The burden of pneumonia in children: an Asian perspective

Socioeconomic burden of pneumonia due to multidrug-resistant Acinetobacter baumannii and Pseudomonas aeruginosa in Korea

We aimed to estimate the socioeconomic burden of pneumonia due to multidrug-resistant Acinetobacter baumannii (MRAB) and Pseudomonas aeruginosa (MRPA). We prospectively searched for MRAB and MRPA pneumonia cases and matched them with susceptible-organism pneumonia and non-infected patients from 10 hospitals. The matching criteria were: same principal diagnosis, same surgery or intervention during hospitalisation, age, sex, and admission date within 60 days. We calculated the economic burden by using the difference in hospital costs, the difference in caregiver costs, and the sum of productivity loss from an unexpected death. We identified 108 MRAB pneumonia [MRAB-P] and 28 MRPA pneumonia [MRPA-P] cases. The estimated number of annual MRAB-P and MRPA-P cases in South Korea were 1309–2483 and 339–644, with 485–920 and 133–253 deaths, respectively. The annual socioeconomic burden of MRAB-P and MRPA-P in South Korea was $64,549,723–122,533,585 and $15,241,883–28,994,008, respectively. The results revealed that MRAB-P and MRPA-P occurred in 1648–3127 patients, resulted in 618–1173 deaths, and caused a nationwide socioeconomic burden of $79,791,606–151,527,593. Multidrug-resistant organisms (MDRO) impose a great clinical and economic burden at a national level. Therefore, controlling the spread of MDRO will be an effective measure to reduce this burden.

Study to evaluate the socio-demographic and environmental factors affecting morbidity and mortality of community acquired pneumonia in children <5years

Aim: To evaluate the socio demographic and environmental factors affecting morbidity and mortality of community acquired pneumonia in children <5years. Materials and methods: The present Observational longitudinal study was carried in the Department of Paediatrics, Dr. D.Y. Patil Medical College, Pune, among 70 children less than 5 years of age admitted in the In-patient department , Neonatal Intensive Care Unit and Paediatric Intensive Care Unit diagnosed as community acquired pneumonia of either sex in the hospital. The study was carried out from may 2019-september 2021. The children who fulfilled the WHO criteria of Community Acquired Pneumonia were in addition to the Chest x-ray and investigations findings suggestive of CAP were enrolled. The details of the patient's personal and demographic profile, clinical presentation, underlying condition, laboratory investigations, therapy and course in the hospital, and the final outcome were all recorded on a pre-designed proforma. Results: Mean age of children presenting with pneumonia (31.92 months) was approximately similar with those presenting with severe pneumonia (30.37 months).

Field testing two existing, standardized respiratory severity scores (LIBSS and ReSViNET) in infants presenting with acute respiratory illness to tertiary hospitals in Rwanda - a validation and inter-rater reliability study

INTRODUCTION

There is a substantial burden of respiratory disease in infants in the sub-Saharan Africa region. Many health care providers (HCPs) that initially receive infants with respiratory distress may not be adequately skilled to differentiate between mild, moderate and severe respiratory symptoms, which may contribute to poor management and outcome. Therefore, respiratory severity scores have the potential to contributing to address this gap.

OBJECTIVES

to field-test the use of two existing standardized bronchiolitis severity scores (LIBSS and ReSViNET) in a population of Rwandan infants (1-12 months) presenting with respiratory illnesses to urban, tertiary, pediatric hospitals and to assess the severity of respiratory distress in these infants and the treatments used.

METHODS

A cross-sectional, validation study, was conducted in four tertiary hospitals in Rwanda. Infants presenting with difficulty in breathing were included. The LIBSS and ReSViNET scores were independently employed by nurses and residents to assess the severity of disease in each infant.

RESULTS

100 infants were recruited with a mean age of seven months. Infants presented with pneumonia (n = 51), bronchiolitis (n = 36) and other infectious respiratory illnesses (n = 13). Thirty-three infants had severe disease and survival was 94% using nurse applied LIBSS. Regarding inter-rater reliability, the intra-class correlation coefficient (ICC) for LIBSS and ReSViNET between nurses and residents was 0.985 (95% CI: 0.98-0.99) and 0.980 (0.97-0.99). The convergent validity (Pearson's correlation) between LIBSS and ReSViNET for nurses and residents was R = 0.836 (p<0.001) and R = 0.815 (p<0.001). The area under the Receiver Operator Curve (aROC) for admission to PICU or HDU was 0.956 (CI: 0.92-0.99, p<0.001) and 0.880 (CI: 0.80-0.96, p<0.001) for nurse completed LIBSS and ReSViNET respectively.

CONCLUSION

LIBSS and ReSViNET were designed for infants with bronchiolitis in resource-rich settings. Both LIBSS and ReSViNET demonstrated good reliability and validity results, in this cohort of patients presenting to tertiary level hospitals. This early data demonstrate that these two scores have the potential to be used in conjunction with clinical reasoning to identify infants at increased risk of clinical deterioration and allow timely admission, treatment escalation and therefore support resource allocation in Rwanda.

Anti-Inflammatory Effects of Neochlorogenic Acid Extract from Mulberry Leaf (Morus alba L.) Against LPS-Stimulated Inflammatory Response through Mediating the AMPK/Nrf2 Signaling Pathway in A549 Cells

Neochlorogenic acid (nCGA) is a phenolic compound isolated from mulberry leaf (Morus alba L.), which possesses multiple pharmacological activities containing antioxidant and anti-inflammatory effects. However, the role of nCGA in the treatment of acute pneumonia and the underlying molecular mechanism are still unclear. Hence, the aim of study is to investigate the anti-inflammatory properties of nCGA on LPS-stimulated inflammation in A549 cells. In the present study, results reported that nCGA without cytotoxicity significantly reduced the production of TNF-α, IL-6, and NO, and further suppressed the proteins of iNOS, COX2, TNF-α, IL-6 expression. Furthermore, nCGA also inhibited NF-κB activation and blocked MAPKs signaling pathway phosphorylation. In addition, we found nCGA significantly increased the expression of HO-1 via activating the AMPK/Nrf2 signaling pathway to attenuate the inflammatory response, whereas this protective effect of nCGA was reversed by pre-treatment with compound C (C.C, an AMPK inhibitor). Therefore, all these results indicated that nCGA might act as a natural anti-inflammatory agent for the treatment of acute pneumonia.

Effects of parental smoking and indoor tobacco smoke exposure on respiratory outcomes in children

The extensive literature has reported adverse effects on environmental tobacco smoke (ETS) on children's health. We aim to analyze associations of ETS with dry night cough, croup, pneumonia, and frequent common cold and to disentangle the effects of prenatal, infancy and childhood exposure by multilevel logistic regression. A cross-sectional study was conducted among 41,176 children aged 3-8 years in 8 major cities of China during 2010-2011, and obtained demographic information, smoke exposure information, and respiratory outcomes. Parents' smoking habit and indoor tobacco smoke odor were considered as two indicators of ETS. The prevalences of respiratory outcomes were 6.0% for croup, 9.5% for frequency common cold, 17.1% for dry night cough and 32.3% for pneumonia respectively in the study. The associations between respiratory outcomes and parental smoking were not obvious, while indoor tobacco smoke odor was clearly and strongly associated with most respiratory outcomes, with adjusted odds ratios ranging from 1.06 to 1.95. Both infancy and childhood exposure to tobacco smoke odor were independent risk factors, but infancy exposure had a higher risk. The results explore that ETS increased the risk of respiratory outcomes in children, highlighting the need for raising awareness about the detrimental effects of tobacco smoke exposure.

Role of bacterial Ser/Thr protein kinases spr 1577 in the pathogenesis of respiratory infections caused by S. pneumoniae

This study investigated the specific role played by conserved membrane eukaryotic-like Ser/Thr protein kinases (StkP) during infection, particularly pneumonia, in order to get deep insights about Ser/Thr protein kinases signaling during infection and pathogenesis. The wild type and mutated Ser/Thr protein kinases (Spr1577) strains were tested on different cell lines to understand their virulence based on gentamicin protection assay, gene expression analysis and the expression of various interleukins. Though there was no uptake of bacterial CFU at the beginning, after 24 h it was 50% less for the mutated in comparison to wild-type strain, thus indicating a possible role of Spr1577 gene in the phagosomal survival of S pneumoniae. The complemented, strain-restored bacterial survival to the similar extent alike wild-type strains suggest that the Spr1577 kinase activity is not critical for the intracellular survival of S. pneumoniae within macrophages. Peak expression of spr1577 post infection indicating that the virulent genes seemed persuaded within the macrophages. Higher induction of pro-inflammatory cytokines by the wild type and complemented strains, but not by mutated strain, suggest its role in the induction of macrophages functions. S. pneumoniae and S. pyogenes are closely-related pathogens having 97% similarity in their gene sequences suggesting that the virulence mechanisms greatly varies and remain poorly understood for S. pneumoniae.

Respiratory compromise in children presenting to an urban emergency department of a tertiary hospital in Tanzania: a descriptive cohort study

BACKGROUND

Respiratory compromise is the leading cause of cardiac arrest and death among paediatric patients. Emergency medicine is a new field in low-income countries (LICs); the presentation, treatment and outcomes of paediatric patients with respiratory compromise is not well studied. We describe the clinical epidemiology, management and outcomes of paediatric patients with respiratory compromise presenting to the first full-capacity Emergency Department in Tanzania.

METHODS

This was a prospective cohort study of paediatric patients (< 18 years) with respiratory compromise (respiratory distress, respiratory failure or respiratory arrest) presenting to the Emergency Medicine Department of Muhimibili National Hospital (EMD-MNH) in Dar es Salaam, from July-November 2017. A standardized case report form was used to record demographics, presenting clinical characteristics, management and outcomes. Primary outcomes were hospital mortality and secondary outcomes were EMD mortality, 24-h mortality, incidence of cardiac arrest in the EMD, length of stay, ICU admission, and risk factors for mortality.

RESULTS

We enrolled 165 children; their median age was 12 months [IQR: 4-36 months], and 90 (54.4%) were male. At presentation 92 (55.8%) children were in respiratory failure. Oxygen therapy was initiated for 143 (86.7%) children, among which 21 (14.7%) were intubated. The most common aetiologies were pneumonia followed by congenital heart disease and sepsis. The majority 147 (89.1%) of children were admitted to the hospital, with 20 (12%) going to ICU. Four (2%) children were discharged from EMD and 14 (8.5%) died in the EMD. In the EMD, 18 children developed cardiac arrest, with two surviving to hospital discharge. Overall 51 (30.9%) children died; 84% of deaths were in children under five years. Risk of mortality was increased in children presenting with decreased consciousness (RR = 2.2 (1.4-3.4)), hypoxia RR = 2.6 (1.6-4.4)) or bradypnoea (RR = 3.9 (2.9-5.0)), and those who received CPR (RR = 3.7 (2.7-5.2)) and intubation (RR = 3.1 (2.1-4.5)).

CONCLUSIONS

In this EMD of a LICs, respiratory compromise in children carries high mortality, with children of young age being the most vulnerable. Many children arrived in respiratory failure and few children received ICU care. Outcomes can be improved by earlier recognition to prevent cardiac arrest, and more intensive treatment, including ICU and assisted ventilation.

Reported incidence and risk factors of childhood pneumonia in India: a community-based cross-sectional study

Background

Pneumonia is responsible for high morbidity and mortality amongst children under five year of age. India accounts for one-third of the total WHO South East Asia burden of under-five mortality. There is a paucity of epidemiological studies indicating the true burden of pneumonia. Identification of the risk factors associated with pneumonia will help to effectively plan and implement the preventive measures for its reduction.

Methods

It was a descriptive cross-sectional study conducted in 16 randomly selected clusters in two districts of Maharashtra state, India. All mothers of under-five children in the selected clusters were included. A validated pretested interview schedule was filled by trained field supervisors through the house to house visits.WHO definition was used to define and classify clinical pneumonia. Height and weight of children were taken as per standard guidelines. Quality checks for data collection were done by the site investigators and critical and noncritical fields in the questionnaire were monitored during data entry. For continuous variables mean and SD were calculated. Chi-square test was applied to determine the association between the variables. Level of significance was considered at 0.05.

Results

There were 3671 under five-year children, 2929 mothers in 10,929 households.Unclean fuel usage was found in 15.1% of households. Mean birth weight was 2.6 kg (SD;0.61). Exclusive breastfeeding till 6 months of age was practiced by 46% of mothers. Reported incidence of ARI was 0.49 per child per month and the reported incidence of pneumonia was 0.075 per child per year. It was not associated with any of the housing environment factors (p > 0.05) but was found to be associated with partial immunization (p < 0.05). Poor practices related to child feeding, hand hygiene and poor knowledge related to signs and symptoms of pneumonia amongst mother were found.

Conclusions

Very low incidence of pneumonia was observed in Pune and Sangli districts of Maharashtra. Partial immunization emerged as a most important risk factor. Reasons for low incidence and lack of association of pneumonia with known risk factors may be a better literacy rate among mothers and better immunization coverage.

Trial registration

Registration number of the trial- CTRI/2017/12/010881; date of registration-14/12/2017.

Residential risk factors for childhood pneumonia: A cross-sectional study in eight cities of China

BACKGROUND

Children's pneumonia is a heavy health burden. Few studies have been carried out on residential risk factors for pneumonia in children. Potential risks associated with dwelling characteristics are still unknown.

METHODS

A cross-sectional study was conducted among children in 8 cities in China during 2010-2011 and 41,176 valid data on children aged 3-8 years old were used in this analysis. To obtain the lifetime-ever incidence of pneumonia in children and identify associations between pneumonia and residential risk factors, chi-square analysis and logistic regression methods were employed. Adjusted odds ratios were used as measures of effect with a 95% confidence interval. Confounding variables in the regression model include children's gender, birthweight, breastfeeding duration, parental smoking and family history of atopy.

RESULTS

The average lifetime-ever incidence of childhood pneumonia was 32.3%. Urban children (33.6%) had more pneumonia than suburban (29.9%) and rural children (24.9%). More residential risk factors were found in urban-dwellings. Boys, low birthweight (<2500 g), breastfeeding duration <6 months, family allergic history, and exposure to parental smoking were found to be associated with higher pneumonia lifetime-ever incidences. Various indicators of dampness, including visible mold spots, damp stains, water damage, water condensation, damp clothing or bedding and mold odor, were also positively associated with pneumonia. Pneumonia incidence increased as the number of dampness indicators increased. Both natural gas and solid cooking fuels were positively associated with pneumonia compared with electricity. Compared with cement, construction materials including synthetic fiber, laminated wood, real wood, paint, emulsion paint and wall paper were positively associated with pneumonia. Daily living habits such as putting bedding to sunshine frequently and cleaning the child's bedroom every day could be effective preventive strategies. A dose-response relationship between the number of residential risk factors and pneumonia was observed when the risk factors number ranged from 7 to 11. Residences with more risk factors had higher lifetime-ever pneumonia odds ratios.

CONCLUSIONS

Indoor environmental factors including dampness, use of solid fuels or natural gas for cooking and use of new construction materials are risk factors for childhood pneumonia. This study gives evidence for the importance of home environment exposures in the occurrence of childhood pneumonia. Actions against the residential risk factors described in this study may help to prevent pneumonia in children.

Direct whole-genome deep-sequencing of human respiratory syncytial virus A and B from Vietnamese children identifies distinct patterns of inter- and intra-host evolution

Human respiratory syncytial virus (RSV) is the major cause of lower respiratory tract infections in children ,2 years of age. Little is known about RSV intra-host genetic diversity over the course of infection or about the immune pressures that drive RSV molecular evolution. We performed whole-genome deep-sequencing on 53 RSV-positive samples (37 RSV subgroup A and 16 RSV subgroup B) collected from the upper airways of hospitalized children in southern Vietnam over two consecutive seasons. RSV A NA1 and RSV B BA9 were the predominant genotypes found in our samples, consistent with other reports on global RSV circulation during the same period. For both RSV A and B, the M gene was the most conserved, confirming its potential as a target for novel therapeutics. The G gene was the most variable and was the only gene under detectable positive selection. Further, positively selected sites inG were found in close proximity to and in some cases overlapped with predicted glycosylation motifs, suggesting that selection on amino acid glycosylation may drive viral genetic diversity. We further identified hotspots and coldspots of intra-host genetic diversity in the RSV genome, some of which may highlight previously unknown regions of functional importance.

Acute respiratory infection in children from developing nations: a multi-level study

BACKGROUND

Worldwide, acute respiratory infections (ARI) are the leading cause of death of children under 5 years of age.

AIM

To assess the accomplishment of the Millennium Development Goal on under-5 mortality particularly related to ARI in developing countries, and to explore the associations between country characteristics and ARI in children under 5 taking into account child, mother and household attributes.

METHODS

The study included a representative sample of 354,633 children under 5 years from 40 developing nations. A multilevel analysis of data from the Demographic and Health Surveys and the World Bank was conducted.

RESULTS

The prevalence of ARI was 13%. Country inequalities were associated with the disease - GINI index (95% CI 1.01-1.04). The country's per capita gross domestic product (GDP) (95% CI 1.00-1.01) and health expenditure (95% CI 1.01-1.01) affected the relationship between immunization and ARI, while inequalities influenced the relationship between household wealth (95% CI 0.99-0.99) and the disease. Other factors positively associated with ARI were male gender, low birthweight, working mothers and a high-risk indoor environment. Factors associated with ARI reduction were older children, immunization, breastfeeding for more than 6 months, older maternal age, maternal education and planned pregnancy.

CONCLUSIONS

In developing countries, public health campaigns to target ARI should consider the country's macro characteristics. At country level, inequalities but not health expenditure or GDP were associated with the disease and were independent of child, family and household characteristics. The effect of immunization on reducing ARI is greater in countries with a higher GDP and health expenditure. The effect of household wealth on ARI is less in countries with fewer inequalities. Reduction of inequalities is an important measure to decrease ARI in developing countries.

Affect of Early Life Oxygen Exposure on Proper Lung Development and Response to Respiratory Viral Infections

Children born preterm often exhibit reduced lung function and increased severity of response to respiratory viruses, suggesting that premature birth has compromised proper development of the respiratory epithelium and innate immune defenses. Increasing evidence suggests that premature birth promotes aberrant lung development likely due to the neonatal oxygen transition occurring before pulmonary development has matured. Given that preterm infants are born at a point of time where their immune system is also still developing, early life oxygen exposure may also be disrupting proper development of innate immunity. Here, we review current literature in hopes of stimulating research that enhances understanding of how the oxygen environment at birth influences lung development and host defense. This knowledge may help identify those children at risk for disease and ideally culminate in the development of novel therapies that improve their health.

Disease patterns and clinical outcomes of patients admitted in intensive care units of tertiary referral hospitals of Tanzania

Background

In sub-Saharan Africa the availability of intensive care unit (ICU) services is limited by a variety of factors, including lack of financial resources, lack of available technology and well-trained staff. Tanzania has four main referral hospitals, located in zones so as to serve as tertiary level referral centers. All the referral hospitals have some ICU services, operating at varying levels of equipment and qualified staff. We analyzed and describe the disease patterns and clinical outcomes of patients admitted in ICUs of the tertiary referral hospitals of Tanzania.

Methods

This was a retrospective analysis of ICU patient records, for three years (2009 to 2011) from all tertiary referral hospitals of Tanzania, namely Muhimbili National Hospital (MNH), Kilimanjaro Christian Medical Centre (KCMC), Mbeya Referral Hospital (MRH) and Bugando Medical Centre (BMC).

Results

MNH is the largest of the four referral hospitals with 1300 beds, and MRH is the smallest with 480 beds. The ratio of hospital beds to ICU beds is 217:1 at MNH, 54:1 at BMC, 39:1 at KCMC, and 80:1 at MRH. KCMC had no infusion pumps. None of the ICUs had a point-of-care (POC) arterial blood gas (ABG) analyzer. None of the ICUs had an Intensive Care specialist or a nutritionist. A masters-trained critical care nurse was available only at MNH. From 2009–2011, the total number of patients admitted to the four ICUs was 5627, male to female ratio 1.4:1, median age of 34 years. Overall, Trauma (22.2%) was the main disease category followed by infectious disease (19.7%). Intracranial injury (12.5%) was the leading diagnosis in all age groups, while pneumonia (11.7%) was the leading diagnosis in pediatric patients (<18 years). Patients with tetanus (2.4%) had the longest median length ICU stay: 8 (5,13) days. The overall in-ICU mortality rate was 41.4%.

Conclusions

The ICUs in tertiary referral hospitals of Tanzania are severely limited in infrastructure, personnel, and resources, making it difficult or impossible to provide optimum care to critically ill patients and likely contributing to the dauntingly high mortality rates.

New insights into the aryl hydrocarbon receptor as a modulator of host responses to infection

The host response to infection is known to be influenced by many factors, including genetics, nutritional status, age, as well as drug and chemical exposures. Recent advances reveal that the aryl hydrocarbon receptor (AhR) modulates aspects of the innate and adaptive immune response to viral, bacterial, and parasitic organisms. Although many of these observations were made using the high affinity but poorly metabolized AhR agonist 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD), not all of the effects are detrimental to the host. Sometimes AhR activation, even with TCDD, was beneficial and improved host resistance and survival. A similar dichotomy is observed in infected AhR-deficient mice, wherein absence of functional AhR sometimes, but not always, alters host resistance. When examined in their totality, current data indicate that AhR controls multiple regulatory pathways that converge with infection-associated signals and depending on the context (e.g., type of pathogen, site of infection), lead to distinct outcomes. This creates numerous exciting opportunities to harness the immunomodulatory action of AhR to transform host responses to infection. Moreover, since many of the mechanisms cued in response to infectious agents are pivotal in the context of other diseases, there is much to be learned about AhR's cellular targets and molecular mechanisms of action.

A retrospective analysis of pathological and clinical diagnoses: report of 240 pediatric autopsies

Reduction of childhood mortality is a worldwide health priority. By investigating the most frequent causes of childhood death and analyzing the major causes of misdiagnosis, this study aims to quantify the value of autopsy and guide further research for improving health services. A total of 240 autopsied cases were recruited into the study. The major causes of death according to the system were respiratory diseases, followed by neoplasms and infectious diseases, while the top three causes of death according to diseases were lobular pneumonia, septicemia, and malignant histiocytosis. Agreement between pathologic and clinical diagnoses was shown in 169 autopsies (70.5%), and the other 71 cases (29.6%) had been misdiagnosed. This study demonstrated the value of the routine autopsy by documenting the high rate of disagreement between clinical and autopsy diagnoses. However, the role of routine autopsy for determining in-born errors of metabolism is limited.

Protein conjugate polysaccharide vaccines: challenges in development and global implementation

Pneumonia and meningitis caused by Haemophilus influenzae type b, Streptococcus pneumoniae, and Neisseria meningitidis are among the leading causes of under five mortality and morbidity. Polysaccharide vaccines to prevent these infections are available since 1980s, but these are not effective in infants and children who are the common targets; therefore, protein conjugated were developed. The aim of this article is to understand the need for peumococcal protein conjugate vaccines, the challenges related to their development and global implementation, and the impact of these vaccines on global child health. Challenges in development of new vaccines are as follows:While pneumonia is a major threat in developing countries, available vaccine 7-valent pneumococcal conjugate vaccine (PCV7) protects against only 30% of invasive disease.Serogroup B of Neisseria meningitidis causes 32% of the cases in the USA and 45-80% or more in Europe. Due to similarity of its capsular polysaccharide with the cell surface glycoprotein on fetal brain tissue, developing a vaccine against this bacterium remains a challenge.Challenges in implementation are as follows:Replacement by nonvaccine serotypes;capsule switching;time duration of the antibody protective effect following vaccination;costs of the vaccines, programme costs, lack of knowledge of the disease burden, and targeting population groups for vaccination.

Pneumonia and poverty: a prospective population-based study among children in Brazil

BACKGROUND

Children in developing country suffer the highest burden of pneumonia. However, few studies have evaluated associations between poverty and pneumonia.

METHODS

A prospective population-based study on pneumonia was carried out as part of the Latin America Epidemiological Assessment of Pneumococcus (LEAP study). Chest x-rays were obtained for children one to 35 months old with suspected pneumonia presenting to emergency care centers and hospital emergency rooms in Goiania, Brazil. Chest radiographs were evaluated according to WHO guidelines. Clustering of radiologically-confirmed pneumonia were evaluated using a Poisson-based spatial scan statistic. Associations between census socioeconomic indicators and pneumonia incidence rates were analyzed using generalized linear models.

RESULTS

From May, 2007 to May, 2009, chest radiographs were obtained from 11 521 children with clinical pneumonia; 3955 episodes were classified as radiologically-confirmed. Incidence rates were significantly higher in very low income areas (4825.2 per 105) compared to high income areas (1637.3 per 105). Spatial analysis identified clustering of confirmed pneumonia in Western (RR 1.78; p=0.001) and Southeast (RR 1.46; p=0.001) regions of the city, and clustering of hospitalized pneumonia in the Western region (RR 1.69; p=0.001). Lower income households and illiteracy were associated with pneumonia incidence.

CONCLUSIONS

In infants the risk of developing pneumonia is inversely associated with the head of household income and with the woman educational level. Areas with deprived socioeconomic conditions had higher incidence of pneumonia and should be targeted for high vaccination coverage.

Arsenic exposure in pregnancy increases the risk of lower respiratory tract infection and diarrhea during infancy in Bangladesh

BACKGROUND

Previous studies have reported associations between prenatal arsenic exposure and increased risk of infant mortality. An increase in infectious diseases has been proposed as the underlying cause of these associations, but there is no epidemiologic research to support the hypothesis.

OBJECTIVE

We evaluated the association between arsenic exposure in pregnancy and morbidity during infancy.

METHODS

This prospective population-based cohort study included 1,552 live-born infants of women enrolled during 2002-2004 in Matlab, Bangladesh. Arsenic exposure was assessed by the concentrations of metabolites of inorganic arsenic in maternal urine samples collected at gestational weeks 8 and 30. Information on symptoms of lower respiratory tract infection (LRTI) and diarrhea in infants was collected by 7-day recalls at monthly home visits.

RESULTS

In total, 115,850 person-days of observation were contributed by the infants during a 12-month follow-up period. The estimated risk of LRTI and severe LRTI increased by 69% [adjusted relative risk (RR) = 1.69; 95% confidence interval (CI), 1.36-2.09)] and 54% (RR = 1.54; 95% CI, 1.21-1.97), respectively, for infants of mothers with urinary arsenic concentrations in the highest quintile (average of arsenic concentrations measured in early and late gestation, 262-977 µg/L) relative to those with exposure in the lowest quintile (< 39 µg/L). The corresponding figure for diarrhea was 20% (RR = 1.20; 95% CI, 1.01-1.43).

CONCLUSIONS

Arsenic exposure during pregnancy was associated with increased morbidity in infectious diseases during infancy. Taken together with the previous evidence of adverse effects on health, the findings strongly emphasize the need to reduce arsenic exposure via drinking water.

Environmental toxicants and the developing immune system: a missing link in the global battle against infectious disease?

There is now compelling evidence that developmental exposure to chemicals from our environment contributes to disease later in life, with animal models supporting this concept in reproductive, metabolic, and neurodegenerative diseases. In contrast, data regarding how developmental exposures impact the susceptibility of the immune system to functional alterations later in life are surprisingly scant. Given that the immune system forms an integrated network that detects and destroys invading pathogens and cancer cells, it provides the body's first line of defense. Thus, the consequences of early life exposures that reduce immune function are profound. This review summarizes available data for pollutants such as cigarette smoke and dioxin-like compounds, which consistently support the idea that developmental exposures critically impact the immune system. These findings suggest that exposure to common chemicals from our daily environment represent overlooked contributors to the fact that infectious diseases remain among the top five causes of death worldwide.

Maternal experiences of intimate partner violence and child morbidity in Bangladesh: evidence from a national Bangladeshi sample

OBJECTIVE

To provide an estimate of the risk of recent acute respiratory tract infection (ARI) and diarrhea among children 5 years and younger based on recent violence against their mothers.

DESIGN

The 2004 Bangladesh Demographic Health Survey, conducted from January 1 to May 31, 2004.

SETTING

Selected urban and rural areas of Bangladesh.

PARTICIPANTS

A total of 1592 women currently married, with at least 1 child 5 years of age or younger, each living with her husband and child(ren). Main Exposure Intimate partner violence (IPV) against women. Outcomes Measures The prevalence of past-year IPV was calculated. The risk of ARI and diarrhea within the past 2 weeks among young children was determined based on maternal experiences of IPV within the past year via analyses adjusted for demographics and environmental risks.

RESULTS

More than 2 of 5 married Bangladeshi mothers (42.4%) with children aged 5 years and younger experienced IPV from their husbands in the past year. Mothers who experienced IPV were more likely to report recent ARI (adjusted odds ratio, 1.37; 95% confidence interval, 1.03-1.83) and diarrhea (adjusted odds ratio, 1.65; 95% confidence interval, 1.15-2.38) among their young children compared with those who did not experience IPV.

CONCLUSIONS

Large numbers of married Bangladeshi women with young children experience IPV. Associations of maternal experiences of IPV with 2 leading causes of childhood mortality strongly suggest that such abuse threatens not only the health of women but also that of their children. Prevention of IPV perpetration by men may be critical to the improvement of maternal and child health.

Costing of severe pneumonia in hospitalized infants and children aged 2-36 months, at a secondary and tertiary level hospital of a not-for-profit organization

OBJECTIVES

To determine health care provider cost and household cost of the treatment of severe pneumonia in infants and young children admitted to secondary and tertiary level health care facilities.

METHODS

The study was done in a private, not-for-profit medical college hospital, in Vellore, India, in mid-2008. Children aged 2-36 months admitted with severe pneumonia with no underlying chronic disease were included in the study. The relatives were interviewed daily on matters relating to patients' view point of the costs. These were direct medical costs, direct non-medical costs which comprised travel, accommodation and special food during the period of illness, and indirect costs of productivity loss for family members. Patient specific resource consumption and related charges were recorded from charts, nursing records, pharmacy lists and hospital bills, and the providers view point of the costs was estimated. Unit cost estimates for bed days, treatment and investigation inputs were calculated.

RESULTS

Total cost to health care provider for one episode of hospitalized childhood pneumonia treated at secondary level was US$ 83.89 (INR 3524) and US$ 146.59 (INR 6158) at tertiary level. At both levels the greatest single cost was the hospital stay itself, comprising 74% and 56% of the total cost, respectively. Diagnostic investigations were a large expense and supportive treatment with nebulization and oxygen therapy added to the costs. Mean household expenditure on secondary level was US$ 41.35 (INR 1737) and at tertiary level was US$ 134.62 (INR 5655), the largest single expense being medicines in the former and the hospitalization in the latter. (one US$=INR 42.1 at time of study)

CONCLUSIONS

A considerable cost difference exists between secondary and tertiary level treatment. Admission at lowest possible treatment level for appropriate patients could decrease the costs borne by the provider and the patient.

The aryl hydrocarbon receptor is a modulator of anti-viral immunity

Although immune modulation by AhR ligands has been studied for many years, the impact of AhR activation on host defenses against viral infection has not, until recently, garnered much attention. The development of novel reagents and model systems, new information regarding anti-viral immunity, and a growing appreciation for the global health threat posed by viruses have invigorated interest in understanding how environmental signals affect susceptibility to and pathological consequences of viral infection. Using influenza A virus as a model of respiratory viral infection, recent studies show that AhR activation cues signaling events in both leukocytes and non-immune cells. Functional alterations include suppressed lymphocyte responses and increased inflammation in the infected lung. AhR-mediated events within and extrinsic to hematopoietic cells has been investigated using bone marrow chimeras, which show that AhR alters different elements of the immune response by affecting different tissue targets. In particular, suppressed CD8(+) T cell responses are due to deregulated events within leukocytes themselves, whereas increased neutrophil recruitment to and IFN-gamma levels in the lung result from AhR-regulated events extrinsic to bone marrow-derived cells. This latter discovery suggests that epithelial and endothelial cells are overlooked targets of AhR-mediated changes in immune function. Further support that AhR influences host cell responses to viral infection are provided by several studies demonstrating that AhR interacts directly with viral proteins and affects viral latency. While AhR clearly modulates host responses to viral infection, we still have much to understand about the complex interactions between immune cells, viruses, and the host environment.

Indoor air pollution: a poverty-related cause of mortality among the children of the world

This article reviews the research on the relation between indoor air pollution exposure and acute respiratory infection (ARI) in children in developing countries. ARI is a cause of death globally, causing approximately 19% of all deaths before the age of 5 years, according to a World Health Organization estimate. Indoor air pollution from biomass fuels, which is strongly poverty related, has long been regarded as an important risk factor for ARI morbidity and mortality. The empirical base for this view is comparatively narrow, with few empirical studies in relation to the magnitude of the global public health importance of the problem. Most existing reports consistently indicate that indoor air pollution is indeed a risk factor for ARI, but studies are generally small and use indirect indicators of pollution, such as use of biomass fuel or type of stove. Exposure assessment for indoor air pollution in developing countries is recognized as a major obstacle because of high cost and infrastructural limitations to chemical pollution sampling. Use of proxy indicators without measurement support may increase the risk of both misclassification of exposure and of confounding by other poverty-related factors. The issue of sufficient sample size further underlines the need for decisions to invest in this research field. Areas where further research is needed also include exploring qualitatively options for interventions that are culturally and economically acceptable to local communities.

Environmental toxins as modulators of antiviral immune responses

Exposure to environmental contaminants has a profound effect on immune function, yet mechanistic understanding of how pollutants deregulate immune responses has, for many chemicals, remained elusive. Available data suggest that certain pollutants alter host immune responses and increase susceptibility to viral infection. In particular, data from a combination of epidemiological and animal studies show that exposure to dioxins, cigarette smoke, diesel exhaust and other air pollutants increase pathology associated with infection. Mechanistically, some of these chemicals disrupt the kinetics and efficacy of innate and adaptive responses to infection, whereas others influence viral latency. While there remain considerable gaps in our knowledge of the complex interactions between viruses, immune cells, and the host environment, these observations indicate that pollutants are important but overlooked contributors to susceptibility and pathogenesis of viral infections.

Respiratory syncytial virus: disease, development and treatment

Respiratory syncytial virus (RSV) is spread by droplets and causes infections of the upper and lower respiratory tract. It is most common in infants, children under the age of five years and the elderly. Due to the nature of the transmission, infections with RSV are contagious but usually short lived. Pharmacological treatment involves the use of antiviral medication. Nurses caring for older people, infants or young children should be aware of the risk of transmission of RSV, pathogenesis and treatment options available to effectively manage the care of patients.

Office pediatrics: current perspectives on the outpatient evaluation and management of lower respiratory infections in children

PURPOSE OF REVIEW

The outpatient evaluation and management of a child with lower respiratory infection (LRI) remain a challenge to clinicians worldwide. This update will discuss current problems and new developments in the outpatient evaluation and treatment of pediatric LRIs.

RECENT FINDINGS

The cause of pediatric LRIs remains partially defined. Mixed infections and 'unknown' organisms may be important sources of clinical illness. A wider incidence of atypical bacteria LRIs (notably Mycoplasma pneumoniae) in children is now recognized. Viral LRIs from rhinoviruses and human metapneumovirus are increasingly detected in children. Human metapneumovirus may compound the clinical severity of pediatric LRIs, specifically in combination with respiratory syncytial virus. Innovations in testing for viral LRIs offer a promising tool for the outpatient evaluation and management of pediatric LRIs.

SUMMARY

Neither clinical symptoms nor findings on chest radiographs can reliably distinguish children with bacterial LRIs from those with viral or atypical pathogens. The efficacy of outpatient antibiotic treatment of atypical bacteria LRIs remains unproven. Multiplex rapid viral testing may ultimately help to refine strategies for outpatient management. The outpatient treatment of viral LRIs remains limited to supportive care; the 'value' of bronchodilators, epinephrine, or corticosteroids for treatment of bronchiolitis is unconfirmed.