Reducing mortality from childhood pneumonia and diarrhoea: The leading priority is also the greatest opportunity

Are the first 1,000 days of life a neglected vital period to prevent the impact on maternal and infant morbimortality of infectious diseases in Latin America? Proceedings of a workshop of experts from the Latin American Pediatric Infectious Diseases Society, SLIPE

While the first 1,000 days of life are a critical period in child's development, limited information on the main determinants affecting this period in the Latin America and the Caribbean (LAC) region is available. Therefore, the Latin American Pediatric Infectious Diseases Society (SLIPE) held an ad hoc workshop in May 2022 with an expert panel designed to analyze the main factors impacting the development of childhood in the region during this period and the main causes of maternal infant morbimortality. The aim was to identify priorities, generate recommendations, and advise practical actions to improve this situation. Considerations were made about the challenges involved in bridging the gap that separates the region from more developed countries regarding an optimal early childhood and maternal care. Extensive discussion was conducted to reach consensus recommendations on general strategies intended to reduce maternal and infant mortality associated with infections and immune-preventable diseases during the first 1,000 days of life in LAC.

Pulmonary sequelae in 2-year-old children after hospitalisation for respiratory syncytial virus lower respiratory tract infection during infancy: an observational study

BACKGROUND

Respiratory syncytial virus (RSV) is the most common cause of hospitalisation for lower respiratory tract infection (LRTI) in children. RSV LRTI during early childhood may increase susceptibility to recurrent wheezing and asthma.

RESEARCH QUESTION

The aim of this study was to describe the pulmonary sequelae at 1 and 2 years of age following RSV LRTI hospitalisation during the first year of life in term infants.

STUDY DESIGN AND METHODS

A longitudinal case-control study was undertaken from April 2016 to December 2019. Cases constituted children hospitalised with PCR-confirmed RSV LRTI during infancy and controls were children not previously hospitalised with LRTI. A questionnaire detailing environmental and medical history, as well as a modified International Study of Asthma and Allergies (ISAAC) questionnaire, was administered, and pulmonary function testing, including oscillometry, tidal breath flow-volume loops and multiple breath wash-out, was performed, at one and two years of age.

RESULTS

One (n=308) and two-year-old (n=214) cases were more likely than one (n=292) and two-year-old (n=209) controls to have experienced clinical pulmonary symptoms, including wheezing ((55% vs 24%; p<0.001) and (61% vs 16%; p<0.001)), received treatment for wheezing ((17 vs 8%; p<0.001) and (51 vs 6%; p<0.001)) and had any admissions for wheezing ((31 vs 6%; p<0.001) and (46 vs 1.4%; p<0.001)) or any LRTI ((24 vs 2%; p<0.001) and (32 vs 1.4%; p<0.001)), after the initial RSV hospitalisation. RSV LRTI during infancy was associated with an increase in airway resistance by two years (22.46 vs 20.76 hPa.s.l^-1 (p=0.022)), along with a decrease in compliance at both one (-4.61 vs -3.09 hPa.s/l (p<0.001)) and two years (-0.99 vs 0.33 hPa.s/l¹ (p<0.001)). There was an increased work of breathing at one year, but this was no longer present at two years.

INTERPRETATION

RSV LRTI during infancy in cases was associated with more clinical and pulmonary function sequelae through to two years of age.

Do Storage Conditions Affect Collected Cookstove Emission Samples? Implications for Field Studies

Cookstove emissions are a significant source of indoor air pollution in developing countries and rural communities world-wide. Considering that many research sites for evaluating cookstove emissions and interventions are remote and require potentially lengthy periods of particulate matter (PM) filter sample storage in sub-optimal conditions (e.g., lack of cold storage), an important question is whether samples collected in the field are stable over time. To investigate this, red oak was burned in a natural-draft stove, and fine PM (PM2.5) was collected on polytetrafluoroethylene filters. Filters were stored at either ambient temperature or more optimal conditions (-20°C or -80°C) for up to 3 months and extracted. The effects of storage temperature and length on stability were evaluated for measurements of extractable organic matter (EOM), PM2.5, and polycyclic aromatic compound (PAC) levels in the filter extracts. A parallel, controlled laboratory condition was also evaluated to further explore sources of variability. In general, PM2.5 and EOM in both simulated field and laboratory samples were similar regardless of the storage condition or duration. The extracts were also analyzed by gas chromatography to quantify 22 PACs and determine similarities and/or differences between the conditions. PAC levels were a more sensitive stability measure in differentiating between storage conditions. The findings suggest that measurements are relatively consistent across storage duration/temperatures for filter samples with relatively low EOM levels. This study aims to inform protocols and filter storage procedures for exposure and intervention research conducted in low- and middle-income countries where studies may be budget- and infrastructure-limited.

Immune Cell Activation in Obesity and Cardiovascular Disease

PURPOSE OF REVIEW

In this review, we focus on immune cell activation in obesity and cardiovascular disease, highlighting specific immune cell microenvironments present in individuals with atherosclerosis, non-ischemic heart disease, hypertension, and infectious diseases.

RECENT FINDINGS

Obesity and cardiovascular disease are intimately linked and often characterized by inflammation and a cluster of metabolic complications. Compelling evidence from single-cell analysis suggests that obese adipose tissue is inflammatory and infiltrated by almost all immune cell populations. How this inflammatory tissue state contributes to more systemic conditions such as cardiovascular and infectious disease is less well understood. However, current research suggests that changes in the adipose tissue immune environment impact an individual's ability to combat illnesses such as influenza and SARS-CoV2. Obesity is becoming increasingly prevalent globally and is often associated with type 2 diabetes and heart disease. An increased inflammatory state is a major contributor to this association. Widespread chronic inflammation in these disease states is accompanied by an increase in both innate and adaptive immune cell activation. Acutely, these immune cell changes are beneficial as they sustain homeostasis as inflammation increases. However, persistent inflammation subsequently damages tissues and organs throughout the body. Future studies aimed at understanding the unique immune cell populations in each tissue compartment impacted by obesity may hold potential for therapeutic applications.

Etiology and the challenge of diagnostic testing of community-acquired pneumonia in children and adolescents

Background

Pneumonia is the leading cause of mortality in pediatric population. The etiology of pneumonia in this population is variable and changes according to age and disease severity and where the study is conducted. Our aim was to determine the etiology of community-acquired pneumonia (CAP) in children aged 1 month to 17 years admitted to 13 Colombian hospitals.

Methods

Prospective cohort study. Hospitalized children with radiologically confirmed CAP and ≤ 15 days of symptoms were included and followed together with a control group. Induced sputum (IS) was submitted for stains and cultures for pyogenic bacteria and Mycobacterium tuberculosis, and multiplex PCR (mPCR) for bacteria and viruses; urinary antigens for pneumococcus and Legionella pneumophila; nasopharyngeal swabs for viruses, and paired serology for atypical bacteria and viruses. Additional cultures were taken at the discretion of primary care pediatricians.

Results

Among 525 children with CAP, 71.6% had non-severe pneumonia; 24.8% severe and 3.6% very severe pneumonia, and no fatal cases. At least one microorganism was identified in 84% of children and 61% were of mixed etiology; 72% had at least one respiratory virus, 28% pyogenic bacteria and 21% atypical bacteria. Respiratory syncytial virus, Parainfluenza, Rhinovirus, Influenza, Mycoplasma pneumoniae, Adenovirus and Streptococcus pneumoniae were the most common etiologies of CAP. Respiratory syncytial virus was more frequent in children under 2 years and in severe pneumonia. Tuberculosis was diagnosed in 2.3% of children. IS was the most useful specimen to identify the etiology (33.6%), and blood cultures were positive in 3.6%. The concordance between all available diagnostic tests was low. A high percentage of healthy children were colonized by S. pneumoniae and Haemophilus influenzae, or were infected by Parainfluenza, Rhinovirus, Influenza and Adenovirus.

Conclusions

Respiratory viruses are the most frequent etiology of CAP in children and adolescents, in particular in those under 5 years. This study shows the challenges in making an etiologic diagnosis of CAP in pediatric population because of the poor concordance between tests and the high percentage of multiple microorganisms in healthy children. IS is useful for CAP diagnosis in pediatric population.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03235-z.

Burden, risk factors and outcomes associated with gestational diabetes in a population-based cohort of pregnant women from North India

Background

The burden of gestational diabetes mellitus (GDM) appears to be increasing in India and may be related to the double burden of malnutrition. The population-based incidence and risk factors of GDM, particularly in lower socio-economic populations, are not known. We conducted analyses on data from a population-based cohort of pregnant women in South Delhi, India, to determine the incidence of GDM, its risk factors and association with adverse pregnancy outcomes (stillbirth, preterm birth, large for gestational age babies) and need for caesarean section.

Methods

We analyzed data from the intervention group of the Women and Infants Integrated Interventions for Growth Study (WINGS), an individually randomized factorial design trial. An oral glucose tolerance test (OGTT) was performed at the time of confirmation of pregnancy, and for those who had a normal test (≤140 mg), it was repeated at 24–28 and at 34–36 weeks. Logistic regression was performed to ascertain risk factors associated with GDM. Risk ratios (RR) were calculated to find association between GDM and adverse pregnancy outcomes and need for caesarean section.

Results

19.2% (95% CI: 17.6 to 20.9) pregnant women who had at least one OGTT were diagnosed to have GDM. Women who had prediabetes at the time of confirmation of pregnancy had a significantly higher risk of developing GDM (RR 2.08, 95%CI 1.45 to 2.97). Other risk factors independently associated with GDM were woman’s age (adjusted OR (AOR) 1.10, 95% CI 1.06 to 1.15) and BMI (AOR 1.04, 95% CI 1.01 to 1.07). Higher maternal height was found to be protective factor for GDM (AOR 0.98, 95% CI 0.96 to 1.00). Women with GDM, received appropriate treatment did not have an increase in adverse outcomes and no increased need for caesarean section

Conclusions

A substantial proportion of pregnant women from a low to mid socio-economic population in Delhi had GDM, with older age, higher BMI and pre-diabetes as important risk factors. These findings highlight the need for interventions for prevention and provision of appropriate management of GDM in antenatal programmes.

Clinical trial registration

Clinical Trial Registry – India, #CTRI/2017/06/008908 (http://ctri.nic.in/Clinicaltrials/pmaindet2.php?trialid=19339&EncHid=&userName=society%20for%20applied%20studies).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04389-5.

Clinical Utility of Respiratory Scores at Admission for Estimating the Definitive Microbiological Diagnosis in Lower Respiratory Tract Infections in Infants

We aimed at determining the clinical utility of respiratory scores and the durations of wheezing or respiratory distress during hospitalization in infants with lower respiratory tract infections (LRTI) at admission for estimating the definitive microbiological diagnosis. We obtained data from a study population of 201 patients, 79 girls and 122 boys. There was a significant divide in the causative agents of LRTI among patients younger and older than 6 months of age (P = .002), and significantly different respiratory score findings were determined in infants with viral LRTI: a low respiratory score in a younger-than-6 month infant suggests Adenovirus as the causative agent and a high respiratory score suggests Parainfluenza 1 or 2; as for infants of 6 months of age or older, a low respiratory score indicates Influenza A or B or a mixed infection, whereas a high respiratory score is likely an indication of Parainfluenza 3 or RSV.

Genotypic and phenotypic characteristics of Streptococcus pneumoniae from community-acquired pneumonia patients and healthy asymptomatic participants in Sichuan province, China

Background

Streptococcus pneumoniae (S. pneumoniae) is the common cause of community-acquired pneumonia (CAP) and is also found in the upper respiratory tract of healthy people. Hence, the study aimed to compare the serotypes, virulence/pili genes, and antibiotic susceptibility of S. pneumoniae from healthy asymptomatic participants and CAP patients.

Methods

Streptococcus pneumoniae were retrospectively collected from health asymptomatic participants and CAP patients in Sichuan, China. The serotypes were tested by multiplex polymerase chain reaction (PCR) or Quellung reaction. Antibiotic susceptibility testing was performed using the broth microdilution method. The molecular epidemiology of S. pneumoniae was analyzed by multilocus sequence typing (MLST). Additionally, the presence of virulence/pili genes were detected using PCR.

Results

A total of 83 pneumococcal isolates were collected in the current study. Of these, 52 and 31 isolates were from healthy asymptomatic participants and CAP patients, respectively. Most of S. pneumoniae were resistant to erythromycin (ERY), clindamycin (CLI), tetracycline (TET) and trimethoprim-sulfamethoxazole (SXT). 90.4% isolates were classified as multidrug resistant (MDR). The predominant serotypes were 3, 19F and 19A in the CAP carriers, whereas 3, 6 and 19F were the main serotypes among the asymptomatic carriers. The overall coverage rates of pneumococcal conjugate vaccine (PCV) 10 and PCV13 serotypes were 34.9% and 66.3%, respectively. The predominant sequence types (STs) were ST271, ST320, and ST3397. There were significant differences in some resistance and virulence characteristics between CAP patients and asymptomatic carriers. Additionally, clonal complex (CC) 271 strains had higher percentage in resistance to cefuroxime (CXM) and cefotaxime (CEF), meropenem (MER) and cefepime (CFP), which mainly carried the rlrA and sipA genes.

Conclusions

High coverage rate of PCV13 and high prevalence of MDR indicated the necessity to expand immunization with PCV13 and rationally use the antibiotics in Sichuan, China. Importantly, long-term surveillance should be conducted to assess effectiveness brought by vaccines. Our findings may supply new guidance for developing new pneumococcal vaccines.

A Systematic Review of Pneumococcal Carriage, Disease, Antimicrobial Resistance, and Vaccination in Egyptian Children Aged 18 Years and Younger

Streptococcus pneumoniae remains an important bacterial pathogen, particularly for young children in low- and middle-income countries. A systematic review was conducted of peer-reviewed literature from PubMed published as of May 13, 2020, to identify articles relevant to invasive pneumococcal disease, pneumonia, otitis media (OM), nasopharyngeal carriage (NPC), antimicrobial resistance (AMR), and vaccination coverage in Egypt, with particular focus on children ≤ 18 years of age. A total of 16 relevant articles spanning three decades were included in this review. Among studies reviewed, S. pneumoniae was the causative agent of meningitis in 21–30% of cases among hospitalized children between 1983 and 2003. One study showed that serotypes 6A and 6B predominated among meningitis cases of pediatric patients aged < 5 years. This review also revealed that S. pneumoniae was the most commonly identified bacterial pathogen of acute mastoiditis, a severe complication of acute OM, among children aged 9 months to 11 years. NPC studies showed that approximately 30% of Egyptian children were carriers of S. pneumoniae. AMR, especially to penicillin, continues to be a growing concern in low- and middle-income countries, including among Egyptian children. Several predominant serotypes were identified to be associated with penicillin resistance, such as 6B, 1, 19A, 23F, and 6A. Currently available pneumococcal vaccines (PCVs) such as PCV10 and PCV13 may provide coverage against the most prevalent circulating serotypes among Egyptian children. Comprehensive disease surveillance and immunization programs are needed to ensure that this vulnerable population is sufficiently protected against pneumococcal disease.

Estimating the Public Health and Economic Impact of Introducing the 13-Valent Pneumococcal Conjugate Vaccine or 10-Valent Pneumococcal Conjugate Vaccines into State Immunization Programs in India

Introduction

Although the pneumococcal conjugate vaccine (PCV) has been introduced into select state immunization programs (SIPs) in India, many children remain unvaccinated. Recently, India’s Advisory Committee on Vaccines & Immunization Practices recommended PCV on the pediatric immunization schedule nationally. This study estimates the public health and economic impact of introducing either Pfizer’s 13-valent PCV (PCV13-PFE), GlaxoSmithKline’s 10-valent PCV (PCV10-GSK), or Serum Institute of India’s 10-valent PCV (PCV10-SII) into every pediatric SIP.

Methods

A model was developed to predict the disease cases, deaths, and costs associated with implementing PCV13-PFE, PCV10-GSK, or PCV10-SII in SIPs compared to no vaccination program across a 5-year period (2021–2025). State and national-level uptake rate and clinical and economic input parameters were collected from published literature. Disease outcomes included invasive pneumococcal disease, inpatient and outpatient pneumonia, and otitis media. Costs were estimated as vaccine-related costs and direct medical costs incurred to the healthcare system. Results were reported by individual state and aggregated nationally.

Results

Estimated over 5 years, implementing PCV13-PFE in SIPs could avert 12.1 million cases and save 626,512 lives among children under 5 years old compared to no vaccination. This corresponds to net national cost savings of over $1.0 billion. Both lower-valent PCVs are estimated to provide less economic savings than PCV13-PFE inclusive of vaccine-related costs. Compared with PCV13-PFE, implementing PCV10-GSK or PCV10-SII nationally is estimated to have a smaller public health impact, with PCV10-GSK averting 8.4 million cases (436,577 deaths) and PCV10-SII preventing 10.3 million cases (531,545 deaths) in India compared to no vaccination, respectively.

Conclusion

Implementation of PCV13-PFE throughout India is estimated to provide greater public health and economic benefits than PCV10-GSK or PCV10-SII SIPs. Our analysis highlights the substantial disease cases, deaths, and health system cost savings that may be realized from implementing PCV programs throughout India.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40121-021-00498-4.

Risk factors for recurrent respiratory tract infection in preschool-aged children

BACKGROUND

We aimed to identify potential risk factors for recurrent respiratory tract infection among Chinese preschool-aged children, and further to construct a nomogram prediction model.

METHODS

This is a cross-sectional survey conducted in Beijing. Utilizing a stratified cluster random sampling strategy, a total of 7222 children from 20 kindergartens were enrolled. Data are analyzed by STATA software and R language.

RESULTS

Five independent factors were identified to be significantly associated with recurrent respiratory tract infection risk overall and by pathogenic sites. The significant odds of recurrent respiratory tract infection was 8.31 (95% confidence interval [CI]: 5.69-12.12, P < 0.001), 2.31 (2.06-2.58, P < 0.001), 1.72 (1.48-1.99, P < 0.001), 1.24 (1.08-1.43, P = 0.002), and 1.19 (1.09-1.31, P < 0.001) for asthma, allergy, initial use of antibiotics <6 months, breastfeeding duration <6 months, and maternal body mass index, respectively. Besides the leading role played by asthma, allergy, initial use of antibiotics, and breastfeeding might exert a graded, dose-dependent effect on recurrent respiratory tract infection susceptibility.

CONCLUSIONS

We have identified five potential risk factors for the risk of recurrent respiratory tract infection from 7222 preschool-aged Chinese children. Notably, asthma plays a leading role, and allergy, initial use of antibiotics, and breastfeeding might exert a graded, dose-dependent effect on recurrent respiratory tract infection susceptibility.

IMPACT

This is the first report of examining the joint contribution of multiple potential risk factors to recurrent respiratory tract infection among Chinese preschool-aged children. We have identified five potential risk factors for the risk of recurrent respiratory tract infection via analyzing survey data from 7222 preschool-aged Chinese children. Asthma plays a leading role, and allergy, initial use of antibiotics, and breastfeeding might exert a graded, dose-dependent effect on recurrent respiratory tract infection susceptibility.

A Narrative Review of Pneumococcal Disease in Children in the Philippines

This narrative review describes the epidemiology of invasive pneumococcal diseases, nasopharyngeal carriage, and antibiotic resistance of Streptococcus pneumoniae serotypes, and vaccination coverage in children in the Philippines. Epidemiological data show that, despite the availability of the free-of-cost 13-valent pneumococcal conjugate vaccine for infants as part of the National Immunization Program, the burden of pneumococcal disease in young children remains high in the Philippines. The significant variability in data reported between studies highlights an urgent need for active and comprehensive disease surveillance for more accurate estimates of pneumococcal disease in the country. Although data from 2001 to 2013 show high rates of pneumococcal carriage in children in the Philippines aged < 5 years, contemporary data are lacking, again emphasizing the need for active surveillance programs. The introduction of pneumococcal conjugate vaccines has resulted in substantial declines in disease caused by pneumococcal serotypes included in the vaccines, but the emergence of pneumococcal disease due to nonvaccine serotypes is an ongoing concern. Surveillance of actively circulating serotypes is critical to better understand vaccine coverage. Antimicrobial resistance of S. pneumoniae remains a significant threat to public health worldwide; data regarding antibiotic resistance in young children in the Philippines are limited, but reports generally show low rates of antibiotic resistance in this group. National immunization rates have increased in recent years, yet many individuals are still unprotected from pneumococcal disease. Overall, there is a critical need for contemporary and accurate disease surveillance in the Philippines. Such data would provide better estimates of pneumococcal disease incidence, serotype distribution, and antibiotic resistance to better inform vaccination strategies and to ensure that children in the Philippines are best protected against pneumococcal disease.

Lung Ultrasound: The Essentials

Although US of the lungs is increasingly used clinically, diagnostic radiologists are not routinely trained in its use and interpretation. Lung US is a highly sensitive and specific modality that aids in the evaluation of the lungs for many different abnormalities, including pneumonia, pleural effusion, pulmonary edema, and pneumothorax. This review provides an overview of lung US to equip the diagnostic radiologist with knowledge needed to interpret this increasingly used modality. Supplemental material is available for this article. © RSNA, 2021.

Seroepidemiology of respiratory syncytial virus infection in rural and semi-rural areas of the Littoral region of Cameroon

Background

The respiratory syncytial virus (RSV) has been established as a leading cause of acute lower respiratory illness (ALRI) in infants and children. In 2015, the global disease burden (GBD) study estimated that the overall RSV-ALRI mortality could be as high as 118,200, with most death occurring in low- and middle-incomes countries (LMIC). This study aimed to assess the burden of RSV infection among children less than 2 years with acute respiratory infections (ARI) in the Littoral region of Cameroon.

Methods

We carried out a cross-sectional study in seven health centres in the Littoral region of Cameroon. Venous blood was collected using serum separation tubes from eligible children who visited these health centres with acute respiratory infections. ELISA (Enzyme-linked immunosorbent assay) testing was used to assess the seroprevalence of anti-IgM RSV for the total population and by selected demographic and health parameters and potential risk factors.

Results

The overall RSV-associated ARI seroprevalence was 33% (95%CI:23.6–42.3; 33/100 children). The only demographic factor significantly associated with RSV acquisition was age of 6 months and below (odds ratio: 7.54 (2.62, 23.36); p = 0.000). Children who were clinically diagnosed to be concomitantly infected with malaria had a lower risk of RSV infection (odds ratio: 0.38 (0.14, 0.95; P = 0.03).

Conclusions

The RSV burden is high among children less than 2 years with ARI in the Littoral region of Cameroon. There is a need for an effective public health RSV surveillance system with standard laboratory techniques and equipment to better understand the RSV disease age-specific incidence, seasonality, risk factors and RSV burden among patients in communities in Cameroon.

Clinical Signs, Prevention and Treatment of Viral Infections in Infants

Certain infectious diseases are common in infants than any other age groups and are associated with morbidities in childhood and adulthood, and even mortality in severe cases. Environment, epidemic and maternal immunity are the main causes of these infections. Early diagnosis using molecular methods and treatment is therefore important to prevent future complications. Vaccines are recommended during infancy and childhood to prevent these infections. This review highlights some of the most commonly reported viral infections in children, their clinical signs, prevention and treatment.

Molecular epidemiology of Streptococcus pneumoniae isolated from pediatric community-acquired pneumonia in pre-conjugate vaccine era in Western China

BACKGROUND

Streptococcus pneumoniae (S. pneumoniae) is one of the most common pathogens which can cause morbidity and mortality in pediatric infections worldwide. This study aimed to describe the phenotypic and molecular characteristics of community-acquired pneumonia (CAP)-causing S. pneumoniae recovered from children in Western China.

METHODS

We retrospectively enrolled pediatric patients younger than 5 years diagnosed with CAP. All 419 S. pneumoniae isolates were tested for antibiotic susceptibility, serotypes, virulence genes, resistance genes, and sequence types. The potential relationships between molecular characteristics were tested by correspondence analysis.

RESULTS

Most of S. pneumoniae isolates were resistant to erythromycin, tetracycline, clindamycin and trimethoprim-sulfamethoxazole, with 93.8% isolates classified as multidrug resistant. The dominant STs were ST271 (30.8%) and ST320 (12.2%), while the prevailing serotypes were 19F (46.8%), 6B (11.5%), 23F (9.5%) and 19A (9.3%). The coverage rates of PCV-7 and PCV-13 were 73.03% and 86.16%, while the coverage rates of PCV13 among children aged < 1 year and 1-2 years were high in 93.18% and 93.62%. We also observed that CC271 expressed more of mef (A/E), lytA, rlrA and sipA than non-CC271 isolates. Moreover, there were strong corresponding relationships between molecular characteristics.

CONCLUSIONS

The high coverage rate of PCV13 suggests the necessity of introducing the PCV13 vaccine in Western China. Our findings underscore the value of monitoring multiple molecular characteristics to provide new guidance for developing future pneumococcal vaccines.

Characterization and Antibiotic Susceptibility Profiles of Pathogenic Escherichia Coli Isolated from Diarrhea Samples within the Buffalo City Metropolitan Municipality, Eastern Cape, South Africa

Objectives:

Developing countries like South Africa are still faced with numerous challenges such as poor environmental sanitation, lack of clean drinking water and inadequate hygiene which have contributed largely to diarrheal infections and deaths in children. This study was aimed at investigating the prevalence of pathotypes, antimicrobial resistance and drug resistance determinants among Escherichia coli (E. coli) isolates from diarrhea stool samples within Buffalo City Municipality, Eastern Cape, South Africa.

Methods:

Fresh diarrheal stool samples were collected from 140 patients attending public health centres within the Municipality and presumptive E. coli isolates were obtained from the stool samples using E. coli chromogenic agar while PCR amplification methods were used to confirm the presumptive isolates as well as delineate them into pathotypes based on the presence of certain virulence genes. In addition, antimicrobial susceptibility and screening of some of the antimicrobial resistant determinants were performed on all the confirmed isolates.

Results:

A total of 394 presumptive E. coli isolates from 140 diarrhea stool samples were subjected to polymerase chain reaction amplification, of which 265 were confirmed positive as E. coli. Pathotypes delineation of the positive E. coli isolates validated the presence of ETEC 106 (40%), EAEC 48 (18%), DAEC 37 (14%), and EPEC 31 (11%) while no EIEC pathotype was detected. All E. coli isolates exhibited maximum susceptibility to gentamicin (95%), amikacin (91%), nitrofurantoin (91%), meropenem (90%), chloramphenicol (91%) norfloxacin (84%) and imipenem (83%). However, the isolates showed multidrug resistance to penicillin G, ampicillin, trimethoprim, tetracycline, doxycycline, and erythromycin, with over 71% of the isolates resistant to the drugs. The prevalence and distribution of the five resistance determinants assessed were as follow; sulphonamides; sulII (12%), beta lactams; [ampC (22%); blaTEM, (25%)], and tetracyclines (tetA (35%).

Conclusion:

The results from this study suggest the probable involvement of E. coli pathotypes as an etiologic agent of diarrhea in the study area and revealed high levels of multidrug resistance among the isolates, which could be a major health burden.

Complete basic childhood vaccination and associated factors among children aged 12-23 months in East Africa: a multilevel analysis of recent demographic and health surveys

Background

Complete childhood vaccination remains poor in Sub-Saharan Africa, despite major improvement in childhood vaccination coverage worldwide. Globally, an estimated 2.5 million children die annually from vaccine-preventable diseases. While studies are being conducted in different East African countries, there is limited evidence of complete basic childhood vaccinations and associated factors in East Africa among children aged 12–23 months. Therefore, this study aimed to investigate complete basic childhood vaccinations and associated factors among children aged 12–23 months in East Africa.

Methods

Based on the Demographic and Health Surveys (DHSs) of 12 East African countries (Burundi, Ethiopia, Comoros, Uganda, Rwanda, Tanzania, Mozambique, Madagascar, Zimbabwe, Kenya, Zambia, and Malawi), secondary data analysis was performed. The study included a total weighted sample of 18,811 children aged 12–23 months. The basic childhood vaccination coverage was presented using a bar graph. Multilevel binary logistic regression analysis was fitted for identifying significantly associated factors because the DHS has a hierarchical nature. The Intra-class Correlation Coefficient (ICC), Median Odds Ratio (MOR), Proportional Change in Variance (PCV), and deviance (−2LLR) were used for checking model fitness, and for model comparison. Variable with p-value ≤0.2 in the bi-variable multilevel analysis were considered for the multivariable analysis. In the multivariable multilevel analysis, the Adjusted Odds Ratio (AOR) with 95% Confidence Interval (CI) were reported to declare the significance and strength of association with full vaccination.

Results

Complete basic childhood vaccination in East Africa was 69.21% (95% CI, 69.20, 69.21%). In the multivariable multilevel analysis; Mothers aged 25–34 years (AOR = 1.21, 95% CI: 1.10, 1.32), mothers aged 35 years and above (AOR = 1.50, 95% CI: 1.31, 1.71), maternal primary education (AOR = 1.26, 95% CI: 1.15, 1.38), maternal secondary education and above (AOR = 1.54, 95% CI: 1.36, 1.75), husband primary education (AOR = 1.25, 95% CI: 1.13, 1.39), husband secondary education and above (AOR = 1.24, 95% CI: 1.11, 1.40), media exposure (AOR = 1.23, 95% CI: 1.13, 1.33), birth interval of 24–48 months (AOR = 1.28, 95% CI: 1.15, 1.42), birth interval greater than 48 months (AOR = 1.35, 95% CI: 1.21, 1.50), having 1–3 ANC visit (AOR = 3.24, 95% CI: 2.78, 3.77), four and above ANC visit (AOR = 3.68, 95% CI: 3.17, 4.28), PNC visit (AOR = 1.34, 95% CI: 1.23, 1.47), health facility delivery (AOR = 1.48, 95% CI: 1.35, 1.62), large size at birth 1.09 (AOR = 1.09, 95% CI: 1.01, 1.19), being 4–6 births (AOR = 0.83, 95% CI: 0.75, 0.91), being above the sixth birth (AOR = 0.60, 95% CI: 0.52, 0.70), middle wealth index (AOR = 1.16, 95% CI: 1.06, 1.28), rich wealth index (AOR = 1.20, 95% CI: 1.09, 1.33), community poverty (AOR = 1.21, 95% CI: 1.11, 1.32) and country were significantly associated with complete childhood vaccination.

Conclusions

In East Africa, full basic childhood vaccine coverage remains a major public health concern with substantial differences across countries. Complete basic childhood vaccination was significantly associated with maternal age, maternal education, husband education, media exposure, preceding birth interval, number of ANC visits, PNC visits, place of delivery, child-size at birth, parity, wealth index, country, and community poverty. Public health interventions should therefore target children born to uneducated mothers and fathers, poor families, and those who have not used maternal health services to enhance full childhood vaccination to reduce the incidence of child mortality from vaccine-preventable diseases.

Epidemiology, Nasopharyngeal Carriage, Serotype Prevalence, and Antibiotic Resistance of Streptococcus pneumoniae in Indonesia

In Indonesia, pneumococcal disease represents a considerable public health concern; however, published data on the epidemiology, nasopharyngeal carriage, serotype prevalence, and antibiotic resistance of Streptococcus pneumoniae in this region are limited. Therefore, this article reviews the available data from a variety of sources and also summarizes pneumococcal conjugate vaccine implementation and recommendations in Indonesia and subsequent impact on pneumococcal disease. Regional pneumococcal vaccination recommendations in Asia were also reviewed. Studies showed that pneumococcal nasopharyngeal carriage prevalence in Indonesia was approximately 43% to 55% in healthy children aged less than 5 years, which varied by age group, region, and year. Serotype analysis of pneumococcal nasopharyngeal carriage isolates in Indonesia revealed that 38% to 60% of isolates would be covered by the 13-valent pneumococcal conjugate vaccine (PCV13). The antimicrobial resistance of pneumococcal disease has increased over time; between 1997 and 2012, resistance to penicillin and sulfamethoxazole increased from 0% to 28% and 9% to 62%, respectively. Inclusion of pneumococcal conjugate vaccines into immunization programs is being implemented gradually. In 2017, Indonesia implemented a regional PCV13 immunization program in Lombok with a 2 + 1 vaccination schedule that was expanded in 2018-2019 to West Nusa Tenggara and Bangka Belitung Provinces; this expansion is predicted to substantially reduce the burden of pneumococcal disease in Indonesia. Overall, the limited data available regarding pneumococcal disease in Indonesia highlight the unmet need for comprehensive disease surveillance studies in this region that can help direct vaccination strategies.

Lung ultrasound findings in pediatric community-acquired pneumonia requiring surgical procedures: a two-center prospective study

BACKGROUND

Lung ultrasound (US) in the evaluation of suspected pediatric pneumonia is increasingly used and has a recognized role in evaluating pleural effusions, although there are no detailed studies specifically addressing its use in the pediatric population.

OBJECTIVES

To define lung US findings of severe pediatric community-acquired pneumonia that required surgical procedures during admission.

MATERIALS AND METHODS

Our prospective case-control study compared lung US findings in patients ages 1 month to 17 years admitted with community-acquired pneumonia that required surgical procedures from findings those who did not. Lung US was performed at admission and always before surgical procedures. Medical treatment, laboratory and microbiological findings, chest X-ray, computed tomography scan and surgical procedures are described.

RESULTS

One hundred twenty-one children with community-acquired pneumonia were included; of these, 23 underwent surgical intervention. Compared with the control group, children requiring a surgical procedure had a significantly higher rate of large consolidations (52.2%; 95% confidence interval [CI]: 30.6% to 73.2%), larger and complicated pleural effusions (100%; 95% CI: 85.2% to 100%), and both liquid and air bronchograms (73.9%; 95% CI: 51.6% to 89.8%).

CONCLUSION

Larger consolidations, larger and more complicated pleural effusions, and liquid and air bronchograms were associated with surgical treatment.

Effectiveness of the baby-friendly community initiative in promoting exclusive breastfeeding among HIV negative and positive mothers: a randomized controlled trial in Koibatek Sub-County, Baringo, Kenya

Background

Although the baby-friendly community initiative (BFCI) has been proposed as a community-level approach to improve infant feeding practices, there is little data on its variation in effectiveness by HIV status. We conducted a study to determine the effectiveness of BFCI in changing knowledge and attitudes towards exclusive breastfeeding (EBF) and increasing the rates among HIV negative and HIV positive women in rural Kenya.

Methods

A community-based cluster-randomized controlled trial was implemented from April 2015 to December 2016 among 901 women enrolled across 13 clusters. The intervention groups received a minimum of 12 personalized home-based counselling sessions on infant feeding by trained community health volunteers from their first or second trimester of pregnancy until 6 months postpartum. Other interventions included education sessions at maternal child clinics, mother-to-mother support group meetings and bi-monthly baby-friendly gatherings targeting influencers. The control group received standard health education at the facility and during monthly routine home visits by community health volunteers not trained on BFCI. Primary outcome measures were the rates of EBF at week 1, months 2, 4 and 6 postpartum. Secondary outcomes included knowledge and attitudes regarding breastfeeding for HIV-exposed infants. Statistical methods included analysis of covariance and logistic regression.

Results

At 6 months, EBF rates among HIV negative mothers were significantly higher in the BFCI intervention arm compared to the control arm (81.7% versus 42.2% p = 0.001). HIV positive mothers in the intervention arm had higher EBF rates at 6 months than the control but the difference was not statistically significant (81.8% versus 58.4%; p = 0.504). In HIV negative group, there was greater knowledge regarding EBF for HIV-exposed infants in the intervention arm than in the control (92.1% versus 60.7% p = 0.001). Among HIV positive mothers, such knowledge was high among both the intervention and control groups (96% versus 100%, p > 0.1). HIV negative and positive mothers in the intervention arm had more favourable attitudes regarding EBF for HIV-exposed infants than the control (84.5% versus 62.1%, p = 0.001) and (94.6% versus 53.8% to p = 0.001) respectively.

Conclusions

BFCI interventions can complement facility-based interventions to improve exclusive and continued breastfeeding knowledge, attitudes, and behaviours among HIV negative and positive women.

Annual and seasonal patterns in etiologies of pediatric community-acquired pneumonia due to respiratory viruses and Mycoplasma pneumoniae requiring hospitalization in South Korea

Background

Community–acquired pneumonia (CAP) is one of the leading worldwide causes of childhood morbidity and mortality. Its disease burden varies by age and etiology and is time dependent. We aimed to investigate the annual and seasonal patterns in etiologies of pediatric CAP requiring hospitalization.

Methods

We conducted a retrospective study in 30,994 children (aged 0–18 years) with CAP between 2010 and 2015 at 23 nationwide hospitals in South Korea. Mycoplasma pneumoniae (MP) pneumonia was clinically classified as macrolide-sensitive MP, macrolide-less effective MP (MLEP), and macrolide-refractory MP (MRMP) based on fever duration after initiation of macrolide treatment, regardless of the results of in vitro macrolide sensitivity tests.

Results

MP and respiratory syncytial virus (RSV) were the two most commonly identified pathogens of CAP. With the two epidemics of MP pneumonia (2011 and 2015), the rates of clinical MLEP and MRMP pneumonia showed increasing trends of 36.4% of the total MP pneumonia. In children < 2 years of age, RSV (34.0%) was the most common cause of CAP, followed by MP (9.4%); however, MP was the most common cause of CAP in children aged 2–18 years of age (45.3%). Systemic corticosteroid was most commonly administered for MP pneumonia. The rate of hospitalization in intensive care units was the highest for RSV pneumonia, and ventilator care was most commonly needed in cases of adenovirus pneumonia.

Conclusions

The present study provides fundamental data to establish public health policies to decrease the disease burden due to CAP and improve pediatric health.

Target-independent high-throughput sequencing methods provide evidence that already known human viral pathogens play a main role in respiratory infections with unexplained etiology

Despite the advanced PCR-based assays available, a fraction of the pediatric respiratory infections remain unexplained every epidemic season, and there is a perception that novel viruses might be present in these specimens. We systematically collected samples from a prospective cohort of pediatric patients with respiratory infections, that returned negative results by validated molecular RT–PCR assays, and studied them with a target-independent, high-throughput sequencing-based approach. We also included a matched cohort of children with no symptoms of respiratory infection, as a contrast study population. More than fifty percent of the specimens from the group of patients with unexplained respiratory infections were resolved. However, the higher rate of detection was not due to the presence of novel viruses, but to the identification of well-known viral respiratory pathogens. Our results show that already known viral pathogens are responsible for the majority of cases that remain unexplained after the epidemic season. High-throughput sequencing approaches that use pathogen-specific probes are easier to standardize because they ensure reproducible library enrichment and sequencing. In consequence, these techniques might be desirable from a regulatory standpoint for diagnostic laboratories seeking to benefit from the many advantages of these sequencing technologies.

Intestinal helminth infection enhances bacteria-induced recruitment of neutrophils to the airspace

Intestinal helminth infections elicit Th2-type immunity, which influences host immune responses to additional threats, such as allergens, metabolic disease, and other pathogens. Th2 immunity involves a shift of the CD4+ T-cell population from type-0 to type-2 (Th2) with increased abundance of interleukin (IL)-4 and IL-13. This study sought to investigate if existing gut-restricted intestinal helminth infections impact bacterial-induced acute airway neutrophil recruitment. C57BL/6 mice were divided into four groups: uninfected; helminth-Heligmosomoides polygyrus infected; Pseudomonas aeruginosa infected; and coinfected. Mice infected with H. polygyrus were incubated for 2 weeks, followed by P. aeruginosa intranasal inoculation. Bronchial alveolar lavage, blood, and lung samples were analyzed. Interestingly, infection with gut-restricted helminths resulted in immunological and structural changes in the lung. These changes include increased lung CD4+ T cells, increased Th2 cytokine expression, and airway goblet cell hyperplasia. Furthermore, coinfected mice exhibited significantly more airspace neutrophil infiltration at 6 hours following P. aeruginosa infection and exhibited an improved rate of survival compared with bacterial infected alone. These results suggest that chronic helminth infection of the intestines can influence and enhance acute airway neutrophil responses to P. aeruginosa infection.

Respiratory virus associated with surgery in children patients

Background

Viral respiratory infection (VRI) is a common contraindication to elective surgery. Asymptomatic shedding among pediatric surgery patients (PSPs) could potentially lead to progression of symptomatic diseases and cause outbreaks of respiratory diseases. The aim of this study is to investigate the incidence of infection among mild symptomatic PSP group and asymptomatic PSP group after surgical procedure.

Methods

We collected the induced sputum from enrolled 1629 children (under 18 years of age) with no respiratory symptom prior to pediatric surgery between March 2017 and February 2019. We tested 16 different respiratory virus infections in post-surgery mild symptomatic PSP group and asymptomatic PSP group using a quantitative real-time reverse transcriptase polymerase chain reaction (qRT-PCR) assay panel. We analyzed symptom data and quantitative viral load to investigate the association between viruses, symptoms and viral quantity in qRT-PCR-positive PSPs.

Results

Out of 1629 children enrolled, a total of 204 respiratory viruses were present in 171 (10.50%) PSPs including 47 patients with mild symptoms and 124 with no symptoms after surgery. Commonly detected viruses were human rhino/enterovirus (HRV/EV, 42.19%), parainfluenza virus 3 (PIV3, 24.48%), coronavirus (CoV NL63, OC43, HKU1, 11.46%), and respiratory syncytial virus (RSV, 9.9%). PIV3 infection with a higher viral load was frequently found in PSPs presenting with mild symptoms, progressing to pneumonia with radiographic evidence after surgery. HRV/EV were the most commonly detected pathogens in both asymptomatic and mild symptomatic PSPs. CoV (OC43, HKU1) infections with a higher viral load were mostly observed in asymptomatic PSPs progressing to alveolar or interstitial infiltration.

Conclusions

Our study suggested that PIV3 is a new risk factor for VRI in PSPs. Employing a more comprehensive, sensitive and quantitative method should be considered for preoperative testing of respiratory viruses in order to guide optimal surgical timing.

Factors associated with fatal cases of acute respiratory infection (ARI) among hospitalized patients in Guatemala

Background

Acute respiratory infection (ARI) is an important cause of mortality in children and adults. However, studies assessing risk factors for ARI-related deaths in low- and middle-income settings are limited. We describe ARI-related death and associated factors among children aged < 2 years and adults aged ≥18 years hospitalized with ARI in Guatemala.

Methods

We used respiratory illness surveillance data in Guatemala from 2007 to 2013. ARI was defined as evidence of acute infection and ≥ 1 sign/symptom of respiratory disease in hospitalized patients. Clinical, sociodemographic, and follow-up data were gathered. Nasopharyngeal/oropharyngeal swabs were collected from patients with ARI and tested for 6 respiratory viruses; urine was collected only from adults with ARI and tested for pneumococcal antigen. Blood cultures and chest radiographs were performed at the physician’s discretion. Radiographs were interpreted per World Health Organization guidelines to classify endpoint pneumonia (i.e. suggestive of bacterial pneumonia). Multivariable logistic regression was used to compare characteristics of patients with fatal cases, including those who died in-hospital or were discharged in a moribund state, with those of patients with non-fatal cases.

Results

Among 4109 ARI cases identified in hospitalized children < 2 years old, 174 (4%) were fatal. Median age at admission was 4 and 6 months for children with fatal and non-fatal cases, respectively. Factors associated with fatality included low weight-for-age, low family income, heart disease, and endpoint pneumonia; breastfeeding and respiratory syncytial virus (RSV) detection were negatively associated with fatality. Among 1517 ARI cases identified in hospitalized adults ≥18 years, 181 (12%) episodes were fatal. Median age at admission was 57 years for adults with fatal and non-fatal cases. Low body mass index, male sex, kidney disease, and endpoint pneumonia were significantly more common among patients with fatal versus non-fatal cases.

Conclusions

Our findings highlight some of the factors that must be addressed in order to reduce ARI-related mortality, including promotion of good nutrition, breastfeeding, management and prevention of chronic comorbidities, and poverty reduction. Although no specific pathogen increased risk for death, endpoint pneumonia was significantly associated with fatality, suggesting that the pneumococcal conjugate vaccine could contribute to future reductions in ARI-related mortality.

High Rate of Serotype Switching and Genetic Variations Indicates Widespread Recombination Between Clinical and Commensal Penicillin-Nonsusceptible Streptococcus pneumoniae in Tehran

A total of 161 Streptococcus pneumoniae were collected between 2013 and 2015 in Tehran, Iran. The strains were tested for antimicrobial susceptibility and minimum inhibitory concentrations, serotyped, and genotyped by multilocus sequence typing (MLST) and pulsed-field gel electrophoresis (PFGE). Penicillin-binding proteins (PBPs) were also typed by restriction fragment length polymorphism (PBP-RFLP). Out of 161 strains, 32 isolates (20%) were highly resistant to penicillin. The most frequent serotypes among the penicillin-nonsusceptible S. pneumoniae (PNSP) were 14 (24%), 23F (18%), and 19F (17%). RFLP of pbp2b, pbp2x, and pbp1a genes revealed 8, 6, and 7 different patterns, respectively. Analysis of 93 PNSP isolates displayed 80 PFGE types with 8 common types constituting 21 (23%) isolates. The remaining 72 isolates (77%) were single types. MLST indicated a high degree of genetic diversity among the 93 PNSP with 36 different sequence types. Six internationally known penicillin resistant clones were identified in our isolates among which Spain^23F-1 (ST81), Spain^6B-2 (ST90), and Spain^9V-3 (ST156) were the predominant clones. The results indicated international identifiable clones of S. pneumoniae, especially Spain^23F-1 with high penicillin resistance could play a major role in spread of antimicrobial resistance in Iran. The extensive sequence variation in PBP2x, PBP2b, and PBP1a in resistant strains of clinical and commensal S. pneumoniae was suggestive of a widespread homologous recombination within S. pneumoniae populations.

The structure and activity of the glutathione reductase from Streptococcus pneumoniae

The glutathione reductase (GR) from Streptococcus pneumoniae is a flavoenzyme that catalyzes the reduction of oxidized glutathione (GSSG) to its reduced form (GSH) in the cytoplasm of this bacterium. The maintenance of an intracellular pool of GSH is critical for the detoxification of reactive oxygen and nitrogen species and for intracellular metal tolerance to ions such as zinc. Here, S. pneumoniae GR (SpGR) was overexpressed and purified and its crystal structure determined at 2.56 Å resolution. SpGR shows overall structural similarity to other characterized GRs, with a dimeric structure that includes an antiparallel β-sheet at the dimer interface. This observation, in conjunction with comparisons with the interface structures of other GR enzymes, allows the classification of these enzymes into three classes. Analyses of the kinetic properties of SpGR revealed a significantly higher value for Km(GSSG) (231.2 ± 24.7 µM) in comparison to other characterized GR enzymes.

Current pharmacotherapeutic options for pediatric lower respiratory tract infections with a focus on antimicrobial agents

Introduction: Antibiotics are frequently prescribed to children in the community and in nosocomial settings, mainly because of lower respiratory tract infections(LRTIs), which include influenza, bronchitis, bronchiolitis, pneumonia, and tuberculosis, in addition to bronchiectasis and cystic fibrosis lung disease. It is important to note, however, that more than 50% of these prescriptions are unnecessary or inappropriate. Areas covered: The current choice of antimicrobial therapy for etiological agents of LRTIs is examined and discussed considering each type of LRTI. Expert opinion: There is a clear need for the appropriate utilization of antibiotics in children. Therefore, accurate drug selection and choice of best dosage and duration of the antibacterial treatment are important to optimize the treatment of LRTIs. It's fundamental to bear in mind that children differ from adults in how LRTIs manifest and evolve not only because of the diversity in the immunological profiles but also the fundamental age-related differences in absorption, distribution, metabolism, and elimination of drugs. Since comprehensive antibiotic guideline recommendations for the treatment of pediatric LRTIs are generally lacking, there is an undeniable need for the introduction of pediatric antimicrobial stewardship programmes in both community and hospital settings.

Antimicrobial Therapy in Community-Acquired Pneumonia in Children

PURPOSE OF REVIEW

Empirical antibiotic therapy remains the cornerstone of treatment in community-acquired pneumonia (CAP). However, the best option for empirical antibiotics for treatment on an ambulatory basis, as well as in those requiring hospitalization, is still unclear. This review tries to answer the question regarding the most appropriate antibiotics in different settings in children with CAP as well as duration of therapy.

RECENT FINDINGS

Recent studies have provided insights regarding use of oral antibiotics in children with mild to moderate CAP, and severe CAP with lower chest retractions but no hypoxia. In view of rapidly emerging resistance among various causative pathogens, several new drugs have been currently approved, or are under trial for CAP in children. Current knowledge suggests that the choice of antibiotics for ambulatory treatment of CAP is oral amoxicillin with a duration of 3-5 days. Children with CAP with lower chest retractions but no hypoxia can be treated with oral amoxicillin. Severe pneumonia can be treated with intravenous antibiotics consisting of penicillin/ampicillin with or without an aminoglycoside. Several new drugs have been developed and approved for use in CAP caused by multidrug-resistant organisms, but these should be used judiciously to avoid emergence of further resistance. Future research is needed regarding the safety and efficacy of newer drugs in children.

Pneumococcal Vaccines: Host Interactions, Population Dynamics, and Design Principles

Streptococcus pneumoniae (the pneumococcus) is a nasopharyngeal commensal and respiratory pathogen. Most isolates express a capsule, the species-wide diversity of which has been immunologically classified into ∼100 serotypes. Capsule polysaccharides have been combined into multivalent vaccines widely used in adults, but the T cell independence of the antibody response means they are not protective in infants. Polysaccharide conjugate vaccines (PCVs) trigger a T cell–dependent response through attaching a carrier protein to capsular polysaccharides. The immune response stimulated by PCVs in infants inhibits carriage of vaccine serotypes (VTs), resulting in population-wide herd immunity. These were replaced in carriage by non-VTs. Nevertheless, PCVs drove reductions in infant pneumococcal disease, due to the lower mean invasiveness of the postvaccination bacterial population; age-varying serotype invasiveness resulted in a smaller reduction in adult disease. Alternative vaccines being tested in trials are designed to provide species-wide protection through stimulating innate and cellular immune responses, alongside antibodies to conserved antigens.

Longitudinal characterization of nasopharyngeal colonization with Streptococcus pneumoniae in a South African birth cohort post 13-valent pneumococcal conjugate vaccine implementation

Monitoring changes in pneumococcal carriage is key to understanding vaccination-induced shifts in the ecology of carriage and impact on health. We longitudinally investigated pneumococcal carriage dynamics in infants. Pneumococcal isolates were obtained from nasopharyngeal (NP) swabs collected 2-weekly from 137 infants enrolled from birth through their first year of life. Pneumococci were serotyped by sequetyping, confirmed by Quellung. Pneumococci were isolated from 54% (1809/3331) of infants. Median time to first acquisition was 63 days. Serotype-specific acquisition rates ranged from 0.01 to 0.88 events/child-year and did not differ between PCV13 and non-PCV13 serotypes (0.11 events/child-year [95% CI 0.07-0.18] vs. 0.11 events/child-year [95% CI 0.06-0.18]). There was no difference in carriage duration between individual PCV13 and non-PCV13 serotypes (40.6 days [95% CI 31.9-49.4] vs. 38.6 days [95% CI 35.1-42.1]), however cumulatively the duration of carriage of non-PCV13 serotypes was greater than PCV13 serotypes (141.2 days (95% CI 126.6-155.8) vs. 30.7 days (95% CI 22.3-39.0). Frequently carried PCV13 serotypes included 19F, 9V, 19A and 6A, while non-PCV13 serotypes included 15B/15C, 21, 10A, 16F, 35B, 9N and 15A. Despite high immunization coverage in our setting, PCV13 serotypes remain in circulation in this cohort, comprising 22% of isolates. Individual PCV13 serotypes were acquired, on average, at equivalent rate to non-PCV13 serotypes, and carried for a similar duration, although the most common non-PCV13 serotypes were more frequently acquired than PCV13 serotypes.

Antibody responses against Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis in children with acute respiratory infection with or without nasopharyngeal bacterial carriage

BACKGROUND

We studied Immunoglobulin G (IgG) antibody responses against Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis in young children with acute viral type respiratory infection and analyzed the findings in a multivariate model including age, nasopharyngeal carriage of the tested bacteria and pneumococcal vaccination.

METHODS

We included 227 children aged 6-23 months with acute respiratory infection. Nasopharyngeal aspirates were tested for bacterial carriage through detection of messenger RNA (mRNA) transcript with nCounter analysis. Acute and convalescent serum samples were tested for IgG antibody response against eight pneumococcal proteins, three proteins from H. influenzae and five proteins from M. catarrhalis in a fluorescent multiplex immunoassay.

RESULTS

A two-fold or greater increase in antibodies to S. pneumoniae, H. influenzae and M. catarrhalis was detected in 27.8, 9.7 and 14.1%, respectively. Nasopharyngeal carriage of each of the studied bacteria was not associated with antibody response detection against each respective bacterium. Furthermore, neither age nor pneumococcal vaccination were independently associated to detection of antibody response against the studied bacteria. Children who carried H. influenzae had higher frequency of colonization by M. catarrhalis (175 [80.3%] vs. 2 [22.2%]; p < .001) than those without H. influenzae. Also, children with acute otitis media tended to have higher frequency of antibody response to S. pneumoniae.

CONCLUSION

Nasopharyngeal colonization by S. pneumoniae, H. influenzae and M. catarrhalis did not induce significant increases in antibody levels to these bacteria. Carriage of pathogenic bacteria in the nasopharynx is not able to elicit antibody responses to protein antigens similar to those caused by symptomatic infections.

Delays in seeking and receiving health care services for pneumonia in children under five in the Peruvian Amazon: a mixed-methods study on caregivers' perceptions

Background

Delays in receiving adequate care for children suffering from pneumonia can be life threatening and have been described associated with parents’ limited education and their difficulties in recognizing the severity of the illness. The “three delays” was a model originally proposed to describe the most common determinants of maternal mortality, but has been adapted to describe delays in the health seeking process for caregivers of children under five. This study aims to explore the caregivers’ perceived barriers for seeking and receiving health care services in children under five years old admitted to a referral hospital for community-acquired pneumonia in the Peruvian Amazon Region using the three-delays model framework.

Methods

There were two parts to this mixed-method, cross-sectional, hospital-based study. First, medical charts of 61 children (1 to 60 months old) admitted for pneumonia were reviewed, and clinical characteristics were noted. Second, to examine health care-seeking decisions and actions, as well as associated delays in the process of obtaining health care services, we interviewed 10 of the children’s caregivers.

Results

Half of the children in our study were 9 months old or less. Main reasons for seeking care at the hospital were cough (93%) and fever (92%). Difficulty breathing and fast breathing were also reported in more than 60% of cases. In the interviews, caregivers reported delays of 1 to 14 days to go to the closest health facility. Factors perceived as causes for delays in deciding to seek care were apparent lack of skills to recognize signs and symptoms and of confidence in the health system, and practicing self-medication. No delays in reaching a health facility were reported. Once the caregivers reached a health facility, they perceived lack of competence of medical staff and inadequate treatment provided by the primary care physicians.

Conclusion

According to caregivers, the main delays to get health care services for pneumonia among young children were identified in the initial decision of caregivers to seek healthcare and in the health system to provide it. Specific interventions targeted to main barriers may be useful for reducing delays in providing appropriate health care for children with pneumonia.

Recurrent wheezing in neonatal pneumonia is associated with combined infection with Respiratory Syncytial Virus and Staphylococcus aureus or Klebsiella pneumoniae

Both viral and bacterial infections can be associated with wheezing episodes in children; however, information regarding combined infections with both viral and bacterial pathogens in full term neonates is limited. We sought to investigate the effects of viral–bacterial codetection on pneumonia severity and recurrent wheezing. A retrospective cohort study was conducted on neonates admitted to our hospital with pneumonia from 2009 to 2015. Of 606 total cases, 341 were diagnosed with RSV only, and 265 were diagnosed with both RSV and a potential bacterial pathogen. The leading four species of bacteria codetected with RSV were Escherichia coli, Klebsiella pneumoniae, Staphylococcus aureus and Enterobacter cloacae. Neonates with RSV and a potential bacterial pathogen were significantly more likely to have worse symptoms, higher C-reactive protein values and more abnormal chest x-ray manifestations with Bonferroni correction for multiple comparisons (P < 0.01). On Cox regression analysis, an increased risk of recurrent wheezing was found for neonates positive for RSV–Staphylococcus aureus and RSV–Klebsiella pneumoniae. Our findings indicate that the combination of bacteria and RSV in the neonatal airway is associated with more serious clinical characteristics. The presence of RSV and Staphylococcus aureus or Klebsiella pneumoniae may provide predictive markers for wheeze.

Etiology of Childhood Pneumonia: What We Know, and What We Need to Know! : Based on 5th Dr. IC Verma Excellence Oration Award

Childhood community acquired pneumonia continues to be an important clinical problem at the individual, institutional and community levels. Determination of microbial etiology is critical to develop evidence-based management (therapeutic and prophylactic) decisions. For decades, the approach to this relied on culture of lung aspirate specimens obtained from children with radiographically confirmed pneumonia, before administering antibiotics. Such studies revealed the major bacteria associated with pneumonia, prompting the World Health Organization to develop a highly sensitive clinical definition of pneumonia and advocate empiric antibiotic therapy; in order to save lives (focusing on community settings lacking resources for diagnostic tests). However, it spawned research studies conducted in/from/by institutions enrolling children with the relatively non-specific WHO definition of pneumonia. Specificity got further compromised by abandoning lung aspiration and using naso/oro pharyngeal specimens; even in children who had received antibiotics. This led to the recovery of viruses more often than bacteria. The use of highly sensitive molecular based diagnostics (especially PCR) facilitated the detection of multiple organisms (bacteria, viruses, atypical organisms and even fungal species); making it difficult to attribute etiology in individual cases. This challenge was sought to be addressed through the multi-site PERCH Study (Pneumonia Etiology Research for Child Health), designed as a case-control study to conclusively determine the etiology of pneumonia. However, despite a slew of publications, the answer to the central question of etiology has not emerged so far. Since none of the PERCH Study sites was located in India, the Community Acquired Pneumonia Etiology Study (CAPES) was conducted at Chandigarh. This turned out to be the largest single-centre pneumonia etiology study, and generated a wealth of data. This article summarizes the current challenges in pneumonia etiology research; outlines the key observations from the PERCH and CAPES projects, as well as other important studies; and suggests a way forward for pneumonia etiology research in the current era.

Burden of hospitalized childhood community-acquired pneumonia: A retrospective cross-sectional study in Vietnam, Malaysia, Indonesia and the Republic of Korea

BACKGROUND

Few studies describe the community-acquired pneumonia (CAP) burden in children in Asia. We estimated the proportion of all CAP hospitalizations in children from nine hospitals across the Republic of Korea (high-income), Indonesia, Malaysia (middle-income), and Vietnam (low/middle-income).

METHODS

Over a one or two-year period, children <5 years hospitalized with CAP were identified using ICD-10 discharge codes. Cases were matched to standardized definitions of suspected (S-CAP), confirmed (C-CAP), or bacterial CAP (B-CAP) used in a pneumococcal conjugate vaccine efficacy study (COMPAS). Median total direct medical costs of CAP-related hospitalizations were calculated.

RESULTS

Vietnam (three centers): 7591 CAP episodes were identified with 4.3% (95% confidence interval 4.2;4.4) S-CAP, 3.3% (3.2;3.4) C-CAP and 1.4% (1.3;1.4) B-CAP episodes of all-cause hospitalization in children aged <5 years. The B-CAP case fatality rate (CFR) was 1.3%. Malaysia (two centers): 1027 CAP episodes were identified with 2.7% (2.6;2.9); 2.6% (2.4;2.8); 0.04% (0.04;0.1) due to S-CAP, C-CAP, and B-CAP, respectively. One child with B-CAP died. Indonesia (one center): 960 CAP episodes identified with 18.0% (17.0;19.1); 16.8% (15.8;17.9); 0.3% (0.2;0.4) due to S-CAP, C-CAP, and B-CAP, respectively. The B-CAP CFR was 20%. Korea (three centers): 3151 CAP episodes were identified with 21.1% (20.4;21.7); 11.8% (11.2;12.3); 2.4% (2.1;2.7) due to S-CAP, C-CAP, and B-CAP, respectively. There were no deaths.

COSTS

CAP-related hospitalization costs were highest for B-CAP episodes: 145.00 (Vietnam) to 1013.3 USD (Korea) per episode.

CONCLUSION

CAP hospitalization causes an important health and cost burden in all four countries studied (NMRR-12-50-10793).

A systematic review about Streptococcus Pneumoniae serotype distribution in children in mainland of China before the PCV13 was licensed

INTRODUCTION

Streptococcus pneumoniae (S. pneumoniae) is a major pathogen of infectious diseases in children. Surveillance of the distribution of pneumococcus serotypes is important for immunization strategies of pneumococcal polysaccharide conjugate vaccines (PCVs). Areas covered: This article is a systematic review of studies conducted from 2006 to 2016 that document serotypes of S. pneumoniae isolated from children less than 14 years old in the mainland of China. A total of 40 studies were included in this review. Serotypes 19F, 19A, 23F, 14 and 6B were the most common. Serotype prevalence and percentage varied by region and associated strains. The serotype coverage rate of PCV13 was higher than that of PCV10 due to the prevalence of serotype 19A, and there were no significant difference between the coverage rate of PCV13 and PPSV23. Expert commentary: To prevent Chinese children from S. pneumoniae infection, it is necessary for the universal immunization of PCV13 or develop new vaccines that include all the prevalent serotypes in China.

Utility of Assessing Cytokine Levels for the Differential Diagnosis of Pneumonia in a Pediatric Population

OBJECTIVES

Although pneumonia is easily diagnosed, determining the causative agent is difficult due to low pathogen detection rates. We performed a prospective observational study to evaluate the utility of measuring inflammatory cytokine levels to discriminate between pneumonia caused by typical bacteria, respiratory syncytial virus, or Mycoplasma pneumoniae in a pediatric population.

DESIGN

Serum inflammatory cytokine levels at early stages of the disease were evaluated for pneumonia caused by the three different pathogenic microorganisms.

SETTING

The Children's Hospital of Zhejiang University School of Medicine, China.

PATIENTS

One hundred sixty-six patients with bacterial pneumonia, 182 with M. pneumonia, and 167 with respiratory syncytial virus pneumonia.

MEASUREMENTS AND MAIN RESULTS

The levels of interleukin-6 for pneumonia were significantly higher with typical bacteria than with either Mycoplasma pneumoniae or respiratory syncytial virus (p < 0.001). The area under the curve for serum concentrations of interleukin-6 was 0.997. A serum interleukin-6 level of greater than or equal to 93.0 pg/mL had 100.0% sensitivity and 99.14% specificity in discriminating bacterial pneumonia from respiratory syncytial virus pneumonia and Mycoplasma pneumoniae pneumonia. The interleukin-6 levels were higher in patients with Mycoplasma pneumoniae pneumonia than in those with respiratory syncytial virus pneumonia (p < 0.001). They also simultaneously had lower interleukin-10 levels than patients with respiratory syncytial virus pneumonia who had interleukin-10 levels comparable to those of patients with bacterial pneumonia, indicating a significant difference in the interleukin-6/interleukin-10 ratio between patients with Mycoplasma pneumoniae pneumonia and respiratory syncytial virus pneumonia (median interleukin-6/interleukin-10 ratio, 2.5 vs 0.5; p < 0.001). At an optimal cut-off value of 0.8, the interleukin-6/interleukin-10 ratio showed 90.3% sensitivity and 88.0% specificity.

CONCLUSIONS

These results suggest that interleukin-6 is a good biomarker for identifying bacterial pneumonia and that the interleukin-6/interleukin-10 ratio is an effective biomarker for discriminating Mycoplasma pneumoniae pneumonia from respiratory syncytial virus pneumonia.