Pneumonia in children admitted to the national referral hospital in Bhutan: A prospective cohort study

Respiratory syncytial virus among hospitalized patients of severe acute respiratory infection in Bhutan: Cross-sectional study

Introduction

Respiratory syncytial virus (RSV) is a leading cause of lower respiratory tract infections worldwide, particularly in young children. In Bhutan, respiratory disease continues to be among the top 10 diseases of morbidity for several years. This study aimed to estimate the prevalence of RSV among hospitalized patients with severe acute respiratory infection (SARI) in Bhutan.

Method

Respiratory specimens were collected from SARI patients of all ages in 2016 and 2018 following influenza surveillance guidelines. Specimens were tested for influenza and RSV, human metapneumovirus, adenovirus, and human parainfluenza virus types 1, 2, and 3 using real-time reverse-transcription polymerase chain reaction assay. Descriptive statistics were used to analyze the result in STATA 16.1.

Result

Of the 1339 SARI specimens tested, 34.8% were positive for at least one viral pathogen. RSV was detected in 18.5% of SARI cases, followed by influenza in 13.4% and other respiratory viruses in 3%. The median age of SARI cases was 3 (IQR: 0.8-21 years) years. RSV detection was higher among children aged 0-6 (Adj OR: 3.03; 95% CI: 1.7-5.39) and 7-23 months (Adj OR: 3.01; 95% CI: 1.77-5.12) compared with the children aged 5-15 years. RSV was also associated with breathing difficulty (Adj OR: 1.73; 95% CI: 1.17-2.56) and pre-existing lung disease, including asthma (Adj OR: 2.78; 95% CI: 0.99-7.8).

Conclusion

Respiratory viruses were detected in a substantial proportion of SARI hospitalizations in Bhutan.

What are the risk factors for death among children with pneumonia in low- and middle-income countries? A systematic review

Background

Knowledge of the risk factors for and causes of treatment failure and mortality in childhood pneumonia is important for prevention, diagnosis, and treatment at an individual and population level. This review aimed to identify the most important risk factors for mortality among children aged under ten years with pneumonia.

Methods

We systematically searched MEDLINE, EMBASE, and PubMed for observational and interventional studies reporting risk factors for mortality in children (aged two months to nine years) in low- and middle-income countries (LMICs). We screened articles according to specified inclusion and exclusion criteria, assessed risk of bias using the EPHPP framework, and extracted data on demographic, clinical, and laboratory risk factors for death. We synthesized data descriptively and using Forest plots and did not attempt meta-analysis due to the heterogeneity in study design, definitions, and populations.

Findings

We included 143 studies in this review. Hypoxaemia (low blood oxygen level), decreased conscious state, severe acute malnutrition, and the presence of an underlying chronic condition were the risk factors most strongly and consistently associated with increased mortality in children with pneumonia. Additional important clinical factors that were associated with mortality in the majority of studies included particular clinical signs (cyanosis, pallor, tachypnoea, chest indrawing, convulsions, diarrhoea), chronic comorbidities (anaemia, HIV infection, congenital heart disease, heart failure), as well as other non-severe forms of malnutrition. Important demographic factors associated with mortality in the majority of studies included age <12 months and inadequate immunisation. Important laboratory and investigation findings associated with mortality in the majority of studies included: confirmed Pneumocystis jirovecii pneumonia (PJP), consolidation on chest x-ray, pleural effusion on chest x-ray, and leukopenia. Several other demographic, clinical and laboratory findings were associated with mortality less consistently or in a small numbers of studies.

Conclusions

Risk assessment for children with pneumonia should include routine evaluation for hypoxaemia (pulse oximetry), decreased conscious state (e.g. AVPU), malnutrition (severe, moderate, and stunting), and the presence of an underlying chronic condition as these are strongly and consistently associated with increased mortality. Other potentially useful risk factors include the presence of pallor or anaemia, chest indrawing, young age (<12 months), inadequate immunisation, and leukopenia.

Performance of host-response biomarkers to risk-stratify children with pneumonia in Bhutan

Pneumonia is the leading cause of post-neonatal death amongst children under five years of age; however, there is no simple triage tool to identify children at risk of progressing to severe and fatal disease. Such a tool could assist for early referral and prioritization of care to improve outcomes and enhance allocation of scarce resources. We compared the performance of inflammatory and endothelial activation markers in addition to clinical signs or scoring scales to risk-stratify children hospitalized with pneumonia at the national referral hospital of Bhutan with the goal of predicting clinical outcome. Of 118 children, 31 evolved to a poor prognosis, defined as either mortality, admission in the paediatric intensive care unit, requirement of chest drainage or requirement of more than five days of oxygen therapy. Soluble triggering receptor expressed on myeloid cells 1 (sTREM-1) was the best performing biomarker and performed better than clinical parameters. sTREM-1 levels upon admission had good predictive accuracy to identify children with pneumonia at risk of poor prognosis. Our findings confirm that immune and endothelial activation markers could be proactively used at first encounter as risk-stratification and clinical decision-making tools in children with pneumonia; however, further external validation is needed.

Aetiology of childhood pneumonia in low- and middle-income countries in the era of vaccination: a systematic review

Background

This systematic review aimed to describe common aetiologies of severe and non-severe community acquired pneumonia among children aged 1 month to 9 years in low- and middle-income countries.

Methods

We searched the MEDLINE, EMBASE, and PubMed online databases for studies published from January 2010 to August 30, 2020. We included studies on acute community-acquired pneumonia or acute lower respiratory tract infection with ≥1 year of continuous data collection; clear consistent case definition for pneumonia; >1 specimen type (except empyema studies where only pleural fluid was required); testing for >1 pathogen including both viruses and bacteria. Two researchers reviewed the studies independently. Results were presented as a narrative summary. Quality of evidence was assessed with the Quality Assessment Tool for Quantitative Studies. The study was registered on PROSPERO [CRD42020206830].

Results

We screened 5184 records; 1305 duplicates were removed. The remaining 3879 titles and abstracts were screened. Of these, 557 articles were identified for full-text review, and 55 met the inclusion criteria - 10 case-control studies, three post-mortem studies, 11 surveillance studies, eight cohort studies, five cross-sectional studies, 12 studies with another design and six studies that included patients with pleural effusions or empyema. Studies which described disease by severity showed higher bacterial detection (Streptococcus pneumoniae, Staphylococcus aureus) in severe vs non-severe cases. The most common virus causing severe disease was respiratory syncytial virus (RSV). Pathogens varied by age, with RSV and adenovirus more common in younger children. Influenza and atypical bacteria were more common in children 5-14 years than younger children. Malnourished and HIV-infected children had higher rates of pneumonia due to bacteria or tuberculosis.

Conclusions

Several viral and bacterial pathogens were identified as important targets for prevention and treatment. Bacterial pathogens remain an important cause of moderate to severe disease, particularly in children with comorbidities despite widespread PCV and Hib vaccination.

Study to evaluate the socio-demographic and environmental factors affecting morbidity and mortality of community acquired pneumonia in children <5years

Aim: To evaluate the socio demographic and environmental factors affecting morbidity and mortality of community acquired pneumonia in children <5years. Materials and methods: The present Observational longitudinal study was carried in the Department of Paediatrics, Dr. D.Y. Patil Medical College, Pune, among 70 children less than 5 years of age admitted in the In-patient department , Neonatal Intensive Care Unit and Paediatric Intensive Care Unit diagnosed as community acquired pneumonia of either sex in the hospital. The study was carried out from may 2019-september 2021. The children who fulfilled the WHO criteria of Community Acquired Pneumonia were in addition to the Chest x-ray and investigations findings suggestive of CAP were enrolled. The details of the patient's personal and demographic profile, clinical presentation, underlying condition, laboratory investigations, therapy and course in the hospital, and the final outcome were all recorded on a pre-designed proforma. Results: Mean age of children presenting with pneumonia (31.92 months) was approximately similar with those presenting with severe pneumonia (30.37 months).

Bacterial etiology of pneumonia in children up to 2 months of age: a systematic review

Background: Following the widespread introduction of childhood pneumococcal conjugate vaccines (PCVs), a significant impact on pneumonia mortality in children under five years of age has been reported. It is still unknown whether PCVs are expected to reduce pneumonia burden in younger children, particularly ≤2 months of age, as current evidence on the role of S. pneumoniae in pneumonia etiology in this age group is scarce. We aimed to summarize the evidence of bacterial etiology of pneumonia in children ≤2 months of age. Methods: We conducted a systematic review considering studies evaluating a variety of syndromes associated with pneumonia, and reporting on laboratory confirmed etiologies, considering any diagnostic method and a variety of clinical specimens.  We searched Medline/PubMed, Embase, WoS, Central and Index Medicus Global published in any language till April 30th, 2021. We included studies addressing the outcomes of interest in children ≤2 months of age and reporting on clinical trials, observational studies, and case series with at least 10 events. Screening of citations and data extraction were conducted in duplicate by independent reviewers, according to the study protocol registered on PROSPERO. Descriptive analyses of the various etiologic agents by syndrome are reported. Results: We identified 3,744 citations, of which 22 publications reporting on 13 studies were included. Study methods varied significantly. Nonetheless, gram positive organisms, in particular S. pneumoniae, were identified as important etiologic agents of pneumonia in children ≤2 months of age. Viral etiologies, in particular Respiratory Syncytial Virus, Rhinovirus, and Influenza were also identified. Conclusions: This review provides the most comprehensive analysis to date of the etiologies of pneumonia in children ≤2 months of age, suggesting that PCV impact is expected to occur in this age group. These results also have major implications for diagnosis and treatment of pneumonia in this age group.

Association of Clinical Signs, Host Biomarkers and Etiology With Radiological Pneumonia in Bhutanese Children

Diagnosing pneumonia and identifying those requiring antibiotherapy remain challenging. Chest radiographs (CXR) are often used as the reference standard. We aimed to describe clinical characteristics, host-response biomarkers and etiology, and assess their relationship to CXR findings in children with pneumonia in Thimphu, Bhutan. Children between 2 and 59 months hospitalized with WHO-defined pneumonia were prospectively enrolled and classified into radiological endpoint and non-endpoint pneumonia. Blood and nasopharyngeal washing were collected for microbiological analyses and plasma levels of 11 host-response biomarkers were measured. Among 149 children with readable CXR, 39 (26.2%) presented with endpoint pneumonia. Identification of respiratory viruses was common, with no significant differences by radiological outcomes. No clinical sign was suggestive of radiological pneumonia, but children with radiological pneumonia presented higher erythrocyte sedimentation rate, C-reactive protein and procalcitonin. Markers of endothelial and immune activation had little accuracy for the reliable identification of radiological pneumonia.

Spatio-temporal patterns of childhood pneumonia in Bhutan: a Bayesian analysis

Pneumonia is one of the top 10 diseases by morbidity in Bhutan. This study aimed to investigate the spatial and temporal trends and risk factors of childhood pneumonia in Bhutan. A multivariable Zero-inflated Poisson regression model using a Bayesian Markov chain Monte Carlo simulation was undertaken to quantify associations of age, sex, altitude, rainfall, maximum temperature and relative humidity with monthly pneumonia incidence and to identify the underlying spatial structure of the data. Overall childhood pneumonia incidence was 143.57 and 10.01 per 1000 persons over 108 months of observation in children aged < 5 years and 5–14 years, respectively. Children < 5 years or male sex were more likely to develop pneumonia than those 5–14 years and females. Each 1 °C increase in maximum temperature was associated with a 1.3% (95% (credible interval [CrI] 1.27%, 1.4%) increase in pneumonia cases. Each 10% increase in relative humidity was associated with a 1.2% (95% CrI 1.1%, 1.4%) reduction in the incidence of pneumonia. Pneumonia decreased by 0.3% (CrI 0.26%, 0.34%) every month. There was no statistical spatial clustering after accounting for the covariates. Seasonality and spatial heterogeneity can partly be explained by the association of pneumonia risk to climatic factors including maximum temperature and relative humidity.

Antibiotic Use and Treatment Outcomes among Children with Community-Acquired Pneumonia Admitted to a Tertiary Care Public Hospital in Nepal

In the era of growing antimicrobial resistance, there is a concern about the effectiveness of first-line antibiotics such as ampicillin in children hospitalized with community-acquired pneumonia. In this study, we describe antibiotic use and treatment outcomes among under-five children with community-acquired pneumonia admitted to a tertiary care public hospital in Nepal from 2017 to 2019. In this cross-sectional study involving secondary analysis of hospital data, there were 659 patients and 30% of them had a history of prehospital antibiotic use. Irrespective of prehospital antibiotic use, ampicillin monotherapy (70%) was the most common first-line treatment provided during hospitalization followed by ceftriaxone monotherapy (12%). The remaining children (18%) were treated with various other antibiotics alone or in combination as first-line treatment. Broad-spectrum antibiotics such as linezolid, vancomycin, and meropenem were used in less than 1% of patients. Overall, 66 (10%) children were required to switch to second-line treatment and only 7 (1%) children were required to switch to third-line treatment. Almost all (99%) children recovered without any sequelae. This study highlights the effectiveness of ampicillin monotherapy in the treatment of community-acquired pneumonia in hospitalized children in a non-intensive care unit setting.

Pneumococcal nasopharyngeal carriage among Bhutanese children hospitalized with clinical pneumonia: serotypes and viral co-infection

BACKGROUND

Pneumococcal nasopharyngeal colonization (PNC) generally precedes pneumococcal disease. The purpose of this study was to determine the prevalence of PNC and to identify the pneumococcal serotypes circulating among Bhutanese children under five years of age admitted with clinical pneumonia, before the introduction of pneumococcal conjugate vaccine (PCV13) in the country. We also aimed to contribute to the understanding of the interplay between PNC and viral co-infection among this population.

METHODS

This was a prospective study conducted at the Jigme Dorji Wangchuck National Referral Hospital in Bhutan over 12 consecutive months. Children aged 2 to 59 months admitted with WHO-defined clinical pneumonia were eligible for recruitment. We collected blood for bacterial culture and molecular identification of S. pneumoniae, and nasopharyngeal washing for screening of respiratory viruses, and for the detection and capsular typing of S. pneumoniae by real-time polymerase chain reaction (RT-PCR).

RESULTS

Overall, 189 children were recruited, and PNC was tested in 121 of them (64.0%). PNC was found in 76/121 children (62.8%) and S. pneumoniae was identified in blood (both by culture and RT-PCR) in a single child. Respiratory viruses were detected in a similar proportion among children with (62/70; 88.6%) and without PNC (36/40; 90.0%; p = 1.000), but rhinovirus detection was less common among children with PNC (20/70; 28.6% versus 19/40; 47.5%; p = 0.046). Capsular typing identified 30 different serotypes. Thirty-nine children (51.3%) were colonised with two to five different serotypes. A third of the children presented with serotypes considered highly invasive. Over half of the children (44/76; 57.9%) were carrying at least one serotype included in PCV13.

CONCLUSIONS

This study provides baseline information on the status of PNC among Bhutanese children admitted with clinical pneumonia prior to the introduction of PCV13, which is valuable to monitor its potential impact. PCV13 could theoretically have averted up to 58% of the pneumococcal infections among the children in this study, suggesting a future role for the vaccine to significantly reduce the burden associated with S. pneumoniae in Bhutan.

Challenges in the prevention or treatment of RSV with emerging new agents in children from low- and middle-income countries

INTRODUCTION

Respiratory syncytial virus (RSV) causes approximately 120,000 deaths annually in children <5 years, with 99% of fatalities occurring in low- and middle-income countries (LMICs).

AREAS COVERED

There are numerous RSV interventions in development, including long-acting monoclonal antibodies, vaccines (maternal and child) and treatments which are expected to become available soon. We reviewed the key challenges and issues that need to be addressed to maximize the impact of these interventions in LMICs. The epidemiology of RSV in LMICs was reviewed (PubMed search to 30 June 2020 inclusive) and the need for more and better-quality data, encompassing hospital admissions, community contacts, and longer-term respiratory morbidity, emphasized. The requirement for an agreed clinical definition of RSV lower respiratory tract infection was proposed. The pros and cons of the new RSV interventions are reviewed from the perspective of LMICs.

EXPERT OPINION

We believe that a vaccine (or combination of vaccines, if practicable) is the only viable solution to the burden of RSV in LMICs. A coordinated program, analogous to that with polio, involving governments, non-governmental organizations, the World Health Organization, the manufacturers and the healthcare community is required to realize the full potential of vaccine(s) and end the devastation of RSV in LMICs.

Incidence and Risk Factors for Severe Pneumonia in Children Hospitalized with Pneumonia in Ujjain, India

Childhood pneumonia is a major public health problem. The aim of this prospective hospital-based study is to determine the incidence and risk factors for community-acquired severe pneumonia in children in Ujjain, India. The study includes 270 children, 161 (60%) boys and 109 (40%) girls, aged between 2 months and 5 years with World Health Organization defined and radiologically confirmed severe pneumonia. Considering the 270 children, 64% (95% confidence interval (CI) 57.9–69.4) have severe pneumonia. The following are identified as risk factors for severe pneumonia from the generalized logistic regression model: Born premature (adjusted odds ratio (AOR) 7.50; 95% CI 2.22–25.31; p = 0.001); history of measles (AOR 6.35; 95% CI 1.73–23.30; p = 0.005); incomplete vaccination (AOR 2.66; 95% CI 1.09–6.48; p = 0.031); acyanotic congenital heart disease (AOR 9.21; 95% CI 2.29–36.99; p = 0.002); home treatment tried (AOR 3.84; 95% CI 1.42–10.39; p = 0.008); living in a kuchha house (AOR 3.89; 95% CI 1.51–10.01; p = 0.027); overcrowding (AOR 4.50; 95% CI 1.75–11.51; p = 0.002);poor ventilation in living area (AOR 16.37; 95% CI 4.67–57.38; p < 0.001); and practicing open defecation (AOR 16.92; 95% CI 4.95–57.85; p < 0.001). Awareness of these risk factors can reduce mortality due to severe pneumonia.