Pneumonia mortality and healthcare utilization in young children in rural Bangladesh: a prospective verbal autopsy study

Determinants of care-seeking for ARI/Pneumonia-like symptoms among under-2 children in urban slums in and around Dhaka City, Bangladesh

Childhood pneumonia affects an estimated 18% of under-five children in Bangladesh. Urban slum-dwellers face challenges in healthcare-seeking. This study examined the factors influencing the healthcare-seeking for childhood pneumonia among under-two children in urban slums in Bangladesh. The study examined influence of children's characteristics (age, sex, number of ARI/pneumonia symptoms, and duration of symptoms), maternal factors (age, education, and working status), and household characteristics (number of household members, wealth quintile, sex of household heads, age of household heads). The outcome variable was receiving care from a qualified medical provider for childhood pneumonia or pneumonia-like symptoms within 14 days before the collection of surveillance data. The research utilized data from the Urban Health and Demographic Surveillance System, which included 155,000 people from five slums in Dhaka and Gazipur City Corporation areas. Overall, 753 out of 4,679 (16%) children under two years of age were included in this study, all of whom had ARI/pneumonia-like symptoms. The mean age of these children was 11.4 months, and 50% were boys. Of them, 350 (46%) sought care from local pharmacies, while 37% sought care from medically trained providers. Logistic regression analyses indicated that children with multiple symptoms (AOR: 2.32, 95% CI: 1.71-3.14) and illness duration over seven days (AOR: 2.61, 95% CI: 1.51-4.51) had higher odds of receiving care from a medically trained provider. Higher maternal education compared to no formal education, having five or more household members compared to four or fewer, household heads aged 40-49 years compared to those under 25 years, a longer duration of living in the slum (more than 10 years compared to less than five years), and belonging to the richest wealth quintile compared to the poorest were protective factors for care-seeking from qualified providers. Further research is required to understand the context for designing appropriate interventions and comprehensive policies for improved child health regarding ARI/pneumonia-like symptoms.

Predicting Escalation of Care for Childhood Pneumonia Using Machine Learning: Retrospective Analysis and Model Development

Background

Pneumonia is a leading cause of mortality in children aged <5 years. While machine learning (ML) has been applied to pneumonia diagnostics, few studies have focused on predicting the need for escalation of care in pediatric cases. This study aims to develop an ML-based clinical decision support tool for predicting the need for escalation of care in community-acquired pneumonia cases.

Objective

The primary objective was to develop a robust predictive tool to help primary care physicians determine where and how a case should be managed.

Methods

Data from 437 children with community-acquired pneumonia, collected before the COVID-19 pandemic, were retrospectively analyzed. Pediatricians encoded key clinical features from unstructured medical records based on Integrated Management of Childhood Illness guidelines. After preprocessing with Synthetic Minority Oversampling Technique-Tomek to handle imbalanced data, feature selection was performed using Shapley additive explanations values. The model was optimized through hyperparameter tuning and ensembling. The primary outcome was the level of care severity, defined as the need for referral to a tertiary care unit for intensive care or respiratory support.

Results

A total of 437 cases were analyzed, and the optimized models predicted the need for transfer to a higher level of care with an accuracy of 77% to 88%, achieving an area under the receiver operator characteristic curve of 0.88 and an area under the precision-recall curve of 0.96. Shapley additive explanations value analysis identified hypoxia, respiratory distress, age, weight-for-age z score, and complaint duration as the most important clinical predictors independent of laboratory diagnostics.

Conclusions

This study demonstrates the feasibility of applying ML techniques to create a prognostic care decision tool for childhood pneumonia. It provides early identification of cases requiring escalation of care by combining foundational clinical skills with data science methods.

Mothers' experience of losing infants by death and its predictors in Ethiopia

BACKGROUND

Although infant deaths worldwide have reduced, many children die before their first birthday. Infant deaths are widespread in low-income countries, and information about the cause of death is limited. In Ethiopia, 53% of infants' deaths occurred in their neonatal period, and 174 infants' deaths occurred from 3684 births. Hence, this study aimed to assess mothers' experiences with infant death and its predictors in Ethiopia.

METHODS

A total of 1730 weighted samples of mothers from the 2019 EDHS dataset, which was collected across the regions of Ethiopia, were included for analysis. A two-stage cluster sampling technique with a cross-sectional study design was used. All mothers whose children were under the age of 0-12 months were included in this study. Six count regression models were considered and compared using Akaike's information criteria and Bayesian information criterion with STATA version 15 software. The strength of the association between the number of infant deaths and possible predictors was determined at a P-value less than 0.05, with a 95% confidence interval. The findings were interpreted by using the incident rate ratio.

RESULTS

A total of 46.3% of mothers had lost at least one infant by death in the last five years before the 2019 EDHS survey was held. The mean and variance of infant deaths were 2.55 and 5.58, respectively. The histogram was extremely picked at the beginning, indicating that a large number of mothers did not lose their infants by death, and that shows the data had positive skewness. Mothers under 25-29 years of age (IRR: 1.75, 95% CI:1.48, 2.24), and 30-34 years of age (IRR: 1.42, 95% CI: 1.12, 2.82), Somali (IRR: 1.47, 95% CI: 1.02, 3.57), Gambela (IRR: 1.33, 95% CI: 1.10, 2.61), and Harari (IRR: 1.39, 95% CI: 1.02, 2.63) regions, rural resident mothers (IRR: 1.68, 95% CI: 1.09, 1.91, and Protestant (IRR = 1.43, 95% CI: 1.14, 2.96), and Muslim (IRR = 1.59, 95% CI: 1.07, 2.62) religion fellow of mothers were associated with a high risk of infants' deaths. Whereas, being rich IRR: 0.37, 95% CI: .27, .81) and adequate ANC visits (IRR: 0.28, 95% CI: .25, .83) were associated with a low risk of infant death.

CONCLUSION

Many mothers have experienced infant deaths, and the majority of infants' deaths occur after the first month of birth. Encouraging mothers to attend antenatal care visits, creating mothers' awareness about childcare, and ensuring equal health services distribution and utilization to rural residents are essential to minimize infant death. Educating lower-aged reproductive mothers would be a necessary intervention to prevent and control infant deaths.

Factors associated with acute respiratory infection and healthcare-seeking behaviour among primary caregivers in Bangladesh: a study based on MICS 2019

Introduction

More than 80% of deaths due to preventable and treatable causes among under 5 (U5) children occur in the sub-Saharan Africa and the South-Asia, pneumonia remains one of the most common such causes. Bangladesh has demonstrated success in achieving the Millennium Development Goals, particularly in relation to target 4. Nevertheless, the country is still among the 10 countries with the highest number of deaths among U5 children in 2019. The current study aimed to identify factors associated with acute respiratory infections (ARIs) and the care-seeking behaviour of the children's care takes in Bangladesh.

Methods

The cross-sectional study used data from the Multiple Indicator Cluster Survey, Bangladesh (2019) . U5 children were included in the analysis (n=22 779). A p<0.05 as considered statistically.

Results

The prevalence of ARI in the past 2 weeks of survey was 2.03%. It was found that age of the child (in months), sex, residence, division, stunting, age of the mother and age of the father had statistically significant association (p<0.05). The adjusted odds ratio (AOR) of ARI were lower among older children aged 24-59 months (AOR 0.53; 95% CI 0.44 to 0.64; p<0.001), female (AOR 0.68; 95% CI 0.56 to 0.83; p<0.001) and children with father aged ≥25 years (AOR 0.61; 95% CI 0.42 to 0.88; p=0.008) and higher (AOR 1.31; 95% CI 1.07 to 1.61; p=0.010) among children with stunting. Among the children with ARI, 16.63% primary caregivers did not seek any treatment. Most of the children with ARI (65.01%) were treated with antibiotics.

Conclusions

The prevalence of ARI was low. However, still a significant proportion of primary caregivers of U5 children with ARI fail to seek healthcare. The proportion of U5 children who are treated with antibiotics requires attention. Focus should be on younger fathers for promoting healthcare-seeking and good feeding practice to reduce malnutrition.

Treatment outcome of pneumonia and its associated factors among pediatric patients admitted to Hiwot Fana Comprehensive Specialized University Hospital, Eastern Ethiopia

Background

Pneumonia is the leading cause of morbidity and mortality among children worldwide. Despite its substantial impact, there exists a dearth of evidence regarding treatment outcomes and related factors, particularly within the Ethiopian context. This study endeavors to address these critical gaps by examining the treatment outcome of pneumonia among pediatric patients hospitalized in the Hiwot Fana Comprehensive Specialized University Hospital.

Method

A facility-based cross-sectional study was conducted on 204 children (≤14 years of age) diagnosed with pneumonia and admitted to the Hiwot Fana Comprehensive Specialized University Hospital. An interview using a structured questionnaire accompanied by a review of medical records was used to collect data from the parents/guardians. A binary logistic regression model with an adjusted odds ratio (AOR) and a 95% confidence interval (CI) was used to identify the associated factors with the outcome variable. Statistical significance was set at P < 0.05 in the multivariable analysis.

Result

Among the 204 children (≤14 years) included in the study, 119 (93.6%, 95% CI: 90.2-96.9) patients with pneumonia survived whereas 13 (6.4%, 95% CI: 3.1-9.7) died. Multivariable logistic regression analysis, after adjustments for potential confounders, revealed that children who had malnutrition (AOR = 3.5, 95% CI: 2.37-12.44), were unvaccinated (AOR =  3.41, 95% CI: 2.25-11.87), had altered mental states during admission (AOR = 4.49, 95% CI: 2.28-17.85), and had complicated types of pneumonia (AOR = 5.70, 95% CI: 2.98-15.09) were independently associated with mortality.

Conclusion

Poor treatment outcome was 6.4% among pediatric patients admitted with pneumonia in this study setting. Being unvaccinated, malnourished, and admitted with a complicated type of pneumonia as well as having altered consciousness at the time of admission were significantly associated with poor treatment outcomes. These findings underscore the critical need to prioritize preventative measures against malnutrition and unvaccinated status in children. Early identification of such children and proper interventions are imperative to reducing such outcomes, particularly in resource-constrained settings.

High-flow nasal oxygen in infants and children for early respiratory management of pneumonia-induced acute hypoxemic respiratory failure: the CENTURI randomized clinical trial

Objective

To compare the effectiveness of early high-flow nasal cannula (HFNC) and low-flow oxygen support (LFOS) in children under 5 years with acute hypoxemic respiratory failure (AHRF) due to severe community-acquired pneumonia in low-middle-income countries.

Methods

An open-label randomized clinical trial enrolled children aged 2-59 months with AHRF due to severe community-acquired pneumonia and randomized into HFNC and LFOS. In the LFOS group, the patient received cold wall oxygen humidified by bubbling through sterile water administered through simple nasal prongs at a fixed flow rate of 2 L/min. In the HFNC group, the patient received humidified, heated (37 °C), high-flow oxygen at a flow rate assigned based on weight range, with a titratable oxygen fraction. The primary outcome was treatment failure in 72 h (escalating the respiratory support method using any modality other than primary intervention).

Results

Data was analyzed intention-to-treat (HFNC = 124; LFOS = 120). Median (IQR) age was 12 (6-20) and 11 (6-27) months, respectively. Treatment failure occurred in a significantly lower proportion in the HFNC group (7.3%, n = 9/124) as compared to the LFOS group (20%, n = 24/120) (relative risk = 0.36, 95% CI 0.18 to 0.75; p = 0.004; adjusted hazard ratio 0.34, 95% CI 0.16 to 0.73; p = 0.006). The intubation rate was significantly lower in the HFNC group (7.3%, n = 9/124 vs. 16.7%, n = 20/120; relative risk = 0.44, 95% CI 0.21 to 0.92, p = 0.023). There were no significant differences noted in other secondary outcomes. No mortality occurred.

Conclusion

High-flow nasal cannula oxygen therapy used as early respiratory support in children under 5 years with acute hypoxemic respiratory failure due to severe community-acquired pneumonia was associated with significantly lower treatment failure compared with standard low-flow oxygen support.

Trial registration

CTRI/2016/04/006788. Registered 01 April 2016, https://ctri.nic.in/Clinicaltrials/advsearch.php.

Supplementary Information

The online version contains supplementary material available at 10.1007/s44253-024-00031-8.

Delay in healthcare seeking for young children with severe pneumonia at Mulago National Referral Hospital, Uganda: A mixed methods cross-sectional study

BACKGROUND

Globally, pneumonia is the leading infectious cause of under-five mortality, and this can be reduced by prompt healthcare seeking. Data on factors associated with delays in seeking care for children with pneumonia in Uganda is scarce.

OBJECTIVES

The study aimed to determine the prevalence, factors associated with delay, barriers, and facilitators of prompt healthcare seeking for children under five years of age with severe pneumonia attending Mulago National Referral Hospital (MNRH) Uganda.

METHODS

A mixed methods cross-sectional study was conducted among 384 caregivers of children with severe pneumonia at MNRH. Quantitative data was collected using interviewer-administered structured questionnaires and qualitative data through focus group discussions with caregivers. Descriptive statistics were used to determine the prevalence of delay in care seeking. Logistic regression analysis was used to determine the factors that were independently associated with delay in seeking healthcare. Content thematic analysis was used to analyze for barriers and facilitators of prompt healthcare seeking.

RESULTS

The prevalence of delay in seeking healthcare was 53.6% (95% CI: 48.6-58.6). Long distance to a hospital (AOR = 1.94, 95% CI 1.22-3.01, p value = 0.003), first seeking care elsewhere (AOR = 3.33, 95% CI 1.85-6.01, p value = 0.001), and monthly income ≤100,000 UGX (28 USD) (AOR = 2.27,95% CI 1.33-3.86, p value = 0.003) were independently associated with delay in seeking healthcare. Limited knowledge of symptoms, delayed referrals, self-medication, and low level of education were barriers to prompt healthcare seeking while recognition of symptoms of severe illness in the child, support from spouses, and availability of money for transport were key facilitators of early healthcare seeking.

CONCLUSION

This study showed that more than half of the caregivers delayed seeking healthcare for their children with pneumonia symptoms. Caregivers who first sought care elsewhere, lived more than 5 km from the hospital, and earned less than 28 USD per month were more likely to delay seeking healthcare for their children with severe pneumonia. Limited knowledge of symptoms of pneumonia, self-medication, and delayed referral hindered prompt care-seeking. Key facilitators of prompt care-seeking were accessibility to health workers, support from spouses, and recognition of symptoms of severe illness in children. There is a need for programs that educate caregivers about pneumonia symptoms, in children less than five years.

Predicting Mortality and Use of RISC Scoring System in Hospitalized Under-Five Children Due to WHO Defined Severe Community Acquired Pneumonia

BACKGROUND

Pneumonia acquired in the community is a leading cause of hospitalization and death in under-five children. Predicting mortality in children remains a challenge. There is a need of consolidated scoring system to predict mortality in under-five children in developing nations.

METHODS

This is a hospital-based prospective nested case-control study, conducted in a tertiary care teaching hospital of north India. Included were under-five hospitalized children due to WHO defined severe community acquired pneumonia (CAP). Those who did not survive were categorized as cases, while those who were discharged were categorized as controls.

RESULTS

The mortality rate among the recruited 180 hospitalized children with severe CAP was 9.4%. The mortality in under-five children was higher among infants, children who resided in rural areas and were unimmunized or partially immunized for the present age. Mortality was also statistically significantly higher among under-five children with weight for age and weight for length/height below -2Z score; SpO2 < 90% at room air at admission, cyanosis, convulsion, high C-reactive protein (CRP), blood culture positive sepsis and end point consolidation. These predictors were found to be independent risk factors for the mortality after analyzing in multivariate model while presence of wheeze and exclusive breast feeding for first six months of life were found to be protective. The receiver operating characteristic (ROC) curve for respiratory index of severity in children (RISC) score has area under curve (AUC) 0.91 while AUC of RISC score with King George's Medical University (KGMU) modification has 0.88 for prediction of mortality. At the cut-off level of 3, the sensitivity of the RISC score in predicting mortality was 94.1% while the specificity was 73.6%. However, the sensitivity of the RISC score with KGMU modification in predicting mortality at cut-off level of 3 was 88.4% with a specificity of 74.8%.

CONCLUSION

Various predictors for mortality under-five children are young age, malnutrition, cyanosis, high CRP, blood culture positive sepsis and end point consolidation. It is also possible to predict mortality using RISC score which comprises simple variables and can be easily used at centers of periphery. Similar accuracy had been also found through the use of an age independent modified score (RISC score with KGMU modification).Lay summaryPneumonia is a primary cause of hospitalization as well as death among the children under the age of five. A variety of severity or mortality predicting scores have been produced for adults, but such scores for children are scarce. Furthermore, their utility in developing nations has not been proven. This is a hospital-based prospective study. Included were children under five (2 to 59 months) hospitalized due to severe community acquired pneumonia (CAP) defined as per World Health Organization (WHO) and were not hospitalized in last 14 days elsewhere. Those who did not survive were classified as cases while those who were discharged were classified as controls. A total of 200 consecutively hospitalized children with severe CAP based on WHO were screened and 180 children were recruited. Among recruited children, the percentage of mortality was 9.4% while 90.6% were discharged. The mortality was higher among children younger than 12 months, those belonged to rural area and were unimmunized or partially immunized for the present age. Mortality was also higher among under-five children with severe malnutrition, anemia, SpO2 < 90% at room air at admission, cyanosis, convulsion, thrombocytopenia, high CRP, blood culture positive sepsis and end point consolidation. After assessing in a multivariate model, these predictors were determined to be independent risk factor for death, while wheezing and exclusive breast feeding throughout the first six months of life were found to be protective. The receiver operating characteristic (ROC) curve for respiratory index of severity in children (RISC) score has an area under curve (AUC) of 0.91 while AUC of RISC score with King George's Medical University (KGMU) modification was 0.88 for the prediction of death in under-five children hospitalized due to severe CAP.

Barriers to seeking timely treatment for severe childhood pneumonia in rural Bangladesh

OBJECTIVE

Delays in seeking medical attention for childhood pneumonia may lead to increased morbidity and mortality. This study aimed at identifying the drivers of delayed seeking of treatment for severe childhood pneumonia in rural Bangladesh.

METHODS

We conducted a formative study from June to September 2015 in one northern district of Bangladesh. In-depth interviews were conducted with 20 rural mothers of children under 5 years with moderate or severe pneumonia. We analysed the data thematically.

RESULTS

We found that mothers often failed to assess severity of pneumonia accurately due to lack of knowledge or misperception about symptoms of pneumonia. Several factors delayed timely steps that could lead to initiation of appropriate treatment. They included time lost in consultation with non-formal practitioners, social norms that required mothers to seek permission from male household heads (eg, husbands) before they could seek healthcare for their children, avoiding community-based public health centres due to their irregular schedules, lack of medical supplies, shortage of hospital beds and long distance of secondary or tertiary hospitals from households. Financial hardships and inability to identify a substitute caregiver for other children at home while the mother accompanied the sick child in hospital were other factors.

CONCLUSIONS

This study identified key social, economic and infrastructural factors that lead to delayed treatment for childhood pneumonia in the study district in rural Bangladesh. Interventions that inform mothers and empower women in the decision to seek healthcare, as well as improvement of infrastructure at the facility level could lead to improved behaviour in seeking and getting treatment of childhood pneumonia in rural Bangladesh.

Healthcare Seeking and Access to Care for Pneumonia, Sepsis, Meningitis, and Malaria in Rural Gambia

Children with acute infectious diseases may not present to health facilities, particularly in low-income countries. We investigated healthcare seeking using a cross-sectional community survey, health facility-based exit interviews, and interviews with customers of private pharmacies in 2014 in Upper River Region (URR) The Gambia, within the Basse Health & Demographic Surveillance System. We estimated access to care using surveillance data from 2008 to 2017 calculating disease incidence versus distance to the nearest health facility. In the facility-based survey, children and adult patients sought care initially at a pharmacy (27.9% and 16.7% respectively), from a relative (23.1% and 28.6%), at a local shop or market (13.5% and 16.7%), and on less than 5% of occasions with a community-based health worker, private clinic, or traditional healer. In the community survey, recent symptoms of pneumonia or sepsis (15% and 1.5%) or malaria (10% and 4.6%) were common in children and adults. Rates of reported healthcare-seeking were high with families of children favoring health facilities and adults favoring pharmacies. In the pharmacy survey, 47.2% of children and 30.4% of adults had sought care from health facilities before visiting the pharmacy. Incidence of childhood disease declined with increasing distance of the household from the nearest health facility with access to care ratios of 0.75 for outpatient pneumonia, 0.82 for hospitalized pneumonia, 0.87 for bacterial sepsis, and 0.92 for bacterial meningitis. In rural Gambia, patients frequently seek initial care at pharmacies and informal drug-sellers rather than community-based health workers. Surveillance underestimates disease incidence by 8-25%.

Impact of pulse oximetry on hospital referral acceptance in children under 5 with severe pneumonia in rural Pakistan (district Jamshoro): protocol for a cluster randomised trial

BACKGROUND

Pneumonia is a leading cause of death among children under 5 specifically in South Asia and sub-Saharan Africa. Hypoxaemia is a life-threatening complication among children under 5 with pneumonia. Hypoxaemia increases risk of mortality by 4.3 times in children with pneumonia than those without hypoxaemia. Prevalence of hypoxaemia varies with geography, altitude and severity (9%-39% Asia, 3%-10% African countries). In this protocol paper, we describe research methods for assessing impact of Lady Health Workers (LHWs) identifying hypoxaemia in children with signs of pneumonia during household visits on acceptance of hospital referral in district Jamshoro, Sindh.

METHODS AND ANALYSIS

A cluster randomised controlled trial using pulse oximetry as intervention for children with severe pneumonia will be conducted in community settings. Children aged 0-59 months with signs of severe pneumonia will be recruited by LHWs during routine visits in both intervention and control arms after consent. Severe pneumonia will be defined as fast breathing and/or chest in-drawing, and, one or more danger sign and/or hypoxaemia (Sa02 <92%) in PO (intervention) group and fast breathing and/or chest in-drawing and one or more danger sign in clinical signs (control) group. Recruits in both groups will receive a stat dose of oral amoxicillin and referral to designated tertiary health facility. Analysis of variance will be used to compare baseline referral acceptance in both groups with that at end of study.

ETHICS AND DISSEMINATION

Ethical approval was granted by the Ethics Review Committee of the Aga Khan University (4722-Ped-ERC-17), Karachi. Study results will be shared with relevant government and non-governmental organisations, presented at national and international research conferences and published in international peer-reviewed scientific journals.

TRIAL REGISTRATION NUMBER

NCT03588377.

Community-based amoxicillin treatment for fast breathing pneumonia in young infants 7-59 days old: a cluster randomised trial in rural Bangladesh, Ethiopia, India and Malawi

INTRODUCTION

Young infants 7-59 days old with fast breathing pneumonia presented to a primary level health facility receive a 7-day course of amoxicillin as per the WHO guideline. However, community-level health workers (CLHW) are not allowed to treat these infants. This trial evaluated the community level treatment of non-hypoxaemic young infants with fast breathing pneumonia by CLHWs.

METHODS

This cluster-randomised, open-label, non-inferiority trial was conducted in rural areas of Bangladesh, Ethiopia, India and Malawi. We randomly allocated clusters (first-level health facility) 1:1, stratified by the population size, to an intervention group (enhanced community case management) or control group (standard community case management). Infants aged 7-59 days with a respiratory rate of ≥60 breaths/min and oxygen saturation (SpO2) ≥90% were enrolled. In the intervention clusters, these infants were treated with a 7-day course of oral amoxicillin (according to WHO weight bands) and were regularly followed up by CLHWs. In the control clusters, CLHWs continued the standard management (assess and refer after pre-referral antibiotic dose) and followed up according to the national programme guideline. The primary outcome of treatment failure was assessed in both groups by independent outcome assessors on days 6 and 14 after enrolment. Secondary outcomes (accuracy and impact of pulse oximetry) were also assessed.

RESULTS

Between September 2016 and December 2018, we enrolled 2334 infants (1168 in intervention and 1166 in control clusters) from 208 clusters (104 intervention and 104 control). Of 2334, 22 infants with fast breathing were excluded from analysis, leaving 2312 (1155 in intervention clusters and 1157 in control clusters) for intention-to-treat analysis. The proportion of treatment failure was 5.4% (63/1155) in intervention and 6.3% (73/1157) in the control clusters, including two deaths (0.2%) in each group. The adjusted risk difference for treatment failure between the two groups was -1.0% (95% CI -3.0% to 1.1%). The secondary outcome showed that CLHWs in the intervention clusters performed all recommended steps of pulse oximetry assessment in 94% (1050/1115) of enrolled patients.

CONCLUSIONS

The 7-day amoxicillin treatment for 7-59 days old non-hypoxaemic infants with fast breathing pneumonia by CLHWs was non-inferior to the currently recommended referral strategy.

TRIAL REGISTRATION NUMBERS

CTRI/2017/02/007761 and ACTRN12617000857303.

Prevalence, risk factors and outcome of Mycoplasma pneumoniae infection among children in Uganda: a prospective study

BACKGROUND

: Atypical bacteria cause 10-40% of all childhood pneumonia.. Data on the burden of atypical pneumonia in sub-Saharan Africa are limited.

AIM

: To determine the prevalence, associated factors, and outcome of Mycoplasma pneumoniae infection in children with respiratory symptoms at Mulago National Referral Hospital, Kampala.

METHODS

: Children aged 2 months to 12 years with cough and/or difficult breathing and fast breathing were recruited. A clinical history and physical examination were undertaken. Blood samples for Mycoplasma pneumoniae IgM antibodies were taken at enrolment and Day 21 and induced sputum for DNA-PCR. Admitted participants were followed for a maximum of 7 days or until discharge or death, whichever came first.

RESULTS

: A total of 385 children were enrolled, and, of these, 368 (95.6%) were <5 years. Overall, 60/385 (15.6%) participants tested positive for M. pneumoniae IgM and/or DNA-PCR. Of these, 56/60 (93.3%) were <5 years of age. Wheezing was present in 21/60 (35.0%) of the children with atypical pneumonia and in 128/325 (39.4%) with typical pneumonia. The factors associated with M. pneumonia were female sex (AOR 1.94, 95% CI 1.22-3.08, p < 0.001), age ≥12 months (AOR 2.73, 95% CI 1.53-4.87, p = 0.01) and a history of prematurity (AOR 2.07, 95% CI 1.23-3.49, p = 0.01). Mortality was 17/352 (4.8%) and, of these, 4/17 (23.5%) had M. pneumonia.

CONCLUSION

: M. pneumonia is common in young children , especially females above 2 years and those with history of prematurity. It presents with severe symptoms. The results of the study highlight the importance of considering atypical bacteria in under-5s with the symptoms of pneumonia.

Sensitivity Patterns of Bacterial Pathogens Isolated from Blood Cultures of Under-Five Children with Pneumonia and Clinical Sepsis

Treatment options for pneumonia and sepsis by antibiotics are limited due to the development of multidrug-resistant bacterial strains. This unmatched case-control study determined the antibiotic sensitivity against bacterial isolates obtained from septic and nonseptic children with pneumonia. Children of either sex aged 0–59 months with a history of cough or shortness of breath and radiologically confirmed pneumonia were enrolled in this study. Cases with clinical signs of sepsis at admission (n = 151) were compared to cases without sepsis as controls (n = 107). A total of 205 children had a performance of blood culture, with 123 children suffering from clinical sepsis. Blood cultures showed bacterial growth in 19% of the septic samples, with 8% coagulase-negative staphylococci and 2.4% Acinetobacter species. Only 1.6% of the cases were infected by Streptococcus pneumonia, Haemophilus influenzae, Salmonella typhi and Klebsiella. In contrast, children without sepsis presented positive blood cultures with growth of Salmonella typhi in 2.4% of the cases and growth of Klebsiella in 1.2%. Bacteria were sensitive to imipenem in 100% of the cases (86% for meropenem, 83% for ceftazidime and 76% for ciprofloxacin). The mortality rate was significantly higher in children with pneumonia complicated by sepsis (odds ratio (OR) = 3.02, 95% confidence interval (CI), 1.11–8.64, p < 0.027). Knowledge about specific laboratory characteristics in children with pneumonia will facilitate an early diagnosis and treatment of sepsis and reduce mortality.

Estimating causes of out-of-hospital deaths in China: application of SmartVA methods

Background

Most deaths in China occur at home, making it difficult to collect reliable cause of death (CoD) information. Verbal autopsy (VA) was applied using the SmartVA tool to a sample of home deaths in China to explore its feasibility as a means of improving the quality of CoD data.

Methods

The study was carried out in 22 districts in 9 provinces, located in north-east, central, and western areas of China during 2017 and 2018. Trained interviewers selected suitable respondents in each household to collect information using the Population Health Metrics Research Consortium (PHMRC) shortened and validated electronic VA questionnaire on tablets. The CoD was diagnosed from the interview data using the SmartVA-Analyze 2.0 software (Tariff 2.0).

Results

Non-communicable diseases (NCDs) dominated the leading causes of death in all age groups and for both sexes. After redistribution of undetermined causes, stroke (24%), ischemic heart diseases (IHD) (21%), chronic respiratory diseases (11%), and lung cancer (6%) were the leading causes of death. The cause fractions for level-one cause categories and ranking of specific causes were similar between SmartVA and results from the Global Burden of Disease (GBD) study.

Conclusion

Evidence from this large pilot study suggests that SmartVA is a feasible and plausible tool and could be a valuable tool to improve the quality and standardization of CoD information across China.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12963-021-00256-1.

The epidemiology of hospital death following pediatric severe community acquired pneumonia

BACKGROUND

Community acquired pneumonia is the primary cause of pediatric hospitalizations and deaths in children under 5 years of age. But the epidemiology of death in pediatric severe community acquired pneumonia was not well characterized.

METHODS

This retrospective observational study was performed at the academic Emergency department and intensive care unit and we investigated the timing, cause, mode and attribution of death in children with severe community acquired pneumonia.

RESULTS

Of 962 subjects with severe community acquired pneumonia, there were 57 non-survivors (5.9% mortality). Median time to death was 7 [IQR 3,16] days from severe community acquired pneumonia recognition. Patients dying ≤7 days were younger, had greater illness severity and higher rate of congenital heart disease, who were more likely to die of a cardiovascular cause. Multiple organ dysfunction syndrome predominated in deaths > 7 days. Unsuccessful cardiopulmonary resuscitation was the most common mode of death at all timepoints. Our findings suggested that in pediatric severe community acquired pneumonia, early deaths were due primarily to cardiovascular dysfunction, while later deaths were more commonly due to multiple organ dysfunction syndrome.

CONCLUSIONS

Deaths from non-pulmonary factors accounted for a substantial portion of non-survivors. Respiratory dysfunction accounted for only a minority of deaths. Our study highlighted limitations associated with rescuing patients with severe pneumonia from death if extrapulmonary organ dysfunctions could not be simultaneously managed.

Global burden of acute lower respiratory infection associated with human metapneumovirus in children under 5 years in 2018: a systematic review and modelling study

BACKGROUND

Human metapneumovirus is a common virus associated with acute lower respiratory infections (ALRIs) in children. No global burden estimates are available for ALRIs associated with human metapneumovirus in children, and no licensed vaccines or drugs exist for human metapneumovirus infections. We aimed to estimate the age-stratified human metapneumovirus-associated ALRI global incidence, hospital admissions, and mortality burden in children younger than 5 years.

METHODS

We estimated the global burden of human metapneumovirus-associated ALRIs in children younger than 5 years from a systematic review of 119 studies published between Jan 1, 2001, and Dec 31, 2019, and a further 40 high quality unpublished studies. We assessed risk of bias using a modified Newcastle-Ottawa Scale. We estimated incidence, hospital admission rates, and in-hospital case-fatality ratios (hCFRs) of human metapneumovirus-associated ALRI using a generalised linear mixed model. We applied incidence and hospital admission rates of human metapneumovirus-associated ALRI to population estimates to yield the morbidity burden estimates by age bands and World Bank income levels. We also estimated human metapneumovirus-associated ALRI in-hospital deaths and overall human metapneumovirus-associated ALRI deaths (both in-hospital and non-hospital deaths). Additionally, we estimated human metapneumovirus-attributable ALRI cases, hospital admissions, and deaths by combining human metapneumovirus-associated burden estimates and attributable fractions of human metapneumovirus in laboratory-confirmed human metapneumovirus cases and deaths.

FINDINGS

In 2018, among children younger than 5 years globally, there were an estimated 14·2 million human metapneumovirus-associated ALRI cases (uncertainty range [UR] 10·2 million to 20·1 million), 643 000 human metapneumovirus-associated hospital admissions (UR 425 000 to 977 000), 7700 human metapneumovirus-associated in-hospital deaths (2600 to 48 800), and 16 100 overall (hospital and community) human metapneumovirus-associated ALRI deaths (5700 to 88 000). An estimated 11·1 million ALRI cases (UR 8·0 million to 15·7 million), 502 000 ALRI hospital admissions (UR 332 000 to 762 000), and 11 300 ALRI deaths (4000 to 61 600) could be causally attributed to human metapneumovirus in 2018. Around 58% of the hospital admissions were in infants under 12 months, and 64% of in-hospital deaths occurred in infants younger than 6 months, of which 79% occurred in low-income and lower-middle-income countries.

INTERPRETATION

Infants younger than 1 year have disproportionately high risks of severe human metapneumovirus infections across all World Bank income regions and all child mortality settings, similar to respiratory syncytial virus and influenza virus. Infants younger than 6 months in low-income and lower-middle-income countries are at greater risk of death from human metapneumovirus-associated ALRI than older children and those in upper-middle-income and high-income countries. Our mortality estimates demonstrate the importance of intervention strategies for infants across all settings, and warrant continued efforts to improve the outcome of human metapneumovirus-associated ALRI among young infants in low-income and lower-middle-income countries.

FUNDING

Bill & Melinda Gates Foundation.

Cesarean delivery and early childhood diseases in Bangladesh: An analysis of Demographic and Health Survey (BDHS) and Multiple Indicator Cluster Survey (MICS)

Introduction

The rate of cesarean delivery (C-section) has been increasing worldwide, including Bangladesh, and it has a negative impact on the mother and child's health. Our aim was to examine the association between C-section and childhood diseases and to identify the key factors associated with childhood diseases.

Methods

We used four nationally representative data sets from multiple indicator cluster survey (MICS, 2012 and 2019) and Bangladesh Demographic and Health Survey (BDHS, 2011and 2014) and analyzed 25,270 mother-child pairs. We used the frequency of common childhood diseases (fever, short or rapid breaths, cough, blood in stools, and diarrhea) as our outcome variable and C-section as exposure variable. We included mother’s age, place of residence, division, mother’s education, wealth index, child age, child sex, and child size at birth as confounding variables. Negative binomial regression model was used to analyze the data.

Results

In the BDHS data, the prevalence of C-section increased from 17.95% in 2011 to 23.33% in 2014. Also, in MICS, the prevalence almost doubled over an eight-year period (17.74% in 2012 to 35.41% in 2019). We did not observe any significant effect of C-section on childhood diseases in both surveys. Only in 2014 BDHS, we found that C-section increases the risk of childhood disease by 5% [Risk Ratio (RR): 1.05, 95% CI: 0.95, 1.17, p = 0.33]. However, the risk of childhood disease differed significantly in all survey years by division, child's age, and child’s size at birth after adjusting for important confounding variables. For example, children living in Chittagong division had a higher risk [(2011 BDHS RR: 1.22, 95% CI: 1.08, 1.38) and (2019 MICS RR: 1.21, 95% CI: 1.08, 1.35)] of having disease compared to Dhaka division. Maternal age, education, and wealth status showed significant differences with the outcome in some survey years.

Conclusion

Our study shows that C-section in Bangladesh continued to increase over time, and we did not find significant association between C-section and early childhood diseases. High C-section rate has a greater impact on maternal and child health as well as the burden on the health care system. We recommend raising public awareness of the negative impact of unnecessary C-section in Bangladesh.

Factors affecting mothers' intentions to visit healthcare facilities before hospitalisation of children with pneumonia in Biliran province, Philippines: a qualitative study

BACKGROUND AND OBJECTIVES

Despite a substantial reduction in the mortality rate of children under 5 years in the past 25 years, pneumonia remains the single-largest infectious cause of child deaths worldwide. This study explored the chronological order of visited healthcare facilities and practitioners, and the factors affecting mothers' intention to seek care before the hospitalisation of children with pneumonia.

METHODS AND ANALYSIS

A qualitative research design was employed using theory of planned behaviour as a framework for the analysis. Using purposive sampling technique, 11 mothers, whose children under 5 years old were hospitalised with severe pneumonia, were recruited for individual semi-structured interviews. Their socio-demographic information was analysed using descriptive statistics.

RESULTS

Mothers brought their sick children to multiple facilities, and 1 to 19 days had passed before hospitalisation. We identified four major factors determining mothers' intentions: (1) doing something useful for the sick child, (2) expecting the child to receive the necessary assessment and treatment, (3) accepting advice to visit a healthcare facility and be referred to a hospital and (4) considering issues and benefits associated with hospitalisation. Mothers noticed their children's unusual symptoms and monitored them while applying home remedies. They also took their children to traditional healers despite knowing that the treatments were not necessarily effective. Mothers expected children to be checked by health professionals and listened to advice from family members regarding the facilities to visit, and from healthcare staff to be referred to a hospital. Financial issues and the double burden of housework and caring for the hospitalised child were mothers' major concerns about hospitalisation.

CONCLUSION

Children were hospitalised after several days because they visited multiple healthcare facilities, including traditional healers. Improving care quality at healthcare facilities and reducing financial and mothers' burden may reduce the hospitalisation delay for children with pneumonia.

Disaggregated level child morbidity in Bangladesh: An application of small area estimation method

Acute respiratory infection (ARI) and diarrhoea are two major causes of child morbidity and mortality in Bangladesh. National and regional level prevalence of ARI and diarrhoea are calculated from nationwide surveys; however, prevalence at micro-level administrative units (say, district and sub-district) is not possible due to lack of sufficient data at those levels. In such a case, small area estimation (SAE) methods can be applied by combining survey data with census data. Using an SAE method for the dichotomous response variable, this study aims to estimate the proportions of under-5 children experienced with ARI and diarrhoea separately as well as either ARI or diarrhoea within a period of two-week preceding the survey. The ARI and diarrhoea data extracted from Bangladesh Demographic and Health Survey 2011 are used to develop a random effect logistic model for each of the indicators, and then the prevalence is estimated adapting the World Bank SAE approach for the dichotomous response variable using a 5% sample of the Census 2011. The estimated prevalence of each indicator significantly varied by district and sub-district (1.4–11.3% for diarrhoea, 2.2–11.8% for ARI and 4.3–16.5% for ARI/diarrhoea at sub-district level). In many sub-districts, the proportions are found double of the national level. District and sub-district levels spatial distributions of the indicators might help the policymakers to identify the vulnerable disaggregated and remote hotspots. Particularly, aid industries can provide effective interventions at the highly vulnerable spots to overcome the gaps between micro and macro level administrative units.

Mortality Predictive Scores for Community-Acquired Pneumonia in Children

PURPOSE OF REVIEW

The use of severity score for the staging of pneumonias has emerged as a necessity for the physician caring for this disease. Although there are several established prognostic scoring systems for community-acquired pneumonia in adults, the availability for children are scarce.

RECENT FINDINGS

Recently, scoring system for risk stratification of children with pneumonia were developed in low- and middle-income countries. They use clinical variables that represent known risk factors for severe outcomes of respiratory illness in children, such as hypoxemia, chest indrawing, refusal to feed, malnutrition, age, and stage of HIV disease among others factors. Although they showed good discriminating power and are very useful in low-resource settings, the characteristics of the patients, the local epidemiology of concurrent diseases, the social conditions, and the facilities of the hospitals make them not applicable to developed countries. A new prognostic scale for estimating mortality based on the modified PIRO scale used in adults with pneumonia can be useful for developed countries. Although several scoring systems for the estimation of mortality in childhood CAP were developed in the last years, most of them come from developing countries and the results are not applicable to patients with pneumonia in developed countries. Prospective studies applying scores adapted to the reality of the developed countries are needed.