Identification of children at risk of influenza-related complications in primary and ambulatory care: a systematic review and meta-analysis

Clinical Evaluation of the BIOFIRE SPOTFIRE Respiratory Panel

The BIOFIRE SPOTFIRE Respiratory (R) Panel is a novel, in vitro diagnostic PCR assay with 15 pathogen targets. The runtime is about 15 min which is the shortest among similar panels in the market. We evaluated the performance of the SPOTFIRE R Panel with 151 specimens, including 133 collected from the upper respiratory tract (URT), 13 from the lower respiratory tract (LRT) and 5 external quality assessment program (EQAP) samples. The respiratory specimens were enrolled throughout the first two post-COVID-19 influenza seasons in Hong Kong (March to December 2023). For URT specimens, full concordance was observed between the SPOTFIRE R Panel and the standard-of-care FilmArray Respiratory 2.1 plus Panel (RP2.1plus) for 109 specimens (109/133, 81.95%). After discrepant analysis, the SPOTFIRE R Panel identified more pathogens than the RP2.1plus in 15 specimens and vice versa in 3 specimens. The per-target negative and positive percentage agreement (NPA and PPA) were 92.86-100% except the PPA of adenovirus (88.24%). For LRT and EQAP samples, all results were fully concordant. To conclude, the performance of the SPOTFIRE R Panel was comparable to the RP2.1plus.

Clinical Profile, Intensive Care Needs and Predictors of Outcome Among Children Admitted with Non-COVID Severe Acute Respiratory Illness (SARI) During the Pandemic

OBJECTIVES

To study the epidemiology of non-coronavirus disease-2019 (non-COVID-19) respiratory viral infections with respect to their clinical profile, intensive care needs and predictors of outcome once the non-pharmacological interventions (NPI) during the coronavirus disease-2019 (COVID-19) pandemic were relaxed.

METHODS

Retrospective analysis of children with Severe Acute Respiratory Illness (SARI) who were SARS-CoV-2 negative, admitted to the Pediatric Emergency/Intensive Care Unit (PICU) from July 2021 through October 2021 was conducted.

RESULTS

One hundred and thirty nine children with median age of 11 (4-28.5) mo were included. Besides respiratory symptoms in all, diarrhea was reported in 90 (64.7%) children. Nearly half (n = 66; 47%) presented in hypoxemic respiratory failure (SpO2 <88%). Fifty-two (37.4%) children had co-morbidities, commonest being congenital heart disease in 12 (23.1%). Baseline parameters revealed leukopenia (specifically lymphopenia) 39 (28%), elevated aspartate transaminase [Serum glutamic-oxaloacetic transaminase (SGOT)] in 108 (77.6%), elevated N-acetyl-cysteine-activated creatinine kinase (CK-NAC) 23 (79%) and lactate dehydrogenase (LDH) 15 (88%). Intensive care needs included mechanical ventilation 51 (36.6%), vasoactive support 34 (24.5%), and renal replacement therapy 10 (7.1%). Forty-two (30.2%) children developed multi-organ dysfunction syndrome (MODS). One hundred and three (74.1%) children were discharged, 31 (22.3%) died, and 5 (3.6%) left against medical advice. On multivariate regression analysis, elevated liver enzymes (>5 times normal), hypoxemic respiratory failure at admission, hypotensive shock and MODS predicted mortality.

CONCLUSIONS

A surge in non-COVID SARI was observed once lockdown measures were relaxed. Nearly 1/3rd progressed to multi-organ failure and died. Elevated liver enzymes, hypoxemic respiratory failure at admission, hypotensive shock and MODS predicted death.

Trends in Outpatient Influenza Antiviral Use Among Children and Adolescents in the United States

BACKGROUND

Influenza antivirals improve outcomes in children with duration of symptoms <2 days and those at high risk for influenza complications. Real-world prescribing of influenza antivirals in the pediatric population is unknown.

METHODS

We performed a cross-sectional study of outpatient and emergency department prescription claims in individuals <18 years of age included in the IBM Marketscan Commercial Claims and Encounters Database between July 1, 2010 and June 30, 2019. Influenza antiviral use was defined as any dispensing of oseltamivir, baloxavir, or zanamivir. The primary outcome was the rate of antiviral dispensing per 1000 enrolled children. Secondary outcomes included antiviral dispensing per 1000 influenza diagnoses and inflation-adjusted costs of antiviral agents. Outcomes were calculated and stratified by age, acute versus prophylactic treatment, influenza season, and geographic region.

RESULTS

The analysis included 1 416 764 unique antiviral dispensings between 2010 and 2019. Oseltamivir was the most frequently prescribed antiviral (99.8%). Dispensing rates ranged from 4.4 to 48.6 per 1000 enrolled children. Treatment rates were highest among older children (12-17 years of age), during the 2017 to 2018 influenza season, and in the East South Central region. Guideline-concordant antiviral use among young children (<2 years of age) at a high risk of influenza complications was low (<40%). The inflation-adjusted cost for prescriptions was $208 458 979, and the median cost ranged from $111 to $151.

CONCLUSIONS

There is wide variability and underuse associated with influenza antiviral use in children. These findings reveal opportunities for improvement in the prevention and treatment of influenza in children.

Platelet count and risk of severe illness in hospitalised children with Influenza-Like illness

AIM

To examine the clinical significance of thrombocytosis (platelets > 500 × 109 /L) in admitted children with an influenza-like illness.

METHODS

We performed a database analysis consisting of patients evaluated at our medical centers with an influenza-like illness between 2009 and 2013. We included paediatric patients and examined the association between platelet count, respiratory viral infections, and admission outcomes (hospital length of stay and admission to the paediatric intensive care unit) using regression models adjusting for multiple variables.

RESULTS

A total of 5171 children were included in the study cohort (median age 0.8 years; interquartile range, 0.2-1.8; 58% male). Younger age, and not the type of viral infection, was associated with a high platelet count (p < 0.001). Elevated platelet count independently predicted admission outcomes (p ≤ 0.05). The presence of thrombocytosis was associated with an increased risk for a prolonged length of stay (odds ratio = 1.2; 95% Confidence interval = 1.1 to 1.4; p = 0.003) and admission to the paediatric intensive care unit (odds ratio = 1.5; 95% Confidence interval = 1.1 to 2.0; p = 0.002).

CONCLUSION

In children admitted with an influenza-like illness, a high platelet count is an independent predictor of admission outcomes. Platelet count may be used to improve risk assessment and management decisions in these paediatric patients.

Severe Influenza Virus and Respiratory Syncytial Virus Infections in Intensive Care Over the Last 15 Years

INTRODUCTION

Influenza virus is a common agent of pediatric infections. Most cases are mild, but severe illness and death can occur. We aimed to analyze severe cases associated the influenza virus and compare it with respiratory syncytial virus (RSV).

METHODS

This is a retrospective study of 0-17-year-old patients admitted to the intensive care unit (ICU) of Hospital Pediátrico, Centro Hospitalar e Universitário de Coimbra (Pediatric Hospital, Coimbra Hospital and University Center), a tertiary pediatric hospital in Coimbra, Portugal, over the last 15 years (2008-2022) due to influenza virus infection. Clinical presentation, severity, and evolution were analyzed. A comparison of children with RSV infection admitted in the same period was performed.

RESULTS

We identified 47 cases of influenza virus infection (34% coinfection with other viruses), median age of 2.3 years (interquartile range (IQR) 6.1), and 38% had comorbidities. The median admissions were three/year (maximum 11 in 2019). Influenza A was identified in 96%. Ninety-six percent had respiratory symptoms, 38% had neurologic symptoms, and 28% had sepsis. The main reason for admission was respiratory failure (68%). The mean pediatric index of mortality 2 (PIM2) at admission was 9±15.9%. Ventilatory support was necessary in 66%, vasoactive support in 19%, and blood products in 17%. The median length of stay was four days (IQR 5). There were four (8.5%) deaths. During the same study period, there were 171 RSV-related admissions. When comparing influenza (group A, without RSV coinfection) and RSV (group B), the first had a higher PIM2 on admission, greater need of ventilatory support, more complications, and higher mortality (p=0.001).

CONCLUSIONS

The number of influenza virus infections admitted to ICU was much lower than RSV. However, influenza was more severe and associated with all deaths registered.

Age Differences in Comorbidities, Presenting Symptoms, and Outcomes of Influenza Illness Requiring Hospitalization: A Worldwide Perspective From the Global Influenza Hospital Surveillance Network

Background

The Global Influenza Hospital Surveillance Network (GIHSN) was established in 2012 to conduct coordinated worldwide influenza surveillance. In this study, we describe underlying comorbidities, symptoms, and outcomes in patients hospitalized with influenza.

Methods

Between November 2018 and October 2019, GIHSN included 19 sites in 18 countries using a standardized surveillance protocol. Influenza infection was laboratory-confirmed with reverse-transcription polymerase chain reaction. A multivariate logistic regression model was utilized to analyze the extent to which various risk factors predict severe outcomes.

Results

Of 16 022 enrolled patients, 21.9% had laboratory-confirmed influenza; 49.2% of influenza cases were A/H1N1pdm09. Fever and cough were the most common symptoms, although they decreased with age (P < .001). Shortness of breath was uncommon among those <50 years but increased with age (P < .001). Middle and older age and history of underlying diabetes or chronic obstructive pulmonary disease were associated with increased odds of death and intensive care unit (ICU) admission, and male sex and influenza vaccination were associated with lower odds. The ICU admissions and mortality occurred across the age spectrum.

Conclusions

Both virus and host factors contributed to influenza burden. We identified age differences in comorbidities, presenting symptoms, and adverse clinical outcomes among those hospitalized with influenza and benefit from influenza vaccination in protecting against adverse clinical outcomes. The GIHSN provides an ongoing platform for global understanding of hospitalized influenza illness.

Immunization status of patients with spinal muscular atrophy receiving nusinersen therapy

BACKGROUND

Children with chronic neurological diseases, including spinal muscular atrophy (SMA), are particularly susceptible to vaccine-preventable infections. We aimed to evaluate the age-appropriate immunization status and its relationship with nusinersen therapy in pediatric patients with SMA.

METHODS

Children with SMA who received nusinersen treatment were included in this cross-sectional prospective study. Data were collected on SMA characteristics, nusinersen therapy, vaccination status according to the National Immunization Program (NIP), administration, and influenza vaccination recommendation.

RESULTS

A total of 32 patients were enrolled. In patients with SMA type 1, the frequency of under-vaccination of hepatitis B, BCG, DTaP-IPV-HiB, OPV, and MMR was statistically higher than in patients with SMA type 2-3 (p<0.001). The influenza vaccine was administered to only 9.3% of patients and was never recommended to 13 (40.6%) parents. The frequency of under-vaccination of hepatitis B, BCG, DTaP-IPV-HiB, OPV, and MMR was statistically higher in patients receiving nusinersen maintenance therapy than in those with loading doses (p<0.001). Physician recommendations for influenza and pneumococcal vaccines were significantly higher in the nusinersen maintenance group (p = 0.029). There was no statistical significance between the groups in terms of administration of influenza and pneumococcal vaccines (p = 0.470).

CONCLUSION

Children with SMA had lower immunization rates and poor compliance with immunization programs. Clinicians should ensure that children with SMA receive the same preventive health measures as healthy children, including vaccinations.

Viral Pneumonia during the COVID-19 Pandemic, 2019-2021 Evoking Needs for SARS-CoV-2 and Additional Vaccinations

Coronaviruses can cause pneumonia, with clinical symptoms that may be similar to the symptoms of other viral pneumonias. To our knowledge, there have been no reports regarding cases of pneumonia caused by coronaviruses and other viruses among hospitalized patients in the past 3 years before and during coronavirus disease 2019 (COVID-19). Here, we analysed the causes of viral pneumonia among hospitalized patients during the coronavirus disease 2019 (COVID-19) pandemic (2019-2021). Between September 2019 and April 2021, patients hospitalized at Shuang Ho Hospital in north Taiwan with a diagnosis of pneumonia were enrolled in this study. Age, sex, onset date, and season of occurrence were recorded. Respiratory tract pathogens were identified with molecular detection using the FilmArray^® platform from nasopharyngeal swabs. In total, 1147 patients (128 patients aged <18 years and 1019 patients aged ≥18 years) with pneumonia and identified respiratory tract pathogens were assessed. Among the 128 children with pneumonia, the dominant viral respiratory pathogen was rhinovirus (24.2%), followed by respiratory syncytial virus (RSV; 22.7%), parainfluenza virus (1 + 2 + 3 + 4) (17.2%), adenovirus (12.5%), metapneumovirus (9.4%), coronavirus (1.6%), and influenza virus (A + B) (1.6%). Among the 1019 adults with pneumonia, the dominant viral respiratory pathogen was rhinovirus (5.0%), followed by RSV (2.0%), coronavirus (2.0%), metapneumovirus (1.5%), parainfluenza virus (1 + 2 + 3 + 4) (1.1%), adenovirus (0.7%), and influenza virus (A + B) (0%). From 2019-2021, older patients (aged >65 years) with pneumonia tested positive for coronavirus most commonly in autumn. Coronavirus was not detected during summer in children or adults. Among children aged 0-6 years, RSV was the most common viral pathogen, and RSV infection occurred most often in autumn. Metapneumovirus infection occurred most often in spring in both children and adults. In contrast, influenza virus was not detected in patients with pneumonia in any season among children or adults from January 2020 to April 2021. Among all patients with pneumonia, the most common viral pathogens were rhinovirus in spring, adenovirus and rhinovirus in summer, RSV and rhinovirus in autumn, and parainfluenza virus in winter. Among children aged 0-6 years, RSV, rhinovirus, and adenovirus were detected in all seasons during the study period. In conclusion, the proportion of pneumonia cases caused by a viral pathogen was higher in children than the proportion in adults. The COVID-19 pandemic period evoked a need for SARS-CoV-2 (severe acute respiratory disease coronavirus 2) vaccination to prevent the severe complications of COVID-19. However, other viruses were also found. Vaccines for influenza were clinically applied. Active vaccines for other viral pathogens such as RSV, rhinovirus, metapneuomoccus, parainfluenza, and adenovirus may need to be developed for special groups in the future.

Outcomes of immunocompromised children hospitalized for influenza, 2010-2021, the Canadian Immunization Monitoring program active (IMPACT)

OBJECTIVES

To evaluate immunocompromising conditions and subgroups of immunocompromise as risk factors for severe outcomes among children admitted for influenza.

METHODS

We performed active surveillance for laboratory-confirmed influenza hospitalizations among children ≤16 years old at the 12 Canadian Immunization Monitoring Program Active hospitals, during 2010-2021. Logistic regression analyses were used to compare outcomes between immunocompromised and non-immunocompromised children, and for different subgroups of immunocompromise. The primary outcome was intensive care unit (ICU) admission; secondary outcomes were mechanical ventilation and death.

RESULTS

Among 8982 children, 892 (9.9%) were immunocompromised; these patients were older (median 5.6 [IQR 3.1 - 10.0] vs 2.4 [1 -6] years, p<0.001) than non-immunocompromised children, had similar frequency of comorbidities excluding immunocompromise and/or malignancy (38% [340/892) vs 40% [3272/8090], p=0.2), but fewer respiratory symptoms, such as respiratory distress (20% [177/892] vs 42% [3424/8090], p<0.001). In multivariable analyses, immunocompromise (adjusted odds ratio [aOR] 0.19, 95% CI 0.14-0.25) and its subcategories immunodeficiency (aOR 0.16, 95% CI 0.10-0.23), immunosuppression (aOR 0.17, 95% CI 0.12-0.23), chemotherapy (aOR 0.07, 95% CI 0.03-0.13) and solid organ transplantation (aOR 0.17, 95% CI 0.06-0.37) were associated with decreased probability of ICU admission in children admitted for influenza. Immunocompromise was also associated with decreased probability for mechanical ventilation (aOR 0.26, 95% CI 0.16-0.38) or death (aOR 0.22, 95% CI 0.03-0.72).

CONCLUSIONS

Immunocompromised children are overrepresented among hospitalizations for influenza, but have decreased probability of ICU admission, mechanical ventilation, and mortality following admission. Admission bias precludes generalizability beyond the hospital setting.

Short Message Service Reminder Nudge for Parents and Influenza Vaccination Uptake in Children and Adolescents With Special Risk Medical Conditions: The Flutext-4U Randomized Clinical Trial

Importance

Children with chronic medical conditions are at increased risk of severe influenza. Uptake of influenza vaccination in children and adolescents with these identified special risk medical conditions (SRMCs) is suboptimal.

Objective

To assess the effectiveness of Flutext-4U, a parent short message service (SMS) reminder nudge intervention, in increasing influenza immunization in children and adolescents with SRMCs.

Design, Setting, and Participants

This randomized clinical trial was conducted at a tertiary pediatric hospital in Adelaide, South Australia, from April 15 to September 30, 2021. Children and adolescents aged 6 months to younger than 18 years with SRMCs and a subspecialist outpatient appointment over a 5-month period during the Australian seasonal influenza vaccination season (April-August 2021) were eligible to participate. Follow-up was until September 30, 2021.

Interventions

Participants were randomly assigned (1:1 ratio) to control: clinician nudges (hospital vaccine availability, ease of access, and recommendation from hospital subspecialists) or SMS intervention (control conditions plus an additional SMS reminder nudge to parents), with randomization stratified by age group (<5 years, 5-14 years, or >14 to <18 years).

Main Outcomes and Measures

The primary outcome was influenza vaccination, as confirmed by the Australian Immunisation Register.

Results

A total of 600 participants (intervention group: 298 [49.7%]; mean [SD] age, 11.5 [4.6] years; 162 female participants [54.4%]; control group: 302 [50.3%]; mean [SD] age, 11.4 [4.7] years; 155 female participants [51.3%]) were included. Influenza vaccination was 38.6% (113 of 293) in the SMS intervention group compared with 26.2% (79 of 302) in the control group (adjusted odds ratio [aOR], 1.79; 95% CI, 1.27-2.55; P = .001). Time to vaccine receipt was significantly lower among SMS participants (adjusted hazard ratio, 1.67; 95% CI, 1.25-2.22; P < .001). For participants randomly assigned by June 15, a significantly greater proportion receiving the SMS intervention were vaccinated during the optimal delivery period April to June 30 (SMS group: 40.0% [76 of 190] vs 25.4% [50 of 197]; aOR, 1.97; 95% CI, 1.28-3.06; P = .002).

Conclusions and Relevance

Results of this randomized clinical trial suggest that an additional SMS reminder nudge for parents delivered in the tertiary care hospital setting to children and adolescents with SMRCs resulted in higher influenza vaccine uptake compared with clinician nudges alone.

Trial Registration

ANZCTR Identifier: ACTRN12621000463875.

Guideline-Concordant Antiviral Treatment in Children at High Risk for Influenza Complications

BACKGROUND

National guidelines recommend antiviral treatment for children with influenza at high risk for complications regardless of symptom duration. Little is known about concordance of clinical practice with this recommendation.

METHODS

We performed a cross-sectional study of outpatient children (aged 1-18 years) at high risk for complications who were diagnosed with influenza during the 2016-2019 influenza seasons. High-risk status was determined using an existing definition that includes age, comorbidities, and residence in a long-term care facility. The primary outcome was influenza antiviral dispensing within 2 days of influenza diagnosis. We determined patient- and provider-level factors associated with guideline-concordant treatment using multivariable logistic regression.

RESULTS

Of the 274 213 children with influenza at high risk for influenza complications, 159 350 (58.1%) received antiviral treatment. Antiviral treatment was associated with the presence of asthma (aOR, 1.13; 95% confidence interval [CI], 1.11-1.16), immunosuppression (aOR, 1.10; 95% CI, 1.05-1.16), complex chronic conditions (aOR, 1.04; 95% CI, 1.01-1.07), and index encounter in the urgent care setting (aOR, 1.3; 95% CI, 1.26-1.34). Factors associated with decreased odds of antiviral treatment include age 2-5 years compared with 6-17 years (aOR, 0.95; 95% CI, .93-.97), residing in a chronic care facility (aOR, .61; 95% CI, .46-.81), and index encounter in an emergency department (aOR, 0.66; 95% CI, .63-.71).

CONCLUSIONS

Among children with influenza at high risk for complications, 42% did not receive guideline-concordant antiviral treatment. Further study is needed to elucidate barriers to appropriate use of antivirals in this vulnerable population.

Obesity as a risk factor for severe influenza infection in children and adolescents: a systematic review and meta-analysis

Obesity has been recently identified as a predisposing factor for a worse prognosis in viral illnesses such as SARS-CoV-2; however, its role in children with influenza is not yet clarified. The current systematic review and meta-analysis aims to assess whether obesity is a risk factor for either hospitalization or a worse prognosis when hospitalized among children infected by influenza. We systematically searched the following databases using a structured algorithm: MEDLINE, Clinicaltrials.gov, and Cochrane Central Register of Controlled Trials (CENTRAL). Statistical meta-analysis was performed using the "meta" package in R software, and included studies were evaluated using the Newcastle-Ottawa scale. Among children with influenza, obesity increased the odds of hospitalization with a pooled OR of 1.89 (95% CI [1.23, 2.9], I² = 0, p = 0.003). When hospitalized, children with obesity were also more likely to have a worse outcome than their healthy-weight counterparts, with a pooled OR of 1.24 (95% Cl [1.02; 1.51], I² = 11, p = 0.03). In an effort to lower heterogeneity, a leave-one-out meta-analysis was conducted. Publication bias was assessed with the visual inspection of funnel plots and the trim-and-fill method. Certainty assessment was evaluated using the GRADE score.

CONCLUSIONS

The findings of our meta-analysis suggest that obesity in children with influenza is associated with a worse prognosis, both hospitalization and ICU admission/death.

WHAT IS KNOWN

• Obesity has been identified as a risk factor for non-communicable as well as communicable diseases. • A previous meta-analysis failed to demonstrate a statistically significant association between obesity and influenza infection severity.

WHAT IS NEW

• Children with high BMI and influenza infection are more likely to get hospitalized. • Pediatric inpatients with increased BMI and influenza infection may have a worse prognosis.

Australian hospital paediatricians and nurses' perspectives and practices for influenza vaccine delivery in children with medical comorbidities

INTRODUCTION

Influenza vaccination of children with medical comorbidities is critical due their increased risks for severe influenza disease. In Australia, hospitals are an avenue for influenza vaccine delivery to children with comorbidities but are not always effectively utilised. Qualitative enquiry sought to ascertainment the barriers and enablers for influenza vaccination recommendation, delivery, and recording of these children at Australian hospitals.

METHODS

Semi-structured interviews and discussion group sessions were conducted with paediatricians and nurses at four tertiary paediatric specialist hospitals and two general community hospitals in three Australian states. Transcripts from interviews and group sessions were inductively analysed for themes. The Capability, Opportunity, Motivation, and Behaviour (COM-B) model was used to explore the elements of each theme and identify potential interventions to increase influenza vaccination recommendation and delivery behaviours by providers.

RESULTS

Fifteen discussion sessions with 28 paediatricians and 26 nurses, and nine in-depth interviews (five paediatricians and four nurses) were conducted. Two central thematic domains were identified: 1. The interaction between hospital staff and parents/patients for influenza vaccine recommendation, and 2. Vaccination delivery and recording in the hospital environment. Six themes across these domains emerged detailing the importance of dedicated immunisation services, hospital leadership, paediatricians' vaccine recommendation role, the impact of comorbidities, vaccination recording, and cocooning vaccinations. Supportive hospital leadership, engaged providers, and dedicated immunisation services were identified as essential for influenza vaccination of children with comorbidities in Australian hospital.

CONCLUSION

Recommendation of influenza vaccination for Australian children with comorbidities is impacted by the beliefs of paediatricians and the perceived impact of influenza disease on children's comorbidities. Dedicated immunisation services and supportive hospital leadership were drivers for influenza vaccine delivery at hospitals. Future interventions targeting hospital-based influenza vaccine delivery for children with comorbidities should take a rounded approach targeting providers' attitudes, the hospital environment and leadership support.

Insights in paediatric virology during the COVID-19 era (Review)

The present article provides an overview of the key messages of the topics discussed at the '7th Workshop on Paediatric Virology', which was organised virtually on December 20, 2021 by the Institute of Paediatric Virology, located on the Island of Euboea in Greece. The workshop's plenary lectures were on: i) viral pandemics and epidemics in the ancient Mediterranean; ii) the impact of obesity on the outcome of viral infections in children and adolescents; and iii) COVID-19 and artificial intelligence. Despite the scarcity of evidence from fossils and remnants, viruses have been recognised as significant causes of several epidemics in the ancient Mediterranean. Paediatric obesity, a modifiable critical health risk factor, has been shown to impact on the development, progression and severity of viral infections. Thus, the prevention of paediatric obesity should be included in formulating public health policies and decision-making strategies against emerging global viral threats. During the current COVID-19 pandemic, artificial intelligence has been used to facilitate the identification, monitoring and prevention of SARS-CoV-2. In the future, it will play a fundamental role in the surveillance of epidemic-prone infectious diseases, in the repurposing of older therapies and in the design of novel therapeutic agents against viral infections. The collaboration between different medical specialties and other diverse scientific fields, including archaeology, history, epidemiology, nutritional technologies, mathematics, computer technology, engineering, medical law and ethics is essential for the successful management of paediatric viral infections. The current COVID-19 pandemic has underscored this need, which should be further encouraged in modern medical education.

Severe acute respiratory illness surveillance for influenza in Kenya: Patient characteristics and lessons learnt

Background

We describe the epidemiology and clinical features of Kenyan patients hospitalized with laboratory‐confirmed influenza compared with those testing negative and discuss the potential contribution of severe acute respiratory illness (SARI) surveillance in monitoring a broader range of respiratory pathogens.

Methods

We described demographic and clinical characteristics of SARI cases among children (<18 years) and adults, separately. We compared disease severity (clinical features and treatment) of hospitalized influenza positive versus negative cases and explored independent predictors of death among SARI cases using a multivariable logistic regression model.

Results

From January 2014 to December 2018, 11,166 persons were hospitalized with SARI and overall positivity for influenza was ~10%. There were 10,742 (96%) children (<18 years)—median age of 1 year, interquartile range (IQR = 6 months, 2 years). Only 424 (4%) of the SARI cases were adults (≥18 years), with median age of 38 years (IQR 28 years, 52 years). There was no difference in disease severity comparing influenza positive and negative cases among children. Children hospitalized with SARI who had an underlying illness had greater odds of in‐hospital death compared with those without (adjusted odds ratio 2.11 95% CI 1.09–4.07). No further analysis was done among adults due to the small sample size.

Conclusion

Kenya's sentinel surveillance for SARI mainly captures data on younger children. Hospital‐based platforms designed to monitor influenza viruses and associated disease burden may be adapted and expanded to other respiratory viruses to inform public health interventions. Efforts should be made to capture adults as part of routine respiratory surveillance.

Using provider-parent strategies to improve influenza vaccination in children and adolescents with special risk medical conditions: a randomised controlled trial protocol

INTRODUCTION

Influenza immunisation is a highly cost-effective public health intervention. Despite a comprehensive National Immunisation Program, influenza vaccination in children and adolescents with special risk medical conditions (SRMCs) is suboptimal. Flutext-4U is an innovative, multi-component strategy targeting paediatric hospitals, general practice and parents of children and adolescents with SRMC. The Flutext-4U study aims to assess the impact of Flutext-4U to increase influenza immunisation in children and adolescents with SRMC.

METHODS AND ANALYSIS

This is a randomised controlled trial involving parents of children and adolescents (aged >6 months to <18 years) with SRMC receiving tertiary care at the Women's and Children's Hospital (WCH), Adelaide, South Australia, who are eligible for funded influenza immunisation with a hospital appointment between the start of the seasonal influenza vaccination season and 31 July 2021, their treating general practitioners (GPs), and WCH paediatric specialists.Parents (of children/adolescents with SRMC) are randomised (1:1 ratio) to standard care plus intervention (SMS reminder messages to parents; reminders (written correspondence) for their child's GP from the hospital's Paediatric Outpatients Department) or standard care (hospital vaccine availability, ease of access and reminders for WCH subspecialists) with randomisation stratified by age-group (<5, 5-14, >14 to <18 years).The primary outcome is influenza vaccination, as confirmed by the Australian Immunisation Register.The proportion vaccinated (primary outcome) will be compared between randomised groups using logistic regression, with adjustment made for age group at randomisation. The effect of treatment will be described using an OR with a 95% CI.

ETHICS AND DISSEMINATION

The protocol and all study materials have been reviewed and approved by the Women's and Children's Health Network Human Research Ethics Committee (HREC/20/WCHN/5). Results will be disseminated via peer-reviewed publication and at scientific meetings, professional and public forums.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ACTRN12621000463875).

Comorbidities in Children with COVID-19 and MIS-C/PIMS-TS and Risk Factors for Hospitalization, Severe Disease, Intensive Care and Death

This narrative review sums up data from the SARS-CoV-2-pandemia on preexisting disease/underlying conditions/comorbidities and risk factors in children for severe COVID-19 and MIS-C/PIMS-TS as well as hospitalization and mortality. Young infants and adolescents are at highest risk of hospital and PICU admission. Two or more comorbidities rather than single entities pose a risk for more severe courses of SARS-CoV-2 infection in children. Asthma and malignancy do not increase complication rates. MIS-C/PIMS-TS is not associated with any specific underlying disease.

Evaluation of immunization status in patients with cerebral palsy: a multicenter CP-VACC study

Children with chronic neurological diseases, including cerebral palsy (CP), are especially susceptible to vaccine-preventable infections and face an increased risk of severe respiratory infections and decompensation of their disease. This study aims to examine age-appropriate immunization status and related factors in the CP population of our country. This cross-sectional prospective multicentered survey study included 18 pediatric neurology clinics around Turkey, wherein outpatient children with CP were included in the study. Data on patient and CP characteristics, concomitant disorders, vaccination status included in the National Immunization Program (NIP), administration, and influenza vaccine recommendation were collected at a single visit. A total of 1194 patients were enrolled. Regarding immunization records, the most frequently administrated and schedule completed vaccines were BCG (90.8%), hepatitis B (88.9%), and oral poliovirus vaccine (88.5%). MMR was administered to 77.3%, and DTaP-IPV-HiB was administered to 60.5% of patients. For the pneumococcal vaccines, 54.1% of children received PCV in the scope of the NIP, and 15.2% of children were not fully vaccinated for their age. The influenza vaccine was administered only to 3.4% of the patients at any time and was never recommended to 1122 parents (93.9%). In the patients with severe (grades 4 and 5) motor dysfunction, the frequency of incomplete/none vaccination of hepatitis B, BCG, DTaP-IPV-HiB, OPV, and MMR was statistically more common than mild to moderate (grades 1-3) motor dysfunction (p = 0.003, p < 0.001, p < 0.001, p < 0.00, and p < 0.001, respectively). Physicians' influenza vaccine recommendation was higher in the severe motor dysfunction group, and the difference was statistically significant (p = 0.029).Conclusion: Children with CP had lower immunization rates and incomplete immunization programs. Clinicians must ensure children with CP receive the same preventative health measures as healthy children, including vaccines. What is Known: • Health authorities have defined chronic neurological diseases as high-risk conditions for influenza and pneumococcal infections, and they recommend vaccines against these infections. • Children with CP have a high risk of incomplete and delayed immunization, a significant concern given to their increased healthcare needs and vulnerability to infectious diseases. What is New: • Influenza vaccination was recommended for patients hospitalized due to pneumonia at a higher rate, and patients were administered influenza vaccine more commonly. • Children with CP who had higher levels of motor dysfunction (levels 4 and 5) were more likely to be overdue immunizations.

Influenza hospitalizations in Australian children 2010-2019: The impact of medical comorbidities on outcomes, vaccine coverage, and effectiveness

BACKGROUND

Children with comorbidities are at greater risk of severe influenza outcomes compared with healthy children. In Australia, influenza vaccination was funded for those with comorbidities from 2010 and all children aged <5 years from 2018. Influenza vaccine coverage remains inadequate in children with and without comorbidities.

METHODS

Children ≤16 years admitted with acute respiratory illness and tested for influenza at sentinel hospitals were evaluated (2010-2019). Multivariable regression was used to identify predictors of severe outcomes. Vaccine effectiveness was estimated using the modified incidence density test-negative design.

RESULTS

Overall, 6057 influenza-confirmed hospitalized cases and 3974 test-negative controls were included. Influenza A was the predominant type (68.7%). Comorbidities were present in 40.8% of cases. Children with comorbidities were at increased odds of ICU admission, respiratory support, longer hospitalizations, and mortality. Specific comorbidities including neurological and cardiac conditions increasingly predisposed children to severe outcomes. Influenza vaccine coverage in influenza negative children with and without comorbidities was low (33.5% and 17.9%, respectively). Coverage improved following introduction of universal influenza vaccine programs for children <5 years. Similar vaccine effectiveness was demonstrated in children with (55% [95% confidence interval (CI): 45; 63%]) and without comorbidities (57% [(95%CI: 44; 67%]).

CONCLUSIONS

Comorbidities were present in 40.8% of influenza-confirmed admissions and were associated with more severe outcomes. Children with comorbidities were more likely experience severe influenza with ICU admission, mechanical ventilation, and in-hospital morality. Despite demonstrated vaccine effectiveness in those with and without comorbidities, vaccine coverage was suboptimal. Interventions to increase vaccination are expected to reduce severe influenza outcomes.

Influenza hospitalizations during childhood in children born preterm

Objective

The objective is to determine if children born preterm were at increased risk of influenza hospitalization up to age five.

Methods

National registry data on all children born in Norway between 2008 and 2011 were used in Cox regression models to estimate adjusted hazard ratios (aHRs) for influenza hospitalizations up to age five in children born preterm (<37 pregnancy weeks). HRs were also estimated separately for very preterm (<32 weeks), early term (37–38 weeks), and post‐term (≥42 weeks) children.

Results

Among 238,628 children born in Norway from January 2008 to December 2011, 15,086 (6.3%) were born preterm. There were 754 (0.3%) children hospitalized with influenza before age five. The rate of hospitalizations in children born preterm was 13.8 per 10,000 person‐years (95% confidence interval [CI] [11.3, 16.7]), and 5.9 per 10,000 person‐years (95% CI [5.5, 6.4]) in children born at term (≥37 weeks). Children born preterm had a higher risk of influenza hospitalization before age 5: aHR 2.33 (95% CI [1.85, 2.93]). The risk increased with decreasing gestational age and was highest among those born extremely/very preterm; aHR 4.07 (95% CI [2.63, 6.31]). Compared with children born at 40–41 weeks, children born early term also had an elevated risk of influenza hospitalization; aHR (37 weeks) 1.89 (95% CI [1.43, 2.50]), aHR (38 weeks) 1.43 (95% CI [1.15, 1.78]).

Conclusion

Children born preterm had a higher risk of influenza hospitalizations before age five. An elevated risk was also present among children born at an early term. Children born preterm could benefit from influenza vaccinations.

Risk factors in pediatric hospitalization for influenza A and B during the seven seasons immediately before the COVID-19 era in Japan

INTRODUCTION

The risk factors in pediatric influenza immediately before the COVID-19 era are not well understood. This study aims to evaluate the risk factors for hospitalization in pediatric influenza A and B for the recent seasons.

METHODS

Children with a fever of ≥38 °C and laboratory-confirmed influenza at 20 hospitals in outpatient settings in Japan in the 2013/14 to 2019/20 seasons were retrospectively reviewed. Possible risk factors, including gender, age, comorbidities, nursery school or kindergarten attendance, earlier diagnosis, no immunization, lower regional temperature, earlier season, and period of onset, were evaluated using binary logistic regression methods.

RESULTS

A total of 13,040 (type A, 8861; B, 4179) children were evaluated. Significant risk factors (p < 0.05) in multivariate analyses were young age, lower regional temperature, earlier season, respiratory illness (adjusted odds ratio [aOR]:2.76, 95% confidence interval [CI]:1.84-4.13), abnormal behavior and/or unusual speech (aOR:2.78, 95% CI:1.61-4.80), and seizures at onset (aOR:16.8, 95% CI:12.1-23.3) for influenza A; and young age, lower regional temperature, respiratory illness (aOR:1.99, 95% CI:1.00-3.95), history of febrile seizures (aOR:1.73, 95% CI:1.01-2.99), and seizures at onset (aOR:9.74, 95% CI:5.44-17.4) for influenza B.

CONCLUSIONS

In addition to previously known factors, including young age, seizures, and respiratory illness, abnormal behavior and/or unusual speech and lower regional temperature are new factors. Negative immunization status was not a risk factor for hospitalization. A better understanding of risk factors may help improve the determination of indications for hospitalization during the future co-circulation of influenza and COVID-19.

Clinical efficacy and safety of high dose trivalent influenza vaccine in adults and immunosuppressed populations - A systematic review and meta-analysis

OBJECTIVES

Influenza is associated with significant morbidity and mortality, especially in older and immunocompromised patients. Few data are available on the clinical benefit of high dose trivalent influenza vaccine (TIV). We aimed to assess the clinical efficacy and safety of high dose TIV.

METHODS

We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs), evaluating high dose versus standard dose TIV for prevention of seasonal influenza in adult population. Primary outcome was laboratory-confirmed influenza. Subgroups analyses included older adults and immunocompromised patients.

RESULTS

We included 16 trials, 47,857 patients; 10 included older adults and three immunocompromised patients. Laboratory confirmed influenza was significantly reduced with high dose TIV (relative risk 0.76, 95% confidence interval 0.64 to 0.9). This outcome stemmed mainly from one trial in older adults. Specifically, A(H3N2) laboratory confirmed influenza, but not A(H1N1) or B lineages, was reduced. No difference in mortality or hospitalizations was demonstrated. Immunological response was significantly higher with high dose vaccine. Serious adverse events were significantly less common in the high dose group.

CONCLUSIONS

High dose TIV lowers the rates of laboratory confirmed influenza, mainly A (H3N2), in older adults vs. standard dose. Further studies should address immunocompromised patients and report clinical outcomes.

Respiratory syncytial virus and influenza hospitalizations in Danish children 2010-2016

OBJECTIVE

To pave the way for universal or risk factor-based vaccination strategies, the present study aimed to describe the epidemiology and compare risk factors for hospitalization associated with respiratory syncytial virus (RSV) and influenza virus infections in Danish children.

METHODS

National register-based cohort study among 403,422 Danish children born 2010-2016.

RESULTS

Prior asthma hospitalization, number of children in the household, chronic disease and maternal history of asthma hospitalization were the most important risk factors for both RSV and influenza hospitalization. The incidence of influenza increased at school start.

CONCLUSIONS

Our findings enable targeted vaccination programs for high-risk children with asthma-like disease, chronic disease, siblings in the household, or maternal history of asthma hospitalization.

Factors That Influence Infant Immunity and Vaccine Responses

The neonatal period and early infancy are times of increased vulnerability to infection. The immune system of infants undergoes rapid changes and a number of factors can influence the maturation and function of the early infant immune system, amongst these factors are maternal infections and immunity. Infants who are HIV-exposed, but uninfected show important immune alterations, which are likely to be associated with the increased morbidity and mortality observed in these infants. Maternally derived antibodies are crucial in early life to protect infants from infection during the time when their own immune system is becoming more experienced and fully mature. However, maternal antibodies can also interfere with the infant's own antibody responses to primary vaccination. Preterm infants are particularly vulnerable to infection, having not had the opportunity to benefit from the transplacental transfer of maternal antibodies in late pregnancy. In addition, further differences have been observed in the innate and adaptive immune system between preterm and term infants. Here, we focus on maternal influences on the infant immune system, using HIV and maternal vaccination as examples and finish by considering how prematurity impacts infant immune responses to vaccination.

Global Ethical Considerations Regarding Mandatory Vaccination in Children

Whether children should be vaccinated against coronavirus disease-2019 (COVID-19) (or other infectious diseases such as influenza) and whether some degree of coercion should be exercised by the state to ensure high uptake depends, among other things, on the safety and efficacy of the vaccine. For COVID-19, these factors are currently unknown for children, with unanswered questions also on children's role in the transmission of the virus, the extent to which the vaccine will decrease transmission, and the expected benefit (if any) to the child. Ultimately, deciding whether to recommend that children receive a novel vaccine for a disease that is not a major threat to them, or to mandate the vaccine, requires precise information on the risks, including disease severity and vaccine safety and effectiveness, a comparative evaluation of the alternatives, and the levels of coercion associated with each. However, the decision also requires balancing self-interest with duty to others, and liberty with usefulness. Separate to ensuring vaccine supply and access, we outline 3 requirements for mandatory vaccination from an ethical perspective: (1) whether the disease is a grave threat to the health of children and to public health, (2) positive comparative expected usefulness of mandatory vaccination, and (3) proportionate coercion. We also suggest that the case for mandatory vaccine in children may be strong in the case of influenza vaccination during the COVID-19 pandemic.

The early use of Antibiotics for at Risk CHildren with InfluEnza-like illness (ARCHIE): a double-blind randomised placebo-controlled trial

INTRODUCTION

The UK government stockpiles co-amoxiclav to treat bacterial complications during influenza pandemics. This pragmatic trial examines whether early co-amoxiclav use reduces re-consultation due to clinical deterioration in "at risk" children presenting with influenza-like illness (ILI) in primary or ambulatory care.

METHODS

"At risk" children aged 6 months to 12 years presenting within f5 days of ILI onset were randomly assigned to oral co-amoxiclav 400/57 or placebo twice daily for 5 days (dosing based on age±weight). "At risk" groups included children with respiratory, cardiac, and neurological conditions. Randomisation was stratified by region and used a non-deterministic minimisation algorithm to balance age and current seasonal influenza vaccination status. Our target sample size was 650 children, which would have allowed us to detect a reduction in the proportion of children re-consulting due to clinical deterioration from 40% to 26% with 90% power and 5% two-tailed alpha error, including allowance for 25% loss to follow-up and an inflation factor of 1.041. Participants, caregivers and investigators were blinded to treatment allocation. Intention-to-treat analysis included all randomised participants with primary outcome data on re-consultation due to clinical deterioration within 28 days. Safety analysis included all randomised participants.

TRIAL REGISTRATION

ISRCTN 70714783. EudraCT 2013-002822-21.

RESULTS

We recruited 271 children between February 11, 2015 and April 20, 2018. Primary outcome data were available for 265 children. Only 61/265 children (23.0%) re-consulted due to clinical deterioration. No evidence of a treatment effect was observed for re-consultation due to clinical deterioration (co-amoxiclav 33/133 (24.8%), placebo 28/132 (21.2%), adjusted risk ratio [RR] 1.16, 95% confidence interval [CI] 0.75 to 1.80). There was also no evidence of a difference between groups in the proportion of children for whom one or more adverse events were reported (co-amoxiclav 32/136 (23.5%), placebo 22/135 (16.3%), adjusted RR 1.45, 95% CI 0.90 to 2.34). Sixty-six adverse events were reported in total (co-amoxiclav n=37, placebo n=29). Nine serious adverse events were reported per group; none were considered related to study medication.

CONCLUSION

Our trial did not find evidence that treatment with co-amoxiclav reduces risk of re-consultation due to clinical deterioration in "at risk" children who present early with ILI during influenza season. Our findings therefore do not support early co-amoxiclav use in children with seasonal ILI.

Ten Years of National Seasonal Surveillance for Severe Complications of Influenza in Australian Children

BACKGROUND

Severe complications of influenza in children are uncommon but may result in admission to hospital or an intensive care unit (ICU) and death.

METHODS

Active prospective surveillance using the Australian Paediatric Surveillance Unit with monthly reporting by pediatricians of national demographic and clinical data on children with <15 years of age hospitalized with severe complications of laboratory-confirmed influenza during ten influenza seasons 2008-2017.

RESULTS

Of 722 children notified, 613 had laboratory-confirmed influenza and at least one severe complication. Most (60%) were <5 years of age; 10% were <6 months, hence ineligible for vaccination. Almost half of all cases were admitted to ICU and 30 died. Most children were previously healthy: 40.3% had at least one underlying medical condition. Sixty-five different severe complications were reported; pneumonia was the most common, occurring in over half of all cases. Influenza A accounted for 68.6% hospitalizations; however, influenza B was more often associated with acute renal failure (P = 0.014), rhabdomyolysis (P = 0.019), myocarditis (P = 0.015), pericarditis (P = 0.013), and cardiomyopathy (P = 0.035). Children who died were more likely to be older (5-14 years), have underlying medical conditions, be admitted to ICU, and have encephalitis, acute renal failure, or myocarditis. Only 36.1% of all children reported received antiviral medications, and 8.5% were known to be vaccinated for seasonal influenza.

CONCLUSIONS

Severe influenza complications cause morbidity and mortality in children, which may increase if coinfection with COVID-19 occurs in the 2020 season and beyond. Increased vaccination rates, even in healthy children, early diagnosis and timely antiviral treatment are needed to reduce severe complications and death.

Improving Influenza Vaccination in Children With Comorbidities: A Systematic Review

CONTEXT

Children with medical comorbidities are at greater risk for severe influenza and poorer clinical outcomes. Despite recommendations and funding, influenza vaccine coverage remains inadequate in these children.

OBJECTIVE

We aimed to systematically review literature assessing interventions targeting influenza vaccine coverage in children with comorbidities and assess the impact on influenza vaccine coverage.

DATA SOURCES

PubMed, Scopus, Embase, Cumulative Index to Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, Allied and Complementary Medicine Database, and Web of Science databases were searched.

STUDY SELECTION

Interventions targeting influenza vaccine coverage in children with medical comorbidities.

DATA EXTRACTION

Two reviewers independently screened articles, extracting studies' methods, interventions, settings, populations, and results. Four reviewers independently assessed risk of bias.

RESULTS

From 961 screened articles, 35 met inclusion criteria. Published studies revealed that influenza vaccine coverage was significantly improved through vaccination reminders and education directed at either patients' parents or providers, as well as by vaccination-related clinic process changes. Interventions improved influenza vaccine coverage by an average 60%, but no significant differences between intervention types were detected. Significant bias and study heterogeneity were also identified, limiting confidence in this effect estimate.

LIMITATIONS

A high risk of bias and overall low quality of evidence limited our capacity to assess intervention types and methods.

CONCLUSIONS

Interventions were shown to consistently improve influenza vaccine coverage; however, no significant differences in coverage between different intervention types were observed. Future well-designed studies evaluating the effectiveness of different intervention are required to inform future optimal interventions.

Association between Maoto Use and Hospitalization for Seasonal Influenza in a Nonelderly Cohort in Japan

Objective Maoto is a traditional Japanese Kampo formula used to treat influenza. However, clinical evidence for maoto has been limited to small-scale studies of its effect in alleviating symptoms. The present study evaluated whether or not the addition of maoto to a neuraminidase inhibitor was associated with a reduction in hospitalization following influenza. Methods Using the JMDC Claims Database, we identified outpatients <60 years old who were diagnosed with influenza by an antigen test from September 2013 to August 2018. One-to-five propensity score matching was conducted between patients who received maoto in addition to a neuraminidase inhibitor and those who received a neuraminidase inhibitor alone. Hospitalization within seven days of the influenza diagnosis was compared in the matched groups using the Mantel-Haenszel test. Results We identified 1.79 million cases of influenza from the database in the 5-year study period. Maoto was prescribed for 3.9% of the 1.67 million cases receiving a neuraminidase inhibitor. In the 64,613 propensity score-matched groups of patients, the 7-day hospitalization rate was 0.116% (n=75) for patients with maoto and 0.122% (n=394) for patients without maoto. The difference between these treatment groups was nonsignificant (common odds ratio, 0.95; 95% confidence interval, 0.74 to 1.22; p=0.695). Conclusion The addition of maoto to a neuraminidase inhibitor was not associated with a decrease in hospitalization among nonelderly patients with influenza. Further research is necessary to clarify the indication and efficacy of maoto.

Immunogenicity and Safety of an MF59-adjuvanted Quadrivalent Seasonal Influenza Vaccine in Young Children at High Risk of Influenza-associated Complications: A Phase III, Randomized, Observer-blind, Multicenter Clinical Trial

BACKGROUND

Vaccination against seasonal influenza is recommended for all children with a history of medical conditions placing them at increased risk of influenza-associated complications. The immunogenicity and efficacy of conventional influenza vaccines among young children are suboptimal; one strategy to enhance these is adjuvantation. We present immunogenicity and safety data for an MF59-adjuvanted quadrivalent influenza vaccine (aIIV4) in healthy children and those at a high risk of influenza-associated complications, based on the results of a recently completed phase III study.

METHODS

Children 6 months to 5 years of age (N = 10,644) were enrolled. The study was conducted across northern hemisphere seasons 2013-2014 and 2014-2015. Subjects received either aIIV4 or a nonadjuvanted comparator influenza vaccine. Antibody responses were assessed by hemagglutination inhibition assay against vaccine and heterologous strains. Long-term antibody persistence was assessed (ClinicalTrials.gov: NCT01964989).

RESULTS

aIIV4 induced significantly higher antibody titers than nonadjuvanted vaccine in high-risk subjects. aIIV4 antibody responses were of similar magnitude in high-risk and healthy subjects. Incidence of solicited local and systemic adverse events (AEs) was slightly higher in aIIV4 than nonadjuvanted vaccinees, in both the healthy and high-risk groups. Incidence of unsolicited AEs, serious AEs and AEs of special interest were similar for adjuvanted and nonadjuvanted vaccinees in the healthy and high-risk groups.

CONCLUSION

aIIV4 was more immunogenic than nonadjuvanted vaccine in both the healthy and high-risk study groups. The reactogenicity and safety profiles of aIIV4 and the nonadjuvanted vaccine were acceptable and similar in 6-month- to 5-year-old high-risk and healthy children.

Factors associated with relapses in relapsing-remitting multiple sclerosis: A systematic review and meta-analysis

BACKGROUND

The relapse is character of relapsing-remitting multiple sclerosis. The therapeutic goal is to reduce the risk of relapse. Factors associated with relapses can help to manage and prevent relapses. In addition, patients and doctors all pay attention to it. However, there are differences between studies. Our aim is to summarize factors associated with relapses in relapsing-remitting multiple sclerosis (RRMS).

METHODS

PubMed, EMBASE, Web of science, Cochrane library, CNKI, Wanfang, SinoMed, and VIP were searched to identify risk factors about relapses in RRMS, which should be in cohort or case-control studies. This article was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The quality of studies was evaluated by the Newcastle-Ottawa Scale (NOS). Meta-analysis, subgroup and sensitivity analyses, and publication bias were all performed with Stata. This research has been registered on the international prospective register of systematic reviews (PROSPERO, CRD42019120502).

RESULTS

43 articles were included. Infection, postpartum period, risk gene, stress, and vitamin D were risk factors for relapses in RRMS. Pregnancy period was the protective factor. Among those, infection increased the risk of relapses in infection period (relative risk [RR], 2.07 [confidence interval (CI), 1.64 to 2.60]). Women in the postpartum period increased the risk of relapses compared with women before pregnancy (RR, 1.43 [CI, 1.19 to 1.72]), or women in pregnancy period (RR, 2.07 [CI, 1.49 to 2.88]). Women in the pregnancy period decreased the risk of relapses (RR, 0.56 [CI, 0.37 to 0.84]) compared with women before pregnancy. However, fewer studies, heterogeneity, and sample size were the limitations.

CONCLUSION

It is reliable to adopt results about infection, pregnancy period, and postpartum period.

Influenza-related hospitalizations due to acute lower respiratory tract infections in a tertiary care children's hospital in Turkey

BACKGROUND

The influenza virus is a significant cause of acute lower respiratory tract infections (LRTI) requiring hospitalization in childhood and leads to severe morbidity and mortality, especially in certain risk groups.

OBJECTIVES

The study aims to evaluate acute LRTI due to influenza in a tertiary care hospital and the risk factors for hospitalization among Turkish children.

STUDY DESIGN

Children between 1 month and 18 years of age who were hospitalized at Dr. Behçet Uz Children's Hospital between January 2016 and March 2018 with lower respiratory tract infection that tested positive for influenza by PCR were included. Children with viral coinfections were excluded. Patient files were retrospectively scanned from the hospital computerized system in terms of age, underlying diseases, whether antiviral therapy was used, and length of hospital stay. Statistical analysis was performed using SPSS statistical software.

RESULTS

The study included 131 patients with a median age of 2 years (1 month-15 years). Sixty-seven (51,1%) patients were younger than two years. Influenza A was isolated in 129 patients and B in 2 patients. Fifty-two patients (39,7%) had underlying medical conditions, and the most common one was malignancies (12/52, 23%). This was followed by neurodevelopmental diseases (9/52, 17,3%), prematurity (9/52 patients, 17,3%), primary immunodeficiency (8/52, 15,4%), asthma (7/52, 13,4%), Down syndrome (4/52, 7,7%), chronic renal disease (2/52, 3,8%) and congenital heart diseases (1/52, 1,9%). The mean length of stay (LOS) was 12,3 ± 9,5 days (2-60 days). The LOS was found to be statistically longer (15,2 ± 12,1 days, 3-60 days) in patients with an underlying disease compared to previously healthy patients (10,4 ± 6,7 days, 2-35 days) (p = 0.01).

CONCLUSIONS

Hospitalization due to influenza-related acute LRTI is not an issue only for patients with an underlying medical condition. Vaccination should be considered not only for those with underlying medical conditions but also for healthy children.

Serious outcomes of medically attended, laboratory-confirmed influenza illness among school-aged children with and without asthma, 2007-2018

Background

Asthma was associated with influenza hospitalizations in children during the 2009 pandemic, but it is unclear if asthma is associated with serious illness during seasonal epidemics. Little is known regarding the effect of vaccination on influenza severity in children with asthma.

Methods

Children aged 5‐17 years in a community cohort presenting with acute respiratory illness were prospectively enrolled and tested for influenza from 2007‐08 through 2017‐18 (excluding the 2009‐10 pandemic season). Data from the electronic health record were extracted to determine asthma status and serious outcomes associated with influenza infection. A serious outcome was defined as hospitalization, emergency department visit, and/or pneumonia diagnosis within 30 days of symptom onset. Multivariable logistic regression models were used to assess asthma status and effect of vaccination on odds of a serious outcome.

Results

One thousand seven hundred and sixty four medically‐attended influenza infections among school‐aged children were included. Asthma was confirmed in 287 (16%) children. A serious influenza‐associated outcome occurred in 104 (6%) children. The odds of a serious outcome did not differ between those with confirmed asthma and those without asthma [adjusted odds ratio (aOR): 1.35, 95% confidence interval (CI): (0.77‐2.35), P = .3]. The effect of vaccination on serious outcomes was not modified by asthma status [aOR for children without asthma: 0.55 (95% CI: 0.28‐1.07), children with asthma: 1.39 (95% CI: 0.53‐3.69); interaction P‐value = .12].

Conclusions

Asthma was not a risk factor for serious illness among children with influenza. Additional studies are needed to better understand the role of influenza vaccination in preventing serious outcomes among children with asthma.

Risk Factors for Influenza Virus Related Severe Lower Respiratory Tract Infection in Children

BACKGROUND

Influenza virus is one of the most common respiratory pathogens for all age groups and may cause seasonal outbreaks. Our aim was to identify risk groups and factors associated with severe clinical course including mortality in children with influenza-related lower respiratory tract infection (LRTI).

METHODS

We conducted a retrospective study in children hospitalized with influenza virus LRTI from 2008 to 2018. Data on demographic features, influenza type, viral coinfection, primary and secondary bacterial infections (SBIs), time of onset of antiviral treatment, comorbidities, hospitalization length, pediatric intensive care unit admission/invasive mechanical ventilation (IMV) need and mortality were collected from medical records.

RESULTS

There were 280 patients hospitalized with LRTI and median hospitalization length was 9 days. Congenital heart disease, neuromuscular disease, SBIs and late-onset antiviral treatment were independent risk factors for prolonged hospital stay (P < 0.05). Pediatric intensive care unit admission was present in 20.4% (57) of the patients and 17.1% (48) of all patients required IMV. SBIs, lymphopenia, neutrophilia, immunosuppression and human bocavirus coinfection were independent risk factors for IMV support (P < 0.05). Eighteen patients died and immunosuppression, lymphopenia and SBIs were independent risk factors for mortality (P < 0.05).

CONCLUSIONS

Presence of comorbidity, SBIs, neutrophilia and lymphopenia at admission identified as risk factors for severe influenza infections including need for IMV and death. Although several studies showed that antiviral treatment reduce hospitalization, complications and mortality, there is a lack of prospective trials and patients for antiviral therapy should be carefully chosen by the clinician.

The burden and clinical manifestation of hospitalized influenza among different pediatric age-groups in the tropics

Introduction

In tropical Singapore, influenza occurs all year‐round. This study of influenza‐confirmed hospitalized pediatric patients compared clinical characteristics and complications by age‐group and differences between influenza A and B.

Methods

This was a retrospective study of pediatric inpatients from January 2013 to December 2014. Patients were grouped into: <6 months, 6 months to <5 years, 5‐ to <10‐year and ≥10 years. Complications were classified into neurologic, pulmonary, and other. We also calculated the incidence of hospitalized influenza cases per 100 000 age‐related population.

Results

There were a total of 1272 patients with a median age of 37 months. The highest hospitalization rates were in the <6 months age‐group. Majority (75.2%) had no comorbidity; 25.6% had complications: neurologic 11.9%, pulmonary 9.6%, other 4.1%. Patients with other complications were older, male, and had the highest influenza B rates and the longest length of stay. Influenza A comprised 76.9% of cases and had higher complication rates especially neurologic, compared to influenza B. Influenza B patients were older and were more likely to develop other complications. The 6‐month to <5‐year‐age‐group had the highest complication rate (30.6%), especially neurologic. However, ≥10 years old had the highest other complications, ICU/ high‐dependency admissions and influenza B Victoria rates.

Conclusions

Infants <6 months had the highest hospitalization rates for influenza. The 6‐month to <5‐year‐age‐group had the highest complication rate especially neurologic. Influenza A patients were younger, had higher seizure rates and complications compared to influenza B.

Effectiveness of Partial and Full Influenza Vaccination Among Children Aged <9 Years in Hong Kong, 2011-2019

BACKGROUND

Two doses of influenza vaccination are recommended for previously unvaccinated children aged <9 years, and receipt of 1 dose is sometimes termed "partial vaccination." We assessed the effectiveness of partial and full influenza vaccination in preventing influenza-associated hospitalization among children in Hong Kong.

METHODS

Using the test-negative design we enrolled 23 187 children aged <9 years admitted to hospitals with acute respiratory illness from September 2011 through March 2019. Vaccination and influenza status were recorded. Fully vaccinated children included those vaccinated with 2 doses or, if previously vaccinated, those vaccinated with 1 dose. Partially vaccinated children included those who should have received 2 doses but only received 1 dose. We estimated vaccine effectiveness (VE) by using conditional logistic regression models matched on epidemiological week.

RESULTS

Overall VE estimates among fully and partially vaccinated children were 73% (95% confidence interval, 69%-77%) and 31% (95% confidence interval, 8%-48%), respectively. A consistently higher VE was observed in children fully vaccinated against each influenza virus type/subtype. The effectiveness of partial vaccination did not vary by age group.

CONCLUSIONS

Partial vaccination was significantly less effective than full vaccination. Our study supports the current recommendation of 2 doses of influenza vaccination in previously unvaccinated children <9 years of age.

Respiratory pathogens and clinical outcomes in children with an asthma exacerbation: A systematic review

BACKGROUND

In asthmatic children, respiratory pathogens are identified in 60%-80% of asthma exacerbations, contributing to a significant burden of illness. The role of pathogens in the clinical evolution of exacerbations is unknown.

OBJECTIVE

We systematically reviewed the association between the presence of pathogens and clinical outcomes in children with an asthma exacerbation.

METHOD

PubMed, EMBASE, BIOSIS, and the Cochrane Central Register of Controlled Trials were searched up to October 2016 for studies reporting on respiratory pathogen exposure and clinical outcome. The Risk of Bias in Non-Randomized Studies of Interventions tool was used for quality assessment.

RESULTS

Twenty-eight observational studies (N = 4,224 children) reported on 112 different associations between exposure to any pathogen (n = 45), human rhinovirus (HRV; n = 34), atypical bacteria (n = 21), specific virus (n = 11), or bacteria (n = 1) and outcomes of exacerbation severity (n = 26), health care use (n = 38), treatment response (n = 19), and morbidity (n = 29). Restricting the analysis only to comparisons with a low to moderate risk of bias, we observed an association between HRV and higher exacerbation severity on presentation (regression p = .016) and between the presence of any pathogen and emergency department treatment failure (odds ratio [OR] = 1.57; 95% CI 1.04% to 2.37%). High-quality evidence for effect on morbidity or health care use is lacking.

CONCLUSIONS

Further research on the role of pathogen-treatment interaction and outcomes is required to inform the need for point-of-care, real-time testing for pathogens. Studies with a sufficiently large sample size that address selection bias, correctly adjust for confounding, and rigorously report core patient-centred outcomes are necessary to improve knowledge.

Influenza in Children With Special Risk Medical Conditions: A Systematic Review and Meta-analysis

BACKGROUND

Children with special risk medical conditions (SRMC) are over-represented in influenza hospitalizations. A systematic review was undertaken to determine whether children with SRMCs experience greater complications or severity following influenza infection.

METHODS

Bibliographies of pertinent articles were searched in MEDLINE and EMBASE (1990 to March 2018) and contact made with the investigators of unpublished studies containing relevant data. Studies of children (aged ≤18 years) with a SRMC hospitalized with influenza were included. Outcomes were pneumonia, intensive care unit (ICU) admission, mechanical ventilation, neurologic outcomes (seizures, encephalopathy), death and length of stay in hospital or ICU.

RESULTS

Twenty-two studies met inclusion criteria. Compared with healthy peers, children with SRMC had higher odds of ICU admission [pooled odds ratio (OR) 1.66 (95% confidence interval (CI): 1.25-2.21)], for mechanical ventilation [pooled OR 1.53 (95% CI: 0.93-2.52)] and death [pooled OR 1.34 (95% CI: 0.74-2.41)]. Additionally, children with SRMC were more likely to develop bacterial pneumonia (crude OR 1.7; 95% CI: 1.1-2.6) or experience prolonged hospital length of stay [adjusted rate ratio 1.75 (95% CI: 1.44-2.11)]. The level of GRADE evidence was low for all outcomes considered in this review.

CONCLUSIONS

While there was evidence that ICU management and bacterial pneumonia increases in children with SRMC, evidence showing an increase in the probability of death or need for mechanical ventilation was inconsistent. Further research using large datasets should evaluate the impact of complications and associated morbidity from influenza in SRMC children.

National retrospective cohort study to identify age-specific fatality risks of comorbidities among hospitalised patients with influenza-like illness in Taiwan

OBJECTIVES

This study aimed to examine comprehensively the prognostic impact of underlying comorbidities among hospitalised patients with influenza-like illness (ILI) in different age groups and provide recommendations targeting the vulnerable patients.

SETTING AND PARTICIPANTS

A retrospective cohort of 83 227 hospitalised cases with ILI were identified from Taiwan's National Health Insurance Research Database from January 2005 to December 2010. Cases were stratified into three different age groups: paediatric (0-17 years), adult (18-64 years) and elderly (≧65 years), and their age, sex, comorbidity and past healthcare utilisation were analysed for ILI-associated fatality.

MAIN OUTCOME MEASURES

ORs for ILI-related fatality in different age groups were performed using multivariable analyses with generalised estimating equation models and adjusted by age, sex and underlying comorbidities.

RESULTS

Hospitalised ILI-related fatality significantly increased with comorbidities of cancer with metastasis (adjusted OR (aOR)=3.49, 95% CI: 3.16 to 3.86), haematological malignancy (aOR=3.02, 95% CI: 2.43 to 3.74), cancer without metastasis (aOR=1.72, 95% CI: 1.54 to 1.91), cerebrovascular (aOR=1.24, 95% CI: 1.15 to 1.33) and heart diseases (aOR=1.19, 95% CI: 1.11 to 1.27) for all age groups. Adult patients with AIDS; adult and elderly patients with chronic kidney disease, tuberculosis and diabetes were significantly associated with elevated risk of death. Severe liver diseases and hypothyroidism among elderly, and dementia/epilepsy among elderly and paediatrics were distinctively associated with likelihood of ILI-related fatality.

CONCLUSIONS

Different age-specific comorbidities were associated with increasing risk of death among hospitalised ILI patients. These findings may help update guidelines for influenza vaccination and other prevention strategies in high-risk groups for minimising worldwide ILI-related deaths.

Evaluation of nasal levels of interferon and clinical severity of influenza in children

BACKGROUND

Experimental data show that type I interferon has a key role in innate immune response against influenza infection.

OBJECTIVE

We compared nasal levels of interferon-α2 and β among inpatients and outpatients with influenza.

STUDY DESIGN

Children younger than 5 years of age with influenza-like illness seeking care at the emergency department within the first 72 h of disease onset were prospectively included. Clinical and demographic data and secretions through nasal wash were obtained. Influenza infection was assessed through reverse-transcription polymerase chain reaction and nasal levels of interferon-α2 and β were measured by enzyme-linked immunosorbent assay. All patients followed until the end of the disease.

RESULTS

One hundred patients were included, of which 24 had confirmed influenza infection, and 5 of them were hospitalized. Subtypes A (H3N2) and B were confirmed in 10 and 14 patients, respectively. Seventy-six patients without influenza, including 48% of outpatients, were recruited as controls. All hospitalized patients were significantly younger regardless of influenza status (age <6 months in 59% vs. 23.2%, p < 0.001). All other data were similar among the groups. Comparing median levels of interferon-α2 among children with influenza, levels were significantly higher in outpatients than in hospitalized patients and were 263.2 pg/mL (25-75 interquartile range: 58.3-634) and detectable in only one patient (90 pg/mL), respectively. The levels of interferon-α2 in controls and those of interferon-β in all groups were not detected.

CONCLUSIONS

Higher levels of interferon-α2 in patients with less severe influenza reinforce experimental evidence about the protective role of interferon-α2 against influenza infection.

Pediatric influenza and illness severity: what is known and what questions remain?

PURPOSE OF REVIEW

Influenza causes a range of illnesses in children, from uncomplicated self-limited illness to severe disease and death. This review provides an update on the severity and burden of influenza in US children over recent seasons.

RECENT FINDINGS

The 2017-2018 influenza season was widespread and severe across all ages, including children. Disease severity is influenced by influenza virologic characteristics and host factors, as well as public health interventions such as influenza vaccination and antiviral treatment. In recent influenza A (H3N2)-predominant seasons (2016-2017 and 2017-2018), influenza vaccination effectiveness was higher in younger children compared with older children and adolescents, although the reasons for this are unclear. Interestingly, even in seasons when influenza A (H3N2) viruses predominate, influenza A (H1N1)pdm09 and B viruses can play a large role in severe pediatric disease. Although children less than 5 years of age and those with underlying medical conditions are at increased risk for severe disease, influenza-associated hospitalizations and deaths occur every season in healthy children.

SUMMARY

Influenza causes a substantial burden of outpatient visits, hospitalizations, and deaths among children. Ongoing research is important to better characterize factors that contribute to influenza severity, and to identify strategies to improve the impact of influenza vaccination and treatment.

Updates on Influenza Vaccination in Children

Influenza vaccination is recommended for all children 6 months of age and older who do not have contraindications. This article provides an overview of information concerning burden of influenza among children in the United States; US-licensed influenza vaccines; vaccine immunogenicity, effectiveness, and safety; and recent updates relevant to use of these vaccines in pediatric populations. Influenza antiviral medications are discussed. Details concerning vaccine-related topics may be found in the current US Centers for Disease Control and Prevention/Advisory Committee on Immunization Practices recommendations for use of influenza vaccines (https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/flu.html). Additional information on influenza antivirals is located at https://www.cdc.gov/flu/professionals/antivirals/index.htm.

Increased Risk of Influenza and Influenza-Related Complications Among 140,480 Patients With Inflammatory Bowel Disease

BACKGROUND

Diseases of immune dysregulation are associated with an increased risk of viral infections, some of which may be preventable. To date, there are very limited data on the incidence and risk of influenza and related complications in patients with inflammatory bowel disease (IBD). Furthermore, the impact of immunosuppressive medications on that risk is unclear. Therefore, the aim of this study was to estimate the incidence and severity of influenza infections in IBD patients. In addition, we looked specifically at the effect of medications on influenza risk.

METHODS

Using the MarketScan Database (January 2008 to December 2011), we conducted a retrospective cohort study to estimate the incidence of influenza and risk of related complications in IBD patients compared with those without IBD. We employed a nested case-control study design to evaluate the potential independent effect of IBD medications on influenza risk.

RESULTS

A total of 140,480 patients with IBD and non-IBD controls were studied. There were 2963 patients with influenza compared with 1941 non-IBD subjects. Inflammatory bowel disease patients had an increased influenza risk compared with those without IBD (incidence rate ratio, 1.54; 95% confidence interval [CI], 1.49-1.63). A higher rate of hospitalizations (162/2994 [5.4%] vs 36/1941 [1.85%]; P < 0.001) was noted. Systemic corticosteroids were found to be independently associated with influenza (odds ratio, 1.22; 95% CI, 1.08-1.38).

CONCLUSIONS

Inflammatory bowel disease patients had an increased risk of influenza compared with those without IBD and were more likely to require hospitalization. Steroids were the only medication class independently associated with flu risk.

Nationwide Study on the Course of Influenza A (H1N1) Infections in Hospitalized Children in the Netherlands During the Pandemic 2009-2010

BACKGROUND

The influenza H1N1 pandemic of 2009-2010, provided a unique opportunity to assess the course of disease, as well as the analysis of risk factors for severe disease in hospitalized children (< 18 years).

METHODS

Retrospective national chart study on hospitalized children with H1N1 infection during the 2009-2010 pH1N1 outbreak.

RESULTS

Nine hundred forty patients (56% boys), median age 3.0 years, were enrolled; the majority were previously healthy. Treatment consisted of supplemental oxygen (24%), mechanical ventilation (5%) and antiviral therapy (63%). Fifteen patients died (1.6%), 5 of whom were previously healthy. Multivariable analyses confirmed pre-existent heart and lung disease as risk factors for intensive care unit admission. Risk factors for mortality included children with a neurologic or oncologic disease and psychomotor retardation.

CONCLUSIONS

This nationwide overview of hospitalized children confirms known risk groups for severe influenza infections. However, most of the acute and severe presentations of influenza occurred in previously healthy children.

Antibiotic use in children with asthma: cohort study in UK and Dutch primary care databases

OBJECTIVES

To compare the rate, indications and type of antibiotic prescriptions in children with and without asthma.

DESIGN

A retrospective cohort study.

SETTING

Two population-based primary care databases: Integrated Primary Care Information database (IPCI; the Netherlands) and The Health Improvement Network (THIN; the UK).

PARTICIPANTS

Children aged 5-18 years were included from January 2000 to December 2014. A child was categorised as having asthma if there were ≥2 prescriptions of respiratory drugs in the year following a code for asthma. Children were labelled as non-asthmatic if no asthma code was recorded in the patient file.

MAIN OUTCOME MEASURES

Rate of antibiotic prescriptions, related indications and type of antibiotic drugs.

RESULTS

The cohorts in IPCI and THIN consisted of 946 143 and 7 241 271 person years (PY), respectively. In both cohorts, antibiotic use was significantly higher in asthmatic children (IPCI: 197vs126 users/1000 PY, THIN: 374vs250 users/1000 PY). In children with asthma, part of antibiotic prescriptions were for an asthma exacerbation only (IPCI: 14%, THIN: 4%) and prescriptions were more often due to lower respiratory tract infections then in non-asthmatic children (IPCI: 18%vs13%, THIN: 21%vs12%). Drug type and quality indicators depended more on age, gender and database than on asthma status.

CONCLUSIONS

Use of antibiotics was higher in asthmatic children compared with non-asthmatic children. This was mostly due to diseases for which antibiotics are normally not indicated according to guidelines. Further awareness among physicians and patients is needed to minimise antibiotic overuse and limit antibiotic resistance.

Randomized Quality Improvement Trial of Opting-In Versus Opting-Out to Increase Influenza Vaccination Rates during Pregnancy

Introduction  Despite strong recommendations, only 40.6% of pregnant women attending two prenatal clinics were vaccinated against influenza during the 2009 pandemic. We tested whether an opting-out approach would improve vaccine uptake. Methods  We conducted a randomized quality improvement (QI) trial to compare opting-out with conventional opting-in consent for influenza immunization. Women age ≥ 18 years attending the University of Texas Health Science Center at Houston (UTHealth) or UT-Medical Branch (UTMB) prenatal clinics during the 2010-2011 influenza season, were eligible. Results  We enrolled 280 women (140 UTHealth, 140 UTMB). Both groups had similar mean age (26.0 ± 5.5 years), mean gestational age (19.4 ± 9.5 weeks), and percent with underlying health conditions (20.7%). Vaccination rates with opting-in and opting-out were similar among all (83 vs. 84%), UTHealth (87 vs. 93%), and UTMB patients (79 vs.76%) ( p  > 0.05). In subsamples of patients assessed, consent strategy did not significantly affect maternal recall of information provided. Conclusion  While prenatal influenza vaccination uptake doubled from the 2009-2010 influenza season, opting-out did not perform better than opting-in, a conclusion opposite that we would have reached had this been a nonconcurrent trial. Vaccination rates dropped posttrial; hence, continued research is needed to increase the prenatal influenza immunizations.

Respiratory Viruses and Treatment Failure in Children With Asthma Exacerbation

: media-1vid110.1542/5771275574001PEDS-VA_2017-4105Video Abstract OBJECTIVES: Respiratory pathogens commonly trigger pediatric asthma exacerbations, but their impact on severity and treatment response remains unclear.

METHODS

We performed a secondary analysis of the Determinants of Oral Corticosteroid Responsiveness in Wheezing Asthmatic Youth (DOORWAY) study, a prospective cohort study of children (aged 1-17 years) presenting to the emergency department with moderate or severe exacerbations. Nasopharyngeal specimens were analyzed by RT-PCR for 27 respiratory pathogens. We investigated the association between pathogens and both exacerbation severity (assessed with the Pediatric Respiratory Assessment Measure) and treatment failure (hospital admission, emergency department stay >8 hours, or relapse) of a standardized severity-specific treatment. Logistic multivariate regressions were used to estimate average marginal effects (absolute risks and risk differences [RD]).

RESULTS

Of 958 participants, 61.7% were positive for ≥1 pathogen (rhinovirus was the most prevalent [29.4%]) and 16.9% experienced treatment failure. The presence of any pathogen was not associated with higher baseline severity but with a higher risk of treatment failure (20.7% vs 12.5%; RD = 8.2% [95% confidence interval: 3.3% to 13.1%]) compared to the absence of a pathogen. Nonrhinovirus pathogens were associated with an increased absolute risk (RD) of treatment failure by 13.1% (95% confidence interval: 6.4% to 19.8%), specifically, by 8.8% for respiratory syncytial virus, 24.9% for influenza, and 34.1% for parainfluenza.

CONCLUSIONS

Although respiratory pathogens were not associated with higher severity on presentation, they were associated with increased treatment failure risk, particularly in the presence of respiratory syncytial virus, influenza, and parainfluenza. This supports influenza prevention in asthmatic children, consideration of pathogen identification on presentation, and exploration of treatment intensification for infected patients at higher risk of treatment failure.

DETECTION OF NON-INFLUENZA VIRUSES IN ACUTE RESPIRATORY INFECTIONS IN CHILDREN UNDER FIVE-YEAR-OLD IN COTE D'IVOIRE (JANUARY - DECEMBER 2013)

BACKGROUND

Influenza sentinel surveillance in Cote d'Ivoire showed that 70% of Acute Respiratory Infections (ARI) cases remained without etiology. This work aims to describe the epidemiological, clinical, and virological pattern of ARI that tested negative for influenza virus, in children under five years old.

MATERIALS AND METHODS

one thousand and fifty nine samples of patients presenting influenza Like Illness (ILI) or Severe Acute Respiratory Infections (SARI) symptoms were tested for other respiratory viruses using multiplex RT-PCR assays targeting 10 respiratory viruses.

RESULTS

The following pathogens were detected as follows, hRV 31,92% (98/307), hRSV 24.4% (75/329), PIV 20.5% (63/307), HCoV 229E 12,05% (37/307), hMPV 6.2% (19/307), HCoVOC43 1.0% (3/307) and EnV 1.0% (3/307). Among the 1,059 specimens analyzed, 917 (86.6%) were ILI samples and 142 (23.4%) were SARI samples. The proportion of children infected with at least one virus was 29.8% (273/917) in ILI cases and 23.9% (34/142) in SARI cases. The most prevalent viruses, responsible for ILI cases were hRV with 35.89% (98/273) and hRSV in SARI cases with 41.2% (14/34) of cases. Among the 1,059 patients, only 22 (2.1%) children presented risk factors related to the severity of influenza virus infection.

CONCLUSION

This study showed that respiratory viruses play an important role in the etiology of ARI in children. For a better understanding of the epidemiology of ARI and improved case management, it would be interesting in this context to expand the surveillance of influenza to other respiratory viruses.