.

Molecular epidemiology of respiratory viruses among Malaysian Young children with a confirmed respiratory infection during 2014-2015

BACKGROUND

In many developing countries, acute respiratory tract infections (ARTIs) are the main cause of morbidity and mortality among young children. This study aims to evaluate the molecular epidemiology of respiratory viruses among Malaysian children with confirmed respiratory infections between July 2014 and July 2015.

METHODS

A total of 394 nasopharyngeal swabs were collected prospectively from children age 0-5 years old with ARTIs from hospitals in Kuala Lumpur. Respiratory viral panel (RVP) assay was used to identify the viral aetiology of respiratory infections.

RESULTS

From a total of 394 samples, the positive detection rate was 79.9% (n=315). A total of 15 types of RNA viruses and a single type of DNA virus were detected. Enterovirus/rhinovirus (n=112, 28.4%), respiratory syncytial virus (RSV) (n=85, 21.6%), adenovirus (n=64, 16.2%), human bocavirus (n=34, 8.6%), and human metapneumovirus (n=29, 7.4%) were the five predominant viruses. Enterovirus/rhinovirus and RSV constituted most of the viral respiratory infections among young children, especially among children less than 1 year old. No coronavirus was detected among children between 3 and 5 years old. Co-infection caused by 2 or 3 respiratory viruses were detected in 52 patients (13.2%). Enterovirus/rhinovirus, adenovirus, and human bocavirus demonstrated pronounced seasonality. The infection rate peaked during mid-year, while the lowest activity occurred during early of the year.

CONCLUSIONS

The use of molecular assay as a routine diagnostic in the hospitals can improve the diagnosis and management of respiratory tract infections among children.

In search of Pan-American indigenous health and harmony

The objective of this article is to describe the state of North, Central, South American and Caribbean (Pan-American) indigenous health. The second objective is to identify recommendations for optimal healthcare and research strategies to achieve indigenous health equity. Current health disparities continue to present between indigenous populations and general populations. Research foci of Pan-American indigenous health center on health outcomes for chronic and acute disease as well as presence of indigenous in data sets. Research is both qualitative and quantitative. Recommendations to improve indigenous health in effort of health equity are variable yet feasible. Stronger epidemiology, continued cohesive Pan-American global strategies, better research alignment with emphasis to quality and comprehensive metric analyses in healthcare delivery are all avenues to improve the health of the indigenous. Research and healthcare delivery on the Pan-American indigenous must be maximized for optimal results, must be representative of the indigenous communities, must be implemented in best practice and must introduce sustainable healthcare delivery for Pan-American indigenous health equity.

The global burden of respiratory infections in indigenous children and adults: A review

This review article focuses on common lower respiratory infections (LRIs) in indigenous populations in both developed and developing countries, where data is available. Indigenous populations across the world share some commonalities including poorer health and socio-economic disadvantage compared with their non-indigenous counterparts. Generally, acute and chronic respiratory infections are more frequent and more severe in both indigenous children and adults, often resulting in substantial consequences including higher rates of bronchiectasis and poorer outcomes for patients with chronic obstructive pulmonary disease (COPD). Risk factors for the development of respiratory infections require recognition and action. These risk factors include but are not limited to socio-economic factors (e.g. education, household crowding and nutrition), environmental factors (e.g. smoke exposure and poor access to health care) and biological factors. Risk mitigation strategies should be delivered in a culturally appropriate manner and targeted to educate both individuals and communities at risk. Improving the morbidity and mortality of respiratory infections in indigenous people requires provision of best practice care and awareness of the scope of the problem by healthcare practitioners, governing bodies and policy makers.

Disparities in infant hospitalizations in Indigenous and non-Indigenous populations in Quebec, Canada

BACKGROUND

Infant mortality is higher in Indigenous than non-Indigenous populations, but comparable data on infant morbidity are lacking in Canada. We evaluated disparities in infant morbidities experienced by Indigenous populations in Canada.

METHODS

We used linked population-based birth and health administrative data from Quebec, Canada, to compare hospitalization rates, an indicator of severe morbidity, in First Nations, Inuit and non-Indigenous singleton infants (< 1 year) born between 1996 and 2010.

RESULTS

Our cohort included 19 770 First Nations, 3930 Inuit and 225 380 non-Indigenous infants. Compared with non-Indigenous infants, all-cause hospitalization rates were higher in First Nations infants (unadjusted risk ratio [RR] 2.05, 95% confidence interval [CI] 1.99-2.11; fully adjusted RR 1.43, 95% CI 1.37-1.50) and in Inuit infants (unadjusted RR 1.96, 95% CI 1.87-2.05; fully adjusted RR 1.37, 95% CI 1.24-1.52). Higher risks of hospitalization (accounting for multiple comparisons) were observed for First Nations infants in 12 of 16 disease categories and for Inuit infants in 7 of 16 disease categories. Maternal characteristics (age, education, marital status, parity, rural residence and Northern residence) partly explained the risk elevations, but maternal chronic illnesses and gestational complications had negligible influence overall. Acute bronchiolitis (risk difference v. non-Indigenous infants, First Nations 37.0 per 1000, Inuit 39.6 per 1000) and pneumonia (risk difference v. non-Indigenous infants, First Nations 41.2 per 1000, Inuit 61.3 per 1000) were the 2 leading causes of excess hospitalizations in Indigenous infants.

INTERPRETATION

First Nations and Inuit infants had substantially elevated burdens of hospitalizations as a result of diseases of multiple systems. The findings identify substantial unmet needs in disease prevention and medical care for Indigenous infants.

Housing characteristics and indoor air quality in households of Alaska Native children with chronic lung conditions

Alaska Native children experience high rates of respiratory infections and conditions. Household crowding, indoor smoke, lack of piped water, and poverty have been associated with respiratory infections. We describe the baseline household characteristics of children with severe or chronic lung disease participating in a 2012-2015 indoor air study. We monitored indoor PM2.5, CO2 , relative humidity %, temperature, and VOCs and interviewed caregivers about children's respiratory symptoms. We evaluated the association between reported children's respiratory symptoms and indoor air quality indicators using multiple logistic regression analysis. Compared with general US households, study households were more likely overcrowded 73% (62%-82%) vs 3.2% (3.1%-3.3%); had higher woodstove use as primary heat source 16% (9%-25%) vs 2.1% (2.0%-2.2%); and higher proportion of children in a household with a smoker 49% (38%-60%) vs 26.2% (25.5%-26.8%). Median PM2.5 was 33 μg/m3 . Median CO2 was 1401 ppm. VOCs were detectable in all homes. VOCs, smoker, primary wood heat, and PM2.5>25 μg/m3 were associated with higher risk for cough between colds; VOCs were associated with higher risk for wheeze between colds and asthma diagnosis. High indoor air pollutant levels were associated with respiratory symptoms in household children, likely related to overcrowding, poor ventilation, woodstove use, and tobacco smoke.

Nasopharyngeal carriage of respiratory pathogens in Warao Amerindians: significant relationship with stunting

OBJECTIVE

To assess risk factors for nasopharyngeal carriage of potential pathogens in geographically isolated Warao Amerindians in Venezuela.

METHODS

In this point prevalence survey, nasopharyngeal swabs were obtained from 1064 Warao Amerindians: 504 children aged 0-4 years, 227 children aged 5-10 years and 333 caregivers. Written questionnaires were completed to obtain information on demographics and environmental risk factors. Anthropometric measurements were performed in children aged 0-4 years.

RESULTS

Carriage rates of Streptococcus pneumoniae, Staphylococcus aureus, Haemophilus influenzae and Moraxella catarrhalis were 51%, 7%, 1% and 13%, respectively. Crowding index, method of cooking and tobacco exposure were not associated with increased carriage. In multivariable analysis, an increase in height-for-age Z score (i.e. improved chronic nutritional status) was associated with decreased odds of S. pneumoniae colonisation (OR 0.76, 95% CI 0.70-0.83) in children aged 0-4 years.

CONCLUSIONS

Better knowledge of demographic and environmental risk factors facilitates better understanding of the dynamics of colonisation with respiratory bacteria in an Amerindian population. Poor chronic nutritional status was associated with increased pathogen carriage in children <5 years of age. The high rates of stunting generally observed in indigenous children may fuel the acquisition of respiratory bacteria that can lead to respiratory and invasive disease.

Infectious Disease Issues in Underserved Populations

Infectious disease has a major impact on the health outcomes of underserved populations and is reported at significantly higher rates among these populations compared with the general population. Overcoming barriers and obstacles to health care access is key to addressing the disparity regarding the prevalence of infectious disease. Enhancing cultural competency and educating practitioners about underserved populations' basic health needs; optimizing health insurance for the underserved; increasing community resources; and improving access to comprehensive, continuous, compassionate, and coordinated health care are strategies for diminishing the burden of infectious disease in underserved populations.

Infectious Disease Hospitalizations Among American Indian/Alaska Native and Non-American Indian/Alaska Native Persons in Alaska, 2010-2011

OBJECTIVE

Reports about infectious disease (ID) hospitalization rates among American Indian/Alaska Native (AI/AN) persons have been constrained by data limited to the tribal health care system and by comparisons with the general US population. We used a merged state database to determine ID hospitalization rates in Alaska.

METHODS

We combined 2010 and 2011 hospital discharge data from the Indian Health Service and the Alaska State Inpatient Database. We used the merged data set to calculate average annual age-adjusted and age-specific ID hospitalization rates for AI/AN and non-AI/AN persons in Alaska. We stratified the ID hospitalization rates by sex, age, and ID diagnosis.

RESULTS

ID diagnoses accounted for 19% (6501 of 34 160) of AI/AN hospitalizations, compared with 12% (7397 of 62 059) of non-AI/AN hospitalizations. The average annual age-adjusted hospitalization rate was >3 times higher for AI/AN persons (2697 per 100 000 population) than for non-AI/AN persons (730 per 100 000 population; rate ratio = 3.7, P < .001). Lower respiratory tract infection (LRTI), which occurred in 38% (2486 of 6501) of AI/AN persons, was the most common reason for ID hospitalization. AI/AN persons were significantly more likely than non-AI/AN persons to be hospitalized for LRTI (rate ratio = 5.2, P < .001).

CONCLUSIONS

A substantial disparity in ID hospitalization rates exists between AI/AN and non-AI/AN persons, and the most common reason for ID hospitalization among AI/AN persons was LRTI. Public health programs and policies that address the risk factors for LRTI are likely to benefit AI/AN persons.

Impact of the 13-Valent Pneumococcal Conjugate Vaccine on Pneumococcal Carriage Among American Indians

BACKGROUND

Community-wide impact of pneumococcal conjugate vaccines (PCV) is conferred by reductions in vaccine-type nasopharyngeal carriage. We evaluated the impact of PCV13 on carriage of PCV13-specific types (1, 3, 5, 6A, 7F and 19A) and 6C among American Indians.

METHODS

A nasopharyngeal specimen was collected from community members of all ages between January 2010 and April 2012 (3 months before and 24 months after PCV13 introduction). Pneumococci were isolated by culture and serotyped using antisera. Monthly carriage prevalence and PCV13 coverage were calculated to identify the timing of vaccine impact relative to PCV13 introduction. Prevalence ratios (PRs) were used to compare PCV13-specific carriage before and in years 1 and 2 of PCV13 use. Coverage was calculated according to age and number of doses received.

RESULTS

6645 participants (2859 <5 years and 3786 ≥5 years of age) provided 6628 specimens. A decline in PCV13-specific and type 6C carriage among children <5 years of age was observed 9 and 15 months after PCV13 introduction, respectively. Among underimmunized children, a decline in PCV13-specific carriage was observed 11 months after PCV13 introduction, when coverage in the community reached 58%. In year 2 of PCV13 use, PCV13-specific and 6C carriage were reduced by 60% and 70%, respectively (PCV13 specific: PR = 0.4, P < 0.001; 6C: PR = 0.3, P < 0.001) among children <5 years of age. The reduction in PCV13-specific carriage among those 5 to <8 years and 18+ years of age in year 2 of PCV13 use was not statistically significant.

CONCLUSIONS

PCV13 reduced PCV13-specific and 6C carriage among children <5 years of age. Low pre-PCV13 carriage prevalence of PCV13-specific types limited confirming this reduction for adults.

Hospitalizations at Nonfederal Facilities for Lower Respiratory Tract Infection in American Indian and Alaska Native Children Younger than 5 Years of Age, 1997-2012

OBJECTIVES

To evaluate hospitalizations at nonfederal facilities for lower respiratory tract infection (LRTI) in American Indian/Alaska Native (AI/AN) children and to compare associated rates and risk factors in AI/AN children and white children.

STUDY DESIGN

We used Kids' Inpatient Database samples from 1997-2012 to identify discharges in non-Hispanic AI/AN and white children ages <5 years with a principal or secondary diagnosis code indicating LRTI. To address systematic underreporting and misclassification of race in administrative databases, population rates were estimated by deriving race- and year-specific denominators from hospital births.

RESULTS

During the study period, LRTI-associated discharge rates (per 1000) declined for white children (from 14.8 to 10.9; P < .001 for trend). For AI/AN children, rates varied widely by census region and were highest in the West, where they ranged from 38.6 in 1997 to 26.7 in 2012 (P = .35 for trend). Discharges in AI/AN children were associated with low household income, Medicaid insurance, and rural residence. In a case-cohort analysis of infants hospitalized with LRTI in 2012, discharge rates were higher for AI/AN infants than for white infants only in the West (72.8 vs 22.2; aOR, 2.5; 95% CI, 1.8-3.4).

CONCLUSIONS

Among young children who use nonfederal hospitals, LRTI-associated hospitalizations occur at substantially higher rates for AI/AN children than for white children. These hospitalizations occur at rates that are particularly high for AI/AN infants in the West, where rates are comparable with those reported for Indian Health Service enrollees.

Increased health service use for asthma, but decreased for COPD: Northumbrian hospital episodes, 2013-2014

The burden of respiratory disease has persisted over the years, for both men and women. The aim of the present study was to investigate the hospital episode rates in respiratory disease and to understand whether and how the use of the health service for respiratory disease might have changed in recent years in the North-East of England. Hospital episode data covering two full calendar years (in 2013–2014) was extracted from the Northumbria Healthcare NHS Foundation Trust, which serves a population of nearly half a million. Hospital episode rates were calculated from admissions divided by annual and small area-specific population size by sex and across age groups, presented with per 100,000 person-years. The use of the health service for influenza and pneumonia, acute lower respiratory infections and chronic obstructive pulmonary disease (COPD) increased with an advancing age, except for acute upper respiratory infections and asthma. Overall, the use of the health service for common respiratory diseases has seemed to be unchanged, except for asthma. There were large increases in young adults aged 20–50 for both men and women and the very old aged 90+ in women. Of note, there were large increases in acute lower respiratory infections for both men and women aged 90+, whereas there was also a large decrease in COPD in women aged 80–90. This is the first study to examine health service use for respiratory diseases by calculating the detailed population size as denominator. Re-diverting funding to improve population health on a yearly basis may serve the changing need in local areas.

Lower respiratory tract infection hospitalizations among American Indian/Alaska Native children and the general United States child population

BACKGROUND

The lower respiratory tract infection (LRTI)-associated hospitalization rate in American Indian and Alaska Native (AI/AN) children aged <5 years declined during 1998-2008, yet remained 1.6 times higher than the general US child population in 2006-2008.

PURPOSE

Describe the change in LRTI-associated hospitalization rates for AI/AN children and for the general US child population aged <5 years.

METHODS

A retrospective analysis of hospitalizations with discharge ICD-9-CM codes for LRTI for AI/AN children and for the general US child population <5 years during 2009-2011 was conducted using Indian Health Service direct and contract care inpatient data and the Nationwide Inpatient Sample, respectively. We calculated hospitalization rates and made comparisons to previously published 1998-1999 rates prior to pneumococcal conjugate vaccine introduction.

RESULTS

The average annual LRTI-associated hospitalization rate declined from 1998-1999 to 2009-2011 in AI/AN (35%, p<0.01) and the general US child population (19%, SE: 4.5%, p<0.01). The 2009-2011 AI/AN child average annual LRTI-associated hospitalization rate was 20.7 per 1,000, 1.5 times higher than the US child rate (13.7 95% CI: 12.6-14.8). The Alaska (38.9) and Southwest regions (27.3) had the highest rates. The disparity was greatest for infant (<1 year) pneumonia-associated and 2009-2010 H1N1 influenza-associated hospitalizations.

CONCLUSIONS

Although the LRTI-associated hospitalization rate declined, the 2009-2011 AI/AN child rate remained higher than the US child rate, especially in the Alaska and Southwest regions. The residual disparity is likely multi-factorial and partly related to household crowding, indoor smoke exposure, lack of piped water and poverty. Implementation of interventions proven to reduce LRTI is needed among AI/AN children.

Eighteen Years of Respiratory Syncytial Virus Surveillance: Changes in Seasonality and Hospitalization Rates in Southwestern Alaska Native Children

BACKGROUND

Alaska Native infants from the Yukon-Kuskokwim Delta (YKD) experienced respiratory syncytial virus (RSV) hospitalization rates 5 times higher and an RSV season twice as long as the general US infant population. We describe trends in hospitalization rates and seasonality during 18 years of continuous RSV surveillance in this population and explore contributions of climate and sociodemographic factors.

METHODS

We abstracted clinical and RSV test information from computerized medical records at YKD Regional Hospital and Alaska Native Medical Center from 1994 to 2012 to determine hospitalization rates and RSV season timing. Descriptive village and weather data were acquired through the US Census and Alaska Climate Research Center, University of Alaska, Fairbanks, respectively.

RESULTS

During 1994-2012, YKD infant RSV hospitalization rates declined nearly 3-fold, from 177 to 65 per 1000 infants/yr. RSV season onset shifted later, from mid October to late December, contributing to a significantly decreased season duration, from 30 to 11 weeks. In a multivariate analysis, children from villages with more crowded households and lacking plumbed water had higher rates of RSV hospitalizations (relative rate, 1.17; P = 0.0005 and relative rate, 1.45; P = 0.0003). No association of temperature or dew point was found with the timing or severity of RSV season.

CONCLUSIONS

Although the RSV hospitalization rate decreased 3-fold, YKD infants still experience a hospitalization rate 3-fold higher than the general US infant population. Overcrowding and lack of plumbed water were associated with RSV hospitalization. Dramatic changes occurred in RSV seasonality, not explained by changes in climate.

Rickets and vitamin D deficiency in Alaska native children

BACKGROUND

Rickets and vitamin D deficiency appeared to increase in Alaskan children starting in the 1990s. We evaluated the epidemiology of rickets and vitamin D deficiency in Alaska native (AN) children in 2001-2010.

METHODS

We analyzed 2001-2010 visits with rickets or vitamin D deficiency diagnosis for AN and American Indian children and the general US population aged <10 years. We conducted a case-control study of AN rickets/vitamin D deficient cases and age- and region-matched controls.

RESULTS

In AN children, annual rickets-associated hospitalization rate (2.23/100,000 children/year) was higher than the general US rate (1.23; 95% CI 1.08-1.39). Rickets incidence increased with latitude. Rickets/vitamin D deficiency cases were more likely to have malnutrition (OR 38.1; 95% CI 4.9-294), had similar breast-feeding prevalence, and were less likely to have received vitamin D supplementation (OR 0.23; 95% CI 0.1-0.87) than controls.

CONCLUSIONS

Our findings highlight the importance of latitude, malnutrition, and lack of vitamin D supplementation as risk factors for rickets.

Recurrent, protracted and persistent lower respiratory tract infection: A neglected clinical entity

Community-acquired pneumonia is a potentially life-threatening disease affecting children worldwide. Recurrent pneumonia episodes can lead to the development of chronic respiratory morbidity. Chronic wet cough, a common pediatric complaint, is defined as a wet cough indicating excessive airway mucus that lasts for a minimum of 4 weeks. Most children with a chronic wet cough do not suffer from underlying debilitating pulmonary disorders. Rather, chronic wet cough is generally associated with neutrophilic airway inflammation and bacterial infections of the conducting airways. Failure to characterize endobronchial infections has led to under-recognition of chronic wet cough as an important clinical entity in children. Under-recognition and under-treatment of protracted bacterial bronchitis (PBB), a diagnosis made by the presence of isolated cough >4 weeks that resolves with appropriate antibiotic treatment, may lead to the development of chronic suppurative lung disease (CSLD) and bronchiectasis. The burden of bronchiectasis is highest in developing countries and in specifically vulnerable populations in developed countries, in particular indigenous children living in remote communities. The incidence, hospitalization rates and risk of long term sequelae of childhood pneumonia in indigenous children are higher than in non-indigenous children residing in the same area. The overlapping clinical and pathophysiological characteristics of PBB, CSLD and bronchiectasis are the presence of a chronic wet cough, impaired mucociliary clearance of the conducting airways, the presence of endobronchial bacterial infection (mainly non-typeable Haemophilus influenzae, Streptococcus pneumoniae and Moraxella catarrhalis) and neutrophilic airway inflammation. The principles of managing PBB, CSLD and bronchiectasis are the same. More research and public health interventions are required to improve the awareness, diagnosis and management of these causes of chronic wet cough in children.

Epidemiology of asthma hospitalizations among American Indian and Alaska Native people and the general United States population

BACKGROUND

Asthma, a common chronic disease among adults and children in the United States, results in nearly one-half million hospitalizations annually. There has been no evaluation of asthma hospitalizations for American Indian and Alaska Native (AI/AN) people since a previous study using data for 1988-2002. In this study, we describe the epidemiology and trends for asthma hospitalizations among AI/AN people and the general US population for 2003-2011.

METHODS

Hospital discharge records with a first-listed diagnosis of asthma for 2003-2011 were examined for AI/AN people, using Indian Health Service (IHS) data, and for the general US population, using the Nationwide Inpatient Sample. Average annual crude and age-adjusted hospitalization rates were calculated.

RESULTS

The average annual asthma hospitalization rates for AI/AN people and the general US population decreased from 2003-2005 to 2009-2011 (32% and 11% [SE, 3%], respectively). The average annual age-adjusted rate for 2009-2011 was lower for AI/AN people (7.6 per 10,000 population) compared with the general US population (13.2 per 10,000; 95% CI, 12.8-13.6). Age-specific AI/AN rates were highest among infants and children 1 to 4 years of age. IHS regional rates declined in all regions except Alaska.

CONCLUSIONS

Asthma hospitalization rates are decreasing for AI/AN people and the general US population despite increasing prevalence rates. AI/AN people experienced a substantially lower age-adjusted asthma hospitalization rate compared with the general US population. Although the rates for AI/AN infants and children 1 to 4 years of age have declined substantially, they remain higher compared with other age groups. Improved disease management and awareness should help to further decrease asthma hospitalizations, particularly among young children.

In utero arsenic exposure and fetal immune repertoire in a US pregnancy cohort

Arsenic has wide-ranging effects on human health and there is evidence that it alters the immune response by influencing CD4+/CD8+ T cell ratios, IL-2 cytokine levels, and the expression of immune-response genes. We investigated the impact of in utero environmental arsenic exposure on immune development and function in newborns participating in a pregnancy cohort in New Hampshire, U.S., where arsenic levels have exceeded the current EPA maximum contaminant level of 10 μg/L. Our results showed that maternal urinary arsenic concentrations were inversely related to absolute total CD45RA+ CD4+ cord blood CD69+ T cell counts (N=116, p=0.04) and positively associated with CD45RA+ CD69- CD294+ cell counts (p=0.01). In placental samples (N=70), higher in utero urinary arsenic concentrations were positively associated with the expression of IL1β (p=0.03). These data provide evidence that relatively low-level arsenic exposure in utero may alter the fetal immune system and lead to immune dysregulation.

Hospitalizations for severe lower respiratory tract infections

BACKGROUND

Hospitalization for lower respiratory tract infections (LRTIs) among children have been well characterized. We characterized hospitalizations for severe LRTI among children.

METHODS

We analyzed claims data from commercial and Medicaid insurance enrollees (MarketScan) ages 0 to 18 years from 2007 to 2011. LRTI hospitalizations were identified by the first 2 listed International Classification of Diseases, Ninth Revision discharge codes; those with ICU admission and/or receiving mechanical ventilation were defined as severe LRTI. Underlying conditions were determined from out- and inpatient discharge codes in the preceding year. We report insurance specific and combined rates that used both commercial and Medicaid rates and adjusted for age and insurance status.

RESULTS

During 2007-2011, we identified 16797 and 12053 severe LRTI hospitalizations among commercial and Medicaid enrollees, respectively. The rates of severe LRTI hospitalizations per 100000 person-years were highest in children aged <1 year (commercial: 244; Medicaid: 372, respectively), and decreased with age. Among commercial enrollees, ≥ 1 condition increased the risk for severe LRTI (1 condition: adjusted relative risk, 2.68; 95% confidence interval, 2.58-2.78; 3 conditions: adjusted relative risk, 4.85; 95% confidence interval, 4.65-5.07) compared with children with no medical conditions. Using commercial/Medicaid combined rates, an estimated 31289 hospitalizations for severe LRTI occurred each year in children in the United States.

CONCLUSIONS

Among children, the burden of hospitalization for severe LRTI is greatest among children aged <1 year. Children with underlying medical conditions are at greatest risk for severe LRTI hospitalization.

American Indian and Alaska Native infant and pediatric mortality, United States, 1999-2009

OBJECTIVES

We described American Indian/Alaska Native (AI/AN) infant and pediatric death rates and leading causes of death.

METHODS

We adjusted National Vital Statistics System mortality data for AI/AN racial misclassification by linkage with Indian Health Service (IHS) registration records. We determined average annual death rates and leading causes of death for 1999 to 2009 for AI/AN versus White infants and children. We limited the analysis to IHS Contract Health Service Delivery Area counties.

RESULTS

The AI/AN infant death rate was 914 (rate ratio [RR] = 1.61; 95% confidence interval [CI] = 1.55, 1.67). Sudden infant death syndrome, unintentional injuries, and influenza or pneumonia were more common in AI/AN versus White infants. The overall AI/AN pediatric death rates were 69.6 for ages 1 to 4 years (RR = 2.56; 95% CI = 2.38, 2.75), 28.9 for ages 5 to 9 years (RR = 2.12; 95% CI = 1.92, 2.34), 37.3 for ages 10 to 14 years (RR = 2.22; 95% CI = 2.04, 2.40), and 158.4 for ages 15 to 19 years (RR = 2.71; 95% CI = 2.60, 2.82). Unintentional injuries and suicide occurred at higher rates among AI/AN youths versus White youths.

CONCLUSIONS

Death rates for AI/AN infants and children were higher than for Whites, with regional disparities. Several leading causes of death in the AI/AN pediatric population are potentially preventable.

Infectious disease mortality among American Indians and Alaska Natives, 1999-2009

OBJECTIVES

We described death rates and leading causes of death caused by infectious diseases (IDs) in American Indian/Alaska Native (AI/AN) persons. Methods. We analyzed national mortality data, adjusted for AI/AN race by linkage with Indian Health Service registration records, for all US counties and Contract Health Service Delivery Area (CHSDA) counties. The average annual 1999 to 2009 ID death rates per 100,000 persons for AI/AN persons were compared with corresponding rates for Whites.

RESULTS

The ID death rate in AI/AN populations was significantly higher than that of Whites. A reported 8429 ID deaths (rate 86.2) in CHSDA counties occurred among AI/AN persons; the rate was significantly higher than the rate in Whites (44.0; rate ratio [RR] = 1.96; 95% confidence interval [CI] = 1.91, 2.00). The rates for the top 10 ID underlying causes of death were significantly higher for AI/AN persons than those for Whites. Lower respiratory tract infection and septicemia were the top-ranked causes. The greatest relative rate disparity was for tuberculosis (RR = 13.51; 95% CI = 11.36, 15.93).

CONCLUSIONS

Health equity might be furthered by expansion of interventions to reduce IDs among AI/AN communities.

Pneumonia and influenza mortality among American Indian and Alaska Native people, 1990-2009

OBJECTIVES

We compared pneumonia and influenza death rates among American Indian/Alaska Native (AI/AN) people with rates among Whites and examined geographic differences in pneumonia and influenza death rates for AI/AN persons.

METHODS

We adjusted National Vital Statistics Surveillance mortality data for racial misclassification of AI/AN people through linkages with Indian Health Service (IHS) registration records. Pneumonia and influenza deaths were defined as those who died from 1990 through 1998 and 1999 through 2009 according to codes for pneumonia and influenza from the International Classification of Diseases, 9th and 10th Revision, respectively. We limited the analysis to IHS Contract Health Service Delivery Area counties, and compared pneumonia and influenza death rates between AI/ANs and Whites by calculating rate ratios for the 2 periods.

RESULTS

Compared with Whites, the pneumonia and influenza death rate for AI/AN persons in both periods was significantly higher. AI/AN populations in the Alaska, Northern Plains, and Southwest regions had rates more than 2 times higher than those of Whites. The pneumonia and influenza death rate for AI/AN populations decreased from 39.6 in 1999 to 2003 to 33.9 in 2004 to 2009.

CONCLUSIONS

Although progress has been made in reducing pneumonia and influenza mortality, disparities between AI/AN persons and Whites persist. Strategies to improve vaccination coverage and address risk factors that contribute to pneumonia and influenza mortality are needed.

Influenza hospitalizations among american indian/alaska native people and in the United States general population

BACKGROUND

Historically, American Indian/Alaska Native (AI/AN) people have experienced a disproportionate burden of infectious disease morbidity compared with the general US population. We evaluated whether a disparity in influenza hospitalizations exists between AI/AN people and the general US population.

METHODS

We used Indian Health Service hospital discharge data (2001-2011) for AI/AN people and 13 State Inpatient Databases (2001-2008) to provide a comparison to the US population. Hospitalization rates were calculated by respiratory year (July-June). Influenza-specific hospitalizations were defined as discharges with any influenza diagnoses. Influenza-associated hospitalizations were calculated using negative binomial regression models that incorporated hospitalization and influenza laboratory surveillance data.

RESULTS

The mean influenza-specific hospitalization rate/100 000 persons/year during the 2001-2002 to 2007-2008 respiratory years was 18.6 for AI/AN people and 15.6 for the comparison US population. The age-adjusted influenza-associated hospitalization rate for AI/AN people (98.2; 95% confidence interval [CI], 51.6-317.8) was similar to the comparison US population (58.2; CI, 34.7-172.2). By age, influenza-associated hospitalization rates were significantly higher among AI/AN infants (<1 year) (1070.7; CI, 640.7-2969.5) than the comparison US infant population (210.2; CI, 153.5-478.5).

CONCLUSIONS

American Indian/Alaska Native people had higher influenza-specific hospitalization rates than the comparison US population; a significant influenza-associated hospitalization rate disparity was detected only among AI/AN infants because of the wide CIs inherent to the model. Taken together, the influenza-specific and influenza-associated hospitalization rates suggest that AI/AN people might suffer disproportionately from influenza illness compared with the general US population.

Indigenous children from three countries with non-cystic fibrosis chronic suppurative lung disease/bronchiectasis

OBJECTIVE

Indigenous children in developed countries are at increased risk of chronic suppurative lung disease (CSLD), including bronchiectasis. We evaluated sociodemographic and medical factors in indigenous children with CSLD/bronchiectasis from Australia, United States (US), and New Zealand (NZ).

METHODS

Indigenous children aged 0.5-8 years with CSLD/bronchiectasis were enrolled from specialist clinics in Australia (n = 97), Alaska (n = 41), and NZ (n = 42) during 2004-2009, and followed for 1-5 years. Research staff administered standardized parent interviews, reviewed medical histories and performed physical examinations at enrollment.

RESULTS

Study children in all three countries had poor housing and sociodemographic circumstances at enrollment. Except for increased household crowding, most poverty indices in study participants were similar to those reported for their respective local indigenous populations. However, compared to their local indigenous populations, study children were more often born prematurely and had both an increased frequency and earlier onset of acute lower respiratory infections (ALRIs). Most (95%) study participants had prior ALRI hospitalizations and 77% reported a chronic cough in the past year. Significant differences (wheeze, ear disease and plumbed water) between countries were present.

DISCUSSION

Indigenous children with CSLD/bronchiectasis from three developed countries experience significant disparities in poverty indices in common with their respective indigenous population; however, household crowding, prematurity and early ALRIs were more common in study children than their local indigenous population. Addressing equity, especially by preventing prematurity and ALRIs, should reduce risk of CSLD/bronchiectasis in indigenous children.

Respiratory infections in Eñepa Amerindians are related to malnutrition and Streptococcus pneumoniae carriage

OBJECTIVES

High acute respiratory tract infection (ARTI) rates are observed in indigenous populations. We assessed the role of viral infections and nasopharyngeal bacterial carriage in ARTIs in Eñepa Amerindians from Venezuela.

METHODS

In 40 children aged 0-10 years with ARTIs, healthy nearest-age sibling controls and their mothers the presence of Streptococcus pneumoniae, Haemophilus influenzae, Staphylococcus aureus, Moraxella catarrhalis, Mycoplasma pneumoniae, Chlamydophila pneumoniae/psittachi and 15 respiratory viruses was investigated.

RESULTS

S. pneumoniae was the most frequently detected pathogen, with carriage rates of 75% and 38% in children and mothers respectively. In children, S. pneumoniae carriage was associated with ARTI risk in multivariate analysis (OR 14.1, 95% CI 1.4-137.7). Viral infections were not associated with ARTI risk. S. pneumoniae carriage was common in children of all ages while viral co-infections were more frequently present in children under 4 years compared to older children (46% vs. 17%, p < 0.01). An increase of one unit height-for-age Z score (i.e. improved chronic nutritional status) was associated with decreased odds of S. pneumoniae colonization in multivariate analysis (OR 0.66, 95% CI 0.44-0.99).

CONCLUSIONS

In Eñepa children high S. pneumoniae carriage rates associated with a poor nutritional status contribute to the development of ARTIs.

Increasing trend in the rate of infectious disease hospitalisations among Alaska Native people

OBJECTIVES

To examine the epidemiology of infectious disease (ID) hospitalisations among Alaska Native (AN) people.

METHODS

Hospitalisations with a first-listed ID diagnosis for American Indians and ANs residing in Alaska during 2001-2009 were selected from the Indian Health Service direct and contract health service inpatient data. ID hospitalisations to describe the general US population were selected from the Nationwide Inpatient Sample. Annual and average annual (2007-2009) hospitalization rates were calculated.

RESULTS

During 2007-2009, IDs accounted for 20% of hospitalisations among AN people. The 2007-2009 average annual age-adjusted ID hospitalisation rate (2126/100,000 persons) was higher than that for the general US population (1679/100,000; 95% CI 1639-1720). The ID hospitalisation rate for AN people increased from 2001 to 2009 (17%, p < 0.001). Although the rate during 2001-2009 declined for AN infants (< 1 year of age; p = 0.03), they had the highest 2007-2009 average annual rate (15106/100,000), which was 3 times the rate for general US infants (5215/100,000; 95% CI 4783-5647). The annual rates for the age groups 1-4, 5-19, 40-49, 50-59 and 70-79 years increased (p < 0.05). The highest 2007-2009 age-adjusted average annual ID hospitalisation rates were in the Yukon-Kuskokwim (YK) (3492/100,000) and Kotzebue (3433/100,000) regions; infant rates were 30422/100,000 and 26698/100,000 in these regions, respectively. During 2007-2009, lower respiratory tract infections accounted for 39% of all ID hospitalisations and approximately 50% of ID hospitalisations in YK, Kotzebue and Norton Sound, and 74% of infant ID hospitalisations.

CONCLUSIONS

The ID hospitalisation rate increased for AN people overall. The rate for AN people remained higher than that for the general US population, particularly in infants and in the YK and Kotzebue regions. Prevention measures to reduce ID morbidity among AN people should be increased in high-risk regions and for diseases with high hospitalisation rates.

Improving the state of health hardware in Australian Indigenous housing: building more houses is not the only answer

BACKGROUND

This article outlines a program of applied research and development known as Housing for Health that, over the period 1999-2012, targeted health-related improvements in housing for Indigenous householders in communities across regional and remote Australia. In essence, the program focuses on measuring the functionality of key appliances and structures (we term this "health hardware") against clear criteria and ensuring identified faults are fixed.

METHODS

Detailed survey and assessment of all aspects of housing was undertaken, particularly focusing on the function of health hardware. All results were entered into a database and analyzed.

RESULTS

The results demonstrate extremely poor initial performance of the health hardware. A key finding is that attention to maintenance of existing houses can be a cost-effective means of improving health outcomes and also suggests the need to superintend the health-conferring qualities of new infrastructure. We briefly outline the early foundations of the Housing for Health program, major findings from data gathered before and after improvements to household amenities, and our efforts to translate these findings into broader policy.

CONCLUSIONS

These data demonstrate that simply injecting funds into housing construction is not sufficient for gaining maximum health benefit.

A prospective study of agents associated with acute respiratory infection among young American Indian children

BACKGROUND

Native American children have higher rates of morbidity associated with acute respiratory infection than children in the general US population, yet detailed information is lacking regarding their principal clinical presentations and infectious etiologies.

METHODS

We pursued a comprehensive molecular survey of bacteria and viruses in nasal wash specimens from children with acute respiratory disease collected prospectively over 1 year (January 1 through December 31, 2009) from 915 Navajo and White Mountain Apache children in their second or third year of life who had been enrolled in an efficacy study of a respiratory syncytial virus monoclonal antibody in the first year of life.

RESULTS

During the surveillance period, 1476 episodes of disease were detected in 669 children. Rates of outpatient and inpatient lower respiratory tract illness were 391 and 79 per 1000 child-years, respectively, and were most commonly diagnosed as pneumonia. Potential pathogens were detected in 88% of specimens. Viruses most commonly detected were respiratory syncytial virus and human rhinovirus; the 2009 pandemic influenza A (H1N1) illnesses primarily occurred in the fall. Streptococcus pneumoniae was detected in 60% of subjects; only human rhinovirus was significantly associated with S. pneumoniae carriage. The presence of influenza virus, human rhinovirus or S. pneumoniae was not associated with increased risk for lower respiratory tract involvement or hospitalization.

CONCLUSIONS

Acute lower respiratory illnesses occur at disproportionately high rates among young American Indian children and are associated with a range of common pathogens. This study provides critical evidence to support reducing the disproportionate burden of acute respiratory disease among young Native Americans.

Breastfeeding and health outcomes for the mother-infant dyad

Worldwide, breastfeeding saves the lives of infants and reduces their disease burden. Breastfeeding also reduces the disease burden for mothers. This article examines who chooses to breastfeed and for how long in the United States. It also reviews the latest evidence about the consequences of breastfeeding for the health of the infant and mother. This review provides support for current national and international recommendations that support breastfeeding.

Viral etiologies of lower respiratory tract infections among Egyptian children under five years of age

Background

Lower respiratory tract infections (LRTI) are responsible for a considerable number of deaths among children, particularly in developing countries. In Egypt and the Middle East region, there is a lack of data regarding the viral causes of LRTI. In this study, we aimed to identify the relative prevalence of various respiratory viruses that contribute to LRTIs in young children. Although, nucleic acid-based methods have gained importance as a sensitive tool to determine the viral infections, their use is limited because of their prohibitive cost in low-income countries. Therefore, we applied three different laboratory methods, and presented the different virus prevalence patterns detected by each method.

Methods

We collected nasopharyngeal aspirate samples, demographic data and, clinical data from 450 children under five years of age who presented with LRTI at Abou El Reesh hospital in Cairo during a one-year period. To identify the viral causes of the LRTI we used direct fluorescence assay, real-time reverse-transcriptase polymerase chain reaction (rt-RT-PCR), and shell vial culture. We tested for eight major respiratory viruses.

Results

Two hundred sixty-nine patients (59.9%) had a viral infection, among which 10.8% had a co-infection with two or more viruses. By all three methods, respiratory syncytial virus (RSV) was the most predominant, and parainfluenza virus type 2 (HPIV-2), influenza B virus (FLUBV) were the least predominant. Other viral prevalence patterns differed according to the detection method used. The distribution of various viruses among different age groups and seasonal distribution of the viruses were also determined.

Conclusions

RSV and human adenovirus were the most common respiratory viruses detected by rt-RT-PCR. Co-infections were found to be frequent among children and the vast majority of co-infections were detected by nucleic acid-based detection assays.