Predictors of Respiratory Syncytial Virus, Influenza Virus, and Human Metapneumovirus Carriage in Children Under 5 Years With WHO-Defined Fast-Breathing Pneumonia in Pakistan

BACKGROUND

Pneumonia is a leading cause of morbidity and mortality in children < 5 years. We describe nasopharyngeal carriage of respiratory syncytial virus (RSV), human metapneumovirus (hMPV), and influenza virus among children with fast-breathing pneumonia in Karachi, Pakistan.

METHODS

We performed a cross-sectional analysis of nasopharyngeal swabs from children aged 2-59 months with fast-breathing pneumonia, enrolled in the randomized trial of amoxicillin versus placebo for fast-breathing pneumonia (RETAPP) (NCT02372461) from 2014 to 2016. Swabs were collected using WHO standardized methods, processed at the Aga Khan University, Pakistan. Viral detection was performed using LUMINEX xTAG respiratory viral panel assay and logistic regression identified clinical and sociodemographic predictors.

FINDINGS

Of the 1000 children tested, 92.2% (n = 922) were positive for viral carriage. RSV, hMPV, and influenza virus were detected in 59 (6.4%), 56 (6.1%), and 58 (6.3%) children and co-infections in three samples (two RSV-hMPV and one influenza-hMPV). RSV carriage was common in infants (56%), we observed a higher occurrence of fever in children with hMPV and influenza virus (80% and 88%, respectively) and fast breathing in RSV (80%) carriage. RSV carriage was positively associated with a history of fast/difficulty breathing (aOR: 1.96, 95% CI 1.02-3.76) and low oxygen saturation (aOR: 2.52, 95% CI 1.32-4.82), hMPV carriage was positively associated with a complete vaccination status (aOR: 2.22, 95% CI 1.23-4.00) and body temperature ≥ 37.5°C (aOR: 2.34, 95% CI 1.35-4.04) whereas influenza viral carriage was associated with body temperature ≥ 37.5°C (aOR: 4.48, 95% CI 2.53-7.93).

CONCLUSION

We observed a high nasopharyngeal viral carriage among children with WHO-defined fast-breathing pneumonia in Pakistan. Fever, difficulty in breathing, hypoxia and vaccination status are important clinical predictors for viral nonsevere community-acquired pneumonia.

Connections matter: Adolescent social connectedness profiles and mental well-being over time

INTRODUCTION

This study examined profiles of social connectedness among early adolescents in grade 7 before the COVID-19 pandemic was declared (Winter 2020), and in grade 8 during the second Wave of the pandemic (Winter 2021).

METHOD

Linked data from 1753 early adolescents (49% female) from British Columbia, Canada who completed the Middle Years Development Instrument survey in grades 7 and 8 were used. Participants reported on life satisfaction, depressive symptoms, and connectedness with peers and adults at home, school and in the community. We used Latent Profile Analysis to identify connectedness profiles at both time points, and Latent Transition Analysis to examine transitions in connectedness profiles over time. Multiple regression analyses examined the associations between profile membership in grade 7 and mental well-being in grade 8, and the associations between transitions in profile membership (i.e., increase vs. decrease in connectedness over time) and mental well-being.

RESULTS

Connectedness in multiple domains in grade 7 was related to significantly higher levels of mental well-being in grade 8, controlling for demographics, well-being in grade 7, and COVID-related mental health worries. Well-being was highest when students felt highly connected in all domains and lowest when they felt lower levels of connection. Increases in connectedness were associated with improvements in mental well-being and decreases with a decline in well-being over time.

CONCLUSIONS

Experiencing connectedness with peers and adults is critical for the mental well-being in early adolescence. Providing opportunities to connect is important in the context of major societal challenges such as the COVID-19 pandemic.

Epidemiological pattern and management of dog bite injuries in Karachi, Pakistan: A cross-sectional study

BACKGROUND

Dog bite injuries are a common problem globally; however, little is known about the epidemiology of dog bite injury from a low-and-middle-income country like Pakistan. This study aims to determine the epidemiology of dog bite injuries among children and adults from a tertiary care hospital in Karachi, Pakistan.

METHODS

We conducted a cross-sectional study on dog bite patients visiting the emergency department from November 2015 to August 2016 of a major public tertiary care hospital. Data was collected using a structured questionnaire on demographic details, bite history, and management of dog bite victims. Descriptive analysis was reported. Chi-square test was applied to check the associations between age-specific dog bite cases and independent variables.

RESULTS

2178 participants were included in the analysis. 715 (38.8%) were children less than 18 years old, and 1463 (61.2%) were adults over 18 years. A majority of the patients were males (1909, 87.7%). Results show that most dog bite injuries (2052, 94.2%) tend to occur outside the house by stray dogs biting without provocation. People aged 18 years and above (61.2%) and males (children: 84.6%, adults: 89.1%) tend to be bitten more often. Lower limbs are most frequently bitten (children: 69.5%, adults: 85.8%). Free-roaming stray dogs (children: 73.4%, adults: 74.9%) were involved in reported biting cases. Many of the patients did not receive appropriate first aid and instead just washed the wound with soap and water (children: 45.1%, adults: 43.7%). 99% of the victims received Tetanus toxoid, Rabies vaccine, and immunoglobulins while in the emergency department.

CONCLUSION

There is a high burden of dog bite injuries from stray dogs in Karachi, Pakistan. Efforts should be made to create awareness among the general public on the risks of dog bites and on seeking appropriate first aid and medical attention for a dog bite injury.

Screen time and developmental health: results from an early childhood study in Canada

Background

Research has shown that longer hours of screen time are negatively associated with children’s healthy development. Whereas most research has focused on school-age children, less is known about this association in early childhood. To fill this gap, we examined the association between screen time and developmental health in preschool-aged children.

Methods

This study draws from a data linkage on children (N = 2983; Mean age = 5.2, SD = 0.3 years, 51% male) in British Columbia (BC), Canada, who entered Kindergarten in public elementary schools in 2019. Parent reports on children’s screen time, health behaviors, demographics, and family income collected upon kindergarten entry (09/2019), were linked to teacher reports on children’s developmental health, collected halfway through the school year (02/2020). Screen time was assessed with the Childhood Experiences Questionnaire. Developmental vulnerability versus developmental health in five domains (physical, social, emotional, language and cognition, and communication skills) was measured with the Early Development Instrument.

Results

Logistic regression analyses using generalized estimating equation showed that children with more than one hour of daily screen time were more likely to be vulnerable in all five developmental health domains: physical health and wellbeing (odds ratio [OR] =1.41; 95% confidence interval [CI], 0.99 - 2.0; p=0.058), social competence (OR=1.60; 95% CI, 1.16 – 2.2; p=0.004), emotional maturity (OR=1.29; 95% CI, 0.96 - 1.73; p=0.097), language and cognitive development (OR=1.81; 95% CI, 1.19 - 2.74; p=0.006) and communication skills (OR=1.60; 95% CI, 1.1 – 2.34; p=0.015) compared to children reporting up to one hour of screen time/day. An interaction effect between income and screen time on developmental health outcomes was non-significant. Results were adjusted for child demographics, family income, and other health behaviors.

Conclusions

Daily screen time that exceeds the recommended one-hour limit for young children, as suggested by the Canadian 24-h Movement Guidelines for Children and Youth (Tremblay et al. BMC Public Health. 17:874, 2017; Tremblay J Physical Activity Health. 17:92–5, 2020) is negatively associated with developmental health outcomes in early childhood. Screen-based activities should thus be limited for young children. Future research needs to examine the underlying mechanisms through which screen time is linked to developmental vulnerabilities.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12701-3.

Screen time and extracurricular activities as risk and protective factors for mental health in adolescence: A population-level study

This study examines adolescents' (N = 28,712; 49% female; M_age = 12.25, SD_age = 0.51) recreational screen time and participation in extracurricular activities during after-school hours in association to indicators of positive (optimism, satisfaction with life) and negative (anxiety, depressive symptoms) mental health and wellbeing. Data were drawn from a population-level study with the Middle Years Development Instrument (MDI) with grade 7 students in British Columbia (BC), Canada. The research was implemented in public school districts between 2014 and 2018. We found that adolescents who participated in extracurricular activities (e.g., sports, arts programs, community programs) were significantly less likely to engage in recreational screen-based activities (e.g., watching programs, browsing the internet, playing computer games) for 2 or more hours after school. Findings from Multilevel Structural Equation Modeling analyses showed that extracurricular participation was associated with higher levels of satisfaction with life and optimism, and lower levels of anxiety and depressive symptoms. In contrast, longer screen time (≥2 h/day) was associated with lower levels of satisfaction with life and optimism, and higher levels of anxiety and depressive symptoms; shorter screen time (<2 h/day) was associated with favorable mental health and wellbeing. For screen time, the effect was moderated by gender; the association between longer screen time and poorer mental health and wellbeing was significantly more pronounced for girls than boys. For both boys and girls, mental health and wellbeing were most favorable if they participated in extracurricular activities and reported less than 2 h of recreational screen time per day.

Randomized Trial of Amoxicillin for Pneumonia in Pakistan

BACKGROUND

The World Health Organization (WHO) recommends oral amoxicillin for patients who have pneumonia with tachypnea, yet trial data indicate that not using amoxicillin to treat this condition may be noninferior to using amoxicillin.

METHODS

We conducted a double-blind, randomized, placebo-controlled noninferiority trial involving children at primary health care centers in low-income communities in Karachi, Pakistan. Children who were 2 to 59 months of age and who met WHO criteria for nonsevere pneumonia with tachypnea were randomly assigned to a 3-day course of a suspension of amoxicillin (the active control) of 50 mg per milliliter or matched volume of placebo (the test regimen), according to WHO weight bands (500 mg every 12 hours for a weight of 4 to <10 kg, 1000 mg every 12 hours for a weight of 10 to <14 kg, or 1500 mg every 12 hours for a weight of 14 to <20 kg). The primary outcome was treatment failure during the 3-day course of amoxicillin or placebo. The prespecified noninferiority margin was 1.75 percentage points.

RESULTS

From November 9, 2014, through November 30, 2017, a total of 4002 children underwent randomization (1999 in the placebo group and 2003 in the amoxicillin group). In the per-protocol analysis, the incidence of treatment failure was 4.9% among placebo recipients (95 of 1927 children) and 2.6% among amoxicillin recipients (51 of 1929 children) (between-group difference, 2.3 percentage points; 95% confidence interval [CI], 0.9 to 3.7). Results were similar in the intention-to-treat analysis. The presence of fever and wheeze predicted treatment failure. The number needed to treat to prevent one treatment failure was 44 (95% CI, 31 to 80). One patient (<0.1%) in each group died. Relapse occurred in 40 children (2.2%) in the placebo group and in 58 children (3.1%) in the amoxicillin group.

CONCLUSIONS

Among children younger than 5 years of age with nonsevere pneumonia, the frequency of treatment failure was higher in the placebo group than in the amoxicillin group, a difference that did not meet the noninferiority margin for placebo. (Funded by the Joint Global Health Trials Scheme [of the Department for International Development, Medical Research Council, and Wellcome] and others; RETAPP ClinicalTrials.gov number, NCT02372461.).

Recurrence of WHO-defined fast breathing pneumonia among infants, its occurrence and predictors in Pakistan: a nested case-control analysis

OBJECTIVES

Studies in low-income and middle-income countries have shown an adverse association between environmental exposures including poverty. There is little literature from South Asia. We aimed to test the associations between housing, indoor air pollution and children's respiratory health and recurrent fast breathing pneumonia in a poor urban setting in Pakistan.

SETTING

Primary health centres in a periurban slum in Karachi, Pakistan.

METHODS

Nested matched case-control study within a non-inferiority randomised controlled trial of fast breathing pneumonia (Randomised Trial of Amoxicillin vs Placebo for Pneumonia (RETAPP)) in periurban slums of Karachi, Pakistan. Cases were children aged 2-60 months enrolled in RETAPP with fast breathing pneumonia who presented again with fast breathing between 8 weeks and 12 months after full recovery. Controls, selected in a 2:1 ratio, were age-matched participants who did not represent. Multivariable conditional logistic regression analysis was undertaken to explore associations with potentially modifiable environmental predictors including housing type, indoor air quality, exposure to tobacco smoke, outdoor pollution, household crowding, water and sanitation quality, nutritional status, immunisation completeness, breast feeding and airways hyperactivity.

RESULTS

Fast breathing recurred in 151 (3.7%) of children out of the total (4003) enrolled in the trial. Poor-quality housing of either katcha or mixed type strongly predicted recurrence with adjusted matched ORs 2.43 (95% CI 1.02 to 5.80) and 2.44 (1.11 to 5.38), respectively. Poor air quality, cooking fuel, inadequate ventilation, nutritional status, water, sanitation and hygiene (WASH) index, wheeze at first presentation and group of initial trial assignment were not independently predictive of recurrence.

CONCLUSION

Poor-quality housing independently predicted recurrence of fast breathing pneumonia.

TRIAL REGISTRATION NUMBER

NCT02372461.

A Community-Based Survey on Health-Care Utilization for Pneumonia in Children in Peri-Urban Slums of Karachi, Pakistan

Pneumonia, as defined by WHO, is a syndromic diagnosis characterized by presence of cough or difficult breathing. Presentation to health-care provider depends on timely identification of signs and symptoms by caretakers. We explored patterns of health-care utilization among caretakers of a randomly selected sample of 1,152 children aged 2-59 months, residing in low-income settlements of Karachi, Pakistan. Information on household demographics, occurrence of pneumonia-specific symptoms, care seeking, air quality, and knowledge regarding preventive measures for pneumonia was collected. Predictors of care seeking were estimated using weighted logistic regression. Prevalence of pneumonia with cough and rapid or difficulty in breathing was found to be 40.8% and 37.1% in infants (2-11 months) and children (12-59 months), respectively. Ninety-five percentage of caretakers sought care, 68.5% privately. Odds ratios (ORs) for independent predictors of care-seeking were as follows: younger age of child (infants compared with children), 3.60 (95% CI = 2.65-4.87); caretaker with primary education compared with none, 3.40 (2.46-4.70); vaccine awareness, 1.65 (1.45-1.87); and breastfeeding awareness, 1.32 (1.13-1.53). Presence of symptoms such as fever OR, 1.51 (1.30-1.76); tachypnea, 1.57 (1.35-1.83); chest indrawing, 2.56 (2.05-3.18); persistent vomiting, 1.69 (1.37-2.09); and recurrent illness, 2.57 (2.23-2.97) were also predictive. There is high health-care utilization for pneumonia with the skewed presentation toward private services. Strategies should be focused on making pneumonia care standardized, efficient and affordable, especially in the private sector.

Should fast breathing pneumonia cases be treated with antibiotics? The scientific rationale for revisiting management in Low and Middle income countries

•

World Health Organization (WHO) recommends oral antibiotic treatment for all children with fast breathing pneumonia.

•

However evidence for the guidance is weak and infections are often viral and self-limiting.

•

Further information regarding the true rationale for conducting non-inferiority trials to test the hypothesis that antibiotics may not be necessary for children with fast breathing as the sole symptomatology.

Background

Pneumonia is the largest single contributor to child mortality and the problem is more acute in low and middle income countries. The World Health Organization (WHO) currently recommends oral antibiotic treatment for all children with fast breathing pneumonia without danger signs. It is, however, widely acknowledged that most such infections are viral and self-limiting and that the evidence for the guidance is weak.

Rationale

Overuse of antibiotics exposes children to adverse events, increases cost for families, burdens already stretched health care resources and may contribute to development of antibiotic resistance.

Conclusion

There is equipoise regarding utility of antibiotic in case of fast breathing pneumonia and no high quality trial evidence exists. This paper provides further information behind the rationale for conducting non-inferiority trials to test the hypothesis that antibiotics may not be necessary for children with fast breathing as the sole symptomatology.

Association of post-traumatic stress disorder and work performance: A survey from an emergency medical service, Karachi, Pakistan

BACKGROUND

The purpose of the study was to explore the association between post-traumatic stress disorder (PTSD) and work performance of emergency medical services personnel in Karachi, Pakistan.

METHODS

Emergency medical service personnel were screened for potential PTSD using Impact of Event Scale-Revised (IES-R). Work performance was assessed on the basis of five variables: number of late arrivals to work, number of days absent, number of days sick, adherence to protocol, and patient satisfaction over a period of 3 months. In order to model outcomes like the number of late arrivals to work, days absent and days late, negative binomial regression was applied, whereas logistic regression was applied for adherence to protocol and linear for patient satisfaction scores.

RESULTS

Mean scores of PTSD were 24.0±12.2. No association was found between PTSD and work performance measures: number of late arrivals to work (RRadj 0.99; 0.98-1.00), days absent (RRadj 0.98; 0.96-0.99), days sick (RRadj 0.99; 0.98-1.00), adherence to protocol (ORadj 1.01; 0.99-1.04) and patient satisfaction (β 0.001%-0.03%) after adjusting for years of formal schooling, living status, coping mechanism, social support, working hours, years of experience and anxiety or depression.

CONCLUSION

No statistically significant association was found between PTSD and work performance amongst EMS personnel in Karachi, Pakistan.

A double blind community-based randomized trial of amoxicillin versus placebo for fast breathing pneumonia in children aged 2-59 months in Karachi, Pakistan (RETAPP)

BACKGROUND

Fast breathing pneumonia is characterized by tachypnoea in the absence of danger signs and is mostly viral in etiology. Current guidelines recommend antibiotic therapy for all children with fast breathing pneumonia in resource limited settings, presuming that most pneumonia is bacterial. High quality clinical trial evidence to challenge or support the continued use of antibiotics, as recommended by the World Health Organization is lacking.

METHODS/DESIGN

This is a randomized double blinded placebo-controlled non-inferiority trial using parallel assignment with 1:1 allocation ratio, to be conducted in low income squatter settlements of urban Karachi, Pakistan. Children 2-59 months old with fast breathing, without any WHO-defined danger signs and seeking care at the primary health care center are randomized to receive either three days of placebo or amoxicillin. From prior studies, a sample size of 2430 children is required over a period of 28 months. Primary outcome is the difference in cumulative treatment failure between the two groups, defined as a new clinical sign based on preset definitions indicating illness progression or mortality and confirmed by two independent primary health care physicians on day 0, 1, 2 or 3 of therapy. Secondary outcomes include relapse measured between days 5-14. Modified per protocol analysis comparing hazards of treatment failure with 95% confidence intervals in the placebo arm with hazards in the amoxicillin arm will be done.

DISCUSSION

This study will provide evidence to support or refute the use of antibiotics for fast breathing pneumonia paving a way for guideline change.

TRIAL REGISTRATION

Clinical Trials (NIH) Register NCT02372461.

Bomb blast injuries: an exploration of patient characteristics and outcome using Pakistan National Emergency Departments Surveillance (Pak-NEDS) data

BACKGROUND

Bomb blast injuries result in premature deaths and burdening of healthcare systems. The objective of this study was to explore the characteristics and outcome of patients presenting to the emergency departments in Pakistan with bomb blast injuries.

METHODS

Active surveillance was conducted in seven major emergency departments of Pakistan from November 2010-March 2011. All the sites are tertiary care urban centers. All the patients who presented to the hospital's emergency department (ED) following a bomb blast injury as per self-report or the ambulance personnel were included in the study. Frequency of demographics, injury pattern, and outcomes were calculated.

RESULTS

A total of 103 patients with bomb blast injuries presented to the selected emergency departments. The median age of patients was 30 years. Around three-fourth of the patients were males (n = 74, 74.7%). Most of the bomb blast patients were seen in Peshawar (n = 41, 39.8%) and Karachi city (n = 31, 30.1%) and the most common mode of arrival was non-ambulance transport (n = 71, 76.3%). Upper limb injuries (n = 12, 40%) were common in the under 18 age group and lower limb injuries (n = 31, 39.2%) in the 18 years and above group. There were a total of 8 (7.7%) deaths reported out of these 103 patients.

CONCLUSION

Bomb blast injuries in Pakistan generally affect young males. Non-ambulance transport is the most common way to access emergency departments (ED). Overall ED mortality is high and capturing data during a disaster in an emergency department is challenging.