Modifiable risk factors for community-acquired pneumonia in children under 5 years of age in resource-poor settings: a case-control study

Recovery Time From Severe Community Acquired Pneumonia and Risk Factors Among Pediatrics, Ethiopia: A Retrospective Follow-Up Study

Introduction. Severe community acquired pneumonia (CAP) is a life-threatening condition, with high rates of morbidity and mortality. This study aimed to determine the recovery time from severe CAP and risk factors among pediatric patients. Methods. A retrospective follow-up study was conducted among 412 pediatric medical charts with severe CAP enrolled at Asella Referral and Teaching Hospital between January 01, 2021 and December 31, 2022. EpiData version 4.6.0.6 and STATA version 14.2 were used for data entry and statistical analysis, respectively. Bivariable and multivariable Cox proportional hazards regression analyzes were performed. Result. The median recovery time from severe CAP among pediatric patients was 5 days (IQR = 3-8 days). IDR of recovery from severe CAP was 13.089 per 100 [95%CI: 11.82, 14.49] pediatric days observations. The cumulative incidence of recovery from severe CAP was 89.56% [n = 369, 95%CI: 86.20, 92.18]. Age [AHR = 1.55, 95%CI: 1.12, 2.13, P = .007], vaccination status [AHR = 1.29, 95%CI: 1.03, 1.63, P = .027], presence of danger signs [AHR = 1.61, 95%CI: 1.26, 2.05, P = .000], presence of comorbidity [AHR = 1.67, 95%CI: 1.33, 2.10, P = .000], duration of seeking care [AHR = 1.71, 95%CI: 1.18, 2.47, P = .004], and oxygen therapy [AHR = 1.45, 95%CI:1.12, 1.87, P = .004] were statistically significant risk factors for recovery time from severe CAP. Conclusions. The median recovery time of patients with severe CAP is relatively high. Age, vaccination status, presence of danger signs, presence of comorbidities, duration of seeking care, and oxygen therapy were statistically significant risk factors of recovery time from severe CAP.

Childhood Pneumonia in Low- and Middle-Income Countries: A Systematic Review of Prevalence, Risk Factors, and Healthcare-Seeking Behaviors

Childhood pneumonia is a major contributor to illness and death in children under the age of five globally. Despite advancements in medical science, the burden of pediatric community-acquired pneumonia (CAP) remains high, particularly in low- and middle-income countries. This systematic review aims to synthesize existing literature on the prevalence, risk factors, and healthcare-seeking behaviors associated with pediatric CAP to inform the development of targeted community-based interventions. An extensive search of various databases such as Medline, EMBASE, Web of Science, Cochrane, PubMed, PubMed Central, Helinet, SpringerLink, Google Scholar, and Biomed Central was performed, resulting in 65 potentially relevant studies. After a thorough evaluation process, 25 studies were selected for the final analysis. These selected studies offered valuable information on the epidemiology, risk factors, and healthcare-seeking behaviors associated with childhood pneumonia. The review revealed that environmental factors such as indoor air pollution, overcrowding, and exposure to tobacco smoke are significant risk factors for pediatric pneumonia. Additionally, socioeconomic factors, including poverty and a lack of access to clean water and sanitation, contribute to the vulnerability of children to this disease. Poor healthcare-seeking behaviors, driven by limited knowledge and awareness of pneumonia symptoms and treatment, further exacerbate the situation. The review also highlighted the critical role of vaccination, particularly against Haemophilus influenzae type b (Hib) and pneumococcus, in preventing pneumonia. However, gaps in vaccination coverage and challenges in accessing healthcare services remain barriers to effective pneumonia control. In light of these findings, the review recommends the implementation of community-based interventions that address the multifaceted determinants of pediatric pneumonia. These interventions should focus on improving environmental conditions, enhancing access to preventive measures such as vaccination, and promoting better healthcare-seeking behaviors through education and awareness campaigns. It is essential for healthcare providers, policymakers, and community members to collaborate in developing and implementing culturally appropriate and sustainable interventions. This cooperation aims to lessen the impact of pneumonia on children and their families.

Population modifiable risk factors associated with under-5 acute respiratory tract infections and diarrhoea in 25 countries in sub-Saharan Africa (2014-2021): an analysis of data from demographic and health surveys

Background

Identifying the critical modifiable risk factors for acute respiratory tract infections (ARIs) and diarrhoea is crucial to reduce the burden of disease and mortality among children under 5 years of age in sub-Saharan Africa (SSA) and ultimately achieving the Sustainable Development Goals (SDGs). We investigated the modifiable risk factors of ARI and diarrhoea among children under five using nationally representative surveys.

Methods

We used the most recent demographic and health survey (DHS) data (2014-2021) from 25 SSA countries, encompassing a total of 253,167 children. Countries were selected based on the availability of recent datasets (e.g., DHS-VII or DHS-VIII) that represent the current socioeconomic situations. Generalised linear latent mixed models were used to compute odds ratios (ORs). Population attributable fractions (PAFs) were calculated using adjusted ORs and prevalence estimates for key modifiable risk factors among ARI and diarrhoeal cases.

Findings

This study involved 253,167 children, with a mean age of 28.7 (±17.3) months, and 50.5% were male. The highest PAFs for ARI were attributed to unclean cooking fuel (PAF = 15.7%; 95% CI: 8.1, 23.1), poor maternal education (PAF = 13.4%; 95% CI: 8.7, 18.5), delayed initiation of breastfeeding (PAF = 12.4%; 95% CI: 9.0, 15.3), and poor toilets (PAF = 8.5%; 95% CI: 4.7, 11.9). These four modifiable risk factors contributed to 41.5% (95% CI: 27.2, 52.9) of ARI cases in SSA. The largest PAFs of diarrhoea were observed for unclean cooking fuel (PAF = 17.3%; 95% CI: 13.5, 22.3), delayed initiation of breastfeeding (PAF = 9.2%; 95% CI: 7.5, 10.5), household poverty (PAF = 7.0%; 95% CI: 5.0, 9.1) and poor maternal education (PAF = 5.6%; 95% CI: 2.9, 8.8). These four modifiable risk factors contributed to 34.0% (95% CI: 26.2, 42.3) of cases of diarrhoea in SSA.

Interpretation

This cross-sectional study identified four modifiable risk factors for ARI and diarrhoea that should be a priority for policymakers in SSA. Enhancing home-based care and leveraging female community health workers is crucial for accelerating the reduction in under-5 mortality linked to ARI and diarrhoea in SSA.

Funding

None.

Causal factors of childhood pneumonia high mortalities and the impact of community case management on child survival in Sub-Saharan Africa: a systematic review

OBJECTIVE

This study aimed to (1) evaluate the effectiveness of community case management (CCM) and validity of its implementation in the context of Sub-Saharan Africa (SSA) region; (2) identify potential differences in pneumonia disease aetiology, geographic region and cultural factors that may impact the implementation and delivery of community-based interventions; and (3) identify strategies that public health practitioners, stakeholders and policymakers could use to implement CCM.

STUDY DESIGN

This was a systematic review.

METHODS

Comprehensive searches were conducted in Cochrane Library, MEDLINE, CINAHL and Scopus databases from 2012 to 2023. Google Scholar, World Health Organization/United Nations Children's Fund websites, unpublished grey literature, PROSPERO (International Register of Systematic Reviews) and a manual search of references lists for relevant articles.

RESULTS

A total of 441 articles were screened, and eight articles were included for the review. Studies were from seven countries in SSA located in three regions: East (Kenya, Tanzania, Ethiopia), West (Nigeria, Senegal, Sierra Leone) and South (South Africa). The study designs of articles included two cluster randomised control trials, four cohorts and two case-control studies. A cross-analysis of the papers identified themes under the subheadings CCM and causal factors and risk factors.

CONCLUSION

Successful impact of implementation and adoption of CCM in the context of SSA culture and environment can be achieved when focused on creating high-demand, dependable and quality healthcare services. Continual monitoring and evaluation of emerging high trends of viral pathogens and co-infections are critical in reducing childhood pneumonia mortalities.

Exclusive Breastfeeding and Childhood Morbidity: A Narrative Review

Globally, diarrheal diseases and acute respiratory infections are the leading causes of morbidity and mortality in children under 5 years old. The benefits of exclusive breastfeeding in reducing the risk of gastrointestinal and respiratory infections are well documented. Optimal breastfeeding may potentially save the lives of about 800,000 children in low-income settings. Despite the evidence, around 63% of infants from birth to 6 months are not exclusively breastfed worldwide. We searched the literature published between 2010 and 2022 in Medline, Embase, and Scopus on the association between exclusive breastfeeding and infectious diseases. We selected and reviewed 70 relevant studies. Our findings expand and confirm the positive association between exclusive breastfeeding and reduced risk of a number of gastrointestinal, respiratory, and other infections in 60 out of 70 studies observed in both low- and high-income settings. Several studies analyzing exclusive breastfeeding duration reported that a longer exclusive breastfeeding duration is protective against many infectious diseases. This review also reported a lack of standardized definition for measuring exclusive breastfeeding in many studies. Overall, the results highlight the benefits of exclusive breastfeeding in many studies and suggests reporting exclusive breastfeeding in future studies using a consistent definition to enable better monitoring of exclusive breastfeeding rates.

Factors associated with community acquired severe pneumonia among under five children in Dhaka, Bangladesh: A case control analysis

Background

Pneumonia is the leading cause of death in children globally with the majority of these deaths observed in resource-limited settings. Globally, the annual incidence of clinical pneumonia in under-five children is approximately 152 million, mostly in the low- and middle-income countries. Of these, 8.7% progressed to severe pneumonia requiring hospitalization. However, data to predict children at the greatest risk to develop severe pneumonia from pneumonia are limited.

Method

Secondary data analysis was performed after extracting relevant data from a prospective cluster randomized controlled clinical trial; children of either sex, aged two months to five years with pneumonia or severe pneumonia acquired in the community were enrolled over a period of three years in 16 clusters in urban Dhaka city.

Results

The analysis comprised of 2,597 children aged 2–59 months. Of these, 904 and 1693 were categorized as pneumonia (controls) and severe pneumonia (cases), respectively based on WHO criteria. The median age of children was 9.2 months (inter quartile range, 5.1–17.1) and 1,576 (60%) were male. After adjustment for covariates, children with temperature ≥38°C, duration of illness ≥3 days, male sex, received prior medical care and severe stunting showed a significantly increased likelihood of developing severe pneumonia compared to those with pneumonia. Severe pneumonia in children occurred more often in older children who presented commonly from wealthy quintile families, and who often sought care from private facilities in urban settings.

Conclusion and recommendation

Male sex, longer duration of illness, fever, received prior medical care, and severe stunting were significantly associated with development of WHO-defined severe childhood pneumonia in our population. The results of this study may help to develop interventions target to reduce childhood morbidity and mortality of children suffering from severe pneumonia.

Indoor air pollution from solid fuel on children pneumonia in low- and middle-income countries: a systematic review and meta-analysis

An updated systematic review was conducted to assessing on the association between indoor air pollution caused by household energy consumption and childhood pneumonia in low- and middle-income countries. We performed a meta-analysis from the electronic databases of PubMed, Cochrane library, Web of Science, EMBASE. Studies were selected when they reported childhood pneumonia or ALRI in relation to indoor air pollution resulted from solid fuel. Studies must provide results on exposure prevalence of children aged below 5 years from Asia or Africa. We devoted ourselves to identifying randomized controlled experiments and observational epidemiological researches, which revealed the relation between household usage of solid fuel and childhood pneumonia. Among 1954 articles, 276 were reviewed thoroughly and 16 conduced to such a meta-analysis. It was found that there is a significant relationship between the solid fuel combustion and increasing risk of childhood pneumonia (OR = 1.66, 95%CI 1.36-2.02). The summary odds ratios from biomass use and mixed fuel use were, respectively, 1.86 (95%CI 1.15-3.02) and 1.58 (95%CI 1.38-1.81), with substantial between study heterogeneity (I² = 87.2% and 29.2%, respectively). According to the subgroup analysis along with the meta-regression analysis, the risk of using solid fuel in Asian regions is higher than that in African regions. Studies based on non-hospital participates (I² = 49.5%) may also a source of heterogeneity. We found that indoor air pollution generated by the usage of solid fuel might be a significant risk factor for pneumonia in children and suggested improving the indoor air quality by promoting cleaner fuel will be important in undeveloped countries.

Pediatricians' Compliance to the Clinical Management Guidelines for Community-Acquired Pneumonia in Infants and Young Children in Pakistan

Community-acquired pneumonia (CAP) is among the most commonly prevailing acute infections in children that may require hospitalization. Inconsistencies among suggested care and actual management practices are usually observed, which raises the need to assess local clinical practices. The current study was conducted to evaluate pediatricians’ compliance with the standard clinical practice guidelines and their antibiotic-prescribing behavior for the management of CAP in children. Methods: A descriptive cross-sectional study was conducted using a self-administered questionnaire; which was provided to pediatricians by the researchers. Statistical analysis was performed with SPSS 25 Statistics; χ² tests (or Fisher-exact tests) with the p-value set at < 0.05 as the threshold for statistical significance. Results: The overall response rate was 59.2%. Male respondents were (n = 101; 42.6%), and the respondents (n = 163; 68.7%) were under 30 years of age. Amoxicillin (n = 122; 51.5%) was considered as the most commonly used first-line treatment for non-severe pneumonia, whereas a smaller proportion (n = 81; 34.2%) of respondents selected amoxicillin–clavulanate. Likewise, amoxicillin (n = 100; 42.2%) was the most popular choice for non-severe pneumonia in hospitalized children; however, if children had used antibiotics earlier to admission, respondents showed an inclination to prescribe a macrolide (n = 95; 40.0%) or second-generation cephalosporin (n = 90; 37.9%). More than 90% responded that children <6 months old with suspected bacterial CAP will probably receive better therapeutic care by hospitalization. Restricting exposure to the antibiotic as much as possible (n = 71; 29.9%), improving antibiotic prescribing (n = 59; 24.8%), and using the appropriate dose of antimicrobials (n = 29; 12.2%) were considered the major factors by the respondents to reduce antimicrobials resistance. Conclusions: The selection of antibiotics and diagnostic approach was as per the recommendations, but indication, duration of treatment, and hospitalization still can be further improved.

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

Background

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

Methods

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

Results

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

Conclusions

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

Supplementary Information

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

Viral-bacterial (co-)occurrence in the upper airways and the risk of childhood pneumonia in resource-limited settings

OBJECTIVE

To examine the association between bacterial-viral co-occurrence in the nasopharynx and the risk of community acquired pneumonia (CAP) in young children living in resource-limited settings.

METHODS

A case-control study was conducted between January and December 2017 in Moshi, Tanzania. Children 2-59 months with CAP and healthy controls were enrolled. RSV and Influenza A/B were detected with a standardized polymerase chain reaction (PCR) method, and a simplified real-time quantitative PCR method, without sample pre-processing, was developed to detect bacterial pathogens in nasopharyngeal samples.

RESULTS

A total of 109 CAP patients and 324 healthy controls were enrolled. Co-detection of H. influenzae and S. pneumoniae in nasopharyngeal swabs was linked with higher odds of CAP (aOR=3.2, 95% CI=1.1-9.5). The majority of the H. influenzae isolated in cases and controls (95.8%) were non-typeable. Of the viruses examined, respiratory syncytial virus (RSV) was most common (n = 31, 7.2%) in cases and controls. Children with RSV had 8.4 times higher odds to develop pneumonia than healthy children (aOR=8.4, 95%CI= 3.2 - 22.1).

CONCLUSIONS

Co-occurence of H. influenzae and S. pneumoniae in the nasopharynx was strongly associated with CAP. The high prevalence of non-typeable H. influenzae might be a sign of replacement as a consequence of Haemophilus influenzae type b vaccination.

Inappropriate treatment of community-acquired pneumonia among children under five years of age in Tanzania

Objective:

To describe the treatment of community-acquired pneumonia (CAP) in children under five years in Tanzania.

Methods:

Between January and December 2017, children aged 2–59 months with chest radiography- confirmed CAP were enrolled. The parents were interviewed to collect information on the patients and home-based medication. Clinical information was derived from the patient files. Nasopharyngeal swab and blood samples were collected for isolation of the causative pathogens. Swab samples were analysed by quantitative PCR whereas blood samples were tested using BacT/Alert 3D.

Results:

Overall, 109 children with CAP were included in this analysis. Provision of care to most children was delayed (median = 4.6 days). A quarter (26.6%) were given unprescribed/leftover antibiotics at home. Only one child had positive bacterial culture. Referrals were associated with nasopharyngeal carriage of Streptococcus pneumoniae (p = 0.003) and Haemophilus influenzae (p = 0.004). Of all admitted children, more than a quarter (n = 29) did not need to be hospitalised and inappropriately received injectable instead of oral antibiotics.

Conclusion:

We found high rates of home treatment, particularly with antibiotics. Appropriate health care was delayed for most children because of home treatment. Efforts are needed at the community level to improve awareness of antimicrobial resistance.