Correlation Between Vitamin D Status and HBsAg Antibody Levels in Indonesian Adolescents Immunised Against Hepatitis B

Introduction

Hepatitis B virus (HBV) infection is a global health problem. Anti-hepatitis B surface antigen (HBsAg) levels increase along with vitamin D levels in adults. However, few studies have examined this relationship in adolescents. Few studies have examined the relationship between vitamin D and HBsAg antibody levels, especially in Indonesia.

Methods

This cross-sectional study examined vitamin D and anti-HBsAg levels before and after hepatitis B immunisation. All subjects blood was taken to check for vitamin D level. This study was part of the Safety and Preliminary of Immunogenicity Following Recombinant Hepatitis B (Bio Farma) Vaccine in Adults and Children Phase I trial.

Results

This study found that 25-hydroxyvitamin D [25(OH)D] status was primarily deficient based on endocrine criteria. The children's hepatitis B antibody response was mostly <10 mIU/mL before and ≥10 mIU/mL after vaccination. There was a relationship between sex and 25(OH)D status, with median 25(OH)D levels higher in females (18.2 ng/mL) than in males (9.8 ng/mL). However, the relationship between vitamin 25(OH)D status and anti-HBsAg levels pre- and post-vaccination was not significant.

Discussion

However, some research found that vitamin D supplementation after immunisation did not impact vaccine response, several studies have reported that vitamin D can decrease HBV replication through various mechanisms, including reducing viral transcription and interfering with viral protein synthesis.

Conclusion

There was no relationship between 25(OH)D status and anti-HBsAg levels. Further research is needed to elucidate the underlying mechanisms and establish optimal treatment strategies.

The Association between Vitamin D, Interleukin-4, and Interleukin-10 Levels and CD23+ Expression with Bronchial Asthma in Stunted Children

Children with stunted growth have an increased risk of wheezing, and studies have shown that low levels of vitamin D and interleukin (IL)-10, along with increased IL-4 levels and CD23+ expression, are present in stunted and asthmatic children. To date, it is not known whether these factors are related to the incidence of asthma in stunted children. This case-control study investigated the association between vitamin D, IL-4, and IL-10 levels and CD23+ expression with bronchial asthma in stunted children. The study included 99 children aged 24-59 months, i.e., 37 stunted-sthmatic children (cases), 38 stunted children without asthma, and 24 non-stunted children with asthma. All children were tested for their 25(OH)D levels using chemiluminescent immunoassay (CLIA), IL-4 and IL-10 levels were measured through enzyme-linked immunosorbent assay (ELISA) testing, and CD23+ expression was measured through flow cytometry bead testing. The data were analyzed using chi-squared, Kruskal-Wallis, and Mann-Whitney tests. The results showed that stunted asthmatic children had a higher incidence of atopic family members than those without asthma. Additionally, stunted asthmatic children had a higher prevalence of vitamin D deficiency (48.6%) than the control group (44.7% and 20.8%). Furthermore, stunted asthmatic children had significantly lower levels of 25(OH)D [20.55 (16.18-25.55), p = 0.042] and higher levels of IL-4 [1.41 (0.95-2.40), p = 0.038], although there were no significant differences in IL-10 levels and CD23+ expression. The study concluded that low vitamin D and high IL-4 levels are associated with bronchial asthma in stunted children, while IL-10 and CD23+ do not show a significant association.

Immunogenicity and safety of Quadrivalent Influenza HA vaccine compared with Trivalent Influenza HA vaccine and evaluation of Quadrivalent Influenza HA vaccine batch-to-batch consistency in Indonesian children and adults

One of the newest strategies developed by the Global Influenza Strategy has been to broaden the composition of the current influenza vaccine formulations from trivalent products to quadrivalent products. This study aimed to assess the immunogenicity and safety of Quadrivalent Influenza HA vaccine (QIV) compared with Trivalent Influenza HA vaccine (TIV) and to evaluate three consecutive batches of QIV equivalence in Indonesian children and adults. This was an experimental, randomized, double blind, four arm parallel group bridging study involving unprimed healthy children and adults aged 9-40 years. A total of 540 subjects were enrolled in this study and randomized into four arm groups. Each subject received one dose of TIV or QIV with three different batch codes. Serology tests were performed at baseline and 28 days after vaccination. Hemagglutination inhibition (HI) antibody titers were analyzed for Geometric Mean Titer (GMT), seroprotection, and seroconversion rates. Solicited, unsolicited, and serious adverse events were observed up to 28 days after vaccination. A total of 537 subjects completed the study per protocol and were analyzed for immunogenicity criteria. All randomized subjects were analyzed for safety criteria. The percentage of the subjects with anti-HI titer ≥1:40 28 days after QIV vaccination was 99.5% for A/H1N1; 99.5% for A/H3N2; 93.1% for B/Texas, and 99.0% for B/Phuket. The seroprotection, GMT, and seroconversion rates of QIV were not significantly different from those of TIV for the common vaccine strains (p > 0.01) and were significantly different from those of TIV for the added B/Phuket strains (p < 0.01). Most solicited injection-site and systemic reactions with either vaccine were mild to moderate and resolved within a few days. Antibody response to QIV were equivalence among vaccine batches and comparable between age groups for each of the 4 strains. QIV was immunogenic and well-tolerated and had immunogenicity and safety profiles compared with TIV for all common strains. The immunogenicity of the three batches of QIV was equivalent for the four strains. Trial registration. Clinical Trial registration: NCT03336593.

In-hospital mortality risk stratification in children aged under 5 years with pneumonia with or without pulse oximetry: A secondary analysis of the Pneumonia REsearch Partnership to Assess WHO REcommendations (PREPARE) dataset

OBJECTIVES

We determined the pulse oximetry benefit in pediatric pneumonia mortality risk stratification and chest-indrawing pneumonia in-hospital mortality risk factors.

METHODS

We report the characteristics and in-hospital pneumonia-related mortality of children aged 2-59 months who were included in the Pneumonia Research Partnership to Assess WHO Recommendations dataset. We developed multivariable logistic regression models of chest-indrawing pneumonia to identify mortality risk factors.

RESULTS

Among 285,839 children, 164,244 (57.5%) from hospital-based studies were included. Pneumonia case fatality risk (CFR) without pulse oximetry measurement was higher than with measurement (5.8%, 95% confidence interval [CI] 5.6-5.9% vs 2.1%, 95% CI 1.9-2.4%). One in five children with chest-indrawing pneumonia was hypoxemic (19.7%, 95% CI 19.0-20.4%), and the hypoxemic CFR was 10.3% (95% CI 9.1-11.5%). Other mortality risk factors were younger age (either 2-5 months [adjusted odds ratio (aOR) 9.94, 95% CI 6.67-14.84] or 6-11 months [aOR 2.67, 95% CI 1.71-4.16]), moderate malnutrition (aOR 2.41, 95% CI 1.87-3.09), and female sex (aOR 1.82, 95% CI 1.43-2.32).

CONCLUSION

Children with a pulse oximetry measurement had a lower CFR. Many children hospitalized with chest-indrawing pneumonia were hypoxemic and one in 10 died. Young age and moderate malnutrition were risk factors for in-hospital chest-indrawing pneumonia-related mortality. Pulse oximetry should be integrated in pneumonia hospital care for children under 5 years.

Comparison of Immunogenicity and Safety of Diphtheria–Tetanus–Pertussis–Hepatitis B–Haemophilus influenza B (Bio Farma) with Pentabio® Vaccine Primed with Recombinant Hepatitis B at Birth (Using Different Source of Hepatitis B) in Indonesian Infants

Satisfying the needs of the national immunization program requires maintaining diphtheria–tetanus–pertussis (DTP)–hepatitis B (HB)–Haemophilus influenza B (Hib) production. Therefore, new hepatitis B sources are needed. This study aimed to evaluate the immunogenicity of the DTP–HB–Hib vaccine (Bio Farma) that used a different source of hepatitis B. A prospective randomized, double-blind, bridging study was conducted. Subjects were divided into two groups with different batch numbers. Healthy infants 6–11 weeks of age at enrollment were immunized with three doses of the DTP–HB–Hib vaccine after a birth dose of hepatitis B vaccine. Blood samples were obtained prior to vaccination and 28 days after the third dose. Adverse events were recorded until 28 days after each dose. Of the 220 subjects, 205 (93.2%) completed the study protocol. The proportion of infants with anti-diphtheria and anti-tetanus titers ≥ 0.01 IU/mL was 100%, with anti-HBsAg titers ≥ 10 mIU/mL was 100%, and with Polyribosylribitol Phosphate-Tetanus Conjugate (PRP-TT) titers > 0.15 µg/mL was 96.1%. The pertussis response rate was 84.9%. No serious adverse events related to the study vaccine occurred. The three-dose DTP–HB–Hib vaccine (Bio Farma) is immunogenic, well tolerated, and suitable to replace licensed-equivalent vaccines.

Immunogenicity and safety in healthy adults of full dose versus half doses of COVID-19 vaccine (ChAdOx1-S or BNT162b2) or full-dose CoronaVac administered as a booster dose after priming with CoronaVac: a randomised, observer-masked, controlled trial in Indonesia

BACKGROUND

Inactivated COVID-19 vaccines effectively prevent death, but their effectiveness for preventing infection or severe illness is known to decrease within 3-6 months following the second priming dose. Here we aimed to evaluate the immunogenicity and safety of three potential booster vaccines administered as a full-dose homologous booster or full-dose or half-dose heterologous boosters among individuals primed with CoronaVac.

METHODS

We did an observer and participant masked, randomised controlled trial study of healthy Indonesian adults from five recruitment sites in Bandung and Jakarta, Indonesia, aged 18 years and older who had previously received two doses of CoronaVac within 3 to less than 6 months or 6 to 9 months before the booster dose. Participants were randomly assigned (1:1:1:1:1) by means of stratified randomisation with random block size to a homologous booster with full-dose CoronaVac or heterologous boosters with ChAdOx1-S or BNT162b2 in full dose or half dose. The primary outcome was to evaluate the seropositive, seroconversion rate, and the geometric mean titres of IgG anti-spike-receptor binding domain and neutralising antibodies, 28 days after booster dose vaccination in the per-protocol population. Safety was assessed as a secondary outcome in all vaccinated booster participants by the incidence rate and intensity of adverse events within 24 h, 7 days, and 28 days after the booster dose. This study is registered with ina-registry.org, INA-GO0HLGB, and is complete.

FINDINGS

Between Nov 26 and Dec 16, 2021, 1015 people were screened, and 960 healthy adults were enrolled; 190-193 were included in each group. 28 days after receiving the booster, combining the 3 to less than 6 months and 6 to 9 months groups, the proportions of seroconversion rates in each vaccine group were ChAdOx1-S 75 (82%) of 92 to 87 (88%) of 99 for full dose and half dose, BNT162b2 92 (92%) of 100 to 90 (98%) of 92 for full dose and half dose, and CoronaVac in 38 (41%) of 92 to 65 (66%) of 98. All booster groups achieved 100% seropositivity 28 days after the booster dose. Participants in the 6 to 9 months priming group achieved higher titres compared with participants in the 3 to less than 6 months priming group. The geometric mean titres in participants in the 6 to 9 months priming group in each vaccine group were ChAdOx1-S 11258·69 (9562·43-13 255·85) and 7853·04 (6698·92-9206·00) for full dose and half dose, BNT162b2 19999·84 (17 720·58-22 572·25) and 17 017·62 (14 694·40-19 708·16) for full dose and half dose and CoronaVac 1440·55 (1172·81-1769·42) achieved higher titres compared with participants in the 3 to less than 6 months priming group which in each vaccine group were ChAdOx1-S 7730·39 (6401·87-9334·60) and 6684·34 (5678·94-7867·73) for full dose and half dose, BNT162b2 16594·08 (13 993·08-19 678·55) and 12 121·67 (9925·21-14 804·19) for full dose and half dose, and CoronaVac 1210·23 (976·49-1499·92). The median percentage inhibition for the surrogate virus neutralisation test against the delta B.1.617.2 and wild-type (WT) variant before the booster and 28 days after the booster dose was very high in all groups (p<0·001), all with greater than 90% inhibition against both delta and WT strains. No serious adverse events were associated with the vaccines. Within the heterologous booster groups, the adverse event rates in the half-dose groups were lower compared with the full-dose groups.

INTERPRETATION

Geometric mean titre values between participants in the 6 to 9 months priming group and the 3 to less than 6 months priming group before the booster dose and between half-dose and full-dose groups 28 days before the booster were not significantly different for half-dose ChAdOx1-S, full-dose BNT162b2, and CoronaVac and were significantly different for full-dose ChAdOx1-S and half-dose BNT162b2. Among individuals primed with CoronaVac, boosting with BNT162b2 (full dose or half dose) or ChAdOx1-S (full dose or half dose) produces substantially better immune responses than in those boosted with CoronaVac. Full-dose and half-dose boosting with either BNT162b2 or ChAdOx1-S produced similar responses. Heterologous booster with half-dose might be considered in adults primed with two doses of CoronaVac vaccine.

FUNDING

Ministry of Health, Indonesia.

TRANSLATION

For the Indonesian translation of the abstract see Supplementary Materials section.

Assembling a global database of child pneumonia studies to inform WHO pneumonia management algorithm: Methodology and applications

Background

The existing World Health Organization (WHO) pneumonia case management guidelines rely on clinical symptoms and signs for identifying, classifying, and treating pneumonia in children up to 5 years old. We aimed to collate an individual patient-level data set from large, high-quality pre-existing studies on pneumonia in children to identify a set of signs and symptoms with greater validity in the diagnosis, prognosis, and possible treatment of childhood pneumonia for the improvement of current pneumonia case management guidelines.

Methods

Using data from a published systematic review and expert knowledge, we identified studies meeting our eligibility criteria and invited investigators to share individual-level patient data. We collected data on demographic information, general medical history, and current illness episode, including history, clinical presentation, chest radiograph findings when available, treatment, and outcome. Data were gathered separately from hospital-based and community-based cases. We performed a narrative synthesis to describe the final data set.

Results

Forty-one separate data sets were included in the Pneumonia Research Partnership to Assess WHO Recommendations (PREPARE) database, 26 of which were hospital-based and 15 were community-based. The PREPARE database includes 285 839 children with pneumonia (244 323 in the hospital and 41 516 in the community), with detailed descriptions of clinical presentation, clinical progression, and outcome. Of 9185 pneumonia-related deaths, 6836 (74%) occurred in children <1 year of age and 1317 (14%) in children aged 1-2 years. Of the 285 839 episodes, 280 998 occurred in children 0-59 months old, of which 129 584 (46%) were 2-11 months of age and 152 730 (54%) were males.

Conclusions

This data set could identify an improved specific, sensitive set of criteria for diagnosing clinical pneumonia and help identify sick children in need of referral to a higher level of care or a change of therapy. Field studies could be designed based on insights from PREPARE analyses to validate a potential revised pneumonia algorithm. The PREPARE methodology can also act as a model for disease database assembly.

Stunting as a Risk Factor for Asthma: The Role of Vitamin D, Leptin, IL-4, and CD23+

Stunting, which results from chronic malnutrition, is common in children from low- and middle-income countries. Several studies have reported an association between obesity and asthma. However, only a handful of studies have identified stunting as a significant risk factor for wheezing, a symptom of asthma, although the underlying mechanism remains unclear. This article aimed to review possible mechanisms underlying asthma in stunted children. Overall, changes in diet or nutritional status and deficiencies in certain nutrients, such as vitamin D, can increase the risk of developing asthma. Vitamin D deficiency can cause linear growth disorders such as stunting in children, with lower levels of 25(OH)D found in underweight and stunted children. Stunted children show a decreased lean body mass, which affects lung growth and function. Low leptin levels during undernutrition cause a Th1–Th2 imbalance toward Th2, resulting in increased interleukin (IL)-4 cytokine production and total immunoglobulin E (IgE). Studies in stunted underweight children have also found an increase in the proportion of the total number of B cells with low-affinity IgE receptors (CD23+). CD23+ plays an important role in allergen presentation that is facilitated by IgE to T cells and strongly activates allergen-specific T cells and the secretion of Th2-driving cytokines. Stunted children present with low vitamin D and leptin levels, impaired lung growth, decreased lung function, and increased IL-4 and CD23+ levels. All of these factors may be considered consequential in asthma in stunted children.

Derivation and validation of a novel risk assessment tool to identify children aged 2–59 months at risk of hospitalised pneumonia-related mortality in 20 countries

Introduction

Existing risk assessment tools to identify children at risk of hospitalised pneumonia-related mortality have shown suboptimal discriminatory value during external validation. Our objective was to derive and validate a novel risk assessment tool to identify children aged 2–59 months at risk of hospitalised pneumonia-related mortality across various settings.

Methods

We used primary, baseline, patient-level data from 11 studies, including children evaluated for pneumonia in 20 low-income and middle-income countries. Patients with complete data were included in a logistic regression model to assess the association of candidate variables with the outcome hospitalised pneumonia-related mortality. Adjusted log coefficients were calculated for each candidate variable and assigned weighted points to derive the Pneumonia Research Partnership to Assess WHO Recommendations (PREPARE) risk assessment tool. We used bootstrapped selection with 200 repetitions to internally validate the PREPARE risk assessment tool.

Results

A total of 27 388 children were included in the analysis (mean age 14.0 months, pneumonia-related case fatality ratio 3.1%). The PREPARE risk assessment tool included patient age, sex, weight-for-age z-score, body temperature, respiratory rate, unconsciousness or decreased level of consciousness, convulsions, cyanosis and hypoxaemia at baseline. The PREPARE risk assessment tool had good discriminatory value when internally validated (area under the curve 0.83, 95% CI 0.81 to 0.84).

Conclusions

The PREPARE risk assessment tool had good discriminatory ability for identifying children at risk of hospitalised pneumonia-related mortality in a large, geographically diverse dataset. After external validation, this tool may be implemented in various settings to identify children at risk of hospitalised pneumonia-related mortality.

Effects of Vitamin D supplementation on resolution of fever and cough in children with pulmonary tuberculosis: A randomized double-blind controlled trial in Indonesia

Background

Various studies in adults have shown a strong association between vitamin D and tuberculosis (TB), both in terms of vitamin D status and the benefits of vitamin D in managing TB. Studies on vitamin D and its relationship with childhood TB still lack in Indonesia as a country with the second-highest TB incidence globally. This study evaluated the effect of vitamin D supplementation on resolution of cough and fever in Indonesian children with pulmonary TB.

Methods

We conducted a randomized controlled trial of vitamin D supplementation in children with pulmonary TB and vitamin D insufficiency. Patients were randomly allocated with 1:1 ratio to receive either 1000 IU vitamin D or placebo daily after starting standard TB treatment. The primary outcome in this study was the resolution of fever and cough symptoms reviewed weekly after starting the treatment until the symptoms are resolved. The secondary outcome in this study was 25-hydroxyvitamin D serum level and nutritional status which was reviewed at the end of the trial. Intention to treat analyses were applied. Differences in clinical outcomes between two groups were calculated using Mann-Whitney U test or χ² test, where appropriate.

Findings

A total of 84 patients met the inclusion criteria, aged 6 to 18 years old, newly diagnosed with pulmonary TB and vitamin D insufficiency. Eighty patients (95,2%) completed the six months follow-up. Faster resolution of fever, cough, improved malnutrition status, and higher vitamin D level were found in the intervention group compared to the placebo group (all P < 0.001).

Conclusions

Vitamin D is beneficial in improving fever and cough resolution, and improving nutritional status in children with pulmonary TB and vitamin D insufficiency. Determination of adequate supplementation levels of more than 1000 IU requires further research to achieve normal vitamin D levels during the duration of treatment for pulmonary TB in children.

Trial registration

ClinicalTrials.gov (NCT05073965).

A phase III, observer-blind, randomized, placebo-controlled study of the efficacy, safety, and immunogenicity of SARS-CoV-2 inactivated vaccine in healthy adults aged 18-59 years: An interim analysis in Indonesia

Background

The WHO declared COVID-19 a pandemic on March 11th, 2020. This serious outbreak and the precipitously increasing numbers of deaths worldwide necessitated the urgent need to develop an effective severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccine. The development of COVID-19 vaccines has moved quickly. In this study, we assessed the efficacy, safety, and immunogenicity of an inactivated (SARS-CoV-2) vaccine.

Methods

We conducted a randomized, double-blind, placebo-controlled trial to evaluate the efficacy, immunogenicity, and safety of an inactivated SARS-CoV-2 vaccine and its lot-to-lot consistency. A total of 1620 healthy adults aged 18–59 years were randomly assigned to receive 2 injections of the trial vaccine or placebo on a day 0 and 14 schedule. This article was based on an interim report completed within 3 months following the last dose of study vaccine. The interim analysis includes safety and immunogenicity data for 540 participants in the immunogenicity subset and an efficacy analysis of the 1620 subjects. For the safety evaluation, solicited and unsolicited adverse events were collected after the first and second vaccination within 14 and 28 days, respectively. Blood samples were collected for an antibody assay before and 14 days following the second dose.

Results

Most of the adverse reactions were in the solicited category and were mild in severity. Pain at the injection site was the most frequently reported symptom. Antibody IgG titer determined by enzyme-linked immunosorbent assay was 97.48% for the seroconversion rate. Using a neutralization assay, the seroconversion rate was 87.15%. The efficacy in preventing symptomatic confirmed cases of COVID-19 occurring at least 14 days after the second dose of vaccine using an incidence rate was 65.30%.

Conclusions

From the 3-month interim analysis, the vaccine exhibited a 65.30% efficacy at preventing COVID-19 illness with favorable safety and immunogenicity profiles.

External validation of the RISC, RISC-Malawi, and PERCH clinical prediction rules to identify risk of death in children hospitalized with pneumonia

BACKGROUND

Existing scores to identify children at risk of hospitalized pneumonia-related mortality lack broad external validation. Our objective was to externally validate three such risk scores.

METHODS

We applied the Respiratory Index of Severity in Children (RISC) for HIV-negative children, the RISC-Malawi, and the Pneumonia Etiology Research for Child Health (PERCH) scores to hospitalized children in the Pneumonia REsearch Partnerships to Assess WHO REcommendations (PREPARE) data set. The PREPARE data set includes pooled data from 41 studies on pediatric pneumonia from across the world. We calculated test characteristics and the area under the curve (AUC) for each of these clinical prediction rules.

RESULTS

The RISC score for HIV-negative children was applied to 3574 children 0-24 months and demonstrated poor discriminatory ability (AUC = 0.66, 95% confidence interval (CI) = 0.58-0.73) in the identification of children at risk of hospitalized pneumonia-related mortality. The RISC-Malawi score had fair discriminatory value (AUC = 0.75, 95% CI = 0.74-0.77) among 17 864 children 2-59 months. The PERCH score was applied to 732 children 1-59 months and also demonstrated poor discriminatory value (AUC = 0.55, 95% CI = 0.37-0.73).

CONCLUSIONS

In a large external application of the RISC, RISC-Malawi, and PERCH scores, a substantial number of children were misclassified for their risk of hospitalized pneumonia-related mortality. Although pneumonia risk scores have performed well among the cohorts in which they were derived, their performance diminished when externally applied. A generalizable risk assessment tool with higher sensitivity and specificity to identify children at risk of hospitalized pneumonia-related mortality may be needed. Such a generalizable risk assessment tool would need context-specific validation prior to implementation in that setting.

An analysis of clinical predictive values for radiographic pneumonia in children

Introduction

Healthcare providers in resource-limited settings rely on the presence of tachypnoea and chest indrawing to establish a diagnosis of pneumonia in children. We aimed to determine the test characteristics of commonly assessed signs and symptoms for the radiographic diagnosis of pneumonia in children 0–59 months of age.

Methods

We conducted an analysis using patient-level pooled data from 41 shared datasets of paediatric pneumonia. We included hospital-based studies in which >80% of children had chest radiography performed. Primary endpoint pneumonia (presence of dense opacity occupying a portion or entire lobe of the lung or presence of pleural effusion on chest radiograph) was used as the reference criterion radiographic standard. We assessed the sensitivity, specificity, and likelihood ratios for clinical findings, and combinations of findings, for the diagnosis of primary endpoint pneumonia among children 0–59 months of age.

Results

Ten studies met inclusion criteria comprising 15 029 children; 24.9% (n=3743) had radiographic pneumonia. The presence of age-based tachypnoea demonstrated a sensitivity of 0.92 and a specificity of 0.22 while lower chest indrawing revealed a sensitivity of 0.74 and specificity of 0.15 for the diagnosis of radiographic pneumonia. The sensitivity and specificity for oxygen saturation <90% was 0.40 and 0.67, respectively, and was 0.17 and 0.88 for oxygen saturation <85%. Specificity was improved when individual clinical factors such as tachypnoea, fever and hypoxaemia were combined, however, the sensitivity was lower.

Conclusions

No single sign or symptom was strongly associated with radiographic primary end point pneumonia in children. Performance characteristics were improved by combining individual signs and symptoms.

Jadwal Imunisasi Anak Umur 0 – 18 tahun Rekomendasi Ikatan Dokter Anak Indonesia Tahun 2020

Ikatan Dokter Anak Indonesia secara periodik mengkaji rekomendasi jadwal imunisasi untuk menyesuaikan dengan berbagai perkembangan yang terkait dengan jadwal imunisasi di Indonesia. Jadwal imunisasi 2020 ini bertujuan agar dapat digunakan oleh anggota IDAI dalam memenuhi keinginan masyarakat mendapatkan vaksin yang lebih lengkap. Perubahan pada  rekomendasi tahun 2020 adalah pada imunisasi Hepatitis B, IPV, BCG, DTP, Hib, Campak /MR/MMR, JE, Varicella, Hepatitis A dan Dengue.  Jadwal imunisasi lain tidak ada perubahan. Untuk memudahkan dalam melaksanakannya dilampirkan juga tabel jadwal imunisasi tahun 2020. Untuk memahami dasar pertimbangan jadwal imunisasi dan perubahannya perlu mempelajari  uraian di dalam artikel ini dan keterangan dibawah tabel tersebut untuk diterapkan ke dalam layanan imunisasi.

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.

Immunogenicity and safety profile of a primary dose of bivalent oral polio vaccine given simultaneously with DTwP-Hb-Hib and inactivated poliovirus vaccine at the 4th visit in Indonesian infants

In this study, we aimed to evaluate the immunological protectivity of infants following four doses of bivalent oral polio vaccine (bOPV; Bio Farma), which were given simultaneously with DTwP-Hb-Hib (Pentabio®), along with one dose of inactivated poliovirus vaccine (IPV) at the fourth visit. A total of 143 newborn infants who fulfilled the inclusion criteria were enrolled and completed the study. Subjects received the first dose of bOPV at birth. On days 60, 90 and 120, bOPV was given simultaneously with Pentabio®. On day 120, one dose of IPV was also administered. Serum samples for serology analysis were collected before the first dose of bOPV (at day 0), before the second dose of bOPV (at day 60) and 30 days after the last dose of bOPV. In addition, the intensity, duration and relationship of each adverse event to the trial vaccines were assessed. Seroprotection rates after the fourth dose of bOPV were 100%, 91.6% and 99.3% for poliovirus P1, P2 and P3, respectively. Seroconversion rates after the fourth dose of bOPV were 100.0%, 93.3% and 100% for poliovirus P1, P2 and P3, respectively. There were no severe adverse events, and systemic reactions were generally mild during the 1-28 day post-vaccination period. Collectively, our findings indicate that bOPV given simultaneously with Pentabio® and one dose of IPV at the 4th visit was immunogenic and well tolerated.

Factors Influencing Empyema in Children

Incidence of empyema in children at Hasan Sadikin General Hospital is still high, commensurate with the high number of cases of pneumonia. Thirty-seven children with empyema were studied from July 1984 to December 1985; 20 of them were females and 17 males with the age ranging between 5 months and 12 years. Three patients (8.1 %) had loculated fluid as observed on chest roentgenographs; the remainder had empyema sinistra and dextra at 43.2% and 48.6% respectively. More than 50% of the patients were undernourished (56. 7%), 5 of whom were marasmic. On admission, 89.2% complained of dyspnea, 24.3% of cough, 16.2% of high fever and 10.8% of chest pain. All patients suffered from acute respiratory tract injection (ARI) 7 to 30 days before admission, 70.3% of whom did not receive adequate medication and 5 individuals received no treatment at all. Chest tube drainage was performed on 34 patients. In the study, 3 patients died (8.1%) due to sepsis. All recovered patients had pleural thickening on chest roentgenographs on discharge. The role of under nutrition, delay of medication and inadequate treatment of ARI seemed to have an1 influence on empyema in the patients observed.

Risk Factors for Acute Respiratory Infections in Underfive Children

A longitudinal study on acute inspiratory infections was conducted from April 1988 until June 1990, in Cikutra, an urban community in the municipality of Bandung, Indonesia. The study consisted of. 3 parts: a presurvey, a cross sectional study, and a one-year prospective study. All children aged less than five years in Cikutra were included in the presurvey. A simple questionnaire was used for collecting data. In the cross sectional study 500 children were selected by stratified random sampling. Field investigators visited the children's homes and interviewed mothers using a standardized questionnaire. For the prospective study 269 children of less than 48 months of age were enrolled, and followed for one year. The prevalence of all ARI was 57-58%, mild-moderate ARl 55-56% , and severe ARJ 5%. On average the children suffered from 6.7 episodes of ARl per child per year, with a mean duration of episode of 5.3 days. Several factors showed significant relationship with the prevalence, incidence, severity of duration of ARI.

DTwP-HB-Hib: antibody persistence after a primary series, immune response and safety after a booster dose in children 18-24 months old

Background

The new combination of DTwP-HB-Hib vaccines has been developed in Indonesia following World Health Organization (WHO) recommendation and integrated into national immunization program. The aims of the study were to measure 1) antibody persistence 12–18 months after a primary series, 2) immune response and safety after a booster dose of DTwP-HB-Hib.

Methods

This was a multi-center, open-labeled, prospective, interventional study. Subjects who had received complete primary dose of DTwP-HB-Hib vaccine from the previous phase III trial were recruited in this trial. Subjects were given one dose of DTwP-HB-Hib (Pentabio®) booster at age 18–24 months old. Diphtheria, tetanus, pertussis, hepatitis B, Hemophilus influenza type B antibodies were measured before and after booster to determine antibody persistence and immune response. Vaccine adverse events were assessed immediately and monitored until 28 days after the booster recorded with parent’s diary cards.

Results

There were 396 subjects who completed the study. Increased proportion of seroprotected subjects from pre-booster to post-booster were noted in all vaccine antigens: 74.5 to 99.7% for diphtheria; 100 to 100% for tetanus; 40.4 to 95.5% for pertussis; 90.2 to 99.5% for hepatitis B; and 97.7 to 100% for Hib. Common systemic adverse events (AEs) were irritability (23.7–25%) and fever (39.9–45.2%). Local AEs such as redness, swelling, and induration were significantly less common in the thigh group (7.7, 11.3, and 7.1%) than in the deltoid group (28.9, 30.7, and 25%) (P < 0.001). Most AEs were mild and resolved spontaneously within three-day follow-up period.

Conclusions

Booster of DTwP-HB-Hib vaccine at age 18–24 months is required to achieve and maintain optimal protective antibody. The vaccine is safe and immunogenic to be used for booster vaccination.

Trial registration

NCT02095314 (retrospectively registered, March 24, 2014).

The quantity and quality of anti-PRP induced by the new Indonesian DTwP-HB-Hib vaccine compared to the Hib vaccine given with the DTwP-HB vaccine

Background A phase II study of DTwP-HB-Hib vaccine compared to Hib (monovalent) vaccine given simultaneously with DTwP-HB vaccine has been done following the success of phase I study in infants, where the new DTwP-HB-Hib has excellent safety profiles and antibody responses in infants.Objective To evaluate the titer (quantity), avidity, and bactericidal capacity (quality of anti-polyribosylribitol phosphate/anti-PRP), of a new combined Bio Farma DTwP-HB-Hib (pentavalent) vaccine, compared to the Hib monovalent vaccine given simultaneously with the DTwP-HB vaccine (DTwP-HB+Hib).Methods The study was a prospective, randomized, open label, phase II trial. Subjects aged 6-11 weeks were allocated according to the randomization list. The pentavalent group received the DTwP-HB-Hib vaccine, while the monovalent group received the Hib monovalent and DTwP-HB vaccines separately. Immunizations were given in three doses with 28-day intervals. Blood specimens were taken before the first dose and 28 days after the last dose. We evaluated anti-PRP titers quantity (geometric mean antibody concentration/GMC) and seroprotection), followed by avidity and bactericidal (quality) testing. Titer and avidity of anti-PRP were tested using a modified version of the improved Phipps ELISA. Bactericidal capacity was evaluated using a Hib killing assay. Immune responses against other antigens in the vaccine were reported separately.Results One hundred five subjects in the pentavalent group and 106 subjects in the Hib monovalent group were tested for anti-PRP titers. Only 102 specimens for each group were available for bactericidal testing, due to insufficient volume for testing. Both vaccines induced similar anti-PRP titers, for GMC and seroprotection. Avidity increases were 82.9% and 76.4% in the pentavalent and Hib monovalent groups, respectively. Bactericidal activities were 94.1% and 89.2%, respectively. Both avidity and bactericidal activity were not significantly different between groups.Conclusion DTwP-HB-Hib vaccine induced anti-PRP quantity and quality comparable to those of the Hib monovalent vaccine given simultaneously with the DTwP-HB vaccine.

Association Between Arg753Gln and Arg677Trp Polymorphisms of TLR2 Gene with Active Pulmonary Tuberculosis in an Indonesian Population

BACKGROUND

Toll-like receptor is a pattern recognition receptor (PRR) that recognize pathogen-associated molecular pattern (PAMP) in a microorganism. Macrophages recognize the presence of mycobacteria through Toll-Like Receptor 2 (TLR2) and signaling further lead to the production of cytokines, both proinflammatory TNF-α, IL-1β, IL-6, IL-12, IL-15, IL-18 and IFN-γ, as well as anti-inflammatory IL4, IL-10 and TGF-β. TLR2 gene polymorphism is strongly determined by ethnicity and geography. Therefore it is necessary to uncovered the existence and association between Arg753Gln and Arg677Trp TLR2 gene polymorphism with TB susceptibility and its underlying mechanisms in Indonesian population in Bandung West Java.

METHODS

analytical observational study with cross-sectional design was conducted in Hasan Sadikin General Hospital Bandung from April 2011 to May 2012. Study population consisted of active pulmonary TB patient with positive AFB smear and Latent TB  to ascertain previous MTb exposure. Polymorphism of gen Arg753Gln and Arg677Trp gene was determined with polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) methods. Plasma levels of IFN-γ, TNF-α, IL-10 and IL-12 were also compared between active and latent TB group.

RESULTS

heterozygote Arg753Gln TLR2 gene polymorphism was found in 9 of 86 pulmonary TB subjects (10.5%) but none in the latent TB group. The Arg677Trp polymorphism was not found in both groups. The odds ratio for Arg753Gln existence was 28.07 (p=0.022). No differences in the levels of IFN-γ, TNF-α, IL-10 and IL-12 between active pulmonary TB and latent TB subjects with and without Arg753Gln TLR2 gene polymorphism. Conlusion: Arg753Gln polymorphism of TLR2 gene is a risk factor for active pulmonary TB while Arg677Trp polymorphism is not. The Increased risk is not mediated by the difference in IFN-γ, TNF-α, IL-10 and IL-12 serum levels.

Global, regional, and national disease burden estimates of acute lower respiratory infections due to respiratory syncytial virus in young children in 2015: a systematic review and modelling study

BACKGROUND

We have previously estimated that respiratory syncytial virus (RSV) was associated with 22% of all episodes of (severe) acute lower respiratory infection (ALRI) resulting in 55 000 to 199 000 deaths in children younger than 5 years in 2005. In the past 5 years, major research activity on RSV has yielded substantial new data from developing countries. With a considerably expanded dataset from a large international collaboration, we aimed to estimate the global incidence, hospital admission rate, and mortality from RSV-ALRI episodes in young children in 2015.

METHODS

We estimated the incidence and hospital admission rate of RSV-associated ALRI (RSV-ALRI) in children younger than 5 years stratified by age and World Bank income regions from a systematic review of studies published between Jan 1, 1995, and Dec 31, 2016, and unpublished data from 76 high quality population-based studies. We estimated the RSV-ALRI incidence for 132 developing countries using a risk factor-based model and 2015 population estimates. We estimated the in-hospital RSV-ALRI mortality by combining in-hospital case fatality ratios with hospital admission estimates from hospital-based (published and unpublished) studies. We also estimated overall RSV-ALRI mortality by identifying studies reporting monthly data for ALRI mortality in the community and RSV activity.

FINDINGS

We estimated that globally in 2015, 33·1 million (uncertainty range [UR] 21·6-50·3) episodes of RSV-ALRI, resulted in about 3·2 million (2·7-3·8) hospital admissions, and 59 600 (48 000-74 500) in-hospital deaths in children younger than 5 years. In children younger than 6 months, 1·4 million (UR 1·2-1·7) hospital admissions, and 27 300 (UR 20 700-36 200) in-hospital deaths were due to RSV-ALRI. We also estimated that the overall RSV-ALRI mortality could be as high as 118 200 (UR 94 600-149 400). Incidence and mortality varied substantially from year to year in any given population.

INTERPRETATION

Globally, RSV is a common cause of childhood ALRI and a major cause of hospital admissions in young children, resulting in a substantial burden on health-care services. About 45% of hospital admissions and in-hospital deaths due to RSV-ALRI occur in children younger than 6 months. An effective maternal RSV vaccine or monoclonal antibody could have a substantial effect on disease burden in this age group.

FUNDING

The Bill & Melinda Gates Foundation.

Prevalence and Risk Factors of Asthma in Children Aged 13-14 Years

To determine the asthma prevalence and the role of some risk factors of asthma in children aged 13-14 years in Bandung, a study was conducted from April to May 1996 using using the International Study of Asthma and Allergies in childhood (ISAAC) written questionnaire. The study was conducted in 12 Junior high schools (SMP), selected by multistage population random sampling from 6 district in municipality of Bandung. A total of 3118 questionnaires were collected. The cumulative prevalence of asthma was 6.4% and the 12 month prevalence was 2.6%. The prevalence was higher in male, with a ratio of male : female of 1.48:1. The prevalence of asthma increased significantly in children with history of atopy in the family (OR 6.1; p<0.01); however no significant differences was found between children with one or both parents having history of atopy. The prevalence of asthma in smoking children, maternal and room mates had also increased significantly (OR = 2.1; 2.3; 2.6 and p=<0.05;<0.01;<0.01 respectively). However there was no significant effect of paternal smoking (p=0.074). The use of mosquito spray in the bedroom and having pets showed no effect on the prevalence of asthma (p=0.86 and 0.56 respectively).

The immunogenicity and safety of the new, Indonesian DTwP-HB-Hib vaccine compared to the DTwP/HB vaccine given with the Hib vaccine

Background Haemophilus influenzae type b (Hib) causes infection with predominant manifestations of pneumonia, meningitis, and other invasive diseases, occurring primarily in children aged under 2 years, particularly in infants.  The World Health Organization (WHO) and Indonesian Technical Advisory Group for Immunization recommend to include the Hib vaccine into the national immunization program. The newly developed DTwP-HB-Hib combination vaccine is anticipated to be the preferred choice for Hib vaccine introduction; it is efficient, simple, and has higher coverage.Objective To evaluate the immunogenicity and safety of a new, combined Bio Farma DTwP-HB-Hib vaccine, compared to the registered Hib monovalent vaccine given simultaneously with the local DTwP-HB vaccine, when used as the primary vaccination of Indonesian infants.Methods A prospective, randomized, open-label, phase II study was conducted on the DTwP-HB-Hib vaccine compared to the Hib (registered) vaccine given simultaneously with the DTwP-HB vaccine, in Bandung from July 2011 to January 2012. Infants were serially vaccinated at 6-11, 10-15, and 14-19 weeks. Serological assessments were done prior to the first vaccine dose and 28 days after the third dose. Safety was assessed from the time of first injection until 1 month after the last injection.Results Of 220 healthy infants enrolled, 211 completed the study, with 105 receiving the combined vaccine and 106 the two separate vaccines. All vaccines were well tolerated. No differences in rates of local and systemic reactions were seen between the two methods of administration. No serious adverse events were considered to be related to the vaccines. In the DTwP-HB-Hib primary-vaccination group, at least 98% of the infants reached protective levels of antibodies (seropositivity) against the antigens employed in the vaccines while 96% in the control group.Conclusion The DTwP-HB-Hib combined vaccine is immunogenic and safe, as well as comparable to the Hib vaccine given simultaneously with to the DTwP-HB vaccine.

Jadwal Imunisasi Anak Usia 0 – 18 tahun Rekomendasi Ikatan Dokter Anak Indonesia 2017

Ikatan Dokter Anak Indonesia melalui Satuan Tugas Imunisasi mengeluarkan rekomendasi Imunisasi IDAI tahun 2017 untuk menggantikan jadwal imunisasi sebelumnya. Jadwal imunisasi 2017 ini bertujuan menyeragamkan jadwal imunisasi rekomendasi IDAI dengan jadwal imunisasi Kementerian Kesehatan RI khususnya untuk imunisasi rutin. Jadwal imunisasi 2017 juga dibuat berdasarkan ketersediaan kombinasi vaksin DTP dengan hepatitis B seperti DTPw-HB-Hib, DTPa-HB-Hib-IPV, dan dalam situasi keterbatasan atau kelangkaan vaksin tertentu seperti vaksin DTPa atau DTPw tanpa kombinasi dengan vaksin lainnya. Hal baru yang terdapat pada jadwal 2017 antara lain: vaksin hepatitis B monovalen tidak perlu diberikan pada usia 1 bulan apabila anak akan mendapat vaksin DTP-Hib kombinasi dengan hepatitis B; bayi paling sedikit harus mendapat satu dosis vaksin IPV (inactivated polio vaccine) bersamaan (simultan) dengan OPV-3 saat pemberian DTP-3; vaksin DTPw direkomendasikan untuk diberikan pada usia 2,3 dan 4 bulan. Hal baru yang lain adalah untuk vaksin influenza dapat diberikan vaksin inaktif trivalen atau quadrivalen, vaksin MMR dapat diberikan pada usia 12 bulan apabila anak belum mendapat vaksin campak pada usia 9 bulan. Vaksin HPV apabila diberikan pada remaja usia 10-13 tahun, pemberian cukup 2 dosis dengan interval 6-12 bulan; respons antibodi setara dengan 3 dosis. Vaksin Japanese Encephalitis direkomendasikan untuk diberikan mulai usia 12 bulan pada daerah endemis atau pada turis yang akan bepergian ke daerah endemis. Vaksin dengue direkomendasikan untuk diberikan pada anak usia 9-16 tahun dengan jadwal 0, 6, dan 12 bulan. Dengan pemberian imunisasi sesuai rekomendasi, diharapkan anak-anak Indonesia terlindungi dari penyakit infeksi yang dapat dicegah dengan imunisasi. 

Epidemiologi Tuberkulosis

Tuberkulosis (TB) masih merupakan penyebab utama morbiditas dan mortalitas pada anak di dunia, namunkurang mendapat prioritas dalam penanggulangannya. Data surveilans dan epidemiologi TB pada anak jarangdidapat. Hal ini disebabkan berbagai faktor antara lain sulitnya diagnosis TB anak, meningkatnya TB ekstraparu pada anak, tidak adanya standar baku definisi kasus, dan prioritas yang kurang diberikan pada TB anakdi banding TB dewasa. Berbagai penelitian menunjukkan prevalensi TB anak tinggi, namun umumnya tanpakonfirmasi pemeriksaan bakteri tahan asam (BTA) positif. Salah satu indikator untuk menilai situasi TB dikomunitas adalah dengan Annual Risk of Tuberculosis Infection (ARTI), adalah indeks epidemiologi yangdipakai untuk evaluasi dan monitor keadaan tuberkulosis di suatu komunitas atau negara. Perbedaan angkamorbiditas dan mortalitas TB di berbagai negara dipengaruhi oleh beberapa faktor risiko, dibedakan antararisiko infeksi TB dan sakit TB.

Hubungan Kadar Feritin Serum dengan Gangguan Fungsi Paru Pasien Thalassemia Mayor Anak

Latar belakang. Gangguan fungsi paru merupakan komplikasi thalassemia yang sering dilupakan. Kelebihan besi yang ditandai peningkatan kadar feritin serum diduga merupakan penyebab terjadinya gangguan fungsi paru pada pasien thalassemia mayor.Tujuan. Menganalisis hubungan kadar feritin serum dengan gangguan fungsi paru pasien thalassemia mayor anak serta menentukan batasan kadar feritin serum yang berhubungan dengan gangguan fungsi paru.Metode. Penelitian cross-sectional dilaksanakan pada bulan April-Mei 2013. Dilibatkan 45 anak thalassemia mayor di Poliklinik Thalassemia RS Dr. Hasan Sadikin, Bandung. Setiap subjek dilakukan anamnesis, pemeriksaan fisis, kadar feritin serum, dan spirometri. Analisis hubungan kadar feritin serum dengan gangguan fungsi paru digunakan uji regresi logistik dengan pertimbangan variabel perancu serta kurva ROC untuk menentukan batasan kadar feritin serum yang berhubungan dengan gangguan fungsi paru.Hasil. Sejumlah 45 anak memenuhi kriteria penelitian. Di antara 45 anak, 16 mengalami gangguan fungsi paru restriktif dengan derajat gangguan bervariasi, 11 anak gangguan ringan, 4 sedang, 1 berat, dan tidak ada yang mengalami gangguan fungsi paru obstruktif atau campuran. Rerata kadar feritin serum � � kelompok gangguan fungsi paru restriktif (7.151,88 μg/L) lebih tinggi dibandingkan kelompok paru normal (3.450,34 μg/L) dan kadar feritin 4.839 μg/L berhubungan dengan gangguan fungsi paru. Pada pasien thalassemia mayor anak didapatkan korelasi kadar feritin serum dengan gangguan fungsi paru (p=0,000, OR=50,754).Kesimpulan. Terdapat hubungan bermakna kadar feritin serum dengan gangguan fungsi paru pasien thalassemia mayor anak dan kadar feritin 4.839 μg/L merupakan batasan kadar feritin yang berhubungan dengan gangguan fungsi paru.

Pengaruh Pemberian Vitamin C terhadap Perubahan Kadar Total Antioksidan Serum pada Penderita Tuberkulosis Paru Anak

Latar belakang. Pada penderita tuberkulosis (TB) paru, terjadi peningkatan Reactive Oxygen Species (ROS) yang menyebabkan kebutuhan antioksidan meningkat sehingga terjadi penurunan kadar antioksidan serum. Pemberian vitamin C dapat meningkatkan kadar total antioksidan serum.Tujuan. Mengetahui pengaruh vitamin C terhadap kadar total antioksidan serum pada penderita TB paru.Metode. Penelitian uji klinis samar tunggal acak terkontrol dilaksanakan bulan April-Juli 2013. Tigapuluh orang penderita TB paru yang baru didiagnosis dilibatkan, berusia 1-14 tahun. Penelitian dilakukan di poli anak Rumah Sakit Dr. Hasan Sadikin Bandung dan RSUD Cibabat, Dibagi 2 kelompok, yaitu mendapat vitamin C dan plasebo, dilakukan selama 2 minggu. Pemeriksaan kadar total antioksidan serum dilakukan sebelum dan sesudah pemberian vitamin C dan plasebo. Perhitungan statistik dengan analisis varian two-way ANOVA digunakan untuk menganalisis perubahan kadar total antioksidan serum berdasarkan waktu (faktor A), pengaruh perlakuan (faktor B), dan interaksi di antara keduanya.Hasil. Subjek terdiri dari 22 anak laki-laki dan 8 perempuan. Tidak terdapat perbedaan bermakna pada usia, jenis kelamin, berat badan, tinggi badan, status gizi, dan asupan gizi pada kedua kelompok. Terdapat perbedaan bermakna pada perubahan kadar total antioksidan serum berdasarkan waktu (p=0,01) dan interaksi antara perubahan kadar total antioksidan serum berdasarkan waktu dengan perlakuan (p=0,01).Kesimpulan. Penelitian ini menunjukkan pemberian vitamin C bermanfaat dalam meningkatkan kadar total antioksidan serum pada penderita TB paru

Association between immunization coverage and atopy in children with or without family history of atopic disease

Background Atopic diseases are determined by the interactionbetween genetic and environmental factors. The possible effectsof immunization, as one of environmental factors, on atopy remaina matter of controversy.Objective We conducted an observational clinical epidemiologyto find out the protective effect of high vaccination coverage toatopy in children.Methods During January through March 2006, 150 of749 childrenat Garuda, Padasuka, and Babakan Sari Primary Health Care inBandung were randomized from group with and without familyhistory of atopic disease. Atopy derived from skin prick test andtotal serum lgE was evaluated. Atopy was defined as a positiveskin test to any of the eight allergens tested. The immunizationswere recorded from Kartu Menuju Sehat (KMS). Statistical analysesincluded Chi square to compare prevalence, independent T-testand Mann-Whitney to compare mean.Results Atopy was found in 28.2% of284 subjects, of which 32.4%with and 23.9% without a family history of atopic disease. Themedian of total serum lgE level was higher in children with familyhistory of atopic disease and in atopy children. Children weregrouped according to total dose of basic immunizations (0-17 and2: 18) based on Program Pengembangan Imunisasi (PPI). There wasnonsignificant association between total doses of immunizationand atopy. Even though no statistically significant, the cumulativeimmunization doses were inversely related to the median of totalserum IgE level.Conclusions The immunization coverage has not decreased atopyrisk.

Optimization and clinical validation of a pathogen detection microarray

New design and optimization of pathogen detection microarrays is shown to allow robust and accurate detection of a range of pathogens. The customized microarray platform includes a method for reducing PCR bias during DNA amplification.

DNA microarrays used as 'genomic sensors' have great potential in clinical diagnostics. Biases inherent in random PCR-amplification, cross-hybridization effects, and inadequate microarray analysis, however, limit detection sensitivity and specificity. Here, we have studied the relationships between viral amplification efficiency, hybridization signal, and target-probe annealing specificity using a customized microarray platform. Novel features of this platform include the development of a robust algorithm that accurately predicts PCR bias during DNA amplification and can be used to improve PCR primer design, as well as a powerful statistical concept for inferring pathogen identity from probe recognition signatures. Compared to real-time PCR, the microarray platform identified pathogens with 94% accuracy (76% sensitivity and 100% specificity) in a panel of 36 patient specimens. Our findings show that microarrays can be used for the robust and accurate diagnosis of pathogens, and further substantiate the use of microarray technology in clinical diagnostics.

The association between duration of breastfeeding and atopy in children with or without family history of atopic disease

Background Atopic diseases (AD) are the most common chronicdiseases in childhood, and their incidence has a tendency to increaserecently. Tendency to have atopy could be triggered by many factorsoriginated in early life, including time of breastfeeding cessation.Objective To determine the association between exclusive andduration of breastfeeding and atopy in children with or withoutfamily history of atopic disease.Methods This was an observational clinical epidemiology studyperformed at Babakansari, Padasuka, Garuda Primary Health CareCenter in Bandung from January to March 2006. One hundredfifty of 749 children were randomized from group with and withoutfamily history of AD. They underwent skin prick tests and totalserum IgE level analysis. Atopy was defined as a positive skinprick test to any of the eight allergens tested. History of exclusiveand duration of breastfeeding was obtained from their parents.Significance tests for contingency tables were on the basis of x 2test for association odds ratio with 95% confidence interval.Results Atopy was found in 28.2% of children, of whom 32.4% withand 23.9% without family history of AD. Children exclusivelybreastfed exhibited a reduced risk of atopy (5.8% v 35.3%, OR=0.11,95%CI= 0.03;0.34, P<0.001). The difference of atopy was stronglysignificant between children who had exclusive breastfeeding andthose without exclusive breastfeeding whether or not the subjectshad family history of AD (P<0.001). There was a highly significantrisk reduction for atopy related to prolonged breastfeeding (=6months) (OR=0.37, 95%CI = 0.19 to 0.72, P=0.001). Thedifference of atopy was strongly significant between children whohad prolonged breastfeeding and short breastfeeding duration whetheror not the subjects had family history of AD (P<0.001)Conclusions Exclusive and prolonged breastfeeding decrease atopyin children with as well as without family history of AD.

The association between fever in the first year of life and atopy in children with or without family history of atopic disease

Background The role of repeated infection in early life in thedevelopment of childhood atopy is still controversy. Fever in thefirst year of life which is frequently associated with infections mightdecrease atopy.Objective The aim of this study was to investigate the associationbetween fever in the first year of life and atopy in children.Methods This was an observational clinical epidemiology studyperformed at Puskesmas Garuda, Padasuka, and Babakan Sari,Bandung, from January to March 2006. From 749 children, werandomly chose 150 subjects each from group with and withoutfamily history of atopic disease. Skin prick test and measurementof total serum immunoglobulin (Ig) E were performed on eachchildren. Atopy was defined as the skin prick test result waspositive to >1 allergen. The number of fever episodes in the firstyear of life was based on parents report. The relationship betweenfever and atopy was analyzed using Mantel Haenszel.Results From 284 subjects, atopy was found in 28.2% of children,of which 32.4% with and 23.9% without a family history of atopicdisease. Generally there was no significant association betweenfever and atopy. There was only decreased odds ratio withincreased fever episodes and trend analysis showed this decreasewas significant (P=0.01). The significant association betweenfever and atopy were found only in group without family historyof atopic disease (P=0.03, OR=0.43, CI 95% 0.18;1.01).Conclusion There is a relationship between fever and atopy inchildren without family history of atopic disease.

Respiratory syncytial virus infection: denominator-based studies in Indonesia, Mozambique, Nigeria and South Africa

OBJECTIVE

To assess the burden of respiratory syncytial virus (RSV)-associated lower respiratory infections (LRI) in children in four developing countries.

METHODS

A WHO protocol for prospective population-based surveillance of acute respiratory infections in children aged less than 5 years was used at sites in Indonesia, Mozambique, Nigeria and South Africa. RSV antigen was identified by enzyme-linked immunosorbent assay performed on nasopharyngeal specimens from children meeting clinical case definitions.

FINDINGS

Among children aged < 5 years, the incidence of RSV-associated LRI per 1000 child-years was 34 in Indonesia and 94 in Nigeria. The incidence of RSV-associated severe LRI per 1000 child-years was 5 in Mozambique, 10 in Indonesia, and 9 in South Africa. At all study sites, the majority of RSV cases occurred in infants.

CONCLUSION

These studies demonstrate that RSV contributes to a substantial but quite variable burden of LRI in children aged < 5 years in four developing countries. The possible explanations for this variation include social factors, such as family size and patterns of seeking health care; the proportion of children infected by human immunodeficiency syndrome (HIV); and differences in clinical definitions used for obtaining samples. The age distribution of cases indicates the need for an RSV vaccine that can protect children early in life.

Nasopharyngeal bacterial carriage and antimicrobial resistance in underfive children with community acquired pneumonia

Lung puncture is the best way to determine the etiology of pneumonia since it yields the highest rate of positive cultures. However, this procedure is difficult, especially for a study in the community. According to WHO, isolates to be tested for antimicrobial resistance in the community should be obtained from nasopharyngeal (NP) swabs. Previous studies support the use of NP isolates to determine antimicrobial resistance patterns of isolates from children with pneumonia. The aim of our study was to know the bacterial patterns of the nasopharynx in underfive children with community acquired pneumonia and their antimicrobial resistance. The study was carried out in 4 Primary Health Clinics in Majalaya sub-district, Bandung, Indonesia. All underfives with cough or difficult breathing and classified as having non-severe pneumonia (WHO guidelines), were included in the study. Nasopharyngeal swabs (CDC/WHO Manual) were obtained by the doctor, the swabs were placed in Amies transport medium and stored in a sterile jar before taken to the laboratory in the same day. All children were treated with co-trimoxazole. During the nine month study, 698 children with clinical signs of non-severe pneumonia were enrolled. About 25% of the nasopharyngeal specimens yielded bacterial isolates; the two most frequently found were S. pneumoniae and S. epidermidis. The antimicrobial resistance test to co-trimoxazole showed 48.2% S. pneumoniae strain had full resistance and 32.7% showed intermediate resistance to co-trimoxazole. This result is almost similar to other studies from Asian countries. It seems that H. influenzae is not a problem in the study area; however, further studies are needed.

Diagnosis of pediatric tuberculosis using The Indonesian National Concencus for Pediatric Tuberculosis

Diagnosing tuberculosis (TB) in children correctly is critical to appropriate treatment. However, diagnosing TB in children may be difficult and can be imprecise. As our national TB control program has not adequately covered TB in children and adult TB cases still in high rank, our national consensus for pediatric population may facilitate TB diagnosed especially in the field. This cross sectional study as part of longitudinal cohort study of epidemiology of Respiratory Syncitial Virus (RSV) in Indonesia (still ongoing) was conducted to know whether criteria used in the algorithm in the consensus compatible to suspected TB diagnosis. The study covered 1000 children under five randomly selected in two districts (Cikutra and Ujung Berung Indah) located in West Java. By using algorithm of The Indonesian National Consensus For Pediatric Tuberculosis (INCPT) with history of known or suspected adult source of TB or early reaction of BCG vaccination and certain general clinical symptoms associated TB as entry criteria for a higher index of suspicion, we diagnosed suspected TB in 57 children. We found that, history of known or suspected adult source of TB and certain general clinical symptoms are two main criteria for suspected TB diagnosis. It appeared that Mantoux test gave a smallest contribution to the diagnosis of suspected TB in the field. No other criterium except known or suspected adult source of TB fulfilled for other five children and prophylactic treatment for TB were given. Those children with suspected TB were given oral anti-tuberculosis (OAT) by Directly Observed Treatment Short course (DOTS) done by local trained persons. 

Plasma retinol level, vitamin A supplementation and acute respiratory infections in children of 1-5 years old in a developing country. Respiratory Diseases Working Group

STUDY OBJECTIVE

To evaluate the relationship between vitamin A supplementation, plasma retinol level (PRL) and incidence, severity and duration of acute respiratory infect ions (ARI) in children 1-5 years old.

DESIGN AND SETTING

A one year prospective randomized intervention study from June 1989 to May 1990 in Cikutra, a suburb of Bandung, Indonesia.

SUBJECTS AND MEASUREMENTS

Out of almost 2000 children aged 12-54 months, 269 were selected by stratified randomization. Vitamin A (200,000 IU orally) was administered at 6-monthly intervals in a double blind, placebo controlled programme. Every 2 weeks, primary health care workers collected data on respiratory symptoms in the children, and every month a pediatrician examined the children. Venous blood samples were obtained at the start and at 3 and 6 months for plasma retinol levels (PRL).

RESULTS

The mean PRL at the start of the study was 20 +/- 8 micrograms/dl; 8% of the children showed a deficient level of less than 10 micrograms/dl. The incidence or ARI was 6.7 +/- 3.5 episodes per child per year with a mean duration of 5.3 +/- 3.1 days per episode. In vitamin A supplemented children the duration of ARI was slightly shorter (5.2 +/- 3.1 versus 5.6 +/- 3.1 days, P < 0.01) but no effect on the incidence or severity of ARI was detected. Low, and especially deficient, PRL had improved after 3 months and even after 6 months, but this was unrelated to vitamin A supplementation. There was also no relationship between PRL and incidence, severity or duration of ARI.

CONCLUSIONS

Only a slight relationship is found between vitamin A supplementation and ARI duration in under-fives.

Vitamin A and acute respiratory infections

By questionnaire we studied the occurrence of acute respiratory infections (ARI) in 1961 children between 0 and 5 years old from a total of 3225 families in Cikutra, Bandung. In 38.7% of them 200.000 IU vitamin A supplement had been given at least once during the preceding year. Mild or moderate ARI occurred in 54.7% of the children during the previous month and in 87.9% during the previous year; severe ARI occurred in 5.5% during the previous month and in 16.8% during the previous year. Surprisingly slightly more ARI occurred in children with vitamin A supplementation. However, vitamin A had been distributed more to low income than high income families, and in the latter group significantly less children suffered from ARI (p less than 0.05; 44% versus 54 a 56%).

Risk factors in smoking habits of high school students

Although the hazards of smoking is well known, the number of smokers among high school students is still high. There are many factors influencing these students to start smoking. This study was conducted to discover the size of the population of smokers among high school students is still high. There are many factors influencing these students to start smoking. This study was conducted to discover the size of the population of smokers among high school students, their smoking behaviour, and what factors might be associated as risk factors. Questionnaires were filled by 1627 respondents between 12 and 22 years of age of which 955 (58.7%) are boys and 672 (41.3%) are girls. Among all male respondents there were found 622 (86.2%) experimental smokers; among all the girls there were only 99 (13.7%) experimental smokers. From the total number of experimental smokers, 377 (95.2%) boys and 19 (4.8%) girls eventually became smokers. One hundred and seventeen (16.2%) students tried smoking before 13 years old, 65 of these students became smokers. This study found that socio-economic status, parents, friends, and siblings who smoked, and social environment, have significant influence on high school students' smoking habits. To prevent and lower the number of smokers among students in high schools, health and smoking education must be started in the schools as early as possible.