A high burden of respiratory syncytial virus associated pneumonia in children less than two years of age in a South East Asian refugee population

RSV Infection in Refugees and Asylum Seekers: A Systematic Review and Meta-Analysis

Respiratory diseases, including respiratory syncytial virus (RSV) infections, are common reasons for seeking healthcare among refugees and asylum seekers. A systematic review with meta-analysis was designed to appraise all the available evidence on RSV infections among individuals in refugee camps. Three medical databases (PubMed, Embase, and Scopus) as well as the preprint repository medRxiv.org were searched for eligible observational studies, and the collected cases were pooled in a random-effects meta-analysis model. Heterogeneity was assessed using the I2 statistics. Funnel plots and a regression analysis were calculated for analyzing reporting bias. Eventually, six studies were retrieved from three areas (Bangladesh, Thailand, and Kenya), with pooled estimates of 129.704 cases per 1000 samples (95% CI 66.393 to 237.986) for RSV compared to 110.287 per 1000 people for influenza A (95% CI 73.186 to 162.889), 136.398 cases per 1000 people (95% CI 84.510 to 212.741) for human adenovirus (HAdV), 69.553 per 1000 people (95% CI 49.802 to 96.343) for parainfluenzavirus (PIFV), and 60.338 per 1000 people (95% CI 31.933 to 111.109) for human metapneumovirus (hMPV). Using influenza A as a reference group, the risk for a positive specimen was greater for RSV (relative risk [RR] 1.514, 95% CI 1.396 to 1.641) and HAdV (RR 1.984, 95% CI 1.834 to 2.146) and lower for influenza B (RR 0.276, 95% CI: 0.239 to 0.319), PIFV (RR: 0.889, 95% CI 0.806 to 0.981), and hMPV (RR 0.594, 95% CI 0.534 to 0.662). In summary, high rates of RSV infections were documented among individuals sheltered in refugee camps, stressing the importance of specifically designed preventive strategies.

Epidemiology and associated factors for hospitalization related respiratory syncytial virus infection among children less than 5 years of age in Northern Thailand

BACKGROUND

Respiratory syncytial virus (RSV) is often the main problem in young children that require hospitalization. The objective of this study was to identify factors associated with RSV-related hospitalizations in young children less than five years old.

METHODOLOGY

A retrospective study was conducted for acute respiratory tract infection (ARTI) at a tertiary care hospital from January 2017 to December 2021 by using binary logistic regression analysis to detect the associated factors with RSV-related hospitalizations in children.

RESULTS

RSV-related hospitalization was detected in 293 of 410 (71.46 %) cases of RSV infection, most of which appeared in the rainy months of August to November. The most common symptoms and signs were 81.5 % rhinorrhea, 70.7 % cough, 68.5 % sore throat, 68.3 % sputum production, and 66.8 % fever. Factors associated with RSV-related hospitalization were age less than or equal to 2 years (aOR = 4.62, 95 % CI = 1.86-11.44), preterm birth (aOR = 2.61, 95 % CI = 1.05-6.10), patients with underlying disease (aOR = 3.06, 95 % CI = 1.21-10.34), and the presenting symptoms with sputum production (aOR = 16.49, 95 % CI = 3.80-71.55). Laboratory blood tests, low levels of hematocrit (aOR = 9.61, 95 % CI = 1.09-84.49) was the associated factor for hospitalization with RSV infection (p < 0.05).

CONCLUSIONS

Factors associated with RSV-related hospitalizations in children were age less than or equal to two years, preterm birth, underlying disease, symptoms of sputum production. The low level of hematocrit was also associated with RSV-related hospitalizations in these children.

Evaluating the impact of Respiratory Syncytial Virus immunisation strategies on antibiotic use and drug resistant bacterial infections in England

Background: Vaccines against viruses have been proposed as a novel means to reduce antibiotic use, which would, in turn, decrease selection for antibiotic resistant bacteria. However, the impact of this intervention is poorly quantified, and likely depends on setting-specific epidemiology. Therefore, with increasing confidence in a new vaccine against respiratory syncytial virus (RSV), it is important to quantify the impact of these vaccines on antibiotic prescribing and any downstream reduction in drug resistant bacterial infections. Methods: Here we integrate results from a dynamic transmission model of RSV and a statistical attribution framework to capture the impact of RSV vaccines on the reduction in antibiotic prescribing due to averted primary care visits in England. Results: Under base case assumptions, we find that the most impactful RSV vaccine strategy targets children aged 5–14 years, resulting in an annual reduction of 10.9 (8.0–14.2) antibiotic courses per 10,000 person years across the entire population, equivalent to reducing annual all-cause primary care prescribing by 0.23%. Our results suggest that this reduction in antibiotic use would gain 130 disability-adjusted life years and avert £51,000 associated with drug resistant bacterial infections. Seasonally administering monoclonal antibodies (mAbs) to high-risk infants under 6 months is the most efficient strategy, reducing per person year antibiotic prescribing by 2.6 (1.9–3.3) antibiotic courses per 1,000 mAb courses. Conclusions: Under optimistic conditions, the cost-effectiveness of RSV vaccine strategies in England would likely not be altered by integrating the benefits of preventing drug resistant infections in addition to RSV disease prevention.

Childhood pneumonia in humanitarian emergencies in low- and middle-income countries: A systematic scoping review

Background

Humanitarian emergencies increase many risk factors for pneumonia, including disruption to food, water and sanitation, and basic health services. This review describes pneumonia morbidity and mortality among children and adolescents affected by humanitarian emergencies.

Methods

We searched MEDLINE, EMBASE, and PubMed databases for publications reporting pneumonia morbidity or mortality among children aged 1 month to 17 years in humanitarian emergencies (eg, natural disaster, armed conflict, displacement) in low- and middle-income countries (LMICs).

Results

We included 22 papers published between January 2000 and July 2021 from 33 countries, involving refugee/displaced persons camps (n = 5), other conflict settings (n = 14), and natural disaster (n = 3). Population pneumonia incidence was high for children under 5 years of age (73 to 146 episodes per 100 patient-years); 6%-29% met World Health Organization (WHO) criteria for severe pneumonia requiring admission. Pneumonia accounted for 13%-34% of child and adolescent presentations to camp health facilities, 7%-48% of presentations and admissions to health facilities in other conflict settings, and 12%-22% of admissions to hospitals following natural disasters. Pneumonia related deaths accounted for 7%-30% of child and adolescent deaths in hospital, though case-fatality rates varied greatly (0.5%-17.2%). The risk for pneumonia was greater for children who are: recently displaced, living in crowded settings (particularly large camps), with deficient water and sanitation facilities, and those who are malnourished.

Conclusion

Pneumonia is a leading cause of morbidity and mortality in children and adolescents affected by humanitarian emergencies. Future research should address population-based pneumonia burden, particularly for older children and adolescents, and describe contextual factors to allow for more meaningful interpretation and guide interventions.

Challenges in the prevention or treatment of RSV with emerging new agents in children from low- and middle-income countries

INTRODUCTION

Respiratory syncytial virus (RSV) causes approximately 120,000 deaths annually in children <5 years, with 99% of fatalities occurring in low- and middle-income countries (LMICs).

AREAS COVERED

There are numerous RSV interventions in development, including long-acting monoclonal antibodies, vaccines (maternal and child) and treatments which are expected to become available soon. We reviewed the key challenges and issues that need to be addressed to maximize the impact of these interventions in LMICs. The epidemiology of RSV in LMICs was reviewed (PubMed search to 30 June 2020 inclusive) and the need for more and better-quality data, encompassing hospital admissions, community contacts, and longer-term respiratory morbidity, emphasized. The requirement for an agreed clinical definition of RSV lower respiratory tract infection was proposed. The pros and cons of the new RSV interventions are reviewed from the perspective of LMICs.

EXPERT OPINION

We believe that a vaccine (or combination of vaccines, if practicable) is the only viable solution to the burden of RSV in LMICs. A coordinated program, analogous to that with polio, involving governments, non-governmental organizations, the World Health Organization, the manufacturers and the healthcare community is required to realize the full potential of vaccine(s) and end the devastation of RSV in LMICs.

Acute respiratory infections in hospitalized children in Vientiane, Lao PDR - the importance of Respiratory Syncytial Virus

The Human respiratory syncytial virus (RSV) is one of the most important viral pathogens, causing epidemics of acute respiratory infection (ARI), especially bronchiolitis and pneumonia, in children worldwide. To investigate the RSV burden in Laos, we conducted a one-year study in children <5 years old admitted to Mahosot Hospital, Vientiane Capital, to describe clinical and epidemiological characteristics and predictive factors for severity of RSV-associated ARI. Pooled nasal and throat swabs were tested using multiplex real-time PCR for 33 respiratory pathogens (FTD® kit). A total of 383 patients were included, 277 (72.3%) of whom presented with pneumonia. 377 (98.4%) patients were positive for at least one microorganism, of which RSV was the most common virus (41.0%), with a peak observed between June and September, corresponding to the rainy season. Most RSV inpatients had pneumonia (84.1%), of whom 35% had severe pneumonia. Children <3-months old were a high-risk group for severe pneumonia, independently of RSV infection. Our study suggests that RSV infection is frequent in Laos and commonly associated with pneumonia in hospitalized young children. Further investigations are required to provide a better overall view of the Lao nationwide epidemiology and public health burden of RSV infection over time.

Non-malaria fevers in a high malaria endemic area of Ghana

Background

The importance of fevers not due to malaria [non–malaria fevers, NMFs] in children in sub-Saharan Africa is increasingly being recognised. We have investigated the influence of exposure-related factors and placental malaria on the risk of non-malaria fevers among children in Kintampo, an area of Ghana with high malaria transmission.

Methods

Between 2008 and 2011, a cohort of 1855 newborns was enrolled and followed for at least 12 months. Episodes of illness were detected by passive case detection. The primary analysis covered the period from birth up to 12 months of age, with an exploratory analysis of a sub-group of children followed for up to 24 months.

Results

The incidence of all episodes of NMF in the first year of life (first and subsequent) was 1.60 per child-year (95 % CI 1.54, 1.66). The incidence of NMF was higher among infants with low birth weight [adjusted hazard ratio (aHR) 1.22 (95 % CI 1.04–1.42) p = 0.012], infants from households of poor socio-economic status [aHR 1.22 (95 % CI 1.02–1.46) p = 0.027] and infants living furthest from a health facility [aHR 1.20 (95 % CI 1.01–1.43) p = 0.037]. The incidence of all episodes of NMF was similar among infants born to mothers with or without placental malaria [aHR 0.97 (0.87, 1.08; p = 0.584)].

Conclusion

The incidence of NMF in infancy is high in the study area. The incidence of NMF is associated with low birth weight and poor socioeconomic status but not with placental malaria.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-016-1654-4) contains supplementary material, which is available to authorized users.

Climate induces seasonality in pneumococcal transmission

Streptococcus pneumoniae is a significant human pathogen and a leading cause of infant mortality in developing countries. Considerable global variation in the pneumococcal carriage prevalence has been observed and the ecological factors contributing to it are not yet fully understood. We use data from a cohort of infants in Asia to study the effects of climatic conditions on both acquisition and clearance rates of the bacterium, finding significantly higher transmissibility during the cooler and drier months. Conversely, the length of a colonization period is unaffected by the season. Independent carriage data from studies conducted on the African and North American continents suggest similar effects of the climate on the prevalence of this bacterium, which further validates the obtained results. Further studies could be important to replicate the findings and explain the mechanistic role of cooler and dry air in the physiological response to nasopharyngeal acquisition of the pneumococcus.

Estimating oxygen needs for childhood pneumonia in developing country health systems: a new model for expecting the unexpected

BACKGROUND

Planning for the reliable and cost-effective supply of a health service commodity such as medical oxygen requires an understanding of the dynamic need or 'demand' for the commodity over time. In developing country health systems, however, collecting longitudinal clinical data for forecasting purposes is very difficult. Furthermore, approaches to estimating demand for supplies based on annual averages can underestimate demand some of the time by missing temporal variability.

METHODS

A discrete event simulation model was developed to estimate variable demand for a health service commodity using the important example of medical oxygen for childhood pneumonia. The model is based on five key factors affecting oxygen demand: annual pneumonia admission rate, hypoxaemia prevalence, degree of seasonality, treatment duration, and oxygen flow rate. These parameters were varied over a wide range of values to generate simulation results for different settings. Total oxygen volume, peak patient load, and hours spent above average-based demand estimates were computed for both low and high seasons.

FINDINGS

Oxygen demand estimates based on annual average values of demand factors can often severely underestimate actual demand. For scenarios with high hypoxaemia prevalence and degree of seasonality, demand can exceed average levels up to 68% of the time. Even for typical scenarios, demand may exceed three times the average level for several hours per day. Peak patient load is sensitive to hypoxaemia prevalence, whereas time spent at such peak loads is strongly influenced by degree of seasonality.

CONCLUSION

A theoretical study is presented whereby a simulation approach to estimating oxygen demand is used to better capture temporal variability compared to standard average-based approaches. This approach provides better grounds for health service planning, including decision-making around technologies for oxygen delivery. Beyond oxygen, this approach is widely applicable to other areas of resource and technology planning in developing country health systems.

A birth cohort study of viral infections in Vietnamese infants and children: study design, methods and characteristics of the cohort

Background

In Ho Chi Minh City, Vietnam, more than one-third of admissions to the two paediatric hospitals are attributable to four infectious syndromes: dengue, diarrhoeal disease, acute respiratory infection, and hand, foot and mouth disease. We have established a large prospective birth cohort study to investigate individual, environmental, virological, and immunological determinants of infection and disease in infants. Specific research questions are focused on the role of maternal antibody in protection against infection in infancy, and the adaptive immune response to vaccination and natural infection. This paper presents the cohort design, methods, and baseline characteristics of the participants enrolled in the first two years.

Methods/design

Women are enrolled prior to delivery at one hospital in each of two catchment areas: an urban district in central HCMC, and a mixed urban/rural district in the Mekong Delta 150 km southwest of HCMC. Infants are enrolled within 3 days of birth, and maternal and cord blood samples are collected. Routine blood samples and data on growth, health status and vaccinations are collected from infants at scheduled visits at 4, 9 and 12 months. Clinical data and specimens are collected from infants presenting at a study clinic, or admitted to hospital, with any of the the four infectious syndromes of interest.

Discussion

In four years since since the study began in July 2009, >6400 infants have been enrolled, and enrolment is ongoing. Attrition is low: 84% of participants have completed the full 12-month follow-up period. Baseline characteristics of the first 4300 enrollees are presented here. We have demonstrated the feasibility of establishing a large prospective study of infectious diseases in infancy in a resource-limited setting, with minimal loss to follow-up. Our linked socio-demographic, clinical and laboratory data will help elucidate the viral aetiology and epidemiology of common infectious diseases of infancy, and can inform the implemention of existing and future vaccines. This study furthermore provides a platform to which additional endpoints could be added in the future.

Role of human metapneumovirus, influenza A virus and respiratory syncytial virus in causing WHO-defined severe pneumonia in children in a developing country

Objective

The role of respiratory viruses in causing severe, life threatening pneumonia in children in developing countries is not well established. Our study aims to determine the role of human metapneumovirus (HMPV), influenza A virus and respiratory syncytial virus (RSV) in children, aged 6 weeks to 2 years, hospitalized with WHO defined severe pneumonia (tachypnea plus any general danger sign or chest in-drawing) at a public sector hospital in Karachi, Pakistan.

Methods

This study was conducted from November 2010 to September 2011 at Abbassi Shaheed Hospital, a large public tertiary care hospital in Karachi, Pakistan. Children admitted with WHO-defined severe pneumonia were enrolled and throat swabs were obtained to detect respiratory viruses using real time RT-PCR. Chest x-rays of all subjects were obtained and independently interpreted by two radiologists to diagnose radiologic pneumonia.

Results

169 children were enrolled. HMPV was detected in 24 (14.2%), influenza A virus in 9 (5.3%) and RSV in 30 (17.8%) children admitted with severe pneumonia. Of 9 patients with influenza A, 8 tested positive for H1N1. Viral etiology was found in 18% of radiologically confirmed pneumonia. HMPV infections peaked in February and April, influenza A was prevalent in January, June and November and RSV infections were most prevalent from June to September.

Conclusion

HMPV, influenza A and RSV are common causes of WHO-defined severe pneumonia in hospitalized children in Karachi. Knowledge regarding the viral etiology of pediatric pneumonia and individual viral seasonality can help in the recommendation and implementation of appropriate management strategies.

Respiratory virus surveillance in hospitalised pneumonia patients on the Thailand-Myanmar border

Background

Pneumonia is a significant cause of morbidity and mortality in the developing world. Viruses contribute significantly to pneumonia burden, although data for low-income and tropical countries are scarce. The aim of this laboratory-enhanced, hospital-based surveillance was to characterise the epidemiology of respiratory virus infections among refugees living on the Thailand-Myanmar border.

Methods

Maela camp provides shelter for ~45,000 refugees. Inside the camp, a humanitarian organisation provides free hospital care in a 158-bed inpatient department (IPD). Between 1st April 2009 and 30th September 2011, all patients admitted to the IPD with a clinical diagnosis of pneumonia were invited to participate. Clinical symptoms and signs were recorded and a nasopharyngeal aspirate (NPA) collected. NPAs were tested for adenoviruses, human metapneumovirus (hMPV), influenza A & B, and RSV by PCR.

Results

Seven hundred eight patient episodes (698 patients) diagnosed as pneumonia during the enhanced surveillance period were included in this analysis. The median patient age was 1 year (range: < 1-70), and 90.4% were aged < 5 years. At least one virus was detected in 53.7% (380/708) of episodes. Virus detection was more common in children aged < 5 years old (<1 year: OR 2.0, 95% CI 1.2-3.4, p = 0.01; 1-4 years: OR 1.4, 95% CI 0.8-2.3, p = 0.2). RSV was detected in 176/708 (24.9%); an adenovirus in 133/708 (18.8%); an influenza virus in 68/708 (9.6%); and hMPV in 33/708 (4.7%). Twenty-eight episodes of multiple viral infections were identified, most commonly adenovirus plus another virus. RSV was more likely to be detected in children <5 years (OR 12.3, 95% CI 3.0-50.8, p = 0.001) and influenza viruses in patients ≥5 years (OR 2.8, 95% CI 1.5-5.4, p = 0.002). IPD treatment was documented in 702/708 cases; all but one patient received antimicrobials, most commonly a beta-lactam (amoxicillin/ampicillin +/−gentamicin in 664/701, 94.7%).

Conclusions

Viral nucleic acid was identified in the nasopharynx in half the patients admitted with clinically diagnosed pneumonia. Development of immunisations targeting common respiratory viruses is likely to reduce the incidence of pneumonia in children living refugee camps and similar settings.