High pneumonia lifetime-ever incidence in Beijing children compared with locations in other countries, and implications for national PCV and Hib vaccination

Protective effect of PCV13 against all-cause hospitalized pneumonia in children in Beijing, China: real-world evidence

BACKGROUND

The study evaluated the protective effect of 13-valent pneumococcal polysaccharide conjugate vaccine (PCV13) against all-cause hospitalized pneumonia in children in Beijing.

METHODS

Based on the vaccination record and inpatient medical record database of Beijing, children born in 2017 in Beijing, matched by age, gender, and district of the children with the ratio of 1:4, were selected as the vaccinated and unvaccinated groups according whether if vaccinated with PCV13. The incidence rate and 95 % confidence interval (95 %CI), vaccine effectiveness (VE) and direct medical costs of all-cause hospitalized pneumonia were calculated and compared within the same period of 12 months, 18 months, 24 months and 30 months after the birth of the child.

RESULTS

The decreased incidence rates of all-cause hospitalized pneumonia were observed at the four points in the PCV13 vaccinated group compared to the unvaccinated group, which were significant at the points of 12 months (0.42 % vs. 0.72 %, P = 0.001), 18 months (0.90 % vs. 1.26 %, P = 0.002) and 24 months (1.37 % vs. 1.65 %, P = 0.046). The VE of PCV13 against all-cause hospitalized pneumonia within 12 months was the highest as 41.9 % (95 % CI 19.6 %, 58.0 %), followed by 29.3 % (95 % CI 11.4 %, 43.5 %) within 18 months, 17.1 % (95 % CI 0.3 %, 31.1 %) within 24 months and it almost disappeared within 30 months. The VE of 4-dose vaccination within 18 months and 24 months were 39.9 % (95 % CI 20.3 %, 54.7 %) and 27.2 % (95 % CI 8.6 %, 42.0 %), respectively. The median hospitalization cost of the children in the vaccinated group was higher at the four points but without significance.

CONCLUSIONS

PCV13 had a certain protective effect on all-cause hospitalized pneumonia, and the booster immunization strategy had the best protective effect with great public health significance to enter the immunization program.

Childhood pneumonia in Beijing: Associations and interactions among selected demographic and environmental factors

Among infectious diseases, pneumonia is the greatest cause of mortality in children less than 5 years old. Approximately 27% of Beijing's 3-8 year-old children have had pneumonia at least once. The sole reservoir of pneumonia pathogens is the human nasopharynx. We investigated associations and interactions among two kinds of environmental risk factors: i) airborne pathogens, namely closed bedroom window and shared bedroom and ii) pollutants, namely traffic pollution and environmental tobacco smoke (ETS). We evaluated breastfeeding's (BF) protective value against childhood pneumonia. The database consists of responses to a questionnaire in a cross-sectional study. Crude and adjusted Odds Ratios were assessed independently for each risk factor. Combinations of the studied risk factors were analyzed using multivariate logistic regression. Risk factors were evaluated for interactions on the additive scale using the metrics Relative Excess Risk due to Interaction (RERI), Attributable Proportion (AP) and Synergy Index (S). All independent risk factors were significant for children's pneumonia. We also found evidence of possible synergistic interaction between pairs of risk factors that was stronger when one of the risk factors was a closed bedroom window. Remarkably, window opening was associated with reduced risk of pneumonia for children living near heavy traffic pollution. Longer duration BF was more protective than shorter, and exclusive BF was more protective than partial BF against childhood pneumonia. In conclusion, low ventilation (closed bedroom windows), shared bedroom, ETS, and traffic exposure were associated with increased risk of pneumonia. Exclusive BF for more than six months had the greatest protective value against pneumonia.

Epidemiological features of Streptococcus pneumoniae in patients with acute respiratory tract infection in Beijing, China during 2009-2020

BACKGROUND

Streptococcus pneumoniae (S. pneumoniae) is one of the common pathogens causing acute respiratory tract infection (ARTI). The study aimed to investigate the prevalence of S. pneumoniae in patients with ARTI in Beijing, and to provide reference evidence for prevention and control of S. pneumoniae.

METHOD

The patients from the surveillance data of ARTI in Beijing from 2009 to 2020 were recruited in the study. All patients were tested for S. pneumoniae and other viral and bacterial pathogens. Logistic regression model was used to explore the epidemiological features of S. pneumoniae.

RESULTS

Totally, 4.63% (253/5468) of the ARTI patients were positive for S. pneumoniae. The age, case type and antibiotic therapy in one week before sampling affected the positive rate of S. pneumoniae in patients. No significant difference on the positive rate of S. pneumoniae between the mild and severe pneumonia. Patients infected with S. pneumoniae had a higher risk of pneumonia in adults and the elderly, but a lower risk in children. The leading bacterial and viral pathogens in patients positive for S. pneumoniae were Haemophilus influenzae (36.36%) and human rhinovirus (35.59%), respectively.

CONCLUSION

This study showed that the prevalence of S. pneumoniae in the patients with ARTI was at a low level in Beijing from 2009 to 2020, which was higher in elderly patients, outpatients and patients without antibiotic therapy. It is necessary to further explore the serotype of S. pneumoniae and PCVs vaccine coverage, and rationally develop vaccine manufacture and vaccination programs to reduce the burden of pneumococcal diseases.

Comprehensive Description of Pathogens and Antibiotic Treatment Guidance in Children With Community-Acquired Pneumonia Using Combined Mass Spectrometry Methods

The objective of this study was to evaluate the value of molecular methods in the management of community-acquired pneumonia (CAP) in children. Previously developed mass spectrometry (MS)-based methods combined with quantitative real-time PCR (combined-MS methods) were used to describe the aetiology and evaluate antibiotic therapy in the enrolled children. Sputum collected from 302 children hospitalized with CAP were analyzed using the combined-MS methods, which can detect 19 viruses and 12 bacteria related to CAP. Based on the results, appropriate antibiotics were determined using national guidelines and compared with the initial empirical therapies. Respiratory pathogens were identified in 84.4% of the patients (255/302). Co-infection was the predominant infection pattern (51.7%, 156/302) and was primarily a bacterial-viral mixed infection (36.8%, 111/302). Compared with that using culture-based methods, the identification rate for bacteria using the combined-MS methods (61.8%, 126/204) increased by 28.5% (p <0.001). Based on the results of the combined-MS methods, the initial antibiotic treatment of 235 patients was not optimal, which mostly required switching to β-lactam/β-lactamase inhibitor combinations or reducing unnecessary macrolide treatments. Moreover, using the combined-MS methods to guide antibiotic therapy showed potential to decrease the length of stay in children with severe CAP. For children with CAP, quantitative molecular testing on sputum can serve as an important complement to traditional culture methods. Early aetiology elucidated using molecular testing can help guide the antibiotic therapy.

Flexible modelling of risk factors on the incidence of pneumonia in young children in South Africa using piece-wise exponential additive mixed modelling

Introduction

Recurrent episodes of pneumonia are frequently modeled using extensions of the Cox proportional hazards model with the underlying assumption of time-constant relative risks measured by the hazard ratio. We aim to relax this assumption in a study on the effect of factors on the evolution of pneumonia incidence over time based on data from a South African birth cohort study, the Drakenstein child health study.

Methods

We describe and apply two models: a time-constant and a time-varying relative effects model in a piece-wise exponential additive mixed model’s framework for recurrent events. A more complex model that fits in the same framework is applied to study the continuously measured seasonal effects.

Results

We find that several risk factors (male sex, preterm birth, low birthweight, lower socioeconomic status, lower maternal education and maternal cigarette smoking) have strong relative effects that are persistent across time. When time-varying effects are allowed in the model, HIV exposure status (HIV exposed & uninfected versus HIV unexposed) shows a strong relative effect for younger children, but this effect weakens as children grow older, with a null effect reached from about 15 months. Weight-for-length at birth shows a time increasing relative effect. We also find that children born in the summer have a much higher risk of pneumonia in the 3-to-8-month age period compared with children born in winter.

Conclusion

This work highlights the usefulness of flexible modelling tools in recurrent events models. It avoids stringent assumptions and allows estimation and visualization of absolute and relative risks over time of key factors associated with incidence of pneumonia in young children, providing new perspectives on the role of risk factors such HIV exposure.

Supplementary Information

The online version contains supplementary material available at (10.1186/s12874-020-01194-6).

Ambient PM2.5 and its chemical constituents on lifetime-ever pneumonia in Chinese children: A multi-center study

The long-term effects of ambient PM_2.5 and chemical constituents on childhood pneumonia were still unknown. A cross-sectional study was conducted in 30,315 children in the China Children, Homes, Health (CCHH) project, involving 205 preschools in six cities in China, to investigate the long-term effects of PM_2.5 constituents on lifetime-ever diagnosed pneumonia. Information on the lifetime-ever pneumonia and demographics were collected by validated questionnaires. The lifetime annual average ambient PM_2.5, ozone and five main PM_2.5 constituents, including SO₄^2-, NO₃^-, NH₄⁺, organic matter (OM) and black carbon (BC), were estimated according to preschool addresses by a combination of satellite remote sensing, chemical transport modeling and ground-based monitors. The prevalence of lifetime-ever diagnosed pneumonia was 34.5% across six cities and differed significantly among cities (p = 0.004). The two-level logistic regression models showed that the adjusted odds ratio for PM_2.5 (per 10 µg/m³) and its constituents (per 1 µg/m³)-SO₄^2-, NO₃^-, NH₄⁺, and OM were 1.12 (95% CI:1.07-1.18), 1.02 (1.00-1.04), 1.06 (1.04-1.09), 1.05 (1.03-1.07) and 1.09 (1.06-1.12), respectively. Children in urban area, aged < 5 years and breastfeeding time < 6 months enhanced the risks of pneumonia. Our study provided robust results that long-term levels of ambient PM_2.5 and its constituents increased the risk of childhood pneumonia, especially NH₄⁺, NO₃^- and OM.

Children's Respiratory Infections in Tianjin Area, China: Associations with Home Environments and Lifestyles

Children spend most of their indoors time at home, which may have substantial influence on their health. We conducted a cross-sectional study in the Tianjin area, China to quantify the incidence of respiratory infections among children, and its association with home environments and lifestyles. The lifetime-ever incidences of croup, pneumonia and ear infection among children aged 0-8 in Tianjin area was 9.2%, 28.7% and 11.6%, respectively. The incidence of common cold infections more than twice per year was 31.3%. Home environments and lifestyles included strong risk factors for childhood respiratory infections. Perceived dry air had the greatest association with childhood common colds (population attributable fraction (PAF = 15.0%). Modern floor covering had the greatest association with croup (PAF = 14.7%) and ear infection (PAF = 34.5%), while infrequent bedding sun-curing had the greatest association with pneumonia (PAF = 18.7%). Condensation (a proxy of poor ventilation) accounted for 12.2% of the incidence of croup (PAF = 12.2%) and frequent common colds (PAF = 8.4%). Our findings indicate that factors related to "modern" home environments and lifestyles are risks for childhood respiratory infections. Modifying such factors might reduce the incidence of respiratory infections among children.

Prevalence and risk factors of acute lower respiratory infection among children living in biomass fuel using households: a community-based cross-sectional study in Northwest Ethiopia

Background

Childhood acute lower respiratory infection in the form of pneumonia is recognized as the single largest cause of childhood death globally accounting for 16% of the overall deaths. Some studies also reported a higher prevalence of childhood acute respiratory infection in Ethiopia, which ranges from 16% up to 33.5%. Concerning the risk factors, there are limited community-based studies in Ethiopia in general, and in the current study region in particular. Therefore, the present study was conducted to investigate the prevalence of childhood acute respiratory infection and associated factors in Northwest Ethiopia.

Methods

As part of the wider stove trial project, a cross-sectional study was conducted in May 2018 among a total of 5830 children aged less than 4 years old in randomly selected clusters. Binary logistic regression was applied to identify factors linked with childhood acute lower respiratory infection and adjusted odds ratios were used as measures of effect with a 95% confidence interval.

Results

A total of 5830 children were included in the study within 100 clusters. Out of which 51.7% were male and 48.3% female. The prevalence of childhood lower acute respiratory infection was 19.2% (95% CI: 18.2–20.2) and found to decrease among children living in homes with chimney, eaves space and improved cookstove than children living in households with no chimney, eaves space and improved cookstove with estimated AOR of 0.60 (95% CI: 0.51–0.70), 0.70 (95% CI: 0.60–0.84) and 0.43 (95% CI: 0.28–0.67) respectively. It was also associated with other cooking-related factors such as cow dung fuel use [AOR = 1.54 (95% CI: 1.02–2.33)], child spending time near stove during cooking [AOR = 1.41 (95% CI: 1.06–1.88), presence of extra indoor burning events [AOR = 2.19 (95% CI: 1.41–3.40)] and with frequent cooking of meals [AOR = 1.55 (95% CI: 1.13–2.13)].

Conclusion

High prevalence of childhood acute lower respiratory infection was demonstrated by this study and it was found to be associated with household ventilation, cooking technology, and behavioral factors. Therefore, we recommend a transition in household ventilation, cooking technologies as well as in child handling and in the peculiar local extra indoor burning practices.

Does Complete Basic Immunization Correlate with Pneumonia Incidents in Children under Five Years in Depok, Indonesia?

Pneumonia is the first globally infectious disease causing death in children under five years of age in which the discovery of cases has increased in Indonesia in recent years. Immunization is a major preventive effort against the disease and is administered through the DPT, Hib, measles, PCV, and rotavirus vaccines. The aim of this study was to understand the correlation between complete basic immunization administration, parental characteristics, and the characteristics of children under five years with the incidence of pneumonia among children in this age group in Depok, Indonesia. The study used a cross-sectional design. There were 104 samples chosen by consecutive sampling. The study was conducted at the public health center in Depok between April and June of 2018. The data collection used questionnaires, parental characteristics, characteristics of children under five years, and complete basic immunization data for the children, which was arranged by the researchers. The questionnaire was tested for validity and reliability. The results of the study showed that complete basic immunization (p: 0.000, α: 0.05), age (p: 0.002, α: 0.05), and nutritional status (p: 0.043, α: 0.05) had a significant correlation with the incidence of pneumonia in children under five years. Health education about the importance of complete basic immunization and balanced nutrition needs to be given to parents who have under-five years of age.

Lifetime-ever pneumonia among pre-school children across China - Associations with pre-natal and post-natal early life environmental factors

BACKGROUND

Biomass burning is associated with childhood pneumonia but few studies exist on other indoor factors.

AIM

To study pneumonia in relation to pre-natal and post-natal exposure among children across China.

METHODS

Children (3-6 y) (n = 39,782) from randomized day care centres in seven cities in China. Information on pneumonia and pre-natal and post-natal exposure to home environment factors were assessed by a parental questionnaire. Life-time outdoor temperature and GDP per capita were assessed on city level. Associations were calculated by multilevel logistic regression adjusting for fourteen co-variates.

RESULTS

Totally 32.0% had ever had pneumonia diagnosed by a physician. Children of farmer mothers (OR = 0.65), with breastfeeding (OR = 0.91) and living in rural (OR = 0.85) or suburban (OR = 0.90) areas had less pneumonia. Buying new furniture one year before conception (OR = 1.11) and after first year of life (OR = 1.10) increased the risk. Redecoration one year before conception (OR = 1.20), during pregnancy (OR = 1.18) and after first year of life (OR = 1.17) increased pneumonia risk. Children with mould (OR = 1.17), window pane condensation (WPC) (OR = 1.20) and mould odour (OR = 1.15) at home at birth only had a higher risk of pneumonia. Similar associations were seen for dampness and mould in the current home. Children in the oldest and newest homes had less pneumonia. Cockroaches (OR = 1.08), mosquitos or flies in the current home (OR = 1.18), an exhaust fan in the bathroom (OR = 1.10) and higher economic development level, measured as GDP per capita on city level (OR 1.11 per 10,000 RMB/year) were associated with childhood pneumonia.

CONCLUSIONS

Perinatal and postnatal exposure to mould, mould odour and window pane condensation at home can be early life risk factors for childhood pneumonia in China. Moreover, pre-natal and post-natal exposure to chemical emissions from new furniture and renovation could increase the risk of childhood pneumonia. Breastfeeding, farm exposure, and living in rural or suburban areas could be protective.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Cost-effectiveness analysis of routine 13-valent pneumococcal conjugate vaccinations in Chinese infants

BACKGROUND

This study aimed to evaluate the cost-effectiveness of the 13-valent pneumococcal conjugate vaccine (PCV-13) compared to a no vaccination strategy in Chinese infants.

METHODS

A Markov process model was developed to examine the outcomes of PCV-13 against a no vaccination strategy using data and assumptions adapted for relevance to China. Outcomes over a lifetime horizon are presented. One-way and probabilistic sensitivity analyses were performed to determine the uncertainty.

RESULTS

Compared to no vaccination, a PCV-13 vaccination program would provide a gain of 0.009 additional quality-adjusted life years (QALYs) per subject. From the health care and societal perspectives, the incremental costs per QALY were $20,709 and 18,483, respectively. When herd effect was included, the cost effectiveness of the PCV-13 vaccination strategy was notably improved. The lower price of PCV-13 will improve the cost-effectiveness.

CONCLUSIONS

The PCV-13 vaccination is likely to be cost-effective at the current Chinese prices and ceiling threshold ($8,382).