Lung ultrasound and procalcitonin, improving antibiotic management and avoiding radiation exposure in pediatric critical patients with bacterial pneumonia: a randomized clinical trial

BACKGROUND

Pneumonia is a major public health problem with an impact on morbidity and mortality. Its management still represents a challenge. The aim was to determine whether a new diagnostic algorithm combining lung ultrasound (LUS) and procalcitonin (PCT) improved pneumonia management regarding antibiotic use, radiation exposure, and associated costs, in critically ill pediatric patients with suspected bacterial pneumonia (BP).

METHODS

Randomized, blinded, comparative effectiveness clinical trial. Children < 18y with suspected BP admitted to the PICU from September 2017 to December 2019, were included. PCT was determined at admission. Patients were randomized into the experimental group (EG) and control group (CG) if LUS or chest X-ray (CXR) were done as the first image test, respectively. Patients were classified: 1.LUS/CXR not suggestive of BP and PCT < 1 ng/mL, no antibiotics were recommended; 2.LUS/CXR suggestive of BP, regardless of the PCT value, antibiotics were recommended; 3.LUS/CXR not suggestive of BP and PCT > 1 ng/mL, antibiotics were recommended.

RESULTS

194 children were enrolled, 113 (58.2%) females, median age of 134 (IQR 39-554) days. 96 randomized into EG and 98 into CG. 1. In 75/194 patients the image test was not suggestive of BP with PCT < 1 ng/ml; 29/52 in the EG and 11/23 in the CG did not receive antibiotics. 2. In 101 patients, the image was suggestive of BP; 34/34 in the EG and 57/67 in the CG received antibiotics. Statistically significant differences between groups were observed when PCT resulted < 1 ng/ml (p = 0.01). 3. In 18 patients the image test was not suggestive of BP but PCT resulted > 1 ng/ml, all of them received antibiotics. A total of 0.035 mSv radiation/patient was eluded. A reduction of 77% CXR/patient was observed. LUS did not significantly increase costs.

CONCLUSIONS

Combination of LUS and PCT showed no risk of mistreating BP, avoided radiation and did not increase costs. The algorithm could be a reliable tool for improving pneumonia management.

CLINICAL TRIAL REGISTRATION

NCT04217980.

Effects of intrauterine and post-natal exposure to air pollution on children's pneumonia: Key roles in different particulate matters exposure during critical time windows

BACKGROUND

Despite mounting evidence linked pneumonia with air pollution, it is unclear what main pollutant(s) exposure in which critical window(s) play a key role in pneumonia.

OBJECTIVE

To examine effects of intrauterine and post-natal exposure to air pollution on children's doctor-diagnosed pneumonia (DDP).

METHODS

A combination of cross-sectional and retrospective cohort study was conducted at Changsha, China during 2019-2020. Personal exposure to outdoor air pollutants at each child's home address was estimated using inverse distance weighted (IDW) method based on data from 10 air quality monitoring stations. Associations between personal air pollution exposure and DDP were evaluated.

RESULTS

Children's DDP was associated with intrauterine and post-natal exposure to PM2.5, PM2.5-10, and PM10, adjusted ORs (95% CI) of 1.17 (1.04-1.30), 1.09 (1.01-1.17), and 1.07 (1.00-1.14) for IQR increase in intrauterine exposure and 1.12 (1.02-1.22), 1.13 (1.06-1.21), and 1.28 (1.16-1.41) for post-natal exposure. Intrauterine PM2.5 exposure and post-natal PM10 exposure were associated with a higher risk of pneumonia. We identified the 2nd trimester, 3rd trimester, and first year as critical windows respectively for PM2.5, PM2.5-10, and PM10 exposure. Daytime exposure to traffic-related air pollution especially during early life increased DDP.

CONCLUSION

Intrauterine and post-natal exposure to particulate matters played a dominant role in children's DDP.

Childhood Pneumonia: What's Unchanged, and What's New?

Childhood pneumonia is still a significant clinical and public health problem. India contributes the highest number of deaths due to pneumonia, accounts for about 20% of global mortality among under five children. Various etiologic agents including bacteria, viruses and atypical organism are responsible for childhood pneumonia. Recent studies suggest that viruses are one of the major causes of childhood pneumonia. Among viruses, respiratory syncytial virus has got great attention and several recent studies are reporting it as an important organism for pneumonia. Lack of exclusive breast feeding during first six months, improper timing of start and content of complimentary feeding, anemia, undernutrition, indoor pollution due to tobacco smoking and use of coal and wood for cooking food and lack of vaccinations are important risk factors. X-ray chest is not routinely performed to diagnose pneumonia while use of lung ultrasound is increasing to detect consolidation, pleural effusion, pneumothorax and pulmonary edema (interstitial syndrome). Role of C-reactive protein (CRP) and procalcitonin is similar, to differentiate between viral and bacterial pneumonia, however duration of antibiotics is better guided by procalcitonin. Newer biomarkers like IL-6, presepsin and triggering receptor expressed on myeloid cells 1 are needed to be evaluated for their use in children. Hypoxia is significantly associated with childhood pneumonia. Therefore, use of pulse oximetry should be encouraged for early detection and prompt treatment of hypoxia to prevent adverse outcomes. Among the available tools for risk of mortality assessment in children due to pneumonia, PREPARE score is the best but external validation will be needed.

Factors associated with childhood pneumonia and care seeking practices in Nepal: further analysis of 2019 Nepal Multiple Indicator Cluster Survey

BACKGROUND

Acute Respiratory Infection (ARI) is still a major public health problem in Nepal. The prevalence of ARI among under five children was 2.1% in 2019 and many children from marginalized families suffer disproportionately and many of them die without proper care and treatment. The objective of this study was to identify factors associated with childhood pneumonia and care-seeking practices in Nepal.

METHODS

This was a secondary analysis of the Nepal Multiple Indicator Cluster Survey (MICS) 2019, which uses multi-stage Probability Proportional to Size sampling. Data from 6658 children were analyzed using SPSS 22. Chi-square test and logistic regression analysis were conducted with odds ratio and its corresponding 95% confidence interval after adjusting for confounders.

RESULTS

Children aged 0 to 23 months had1.5 times higher odds of pneumonia compared to the age group 24 to 59 months (AOR = 1.5, CI 1.0-2.3) and children from rural area had 1.9 times the odds of having pneumonia than urban children (AOR = 1.9, CI 1.2-3.2). Underweight children had 2.3 times greater odds of having pneumonia than normal weight children (AOR = 2.3, CI 1.4-3.9). The odds of having pneumonia were 2.5 higher among children of current smoking mothers compared those with non-smoking mothers (AOR = 2.5, CI 1.1-5.7). Similarly, children from disadvantaged families had 0.6 times protective odds of pneumonia than children from non-disadvantaged families (AOR = 0.6, CI 0.4-1.0). Only one quarter of children received treatment from public facilities. Of those who received treatment, nearly half of the children received inappropriate treatment for pneumonia. One in ten children with pneumonia did not receive any kind of treatment at all.

CONCLUSIONS

Pneumonia is still a public health problem in low-income countries. Public health program and treatment services should be targeted to younger children, careful attention should be given to underweight children, and awareness and nutrition related activities should be focused on rural areas. Addressing inequity in access to and utilization of treatment of childhood illnesses should be prioritized.

Risk factors for childhood pneumonia at Adama Hospital Medical College, Adama, Ethiopia: a case-control study

BACKGROUND

Pneumonia is an acute respiratory infection of the lungs. A child dies of pneumonia every 39 s globally. Even though pneumonia affects children worldwide, the risk and repercussions of the disease are more prevalent in poor and middle-income nations. Despite the initiatives by the Ethiopian government, there are still numerous instances and deaths caused by childhood pneumonia. Therefore, this study aimed to identify the risk factors for pneumonia among 2-59 months-old children visiting Adama Hospital Medical College, Adama, Ethiopia.

METHODS

An institution-based unmatched case-control study was conducted among 124 cases and 124 controls from January 1, 2021, to March 15, 2021. Cases were selected using a consecutive sampling technique. For each case, the next patient from the same pediatric outpatient room who met the inclusion criteria was taken as a control. Data were collected using a pretested, structured interviewer-administered questionnaire containing sociodemographic, environmental, and nutritional factors, comorbid illnesses, and related care practices. A multiple logistic regression model was fitted.

RESULTS

Family size of ≥ 5 compared to < 5 (Adjusted odds ratio (AOR): 3.08, 95% CI: 1.23, 7.71), household monthly income of < 2500 compared to > 5000 birr (AOR: 3.94, 95% CI: 1.06, 14.6), use of charcoal as the main fuel for cooking (AOR: 7.03, 95% CI: 2.38, 20.78), and wood or dung as the main fuel for cooking compared to electricity (AOR: 6.58, 95% CI: 2.07, 20.9), malnutrition compared to no malnutrition (AOR: 4.77, 95% CI: 1.89, 12.06), diarrhea compared to no diarrhea in the past 2 weeks (AOR: 3.3, 95% CI: 1.52, 7.14) and upper respiratory tract infection (URTI) compared to no infection in the past 2 weeks (AOR: 3.29, 95% CI: 1.31, 8.23) were found to be risk factors for pneumonia.

CONCLUSION

In this study, risk factors for pneumonia were family size, monthly income, type of energy used for cooking, malnutrition, and diarrhea or URTI in the past 2 weeks. Relatively simple interventions such as cooking with electricity, and other interventions like prevention, early detection and treatment of malnutrition, diarrhea, and URTI, and promotion of family planning are important.

Effect of preconceptional, prenatal and postnatal exposure to home environmental factors on childhood pneumonia: A key role in early life exposure

BACKGROUND

Increasing evidence have associated pneumonia with early exposure to ambient air pollution. However, the role of indoor environmental factors exposure in early life on childhood pneumonia remains unclear.

OBJECTIVE

To examine the association between indoor environmental factors exposure during different timing windows and childhood pneumonia, and to identify the key indoor factor(s) in different critical window(s).

METHODS

A retrospective cohort study of 8689 pre-schoolers was performed in Changsha, China during 2019-2020. Our questionnaire survey was designed to collect information on pre-schooler's outcome and residential environmental exposure containing indoor pollution and allergens during 1 year before pregnancy, pregnancy, first year, and past year. The associations were further estimated stratified by personal exposure level of outdoor NO₂, CO, temperature (T) and different covariates. Associations were assessed by multiple logistic regression model in terms of odds ratio (OR) of 95% confidence interval (CI).

RESULTS

Pre-schooler's pneumonia was significantly related with exposure of new furniture, redecoration, mold/damp stains, and mold or damp clothing or bedding exposure during the four periods, with the strongest associations observed during 1 year before pregnancy based on multi-window model, with ORs (95% CI) of 1.27 (1.12-1.44), 1.26 (1.09-1.46), 1.34 (1.14-1.57), and 1.28 (1.05-1.56) respectively. Environmental tobacco smoke (ETS) including both parental and grandparental smoking were significantly related with increased risk of pre-schooler's pneumonia, and ETS played a more important role in early life, with ORs (95% CI) of 1.17 (1.01-1.36) and 1.19 (1.02-1.39) in pregnancy and first year. Indoor plants particularly nonflowering plants significantly elevated pneumonia risk but only in past year, with ORs (95% CI) of 1.17 (1.05-1.30) and 1.14 (1.03-1.26). Higher pneumonia risk was observed for renovation exposure in pre-birth compared to post-birth, while mold/dampness exerted an accumulative effect with the highest risk for exposure during both pre- and post-birth. Living near traffic road and exposure to high level of traffic-related air pollution and high temperature significantly increased pneumonia risk. Sensitivity analysis found that some sub-groups were more susceptible to pneumonia risk of home environment exposure.

CONCLUSION

Early life exposure to indoor environmental factors plays an important role in pneumonia development, supporting the hypothesis of "Preconceptional and Fetal Origin of Childhood Pneumonia" and "Developmental Origins of Health and Pneumonia".

Chest radiography in children aged 2-59 months enrolled in the Innovative Treatments in Pneumonia (ITIP) project in Lilongwe Malawi: a secondary analysis

BACKGROUND

Pneumonia is the leading infectious cause of death in children aged under 5 years in low- and middle-income countries (LMICs). World Health Organization (WHO) pneumonia diagnosis guidelines rely on non-specific clinical features. We explore chest radiography (CXR) findings among select children in the Innovative Treatments in Pneumonia (ITIP) project in Malawi in relation to clinical outcomes.

METHODS

When clinically indicated, CXRs were obtained from ITIP-enrolled children aged 2 to 59 months with community-acquired pneumonia hospitalized with treatment failure or relapse. ITIP1 (fast-breathing pneumonia) and ITIP2 (chest-indrawing pneumonia) trials enrolled children with non-severe pneumonia while ITIP3 enrolled children excluded from ITIP1 and ITIP2 with severe pneumonia and/or selected comorbidities. A panel of trained pediatricians classified the CXRs using the standardized WHO CXR research methodology. We analyzed the relationship between CXR classifications, enrollee characteristics, and outcomes.

RESULTS

Between March 2016 and June 2018, of 114 CXRs obtained, 83 met analysis criteria with 62.7% (52/83) classified as having significant pathology per WHO standardized interpretation. ITIP3 (92.3%; 12/13) children had a higher proportion of CXRs with significant pathology compared to ITIP1 (57.1%, 12/21) and ITIP2 (57.1%, 28/49) (p-value = 0.008). The predominant pathological CXR reading was "other infiltrates only" in ITIP1 (83.3%, 10/12) and ITIP2 (71.4%, 20/28), while in ITIP3 it was "primary endpoint pneumonia"(66.7%, 8/12,; p-value = 0.008). The percent of CXRs with significant pathology among children clinically cured (60.6%, 40/66) vs those not clinically cured (70.6%, 12/17) at Day 14 was not significantly different (p-value = 0.58).

CONCLUSIONS

In this secondary analysis we observed that ITIP3 children with severe pneumonia and/or selected comorbidities had a higher frequency of CXRs with significant pathology, although these radiographic findings had limited relationship to Day 14 outcomes. The proportion of CXRs with "primary endpoint pneumonia" was low. These findings add to existing data that additional diagnostics and prognostics are important for improving the care of children with pneumonia in LMICs.

TRIAL REGISTRATION

ITIP1, ITIP2, and ITIP3 were registered with ClinicalTrials.gov ( NCT02760420 , NCT02678195 , and NCT02960919 , respectively).

Experiences From an Implementation Model of ARI Diagnostic Device in Pneumonia Case Management Among Under-5 Children in Peripheral Healthcare Centers in India

OBJECTIVES

To address pneumonia, a major killer of under-5 children in India, a multimodal pulse oximeter was implemented in Health and Wellness Centers. Given the evidence of pulse oximetry in effective pneumonia management and taking into account the inadequate skills of front-line healthcare workers in case management, the device was introduced to help them readily diagnose and treat a child and to examine usability of the device.

DESIGN

The implementation was integrated with the routine OPD of primary health centers for 15 months after healthcare workers were provided with an abridged IMNCI training. Monthly facility data was collected to examine case management with the diagnostic device. Feedback on usefulness of the device was obtained.

SETTING

Health and Wellness Centers (19) of 7 states were selected in consultation with state National Health Mission based on patient footfall.

PARTICIPANTS

Under-5 children presenting with ARI symptoms at the OPD.

RESULTS

Of 4846 children, 0.1% were diagnosed with severe pneumonia and 23% were diagnosed with pneumonia. As per device readings, correct referrals were made of 77.6% of cases of severe pneumonia, and 81% of pneumonia cases were correctly given antibiotics. The Pulse oximeter was highly acceptable among health workers as it helped in timely classification and treatment of pneumonia. It had no maintenance issue and battery was long-lasting.

CONCLUSION

Pulse oximeter implementation was doable and acceptable among health workers. Together with IMNCI training, PO in primary care settings is a feasible approach to provide equitable care to under-5 children.

LncRNA GAS5 participates in childhood pneumonia by inhibiting cell apoptosis and promoting SHIP-1 expression via downregulating miR-155

Background

LncRNA GAS5 and miR-155 are reported to play opposite roles in lung inflammatory responses. Lung inflammation participates in childhood pneumonia, indicating the involvement of GAS5 and miR-155 in pneumonia. The study aimed to analyze the potential interaction between GAS5 and miR-155 in childhood pneumonia.

Methods

GAS5 and miR-155 levels in plasma samples from pneumonia patients and controls were detected using RT-qPCR. The role of GAS5 in miR-155 RNA gene methylation in human bronchial epithelial cells (HBEpCs) was analyzed by methylation analysis. Flow cytometry and RT-qPCR were applied to analyze cell apoptosis and SHIP-1 expression, respectively.

Results

GAS5 was downregulated in pneumonia, and miR-155 was upregulated in pneumonia. GAS5 and miR-155 were inversely correlated. GAS5 overexpression decreased miR-155 expression in HBEpCs, while miR-155 overexpression showed no significant effects on GAS5 expression. In addition, GAS5 suppressed LPS-induced HBEpC apoptosis, promoted SHIP-1 expression, and reduced the enhancing effect of miR-155 on cell apoptosis and SHIP-1 expression.

Conclusions

GAS5 may participate in childhood pneumonia by inhibiting cell apoptosis and promoting SHIP-1 expression via downregulating miR-155.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-021-01724-y.

Performance of five pulse oximeters to detect hypoxaemia as an indicator of severe illness in children under five by frontline health workers in low resource settings - A prospective, multicentre, single-blinded, trial in Cambodia, Ethiopia, South Sudan, and Uganda

BACKGROUND

Low blood oxygen saturation (SpO₂), or hypoxaemia, is an indicator of severe illness in children. Pulse oximetry is a globally accepted, non-invasive method to identify hypoxaemia, but rarely available outside higher-level facilities in resource-constrained countries. This study aims to evaluate the performance of different types of pulse oximeters amongst frontline health workers in Cambodia, Ethiopia, South Sudan, and Uganda.

METHODS

Five pulse oximeters (POx) which passed laboratory testing, out of an initial 32 potential pulse oximeters, were evaluated by frontline health workers for performance, defined as agreement between the SpO₂ measurements of the test device and the reference standard. The study protocol is registered with the Australia New Zealand Clinical Trials Registry (Ref: ACTRrn12615000348550).

FINDINGS

Two finger-tip pulse oximeters (Contec and Devon), two handheld pulse oximeters (Lifebox and Utech), and one phone pulse oximeter (Masimo) passed the laboratory testing. They were evaluated for performance on 1,313 children under five years old by 207 frontline health workers between February and May 2015. Phone and handheld pulse oximeters had greater overall agreement with the reference standard (56%; 95% CI 0.52 - 0.60 to 68%; 95% CI 0.65 - 0.71) than the finger-tip POx (31%; 95% CI 0.26 to 0.36 and 47%; 95% CI 0.42 to 0.52). Fingertip POx performance was substantially lower in the 0-2 month olds; having just 17% and 25% agreement. The finger-tip devices more often underreported SpO₂ readings (mean difference -7.9%; 95%CI -8.6,-7.2 and -3.9%; 95%CI -4.4,-3.4), and therefore over diagnosed hypoxaemia in the children assessed.

INTERPRETATION

While the Masimo phone pulse oximeter performed best, all handheld POx with age-specific probes performed well in the hands of frontline health workers, further highlighting their suitability as a screening tool of severe illness. The poor performance of the fingertip POx suggests they should not be used in children under five by frontline health workers. It is essential that POx are performance tested on children in routine settings (in vivo), not only in laboratories or controlled settings (in vitro), before being introduced at scale.

FUNDING

Bill & Melinda Gates Foundation [OPP1054367].

Weather Variability, Socioeconomic Factors, and Pneumonia in Children Under Five-Years Old - Bangladesh, 2012-2016

What is already known on this topic?

Different socioecological factors were associated with childhood pneumonia in Bangladesh. However, previous studies did not assess spatial patterns, and socioecological factors and spatial variation have the potential to improve the accuracy and predictive ability of existing models.

What is added by this report?

The spatial random effects were present at the district level and were heterogeneous. Average temperature, temperature variation, and population density may influence the spatial pattern of childhood pneumonia in Bangladesh.

What are the implications for public health practice?

The study results will help policymakers and health managers to identify the vulnerable districts, plan further investigations, help to improve proper resource allocation, and improve health interventions.

Preconceptional and prenatal exposure to diurnal temperature variation increases the risk of childhood pneumonia

Background

Pneumonia is the leading cause of death and hospitalization among young children worldwide, but its risk factors remain unclear.

Objective

To evaluate the effect of maternal exposure to diurnal temperature variation (DTV) during preconceptional and prenatal periods on childhood pneumonia.

Methods

A retrospective cohort study by case-control design was conducted for pneumonia (N = 699) and normal (N = 811) children under age of 14 who were enrolled in XiangYa Hospital, Changsha, China from May 2017 to April 2019. Demographic data including gender, age, birth season, gestational age, parity, mode of delivery, and parental atopy were collected from the electronic medical records in the hospital system. We obtained the data of daily DTV in Changsha during 2003–2019 from China Meteorological Administration. Maternal exposure to DTV during preconceptional and prenatal periods was respectively calculated by the average of daily DTV during one year and three months before conception and entire pregnancy as well as the three trimesters. The association between maternal exposure to outdoor DTV and childhood pneumonia was analyzed by multiple logic regression model.

Results

We found that childhood pneumonia was significantly associated with exposure to an increase in DTV during one year before conception and entire pregnancy, with ORs (95 % CI) = 2.53 (1.56–4.10) and 1.85 (1.24–2.76). We further identified a significant risk of pneumonia of DTV exposure during the first and second trimester of pregnancy. Sensitivity analysis showed that boys were more susceptible to the effect of prenatal exposure to outdoor DTV during pregnancy particularly in the first two trimesters compared to girls.

Conclusions

Preconceptional and prenatal exposure to DTV plays an important role in development of childhood pneumonia, especially during the first and second trimesters of pregnancy.

Long non-coding RNA GAS5 regulates Th17/Treg imbalance in childhood pneumonia by targeting miR-217/STAT5

The imbalance of helper T (Th) 17 and regulatory T (Treg) cells plays an important role in the pathogenesis of pneumonia. This study aims to investigate the role and mechanism of long non-coding RNA growth arrest-specific 5 (GAS5) in the differentiation of Th17 cells and Tregs in childhood pneumonia. Expression of GAS5, miR-217, signal transducer and activator of transcription-5 (STAT5), receptor-related orphan receptor γt (RORγt), and transcription factor Forkhead box P3 (Foxp3) were examined by qRT-PCR and western blot. The percentage of Th17 cells and Tregs in CD4⁺ T cells were measured by flow cytometry. The interaction between miR-217 and GAS5 or STAT5 was analyzed by luciferase reporter assay. Downregulated GAS5 expression and Treg cell percentage, and upregulated Th17 cell percentage were observed in pneumonia patients when compared with the healthy controls. Furthermore, GAS5 overexpression corrected the imbalanced Th17/Treg in peripheral blood CD4⁺ T cells derived from pneumonia patients, and this effect was reversed by miR-217 mimic and STAT5 silencing. Mechanistically, GAS5 acted as a sponge of miR-217 to reduce binding of miR-217 to its target STAT5, leading to upregulation of STAT5 expression. Taken together, GAS5 corrects the Treg/Th17 imbalance by targeting the miR-217/STAT5 axis in childhood pneumonia.

Preconceptional and prenatal exposure to air pollution increases incidence of childhood pneumonia: A hypothesis of the (pre-)fetal origin of childhood pneumonia

BACKGROUND

Increasing evidence has linked childhood pneumonia with early exposure to ambient air pollution. However, the impact of exposure to air pollutants before birth is unclear.

OBJECTIVE

To further clarify whether exposure to a particular pollutant during preconceptional and prenatal periods, may pose a higher risk of developing childhood pneumonia.

METHODS

This case-control cohort study consisted of 1510 children aged 0-14 years in Changsha, China between 2017 and 2019. Data of children's history of pneumonia and blood biomarkers were obtained from the XiangYa Hospital records. Each child's exposure to air pollutants, including nitrogen dioxide (NO₂), sulfur dioxide (SO₂), and particulate matter with an aerodynamic diameter ≤ 10 µm (PM₁₀), was calculated using data from ten air pollution monitoring stations. A multivariate logistic regression model was used to quantify the relationship between childhood pneumonia and exposure to ambient air pollution during the preconceptional and prenatal periods.

RESULTS

Childhood pneumonia was significantly associated with preconceptional and prenatal exposure to the industrial-related air pollutant, SO₂, for 1 year before conception, for 3 months before conception and for the entire pregnancy, with ORs(95% CI)= 4.01(3.17-5.07), 4.06(3.29-5.00) and 6.51(4.82-8.79). Also, children who were sick with pneumonia had higher white blood cell and neutrophil counts, and children with low eosinophil count or hemoglobin are likely to get pneumonia. Sensitivity analysis showed that boys, and children in high temperature area were susceptible to the effect of both preconceptional and prenatal exposure to industrial SO₂.

CONCLUSION

Preconceptional and prenatal exposure to industrial-related air pollution plays a significant role in the incidence and progression of childhood pneumonia, supporting the hypothesis of "(pre-)fetal origin of childhood pneumonia".

Experiences with use of a pulse oximeter multimodal device in outpatient management of children with Acute Respiratory Infection during Covid pandemic

Background:

While Covid-19 infection rate in children is low, respiratory symptoms are a common mode of presentation which calls for better management of such symptoms. However, ARI case managemnet in primary health settings settings has challenges as health workers lack skills to count respiratory rate and check chest indrawing. To address this multimodal pulse oximeters have been introduced in health and wellness centres of seven states to ease the work of front line health workers. A study was undertaken to understand the usability of the multimodal pulse oximeter during Covid times.

Methods:

A qualitative study was conducted with the aid of indepth interviews among a convenience sample of eleven health care workers from ten health and wellness centres. Interviews were conducted and recorded over phone, after obtaining consent. Transcribed interviews were coded and analysed on a qualitative analysis software. Content analysis was conducted.

Results:

Total children screened during covid lockdown period (April 1-May 31) is 571, those diagnosed with pneumonia and severe pneumonia is 68 and 2. Health care workers were satisfied with pulse oximeter as it helped in timely diagnosis and treatment, and offered protection from possible infection as it mitigated the need for physical contact.

Conclusion:

The multimodal pulse oximeter is well accepted among providers as it is easy to use aiding in timely management of ARI in children. It has an added protection as it's use reduces the need for physical contact. It can be adopted in other HWC and primary health facilities.

Fast-breathing vs chest-indrawing childhood pneumonia: baseline characteristics

•

Comparison of fast-breathing vs chest-indrawing community-acquired pneumonia.

•

Male and younger children appear more vulnerable to chest-indrawing pneumonia.

•

Understanding sex-, age-, and nutrition-related differences informs interventions.

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

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

Impact of climate variability on length of stay in hospital for childhood pneumonia in rural Bangladesh

OBJECTIVES

Pneumonia is a significant contributor to mortality and morbidity in children aged <5 years, and it is also one of the leading causes of hospitalisation for children in this age group. This study assessed the association between climate variability, patient characteristics (i.e. age, sex, weight, parental education, socio-economic status) and length of stay (LOS) in hospital for childhood pneumonia and its economic impact on rural Bangladesh.

STUDY DESIGN

An ecological study design was used.

METHODS

Data on daily hospitalisation for pneumonia in children aged <5 years (including patient characteristics) and daily climate data (temperature and relative humidity) between 1st January 2012 and 31st December 2016 were obtained from the Matlab Hospital (the International Centre for Diarrhoeal Disease Research, Bangladesh) and the Bangladesh Meteorological Department, respectively. A generalised linear model with Poisson link was used to quantify the association between climate factors, patient characteristics and LOS in hospital.

RESULTS

The study showed that average temperature, temperature variation and humidity variation were positively associated with the LOS in hospital for pneumonia. A 1°C rise in average temperature and temperature variation during hospital stay increased the LOS in hospital by 1% (relative risk [RR]: 1.010, 95% confidence interval [CI]: 1.001-1.018) and 9.3% (RR: 1.093, 95% CI: 1.051-1.138), respectively. A 1% increase in humidity variation increased the LOS in hospital for pneumonia by 2.2% (RR: 1.022, 95% CI: 1.004-1.039). In terms of economic impact, for every 1° C temperature variation during the period of hospital stay, there is an addition of 0.81 USD/day/patient as a result of direct costs and 1.8 USD/day/patient for total costs. Annually, this results in an additional 443 USD for direct and 985 USD for total costs.

CONCLUSIONS

Climate variation appears to significantly contribute to the LOS in hospital for childhood pneumonia. These findings may help policymakers to develop effective disease management and prevention strategies.

Weather factors, PCV intervention and childhood pneumonia in rural Bangladesh

Available evidence is limited on the association between weather factors and childhood pneumonia, especially in developing countries. This study examined the effects of weather variability on childhood pneumonia after the introduction of pneumococcal conjugate vaccines (PCV) intervention in rural Bangladesh. Data on pneumonia cases and weather variables (temperature and relative humidity) between the 1st January 2012 and the 31st December 2016 were collected from Matlab Hospital, International Centre for Diarrhoeal Disease Research, Bangladesh, and Bangladesh Meteorological Department, respectively. Time series cross-correlation functions were applied to identify the time lags of the effect of each weather factor on pneumonia. Generalized linear regression model with Poisson link was used to quantify the association between weather factors and childhood pneumonia after adjustment of PCV intervention. The annual incidence rate of pneumonia reduced from 5691/100,000 to 2000/100,000 after PCV intervention. Generalized linear regression model suggested that temperature had a negative association with childhood pneumonia (relative risk, 0.985; 95% confidence interval (CI), 0.974-0.997), and PCV intervention was a protective factor with the relative risk estimate of 0.489 (95% CI, 0.435-0.551). However, no substantial association was found with relative humidity. PCV intervention appeared protective against childhood pneumonia, and temperature might be associated with this disease in children. Our findings may help inform public health policy, including the potential of development of early warning systems based on weather factors and PCV for the control and prevention of pneumonia in lower middle-income country like Bangladesh.

Understanding key drivers and barriers to implementation of the WHO recommendations for the case management of childhood pneumonia and possible serious bacterial infection with amoxicillin dispersible tablets (DT) in Bangladesh: a qualitative study

BACKGROUND

Pneumonia and possible serious bacterial infection (PSBI) are leading causes of death among under-five children. The World Health Organization (WHO) issued global recommendations for the case management of childhood pneumonia and PSBI when referral is not feasible with oral amoxicillin. However, few governments to date have incorporated child-friendly amoxicillin dispersible tablets (DT) into their national treatment guidelines and policies. We aimed to understand the key drivers to the implementation of WHO recommendations for childhood pneumonia and PSBI using amoxicillin DT in Bangladesh.

METHODS

A qualitative study was conducted from October 2017 to March 2018 in two districts of Bangladesh. Interviews were completed with 67 participants consisting of government officials and key stakeholders, international development agencies, health service providers (HSPs), and caregivers of young children diagnosed and treated with amoxicillin for pneumonia or PSBI. Data were analyzed thematically.

RESULTS

Policies and operational planning emerged as paramount to ensuring access to essential medicines for childhood pneumonia and PSBI. Though amoxicillin DT is included for National Newborn Health Programme and Integrated Management of Childhood Illnesses in the Operational Plan of the Directorate General of Health Services, inclusion in Community-Based Healthcare Project and Directorate General of Family Planning policies is imperative to securing national supply, access, and uptake. At the sub-national level, training on the use of amoxicillin DT as a first line intervention is lacking, resulting in inadequate management of childhood pneumonia by HSPs. Advocacy activities are needed to create community-wide demand among key stakeholders, HSPs, and caregivers not yet convinced that amoxicillin DT is the preferred formulation for the management of childhood pneumonia and PSBI.

CONCLUSION

Challenges in policy and supply at the national level and HSP preparedness at the sub-national levels contribute to the slow adoption of WHO recommendations for amoxicillin DT in Bangladesh. A consultation meeting to disseminate study findings was instrumental in driving the development of recommendations by key stakeholders to address these challenges. A comprehensive and inclusive evidence-based strategy involving all divisions of the Ministry of Health and Family Welfare will be required to achieve national adoption of WHO recommendations and country-wide introduction of amoxicillin DT in Bangladesh.

The Association of Childhood Pneumonia with Household Air Pollution in Nepal: Evidence from Nepal Demographic Health Surveys

INTRODUCTION

Childhood pneumonia is a major cause of mortality worldwide while household air pollution (HAP) is a major contributor to childhood pneumonia in low and middle-income countries. This paper presents the prevalence trend of childhood pneumonia in Nepal and assesses its association with household air pollution.

METHODS

The study analysed data from the 2006, 2011 and 2016 Nepal Demographic Health Surveys (NDHS). It calculated the prevalence of childhood pneumonia and the factors that cause household air pollution. The association of childhood pneumonia and HAP was assessed using univariate and multi-variate analysis. The population attributable fraction (PAF) of indoor pollution for causing pneumonia was calculated using 2016 NDHS data to assess the burden of pneumonia attributable to HAP factors.

RESULTS

The prevalence of childhood pneumonia decreased in Nepal between 2006 and 2016 and was higher among households using polluting cooking fuels. There was a higher risk of childhood pneumonia among children who lived in households with no separate kitchens in 2011 [Adjusted risk ratio (ARR) 1.40, 95% CI 1.01-1.97] and in 2016 (ARR 1.93, 95% CI 1.14-3.28). In 2016, the risk of children contracting pneumonia in households using polluting fuels was double (ARR 1.98, 95% CI 1.01-3.92) that of children from households using clean fuels. Based on the 2016 data, the PAF for pneumonia was calculated as 30.9% for not having a separate kitchen room and 39.8% for using polluting cooking fuel.

DISCUSSION FOR PRACTICE

Although the occurrence of childhood pneumonia in Nepal has decreased, the level of its association with HAP remained high.

Examining the relationship between household air pollution and infant microbial nasal carriage in a Ghanaian cohort

BACKGROUND

Pneumonia, a leading cause of childhood mortality, is associated with household air pollution (HAP) exposure. Mechanisms between HAP and pneumonia are poorly understood, but studies suggest that HAP may increase the likelihood of bacterial, instead of viral, pneumonia. We assessed the relationship between HAP and infant microbial nasal carriage among 260 infants participating in the Ghana Randomized Air Pollution and Health Study (GRAPHS).

METHODS

Data are from GRAPHS, a cluster-randomized controlled trial of cookstove interventions (improved biomass or LPG) versus the 3-stone (baseline) cookstove. Infants were surveyed for pneumonia during the first year of life and had routine personal exposure assessments. Nasopharyngeal swabs collected from pneumonia cases (n = 130) and healthy controls (n = 130) were analyzed for presence of 22 common respiratory microbes by MassTag polymerase chain reaction. Data analyses included intention-to-treat (ITT) comparisons of microbial species presence by study arm, and exposure-response relationships.

RESULTS

In ITT analyses, 3-stone arm participants had a higher mean number of microbial species than the LPG (LPG: 2.71, 3-stone: 3.34, p < 0.0001, n = 260). This difference was driven by increased bacterial (p < 0.0001) rather than viral species presence (non-significant). Results were pronounced in pneumonia cases and attenuated in healthy controls. Higher prevalence bacterial species were Haemophilus influenzae, Streptococcus pneumoniae, and Moraxella catarrhalis. Exposure-response relationships did not yield significant associations between measured CO and nasal microbial carriage.

CONCLUSIONS

Our intention-to-treat findings are consistent with a link between HAP and bacterial nasal carriage. No relationships were found for viral carriage. Given the null results in exposure-response analysis, it is likely that a pollutant besides CO is driving these differences.

Performance of Four Respiratory Rate Counters to Support Community Health Workers to Detect the Symptoms of Pneumonia in Children in Low Resource Settings: A Prospective, Multicentre, Hospital-Based, Single-Blinded, Comparative Trial

BACKGROUND

Pneumonia is one of the leading causes of death in children under-five globally. The current diagnostic criteria for pneumonia are based on increased respiratory rate (RR) or chest in-drawing in children with cough and/or difficulty breathing. Accurately counting RR is difficult for community health workers (CHWs). Current RR counting devices are frequently inadequate or unavailable. This study analysed the performance of improved RR timers for detection of pneumonia symptoms in low-resource settings.

METHODS

Four RR timers were evaluated on 454 children, aged from 0 to 59 months with cough and/or difficulty breathing, over three months, by CHWs in hospital settings in Cambodia, Ethiopia, South Sudan and Uganda. The devices were the Mark Two ARI timer (MK2 ARI), counting beads with ARI timer, Rrate Android phone and the Respirometer feature phone applications. Performance was evaluated for agreement with an automated RR reference standard (Masimo Root patient monitoring and connectivity platform with ISA CO₂ capnography). This study is registered with ANZCTR [ACTRN12615000348550].

FINDINGS

While most CHWs managed to achieve a RR count with the four devices, the agreement was low for all; the mean difference of RR measurements from the reference standard for the four devices ranged from 0.5 (95% C.I. - 2.2 to 1.2) for the respirometer to 5.5 (95% C.I. 3.2 to 7.8) for Rrate. Performance was consistently lower for young infants (0 to < 2 months) than for older children (2 to ≤ 59 months). Agreement of RR classification into fast and normal breathing was moderate across all four devices, with Cohen's Kappa statistics ranging from 0.41 (SE 0.04) to 0.49 (SE 0.05).

INTERPRETATION

None of the four devices evaluated performed well based on agreement with the reference standard. The ARI timer currently recommended for use by CHWs should only be replaced by more expensive, equally performing, automated RR devices when aspects such as usability and duration of the device significantly improve the patient-provider experience.

FUNDING

Bill & Melinda Gates Foundation [OPP1054367].

Normal axillary thickness thresholds as a metric for nutritional status of children

Introduction

Childhood pneumonia is a major cause of death in the 3rd world, and undernourishment increases the severity of the condition. We considered axillary thickness as a simple measurement to evaluate nutritional status that can be performed simultaneously with lung ultrasound. Our goal was to determine the distribution of axillary thickness in a cohort of children to determine a threshold for malnutrition.

Methods

Clinical databases were scanned to identify chest computed tomograms (CT) in children between the ages of 0 and 5 years with non-debilitating disease. The bilateral axillary thicknesses of the cohort were determined using equivalent width, and these measurements were segmented by age, sex, and laterality to determine cutoff thresholds. Data was evaluated using single factor analysis of variance (ANOVA) and 5th percentile analysis to determine the lower bound thresholds of axillary thickness.

Results

247 scans met inclusion criteria. ANOVA demonstrated no significant differences in the mean measurements in the 5 groups (p = 0.377). 95% confidence limits on the 5th percentile plots showed an axillary thickness of 1.5 cm was a reasonable threshold for malnutrition detection for all age groups and sexes except for males between 0 and 1 years old where a 1.1 cm threshold may be required.

Discussion

CT scans of the chests in a cohort of children without debilitating disease revealed a remarkably uniform axillary thickness threshold for malnutrition assessment of 1.5 cm. This suggests that there may be a threshold for nutritional assessment for children undergoing lung ultrasound scans for childhood pneumonia.

•

Determined normal axillary thickness distributions in children aged 0–5 as a proxy to reflect childhood nutritional status

•

Equivalent width of axillae were determined from CT scans as a measure of thickness

•

A cutoff of 1.5 cm suffices for all ages except for boys between 0 and 1 years of age where 1.1 cm may be more appropriate

Operationalising integrated community case management of childhood illnesses by community health workers in rural Haryana

AIM

To conduct implementation research in integrated community case management (ICCM) of childhood pneumonia, diarrhoea and fever by promoting accredited social health activists as treatment providers and generate lessons for upscaling this approach.

METHODS

In this one-sample study, 49 Accredited Social Health Activists were trained in ICCM. Community awareness and demand generation activities undertaken included announcements, pamphlets and posters. Supplies of medicines and supervision of activists were maintained throughout the 10-month implementation period. Three cross-sectional surveys were conducted in households with children aged 2-59 months for documenting two-week prevalence of illnesses and care-seeking practices. Focus group discussions and in-depth interviews were carried out with mothers/grandmothers and activists for documenting perceptions about health activists as treatment providers.

RESULTS

One third of pneumonia (113/334) and one quarter of diarrhoea (102/408) cases at end-line were treated by Accredited Social Health Activists. Proportion of households seeking care from private providers (mostly unqualified) reduced significantly from baseline to endline (81-56% for diarrhoea, p < 0.01; 78-48% for pneumonia, p < 0.01). At endline, activists were considered an acceptable and attractive source for treatment near home.

CONCLUSION

Trained Accredited Social Health Activists can treat uncomplicated childhood illnesses and are accepted by the community in this role.

Methods for conducting a double-blind randomized controlled clinical trial of three days versus five days of amoxicillin dispersible tablets for chest indrawing childhood pneumonia among children two to 59 months of age in Lilongwe, Malawi: a study protocol

Background

Pneumonia is the leading infectious cause of death in children under 5 years of age around the globe. In addition to preventing pneumonia, there is a critical need to provide greater access to appropriate and effective treatment. Studies in Asia have evaluated the effectiveness of 3 days of oral amoxicillin for the treatment of fast-breathing pneumonia; however, further evidence is needed to determine if 3 days of oral amoxicillin is also effective for the treatment of chest indrawing pneumonia.

Methods

This is a double-blind, randomized, non-inferiority trial with the objective to assess the effectiveness of shorter duration amoxicillin dispersible tablet (DT) treatment of chest indrawing childhood pneumonia in a malaria-endemic region of Malawi. The primary objective of this study is to determine whether 3 days of treatment with oral amoxicillin DT in HIV-uninfected Malawian children two to 59 months of age with chest indrawing pneumonia is as effective as 5 days of treatment. The study will enroll 2000 children presenting to Kamuzu Central or Bwaila District Hospitals in Lilongwe, Malawi. Each child will be randomized to either 3 days of amoxicillin DT followed by 2 days of placebo DT or 5 days of amoxicillin DT. Children in the study will be hospitalized for 48 h after enrollment and will have scheduled study visits at Days 2, 4, 6 and 14. Treatment failure by Day 6 is the primary outcome. We hypothesize that the rates of treatment failure will be similar in both arms and that 3 days of treatment will be non-inferior to 5 days of amoxicillin DT for chest indrawing pneumonia using a relative non-inferiority margin of 1.5. This trial was approved by the Western Institutional Review Board and Malawi College of Medicine Research and Ethics Committee.

Discussion

Given the paucity of data from Africa, African-based research is necessary to establish appropriate duration of treatment with amoxicillin DT for chest indrawing childhood pneumonia in malaria-endemic settings in the region. An expanded evidence base will contribute to future iterations of World Health Organization Integrated Management of Childhood Illness guidelines.

Trial registration

NCT02678195: Pre-results. Date registered February 9, 2016.

Electronic supplementary material

The online version of this article (10.1186/s12879-018-3379-z) contains supplementary material, which is available to authorized users.

Childhood pneumonia diagnostics: community health workers' and national stakeholders' differing perspectives of new and existing aids

Background: Pneumonia heavily contributes to global under-five mortality. Many countries use community case management to detect and treat childhood pneumonia. Community health workers (CHWs) have limited tools to help them assess signs of pneumonia. New respiratory rate (RR) counting devices and pulse oximeters are being considered for this purpose.

Objective: To explore perspectives of CHWs and national stakeholders regarding the potential usability and scalability of seven devices to aid community assessment of pneumonia signs.

Design: Pile sorting was conducted to rate the usability and scalability of 7 different RR counting aids and pulse oximeters amongst 16 groups of participants. Following each pile-sorting session, a focus group discussion (FGD) explored participants’ sorting rationale. Purposive sampling was used to select CHWs and national stakeholders with experience in childhood pneumonia and integrated community case management (iCCM) in Cambodia, Ethiopia, Uganda and South Sudan. Pile-sorting data were aggregated for countries and participant groups. FGDs were audio recorded and transcribed verbatim. Translated FGDs transcripts were coded in NVivo 10 and analysed using thematic content analysis. Comparative analysis was performed between countries and groups to identify thematic patterns.

Results: CHWs and national stakeholders across the four countries perceived the acute respiratory infection (ARI) timer and fingertip pulse oximeter as highly scalable and easy for CHWs to use. National stakeholders were less receptive to new technologies. CHWs placed greater priority on device acceptability to caregivers and children. Both groups felt that heavy reliance on electricity reduced potential scalability and usability in rural areas. Device simplicity, affordability and sustainability were universally valued.

Conclusions: CHWs and national stakeholders prioritise different device characteristics according to their specific focus of work. The views of all relevant stakeholders, including health workers, policy makers, children and parents, should be considered in future policy decisions, research and development regarding suitable pneumonia diagnostic aids for community use.

Influence of different delivery modes on the clinical characteristics of Chlamydia trachomatis pneumonia

We analyzed the effects of delivery methods on Chlamydia trachomatis pneumonia in infants. Three hundred forty-four children hospitalized with Chlamydia trachomatis pneumonia were enrolled. They were divided into the vaginal delivery group and the cesarean delivery group. We compared and analyzed their age of onset, peripheral blood white blood cell count, liver enzymes, chlamydia trachomatis titers, and chest radiograph scores. Seventy-eight (22.7%) were delivered by a cesarean, and 266 (77.3%) were delivered vaginally. There were no statistically significant differences between groups when compared by sex and age (P > 0.05). Copy numbers and white blood cell counts in the peripheral blood of children with Chlamydia trachomatis in respiratory secretions of the vaginal delivery group were significantly higher than those of the cesarean delivery group (P < 0.05). The alanine aminotransferase and aspartate aminotransferase levels between groups were not statistically significant. Comparisons of admission chest radiography scores, discharge radiography scores, and score differences showed no statistical differences (P > 0.05).

CONCLUSION

Infants delivered by cesarean comprise approximately one-fifth of those affected. The Chlamydia trachomatis titers and peripheral blood leukocyte counts of the vaginal delivery group were higher than those of the cesarean delivery group. Age of onset, liver enzymes, pulmonary inflammation, and pneumonia absorption were not different between groups. What is Known: • Chlamydia trachomatis is an important pathogen that causes lower respiratory tract infections in infants. • C. trachomatis is primarily transmitted to infants through the infected mother, resulting in Chlamydia trachomatis pneumonia subsequently. What is New: • Vaginal delivery and cesarean delivery can result in Chlamydia trachomatis pneumonia transmission; however, cesarean delivery accounts for ~ 20% of cases. • C. trachomatis volume in the respiratory tract and the number of peripheral blood leukocytes in infants delivered vaginally were higher than those in infants delivered by cesarean.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Resveratrol improves efficacy of oral amoxicillin against childhood fast breathing pneumonia in a randomized placebo-controlled double blind clinical trial

Childhood pneumonia has been considered as a major cause of child morbidity and mortality worldwide. We aimed to investigate the effect of resveratral in synergizing with oral amoxicillin to improve the treatment outcome of oral amoxicillin administration against childhood fast breathing pneumonia. 647 children diagnosed fast breathing pneumonia were recruited and randomized to receive oral amoxicillin plus either resveratrol (AX + RV) or placebo (AX + placebo). The primary outcome was defined as treatment failure up to day 3, while the secondary outcome was defined as treatment failure at day 6 and 12 upon follow up. Incidences of treatment failure up to day 3 was significantly lower in the AX + RV group than the AX + placebo group. From day 6-12, the incidences of treatment failure were increased in both treatment groups. However, treatment failure cases were still much lower in the AX + RV group on both revisits. No serious adverse reaction to treatment drugs were found in either of the two groups. Resveratrol improves efficacy of oral amoxicillin against childhood fast breathing pneumonia, supporting the clincial potential of reseveratrol as a potent adjuvent of oral amoxicillin in the treatment of childhood pneumonia with no adverse effects.

Risk assessment of infected children with Pseudomonas aeruginosa pneumonia by combining host and pathogen predictors

The current criteria of pneumonia severity, which mainly depend on clinical manifestations and laboratory findings from blood routine tests and X-ray examination, are still of great significance in preliminary diagnosis. However, the utility of traditional severe pneumonia indexes (SPI) without considering high virulence and multidrug resistance of Pseudomonas aeruginosa has limitations. Thus, it is of great value to make a risk assessment, which can serve as a complementary option for incomplete clinical diagnosis. This study aims to determine risk factors related to severe pneumonia and to comprehensively evaluate the risk conditions of infected children with P. aeruginosa pneumonia. We collected the clinical information of 184 hospitalized children with P. aeruginosa pneumonia and measured pathogen data on virulence factors and drug resistance. The risk assessment matrix was formed from the significant host and pathogen predictors, and the risk score was determined by the clinical references and the optimal critical values (OCV) of the receiver operator characteristic (ROC) curves. There were 103 (56%) and 81 (44%) infected children diagnosed as mild and severe pneumonia by SPI, respectively. Seven risk factors were significantly associated with severe pneumonia, including body temperature, respiratory rate, C-reactive protein, elastase, exotoxin-A, exoenzyme-U and multidrug resistances. Among 184 infected children, the risk assessment matrix displayed 62 cases (34%) at high risk, 51 cases (28%) at medium risk, and 71 cases (38%) at low risk in terms of pneumonia severity. On the basis of the SPI preliminary diagnosis, the risk assessment prompted that 31% (32/103) mild patients would be faced with a poorer outcome and 23% (19/81) severe patients might get a better prognosis. Therefore, the well-established assessment indicates that the interplay between host response, antibiotic resistance, and virulence may modulate the severity of P. aeruginosa pneumonia in infected children.

Geographic disparities in pneumonia-specific under-five mortality rates in Mainland China from 1996 to 2015: a population-based study

OBJECTIVES

This study aimed to investigate the disparities in pneumonia-specific under-five mortality rates (U5MRs) among and within three geographic regions in Mainland China from 1996 to 2015.

METHODS

Data were obtained from the national Under-Five Child Mortality Surveillance System and grouped into 2-year periods. The Cochran-Armitage trend test and Cochran-Mantel-Haenszel test were used to assess trends and differences in the pneumonia-specific U5MRs among and within geographic regions. Relative risks (RRs) and 95% confidence intervals (95% CIs) were calculated.

RESULTS

The pneumonia-specific U5MR decreased by 90.6%, 89.0%, and 83.5% in East, Middle, and West China, respectively, with a larger decrease in rural areas. The pneumonia-specific U5MR was highest in West China, and was 7.2 (95% CI 5.9-8.7) times higher than that in East China in 2014-2015. In 2014-2015, the RRs were 1.7 (95% CI 1.2-2.5), 1.6 (95% CI 1.1-2.1), and 3.4 (95% CI 2.8-4.0) between rural and urban areas in East, Middle, and West China, respectively.

CONCLUSIONS

Pneumonia-specific U5MRs decreased from 1996 to 2015 across China, particularly in rural areas. However, disparities remained among and within geographic regions. Additional strategies and interventions should be introduced in West China, especially the rural areas, to further reduce the pneumonia-specific U5MR.

The impact of pneumococcal conjugate vaccine on community-acquired pneumonia hospitalizations in children with comorbidity

The burden of community-acquired pneumonia (CAP) in high-income countries is still significant. The introduction of pneumococcal conjugate vaccines (PCV) has reduced the overall need for hospitalization for CAP. However, it is not clear whether children with underlying disease also have benefitted from the PCV immunization programme. Children 0 to <5 years of age hospitalized with CAP and discharged with an ICD-10 code of J13-J18.9 between November 1, 2005, and April 30, 2007 (pre-vaccination period), and November 1, 2010, and April 30, 2012 (post-vaccination period), were eligible for this study. Data on hospitalization and discharge diagnoses were retrieved from the Hospital Registry. In addition, chart review was performed in 50% of the patients. Our result confirmed a decrease in hospitalization rate for CAP in the PCV13 period. Chart review revealed that half of the patients had underlying comorbidity and these children had more severe symptoms and required longer hospital stay. Intensive care was provided to less than 10% of the children and mostly for children with an underlying neurological disease.

CONCLUSIONS

We show that all children have benefitted from the reduction of CAP hospitalization after introduction of PCV. Our finding emphasizes the importance of children with chronic diseases receiving adequate vaccinations that may protect from lower respiratory diseases. What is known? • Community-acquired pneumonia is a leading infectious cause of hospitalizations and death among children <5 years of age globally • Pneumococcal conjugate vaccine reduces the hospitalizations of all-cause pneumonia What is new? • We show that also children with underlying comorbidities have benefitted from PCV immunization with a reduction of CAP hospitalization • We show that approximately half of all children hospitalized with CAP also have underlying comorbidities.

Global control of pneumococcal infections by pneumococcal vaccines

Streptococcus pneumoniae is a major worldwide cause of morbidity and mortality. Pneumococcal carriage is considered to be an important source of horizontal spread of this pathogen within the community. Pneumococcal conjugate vaccine (PCV) is capable of inducing serotype-specific antibodies in sera of infants, and has been suggested to reduce nasopharyngeal carriage of vaccine-type pneumococci in children. PCV is generally immunogenic for pediatric patients with invasive pneumococcal disease, with an exception for the infecting serotypes. Based on evidences from the clinical trials of PCV, the health impact of childhood pneumococcal pneumonia appears to be high in developing countries where most of global childhood pneumonia deaths occur. PCV vaccination may prevent hundreds of deaths per 100,000 children vaccinated in developing countries, while PCV vaccination is expected to prevent less than 10 deaths per 100,000 children vaccinated in the developed countries. Therefore, the WHO has proposed a strategy to reduce the incidence of severe pneumonia by 75% in child less than 5 years of age compared to 2010 levels by 2025.

Associations between particulate matter elements and early-life pneumonia in seven birth cohorts: results from the ESCAPE and TRANSPHORM projects

Evidence for a role of long-term particulate matter exposure on acute respiratory infections is growing. However, which components of particulate matter may be causative remains largely unknown. We assessed associations between eight particulate matter elements and early-life pneumonia in seven birth cohort studies (N total=15,980): BAMSE (Sweden), GASPII (Italy), GINIplus and LISAplus (Germany), INMA (Spain), MAAS (United Kingdom) and PIAMA (The Netherlands). Annual average exposure to copper, iron, potassium, nickel, sulfur, silicon, vanadium and zinc, each respectively derived from particles with aerodynamic diameters ≤ 10 μm (PM10) and 2.5 μm (PM2.5), were estimated using standardized land use regression models and assigned to birth addresses. Cohort-specific associations between these exposures and parental reports of physician-diagnosed pneumonia between birth and two years were assessed using logistic regression models adjusted for host and environmental covariates and total PM10 or PM2.5 mass. Combined estimates were calculated using random-effects meta-analysis. There was substantial within and between-cohort variability in element concentrations. In the adjusted meta-analysis, pneumonia was weakly associated with zinc derived from PM10 (OR: 1.47 (95% CI: 0.99, 2.18) per 20 ng/m(3) increase). No other associations with the other elements were consistently observed. The independent effect of particulate matter mass remained after adjustment for element concentrations. In conclusion, associations between particulate matter mass exposure and pneumonia were not explained by the elements we investigated. Zinc from PM10 was the only element which appeared independently associated with a higher risk of early-life pneumonia. As zinc is primarily attributable to non-tailpipe traffic emissions, these results may suggest a potential adverse effect of non-tailpipe emissions on health.

Seventeen-year study shows rise in parapneumonic effusion and empyema with higher treatment failure after chest tube drainage

AIM

To evaluate epidemiology, pre-admission characteristics and management of paediatric parapneumonic effusions (PPEs) and empyema in a tertiary paediatric pulmonary centre between 1993 and 2010.

METHODS

Retrospective chart review study using paediatric and thoracic database searches, with particular emphasis on pre-admission characteristics, disease stage (simple or complex effusion or empyema), general management and surgical procedures.

RESULTS

One hundred children were eligible, exhibiting a significant increase in incidence from 0.5 to 2.6 per 100 000 across the study period. Baseline characteristics were similar across disease stages. Streptococcus pneumoniae was the most common pathogen. Surgical intervention beyond chest tube drainage (CTD) was required in 50%; this rate showed a particular increase in children aged 0-5 years (OR, 3.1), but was otherwise not influenced by baseline characteristics, disease stage or use of intrapleural fibrinolytics. Length of hospitalisation did not differ across disease stages or primary interventional procedures.

CONCLUSION

This study confirmed an increasing incidence of PPEs and empyema in a Scandinavian tertiary paediatric pulmonary centre. Young children exhibited higher treatment failure after CTD. Length of hospitalisation was similar across disease stages and was comparable to previous reports according to primary interventional procedure.