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Mahtab S, Blau DM, Madewell ZJ, Ogbuanu I, Ojulong J, Lako S, Legesse H, Bangura JS, Bassat Q, Mandomando I, Xerinda E, Fernandes F, Varo R, Sow SO, Kotloff KL, Tapia MD, Keita AM, Sidibe D, Onyango D, Akelo V, Gethi D, Verani JR, Revathi G, Scott JAG, Assefa N, Madrid L, Bizuayehu H, Tirfe TT, El Arifeen S, Gurley ES, Islam KM, Alam M, Zahid Hossain M, Dangor Z, Baillie VL, Hale M, Mutevedzi P, Breiman RF, Whitney CG, Madhi SA. Post-mortem investigation of deaths due to pneumonia in children aged 1-59 months in sub-Saharan Africa and South Asia from 2016 to 2022: an observational study. THE LANCET. CHILD & ADOLESCENT HEALTH 2024; 8:201-213. [PMID: 38281495 PMCID: PMC10864189 DOI: 10.1016/s2352-4642(23)00328-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 12/01/2023] [Accepted: 12/01/2023] [Indexed: 01/30/2024]
Abstract
BACKGROUND The Child Health and Mortality Prevention Surveillance (CHAMPS) Network programme undertakes post-mortem minimally invasive tissue sampling (MITS), together with collection of ante-mortem clinical information, to investigate causes of childhood deaths across multiple countries. We aimed to evaluate the overall contribution of pneumonia in the causal pathway to death and the causative pathogens of fatal pneumonia in children aged 1-59 months enrolled in the CHAMPS Network. METHODS In this observational study we analysed deaths occurring between Dec 16, 2016, and Dec 31, 2022, in the CHAMPS Network across six countries in sub-Saharan Africa (Ethiopia, Kenya, Mali, Mozambique, Sierra Leone, and South Africa) and one in South Asia (Bangladesh). A standardised approach of MITS was undertaken on decedents within 24-72 h of death. Diagnostic tests included blood culture, multi-organism targeted nucleic acid amplifications tests (NAATs) of blood and lung tissue, and histopathology examination of various organ tissue samples. An interdisciplinary expert panel at each site reviewed case data to attribute the cause of death and pathogenesis thereof on the basis of WHO-recommended reporting standards. FINDINGS Pneumonia was attributed in the causal pathway of death in 455 (40·6%) of 1120 decedents, with a median age at death of 9 (IQR 4-19) months. Causative pathogens were identified in 377 (82·9%) of 455 pneumonia deaths, and multiple pathogens were implicated in 218 (57·8%) of 377 deaths. 306 (67·3%) of 455 deaths occurred in the community or within 72 h of hospital admission (presumed to be community-acquired pneumonia), with the leading bacterial pathogens being Streptococcus pneumoniae (108 [35·3%]), Klebsiella pneumoniae (78 [25·5%]), and non-typeable Haemophilus influenzae (37 [12·1%]). 149 (32·7%) deaths occurred 72 h or more after hospital admission (presumed to be hospital-acquired pneumonia), with the most common pathogens being K pneumoniae (64 [43·0%]), Acinetobacter baumannii (19 [12·8%]), S pneumoniae (15 [10·1%]), and Pseudomonas aeruginosa (15 [10·1%]). Overall, viruses were implicated in 145 (31·9%) of 455 pneumonia-related deaths, including 54 (11·9%) of 455 attributed to cytomegalovirus and 29 (6·4%) of 455 attributed to respiratory syncytial virus. INTERPRETATION Pneumonia contributed to 40·6% of all childhood deaths in this analysis. The use of post-mortem MITS enabled biological ascertainment of the cause of death in the majority (82·9%) of childhood deaths attributed to pneumonia, with more than one pathogen being commonly implicated in the same case. The prominent role of K pneumoniae, non-typable H influenzae, and S pneumoniae highlight the need to review empirical management guidelines for management of very severe pneumonia in low-income and middle-income settings, and the need for research into new or improved vaccines against these pathogens. FUNDING Bill & Melinda Gates Foundation.
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Affiliation(s)
- Sana Mahtab
- South African Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Dianna M Blau
- Global Health Center, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Zachary J Madewell
- Global Health Center, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | | | - Sandra Lako
- Aberdeen Women's Centre, Freetown, Sierra Leone
| | | | | | - Quique Bassat
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique; ISGlobal - Hospital Clínic, Unversitat de Barcelona, Barcelona, Spain; Institutó Catalana de Recerca I Estudis Avançats, Barcelona, Spain; Pediatrics Department, Hospital Sant Joan de Déu, Universitat de Barcelona, Esplugues, Barcelona, Spain; Consorcio de Investigación Biomédica en Red de Epidemiología y Salud Pública, Madrid, Spain
| | - Inacio Mandomando
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique; Instituto Nacional de Saúde, Maputo, Mozambique
| | - Elisio Xerinda
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
| | - Fabiola Fernandes
- Department of Pathology, Maputo Central Hospital, Maputo, Mozambique
| | - Rosauro Varo
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique; ISGlobal - Hospital Clínic, Unversitat de Barcelona, Barcelona, Spain
| | - Samba O Sow
- Centre pour le Développement des Vaccins, Ministère de la Santé, Bamako, Mali
| | - Karen L Kotloff
- Department of Pediatrics and Department of Medicine, Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Milagritos D Tapia
- Department of Pediatrics and Department of Medicine, Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Adama Mamby Keita
- Centre pour le Développement des Vaccins, Ministère de la Santé, Bamako, Mali
| | - Diakaridia Sidibe
- Centre pour le Développement des Vaccins, Ministère de la Santé, Bamako, Mali
| | | | - Victor Akelo
- Centers for Disease Control and Prevention-Kenya, Kisumu, Kenya
| | - Dickson Gethi
- Kenya Medical Research Institute-Center for Global Health Research (KEMRI-CGHR), Kisumu, Kenya
| | - Jennifer R Verani
- National Center for Immunization and Respiratory Disease, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Gunturu Revathi
- Department of Pathology, Aga Khan University, Nairobi, Kenya
| | - J Anthony G Scott
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Nega Assefa
- College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Lola Madrid
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK; College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Hiwot Bizuayehu
- Department of Microbiology, Addis Ababa Burn, Emergency and Trauma Hospital, Addis Ababa, Ethiopia
| | | | - Shams El Arifeen
- International Center for Diarrhoeal Diseases Research, Dhaka, Bangladesh
| | - Emily S Gurley
- International Center for Diarrhoeal Diseases Research, Dhaka, Bangladesh; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Kazi Munisul Islam
- International Center for Diarrhoeal Diseases Research, Dhaka, Bangladesh
| | - Muntasir Alam
- International Center for Diarrhoeal Diseases Research, Dhaka, Bangladesh
| | | | - Ziyaad Dangor
- South African Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Vicky L Baillie
- South African Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Martin Hale
- National Health Laboratory Service, Department of Anatomical Pathology, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Portia Mutevedzi
- Emory Global Health Institute, Emory University, Atlanta, Georgia, USA
| | - Robert F Breiman
- Wits Infectious Diseases and Oncology Research Institute, University of the Witwatersrand, Faculty of Health Sciences, Johannesburg, South Africa
| | - Cynthia G Whitney
- Emory Global Health Institute, Emory University, Atlanta, Georgia, USA
| | - Shabir A Madhi
- South African Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Wits Infectious Diseases and Oncology Research Institute, University of the Witwatersrand, Faculty of Health Sciences, Johannesburg, South Africa.
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